Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts.

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.

Youth Firearm Injury: A Review for Pediatric Critical Care Clinicians.

Firearms are now the leading cause of death among youth in the United States, with rates of homicide and suicide rising even more steeply during the SARS-CoV-2 pandemic. These injuries and deaths have wide-ranging consequences for the physical and emotional health of youth and families. While pediatric critical care clinicians must treat the injured survivors, they can also play a role in prevention by understanding the risks and consequences of firearm injuries; taking a trauma-informed approach to the care of injured youth; counseling patients and families on firearm access; and advocating for youth safety policy and programming.

Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review.

Introduction: Lethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice. Methods: To better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research. Findings: Of the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC. Conclusion: This synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt]. Systematic review registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study.

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Implementation mapping to plan for a hybrid trial testing the effectiveness and implementation of a behavioral intervention for HIV medication adherence and care retention.

Background: Implementation mapping is a systematic, collaborative, and contextually-attentive method for developing implementation strategies. As an exemplar, we applied this method to strategy development for Managed Problem Solving Plus (MAPS+), an adapted evidence-based intervention for HIV medication adherence and care retention that will be delivered by community health workers and tested in an upcoming trial. Methods: In Step 1: Conduct Needs Assessment, we interviewed 31 stakeholders to identify determinants of MAPS+ implementation in 13 clinics serving people with HIV in Philadelphia County. In Step 2: Develop Logic Model, we used these determinants as inputs for a working logic model guided by the Consolidated Framework for Implementation Research. In Step 3: Operationalize Implementation Strategies, our team held a virtual stakeholder meeting to confirm determinants. We synthesized stakeholder feedback, then identified implementation strategies that conceptually matched to determinants using the Expert Recommendations for Implementing Change taxonomy. Next, we operationalized implementation strategies with specific examples for clinic settings. We linked strategies to behavior change theories to allow for a mechanistic understanding. We then held a second virtual stakeholder meeting to present the implementation menu for feedback and glean generalizable insights for how these strategies could be operationalized in each stakeholder's clinic. In Step 4: Protocolize Strategies, we incorporated stakeholder feedback and finalized the implementation strategy menu. Findings: Implementation mapping produced a menu of 39 strategies including revise professional roles, identify and prepare champions, use warm handoffs, and change record systems. The process of implementation mapping generated key challenges for implementation strategy development: lack of implementation strategies targeting the outer setting (i.e., sociopolitical context); tension between a one-size-fits-all and individualized approach for all clinics; conceptual confusion between facilitators and strategies; and challenges in translating the implementation science lexicon for partners. Implications: This case exemplar advances both MAPS+ implementation and implementation science methods by furthering our understanding of the use of implementation mapping to develop strategies that enhance uptake of evidence-based interventions. The implementation menu will inform MAPS+ deployment across Philadelphia in an upcoming hybrid trial. We will carry out Step 5: Test Strategies to test the effectiveness and implementation of MAPS+.

Stakeholder Perspectives on MAPS.

BACKGROUND: Managed problem solving (MAPS) is an evidence-based intervention that can boost HIV medication adherence and increase viral suppression, but it is not widely used in community clinics. Deploying community health workers to deliver MAPS could facilitate broader implementation, in support of the Ending the HIV Epidemic (EHE) initiative's goal of reducing new HIV infections in the US by 90% by 2030. SETTING: Ryan White-funded clinics in Philadelphia, 1 of 48 US counties prioritized in the EHE. METHODS: Semistructured stakeholder interviews were conducted with 13 clinics and 4 stakeholder groups: prescribing clinicians, nonprescribing clinical team members (eg, medical case managers), clinic administrators, and policymakers. Interviews were based on the Consolidated Framework for Implementation Research and investigated perceived barriers to and facilitators of MAPS delivery by community health workers. Rapid qualitative analytic techniques were used to synthesize interview data and identify key categories along an implementation pathway. Core determinants (ie, barriers and facilitators) of MAPS implementation were grouped within each category. RESULTS: Stakeholders were receptive to CHW-delivered MAPS and offered critical information on potential implementation determinants including preferences for identification and referral of patients, and the importance of integration and communication within the care team. CONCLUSIONS: This study elucidates insights regarding barriers and facilitators to delivering an evidence-based behavioral intervention in clinics serving people with HIV (PWH) and extends a rapid qualitative approach to HIV care that rigorously incorporates stakeholder data into the development of implementation strategies. It also offers insights for national implementation efforts associated with EHE.

Screening Adolescents for Sensitive Health Topics in Primary Care: A Scoping Review.

We sought to aggregate common barriers and facilitators to screening adolescents for sensitive health topics (e.g., depression, chlamydia) in primary care, as well as those that are unique to a given health topic. We conducted a literature search of three databases (PsycInfo, MEDLINE, and CINAHL) and reference lists of included articles. Studies focused on barriers and facilitators to screening adolescents (ages 12-17 years) for sensitive health topics in primary care that are recommended by national guidelines. Articles were peer-reviewed, presented empirical data, and were published in English in 2006-2021. We coded barriers and facilitators using the Consolidated Framework for Implementation Research, a well-established framework within implementation science. In total, 39 studies met inclusion criteria and spanned several health topics: depression, suicide, substance use, HIV, and chlamydia. We found common barriers and facilitators to screening across health topics, with most relating to characteristics of the primary care clinics (e.g., time constraints). Other factors relevant to screening implementation ranged from confidentiality concerns to clinician knowledge. Barriers and facilitators specific to certain health topics, such as the availability of on-site laboratories for HIV screening, were also noted. Findings can guide refinements to screening implementation.

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care.

BACKGROUND: Insights from behavioral economics, or how individuals' decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., "Nudge") powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? METHODS: The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians' use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. DISCUSSION: The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04844021 . Registered 14 April 2021.

Applying NUDGE to Inform Design of EBP Implementation Strategies in Community Mental Health Settings.

We demonstrate the application of NUDGE (Narrow, Understand, Discover, Generate, Evaluate), a behavioral economics approach to systematically identifying behavioral barriers that impede behavior enactment, to the challenge of evidence-based practice (EBP) use in community behavioral health. Drawing on 65 clinician responses to a system-wide crowdsourcing challenge about EBP underutilization, we applied NUDGE to discover, synthesize and validate specific behavioral barriers to EBP utilization that directly inform the design of tailored implementation strategies. To our knowledge, this is the first study to apply behavioral economic insights to clinician-proposed solutions to implementation challenges in order to design implementation strategies. The study demonstrates the successful application of NUDGE to implementation strategy design and provides novel targets for intervention.

Applying Behavioral Economics to Enhance Safe Firearm Storage.

Behavioral economics applies key principles from psychology and economics to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ∼4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation prompts, in-group messengers, and increased salience as behaviorally informed strategies that may counter these biases and subsequently enhance safe firearm storage. We also describe other opportunities to leverage the behavioral economic tool kit. By better understanding the individual behavioral levers that may impact decision-making around firearm storage, behavioral scientists, pediatric providers, and public health practitioners can partner to design and test tailored interventions aimed at decreasing pediatric firearm injuries. Further empirical study is warranted to identify the presence of specific biases and heuristics and determine the most effective behavior change strategies for different subpopulations.

Acceptability of financial incentives for health-related behavior change: An updated systematic review.

Despite the successes of financial incentives in increasing uptake of evidence-based interventions, acceptability is polarized. Given widespread interest in the use of financial incentives, we update findings from Giles and colleagues' 2015 systematic review (n = 81). The objectives of this systematic review are to identify what is known about financial incentives directed to patients for health-related behavior change, assess how acceptability varies, and address which aspects and features of financial incentives are potentially acceptable and not acceptable, and why. PRISMA guidelines were used for searching peer-reviewed journals across 10 electronic databases. We included empirical and non-empirical papers published between 1/1/14 and 6/1/18. After removal of duplicates, abstract screening, and full-text reviews, 47 papers (n = 31 empirical, n = 16 scholarly) met inclusion criteria. We assessed empirical papers for risk of bias and conducted a content analysis of extracted data to synthesize key findings. Five themes related to acceptability emerged from the data: fairness, messaging, character, liberty, and tradeoffs. The wide range of stakeholders generally preferred rewards over penalties, vouchers over cash, smaller values over large, and certain rewards over lotteries. Deposits were viewed unfavorably. Findings were mixed on acceptability of targeting specific populations. Breastfeeding, medication adherence, smoking cessation, and vaccination presented as more complicated incentive targets than physical activity, weight loss, and self-management. As researchers, clinicians, and policymakers explore the use of financial incentives for challenging health behaviors, additional research is needed to understand how acceptability influences uptake and ultimately health outcomes.

The clinician crowdsourcing challenge: using participatory design to seed implementation strategies.

BACKGROUND: In healthcare settings, system and organization leaders often control the selection and design of implementation strategies even though frontline workers may have the most intimate understanding of the care delivery process, and factors that optimize and constrain evidence-based practice implementation within the local system. Innovation tournaments, a structured participatory design strategy to crowdsource ideas, are a promising approach to participatory design that may increase the effectiveness of implementation strategies by involving end users (i.e., clinicians). We utilized a system-wide innovation tournament to garner ideas from clinicians about how to enhance the use of evidence-based practices (EBPs) within a large public behavioral health system. METHODS: Our innovation tournament occurred in three phases. First, we invited over 500 clinicians to share, through a web-based platform, their ideas regarding how their organizations could best support use of EBPs. Clinicians could rate and comment on ideas submitted by others. Second, submissions were judged by an expert panel (including behavioral scientists, system leaders, and payers) based on their rated enthusiasm for the idea. Third, we held a community-facing event during which the six clinicians who submitted winning ideas presented their strategies to 85 attendees representing a cross-section of clinicians and system and organizational leaders. RESULTS: We had a high rate of participation (12.3%), more than double the average rate of previous tournaments conducted in other settings (5%). A total of 65 ideas were submitted by 55 participants representing 38 organizations. The most common categories of ideas pertained to training (42%), financing and compensation (26%), clinician support and preparation tools (22%), and EBP-focused supervision (17%). The expert panel and clinicians differed on their ratings of the ideas, highlighting value of seeking input from multiple stakeholder groups when developing implementation strategies. CONCLUSIONS: Innovation tournaments are a useful and feasible methodology for engaging end users, system leaders, and behavioral scientists through a structured approach to developing implementation strategies. The process and resultant strategies engendered significant enthusiasm and engagement from participants at all levels of a healthcare system. Research is needed to compare the effectiveness of strategies developed through innovation tournaments to strategies developed through design approaches.

Frontal lobe abnormalities on MRS correlate with poor letter fluency in ALS.

OBJECTIVE: To examine whether frontal lobe abnormalities on magnetic resonance spectroscopy (MRS) in amyotrophic lateral sclerosis (ALS) correlate with poor letter fluency (LF). METHODS: Twenty-five patients with ALS (20 with definite, probable, or possible ALS and 5 with progressive muscular atrophy) performed an LF task, involving F word generation in 1 minute, and underwent MRS. Comparisons were made between patients with ALS with impaired LF and unimpaired LF based on an empirically derived cutoff score. A Spearman correlation was performed between the patient's N-acetyl acetate/creatinine-phosphocreatinine ratio (NAA/Cr) and the number of F words generated. RESULTS: LF was impaired in 50% of patients with ALS. Patients with impaired LF had reduced NAA/Cr in the DLPFC compared with those with unimpaired LF (p = 0.007). There was a significant correlation between LF and NAA/Cr in the DLPFC (r = 0.51, p = 0.0009). The ALS Functional Rating Scale score, clinical region of motor onset, and disease category had no effect on LF or NAA/Cr in the DLPFC. CONCLUSIONS: A reduced NAA/Cr in the DLPFC of patients with ALS is a marker of neuronal dysfunction and correlates with impaired performance on a clinical measure of executive function.

Cross-sectional evaluation of clinical neuro-ophthalmic abnormalities in an amyotrophic lateral sclerosis population.

OBJECTIVE: Ocular motility abnormalities may be a marker of neuro-degeneration beyond motor neurons in amyotrophic lateral sclerosis (ALS). We formally compared clinical neuro-ophthalmic abnormalities in ALS patients and a control population. METHODS: Patients attending a multidisciplinary ALS clinic (n=63, age 60.8+/-16.4 years) and their caregivers serving as controls (n=37, ages 55.0+/-12.7 years) participated in this cross-sectional study. Visual acuity was assessed. Video recordings of a standardized ocular motility exam including gaze fixation, voluntary saccades, reflex saccades, smooth pursuit, eyelid opening and Bell's phenomenon were rated by two senior neuro-ophthalmologists who were masked to subject group. RESULTS: Visual acuity was lower in ALS patients versus control subjects (OR 0.81 (0.71-0.93), p=0.003, logistic regression). Inter- and intra-rater reliability for ocular motility examination ratings were good (Cohen's Kappa>0.6). Findings observed only in ALS subjects included gaze impersistence (14%, p=0.01), moderately or severely restricted voluntary upgaze (13%, p=0.01), and moderate or severe eyelid opening apraxia (27%, p=0.0002). Accounting for age, moderately or severely saccadic horizontal smooth pursuits distinguished ALS from control subjects (OR 3.6 (1.2-10.9), p=0.02, logistic regression). CONCLUSIONS: Clinical findings of decreased visual acuity, gaze impersistence, voluntary upgaze restriction, eyelid opening apraxia, and saccadic horizontal smooth pursuits are more frequent in patients with ALS than in similar-aged controls. These findings are potential clinical markers of neurodegeneration beyond upper and lower motor neuron disease in ALS. Further study is warranted regarding their application to disease categorization and outcomes assessment.