Talking About "Firearm Injury" and "Gun Violence": Words Matter

"I am a survivor!": Violently Injured Black Men's Perceptions of Labeling After a Violent Firearm Injury

Self-appraisal after a life-altering event is a critical process for individuals, often comprised by assigned labels that may not align with an individuals' perceptions of themselves or of their situation. Existing research within this victim-survivor dichotomy largely rests in the interpersonal violence space, with a victim assuming legal recourse and wrongdoing, and a survivor associating with positive personal characteristics like grit and resilience. Much existing literature on self-appraisal after interpersonal injury is heavily concentrated within the sexual violence literature, and this study applies these concepts to a sample of Black men injured by firearms. Ten Black men enrolled in a hospital-based violence intervention program (HVIP) were interviewed to understand how they label their experience of firearm injury, and if their perceptions aligned with common labels seen among other populations and/or in other areas of study (e.g., cancer, domestic violence). Each participant assigned themselves their own label, with three labels emerging: survivor, victim and survivor, and neither victim nor survivor. The results illustrate the nuance of experiences beyond the victim-survivor dichotomy, and how labels and personal identities may shift following injury into new terms and considerations of resilience and trauma processing. More research is warranted to understand the factors that shape self-labeling within this population, including influences of masculine norms, racialized stereotypes, community context, and availability of services. Findings support public awareness campaigns to reframe surviving violence as a strength, and for community partners and practitioners to increase access to culturally competent and trauma-informed mental healthcare.

Public health framing of firearm violence on local television news in Philadelphia, PA, USA: a quantitative content analysis

BACKGROUND

Firearm violence is an intensifying public health problem in the United States. News reports shape the way the public and policy makers understand and respond to health threats, including firearm violence. To better understand how firearm violence is communicated to the public, we aimed to determine the extent to which firearm violence is framed as a public health problem on television news and to measure harmful news content as identified by firearm-injured people.

METHODS

This is a quantitative content analysis of Philadelphia local television news stories about firearm violence using a database of 7,497 clips. We compiled a stratified sample of clips aired on two randomly selected days/month from January-June 2021 from the database (n = 192 clips). We created a codebook to measure public health frame elements and to assign a harmful content score for each story and then coded the clips. Characteristics of stories containing episodic frames that focus on single shooting events were compared to clips with thematic frames that include broader social context for violence.

RESULTS

Most clips employed episodic frames (79.2%), presented law enforcement officials as primary narrators (50.5%), and included police imagery (79.2%). A total of 433 firearm-injured people were mentioned, with a mean of 2.8 individuals shot included in each story. Most of the firearm-injured people featured in the clips (67.4%) had no personal information presented apart from age and/or gender. The majority of clips (84.4%) contained at least one harmful content element. The mean harmful content score/clip was 2.6. Public health frame elements, including epidemiologic context, root causes, public health narrators and visuals, and solutions were missing from most clips. Thematic stories contained significantly more public health frame elements and less harmful content compared to episodic stories.

CONCLUSIONS

Local television news produces limited public health coverage of firearm violence, and harmful content is common. This reporting likely compounds trauma experienced by firearm-injured people and could impede support for effective public health responses to firearm violence. Journalists should work to minimize harmful news content and adopt a public health approach to reporting on firearm violence.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.

Locked and loaded: correlates of in-home firearm storage beliefs and behaviours

OBJECTIVES

To understand how crime and victimisation fears and risks operate alongside social status threats and motivations to shape unsafe in-home firearm storage practices and beliefs.

METHODS

Using data from firearm owners identified in a nationwide sample surveyed in 2023, this study examined how in-home loaded firearm accessibility, firearm storage practice and firearm safety beliefs are associated with: fear of crime and victimisation; perceived and personal victimisation; racial resentment; cultural and status threats; and masculinity threats. Regression models also accounted for the role of gender, race, marital status, political affiliation, geographic region and protective motivation for firearm ownership.

RESULTS

Over 40% of firearm owners reported having a loaded firearm 'always accessible' at home, and almost half think homes with firearms are safer than those without. About one-third of owners reported storing firearms locked but still loaded. Crime and victimisation fears and threats were unrelated to firearm storage behaviours and beliefs; however, firearm owners who experience higher levels of sociocultural anxiety are more likely to always have a loaded firearm accessible at home, store firearms locked and loaded, and believe that firearms make homes safer.

CONCLUSIONS

Identifying the barriers to safer storage beliefs and behaviours is essential for refining and enhancing effective firearm injury prevention strategies. Sociocultural anxieties may not reflect concrete threats to physical safety, but they can be experienced as feelings of insecurity, instability and distress that-for some Americans-may be managed by knowing they have a (loaded) firearm within reach.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

'Whether it's your weapon or not, it's your home': US military spouse perspectives on personal firearm storage

INTRODUCTION

In the USA, an estimated 45% of veterans personally own firearms. Firearm access increases the risk of suicide, so suicide prevention efforts in the US Department of Defense (DoD) focus on lethal means safety, including reducing firearm access. Spouse input may enhance effective messaging and intervention delivery of lethal means safety. This study used qualitative methods to explore the perspectives of military spouses or partners on personal firearm storage, including at-home decisions, on-base storage and existing messaging from the DoD.

MATERIALS AND METHODS

Qualitative data were obtained using 1:1 interviews and focus groups with spouses/partners of US military service members (active duty, Reserve, National Guard, recently separated from the military) and representatives from military support organisations. Sessions focused on personal firearm storage (at home or on military installations) and military messaging around secure firearm storage and firearm suicide prevention. Data were analysed using a team-based, mixed deductive-inductive approach.

RESULTS

Across 56 participants (August 2022-March 2023), the themes were variability in current home firearm storage and spousal participation in decision-making; uncertainty about firearm storage protocols on military installations; mixed awareness of secure firearm storage messaging from the military; and uncertainty about procedures or protocols for removing firearm access for an at-risk person.

CONCLUSION

US military spouses are important messengers for firearm safety and suicide prevention, but they are currently underutilised. Tailored prevention campaigns should consider spousal dynamics and incorporate education about installation procedures.

Racial and ethnic differences in the effects of state firearm laws: a systematic review subgroup analysis

BACKGROUND

Despite growing evidence about how state-level firearm regulations affect overall rates of injury and death, little is known about whether potential harms or benefits of firearm laws are evenly distributed across demographic subgroups. In this systematic review, we synthesized available evidence on the extent to which firearm policies produce differential effects by race and ethnicity on injury, recreational or defensive gun use, and gun ownership or purchasing behaviors.

MAIN BODY

We searched 13 databases for English-language studies published between 1995 and February 28, 2023 that estimated a relationship between firearm policy in the USA and one of eight outcomes, included a comparison group, evaluated time series data, and provided estimated policy effects differentiated by race or ethnicity. We used pre-specified criteria to evaluate the quality of inference and causal effect identification. By policy and outcome, we compared policy effects across studies and across racial/ethnic groups using two different ways to express effect sizes: incidence rate ratios (IRRs) and rate differences. Of 182 studies that used quasi-experimental methods to evaluate firearm policy effects, only 15 estimated policy effects differentiated by race or ethnicity. These 15 eligible studies provided 57 separate policy effect comparisons across race/ethnicity, 51 of which evaluated interpersonal violence. In IRR terms, there was little consistent evidence that policies produced significantly different effects for different racial/ethnic groups. However, because of different baseline homicide rates, similar relative effects for some policies (e.g., universal background checks) translated into significantly greater absolute differences in homicide rates among Black compared to white victims.

CONCLUSIONS

The current literature does not support strong conclusions about whether state firearm policies differentially benefit or harm particular racial/ethnic groups. This largely reflects limited attention to these questions in the literature and challenges with detecting such effects given existing data availability and statistical power. Findings also emphasize the need for additional rigorous research that adopts a more explicit focus on testing for racial differences in firearm policy effects and that assesses the quality of race/ethnicity information in firearm injury and crime datasets.

Firearm Injury Prevention

Firearms are the leading cause of death for US youth, overtaking motor vehicle collisions in 2020. Approximately 65% are due to homicide, 30% are due to suicide, 3.5% are due to unintentional injuries, 2% are undetermined intent, and 0.5% are from legal interventions. In homes with firearms, the likelihood of unintentional death, suicide, and homicide is three to four times higher than those without firearms. Secure storage of firearms, having them locked, unloaded, and separate from ammunition can prevent unintentional firearm injuries.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL IMPLICATIONS

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

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE

Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED).

METHODS

We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI).

RESULTS

Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1).

CONCLUSIONS

We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Bystander intervention to prevent firearm injury: A qualitative study of 4-H shooting sports participants

This qualitative study examines how youth and adult members of 4-H Shooting Sports clubs perceive firearm injury risk and risk reduction, and the applicability of a bystander intervention (BI) risk reduction framework in this community. Semistructured interviews were conducted with 11 youth and 13 adult members of 4-H Shooting Sports clubs across nine US states from March to December of 2021 until thematic saturation was reached. Deductive and inductive thematic qualitative analyses were performed. Six overarching themes emerged: (1) The tendency to view firearm injury as predominantly unintentional in nature; (2) Acknowledgment of a wide array of risks for firearm injury; (3) Perceived barriers to bystander action to prevent firearm injury including knowledge, confidence, and consequences of action; (4) Facilitators of bystander action including a sense of civic responsibility; (5) Direct and indirect strategies to address potential risks for firearm injury; and (6) Belief that BI skills training would be useful for 4-H Shooting Sports. Findings lay the groundwork for applying BI skills training as an approach to firearm injury prevention in 4-H Shooting Sports, similar to how BI has been applied to other types of injury (i.e., sexual assault). 4-H Shooting Sports club members' sense of civic responsibility is a key facilitator. Prevention efforts should attend to the broad array of ways in which firearm injury occurs, including suicide, mass shootings, homicide, and intimate partner violence, as well as unintentional injury.

Assessing the Gun Violence Archive as an Epidemiologic Data Source for Community Firearm Violence in 4 US Cities

Importance

Firearm injury is a major public health burden in the US, and yet there is no single, validated national data source to study community firearm violence, including firearm homicide and nonfatal shootings that result from interpersonal violence.

Objective

To assess the validity of the Gun Violence Archive as a source of data on events of community firearm violence and to examine the characteristics of individuals injured in shootings.

Design, Setting, and Participants

This cross-sectional observational study compared data on community firearm violence from the Gun Violence Archive with publicly available police department data, which were assumed to be the reference standard, between January 1, 2015, and December 31, 2020. Cities included in the study (Philadelphia, Pennsylvania; New York, New York; Chicago, Illinois; and Cincinnati, Ohio) had a population of greater than 300 000 people according to the 2020 US Census and had publicly available shooting data from the city police department. A large city was defined as having a population greater than or equal to 500 000 (ie, Philadelphia, New York City, and Chicago). Data analysis was performed in December 2022.

Main Outcomes and Measures

Events of community firearm violence from the Gun Violence Archive were matched to police department shootings by date and location. The sensitivity and positive predictive value of the data were calculated (0.9-1.0, excellent; 0.8-0.9, good; 0.7-0.8, fair; 0.6-0.7, poor; and <0.6, failed).

Results

A total of 26 679 and 32 588 shooting events were documented in the Gun Violence Archive and the police department databases, respectively, during the study period. The overall sensitivity of the Gun Violence Archive over the 6-year period was 81.1%, and the positive predictive value was 99.0%. The sensitivity steadily improved over time. Shootings involving multiple individuals and those involving women and children were less likely to be missing from the Gun Violence Archive, suggesting a systematic missingness.

Conclusions and Relevance

These findings support the use of the Gun Violence Archive in large cities for research requiring its unique advantages (ie, spatial resolution, timeliness, and geographic coverage), albeit with caution regarding a more granular examination of epidemiology given its apparent bias toward shootings involving multiple persons and those involving women and children.

Firearm Injury Prevention Advocacy: Lessons Learned and Future Directions

Injuries and deaths due to firearms in children and young adults is a public health crisis in the United States. Pediatric clinicians are powerful advocates to reduce harm due to firearms. By forming coalitions with legislators on a bipartisan basis, working with government relations teams in the hospitals, and partnering with community allies and stakeholders, pediatric clinicians can work to enact legislation and influence policies at the individual, state, and national levels. This can include advocacy for strengthening Child Access Prevention Laws and firearm safer storage campaigns.

How Americans encounter guns: Mixed methods content analysis of YouTube and internet search data

Firearm-related injury and death is a serious public health issue in the U.S. As more Americans consume news and media online, there is growing interest in using these channels to prevent firearm-related harms. Understanding the firearm-related narratives to which consumers are exposed is foundational to this work. This research used the browsing behavior of a representative sample of American adults to identify seven firearm-related content "ecosystems" (defined as naturally occurring networks of channels watched by the same users) on YouTube; we then described the demographics and internet search patterns of users affiliated with each ecosystem. Over the 9-month study period, 72,205 panelists had 16,803,075 person-video encounters with 7,274,093 videos. Among these, 282,419 were related to firearms. Using fast greedy clustering, we partitioned users and channel interactions into seven distinct channel-based content ecosystems that reached more than 1/1000 YouTube users per day. These ecosystems were diverse in reach, users, and content (e.g., guns for self-protection, guns for fun). On average, 0.5% of panelists performed a firearm-related internet search on a given day. The vast majority of searches were related to mass shootings or police-involved shootings (e.g., "active shooter"), and virtually none were about more common firearm harm such as suicide. Searches for firearm safety information were most common among panelists affiliated with the "Hunting & Fishing" and "Guns & Gear" ecosystems, which were watched primarily by older, white men. These findings identify an opportunity for analyzing firearm-related narratives and tailoring firearm safety messaging for users affiliated with specific online content ecosystems.

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

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

Rethinking "recidivism" in firearm injury research and prevention

Interpersonal firearm injuries pose a persistent public health threat in the United States (US). Strategic interventions to curb these injuries require evaluation of measurable outcomes that prove effectiveness and substantiate efforts for wider scaling and implementation. One common outcome of interest used among injury prevention researchers and practitioners is 'recidivism' referring to recurrent injury from acts of violence in a previously firearm injured person. In this commentary we urge that the term which can insinuate racialized criminality and reinforce stigma, no longer be used to describe people who experience firearm injuries. We also advocate for reconsideration of 'recidivism' as an ideal evaluation metric for the success of tertiary firearm injury prevention programs.

The Florida Violent Death Reporting System 2019 Data Findings Including a Qualitative Focus on Suicide Deaths of Young Black Males

The Florida Violent Death Reporting System (FLVDRS) includes violent death data abstracted from death certificates (DC), medical examiner (ME) reports, and law enforcement (LE) records. Abstractors also produce narratives from the ME and LE information. This manuscript focuses on the findings from the 2019 FLVDRS. Quantitative data were reviewed using SPSS and STATA and MAXQDA was used for the qualitative analysis. Results showed that most deaths were suicides (69.0%). Males comprised most of all the violent deaths (77.4%). Qualitative analysis focused on available narratives of Black males regardless of ethnicity, ages 10–24 years, who died of suicide (n = 19). The most prominent codes from the qualitative analysis included scene location, suicide method, engagement with LE, known history of psychiatric conditions, known history of self-injurious behavior, and recent life events. Subcodes related to the parent codes are also provided for further explanation of the findings. Future research will allow confirmation of findings and development of targeted intervention programs.

The effectiveness of value-based messages to engage gun owners on firearm policies: a three-stage nested study

Background

Although gun owners overwhelmingly support violence prevention policies, they are hesitant to speak up publicly to advocate for these policies. We tested a series of communication messages on gun owners’ level of support for various firearm violence prevention policies and on their willingness to engage in gun violence prevention advocacy.

Methods

We conducted three consecutive experiments, testing a total of thirteen messages on a sample of gun owners over 18 years old who live in the U.S. The first was a random experiment, the second a quasi-experiment, and the third a randomized control trial. The goal of having these varied methods was to develop messages applicable to different contexts with different levels of information about the audience.

Results

The most effective message was a script showing respect for gun owners’ decisions to purchase a firearm and proposing a balanced policy roadmap to end gun violence, which led to an increase in gun owner’s willingness to engage in eight different advocacy activities. We also found a value-based message conveying loyalty to increase support for domestic violence related prohibitions and willingness to engage in advocacy for gun violence prevention policies.

Conclusions

Public health professionals need to develop communication strategies that are aligned with gun owners’ values and that affirm respect for gun culture and for gun owners’ decisions to own a gun.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-022-00394-6.

Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury

The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes.

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].

Advocacy training tool for pediatric residents to strengthen firearm safety laws

Firearm injury is the leading cause of death in children and adolescents in the US, surpassing motor vehicle crashes. There is a need for greater legislative advocacy around firearm injury prevention, specifically around safer storage of firearms. A national medical trainee-based program convened in 2021 with the goal of increasing advocacy efforts around common causes of pediatric injury. A focus was to create a set of advocacy training tools that could be utilized by a wide variety of stakeholders. The subgroup sought to design policy-based training tools; one focused on general firearm injury prevention principles and another specifically focused on Child Access Prevention (CAP) laws. We explicate the utility of these documents and the need for greater advocacy around pediatric firearm injuries.