Firearm injury prevention counseling by pediatricians and family physicians. Practices and beliefs

Conversation starters: Understanding the facilitators and barriers to physician-initiated secure firearm storage conversations

OBJECTIVE

This paper aims to understand what general practice physicians (GPs) perceive as facilitators and barriers to initiating anticipatory guidance around firearm safety.

METHODS

We employ qualitative interviewing to have in-depth conversations with 18 GPs. Participants were randomly selected from a national panel of physicians and screened for specialty (general practice or internist), practice setting (not hospital-based), and time spent on direct patient care (80% +). The sample was stratified at the state level by the presence of safe storage or child access protection laws, with half of the participants selected from each stratum.

RESULTS

We identify five physician-perceived barriers to providing secure firearm storage counseling, including inadequate screening mechanisms to trigger conversations, physician perceptions of who is at risk for firearm injury, time pressures, concerns about patient receptivity, and a need for training.

CONCLUSION

Prior to focusing on how to have conversations about firearm safety, interventions designed to increase the incidence of physician-initiated guidance need to address the structural issues of why those conversations typically do not occur.

PRACTICE IMPLICATIONS

Findings indicate the need for revised screening tools and improved physician education as to who is at risk for gun injury and how to best approach firearm safety conversations.

Implementation of a firearm safety guidance training program for pediatric providers

PURPOSE

Pediatric unintentional firearm injuries are potentially preventable with firearm safety guidance (FSG). In baseline assessment, we learned that providers feel uncomfortable delivering FSG due to lack of training, but are inclined to learn. Here we present the development and concept testing of an FSG training program.

METHODS

Using Kern's 6 rules of curriculum development, a training template was developed: 1. Program development, 2. Review by multidisciplinary expert team, 3. Concept testing, and 4. Modifications. Foundations included: raising awareness, increasing provider knowledge of safe storage methods, introducing a visual aide (American Academy of Pediatrics [AAP] infographic), and providing examples of guidance delivery. In-person training was provided and modifications made until there was uniform provider satisfaction. Program effectiveness and satisfaction were evaluated through surveys and focus groups. Descriptive statistics and univariate analyses were utilized.

RESULTS

Over one year, in-person training was provided to 44 pediatric providers (residents and practicing pediatricians) at 8 clinics. Modifications included: addition of a Spanish-version visual aide, instruction on safety device use, simulation scenarios, making the handout more child-friendly, and development of a home safety video to include firearm safety with other topics. Following training, routine FSG by pediatricians increased from 34% to 71% (p = 0.001). Focus groups revealed provider satisfaction with the AAP infographic and increased comfort of FSG delivery.

CONCLUSION

Following development and quality improvement, our FSG training model received positive feedback and increased provider delivery by pediatric providers. This model could be used for development of FSG training programs in other settings.

The 5 A's of firearm safety counseling: Validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial

The 5 A's of Firearm Safety Counseling is a novel framework by which clinicians can approach firearm injury prevention counseling. To evaluate this methodology as a tool for clinicians, a single-center, simulation-based randomized controlled trial was performed with clinical trainees in psychiatry, medicine, and pediatrics in an urban quaternary care center. Participants received didactic education on firearm injury epidemiology and evidence-based policies and training on a specific counseling framework, the 5 A's of Firearm Safety Counseling which they then implemented in a simulation setting with standardized patients. Of the 29 participants who were randomized, 28 completed the trial. Most participants were psychiatry trainees (residents or subspecialty fellows). While over 60% of participants were uncomfortable or extremely uncomfortable counseling on firearm injury prior to the interventions, only 4% reported being uncomfortable after receiving education and participating in simulated encounters. There was no significant difference between the quality and content of the counseling provided before and after the didactic-only session. There was a significant difference between the quality and content of the counseling provided before and after the specific training on the 5 A's for Firearm Safety Counseling strategy. The 5 A's for Firearm Safety Counseling is a promising educational tool to improve quality, content, and comfort delivering patient-centered counseling on firearm injury prevention in a simulation-based setting. These findings suggest that further validation in a clinical setting is warranted given there is an urgent need for feasible and effective firearm injury prevention strategies among clinicians.

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.

Talking about firearm injury prevention with patients: a survey of medical residents

BACKGROUND

Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention.

METHOD

A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers.

RESULTS

The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms.

CONCLUSIONS

Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Firearm injuries in children: a missed opportunity for firearm safety education

BACKGROUND

Surgeons frequently care for children who have sustained gunshot wounds (GSWs). However, firearm safety education is not a focus in general surgery training. We hypothesised that firearm safety discussions do not routinely take place when children present to a trauma centre with a GSW.

METHOD

A retrospective review of patients <18 years presenting with GSWs to a level 1 paediatric trauma centre from 2009 to 2019 was performed. The primary outcome was discussion of firearm safety with the patient or family. The secondary outcome was notification of child protective services (CPS).

RESULTS

A total of 226 patients with GSWs were identified, 22% were unintentional and 63% were assault. Firearm safety discussions took place in 10 cases (4.4%). Firearm safety discussions were more likely to occur after unintentional injuries compared with other mechanisms (16.0% vs 1.3%, p<0.001). CPS was contacted in 29 cases (13%). CPS notification was more likely for unintentional injuries compared with other mechanisms (40% vs 3.9%, p<0.001) and for younger patients (7 years vs 15 years, p<0.001).

CONCLUSION

At a paediatric trauma centre, firearm safety discussions occurred in 4.4% of cases of children presenting with a GSW. There is a significant room for improvement in providing safety education interventions.

Physician Involvement in Promoting Gun Safety

Firearm-related deaths are on the rise in the United States, especially among our youth. Tragically, proper firearm storage and safety could have prevented a great number of these deaths. Professional and public health organizations have thus encouraged physicians to provide direct patient counseling on firearm safety. Yet, even with these recommendations, the majority of physicians are still not talking to their patients about this issue. There may be many reasons for this, including concerns about liability, feeling unprepared, patient discomfort, and lack of time during office visits. Despite these concerns, we argue that physicians have an ethical obligation to discuss firearm safety with their patients. Making these discussions a part of routine clinical care would go a long way in the bipartisan effort to protect public safety and improve public health.

Gun safety discussions with caregivers: timing and demographic associations in a retrospective study

This study examined individuals' recollection of gun safety conversations during childhood, and with whom these conversations occurred. Data were collected using a retrospective survey of 298 college students aged 18-54 from three campuses of a university in the USA. Respondents reported whether they recalled discussing guns or gun safety with a parent, doctor, or school official in childhood as well as what age they recalled first discussing guns or gun safety with this adult. Those growing up in gun-owning households were more likely to report gun safety conversations with parents and to report having these conversations at earlier ages. More affluent youth were more likely to report gun safety conversations with school officials and to report having gun safety discussions with adults in a variety of roles. Few respondents recalled discussing guns with a doctor or paediatrician. Future investigations are needed to assess the content and form of gun safety conversations between children and caregivers.

An educational intervention for medical students to improve self-efficacy in firearm injury prevention counseling

Background

Most physicians support counseling patients about firearm injury prevention (FIP), but infrequently do so due to lack of training and low confidence. Interventions to increase counseling frequency should focus on improving physician self-efficacy. Firearm injuries affect many clinical specialties; therefore, trainees would benefit from early FIP education. This study aims to determine if a 20-min educational intervention improves self-efficacy in FIP counseling in third-year medical students. Knowledge and beliefs were also assessed as secondary indicators of self-efficacy.

Methods

This was a prospective study performed at a medical school associated with a tertiary care children’s hospital during the 2016–17 academic year. Groups of 12–15 different third-year medical students were selected to receive either a 20-min intervention or control lecture during their monthly pediatric lectures. The intervention consisted of two clinical vignettes, a brief discussion about the importance of FIP, and suggestions for clinical integration. The control session was a case-based lecture about pediatric emergencies. Participants completed baseline electronic assessments. Intervention students also completed post-intervention assessments immediately following each session. All participants completed final assessments at 6 months. Data were analyzed using Wilcoxon signed-rank tests and Wilcoxon rank-sum.

Results

We surveyed a total of 130 students. Sixty-five students completed the entire series of assessments – 22 from the control and 43 from the intervention group. There were no significant differences between the control and intervention groups at baseline. Immediately after, intervention, participants reported feeling more self-efficacious, had improved knowledge of FIP risk factors, and had beliefs more consistent with providing FIP anticipatory guidance (p <  0.001 for all three measures). After 6 months, participants sustained improvement in one of two self-efficacy questions (“I feel ready to counsel patients about firearm injury prevention”) and retained knowledge of risk factors (p <  0.05 for both). However, their beliefs did not significantly favor FIP counseling, and they were not more likely to engage in a conversation about firearm safety.

Conclusions

A 20-min educational intervention acutely improved self-efficacy in FIP counseling in third-year medical students, but improvements weakened after six months. Without further training, the beneficial effects of a one-time intervention will likely wane with time.

Pediatric resident firearm-related anticipatory guidance: Why are we still not talking about guns?

This study characterizes the current firearm-related anticipatory guidance practices of pediatricians-in-training and the factors affecting those practices. In this study of Pediatric residents in the Mid-Atlantic region, surveys were distributed to 189 trainees at three hospitals. Eighty-one responses were collected between June 2017 and March 2018. The survey gathered information about the residents' values related to firearms, firearm-specific counseling practices, barriers to providing counseling, and educational needs related to firearms. The residents surveyed overwhelmingly agreed (96%) that physicians have a responsibility to counsel patients on the risks posed by firearms. However, most (63%) never provide firearm-related counseling or do so in only 1-5% of well-child visits. Their unfamiliarity with safe storage devices contributes to a lack of comfort providing counseling. For pediatricians to provide potentially lifesaving counseling on firearm safety, they must be well-versed in the subject and feel comfortable and confident in doing so. Educational interventions addressing physician self-efficacy are necessary to accomplish this. There is an urgent need to develop a comprehensive firearm safety education program for physicians and trainees to improve firearm counseling.

Preventing Firearm-Related Death and Injury

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

A quality improvement program in pediatric practices to increase tailored injury prevention counseling and assess self-reported changes made by families

Background

Many pediatric providers struggle to screen families for the majority of age-appropriate injury risks and educate them when appropriate. Standardized tools have helped physicians provide effective, more purposeful counseling. In this study, pediatricians utilized a standardized, injury prevention screening tool to increase targeted discussions and families were re-screened at subsequent visits to determine changes in their behavior.

Methods

Pediatric practices, recruited from the Ohio Chapter, American Academy of Pediatrics database, self-selected to participate in a quality improvement program. Two screening tools, for children birth-4 month and 6–12 month, with corresponding talking points, were to be implemented into every well child visit. During the 7-month collaborative, screening results and pediatrician counseling for reported unsafe behaviors were calculated. Patients who completed a screening tool at subsequent visits were followed up at a later visit to determine self-reported behavior changes. We examined statistically significant differences in frequencies using the X² test. Providers received maintenance of certification IV credit for participation.

Results

Seven practices (39 providers) participated. By the second month, participating providers discussed 75% of all inappropriate responses for birth-4 month screenings and 87% for 6–12 months. Of the 386 families who received specific counseling and had a follow-up visit, 65% (n = 94/144) of birth-4 month and 65% (n = 59/91) of 6–12 month families made at least one behavior change. The X² test showed that families who received counseling versus those that did not were significantly more likely to change inappropriate behaviors (p < 0.05). Overall, of all the risks identified, 45% (136) of birth-4 month and 42% (91) of 6–12 month behaviors reportedly changed after a practitioner addressed the topic area.

Conclusions

Participation in a quality improvement program within pediatric offices can increase screening for injury risks and encourage tailored injury prevention discussions during an office encounter. As a result, significantly more families reported to practice safer behaviors at later visits.

Discussing Firearm Ownership and Access as Part of Suicide Risk Assessment and Prevention: "Means Safety" versus "Means Restriction"

The goal of this study was to describe the relative utility of the terms "means safety" versus "means restriction" in counseling individuals to limit their access to firearms in the context of a mock suicide risk assessment. Overall, 370 participants were randomized to read a vignette depicting a clinical scenario in which managing firearm ownership and access was discussed either using the term "means safety" or "means restriction." Participants rated the term "means safety" as significantly more acceptable and preferable than "means restriction." Participants randomized to the "means safety" condition reported greater intentions to adhere to clinicians' recommendations to limit access to a firearm for safety purposes (F[1,367] = 7.393, p = .007, [Formula: see text]). The term "means safety" may be more advantageous than "means restriction" when discussing firearm ownership and access in clinical settings and public health-oriented suicide prevention efforts.

What Are Parents Willing to Discuss with Their Pediatrician About Firearm Safety? A Parental Survey

OBJECTIVE

To determine if parents are receptive to discussing firearm safety with their pediatrician.

STUDY DESIGN

Parents completed a self-administered paper survey during a pediatric office visit. Responses of those who confirmed and denied household firearms were compared using Fisher exact test.

RESULTS

Between March 23 and May 21, 2015, 1246 of 1363 eligible parents (91.4%) completed the survey (22.6% African American, 79.5% at least some college education); 36% of respondents reported household firearms (owners). An additional 14.3% reported that their child was often in homes that contained firearms. Of the 447 owners, 25.1% reported ≥1 firearm was stored loaded, and 17.9% carried a firearm when leaving the house. Seventy-five percent of parents thought the pediatrician should advise about safe storage of firearms (owners 71.1%, others 77.5%), 16.9% disagreed (owners 21.9%, others 13.4%), and 8.2% were uncertain. Sixty-six percent thought pediatricians should ask about the presence of household firearms (owners 58.4%, others 70.9%), 23.2% disagreed (owners 31.5%, others 17.8%), and 10.5% were uncertain. Differences in parental opinions between owners and other parents were statistically significant. Twenty-two percent of owners would ignore advice to not have household firearms for safety reasons, and 13.9% would be offended by such advice. Only 12.8% of all parents reported a discussion about firearms with the pediatrician.

CONCLUSIONS

Avoiding direct questioning about firearm ownership and extending the discussion about why and how to ensure safe storage of firearms to all parents may be an effective strategy to decrease firearm-related injuries and fatalities in children.

Evaluating the reliability of an injury prevention screening tool: Test-retest study

BACKGROUND

A standardized injury prevention (IP) screening tool can identify family risks and allow pediatricians to address behaviors. To assess behavior changes on later screens, the tool must be reliable for an individual and ideally between household members. Little research has examined the reliability of safety screening tool questions. This study utilized test-retest reliability of parent responses on an existing IP questionnaire and also compared responses between household parents.

METHODS

Investigators recruited parents of children 0 to 1 year of age during admission to a tertiary care children's hospital. When both parents were present, one was chosen as the "primary" respondent. Primary respondents completed the 30-question IP screening tool after consent, and they were re-screened approximately 4 hours later to test individual reliability. The "second" parent, when present, only completed the tool once. All participants received a 10-dollar gift card. Cohen's Kappa was used to estimate test-retest reliability and inter-rater agreement. Standard test-retest criteria consider Kappa values: 0.0 to 0.40 poor to fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 as almost perfect reliability.

RESULTS

One hundred five families participated, with five lost to follow-up. Thirty-two (30.5%) parent dyads completed the tool. Primary respondents were generally mothers (88%) and Caucasian (72%). Test-retest of the primary respondents showed their responses to be almost perfect; average 0.82 (SD = 0.13, range 0.49-1.00). Seventeen questions had almost perfect test-retest reliability and 11 had substantial reliability. However, inter-rater agreement between household members for 12 objective questions showed little agreement between responses; inter-rater agreement averaged 0.35 (SD = 0.34, range -0.19-1.00). One question had almost perfect inter-rater agreement and two had substantial inter-rater agreement.

CONCLUSIONS

The IP screening tool used by a single individual had excellent test-retest reliability for nearly all questions. However, when a reporter changes from pre- to postintervention, differences may reflect poor reliability or different subjective experiences rather than true change.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.

A pilot quality improvement program to increase pediatrician injury anticipatory guidance

BACKGROUND

Because of a lack of time and training, many pediatricians often address few, if any, injury topics during well-child visits. The project goal was to increase the injury anticipatory guidance topics covered by pediatricians during well-child visits by offering screening tools and focused talking points through a quality improvement learning collaborative.

METHODS

Screening tools were developed and pretested. Pediatric practices, recruited through the Ohio American Academy of Pediatrics, were taught quality improvement theory and injury prevention strategies at a learning session. Pediatricians worked to implement screening tools and talking points into every well-child visit for children 1 year or younger. Monthly, providers reviewed five random charts for each of the six well-child visits for screening tool use and age-appropriate injury prevention discussion. Providers received maintenance of Certification IV credit.

RESULTS

Sixteen pediatricians (six practices) participated. Screening tool use increased from 0% to 97.2% in just 3 months of the program. For each well-child care visit, injury prevention discussion increased by 89.5% for newborn visit, 88.1% for 2-month, 93.6% for 4-month, 94.0% for 6-month, 88.1% for 9-month, and 90.3% for 12-month-old babies. During the quality improvement program, discussion points for all children 1 year or younger increased for all age-appropriate topics. The greatest percent increase in discussions occurred with water safety (from 10.8% to 95.7%, n = 231), play safety (from 17.9% to 93.5%, n = 154), and supervision safety (from 20.8% to 94.4%, n = 251). More commonly addressed topics also had a significant increase in discussions: sleep safety (from 48% to 93.9%, n = 262), choking (from 44.7% to 95.4%, n = 172), and car safety (from 41.2% to 80.1%, n = 332).

CONCLUSION

Participation in a maintenance of Certification IV quality improvement program within pediatric offices can increase screening and discussion of injury anticipatory guidance.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Physician assistants training on firearm injury prevention

OBJECTIVE

The purpose of this study was to assess physician assistant training programs incorporation of firearm injury prevention training in their curricula. Also, content of such programs as well as perceived benefits and barriers of providing such training were explored.

METHODS

A three-wave postal mailing of a 24-item questionnaire was sent to the population (n=145) of physician assistant program directors.

RESULTS

The majority (77%) of directors responded. The majority (81.3%) reported they had not seriously thought about providing such training (pre-contemplation). The three most important barriers to providing firearm injury prevention training were: lack of time, lack of faculty expertise on the topic, and lack of standardized teaching materials. Those programs that offered training averaged one-half hour. Yet, 77.7% thought that firearm injuries were a very large or large problem to the health and wellbeing of the U.S. population.

CONCLUSION

There is a paucity of professional training for physician assistants regarding firearm injury prevention. It appears unlikely that physician assistants are playing a role in helping to reduce one of the leading causes of death in the U.S., firearm trauma. The American Academy of Physician Assistants needs to take the lead in improving training in this area for physician assistants.

PRACTICE IMPLICATIONS

Physician Assistant training program directors should consider offering firearm injury prevention training to help reduce patient suicides and homicides.

A randomized trial of a home safety education intervention using a safe home model

BACKGROUND

Young children are at risk for injuries in the home. This study was to compare a safe house model to The Injury Prevention Program (TIPP) sheet for providing injury prevention information.

METHODS

Parents of children who were younger than 6 years were randomized to injury prevention education using a safe home model or an age appropriate TIPP sheet. There was a pretest before the intervention. The recall of injury prevention information was assessed by a telephone posttest 4 weeks to 6 weeks after the intervention. To obtain a sample broadly representative of community demographics, we recruited families in the dermatology clinic of a teaching hospital.

RESULTS

We collected complete information for 371 families of which 181 were in the safe home model group and 190 were in the TIPP group. There were no differences between groups in percent minority race, education, or insurance; the parents in the safe home group were slightly older (34.4 ± 6.5 vs. 32.9 ± 5.8). More than 80% in each group had education beyond high school. There was no difference between groups in pretest scores, 8.0 ± 1.3 for the safe home model group and 8.1 ± 1.1 for the TIPP group. There was no difference between groups in posttest scores, 9.0 ± 0.8 for the safe home model group and 9.1 ± 0.9 for the TIPP group.

CONCLUSIONS

The safe home model and the TIPP sheets were both effective in improving safety knowledge. The use of a safe home model complements current strategies to improve injury prevention knowledge.

Implementing and evaluating an injury prevention curriculum within a pediatric residency program

BACKGROUND

Many pediatric residency programs struggle to incorporate injury prevention training into their curricula.

OBJECTIVE

To analyze whether a 2-week injury prevention course helps pediatric residents to learn and retain more information than their peers who receive the standard education on injury prevention topics.

METHODS

A mandatory 2-week injury prevention course is provided for all interns at Cincinnati Children's Hospital Medical Center (CCHMC). Residents at CCHMC, completed a 50-question test on basic injury prevention topics at intern orientation and at the end of their first and third years of training. A control group of two intern classes from comparable children's hospitals who did not receive the injury prevention course were given the identical test at similar time periods. Data were analyzed using SPSS, and t tests were used to calculate and compare the mean percent change in test scores.

RESULTS

Seventy-six pediatric interns were enrolled (33 intervention and 43 controls). After internship, posttests were obtained on 29 (88%) intervention residents and 38 (88%) controls. On completing residency, posttests were received from 16 (48%) CCHMC residents and 22 (51%) controls. There was no difference in demographics or prior injury prevention training between the groups at study enrollment. A total of 63.6% of controls reported receiving injury prevention training by the end of their residency. There was a significant difference in the improvement of mean test scores between the intervention and control groups after internship (14.1% vs. 3.2%; p < 0.001) and again after the third year (11.9% vs. 5.5%; p = 0.02).

CONCLUSIONS

An injury prevention curriculum for pediatric residents can significantly increase and sustain their fund of knowledge on these important topics.

Clinical psychologists' firearm risk management perceptions and practices

The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.

Injury prevention in the emergency department: a caregiver's perspective

BACKGROUND

Emergency medicine physicians and their staff care for high-risk injured patients, making the emergency department (ED) an appropriate place to discuss injury prevention (IP).

OBJECTIVE

To determine family receptiveness to and short-term effectiveness of IP information delivery during an ED visit.

METHODS

A cross-sectional survey was conducted in an urban pediatric ED. Caregivers of children younger than 15 years, with any chief complaint, were approached to participate. The survey consisted of caregiver's background, IP information received by their primary care pediatrician, and their wishes for receiving IP information in the ED. At survey completion, participants were given an age-appropriate IP handout. Follow-up phone surveys were made at 2 weeks to determine caregiver satisfaction and any self-reported IP changes made.

RESULTS

Two hundred fifty-one caregivers were approached. Two hundred forty-six (98%) were interested in receiving IP information in the ED, and 217 (86%) consented to participate. Ninety-three percent felt that the ED should provide IP information; 83% believed it should be offered even if it prolonged their ED visit. There was no significant difference among participants with regard to who should provide the information or how it should be provided. One hundred thirty (60%) of 217 completed the follow-up survey. Ninety-seven percent felt that the IP information was useful, and 63% kept the handout in a retrievable place. Twenty-eight percent of caregivers who completed the follow-up survey reported to change their safety behavior as a result of their ED encounter.

CONCLUSIONS

Many families surveyed in an urban pediatric ED wished for IP information in the ED setting. A simple IP intervention in an ED setting may encourage families to practice safer behaviors for their children.

Differences in pediatric preventive care counseling by provider type

OBJECTIVE

Many children in the United States do not receive advice about health behaviors and injury prevention during routine preventive care visits. We investigated the role of provider type in the probability of receiving advice.

METHODS

We analyzed children aged 3 to 17 in the Medical Expenditure Panel Data 2002 to 2003 surveys who had only 1 preventive clinic or office visit in the past year. We examined whether provider type affects whether the child is advised about healthy eating, physical activity, the harmful effects of smoking in the home, proper safety restraints in a car, and use of a helmet when riding a bicycle.

RESULTS

Pediatricians were more likely to advise about healthy eating (63.6% vs 46.8% for other physicians and 41.1% for nonphysicians; P < .01). They were also more likely than nonphysicians to advise about exercise (40.1% vs 22.2%), the harmful effects of parental smoking (42.4% vs 21.4%), proper safety restraints in a car (39.9% vs 20.5%), and use of a bicycle helmet (45.7% vs 20.9%). Regardless of provider type, rates of advice were low.

CONCLUSION

Many pediatric providers, particularly those not trained as pediatricians, are missing opportunities to advise about health behaviors and injury prevention.

Pediatricians' involvement in gun injury prevention

BACKGROUND

Injuries from small arms are of concern internationally. The health perspective is an emerging aspect of international work to reduce these injuries. This aspect has been evident in US firearm injury prevention work for over a decade, exhibited by strong statements from the American Academy of Pediatrics (AAP) to remove firearms from children's environments.

OBJECTIVES

To assess trends among US pediatricians related to firearm injury prevention counseling practices and attitudes toward gun legislation.

DESIGN

National random sample, mailed surveys of AAP members: (1) 1994 (response rate = 68.9%, n = 982); (2) 2000 (response rate = 62.4%, n = 922). chi(2) Tests were used to assess bivariate relationships and logistic regression to assess multivariate relationships regarding counseling practices.

RESULTS

Respondents in both years believed that violence prevention should be a priority for pediatricians (91.4% and 92.0%) and reported always or sometimes recommending handgun removal from the home (46.2% and 55.9%, respectively). In 2000, 74% of the respondents were comfortable discussing firearm safety; fewer thought they had sufficient training (32.7%) or time (27.5%) to discuss firearms. In 1994 and 2000, the likelihood of counseling on handgun removal was positively related to recent experience treating a gun injury, female sex and not owning a gun. In both years, >80% of pediatricians thought that gun control legislation or regulations would reduce injury and death.

CONCLUSIONS

US pediatricians continue to adopt policies promoting gun injury prevention. The practices and attitudes of pediatricians may be important for public education strategies regarding firearm injury prevention in the US and internationally.

Preventive care for children in the United States: quality and barriers

Our objective was to examine the academic literature covering quality of childhood preventive care in the United States and to identify barriers that contribute to poor or disparate quality. We systematically reviewed articles related to childhood preventive care published from 1994 through 2003, focusing on 58 large observational studies and interventions addressing well-child visit frequency, developmental and psychosocial surveillance, disease screening, and anticipatory guidance. Although many children attend recommended well-child visits and receive comprehensive preventive care at those visits, many do not attend such visits. Estimates of children who attend all recommended visits range widely (from 37%-81%). In most studies, less than half is the proportion of children who receive developmental or psychosocial surveillance, adolescents who are asked about various health risks, children at risk for lead exposure who are screened, adolescents at risk for Chlamydia who are tested, or children and adolescents who receive anticipatory guidance on various topics. Major barriers include lack of insurance, lack of continuity with a clinician or place of care, lack of privacy for adolescents, lack of clinician awareness or skill, racial/ethnic barriers, language-related barriers, clinician and patient gender-related barriers, and lack of time. In summary, childhood preventive care quality is mixed, with large disparities among populations. Recent research has identified barriers that might be overcome through practice and policy interventions.

Firearm ownership and storage practices, U.S. households, 1992-2002. A systematic review

BACKGROUND

Because the presence and improper storage of household firearms are risk factors for injury, it is important to understand the prevalence of ownership and storage practices within households to help guide intervention development. This systematic review of published articles (1992 to 2002) provides prevalence estimates of firearm ownership and storage practices in U.S. households.

METHODS

A search of bibliographic databases (MedLine, CINAHL, PsycInfo, Sociological Abstracts) was completed in January 2003.

RESULTS

Although all were cross-sectional, the 42 articles included in this review varied in type; there were seven national and five state prevalence studies, as well as studies using clinic-based convenience samples (n =14) and samples of professionals (n =10). Published studies indicate that firearms are present in about one third of U.S. households. Handguns in particular are present in more than half of U.S. households with firearms, or about 19% of all U.S. households. The prevalence of firearms and handguns in households with young people was similar to the prevalence overall. Firearm ownership was highest in the South.

CONCLUSIONS

Although the methodologic rigor of published articles varies substantially, the literature clearly establishes that firearms are common in U.S. households, even in the homes of medical professionals and those with children.

Pediatrician counseling about preventive health topics: results from the Physicians' Practices Survey, 1998-1999

OBJECTIVE

Government agencies and national organizations recommend that physicians counsel their child and adolescent patients about preventive health topics. Using data from a national survey, we describe the counseling patterns of pediatricians in regard to 9 recommended preventive health topics.

METHODOLOGY

Between October 1998 and April 1999, information was collected from 907 of 1760 primary care pediatricians randomly selected from a nationally representative sample. Through either a telephone interview or a mail survey, pediatricians were asked how frequently in the past month they counseled about 9 preventive health topics during the well-care visits or routine check-ups of their patients. Pediatricians answered questions regarding their patients aged 2 to 5, 6 to 12, and 13 to 18 years.

RESULTS

Over 80% of the pediatricians counseled about 1 or more recommended preventive health topics during the well-care visits or routine check-ups of their patients. As compared with pediatricians who did not counsel about any topic, pediatricians who counseled were significantly more likely to be female and spend longer amounts of time with their patients during these visits. The frequency with which specific preventive health topics were discussed varied with the topic and the age of the patient.

CONCLUSION

Most pediatricians routinely counsel about some, but not all, recommended preventive health topics. An understanding of why pediatricians selectively counsel about specific topics is needed.

Childhood injury: a status report, part 2

The October issue of The Journal of Pediatric Nursing carried the first of two parts on childhood injury. That article reviewed the importance of prevention, the short- and long-term effects of injury on the child and the family, and how to incorporate prevention strategies at home and at work. Also reviewed were three of the most common mechanisms of injury, motor vehicle crashes, bicycle crashes, and pool drowning, and prevention measures. In this second part, the remaining primary areas of concern for common pediatric injuries are addressed: poisoning, fires and burns, and firearms.

Attitudes of New York City high school students regarding firearm violence

OBJECTIVES

To assess prevalence of gun possession, attitudes regarding gun possession and gun violence, knowledge and influences of gun violence, and the potential role of physicians in gun violence prevention education among adolescents.

METHODS

An anonymous questionnaire was distributed to 9th through 12th grade high school students at 3 public high schools in New York City.

RESULTS

Three hundred forty-two surveys were distributed and returned. The prevalence of guns in the homes was 19.6%. Of respondents, 43.2% thought it was okay for anyone to have guns, and 57.3% had been injured or have had a relative injured by a gun. Although 11.6% of adolescents had felt the need to talk to an adult about guns, only 3.0% listed their physicians as one of these adults. However, if asked by their physician, 63.8% would discuss the issue with them. Only 5.7% of adolescents have had a physician speak to them about guns.

CONCLUSIONS

The adolescent population surveyed is frequently exposed to gun violence. Although physicians rarely counsel adolescents regarding gun violence and firearm safety, many adolescents would be receptive to this mode of intervention.adolescence, attitude, firearm ownership, firearm violence, physician role.

Firearms and suicide

The evidence linking firearms in the home to risk for suicide is reviewed. These data come from epidemiological, case-control, quasiexperimental, and prospective studies. The convergent finding from this wide range of studies is that there is a strong relationship between firearms in the home and risk for suicide, most firmly established in the United States.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression

OBJECTIVE

To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial.

METHOD

The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up.

RESULTS

Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition.

CONCLUSIONS

Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Physician firearm ownership as a predictor of firearm injury prevention practice

OBJECTIVES

This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention.

METHODS

Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable.

RESULTS

Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling.

CONCLUSIONS

Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.

Firearm safety counseling in primary care pediatrics: a randomized, controlled trial

CONTEXT

Physicians have been encouraged to counsel families about risks associated with gun ownership, but the effectiveness of physician counseling regarding gun safety is unknown.

OBJECTIVE

To determine the effectiveness of gun safety counseling during well-child care visits.

DESIGN

Group randomized, controlled trial. Physicians, nurse practitioners, and physician assistants were randomized to either the intervention group or a control group.

SETTING

Group Health Cooperative, a staff-model health maintenance organization. Patients. Consecutive sample of families (n = 1295) seen for a scheduled appointment for well-child care for a child <18 years of age. Of the families originally scheduled for a visit, 80. 3% were seen and completed the outcomes surveys.

INTERVENTION

Each family in the intervention group was given a 60-second message by their practitioner that depended on the presence of guns in the home. Families without guns were informed of the health risks associated with gun ownership and given a standard information pamphlet. Families with guns were given the same information about risks and were told that if they chose to keep a gun, they should store it locked and unloaded. They were given instructions on storage and a folder with material, including the same pamphlet, a letter from the police department, written storage guidelines, and discount coupons for gun storage devices.

MAIN OUTCOME MEASURE

Changes in the following self-reported events: 1) acquisition of a safe storage device; 2) removal of firearms from the home; and 3) acquisition of firearms. Results. There were no important differences between intervention and control groups in the rate of acquisition of new guns (intervention: 1.3% vs control:.9%) after the intervention. Among households with guns at baseline, there were also no differences between groups in the removal of guns (intervention: 6.7% vs control: 5.7%), but there was a fairly large nonsignificant difference in the proportion who purchased trigger locks (intervention: 8.0% vs control: 2.5%).

CONCLUSIONS

A single firearm safety-counseling session during well-child care, combined with economic incentives to purchase safe storage devices, did not lead to changes in household gun ownership and did not lead to statistically significant overall changes in storage patterns.

Injury-prevention counseling among residents of internal medicine

BACKGROUND

The U.S. Preventive Service Task Force's Guide to Clinical Preventive Services and Healthy People 2000 recommend that physicians participate in various counseling activities, including injury prevention. Despite recommendations, rates of physician counseling, particularly injury prevention, are low. This study assessed clinical preventive services and attitudes among physicians. Furthermore, the study illustrates how physicians prioritize injury-prevention counseling relative to other prevention recommendations.

METHODS

Personal characteristics (i.e., demographics, specialty orientation, attitudes toward prevention, and personal health behaviors) of the residents were collected by a self-administered survey. We performed a 12-month retrospective chart review of 184 new doctor-patient encounters to determine rates of clinical preventive services that included four injury-prevention services: the use of seatbelts, helmets, and smoke detectors; and the safe storage of firearms.

RESULTS

Overall, attitudes toward injury prevention in the context of other clinical preventive services were low. Seatbelt counseling was the only injury-prevention service documented in the charts, and was performed at only one of four clinic sites.

CONCLUSIONS

Clinic site as a key predictor of preventive practice may be suggestive of the importance of organizational priorities and professional norms. Future injury-prevention education efforts must aim at improving attitudes of current and future physicians to facilitate positive professional norms.

Firearm storage patterns in US homes with children

OBJECTIVES

This study determined the prevalence and storage patterns of firearms in US homes with children.

METHODS

We analyzed data from the 1994 National Health Interview Survey and Year 2000 objectives supplement. A multistage sample design was used to represent the civilian noninstitutionalized US population.

RESULTS

Respondents from 35% of the homes with children younger than 18 years (representing more than 22 million children in more than 11 million homes) reported having at least 1 firearm. Among homes with children and firearms, 43% had at least 1 unlocked firearm (i.e., not in a locked place and not locked with a trigger lock or other locking mechanism). Overall, 9% kept firearms unlocked and loaded, and 4% kept them unlocked, unloaded, and stored with ammunition; thus, a total of 13% of the homes with children and firearms--1.4 million homes with 2.6 million children--stored firearms in a manner most accessible to children. In contrast, 39% of these families kept firearms locked, unloaded, and separate from ammunition.

CONCLUSIONS

Many children live in homes with firearms that are stored in an accessible manner. Efforts to prevent children's access to firearms are needed.

Emergency medical services for children: a general pediatrician's perspective

The EMSC movement is still in its infancy, and there is much that remains to be done. The primary care pediatrician plays a major role in the EMSC system and should continue to advocate for efficient, high-quality pediatric emergency care. In summary, there are several ways that the office-based pediatrician can and should become involved with EMSC: 1. Pediatricians should emphasize safe and injury prevention at each health maintenance visit throughout a child's life. 2. Pediatricians should encourage all parents to become certified in BLS/CPR. Ideally, training in CPR should be provided during prenatal and childbirth classes. 3. Pediatricians should advocate for injury prevention and safety campaigns in their communities. They can also become involved with efforts to develop legislation dealing with issues in injury prevention and safety. 4. Pediatricians should ensure that all children receive the appropriate immunizations. 5. Pediatricians need to maintain office emergency preparedness. All office personnel should maintain certification in BLS as a minimum and ideally, PALS. Equipment used for pediatric resuscitation should be available and functional. Monthly mock codes should be scheduled to ensure that all personnel clearly know their roles and responsibilities in the event of an emergency. 6. Pediatricians should maintain their skills in emergency pediatrics. In addition, they should maintain certification in PALS. Continuing medical education (CME) workshops and conferences in emergency pediatrics are available throughout the year. Also, pediatricians can maintain their airway management skills by practicing endotracheal intubation in the operating room setting. 7. Pediatricians must become familiar with the prehospital care providers, EDs, and transport services in their communities. Association with a pediatric intensive care unit at a tertiary care center would also be beneficial. 8. Pediatricians must be available for consultation to local EDs. They must realize that, in many instances, they may represent the physician who is most experienced with caring for the critically ill or injured child. 9. Pediatricians can serve as medical advisors to the EMS systems in their communities. 10. Pediatricians should stay well informed on issues pertaining to EMSC.

Firearm injury prevention counseling: are We missing the mark?

OBJECTIVE

To determine whether pediatricians accurately estimate the likelihood of gun ownership among their patients' families. Design. Self-administered, written surveys completed simultaneously by pediatricians and their patients' parents.

SETTING

A total of 23 pediatric practices and hospital-based clinics in three cities in the United States.

SUBJECTS

A total of 66 pediatricians paired with 169 of their patients' parents.

MAIN OUTCOME MEASURES

Parent survey: ownership and storage of guns, willingness to admit gun ownership, and previous counseling by pediatrician. Pediatrician survey: estimated prevalence of gun ownership, likelihood of gun ownership by each participant family, and beliefs about firearm injury prevention counseling.

RESULTS

All parents who owned guns indicated they would acknowledge owning a gun if asked by their pediatricians. Of the participating families, 28% owned at least one gun; 39% of the homes with guns contained a gun that was unlocked, loaded, or both. Of the parents, 11% reported that their pediatrician had discussed firearm safety with them. Pediatricians' average estimate of the overall prevalence of gun ownership in their patient populations was 25%. When asked to predict the likelihood of gun ownership by the specific families in the study, pediatricians predicted a 0% likelihood of gun ownership for 33% of the families. Of those families, 30% reported owning at least one gun. Considering physician predictions of any likelihood of gun ownership >0% (1%-100%) to be a positive prediction and using parent reports as the gold standard, physician estimates of gun ownership were only 65% sensitive. Approximately half (55%) of the participating pediatricians believed that pediatricians should discuss gun safety with all families, and 98% believed that pediatricians should discuss gun safety with all gun-owning families.

CONCLUSIONS

Pediatricians believe that all families with guns should receive firearm safety counseling. However, pediatricians significantly underestimate the likelihood of gun ownership by specific families. Parents who own guns indicate that they would acknowledge gun ownership if their pediatrician asked about guns in the home. Therefore, rather than relying on assumptions about whether particular patients seem likely to be gun owners, pediatricians should ask all families whether they own guns.

Barriers to pediatric injury prevention counseling

OBJECTIVES

Physicians cite numerous barriers to incorporating injury prevention counseling into routine care. Health behavior models suggest that beliefs about barriers are associated with physician characteristics. This study explores associations between physician characteristics and physician perceptions of barriers.

METHODS

Self administered structured questionnaires were sent to all five North Carolina (United States) pediatric residency programs. A total of 160 (72%) physicians training in pediatrics or medicine-pediatrics in these programs replied. Associations between perceived barriers and knowledge, gender, training, experience, and correlation between perceived barriers and other physician beliefs about injury prevention counseling, were measured.

RESULTS

Although most residents believed that talking to parents about injury prevention during routine visits was important, they felt they lacked time, did not think to ask parents about injury prevention, or had more important things to do. The more importance residents placed on asking parents about hazards, the less the extent to which barriers were perceived (r = 0.32). Barriers were perceived to a greater extent by residents who thought their preceptors did not expect them to counsel about injury prevention (r = 0.28), lacked confidence that their counseling helped parents (r = 0.32), or felt uncomfortable counseling parents about injury prevention (r = 0.18). Knowledge, residency year, training, and previous experience with injury were not related to perceived barriers.

CONCLUSIONS

Residency programs should teach the importance of injury prevention; provide opportunities for residents to become comfortable talking with parents about this; and train residents in the appropriate use of counseling as one strategy for addressing injury prevention.

Personality traits in juvenile delinquents: relation to criminal behavior and recidivism

OBJECTIVE

To examine the relation between personality traits and criminal behavior and to determine whether such factors are predictive of future recidivism.

METHOD

A sample of 481 incarcerated males (mean age = 16 years) completed questionnaires assessing distress and restraint relating to personality characteristics. In addition, official criminological data were gathered from subjects' records. A subsample of 148 juveniles was followed up to 4.5 years after release and examined for rearrests and time out of prison since last incarceration.

RESULTS

Results indicate a significant association between self-reported levels of distress and restraint and prior criminal behavior as well as behavior during incarceration. Furthermore, of the sample surveyed, 67% were rearrested. Personality traits measured during incarceration were predictive of recidivism rates, above and beyond the effects of such criminological factors as age and number of prior offenses.

CONCLUSIONS

The results support the view that juvenile delinquents are a heterogeneous population in terms of personality features. These traits have discriminant and predictive validity. Adding personality measures to the assessment of delinquents may further our understanding of how personality influences criminal activity and future recidivism. We may be able to use this understanding to target specific domains of functioning to develop more effective intervention strategies.

Primary care physicians' screening of adolescent patients: a survey of California physicians

PURPOSE

To determine how often primary care physicians screen adolescents for important risk factors and to determine how rates of screening vary by physicians' specialty and practice setting, patients' age, and type of risk factor.

METHODS

A stratified random sample of 343 California physicians who are Board certified in pediatrics, family practice, or internal medicine, and physicians in these specialties who specialized in adolescent medicine were surveyed about their screening practices using a mailed questionnaire. Subjects were asked the percentage of routine comprehensive physical examination during which they personally queried or screened each age group of adolescents (11-14 years old and 15-18 years old) for each of the following risk factors: high blood pressure, alcohol use, cigarette use, sexual activity, and drug use.

RESULTS

The frequency with which primary care physicians reported actually screening younger and older adolescents for the various risks were approximately: 93% and 96% for high blood pressure, 70% and 84% for alcohol use, 74% and 82% for drug use, 67% and 83% for sexual activity, and 76% and 86% for smoking, respectively. For all risk factors, providers screened older adolescents more frequently than younger adolescents (p < 0.01). Finally, screening rates varied by specialty (p < 0.01) but not by practice setting.

CONCLUSIONS

This study found that California physicians frequently screen adolescents for a variety of risk factors. However, the reported rates may not be consistent with published guidelines. Interventions may need to be developed which focus on improving primary care physicians' adolescent-specific screening practices.

Family practice physicians' firearm safety counseling beliefs and behaviors

The purpose of this study was to identify family physicians' firearm safety counseling beliefs and behaviors. A survey was mailed to a random sample of 600 members of the American Academy of Family Physicians. A three wave mailing technique was used to maximize the response rate and yielded 271 usable surveys (55% response rate). Outcome measures included training experience in firearm safety counseling, the prevalence of firearm safety counseling by family physicians, and their perceptions regarding such counseling. The majority (78%) of family physicians lacked formal training on how to counsel patients about firearm safety and 49% believed more time should be spent in residency programs on firearm safety counseling. The majority (84%) of respondents never or rarely counseled patients on firearm safety and 50% believed firearm safety counseling should be a low priority in their delivery of primary care. The majority of respondents did not regularly counsel patients about firearm safety, did not believe firearm safety counseling should be a priority, and did not believe firearm safety counseling would be effective in reducing firearm-related trauma.