An Antiracist Approach to Firearm Injury Prevention Screening and Safety Counseling

Since 2019, firearms have been the leading cause of death for children and adolescents aged 1 to 19 years.1 In response, some clinicians and health systems have recognized that providing families with counseling on secure firearm storage and firearm injury prevention falls within their scope of practice.2 Storing firearms unloaded, locked in a safe, and separate from ammunition is an evidence-based practice to reduce firearm injury.2Stark disparities in firearm injury rates among racial and ethnic minority groups,3–5 including Black, Hispanic, and American Indian/Alaska Native (AI/AN) populations, alongside rising firearm ownership rates among these groups, highlight the need to recognize and address the effects of racism on firearm ownership and firearm injury prevention.6,7 This commentary presents an antiracist framework for firearm injury prevention screening and safety counseling in clinical settings.An antiracist approach recognizes that policies and practices can either perpetuate or disrupt racism and seeks to intentionally design systems that advance racial equity.8 In the context of firearm safety counseling, this approach involves identifying and anticipating inequities that could result from existing counseling strategies and proposing alternative interventions that actively counteract or mitigate the effects of racism. Specifically, this framework addresses racism at structural, institutional, and interpersonal levels and offers strategies for intervention development, safety risk assessment, documentation, resource distribution, and family- and community-centered support (Figure 1).9,10 Applying an antiracism framework to firearm safety counseling could improve equitable access to resources that reduce firearm injury risk.Most existing literature on firearm ownership among racial and ethnic minority communities focuses on Black or African American individuals. Structural racism likely also shapes firearm ownership practices for Hispanic, Asian American, and AI/AN families, yet there remains a notable gap in research on firearm access, ownership, and storage practices in these communities. We offer strategies that could apply broadly across racial and ethnic minority populations.Disparities in firearm victimization are caused by policies and practices rooted in racism. Discriminatory policies, such as redlining, have contributed to increased firearm violence within Black communities in the United States. Redlining and associated financial disinvestment by banking and real-estate institutions reshaped the built environment in these communities, creating segregated areas of concentrated poverty, limited employment and educational opportunities, and decreased access to health care.11–14 This concentration of poverty and limited economic resources and opportunities increases the likelihood of firearm violence.15 Consequently, children from racial and ethnic minority groups are disproportionately impacted by firearm violence.4Black, AI/AN, and Hispanic adolescents are more likely to be victims of firearm homicides than their white counterparts.4 Between 2019 and 2020, firearm suicide rates increased for AI/AN males aged 10 to 44 years, and in 2022, the rate of firearm suicide among Black youth aged 10 to 19 years in the United States outpaced the rate among white youth for the first time.5,16 Additionally, from 2019 to 2023, the crude death rate from unintentional firearm injuries among Black children has remained 5 times higher than that of white children.17Simultaneously, firearm ownership rates among racial and ethnic minority adults have increased from 2015 to 2021, with surges in purchasing during the COVID-19 pandemic.6,7 In a survey study conducted from January 2019 to April 2021, 21% of new firearm owners identified as non-Hispanic Black adults, compared with 9% prior to 2019.6,7 Additionally, 20% of new firearm owners during this period self-identified as Hispanic.6 In a nationally representative 2022 survey of 527 individuals self-identifying as AI/AN, 45.5% reported access to a firearm.18Although motivations behind this trend are an active area of research, historical contexts may provide some insights. During the Jim Crow era, laws rooted in white supremacy barred racial and ethnic minority individuals from legally owning or purchasing firearms.19,20 These laws were founded on racist beliefs that Black individuals were inherently dangerous and intentionally disarmed and disempowered Black communities to reinforce social hierarchies and suppress resistance.20 For example, the 1967 Mulford Act in California, which prohibited public carrying of loaded firearms, was crafted in response to the Black Panther Party's armed patrols against police brutality.21Similarly, firearms were used as a tool of oppression, colonization, genocide, and forced removal of AI/AN individuals from their ancestral land.22 Despite this history, firearm ownership has remained high among AI/AN individuals, partly due to the critical role of firearms in subsistence hunting and other AI/AN cultural practices.22 Understanding this history is critical to engaging patients in culturally responsive safety counseling.An antiracist approach to firearm safety intervention development requires recognizing racism as a root cause of disparities in firearm injury, acknowledging the diversity of firearm owners and reasons for firearm ownership, and challenging racial stereotypes related to ownership.23–25 Regarding the latter, one study found that white individuals with anti-Black bias were more likely to associate firearm rights with white Americans and were less supportive of extending those rights to Black Americans.24 In reality, some Black Americans and first-generation immigrants may see firearm ownership as an exercise of their rights and a strategy for self-protection against racism.17,18 For example, during the COVID-19 pandemic, firearm ownership among Asian Americans increased, motivated in part by experiences of interpersonal racism.25Firearm injury prevention interventions should therefore center on safety and avoid questioning families' motivations for firearm ownership. Although evidence demonstrates that the safest home is one without firearms, we recognize that removing firearms from the home may not be a feasible or desirable first step for some individuals.2,26–29 Pediatricians should adopt strengths-based, family-centered approaches to collaboratively develop firearm safety practices that honor families' values while reducing the risk of intentional or unintentional injury.For instance, a caregiver may choose to keep a loaded firearm in her car while driving through an unsafe neighborhood to take her son to school. This decision might reflect her concern for her family's safety and commitment to her child's education. These priorities should be recognized and affirmed as strengths. Rather than focusing on risk alone, a clinician might ask: "How can we work together to find a way for you to feel safe, get your child to school, and also reduce the chances that your child or someone else could gain access to your firearm, leading to an injury?" This reframing could create space for shared problem-solving that aligns evidence-based recommendations with the caregiver's lived experience and values, grounding firearm safety counseling in empathy, trust, and collaboration. Positive individual-level interactions between providers and patients around firearm injury prevention have the potential to mitigate disparities and enhance trust.Health systems should aim to implement trauma-informed and targeted universal approaches to firearm safety counseling.30 All health care providers should be trained in performing firearm safety counseling in a trauma-informed manner, as this has been noted as a critical barrier to implementation.2 A trauma-informed approach recognizes that many racial and ethnic minority families experience trauma related to community and racialized violence, discriminatory policing, and systemic inequities. For some families, firearm acquisition may represent a rational response to lived experiences of danger and the absence of reliable institutional protections. Trauma-informed counseling seeks to understand families within this social and historical context and to partner with them to promote safety in a respectful, nonjudgmental way. Examples of trauma-informed techniques for addressing safety risks could include encouraging incremental steps toward safety, such as the purchase of a lockbox or safe, and identifying local spaces where children and families can gather safely and feel supported.31Recent evidence suggests that patients from racial and ethnic minority groups are less likely to be screened for firearm access.32 However, a recent national survey found that unsecure firearm storage is most prevalent among Black firearm owners, suggesting that individuals from this community might be most likely to benefit from safe storage interventions.33 Although universal screening and counseling may help mitigate stigma and maximize the reach of firearm safety interventions, targeted universalism goes a step further by refining strategies to assess and address safety risk within specific subpopulations, improving outreach and intervention effectiveness and preventing unintended consequences, such as erosion of trust. This approach reflects an antiracist commitment to equity rather than equality, addressing community-specific barriers and engaging local partners to co-design outreach and assessment tools that achieve a common goal across all populations.For example, Da El Siguiente Paso, a national public education campaign on secure firearm storage featuring 2 Hispanic fathers and firearm owners, was created by the Ad Council to maximize the cultural relevance of safe storage messaging for Hispanic firearm owners.34 In another example, a pilot intervention in 2 predominantly Alaska Native villages in Bristol Bay, Alaska, partnered with local village public safety officers, firearm owners, and medical, mental health, and law enforcement professionals to co-develop a firearm safe and trigger lock distribution program. At a 3-month follow-up, 86% of the safes distributed were in use with firearms stored inside, demonstrating both feasibility and cultural acceptability.35Health systems should ideally track rates of screening and resource provision across demographic groups to identify and address inequities as they arise. One strategy to achieve this could involve a quality improvement analyst regularly tracking rates of firearm safety screening and resource provision, disaggregated by race, ethnicity, preferred language, and insurance status. Additionally, health systems should ideally provide multilingual educational materials on safe storage to improve access for families who prefer a language other than English.Health systems adopting firearm injury prevention screening should ensure they have the resources to support families effectively. Rather than just documenting families' firearm storage practices, health systems should provide tangible, concrete resources like educational information about secure storage practices, locking devices, and temporary storage maps.Health systems should also ensure their own practices reflect antiracist principles, for example, through thoughtful and nonjudgmental documentation of firearm safety discussions in electronic health records. Documentation that avoids stigmatizing phrases, such as "family refused [firearm safety counseling]," may help preserve patient-provider trust, especially given that patients and families can access their medical records. Instead, providers could use phrasing that emphasizes families' strengths and priorities, such as "family expressed a strong commitment to protecting their child from community violence. Educational materials on firearm safety were provided, and they were open to discussing this further at future visits."Biases in documentation of firearm practices could also lead to unintended consequences if used inappropriately to, for example, support child neglect reporting.36,37 For example, a caregiver may be documented as engaging in unsecure storage despite never receiving education on how to store their firearm safely. This documentation could then be misinterpreted as neglect, despite the issue stemming from a lack of awareness and access to safe storage resources.38,39 Documentation of firearm storage practices should only be linked to child neglect cases if these practices directly result in injury or are adjudicated separately under child access prevention laws. Standardized documentation templates that minimize bias may help mitigate these risks.Clinicians should guide patients along a spectrum of storage practices toward the safest standards, identifying opportunities for education, shared decision-making, and support, and building on shared values like family safety and well-being.Successful implementation of an antiracist approach to screening and counseling also requires authentic, longitudinal partnerships with community-based organizations (CBOs) engaged in firearm injury prevention. External partnerships should avoid exacerbating existing inequities and eroding trust. For example, referring families to law enforcement agencies to obtain locking devices may have unintended consequences, as protection from law enforcement has been cited as a reason for firearm purchasing among racial and ethnic minority individuals.18,23,40 Although law enforcement agencies can be important partners in firearm safety promotion, health systems should, when possible, invest in community-based device distribution as an additional approach. For example, Youth Empowerment for Advancement Hangout (YEAH Philly) is a CBO that serves the community near our hospital and primary care sites and that promotes violence prevention among Black adolescents and young adults through peer mediation, conflict resolution, and community-based distribution of firearm locks.41Family and community involvement is critical to promoting culturally responsive firearm safety strategies. Gathering ongoing feedback from families from minoritized racial and ethnic backgrounds can help ensure strategies are responsive to community needs.Structural, institutional, and interpersonal racism may influence clinicians' ability to provide effective firearm safety counseling to patients and families from racial and ethnic minority groups. Health systems engaging in firearm safety counseling should aim to mitigate individual and institutional biases, use data to identify and address disparities, and prioritize community partnerships. By embedding antiracist principles into aspects of firearm injury prevention, health systems can better serve diverse communities and advance health equity.