This case study was developed with funding and support from the Implementation Research Institute at Washington University in St. Louis.
Firearms are the second leading cause of death for youth in the United States, with fatal firearm injuries on the rise since 2013.1,2 A national survey found that at least one firearm is present in 42% of U.S. households,3 and firearm sales have surged since the start of the COVID-19 pandemic.4 Despite recommendations from the American Academy of Pediatrics5 and other leading organizations6 that firearms be stored locked, unloaded, and separately from ammunition, an estimated 4.6 million children live in homes with at least one firearm stored unlocked and loaded.7 Simulation research has found that even a modest increase in secure firearm storage could prevent as many as 32% of youth firearm deaths due to suicide and accidents.8 The availability of firearms, coupled with their lethality, amplifies the importance of firearm storage programs directed to parents and caregivers of youth.
To increase implementation of secure firearm storage interventions, a team of experts from the University of Pennsylvania, Henry Ford Health System, Baylor Scott & White Health, and Kaiser Permanente Colorado interviewed pediatric clinicians, health system leaders, firearm safety experts, and parents who own firearms about needed changes to an existing evidence-based practice for safe firearm promotion, Safety Check.9-11 The team also asked about implementation barriers and preferred implementation strategies.
Based on their input, they adapted the original program and renamed it S.A.F.E. Firearm. The new program kept Safety Check’s core components in place: (1) brief counseling by pediatric primary care clinicians on firearm storage and (2) offering free firearm cable locks to all parents, while also making several changes. S.A.F.E. Firearm expanded the age range (i.e., parents of children ages 5-17) and changed the entry point of the counseling conversation from an identified concern by parents to universal counseling for all parents. Parents are not asked about firearm ownership status, and self-disclosure about ownership is not documented in the electronic health record (EHR). Parents are also offered additional resources (e.g., a pamphlet describing alternative storage options).
The next phase of the research is to test the most effective way to implement S.A.F.E. Firearm among 30 clinics, 158 clinicians, and 48,475 youth in two health systems in Michigan and Colorado. Half of the clinics will be randomized to receive EHR reminders (Nudge); the other half will receive Nudge plus one year of facilitation to target clinician and organizational implementation barriers (Nudge+).12
Rinad Beidas, PhD (primary contact), Professor of Psychiatry, Medical Ethics and Health Policy, and Medicine; Director, Penn Medicine Nudge Unit; Founder and Director, Penn Implementation Science Center at the Leonard Davis Institute of Health Economics
Perelman School of Medicine at the University of Pennsylvania
ASPIRE Team (colleagues from the University of Pennsylvania, Henry Ford Health System, and Kaiser Permanente Colorado)
Funded by a National Institute of Mental Health, National Institutes of Health R01 grant
Check out the Impact Profile, a one-page summary of project impact.
Learn more about the project
- S.A.F.E. Firearm website
- Team Awarded R01 to Study Gun-Safe Interventions in Pediatric Primary Care (UPenn Center for Health Incentives & Behavioral Economics)
- Safe firearm storage will save lives as gun demand surges during COVID | Opinion (Philadelphia Inquirer)
Pediatric clinicians are valuable partners in sharing information about firearm safety, and parents are comfortable receiving this information from them. This study can improve implementation of firearm storage interventions and identify the best approach to national implementation, with the ultimate goal of saving the lives of American youth. So far, the project has gathered stakeholder input about implementation and amplified the voice of firearm stakeholders such as parents who own firearms, firearm safety course instructors, members of law enforcement, and firearm retailers, who are not always heard in the research process.9,10
Increasing secure firearm storage also has implications for minority health disparities. While the overall suicide rate in the United States has been decreasing in recent years, the suicide rate for Black populations has increased.13 The team will study any potential disparities that might emerge in implementation as part of work led by fellow, Dr. Katie Hoskins, particularly for Black or African American families.
Demonstrated benefits are those that have been observed and are verifiable. Potential benefits are those logically expected with moderate to high confidence.
The team will provide two large U.S. health systems with interventions to promote firearm counseling by pediatricians. Potential.
The project will identify the implementation strategies that are most effective at increasing the delivery of firearm counseling. Potential.
S.A.F.E. Firearm will increase the use of evidence-based approaches to talk with parents about secure firearm storage in two large health systems. Potential.
Increasing secure firearm storage will reduce youth suicide and childhood injury and death due to firearms. Potential.
This project will help understand the most cost-effective way to implement S.A.F.E. Firearm in health systems. Potential.
A lead researcher on the project, Dr. Rinad Beidas, presented at a National Academies workshop on Health System Interventions to Prevent Firearm Injuries and Fatalities. The workshop proceedings were published by the National Academies in 2019.14 Demonstrated.
Several states are considering adopting legislation requiring training for clinicians in counseling families on secure firearm storage. Potential.
This research has community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.
Community: The next phase of the project (known as the ASPIRE trial) will serve two large health systems in Michigan and Colorado. The project will improve the quality of pediatric primary care for nearly 50,000 youth by increasing the implementation of evidence-based approaches to talk with parents about secure firearm storage. The trial will also provide cable locks, which have the potential to prevent firearm injury and mortality, including suicide. By identifying and disseminating the implementation strategies that are most effective at increasing the delivery of firearm counseling, the project has the potential to improve delivery methods at additional health systems. Ultimately, increasing secure firearm storage will reduce youth suicide and childhood injury and death due to firearms.
Economic: The ASPIRE trial will help the research team understand the most cost-effective way to implement S.A.F.E. Firearm and other, similar sensitive interventions in health systems (i.e., nudging clinicians using the electronic health record, or nudging plus ongoing facilitation such as support and problem-solving).
Policy: Half of the states in the United States have Child Access Prevention laws that prevent pediatric unauthorized access to firearms.15 Several states are considering adopting legislation requiring training for pediatric clinicians to counsel families on secure firearm storage, informed by findings from the original Safety Check intervention. The research team also presented early research from Safety Check during a workshop convened by the National Academies to inform future research priorities on health system interventions to prevent firearm injuries and deaths. The workshop proceedings were published in 2019.14
Partnership has been the key ingredient for this work to be possible. Centering and amplifying the voice of all stakeholders involved allowed the project team to ensure an implementable intervention supported by acceptable and feasible implementation strategies. Partnerships with the health systems involved allow us to deploy and evaluate the approach. This is truly work representing hundreds of people – without whom, the work would not be possible.
- Centers for Disease Control and Prevention. About compressed mortality, 1999-2019. CDC WONDER website. Accessed October 21, 2021.
- Centers for Disease Control and Prevention. About underlying cause of death, 1999-2019. CDC WONDER website. Accessed October 21, 2021.
- Guns. Gallup website. Accessed October 13, 2021.
- Collins K, Yaffe-Bellany D. About 2 million guns were sold in the US as virus fears spread. The New York Times. Published April 1, 2020. Accessed October 20, 2021.
- Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416-e1423. doi:10.1542/peds.2012-2481
- Parents & Gun Owners. Project ChildSafe website. Accessed October 20, 2021.
- Azrael D, Cohen J, Salhi C, Miller M. Firearm Storage in Gun-Owning Households with Children: Results of a 2015 National Survey. J Urban Health Bull N Y Acad Med. 2018;95(3):295-304. doi:10.1007/s11524-018-0261-7
- Monuteaux MC, Azrael D, Miller M. Association of Increased Safe Household Firearm Storage With Firearm Suicide and Unintentional Death Among US Youths. JAMA Pediatr. 2019;173(7):657-662. doi:10.1001/jamapediatrics.2019.1078
- Benjamin Wolk C, Van Pelt AE, Jager-Hyman S, et al. Stakeholder Perspectives on implementing a firearm safety intervention in pediatric primary care as a universal suicide prevention strategy: a qualitative study. JAMA Netw Open. 2018;1(7):e185309. doi:10.1001/jamanetworkopen.2018.5309
- Jager-Hyman S, Benjamin Wolk C, Ahmedani BK, et al. Perspectives from firearm stakeholders on firearm safety promotion in pediatric primary care as a suicide prevention strategy: a qualitative study. J Behav Med. 2019;42(4):691-701. doi:10.1007/s10865-019-00074-9
- Barkin SL, Finch SA, Ip EH, et al. Is Office-Based Counseling About Media Use, Timeouts, and Firearm Storage Effective? Results From a Cluster-Randomized, Controlled Trial. Pediatrics. 2008;122(1):e15-e25. doi:10.1542/peds.2007-2611
- Ross M. Team Awarded R01 to Study Gun-Safe Interventions in Pediatric Primary Care. Center for Health Incentives and Behavioral Economics website. Published September 11, 2020. Accessed September 13, 2021.
- Black Populations. Suicide Prevention Resource Center at the University of Oklahoma Health Sciences Center website. Accessed September 13, 2021.
- National Academies of Sciences, Engineering, and Medicine. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. (Alper J, French M, Wojtowicz A, eds.). The National Academies Press; 2019. doi:10.17226/25354
- Child Access Prevention. Giffords Law Center website. Accessed September 13, 2021.