Date of Award

1-1-2023

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Kirsten Bechtel

Abstract

ABSTRACTBackground: Firearm injury is a major cause of death and disability in the United States, with a high burden of injury among children and young adults. Multimodal interventions are likely needed to reduce firearm injury among children and young adults. We present findings from a qualitative study of determinants of parental firearm storage practices, and a mixed-methods evaluation of a hospital-based violence intervention program (HVIP). Methods: Qualitative Evaluation of Determinants of Parental Firearm Storage: We recruited parents who kept firearms in the home to participate in semi-structured interviews designed to elicit participants’ attitudes, practices and beliefs related to firearm storage. Descriptive codes were iteratively assigned, revised, and organized, and themes were derived directly from the data. Mixed-methods evaluation of a hospital-based violence intervention program: We conducted a mixed-methods evaluation of a hospital-based violence intervention program using the RE-AIM framework. We completed a retrospective review of the electronic medical record and HVIP records during the first two years of HVIP implementation as well as clinician survey data to complete a quantitative analysis of recruitment, violent re-injury outcomes, service provision, clinician referral and support for the HVIP. Semi-structured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes to summarize the qualitative data. Results: Qualitative Evaluation of Determinants of Parental Firearm Storage: The final cohort consisted of 20 individuals. We identified the following five themes: 1) firearm storage must be compatible with a specific context of use; 2) Some parents engage in higher-risk storage because they believe it is adequate to reduce risk of injury; 3) firearm storage practices are influenced by one’s social network and lived experience; 4) parents who own firearms may be amenable to changing storage practices; 5) parents’ conceptualization of firearm injury prevention is multimodal involving storage, education of owners and children, and legislation. Mixed-methods evaluation of a hospital-based violence intervention program: Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Of the 319 HVIP eligible individuals who presented with nonfatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 – 5.2; p = 0.01). For the Effectiveness domain, participants reported some success with meeting needs, but identified some key areas of focus where needs were not met including housing and symptoms of mental illness. The program’s impact on violent re-injury was not statistically significant (OR 0.70, 95% CI 0.16-3.1). Participants described strengths of Implementation that centered the program administrators, highlighting the deep relationships built with clients. Service process measures identified key areas for improvement in referrals and unconditional cash transfers. Limited awareness of HVIP services was a barrier to Adoption, with only 38% of clinician survey respondents reporting they were aware of YNH HVIP services. For the long-term Maintenance of the program, both clinicians and YNH HVIP clients reported that there is a need for HVIP services for victims of violence. Conclusions: Qualitative Evaluation of Determinants of Parental Firearm Storage: Our findings suggest that parental decisions around firearm storage and beliefs about firearm injury prevention are complex and variable between individuals. These findings suggest that counseling strategies targeting the adoption of safer firearm storage practices must be individualized and consider unique parental attitudes and beliefs. Mixed-methods evaluation of a hospital-based violence intervention program: We identified key facilitators and barriers to HVIP recruitment, effectiveness, adoption, implementation, and maintenance using the RE-AIM framework adapted to an emerging HVIP. These findings may serve as a model for HVIP program evaluation using the RE-AIM framework to further standardize HVIP implementation.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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