DOI: 10.3886/e169601v1
title: Adapting the Safety Check Intervention for Wide-Scale Implementation in Health Systems as a universal suicide prevention strategy

description: This project sought to adapt an evidence-based firearm storage program called Safety Check (Barkin et al., 2008, Pediatrics) to prepare it for use in a hybrid effectiveness-implementation trial targeting universal suicide prevention. This work built on prior work done in a NIMH-funded R21 (MH109878; PI Beidas; 2016-18) in which we partnered with two health systems within the Mental Health Research Network (MHRN), a consortium of 13 US healthcare systems, to better understand how to implement firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. We investigated the acceptability and use of the firearm components of the Safety Check program (screening, counseling, and giving out cable locks) by surveying 140 medical directors and pediatric primary care providers. We subsequently conducted semi-structured interviews with 70 stakeholders, including parents, clinicians, health system leaders, firearm safety course instructors, and firearm owners. We found that pediatric clinicians see firearm safety programs such as Safety Check as acceptable and within scope of practice, but they do not routinely use them. At the same time, we gathered suggested adaptations to the program to target suicide prevention specifically, and a set of stakeholder-recommended implementation strategies to help bridge the gap between clinician beliefs about the importance of firearm safety promotion and low rates of implementation. The strategies include training, leadership endorsement, facilitation to address workflow issues and other barriers, and integration of the program into the electronic health record (EHR). <br> <br>The present project had two specific aims: <br><b><br>Aim 1: To adapt Safety Check using an established adaptation framework (i.e., ADAPT-ITT) and create parent tools to support delivery in collaboration with a stakeholder advisory board.</b> We proposed to adapt Safety Check to optimize its effectiveness for suicide prevention and to create parent and clinician tools to support its delivery and implementation. <br><b><br>Aim 2: To obtain acceptability ratings of the adapted program and delivery tools.</b> We surveyed firearm owning and non-owning parents to garner acceptability ratings of the adapted program.
description: n/a
description: Response Rates: <b>Aim 1 qualitative:</b> 9 participants contacted, 9 participants completed <br><br><b>Aim 1 quantitative:</b> We are unable to determine number of eligible MTurk workers because this is not public information. Of 2169 MTurk workers who completed the pre-screening survey, 1332 were not eligible for the full surveys because they did not indicate that they were parents. 438 parents who indicated having firearms in the home and 399 parents who indicated not having firearms in the home were made eligible for the full survey based on the pre-screening survey. Participants were eligible to complete either or both of the surveys (name survey, logo survey). 529 name surveys and 554 logo surveys were received. After excluding survey responses due to conflicting answers with the pre-screening survey, incompleteness, failure of the attention check, and conflicts within surveys or between the name and logo survey, 337 name surveys and 337 logo surveys were included in analyses (with 171 participants having completed both surveys). <br><br><b>Aim 2 quantitative:</b> We are unable to determine number of eligible MTurk workers because this is not public information. Of 402 MTurk workers who completed the pre-screening survey, 199 were not eligible for the full surveys because they indicated they were not parents or had children who don’t attend well-visits. 203 participants were made eligible for the full survey. 116 participants completed the full survey. After excluding survey responses due to incompleteness, failure of the attention check, and conflicts within the survey, 97 participants were included in analysis. <br><br><b>Aim 2 qualitative:</b> Of the 116 completed surveys, 34 participants expressed interest in the qualitative interview. Of these 34 interested participants, 11 completed an interview. Of the remaining 23 participants, 22 did not respond to the research team’s outreach attempts and 1 responded to outreach attempts but was not able to schedule an interview.
description: Presence of Common Scales: <b>Aim 1 qualitative:</b> n/a <br><br><b>Aim 1 quantitative:</b> <br>One question each from: Acceptability of Intervention Measure, Intervention Appropriateness Measure (Weiner et al., 2017, Implementation Science) <br><b>Aim 2 quantitative:</b> <br>Acceptability of Intervention Measure (Weiner et al., 2017, Implementation Science) Patient-Doctor Depth-of-Relationship scale (Ridd et al., 2011, Annals of Family Medicine) Three-item trust measure from the Firearm Safety Among Children and Teens Consortium National Survey, which adapted the validated Wake Forest Physician Trust Scale (Hall et al., 2002, Medical Care Research and Review) <br><b> Aim 2 qualitative:</b> n/a
description: <b>Aim 1 qualitative: </b>convenience and snowball sampling <br><br><b>Aim 1 quantitative:</b> convenience sample <br><br><b>Aim 2 quantitative:</b> convenience sample <br><br><b>Aim 2 qualitative:</b> convenience sample
description: <b>Aim 1 qualitative:</b> Individuals who expressed interest in participating in research related to firearm safety and suicide prevention with the research team and/or the Firearm Safety Among Children and Teens (FACTS) Consortium (https://www.icpsr.umich.edu/web/pages/facts/index.html) <br> <b><br>Aim 1 quantitative: </b>MTurk workers with at least a 95% MTurk task acceptance rate and at least 100 accepted tasks on MTurk, and who live in the United States or Minor Outlying Territories, and who indicated on a pre-screening survey that they were the parent of at least one child under age 18. <br><b><br>Aim 2 quantitative:</b> MTurk workers with an MTurk task approval rate of at least 95% and at least 100 completed MTurk tasks, and who were located in the U.S. or U.S. Minor Outlying Territories, and who indicated on a pre-screening survey that they were the parent or guardian of at least one child under age 18 who attends well-child visits. To obtain new feedback, we required participants to have had no prior participation in the Aim 1 surveys. <br><b><br>Aim 2 qualitative:</b> Interested individuals who had completed the Aim 2 quantitative survey and indicated interest in completing a qualitative interview. . Smallest Geographic Unit: Aim 1 qualitative: n/a; Aim 1 quantitative: n/a; Aim 2 quantitative: State; Aim 2 qualitative: State
description: other; telephone interview; web-based survey; <b>Aim 1 qualitative: </b>We recruited a convenience sample of individuals who expressed interest in participating in research related to firearm safety and suicide prevention with the research team and/or the Firearm Safety Among Children and Teens (FACTS) Consortium (https://www.icpsr.umich.edu/web/pages/facts/index.html) to confirm acceptability of the proposed adaptations gleaned from prior R21 work (MH109878; PI Beidas; 2016-18). Individuals participated in a one-hour small group discussion or individual interview, based on schedule and/or preference. During the meetings, we summarized the original Safety Check program, presented each proposed adaptation with a brief rationale for the change, and asked stakeholders to provide feedback. <br><br><b>Aim 1 quantitative:</b> Due to equivocal findings from our Aim 1 qualitative interviews with respect to the name and branding of the adapted Safety Check program, we used an online platform to crowdsource name and logo design ideas for the adapted program. After receiving 1419 name entries and 299 logo entries, the research team chose the 10 names and 10 logos that best fit the program content, context, and prior stakeholder feedback, and obtained quantitative feedback from firearm owning and non-firearm owning parents via Amazon Mechanical Turk (MTurk) in 2 separate surveys (1 survey for program name, 1 survey for program logo). <br><br><b>Aim 2 quantitative:</b> Participants watched a 6.5-minute video depicting a telehealth visit in which the adapted Safety Check program (now called S.A.F.E. Firearm) is delivered by a pediatrician to a parent. The video was recorded by a practicing pediatrician, with the study’s principal investigator acting as the parent recipient of the program. Participants were presented with written instructions asking them to imagine that their pediatric primary care clinician had just had a similar conversation with them at their child’s well-child visit and to complete the survey with this in mind. Participants were then asked a number of other survey questions. Finally, they were asked to indicate whether they would like to be contacted for a follow-up interview. <br><br><b>Aim 2 qualitative:</b> Study staff provided a link to the same S.A.F.E. Firearm video used in the quantitative survey and requested that participants re-watch the video prior to the scheduled interview. Interviews followed a semi-structured interview guide developed and piloted by the research team. In the first part of the interview, participants completed a modified Think Aloud exercise, in which they paused the video on their personal electronic device at 3 pre-specified points based on natural shifts in the counseling conversation. Interviewers first asked participants to provide immediate reactions to each section and probed thought processes (e.g., can you talk through why you’re thinking that?) to elicit nuanced feedback on specific program components. Participants were then asked about main takeaways of the program and prior experiences with firearm counseling in a pediatric primary care setting. Firearm-owning participants were asked about current firearm storage practices and preferences for post-visit program follow-up, given equivocal findings in the Aim 1 qualitative interviews.