Review of evaluations of educational approaches to promote safe storage of firearms

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.

Firearm Violence in the United States: An Issue of the Highest Moral Order

Firearm violence in the United States produces over 36,000 deaths and 74,000 sustained firearm-related injuries yearly. The paper describes the burden of firearm violence with emphasis on the disproportionate burden on children, racial/ethnic minorities, women and the healthcare system. Second, this paper identifies factors that could mitigate the burden of firearm violence by applying a blend of key ethical theories to support population level interventions and recommendations that may restrict individual rights. Such recommendations can further support targeted research to inform and implement interventions, policies and laws related to firearm access and use, in order to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and society-at-large. By incorporating a blended public health ethics to address firearm violence, we propose a balance between societal obligations and individual rights and privileges.

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.

Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review

INTRODUCTION

Lethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice.

METHODS

To better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research.

FINDINGS

Of the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC.

CONCLUSION

This synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt].

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].

Keeping Children Safe at Home: Parent Perspectives to Firearms Safety Education Delivered by Pediatric Providers

OBJECTIVES

The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors.

METHODS

The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ² tests.

RESULTS

Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%).

CONCLUSIONS

Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education.

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.

A randomized controlled trial of public messaging to promote safe firearm storage among U.S. military veterans

BACKGROUND

The objectives of this study were to determine whether short-term exposure to firearm safety messaging significantly improved (1) firearm storage practices, and (2) attitudes of safe firearm storage behaviors among U.S. veterans, a group at elevated risk for firearm suicide.

DESIGN

A three-arm, parallel-group RCT was conducted online in the U.S. nationwide from December 2015 to January 2016.

SETTING

A national random sample of U.S. veterans (N = 358) was recruited from the GfK KnowledgePanel, a probability-based internet panel representative of U.S. adults. All study activities were administered online over a three-week study period.

INTERVENTION

Participants were randomized and exposed three times (once per week) to either (a) firearm safety message only (n = 115); (b) firearm safety and mental health promotion messages (n = 133); or (c) active control group exposed to mental health promotion message only (n = 110). Each message was less than two minutes long.

MEASURES

Assessments were completed at baseline (pre-randomization) and at end-of-trial. Changes in awareness of risk for injuries, attitudes/beliefs related to safe storage practices, behavioral intentions, and storage practices were measured using self-reported surveys. Linear mixed effect models with weighted generalized estimating equations were used to test for exposure effects. Analyses were conducted February 2018.

RESULTS

Analyses restricted to those with baseline firearm access (n = 195) identified no significant changes for intentions or safe storage practices across exposure groups. At baseline, participants' attitudes and beliefs were generally supportive of safe firearm storage. The Firearm Safety message yielded small increases in agreement with the concept that secure storage is "important during emotional or stressful times" (0.36; 95% CI = 0.08, 0.64). Other significant changes in awareness and beliefs were found, but across all study conditions.

CONCLUSION

Results reinforce the critical need for considerable research and testing prior to the widespread implementation of public messages to increase the likelihood for desired exposure effects.

Firearm Ownership in High-Conflict Families: Differences According to State Laws Restricting Firearms to Misdemeanor Crimes of Domestic Violence Offenders

This study examines the association between state laws that prohibit firearm ownership for offenders convicted of misdemeanour crimes of domestic violence (MCDV) and firearm ownership in two-parent families with high-conflict male partners with arrest histories. Mixed effects logistic regression models applied to data from the Early Childhood Longitudinal Study-Birth cohort (n = 5,350) determined that living in a state with laws that prohibited firearm ownership for convicted MCDV offenders decreased the likelihood of firearm ownership among families with high-conflict males by 62%. The length of the time limit length on firearm prohibition was correlated with incremental decreases in firearm ownership in such families, with the probability of firearm ownership among families with high-conflict males decreasing from 30% in states with no MCDV laws restricting access from firearms to 12% in states with permanent prohibition on firearm ownership. These findings have significance for public health policy aimed at decreasing intimate-partner homicide.

Storage Practices of US Gun Owners in 2016

OBJECTIVES

To examine gun storage practices and factors influencing those practices among gun owners.

METHODS

We conducted a nationally representative online survey of US gun owners (n = 1444) in 2016 to assess gun storage practices and attitudes, factors influencing storage practices, and groups that might effectively communicate regarding safe storage. We generated descriptive statistics by using cross-tabulations and used logistic regression to estimate characteristics that influenced safe storage practices.

RESULTS

Forty-six percent of gun owners reported safely storing all of their guns. Factors associated with higher odds of reporting safe storage were having a child in the home (adjusted odds ratio [AOR] = 1.44; 95% confidence interval [CI] = 1.03, 2.03), only owning handguns (AOR = 1.84; 95% CI = 1.24, 2.73), and reporting that storage decisions were influenced by a gun safety course (AOR = 2.05; 95% CI = 1.54, 2.74) or discussions with family members (AOR = 1.39; 95% CI = 1.05, 1.86). Gun owners ranked law enforcement, hunting or outdoors groups, active-duty military, and the National Rifle Association as most effective in communicating safe storage practices.

CONCLUSIONS

Public health campaigns to promote safe gun storage should consider partnering with groups that garner respect among gun owners for their experience with safe use of guns.

Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network

OBJECTIVE

The objective was to describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network and assess the influence of both individual and neighborhood factors on firearm-related injury risk.

METHODS

This was a retrospective, multicenter cross-sectional analysis of children (<19 years old) presenting to 16 pediatric EDs (2004-2008). ICD-9-CM E-codes were used to identify and categorize firearm injuries by mechanism/intent. Neighborhood variables were derived from home address data. Multivariable analysis examined the influence of individual and neighborhood factors on firearm-related injuries compared to nonfirearm ED visits. Injury recidivism was assessed.

RESULTS

A total of 1,758 pediatric ED visits for firearm-related injuries were analyzed. Assault (51.4%, n = 904) and unintentional injury (33.2%, n = 584) were the most common injury mechanisms. Among children with firearm injuries, 68.3% were older adolescents (15-19 years old), 82.3% were male, 68.2% were African American, and 76.3% received public insurance/were uninsured. Extremity injuries were most common (75.9%), with 20% sustaining injuries to multiple body regions, 48.1% requiring admission and 1% ED mortality. Multivariable analysis identified firearm injury risk factors, including adolescent age (p < 0.001), male sex (p < 0.001), non-Caucasian race/ethnicity (p < 0.001), public payer/uninsured status (p < 0.001), and higher levels of neighborhood disadvantage (p < 0.001). Among children with firearm injuries, 12-month ED recidivism for any reason was 22.4%, with < 1% returning for another firearm injury.

CONCLUSION

Among children receiving ED treatment within the PECARN network, there are distinct demographic and neighborhood factors associated with firearm injuries. Among younger children (<10 years old), unintentional injuries predominate, while assault-type injuries were most common among older adolescents. Overall, among this PECARN patient population, male adolescents living in neighborhoods characterized by high levels of concentrated disadvantage had an elevated risk for firearm injury. Public health efforts should focus on developing and implementing initiatives addressing risk factors at both the individual and the community level, including ED-based interventions to reduce the risk for firearm injuries among high-risk pediatric populations.

Evaluation of a community-based safe firearm and ammunition storage intervention

BACKGROUND

Safe firearm storage practices are associated with a lower risk of unintentional and self-inflicted firearm injuries among household members, though many firearms remain unlocked and/or loaded.

OBJECTIVES

Conduct a preliminary evaluation of a community-based firearm safety intervention and assess participants' preferences for firearm locking devices and their comfort with potential firearm safety counsellors.

DESIGN/METHODS

Baseline event and follow-up surveys among adult participants to assess changes in firearm storage practices, including whether all household firearms were stored locked, all were unloaded, all ammunition was locked, and a composite measure assessing whether all firearms were locked and unloaded and all ammunition was stored locked.

RESULTS

A total of 206 out of 415 participants completed both surveys and were included. Nearly 9 in 10 respondents preferred the firearm lock box rather than a trigger lock. At follow-up, a significantly greater proportion reported that all household firearms were locked (+13.7%) and unloaded (+8.5%) and a non-significantly greater proportion reported that all ammunition was locked (+6.3%). A significantly greater proportion reported practising all three safe firearm and ammunition storage practices at follow-up (+12.6%). A majority reported they would be comfortable or very comfortable discussing firearm safety with various safety counsellors, though women were less likely to do so than men.

CONCLUSION

This intervention that included distribution of a free, participant-selected locking device improved safe firearm storage practices among participants. Differences in participant preferences for devices and safety counsellors suggest that a 'one size fits all' approach may be inadequate in affecting population-level storage practices.

The Link Between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice

The United States has substantially higher levels of firearm violence than most other developed countries. Firearm violence is a significant and preventable public health crisis. Mental illness is a weak risk factor for violence despite popular misconceptions reflected in the media and policy. That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness. This article summarizes existing evidence about the interplay among mental illness, violence, and firearms, with particular attention paid to the role of active symptoms, addiction, victimization, and psychosocial risk factors. The social and legal context of firearm ownership is discussed as a preface to exploring practical, evidence-driven, and behaviorally informed policy recommendations for mitigating firearm violence risk.

Effectiveness of Interventions to Promote Safe Firearm Storage

Despite supportive evidence for an association between safe firearm storage and lower risk of firearm injury, the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, we conducted a systematic review of randomized and quasi-experimental controlled studies of safe firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language, year, or location from inception through May 27, 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Collaboration's domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000-2012 using counseling with or without safety device provision met the inclusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices, while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies precluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recommendations for conducting future studies. Although additional studies are needed, the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely.

Disparities in firearms ownership and storage practices in North Carolina

OBJECTIVE

Because household firearms pose a risk to children, this study examined firearms accessibility in North Carolina households with children.

METHODS

In 2008, parents completing the North Carolina Child Health Assessment and Monitoring Program survey were asked how many firearms they owned and their firearms storage practices. Weighted analyses provided estimates of ownership and storage practices and examined variation by sociodemographics.

RESULTS

A total of 37% of 2885 parents reported owning firearms. Whites (adjusted odds ratio [aOR] 3.9 [95% confidence interval {CI} 2.9-5.2]), households with income >200% of the federal poverty level (aOR 1.7 [95% CI 1.2-2.5]) and married parents (aOR 2.4 [95% CI 1.8-3.4]) were more likely to own firearms. Ownership of more than one firearm was greater among whites (aOR 2.2 [95% CI 1.4-3.4]) and married parents (aOR 1.8 [95% CI 1.5-2.8]) than other groups. The number of firearms owned increased with children's age. Although most parents reported keeping firearms locked and unloaded (57%), many reported unsafe storage practices, which varied by race/ethnicity. Whites were more likely (45%) to store firearms unlocked and/or loaded than other groups (35%).

CONCLUSIONS

Many North Carolina youth have access to household firearms, with white youth being more likely to have firearms, a greater number of firearms, and less safely stored firearms than other race/ethnicity groups. Further interventions and policies to reduce youth access to household firearms are needed. Future research should examine and address why whites, married couples, and those with socioeconomic advantages are more likely than individuals not belonging to these groups to own household firearms and store them unsafely.

Storage of household firearms: an examination of the attitudes and beliefs of married women with children

Although safe firearm storage is a promising injury prevention strategy, many parents do not keep their firearms unloaded and locked up. Using the theory of planned behavior as a guiding conceptual framework, this study examines factors associated with safe storage among married women with children and who have firearms in their homes. Data come from a national telephone survey (n=185). We examined beliefs about defensive firearm use, subjective norms, perceived behavioral control and firearm storage practices. A Wilcoxon-Mann-Whitney test was conducted to assess associations between psychosocial factors and firearm storage practices. Women were highly motivated to keep firearms stored safely. Those reporting safe storage practices had more favorable attitudes, more supportive subjective norms and higher perceptions of behavioral control than those without safe storage. One-fourth believed a firearm would prevent a family member from being hurt in case of a break-in, 58% believed a firearm could scare off a burglar. Some 63% said they leave decisions about firearm storage to their husbands. Women were highly motivated to store firearms safely as evidenced by favorable attitudes, supportive subjective norms and high perceptions of behavioral control. This was especially true for those reporting safer storage practices.

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.

The effect of child access prevention laws on unintentional child firearm fatalities, 1979-2000

OBJECTIVE

Unintentional firearm deaths among children have been declining steadily in the United States. This study investigates whether Child Access Prevention (CAP) laws are associated with this decline.

METHODS

Pooled cross-sectional time- series data (1979-2000) for 50 states and negative binomial regression methods were used to estimate the effect of Child Access Prevention laws on unintentional firearm deaths among children.

RESULTS

Most states that enacted CAP laws experienced greater subsequent declines in the rate of unintentional firearm deaths for children age 0 to 14 compared with states not enacting the laws; however when adjusted for firearm prevalence and state and national effects the laws were associated with statistically significant declines only in Florida and California. In a comparison group of adults age 55 to 74, a group less likely to have young children in the home and thus less likely to be influenced by CAP laws, there was no indication that CAP laws affected unintentional firearm death rates.

CONCLUSIONS

Unintentional firearm deaths are declining in the United States, with the rate for children under age 15 declining faster than adults. States that allowed felony prosecution of offenders experienced a greater effect of CAP laws than states that did not. CAP laws may have had some influence on the continued reduction in national death rates.

Are household firearms stored less safely in homes with adolescents?: Analysis of a national random sample of parents

OBJECTIVE

To examine whether firearms are more frequently stored loaded, unlocked, or both in households with adolescents only (aged 13-17 years) compared with households with younger children only (aged 0-12 years).

DESIGN

Random-digit-dial survey on firearms (n = 2770). We computed bivariate associations between the presence of adolescents and firearm storage practices. Statistical significance was assessed using prevalence ratios with 95% confidence intervals.

SETTING

United States.

PARTICIPANTS

Survey respondents with children (aged <18 years) who reported the presence of a household firearm.

MAIN OUTCOME MEASURES

Prevalence of firearms in the home stored loaded and/or unlocked.

RESULTS

Of the 392 respondents, 22% had a loaded firearm, 32% had an unlocked firearm, and 8% had a firearm stored loaded and unlocked. Compared with households with younger children, households with adolescents only were somewhat more likely to store a firearm unlocked (42% vs 29%; prevalence ratio, 1.48; 95% confidence interval, 1.04-2.02), loaded (26% vs 20%; prevalence ratio, 1.25; 95% confidence interval, 0.82-1.91), or both (10% vs 8%; prevalence ratio, 1.43; 95% confidence interval, 0.64-3.19).

CONCLUSIONS

Parents of adolescents appear to be more likely to keep household firearms stored unsafely, especially with regard to keeping firearms unlocked. This is of concern because most youth firearm injuries happen to adolescents. Firearm injury prevention programs should directly target parents of adolescents to promote safe firearm storage.

Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002

OBJECTIVES

To examine the prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia and estimate the number of children exposed to unsafe storage practices.

METHODS

We analyzed data from the 2002 cross-sectional Behavioral Risk Factor Surveillance System survey of 240735 adults from randomly selected households with telephones in the 50 states and the District of Columbia.

RESULTS

Nationally, 32.6% of adults reported that firearms were kept in or around their home. The prevalence of adults with household firearms ranged from 5.2% in the District of Columbia to 62.8% in Wyoming (median: 40.8%). The prevalence of adults with loaded household firearms ranged from 1.6% in Hawaii, Massachusetts, and New Jersey to 19.2% in Alabama (median: 7.0%), and the prevalence of adults with loaded and unlocked household firearms ranged from 0.4% in Massachusetts to 12.7% in Alabama (median: 4.2%). Among adults with children and youth <18 years old, the prevalence of loaded household firearms ranged from 1.0% to 13.4% (median: 5.3%), and the prevalence of loaded and unlocked household firearms ranged from 0.3% to 7.3% (median: 2.3%); in each instance, Massachusetts had the lowest prevalence and Alabama had the highest. Findings indicate that approximately 1.69 million (95% confidence interval: 1.57-1.82 million) children and youth in the United States <18 years old are living with loaded and unlocked household firearms.

CONCLUSIONS

Substantial state variations exist in the prevalence of household firearms and firearm-storage practices. It is vital that surveillance systems such as the Behavioral Risk Factor Surveillance System continue to monitor the prevalence of household firearms and firearm-storage practices so that future interventions to promote safe storage of firearms can be evaluated and more widely implemented based on their efficacy.

Do partners with children know about firearms in their home? Evidence of a gender gap and implications for practitioners

OBJECTIVE

The gender gap describing the apparent differences in male and female reports of firearm-ownership and -storage habits has never been evaluated among individuals who live in the same household. Thus, the objective of this study was to examine the level of agreement on household firearms and storage practices among cohabiting partners.

METHODS

Data for this investigation came from follow-up telephone interviews of participants who underwent a randomized, controlled trial to test the effect of home-safety counseling, including firearm safety, on behavior change. Baseline interviews were conducted at a level 1 pediatric emergency department in North Carolina with adults who took a child or adolescent who was under his or her care to a pediatric emergency department. Follow-up interviews were conducted via telephone at 18 months after intervention with participants who reported household firearms at baseline. Participants then were asked whether their partners could be contacted for a separate telephone interview. The measured outcomes were number and type of household firearms and firearm-storage practices. The strength of agreement between partners' reported firearm-ownership and -storage practices was measured with the kappa statistic.

RESULTS

Seventy-six partner-respondent pairs completed the study (62% response rate). Most initial respondents were white (89%), female (76%), and college graduates (52%); the median age was 37. There were no same-gender partners, and 91% reported that they were spouses. There was not perfect agreement among male and female partners with regard to the presence of household firearms. More men (80%) reported the presence of household firearms than did women (72%; kappa = .64). The discordance between partner pairs regarding the number of household firearms and type was poor to fair (kappa = .35 and .34, respectively). Although similar proportions of men and women reported storing any household firearms loaded (10%) and storing all household firearms locked up (63% men and 62% women), the kappa values demonstrated only moderate agreement (kappa = .56-.60). Most men (88%) and women (83%) reported that firearm storage was the husband's responsibility; 82% of men compared with 17% of women reported that they personally owned all of the firearms.

CONCLUSIONS

A gender gap does exist in the reporting of firearm ownership with regard to the number and type of firearms owned. There are also differences in reported firearm-storage practices, which are likely related to the finding that men were reported to be the primary owner of firearms in most households as well as the person more commonly responsible for firearm storage. Firearm-safety counseling should include male partners in the history-taking process to improve knowledge about the presence and storage patterns of household firearms.

Evaluation of a community-based handgun safe-storage campaign

OBJECTIVE

Safe storage of firearms has been recommended as a means of preventing gun-related pediatric injuries, yet few interventions have led to significant improvements in storage practices. This study examined a multifaceted community education campaign to promote safe handgun storage and the campaign's impact on firearm locking and loading practices in households with children.

METHODS

Beginning in 1997, a safe-storage campaign consisting of television and radio announcements, educational materials, billboards, and discount coupons for lock boxes was conducted in King County, Washington. The campaign evaluation used a quasi-experimental design and compared the intervention site with 9 control counties outside Washington State and west of the Mississippi River. Cross-sectional, random-digit-dial telephone surveys of handgun-owning households with children were conducted in all study counties both before the intervention in 1996 (n = 302) and again in 2001 (n = 255). The main analyses assessed whether greater improvements in household firearm-storage practices occurred between 1996 and 2001 in the intervention, compared with the control, counties. Primary outcomes were based on up to 3 handguns per household and included (1) all stored with trigger locks, lock boxes, or gun safes (formal locking devices), (2) all stored in lock boxes or gun safes, (3) any stored loaded, (4) any stored loaded without a formal locking device, and (5) any stored loaded and not in a lock box or gun safe. Data were also collected on up to 1 long gun per household; long-gun outcomes included (1) stored with a trigger lock or gun safe and (2) stored loaded.

RESULTS

Overall, handguns and long guns were generally more likely to be stored locked and less likely to be loaded in 2001 compared with 1996, with these trends seeming to be more consistent in the intervention county. Even so, more than one quarter of households with children and handguns in 2001 failed to store all of their handguns with a formal locking device, and up to 8% continued to possess at least 1 loaded handgun that was not stored with a formal device. The majority of households that stored their handguns with formal devices used lock boxes or gun safes. Storage of handguns in lock boxes or gun safes became more common in both the intervention (adjusted odds ratio [aOR]: 1.71; 95% confidence interval [CI]: 1.03-2.84) and control households (aOR: 1.66; 95% CI: 1.01-2.72) between 1996 and 2001. None of the other measured changes reached statistical significance, such as storing any household handgun loaded (aOR: 0.71; 95% CI: 0.35-1.42 [intervention]; aOR: 1.08; 95% CI: 0.58-2.00 [control]) or keeping any household handgun loaded and not stored in a lock box or gun safe (aOR: 0.59; 95% CI: 0.22-1.55 [intervention]; aOR: 0.67; 95% CI: 0.30-1.49 [control]). Moreover, the intervention county did not experience significantly greater overall improvements in household storage practices for handguns or long guns than did control counties.

CONCLUSIONS

In both the intervention and control counties, households were more likely to lock all handguns in 2001 compared with 1996. After accounting for temporal trends, this educational campaign, combined with economic incentives to purchase lock boxes, did not seem to significantly change safe storage practices in households with handguns and children. Even if the campaign did result in small improvements in firearm safe storage, simultaneous national and state-specific gun-safety activities or legislative efforts may have drawn increasing attention to gun-related issues in the control counties, thereby making it more difficult to identify effects of our specific handgun storage intervention.

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.