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Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community

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To evaluate the effectiveness of gun-safety counseling, a gun-safety brochure, and a free gun lock in subsequent gun removal and safe storage. In a predominantly Hispanic pediatric clinic, gun-owning families were identified and assigned to either an intervention group (gun-safety counseling, gun-safety brochure, and a free gun lock) or a control group (usual anticipatory guidance). Families were resurveyed 1 month later for changes in the proportion of gun owners, changes in frequency of unloaded and locked gun storage, and changes to the use of locked storage. Two hundred six (7.8%) of the 2649 parents initially surveyed kept guns in their households. At follow-up, 16% of the control group removed all guns from their homes as compared with 22% of the intervention group (P = .41). Among the families who received the intervention, 61.6% either removed all guns from their homes or improved their gun storage safety practice in some way. Only 26.9% of the families in the control group showed similar types of improvement (P<.001). In those households still with guns at follow-up, 50.9% of the intervention group had some type of improvement in safe gun storage compared with 12.3% of the control group (P<.001). More specifically, 25.0% in the intervention group improved the frequency of locked storage of guns compared with 4.8% of those in the control group (P = .003). Twenty-six percent of the intervention group improved the use of locked storage compared with 3.1% in the control group (P<.001). A brief gun-safety counseling session supported with written information along with a gun lock giveaway resulted in significant improvements in safe gun storage behaviors. It did not significantly influence the removal of guns from the home. This study gives support to the recommendations of the American Academy of Pediatrics (Elk Grove Village, Ill) and other professional organizations to discuss gun safety with families and encourages research in this area. It also suggests that providing tools such as gun locks to enable the desired behavior may improve safe storage.
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ARTICLE
Effectiveness of Gun-Safety Counseling
and a Gun Lock Giveaway in a Hispanic Community
Paul S. Carbone, MD; Conrad J. Clemens, MD, MPH; Thomas M. Ball, MD, MPH
Objective:To evaluate the effectiveness of gun-safety
counseling, a gun-safety brochure, and a free gun lock
in subsequent gun removal and safe storage.
Methods:In a predominantly Hispanic pediatric clinic,
gun-owning families were identified and assigned to either
an intervention group (gun-safety counseling, gun-
safety brochure, and a free gun lock) or a control group
(usual anticipatory guidance). Families were resur-
veyed 1 month later for changes in the proportion of gun
owners, changes in frequency of unloaded and locked gun
storage, and changes to the use of locked storage.
Results:Two hundred six (7.8%) of the 2649 parents
initially surveyed kept guns in their households. At follow-
up, 16% of the control group removed all guns from their
homes as compared with 22% of the intervention group
(P=.41).Amongthefamilieswhoreceivedtheinterven-
tion, 61.6% either removed all guns from their homes or
improved their gun storage safety practice in some way.
Only 26.9% of the families in the control group showed
similar types of improvement (P!.001). In those house-
holds still with guns at follow-up, 50.9% of the inter-
vention group had some type of improvement in safe gun
storage compared with 12.3% of the control group
(P!.001). More specifically, 25.0% in the intervention
group improved the frequency of locked storage of guns
compared with 4.8% of those in the control group
(P=.003). Twenty-six percent of the intervention group
improved the use of locked storage compared with 3.1%
in the control group (P!.001).
Conclusions:Abriefgun-safetycounselingsessionsup-
ported with written information along with a gun lock
giveaway resulted in significant improvements in safe gun
storage behaviors. It did not significantly influence the
removal of guns from the home. This study gives sup-
port to the recommendations of the American Academy
of Pediatrics (Elk Grove Village, Ill) and other profes-
sional organizations to discuss gun safety with families
and encourages research in this area. It also suggests that
providing tools such as gun locks to enable the desired
behavior may improve safe storage.
Arch Pediatr Adolesc Med. 2005;159:1049-1054
GUN-RELATED DEATH AND
injury are a major public
health problem in the
United States, resulting in
tremendous losses to so-
ciety, especially in the pediatric and young
adult population. In 2001, 2937 children and
teenagers died as a result of gun-related in-
juries. Sixty-one percent of all gun-related
deaths among children were the result of ho-
micide and 32% were attributed to suicide.1
Gun ownership has been identified as a risk
factor for homicide and suicide in the home.2,3
The American Academy of Pediatrics (Elk
Grove Village, Ill) recommends violence pre-
vention anticipatory guidance at every health
maintenance visit, including urging gun re-
moval from homes.4The American Academy
of Pediatrics also supported the evaluation
of safe storage techniques such as lock boxes
and gun locks.5
Pediatricians agree that handguns in
the home are hazardous and that steps
should be taken to reduce this hazard
through legislation and parent counsel-
ing.6Children attending public urban
pediatric clinics are exposed to guns in
their homes, and their parents appear to
be receptive to gun-safety counseling.7
A significant percentage of gun-owning
parents store their guns loaded or un-
locked, substantially underestimating the
risk of injury to their children.8Yet
despite these facts, most practitioners fail
to counsel on gun safety with only 1 in 5
counseling more than 10% of their pa-
tient families.9
In spite of these recommendations, cur-
rent evidence generally does not support
gun-safety counseling. Previous studies of
gun-safety counseling in a pediatric out-
For editorial comment
see page 1081
Author Affiliations: Children’s
Primary Care Medical Group,
San Diego, Calif (Dr Carbone);
and Department of Pediatrics
and Steele Memorial Research
Center, University of Arizona,
Tucson (Drs Clemens and Ball).
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patient setting have not shown significant changes in
household gun ownership or storage patterns.10,11
Furthermore, gun-safety counseling as well as gun
ownership patterns in the Hispanic population have been
understudied. The impact of gun-related morbidity and
mortality on the Hispanic community is disproportion-
ately high when compared with the population as a whole.
Hispanic people are far less likely to own guns12 yet are
murdered with guns at rates second only to those for black
people. Gun homicide was the leading cause of death for
Hispanic people aged 15 to 34 years.1The data suggest
that efforts to prevent gun injury and death should fo-
cus special attention on minority populations.
Our objective was to determine the effectiveness of a
single, brief gun-safety counseling session within the con-
text of a pediatric visit that was then reinforced with writ-
ten material and a donated gun lock.
METHODS
SITE
This study was conducted at a pediatric clinic within the El Rio
Community Health Center in Tucson, Ariz. This urban com-
munity health center is the largest of its kind in the state and
the 29th largest in the United States. The El Rio Community
Health Center serves a population that is approximately 85%
minority (59% Hispanic, 16% unreported, 14% white, 8.6% Na-
tive American, 2% African American, 0.4% Asian or Pacific Is-
lander).
SUBJECT SELECTION
At check-in, all parents of children younger than 18 years old
were asked by the bilingual front-office staff to complete an
anonymous safety questionnaire in English or Spanish for a study
being conducted at the clinic. Along with general safety ques-
tions and basic demographic information, the questionnaire con-
tained embedded questions that specifically addressed gun own-
ership, type and frequency of gun storage, and whether or not
the gun was kept loaded. Respondents were screened for gun
ownership with the question, “Is there a gun (handgun or rifle)
currently kept in your household?” Questions that were not
simply yes/no responses used a 4-point Likert scale (never, some
of the time, most of the time, always). Pertinent questions re-
lating to guns contained in the questionnaire are listed in
Table 1. Upon receiving the completed baseline safety ques-
tionnaire back from the parent, a member of the front-office
staff reviewed it only to ascertain whether the parent was a gun
owner. Families not owning guns were excluded from study
participation. Informed consent was obtained in the parent’s
preferred language from gun-owning families willing to par-
ticipate in the study. A family could participate only once in
the study.
DESIGN
The study used a nonconcurrent, controlled pretest-posttest de-
sign. The control group was recruited prior to the interven-
tion group and prior to the providers having any specific knowl-
edge of the study. Previous studies have shown that few providers
perform regular gun-safety counseling,9so we assumed that very
few families in the control group received counseling. After the
recruitment of the control group, the providers were given train-
ing in gun-safety counseling. The training was facilitated by 1
of us (P.S.C.) using the program Steps to Prevent Firearm In-
jury in the Home (STOP 2).13 All of the 9 possible providers
during the study period were board-certified pediatricians and
all chose to participate in the study.
The program STOP 2 was designed for all health care pro-
viders across disciplines who work with diverse patient popu-
lations. It is an educational program developed jointly by the
American Academy of Pediatrics and the Brady Center to Pre-
vent Gun Violence (Washington, DC) to use when counseling
patients on the inherent risk of guns in the community.
During the 30-minute training presentation by 1 of us
(P.S.C.), each provider received a STOP 2 kit. The kit con-
sisted of a health care provider reference manual, family bro-
chures, and posters. The patient portions of the kit were printed
in both English and Spanish. The brochures in the packet were
identical to those given to families recruited to the interven-
tion group. Providers were instructed to comply with a stan-
dardized 1- to 2-minute message to the gun-owning partici-
pant families during the visit. Two simple messages were given
to all families in the intervention group in accordance with the
STOP 2 program: first, “a gun in your home is a risk to your
Table 1. Questions Pertaining to Guns in Baseline and Follow-up Questionnaires
Question Response Type
Baseline and follow-up questionnaire
Is there a gun (handgun or rifle) currently kept in your household? Yes/no/not sure
Have you discussed with your children what to do if they find a gun? Yes/no/not sure
How many guns are kept in the household? Choices to circle are 1, 2, 3, or more than 3
What type(s) of gun(s) is (are) kept in the household? Choices to circle are handgun, rifle, or both
Is (Are) the gun(s) kept loaded? Likert scale*
Is (Are) the gun(s) stored in a safe, in a lock box, or with a gun lock? (Specify which.) Write in
Does your child know where the guns are kept? Yes/no/not sure
Follow-up questionnaire only
Were any or all of the guns that you had 1 month ago removed from your household? Yes/no/not sure
The reason you choose to keep a gun in your household is Choices to circle are protection, sport/recreation,
required for occupation, collector, and other
Has your child’s doctor ever spoken to you about gun safety? Yes/no/not sure
Did your child’s doctor seem knowledgeable about gun safety? Yes/no/not sure
Was the advice your children’s doctor gave you helpful in deciding whether to keep
a gun in your household or how to store your gun?
Yes/no/not sure
*Likert scale responses are always, most of the time, some of the time, and never.
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family,” and second, “the safest thing is not to keep a gun in
the home, but if you keep a gun, unload it and lock it up.” A
Spanish language translator was available.
One week after providers were trained in gun-safety coun-
seling, the intervention group was recruited. Data were col-
lected and compared by using baseline and follow-up ques-
tionnaires. A timeline of the study is shown in the Figure.
INTERVENTION
All families in the intervention group received the physician
gun-safety counseling previously described, a STOP 2 family
brochure to reinforce the counseling, and a gun lock with printed
instructions on its use. Clinic staff clearly identified families
in the intervention group for the provider by attaching a STOP
2patientbrochureandagunlocktoeachmedicalrecordplaced
outside the examination room. The gun lock used in the study
was the Universal safeTclaw from Safegun Corporation (Forest-
ville, Md). It fits all handguns and long guns in all calibers and
has illustrated instructions. Its list price is $6.99.
One month after their respective enrollments, participants
in both the control and intervention groups were mailed a fol-
low-up questionnaire. The follow-up questionnaire ascer-
tained data regarding any removal of guns since enrollment along
with any changes in gun storage patterns. With regards to gun
storage patterns, subjects were asked about the frequency of
unloaded storage (gun lock–independent behaviors) as well
as the type and frequency of locked storage (gun lock–
dependent behaviors). Questions in the follow-up question-
naire regarding the presence of guns in the household and the
type and frequency of storage were identical to those in the base-
line questionnaire. Study subjects who did not return the fol-
low-up questionnaire after 2 weeks were contacted by a re-
search assistant and asked to complete the survey by telephone.
OUTCOME ASSESSMENT
The primary outcomes of this study were 2-fold. The first was
the removal of all guns from a household, which was ascer-
tained by asking, “Is there still a gun currently kept in your
household?” at follow-up. The second was the improvement
of gun storage by subjects who kept a gun in the household at
follow-up. Table 2 outlines the 4 different ways improve-
ment could occur and how each was defined.
Comparisons between the control and intervention groups
were made by using the "2test with a 2-tailed #!.05 consid-
ered statistically significant. We analyzed the outcomes of gun
storage behavior in 2 ways. First, we compared the percentage
in each group demonstrating improvement in each behavior
using the "2test. Second, we compared the change in baseline
and follow-up Likert scale responses using the Mann-
Whitney Utest.
None of the distributions of the potentially confounding vari-
ables were significantly different between the intervention and
control groups (P!.10). Because of our sample size, however,
we confirmed our findings using logistic regression, adjusting
for a teenager in the household, primary language spoken at
home, perceived danger of the neighborhood, and type of gun
in the household. None of these variables significantly altered
our results and are therefore not included. The investigational
review board of the El Rio Community Health Center ap-
proved the study.
RESULTS
Baseline questionnaires were completed by 2649 fami-
lies. Of these, 206 (7.8%) reported 1 or more guns at home.
Informed consent was obtained for 180 (87.4%) of these
gun-owning families. In the 26 cases where informed con-
sent was not obtained, all were due to oversight of the
research team rather than family refusal. Of the 180 con-
senters, 151 (83.9%) successfully completed both the base-
line and follow-up questionnaire. Overall, the study was
completed on 73.3% (151/206) of the original gun-
owning families. The percentage of families that re-
quired telephone follow-up was 41% in both the control
and intervention groups.
Baseline characteristics of control and intervention
groups were similar (Table 3) with the exception that
the control group was significantly more likely to have
proper storage of their guns at baseline (65.4% vs 46.6%,
P=.05). Mean Likert scale scores were similar at base-
line between the control and intervention groups with
regard to frequency of gun storage, use of storage de-
vices (including gun locks), and frequency of storing guns
unloaded (data not shown).
Did the intervention improve overall gun-safety prac-
tices? At follow-up, families who received the interven-
tion were more likely to have improved overall gun-
safety practices compared with the control group (61.6%
vs 26.9%; relative risk [RR], 2.29; 95% confidence inter-
val [CI], 1.52-3.44; P!.001).
Control Group
Received Usual
Anticipatory
Guidance
(n
=
78)
Follow-up
Questionnaires
1 Month After
Recruitment
Follow-up
Questionnaires
1 Month After
Recruitment
Provider Training
Session on Gun-
Safety Counseling
Intervention
Group Received
Gun-Safety
Counseling, STOP
2 Written Material,
and Gun Lock
(n
=
73)
Time, mo
0123
Figure. Study timeline. STOP 2 indicates Steps to Prevent Firearm Injury in
the Home.
Table 2. Type and Definition of Improvement in Safe Gun Storage
Type Definition
Any improvement One or more of the types of improvements listed below
Greater frequency of locked storage (the amount of time a gun
is stored with a gun lock and/or with a lock box)
A positive change in Likert scale score at follow-up compared
with baseline (never, some of the time, most of the time, always)
Improved type of gun storage A positive change in Likert scale score at follow-up compared
with baseline (none, lock box or a gun lock, lock box and a gun lock)
Greater frequency of storing gun unloaded A positive change in Likert scale score at follow-up compared
with baseline (never, some of the time, most of the time, always)
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Did the intervention decrease gun ownership? At
follow-up, 13 (16.6%) families in the control group and
16 (22%) families in the intervention group reported hav-
ing removed all guns from the home (RR, 1.31; 95% CI,
0.68-2.54; P=.41).Inaddition,8(10.2%)familiesinthe
control group and 7 (10%) families in the intervention
group reported removing some (but not all) guns from
the home (RR, 0.96; 95% CI, 0.54-1.70; P=.89).
Did the intervention improve safe gun storage? To as-
sess the impact of the intervention on families improp-
erly storing guns at baseline, we excluded all families who
at follow-up had removed all guns from their home. In
the next few paragraphs, we examine each variable of safe
gun storage as defined in Table 2.
When gauging any improvement, we found that
50.9% of respondents in the intervention group
improved either their gun lock storage frequency, their
gun storage type, or the frequency of storing a gun
unloaded. This was compared with 12.3% of those
respondents in the control group. This difference was
statistically significant (RR, 4.13; 95% CI, 2.06-8.30;
P!.001; Table 4).
Regarding the frequency of locked storage, 25% of the
intervention group showed some improvement at fol-
low-up in the frequency a gun was stored with a gun lock
or in a lock box compared with 4.8% of the control group
(RR, 5.20; 95% CI, 1.59-17.32; P=.003; Table 4). This
finding was confirmed by comparing the Likert scale
change between the 2 groups with the intervention group
having a significantly improved frequency of storage com-
pared with the control group (Mann-Whitney UTest,
P=.01).Because thecontrolgroup wasslightlymore likely,
although not significantly so, to always store guns with
a gun lock or lock box at baseline, we also repeated the
analysis with only those families who at follow-up still
owned a gun and at baseline were not always properly
storing their guns. The results remained similar with
greater improvement seen among the intervention group
(RR, 3.18; 95% CI, 1.10-9.19; P=.02).
With regard to the type of storage used, at follow-up
26.3% of the intervention group improved their type of
storage compared with only 3.1% of the control group
(RR, 8.55; 95% CI, 2.04-35.81; P!.001; Table 4). Again,
this finding was confirmed by comparing the Likert scale
change between the 2 groups with the intervention group
being significantly more likely to use a proper storage de-
vice at follow-up compared with the control group (Mann-
Whitney Utest, P!.001).
The frequency with which the families stored their guns
unloaded at follow-up did not significantly differ be-
tween the intervention and control groups (RR, 2.25; 95%
CI, 0.82-6.18; P=.11; Table 4). This finding was con-
firmed by comparing the Likert scale change between the
2groups(Mann-WhitneyUtest, P=.45). Becausethecon-
trol group was slightly more likely, although not signifi-
cantly so, to always store guns unloaded at baseline, we
also repeated the analysis with only those families who
at follow-up still owned a gun and at baseline were not
always storing their guns unloaded. The results re-
mained similar with no difference seen between the con-
trol and intervention groups (RR, 1.00; 95% CI, 0.49-
2.05; P=1.00; Table 4).
In all outcomes measured, no results were signifi-
cantly changed in multivariate analysis (data not shown).
However, those in the intervention group who owned a
handgun were more likely to show overall gun storage
improvement when compared with those who owned only
arifle(P!.05). None of the other variables listed in Table 3
predicted improved gun storage behavior.
Of the 43 families in the intervention group who were
not using gun locks at baseline, 12 (27.9%) were using
gun locks at follow-up. Of the 43 similar families in the
control group, 7 (14.9%) were using gun locks at fol-
low-up (RR, 1.45; 95% CI, 0.94-2.23; P=.13).
Table 3. Baseline Characteristics of Control
and Intervention Group
Characteristic
Control
Group
(n = 78)
Intervention
Group
(n = 73)
Child age, mean (SD), y 5.9 (5.4) 6.5 (5.9)
Households with at least 1 male child, % 71.1 80.0
Households with more than 1 child, % 73.7 74.6
Households with at least 1 teenager, % 39.0 45.5
Male head of household, % 84.2 82.1
Annual household income !$20 000, % 52.1 51.5
Spanish language, % 23.4 26.0
Own gun for protection, % 64.0 75.3
Perceive neighborhood as dangerous, % 15.4 11.0
Know any victims of violence, % 43.6 30.1
Guns in household, mean (SD), No. 1.9 (1.1) 1.6 (0.9)
Handgun owners, % 61.5 72.6
Gun always locked, % 74.3 63.0
Lock box or gun lock used for storage, % 64.1 72.6
Guns always stored unloaded, % 84.6 71.3
Gun lock usage, % 21.5 23.5
Proper gun storage, %*65.4 45.2
*Proper gun storage is defined as a gun that is always stored unloaded in
a lock box or secured with a gun lock.
Table 4. Percentages of Families Improving Gun Storage After Intervention Among Households Still With Guns at Follow-up*
Improvement
% (No./No.) Relative Risk
(95% Confidence
Interval) PValueControl Intervention
Any improvement in gun storage 12.3 (8/65) 50.9 (29/57) 4.13 (2.06-8.30) !.001
Greater frequency of locked storage 4.8 (3/63) 25.0 (14/56) 5.20 (1.59-17.32) .003
Improved type of gun storage 3.1 (2/65) 26.3 (15/57) 8.55 (2.04-35.81) !.001
Greater frequency of storing gun unloaded 7.8 (5/64) 17.5 (10/57) 2.25 (0.82-6.18) .11
*Each denominator represents those subjects who did not remove all guns from the household at follow-up. Each numerator represents those subjects who
showed improvement at follow-up with regard to the outcome being measured.
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COMMENT
This study provides reason to be optimistic about the ef-
fectiveness of a brief gun-safety counseling session, re-
inforced with written material and a gun lock giveaway.
Overall, those gun-owning families who received the in-
tervention were more than twice as likely to show some
type of improvement in their gun-safety practices. More
specifically, although our intervention did not appear to
significantly influence the removal of guns from the home,
it did significantly improve safe gun storage practices.
Of those who chose not to remove all guns from their
home, the greatest improvements were seen in gun lock–
dependent behaviors (type of storage and gun lock stor-
age frequency) as opposed to gun lock–independent be-
haviors (the frequency of unloaded storage). Given this,
one might speculate that the critical part of the interven-
tion was the gun lock giveaway. Although only one quar-
ter of the gun locks that were given out were reportedly
used, almost twice as many families in the intervention
group were using gun locks at follow-up compared with
the control group. This trend, however, did not reach sta-
tistical significance. A recently published study of gun
owners who were native to Alaska showed similar rates
of acceptance of free trigger locks.14
To our knowledge, this is the first trial of gun-safety
counseling in an outpatient pediatric setting that has
shown a positive effect of such an intervention. The
intervention fit into the time constraints of a health su-
pervision visit and was well received by providers and
patients. Given the gravity and pervasiveness of this pub-
lic health problem, our findings suggest that an in-
creased effort be made to address gun safety during well-
child visits.
Our finding that handgun owners were more likely to
improve gun storage behaviors compared with long gun
owners may make this group an especially good target for
further interventions, as suggested by the American Acad-
emy of Pediatrics recommendations for gun-safety coun-
seling. Considering that handguns account for the major-
ity of deaths and injuries from guns in the United States,15
any improvement in their storage could potentially lead
to a significant decrease in gun-related morbidity and mor-
tality. The STOP 2 program focuses on the danger of hand-
guns, and thus the improvements in storage might be re-
lated to the strength of that message.
We hypothesize that our results differ from prior stud-
ies showing educational interventions to be ineffective
because we formed a partnership with local law enforce-
ment that enabled us to give free gun locks directly to
gun-owning families along with counseling. The gun lock
might have provided a cue to action, which is felt to im-
pact health behavior decisions, that led to the desired gun
storage behaviors.16 Injury prevention efforts are most ef-
fective when combining an array of health education and
behavior change strategies such as counseling and the pro-
vision of subsidized safety devices.17
To our knowledge, this is one of only a few studies to
examine a gun-safety intervention in a predominantly His-
panic community.18 A previous survey has shown a gun
ownership rate of 14.7% among Hispanic families com-
pared with 43% of white families with children.12 This
is slightly higher than the 7.8% gun ownership rate in
our study. Data from the same survey, however, showed
lower gun ownership rates for families living in pov-
erty, families with lower education levels, and families
living in the western United States, all attributes of the
majority of families in our study.
This study has some limitations. Given the noncon-
current design, it is important to note that we know of no
significant community gun-related program or event that
occurred during the study period that might have influ-
enced the results. We were also limited by an assumption
that all guns in a given household were stored in a similar
fashion. Finally, reliance on self-report of behaviors can
introduce bias. This is especially relevant in this study given
the socially and politically charged nature of gun owner-
ship in this country coupled with the vulnerability some-
times felt by the Hispanic population in the Southwest.
However, the successful integration that the El Rio Com-
munity Health Center has achieved in its community and
the lack of child safety lock and child access prevention
laws in Arizona make us confident that such a bias is mini-
mized. Previous studies validate the self-reporting of gun
ownership,19,20 although evidence validating self-
reporting of gun storage patterns is lacking.
We found that a brief gun-safety counseling session
reinforced with written material and a gun lock give-
away resulted in improvement in safe gun storage prac-
tices. It did not, however, appear to significantly influ-
ence the removal of guns from the home. This study
provides support to the American Academy of Pediat-
rics recommendations to discuss gun safety with fami-
lies and encourages further research in this area.
Accepted for Publication: June 3, 2005.
Correspondence: Paul S. Carbone, MD, Children’s Pri-
mary Care Medical Group, 3702 Ruffin Rd, No. 205, San
Diego, CA 92123 (pcarbone@chsd.org).
Funding/Support: This study was funded by a grant from
the American Academy of Pediatrics Research in Pedi-
atric Practice Fund, Elk Grove Village, Ill.
Previous Presentation: This study was presented as a plat-
form presentation at the annual meeting of the Pediatric
Academic Society; April 3, 2004; San Francisco, Calif.
Acknowledgment: We owe thanks to the Brady Center to
Prevent Gun Violence, Washington, DC, for the donation
of Steps to Prevent Firearm Injury in the Home (STOP 2)
material. Additional thanks go to the Pima County attor-
ney’s office for donating the gun locks used in the study.
The assistance of Guimel Acton; Terry Brown; and Hector
Acton, MD, was invaluable in the completion of the study.
We also thank the administration, pediatricians, and nurs-
ing staff from the El Rio Community Health Center in Tuc-
son, Ariz, for their enthusiastic support and participation
in the study. We acknowledge Catherine Jolma, MD, for
her help in reviewing the manuscript.
REFERENCES
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Treatment of influenza: quinine, the hydro-
chloride, daily as prophylactic, has specific
action as shown by experience with hussars
at Bonn during the epidemic of 1889-90.
Cinnamon is a valuable remedy, if used early
the patient will return to his usual avoca-
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... Lethal Means Counseling (LMC) is a type of safety education that advises securement or removal of potentially hazardous household items such as medications, caustic cleaners, firearms, and other weapons. Several studies have demonstrated that counseling in health care settings can motivate families to improve home safety behaviors (Barkin et al. 2008;Albright and Burge 2003;Gittelman et al. 2006;Runyan et al. 2016;Uspal et al. 2021;Carbone et al. 2005). Moreover, when families receive tangible products, such as booster seats or home safety kits (Posner et al. 2004), they are more likely to make positive changes in home safety practices when compared to receiving education alone (Barkin et al. 2008;Gittelman et al. 2006;Uspal et al. 2021;Carbone et al. 2005). ...
... Several studies have demonstrated that counseling in health care settings can motivate families to improve home safety behaviors (Barkin et al. 2008;Albright and Burge 2003;Gittelman et al. 2006;Runyan et al. 2016;Uspal et al. 2021;Carbone et al. 2005). Moreover, when families receive tangible products, such as booster seats or home safety kits (Posner et al. 2004), they are more likely to make positive changes in home safety practices when compared to receiving education alone (Barkin et al. 2008;Gittelman et al. 2006;Uspal et al. 2021;Carbone et al. 2005). Similarly, firearm safety counseling without the provision of safety devices frequently results in subpar storage practices (Rowhani-Rahbar et al. 2016). ...
... A sample size of 200 patients was determined based on a 95% confidence interval with an 80% power to detect a 30% difference in primary outcome-based on described outcome differences in previous clinic-based trials (Carbone et al. 2005). Sample size calculations accounted for an estimated 30% loss to follow-up, based on prior survey-based projects within CCHMC PED (Gittelman et al. 2006). ...
Article
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Background Suicide-related presentations to pediatric emergency departments (PED) have increased in recent years. PED providers have the opportunity to reduce suicide risk by counseling on restricting access to lethal means. Supplementing lethal means counseling (LMC) with safety device distribution is effective in improving home safety practices. Data on PED-based LMC in high-risk patient populations is limited. The objective of this study was to determine if caregivers of children presenting to PED for mental health evaluation were more likely to secure all household firearms if given cable-style gun locks in addition to LMC. Methods In this randomized controlled trial, caregivers completed a survey regarding storage practices of firearms and medication in the home. Participants were randomized to receive LMC (control) or LMC plus 2 cable-style gun locks (intervention). Follow-up survey was distributed 1 month after encounter. Primary outcome was proportion of households reporting all household firearms secured at follow-up. Secondary outcomes included: removal of lethal means from the home, purchase of additional safety devices, use of PED-provided locks (intervention only), and acceptability of PED-based LMC. Results Two hundred participants were enrolled and randomized. Comparable portions of study groups completed follow-up surveys. Control and intervention arms had similar proportions of households reporting all firearms secured at baseline (89.9% vs. 82.2%, p = 0.209) and follow-up (97.1% vs. 98.5%, p = 0.96), respectively. Other safety behaviors such as removal of firearms (17.6% vs. 11.8%, p = 0.732), removal of medication (19.1% vs. 13.2%, p = 0.361), and purchase of additional safety devices (66.2% vs. 61.8%, p = 0.721) were also alike between the two groups. Both groups held favorable views of PED-based counseling. Within the intervention group, 70% reported use of provided locks. Preference for a different style of securement device was the most cited reason among those not using PED-provided locks. Conclusions PED-based LMC is a favorably-viewed, effective tool for improving home safety practices in families of high-risk children. Provision of cable-style gun locks did not improve rate of firearm securement compared LMC alone—likely due to high baseline rates of firearm securement and preference for different style of lock among non-utilizers. Clinical Trial Registration ID: NCT05568901 . Clinicaltrials.gov. https://clinicaltrials.gov/ . Retrospectively registered October 6, 2022. First participant enrollment: June 28, 2021.
... method using 11 quadrature points. All analyses were conducted using the R program language and the "lmerTest" package for GLMM [18][19][20]. ...
... Prior studies of means restriction education programs have reported variable impact. One intervention with Hispanic families in a pediatric clinic found that 61.6% removed or improved firearm storage with the education and tools provided [18]. In another study involving mostly middle-aged men participating at community events 14.8% reported changes in firearm storage, while 6.8% reported changes in medication storage [19]. ...
Article
Full-text available
Background: Means restriction is an approach to suicide prevention that has been shown to be effective but is underutilized in the United States. For the current study, we sought to determine if a webinar-based education intervention could impact caregiver means restriction knowledge and behaviors. Methods: Nine webinars for caregivers were offered by a children's hospital in conjunction with community groups. Education on raising teenagers was paired with information about suicide prevention, including the importance of securing medications and firearms. Participants completed surveys prior to the presentation, immediately following and two weeks later to measure change in knowledge and storage of medications and firearms. Participants were provided a safety toolkit to secure medications and firearms. Results: Of the 327 participants who completed the baseline survey, 299 and 257 completed the second and third surveys. By the conclusion of the study, 46.6% of participants reported they had disposed of unneeded medications and 44.1% had locked up medications. Among firearm owners, use of a cable gun lock rose from 13.7% to 25.8%. In addition, 40.2% of firearm owners reported learning more about how their firearms were stored at the final survey. Most participants (88.3%) strongly agreed that the presentation provided value. Conclusion: This study shows that a webinar on safe storage appears to have some impact on behavior changes for caregivers of adolescents. A controlled study could help to clarify if the webinar format or the timing during the Covid-19 pandemic might have played a role in the degree of behavior change reported.
... Numerous medical governing bodies have placed emphasis on firearm screening and counseling in the healthcare setting (American Academy of Family Physicians 2018; Dowd et al. 2012; The American College of Obstetricians and Gynecologists 2022). Additionally, previous reports have demonstrated the benefits of firearm screening and safety interventions, for example in pediatric (Barkin, Finch, Ip, et al. 2008;Carbone, Clemens, and Ball 2005;Wolk et al. 2017), trauma (Zatzick, Russo, Lord, et al. 2014), and psychiatric (Brent, Baugher, Birmaher, et al. 2000) settings. ...
Article
Full-text available
Firearm ownership is associated with an increased risk of adverse health outcomes, including violence, suicide, and accidental firearm injury. Numerous medical governing bodies have placed emphasis on firearm screening and counseling within the healthcare setting. However, few physicians discuss firearm ownership and safety with patients, likely due to limited physician familiarity with firearms or perceived risk to the doctor-patient relationship, among other barriers. Clinical trainees have the capability to confidentially screen for unsafe firearm practices and potentially prevent fatal injury. In this study, we provide one of the first reports of a universal firearm screening and safety intervention developed and implemented by medical and physician assistant students in an adult primary care clinic as part of a longitudinal clerkship experience. Students learned the basics of firearm ownership and storage, developed interview skills for sensitive topics, developed a screening tool for safe firearm storage, and gained a better understanding of firearm safety in the community. Through partnership with the Chicago Police Department, students offered firearm cable locks to all patients who screened positive for unsafe firearm storage practices. Overall, this study aimed to assess the feasibility of a universal firearm safety screening tool and intervention in a primary care clinic. We conclude that such a tool is feasible in a student-led primary care clinic, provides unique educational opportunities for students, and can be adopted in numerous healthcare teaching settings. Future steps may include evaluating other ways to promote firearm safety, such as screening for intimate partner violence and/or concomitant mental illness.
... A survey in 2004 showed more than 1 firearm was held by over 20% US households and more than 3 firearms were held by about half of the firearm owners [ 9 ]. While gun ownership is not directly annually surveyed in every state, gun sales and suicides which proxy gun ownership by state have been rising from 2013 to 2022 [9][10][11]. Practices for safe gun storage include keeping the guns unloaded and locked up with ammunitions locked separately have been widely emphasized to reduce risk of injury to children at homes [ 7 ,8 ,12 ]. ...
Article
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A 6 year old girl accidentally discovered a gun in her home and shot herself in her mouth. A bullet lodged in her right frontal lobe, but she remained neurologically intact with minimal symptoms. Her diagnosis was delayed due to the family leaving the emergency room for long wait times and later noticed over 72 hours from the injury at a dentist appointment. She was sent back to the emergency department, where head imaging revealed the injury to be inoperable. Six months later, the patient developed focal impaired awareness seizures. This was treated with oxcarbazepine, and patient responded well with no further spells. The case was highly unusual as the neurological symptoms were mild compared to the severity and the risk of initial intracranial injury. It emphasizes the frequently overlooked risk of leaving guns unsecured in households with children.
... 23 Interventions that provide Firearm Safe Storage Devices to individuals have been studied previously and highlight important considerations for policy makers and public health professionals. [23][24][25][26][27][28][29] Evidence suggests that costs matter and that Firearm Safe Storage Devices that were distributed at an economic cost to the consumer were not as effective in promoting safe firearm storage practices in comparison to improvements in safe firearm storage practices when they were provided free of charge. 12 23-29 By providing these Firearm Safe Storage Devices at no charge, economic and time barriers are removed. ...
Article
Full-text available
This study assesses the feasibility and acceptability of a Firearm Safe Storage Device Distribution Program. The distribution took place at the Break the Cycle of Violence Summit hosted by the Johns Hopkins Medicine, the Break the Cycle Hospital Violence Intervention Program, and the Johns Hopkins Bloomberg School of Public Health Center for Gun Violence Solutions. The findings will guide future efforts to distribute safe storage devices in clinical settings. Attendees of the Break the Cycle of Violence Summit could choose from three types of safe storage devices to provide to their patients within their practice. Those attendees who participated were asked to participate in an electronic survey to assess the feasibility and acceptability of the safe firearm storage device distribution at the Summit. 24 participants received safe storage devices at the Break the Cycle of Violence Summit. Of the 24 participants, 15 participated in our evaluation. 86% of participants distributed most of the devices by the time of the survey and 57% of participants stated that by having safe storage devices to distribute, they were more likely to provide safe gun storage counseling. All participants would like to see continued safe gun storage distribution programs in their community. The provision of free safe storage devices allowed for open conversations about firearms and safe storage with patients and clients. This study can be used as a model to guide future efforts in safe storage device distribution in a hospital or clinic-based setting and showed feasibility, effectiveness, and efficacy.
Article
Importance Injuries from firearms and motor vehicle crashes (MVCs) are the leading causes of death among US children and youths aged 0 to 19 years. Examining the intersections of age group, sex, race, and ethnicity is essential to focus prevention efforts. Objective To examine firearm and motor vehicle fatality rates by population subgroups and analyze changes over time. Design, Setting, Participants This cross-sectional study of firearm and MVC fatalities among US children and youths aged 0 to 19 years from the Centers for Disease Control and Prevention Web-Based Injury Statistics and Query Reporting System from 2011 to 2021. Participants included American Indian and Alaska Native; Asian, Hawaiian Native, and Pacific Islander; Black; Hispanic; and White youths. Data analysis was conducted from July 2023 to May 2024. Exposure Firearm or MVC fatality. Main Outcome Measures Firearm and MVC fatality rates by year and over time, as measured by the Joinpoint regression annual percent change (APC). Results From 2011 to 2021 there were 35 684 firearm and 40 735 MVC fatalities among US youths aged 0 to 19 years. For firearm fatalities, there were 21 332 homicides (59.8%), 12 113 suicides (33.9%), 1359 unintentional shootings (3.8%), 277 by legal enforcement (0.8%), and 603 from unknown intents (1.6%). When considering the intersections of age group, sex, race, and ethnicity, for firearm homicides among youths aged 15 to 19 years, the APCs were similar for Black (21.8%) and Hispanic (22.2%) males from 2018 to 2021, although with different peak rates (104.22 per 100 000 individuals and 17.80 per 100 000 individuals, respectively, in 2021). Black females aged 15 to 19 years demonstrated a dramatic APC increase of 40.7% from 2019 to 2021 (peak rate, 14.07 per 100 000 individuals). For firearm suicide in youths aged 10 to 19 years by sex, Black females had the greatest APC increase of 22.0% from 2016 to 2021. For MVC fatalities, the highest APC increase of 24.9% occurred among American Indian and Alaska Native females aged 15 to 19 years from 2018 to 2021. The highest MVC fatality rates occurred in 2021 among American Indian and Alaska Native males (38.16 per 100 000 individuals) and females (29.31 per 100 000 individuals) aged 15 to 19 years. Conclusions and Relevance In this cross-sectional study, US youths aged 0 to 19 years experienced important disparities in firearm and MVC fatality rates and increases over time when considering the intersectionality by age group, sex, race, and ethnicity. These findings suggest that a multipronged strategy focused on individual, community, and policy level approaches for specific high-risk groups for each injury mechanism is necessary to address these leading causes of death in US youths.
Article
LAY SUMMARY Firearms are the most common lethal means of suicide used by Veterans. Secure storage of firearms is linked to decreased risk for suicide. To prevent death by suicide via firearm, Veterans’ viewpoints on secure firearm storage and discussions on lethal means safety need to be understood. As part of a quality improvement project, the authors interviewed Veterans who experienced suicidal thoughts or attempts, as well as their family members or friends (designated as concerned significant others, or CSOs), to understand their views, practices, and recommendations on secure firearm storage. Overall, Veterans understood the importance of safe firearm storage practices and wanted to have open and direct conversations about secure firearm storage and mental health. The Veterans’ CSOs had similar viewpoints in that all were willing to assist with safe firearm storage in times of suicidal distress or crisis, and they would approach discussions on secure firearm storage and suicide prevention directly. Findings support the acceptability of involving a CSO in a lethal means safety intervention for Veterans who own firearms.
Chapter
Firearm violence is the leading cause of death in children and adolescents in the United States, impacting children of all socioeconomic status, race, and ethnicity, though with significant burden in minority populations. Pediatricians have a unique role in prevention of firearm injury and mortality through intervention, education, and advocacy. Specifically, pediatricians can screen to identify those at risk, counsel patients and families to prevent firearm injuries, work within local communities to improve targeted intervention strategies, and participate in national advocacy groups. By taking a personal responsibility and a public health approach, pediatric health care providers play a pivotal in decreasing the burden of firearm injury, mortality, and adherence to gun safety.
Article
It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period. For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5). Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.
Article
While survey-based data on firearm ownership are essential for epidemiologic studies of the relation between gun ownership and injuries, the validity of respondent answers to questions about gun ownership has not been confirmed. In order to assess the accuracy of interview data about firearms, in June to August 1987, the authors attempted to contact residents of 75 homes in the cities of Memphis, Tennessee and Seattle, Washington listed as the address of the owner of a recently registered handgun. Despite problems with inaccurate registration data, contact was ultimately made with 55 households, 35 of which consented to a general interview that included a series of questions about gun ownership. Respondents in 31 of these 35 households (88.6%) readily acknowledged that one or more guns were kept in their home. Respondents in three of the remaining four households (8.6%) stated that guns were recently kept in their homes but were no longer kept there. Only one respondent (2.9%) denied categorically that guns of any kind were kept in her home. The authors conclude that, at least among registered gun owners, respondent answers to questions about gun ownership are generally valid and that survey data of this type can be utilized with confidence.
Article
To examine characteristics and experiences associated with gun ownership among parents of pediatric patients who attend urban pediatric clinics and to determine the receptivity of these parents to firearm injury prevention counseling. A focus group discussion was followed by a cross-sectional survey. Four public pediatric clinics in a large metropolitan area were included. A focus group discussion was held with parents and was used to develop the questionnaire, which was then distributed over a 6-week period to parents accompanying children to the clinic. The anonymous, self-administered questionnaire was completed by 510 parents or guardians, with an 88% response rate. Twenty percent of respondents reported that they had a firearm in the home. Twenty-seven percent of respondents had experienced having a family member shot. Eighty-two percent of all respondents indicated that they would find information about the safest way to store a gun helpful or very helpful. Of all respondents, 47% would follow and an additional 37% would think over a provider's advice not to keep guns in the home. Gun owners were less inclined to report that they would follow this advice (19%), but 55% of the gun owners would think over this advice. Only 6% of all respondents reported that they would ignore or be offended by such advice. Children attending public urban pediatric clinics are exposed to guns in their homes, and their parents appear to be receptive to firearm injury prevention counseling from their child's health care providers.
Article
The validity of self-reported data on the presence of guns in the home obtained in a telephone survey was assessed in samples of households where a hunting license had been purchased or a handgun registered. The survey was conducted among a random sample of Ingham County, MI, residents who had purchased a hunting license between April 1990 and March 1991 and among those registering a handgun during 1990. A third study sample was selected from the county's general adult population using a random digit dialing method. The interviews were conducted between November 1991 and January 1992. The proportion of respondents who reported that at least one gun was kept in their household was 87.3 percent among handgun registration households and 89.7 percent among hunting license households. In the survey of the general population of the county, approximately one-third of the respondents reported keeping a gun in the household, 67 percent of them for hunting and 23 percent for safety. Despite some limitations, the data indicate that a question on gun presence in a household can be used in a in a telephone survey.
Article
It is unknown whether keeping a firearm in the home confers protection against crime or, instead, increases the risk of violent crime in the home. To study risk factors for homicide in the home, we identified homicides occurring in the homes of victims in three metropolitan counties. After each homicide, we obtained data from the police or medical examiner and interviewed a proxy for the victim. The proxies' answers were compared with those of control subjects who were matched to the victims according to neighborhood, sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. During the study period, 1860 homicides occurred in the three counties, 444 of them (23.9 percent) in the home of the victim. After excluding 24 cases for various reasons, we interviewed proxy respondents for 93 percent of the victims. Controls were identified for 99 percent of these, yielding 388 matched pairs. As compared with the controls, the victims more often lived alone or rented their residence. Also, case households more commonly contained an illicit-drug user, a person with prior arrests, or someone who had been hit or hurt in a fight in the home. After controlling for these characteristics, we found that keeping a gun in the home was strongly and independently associated with an increased risk of homicide (adjusted odds ratio, 2.7; 95 percent confidence interval, 1.6 to 4.4). Virtually all of this risk involved homicide by a family member or intimate acquaintance. The use of illicit drugs and a history of physical fights in the home are important risk factors for homicide in the home. Rather than confer protection, guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance.
Article
In 1992, the American Academy of Pediatrics issued statements calling for aggressive actions to reduce the dangers of firearms to children and adolescents, including removing handguns from homes with children and working toward a ban on the manufacture, sale, and private possession of handguns. To determine the extent to which pediatricians support these positions against firearms and to describe the demographic and practice determinants of their views. In 1994, data were obtained from 982 pediatricians involved in direct patient care in a national, random-sample survey of American Academy of Pediatrics members (response rate, 68.9%). This article focuses on 4 areas: (1) recent experience treating gun injuries, (2) attitudes toward legislation to reduce the availability of guns, (3) attitudes toward gun safety counseling by pediatricians, and (4) current gun safety counseling practices. Wherever possible, chi 2 and t tests were used to compare responses to a similar 1988 survey of American Academy of Pediatrics members. Logistic regression was used to examine the multivariate relationships between the outcome variables and demographic and practice characteristics of the responding pediatricians. Almost 1 in 5 pediatricians treated a gun injury in the past 12 months. In 1988, 86.5% of pediatricians supported restricting the sale and possession of handguns; in 1994, support for such legislation increased to 92.5% (P < .01). Also in 1994, 76% supported banning the sale or possession of handguns. Most respondents (82%) believe anticipatory guidance on firearm safety can reduce injury and death; 95% support asking parents to unload and lock firearms, and 66% support encouraging parents to remove handguns from the home. Current counseling practices lag behind attitudinal support of anticipatory guidance on firearm safety (eg, half of respondents report never identifying families with firearms in the home). Demographic factors as well as professional experience were found to affect attitudes (eg, women, older pediatricians, and those who did not own guns were more likely to support gun-control legislation; and pediatricians who have recently treated gun injuries and those practicing in the inner city are more likely to counsel families about gun safety). The data indicate that practicing pediatrician overwhelmingly agree that handguns in the home are hazardous and that steps should be taken to reduce this hazard through legislation and patient counseling. They support the policies on firearms and handguns of the American Academy of Pediatrics; most support even the strongest recommendation, which is a ban on handguns. A substantial lag between attitudes that favor counseling about firearms and reported practices indicates the need for further training in and evaluation of firearm counseling in office settings.
Article
To describe clinicians' behavior regarding firearm safety counseling practices, develop a model to predict current counseling behavior, and identify resources that might positively influence willingness to counsel according to medical guidelines. Four hundred sixty-five primary care Los Angeles County, California, pediatricians, family physicians, and pediatric nurse practitioners who serve families with children aged 5 years and younger received mailed questionnaires; 325 (70%) responded. Clinician self-reported behavior. Of the respondents, 80% stated that they should counsel on firearm safety; only 38% do so. Of those clinicians who currently counsel, only 20% counsel more than 10% of their patient families. Firearm safety counseling behavior is positively associated with a clinician being 49 years or younger (odds ratio [OR]=2.19, P=.02); a perception that counseling is beneficial (OR=2.62, P=.02); and household handgun ownership (OR=2.47, P=.02). Clinician households that report gun ownership counsel differently than those clinicians who report not possessing a household gun. There are no significant differences in the rates of counseling across specialties and crime area types. Forty-one percent of clinicians report that patient education handouts would increase their likelihood of counseling. In Los Angeles County gaps exist between clinicians' views of the benefits of counseling families with young children regarding firearm safety and their actual behavior. Guidelines and handouts are available from major medical organizations. Research should focus on how to get practitioners to use available materials, enabling them to better adhere to guidelines.
Article
To estimate the prevalence of gun ownership and methods of gun storage in homes of pediatric patients before and after an educational intervention. Before and after trial. Hospital based, inner city, pediatric primary care practice. Consecutive sample of parents of patients with appointments August to November 1994. Before the intervention, participants completed an anonymous questionnaire regarding ownership and storage of guns in their home. The intervention followed the Steps to Prevent Firearm Injury program of the American Academy of Pediatrics. It began after the parent completed the questionnaire and was reinforced at subsequent visits until July 1995. Families completing a baseline questionnaire and returning to the office July to October 1995 were resurveyed. Reported change in gun ownership and methods of storage. A gun(s) in the home was reported by 8.7% of respondents. Matched baseline and follow up questionnaires were available for 23.6% of families. In these, gun ownership reportedly decreased after intervention from 9.4% to 7.0%, handgun ownership fell from 5.4% to 3.0%, and long gun ownership fell from 6.1% to 5.5%. Storing guns outside of a locked container did not change from the baseline prevalence of 2.7%, but keeping any gun loaded fell from 1.6% to 0.5%. All p values were >0.05. This study was unable to demonstrate a statistically significant decline in gun ownership or improvement in gun storage after a practice based intervention designed to encourage these behaviors.