Pilot of an Asynchronous Web-Based Video Curriculum to Improve Firearm Safety Counseling by Pediatric Residents

Firearms are the second leading cause of death among children and adolescents.¹ One in three US households contains at least one firearm and among these households with children, ~20% store firearms unsafely, increasing risk for firearm injury.² The American Academy of Pediatrics encourages physician counseling on firearm safe storage as an effective injury prevention measure.³

While brief physician-counseling interventions can increase safe storage practices,⁴ a minority of pediatricians regularly counsel on safe firearm storage/temporary removal during high-risk periods at well-child visits (WCEs) (23% and 16%, respectively).⁵ Screening/counseling barriers include time constraints, concerns about effectiveness of screening/counseling, and inadequate training in counseling methods and technical aspects of firearm injury prevention (i.e., storage/locking mechanisms).⁶ Pediatricians with higher perceived self-efficacy in discussing such techniques are more likely to discuss these topics with families.⁵

There is a need to develop comprehensive firearm injury prevention education for residents.⁷ Many programs do not provide this training.⁸ One previously published curriculum has been developed/tested⁹; however, this was implemented in an urban residency program where baseline knowledge was high. Many suburban residency programs have less exposure to pediatric firearm violence/injury, and residents may benefit from more comprehensive training.

Here, we describe a web-based asynchronous curriculum that includes firearm injury epidemiology, safe storage, and injury prevention counseling to improve residents’ ability to provide firearm safety anticipatory guidance during WCEs.

Educational Approach/Innovation

Curriculum Design

Curriculum development utilized an adapted-Kerns approach.¹⁰ A 2014 baseline needs assessment survey of University of Michigan pediatric residents found <20% always asked about firearms. Literature review and opinion from injury prevention experts guided development of educational goals/objectives using adult learning principles based on the conceptual framework of Bandura’s Social Cognitive Theory.¹¹ Educators created web-based video modules (Figure, www.childfirearmsafety.org) using free recording studios and Camtasia software. Web-based design allowed integration into residents’ required Pediatric Community Health (PCH) rotation and asynchronous review, on residents’ own time, in an online education platform (Canvas). Video format facilitated a demonstration of firearms and their safe storage—an option not allowable in person on hospital campus due to safety restrictions and difficult to replicate at an off-site location for each resident. Additional module content included epidemiology, medical record documentation recommendations and clinical scenarios demonstrating motivational interviewing techniques giving residents an opportunity to observe and emulate counseling techniques. A handout provided residents a relevant takeaway.

Figure.

Overview of pediatric firearm injury prevention curriculum.

Setting and Participantstaggedend

Pediatric residents completed the curriculum once within their PCH rotation, occurring in the second or third year of training at a large Michigan tertiary hospital system. Medicine-pediatric residents completed the curriculum in their second year PCH rotation.

Measures

Primary outcome measures included self-efficacy to provide firearms safety behavioral counseling, confidence providing technical education about storage techniques, and knowledge about access to written resources. This three-item scale (α = .83) was adapted from standard measures.^12,13 A 5-item Likert response scale (1 = Not at all; 5 = Extremely) was used for each item and mean scores were used in analyses. These were assessed on immediate post-test and 6-month follow-up surveys.

At baseline and 6-month post-training, participants self-reported frequency of providing firearm safety counseling on a 5-point Likert scale (1 = Never; 5 = Always). Counseling barriers were assessed; response options were adopted from prior qualitative literature.^6,8

Participants completed a post-test immediately following the modules. Data on completion time, curriculum quality (1 = Very Poor; 5 = Excellent), and likelihood of utilization of training in future practice (1 = Strongly Disagree; 5 = Strongly Agree) were collected. Additional data collected included household exposure to firearms in childhood, firearm ownership, and belief that physicians should ask about and provide safe storage counseling (1 = Strongly Disagree; 5 = Strongly Agree).

Chart reviews were conducted by research assistants (RAs), abstracting data from 25 consecutive WCEs per resident preceding/following curriculum completion. Data on resident documentation of family firearm ownership and/or provision of safety counseling were abstracted. The project manager trained RAs and performed spot checks to assure quality/fidelity. The number of charts (out of 25) including documentation of screening/counseling was recorded and mean number of charts was used in analyses.

Analysis

We evaluated implementation/educational outcomes, including resident participation, curricular satisfaction, and learning using Moore’s model of assessment.¹⁴ Learning was assessed using self-reported self-efficacy/confidence, knowledge, and barrier measures (Appendix A). Behavior change was assessed with chart review of documented screening/counseling from WCEs. Descriptive statistics were utilized to characterize the sample and immediate post-training measures. Mean scores for the primary outcome measures at baseline, immediately after completion of curriculum and 6 months post-training were compared using standard t tests. Mean scores for behavior change measures at baseline and 6 months post-training were compared using standard t tests. The study was IRB exempt as quality improvement work.

Results

Seventy-one of 77 assigned residents (92%) completed the curriculum (n = 38 [2016]; n = 33 [2017]), including 11 medicine-pediatrics residents and 60 pediatric residents. All of these residents completed the baseline survey and post-test, with 76% completing the 6-month post-training survey. Among those completing the curriculum (n = 71), 93% (n = 65) practiced in suburban clinics. Seven percent (n = 5) personally owned firearms with 27% (n = 19) raised in homes with firearms.

At baseline, most residents (94%, n = 67) believed pediatricians should screen/provide anticipatory guidance on firearm safety; only 30% (n = 21) reported always doing so. Key barriers reported were lack of knowledge/confidence (42%, n = 30). Post-test results demonstrated a majority completion time of 1 to 3 hours (82%). Most rated the module as good/excellent (99%) and strongly agreed/agreed (96%) higher likelihood of discussing firearm safety with families.

Among those completing training, mean scores for self efficacy to provide counseling (2.7 vs 3.8; P < .001), confidence providing technical education about safe storage techniques (2.5 vs 4.0; P < .001), and knowledge about access to written firearm safety resources (2.3 vs 4.3; P < .001) increased from the baseline to immediate postcurriculum assessment. Similar findings were seen on 6-month follow up survey with increases in mean scores from baseline for self-efficacy (2.7 vs 3.5; P < .001), confidence (2.5 vs 3.5; P < .001), and knowledge (2.3 vs 3.6; P < .001). The proportion of residents reporting lack of confidence (44% vs 18%, P < .05) and knowledge (39% vs 8%, P < .001) as barriers also decreased at 6-months; 63% continued to identify time as a barrier. Among 25 charts per resident reviewed pre- and post-training, the mean number with documented efforts to screen/counsel families about firearm safety increased (Mean [SD]: 7.6 (6.1) vs 8.7 (6.3), P = .38), but did not reach statistical significance.

Discussion/Next Steps

Our web-based asynchronous training on firearm safety demonstrated promising increases in behavioral counseling self-efficacy, technical knowledge about safe storage, and decreases in perceived barriers to counseling. The curriculum addresses a need for firearm safety educational programs for pediatric residents. While this training improves resident self-efficacy, future work should address the potential need for additional training such as observed practice to reinforce concepts. Web-based platform uniquely allowed demonstration of firearms and their safe storage options not allowable in person due to hospital safety restrictions. This pilot study was limited to one suburban residency program, yet this is likely a similar sample to other pediatric training programs. Evidence from other investigators suggests injury prevention and violence educational programs for pediatricians lead to reported changes in counseling efforts;⁴ however, our study did not have enough power to measure behavioral outcomes. Future large-scale, fully powered trials are still required to demonstrate efficacy. Our curriculum suggests a promising method for providing physician education on such interventions. Future work should focus on fully testing this training within an implementation framework to evaluate efficacy increasing behavioral counseling practices, and to identify mechanisms for addressing implementation challenges, including individual and organizational barriers.

What’s New.

Pediatric residents report lack of confidence in providing firearm safety anticipatory guidance. A self-paced online curriculum, including video demonstration of firearms, safe storage options, and counseling methods for families improved resident self-efficacy, confidence, and knowledge surrounding firearm injury prevention counseling.