Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80

A PRISMA Scoping Review to Explore Interventions to Prevent Firearm-Related Injury and Suicide in Older Adults

OBJECTIVES

This scoping review aims to examine existing research into firearm safety interventions designed to prevent firearm injury and suicide in older adults.

METHODS

Select databases were searched in 5/2023. Included articles involved an/a 1. aim to develop or investigate firearm safety interventions, 2. focus on adults 50 years and older, and 3. primary analysis.

RESULTS

The search yielded 10 articles which primarily focused on firearm safety counseling with older adults with suicide risk or emerging impairment. The review found that older adults may be open to receiving firearm safety counseling but that providers feel ill-equipped to have these conversations and to reliably identify suicide risk. Two studies presented promising data on the impact and acceptability of training providers in a firearm safety intervention. The review also identified the importance of building trust between older patients and providers to have helpful discussions regarding firearms, and highlighted specific approaches that facilitate openness to participate in these exchanges.

CONCLUSIONS

Further research into adapting interventions to meet the clinical needs of older adults and treatment efficacy trials is necessary.

CLINICAL IMPLICATIONS

Training healthcare providers to conduct firearm safety interventions with older adults may be an acceptable and impactful avenue to prevent suicide.

Situational and Victim Correlates of Increased Case Fatality Rates in Los Angeles Shootings, 2005-2021

The gun assault case fatality rate measures the fraction of shooting victims who die from their wounds. Considerable debate has surrounded whether gun assault case fatality rates have changed over time and what factors may be involved. We use crime event data from Los Angeles to examine the victim and situational correlates of gun assault case fatality rates over time. We estimated log binomial regression models for the probability of death in each year from 2005 to 2021, conditioned on situational and victim characteristics of the crime. Case fatality rates increased by around 1.3% per year between 2005 and 2021 from around 15.9 to 19.7%. Baseline case fatality rates differed systematically by most situational and victim but followed similar temporal trends. Only victim age significantly covaried with the temporal trend in case fatality rates. An individual shot in Los Angeles in 2021 was 23.7% more likely to die than the equivalent victim in 2005. The steady increase in case fatality rates suggests that there were around 394 excess fatalities over what would have occurred if case fatality rates remained at the 2005 level. Increases in the average age of victims over time may contribute to the general temporal trend. We hypothesize that older victims are more likely to be shot indoors where lethal close-range wounds are more likely.

Firearm suicide risk beliefs and prevention: The role of fear of community violence and firearm ownership for protection

INTRODUCTION

Household firearm availability is a risk factor for firearm suicide when a household member at-risk for suicide. Firearm ownership for protection and perceptions of community violence may reduce the likelihood of limiting access to firearms as a way to prevent suicide. The association between a firearm suicide risk belief and the intention to reduce firearm access as a means of preventing suicide, with fear of community violence and firearm ownership for protection as moderators, was examined.

MATERIALS AND METHODS

The analytic sample consisted of 388 Missouri firearm owners from a cross-sectional, statewide survey of Missouri adults. Logistic regression models were estimated.

RESULTS

Among Missouri firearm owners, firearm suicide risk belief was positively associated with the intention of reducing firearm access for firearm owners who were not afraid of community violence and owned a firearm for non-protection reasons (e.g., hunting).

DISCUSSION

Findings suggest that firearm suicide prevention efforts must be tailored to address the underlying beliefs about their violence risk among firearm owners who indicate they principally own for protection.

Engagement with Preventive Health Behaviors and Safe Firearm Storage Practices Using the 2017 Behavioral Risk Factor Surveillance System

PURPOSE

"Behavioral bundling" is a theory that explains how some health behaviors reinforce one another. This study aims to investigate the relationship between preventive health behaviors (PHBs) and safe firearm storage.

DESIGN

This study used a cross-sectional design using 2017 Behavioral Risk Factor Surveillance Survey data.

SETTING

Survey participants resided in California, Idaho, Kansas, Oregon, Texas, and Utah.

SUBJECTS

There were 12,817 people living in households with a firearm included in this study.

MEASURES

We classified individuals' engagement in 5 PHBs: cholesterol screening, influenza immunization, physical activity, primary care, and seatbelt use. We defined safe firearm storage as storing a firearm unloaded, or loaded but locked.

ANALYSIS

Using Poisson regression models, we calculated adjusted prevalence ratios (aPRs) to estimate the association between engagement in the five PHBs with safe firearm storage.

RESULTS

Most firearm owners reported safe firearm storage (80.3%). The prevalence of safe firearm storage was 3% higher for each additional PHB engaged in (aPR = 1.03 [1.01, 1.05]). There was a higher prevalence of safe firearm storage among those who always wore a seatbelt while driving or riding in a car compared to those who did not (aPR = 1.12 [1.05, 1.18]).

CONCLUSION

This study found preliminary evidence to suggest that engagement in seatbelt usage may be bundled with safe firearm storage, though we are not able to determine causality.

Perceptions of the utility of secure firearm storage methods as a suicide prevention tool among firearm owners who currently store their firearms loaded and unlocked

BACKGROUND

Although secure firearm storage can prevent firearm injury and death, secure storage is relatively rare. This tendency may be driven in part by a perceived lack of utility for secure storage in preventing suicide and other gun violence-related outcomes.

METHOD

We recruited a large (n = 3510) representative sample of residents from five US states and assessed the degree to which those who do and do not store their firearms securely perceive different utility in specific firearm storage practices for suicide prevention. To test for specificity, we examined if those differences hold when considering unintentional shooting and firearm theft prevention.

RESULTS

Those who currently store their firearms unsecured reported lower perceived utility in several firearm storage practices, particularly for suicide and theft prevention.

CONCLUSIONS

Our findings highlight that a lack of perceived utility in secure firearm storage may partially drive unsecure firearm storage. Efforts to promote secure storage must address this misperception.

Associations between experiencing violence, owning a firearm for protection and firearm storage: a nationally representative analysis of US caregivers of teens

OBJECTIVE

To study the interaction between violence exposure and motivations for firearm ownership in their associations with firearm storage among caregivers of teens in the United States.

METHODS

In June-July 2020, we conducted a national survey of 2924 caregivers of US teens. We estimated multivariable logistic regressions among caregivers who owned a firearm (n=1095) to evaluate associations between the exposures of community violence, interpersonal violence, and firearm ownership motivations (protection motivations vs non-protection motivations) and the outcome of firearm storage patterns (locked and unloaded vs unlocked and/or loaded). We assessed for a potential interaction between violence exposures and motivations for firearm ownership in their associations with firearm storage.

RESULTS

We observed no associations between community (adjusted OR [aOR]: 0.86; 95% CI [0.55 to 1.36]) or interpersonal violence exposure (aOR: 0.60; 95% CI [0.22 to 1.65]) and firearm storage behaviours, and these associations did not vary according to firearm ownership motivations (relative excess risk due to interaction: -0.09 [-1.90 to 1.73]; -2.04 [-6.00 to 1.92]). Owning a firearm for protection was associated with increased odds of storing at least one firearm unlocked and/or loaded (aOR: 3.48; 95% CI [2.11 to 5.75]), and this association persisted across all strata of violence exposures (aORs: 1.51-3.98; 95% CIs [0.52 to 8.31]-[1.96 to 8.08]).

CONCLUSIONS

The motivation to own a firearm for protection was associated with storing a firearm unlocked and/or loaded. The results suggest the associations between violence exposure and firearm storage are more complicated than anticipated because (1) exposure to violence was not associated with firearm storage practices and (2) motivations for firearm ownership do not appear to explain why people differ in firearm storage following violence exposure.

Older Adults' Preferences Regarding Firearm Locking Device Use: Results of a National Survey

OBJECTIVES

Use of firearm locking devices may reduce the risk of suicide and injury among older adults. This study describes older adults' preferences when choosing a firearm locking device.

METHODS

We conducted a secondary analysis of a nationally representative survey of US adult firearm owners (N = 2,152). We compared older adults (≥65y) with relatively younger adults (<65y), stratified by self-reported gender.

RESULTS

The top three factors cited as impacting firearm locking device selection included speed (53.6%) and ease of firearm access from device (52.4%), and cost of the device (28.7%). These top factors were comparable for all adults across genders. A larger proportion of older vs younger males reported that a primary preference was whether the device allows the firearm to remain loaded with ammunition; smaller proportions of older vs younger males reported strength of device (device durability) and costs.

CONCLUSIONS

Preference among older adults, particularly older males, for locking devices that maintain the firearms easy to access - especially, loaded with ammunition - might impact firearm injury prevention efforts for this high-risk group.

CLINICAL IMPLICATIONS

For harm reduction, use of any firearm locking device may reduce the risk of firearm injury or death. Clinicians are encouraged to explore reasons for locking device selection within motivational interviewing frameworks.

Firearm use risk factors and access restriction among suicide decedents age 75 and older who disclosed their suicidal intent

Background and aims

A majority of older adult suicide decedents used firearms. In this study, we focused on suicide decedents age 75+ who disclosed their suicidal intent within a month of their injury/death to examine demographic and clinical characteristics associated with firearm use and firearm access restriction attempts by their family members.

Methods

The 2017-2019 U.S. National Violent Death Reporting System provided data (N = 1,734 suicidal intent disclosers; 1,476 males and 258 females; 21.4% of decedents age 75+). Generalized linear model (GLM) for a Poisson distribution with a log link was used to examine firearm use risk factors. Firearm access restriction attempts by decedents' family members were examined based on coroner/medical examiner and law enforcement (CME/LE) reports.

Results

Nearly three quarters of disclosers disclosed their intent to family members, and 82.9% of males and 27.5% of females used firearms. GLM results showed males, non-Hispanic white people, and residents in the South and West regions had higher likelihood of firearm use. CME/LE reports of 140 out of 1,294 firearm decedents included narratives related to firearm restriction attempts or lack thereof. Firearm access restrictions were not attempted in 65 cases because family members did not take suicidal intent disclosure seriously or because decedents promised no self-harm. Partial or complete removal of firearms in 75 cases were not effective as decedents had hidden a firearm or purchased a new one. Others used different lethal methods.

Implications

The findings indicate a need for: (a) training family members of older adults who are at risk of suicide in effective means safety/access restriction and strategies to prevent means substitution; (b) more comprehensive legislative reforms reducing access to firearms by those at risk of suicide; and (c) more comfort and palliative care and counseling for psychosocial risk factors.

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care

OBJECTIVES

Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients.

METHODS

From March - August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes.

RESULTS

Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement.

CONCLUSIONS

There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage.

CLINICAL IMPLICATIONS

Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

Firearm Safety and Suicide Prevention for Medically Complex Older Veterans: Perspectives of VA Home-Based Primary Care Directors and Psychologists

OBJECTIVES

Determine strategies and resources used by VA Home-Based Primary Care (HBPC) teams to discuss firearm safety and suicide risk with older veterans and their families or caregivers. Training and resource needs for promoting firearm safety with older veterans were also ascertained.

METHODS

Ten focus groups (N = 37) were conducted virtually in 2022 with HBPC directors and psychologists. Qualitative rapid response coding identified domains and themes within transcripts.

RESULTS

Analysis revealed three major domains: firearm safety, suicide risk, and resources/trainings. Firearm safety themes included discussions during clinical procedures, firearm-related challenges, veteran culture, and barriers and facilitators to effective conversations. Suicide risk themes included assessment procedures, frequency/types of risk conversations, factors related to suicidal ideation/behavior, challenges, and strategies to enhance communication. Resource/training themes included those currently used and perceived needs.

CONCLUSIONS

Participants described strategies for facilitating firearm safety and suicide prevention discussions with older veterans, their families, and caregivers. Using respectful language and attending to values related to firearm ownership were identified as essential.

CLINICAL IMPLICATIONS

Additional clinician/staff training/resources are needed for addressing older veteran firearm safety and suicide risk, including how to conduct more effective conversations with older veterans on these topics and better engage families/caregivers in prevention efforts.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study

OBJECTIVES

Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia.

METHODS

We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment.

RESULTS

Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160).

CONCLUSIONS

Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness.

CLINICAL IMPLICATIONS

ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

When safe firearm storage isn't enough: Examining risk profiles among firearm suicide decedents

INTRODUCTION

Suicide is a leading cause of death in the United States, and firearms are the most frequently used suicide method. Research suggests risk for firearm suicide increases with greater access to firearms (e.g., storing loaded or unlocked). Although safe firearm storage is promoted as a means of risk reduction, no studies have explored factors differentiating firearm suicide decedents who stored firearms safely vs. those who stored unsafely prior to death.

METHODS

Utilizing data from the National Violent Death Reporting System, the current study aimed to determine which factors distinguish firearm suicide decedents who stored firearms safely vs. those who stored unsafely. The current sample included decedents for whom data were available on whether the firearm used in the suicide was stored loaded or unloaded (n = 4269) and unlocked or locked (n = 6273) prior to their death.

RESULTS

Results revealed using a long gun in the suicide (as opposed to a handgun) was associated with five times greater odds of storing unloaded prior to death, suggesting this safe firearm storage practice alone does not mitigate risk among all long gun owners.

CONCLUSION

These findings indicate a need to increase suicide prevention efforts within the long gun owning community.

Assessment of Firearm Storage Practices in the US, 2022

IMPORTANCE

Secure firearm storage may help reduce firearm injury and death. Broad implementation requires more granular assessments of firearm storage practices and greater clarity on circumstances that may prevent or promote the use of locking devices.

OBJECTIVE

To develop a more thorough understanding of firearm storage practices, obstacles to using locking devices, and circumstances in which firearm owners would consider locking unsecured firearms.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, nationally representative survey of adults residing in 5 US states who owned firearms was administered online between July 28 and August 8, 2022. Participants were recruited via probability-based sampling.

MAIN OUTCOMES AND MEASURES

Firearm storage practices were assessed via a matrix provided to participants in which firearm-locking devices were described both via text and images. Locking mechanisms (key/personal identification number [PIN]/dial vs biometric) were specified for each type of device. Obstacles to the use of locking devices and circumstances in which firearm owners would consider locking unsecured firearms were assessed via self-report items developed by the study team.

RESULTS

The final weighted sample included 2152 adult (aged ≥18 years), English-speaking firearm owners residing in the US; the sample was predominantly male (66.7%). Among the 2152 firearm owners, 58.3% (95% CI, 55.9%-60.6%) reported storing at least 1 firearm unlocked and hidden, with 17.9% (95% CI, 16.2%-19.8%) reporting storing at least 1 firearm unlocked and unhidden. Gun safes were the most frequently used device both among participants who use keyed/PIN/dial locking mechanisms (32.4%; 95% CI, 30.2%-34.7%) and those who use biometric locking mechanisms (15.6%; 95% CI, 13.9%-17.5%). Those who do not store firearms locked most frequently noted a belief that locks are unnecessary (49.3%; 95% CI, 45.5%-53.1%) and a fear that locks would prevent quick access in an emergency (44.8%; 95% CI, 41.1%-48.7%) as obstacles to lock usage. Preventing access by children was the most often reported circumstance in which firearm owners would consider locking unsecured firearms (48.5%; 95% CI, 45.6%-51.4%).

CONCLUSIONS AND RELEVANCE

In this survey study of 2152 firearm owners, consistent with prior research, unsecure firearm storage was common. Firearm owners appeared to prefer gun safes relative to cable locks and trigger locks, indicating that locking device distribution programs may not match firearm owners' preferences. Broad implementation of secure firearm storage may require addressing disproportionate fears of home intruders and increasing awareness of the risks associated with household firearm access. Furthermore, implementation efforts may hinge on broader awareness of the risks of ready firearm access beyond unauthorized access by children.

Firearm safety counseling among caregivers of high-school age teens: Results from a National Survey

Firearms are the leading cause of death for high-school age teens. To inform prevention efforts, we characterize the prevalence of healthcare provider (HCP) counseling of caregivers of teens around firearm safety, safety conversation elements, and caregiver receptivity towards counseling. A cross-sectional web survey (6/24/2020-7/22/2020) was conducted among caregivers (n = 2924) of teens (age:14-18). Weights were applied to generate nationally representative estimates. Bivariate analyses and multivariate regressions were examined. Among respondents, 56.0% were women, 75.1% were non-Hispanic White, and mean (SD) age was 47.4. Firearm safety was the least discussed topic among caregivers reporting their teen received HCP preventative counseling (14.9%). For caregivers receiving counseling, the most common issues discussed were household firearms screening (75.7%); storing firearms locked (66.8%); and storing firearms unloaded (53.0%). Only 24.6% of caregivers indicated firearm safety was an important issue for teen HCPs to discuss and only 21.9% trusted teen HCPs to counsel about firearm safety. Female caregivers (aOR = 1.86;95%CI = 1.25-2.78), those trusting their teen's HCP to counsel on firearm safety (aOR = 9.63;95%CI = 6.37-14.56), and those who received teen HCP firearm safety counseling (aOR = 5.14;95%CI = 3.02-8.72) were more likely to favor firearm safety counseling. Caregivers of teens with prior firearm safety training (aOR = 0.50;95%CI = 0.31-0.80) were less likely to agree that firearm safety was an important preventative health topic. In conclusion, few caregivers receive preventive counseling on firearm safety from their teen's HCP, with trust a key barrier to effective intervention delivery. Future research, in addition to understanding barriers and establishing effective strategies to increase safety practices, should focus on increasing provider counseling competency.

Voluntary, temporary out-of-home firearm storage: A survey of firearm retailers and ranges in two states

Out-of-home storage of personal firearms is one recommended option for individuals at risk of suicide, and statewide online maps of storage locations have been created in multiple states, including Colorado and Washington. We sought to examine both the extent to which firearm retailers and ranges offer temporary, voluntary firearm storage and the perceived barriers to providing this service. We invited all firearm retailers and ranges in Colorado and Washington to complete an online or mailed survey; eligible sites had to have a physical location where they could provide storage. Between June-July 2021, 137 retailers/ranges completed the survey (response rate = 25.1%). Nearly half (44.5%) of responding firearm retailers/ranges in Colorado and Washington State indicated they had ever provided firearm storage. Among those who had ever offered storage, 80.3% currently offered storage while 19.7% no longer did. The majority (68.6%) of participants had not heard of the Colorado/Washington gun storage maps and 82.5% did not believe they were currently listed on the maps. Respondents indicated liability waivers would most influence their decision about whether to start or continue providing temporary, voluntary storage of firearms. Understanding current practices, barriers, and concerns about providing out-of-home storage by retailers and ranges may support development of more feasible approaches for out-of-home firearm storage during times of suicide risk.