California Public Opinion On Health Professionals Talking With Patients About Firearms

Firearm-related injury and death are significant public health problems in the United States. US rates of death and injury from firearms are uniquely high relative to those of other high-income nations.¹ In 2017 the number of deaths attributed to firearms in the US surpassed the number of deaths from motor vehicle crashes for the first time in the nation’s history, and firearm-related injuries were the leading cause of death at each year of age from fourteen through twenty-two.² The case fatality rate for firearm injuries (that is, the proportion of cases presenting that result in a fatality) has remained stable since the early 2000s, and both hospitalization costs and lengths-of-stay have increased.^3,4 The total annual cost of firearm-related harm in the US has been estimated to exceed $229 billion.⁵

Major medical societies have issued statements describing firearm-related harm as a health problem and discussing the role that health professionals can play in its reduction.^6–8 A 2019 meeting of representatives of forty-four medical and public health organizations and the American Bar Association agreed on a nine-point plan for firearm injury prevention, including counseling by health care providers on the safe storage of firearms.⁹ Prior surveys have found that health professionals overwhelmingly believe that the prevention of firearm death and injury is within their clinical responsibilities.^10,11 Recently, firearm violence as a public health problem and the role of the health professional in its prevention have become prominent elements of public discourse.¹²

There are individual-level risk factors for firearm-related harm—such as a prior history of violence, ideation of harm to self or others, cognitive impairment, and substance misuse—that health care providers can reasonably identify during routine patient care.^13–18 In some situations, these risk factors are the reasons why patients come into contact with their health care providers.¹⁹ As suicides make up the largest share of firearm deaths and firearms are the most lethal method of suicide, provider-initiated lethal means assessments and firearm safety counseling when indicated may be especially important for firearm suicide prevention.^2,20

Having a firearm in the home increases the risk for firearm-related death for all household members.²¹ Unsecure firearm storage also raises the risk of harm, particularly from suicide and unintentional injury.^22–24 Limited evidence suggests that counseling on the importance of secure firearm storage improves patients’ storage habits,²⁵ which reduces access by unauthorized people. When someone at imminent risk has access to a firearm, counseling might not be enough: Health professionals may need to take further action, such as contacting the patient’s family or a mental health professional and discussing with the patient the possibility of a legal temporary transfer of firearms to a family member or another trusted person.^19,26,27

Yet conversations between health professionals and patients about risk and firearm safety remain uncommon, in part because of uncertainty among providers about identifying risk and appropriate safety recommendations.¹⁹ Few medical training and continuing education programs educate trainees on this topic.²⁸ Providers also report concern that patients might not be receptive to discussions about firearms.^11,19

According to the 2015 National Firearms Survey, roughly two-thirds of a representative sample of US adults reported that provider discussion about firearms was generally appropriate.²⁹ Other research suggests that majorities of patients find health professional discussions of firearm risk and safety appropriate, especially when clinical relevance is established.¹¹ However, neither the survey nor other studies have included questions about the appropriateness of these discussions when a patient has a specific risk factor or about specific provider interventions when risk is imminent.

While California has relatively low rates of firearm ownership³⁰ and firearm-related death,³¹ it had the second-highest number of firearm deaths among all states in 2017, and nearly half of all violent deaths in the state involve firearms.^2,32

Using state-representative data on 2,558 respondents to the 2018 California Safety and Wellbeing Survey (CSaWS), this study extends the existing literature by examining not only the perceived appropriateness of health professionals’ discussing firearm safety with their patients in general, but also the perceived appropriateness of these conversations when specific risk factors are present and the perceived appropriateness of specific provider interventions when someone is at imminent risk of harm. The findings may be useful in the context of developing clinical strategies for injury prevention.

Study Data And Methods

Data Sources And Study Sample

The 2018 CSaWS was an online statewide survey designed by the University of California Davis Violence Prevention Research Program and administered in fall 2018 by Ipsos Public Affairs, LLC (formerly the GfK Group). The survey collected information on topics including exposure to and consequences of violence, opinions on selected violence prevention policies, and firearm ownership.

Respondents were drawn from the Ipsos KnowledgePanel, a 55,000-member nationwide research panel that included approximately 6,700 California residents at the time CSaWS was fielded. Panel members are randomly selected on an ongoing basis with address-based sampling from the Delivery Sequence File of the US Postal Service. Latinx households and households with at least one member ages 18–24 are oversampled. Panel-member households are provided with internet access and a web-enabled device as needed.

All panel members ages eighteen and older and residing in California, except those currently serving in the US Armed Forces, were eligible to participate in CSaWS, which was offered in both English and Spanish. Demographic information was provided by panel members at the time of enrollment in the panel and included age, sex, race/ethnicity, education, income, veteran status, and presence of children in the home. Of the 5,232 eligible panel members who were emailed an invitation to participate, 2,558 (49 percent) completed the survey. The median completion time was nineteen minutes.

Survey Instrument And Key Variables

Respondents were asked, “In general, how often is it appropriate for doctors and other health professionals to talk to their patients about” six health-related topics (seat belt use, cigarette smoking, alcohol and drinking, healthy diet, physical activity, and gun safety), which appeared in a random order. Next, respondents were asked, “How often is it appropriate for doctors or other health professionals to talk to patients about gun safety when the patient has guns in the home and” exhibits one of an array of personal risk factors (for example, thoughts of suicide, substance misuse, or dementia). Respondents were then asked, “When a doctor learns that their patient has a gun and is thinking of using it to hurt themselves or someone else, how often is it appropriate to” intervene by counseling the patient not to hurt anyone, counseling the patient to have someone else keep the gun, informing the patient’s family, informing the police, or informing a mental health professional. Respondents could answer “never,” “sometimes,” “usually,” or “always appropriate” or “don’t know” to each question. The exact questionnaire wording is in online appendix exhibit 1.³³

We examined the distributions of responses to these three questions and collapsed “sometimes” and “usually appropriate” into one category. For readability and consistency with prior research, in the text we generally refer to “sometimes,” “usually,” and “always appropriate” as “at least sometimes appropriate.”²⁹ Respondents who refused to answer these questions (1.1–3.0 percent, depending on the question) were excluded from analyses.

Respondents were grouped by firearm ownership status: those who owned one or more firearms (“owners”), those who did not own a firearm but who lived in homes with one or more firearms (“lived with owners”), and those who neither owned a firearm nor lived in a home with a firearm (“non-owners”). Respondents who refused to answer ownership questions (0.7 percent) or did not know if someone in their home owned firearms (3.4 percent) were excluded from analyses stratified by this item. A breakdown of counts and percentages of respondents in each ownership category is in appendix exhibit 2.³³

We also asked all respondents whether they had grown up in homes with firearms, and we asked owners about firearm storage practices in the home (that is, were firearms kept locked up or unlocked and unloaded or loaded).

Statistical Analysis

CSaWS data have been weighted to be representative of the adult population of California. The final weight variable combined a base weight (which accounted for the probability of selection into the KnowledgePanel) and a CSaWS-specific poststratification weight (which accounted for survey nonresponse and differences in categories of age, sex, race/ethnicity, Latinx origin, education, household income, and English-Spanish language proficiency between respondents and the adult population of California, as reflected in the Census Bureau’s 2016 American Community Survey).

To examine public opinion on health professionals talking with patients about firearms, we calculated weighted proportions with 95% confidence intervals for each measure or cross-tabulation of measures using Stata SE, version 15.1, and the SVY suite of commands.

CSaWS was approved by the University of California Davis Institutional Review Board.

Limitations

This study had several limitations. First, some stratifications resulted in small subgroups, which made some secondary analyses untenable.

Second, the findings might not be generalizable to other states, relative to which California has low rates of gun ownership, low rates of firearm suicide, and more comprehensive firearm regulations. Because of the survey design and sample size, we were unable to estimate geographic variation in opinions or variation between urban and rural respondents within the state.

Third, CSaWS relies on self-report and is subject to nonresponse bias. However, nonresponse rates were low in our sample, particularly for firearm-related questions. Furthermore, evidence suggests that completion rates are higher and social desirability bias lower in online panel surveys than in those using the random-digit-dialing survey approach.^34,35 Compared with respondents to our survey, KnowledgePanel members who were invited to participate in the survey but did not do so were more likely to be younger, female, Latinx, and less educated; to have a lower income; and to live in a home with children.

Study Results

Minorities of respondents were owners (14.4 percent; 95% CI: 12.5, 16.4) or lived with owners (10.5 percent; 95% CI: 8.7, 12.6) of firearms. Respondents’ demographic characteristics by ownership status are in appendix exhibit 3.³³

Appropriateness Of Firearm Safety Conversations In General

Approximately two-thirds (67.1 percent; 95% CI: 64.0, 69.9) of respondents indicated that, in general, it was at least sometimes appropriate for health professionals to talk with their patients about gun safety (appendix exhibit 4).³³ Conversations about smoking, healthy diet, physical activity, alcohol and drinking, and seat belt use received more support.

Fewer firearm owners reported that conversations about gun safety were at least sometimes appropriate (52.3 percent; 95% CI: 45.1, 59.4), compared with respondents who lived with owners (75.0 percent; 95% CI: 66.4, 81.9) and nonowners (69.8 percent; 95% CI: 66.1, 73.2) ($p<0.0001$ for all comparisons; appendix exhibit 5).³³ Two-fifths of owners (40.6 percent; 95% CI: 33.6, 48.0) reported that gun safety conversations, in general, were never appropriate (appendix exhibit 5).³³

Larger proportions of women, respondents ages 30–44, and those living in households with children younger than age 18 reported that these conversations were at least sometimes appropriate (appendix exhibits 6–10).³³

Appropriateness In Specific Risk Scenarios

In each of five selected scenarios of specific risk, more than 80 percent of respondents indicated that it was at least sometimes appropriate for health professionals to talk with patients who have guns in the home about gun safety (exhibit 1). The largest majority of respondents (90.2 percent; 95% CI: 88.1, 92.0) found these discussions appropriate when the patient had trouble with drugs or alcohol, followed by when a patient had thoughts of suicide (89.7 percent; 95% CI: 87.4, 91.6) (exhibit 1 and appendix exhibit 11).³³ A smaller share of respondents found these conversations appropriate when there were children or teens in the patient’s home (83.7 percent; 95% CI: 81.2, 85.9).

SOURCE Authors’ analysis of information from the 2018 CSaWS database. NOTES Analyses include all respondents regardless of missingness on household gun ownership status. All percentages are weighted. Online appendix exhibit 11 contains the data and 95% confidence intervals for the exhibit (see note 33 in text).

Generally, for all of the risk scenarios, larger proportions of older respondents, females, and respondents living in households with children reported that the conversations were at least sometimes appropriate (appendix exhibits 6–10).³³

Levels of perceived appropriateness did not differ substantially by firearm ownership status for four of the five selected risk factors (exhibit 2). However, compared with other ownership groups, fewer owners reported that gun safety conversations were at least sometimes appropriate when the patient lived with children or teens.

Appropriateness Of Specific Interventions, Given Risk

When a patient was said to have a gun and to have thoughts of self- or other-directed harm, most respondents indicated that it was at least sometimes appropriate for a doctor to intervene (exhibit 3). The largest proportions of respondents reported that counseling the patient not to hurt anyone (89.9 percent; 95% CI: 87.8, 91.7) and informing the patient’s family (88.6 percent; 95% CI: 86.4, 90.4) were at least sometimes appropriate (exhibit 3 and appendix exhibit 12).³³ The perceived appropriateness of informing the police was slightly lower (84.0 percent; 95% CI: 81.5, 86.1).

SOURCE Authors’ analysis of information from the 2018 CSaWS database. NOTES Analyses include all respondents regardless of missingness on household gun ownership status. All percentages are weighted. Online appendix exhibit 12 contains the data and 95% confidence intervals for the exhibit (see note 33 in text).

Demographic patterns in support for all five interventions were similar to those observed for the risk scenarios (appendix exhibits 6–10).³³

Owners, people living with owners, and nonowners had high and generally similar levels of support for intervention when the patient had a firearm and thoughts of self- or other-directed harm (exhibit 4).

Respondents Who Reported That Conversations Are Never Appropriate ‘In General’

Of the respondents who reported that it was never appropriate to discuss gun safety with patients “in general” (20.3 percent; 95% CI: 17.9, 22.9) (appendix exhibit 4),³³ majorities felt that these conversations were at least sometimes appropriate when the provider knew there was a gun in the home and there was specific risk: 83.1 percent (95% CI: 77.5, 87.5) when a patient had suicidal thoughts, for example, and 59.7 percent (95% CI: 52.9, 66.1) when children or teens were in the home (appendix exhibit 13).³³ Majorities of these respondents also found each of the provider interventions at least sometimes appropriate: for example, 80.2 percent (95% CI: 74.0, 85.2) for contacting the patient’s family and 78.2 percent (95% CI: 71.9, 83.4) for counseling the patient to have someone else keep the gun.

Discussion

In this 2018 survey that is weighted to be representative of the California population of adults, two-thirds of respondents reported that doctors and other health professionals talking with their patients about gun safety was at least sometimes appropriate in general—a finding nearly identical to that of the National Firearms Survey from 2015. Overall, in comparison to that survey, we found similar demographic patterns among respondents who reported that gun safety conversations were at least sometimes appropriate.

Support For Gun Safety Conversations Increased When Risk Was Elevated

Reported appropriateness for conversations in general differed among ownership groups, but appropriateness when a specific risk was present did not. While two-fifths of owners reported that these conversations were never appropriate in general, more than four-fifths of owners found that these conversations were at least sometimes appropriate for four of the five selected risk scenarios.

Health professionals may hesitate to discuss firearm safety with patients for fear of alienating or offending them, but our findings suggest that most patients are receptive—especially when the conversations happen in the context of risk reduction (that is, providers use the recommended risk-based, rather than universal, approach).^19,27 While providers may be especially hesitant to discuss firearm safety with firearm-owning patients, our results suggest that owners are also receptive when risk factors are present. Gun-owning patients may find this risk-based approach, and a conversation that is culturally appropriate and directly relevant to the health and safety of the patient or someone in the patient’s home, to be most appropriate.²⁷

Fewer owners found gun safety conversations appropriate when a gun-owning patient lived with children or teens than when individual risk factors—for example, substance misuse or cognitive impairment—were present. This finding may suggest that owners perceive more risk among those with individual-level risk characteristics than those at risk by belonging to a demographic group at elevated risk (such as children and adolescents).

Yet prior research shows that parents who own firearms may underestimate their children’s access to and handling of firearms in the home and that firearm safety programs for children do not decrease the likelihood of unsupervised firearm handling.^36–38 Conversations between pediatric providers and parents may differ depending on whether the parent is the firearm owner or not. When providers talk about firearm safety with parents, it may be important to discuss elevated risk of injury and death for children, both for unintentional injury and for self-harm,³⁹ when there is access to firearms.

Given Imminent Risk, Respondents Supported Provider Intervention

These findings also suggest that, given imminent risk (that is, a patient has a firearm and thoughts of self- or other-directed harm), respondents of all ownership status groups find health professional intervention at least sometimes appropriate.

To our knowledge, there are no other estimates of public support for counseling patients to have someone else keep their firearms when they have expressed thoughts of self- or other-directed harm. Temporary transfer is a recommended practice for reducing access to firearms during times of crisis, and these results suggest that many owners believe this is an appropriate risk-reduction intervention. Health professionals should understand mechanisms and practices in their states for intervening to reduce risk of injury in extreme risk situations. For example, states’ regulations regarding the temporary transfer of firearms to others during crises vary, and understanding local policies may help health professionals make lawful and realistic recommendations.⁴⁰

Conclusion

A majority of Californians find conversations about gun safety between health professionals and their patients appropriate when a patient has a gun and a risk factor for firearm-related harm is present. Although fewer gun owners find these conversations appropriate in general compared with nonowners, these results support the current recommendation for providers to use a focused, risk-based approach to firearm safety counseling. Our results can inform health professionals who may be hesitant to engage in conversations about firearm safety with at-risk patients.

Given that these conversations are broadly acceptable, health professionals, professional societies, researchers, and others from the fields of injury and suicide prevention should work with gun owners, firearm safety instructors, and experts in firearm safety to develop and evaluate curricula for medical trainees and practitioners on identifying risk and discussing risk and firearm safety with patients in a culturally appropriate manner.

In California and elsewhere, education on available interventions to reduce firearm access for patients at imminent risk of firearm-related harm could be especially useful. The 2019–20 California state budget includes support for statewide health professional training on clinical strategies for firearm injury prevention.^41,42 Future research should evaluate the effectiveness of this training for reducing firearm-related harm, as well as additional mechanisms to increase the involvement of health care providers in efforts to prevent firearm injury and death.

ACKNOWLEDGMENTS

This research was supported by the University of California Firearm Violence Research Center with funds from the State of California. Additional support came from the California Wellness Foundation (Award No. 2014-255), the Heising-Simons Foundation (Award No. 2017-0447), the Langeloth Foundation (Award No. 1824), and the University of California Davis Violence Prevention Research Program.

NOTES

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