Asking about firearm access can normalize and support dialogue for patients

Findings provide roadmap for addressing barriers and improving suicide prevention

Both patients and clinicians said in interviews that a standardized question about access to firearms during a health screening was valuable, according to a new study led by researcher Julie Richards, PhD, MPH, and published in JAMA Health Forum.

Patients commented that the question was straightforward and nonjudgmental, and they found that it opened space for dialogue. They also highlighted important challenges in answering the question that can help guide implementation of questions like this for suicide prevention.

In the U.S., residents report broad access to firearms. Suicide accounts for more than half of firearm deaths in the country, and a majority of people who attempt suicide with a firearm do not survive. However, standardized questions about firearm access during routine health care are uncommon, and often organizations rely on individual clinicians to make decisions about when and how to address the topic with patients.

“Asking patients about firearm access may help prevent suicide,” said Richards, a senior collaborative scientist at Kaiser Permanente Washington Health Research Institute (KPWHRI). “We know patients will answer standardized questions, but also know some patients at risk of suicide choose not to report access. The goal of this project was to understand how we can improve patient-centeredness of the practice of asking.”

The researchers interviewed 36 patients and 30 clinicians at Kaiser Permanente Washington, where mental health and primary care clinics incorporated a standard question about access to firearms into a health screening questionnaire between 2016 and 2018. All of the patients who were interviewed had received the question within the prior 2 weeks, although not all had answered it.

Overall, the respondents said that they understood the reason for asking the question and valued the potential for suicide prevention. They also spoke in detail about potential barriers to answering.

"Our interviewees reported challenges such as anticipated stigma, fear of losing autonomy, and beliefs about the inevitability of suicide as reasons that they might not answer the question or might find it difficult to answer," said Richards. "This is crucial feedback for us and for other health care systems that points to the importance of building trust and communicating with patients about this topic in an open and transparent way."

Despite reporting barriers, patients who were interviewed generally said they felt positive about the question, and both patients and clinicians highlighted its usefulness in making space to talk further about why the question was asked and engage in conversations about safety planning.

Many patients offered ideas for how clinicians could make the conversation feel more comfortable and help them feel safe talking about firearm access. They emphasized care, respect, and non-judgment, and both patients and clinicians mentioned the importance of follow-up on the response — or lack of response — to the question. It was also important to patients to feel that they could discuss their reasons for owning firearms.

The findings underscore the need to communicate to patients that questions about firearm access are intended to support conversations about suicide prevention, not limit their autonomy, said the researchers. They also pointed to the value of a trauma-informed approach to initiating dialogue as a tool for clinicians asking patients about firearm access.

This work is part of a study led by Richards that was one of the first 3 projects funded by the Kaiser Permanente Task Force for Firearm Injury Prevention. A new grant from the Centers for Disease Control and Prevention will support work to build on these findings. Richards will be working with colleagues at the Southcentral Foundation and Kaiser Permanente Colorado on a 3-year project using community-based participatory research and user-centered design to inform implementation strategies in 3 health care systems in communities with high rates of firearm ownership and suicide.

In addition to Richards, the study authors are Elena Kuo, PhD, MPH; Ursula Whiteside, PhD; Lisa Shulman, MSW; Marian Betz, MD, MPH; Rebecca Parrish, LICSW; Jennifer Boggs, PhD, MSW; Ali Rowhani-Rahbar, MD, MPH; and Gregory Simon, MD, MPH.

By Amelia Apfel