A comparative effectiveness trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care (ASPIRE)

Grant Details

Funder: NIMH

Grant number: R01MH123491

Project period: 08/15/2020 – 06/30/2025

Lead site: Northwestern University (PI Rinad Beidas)

Participating sites:

  • Kaiser Permanente Colorado (Site PI Jennifer Boggs)
  • Henry Ford Health System (Site PI Brian Ahmedani)
  • University of Pennsylvania (Site PI Kristin Linn)

Abstract: The proposed study will work to reduce firearm-related suicide deaths in young people by investigating the most effective way to implement a universal secure firearm storage program in pediatric primary care. The number of young people dying by suicide in the United States continues to rise, and risk for suicide death is much greater when there is an unlocked, loaded firearm in the home. A simulation study found that a modest increase in secure firearm storage could prevent up to 32% of firearm-related deaths in youth. Pediatric primary care is an ideal setting for universal suicide prevention strategies to reduce unauthorized access to firearms, and prior research has shown that both health care clinicians and parents find firearm safety to be an appropriate topic to discuss, yet these conversations do not happen routinely. Safety Check, an evidence-based practice for firearm safety promotion that involves brief counseling and provision of a free cable lock, has been shown to double the odds of self-reported secure storage among parents, but has not been implemented widely. Using feedback from pediatric clinicians, health system leaders, and firearm-owning parents regarding attitudes and barriers related to broader use of the program, the proposed study incorporates recommendations on how to boost the acceptability and feasibility of Safety Check for use as a universal suicide prevention strategy. Combining this feedback with insights from behavioral economics, we will conduct a hybrid type III effectiveness-implementation trial with a longitudinal cluster randomized design. The study will allow us to compare two approaches to implementing the program in pediatric primary care and evaluate the effectiveness of the adapted intervention, now named S.A.F.E. Firearm. The study will include 158 clinicians in 30 clinics who serve 48,475 youth annually in two MHRN health systems in Michigan and Colorado. All 30 clinics in the two participating health systems will receive S.A.F.E. Firearm materials, including brief training and cable locks. Half of the clinics (k = 15) will be randomized to receive the electronic health record (EHR) implementation strategy (Nudge); the other half will be randomized to receive Nudge plus 1 year of facilitation to target additional clinician and organizational implementation barriers (Nudge+). We will collect the primary implementation outcome, reach (proportion of eligible families that received the intervention), during the active implementation year and for 1 year following to allow for comparisons between the active and sustainment periods. Results will guide future efforts to promote firearm safety as a universal suicide prevention strategy. In Aim 1, we will identify the effect of the implementation strategies on implementation outcomes (i.e., reach, parent-reported receipt of the program [fidelity], cable lock distribution, acceptability, and cost). In Aim 2, we will also test potential implementation strategy mechanisms (i.e., how it worked). In Aim 3, we will examine clinical outcomes including parent-reported secure storage behavior. This study can improve implementation of firearm safety interventions and identify the best approach to national implementation, with the ultimate goal of saving the lives of American youth, in alignment with NIMH Objective 4.

Current status:

Enrolling by invitation.

Summary of findings:

The active implementation year will end in March 2023, and data analysis will be conducted during summer 2023. Manuscripts detailing study findings will submitted for peer review thereafter.


Beidas, R. S., Ahmedani, B. K., Linn, K. A., Marcus, S. C., Johnson, C., Maye, M., … & Boggs, J. M. (2021). Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care. Implementation Science16.

Davis, M., Johnson, C., Pettit, A. R., Barkin, S., Hoffman, B. D., Jager-Hyman, S., … & Beidas, R. S. (2021). Adapting Safety Check as a universal suicide prevention strategy in pediatric primary care. Academic Pediatrics21(7), 1161-1170.

Hoskins, K., Johnson, C., Davis, M., Pettit, A. R., Barkin, S., Jager-Hyman, S., … & Beidas, R. S. (2021). A mixed methods evaluation of parents’ perspectives on the acceptability of the S.A.F.E. Firearm program. Journal of Applied Research on Children: Informing Policy for Children at Risk12(2).

Hoskins, K., Linn, K. A., Ahmedani, B. K., Boggs, J. M., Johnson, C., Heintz, J., … & Beidas, R. S. (2022). Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study. Preventive Medicine165.

Optimizing Firearm Suicide Prevention in Healthcare

Grant Details

Funder: CDC

Grant Number: 1 R01CE003460-01-00    

Project Period: 9/30/2022-9/29/2025

Brief Narrative: Suicide accounts for 60% of U.S. firearm deaths, with even higher rates in Alaska, Colorado, and Washington.  Firearms are the most common method of suicide in the U.S., and firearm access is linked to increased suicide risk. Most people who die by suicide see a health care provider in the prior year, including populations at higher risk for suicide such as youth and young adults and Alaska Native and American Indians (AN/AI). Many healthcare systems conduct systematic suicide risk screening; however, systematic screening for firearm access is uncommon, particularly in primary care. Promising clinical practices to prevent firearm suicide also include collaborative discussions about reducing firearm access. Unfortunately, gun ownership is a contentious issue in the U.S, and there is a dearth of evidence available to guide implementation of firearm access assessment and intervention. Our team has been recently addressing this evidence gap. We established that primary care and mental health patients will answer questions about firearms and limiting screening to mental health care recipients misses many at risk patients.  We found that concerns about privacy, autonomy, and ownership rights impact patient responses, and we catalogued patient/clinician suggestions for improving assessment and intervention.

      This study will build on these findings and address the critical need for patient-centered strategies to identify and engage patients at high-risk of firearm suicide through Objective One of CDC’s RFA-CE-22-004: Research to inform the development of innovative and promising firearm injury/mortality prevention strategies.  Human Centered Design and Community Based Participatory Research approaches will support Option B for new data collection activities and the implementation of prevention activities. We will employ CBPR and the Discover, Design and Build, and Test (DDBT) HCD framework to inform implementation strategies in three healthcare systems serving ~1.5 million people in communities with high rates of firearm ownership and suicide. We will:

1 (DISCOVER): Explore stakeholder (patient, clinician, leader) perspectives on clinical practices for identifying and engaging individuals at risk of firearm suicide, and to identify opportunities for practice improvement via retrospective chart review and descriptive analyses of medical records.

2 (DESIGN/BUILD):  Partner with clinical and quality improvement staff and leadership to design intervention strategies to support evidence-based clinical practices for firearm suicide prevention.

3 (TEST): Pilot test clinical intervention strategies in three healthcare systems to demonstrate feasibility, acceptability, and usability; and to measure reach for future effectiveness evaluations.

Our work will lay a strong foundation for future dissemination of patient-centered firearm suicide prevention practices and evaluations of effectiveness.

  • Lead Site:
    • KPWA (PI Julie Richards)
  • Participating Sites:
    • Southcentral Foundation (co-I Jennifer Shaw)
    • KPCO (co-I Jenn Boggs)

Current Status

Summary of Findings

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