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Firearm storage practices in households with children: A survey of community-based firearm safety event participants
Journal Pre-proof Firearm storage practices in households with children: A survey of community-based firearm safety event participants
Aisha King, Joseph Simonetti, Elizabeth Bennett, Cassie Simeona, Lauren Stanek, Alison C. Roxby, Ali Rowhani-Rahbar PII:
S0091-7435(19)30435-9
DOI:
https://doi.org/10.1016/j.ypmed.2019.105952
Reference:
YPMED 105952
To appear in:
Preventive Medicine
Received date:
2 July 2019
Revised date:
5 October 2019
Accepted date:
30 November 2019
Please cite this article as: A. King, J. Simonetti, E. Bennett, et al., Firearm storage practices in households with children: A survey of community-based firearm safety event participants, Preventive Medicine(2019), https://doi.org/10.1016/j.ypmed.2019.105952
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof Full Title: Firearm storage practices in households with children: A survey of community-based firearm safety event participants Authors: Aisha King,a* Joseph Simonetti, MD, MPH,b,c Elizabeth Bennett, MPH, MCHES,d,e, Cassie Simeona,d MPH, Lauren Stanek,d Alison C. Roxby, MD, MPH,a,f,g Ali Rowhani-Rahbar, MD, MPH, PhDf,h,i Affiliations:
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a: Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA b: Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO c: Rocky Mountain Mental Illness Research, Education, and Clinical Center, Veterans Health Administration, Aurora, CO d: Seattle Children’s, Seattle, Washington, USA e: Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA f: Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA g: Department of Medicine, University of Washington, Seattle, Washington, USA h: Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington, USA i: Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
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*Corresponding author: Aisha King; Department of Global Health, University of Washington, Harris Hydraulics Laboratory, Box 357965; Phone: 484-995-1273; Email: [email protected]
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Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to disclose.
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Abstract word count: 242/250 Revised Manuscript word count: 3030/3500 Number of Tables/Figures: 3/5 Number of References: 38/40 Article Type: Research Paper Corresponding Author’s Organization: University of Washington, Seattle Keywords: prevention & control; intervention; injury prevention; firearm
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Abstract
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Safe firearm storage is associated with lower risk of unintentional and intentionally self-inflicted firearm injuries among children and adolescents. Ten community-based firearm safety events were conducted across Washington state from 2015-2018. We sought to describe characteristics of event participants and assess whether presence and age of children in the household were associated with household firearm locking practices. We assessed demographic characteristics and baseline firearm storage behaviors of participants using a 13-item survey. Multivariable Poisson regression models were used to estimate prevalence ratios (PR) and corresponding confidence intervals (CI) for the association of presence and age of children in households with prevalence of storing a household firearm unlocked. Of 2,956 participants, 58.3% were male and 57.8% lived with an individual under 18 years. Among the 89.8% participants living with firearms, 40.1% stored at least one firearm unlocked and 39.1% stored at least one firearm loaded. In adjusted analyses, there was no statistically significant difference in prevalence of storing a household firearm unlocked between those living with no children (reference group) and those living with a child <11 years (PR=0.91; 95% CI: 0.80,1.04), or a child aged 11-18 years (PR=0.94; 95% CI: 0.81,1.09). A high proportion of participants stored a firearm unlocked or loaded at home and neither living with young children nor adolescents was associated with safe locking practices. In comparison with firearm safety interventions conducted in clinic settings, a majority of the participants in these community-based interventions were male and owned firearms.
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Journal Pre-proof INTRODUCTION Approximately 15,000 children and adolescents aged 18 years or younger were injured or killed by firearms in the United States (U.S.) in 2017.(“Web-based Injury Statistics Query and Reporting System (WISQARS,” n.d.) The presence of a firearm in the home is an independent risk factor for suicide and unintentional firearm death and injury among children.(Anglemyer et al., 2014; Grossman DC et al., 2005; Miller et al., 2013; Wiebe, 2003) Almost 90% of firearm-related fatalities of young children (0-14 years) occur in the home,(Hemenway and Solnick, 2015) and a majority of all unintentional, firearmrelated child and adolescent (0-18 years) fatalities involve a firearm found in the home.(Grossman and
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Reay, 1999) A 2005 study found that storing household firearms unloaded (as opposed to loaded) or locked (as opposed to unlocked) was associated with a respective 70% and 73% reduction in risk of
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unintentional and self-inflicted firearm injuries among individuals under 20 years of age.(Grossman DC et al., 2005) Ecologic studies have also shown that rates of unintentional firearm injuries are higher in states
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where firearm owners are more likely to store their firearms loaded, or loaded and unlocked.(Miller et al.,
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2005) Some estimates suggest that safe firearm storage could prevent 6-32% of all unintentional and intentionally self-inflicted firearm deaths among U.S. youths aged 0-19 years.(Monuteaux et al., 2019)
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However, of the approximately 22-30% of U.S. adults who report owning a firearm, more than one-half report that they keep at least one household firearm unlocked, loaded, or both.(Crifasi et al., 2018;
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Deborah Azrael et al., 2017; Kalesan et al., 2016; Parker et al., 2017) In 2015, approximately 4.6 million U.S. children resided in a household with an unlocked and loaded firearm; a nearly 3-fold increase from
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2002.(Azrael et al., 2018; Okoro et al., 2005)
Improving our understanding of factors associated with firearm storage practices is critical for
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informing firearm-related policies and interventions. A key question is whether firearm storage practices vary based on the presence and age of children residing in the home. Several population-level survey studies have found that adults living in households with children are more likely to report safe firearm storage practices than those in households with no children present.(Crifasi et al., 2018; Okoro et al., 2005; Schuster et al., 2000) Surveys from the early 2000s also found that, among individuals residing in households with both firearms and children, firearms are more likely to be stored safely if children in the home are under the age of 13 rather than 13 and older.(Azrael et al., 2000; Johnson et al., 2006; Schuster et al., 2000) In comparison with these findings, investigators assessing firearm storage practices among participants of a community-based firearm safety intervention in 2001 found that, prior to the intervention, the presence of children in the home was associated with less safe storage practices among participants.(Coyne-Beasley et al., 2001) These findings raise a question as to whether the storage
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Journal Pre-proof practices of those who elect to attend firearm safety events might differ from those reported by respondents to population-level surveys. Another important question for those aiming to promote firearm safety is how best to reach different populations. Most clinic-based firearm safety interventions have promoted firearm safety within the context of pediatric injury prevention and in pediatric or family practice settings.(Rowhani-Rahbar et al., 2018) As a majority of parents or guardians who attend such visits are female,(Barkin et al., 2008; Carbone et al., 2005; Garbutt et al., 2016; Oatis et al., 1999) these interventions may overlook important populations. A majority of U.S. firearm owners are male, and males in firearm-owning households are
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more likely to be responsible for making decisions about firearm storage practices.(Azrael et al., 2000; Coyne-Beasley, 2005) Some patients and parents may also be reluctant to discuss firearm safety during
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clinical encounters.(Betz et al., 2016) Community-based interventions may have the potential to reach distinct populations and may be helpful in reaching firearm owners who are less likely to be encountered
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or engage in firearm-related discussions in clinical settings. However, few effective community-based interventions have been reported in the literature.(Rowhani-Rahbar et al., 2016; Simonetti et al., 2017)
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Those interventions enrolled small numbers of participants (40-255), which limits our ability to study
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how these participants may differ from those represented in population-based studies or clinic-based interventions.
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Community-based firearm safety interventions are an important component of a multi-faceted, public health approach to reducing firearm injuries in the U.S. As such, it is important to improve our understanding of characteristics of individuals who attend such events and factors that may influence their
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firearm storage practices. This information can be used to tailor intervention content, improve
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effectiveness, and reach potentially high-risk populations. In this study, which includes data from nearly 3,000 participants in 10 community-based firearm safety events occurring in Washington state from 20152018, we sought to [1] characterize the sociodemographic characteristics and firearm safety practices of event participants; and [2] assess whether the presence and age of children in the household are associated with firearm storage practices. METHODS Study design We conducted a cross-sectional study using self-administered surveys of participants at 10 communitybased firearm safety events held across Washington state from 2015 to 2018. All participants were 18 years of age or older, spoke English or Spanish, and signed a liability release form necessary for event participation.
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Journal Pre-proof Firearm safety events Event sites were chosen with the intention of reaching communities across Washington State and were held in large urban areas, smaller urban or suburban areas, and cities in rural areas. Events were held in large sporting goods stores that sold firearms and safe storage devices. Event promotion was identical across sites. Additional information on event locations and urbanicity can be found in the Appendix (Table A1). Participants were recruited using print and digital placements in local newspapers, radio, social media posts, and printed and electronic flyers. Recruitment materials emphasized learning about firearm safety and focused on households where children and teenagers spend time. Materials and an
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event planning toolkit can be found online at https://www.seattlechildrens.org/health-safety/keeping-kidshealthy/prevention/gun-safety.
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All events were conducted uniformly. Participants received counseling on safe firearm storage, training on and practice with the proper use of storage devices, and their choice of a free firearm lockbox
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or trigger lock. Event materials were developed using principles of social marketing and the theory of
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reasoned action and were designed to increase awareness and action around the safe storage of firearms to reduce child and youth firearm injuries. Safety messaging emphasized keeping children and families safe
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using “triple safe storage” – storing firearms unloaded and locked, with ammunition stored separately in a locked place. Event details have been further described in a previous evaluation of the
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intervention.(Simonetti et al., 2017) Data collection
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Prior to training and receiving a safety device, participants completed a 13-item voluntary, selfadministered survey. The survey included multiple choice and open-ended items assessing
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sociodemographic characteristics (including presence and age of children in the home), current and intended firearm and ammunition storage practices, feedback on event location and promotion methods, and reason(s) for wanting a storage device. Co-investigators JS, EB, and ARR developed the survey, which was piloted for readability, acceptability, and brevity (given the short time period available for data collection during events). See Appendix for the full questionnaire. Statistical analysis We described the sociodemographic characteristics of respondents overall and by firearm ownership and storage practices. We compared sociodemographic characteristics between those who preferred to receive the firearm lockbox and those who received a trigger lock. Storage practices were categorized in the following manner, consistent with the previous evaluation of this intervention(Simonetti et al., 2017): firearms stored locked (all, some, none), firearms stored loaded (all, some, none), and ammunition stored 5
Journal Pre-proof locked (all, some, none). A composite variable was constructed to measure triple safe storage: all firearms locked, no firearms loaded, and all ammunition locked (yes/no). In multivariable analyses, we classified the exposure of ‘presence of children in the household’ into three mutually exclusive groups: (1) no children (reference group), (2) at least one child aged 10 or younger (including households in which older children were present), and (3) at least one child aged 11 or older and no children aged 10 or younger. We defined firearm locking practices as (1) all household firearms are locked or (2) at least one household firearm is unlocked. Among firearm-owning households, we conducted Poisson regression models to obtain prevalence ratios (PRs) and 95% confidence intervals
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(CIs) to compare the prevalence of having at least one unlocked firearm by presence and age of a child in the household. We reported the crude prevalence ratio and the prevalence ratio adjusted for a priori-
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selected covariates of age and gender of the participants. Covariates were selected based on literature review of prior studies, which have consistently demonstrated gender- and age-based differences in
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likelihood of firearm ownership and reporting of firearm storage practices.(Azrael et al., 2000; Crifasi et al., 2018; Wolfson et al., 2018) The survey used in this research was approved by Seattle Children’s
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Institutional Review Board. We conducted analyses with Stata Release 15.1 (StataCorp LP).
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RESULTS Respondent characteristics
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Of the 3,121 participants, 2,956 (94.7%) completed the survey (mean age = 43.6 years, range = 18 – 88 years). A majority of respondents were male (58.3%), lived with a spouse or significant other (70.1%),
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and lived with at least one child and/or adolescent in the household (57.9%). Additional household statistics can be found in the Appendix (Table A2). Nine out of 10 respondents lived with at least one
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firearm in the household. The most common reasons for wanting a safety device were overall firearm safety (56.9%) and child safety (42.0%; Table 1). Nearly 9 out of 10 participants preferred to receive a lockbox rather than a trigger lock. There were no notable differences among sociodemographic characteristics between those who chose a lockbox in comparison with those who chose a trigger lock. Preferences for safety devices have been described in detail in a previously published paper.(Simonetti et al., 2019)
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Journal Pre-proof Table 1. Characteristics of event participants a Total (n = 2,956) % (n)
Characteristic Age, years 18-29 30-44 45-64 ≥ 65
18.2 (473) 37.8 (983) 33.3 (864) 10.7 (278)
70.1 (2071) 29.9 (885)
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Living in household Spouse/ significant other Yes No Children b Child of any age Child ≤ 10 years old Child > 10 years old No children
58.3 (1614) 41.4 (1145) 0.36 (10)
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Gender Male Female Other
57.9 (1501) 39.3 (1019) 29.0 (751) 42.1 (1093)
31.9 (942) 21.6 (638) 13.9 (412) 9.1 (268) 7.7 (226) 1.3 (37) 15.9 (471)
Main reason for wanting safety device b Overall gun safety To keep kids safe Protect guns from theft Store other valuables (not guns) Gift for someone Other
56.9 (1683) 42.0 (1241) 9.6 (284) 3.7 (109) 2.8 (82) 0.9 (25)
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How did you hear about the event? b Social media Word of mouth Came to the store Newspaper Event flyer Works at store Other
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89.6 (2527) 8.4 (236) 1.9 (54) 0.1 (3)
Firearm(s) in household a Yes No
89.8 (2480) 10.2 (282)
Gun safety device currently used b Gun safe Gun lock box Cable lock Trigger lock None Other
38.3 (1131) 12.7 (376) 18.0 (531) 16.1 (476) 28.6 (844) 4.9 (144)
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Preferred safety device to receive Lock box Trigger lock No preference Came for information - did not receive device
60.0 (1487) 23.5 (582) 16.6 (411)
Firearms in home currently stored loadedc Yes, all Yes, some None
12.0 (289) 27.1 (654) 60.9 (1469)
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Firearms in home currently stored in a locked place or using a locking devicec Yes, all Yes, some None
Ammunition in home currently stored in a locked place Yes, all Yes, some None No ammunition in home
48.7 (1323) 19.0 (517) 20.9 (567) 11.4 (310)
Plans to use this safety device to store firearms in the next week Yes No Not sure
89.0 (2516) 5.1 (144) 5.9 (166)
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Missingness is not factored into percentages Percentages may add up to more than 100; participants were instructed to select all that apply 8
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% only apply to those who have guns in the home
Firearm storage practices Of those living with firearms in the home, 60.0% reported storing all firearms locked or in a locked place and 60.9% reported storing all firearms unloaded (Table 1). Less than half (48.7%) of participants reported storing all ammunition in a locked place (Table 1). Just over one third (36.0%) reported that all firearms in the home were stored locked and unloaded, and only 23.7% of respondents practiced triple safe storage (all firearms locked and unloaded, and all ammunition locked separately; Data not shown).
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Table 2 describes participants by their current firearm storage practices. A small proportion of
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participants either were unsure of storage practices (1.5%) or did not answer that survey item (5.0%) and
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were not included in Table 2.
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Journal Pre-proof Table 2. Characteristics of event participants by current firearm storage practices Firearm-Owning Householdsa
Non-FirearmOwning Households
All firearms currently locked
Some firearms No firearms currently locked currently locked
Characteristic All respondents
% (n) 53.8 (1,487)
% (n) 21.1 (582)
Age, years 18-29 30-44 45-64 ≥ 65
17.4 (235) 40.8 (552) 32.3 (437) 9.4 (128)
16.8 (92) 35.0 (192) 35.3 (194) 12.9 (71)
Gender Female Male Other
38.4 (559) 61.2 (891) 0.3 (5)
37.4 (214) 62.4 (357) 0.2 (1)
44.1 (177) 55.4 (222) 0.5 (2)
56.9 (157) 42.4 (117) 0.7 (2)
76.6 (446) 23.4 (136)
68.1 (280) 31.9 (131)
58.2 (164) 41.8 (118)
58.7 (813) 37.7 (561) 28.0 (417) 41.3 (571)
57.0 (312) 33.3 (194) 28.4 (165) 43.0 (235)
51.7 (186) 33.3 (137) 18.6 (75) 48.3 (174)
64.6 (155) 36.5 (103) 27.3 (77) 35.4 (85)
33.7 (500) 20.6 (306) 15.1 (224) 9.2 (136) 8.3 (123) 1.4 (21) 16.2 (241)
33.1 (193) 23.4 (136) 16.7 (97) 10.0 (58) 7.0 (41) 2.1 (12) 15.0 (87)
33.8 (139) 20.9 (86) 12.9 (53) 10.5 (43) 8.5 (35) 0.5 (2) 16.8 (69)
30.5 (86) 33.3 (94) 8.9 (25) 5.3 (15) 6.4 (18) 0.3 (1) 20.6 (58)
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76.1 (1132) 23.9 (355)
How did you hear about the event?b Social media Word of mouth Came to the store Newspaper Event flyer Works at store Other
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19.2 (50) 40.0 (104) 33.7 (88) 7.3 (19)
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21.4 (81) 30.9 (117) 34.8 (132) 12.9 (49)
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Children Child of any age Child ≤ 10 years old Child > 10 years old No children
% (n) 10.2 (282)
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Living in household Spouse/ significant other Yes No
% (n) 14.9 (411)
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53.2 (150) 41.5 (117) 12.4 (35) 6.7 (19) 9.6 (27) 0.7 (2)
90.1 (1,326) 8.5 (125) 1.4 (21) -
90.2 (523) 7.9 (46) 1.9 (11) -
87.2 (353) 9.1 (37) 3.5 (14) 0.3 (1)
90.0 (252) 7.9 (22) 1.8 (5) 0.3 (1)
13.6 (192) 24.8 (351) 61.6 (872)
6.4 (36) 42.4 (240) 51.2 (290)
14.1 (55) 14.8 (58) 71.1 (278)
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55.7 (229) 48.4 (199) 3.2 (13) 12.7 (52) 2.4 (10) 1.5 (6)
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Firearms in home currently stored loadeda Yes, all Yes, some None
56.7 (330) 45.9 (267) 2.2 (13) 11.2 (65) 0.9 (5) 1.2 (7)
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Preferred safety device to receive Lock box Trigger lock No preference Came for information - did not receive device
62.2 (925) 41.5 (617) 3.2 (47) 9.6 (142) 2.5 (37) 0.6 (9)
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Main reason for wanting safety device b Overall gun safety To keep kids safe Store other valuables (not guns) Protect guns from theft Gift for someone Other
74.4 (1,069) 15.0 (216) 8.9 (128) 1.7 (24)
31.4 (179) 45.3 (258) 21.4 (122) 1.9 (11)
10.9 (43) 8.6 (34) 73.9 (291) 6.6 (26)
4.4 (12) 1.1 (3) 5.1 (14) 89.5 (246)
Plans to use this safety device to store firearms in the next week Yes No Not sure
93.8 (1,389) 2.5 (37) 3.7 (55)
96.0 (558) 0.9 (5) 3.1 (18)
94.6 (385) 3.0 (12) 2.5 (10)
42.3 (118) 30.8 (86) 26.9 (75)
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Ammunition in home currently stored in a locked place Yes, all Yes, some None No ammunition in home
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Excludes those who were unsure of current storage practices Percentages may add up to more than 100; participants were instructed to select all that apply
Note: Participants who were unsure of storage practices or did not respond to storage questions are not included in this table
Compared to individuals who stored all of their firearms unlocked, a greater proportion of participants who stored all of their firearms locked or in a locked place were between the age of 30 and 44 11
Journal Pre-proof (40.8% vs. 30.9%), were male (61.2% vs. 55.4%), and stored all household ammunition locked (74.4% vs. 10.9%; Table 2). A smaller proportion of individuals who stored all of their firearms unlocked lived with a spouse or significant other in comparison with individuals who stored all or some of their firearms locked (68.1% vs. 76.1% vs. 76.6%). Across storage practices, only a small proportion of participants stored all of their firearms loaded, although a greater proportion of individuals who stored some of their firearms unlocked also stored some of their firearms loaded as compared to those who locked all or none of their firearms (42.4% vs. 24.8% vs. 14.8%). Regardless of current storage practices, a majority of respondents cited overall gun
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safety as a main reason for wanting a storage device and preferred to receive a lockbox rather than a trigger lock.
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As compared to participants who resided in households with firearms, a greater proportion of
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participants living without firearms were female and lived without a spouse or significant other (Table 2). In adjusted analyses, in comparison with participants who reported no children in the home,
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neither living in a household with at least one child aged 10 or younger (PR = 0.91; 95% CI = 0.80, 1.04) nor living exclusively with a child aged 11 or older (PR = 0.94; 95% CI = 0.81, 1.09) were significantly
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associated with prevalence of keeping an unlocked firearm in the home (Table 3).
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Journal Pre-proof Table 3. Crude and adjusted prevalence ratios for the association between presence and age of children in the home and presence of an unlocked firearm among participants living with firearms Prevalence of an unlocked firearm at homea
Model 1b
Model 2c
% (95% CI) 41.7 (38.7, 44.9) 37.2 (34.0, 40.4) 39.8 (35.2, 44.5)
PR (95% CI) 1 (reference) 0.89 (0.79, 0.99) 0.95 (0.83, 1.09)
PR (95% CI) 1 (reference) 0.91 (0.80, 1.04) 0.94 (0.81, 1.09)
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No children At least one child ≤ 10 At least one child > 10 and no children ≤ 10 PR = Prevalence Ratio; CI = Confidence Interval a Compared to all locked b Crude c Adjusted for age and gender of respondent
DISCUSSION
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To the best of our knowledge, this is the largest study of participants of community-based firearm safety
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events to date. Four in ten firearm-owning participants reported having an unlocked firearm in their home, and only one-third stored all household firearms locked and unloaded. Fewer than one-quarter stored all firearms locked and unloaded with ammunition locked separately. Adults living with children of any age
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were just as likely as those living with no children to report keeping an unlocked firearm in the home. A majority of participants were male, under 45 years old, lived with a spouse or significant other, and lived
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with a child and/or adolescent. There have been few published investigations into the general characteristics and storage behaviors of firearm safety event participants, and those studies have reported
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sample sizes of under 300 participants. By characterizing nearly 3,000 participants, this study adds to the limited literature on community-based firearm safety interventions and highlights the potential benefit of such events in reaching unique populations. This study demonstrates that community-based firearm safety interventions have the potential to reach a unique audience in comparison with clinic-based interventions. In these events, 90% of participants lived with firearms and more than one-half lived with children. Compared to pediatric clinicbased interventions, which have generally found that 8 - 36% of their patient populations live in firearm owning households, 90% of our event participants who lived with a child also lived with a firearm.(Barkin et al., 2008; Carbone et al., 2005; Garbutt et al., 2016) In further contrast to clinic-based firearm safety interventions, in which a majority of parent or guardian participants are female,(Albright and Burge, 2003) 58% of our participants were male. This is highly relevant as males are more often 13
Journal Pre-proof reported as being the owner of a firearm and responsible for its storage.(Azrael et al., 2000; CoyneBeasley, 2005) It is possible that this could incline them to attend firearm-related events in the community and partially explain the high proportion of males in our population compared to clinical populations. This finding is particularly important as non-firearm-owning partners who live in the same home are less likely to be aware of presence and storage practices of household firearms.(Azrael et al., 2000) In light of recommendations to store firearms safely in the presence of children and results from national surveys,(Crifasi et al., 2018; Okoro et al., 2005; Schuster et al., 2000) we expected that adults living with children (especially young children) would be more likely to report safe storage practices.
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However, we found no significant difference between storage practices in households with either young children or adolescents compared to households with no children. This finding is in contrast to prior
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studies showing that firearms are more likely to be stored safely in households with younger children (<13 years) compared to households with older children(Johnson et al., 2006). Although the reason is
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unclear, one possible explanation is that we dichotomized households using a younger age group of
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children (<11 years). If storage practices of households with children aged 11 or 12 years are sufficiently different from those with children older than 12 years, grouping households with 11- or 12-year-old
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children into an ‘older child’ category would serve to make that group’s storage practices appear more similar to households with children under 11 years old and contribute to our null findings. Alternatively, participants of firearm safety events may underestimate the risk of self-injury and harm that an unlocked
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firearm poses to children and adolescents.(Anestis et al., 2017) Participants may focus on training older children in firearm safety as a protective measure rather than keeping firearms locked and unloaded, and
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may believe that younger children are not aware or capable of using of firearms in the house.(Baxley and Miller, 2006; Marino et al., 2018) It is also possible that those who attend these events may differ from
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other samples with respect to characteristics that affect storage practices. Given the limited amount of time available for data collection during events, we were unable to measure and subsequently adjust for factors known to affect storage practices, such as household urbanicity or the number and types of firearms owned (Azrael et al., 2018; Nance et al., 2002; Nordstrom et al., 2001). We also did not assess reasons for firearm ownership, which has been shown to correlate with firearm storage practices. Individuals who keep firearms for protection are less likely to store their firearms locked than those who own for other reasons (e.g. hunting)(Simonetti et al., 2018). We also did not account for factors that may have affected the accurate reporting of storage practices, such as whether the survey respondent was a primary firearm owner or a non-owner who resided in a household with a firearm(Azrael et al., 2000). There are limitations of this study to consider. Given the restricted ability to measure other factors known to affect storage practices, there was a risk of residual confounding in the adjusted analyses 14
Journal Pre-proof presented in this study. Additionally, participant reporting of firearm ownership and storage practices could have been affected by social desirability or recall biases. To limit the risk of social desirability bias, participants were not approached while completing the survey and surveys were anonymous. Study data were collected from a convenience sample of participants across ten events occurring in Washington state. Although promotion and event content followed identical scripts, findings may not be generalizable to other settings. Nonetheless, this study is based on the largest sample of community-based event attendees to date and provides important insights that can be used to inform future interventions. Despite these limitations, this study adds meaningful information to the literature on firearm
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injury prevention efforts. Nationally, a majority of firearm-owners (66%) and non-firearm-owners (90%) agree that it is important to lock household firearms when there are children in the home,(Parker et al.,
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2017) and 4 in 10 participants of this intervention cited keeping children safe as a primary reason for wanting a safety device. Qualitative studies indicate that successful safety promotion requires the
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emphasis of trust in the message and in the messenger(Marino et al., 2016), indicating that basing firearm
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safety interventions on the needs and priorities of communities is essential as we move toward the common goal of keeping children safe.
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CONCLUSION
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A multi-faceted approach is likely to be necessary in reducing the endemic burden of firearm injuries in the US, which is likely to include community-based firearm safety events. This study provides valuable information on a subset of the firearm-owning population who chose to attend this firearm safety
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intervention, and has important and practical policy implications for firearm injury prevention efforts.
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Community-based firearm safety events can attract large numbers of individuals who live in households with firearms. As this study shows, such events have the potential to reach unique groups of individuals (e.g., males) with a high prevalence of firearm ownership who might not otherwise be encountered by interventions implemented in other settings. Future research may be helpful in assessing whether the presence and age of children in firearm-owning households impacts the safety practices of firearm users in other settings, and how best to tailor intervention content to mitigate the risk unlocked firearms pose to children and adolescents.
Acknowledgements: We would like to acknowledge the substantial contributions of Chelsie Gallagher (Seattle Children’s) and the Seattle Children’s Firearm Injury Prevention Research Team in the planning and implementation of
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Journal Pre-proof these events and data collection for this study. We would also like to acknowledge the substantial contributions of the volunteers and community partners who made these events possible, including Seattle Children’s, the Harborview Injury Prevention & Research Center, Public Health Seattle & King County’s Lock It Up program, community hospitals, public health departments and Safe Kids Coalitions across Washington State. Competing Interests: None declared. Funding: Funding for the intervention described in this paper was provided by Seattle Children’s.
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Ethics Approval: Seattle Children’s Institutional Review Board, Seattle, Washington, USA
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Journal Pre-proof References Albright, T.L., Burge, S.K., 2003. Improving firearm storage habits: impact of brief office counseling by family physicians. J. Am. Board Fam. Pract. 16, 40–6. https://doi.org/10.1016/j.chb.2014.04.043 Anestis, M.D., Butterworth, S.E., Houtsma, C., 2017. Perceptions of firearms and suicide: The role of misinformation in storage practices and openness to means safety measures. J. Affect. Disord. 227, 530–535. https://doi.org/10.1016/j.jad.2017.11.057 Anglemyer, A., Horvath, T., Rutherford, G., 2014. The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members. Ann. Intern. Med. 160, 101–110. https://doi.org/10.7326/M13-1301
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Azrael, D., Cohen, J., Salhi, C., Miller, M., 2018. Firearm Storage in Gun-Owning Households with Children: Results of a 2015 National Survey. J. Urban Heal. 95, 295–304. https://doi.org/10.1007/s11524-018-0261-7
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Azrael, D., Miller, M., Hemenway, D., 2000. Are Household Firearms Stored Safely? It Depends on Whom You Ask. Pediatrics 106, e31–e31. https://doi.org/10.1542/peds.106.3.e31
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Barkin, S.L., Finch, S.A., Ip, E.H., Scheindlin, B., Craig, J.A., Steffes, J., Weiley, V., Slora, E., Altman, D., Wasserman, R.C., 2008. Is Office-Based Counseling About Media Use, Timeouts, and Firearm Storage Effective? Results From a Cluster-Randomized, Controlled Trial. Pediatrics 122, e15–e25. https://doi.org/10.1542/peds.2007-2611 Baxley, F., Miller, M., 2006. Parental misperceptions about children and firearms. Arch. Pediatr. Adolesc. Med. 160, 542–547. https://doi.org/10.1001/archpedi.160.5.542
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Betz, M.E., Azrael, D., Barber, C., Miller, M., 2016. Public opinion regarding whether speaking with patients about firearms is appropriate: Results of a national survey. Ann. Intern. Med. 165, 543–550. https://doi.org/10.7326/M16-0739
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Carbone, P.S., Clemens, C.J., Ball, T.M., 2005. Effectiveness of gun safety counseling and gun lock give away in a Hispanic community. Arch Pediatr Adolesc Med 159, 1049–1054. https://doi.org/10.1001/archpedi.159.11.1049 Coyne-Beasley, T., 2005. Do Partners With Children Know About Firearms in Their Home? Evidence of a Gender Gap and Implications for Practitioners. Pediatrics 115, e662–e667. https://doi.org/10.1542/peds.2004-2259 Coyne-Beasley, T., Schoenbach, V.J., Johnson, R.M., 2001. “Love Our Kids, Lock Your Guns.” Arch. Pediatr. Adolesc. Med. 155, 659. https://doi.org/10.1001/archpedi.155.6.659 Crifasi, C.K., Doucette, M.L., McGinty, E.E., Webster, D.W., Barry, C.L., 2018. Storage practices of US gun owners in 2016. Am. J. Public Health 108, 532–537. https://doi.org/10.2105/AJPH.2017.304262 Deborah Azrael, Lisa Hepburn, David Hemenway, Matthew Miller, 2017. The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey. RSF Russell Sage Found. J. Soc. Sci. 3, 38. https://doi.org/10.7758/rsf.2017.3.5.02 Garbutt, J.M., Bobenhouse, N., Dodd, S., Sterkel, R., Strunk, R.C., 2016. What Are Parents Willing to Discuss with Their Pediatrician About Firearm Safety? A Parental Survey. J. Pediatr. 179, 166–171. https://doi.org/10.1016/j.jpeds.2016.08.019 17
Journal Pre-proof Grossman, D., Reay, D., 1999. Self-inflicted and Unintentional Firearm Injuries Among Children and Adolescents: The Source of the Firearm.(Statistical Data Included) - Northeastern University. Arch. Pediatr. Adolesc. Med. 153, 875. Grossman DC, Mueller BA, Riedy C, Dowd MD, Villaveces A, Prodzinski J, Nakagawara J, Howard J, Thiersch N, Harruff R., 2005. Gun storage practices and risk of youth suicide. Jama 293, 707–714. Hemenway, D., Solnick, S.J., 2015. Children and unintentional firearm death. Inj. Epidemiol. 2. https://doi.org/10.1186/s40621-015-0057-0 Johnson, R.M., Miller, M., Vriniotis, M., Azrael, D., Hemenway, D., 2006. Are Household Firearms Stored Less Safely in Homes With Adolescents? Arch. Pediatr. Adolesc. Med. 160, 788. https://doi.org/10.1001/archpedi.160.8.788
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Kalesan, B., Villarreal, M.D., Keyes, K.M., Galea, S., 2016. Gun ownership and social gun culture 101, 216–220. https://doi.org/10.1136/injuryprev-2015-041586
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Marino, E., Wolsko, C., Keys, S., Wilcox, H., 2018. Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk. Arch. Suicide Res. 22, 394–404. https://doi.org/10.1080/13811118.2017.1355285
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Marino, E., Wolsko, C., Keys, S.G., Pennavaria, L., 2016. A culture gap in the United States: Implications for policy on limiting access to firearms for suicidal persons. J. Public Health Policy 37, S110–S121. https://doi.org/10.1057/s41271-016-0007-2
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Miller, M., Azrael, D., Hemenway, D., Vriniotis, M., 2005. Firearm storage practices and rates of unintentional firearm deaths in the United States. Accid. Anal. Prev. 37, 661–667. https://doi.org/10.1016/j.aap.2005.02.003
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Miller, M., Barber, C., White, R.A., Azrael, D., 2013. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am. J. Epidemiol. 178, 946–955. https://doi.org/10.1093/aje/kwt197
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Monuteaux, M.C., Azrael, D., Miller, M., 2019. Association of Increased Safe Household Firearm Storage With Firearm Suicide and Unintentional Death Among US Youths. JAMA Pediatr. 02115, 1–7. https://doi.org/10.1001/jamapediatrics.2019.1078 Nance, M.L., Denysenko, L., Durbin, D.R., Branas, C.C., Stafford, P.W., Schwab, C.W., 2002. The ruralurban continuum: variability in statewide serious firearm injuries in children and adolescents. Arch. Pediatr. Adolesc. Med. 156, 781–5. https://doi.org/10.1542/peds.2017-3318 Nordstrom, D.L., Zwerling, C., Stromquist, A.M., Burmeister, L.F., Merchant, J.A., 2001. Rural population survey of behavioral and demographic risk factors for loaded firearms. Inj. Prev. 7, 112– 116. https://doi.org/10.1136/ip.7.2.112 Oatis, P.J., Fenn Buderer, N.M., Cummings, P., Fleitz, R., 1999. Pediatric practice based evaluation of the Steps to Prevent Firearm Injury program. Inj. Prev. 5, 48–52. https://doi.org/10.1136/ip.5.1.48 Okoro, C.A., Nelson, D.E., Mercy, J.A., Balluz, L.S., Crosby, A.E., Mokdad, A.H., 2005. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics 116, e370-6. https://doi.org/10.1542/peds.2005-0300 Parker, K., Horowitz, J., Igielnik, R., Oliphant, B., Brown, A., 2017. America’s Complex Relationship 18
Journal Pre-proof with Guns. Rowhani-Rahbar, A., Lyons, V.H., Simonetti, J.A., Azrael, D., Miller, M., 2018. Formal firearm training among adults in the USA: Results of a national survey. Inj. Prev. 24, 161–165. https://doi.org/10.1136/injuryprev-2017-042352 Rowhani-Rahbar, A., Simonetti, J.A., Rivara, F.P., 2016. Effectiveness of Interventions to Promote Safe Firearm Storage. Epidemiol. Rev. 38, 111–124. https://doi.org/10.1093/epirev/mxv006 Schuster, M.A., Franke, T.M., Bastian, A.M., Sor, S., Halfon, N., 2000. Firearm storage patterns in US homes with children. Am. J. Public Health 90, 588–94. https://doi.org/10.2307/6005
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Simonetti, J., Simeona, C., Gallagher, C., Bennett, E., Rivara, F., Rowhani-Rahbar, A., 2019. Preferences for Firearm Locking Devices and Device Features Among Participants in a Firearm Safety Event. West. J. Emerg. Med. 20, 552–556. https://doi.org/10.5811/westjem.2019.5.42727
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Simonetti, J.A., Azrael, D., Rowhani-Rahbar, A., Miller, M., 2018. Firearm Storage Practices Among American Veterans. Am. J. Prev. Med. 55, 445–454. https://doi.org/10.1016/j.amepre.2018.04.014
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Simonetti, J.A., Rowhani-Rahbar, A., King, C., Bennett, E., Rivara, F.P., 2017. Evaluation of a community-based safe firearm and ammunition storage intervention. Inj. Prev. 1–6. https://doi.org/10.1136/injuryprev-2016-042292
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Web-based Injury Statistics Query and Reporting System (WISQARS [WWW Document], n.d. . Off. Stat. Program. Natl. Cent. Inj. Prev. Control. CDC. Natl. Cent. Heal. Startistics (NCHS), Natl. Vital Statsticsystem. URL https://www.cdc.gov/injury/wisqars/index (accessed 1.9.18).
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Wiebe, D.J., 2003. Homicide and suicide risks associated with firearms in the home: A national casecontrol study. Ann. Emerg. Med. 41, 771–782. https://doi.org/10.1067/mem.2003.187
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Wolfson, J.A., Azrael, D., Miller, M., 2018. Gun ownership among US women. Inj. Prev. 1–6. https://doi.org/10.1136/injuryprev-2018-042991
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Journal Pre-proof Highlights
Community-based interventions can promote safer firearm storage, but little is known about those who attend.
We compared firearm storage practices of participants who lived with children to those who did not.
There was high prevalence of unlocked household firearms regardless of presence of children in
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This intervention reached a key population; adults who lived in households with children.
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the home.
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Aisha King, Joseph Simonetti, Elizabeth Bennett, Cassie Simeona, Lauren Stanek, Alison C. Roxby, Ali Rowhani-Rahbar PII:
S0091-7435(19)30435-9
DOI:
https://doi.org/10.1016/j.ypmed.2019.105952
Reference:
YPMED 105952
To appear in:
Preventive Medicine
Received date:
2 July 2019
Revised date:
5 October 2019
Accepted date:
30 November 2019
Please cite this article as: A. King, J. Simonetti, E. Bennett, et al., Firearm storage practices in households with children: A survey of community-based firearm safety event participants, Preventive Medicine(2019), https://doi.org/10.1016/j.ypmed.2019.105952
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof Full Title: Firearm storage practices in households with children: A survey of community-based firearm safety event participants Authors: Aisha King,a* Joseph Simonetti, MD, MPH,b,c Elizabeth Bennett, MPH, MCHES,d,e, Cassie Simeona,d MPH, Lauren Stanek,d Alison C. Roxby, MD, MPH,a,f,g Ali Rowhani-Rahbar, MD, MPH, PhDf,h,i Affiliations:
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a: Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA b: Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO c: Rocky Mountain Mental Illness Research, Education, and Clinical Center, Veterans Health Administration, Aurora, CO d: Seattle Children’s, Seattle, Washington, USA e: Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA f: Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA g: Department of Medicine, University of Washington, Seattle, Washington, USA h: Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington, USA i: Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
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*Corresponding author: Aisha King; Department of Global Health, University of Washington, Harris Hydraulics Laboratory, Box 357965; Phone: 484-995-1273; Email: [email protected]
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Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to disclose.
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Abstract word count: 242/250 Revised Manuscript word count: 3030/3500 Number of Tables/Figures: 3/5 Number of References: 38/40 Article Type: Research Paper Corresponding Author’s Organization: University of Washington, Seattle Keywords: prevention & control; intervention; injury prevention; firearm
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Abstract
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Safe firearm storage is associated with lower risk of unintentional and intentionally self-inflicted firearm injuries among children and adolescents. Ten community-based firearm safety events were conducted across Washington state from 2015-2018. We sought to describe characteristics of event participants and assess whether presence and age of children in the household were associated with household firearm locking practices. We assessed demographic characteristics and baseline firearm storage behaviors of participants using a 13-item survey. Multivariable Poisson regression models were used to estimate prevalence ratios (PR) and corresponding confidence intervals (CI) for the association of presence and age of children in households with prevalence of storing a household firearm unlocked. Of 2,956 participants, 58.3% were male and 57.8% lived with an individual under 18 years. Among the 89.8% participants living with firearms, 40.1% stored at least one firearm unlocked and 39.1% stored at least one firearm loaded. In adjusted analyses, there was no statistically significant difference in prevalence of storing a household firearm unlocked between those living with no children (reference group) and those living with a child <11 years (PR=0.91; 95% CI: 0.80,1.04), or a child aged 11-18 years (PR=0.94; 95% CI: 0.81,1.09). A high proportion of participants stored a firearm unlocked or loaded at home and neither living with young children nor adolescents was associated with safe locking practices. In comparison with firearm safety interventions conducted in clinic settings, a majority of the participants in these community-based interventions were male and owned firearms.
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Journal Pre-proof INTRODUCTION Approximately 15,000 children and adolescents aged 18 years or younger were injured or killed by firearms in the United States (U.S.) in 2017.(“Web-based Injury Statistics Query and Reporting System (WISQARS,” n.d.) The presence of a firearm in the home is an independent risk factor for suicide and unintentional firearm death and injury among children.(Anglemyer et al., 2014; Grossman DC et al., 2005; Miller et al., 2013; Wiebe, 2003) Almost 90% of firearm-related fatalities of young children (0-14 years) occur in the home,(Hemenway and Solnick, 2015) and a majority of all unintentional, firearmrelated child and adolescent (0-18 years) fatalities involve a firearm found in the home.(Grossman and
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Reay, 1999) A 2005 study found that storing household firearms unloaded (as opposed to loaded) or locked (as opposed to unlocked) was associated with a respective 70% and 73% reduction in risk of
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unintentional and self-inflicted firearm injuries among individuals under 20 years of age.(Grossman DC et al., 2005) Ecologic studies have also shown that rates of unintentional firearm injuries are higher in states
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where firearm owners are more likely to store their firearms loaded, or loaded and unlocked.(Miller et al.,
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2005) Some estimates suggest that safe firearm storage could prevent 6-32% of all unintentional and intentionally self-inflicted firearm deaths among U.S. youths aged 0-19 years.(Monuteaux et al., 2019)
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However, of the approximately 22-30% of U.S. adults who report owning a firearm, more than one-half report that they keep at least one household firearm unlocked, loaded, or both.(Crifasi et al., 2018;
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Deborah Azrael et al., 2017; Kalesan et al., 2016; Parker et al., 2017) In 2015, approximately 4.6 million U.S. children resided in a household with an unlocked and loaded firearm; a nearly 3-fold increase from
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2002.(Azrael et al., 2018; Okoro et al., 2005)
Improving our understanding of factors associated with firearm storage practices is critical for
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informing firearm-related policies and interventions. A key question is whether firearm storage practices vary based on the presence and age of children residing in the home. Several population-level survey studies have found that adults living in households with children are more likely to report safe firearm storage practices than those in households with no children present.(Crifasi et al., 2018; Okoro et al., 2005; Schuster et al., 2000) Surveys from the early 2000s also found that, among individuals residing in households with both firearms and children, firearms are more likely to be stored safely if children in the home are under the age of 13 rather than 13 and older.(Azrael et al., 2000; Johnson et al., 2006; Schuster et al., 2000) In comparison with these findings, investigators assessing firearm storage practices among participants of a community-based firearm safety intervention in 2001 found that, prior to the intervention, the presence of children in the home was associated with less safe storage practices among participants.(Coyne-Beasley et al., 2001) These findings raise a question as to whether the storage
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Journal Pre-proof practices of those who elect to attend firearm safety events might differ from those reported by respondents to population-level surveys. Another important question for those aiming to promote firearm safety is how best to reach different populations. Most clinic-based firearm safety interventions have promoted firearm safety within the context of pediatric injury prevention and in pediatric or family practice settings.(Rowhani-Rahbar et al., 2018) As a majority of parents or guardians who attend such visits are female,(Barkin et al., 2008; Carbone et al., 2005; Garbutt et al., 2016; Oatis et al., 1999) these interventions may overlook important populations. A majority of U.S. firearm owners are male, and males in firearm-owning households are
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more likely to be responsible for making decisions about firearm storage practices.(Azrael et al., 2000; Coyne-Beasley, 2005) Some patients and parents may also be reluctant to discuss firearm safety during
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clinical encounters.(Betz et al., 2016) Community-based interventions may have the potential to reach distinct populations and may be helpful in reaching firearm owners who are less likely to be encountered
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or engage in firearm-related discussions in clinical settings. However, few effective community-based interventions have been reported in the literature.(Rowhani-Rahbar et al., 2016; Simonetti et al., 2017)
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Those interventions enrolled small numbers of participants (40-255), which limits our ability to study
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how these participants may differ from those represented in population-based studies or clinic-based interventions.
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Community-based firearm safety interventions are an important component of a multi-faceted, public health approach to reducing firearm injuries in the U.S. As such, it is important to improve our understanding of characteristics of individuals who attend such events and factors that may influence their
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firearm storage practices. This information can be used to tailor intervention content, improve
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effectiveness, and reach potentially high-risk populations. In this study, which includes data from nearly 3,000 participants in 10 community-based firearm safety events occurring in Washington state from 20152018, we sought to [1] characterize the sociodemographic characteristics and firearm safety practices of event participants; and [2] assess whether the presence and age of children in the household are associated with firearm storage practices. METHODS Study design We conducted a cross-sectional study using self-administered surveys of participants at 10 communitybased firearm safety events held across Washington state from 2015 to 2018. All participants were 18 years of age or older, spoke English or Spanish, and signed a liability release form necessary for event participation.
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Journal Pre-proof Firearm safety events Event sites were chosen with the intention of reaching communities across Washington State and were held in large urban areas, smaller urban or suburban areas, and cities in rural areas. Events were held in large sporting goods stores that sold firearms and safe storage devices. Event promotion was identical across sites. Additional information on event locations and urbanicity can be found in the Appendix (Table A1). Participants were recruited using print and digital placements in local newspapers, radio, social media posts, and printed and electronic flyers. Recruitment materials emphasized learning about firearm safety and focused on households where children and teenagers spend time. Materials and an
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event planning toolkit can be found online at https://www.seattlechildrens.org/health-safety/keeping-kidshealthy/prevention/gun-safety.
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All events were conducted uniformly. Participants received counseling on safe firearm storage, training on and practice with the proper use of storage devices, and their choice of a free firearm lockbox
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or trigger lock. Event materials were developed using principles of social marketing and the theory of
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reasoned action and were designed to increase awareness and action around the safe storage of firearms to reduce child and youth firearm injuries. Safety messaging emphasized keeping children and families safe
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using “triple safe storage” – storing firearms unloaded and locked, with ammunition stored separately in a locked place. Event details have been further described in a previous evaluation of the
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intervention.(Simonetti et al., 2017) Data collection
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Prior to training and receiving a safety device, participants completed a 13-item voluntary, selfadministered survey. The survey included multiple choice and open-ended items assessing
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sociodemographic characteristics (including presence and age of children in the home), current and intended firearm and ammunition storage practices, feedback on event location and promotion methods, and reason(s) for wanting a storage device. Co-investigators JS, EB, and ARR developed the survey, which was piloted for readability, acceptability, and brevity (given the short time period available for data collection during events). See Appendix for the full questionnaire. Statistical analysis We described the sociodemographic characteristics of respondents overall and by firearm ownership and storage practices. We compared sociodemographic characteristics between those who preferred to receive the firearm lockbox and those who received a trigger lock. Storage practices were categorized in the following manner, consistent with the previous evaluation of this intervention(Simonetti et al., 2017): firearms stored locked (all, some, none), firearms stored loaded (all, some, none), and ammunition stored 5
Journal Pre-proof locked (all, some, none). A composite variable was constructed to measure triple safe storage: all firearms locked, no firearms loaded, and all ammunition locked (yes/no). In multivariable analyses, we classified the exposure of ‘presence of children in the household’ into three mutually exclusive groups: (1) no children (reference group), (2) at least one child aged 10 or younger (including households in which older children were present), and (3) at least one child aged 11 or older and no children aged 10 or younger. We defined firearm locking practices as (1) all household firearms are locked or (2) at least one household firearm is unlocked. Among firearm-owning households, we conducted Poisson regression models to obtain prevalence ratios (PRs) and 95% confidence intervals
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(CIs) to compare the prevalence of having at least one unlocked firearm by presence and age of a child in the household. We reported the crude prevalence ratio and the prevalence ratio adjusted for a priori-
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selected covariates of age and gender of the participants. Covariates were selected based on literature review of prior studies, which have consistently demonstrated gender- and age-based differences in
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likelihood of firearm ownership and reporting of firearm storage practices.(Azrael et al., 2000; Crifasi et al., 2018; Wolfson et al., 2018) The survey used in this research was approved by Seattle Children’s
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Institutional Review Board. We conducted analyses with Stata Release 15.1 (StataCorp LP).
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RESULTS Respondent characteristics
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Of the 3,121 participants, 2,956 (94.7%) completed the survey (mean age = 43.6 years, range = 18 – 88 years). A majority of respondents were male (58.3%), lived with a spouse or significant other (70.1%),
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and lived with at least one child and/or adolescent in the household (57.9%). Additional household statistics can be found in the Appendix (Table A2). Nine out of 10 respondents lived with at least one
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firearm in the household. The most common reasons for wanting a safety device were overall firearm safety (56.9%) and child safety (42.0%; Table 1). Nearly 9 out of 10 participants preferred to receive a lockbox rather than a trigger lock. There were no notable differences among sociodemographic characteristics between those who chose a lockbox in comparison with those who chose a trigger lock. Preferences for safety devices have been described in detail in a previously published paper.(Simonetti et al., 2019)
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Journal Pre-proof Table 1. Characteristics of event participants a Total (n = 2,956) % (n)
Characteristic Age, years 18-29 30-44 45-64 ≥ 65
18.2 (473) 37.8 (983) 33.3 (864) 10.7 (278)
70.1 (2071) 29.9 (885)
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Living in household Spouse/ significant other Yes No Children b Child of any age Child ≤ 10 years old Child > 10 years old No children
58.3 (1614) 41.4 (1145) 0.36 (10)
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Gender Male Female Other
57.9 (1501) 39.3 (1019) 29.0 (751) 42.1 (1093)
31.9 (942) 21.6 (638) 13.9 (412) 9.1 (268) 7.7 (226) 1.3 (37) 15.9 (471)
Main reason for wanting safety device b Overall gun safety To keep kids safe Protect guns from theft Store other valuables (not guns) Gift for someone Other
56.9 (1683) 42.0 (1241) 9.6 (284) 3.7 (109) 2.8 (82) 0.9 (25)
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How did you hear about the event? b Social media Word of mouth Came to the store Newspaper Event flyer Works at store Other
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89.6 (2527) 8.4 (236) 1.9 (54) 0.1 (3)
Firearm(s) in household a Yes No
89.8 (2480) 10.2 (282)
Gun safety device currently used b Gun safe Gun lock box Cable lock Trigger lock None Other
38.3 (1131) 12.7 (376) 18.0 (531) 16.1 (476) 28.6 (844) 4.9 (144)
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Preferred safety device to receive Lock box Trigger lock No preference Came for information - did not receive device
60.0 (1487) 23.5 (582) 16.6 (411)
Firearms in home currently stored loadedc Yes, all Yes, some None
12.0 (289) 27.1 (654) 60.9 (1469)
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Firearms in home currently stored in a locked place or using a locking devicec Yes, all Yes, some None
Ammunition in home currently stored in a locked place Yes, all Yes, some None No ammunition in home
48.7 (1323) 19.0 (517) 20.9 (567) 11.4 (310)
Plans to use this safety device to store firearms in the next week Yes No Not sure
89.0 (2516) 5.1 (144) 5.9 (166)
a b
Missingness is not factored into percentages Percentages may add up to more than 100; participants were instructed to select all that apply 8
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% only apply to those who have guns in the home
Firearm storage practices Of those living with firearms in the home, 60.0% reported storing all firearms locked or in a locked place and 60.9% reported storing all firearms unloaded (Table 1). Less than half (48.7%) of participants reported storing all ammunition in a locked place (Table 1). Just over one third (36.0%) reported that all firearms in the home were stored locked and unloaded, and only 23.7% of respondents practiced triple safe storage (all firearms locked and unloaded, and all ammunition locked separately; Data not shown).
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participants either were unsure of storage practices (1.5%) or did not answer that survey item (5.0%) and
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were not included in Table 2.
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Journal Pre-proof Table 2. Characteristics of event participants by current firearm storage practices Firearm-Owning Householdsa
Non-FirearmOwning Households
All firearms currently locked
Some firearms No firearms currently locked currently locked
Characteristic All respondents
% (n) 53.8 (1,487)
% (n) 21.1 (582)
Age, years 18-29 30-44 45-64 ≥ 65
17.4 (235) 40.8 (552) 32.3 (437) 9.4 (128)
16.8 (92) 35.0 (192) 35.3 (194) 12.9 (71)
Gender Female Male Other
38.4 (559) 61.2 (891) 0.3 (5)
37.4 (214) 62.4 (357) 0.2 (1)
44.1 (177) 55.4 (222) 0.5 (2)
56.9 (157) 42.4 (117) 0.7 (2)
76.6 (446) 23.4 (136)
68.1 (280) 31.9 (131)
58.2 (164) 41.8 (118)
58.7 (813) 37.7 (561) 28.0 (417) 41.3 (571)
57.0 (312) 33.3 (194) 28.4 (165) 43.0 (235)
51.7 (186) 33.3 (137) 18.6 (75) 48.3 (174)
64.6 (155) 36.5 (103) 27.3 (77) 35.4 (85)
33.7 (500) 20.6 (306) 15.1 (224) 9.2 (136) 8.3 (123) 1.4 (21) 16.2 (241)
33.1 (193) 23.4 (136) 16.7 (97) 10.0 (58) 7.0 (41) 2.1 (12) 15.0 (87)
33.8 (139) 20.9 (86) 12.9 (53) 10.5 (43) 8.5 (35) 0.5 (2) 16.8 (69)
30.5 (86) 33.3 (94) 8.9 (25) 5.3 (15) 6.4 (18) 0.3 (1) 20.6 (58)
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76.1 (1132) 23.9 (355)
How did you hear about the event?b Social media Word of mouth Came to the store Newspaper Event flyer Works at store Other
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19.2 (50) 40.0 (104) 33.7 (88) 7.3 (19)
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21.4 (81) 30.9 (117) 34.8 (132) 12.9 (49)
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Children Child of any age Child ≤ 10 years old Child > 10 years old No children
% (n) 10.2 (282)
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Living in household Spouse/ significant other Yes No
% (n) 14.9 (411)
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53.2 (150) 41.5 (117) 12.4 (35) 6.7 (19) 9.6 (27) 0.7 (2)
90.1 (1,326) 8.5 (125) 1.4 (21) -
90.2 (523) 7.9 (46) 1.9 (11) -
87.2 (353) 9.1 (37) 3.5 (14) 0.3 (1)
90.0 (252) 7.9 (22) 1.8 (5) 0.3 (1)
13.6 (192) 24.8 (351) 61.6 (872)
6.4 (36) 42.4 (240) 51.2 (290)
14.1 (55) 14.8 (58) 71.1 (278)
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55.7 (229) 48.4 (199) 3.2 (13) 12.7 (52) 2.4 (10) 1.5 (6)
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Firearms in home currently stored loadeda Yes, all Yes, some None
56.7 (330) 45.9 (267) 2.2 (13) 11.2 (65) 0.9 (5) 1.2 (7)
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Preferred safety device to receive Lock box Trigger lock No preference Came for information - did not receive device
62.2 (925) 41.5 (617) 3.2 (47) 9.6 (142) 2.5 (37) 0.6 (9)
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Main reason for wanting safety device b Overall gun safety To keep kids safe Store other valuables (not guns) Protect guns from theft Gift for someone Other
74.4 (1,069) 15.0 (216) 8.9 (128) 1.7 (24)
31.4 (179) 45.3 (258) 21.4 (122) 1.9 (11)
10.9 (43) 8.6 (34) 73.9 (291) 6.6 (26)
4.4 (12) 1.1 (3) 5.1 (14) 89.5 (246)
Plans to use this safety device to store firearms in the next week Yes No Not sure
93.8 (1,389) 2.5 (37) 3.7 (55)
96.0 (558) 0.9 (5) 3.1 (18)
94.6 (385) 3.0 (12) 2.5 (10)
42.3 (118) 30.8 (86) 26.9 (75)
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Ammunition in home currently stored in a locked place Yes, all Yes, some None No ammunition in home
a b
Excludes those who were unsure of current storage practices Percentages may add up to more than 100; participants were instructed to select all that apply
Note: Participants who were unsure of storage practices or did not respond to storage questions are not included in this table
Compared to individuals who stored all of their firearms unlocked, a greater proportion of participants who stored all of their firearms locked or in a locked place were between the age of 30 and 44 11
Journal Pre-proof (40.8% vs. 30.9%), were male (61.2% vs. 55.4%), and stored all household ammunition locked (74.4% vs. 10.9%; Table 2). A smaller proportion of individuals who stored all of their firearms unlocked lived with a spouse or significant other in comparison with individuals who stored all or some of their firearms locked (68.1% vs. 76.1% vs. 76.6%). Across storage practices, only a small proportion of participants stored all of their firearms loaded, although a greater proportion of individuals who stored some of their firearms unlocked also stored some of their firearms loaded as compared to those who locked all or none of their firearms (42.4% vs. 24.8% vs. 14.8%). Regardless of current storage practices, a majority of respondents cited overall gun
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safety as a main reason for wanting a storage device and preferred to receive a lockbox rather than a trigger lock.
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As compared to participants who resided in households with firearms, a greater proportion of
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participants living without firearms were female and lived without a spouse or significant other (Table 2). In adjusted analyses, in comparison with participants who reported no children in the home,
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neither living in a household with at least one child aged 10 or younger (PR = 0.91; 95% CI = 0.80, 1.04) nor living exclusively with a child aged 11 or older (PR = 0.94; 95% CI = 0.81, 1.09) were significantly
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associated with prevalence of keeping an unlocked firearm in the home (Table 3).
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Journal Pre-proof Table 3. Crude and adjusted prevalence ratios for the association between presence and age of children in the home and presence of an unlocked firearm among participants living with firearms Prevalence of an unlocked firearm at homea
Model 1b
Model 2c
% (95% CI) 41.7 (38.7, 44.9) 37.2 (34.0, 40.4) 39.8 (35.2, 44.5)
PR (95% CI) 1 (reference) 0.89 (0.79, 0.99) 0.95 (0.83, 1.09)
PR (95% CI) 1 (reference) 0.91 (0.80, 1.04) 0.94 (0.81, 1.09)
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No children At least one child ≤ 10 At least one child > 10 and no children ≤ 10 PR = Prevalence Ratio; CI = Confidence Interval a Compared to all locked b Crude c Adjusted for age and gender of respondent
DISCUSSION
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To the best of our knowledge, this is the largest study of participants of community-based firearm safety
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events to date. Four in ten firearm-owning participants reported having an unlocked firearm in their home, and only one-third stored all household firearms locked and unloaded. Fewer than one-quarter stored all firearms locked and unloaded with ammunition locked separately. Adults living with children of any age
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were just as likely as those living with no children to report keeping an unlocked firearm in the home. A majority of participants were male, under 45 years old, lived with a spouse or significant other, and lived
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with a child and/or adolescent. There have been few published investigations into the general characteristics and storage behaviors of firearm safety event participants, and those studies have reported
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sample sizes of under 300 participants. By characterizing nearly 3,000 participants, this study adds to the limited literature on community-based firearm safety interventions and highlights the potential benefit of such events in reaching unique populations. This study demonstrates that community-based firearm safety interventions have the potential to reach a unique audience in comparison with clinic-based interventions. In these events, 90% of participants lived with firearms and more than one-half lived with children. Compared to pediatric clinicbased interventions, which have generally found that 8 - 36% of their patient populations live in firearm owning households, 90% of our event participants who lived with a child also lived with a firearm.(Barkin et al., 2008; Carbone et al., 2005; Garbutt et al., 2016) In further contrast to clinic-based firearm safety interventions, in which a majority of parent or guardian participants are female,(Albright and Burge, 2003) 58% of our participants were male. This is highly relevant as males are more often 13
Journal Pre-proof reported as being the owner of a firearm and responsible for its storage.(Azrael et al., 2000; CoyneBeasley, 2005) It is possible that this could incline them to attend firearm-related events in the community and partially explain the high proportion of males in our population compared to clinical populations. This finding is particularly important as non-firearm-owning partners who live in the same home are less likely to be aware of presence and storage practices of household firearms.(Azrael et al., 2000) In light of recommendations to store firearms safely in the presence of children and results from national surveys,(Crifasi et al., 2018; Okoro et al., 2005; Schuster et al., 2000) we expected that adults living with children (especially young children) would be more likely to report safe storage practices.
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However, we found no significant difference between storage practices in households with either young children or adolescents compared to households with no children. This finding is in contrast to prior
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studies showing that firearms are more likely to be stored safely in households with younger children (<13 years) compared to households with older children(Johnson et al., 2006). Although the reason is
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unclear, one possible explanation is that we dichotomized households using a younger age group of
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children (<11 years). If storage practices of households with children aged 11 or 12 years are sufficiently different from those with children older than 12 years, grouping households with 11- or 12-year-old
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children into an ‘older child’ category would serve to make that group’s storage practices appear more similar to households with children under 11 years old and contribute to our null findings. Alternatively, participants of firearm safety events may underestimate the risk of self-injury and harm that an unlocked
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firearm poses to children and adolescents.(Anestis et al., 2017) Participants may focus on training older children in firearm safety as a protective measure rather than keeping firearms locked and unloaded, and
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may believe that younger children are not aware or capable of using of firearms in the house.(Baxley and Miller, 2006; Marino et al., 2018) It is also possible that those who attend these events may differ from
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other samples with respect to characteristics that affect storage practices. Given the limited amount of time available for data collection during events, we were unable to measure and subsequently adjust for factors known to affect storage practices, such as household urbanicity or the number and types of firearms owned (Azrael et al., 2018; Nance et al., 2002; Nordstrom et al., 2001). We also did not assess reasons for firearm ownership, which has been shown to correlate with firearm storage practices. Individuals who keep firearms for protection are less likely to store their firearms locked than those who own for other reasons (e.g. hunting)(Simonetti et al., 2018). We also did not account for factors that may have affected the accurate reporting of storage practices, such as whether the survey respondent was a primary firearm owner or a non-owner who resided in a household with a firearm(Azrael et al., 2000). There are limitations of this study to consider. Given the restricted ability to measure other factors known to affect storage practices, there was a risk of residual confounding in the adjusted analyses 14
Journal Pre-proof presented in this study. Additionally, participant reporting of firearm ownership and storage practices could have been affected by social desirability or recall biases. To limit the risk of social desirability bias, participants were not approached while completing the survey and surveys were anonymous. Study data were collected from a convenience sample of participants across ten events occurring in Washington state. Although promotion and event content followed identical scripts, findings may not be generalizable to other settings. Nonetheless, this study is based on the largest sample of community-based event attendees to date and provides important insights that can be used to inform future interventions. Despite these limitations, this study adds meaningful information to the literature on firearm
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injury prevention efforts. Nationally, a majority of firearm-owners (66%) and non-firearm-owners (90%) agree that it is important to lock household firearms when there are children in the home,(Parker et al.,
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2017) and 4 in 10 participants of this intervention cited keeping children safe as a primary reason for wanting a safety device. Qualitative studies indicate that successful safety promotion requires the
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emphasis of trust in the message and in the messenger(Marino et al., 2016), indicating that basing firearm
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safety interventions on the needs and priorities of communities is essential as we move toward the common goal of keeping children safe.
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CONCLUSION
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A multi-faceted approach is likely to be necessary in reducing the endemic burden of firearm injuries in the US, which is likely to include community-based firearm safety events. This study provides valuable information on a subset of the firearm-owning population who chose to attend this firearm safety
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intervention, and has important and practical policy implications for firearm injury prevention efforts.
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Community-based firearm safety events can attract large numbers of individuals who live in households with firearms. As this study shows, such events have the potential to reach unique groups of individuals (e.g., males) with a high prevalence of firearm ownership who might not otherwise be encountered by interventions implemented in other settings. Future research may be helpful in assessing whether the presence and age of children in firearm-owning households impacts the safety practices of firearm users in other settings, and how best to tailor intervention content to mitigate the risk unlocked firearms pose to children and adolescents.
Acknowledgements: We would like to acknowledge the substantial contributions of Chelsie Gallagher (Seattle Children’s) and the Seattle Children’s Firearm Injury Prevention Research Team in the planning and implementation of
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Journal Pre-proof these events and data collection for this study. We would also like to acknowledge the substantial contributions of the volunteers and community partners who made these events possible, including Seattle Children’s, the Harborview Injury Prevention & Research Center, Public Health Seattle & King County’s Lock It Up program, community hospitals, public health departments and Safe Kids Coalitions across Washington State. Competing Interests: None declared. Funding: Funding for the intervention described in this paper was provided by Seattle Children’s.
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Ethics Approval: Seattle Children’s Institutional Review Board, Seattle, Washington, USA
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Journal Pre-proof References Albright, T.L., Burge, S.K., 2003. Improving firearm storage habits: impact of brief office counseling by family physicians. J. Am. Board Fam. Pract. 16, 40–6. https://doi.org/10.1016/j.chb.2014.04.043 Anestis, M.D., Butterworth, S.E., Houtsma, C., 2017. Perceptions of firearms and suicide: The role of misinformation in storage practices and openness to means safety measures. J. Affect. Disord. 227, 530–535. https://doi.org/10.1016/j.jad.2017.11.057 Anglemyer, A., Horvath, T., Rutherford, G., 2014. The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members. Ann. Intern. Med. 160, 101–110. https://doi.org/10.7326/M13-1301
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Journal Pre-proof Grossman, D., Reay, D., 1999. Self-inflicted and Unintentional Firearm Injuries Among Children and Adolescents: The Source of the Firearm.(Statistical Data Included) - Northeastern University. Arch. Pediatr. Adolesc. Med. 153, 875. Grossman DC, Mueller BA, Riedy C, Dowd MD, Villaveces A, Prodzinski J, Nakagawara J, Howard J, Thiersch N, Harruff R., 2005. Gun storage practices and risk of youth suicide. Jama 293, 707–714. Hemenway, D., Solnick, S.J., 2015. Children and unintentional firearm death. Inj. Epidemiol. 2. https://doi.org/10.1186/s40621-015-0057-0 Johnson, R.M., Miller, M., Vriniotis, M., Azrael, D., Hemenway, D., 2006. Are Household Firearms Stored Less Safely in Homes With Adolescents? Arch. Pediatr. Adolesc. Med. 160, 788. https://doi.org/10.1001/archpedi.160.8.788
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Monuteaux, M.C., Azrael, D., Miller, M., 2019. Association of Increased Safe Household Firearm Storage With Firearm Suicide and Unintentional Death Among US Youths. JAMA Pediatr. 02115, 1–7. https://doi.org/10.1001/jamapediatrics.2019.1078 Nance, M.L., Denysenko, L., Durbin, D.R., Branas, C.C., Stafford, P.W., Schwab, C.W., 2002. The ruralurban continuum: variability in statewide serious firearm injuries in children and adolescents. Arch. Pediatr. Adolesc. Med. 156, 781–5. https://doi.org/10.1542/peds.2017-3318 Nordstrom, D.L., Zwerling, C., Stromquist, A.M., Burmeister, L.F., Merchant, J.A., 2001. Rural population survey of behavioral and demographic risk factors for loaded firearms. Inj. Prev. 7, 112– 116. https://doi.org/10.1136/ip.7.2.112 Oatis, P.J., Fenn Buderer, N.M., Cummings, P., Fleitz, R., 1999. Pediatric practice based evaluation of the Steps to Prevent Firearm Injury program. Inj. Prev. 5, 48–52. https://doi.org/10.1136/ip.5.1.48 Okoro, C.A., Nelson, D.E., Mercy, J.A., Balluz, L.S., Crosby, A.E., Mokdad, A.H., 2005. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics 116, e370-6. https://doi.org/10.1542/peds.2005-0300 Parker, K., Horowitz, J., Igielnik, R., Oliphant, B., Brown, A., 2017. America’s Complex Relationship 18
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Journal Pre-proof Highlights
Community-based interventions can promote safer firearm storage, but little is known about those who attend.
We compared firearm storage practices of participants who lived with children to those who did not.
There was high prevalence of unlocked household firearms regardless of presence of children in
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This intervention reached a key population; adults who lived in households with children.
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the home.
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