Secure firearm storage counseling is repeatedly implicated as a key factor in the reduction of firearm-related injury and death, and pediatricians have a unique role in promoting this practice within clinical encounters. The American Academy of Pediatrics, in its recent policy statement “Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction,” advocates for a multipronged approach to firearm injury prevention.1 The statement calls for well-child visits to include firearm safety anticipatory guidance,1 thus affirming the role of pediatricians to lead in the effort to reduce firearm injury. However, implementation has been hindered as the result of barriers in time and comfort level, and thus it is imperative to continue to investigate factors that can improve the message delivery in an evidence-based, culturally competent manner. March et al in their paper recently published in The Journal reinforce much of what we understand about preferences of firearm owners, including nonjudgmental questions about safe storage practices with the presumption of firearm ownership and the use of trusted messengers.2, 3, 4, 5 The paper also underscores the importance of using accurate but acceptable terminology for firearms when approaching this potentially polarizing topic.6,7
It is essential to have conversations with families that are culturally competent. For example, March et al highlight the importance of using the term “firearm” over weapon, consistent with previous studies about the significance of using appropriate language within the clinical encounter. In all forms of anticipatory guidance, effective messaging is key to influence behavior change.1,2,7 Assessment of risk perception is essential during the conversation. If the parent does not perceive the risk of injury to the child, then it is more challenging to change the storage behaviors. Studies have found that using harm-reduction strategies can be helpful in the discussion of risk, formulating tailored suggestions for modification of behavior, ideally combined with provision of a safety device such as a cable lock.8, 9, 10 Using a patient-centered, nonjudgmental approach in a broad context of home safety is likely to be more acceptable among firearm owners.11
A significant barrier to secure firearm storage counseling among pediatricians is the lack of comprehensive training on the topic in undergraduate and graduate medical education. In one survey of pediatric residents, only 22% reported receiving any didactic education on firearm injury prevention, despite 96% saying that they felt they had a responsibility to counsel patients on the risks posed by firearms.12 The importance of being trained to use screening tools and incorporate appropriate interventions to reduce firearm injury is recognized across medical specialities.13 Adequate preparation of pediatric trainees and other health professionals to help get out of their comfort zone to address firearms risk in clinic settings is critical. In an environment of increased skepticism about science and reduced trust with medical institutions, having the communication skills to engage on this and other sensitive topics is arguably as important as many technical proficiencies future pediatricians acquire. These communication skills entail more than knowledge but require simulation and practical training to equip physicians with competence to engage constructively. Otherwise, families for whom firearm ownership and use is normative may find these conversations intrusive or offensive if approached in a disapproving manner. Training programs involving case-based simulation, computer-based modules, or simulated patients have demonstrated success in improving provider knowledge, comfort level, and in several cases even behavior patterns.14, 15, 16 It is imperative to implement the training tools currently available and continue to investigate how to improve processes to promote best practices.
Importantly, the authors acknowledge that the participants in the study by March et al were drawn from community groups with strong firearms safety and violence prevention missions. Thus, these individuals were possibly more predisposed to receiving education about safe storage. Unfortunately, preaching to the choir only gets us so far. We must engage with the wider community of firearms owners to develop constructive approaches to meaningful education and behavior change. Research must engage more varied perspectives to avoid an echo chamber—including recruitment of adequate numbers of firearm owners and active outreach to those with varied backgrounds and affiliations. Representation of active and former military and law enforcement populations, firearms retailers, and gun rights activists in focus groups is imperative to understand the messaging needed to shift behavior change within the larger firearm-owning community. Understanding the perspectives of all viewpoints within a population can help to highlight key messages, trusted messengers, and preferred terminology that will promote meaningful conversation to promote behavior change. Currently there are numerous examples of academic medicine-public health-firearm retailer partnerships that seek to not only gain the perspective of the firearm owning community but also work with them to develop community-based initiatives on firearm suicide prevention.17,18 In addition, “gun shop projects” exist in more than 20 states and are prime examples of how unlikely partnerships can lead to substantial change.19
Secure firearm storage counseling is an essential skill for every pediatrician, and this training should be prioritized to address some of the barriers felt among providers. This study contributes to the existing literature about the need for culturally competent messaging when discussing firearms with families. It also highlights the need to engage with a broad range of stakeholders. We must embrace diversity in our research methods and partnerships, using academic-community partnerships to bridge gaps and help us identify novel methods to address firearm violence. Continuing to work collectively to build knowledge and test effectiveness of interventions is critical, both inside and outside of the clinic.
CRediT authorship contribution statement
Sandra McKay: Writing – original draft, Writing – review & editing. Mary E. Aitken: Writing – original draft, Writing – review & editing.
Declaration of Competing Interest
The authors declare no conflict of interest.
Footnotes
Submitted for publication Feb 21, 2024; accepted Feb 24, 2024.
References
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