A Parent Survey Assessing Association of Exposure to Gun Violence, Beliefs, and Physician Counseling Free

This cross-sectional survey of 225 parents was part of a larger randomized controlled intervention study of FIP education for parents.¹⁷  This single-center study occurred at a quaternary care, academic children’s hospital, nontrauma center in a large city. Participants completed in-person surveys during their child’s inpatient stay (March 2017 to July 2019). Eligible participants were English- or Spanish-speaking parents residing with any hospitalized patient <20 years old. Exclusion criteria were parents of critically ill patients and previous study enrollment.

After obtaining informed consent, study personnel (trained by the primary investigator using scripts, role-play, and observations) collected information on attitudes, beliefs, and exposures regarding firearms through face-to-face verbally administered surveys (Supplemental Fig 1). Questions were adapted from previously published studies and piloted in the potential study population.^17–22  Responses were recorded on paper by researchers. Data were verified, coded, entered in a secure password-protected, Health Insurance Portability and Accountability Act-compliant electronic database, and double-checked. Study data were analyzed with Wilcoxon rank-sum test, χ² test, or Fisher’s exact test, as appropriate.

Beliefs were analyzed by mean Likert score (1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree), with SD, as well as by the proportion of parents who “agree” or “strongly agree” with each belief statement. Exposure to GV was indicated by a “yes” response to either: “Have you ever heard gunshots in your neighborhood?” or “Have any of your friends or relatives ever been shot with a gun?” We chose these questions as a marker of GV exposure for two reasons: (1) given the subjects are parents, these exposures may approximate the child’s GV exposure, and (2) there was high exposure to both variables in our population (60% heard gunshots in their neighborhood and 42% had a friend or relative shot by a gun), increasing feasibility to assess for possible associations. We used t test, χ², or Fisher’s exact tests, as appropriate, to compare mean Likert score between groups exposed to GV versus not exposed. To assess for any effect of a particular exposure, methods were repeated with each type of GV exposure individually (Supplemental Fig 1). The Albert Einstein College of Medicine Institutional Review Board approved this study.

Among 225 parents, there were no differences in characteristics between those with and without GV exposure. Most subjects were female (Table 1). There was borderline greater GV exposure in parents whose preferred language was English versus Spanish (P = .05). Nearly 42% reported a friend or relative had been shot, and 60% have heard gunshots in their neighborhood (Table 2). Nearly 1/3 of parents have both heard gunshots and had a friend or relative shot. Overall, three-quarters of parents agreed doctors should talk to parents about FIP with no difference between GV exposure groups (77.2% vs. 71.6%, P = .37) (Table 3), yet only 8.9% report discussing FIP with their pediatrician (Table 1). However, responses to “Doctors should advise parents/guardians to remove guns from the home” had a wider distribution across levels of agreement, with only slightly more than half (52.4%) responding agree or strongly agree. Although 93.8% of parents agree/strongly agree that it is important to ask about guns in the homes of others when their child goes there, 90.1% report having “never” asked.

The overwhelming majority agree or strongly agree that people with guns should use gunlocks, regardless of parental GV exposure (98.7% vs. 94.0%, P = .07) (Table 3). Similarly, the majority agree there should be stricter laws for background checks irrespective of GV (98.7% vs 94.0%, P = .07). Although not statistically significant, a slightly higher proportion of parents with GV exposure than those without agree or strongly agree that people should have the right to carry guns for protection (43.5% vs. 31.3%, P = .08).

Analysis by type of GV exposure (Supplemental Tables 4 and 5) reveals no differences in beliefs, excluding comparison of the proportion of participants who agree or strongly agree that “People who have guns should use gunlocks.” One hundred percent of parents with a friend or relative who has been shot agree or strongly agree, compared with 95.4% (P = .04) (Supplemental Table 5). (Supplemental Tables 4). Although statistically significant, this distinction has fewer practical implications.

This study found high exposure to GV overall in this population and concern for FIP among parents surveyed, with no differences in demographic characteristics. There were no differences in beliefs about GV or FIP regardless of GV exposure. Most parents agreed with the AAP’s recommendation for clinicians to discuss FIP, yet less than 10% of parents reported receiving this counseling. It is possible pediatricians counsel, but parents are not recognizing or processing these discussions; regardless, the reported rate is low. Our population reports overall high GV exposure among parents which may provide some approximation for GV exposure of their children, particularly in a sample with a median child’s age of 5 years.^12,13 

The implications of such substantial GV exposure are broad given its classification as an ACE¹²  with significant effects on children,¹⁴  including increasing the risk of their own gun-carrying in the future.^16,23,24  Parents are receptive to FIP counseling and, in our at-risk population, additional efforts are needed to enable more clinician counseling.²⁵  A low rate of FIP discussions exists despite high rates of GV exposure in this community and willingness to discuss FIP with pediatricians. There is also overwhelmingly parental agreement that asking about guns when your child goes to another’s home is important, yet >90% report never asking. Promotion of practices including proper gun storage and asking other parents if they have a gun at home would therefore be appropriate. In addition, raising the topic may be an opportunity to assess the ACE of GV exposure, its potential effects, and a way for the clinician to better provide trauma-informed care.^12,13  Pediatricians have many topics to counsel on during visits and incorporating FIP adds more to each encounter. Proposed interventions should be both time-efficient and relevant to the parent’s unique needs.

Hospitalization presents a unique opportunity for hospitalists to reiterate or supplement FIP discussions by the primary care provider, as well as to engage other family members who may not have been at clinic visits.^26,27  Pediatric hospitalists have shown success with other preventive topics such as tobacco smoke exposure counseling²⁸ ; FIP is another chance for hospitalists to impact child wellbeing outside the hospital.

In our population, there was a relatively low report of gun ownership compared with GV exposure, which may indicate underreporting or a lower likelihood to participate in a research study among gun owners. Despite low ownership and high GV exposure, few (8.9%) report they would feel safer if they had a gun in the home. Notably, despite a majority agreement that pediatricians should discuss FIP, the level of agreement is far lower with the statement “Doctors who take care of children should advise parents/guardians to remove guns from the home.”

Study limitations include its single-center nature, so it may not be generalizable to other settings. This is also a sample of parents of hospitalized children, so some may not get regular outpatient pediatric care, lack routine opportunities for FIP discussions, or have unique risk factors, including various social determinants of health. In developing the survey, questions were adapted from other previously published surveys, piloted in our population, and edited in response to feedback; however, we did not assess in other areas with possibly different “gun culture,” potentially limiting its construct validity. Additionally, our findings were part of a larger study and therefore not designed to be powered for these specific outcomes. Lack of differences between exposure groups could be due to insufficient power. However, given the paucity of published data on this topic, we provide a basis for future research. Despite these limitations, our findings provide unique information from a group of parents with high GV exposure. This population may be a biased sample, given those choosing to enroll in the larger study versus those who do not may have different characteristics/beliefs. Measures of GV exposure in this study (chosen because of high levels in our population) were exposure to friends/relatives/community GV. Beliefs for those with personal/direct experiences of GV could vary from our findings, unaccounted for in our measures. In addition, although beliefs are strong about guns in general, in a community with high rates of GV exposure, other factors, such as community conversations and media, may heighten awareness and concerns over firearm-related issues.

In this population with overall high exposure to GV, parental GV exposure does not appear to affect gun-related beliefs and parents are receptive to FIP counseling by physicians. Although other studies have revealed regional differences in gun-related beliefs, we did not find associations in our population’s GV exposure and gun-related beliefs; therefore, additional factors may contribute to any variations. A large unmet need exists regarding physicians providing FIP information to parents; hospitalization may be an opportunity for such discussions. In addition, although nearly all parents believed it is important to ask about guns in the homes of others, few reported doing so routinely. This may point to an area of uncertainty for parents on how to ask these questions; perhaps pediatricians could also provide this guidance.

In communities with high rates of GV exposure, future studies should examine effects on children themselves, including responses and level of distress resulting from GV exposure as an ACE. In addition, investigations should determine effective ways to address FIP with parents and implement reliable processes for clinicians to effectively counsel families on safe practices. Identifying barriers to and ideal settings for these discussions through qualitative work with providers and families in a variety of regions with varied gun culture would be worth investigating.

The authors thank the patients and families who participated in this study. We also thank Henna Boolchandani, Shana Burstein, Christine Knauer, Karolina Mieczkowska, Casey Pitts, Jessica Tugetman, and Grace Ye for their assistance in enrolling participants in the study and assistance with data collection and data entry. We also thank Ms Ruth Eisenberg and Dr Mimi Kim for their assistance with data analysis.