Store Safely: A firearm injury prevention strategy for rural families

Abstract

Firearms are the leading cause of death for youth in the US. Safe firearm storage is an evidence-based risk reduction technique, yet many families with children maintain unsecured firearms. In rural areas where gun ownership is common and rates of firearm-related suicides are increasing, developing culturally acceptable and feasible safe storage prevention strategies may have promise for reducing morbidity and mortality. This pilot study used a community-based participatory approach to develop a culturally tailored multi-component online safe storage preventive intervention called Store Safely. Participants were 45 rural firearm owning parents representing 45 unique families (35% male, 65% female, M age = 37.88, SD = 6.14) who had at least one child living at home. Acceptability, feasibility, and preliminary impact on firearm storage behaviors were measured via pre-test and post-test self-report surveys. Of the 43 parents (43 families) retained at follow-up, 97.7% completed the intervention and 86% utilized a home safety checklist. 40% of participants reported improving their storage, offering examples such as purchasing gun locks, safes, or lockboxes; separating ammunition from weapons; reviewing or discussing the safety of current storage; and relocating firearms to reduce child access. 84% found the website culturally sensitive and would recommend the materials to other parents. This firearm safe storage preventive intervention, developed in partnership with a rural community and tailored to reflect community norms and values, was associated with high levels of parental acceptability, engagement, and behaviors in support of safe firearm storage, suggesting its promise as a firearm injury prevention strategy.

Introduction

Firearm-related injuries are now the leading cause of death among children and adolescents in the US (Goldstick et al., 2021). From 2019–2021, pediatric firearm-related deaths increased by 50% (Gramlich, 2023), with 60% of pediatric deaths in 2021 due to homicide, 32% to suicide, and 5% to unintentional injury (Centers for Disease Control and Prevention [CDC], 2021; Gramlich, 2023). Patterns of firearm mortality are not equitably distributed, with age-adjusted suicide rates in rural counties more than two times higher (10.9/100,000) those in urban counties (4.98/100,000) (Goldstick et al., 2021). Given the current declared crisis in child and adolescent mental health (American Academy of Pediatrics, 2021) and the high lethality of firearms when used in a suicide attempt (Conner et al., 2019), the development of effective firearm injury prevention strategies that are culturally sensitive and acceptable to rural communities is an urgent national priority (National Research Council, 2013).

Safe Storage

In the US, 13 million children and adolescents are estimated to reside in a home with at least one firearm and, for 4.6 million, these firearms are not securely stored (i.e., they are stored loaded and/or unlocked) (Azrael et al., 2018). Living in a home with a firearm is an independent risk factor for firearm injury and mortality (Andrews et al., 2022). Firearms in homes where a child or adolescent is injured or killed are more likely to be stored unlocked, loaded, or with accessible ammunition. Safe firearm storage has been endorsed by a host of multidisciplinary groups, including the American Academy of Pediatrics (2023) and the Children’s Hospital Association (2022) to reduce risk of firearm related harms among children and adolescents.

Need for a Primary Prevention Approach to Firearm-Related Youth Suicide

The National Strategy for Suicide Prevention (Office of the Surgeon General, Action Alliance for Suicide Prevention, 2012), the CDC (2022) and a consortium of firearm injury prevention experts (Cunningham et al., 2019) are aligned in recommending strategies that create protective environments by reducing access to lethal means. Reducing firearm access has the potential to lower suicide rates nationally because firearms account for 55% of adult and 46% of youth suicide deaths in the US (CDC, 2021) and have case fatality rates of over 90% (Conner et al., 2019). A majority of firearms used in youth suicides are obtained at home or from extended family members (Barber et al., 2022). Most firearm-focused suicide prevention strategies take an indicated prevention approach, offering counseling on access to lethal means once suicide risk is identified during a health care contact (Runyan et al., 2018). Other firearm safety interventions for youth also rely on healthcare providers, such as pediatricians, to impart education during well-child visits (Ngo et al., 2019). In the context of the current crisis in child and adolescent mental health (American Academy of Pediatrics, 2021), the lack of providers in rural areas (Graves et al., 2020), and insurance and transportation barriers (Fontanella et al., 2015), community-based approaches to safe storage that do not rely on health care providers, but rather focus on safe storage in all homes where youth reside, are needed.

Despite their promise to reduce injury, interventions to promote safe storage are limited (Ngo et al., 2019), and this is especially true in rural communities (Butterworth et al., 2018). A recent review across almost 30 years of published firearm injury prevention research found only 23 studies focused on safe storage promotion and, of those located in community (as opposed to healthcare) settings, the majority involved gun buy-back programs, a firearm removal rather than safe storage option, unlikely to be effective in rural areas where firearms are a critical part of community life (Ngo et al., 2019). Authors of two recent reviews (Ngo et al., 2019; Rowhani-Rahbar et al., 2016) agreed that the field of firearm injury prevention is characterized by a) a paucity of evidence-based strategies to promote safe storage, b) a lack of methodological rigor, and c) limited measurement of behavioral outcomes. Additional rigorous research is needed to ascertain the most effective methods to promote changes in firearm storage behaviors.

Rural Culture and Need for Tailored Strategy

Promoting safe storage of firearms in rural areas requires a nuanced and tailored approach. Rates of gun ownership are substantially higher in rural than suburban and urban regions (Parker et al., 2017), and firearms are an important part of family and community life in many rural areas (Ewell Foster et al., 2023). Relative to other regions, individuals in rural communities are more likely to use firearms for hunting or sport, to have grown up using guns, to view ownership positively, and to report that most of their friends own guns (Parker et al., 2017). Firearm owners who hunt are also more likely to own five or more firearms (Parker et al., 2017). In communities of firearm owners, conversations about reducing firearm access can be politically contentious, culturally sensitive, and seen as intrusive (Celinska, 2007).

Rural communities are characterized by a wealth of protective factors, including a sense of community, resource-sharing, and collaboration (Rural Youth Suicide Prevention Workgroup, 2008). Harnessing these strengths by elevating trusted community messengers and messages that reflect the strengths of rural culture may have untapped potential to increase safe storage in rural communities. In a study of lethal means counseling for adults with suicide risk, Marino and colleagues (2018) collaborated with a rural community to develop tailored firearm safety messaging. Pairing suicide prevention information with culturally tailored messages was associated with greater behavioral intentions to restrict firearm access in the presence of suicide risk and greater willingness to be honest about firearm ownership and storage with a physician, especially among those identifying as conservative or gun rights advocates. Similarly, in a sample of firearm owning veterans, tailored messages provided by credible messengers resulted in stronger willingness to store safely (Anestis et al., 2022). Taken together, these studies emphasize the promise of tailored messaging as a strategy to connect with firearm owning communities (Anestis et al., 2022; Butterworth et al., 2019); yet neither of these studies assessed actual storage behaviors, pointing to a need to expand measurement of behavioral outcomes.

Store Safely: A Community-Based Primary Prevention Strategy for Rural Families

Using a community-based participatory research (CBPR) approach (Israel et al., 2018), Store Safely was designed collaboratively via a years-long partnership that included injury prevention researchers, a rural county health department and suicide prevention coalition, and a community advisory board (CAB) of 35 rural residents. Key principles of CBPR reflected in this project include: 1) viewing the rural community as a unit of identity with shared norms and values; 2) developing an intervention that builds on community strengths; 3) establishing collaborative and equitable relationships between academic and community partners; 4) co-learning and capacity building, such that partners learn from one another; 5) focus on a problem prioritized by the community; 6) balancing science and community action; 7) a commitment to dissemination and sustainability (Israel et al., 2018).

A series of focus groups and key informant interviews with 40 rural community members (Ewell Foster et al., 2023) guided intervention development, with community members identifying the messengers, message content, and delivery mechanisms that would be most acceptable, feasible, and likely to increase safe storage practices in their rural community. A number of key themes emerged from these community conversations, including the extent to which firearms were viewed as a “way of life” and family tradition as well as the influence of reasons for firearm ownership (especially hunting and protection) on family storage decisions. Use of respected firearms experts as messengers was preferred, along with a strong desire for locally derived data in educational information, and message content that reflected community pride in firearm safety and responsible ownership (Ewell Foster et al., 2023).

Store Safely is a multi-component strategy comprised of 1) a brief video featuring preferred and credible community messengers (elder members of a family; firearm safety instructor), 2) a fact sheet infographic utilizing local firearm injury and mortality data, 3) an interactive safe storage decision aid (Asarnow et al., 2021) focused on suicide prevention, and 4) downloadable resources including a home safety checklist and information about where to purchase and how to use various storage options (Project Child Safe, 2020). Designed as an online intervention, based on focus group participant preference to reduce access barriers, Store Safely uses both visual cultural tailoring (e.g., use of hunter’s orange and green), as well as content-tailoring (e.g., use of a father and grandfather describing the strong community value placed on ensuring youth are safe around firearms).

Influenced by Health Behavior Change Theories (Hayden, 2022), Motivational Interviewing (MI; Miller & Rose, 2009), Harm Reduction (Marlatt, 1996), and best practices in health communication and cultural tailoring (Palmer-Wackerly et al., 2014), Store Safely is designed to promote safe storage behavior change via mechanisms of action that include changes in attitudes, subjective norms, self-efficacy, and behavioral intentions (Ajzen & Fishbein, 1980; Hayden, 2022). (A figure depicting the intervention logic model is available as supplementary material). Principles of MI, including the emphasis on personal responsibility and autonomy, providing a menu of options, and use of a non-judgmental and collaborative tone, have been shown to be effective in reducing risky behaviors and promoting adaptive behaviors (Miller & Rose, 2009). Store Safely also reflects a harm reduction philosophy (Marlatt, 1996) which intentionally avoids all-or-none definitions of firearm safety. By “meeting people where they are,” harm reduction views risky behaviors dimensionally and encourages any steps in the right direction as markers of positive change (Marlatt, 1996).

The Current Study

Following best practices in implementation science (Proctor et al., 2011), the primary aims of this pilot study were to implement Store Safely in a rural community to assess feasibility, acceptability, and preliminary impact (Proctor et al., 2011). Feasibility was defined as the extent to which families agreed to participate in the study, accessed and engaged with the Store Safely website, and were open to sharing information about their firearm ownership and storage practices. Intervention acceptability was defined as family satisfaction ratings following engagement with Store Safely. Preliminary intervention impact was measured via self-reported 1) behavioral intentions to improve safe storage, 2) number of firearms stored locked and unloaded, and 3) harm reduction behaviors defined as additional steps a parent might take toward improving safety (e.g., home audits, establishing family safety rules, etc.). We hypothesized that engagement with Store Safely would be associated with 1) increases in behavioral intentions to store firearms safely, 2) improvements in locked/unloaded storage, and 3) increased parental engagement in harm reduction behaviors from baseline to follow-up.

Method

Participants

Eligible participants were adults residing in a rural region of the midwestern US (served by the study’s local health department partner) who kept at least one firearm in their home or on their home’s property and had at least one child under age 18 living at home. Individuals who were non-English speaking or unable to provide informed consent were ineligible. Recruitment occurred via the networks of the health department, local suicide prevention coalition, and community advisory board (CAB) using fliers and social media posts. Within a three-week period, 58 parents expressed interest in enrolling; of these, 6 were excluded (10%) as ineligible and 2 declined to participate (3%; see Figure 1), reflecting a 97% consent rate of those eligible.

Figure 1.

Consort Diagram

Note: N’s reflected in the consort diagram reflect individual parents, each from a unique family. Thus 58 parents from 58 unique families were assessed for eligibility; 45 parents from 45 unique families were allocated to intervention; and 43 parents from 43 unique families completed the follow-up. In two parent households, both parents were encouraged to participate in the intervention and complete surveys. The final sample, as reflected above, includes only one informant per household but reflects the father’s response when it was available.

To optimize participation from fathers (who our CAB suggested bore most responsibility for firearm storage decisions), all adults in the household were encouraged to participate. Due to a limited budget, the second adult was not directly incentivized. Adult #1 received a $25 gift card for each completed survey. Families with two parents completing surveys were entered into a lottery for an additional $100 gift card. In 33% of the 45 enrolled households, both parents completed the baseline survey and, in 12%, both parents completed the follow-up. Analyses presented below include only one informant per household but reflect the father’s response when it was available. To ensure a range of children’s developmental periods, a balanced recruitment strategy was used with 35.6% of the 45 enrolled participants reporting a child ages 6 months-3 years, 37.8% with a child ages 8–12, and 26.7% with a child ages 13–17; child age was used to eliminate the 5 families who were interested but could not be enrolled due to budget limitations.

Participants in the final sample (one informant per family; n=45, 35% male parent, 65% female parent; 98% White, 5% American Indian¹; 68% college graduates) ranged in age from 26 to 52 years (M = 37.88, SD = 6.14) with an average of 2.3 children at home. Most (92%) identified as a biological parent and 6.7% identified as a stepparent, with 83% married, 8.3% divorced, and 1.7% separated. Forty-three parents completed the 2- to 4-week follow-up survey (attrition rate of 5%). The rural region has been previously described (Ewell Foster et al., 2023) and is classified as rural according to US Census, Office of Management and Budget, and US Department of Agriculture criteria (Rural Health Information Hub, n.d.).

Procedure

Participants indicated interest in the study by either completing a brief online survey or contacting a study email address; they were contacted by phone to confirm eligibility and computer access, and for informed consent and enrollment. Participants were then provided with an individualized baseline survey link. After survey completion, participants received a link and password to the Store Safely website. At the website, participants clicked “Start” and proceeded through the intervention’s four steps. Step 1: video with credible messengers and tailored content; Step 2: locally derived statistics presented via tailored infographic; Step 3: Decision Aid Tool (Asarnow et al., 2021) modified to reflect a universal prevention approach; Step 4: a downloadable Family Firearm Storage Action Plan, which included a home safety checklist and space to record actionable steps towards safer storage. Participants marked a checkbox on the website to reflect completion of each component. Two to four weeks later, participants received the online follow-up survey. All procedures were approved by the Institutional Review Board.

Measures

At baseline, parents provided family demographic information including age, gender, race, ethnicity, education level, annual family income, marital status, and the number and ages of adults and children living in the home. Behavioral intentions to improve safe storage in the home were measured using a modified version of the Suicide Prevention Behavioral Likelihood Survey (Marino et al., 2018). This 7-item questionnaire employs Likert scale anchors ranging from 0 (I am not ready to do this/I have no interest in doing this) to 10 (I already did this) to indicate readiness to engage in firearm safety behaviors such as seeking information about safe storage options, purchasing safe storage equipment, and actually improving storage. Cronbach’s alpha was .91 at baseline. The 7 items were averaged, with possible scores ranging from 0 to 10. Higher scores reflect stronger behavioral intentions.

Firearm ownership and storage was assessed using items from the Firearm Safety in Children and Teens (FACTS) National Survey-Parent Edition (Sokol et al., 2021). Directions specified that parents were to consider “firearms that are kept anywhere in your home, apartment, garage, family vehicles, or other buildings like a barn or shed [but not] firearms kept on family properties not adjacent to your home (like hunting camp).” Firearms were defined as “guns that are in working order and capable of being fired. This includes pistols, revolvers, shotguns, and rifles, but does not include air guns, bb guns, start pistols, or paintball guns.” Families reported on the type (handgun vs long gun/rifle) and number of weapons owned, answering questions about how each firearm was stored. A continuous measure reflecting storage practices was calculated by summing across all firearms to create a count of the number of firearms that were stored 1) locked, 2) unloaded, and 3) unlocked and loaded (range 0–30).

Participants completed an online Qualtrics follow-up survey 2–4 weeks after the baseline, reporting whether they engaged with each component of the intervention (yes/no) and rating the acceptability of each component on a Likert scale (1=not at all to 5=extremely; e.g., “The video was useful”). Parents used the same scale to rate the extent to which Store Safely was culturally sensitive, with higher scores indicating more perceived cultural tailoring. Parents were also encouraged to provide open-ended feedback, which was analyzed descriptively. Behavioral intentions and storage practices were re-assessed using the measures described above. In addition, parents responded to one item querying whether they had made any changes to their storage (yes/no) and to describe the actions they took. Parents completed the Family Firearm Storage Behaviors Survey, which reflects input from the project’s CAB and focus groups (Ewell Foster et al., 2023) as well as modified items from the FACTS National Survey-Parent Edition (Sokol et al., 2021) and the Behavioral Likelihood Survey (Marino et al., 2018). Parents reported (yes/no) on their engagement in 7 harm reduction behaviors, including moving firearms to a location less accessible to children, preparatory actions toward purchasing safe storage equipment, and having conversations with children about safety and rules.

Data Analysis

Using a final sample of one adult per enrolled family, descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated to assess feasibility, acceptability, and preliminary impact of Store Safely. Paired-sample t-tests (two-tailed; p<.05) were used to examine changes in behavioral intentions to store safely, firearm safe storage, and engagement in harm reduction behaviors from baseline to follow-up. Effect sizes (Cohen’s d) were calculated when possible given the small sample size. Analyses were completed using SPSS v 28.

Results

Feasibility

Feasibility of Recruitment and Delivery Mechanism.

Recruitment of firearm-owning parents with children was highly feasible in this rural community, with the recruitment target reached within a 3-week period and a 97% consent rate of those who expressed interest. One third of participating families had both adults in the home complete baseline surveys, despite limited incentives, and 43/45 households (95.6%) were retained at follow-up. During recruitment, no participants were excluded due to lack of access to a computer or WIFI. Families were given contact information for technical support; however, no families requested assistance.

Feasibility of Assessment of Family Firearm Ownership and Storage Practices.

All families in the study confirmed ownership of at least one firearm. Most families (91%) were open to reporting specific details about their firearm ownership and storage via online survey following informed consent. Participants (n = 41; with n = 4 families leaving the item blank) reported storing an average of 7 (SD = 5.86) firearms on their property.

Engagement with Intervention.

Table 1 describes parents’ report of engagement with the Store Safely intervention, with 97.7% of participants reportedly engaging with all intervention components (i.e., video, infographic, decision aid tool, and home safety checklist).

Table 1.

Intervention Engagement and Acceptability Ratings (n = 43)

Intervention Component	n	%
Watched Video	42	97.7
Reviewed the Safety Infographic	43	100
Reviewed the Decision Aid Tool	43	100
Completed the Decision Aid Tool	37	86
Reviewed the Home Safety Checklist	43	100
Completed the Home Safety Checklist	37	86
Outcomes on Likert/Rating Scales	M	SD
The information and other materials on the website were useful (1–5)a	4.07	.80
I would recommend the website materials to other parents (1–5)a	4.21	.83
The website was sensitive to our culture (1–5)a	4.23	.78
Enough information was included to help families decide on ways to improve safe storage at home (0–1)b	.95	.21

^aItem measured using a 5-point Likert scale measuring level of agreement with the statement where 1 = Not at all, 2 = A little, 3 = Somewhat, 4 = Quite a bit, and 5 = Extremely.

^bDichotomous item measuring agreement with the statement where 0 = No and 1 = Yes.

Acceptability

Table 1 also describes parent ratings of the acceptability of Store Safely intervention content. 93% of parents described the amount of information provided in the intervention as “just right,” 84% agreed “quite a bit” or “extremely” that the intervention was culturally sensitive, and 84% reported that they would recommend the materials to other parents.

Preliminary Results of Intervention Impact

Behavioral Intentions.

Parents reported on their behavioral intentions to store firearms safely. Mean scores (possible range of 1–10) increased slightly from pre-test (M = 6.86, SD = 2.71) to follow-up (M = 7.03, SD = 2.18) following engagement with the intervention but the change was non-significant (t(40) = −0.38, p = .704; Cohen’s d = 0.06).

Firearm Safe Storage.

40% of families self-reported making an improvement to their firearm safe storage. Parents reported a significant increase (t(37) = −2.08, p = .045; Cohen’s d = 0.34) in number of firearms stored locked from pre-test (M = 6.45, SD = 7.07) to follow-up (M = 7.63, SD = 8.59). There was a non-significant increase in the number of firearms stored unloaded (t(37) = −1.57, p= .126; Cohen’s d = 0.25) from pre-test (M = 6.97, SD = 6.51) to follow-up (M = 7.82, SD = 8.36). The base rate of firearms reportedly stored unlocked and loaded was low in this sample (n = 12); 28% reported an unlocked and loaded firearm accessible some of the time (n = 2), most of the time (n = 2), or all of the time n = 8). There was no significant change (t(38) = .57, p = .570; Cohen’s d = 0.09) in firearms stored unlocked and loaded between pre-test (M = .10, SD = .31) and follow-up (M = .08, SD = .27).

Harm Reduction Behaviors.

As depicted in Table 2, all parents who participated in the follow-up survey reported engaging in at least 1 harm reduction behavior related to safe storage with an average of 2.81 behaviors per participant.

Table 2.

Harm Reduction Behaviors Toward Safe Storage (n =43)

	n	%
Discussed firearm safety with other adults in home	38	88.4
Discussed firearm safety with children in home	29	67.4
Audited location(s) where firearm(s) kept	32	74.4
Purchased or obtained safe storage equipment	9	20.9
Trigger lock	4	9.3
Cable lock	1	2.2
Traditional gun safe or lock box	4	9.3
Made firearms less accessible to children	4	9.3
Moved firearm(s) to a locked room or closet	1	2.3
Hid 1 or more firearms	4	9.3
Made ammunition less accessible to children	7	16.3
Removed ammunition from 1 or more firearms	2	4.7
Moved ammunition to another location	4	9.3
Hid ammunition	2	4.7

Discussion

This pilot study examined the feasibility, acceptability, and preliminary impact of Store Safely, an online multi-component prevention strategy designed with a community-based participatory approach and tailored for rural firearm-owning families. Results from a sample of 45 parents with children ranging from infancy through adolescence suggest that Store Safely is both feasible and acceptable. There was strong interest in participating evidenced by the speed of recruitment and a 97% consent rate. No families were excluded due to lack of computer or Wi-Fi access and no technological difficulties reported. All families acknowledged owning at least one firearm and 91% provided details on the types of firearms owned, their purpose, and their storage, suggesting measurement feasibility. Of the 43 parents retained at follow-up, 97.7% reported engaging with all intervention components and 86% completed the downloadable home safety checklist. Participants described the intervention as “clear” and “easy to navigate.”

Given high rates of firearm ownership in rural areas (Parker et al., 2017), alarming increases in youth firearm suicides (Goldstick et al., 2021), and data suggesting that safe storage can greatly reduce risk (Grossman et al., 2005), the development, evaluation, and dissemination of feasible and culturally acceptable safe storage prevention strategies are a high priority. In a recent epidemiological sample, over 70% of youth suicides occurred on a first attempt and three quarters involved a firearm (McKean et al., 2018). Understanding that many youth attempt suicide without parents or health providers being aware of their distress (Ahmedani et al., 2014) and acknowledging the fatality rates associated firearm suicide attempts (Conner et al., 2019), the urgent need for primary prevention focused on safe firearm storage is clear.

Across a range of issues, culturally tailored communications have been shown to lead to better engagement with information and better decision-making (Palmer-Wackerly et al., 2014). With respect to firearm safety, messaging may be more acceptable if it reflects community norms, values, and beliefs. In a recent study, many firearm owners reported believing that keeping firearms loaded and accessible for self-defense makes their homes safer (Salhi et al., 2020). Recommendations for messaging in the presence of “guns are safe” beliefs include focusing less on statistical associations between firearm ownership and risk, and more on flexibility and safety (Simonetti & Rowhani-Rahbar, 2019). Similar ideas were shared in the focus groups that preceded the development of Store Safely, with participants stating that they would “check out” if it was implied that their ownership of firearms made their home unsafe for their children (Ewell Foster et al., 2023). Building upon community input (Ewell Foster et al., 2023), and using a CBPR emphasis on community strengths, Store Safely’s messaging emphasizes community pride in keeping children safe around firearms and reflects common community reasons for ownership (hunting, sport, protection). Within Step 1 of Store Safely, a firearm safety instructor reviews a variety of storage options (safes, cable locks, etc.) along with the pros and cons of each relative to the purpose of the firearm. In the pilot, 84% of participants rated the website as culturally sensitive and would recommend the materials to other parents. One participant noted that engaging with Store Safely felt like “it could have been my neighbor talking to me.” Given the cultural significance of firearms in many regions of the US, it is unlikely that a “one size fits all” approach to safe storage will be effective, pointing to a need to further study the types of messengers and message content that are acceptable and impactful in different communities of firearm owners (Celinska, 2007; Simonetti & Rowhani-Rahbar, 2019).

Although not powered to detect an effect, results of this small pilot found a significant increase in the self-reported number of locked firearms from pre-test to follow-up, but no significant change in number of firearms stored unloaded or unlocked and loaded. Using The Family Firearm Storage Behaviors Survey (available upon request), 100% of participants reported engaging in at least one harm reduction step toward improving firearm safe storage, such as discussing firearm safety with other adults or children in the home; purchasing gun locks, safes, or lockboxes; separating ammunition from weapons; auditing the safety of current storage practices; or relocating firearms to a location harder to access by their children. Celebrating small steps to improve safety is consistent with the harm reduction philosophy that informed the development of Store Safely. Improving measurement of firearm storage behavior has been identified as a critical need in the field (Ngo et al., 2019) in order to move beyond measures of behavioral intentions (e.g., Marino et al., 2018) or more simplistic categorization of homes as “safe” or “unsafe” or firearms as “locked” or “unlocked” (Simonetti & Rowhani-Rahbar, 2019). Such measures are not nuanced enough for rural areas where families own a multitude of firearms for different purposes (Ewell Foster et al., 2023) and may not be sensitive to potentially important behavioral changes made in response to safety interventions. A contribution of this study is the use of multiple measures of storage behavior, including a continuous measure of the number of firearms stored locked, stored unloaded, and stored unlocked and loaded in each home. Future research is needed to continue to refine theoretically driven and community-engaged assessment of a range of possible behavioral outcomes of firearm safe storage interventions in the family context and to determine the extent to which small harm reduction steps may enhance children’s safety or lead to actual storage improvements.

Limitations

This study has several limitations, including a small sample of 45 parents recruited in one county in an upper Midwest region of the United States. It is unclear to what extent messaging developed for this community would generalize to or need to be modified for rural areas in different parts of the US. Because of the wide range of youth ages in the sample, we cannot determine how developmental period may impact parent storage decisions and whether there may be key windows for parents to receive firearm safety education, such as when children are young and parents are highly motivated to “baby proof” their homes. The lack of a strong evidence-base with respect to firearm storage measurement in families who own multiple firearms is also a limitation, as well as the fact that some families in our sample entered the study already storing all firearms in the safest manner possible, creating a potential ceiling effect. Finally, the lack of a control group and randomized assignment in addition to the brief 2–4-week follow-up window are methodological limitations of the current study.

Conclusion

Store Safely, a culturally tailored intervention designed in close partnership with the community may have promise in terms of its acceptability, feasibility and association with parents’ safety intentions and behaviors. Given the growing rates of firearm injury and death among US youth, the development of firearm injury prevention strategies is a public health priority.

Public Health Significance Statement:

This study is important because firearms are now the leading cause of death for children and adolescents in the US. Although safe storage (locking firearms and ammunition separately) has been shown to reduce the risk of injury, many families have unsecured weapons in their home. Developing interventions in collaboration with the community may increase their acceptability. This study demonstrates that Store Safely was acceptable to rural families and had promising preliminary results, with 40% of parents taking steps to improve the safety of their firearm storage practices.