Defense Articles

Background. Firearm injuries are the eighth leading cause of death in the United States. Evidence suggests that availability of guns in the home is associated with an increased risk of homicide, suicide, and unintentional injuries and fatalities. Our study examined five demographically diverse primary care practices in Oregon to determine the extent to which patients and members of their households might be at risk for firearm injuries.

Methods. Six hundred and four consecutive English-speaking patients who were at least 18 years old and seeking care at the five different practices were surveyed. Participants were asked about the presence of firearms in the home, methods of storage, history of firearm safety training, and history of firearm counseling by their physicians.

Forty-two percent of respondents reported having at least one firearm in the home. In homes with firearms, 48% contained at least one firearm that was stored unlocked, and 26% contained at least one firearm stored loaded. Twenty percent of homes with children contained at least one unlocked firearm, and 10% contained a loaded firearm. Forty-seven percent of those homes with both children and firearms had at least one gun that was stored unlocked, and 26% contained at least one loaded firearm. Those who reported having had formal firearm safety training were no more likely to store their firearms safely than those without such training. Only 3% of respondents reported that their physician had ever talked with them about gun safety.

Conclusions. Our data indicate that a substantial number of patients cared for by primary care physicians are at risk for firearm injuries.

Key words. Firearms; primary health care; accident prevention; safety. (J Fam Pract 1995; 41:158-162)

In 1992, firearm injury resulted in 37,776 deaths in the United States, making it the eighth leading cause of death.(1) It is estimated that for every firearm fatality, there are 2.6 nonfatal firearm injuries.(2) The economic cost of firearm injuries in 1990 was calculated to be $20.4 billion, and the cost per firearm fatality is higher than that associated with any of the four leading causes of death.(3)

In recent years, violence and firearm-related injury and death have become increasingly recognized as public health problems.(4)(5) Accordingly, reports describing firearm ownership and safety practices have begun to emerge in the medical literature.(6)(7) Although most of these studies have focused on adolescent populations or families with children, firearms present a potential danger to all persons regardless of age.

Evidence suggests that availability of guns in the home is associated with an increased risk of homicide, suicide, and unintentional injuries and fatalities.(8)(9)(10)(11) It is estimated that there are over 200 million firearms in civilian hands and that firearms are present in almost one half of all US homes.(12)(13) A national survey of gun owners revealed that more than one third stored their gunds loaded, and 53% did not store their firearms under lock.(12)

Primary care physicians are expected to routinely counsel their patients about lifestyle issues and health behaviors, but little is known about physicians’ attitudes and practices concerning counseling on firearm injury prevention. Many physicians are unaware of which patients in their practices are at risk for firearm injuries. A study of Maryland pediatricians revealed that only 10% reported counseling at least one fourth of the families in their practices about firearm hazards.(14) Many of these physicians believed that their patients were not at risk for fiearm injuries.

The purpose of our study was to examine five demographically diverse primary care practices in Oregon to determine the extent to which patients and members of their households might be at risk for firearm injuries and to assess whether these patients received counseling on firearm injury prevention from their physicians.

Methods

Physicians at five different primary care offices in Oregon were contacted regarding participation in a study of their patients’ firearm ownership and safety practices. This was a convenience sample chosen to represent a variety of practice styles and geographic and socioeconomic services areas in Oregon. Each one of the primary care offices contacted agreed to participate. The group included (1) a university-based family practice center in an urban area (referred to as “university”), (2) a multiphysician family practice office in a suburban neighborhood (”suburban”), (3) a county health department primary care clinic in an urban area (”health department”), (4) a solo private practice in a rural area (”rural–solo”), and (5) a multiphysician, rural family practice office 200 miles from the other rural locale (”rural–group”).

Six hundred four consecutive English-speaking patients who were at least 18 years old and seeking care at the five practices were surveyed. Each potential subject was approached by the same research assistant, informed that the office was participating in a project on firearm safety, and asked to privately complete an 11-question survey instrument. Potential subjects were informed that disclosed information would be kept confidential and were asked not to record any identifying information on the questionnaire. Participants were asked questions regarding the presence of firearms in the home, methods of storage, history of firearm safety training, history of firearm counseling by their physicians, and basic demographic information.(*)

The overall annual rates of nonfatal and fatal firearm-related injuries in the United States declined consistently from 1993 through 1997, according to a recent report. The annual nonfatal rate decreased by 40.8 percent, from 40.5 per 100,000 persons in 1993 to 24.0 per 100,000 persons in 1997. The annual mortality rate also declined by 21.1 percent, from 15.4 per 100,000 persons in 1993 to 12.1 per 100,000 persons in 1997. The report appears in the November 19, 1999 issue of Morbidity and Mortality Weekly Report.

A firearm-related injury was defined as a penetrating injury or gunshot wound caused by a weapon that uses a powder charge to fire a projectile (e.g., handguns, rifles and shotguns). Data on nonfatal firearm-related injuries that were treated in the emergency departments of U.S. hospitals were obtained from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission.

The declines in the rates of nonfatal and fatal firearm-related injury were generally consistent across all population subgroups. The decreases in the rates of nonfatal and fatal injury were similar in men and women. Declines in fatality rates in blacks and Hispanics were similar, and were both greater than the decline in non-Hispanic whites. In the rates of nonfatal injury, no consistent pattern was seen in the estimated decline across age groups, but in the rates of fatal injury, age and percentage change were inversely related.

To examine trends in the rates of nonfatal firearm-related injury, cases with unknown intent were allocated to one of three known categories: assault/legal intervention, intentionally self-inflicted and unintentional injury. Most of the nonfatal injuries occurred among men 15 to 44 years of age, were self-inflicted and were associated with hunting, target shooting and routine gun handling.

Numerous factors may have contributed to the decline in the rates of nonfatal and fatal assaultive firearm-related injury. These factors include: improvements in economic conditions; the aging of the population; the decline in the “crack” cocaine market; changes in legislation, sentencing guidelines and law-enforcement practices; and improvements associated with violence prevention programs.

The British Shooting Sports Council yesterday argued against a complete ban on the possession of firearms. And on the first day of the inquiry into the Dunblane shootings, it urged Lord Cullen not to dismiss the current gun laws out of hand as ineffective.

Speaking about the written evidence it had submitted to the inquiry, Patrick Johnson, secretary of the British Shooting Sports Council, said: “We have made a number of positive proposals to Lord Cullen for increasing public safety - largely through more effective practice of the systems and safeguards which already exist - without putting a complete ban on possession of firearms of one sort of another. The current laws and rules should not be dismissed out of hand as ineffective.”

“Lord Cullen has control of the proceedings and his hearings are about to begin,” Mr Johnson said. “It would be wrong of anyone to seek to influence the outcome by making public statements about gun control while his inquiry is in progress.”

Coinciding with the opening of the Cullen inquiry, a report by head teachers said yesterday that schools should install panic alarms, bright lighting, security barriers and prickly bushes to deter intruders. The National Association of Head Teachers (NAHT) will advise its members to review their policies for ensuring that pupils and teachers are safe.

Walls and fences should be low and topped with railings to prevent intruders from hiding behind them, and impenetrable bushes should be planted near them to make access more difficult, the association’s annual conference heard yesterday. Visitors should be directed through just one entrance and, if possible, the school office should overlook it so that everyone coming on to the site can be seen. Crisis policies should also cover the possibility of bomb threats, terrorism, natural disasters or a pupil or teacher being taken hostage.

Emergency procedures should be drawn up to include informing parents, bringing in counsellors where necessary and making staff aware of the effects of post-traumatic stress disorder, the report says.

When a serious incident does occur, injured pupils and staff should be visited in hospital and, if someone has died, representatives of the school should attend the funeral. In such cases, a school should consider setting up a memorial or holding a special assembly. David Hart, NAHT general secretary, said that more funding was needed to improve school security.