Impact of a clinician-directed educational program on communicating with patients regarding gun violence at two community urban healthcare centers

Methods

Study design

The study design (Figure 1) included a quasi-experimental, cross-sectional, survey-based, quality-improvement evaluation of a clinician-directed educational program, which included pre-, mid-, and posttraining surveys administered to patients and clinicians participating in an educational program.

Figure 1:

Study methodology. This figure depicts the project timeline with patient surveys (three cycles), clinician surveys (three cycles) and educational interventions (two cycles including clinician-directed presentations and office enhancements). Patient surveys were administered to all patients after they finished their appointments over three separate one-week periods of time (February 5-9, March 4-8, and April 8-12, 2024).

Results

Patient survey responses

Of the 542 patients seen over the 3 weeks of survey collection, 428 completed the survey (response rate of 79 %): 153 patients (February 5-9, 2024), 135 (March 4-8, 2024), and 140 (April 8-12, 2024). Approximately 67 % of patients were seen at the Lancaster location, and the remaining 33 % were seen at the Cambria location.

Of the 428 patients surveyed, 275 (64.3 %) acknowledged being impacted by gun violence (Figure 2), and 268 (63.0 %) indicated a desire for more information or resources concerning the impact of gun violence. When asked if their doctor or physician assistant seemed knowledgeable about gun safety or ways to support the family, 210 (49.1 %) strongly agreed or agreed, and 193 (45.1 %) responded that they did not know. Averaged across all three survey cycles, 76 (18.0 %) reported noticing materials related to gun violence in the waiting areas, 51 (12.0 %) indicated that the clinician discussed guns or gun violence, and 29 (6.8 %) said that they discussed ways to prevent gun injury during the visit. Positive trends were seen as the study progressed (Table 1).

Figure 2:

Patient impact by gun violence. Among the 428 study participants, 275 (64.3 %) reported that they have been impacted by gun violence. Among those who reported that they were impacted, they were encouraged to elaborate on two conditional questions: How have they been impacted and what services/resources were offered. Not all patients responded to conditional questions, and some identified more than one response.

Table 1:

Patient survey responses.

Survey question	Survey date	Yes	No	I Cannot remember/not sure/maybe
Did you take or see any materials related to gun violence in our waiting room today?	Week 1 (Feb)	13 (8.5 %)	129 (84.3 %)	11 (7.2 %)
	Week 2 (Mar)	27 (20.0 %)	96 (71.1 %)	12 (8.9 %)
	Week 3 (Apr)	36 (25.7 %)	97 (69.3 %)	7 (5.0 %)
	Total	76 (17.8 %)	322 (75.2 %)	30 (7.0 %)
Did your doctor (or physician assistant) talk to you about guns or gun violence today?	Week 1 (Feb)	11 (7.2 %)	141(92.2 %)	1 (0.6 %)
	Week 2 (Mar)	13 (9.6 %)	121 (89.6 %)	1 (0.7 %)
	Week 3 (Apr)	27 (19.3 %)	113 (80.7 %)	0 (0 %)
	Total	51 (11.9 %)	375 (87.6 %)	2 (0.5 %)
Did your doctor (or physician assistant) talk to you today about ways to prevent gun injury?	Week 1 (Feb)	7 (4.6 %)	146 (95.4 %)	0 (0 %)
	Week 2 (Mar)	2 (1.5 %)	131 (97 %)	2 (1.5 %)
	Week 3 (Apr)	20 (14.3 %)	119 (85 %)	1 (0.7 %)
	Total	29 (6.8 %)	396 (92.5 %)	3 (0.7 %)
Would you like more information or resources available to those impacted by gun violence?	Week 1 (Feb)	85 (55.6 %)	53 (34.6 %)	15 (9.8 %)
	Week 2 (Mar)	80 (59.3 %)	53 (39.3 %)	2 (1.5 %)
	Week 3 (Apr)	104 (74.3 %)	34 (24.3 %)	2 (1.4 %)
	Total	269 (62.9 %)	140 (32.7 %)	19 (4.4 %)

Survey question	Survey date	Strongly agree	Agree	Disagree	Strongly disagree	I don’t know
My doctor (or physician assistant) seemed knowledgeable about gun safety and ways to support my family.	Week 1 (Feb)	28 (18.3 %)	28 (18.3 %)	13 (8.5 %)	0 (0 %)	84 (54.9 %)
	Week 2 (Mar)	47 (34.8 %)	34 (25.2 %)	3 (2.2 %)	6 (4.4 %)	45 (33.3 %)
	Week 3 (Apr)	36 (25.7 %)	37 (26.4 %)	3 (2.1 %)	0 (0 %)	64 (40.7 %)
	Total	111 (25.9 %)	99 (23.1 %)	19 (4.4 %)	6 (1.4 %)	193 (45.1 %)

1. Patient surveys were administered to all patients after they finished their appointments over three separate one-week periods over the course of the clinician-directed educational program (February 5-9, March 4-8, and April 8-12, 2024). Among the 542 patients seen during the three weeks of survey collection, 428 completed the survey, a response rate of 79 %. Of the 428 patients who responded, 153 responded in week 1 (February), 135 in week 2 (March), and 140 in week 3 (April).

A chi-square analysis was performed to investigate whether the gun violence educational program impacted patient awareness of gun violence resources displayed in waiting areas. A significant increase was detected in the number of patients noticing materials related to gun violence in the waiting room (χ²[4]=16.90, p=0.002). Specifically, from time one to time three, there was a 17.2 % increase in patients being aware of gun violence–related materials in the waiting room. Regarding patient accounts of discussing guns or gun violence with their clinician, there was a significant increase in prevalence from 7.2 % at time one to 19.3 % at time three (χ²[4]=12.01, p=0.017). There was a 9.7 % increase in the number of patients who indicated that the care provider discussed ways to prevent gun injury from time one to time three (χ²[4] = 21.87, p<0.001).

Clinician survey responses

Anonymous survey responses were collected from the six participating clinicians at three points of the study: pre-, mid-, and posttraining. One clinician was unable to participate for the entire program and responded to only the first survey. Because of the small sample size, a formal statistical analysis was not feasible. However, clinician responses to questions addressing their comfort levels with talking to patients about gun violence appear to have increased throughout the program (Figure 3).

Figure 3:

Clinician survey responses. Participating clinicians responded to these first seven questions at three points of the study: Pre-, mid- and posttraining. Participating clinicians also responded to the last five likert-type questions at the end of the educational program. Six clinicians (five physicians and one physician assistant) began the program, with one physician leaving after the first month of the study.

In addition to responding to the seven standard questions across surveys (Figure 3), clinicians were invited to review a summary of patient data from the first two patient surveys and respond to three open-ended quality-improvement questions for the midpoint survey. Responses to the question “What additional strategies would you consider to improve our ability to communicate with Lancaster and Cambria patients regarding gun violence, prevention strategies, and available resources?” included being more intentional about asking patients about gun violence, handing out materials, engaging staff and medical students to help ask screening questions, and embedding screening questions in the electronic medical record. Responses to the question “Realistically, which strategies would you consider immediately (in the next 2 weeks) before this pilot study concludes?” included being more intentional about asking patients about gun violence, and providing pamphlets for families seeking mental health support services regarding gun violence. Responses to the question “What additional resources do you need to improve our ability to talk to patients and families about gun violence?” included being more intentional about talking to patients about gun violence, attending more training sessions, hosting group therapy sessions with patients and counselors, providing more handouts and resources for families, and hiring a social worker.

In addition to responding to the seven standard questions across surveys (pre-, mid-, and posttraining), clinicians were invited to answer five Likert-type questions regarding their experience with the educational program (Figure 3) and to respond to two open-ended questions for the final survey. Responses were generally positive. Reported strengths of the program included the importance of the topic, raising awareness, presentations, and patient engagement. As an example, one clinician reported “the patients being able to talk about their experiences” as a strength of the program. Reported areas for improvement included handouts for each patient, solution-based interventions, and face-to-face focus groups with clinicians, staff, patients, and families. As one clinician reported, “I would be interested in participating in a face-to-face focus group with physicians, staff, and patients. That would be helpful in determining the role of the physician, as it applies to gun violence. With such a ‘big' issue, what is the role of the physician in helping families address gun violence? Open community-based discussions may shed light on this.”

Discussion

Nearly 64 % of patients in this study reported being affected by gun violence, including the death of a loved one or friend, followed by witnessing a shooting, or being shot themselves. Disproportionately high rates of gun-related homicides occur in the areas surrounding the urban healthcare centers in West and North Philadelphia [30]. Study findings are consistent with reports from other urban, low-income, and black communities [2], 4], 8], 22]. For instance, in a study of patients from four urban cities (Baltimore, New York, Philadelphia, and Washington D.C.), 24 % reported exposure to a gun violence fatality, and nearly 25 % reported knowing someone who died from gun violence [4]. In a study of hospitalized children in the Bronx, New York, 60 % reported hearing gunshots and 41.8 % reported that a friend or relative had been shot [22]. Although not explicitly asked in our survey, only one patient volunteered having a relative who died due to gun-related suicide. Suicide accounts for more than one-half of deaths by firearm in the United States [34]. Therefore, gun-related suicide appears underrepresented in our study.

Throughout the three stages of the study, patients reported significant increases in conversations with their clinicians with regard to gun violence exposure and strategies to prevent gun injury. Clinicians participated in the educational program, which included three lunchtime educational presentations addressing prevalence, impacts on mental health, prevention, local support resources, and communication strategies when talking to patients about gun violence. Clinicians reported high levels of satisfaction and increasing confidence when talking to patients about gun violence at the end of the program. At the end of the study, however, only 19.3 % (increased from 7.2 %) of patients reported discussions about gun violence and 14.3 % (increased from 4.6 %) about strategies to prevent gun injury. Despite significant increases in discussions about gun violence and prevention, opportunities for improvement remain. The data suggest that although the educational program likely played a role in increasing clinician–patient communication, additional measures are needed to address the gun violence epidemic and its effects on the mental health of patients.

Surveyors reported that patients often seemed surprised that physicians and healthcare students were asking about gun violence and how gun violence impacts their daily lives. Gun violence directly and indirectly impacts the mental health of patients, families, and communities [2], [6], [7], [8], [9], and clinicians are well-positioned to ask patients about gun violence, promote gun injury prevention, evaluate mental health, and direct families to appropriate support and counseling services [8], [20], [21], [22, 35]. Patients may express a willingness to share information and discuss exposure to gun violence with their physicians [36], but others believe that clinicians should have a more limited role in discussing topics related to guns and gun ownership [25]. Among survivors of firearm injury in Indianapolis, most preferred to receive emotional support from family members rather than healthcare providers or mental health practitioners [27]. Participants also advocated for the use of credible messengers [27]: those who have shared lived experiences, endured a significant life change, considered part of the community, and are skilled in relationship building and communication [37], 38]. Establishing trust in a nonjudgmental and supportive manner is critical for fostering therapeutic relationships. Supporting patients, families, and communities affected by gun violence likely requires a holistic approach with support from both clinicians and nonclinician credible messengers.

We elected to administer the surveys verbally, largely to ensure that all patients could participate in the study regardless of visual acuity or reading level. There were a few unanticipated positive outcomes. First, patients shared freely and elaborated on their experiences with gun violence. The survey served as a method to encourage discourse, rather than simply soliciting responses to Likert-scale–type questions. Second, verbal survey administration allowed surveyors to build rapport and begin to foster a trusted relationship with the patients.

Patients noticed office enhancements (fliers and posters) placed in the waiting areas and examination rooms as the study progressed. By the end of the program, 25 % reported seeing materials related to gun violence in the waiting areas. Additionally, nearly 66 % of patients requested additional information about resources for those impacted by gun violence. Providing educational materials in waiting areas and showing short videoclips regarding various public health initiatives has been shown to be an effective strategy for reaching patients [39], [40], [41]. Therefore, providing durable materials, such as fliers and posters, may help to educate patients and families about gun violence, prevention, and resources to support those affected by gun violence.

Prevention remains the cornerstone of addressing community and public health crises [42]. Preventing gun violence would eliminate the need to treat sequalae, including tragic mental and emotional impacts. To effectively address gun violence as a public health crisis, a comprehensive strategy must consider not only medical interventions but also the complex interplay of social, cultural, economic, psychological, and environmental factors that contribute to well-being [43], [44], [45]. Osteopathic medicine, with its focus on treating the whole person and addressing root causes [46], is uniquely positioned to contribute to this effort. By integrating behavioral health, engaging with communities, and advocating for policies that address social determinants of health, osteopathic physicians can play a crucial role in preventing gun violence and promoting community well-being.

Although this study showed improvement in clinician–patient communication, there are some limitations to the current study design. First, the study was limited to two urban healthcare centers with only six clinicians; expanding the study to include additional locations and populations may improve generalizability. Second, in efforts to keep the survey brief, demographic information was not collected. Information about age, address, race, ethnicity, and socioeconomic status would provide additional insight. Third, patients were not asked explicitly about gun violence as it pertains to suicide, likely leading to underreporting. Because suicide is the leading cause of firearm-related mortality in the United States [34], adding an explicit question about suicide will be informative for future studies. Fourth, the survey was issued to all patients whether the appointment was for a general well-check or a focused complaint unrelated to gun violence (e.g., sore throat, back pain). Patients are likely to benefit the most when discussions occur during routine well-checks, preventative visits, and relevant focused appointments [21]. Directing communication efforts during the most appropriate visits will be important to consider for future programs. Fifth, although supervised by a standard group of six clinicians, medical students generally initiate patient visits. Medical students rotated every 4 weeks and were not present for the entire 3-month educational program. Overall, the study did not incorporate the important role that medical students play in communication with patients related to gun violence. Sixth, the patient survey was administered verbally, and therefore, body language, facial expressions, and tone of voice may have influenced patient responses. Incorporating other survey methods [47], validating questions, or administering surveys by credible messengers [27] may address survey bias in future studies. Addressing these limitations in future studies will provide additional insights for supporting patients and families affected by gun violence.

Conclusions

A large number of patients in two urban healthcare centers reported being impacted by gun violence, including the death of a loved one, witnessing a shooting, or being shot themselves. This well-received clinician-directed educational program helped improve the frequency with which clinicians discussed guns, gun violence, prevention, and available resources to assist affected families within an urban community. Approaching gun violence as a public health crisis requires a holistic and multifaceted intervention aimed at educating healthcare professionals, engaging health systems, and disseminating information about resources available to families who have been impacted by gun violence.