Engagement with Preventive Health Behaviors and Safe Firearm Storage Practices Using the 2017 Behavioral Risk Factor Surveillance System

Abstract

Purpose

“Behavioral bundling” is a theory that explains how some health behaviors reinforce one another. This study aims to investigate the relationship between preventive health behaviors (PHBs) and safe firearm storage.

Design

This study used a cross-sectional design using 2017 Behavioral Risk Factor Surveillance Survey data.

Setting

Survey participants resided in California, Idaho, Kansas, Oregon, Texas, and Utah.

Subjects

There were 12,817 people living in households with a firearm included in this study.

Measures

We classified individuals’ engagement in 5 PHBs: cholesterol screening, influenza immunization, physical activity, primary care, and seatbelt use. We defined safe firearm storage as storing a firearm unloaded, or loaded but locked.

Analysis

Using Poisson regression models, we calculated adjusted prevalence ratios (aPRs) to estimate the association between engagement in the five PHBs with safe firearm storage.

Results

Most firearm owners reported safe firearm storage (80.3%). The prevalence of safe firearm storage was 3% higher for each additional PHB engaged in (aPR = 1.03 [1.01, 1.05]). There was a higher prevalence of safe firearm storage among those who always wore a seatbelt while driving or riding in a car compared to those who did not (aPR = 1.12 [1.05, 1.18]).

Conclusion

This study found preliminary evidence to suggest that engagement in seatbelt usage may be bundled with safe firearm storage, though we are not able to determine causality.

Keywords

behavior bundling safe firearm storage preventive health behaviors health engagement cross-sectional study behavioral risk factor surveillance system

Purpose

Each year, there are approximately 85,000 emergency department visits for nonfatal firearm injuries and nearly 35,000 firearm-related deaths in the United States.¹ These high numbers have sparked numerous calls to address this epidemic of firearm injuries and deaths.^2,3 The presence of firearms in the home increases the risk of death by suicide, homicide, and unintentional firearm injury for household members, and the risk increases when firearms are unlocked.^4,5 Many studies have shown that when a firearm is stored securely, there is reduced risk for firearm-related injuries and deaths.^6,7 Thus, interventions that mitigate the risk of firearm-related injuries and deaths by encouraging owners to store their firearms unloaded and in locked compartments (via cable locks, gun cases, locked cabinets, or safes) have become a central pillar of public health efforts.⁸

A nationally representative survey of firearm owners in 2022 found that approximately two-thirds of firearm owners store at least one firearm unlocked. According to this survey, the lack of firearm storage did not vary based on the reasons for ownership or types of firearms owned.^9,10 These patterns of unsafely stored firearms persist among all households, including high-risk households with children and older adults.^11–14 Prior studies have sought to identify the correlates to unsafe firearm storage, including alcohol use,^15,16 reasons for ownership,^17,18 and children living in the home to identify possible points of intervention.^11,15,16 Wintemute et. al aimed to quantify the association between alcohol use and unsafe firearm storage. This study found that firearm owners who engage in unsafe firearm storage are more likely to engage in alcohol use, compared to firearm owners who engage in safe firearm storage.¹⁹ Another study found that 96% of firearm owners who did not practice safe firearm storage also reported unsafe medication storage practices, indicating that unsafe firearm storage might coincide with other risky behaviors that could result in an unsafe home environment.²⁰ There is a substantial body of evidence identifying correlates of unsafe firearm storage, yet little is known about the correlates of safe firearm storage.

While few studies have examined the correlation between preventive health behaviors and safe firearm storage, previous research has explored how preventive behaviors may be correlated or promote other health behaviors. This concept of behavior co-occurrence, known as “behavioral bundling”, explains how some health behaviors promote and reinforce one another.^21,22 Behavioral scientists often use the term to characterize how an individual’s health behaviors are functionally interrelated.²² That is, individuals who engage in one type of health behavior, such as exercise, are more likely to engage in another type of health behavior, such as wearing a seatbelt. Traditionally, health behaviors have been studied as a single behavior and have provided little guidance on the mechanisms behind multiple behaviors and behavioral change.²³ A benefit to investigating behavioral bundling is that when intervening upon one health behavior, subsequent changes in and reinforcement of other healthy behaviors are probable.²² Thus, understanding associations between health behaviors can be used to reinforce healthy behaviors or reduce unhealthy behaviors. A study in 2017 focused on better understanding the linkages between healthy behaviors or how perceptions about one behavior may shape perceptions about another behavior among individuals who had a stroke.²⁴ This study found that participants routinely engaging in multiple health behaviors described having perseverance and persistence, and often engaged in health behaviors to avoid stress associated with the negative consequences of not engaging in the healthy behaviors.²⁴

Examples of behavior bundling are shown in a few recent studies focused on correlates to physical activity.^21,25 These studies found that individuals who were more physically active, compared to those who were less physically active, were more likely to also engage in other healthy preventive behaviors such as receiving influenza immunizations and human immunodeficiency virus (HIV) tests, attending medical checkups, and wearing a seatbelt.^21,25,26 As safe firearm storage is a preventive health behavior (PHB), it is plausible that safe firearm storage may be associated (bundled) with other PHBs.

No studies to date have examined behavioral bundling in the context of safe firearm storage. Our study sought to fill this gap by evaluating the association between engagement in five common PHBs (cholesterol screening, influenza immunization, physical activity, primary healthcare visits, seatbelt usage) and safe firearm storage practices among firearm owners in six states. We hypothesized that there would be a positive association between engagement in PHBs and safe firearm storage. Specifically, our study aimed to:

1. Quantify the association between overall engagement in the five PHBs and safe firearm storage to evaluate if an individual’s engagement in health prevention efforts is associated with safe firearm storage.

2. Evaluate the independent associations between each of the five PHBs and safe firearm storage to identify the specific behaviors that may be bundled with safe firearm storage.

Methods

Design

This study used cross-sectional data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a state-administered survey developed in collaboration with the Centers for Disease Control and Prevention (CDC) that collects data from residents in all 50 states, the District of Columbia, and three U.S. territories regarding their health-related risk behaviors, chronic health conditions, and use of preventive services.²⁷ The 2017 BRFSS data consisted of interviews with over 400,000 non-institutionalized adults over 18 years old selected by random digit dialing of cell phones and landline telephones.^27,28 Interviews included a core component administered in all states and territories, optional modules (including one covering firearm safety) adopted on a state-by-state basis, and additional questions to address state-specific needs. The authors’ Institutional Review Board (IRB) states that BRFSS does not involve human subjects and therefore, their use requires neither IRB review nor exempt determination.

Sample

Questions regarding the five PHBs of interest were included in the BRFSS core component and asked of all participants. The optional firearm safety module was completed by six states in 2017 (California, Idaho, Kansas, Oregon, Texas, and Utah). We included respondents residing in these six states who answered “yes” to the question, “Are there any firearms kept in or around your home?”. We excluded individuals with missing data for any of the firearm storage questions or did not answer any of the questions regarding PHBs (<5% of study respondents) (Figure 1).

Figure 1.

Flowchart of Study population.

Measures

The exposures of interest for this study were the following five PHBs: cholesterol screening, influenza immunization, physical activity, primary healthcare visits, and seatbelt usage. We chose these behaviors because they encompass a diverse range of preventive health measures that are broadly applicable to the public, and were readily available within the data.^21,29–32 Using national health guidelines as a reference, a participant’s engagement in each of the five PHBs was classified as either “satisfactory” or “unsatisfactory” (Table 1). Those who refused to answer or answered “I don’t know” were excluded.

Table 1.

Preventive Health Behavior (PHB) Guidelines and Key Variables Defined.

	Criteria for “Satisfactory” Engagement with Preventive Health Behaviors	BRFSS Questions and Responses (bolded answers are “Satisfactory”)
Cholesterol Screening^a	“Every 5 years for people aged 20 or older who are at low risk for cardiovascular disease.” - US Centers for Disease Control and Prevention³³	“Blood cholesterol is a fatty substance found in the blood. About how long has it been since you last had your blood cholesterol checked?”
		• Never
		• Within the past year
		• Within the past 2 years
		• Within the past 5 years
		• 5 or more years ago
Influenza Immunization^a	“Everyone 6 months of age and older should get an influenza (flu) vaccine every season with rare exception.” - US Centers for Disease Control and Prevention³⁴	“During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose? (A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.)”
		• Yes
		• No
Physical Activity^a	“Active is doing the equivalent of 150 min to 300 min of moderate-intensity physical activity a week. This level meets the key guideline target range for adults” - US Department of Health & Human services³¹	Respondents who reported doing 150- + minutes (or vigorous equivalent) of physical activity
		• Meet aerobic recommendations
		• Did not meet aerobic recommendation
Primary Care^a	No formal guideline available; most institutions recommend seeing a primary care provider every 1-2 years.³⁵	“About how long has it been since you last visited a doctor for a routine checkup? [A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.]”
		• Within the past year
		• Within the past 2 years
		• Within past 5 years
		• 5 or more years ago
		• Never
Seatbelt Use^a	“Wear a seatbelt every time-- no matter how uncomfortable it feels or how far you are going” - National Highway Traffic Safety Administration²⁹	“How often do you use seat belts when you drive or ride in a car? Would you say—”
		• Always
		• Nearly Always
		• Sometimes
		• Seldom
		• Never

^a“Don’t Know/Not Sure”, “Refused”, “Missing”, and “Never drive or ride in a car” survey responses were considered missing or not applicable and removed from the complete-case analysis.

We calculated a composite score (ranging from 1 to 5), referred to as the PHB composite score, for each respondent by summing the total number of PHBs with “satisfactory” engagement. Individuals with a PHB composite score of 0 and 1 were treated as one group (PHB composite score = 1) due to the small sample size and presumed similar characteristics between individuals with low engagement in PHBs.

The outcome of interest was safe firearm storage, which was determined based on responses to the following questions: “Are any of [the firearms kept in and around your home] now loaded?” and “Are any of these loaded firearms also unlocked?”. Safe firearm storage was defined as firearms that were stored (1) unloaded, or (2) loaded and locked (Figure 1). We utilized this classification scheme because we sought to identify firearm owners who took at least one proactive action (unloading or locking) to store their firearm in a safer manner. Additionally, the survey skip logic for the BRFSS optional firearm module did not permit the identification of firearms that were stored (1) unloaded and locked, or (2) unloaded and unlocked, as individuals who reported storing firearms unloaded were not asked whether their firearms were locked.

Analysis

All analyses were conducted using the statistical software R version 4.0.2 between September 2021 and March 2022. Analyses were unweighted as firearm owners in the six states included (California, Idaho, Kansas, Oregon, Texas, and Utah) were not representative of all firearm owners in the United States, and we did not intend for our findings to be generalized to the entire United States population. We calculated demographic summary statistics for our study population, stratified by PHB composite score categories (1–5) as well as PHB-specific engagement (satisfactory vs unsatisfactory). We used Poisson regression to calculate adjusted prevalence ratio (aPR) and associated 95% confidence intervals of associations between the PHB composite score and safe firearm storage. This model compared the prevalence of safe firearm storage for a one-point difference in PHB composite score to determine if there was a relationship between overall engagement with PHBs and safe firearm storage.

To look at each PHB individually, we used Poisson regression to calculate aPRs comparing the prevalence of safe firearm storage among respondents with satisfactory engagement in each individual PHB to the prevalence of safe storage among respondents with unsatisfactory engagement. We adjusted for age (defined as 10 year age groups), sex, and presence of children in the home, all of which were identified as potential confounders based on previous literature.¹¹ Additionally, we adjusted for: (1) education level (as a proxy for socio-economic status), categorized by “high school graduate or less” and “some college or more”, and (2) state, to account for conditions that could influence engagement in preventive health behaviors and safe firearm storage such as access to healthcare, seatbelt laws, firearm-related laws.

Results

Demographics

Our final study population consisted of 12,817 respondents who reported having a firearm in their home (Figure 1) and had complete information for all of the PHBs. Of those, 10,290 (80.3%) reported safe firearm storage. Most of our study population resided in Texas (26.8%), followed by Kansas (26.6%) (Table 2). Compared with respondents with a PHB composite score of 1, individuals with a score of 5 were more likely to be female (51.5% vs 32.2%), 60 years or older (64.7% vs 19.4%), and have one or more years of college education (81.0% vs 59.2%) (Table 2). The distribution of sex, children under 18 years living in the home, race and ethnicity, education, and state of residence for respondents with satisfactory engagement was similar across each PHB (Table 3).

Table 2.

Demographics and Characteristics of Firearm Owners by Preventive Health Behavior Composite Score^a.

	Number of Respondents by Preventive Health Behavior composite score (Percentage)^b
	1 (N = 625)	2 (N = 1398)	3 (N = 3373)	4 (N = 4784)	5 (N = 2637)	Overall (N = 12817)
Sex^c
Female	201 (32.2)	533 (38.1)	1585 (47.0)	2521 (52.7)	1359 (51.5)	6199 (48.8)
Male	423 (67.7)	864 (61.8)	1788 (53.0)	2263 (47.3)	1278 (48.5)	6616 (51.8)
Age (years)^c
18–29	149 (23.8)	257 (18.4)	340(10.1)	257 (5.4)	81 (3.1)	1084 (8.5)
30–39	146 (23.4)	246 (17.6)	404 (12.0)	457 (9.6)	179 (6.8)	1432 (11.2)
40–49	102 (16.3)	236 (16.9)	539 (16.0)	571 (11.9)	240 (9.1)	1688 (13.2)
50–59	107 (17.1)	279 (20.0)	674 (20.0)	939 (19.6)	433 (16.4)	2432 (19.0)
60–69	78 (12.5)	257 (18.4)	761 (22.6)	1321 (27.6)	798 (30.3)	3215 (25.1)
70–79	31 (5.0)	85 (6.1)	466 (13.8)	888 (18.6)	674 (25.6)	2144 (16.7)
80+	12 (1.9)	35 (2.5)	176 (5.2)	338 (7.1)	232 (8.8)	793 (6.2)
Children under 18 Living in the Home^c
Yes	271 (43.4)	548 (39.2)	1081 (32.0)	1126 (23.5)	503 (19.2)	3529 (27.5)
No	352 (56.3)	846 (60.2)	2286 (67.8)	3654 (76.4)	2130 (80.8)	9268 (72.3)
Race & Ethnicity
American Indian/Alaskan Native, Non-Hispanic	8 (1.3)	16 (1.1)	41 (1.2)	43 (.9)	22 (.8)	130 (1.0)
Asian, Non-Hispanic	2 (.3)	6 (0.4)	20 (0.6)	28 (0.6)	17 (0.6)	73 (0.6)
Black, Non-Hispanic	13 (2.1)	22 (1.6)	94 (2.8)	122 (2.6)	43 (1.6)	294 (2.3)
Hispanic	37 (5.9)	96 (6.9)	236 (7.0)	303 (6.3)	107 (4.1)	779 (6.1)
Other race, Non-Hispanic	19 (3.0)	30 (2.1)	67 (2.0)	100 (2.1)	58 (2.2)	274 (2.1)
White, Non-Hispanic	546 (87.4)	1228 (87.8)	2915 (86.4)	4188 (87.5)	2390 (90.6)	11267 (87.9)
Education^c
Graduated high school (or less)	243 (37.7)	522 (37.3)	1076 (31.9)	1199 (25.1)	500 (19.0)	3540 (27.6)
Some college (or more)	382 (59.2)	876 (62.7)	2297 (68.1)	3585 (74.9)	2137 (81.0)	9277 (72.4)
State^c
California	13 (2.1)	47 (3.4)	155 (4.6)	238 (4.0)	173 (6.6)	626 (4.9)
Idaho	158 (25.3)	311 (22.2)	566 (16.8)	697 (14.6)	353 (13.4)	2085 (16.3)
Kansas	188 (30.1)	396 (28.3)	915 (27.1)	1224 (25.6)	681 (25.8)	3404 (26.6)
Oregon	44 (7.0)	130 (9.3)	330 (9.8)	538 (11.2)	306 (11.6)	1348 (10.5)
Texas	110 (17.6)	273 (19.5)	905 (26.8)	1428 (29.8)	716 (27.2)	3432 (26.8)
Utah	112 (17.9)	241 (17.2)	502 (14.9)	659 (13.8)	408 (15.5)	1922 (15.0)

^aPreventive Health Behavior (PHB) Composite Score is a composite score (ranging from 1 to 5) that is calculated based on the number of PHBs a respondent had “Satisfactory” engagement with per national health guidelines (Table 1). The five PHBs included in this composite score are: Cholesterol Screening, Influenza Immunization, Physical Activity, Primary Care, and Seatbelt Use.

^bMissingness is presented when missing responses accounted for greater than or equal to 5% of the total responses of the strata. Therefore, column percentages may not sum to 100%.

^cCovariates that were included in the regression models.

Table 3.

Demographics and Characteristics of Firearm Owners by Level of Engagement With Five Preventive Health Behaviors.

	Number of Respondents with Satisfactory Engagement with each Preventive Health Behavior (Percentages)^a
	Cholesterol Screening	Influenza Immunization	Physical Activity	Primary Care	Seatbelt Use
	Satisfactory N = 11440	Satisfactory N = 5730	Satisfactory N = 6970	Satisfactory N = 10695	Satisfactory N = 10901
Sex^b
Female	5621 (49.1)	2943 (51.4)	3362 (48.2)	5341 (49.9)	5601 (51.4)
Male	5818 (50.9)	2787 (48.6)	3608 (51.8)	5353 (50.1)	5299 (48.6)
Age (years)^b
18-29	722 (6.3)	288 (5.0)	553 (7.9)	717 (6.7)	809 (7.4)
30-39	1129 (9.8)	490 (8.6)	767 (11.0)	1014 (9.5)	1150 (10.5)
40-49	1444 (12.6)	546 (9.5)	908 (13.0)	1320 (12.3)	1433 (13.1)
50-59	2239 (19.6)	985 (17.2)	1270 (18.2)	2016 (18.8)	2078 (19.1)
60-69	3053 (26.7)	1622 (28.3)	1801 (25.8)	2851 (26.7)	2809 (25.8)
70-79	2065 (18.1)	1291 (22.5)	1260 (18.1)	1997 (18.7)	1902 (17.3)
80+	769 (6.7)	491 (8.6)	411 (5.9)	755 (7.1)	695 (6.4)
Children under 18 Living in the Home^b
Yes	2907 (25.4)	1255 (21.9)	1841 (26.4)	2661 (24.9)	2914 (26.7)
No	8517 (74.4)	4468 (78.0)	5119 (73.4)	8019 (75.0)	7972 (73.1)
Race & Ethnicity
American Indian/Alaskan Native, Non-Hispanic	109 (1.0)	47 (.8)	68 (1.0)	109 (1.0)	109 (1.0)
Asian, Non-Hispanic	68 (.6)	37 (.6)	38 (.5)	60 (.6)	68 (.6)
Black, Non-Hispanic	277 (2.4)	103 (1.8)	133 (1.9)	271 (2.5)	257 (2.4)
Hispanic	687 (6.0)	307 (5.4)	378 (5.4)	608 (5.7)	697 (6.4)
Other race, Non-Hispanic	232 (2.0)	113 (2.0)	154 (2.2)	229 (2.1)	241 (2.2)
White, Non-Hispanic	10067 (88.0)	5123 (89.4)	6199 (88.9)	9418 (88.1)	9529 (87.4)
Education^b
<= High school graduate	3031 (26.5)	1355 (23.6)	1633 (23.4)	2886 (27.0)	2856 (26.2)
>= one year in college	8409 (73.5)	4375 (76.4)	5337 (76.6)	7809 (73.0)	8045 (73.8)
State^b
California	574 (5.0)	277 (4.8)	405 (5.8)	535 (5.0)	596 (5.5)
Idaho	1770 (15.5)	853 (14.9)	1168 (16.8)	1614 (15.1)	1585 (14.5)
Kansas	3067 (26.8)	1515 (26.4)	1779 (25.5)	2894 (27.1)	2731 (25.0)
Oregon	1195 (10.4)	577 (10.1)	830 (11.9)	1108 (10.4)	1262 (11.6)
Texas	3178 (27.8)	1693 (29.5)	1616 (23.2)	2991 (28.0)	3164 (29.0)
Utah	1656 (14.5)	815 (14.2)	1172 (16.8)	1553 (14.5)	1563 (14.3)

^aMissingness is presented when missing responses accounted for greater than or equal to 5% of the total responses for that stratum. Therefore, some columns may not sum to 100%.

^bCovariates that were included in the regression models.

Preventive Health Behavior Composite Score and Safe Firearm Storage

The mean PHB composite score was similar between those who reported safe (mean = 3.6, SD = 1.1) and unsafe (mean = 3.9, SD = 1.1) firearm storage. Of those with a PHB composite score of 5, 83% stored their firearms safely, while 78.3% of those with a PHB composite score of 1 stored their firearms safely. After adjusting for age, sex, children in the home, education, and state, we found that the prevalence of safe firearm storage was 3% higher (aPR = 1.03, 95% CI: 1.01, 1.05) for each one-point PHB composite score increase (p-value for trend <.001) (Table 4).

Table 4.

Prevalence of Safe Firearm Storage by Engagement With Preventive Health Behaviors Among Firearm Owning.

Exposure	Respondents (N = 14,082)			Prevalence Ratio (95% CI)
Exposure	Safely stored firearm (N)	Total (N)	%	Unadjusted	Adjusted^a
Preventive Health Behavior Composite Score (PHBCS)^b
1	487	625	77.9	1.02^c (1.01, 1.04)	1.03^c (1.01, 1.05)
2	1067	1398	76.3
3	2647	3373	78.5
4	3899	4784	81.5
5	2190	2637	83.0
Cholesterol screening^d
Satisfactory	9177	11440	80.2	.98 (.91, 1.05)	1.00 (.93, 1.08)
Unsatisfactory	1113	1377	80.8	--	--
Influenza Immunization^d
Satisfactory	4661	5730	81.3	1.02 (.98, 1.06)	1.03 (.99, 1.07)
Unsatisfactory	5629	7087	79.4	--	--
Physical Activity^d
Satisfactory	5697	6970	81.7	1.04 (1.00, 1.08)	1.02 (.99, 1.07)
Unsatisfactory	4593	5847	78.6	--	--
Primary Care^d
Satisfactory	8589	10695	80.3	1.00 (.94, 1.05)	1.00 (.95, 1.06)
Unsatisfactory	1701	2122	80.2	--	--
Seatbelt Use^d
Satisfactory	8894	10901	81.6	1.12^c (1.06, 1.18)	1.12^c (1.05, 1.18)
Unsatisfactory	1396	1916	72.9	--	--

^aPrevalence Ratios adjusted for age, sex, presence of children in the home, education, and state.

^bNumber of preventive health behaviors where the respondent met recommended guidelines.

^cBoldface indicates statistical significance (p < .05).

^dSee Table 1 for Satisfactory and Unsatisfactory classification criteria.

Individual Preventive Health Behaviors and Safe Firearm Storage

There was a significantly higher prevalence of safe firearm storage among study participants with satisfactory engagement in seatbelt use. The prevalence of safe firearm storage did not differ significantly among those with satisfactory vs unsatisfactory engagement in cholesterol screening, influenza immunization, physical activity, and primary care visits (Table 4). For seatbelt use, 81.6% of those who reported always using a seatbelt stored their firearm safely, compared to 72.9% of those who did not report always using a seatbelt (aPR = 1.12, 95% CI: 1.05, 1.18) (Table 4).

Discussion

This study is among the first to quantify the association between engagement in a broad range of PHBs and safe firearm storage to better understand if safe firearm storage is “bundled” with other PHBs. We found that each one-point increase in PHB composite score was associated with a 3% higher prevalence of safe firearm storage, and that always wearing a seatbelt while driving or riding in a car was associated with an 12% higher prevalence of safe firearm storage. The strength of these associations was consistent with observations from other studies examining the relationship between multiple health behaviors.^26,36–38 A 2014 study found weak but statistically significant relationships between increases in leisure-time physical activity, as well as decline in alcohol consumption and reductions in tobacco use.²⁶ DeRuiter and colleagues also state that finding weak associations between multiple behaviors is not unusual.²⁶ Our results provide preliminary evidence supporting the presence of behavioral bundling between engagement in PHBs and safe firearm storage. However, the strength of these associations indicates that any influence these PHBs may have on safe firearm storage is limited. It is possible that seatbelt usage is driving most of this relationship, and that there could be other PHBs not captured within BRFSS data that may be bundled more strongly with safe firearm storage.

The significant association between seatbelt use with safe firearm storage may be because they are both frequent, habitual behaviors aimed at precluding preventable negative health outcomes. Initiation and maintenance of behaviors can be driven by habit formation,³⁹ and engagement with seatbelt use on a regular basis facilitates the development of habitual behavior. Similarly, engagement with safe firearm storage on a regular basis (i.e., after each use), may facilitate the development of habitual firearm storage practices. Along with habitual behaviors, engagement in PHBs and safe firearm storage can depend on risk perception of the behavior, which refers to people’s beliefs and feelings about the possibility of harm to health.⁴⁰ Perceived risk is a key predictor of both motivations to take protective action, and subsequent performance (i.e., habitual engagement).⁴¹ The perceived risks of not engaging in seatbelt usage and safe firearm storage use are well known and severe, thus making it more compelling to perform these PHBs. This falls in line with risk perception and the health behavior theory that motivation to engage in preventive behaviors is driven by beliefs about the probability that a health consequence will occur.^40,42

The absence of significant associations between cholesterol screening, influenza immunization, physical activity, and primary healthcare visits with safe firearm storage were unexpected given recent efforts to integrate firearm safety briefings into primary healthcare visits and throughout the healthcare system.⁴³ However, evidence on the effectiveness of traditional approaches to reducing risky health behaviors, including clinical interventions, have been mixed.⁴⁴ There is evidence that clinicians who counsel patients (mostly families with children) can effectively promote safe firearm storage practices, particularly if storage devices are given away for free.⁴⁵ On the other hand, despite a push for clinicians to discuss firearm storage practices with their patients, a 2016 national survey of firearm owners which asked “how good or poor do you think the following groups would be as messengers to teach gun owners about safe gun storage?”, only 19% of respondents rated physicians as “excellent” or “good” safe firearm storage messengers options, as compared to law enforcement (77%), hunting and outdoor organizations (73%), active-duty military (72%), military veterans (72%), and the NRA (71%).¹⁸ This is consistent with previous research that many firearm-owners feel that physicians lack an understanding of fun safety or gun culture.⁴⁶ As such, physicians and other health professionals may have more credibility discussing safe firearm storage in the context of child and adolescent risk taking and suicidal ideation.^47,48 This finding could indicate low levels of implementation across diverse settings and that these firearm safety interventions may not be successfully reaching all firearm owners.⁴⁹

Limitations

This study has several limitations. First, we utilized a modified definition of safe firearm storage that differs from the American Academy of Pediatrics (AAP) guidelines which recommend that firearms be stored locked and unloaded, with ammunition locked separately.³⁹ Due to the BRFSS skip patterns, we were unable to identify whether unloaded firearms are also stored locked or unlocked. Additionally, no questions were asked regarding the storage practices of firearm ammunition. Thus, the results from our study may be interpreted differently than studies which used the AAP definition. Second, the optional firearm module questions were only asked to respondents in six states (CA, ID, KS, OR, TX, UT), and included respondents that were more likely to be white than previous nationally representative firearms surveys (Study Sample = 87.9% White, National Census = 70.5% White).⁴⁰ As a result, our findings may not generalize beyond the firearm owners in the six states included, and likely underrepresents firearm owners who identify as Black or Hispanic/Latinx. This limitation could be addressed by promoting the adoption of the optional firearms modules by additional states to diversify representation in BRFSS-based firearm statistics. Third, because of the cross-sectional nature of the data, we were unable to determine the temporal relationship between the PHBs and safe firearm storage. Thus, we cannot determine if one behavior caused another behavior, only that they co-occurred.

So What?

What is Already Known on This Topic?

Safe firearm storage reduces the risk of firearm-related injuries and deaths. Behavioral bundling is a theory that explains how some health behaviors promote and reinforce one another. Understanding associations between health behaviors can be used to reinforce healthy behaviors or reduce unhealthy behaviors.

What Does This Article Add?

This study laid a foundation for assessing behavioral bundling in the context of safe firearm storage. Our results provide preliminary evidence that engagement in seatbelt usage is bundled with safe firearm storage.

What are the Implications for health Promotion Practice or Research?

Future studies should examine the relationship between other PHBs and safe firearm storage and investigate the mechanisms by which PHBs are bundled with safe firearm storage. This concept may prove valuable in promoting safe firearm storage by encouraging positive health behaviors, rather than solely discouraging negative behaviors.

Footnotes

Author Contributions

NA, SB, TB, BM, and AL made a substantial contribution to the concept and design of the work; NA, SB, and TB conducted the analysis and interpretation of the data, and drafted the article; BM and AL revised article critically for important intellectual content; NA, SB, TB, BM, and AL participated sufficiently and approved the version to be published.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nicole Asa

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