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Firearm Ownership and Storage Patterns Among Families With Children Who Receive Well-Child Care in Pediatric Offices

^a Departments of Pediatrics
^b Social Science and Health Policy
^e Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
^c Rocky Mountain Youth Clinics, Denver, Colorado
^d Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
^f Department of Pediatrics, University of Vermont, Burlington, Vermont

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
OBJECTIVE. In this study we examined firearm storage patterns and their associations in a diverse sample of families who attended pediatric practices from both rural and nonrural areas across the United States.

METHODS. Parents who brought their children who were aged 2 to 11 years (N = 3745) to 96 Pediatric Research in Office Settings practices from 45 states, Canada, and Puerto Rico participated in an office-based survey before a well-child examination. The survey measured demographic variables; family history of guns in the home; and firearm types, storage behaviors, and ownership.

RESULTS. Twenty-three percent of families reported firearm ownership. The majority (60%) of respondents reported making firearm storage decisions. Only one third of firearm owners reported safe firearm storage. Gun type owned was associated with storage habits, with long-gun owners storing their gun in places other than locked cabinets but with ammunition separate from guns and handgun users more likely to store guns loaded and to use gun locks. In a multivariate analysis, not being raised with a firearm was associated with safe storage behaviors. Families who had children aged 2 to 5 years and owned long guns were more likely to store their guns safely than families with older children.

CONCLUSIONS. Few families reported safe firearm storage. Storage patterns are most influenced by firearm type(s) owned, family socialization with guns, and the age of the child. Primary care providers need to understand better not only whether firearms are in the home but also which types are present and whether parents were raised in homes with guns.

Key Words: anticipatory guidance • children and adolescents • behavior • injury prevention and control • firearms

Abbreviations: PROS—Pediatric Research in Office Settings • AAP—American Academy of Pediatrics • RUCA—rural/urban community area

There are between 192 and 200 million privately owned guns in the United States; 33% to 41% of all US homes report at least 1 gun in the home.^1–4 Gun ownership varies nationally from 5.2% of homes in the District of Columbia to 62.8% in Wyoming.² Among adults with children who are younger than 18 years, the prevalence of loaded household firearms ranged from 1% in Massachusetts to 13.4% in Alabama.² More than 22 million children (35% of homes with children) live in homes in which respondents reported the presence of a firearm.³ Among homes with children and firearms, between 41.5% and 43% had at least 1 unlocked firearm,³ which compares with 20% of all gun-owning households that stored guns unlocked and loaded.⁵

Although the findings from the research vary, these data indicate that substantial numbers of pediatricians' patients either live in or visit a home where a gun is present.^3–7 There is strong evidence attesting to the magnitude and the nature of the threat that is posed by the prevalence of firearms, especially when stored unsafely.^3,8–10 The accessibility of guns in the home has been associated with an increased risk for suicide and unintentional injury.^11,12 A recent case-control study of youth suicide and unintentional injury with firearms showed that the individual practices of storing guns (1) locked, (2) unloaded, (3) with ammunition locked, and (4) with ammunition in a separate location from the gun each significantly reduced the risk to children for a firearm-related injury.⁸ If children and adolescents are living in a home with a firearm, then proper gun storage is critical to lessening their risk for injury or death.^7,13–16 Organizations that support gun ownership and those that are involved in child advocacy recommend safe storage practices.^17,18 Surveys of gun-owning families with children, however, have revealed that from 43% to 95% stored at least 1 gun unlocked and 9% to 20% stored at least 1 gun loaded.^{2,3,7,14–16} Differences in firearm storage have been cited according to geographic region. In Connor's¹⁴ recent study of random samples of urban and rural adults, 31% of rural households, as compared with only 13% of urban households, reported firearm ownership. Respondents with children in the home reported significantly lower gun ownership (20%) than respondents without children (29%). However, safe firearm storage (locked or locked up and separate from ammunition) did not differ significantly on the basis of the presence of children in the home after controlling for rural versus urban setting; safe storage patterns did not differ from rural versus urban families. However, Nordstrom et al¹⁹ found that although the prevalence of firearms in the home was higher in rural areas than in nonrural areas, the prevalence of loaded, unlocked guns was actually lower in rural areas than in urban areas. Further complicating the issue are the studies reporting that >1 firearm is more likely to be found in homes in rural areas than in urban regions,^3,14 creating a situation of children's increased exposure to potentially unsafely stored firearms. Even so, Nance et al²⁰ found that rates of serious firearm injuries among children and adolescents were 10-fold higher in urban than in nonurban regions.

Rural-urban differences in gun ownership and storage practices reflect long established cultural differences in the types and the number of guns owned and the reasons for firearms ownership.^5,6,14,20,21 For example, in rural areas, many gun owners possess firearms for recreational purposes, in contrast to urban areas, where many guns are owned for protection.^5,14,20–22 In Baxley and Miller's²¹ study of rural parents, owners of guns for recreation were more likely to store guns locked and unloaded (70%) than parents who owned guns for protection (52%). Other factors that were found to be associated with safe firearm storage in various populations include having a 4-year college education, total family income of $65000 per year or more,¹⁴ owning handguns in contrast to long guns,^6,19 children's knowing the storage location of the firearms in the home and having handled firearms,²¹ living in a rural town rather than a farm household, not taking a gun safety course, and the absence of a history of drug or alcohol abuse in the family.¹⁹

Although considerable research has been done to identify factors that are associated with firearm storage practices of parents who seek primary health care for their children, there is still a lack of consensus on what are the most important risk factors for unsafe firearm storage. Part of the reason is that definitions for rural, urban, nonrural, and nonurban have varied across studies or have not been defined at all.^{3,6,12,14,19–22} As expected, risk factors that have been found to be specific to geographic locations have also varied. In addition, many previous studies have lacked racial/ethnic diversity, differed in how safe firearm storage was defined, been limited in geographic scope, and varied in whether the respondent was responsible for making firearm storage decisions in the home.^3–7,14

For development of more effective provider counseling approaches about gun safety, variables that are associated with firearm ownership and storage practices need to be specified. In this study we examined differences between gun-owning and non–gun-owning families from a diverse sample of pediatric practices in both rural and nonrural areas across the United States. We examined storage patterns and their associations reported by firearm owners.

	METHODS

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Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics (AAP), conducted this study as part of a group randomized, interventional study to reduce violence by teaching families skills to decrease media use, increase the use of noncorporal discipline, and promote safe firearm storage. Using standard methods for all PROS studies, all PROS practices were sent information and an invitation to participate in the study. State coordinators of PROS were asked to identify and recruit practices for the study. State coordinators were particularly helpful in recruiting pediatric practices that serve large populations of minority racial/ethnic children. Parents and guardians who brought their children to 138 PROS practitioners in 96 practices from 45 states, Canada, and Puerto Rico participated in an office-based survey before the well-child visit for children who were 2 to 11 years of age (N = 3745) (see "Acknowledgments" for a list of participating practices). Latino and rural parents were oversampled at the practice level to ensure adequate sample sizes of these subgroups for analyses. Enrollment was limited to 1 child per family. Institutional review board approval was obtained from the Wake Forest University School of Medicine and the AAP.

Parents who brought their children to PROS practices for well-child visits were invited by trained research coordinators in each office to participate in a study titled Safety Check. When the parent agreed verbally to participate, the parent provided written informed consent and completed a previsit questionnaire while in the waiting room or the examination room. Only the legal guardian/parent who reported spending the majority of time with the child when at home served as the respondent. The questionnaires were kept confidential, containing only a study number that could link the previsit questionnaire to 2 postvisit telephone surveys. Parents put their surveys in a sealed envelope after completing it, and the participating pediatricians did not have access to this survey. Each pediatrician enrolled parents/legal guardians until 30 parents were enrolled per provider. Of 4499 parents, 266 were determined to be ineligible and 485 (11.5%) of 4230 refused to participate in the study. Of the 3745 completed pretest surveys, 204 were completed in Spanish. The data for this article were derived from baseline surveys that were gathered before the patient visit.

Survey Instrument
The distinction between rural and nonrural practice settings was determined by asking the health care provider the question, "How would you describe the area in which your practice is located?" with response categories "urban, inner city," "urban, not inner city," "suburban," and "rural." This method has been used by PROS since 1993 to classify practice demographics. From 1993 to 1997, US census metropolitan statistical area population categories were also used, but these were discontinued in 1998 because of the redundancy of the classifications. We considered using rural/urban community areas (RUCAs) zip code approximations to classify rural-urban practice setting. On the basis of recommendations by Hart et al,²³ we did not use this method because of the disconnection between health data from the local level and RUCA codes and the lack of stability of RUCA codes over time in general. Because firearm storage patterns did not differ among urban inner city, urban not-inner city, and suburban, we collapsed these into a single subgroup that we termed nonrural. Parents/legal guardians completed questions that included demographic variables (eg, age of child, number of children in the home, race/ethnicity of the child, parental home structure, maternal education), firearm ownership, firearm storage behaviors, parental firearm concern, firearm owner (responsible for firearm storage decisions), and parental history of guns in the home and owned for protection (firearm family socialization).

Firearm storage–related behavior questions included the following: "Are any guns stored or hidden in a place other than a locked cabinet or gun safe?" "Are all guns stored with a gunlock on them?" "Are bullets stored separate from all guns?" These responses were rated as "yes," "no," or "don't know." To gauge parental concern about children's exposure to firearms, parents responded "yes" or "no" to the question, "I worry that if this child found a gun, [he or she] would play with it." Questions were also asked about the primary caregiver's own childhood experience with firearms (firearm family socialization): "I was raised in a home with guns in it," and, "My family owned a gun for protection."

Statistical Analysis
Descriptive summaries were obtained to provide a comparison between the characteristics of gun-owning households (n = 872) and non–gun-owning households (n = 2800). We then compared gun ownership and storage patterns by rural versus nonrural status. Firearm storage patterns were compared across 3 groups: (1) handgun owner only, (2) long-gun owner only (rifle or shotgun), or (3) combination gun type owner (both long guns and handguns). We then identified the subsample of gun-owning respondents who reported that they were the firearm storage decision-maker (n = 516) by asking the question, "In your home, who makes decisions most of the time about gun storage?" For these, we conducted a bivariate analysis of firearm storage variables related to handgun only, long gun only, and combination ownership. Finally, we performed a multivariate logistic regression analysis of the factors from the literature^{3,4,6–8,15,16} that would be expected to affect safe firearm storage practices. The 3 survey items that were used to form the dependent variable of safe storage included all guns stored in locked cabinet or safe, all guns stored with gunlocks on them, and bullets stored separate from all guns. The list of independent variables included (1) gun type, with long gun only or combination ownership compared with handgun only ownership; (2) firearm family socialization; and (3) demographics. The demographic variables included rural versus nonrural, child's race/ethnicity, child's age, and maternal education level. Race/ethnicity categories included white, black, Latino, multirace, and "other" (when parents checked multiple ethnicities, the child was coded as "multirace"). Household income was found to have a high correlation with maternal education; therefore, income was not included in the final model.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The study sample was drawn from 96 practices from 45 states, Canada, and Puerto Rico and oversampled practices with Latino children (19% vs 14%) and families who lived in rural areas (37% vs 21%). This sample approximated national census data regarding black and white children and maternal education level.²⁴ Ninety percent of the parents who completed the previsit survey were female.

For the complete sample (N = 3745), 23.2% of families reported gun ownership. The rates of firearm ownership were lower in nonrural regions (19.6%) compared with rural regions (34.4%). Table 1 displays the demographic variables of the overall sample and compares the demographic variables of firearm owners with non–firearm owners. White families were more likely to own firearms than families from other race/ethnic groups. Firearm ownership was lowest in families in which parental education was less than a high school graduate. Gun ownership was highest in families with 2 adults in the home when compared with any other family configuration. Also, families with 3 or more adolescents in the home were less likely to own firearms.

Examining firearm decision-makers only (n = 516), the types of guns owned were significantly associated with the gun storage practices of families (Table 3). Families who owned only long guns were more likely than families who owned only handguns or a combination of gun types to store their gun in places other than locked cabinets. The use of gun locks on all of the guns in the home was highest among handgun-only owners, followed by long gun–only owners, and then combination gun owners. In contrast, the practice of storing bullets and shells separately from guns was highest among long-gun owners, followed by combination gun owners. Handgun-only owners were the most likely parents to store guns and bullets together. Families who owned both long guns and handguns were the most likely to have been raised in a family with guns, followed by long gun–only owners. Families who were combination gun owners were also more likely to report that they owned a gun for protection. Handgun-only owners were the most likely to believe that it was very important to use gun locks with guns. When these same relationships were examined for all of the respondents who reported having a firearm in the home (regardless of whether they were decision-makers), the relationships did not change.

	DISCUSSION

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Families in rural areas were more likely to report firearm ownership; however, gun ownership among rural families was lower in this study than has been reported previously.^3,6 Rural families in this study owned combination type firearms to the same degree as families in nonrural areas, but children in rural areas were more likely to be exposed to rifles and shot guns, whereas children in nonrural areas were more likely to be exposed to handguns. One study found that handguns were the most common weapon used among children and adolescents who sustained serious firearm-related injuries and that the rate of injuries were 10-fold higher in urban areas than in rural areas.²⁰ Our study findings indicate that although approximately one third of both rural and nonrural firearm owners store their firearms safely, rural families are more likely to own firearms than families in nonrural areas. These findings, taken in the context of previous studies,²¹ suggest that interventions for all firearm owners to store firearms safely are needed, regardless of where they live.

The risk to children for a firearm-related injury is associated with firearm storage.^19–22 Previous studies have recommended (1) storage in a locked cabinet/gun safe or with a gun lock, (2) unloaded, (3) with bullets and shells stored in a separate location, and (4) with ammunition locked.⁸ In this study, we examined 3 of these storage patterns and noted that they varied by the types of firearms owned. Families who owned only rifles and shotguns were more likely to store guns in a hidden place other than a locked cabinet but to store ammunition separate from their guns. Handgun-only owners were more likely to store guns locked or use a gun lock but least likely to store bullets separately from their handgun. Families who owned both handguns and long guns were the least likely to use any locking procedures with guns in the home. Although there were significant differences in types of firearms owned, rural versus nonrural residence did not seem to influence safe storage practices. Moreover, our findings suggest that firearm family socialization resulted in parents' having a less cautious approach to their family's storage patterns. The multivariate analysis suggests that this was an important factor, in contrast to rural or nonrural region, in identifying parents who were at higher risk of unsafe firearm storage. Also, families who had younger children and owned only long guns were much more likely to store guns safely than any other subgroup. It seems that families may consider that using only 1 safe storage technique is sufficient and that the firearm type(s) owned affects which of these storage techniques is used. Although pediatricians should encourage parents to use all 3 safe storage practices in their homes, parents who are reluctant to comply with these recommendations should be encouraged at least to lock all of their firearms in a locked cabinet or gun safe and/or use gun locks such as cable locks.¹⁷

Limitations of this study include that firearm patterns are self-reported. A previous study revealed that individuals who are not the firearm owner underestimate the unsafe storage practice and even the presence of firearms.¹⁵ To increase validity of reported safe storage, we included in regression analysis only respondents who reported being the firearm storage decision-maker. We noted that both of these groups (those who reported firearm presence in the home and the subset of firearm storage decision-makers) did not differ in their reports of storage patterns. Our overall gun ownership rate was lower than is represented by other national studies, which might have been because of high minority representation in the study.¹⁶ In addition, social desirability could have influenced who participated in the study. Last, we defined rural and nonrural status on the basis of location of the pediatric practice, which might have resulted in some rural families' being classified as nonrural; however, it is unlikely that the opposite misclassification occurred (suburban or urban families traveling to a rural-based provider).

	CONCLUSIONS

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If guns will not be removed from homes where children live and play, then the safe storage of those guns becomes a health priority for the well-being of children. Primary care providers need to understand better not only whether firearms are in the home but also which types are present. This should inform a tailored safe storage counseling approach for gun-owning families who are at increased risk for not using safe storage practices.

	ACKNOWLEDGMENTS

 
This study was supported by National Institute of Child Health and Human Development grant HD 42260, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Generalist Faculty Scholars Program, the AAP's Friends of Children Fund, and the Wachovia Foundation. In-kind support was provided through the US Department of Justice.

We especially appreciate the efforts of the PROS practices and practitioners. The pediatric practices or individual practitioners who enrolled participants in this study are listed here by AAP chapter: Alaska: Anchorage Pediatric Group, LLC (Anchorage) and Joy Neyhart, MD (Juneau); Alabama: Pediatric Care Group (Montgomery); Arizona: Orange Grove Pediatrics (Tucson) and Tanque Verde Pediatrics (Tucson); California-1: Arthur S. Dover, MD (Freedom), Palo Alto Medical Foundation (Palo Alto), and Pediatric & Adolescent Medical Associates (Salinas); Colorado: Rocky Mountain Health Centers, North (Denver) and Lamar Pediatrics (Lamar); Connecticut: Pediatric Associates of Connecticut, PC (Waterbury), and Jeff Cersonsky, MD (Southbury); Florida: Atlantic Coast Pediatrics (Merritt Island), Family Health Center East & Oviedo Children's Health Center (Orlando), and Heartland Pediatrics of Lake Placid (Lake Placid); Georgia: the Pediatric Center (Stone Mountain), Victor Lui, MD (Chamblee), Nandlal Chainani, MD (Ocilla), Gwinnett Pediatrics & Adolescent Medicine (Lawrenceville), and Snapfinger Woods Pediatric Associates, PC (Decatur); Hawaii: Children's Medical Association (Aiea); Iowa: Children's Hospital Physicians (Des Moines); Illinois: Yacktman Children's Pavillion (Park Ridge) and SW Pediatrics (Orland Park); Indiana: Georgetown Pediatrics (Indianapolis) and Jeffersonville Pediatrics (Jeffersonville); Kansas: Ashley Clinic (Chanute); Louisiana: Carousel Pediatrics (Metairie) and Shalom Clinic for Children (Natchitoches); Maine: Maine Coast Pediatrics (Ellsworth); Maryland: Steven E. Caplan, MD, PA (Baltimore), Dundalk Pediatric Associates (Baltimore), and Ralph Brown, MD (Baltimore); Massachusetts: Burlington Pediatrics (Burlington), Pediatric Associates of Norwood (Franklin), Holyoke Pediatric Associates (Holyoke), and Mary Lane Pediatric Associates (Ware); Michigan: Pediatric & Adolescent Medicine (Bay City) and Pediatric Health Care (Sterling Heights); Minnesota: Brainerd Medical Center, PA (Brainerd), and Lakeview Clinic-Watertown Pediatrics (Watertown); Missouri: Children's Mercy Hospital Pediatric Care Center (Kansas City) and Tenney Pediatric and Adolescent LLC (Kansas City); New Hampshire: Foundation Pediatrics (Nashna); New Jersey: Chestnut Ridge Pediatric Associates (Woodcliff Lake) and Lourdes Pediatric Associates (Camden); New Mexico: Santa Fe Pediatric Associates, PC (Santa Fe), and Presbyterian Family Healthcare-Rio Bravo (Albuquerque); New York-1: Lewis Pediatrics (Rochester) and Elmwood Pediatric Group (Rochester); New York-3: Montefiore Medical Center (Bronx); North Carolina: Aegis Family Health Center-Winston East Pediatrics (Winston-Salem), Goldsboro Pediatrics, PA (Goldsboro), and Guilford Child Health-High Point (High Point); Ohio: Pediatric Associates of Lancaster (Lancaster) and Oxford Pediatrics & Adolescents (Oxford); Oklahoma: Oklahoma State University-Center for Health Sciences (Tulsa) and Pediatric & Adolescent Care, LLP (Tulsa); Ontario: Richard J. MacDonald, MD (Oakville); Oregon: NBMC (Coos Bay); Pennsylvania: Buckingham Pediatrics (Buckingham), Pennridge Pediatric Associates (Sellersville), Pediatric Practices of Northeastern Pennsylvania (Honesdale), and Laurel Health Center-Blossburg (Blossburg); Puerto Rico: Ethel Lamela, MD (Isabela); Quebec: Clinique Enfant-Medic (Dollard des Ormeaux); Rhode Island: Rhode Island Hospital-Rainbow Pediatrics (Providence); South Carolina: Oakbrook Pediatrics (Summerville) and Palmetto Pediatrics & Adolescent Clinic, PA (Columbia); Tennessee: Memphis and Shelby County Pediatric Group (Memphis) and ETSU Physicians & Associates (Johnson City); Texas: Su Clinica Familiar (Harlingen); Utah: Willow Creek Pediatrics-Draper (Draper) and Utah Valley Pediatrics, LC (American Fork); Vermont: Springfield Pediatric Network (Springfield), Rebecca Collman, MD (Colchester), Brattleboro Primary Care (Brattleboro), Pediatric Medicine (South Burlington), University Pediatrics, UHC Campus (Burlington), and University Pediatrics (Williston); Virginia: Fishing Bay Family Practice (Deltaville), Drs Casey, Goldman, Lischwe, Garrett, Kim & Pease (Arlington), Alexandria Lake Ridge Pediatrics (Alexandria), and Hampton Roads Pediatrics/CMG (Hampton); Washington: Central Washington Family Medicine (Yakima) and Harbor Pediatrics (Gig Harbor); West Virginia: Grant Memorial Pediatrics (Petersburg); Wisconsin: Gundersen Clinic-Whitehall (Whitehall); and Wyoming: Jackson Pediatrics, PC (Jackson).

	FOOTNOTES

 
Accepted Nov 17, 2006.

Address correspondence to Robert H. DuRant, PhD, Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157. E-mail: rdurant{at}wfubmc.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by DuRant, R. H. Articles by Wasserman, R. C. Search for Related Content PubMed Articles by DuRant, R. H. Articles by Wasserman, R. C. Related Collections Office Practice

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