Beliefs Among Veteran Firearm Owners Regarding Whether Clinicians Should Discuss Firearm Safety With Patients

Key Points Question What proportion of US veterans who own firearms believe that firearm safety counseling should occur in clinical settings when a patient or a patient’s family member is at risk of firearm injury? Findings This cross-sectional study of 678 adults found that most veteran firearm owners believed that clinicians should “at least sometimes” discuss firearm safety across all 6 clinical contexts examined (elevated suicide risk, mental health or behavioral problems, drug or alcohol problems, domestic violence, having a hard time, and dementia). Meaning These findings suggest that discussing firearm access in clinically indicated situations is viewed as an acceptable routine practice by most veteran firearm owners.


DESIGN, SETTING, AND PARTICIPANTS
In this cross-sectional study, data were from a probabilitybased online survey of self-identified veterans who reported owning at least 1 firearm (National Firearms Survey, July 1 to August 31, 2019) and were weighted to generate nationally representative estimates.Data were analyzed from June 2022 to March 2023.

MAIN OUTCOMES AND MEASURES
Participants were asked, "As part of routine care, should physicians and/or other health care professionals talk with their patients about firearms and firearm safety if their patient or their patient's family member (is at risk of suicide; has mental health or behavioral problems; is abusing or addicted to alcohol or drugs; is a victim of domestic violence; has Alzheimer's disease or another dementia; or is going through a hard time)."Response options included "No," "Yes, sometimes," and "Yes, always."In addition, responses were dichotomized as "Yes, at least sometimes" and "No."
CONCLUSIONS AND RELEVANCE This study's findings suggest that most veteran firearm owners believe that clinicians should provide firearm counseling during routine care when a patient or family member is at heightened risk of firearm injury.These findings belie concerns that discussing firearm access with veteran firearm owners is an unacceptable practice.

Introduction
For the past 2 decades, although not prior, [1][2][3][4] the suicide rate among US veterans has been higher than among age-and sex-matched nonveterans, in part because of higher rates of firearm suicide. 2,5 2019, in response to persistently elevated veteran suicide rates, the US Department of Veterans Affairs (VA) and the US Department of Defense updated their Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide. 6These guidelines included recommendations that clinicians assess firearm access as part of a broader strategy to identify suicide risk factors and discuss ways to reduce firearm access with veterans identified as at heightened risk.
Although the effectiveness of these recommendations on clinical care and veteran suicide is not yet known, the success of these efforts will depend, at minimum, on clinicians' willingness to discuss firearm-related risk with the approximately 50% of veterans who own firearms. 6To date, however, studies in the general US population 7,8 and among veterans 9 find that clinician-initiated discussions about firearm safety are uncommon, even among patients who are receiving care for mental health conditions. 10e perception that firearm owners may be opposed to discussing firearms has been cited as 1 reason clinicians seldom initiate these conversations. 7,11The validity of this perception, however widespread it may be, has been called into question by the few empirical studies [12][13][14][15] that have sought to examine why clinicians rarely engage in such discussions.Qualitative studies, for example, conducted among veteran and nonveteran samples, suggest that interventions focusing on reducing firearm access are generally considered to be appropriate 13,14 or appropriate under specific circumstances (eg, delivered by a trusted clinician). 16Survey-based research conducted among firearm owners has come to similar conclusions.For example, a recent national study 15 found that 80% of US adult firearm owners believed that clinicians should "sometimes" or "always" discuss firearm safety with patients when a patient or a patient's family member is at risk of suicide.To our knowledge, the current study is the first nationally representative survey to assess the extent to which veteran firearm owners endorse firearm safety counseling in clinical settings when a patient or a patient's family member is at risk of firearm injury.

Design and Study Sample
Data for this cross-sectional study come from the 2019 National Firearms Survey, which was designed by the investigators (M.M. and D.A.) and conducted by the research firm Ipsos from July 1 to August 31, 2019.Race and ethnicity data were included because perceptions about the appropriateness of counseling about firearm safety may differ by race and ethnicity.Race and ethnicity were self-reported at the time respondents joined the panel.Participants were drawn from a nationally representative sample from the 55 000 English-speaking adults (aged Ն18 years) in Ipsos' probability-based web panel (KnowledgePanel).KnowledgePanel members complete an annual survey assessing firearm ownership and other measures, which allows researchers to draw a subsample using predefined characteristics.Respondents who indicated they lived in a household with firearms were invited to participate in the study.Those who accepted the invitation were then asked additional survey questions, including questions about their veteran status and questions that confirmed both that they lived in a household with firearms and whether they personally owned firearms.Item language and response options are included in eTable 1 in Supplement 1.The study design has been described in detail elsewhere. 17

Measures
The primary outcome was veterans' responses to 6 variations of the survey item: "As part of routine care, should physicians and/or other health care professionals talk with their patients about firearms and firearm safety if their patient or their patient's family member (is at risk of suicide; has mental health or behavioral problems; is abusing or addicted to alcohol or drugs; is a victim of domestic violence; has Alzheimer's disease or another dementia; or is going through a hard time)."Response options included "No," "Yes, sometimes," and "Yes, always."We also dichotomized responses as "Yes, at least sometimes" or "No."Additional items assessed sociodemographic and military service characteristics of respondents and use of Veterans Health Administration (VHA) health care services in the last 12 months (eTable 1 in Supplement 1).

Statistical Analysis
Data were analyzed from June 2022 to March 2023.Analyses used survey weights provided by Ipsos.
These weights account for survey nonresponse and undercoverage or overcoverage imposed by the study-specific sample design.Weights also adjust for benchmark demographic distributions and for population characteristics.For this study, data were weighted to benchmark distributions of firearmowning households from weighted KnowledgePanel data for sex, age, race/ethnicity, US Census region, metropolitan statistical area status, educational level, household income, and presence of children in the home.We report weighted proportions and corresponding 95% CIs.Analyses were conducted using Stata software, version 16 (StataCorp LLC).
Across the 6 clinical contexts, support for clinicians "at least sometimes" discussing firearm safety as part of routine care ranged from 73.4% (95% CI, 69.1%-77.3%)when someone is "going through a hard time" to 88.2% (95% CI, 84.8%-90.9%)when someone has "mental health or behavioral problems" (Table 2).When a patient or family member is at risk for suicide, 79.4% (95% CI, 75.5%-82.8%) of veteran firearm owners responded that clinicians should "at least sometimes" discuss firearms and firearm safety.
Compared with veteran firearm owners who did not use VHA services within the prior year, those who did were at least as favorably disposed to routine firearm-related conversations in each clinical context (eTable 2 in Supplement 1).Regional differences in how veteran firearm owners responded to our questions were minor; regardless of where firearm owners lived, at least two-thirds endorsed routine lethal means counseling "at least sometimes" (eTable 3 in Supplement 1).

Discussion
In this nationally representative cross-sectional study, we found that 73% to 88% of veteran firearm owners, including those who received care at the VHA, reported that firearm counseling should be delivered as part of routine care when a patient or someone in their family is at increased risk of firearm injury.These findings are consistent with those from a national survey of firearm owners in which veteran status was not examined 15 and a geographically diverse sample of veterans receiving mental health treatment. 19r study does not explain why some respondents report that clinicians should never ask about firearms in the clinical contexts we examined (12%-27% depending on the scenario); further work is needed to better understand the perspectives of these individuals.Prior studies 11,13,16,20,21 suggest that concerns about privacy, the impact of disclosing firearm status on Second Amendment rights, and the potential for discrimination from health care systems and clinicians may be factors that affect the acceptability of clinic-based firearm discussions for some patients.
Our study does not assess how prior experience discussing firearms with clinicians may influence whether these conversations are seen as an acceptable part of routine care.Positive past experiences might favor veterans endorsing these discussions during routine clinical care, whereas negative past experiences might reinforce the opposite.In addition, some firearm owners may have concerns about privacy when disclosing information about firearm ownership or storage to certain clinicians (eg, those they trust less) or in specific systems, such as federal health care systems.
However, in our study at least, compared with veteran firearm owners who had not received VHA services in the last year, those who recently received VHA services were at least as likely to endorse firearm counseling.
Most efforts aiming to prevent firearm injuries among adults in clinical spaces have focused on suicide.However, assault-related and unintentional firearm injuries are also important causes of morbidity and mortality in the US, including among veterans.Because the question stem for our primary outcome was not specific to suicide and we assessed scenarios that also place people in the home at heightened risk of firearm assault and unintentional firearm injury, our findings provide support for clinic-based initiatives aiming to prevent injuries from other intents or within other clinical scenarios, such as in dementia care or within the context of intimate partner violence.

JAMAFindings
Network Open.2023;6(6):e2321219.doi:10.1001/jamanetworkopen.2023.21219Key Points Question What proportion of US veterans who own firearms believe that firearm safety counseling should occur in clinical settings when a patient or a patient's family member is at risk of firearm injury?This cross-sectional study of 678 adults found that most veteran firearm owners believed that clinicians should "at least sometimes" discuss firearm safety across all 6 clinical contexts examined (elevated suicide risk, mental health or behavioral problems, drug or alcohol problems, domestic violence, having a hard time, and dementia).Meaning These findings suggest that discussing firearm access in clinically indicated situations is viewed as an acceptable routine practice by most veteran firearm owners.
For this study, we included firearm owners who selfidentified as veterans.Data were deidentified, and the survey was deemed not human participant research under federal guidelines by the institutional review boards at Northeastern University and the Harvard School of Public Health.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.18

Table 1 .
Demographic and Military Service Characteristics of 678 Veteran Firearms Owners, 2019 24,23LimitationsOur study is subject to limitations.As with any survey, data are self-reported (including veteran status) and thus misclassification is possible, and social desirability or selection biases may have skewed findings.Although residual bias is possible, panel-based surveys have been shown to minimize such biases.24

Table 2 .
Beliefs of 678 Veteran Firearm Owners Regarding Whether Clinicians Should Discuss Firearms and Firearm Safety With Patients Across 6 Clinical Contexts, 2019