Parents' behaviors, knowledge, and beliefs related to unintentional firearm injuries among children and youth in the southwest

ORIGINAL ARTICLE

Parents' Behaviors, Knowledge, and Beliefs Related to Unintentional Firearm • ur i es A mo n g Children and Youth in the Southwest Kelly

Knight-Bohnhoff,

& Mary

ents for having a gun was for orotection (61%). Only 8% of parents reported having discussed f rearm safety with a health care worker. None of the parents had discussed firearm safety with a pediatrician. A test of knowledge about firearm injuries revealed some gaps in knowledge~ with no significant differences between men and women or gun owners and non-gun owners. Discussion: Results suggest that firearms in the home continue to pose a significant risk to children. Anticipatory guidance from NPs and pediatricians is needed to protect children from unintentional firearm injuries. J Pediatr Health Care. (1998). 12, 139-146.

May/June 1998

B. H a r r i s ,

MSN, PhD

According to a recent report by the Centers for Disease Control (CDC) as cited in Meyer (1997), children in the United States are 12 times more likely to be killed than children in other industrialized countries. In 1990, 4941 children in the United States who were younger than 19 years of age died of gunshot wounds; 538 of these children were shot unintentionally (Fingerhut, 1993). Most unintentional deaths or injuries of children occur while they are playing with a handgun (Beaver et al., 1990) that they found loaded and unlocked in their home or in the home of a family member or friend (Camosy, 1996). Other factors identified in childhood shootings include easy availability of a gun (Lee & Sacks, 1990), lack of supervision by adults (CDC, 1995), male gender, black race, age from 15 to 19 years (Hammett, Powell, O'Carroll, & Clanton, 1992), living in the South and West (Christoffel, 1991), and living in nonmetropolitan regions (Hammett et al., 1992).

Kelly Knight-Bohnhoffis a Doctoral Candidatein the Collegeof Educationat the Universityof New Mexico, PsychologicalFoundations,in A]buquerque,New Mexico. Mary B. Harrisis a Professorin the Collegeof Educationat the Universityof New Mexico,Psychological Foundations,in Albuquerque,New Mexico. Reprintrequests:KellyKnight-Bohnhoff,MSN, 7008 PortulacaDr., NW, Albuquerque,NM 87120. Copyright© 1998 by the NationalAssociationof PediatricNurseAssociates& Practitioners. 0891-5245/98/$5.00+ 0 25/1/81364

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ORIGINALARTICLE

GUN OWNERSHIP AND STORAGE In the United States approximately 50% of American homes contain firearms (U.S. Department of Justice, 1993), and persons in households that contain guns report that they own an average of four guns (Cook, 1993). As many as 150 to 211 million firearms are in the hands of private citizens (U.S. Bureau of Alcohol, Tobacco and Firearms, 1991). An estimated 35 to 60 milhon handguns can be found in the United States, and approximately 2 million more handguns are manufactured in the United States annually (Zimring, 1991). Gun owners cite protection as the number one reason for owning a gun (Blendon, Young, & Hemenwa~ 1996). However, a recent study conducted by Kellermann et al. (1993) suggests that a gun kept in the home for personal protection is independently associated with an increased risk of homicide in the home. Furthermore, research suggests that people who grew up with guns in the home are more likely to own guns (Blendon et al., 1996).

Knight-Bohnhoff & Harris

Duggan, and Pakula (1992b) reported that half of all parents who owned guns believed that active strategies (i.e., education and supervision) were the best method of preventing gun injuries to children older than 12 years of age, although these strategies have generally been identified as much less effective than keeping guns out of the home (American Academy of Pediatrics, 1987).

STUDIES OF PARENTS The few published studies on parents and firearm safety beliefs and behaviors indicate that some parents have at least one gun in the home (Senturia, Christoffel, & Donovan, 1994; Wiley & Casey, 1993), that some parents who own guns (approximately 20%) keep them loaded, unlocked, and within reach of a child (Hemenwa~ Solnick, & Azreal, 1995; Senturia, et al., 1994; Wiley & Casey, 1993), and that handguns (27%) are more likely than rifles (3%) to be kept loaded in the house (Senturia et al., 1994). Previous research suggests that unrealistic beliefs about children's capabilities and behavioral tendencies related to guns are common among parents who own guns. Patterson and Smith (1987) found a marked discrepancy between gun owners and nonowners regarding the age at which parents believed children should be taught gun safety. Parents with a gun in their home gave an average age of 7.5 years as the ideal age at which children should be taught gun safety, whereas parents without guns considered 4.8 years to be the appropriate age (Patterson & Smith, 1987). Furthermore, Webster, Wilson,

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to attend.

knowledge, and beliefs concerning firearm safety. This study was designed as an exploratory descriptive study to provide some data about these practices and beliefs. In addition to collecting descriptive data, the relationship of behaviors, knowledge, and beliefs about firearm safety to two demographic variables, gender and gun ownership, was explored. It was hypothesized that men would be more likely to own guns than women and that gun owners would be less knowledgeable about gun injuries to children and youth than persons who did not own guns. Based on the findings of Patterson and Smith (1987) and Webster et al. (1992b), it was expected that parents would demonstrate gaps in their knowledge about firearm injuries to children and youth. The final prediction concerned the safety practices of gun owners. Based on previous research (Hemenway et al., 1995), it was predicted that approximately 20% of parents with children would admit to keeping a firearm within reach of a child and that a simi~ lar percentage would admit to either storing their firearms loaded or keeping the ammunition within reach of a child.

METHOD Only a small percentage (12%) of parents who own guns had spoken with pediatricians about gun safety (Patterson & Smith, 1987). Moreover, Webster et al. (1992b) found that 39% of parents who stated that they would be unlikely to follow a pediatrician's advice about gun safety said that they knew more about gun safety than their pediatrician or that they already followed gun safety procedures.

PURPOSES AND HYPOTHESES The research suggests that (a) firearm injuries are a serious risk factor for children and youth, (b) such injuries may be exacerbated by unsafe gun storage practices, and (c) parents may lack knowledge about how to prevent such injuries. Individual and communitybased interventions and safety counseling might serve to reduce the incidence of children's firearms injuries, but an effective program would require an understanding of parents' gun ownership patterns and their behaviors,

Participants Participants were 80 parents (43 men and 37 women) whose children attended a Kindercare Learning Center at one of six locations in a Southwestern city during the summer months of 1995. Their ages ranged from 22 to 49 years, with a mean of 34 years (SD = 5.70 years) and a median of 34 years. The typical respondent was male (54%), Anglo-American (70%), married (73%), lived in an urban or suburban area (81%), a homeowner (65%), had a college degree (70%), and had one (55%) or two (32%) children.

Procedure After approval from appropriate authorities had been obtained, parents from all six Kindercare sites in a Southwestern city were invited to fill out an anonymous voluntary questionnaire concerning their behaviors, knowledge, and beliefs about firearm injuries to children. The questionnaires were

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TABLE 1 Percentagesof correct responses to knowledge questions by gun ownership Gun owners (n = 38)

Non-gun owners (n = 42)

Total correct

Knowledgeitem

n (%)

n (%)

n (%)

1. The number-one killer of children is injuries 2. A gun in the home is much less likely to kill an intruder than a family member 3. Nearly all unintentional childhood shooting deaths occur in the home 4. Approximately 200,000,000 guns are owned by Americans 5. Boys (14 years old or younger) are more likely to be killed by handguns than girls 6. The majority of gun-related deaths in children are suicides and unintentional shootings 7. Most people arrested for murder have not been previously convicted of a felony 8. The risk of death from firearm injuries increases substantially from ages 10-20 years 9. People who are poor are more likely to be victims of violence than middle class or wealthy people 10. More than one half of handgun owners keep a gun loaded in the house at least some of the time

35 (92) 21 (55)

41 (98) 26 (62)

76 (95) 47 (59)

34 (90) 18 (47) 34 (90)

38 (91) 16 (38) 34 (81)

72 (90) 34 (43) 68 (85)

6 (16)

10 (24)

16 (20)

15 (40)

14 (33)

29 (36)

31 (82)

33 (79)

64 (80)

22 (58)

15 (36)

37 (46)

36 (95)

40 (95)

76 (95)

Datafrom Baker,S.P.,O'Neill, B., Karpf,R. (1984);Centersfor DiseaseControl(1990);Christoffel,K. (1991); Copeland,A. (1991); FederalBureauof Investigation(1993); Fingerhut,L.A.(1993);The GallupOrganization(1991); Kellermann,et al. (1993);Mercy,J.A.(1993);Wintemute,G., Teret,S., Kraus,J. (1987).

distributed while the parents were waiting to drop off or pick up their children or during special events; the questionnaires were returned to an envelope that was subsequently collected by the researchers. Educational workshops on firearm safety were offered at the centers after the parents had filled out the questionnaires, but only three parents, all from one center, chose to attend. Twenty questionnaires were provided to each site director to be distributed to the parents. One center director requested three additional questionnaires. Of the 123 questionnaires distributed to the six Kindercare sites, 80 were returned. This constitutes 65% of the total number of questionnaires distributed and 12% of the approximately 662 families with children at these sites.

Instrument The instrument was an anonymous five-page questionnaire. It began with questions concerning demographic information, gun ownership and storage, experiences related to firearm injury and crime, and discussions with others regarding firearm safety. To

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measure knowledge about firearm injuries to children, 10 multiple choice and true/false items were asked. A subsequent section of the questionnaire dealt with safety beliefs. Two openended questions asked participants to list the three most important things that parents who own guns can do to ensure the safety of a 5-year-old and a 12-year-old child. Additional questions concerned the importance of keeping guns out of the house, keeping guns unloaded, keeping ammunition stored away from guns, and teaching children h o w guns work. These answers were rated on a 7-point Likert scale ranging from 0 (not at all important) to 6 (extremely important). Participants were also asked about their interest in the following firearm safety features: a safety light, a child-proof trigger, and an owner combination or fingerprint lock mechanism.

edge test was established by using items for which correct answers have been documented (Table 1) and the fact that the expert answered all questions correctly. However, the internal consistency was low (Cronbach's alpha = 0.14), indicating that the items did not form a cohesive scale.

with a pediatrician,

Reliability and Validity To evaluate the content validity of the questionnaire, an expert in firearm prevention examined all the items for relevance and representativeness of the content domain. Validity of the knowl-

Data Analysis Data were analyzed with the Statistical Package for the Social Sciences X: Version 4.1 (Norusis & SPSS, Inc., 1988). The demographic characteristics

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TABLE 2 Things parents can do to ensure the safety of a 5-year-old child (n = 80) Listedfirst

Responses*~

Gun owners %

Teach/educate Keep guns unloaded Keep guns outof reach Keep guns out of the home Keep bullets separate from gun Hide the gun Get rid of the gun Lock the gun up Do not show gun to children

30 16 19 0 5 0 3 24 3

Listedsecond

Non-gun owners % 23 16 8 8 5 3 13 26 8

Gun owners % 24 14 3 0 16 3 3 19 0

Non-gun owners %

Didn't list

Listedthird Gun owners %

10 23 10 0 13 5 0 28 2

24 5 8 0 11 8 0 6 5

Non-gun owners % 21 10 3 0 21 2 2 13 0

Gun owners % 22 65 70 100 68 89 94 51 92

Non-gun owners % 46 51 79 92 61 90 85 33 90

*Responsesare not mutuallyexclusive.

fPercentagesdo not includenonrespondents.

of the sample were analyzed with descriptive statistics including means, standard deviations, frequencies, and percentages. Chi-squared tests of independence were used to examine the relationships among selected categoric variables. Factorial analysis of variance (ANOVA) was used to examine mean differences between groups. RESULTS

ing shot by a firearm (10%), immediate family members having been the victim of a crime (not defined on the questionnaire) (54%), their children playing with toy guns (77%), and having received firearm training (74%), a chisquared test of independence revealed that gun owners were significantly more likely to have had a gun in the home while growing up, chi-squared test (1, n = 80) = 16.08, p < 0.0001.

Gun Ownership and Exposure to Firearms Men in this study were more likely to own guns (66%) than were w o m e n (34%), chi-squared analysis (1, n = 80) = 4.22, p < 0.05. An ANOVA revealed that gun owners (mean = 34.63, SD = 5.35) and n o n - g u n owners (mean = 34.12, SD = 6.03) did not differ from each other with respect to age, F(1, 72) = 0.119, p > 0.05. Subsequent c_hi-squared tests of independence indicated that gun owners and n o n - g u n owners did not differ with regard to ethnicity, chisquared test (1, n = 80) = 2.69, p > 0.05, residence, chi-squared test (2, n = 80) = 3.51, p > 0.05, or living environment, chi-squared test (4, n = 80) = 7.16, p > 0.05. Experiences with Firearms and Crime Although both gun owners and those who did not own guns had similar experiences with family members having had a firearm accident (5%) or be-

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ment (3%), collection (3%), and snake shooting (3%). A slight majority of participants who owned guns (52%) indicated that they would pay extra to purchase a gun with a safety trigger (mean = $87.00), safety combination (mean = $93.93), or safety light (mean -- $82.14). Reasons given by parents for not owning guns were placed into mutually exclusive categories. The reasons reported by those who did not own guns were fear (10%), young children in the home (14%), too dangerous (24%), do not believe in guns (19%), and belief that guns are unnecessary (31%). Firearm Safety Behaviors of Gun Owners

guns in the house.

Most parents who owned guns kept bullets for the gun(s) in the house (74%). Half of the participants (50%) reported having shown the gun(s) to children living in their home. Most parents reported keeping the bullets within 5 feet of the gun(s) (42%), keeping the gun(s) loaded in the house (37%), and keeping the gun within reach of a child (18%). Twenty-nine percent of parents indicated that their children knew where the gun(s) were located in the house.

Reasons for Owning and Not Owning Guns

Firearm Safety Counseling

Gun owners reported owning a handgun (55%), rifle (71%), shotgun (40%), a n d / o r BB gun (24%). Reasons given by gun owners for purchasing the gun(s) were protection (61%), hunting (50%), recreation (45%), law enforce-

It was surprising that not one parent with a gun in the home reported having discussed firearm safety with a pediatrician. Only 8% of parents who owned guns reported having discussed firearm safety with another health care

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TABLE 3 Things parents can do to ensure the safety of a 12-year-old child (n = 80) Listedfirst

Listed second

Gun owners %

Non-gun owners %

Teach/educate

51

34

14

11

Keep guns unloaded Keep guns out of reach Keep guns out of the home Keep bullets separate from gun

14 8 0 3

11 8 2 0

17 3 0 11

0 0

2 10

11 0 8 5 5

18 3 8 3 0

Responses*'l"

Hide the gun Get rid of the gun Lock the gun up Do not show gun to children Professional instruction Firearm training Firearm practice

Gun owners %

Listed third Gun owners %

Didn't list

Non-gun owners %

Gun owners %

Non-gun owners %

19

10

16

45

24 8 2 16

2 6 3 8

18 0 6 16

67 83 97 78

47 84 90 68

0 0

6 2

0 0

2 5

100 100

90 74

20 0 6 3 3

13 3 2 0 0

13 0 0 3 0

11 0 0 0 0

56 100 86 89 92

58 94 90 97 100

Non-gun owners %

*Responsesarenot mutuallyexclusive. 4-Percentagesdo not includenonrespondents.

worker; 66% h a d discussed it with their spouse; 42% h a d discussed it with their children y o u n g e r than 12 years of age; 13% h a d discussed it with their children older than 12 years of age; a n d 21% indicated "none of the above."

Responses to Knowledge Questions Table i presents the items on the knowledge test a n d the percentages of g u n o w n e r s a n d n o n - g u n o w n e r s w h o answered them correctly. A 2 (gender) b y 2 (gun o w n e r s h i p ) A N O V A indicated that n o significant m e a n differences were f o u n d In the k n o w l e d g e scores b e t w e e n m e n ( m e a n = 6.80, SD = 1.16) a n d w o m e n ( m e a n = 6.39, SD = 1.55), F(1, 64) = 1.16, p > 0.05, n o r b e t w e e n g u n o w n e r s ( m e a n = 6.77, SD = 1.33) a n d n o n - g u n owners (mean = 6.48, SD = 1.35), F(1, 64) = 0.414, m e a n square error (MSE) = 1.80, p > 0.05.

Parents' Beliefs About Children's Abilities to Avoid Firearm Injury Parents were asked to indicate at w h a t age they t h i n k a child can be t a u g h t about g u n safety, can be taught h o w to shoot a g u n , can tell the difference b e t w e e n a real a n d a toy g u n , a n d can pull the trigger of a real gun. G u n owners ( m e a n = 5.85, SD = 3.85) indicated

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that a child should be taught g u n safety at a later age t h a n p a r e n t s w h o were n o n - g u n o w n e r s ( m e a n = 4.15, SD = 2.49), F(1, 69) = 5.10, MSE = 10.45, p < 0.05. There were n o significant effects of gender regarding the ages in years at w h i c h a child s h o u l d be t a u g h t g u n safety ( m e a n = 4.95, SD = 3.28), could distinguish between a real a n d toy g u n (mean = 7.55, SD = 3.61), could pull the trigger of a real g u n (mean = 3.64, SD = 2.58), or should be taught h o w to shoot a real g u n (mean = 12.22, SD = 4.26).

Parents' Ideas About Ensuring Children's Safety Related to Firearms Responses to a question asking parents to list in order the three most important things parents w h o o w n guns can do to ensure a 5-year-old child's safety (Table 2) a n d a 12-year-old child's safety (Table 3) were classified into eight different categories. These responses were n o t m u t u a l l y exclusive. C h i - s q u a r e d tests of independence comparing those w h o d i d a n d d i d n o t m e n t i o n each action revealed that g u n o w n e r s were significantly more likely t h a n n o n - g u n o w n e r s to m e n t i o n teaching or education to ensure a 5-year-old child's safety, chi-squared test (1, n = 76) = 5.07, p < 0.05 a n d a 12-year-old child's safety, chi-squared test (1, n = 75) = 7.17, p <

0.01. In addition, Fisher's exact test revealed that n o n - g r i n o w n e r s were significantly more likely t h a n g u n owners to m e n t i o n getting rid of a g u n as a w a y to ensure a 12-year-old's safety, p < 0.05. No other differences b e t w e e n g u n owners and n o n - g u n owners were statistically significant.

Parents' Beliefs About Firearm Safety in the Home A 2 (gender) b y 2 ( g u n ownership) A N O V A revealed that g u n o w n e r s ( m e a n = 2.00, SD = 2.03) considered k e e p i n g g u n s o u t of the h o m e as less i m p o r t a n t t h a n did n o n - g u n o w n e r s ( m e a n = 5.02, SD = 1.76), F(1,72) = 45.49, MSE = 3.67, p < 0.001. A second 2 x 2 A N O V A revealed that g u n o w n e r s ( m e a n = 4.61, SD = 1.84) considered it less i m p o r t a n t to keep g u n s u n l o a d e d than did non-gun owners (mean = 5.87, SD = 0.80), F(1,71) = 13.06, MSE = 2.00, p < 0.001. The score for n o n - g u n o w n e r s was v e r y close to the maxim u m possible score of 6 (extremely important) on this measure. G u n owners ( m e a n = 4.33, SD = 1.88) also con~ sidered it less i m p o r t a n t to keep a m m u n i t i o n separate from the g u n s than did n o n o w n e r s (mean = 5.82, SD = 0.82), F(1,71) = 17.29, MSE = 2.10, p < 0.001. Teaching children h o w g u n s w o r k w a s e q u a l l y i m p o r t a n t for g u n

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I ~ ORIGINALARTICLE owners (mean = 5.14, SD = 1.48) and n o n - g u n owners (mean = 5.11, SD = 1.49), F(1,71) = 0.053, p > 0.05. No significant effects of gender were found with regard to keeping guns out of the house, keeping guns unloaded, keepins ammunition stored away from guns, or teaching children how guns work.

Knight-Bohnhoff& Harris parents do not understand or care about the risks associated with firearms and how to avoid firearm injuries to the children living in their home.

DISCUSSION Firearm Ownership and Safety Behaviors Most of the findings with respect to gun ownership and safety behaviors are consistent with the results of other surveys, suggesting that these respondents are similar to other samples. Approximately half of parents surveyed were gun owners, with men more likely than w o m e n to own firearms. Consistent with previous findings, gun owners were more likely than n o n - g u n owners to have had a gun in the home while growing up (Blendon et al., 1996). This study supported the findings of others that the primary reason given for owning a gun is protection (Hemenway et al., 1995; Wiley & Casey, 1993). Of the 80 participants, 38 (48%) of parents surveyed reported keeping one or more guns in the home, which is comparable to other research studies (Cook 1993) and national gun ownership estimates (U.S. Bureau of Alcohol, Tobacco and Firearms, 1991). Contrary to other studies (Ropp, Visitainer, Uman, & Treolar, 1992) no statistically significant relationship was seen between gun ownership and urban, suburban, or rural residence. However, this finding may be a result of the small size of the study sample.

Firearm Safety Contrary to the recommendations of experts (American Academy of Pediatrics, 1987), most parents in this study who owned guns kept bullets for their guns in the house. Half of them had shown the guns to their children, and most of them either kept the gun loaded or kept the bullets within 5 feet of the gun(s). Some parents reported that their children knew where the guns were located (29%) and kept guns within the reach of a child (18%). These storage practices indicate that some

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Parents' Knowledge About Firearms and Unintentional Injuries Among Children To the best of our knowledge this is the first study that specifically asked parents to answer knowledge-based questions about firearm injuries and children. For the most part parents knew that injuries kill a large number of children each year, that nearly all unintentional childhood shooting deaths occur in the home, that boys are more likely than girls to be killed by handguns, and that half of handgun owners keep their gun loaded in the home at least some of the time. However, many parents did not know approximately how many guns are owned by Americans, the incidence of gun-related deaths among children, that most people arrested for murder have not been previously convicted, that the poor are more likely to be victims of violence than middle class or wealthy people, and that a gun in the home is much less likely to kill an intruder than a family member. These gaps in knowledge suggest that parents need to acquire information about how to protect their children from unintentional firearm injuries.

Parents' Firearm Safety Beliefs Most participants indicated that they needed a firearm for protection despite evidence that suggests that a gun kept in the home for protection increases the risk of homicide in the home (Kell-

ermann et al., 1993). Furthermore, the beliefs of parents who owned guns about firearm injury prevention were not consistent with the American Academy of Pediatrics' recommendations and those of other firearm injury prevention experts. The recommended passive strategies are: (a) removing a gun from the home, (b) storing guns unloaded and locked, and (c) storing the ammunition away from the gun in a locked area (American Academy of Pediatrics, 1987). When parents were asked to list the three most important things that parents who own guns could do to ensure a 5-year-old and a 12-year-old child's safety, 55% of gun owners and 45% of nonowners did not list any of the passive strategies recommended. Instead, 45% of gun-owning parents listed only relatively ineffective approaches as identified by the American Academy of Pediatrics (1987). Furthermore, none of the gun owners listed keeping guns out of the home as a means to ensure the safety of a 5year-old child. Only one gun owner listed keeping guns out of the home as a means to ensure the safety of a 12year-old child. Another indication of parents' misconceptions related to children's developmental capabilities involved the ages at which parents believed children could be taught firearm safety. As Patterson and Smith (1987) reported, gun owners suggested that gun safety be taught at a later age than parents who were n o n - g u n owners. These results suggest that some parents do not understand the developmental capabilities of their children.

A Role for Nurse Practitioners and Pediatricians Not one parent reported having discussed firearm safety with a pediatrician. Webster et al. (1992a) suggested that pediatricians and other health professionals could help educate parents and provide counseling about firearm injury prevention but are not yet doing so routinely. The results of this study appear to support this finding. Camosy (1996) also recommended that physicians ask parents about the presence of guns in their home and advise them on gun safety. When discussing firearm injury prevention with parents, health care pro-

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fessionals need to be aware that the important message for parents to receive is that gun(s) kept in the home are a hazard for children and that firearm injuries are preventable. Nurse practitioners and other health care professionals can fill the void by providing accurate information and education to parents and children. In accordance with national guidelines (STOP: Steps to Prevent Firearm Injury, 1996) health care professionals should dispel misconceptions parents may have about the benefits of gun ownership for protection. Parents should also be taught which behaviors are effective (remove the gun(s), keep the gun(s) unloaded, and/or lock up the gun(s) and ammunition separately) and which behaviors are ineffective (firearm training, telling children not to touch the gun(s), and/or hiding the gun[s] from children living in the home) (American Academy of Pediatrics, 1987). The firearm injury prevention role for nurse practitioners and other primary care providers can also include adding firearm safety counseling as a routine part of general injury prevention counseling, presenting firearm safety information to parents based on the developmental level of their children, and placing firearm injury prevention posters and brochures in waiting areas and examination rooms. Directing parents to resources like the American Academy of Pediatrics and the Center to Prevent Handgun Violence can also play an important role in educating parents about the risks of owning a gun that is accessible to children. Also, nurse practitioners and other health care professionals can be influential proponents of laws that prohibit the availability of guns and require that gun manufacturers add safety features to all guns made in the United States.

Methodologic Issues Three methodologic issues should be considered in interpreting the results of this study. First, the fact that this is a convenience sample of parents with children in day care in a single city limits the generalizability of the findings. It should be kept in mind that the number of parents surveyed was relatively small and that 35% of the question-

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naires distributed were not returned. A 4-month data collection period was used to permit parents with irregular schedules to participate, but some parents still chose not to complete the questionnaire. Nonparticipants may have been busier, less interested, or more hesitant to participate in research on this topic than participants. Second, the knowledge test had low internal consistency, possibly because of the small number and difficulty of items. A third methodologic issue is the validity of the questionnaire, because it depends on self-report. However, having the questionnaire be anonymous should have increased the validity of the responses.

~arentS~awareness O f firearm safety.

R e c o m m e n d a t i o n s for Future Research

The findings of this study suggest several areas for future research. Further inquiry into the influences of demographic variables such as gender, socioeconomic status, and ethnicity on gun ownership and firearm safety is needed. Based on the poor attendance for the educational workshops provided to parents in this study, further research on how to increase parents' interest in firearm safety counseling is of the utmost importance. The effects that the media and the culture of firearms in the United States have on beliefs about guns and gun ownership should be studied. Of particular interest is how firearm safety beliefs, behaviors, and knowledge of health care professionals affect their injury prevention

counseling behavior. Finally, a study of the barriers that exist in discussing firearm safety with parents would provide further insight about how to increase firearm safety° counseling among health care professionals.

CONCLUSIONS Despite the limitations of this stud)5 important insights can be gained from the responses of the parents who participated. First, some families with children keep loaded and unlocked guns in the home for protection, even though national organizations such as the American Academy of Pediatrics and Center to Prevent Handgun Violence warn parents of the danger of this practice (STOP: Steps to Prevent Firearm Injur~ 1996). Second, parents continue to have misconceptions about their children's developmental capabilities related to firearm safety practices. Either they do not take into account their children's emotional, psychological, and physical abilities, or they have not received the education needed to understand how to ensure their children's safe~. Education and changes in gun safety practices are clearly needed. Because parents live in a culture that glamorizes firearms, it is not surprising that they lack accurate knowledge about the effect of firearms and ways in which the risk of firearm injuries to children can be reduced. Television programming, movies, and other mass media may lead parents to purchase guns without recognizing the inherent risks to themselves or to their children living in the home. Health care professionals need to provide parents with clear and accurate information about firearm injury prevention so that these myths and misconceptions can be eliminated. A study of parents' beliefs about preventing gun injuries to children (Webster et al., 1992b) found that regardless of gun ownership status, 9 of every 10 parents indicated that they would be willing to tell their child's pediatrician whether they kept a gun in the home. As advocates for children and youth, nurse practitioners and physicians can play a critical role in increasing parents' awareness of firearm safety. Anticipatory guidance must begin to include questions about gun ownership and counseling about firearms.

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~_~ ORIGINALARTICLE We thank Kindercare Learning Centers, Inc., and the parents who participated. A special thanks to Ann Muscari, Janis Kuykendall, Cindy Keithley, Cathryn Newman, Kimberly Bryer, Pat Merewether, Ethel Johnson, and Cathey Purin-Halvorsen, who were instrumental in the distribution of the questionnaires.

REFERENCES American Academy of Pediatrics. (1987). Injury controlfor children and youth (pp. 136-144). Elk Grove Village, IL: American Academy of Pediattics. Baker, S. P., O'Neill, B., & Karpf, R. (1984). The injuryfact book:Lexington (Mass.) Books. Beaver, B., Moore, V., Peclet, M., Haller, J., Smialek, J., & Hill, L. (1990). Characteristics of pediatric firearm fatalities. Journal ofPediatricSurgery, 25, 98-100. Becket, T. M., Olson, L., & Vick, J. (1993). Children and firearms: A gunshot injury prevention program in New Mexico. American Journal of Public Health, 83, 282-283. Blendon, R. J., Young, J. T., & Hemenway, D. (1996). The American public and the gun control debate. Journal of the American MedicalAssociation, 275,1719-1722. Camosy, P. A. (1996). Incorporating gun safety into clinical practice. American Family Physician, 54, 971-975. Centers for Disease Control (CDC). (1995). BB and Pellet Gun Related Injuries- United States, June 1992-May 1994. Morbidity and Mortality Weekly Report, 44, 909-912. Centers for Disease Control (CDC). Fatal Injuries to Children-United States, 1986 (1990). Morbidity and Mortality Weekly Report, 39, 442-445, 451.

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Christoffel, K. (1991). Toward reducing pediatric injuries from firearms: Charting a legislative and regulatory course. Pediatrics,88, 294-305. Cook, P. J. (1993). Notes on the availability and prevalence of firearms. Journal of Preventative Medicine, 9(Supp. 1), 33-38. Copeland, A. (1991). Childhood firearms fatalities: The Metropolitan Dade County experience. Southern Medical Journal, 84,175-178. Federal Bureau of Investigation. (1993). Crime in the United States. Uniform Crime Reports, 1992. Washington, DC: U.S. Department of Justice. Fingerhut, L. A. (1993).Firearmmortality among children, youth, and young adults 1-34 years of age, trends and current status: United States, 19851990. Hyattsville, Maryland: U.S. Department of Health and Human Services, Public Health Service, CDC, 1993. (Advance data from vital and health statistics; no. 231). Gallup Organization. (1991). Handgun ownership in America. Princeton, NJ. Distributed by the Los Angeles Times Syndicate, May 19,1991. Hammett, M., Powell, K., O'CarroU, P., & Clanton, S. (1992). Homicide surveiliance---United States, 1979-1988. Morbidity and Mortality Weekly Report, CDC Surveillance, 41,1-33. Hemenway, D., Solnick, S., & Azrael, D. (1995). Firearm training and storage. Journal of the American Medical Association, 273, 46-50. Kellermenn, A., Rivara, F., Rushforth, N., Banton, J., Reay, D., Francisco, J., Locci, A., Prodzinski, J., Hackman, B., & Somes, G. (1993). Gun ownership as a risk factor for homicide in the home. The New England lournal of Medicine, 329,10841091. Lee, R. K., & Sacks, J. J. (1990). Latchkey children and guns at home. Journal of the American Medical Association, 264, 2210. Mercy, J. A. (1993). The public health impact of firearm injuries. JournalofPreventativeMedicine, 9(Suppl. 1), 8-11.

Meyer, T. (1997, February 7). Study: Guns kill more U.S. Kids. The Associated Press, Albuquerque Journal, p. AT. Norusis, M. J., & SPSS, Inc. (1988). SPSS-X introductory statistics guide: For Release 3. Chicago, IL: SPSS, Inc. Patterson, P., & Smith, L. (1987). Firearms in the home and child safety. American Journal of Diseases of Children, 141,221-223. Ropp, L., Visitainer, P., Uman, J., & Treolar, D. (1992). Death in the city: An American childhood tragedy. Journal of the American Medical Associations, 267, 2905-2910. Senturia, Y. D., Christoffei, K. K., & Donovan, M. (1994). Children's household exposure to guns: A pediatric practice-based survey. Pediatrics, 93, 469-475. STOP: Steps to Prevent Firearm Injury. (1996). American Academy of Pediatrics and Center to Prevent Handgun Violence(2nd ed). U.S. Bureau of Alcohol, Tobacco and Firearms (1991). How manyguns? Washington,D.C.: Author. U.S. Department of Justice, Bureau of Justice Statistics. 1993 Crime Victimization in the United States. Washington, D,C.: Author. Webster, D., Wilson, M., Duggan, A., & Pakula, L. (1992a). Firearm injury prevention counseling: A study of pediatricians' beliefs and practices. Pediatrics, 89, 902-907. Webster, D., Wilson, M., Duggan, A., & Pakula, L. (1992b). Parents' beliefs about preventing gun injuries to children. Pediatrics, 89, 908-914. Wiley, C., & Casey, R. (1993). Family experiences, attitudes, and household safety practices regarding firearms. Clinical Pediatrics,32, 71-76. Wintemute, G., Teret, S., & Kraus, J. (1987). The epidemiology of firearm deaths among residents of California. WesternJournal ofMedicine, 146, 374-377. Zimring, F. E. (1991, November). Firearms, violence, and public health policy. ScientificAmerican, 48-54.

NAPNAP's 20th Annual Nursing Conference on Pediatric Primary Care April 7-10, 1999 Marriott Rivercenter San Antonio, Texas Contact: Maureen Walker, A. J. J., Inc. (609) 256-2300

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