The mission of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC
) in Portland, Oregon is to conduct research that empowers Veterans to improve their health through engagement in self-care, engagement with VA and non-VA healthcare systems, and engagement in the research process.
According to the 2020 National Veteran Suicide Prevention Annual Report, between 2017 and 2018 the suicide rate among Veterans who had recently used VA healthcare decreased by 2.4%, while the rate of suicide increased by 2.5% among Veterans who did not use VA healthcare. Despite signs of hope, the suicide rate among male Veterans was 1.3 times higher than that of non-Veteran males. Veterans are significantly more likely to use firearms as a means of suicide than the general population – and reducing access to such lethal means is one of the few empirically supported approaches for lowering suicide rates. VA is investing in efforts to move suicide prevention efforts “upstream” – to populations not necessarily known to be at high risk. As one upstream approach, primary care teams could encourage patients to take steps to improve household safety and reduce risk for suicide by putting distance between their firearms and themselves, particularly during times of emotional distress.
Led by Steven Dobscha, MD, Director of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC), this quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. In late 2018 and early 2019, investigators conducted focus groups and interviews with 68 Veterans to:
- Assess acceptance of FSS discussions during primary care visits;
- Ascertain facilitators and barriers to conducting FSS discussions; and
- Identify strategies for primary care teams to use to effectively conduct these discussions with Veterans.
Veteran Research Participants
Of the 68 Veterans who generously gave their time to participate in this study, 50 Veterans were part of the Vancouver Community Military Appreciation Committee (CMAC), an organization created to connect Veteran advocacy organizations in and around Southwest Washington (state); 10 were part of the VA Portland Veteran and Family Advisory Board (VFAB), which promotes opportunities for cultural transformation in healthcare by giving voice to Veterans and their families through the VA Portland Health Care System; 5 were members of CIVIC’s Veteran Engagement Group (VEG), which is a platform for Veterans to share their perspectives with other Veterans and VA Portland researchers; and 3 Veterans were identified through existing VA contacts to serve as consultants to the research team to provide input in all phases of this project.
Facilitation of firearms storage safety discussions with Veterans in primary care settings may be a promising upstream approach to complement other suicide prevention efforts.
- Most Veterans agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Firearms are a sensitive topic for many Veterans.
- Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about it, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or of having limitations placed on their access to firearms.
- Veterans also noted the need to provide a clear reason for why a discussion on FSS was taking place, such as concern for household safety or general wellbeing.
To help address fears about disclosure, this Veteran suggested that primary care staff should have up-to-date knowledge on state and federal laws regarding firearm safety.
I think it’s important to know the Oregon state laws surrounding firearms safety and firearms. I know a lot of people don’t know the laws surrounding that, and then they want to give advice like, ‘well, just give your firearm to a friend’ or ‘give it to a loved one.’ But there needs to be more education surrounding what are the repercussions of doing that, and what are the laws about doing that.
Disclosure of ownership was of special concern to Veterans with mental health conditions.
…if I ever did want to get a gun because of civil unrest, and I felt like I needed to protect myself, am I already on a ‘can’t get gun list’ because I have PTSD?
…until 2011 we weren’t even allowed to have mental health issues, including PTSD. We had to hide it because we’d lose our security clearance. So there’s a lot of avoidance of talking about mental health issues that confound this.
Just kind of not saying like, ‘not in the right state of mind’ to be handling weapons… It’s sort of off-putting, almost like you are saying, ‘you’re kind of crazy sometimes, and so maybe you should not have your firearms’.
Veterans expressed negative attitudes toward formulaic screening processes and preferred more authentic connections with primary care staff.
Yeah, I mean instilling them to be a little bit more sincere with the Veterans they meet instead of just being like [In a disinterested tone] ‘Hey you got a firearm at home? Okay, you know you should keep it locked up.’ Umm, next thing: you’re a little overweight. Cool. You should probably go on a diet.
One Veteran cautioned that primary care staff should be aware of verbal and non-verbal expressions of judgment in interactions with Veterans during firearms safety discussions.
I remember just the general shock at providers when they’re like ‘Do you own firearms?’ and I said, ‘yeah.’ And they go ‘Oh my god,’ and they start looking at me weird where they’d scoot over across the room, so their behaviors, their reactions are just something that need to be worked on.
Another important aspect of engaging Veterans in firearms safety discussions involves primary care staff conveying care for the health and wellbeing of Veterans.
Just explaining, ‘This is why I’m asking you these questions. It’s because I care, and I don’t want to see you end up hurt.’ You know, actually showing concern instead of just like, ‘Do you have—’ and reading off of a checklist.
Several Veterans offered actual “scripts” that providers could use to directly engage Veterans about firearms without asking about whether a Veteran owns a firearm.
Hey, I know you’re a Veteran and a lot of you guys own guns. I don’t care if you do or don’t. I would encourage you to add some barriers between you and your weapon, whether that be removing a firing pin, or handing your [gun lock] keys to a spouse. Don’t do something you can’t take back.
Do you have a way to secure your firearm? Is it currently safe? If not, how can we help you secure that firearm and what would be the most useful tool to you?
One Veteran suggested tying firearms storage safety to the VHA Whole Health Initiative – a holistic and patient-centered approach to health and wellbeing.
The VA is changing its mindset into a whole health approach, and this would be a nice tie into the whole health approach.
This feedback shows that to be most effective, FSS discussions in primary care must be personalized, using a caring and conversational approach rather than a highly scripted or checklist approach, engaging Veterans in a non-judgmental manner, and conveying respect for Veterans’ knowledge of firearms.
Dr. Dobscha has consulted with VA’s Office of Mental Health and Suicide Prevention (OMHSP), who supported this study, as well as other subject matter experts working on lethal means safety in VA about training programs for primary care providers.
Dobscha S, Clark K, Newell S, et al. Strategies for Discussing Firearms Storage Safety in Primary Care: Veteran Perspectives. Journal of General Internal Medicine. January 26, 2021; online ahead of print.
HSR&D is currently conducting initiatives and studies on suicide prevention in areas that include but are not limited to: the Suicide Prevention Research Impact NeTwork (SPRINT); Implementing Caring Contacts for Suicide Prevention in Non-Mental Health Settings Randomized Evaluation of Caring Letters; Improving Sleep as a Strategy to Reduce Suicide Risk among At-risk Veterans; Rapid Referral to Suicide-Specific Intervention in Psychiatric Emergency Care; and Understanding Suicide Risks among LGBT Veterans in VA Care. For more information, visit HSR&D’s Suicide research page.