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Pediatric Residents' Attitudes and Behaviors Related to Counseling Adolescents and Their Parents About Firearm Safety
Barry S. Solomon, MD, MPH;
Anne K. Duggan, ScD;
Daniel Webster, ScD, MPH;
Janet R. Serwint, MD
Arch Pediatr Adolesc Med. 2002;156:769-775.
ABSTRACT
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Background Firearms continue to be a major cause of mortality in adolescence. Although
the American Academy of Pediatrics strongly encourages pediatricians to counsel
adolescents and their parents on firearm safety, few residency programs educate
their trainees in this area. More in-depth information is needed to design
effective educational interventions.
Objectives To determine the attitudes, beliefs, and practices of pediatric residents
regarding firearm safety counseling and to compare their counseling practices
for adolescents and parents of adolescents during health maintenance visits.
Design Cross-sectional survey.
Participants Pediatric residents from 9 programs in the mid-Atlantic region.
Results Of the 322 respondents (76% response rate), few believed that it is
not a pediatrician's responsibility to counsel, that their patients are not
at risk for firearm injury, and that children are safer with a gun in the
home. However, only 50% reported routine counseling, and more than 20% reported
almost never counseling adolescents and their parents on firearm safety. Barriers
included inadequate training (38%), insufficient time (26%), and a lack of
preceptor expectation (13%). The strongest predictors for counseling adolescents
included the belief that gun-related media coverage influences counseling
practice, level of training, and personal experience with guns in the home.
The strongest predictors for counseling parents of adolescents were the belief
in the media's influence on counseling practice, perceived counseling effectiveness,
and discomfort with firearm safety counseling.
Conclusions To increase counseling practices, clinical preceptors should aim to
strengthen residents' comfort in counseling and to develop specific ways to
enhance their perceived effectiveness in counseling parents.
INTRODUCTION
ALTHOUGH RECENT US data show a decrease in firearm-related mortality,
firearms continue to be a significant threat to the lives of children and
adolescents. In 1999, there were 1990 homicides, 1078 suicides, and 297 unintentional
or undetermined firearm-related deaths in children 19 years old and younger.
Eight-five percent of these fatalities occurred among individuals 15 to 19
years old.1 Thirty percent to 40% of households
contain firearms, and one third to half of these firearms are kept loaded,
unlocked, and easily accessible.2-3
A 1999 study found that more than 75% of the firearms used in youth suicides
and unintentional shootings had been stored in the child's home or in the
home of a friend or relative.4 Because of the
impulsive nature of many of these deaths, a significant proportion may have
been prevented if firearms were stored appropriately.5-6
Promoting safe firearm storage is a national priority and is strongly
encouraged by major health organizations. Healthy People
2000 recommends the development of educational interventions to "convince
parents to decrease their children's access to loaded firearms."7(p237) Healthy People 2010 strengthened its objectives with the
aim "to reduce the proportion of persons living in homes with firearms that
are loaded and unlocked."8(p15) In April 2000,
the American Academy of Pediatrics reaffirmed its previous recommendation
urging pediatricians to counsel patients and families about firearm safety
during health maintenance visits.9 Although
a recent study of practice-based firearm safety counseling failed to show
a significant effect on parental gun safety behavior,10
the educational intervention was a brief, one-time message that may not have
successfully applied effective patient-physician communication strategies.
Since pediatric health care providers continue to encounter families who store
guns inappropriately,3, 11 they
have a unique opportunity and responsibility to address this important issue.
Although pediatricians do believe they have a responsibility to educate
parents on firearm safety,12-13
and parents report being receptive to such counseling,14-15
few pediatricians routinely provide this guidance to families.13, 16-17
One important barrier to counseling is the lack of education during residency
training.18 In a recent national survey of
US pediatric residency program directors, only one third of the pediatric
residency programs offered their residents formal training on firearm safety
counseling. In residency programs without training, major barriers included
the lack of educational materials and the absence of trained personnel.19
While prior studies have investigated practicing physicians' violence
prevention screening,12, 18, 20
to our knowledge, none has specifically addressed residents' firearm safety
counseling practices during adolescent visits. Considering that adolescents
are at a disproportionately greater risk than younger children, we felt a
more in-depth evaluation was needed to identify the strongest determinants
for counseling. This study investigates pediatric residents' attitudes, beliefs,
and practices regarding firearm safety counseling and compares practices for
adolescents and parents of adolescents during health maintenance visits. The
results will be helpful for the design of resident educational interventions
on firearm safety counseling.
MATERIALS AND METHODS
QUESTIONNAIRE DEVELOPMENT
A 30-item questionnaire on attitudes, beliefs, and firearm safety counseling
practices was developed and administered to pediatric residents. The questionnaire
design was based on a conceptual framework, a review of the literature, previously
used instruments,13, 18, 21
and information obtained in 2 focus groups.
Guided by the Precede-Proceed Planning Model framework22
and the Health Belief Model,23 we developed
a conceptual framework to characterize our hypothesized personal, interpersonal,
and environmental factors influencing a pediatric resident's firearm safety
counseling practice. Two focus groups were then conducted using prewritten,
open-ended questions, and a facilitator-led discussion. The focus groups were
composed of fourth-year medical students entering pediatric residency programs
and graduating pediatric residents from The Johns Hopkins University School
of Medicine, Baltimore, Md. We felt these groups would enable us to assess
residents' beliefs prior to and at the completion of their residency training.
Personal factors from the focus groups included the experience growing up
with a gun in the home and beliefs about the importance of counseling. Interpersonal
factors included preceptor expectations, while environmental factors included
time constraints during visits and the availability of educational handouts.
Questionnaire items were developed to measure these concepts as well as previously
identified determinants from studies of pediatricians and resident physicians.11, 13, 24
The questionnaire collected demographic information about each participant,
as well as clinical experience with firearm-related injury and perceived counseling
effectiveness. Residents were asked to report their frequency of anticipatory
guidance counseling on several age-specific topics recommended by Bright Futures25 and the American Academy
of Pediatrics.26 Age-specific items were used
since the content, style, and frequency of counseling for patients and parents
are likely to vary for different-aged children. Several focus group members
commented on the challenges of adjusting their counseling style for children
and adolescents, compared with counseling for parents. Therefore, we assessed
counseling frequency during adolescent visits separately for adolescents and
parents of adolescents. Adolescents were defined as children 12 years or older.
For each topic, counseling frequency was defined as the proportion of adolescents
and parents the residents report counseling during routine health maintenance
visits. Responses to these counseling frequency items were based on a 5-point
ordinal scale, ranging from "almost never"(1) to "almost always" (5). In addition,
questionnaire items assessed the residents' agreement with 16 statements based
on our hypothesized determinants. After the questionnaire was developed, it
was piloted with 6 recent pediatric residency program graduates. Prior to
study implementation, approval was obtained from the institutional review
board of The Johns Hopkins University School of Medicine, as well as other
institutions as necessary.
SURVEY ADMINISTRATION
The principal investigator (B.S.S.) contacted residency directors of
12 pediatric programs in the mid-Atlantic region to invite their participation
in the study. Nine residency directors agreed to participate. In most programs,
pediatric residents rotate through a separate adolescent clinic in addition
to maintaining a small panel of adolescent patients in their continuity clinic.
The survey included categorical pediatric residents in these programs between
February 5, 2001, and April 27, 2001. Questionnaires were mailed or hand-delivered
to the director of each program. Either the program director or chief resident
distributed, collected, and mailed back the completed questionnaires. At the
program directors' discretion, residents completed the surveys in a group
(eg, prior to a clinic conference) or during their free time. Confidentiality
was assured and residents were offered a bookstore gift certificate as compensation
for participating in the study.
DATA ANALYSIS
Our 2 primary outcome variables were the residents' reported frequency
of firearm safety counseling for adolescents and for parents of adolescents
during health maintenance visits. Since we aimed to examine differences in
residents who counsel less frequently compared with those who counsel more
routinely, the 5-point response scale (1 indicates almost never counsel; 2,
sometimes counsel [approximately one quarter of the patients and/or their
families]; 3, counsel half of the patients and/or their families; 4, usually
counsel [approximately three quarters of the patients and/or their families];
and 5, almost always counsel) was dichotomized into responses of less than
half (responses 1 and 2) and about half or more of their patients and/or their
families (responses 3-5). For the remainder of the analysis and discussion,
we define "routine firearm safety counseling" as counseling about half or
more adolescents and/or their parents during health maintenance visits (responses
3-5). To assess responses regarding our hypothesized determinants, we used
a 5-point Likert scale ranging from "strongly disagree" (1) to "strongly agree"
(5).
Survey responses were analyzed using Stata version 6.027
and SPSS version 10.0,28 and descriptive statistics
were used to characterize the study population. Our 16 questionnaire items
related to firearm safety counseling were thought to be related to one another,
which could lead to multicollinearity. To avoid this problem, principal component
factor analysis with variance maximization rotation was used to identify sets
of items with a high degree of intercorrelation that represent conceptually
meaningful constructs. A factor loading cutoff of 0.4 was used and additive
scales were developed for the 2 factors identified: discomfort in firearm
safety counseling and perceived ineffectiveness in counseling ability. Both
factor scales showed good inter-item correlation using the Cronbach 
test of reliability (>.7). Questionnaire items that did not fall into
these constructs were used as independent variables in the analysis.
Using binary logistic regression, each independent variable was evaluated
for association with the 2 dependent variables related to routine firearm
safety counseling. Generalized estimating equations enabled us to cluster
the analyses to account for the lack of independence of observations within
residency programs. Variables with association approaching statistical significance
(P<.10) were then placed into 2 multivariate logistic
regression models to identify the independent effects of our hypothesized
determinants, controlling for all other variables. After regression models
are developed, variance inflation factors are commonly used to detect multicollinearity
among independent variables. If a model contains collinear predictors, the
variance estimates are typically inflated. Variance inflation factors were
used to assess collinearity of independent variables, with a cutoff of <10.
RESULTS
Questionnaires were completed by 322 (76% response rate) of the 421
residents in 9 participating residency programs. Table 1 summarizes the sample demographics. The median age of survey
respondents was 28 years, and there was a fairly uniform distribution by level
of training. Two thirds were female and most were white. Most reported their
residency program was located in an urban setting and about one third plan
to enter private practice after completion of their training.
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Table 1. Characteristics of 322 Surveyed Residents*
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Figure 1 compares firearm
safety counseling practices among respondents during health maintenance visits
for adolescents and parents of adolescents using the 5-point ordinal scales
from the questionnaire. When the outcome variables were dichotomized for analysis
and interpretation (responses 3-5), reported routine counseling rates for
adolescents and parents of adolescents were 51% and 46%, respectively.
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Frequency of firearm safety counseling during adolescent health maintenance
visits.
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There was considerable variability in residents' responses to the questionnaire
items related to firearm safety counseling. More than one third of the residents
believed they have not been adequately trained to discuss firearm safety,
and 32% did not think their advice would change a family's behavior regarding
firearm removal from the home. Few residents (1%) believed their patients
are not at risk for firearm injury, that children are safer with a gun in
the home, and that it is not a pediatrician's responsibility to talk about
guns. Twenty-eight percent of the residents reported growing up with a gun
in the home and more than half have had clinical experience with firearm-related
injuries. More than one third believed that gun-related media coverage has
motivated them to counsel, and only 13% believed their continuity clinic preceptors
did not expect them to counsel. About half of the residents believed their
continuity clinics lacked educational materials and 26% felt they did not
have time to counsel.
At the bivariate level of analysis, many personal determinants were
significantly associated with routine firearm safety counseling (Table 2 and Table 3). Not surprisingly, residents who felt more discomfort and
ineffective in their counseling skills were less likely to counsel routinely.
The odds of counseling for residents who have a gun in the home, compared
with those without a gun in the home, were about 50% less for counseling adolescents
(odds ratio [OR], 0.47; 95% confidence interval [CI], 0.29-0.77) and almost
50% less for counseling parents (OR, 0.53; 95% CI, 0.30-0.93). Third-year
residents were almost twice as likely as first-year residents to counsel adolescents
routinely (OR, 1.9; 95% CI, 1.2-3.1), but this relationship did not persist
for counseling parents.
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Table 2. Bivariate Predictors of Routine Firearm Safety Counseling
for Adolescents
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Table 3. Bivariate Predictors of Routine Firearm Safety Counseling
for Parents of Adolescents
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The 2 hypothesized interpersonal factors—preceptor expectations
and the belief that gun-related media coverage motivated the resident to counsel—were
also significantly associated with counseling at the bivariate level. The
only statistically significant environmental barrier to routine counseling
was the perception of time constraints during well-child care visits. The
odds of counseling for residents who agreed they do not have time to counsel
were about 40% to 50% less than the odds for those who disagreed.
Table 4 summarizes the final
multivariate models. The following 3 factors were independently associated
with counseling for adolescents: level of training (third-year residents vs
first-year residents: OR, 1.8; 95% CI, 1.04-3.2), personal gun-related experience
(grew up with a gun in the home: OR, 0.67; 95% CI, 0.50-0.91), and the belief
that gun-related media coverage has motivated the resident to counsel (OR,
1.8; 95% CI, 1.2-2.8). Factors associated with counseling parents of adolescents
included perceived counseling effectiveness (somewhat vs not or little: OR,
3.6; 95% CI, 1.6-8.0; and very/extremely vs not or little: OR, 4.8; 95% CI,
2.1-10.9), discomfort in firearm safety counseling (OR, 0.77; 95% CI, 0.65-0.91),
and the belief that gun-related media coverage has motivated the resident
to counsel (OR, 1.6; 95% CI, 1.02-2.5). Collinearity did not exist among independent
variables in the multivariate models (all variance inflation factors <10).
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Table 4. Multivariate Predictors of Routine Firearm Safety Counseling
During Adolescent Visits
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COMMENT
Since 1992 the American Academy of Pediatrics has published recommendations
strongly encouraging pediatricians to counsel families about firearm safety,
but counseling practices continue to lag behind. Our finding that 50% of residents
routinely counsel adolescents and their parents is considerably greater than
estimates found in prior studies.17-18,24
Even so, we found that about 20% to 25% of residents almost never counsel
in this area. While these numbers are somewhat disappointing, they should
not be surprising. Residents attain their clinical knowledge and skills through
formal education, informal teaching discussions, and faculty modeling.29 Since only one third of pediatric residency programs
educate their trainees about firearm safety counseling,19
it is understandable that residents do not routinely provide this type of
guidance. In our study, although only 13% of residents believe their preceptors
do not expect them to discuss firearm safety, 38% feel they have not been
adequately trained to do so.
Various violence prevention curricula have successfully been integrated
into residency programs and some have shown positive effects on residents'
practices. Johnson et al30 found that a one-time
intervention led to a significant increase in the percentage of visits in
which a resident discussed guns or violence. In an intervention study focusing
on adolescent violence, Abraham et al31 showed
improved physician comfort and violence screening practices. In our study,
we specifically focused on residents' attitudes, beliefs, and practices on
firearm safety counseling to assist with the development of educational interventions.
In our multivariate analyses, different factors predicted counseling for adolescents
vs parents of adolescents. Taking a closer look at the actual factors, we
suggest how different educational approaches might be used to promote counseling
for these 2 audiences.
For counseling adolescents, third-year residents are more likely than
first-year residents to discuss firearm safety, but this relationship does
not persist for counseling parents of adolescents. Perhaps senior-level residents
feel more comfortable than less experienced residents in addressing sensitive
issues with teenagers. This difference may be related to the perception of
greater counseling ability with a higher level of training. Prior literature
does suggest that perceived counseling effectiveness is associated with physician
counseling behavior.32 To investigate this
further we assessed residents' perceived effectiveness for counseling on firearm
safety, as well as for counseling in general. Although perceived general counseling
effectiveness is strongly associated with counseling parents, it is not a
significant factor for counseling adolescents. This might be explained by
the type of adolescent education residents receive. It has become common for
residents to use structured frameworks for interviewing adolescents. These
interviewing frameworks provide physicians with an organizational structure,
often using mnemonics to guide the psychosocial history.33
With such frameworks, perhaps more experienced residents develop greater comfort
with the adolescent interview, regardless of their perceived effectiveness.
Conversely, when discussing sensitive issues with parents, residents may be
more aware of their counseling strategies, and perceived effectiveness may
play a stronger role. An alternate explanation is that when residents are
trained to use structured interview frameworks with adolescents, they assume
the framework has been tested and is an effective communication tool. In applying
these concepts to an intervention, educators may wish to focus on strengthening
residents' perceived counseling effectiveness for parent encounters (eg, using
role play) or perhaps incorporating similar frameworks into educational curricula
for talking with parents.
Another personal factor associated with counseling adolescents, but
not parents, is a resident's personal gun-related experience. In a survey
in 1998, Barkin et al17 found that gun-owning
physicians are more likely to counsel on firearm safety than those without
this experience. Although our preliminary focus groups supported this finding,
our survey analysis revealed different results. Residents who grew up with
guns in the home were less likely to report routine counseling than those
without this experience. In addition to personal gun-related experience, clinical
experience has also been shown to influence counseling practices, with greater
physician experience associated with greater counseling frequency.16 We found no such association for the 2 groups in
our analyses. Residents who reported caring for children injured or killed
by firearms are as likely as those without these experiences to counsel routinely.
Without further information related to the nature of the residents' personal
and clinical experiences, it is difficult to speculate on these findings.
However, knowing that those residents with personal experiences are less likely
to counsel, an educational intervention could include a discussion of this
factor in an introductory needs assessment.
We found the same significant environmental factor for counseling both
adolescents and their parents: the resident's belief that gun-related media
coverage has motivated him or her to counsel. Residents with this belief are
almost twice as likely to counsel routinely. In recent years greater media
attention has been given to child and adolescent firearm-related deaths. Public
service campaigns, such as ASK (Asking Saves Kids) have aired television advertisements
urging parents to ask neighbors about guns in the home prior to sending their
children over to play.34 This increase in media
attention could either be a reflection of or a facilitator for shifts in societal
norms. As indicated in our study, this shift may already be positively influencing
pediatric residents to provide counseling about firearm safety.
We recognize that there are several limitations in this study. Although
confidentiality was assured, some residents may have been concerned that faculty
might see their responses. If social desirability bias occurred, however,
it would have probably favored residents reporting a greater frequency of
firearm safety counseling, resulting in an overestimate for routine counseling.
The residents' self-reported behaviors and beliefs may also have been influenced
by the context in which the survey was administered. Although most residency
programs distributed questionnaires individually, some administered the survey
in a group setting (eg, prior to a lecture). In the group setting, time constraints
and perceived colleague and preceptor expectations could have influenced the
residents' responses.
Another important limitation relates to nonrespondent bias. Although
we were able to survey a large proportion of the residents in the participating
programs (76%), we do not have information on nonrespondents, whose counseling
practices may differ. Again, if we assume that nonrespondents are less likely
to counsel, our results would be an overestimate for residents who counsel
routinely. In the interpretation of our findings we must also consider the
generalizability of these results to pediatric residents excluded from the
study population. Our sample included categorical pediatric residents training
in 9 programs, mostly in the mid-Atlantic region. Although practices may vary
by geographic region, the gender breakdown and career plans of our sample
seem representative of pediatric residents nationally, with about two thirds
being female and about one quarter entering careers in pediatric subspecialties.35
CONCLUSIONS
Since residents do not routinely counsel adolescents and their parents
on firearm safety, we greatly encourage residency programs to restructure
existing curricula or develop new educational interventions in the area. To
address the specific needs identified in our analyses, educators should aim
to strengthen residents' comfort in counseling and enhance their perceived
effectiveness in counseling parents. Although these key factors are related
to counseling on firearm safety, we believe these principles could positively
influence resident counseling for other sensitive topics.
| What This Study Adds
One of the pediatrician's major roles in the prevention of youth violence
is to counsel patients and families on firearm safety. Prior research has
shown that counseling practices are discouragingly low, and few studies have
specifically addressed this issue during pediatric residency training. Considering
that adolescents have a relatively high risk of firearm-related mortality,
residents should feel competent in providing firearm safety counseling for
this population. To support the design of an educational intervention tailored
to the needs of pediatric residents, we developed a theory-based questionnaire
and conducted a cross-sectional survey in 9 mid-Atlantic residency programs.
The major predictors for routine firearm safety counseling that are amenable
to change included comfort with and perceived effectiveness in counseling.
These factors should be considered in the design of educational interventions
to promote firearm safety counseling.
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AUTHOR INFORMATION
Accepted for publication April 2, 2002.
This study was funded by grants from the Thomas Wilson Sanitarium of
Baltimore City, and Region IV of the Ambulatory Pediatric Association, Baltimore;
and National Research Service Award training grant from the Health Resources
and Services Administration, Bureau of Health Professions, US Department of
Health and Human Services, Washington, DC (Dr Solomon).
This study was presented as an abstract at the annual meeting of the
2002 Pediatric Academic Societies', Baltimore, Md, May 6, 2002.
We thank the residency program directors, chief residents, and house
staff at the following participating residency training programs: Eastern
Virginia University, Norfolk; George Washington University, Washington, DC;
Johns Hopkins University, Baltimore, Md; Medical College of Virginia, Richmond;
Naval Medical Center, Bethesda, Md; Naval Medical Center, Portsmouth, Va;
University of Maryland, Baltimore; University of Pittsburgh, Pittsburgh, Pa;
and the University of Virginia, Charlottesville.
Corresponding author and reprints: Barry Solomon, MD, MPH, The Johns
Hopkins University School of Medicine, Division of General Pediatrics and
Adolescent Medicine, 600 N Wolfe St, Children's Medical and Surgical Center
149, Baltimore, MD 21287 (e-mail: bsolomo{at}jhmi.edu).
From The Johns Hopkins University School of Medicine, Division of General
Pediatrics and Adolescent Medicine (Drs Solomon, Duggan, and Serwint), and
Johns Hopkins University Center for Injury Research and Policy (Dr Webster),
Baltimore, Md.
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