Pediatric Healthcare Worker Perspectives on Implementation of a Secure Firearm Storage Program: A Qualitative Study.

Background: Primary care-based secure firearm storage programs are well-positioned to prevent firearm-related injury, the leading cause of death for young people in the United States. While recommended by the American Academy of Pediatrics and US Surgeon General, these programs have yet to become routine practice. Our cluster randomized hybrid effectiveness-implementation trial tested implementation strategies across 30 clinics in two large health systems for a universal evidence-based secure firearm storage program, S.A.F.E. Firearm (Suicide and Accident Prevention through Family Education). S.A.F.E. Firearm includes a brief discussion between a clinician and parent on secure firearm storage and an offer of free cable locks at pediatric well-child visits for youth ages 5-17. The ASPIRE trial demonstrated meaningful clinician behavior change, with S.A.F.E. Firearm delivered to a significantly higher percentage of patient families in the clinics that received both implementation strategies (49%) versus only one (22%). The present study qualitatively explores factors influencing the successful implementation of S.A.F.E. Firearm, centering healthcare worker (HCW) perspectives. Methods: Semi-structured qualitative interviews were conducted with leaders, clinic change agents, and clinicians involved in implementation from 2023-2024 (N = 38). The interview guide was informed by the original and updated Consolidated Framework for Implementation Research. Interviews were coded and analyzed using an abductive, integrated (i.e., deductive and inductive) approach. Inter-rater reliability (Kappa = 0.87) was strong. Results: Interviews elucidated four interconnecting themes. HCWs unanimously expressed pediatric HCWs' responsibility to promote firearm safety (role of pediatrics in firearm safety) across heterogeneous community and healthcare firearm cultures. By preserving families' autonomy and privacy around firearms, S.A.F.E. Firearm's nonjudgemental and universal approach promoted program acceptability and delivery. Consequently, HCWs' understanding versus confusion around this universal, privacy-focused harm reduction approach was foundational to implementation. Conclusions: Health systems can harness HCWs' shared commitment to firearm safety by deploying brief programs that preserve recipient autonomy and privacy. To scale these evidence-based approaches, we recommend offering clear, simple trainings and collaboratively adapting programs to meet HCW and recipient needs. Trial registration: Registry: https://clinicaltrials.gov/study/NCT04844021, TRN: NCT04844021, first registered on April 14, 2021.