Project Name:
Intervention mapping to develop multi-level implementation strategies in partnership with stakeholders: Firearms means restriction for suicide prevention in pediatric primary care

Principal Investigator:
Rinad Beidas, PhD

Principal Investigator Contact Information:
rbeidas@upenn.edu

Principal Investigator institution:
University of Pennsylvania

Funder:
NIMH

Funding Period:
05/2016 – 07/2018

Abstract:
Suicide is a leading cause of death in children and adolescents and a critical public health concern. One promising suicide prevention strategy that is under-utilized includes reducing access to lethal means, or means restriction. Firearms are an important target for means restriction given that 1 in 3 homes possess a firearm and firearms are the most lethal manner by which suicide is attempted. Primary care is an ideal setting in which to provide firearms means restriction given that almost half of youth who die by suicide do not access specialty mental health services in the 12 months preceding their attempt. The Safety Check intervention is an evidence-based practice for implementing firearms means restriction in pediatric primary care (including pediatrics, family medicine, and adolescent medicine). Despite the existence of this intervention and recommendations from the American Academy of Pediatrics, providers rarely discuss means restriction or firearms during visits, suggesting the need for a better understanding of the barriers and facilitators to implementing means restriction in pediatric primary care. Implementation science frameworks, including the Consolidated Framework for Implementation Research (CFIR), suggest the importance of attending to multiple levels of context during implementation, including provider (e.g., self-efficacy), organizational (e.g., expectations about provider behavior), system (e.g., prompts in the electronic health records), and intervention (e.g., acceptability) factors. The NIMH-funded Mental Health Research Network (MHRN), a consortium of 13 healthcare systems across the United States, affords a unique opportunity to better understand how to implement means restriction in pediatric primary care from a system-level perspective. Our objective in this application is to collaboratively develop implementation strategies in partnership with MHRN stakeholders to increase the use of means restriction in pediatric primary care. In Aim 1, we will survey leadership and primary care providers of 96 primary care practices within 2 MHRN systems (Henry Ford Health System and Baylor Scott & White Health) to understand acceptability and use of the three components of the Safety Check intervention (i.e., screening, brief counseling around gun safety, and provision of gunlocks). In Aim 2, in collaboration with MHRN stakeholders in these 2 systems, we will use intervention mapping and the CFIR to systematically develop and evaluate a multi-level menu of implementation strategies for firearm means restriction in pediatric primary care. The proposed work is consistent with the NIMH strategic plan, specifically Objective 4, to strengthen the public health impact of NIMH-supported research, and will lead to a hybrid effectiveness-implementation R01 proposal. The long-term goal of this line of research is to reduce death by suicide by increasing the use of evidence-based strategies in pediatric primary care while also promoting multi-level implementation strategies informed by a systematic and rigorous development approach.

Grant Number:
1R21MH109878-01

Participating Sites:
Henry Ford Health System
Baylor Scott & White Health

Investigators:
Rinad Beidas, PhD
Brian Ahmedani, PhD
John Zeber, PhD
Steven Marcus, PhD
Courtney Benjamin Wolk, PhD
Shari Mintz, PhD
Joel Fein, MD, MPH
Gregory Brown, PhD

Major Goals:
To partner with MHRN stakeholders and engage in quantitative and qualitative inquiry around how to implement an evidence-based program for firearm safety as a suicide prevention strategy for youth in primary care.

Description of study sample:

The sample for Aim 1 includes leaders from HFHS and BSW; and primary care providers from HFHS and BSW. 204 PCPs and 57 CLs were eligible for the survey; 103 (50.4%) PCPs and 40 (70.2%) CLs participated. 

The sample from Aim 2 includes 4-12 individuals from each of the following stakeholder groups (n=70): parents of youth that receive pediatric primary care at a HFHS clinic; physician providers; non-physician providers; leaders of primary care practices; leaders of behavioral health; leaders of quality improvement; system leaders; third-party payers, members of national credentialing bodies, and gun-owning constituents.

Current Status:

9/27/18
Aim 1:
We collected quantitative primary data about the acceptability and use of the three EBPs in the survey, as reported previously. We also collected secondary data via publicly available data sources, including data from the MHRN virtual data warehouse and the National Center for Health Statistics’ National Vital Statistics System. Additionally, we extracted youth (aged 12-24) suicide deaths over the past five years by firearm at the county level for each primary care practice location from the National Vital Statistics System. We have submitted the manuscript summarizing Aim 1 findings, and it is currently under peer review.

Aim 2:
We trained research staff and successfully conducted qualitative interviews for all stakeholder groups (n=70). We added a stakeholder group (gun-owning constituents) given our experiences with the qualitative interviews. We have completed all interviews and enrolled 7 parents, 7 primary care physicians, 7 non-physician providers, 7 clinical leaders, 6 system leaders, 6 leaders of behavioral health, 7 leaders of quality improvement, 4 third-party payers, 7 members of national credentialing bodies, and 12 gun owners. We evaluated all interviews to identify common themes related to barriers, facilitators, and implementation strategies. Upon gathering this information, we used the spirit of intervention mapping, in concert with the Consolidated Framework for Implementation Research (CFIR), to inform the development of a menu of implementation strategies. All interviews were transcribed and loaded into NVivo software for data management. Our team developed two different comprehensive coding schemes, one for the original set of stakeholders and one for gun-owner constituents, given that different themes emerged. We completed coding of all transcripts, and the coders maintained excellent reliability.

From the interviews, we gleaned a number of themes around barriers, facilitators, and implementation strategies regarding the potential implementation of our intervention of interest. Overall, the interviews underscored the importance of considering how to best support providers to improve their self-efficacy and implement new practices (e.g. providing ongoing consultation, leveraging existing mental health screening/ suicide prevention initiatives), since providers are already overextended and have little time to implement additional practices. The manuscript is currently under review. Currently, we are preparing a manuscript specifically detailing the views of the gun-owner constituents,.

Through the use of intervention mapping, we developed a list of implementation strategies, based off feedback from stakeholders who completed the qualitative interviews. After compiling the list, we returned to those original stakeholders and asked them to complete a brief online survey assessing feasibility, acceptability, and importance of each strategy. In total, we received 35 responses (roughly 69%). By administering the online survey, we were able to generate a refined list of the most feasible and acceptable implementation strategies under each level. We are currently drafting a manuscript that describes how our team selected the implementation strategies, using the process of intervention mapping.

Study Registration:
N/A

Publications:
Wolk CB, Jager-Hyman S, Marcus SC, Ahmedani BK, Zeber JE, Fein JA, Brown GK, Lieberman A, Beidas RS. Developing implementation strategies for firearm safety promotion in paediatric primary care for suicide prevention in two large US health systems: a study protocol for a mixed-methods implementation study.  BMJ Open. 2017 Jun 24;7(6):e014407. doi: 10.1136/bmjopen-2016-014407.

Jager-Hyman, S., Wolk, C. B., Ahmedani, B. K., Zeber, J. E., Fein, J. A., Brown, G. K., Byeon, Y. V., Listerud, H., Gregor, C. A., Lieberman, A., & Beidas, R. S. (in press). Perspectives from firearm stakeholders on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy: A qualitative study. Journal of Behavioral Medicine.

Beidas, R. S., Jager-Hyman, S., Becker-Haimes, E., Wolk, C., Ahmedani, B., Zeber, J., Fein, J., Brown, G., Gregor, C., Lieberman, A., & Marcus, S.: Acceptability and use of evidence-based practices for firearm storage in pediatric primary care. Academic Pediatrics. November 2018.

Wolk, C. B., Van Pelt, A., Jager-Hyman, S., Ahmedani, B., Zeber, J., Fein, J., Brown, G., Gregor, C., Lieberman, A., & Beidas, R. S.: Stakeholder perspectives on implementing a firearm safety intervention in pediatric primary care as a universal suicide prevention strategy: A qualitative study. JAMA Network Open. November 2018.

Beidas, R.: How your child's primary-care doctor can prevent gun injury and death. Philly.com. December 2018. (OP ED)

Resources:
N/A

Lessons Learned:
N/A

What’s next?
We will submit an application to NIMH in 2019 to conduct a hybrid trial evaluating both the effectiveness of the adapted Safety Check in pediatric primary care and the implementation strategies we use to implement it.