Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial

Abstract

Objective: The objective of this study was to determine whether patients' families' violence-prevention behaviors would be affected by their primary care practitioner's use of a violence-prevention clinical intervention during the routine well-child examination.

Methods: In this cluster-randomized, controlled trial (2002-2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months. Practitioners were trained to (1) review a parent previsit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children's exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use <120 minutes per day, use of timeouts, and use of firearm cable locks.

Results: Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to <120 minutes per day. There was no significant effect for timeout use. There was a substantial increase in storing firearms with cable locks for the intervention group versus a decrease for the control group.

Conclusions: This randomized, controlled trial demonstrated decreased media exposure and increased safe firearm storage as a result of a brief office-based violence-prevention approach.

Figure 1

Flow of participants through the trial.

Figure 2

The SC trial compared the office-based violence-prevention approach (intervention group) with a reading-aloud passive educational program (control group). The time scale of the trial runs from top to bottom Components of the intervention delivered consecutively are shown 1 beneath the other. Components delivered concurrently are depicted side by side. Components are categorized as either objects or activities. Objects are represented by squares, reflecting their fixed nature. Activities are represented by circles, reflecting their flexibility. A, Intervention practitioners were trained to (1) complete (or have 1 of their staff complete) a worksheet that identified local agency resources for childhood aggression or anger/behavior management, (2) review the parent previsit survey regarding patient-family behavior and parental concern about child's media use, discipline strategies, and children's exposure to firearms, (3) counsel using brief principles of MI, (4) instruct patient-families to use tangible tools (minute timers to monitor media time and timeouts and firearm cable locks to store firearms more safely where children live or play), and (5) provide local agency referral (resources identified in SC component 1) when either parent or practitioner concerned at the time of the visit. B, Practitioners received SC materials: (1) local agency violence-prevention worksheets, (2) patient-family previsit surveys to assess patient-family behavior and parental concern about child's media use, firearm accessibility/storage, and discipline/childhood aggression, (3) practitioner brief MI pocket cards, (4) recommendation guides (for patient education) on media use, discipline, and firearm safety, (5) tangible tools (minute timers to monitor media time and timeouts and firearm cable locks to store firearms more safely), and (6) training videotapes for the practice (enrolling eligible patients, conducting informed consent, gathering data) and audiotapes for the practitioner (brief MI training included). Training for the practice (10-minute videotape) and training for the provider (20-minute audiotape) were considered to be a study-specific requirement. C, As part of the routine well-child visit, 8-page previsit surveys were completed by the patient-family to determine whether media use was >2 hours per day, which discipline techniques were used, and whether firearms were present where the child lives or plays and to elicit whether patient-family had any concerns about media use, discipline/childhood aggression, and firearm accessibility/storage (study-related requirement; 10–20 minutes for families to complete). D, The practitioner reviewed the previsit survey summary page and identified patient-family behaviors and concerns during the visit (intervention-related requirement;<1 minute for providers). E, During the visit, the practitioner used brief principles of MI to counsel patient-family on violence-prevention behaviors specific to media use, discipline concerns, and firearm accessibility/storage (intervention-related requirement; 2–4 minutes of provider discussion). F, The patient-family received tangible tool(s) (minute timer and/or cable gun lock) and/or referral to local agency during visit when indicated by either parental concern of excessive childhood aggression or practitioner concern. Note: In this study, practitioners offered free cable locks to parents who lived in homes with children where guns were stored. Cable locks have several advantages over other locks, such as trigger locks. First, they are easily installed on a wide variety of guns, and explaining to a parent how to use the lock properly is quick and simple and can be done with written instructions with illustrations. Second, although guns should be stored unloaded, if parents choose to have a loaded firearm in the home, then a cable lock will prevent the firing pin from making contact with a bullet or shell, thereby preventing the accidental firing of the gun (intervention-related requirement; time included with that noted in E). G, The patient-family received the Recommendation Guide, a trifold educational handout that reviews AAP recommendations on media use, discipline techniques, and firearm accessibility/storage (intervention-related requirement; time included in E). H, The control practitioners were trained (via audiotape) to provide literacy promotion recommendations and to distribute a literacy handout explaining the value of reading aloud to children. I, The practitioner received literacy promotion handouts. J, The practitioner delivered usual care regarding injury/violence prevention and used the reading handout to discuss family reading habits during the visit (control group–required component; <1 minute). K, The patient-family received a literacy promotion handout.