Abstract
Objectives:
Our primary objective was to gather feedback from Black adults with access to firearms in their homes on their comfort with talking to healthcare professionals about firearm safety. We also explored participants’ comfort with discussing firearm safety with community professionals, recognizing that limited comfort in clinical settings may influence where such conversations are perceived to be acceptable. These insights were intended to help inform efforts to promote safe firearm storage and suicide prevention among Black adults in the U.S.
Methods:
This study involved semi-structured interviews and rapid qualitative analysis. The study sample included 15 Black adults ages 18 years and older in the U.S. who had access to firearms in their homes. We developed a Transcript Summary Template to deductively condense all relevant information for 2 topics. Matrix analysis techniques were used to identify emerging key concepts in the responses to each topic.
Results:
Participant comfort with discussing firearm safety with healthcare professionals was shaped by several factors: longstanding trust with clinicians (typically primary care providers), legal firearm ownership, and transparency about the rationale for asking firearm-related questions. Discomfort was driven by fears of punitive consequences, historical mistrust of healthcare and other institutions in Black communities, and stigma surrounding mental health. Participants described substantial comfort with discussing firearm safety in familiar community spaces, as well as with trusted individuals who share cultural experiences and faith leaders.
Conclusions:
Our findings suggest a need for trust-building and clear communication about the intent of firearm-related questions and how that information will be used in clinical settings, alongside community-based strategies that leverage trusted relationships and familiar spaces (eg, faith organizations), as potential pathways to improving safe firearm storage among Black adults.
Introduction
In 2023, firearms accounted for about half of suicide deaths overall in the U.S., but nearly 6-in-10 suicide deaths among Black adults. 1 Since 2010, rates of suicide death involving firearms among Black adults have increased by 88.4% (ie, from 3.53 to 6.65 deaths per 100 000 persons in 2023). 1 Crucially, firearm industry data suggest there were significant increases in firearm ownership among Black adults since the COVID-19 pandemic.2-4 Although firearms alone do not cause individuals to become suicidal, numerous studies have demonstrated significantly higher odds of suicide death among persons with access to firearms in their homes compared to those without access to firearms. 5
As outlined in the 2024 National Strategy for Suicide Prevention, the secure storage of lethal means – such as storing firearms locked and unloaded and keeping ammunition separate – is a promising intervention for suicide prevention. 6 One clinical strategy, lethal means assessment and counseling (LMC), enables healthcare professionals to work collaboratively with patients to improve firearm safety in their homes or voluntarily limit access before suicide crises emerge. LMC has been shown to improve safe firearm storage practices 7 and may reduce the risk of suicide attempts. 8 Because LMC involves conversations about firearm access and storage, understanding how patients perceive these discussions is important. One recent study involving semi-structured interviews demonstrated that adult participants with documented mental health diagnoses were generally positive about firearm access questions being asked during clinical encounters, especially in the context of harm reduction and suicide prevention; notably, the study included participants with a mix of racial and ethnic identities, the majority of whom were white. 9 Despite this potential, Black adults report being screened for firearm access infrequently in healthcare settings. 10 Moreover, even though some evidence suggests Black adults may be willing to talk to clinicians about firearm safety,11,12 in-depth qualitative research focusing on Black adults’ comfort with discussing firearm safety with healthcare professionals remains limited.
This gap is concerning for suicide prevention because comfort is a “defining aspect of patient experience” from the patient’s perspective, 13 (p.159) and numerous studies have shown that patients’ willingness to engage in clinical care (eg, reporting symptoms, confiding in clinicians) increases when they feel comfortable with healthcare staff. 13 In the context of mental health, greater comfort with speaking with healthcare professionals is associated with an increased likelihood of seeking specialty mental health services (eg, psychiatrist or psychologist) in the past 12 months. 14 Comfort likely shapes Black adults’ willingness to engage in LMC, as prior research involving predominantly white participants has suggested that the acceptability of LMC depends, in part, on feeling comfortable with a provider. 15 At the same time, firearm safety practices and comfort with discussing firearm safety are likely shaped by community context and experiences, with Black adults potentially navigating distinct concerns related to personal protection, trust, or interactions with clinicians compared to other demographic groups.16-18
To address this knowledge gap, our primary objective was to gather feedback from Black adults with access to firearms in their homes on their comfort with talking to healthcare professionals about firearm safety. We also explored their comfort with discussing firearm safety with community professionals, recognizing that limited comfort in clinical settings may influence where such discussions are perceived to be more acceptable. These insights were intended to help inform efforts to promote safe firearm storage and suicide prevention among Black adults in the U.S.
Methods
Study Design
This study is a companion analysis to our previously published article on firearm experiences and storage practices among Black adults living in homes with firearms. 19 This was a basic qualitative study involving semi-structured interviews and rapid qualitative analysis (RQA).20-23 Given the urgency of the recent increase in firearm-involved suicide deaths among Black Americans,1,19 we conducted RQA to expeditiously generate and disseminate new insights across multiple dissemination products locally and beyond. Additional details about the study design, recruitment, interview procedures, and full analytic process are provided in the companion paper. 19 The present article examines responses to 2 conceptually distinct interview questions focused on participants’ comfort with discussing firearm safety with healthcare and community professionals. Additional information on the reasons for firearm ownership and access is provided in the companion paper. This study was approved by the University of Utah Institutional Review Board (IRB_00169397).
Participant Recruitment
Given the sensitivity of the topic of firearms in Black American communities, we anticipated that participation might be limited. As such, through our grant funded by the National Institutes of Health, we had a pre-established a participation goal of 10 to 15 interviewees. To help address anticipated recruitment challenges, individuals were recruited using a combination of purposive and snowball sampling techniques, 19 including word-of-mouth referrals from participants who completed interviews; study advertising shared electronically with Black-owned gun clubs/businesses; and Study Locator, a recruitment tool to help inform the public about research opportunities.20,24,25 Inclusion criteria were: (1) self-identifying as Black or African American, (2) age ≥18 years, (3) residing in the U.S., and (4) living in a household with firearms. Individuals of all genders and from any U.S. state were eligible.
Recruitment continued until (1) the expected range of participants was met and (2) information saturation was deemed satisfactory. We assessed information saturation by calculating new information emerging from the interviews per topic based on Guest et al’s 26 approach. Specifically, we used a base set of 9 interviews, as Hennink and Kaiser 27 suggest that saturation is typically achieved after at least 9 interviews, and a run of each successive interview from 10 to 15. 26 For example, by the final interview, for each topic, we retrospectively calculated the quotient of new, relevant ideas documented in the interview’s transcript summary divided by the total number of unique, relevant ideas documented in the base set of transcript summaries. All participants received an IRB-approved informed consent cover letter, provided verbal consent, and were compensated $50.
Data Generation
Individual interviews were conducted by the Principal Investigator via telephone between May and October 2024. The interview guide was developed in 2023, piloted, and finalized prior to conducting interviews. Initial questions were informed conceptually by prior research on the role of comfort in patient-provider interactions, 13 as well as a review of interview questions from prior studies related to firearm safety. The guide was further refined in consultation with a study team member with expertise in semi-structured interviewing with community members. 19 The core interview guide contained 6 core questions. The current analysis focuses on 2 questions addressing comfort with firearm safety conversations:
1. “How comfortable would you be discussing firearm safety with a healthcare provider, such as a doctor or nurse?” and
2. “Are there other types of community professionals or community organizations you would feel comfortable discussing firearm safety with?”
These questions were designed to elicit participants’ perceptions of firearm-safety discussions in healthcare and community settings. Silent probes (ie, intentional pauses) and follow-up questions were used as needed to encourage participants to expand on brief answers (eg, “Can you talk a bit more about that?” and “Can you describe why [or why not]?”) to the initial questions and to clarify ambiguous responses. If a participant requested clarification on the term “healthcare provider,” the interviewer explained that “healthcare provider” could include a doctor, nurse, mental health professional, or other clinician. Interviews were audio-recorded with permission, professionally transcribed verbatim, and reviewed for accuracy.
Data Analysis
We followed the procedures described in our companion paper. 19 Specifically, we followed established steps for RQA.21,22 First, we drafted 2 topics, each directly mapped to one of the interview questions. The purpose of these topics was to keep the analysis closely aligned with the questions (and thus the study objectives) in a clear and organized manner, enable the research team to efficiently summarize interview transcripts for relevant information, and support comparison across participants. Through team discussion, we finalized each topic name to ensure it reflected the central idea of its corresponding question. This process was intended to enhance consistency across the multiple authors who summarized the transcripts.
Second, we created a Transcript Summary Template. The template included space to deductively condense and document all relevant information shared by each participant for each topic. Third, to pilot and calibrate the Transcript Summary Template, 2 authors independently summarized 3 interview transcripts. Discrepancies were discussed and resolved by consensus to ensure that (1) all relevant information for each topic was captured and (2) the topics were clearly understood and appropriately named prior to summarizing the remaining transcripts. Fourth, 1 study team member summarized the remaining transcripts, while a second study team member reviewed each summary for accuracy against the original transcripts. Transcript summarization was done at a semantic level (ie, describing relevant information provided by the participants rather than interpreting it). 28
Finally, 2 study team members used matrix analysis techniques to identify emerging key concepts in the responses to each topic. As opposed to fully developed themes, the key concepts reflect early patterns observed across participants and serve as a useful foundation for collaborative team interpretation and dissemination. This entailed inputting all information included in the transcript summary documents into 1 matrix (ie, spreadsheet file) with individual columns by topic and rows for each participant. Then, by topic, 2 study team members reviewed the matrix for recurring patterns across the summarized, relevant insights; consolidated the recurring concepts into a separate page; and discussed and named each key concept. 29 The 2 study team members shared positionality statements, wrote reflexive memos, and met weekly as they summarized the transcripts and compiled the matrices. The purpose of the reflexive activities was to acknowledge their personal thoughts and reactions during data analysis, reflect on potential biases, and limit their positionality from influencing how they interpreted meaning from the subjective truths experienced by the participants. The final topic labels were: (1) Comfort with Talking to Healthcare Professionals about Firearm Safety and (2) Comfort with Talking to Other Community Professionals about Firearm Safety.
Results
We interviewed 15 Black adults in the U.S. who had access to firearms in their homes. The participants were 40 years old on average (Table 1). Ten (67%) of the participants were male, and 5 (33%) were female. Geographically, participants represented 10 states (CA, FL, GA, IL, LA, MA, MI, NC, UT, and TX) from all U.S. Census Regions. On average, the interviews lasted 44 min. By the final interview, 6.2% and 0% of the final participant’s relevant insights were deemed new information for Topics 1 and 2, respectively. This pattern suggests little new information was provided by the final interview in response to the 2 questions.
Participant Characteristics (n = 15).
Topic 1: Comfort With Talking to Healthcare Professionals About Firearm Safety
Seven (47%) of the participants were comfortable discussing firearm safety with a healthcare provider, whereas 8 (53%) were not. Among these groups, several key concepts emerged.
Key Concept 1.1: Comfort Rooted in Trust Amid Mental Health Reluctance
Multiple participants reported feeling comfortable discussing their firearm ownership with anyone; a greater number of participants described feeling at ease talking with healthcare professionals about firearm safety. While several participants described valuing openness and transparency in conversations with clinicians, others underscored that trust was the foundation of their comfort with discussing firearm safety with their providers, especially primary care providers. As 1 participant described it, they felt at ease because they had known their primary care doctor for years, emphasizing that medical trust can take time to develop in Black communities: You know, for me, because I’ve been with my doctor for years and years and years and years and years, I would feel comfortable. And I think that’s the biggest thing. People in [the Black community] don’t have the luxury of being able to trust that someone that they don’t know has their best interest at heart. (Participant 4)
Additionally, several participants linked their comfort to their legal firearm ownership, emphasizing that they felt they had nothing to hide from trusted healthcare professionals. However, they would not feel comfortable engaging in these conversations if their firearms were obtained unlawfully, worrying they might get in trouble for divulging such information. Notably, no participants reported whether their firearms were acquired illegally.
Although these participants emphasized that firearm discussions with healthcare professionals were not a source of discomfort, several participants raised a broader concern about their reluctance to engage in mental healthcare. Specifically, they noted that adults in Black communities often do not feel comfortable disclosing mental health issues to clinicians and that mental health remains a stigmatized topic, which, irrespective of their comfort with discussing firearm safety, may limit opportunities for LMC. One participant shared a metaphor to convey their view that mental health stigma, not firearms themselves, was the bigger barrier to preventing suicide in Black communities through clinical intervention: So, there’s this meme. There were a whole bunch of sheep that were looking at this wolf that came and ate up one of the sheep. So, they saw the wolf, and they saw that he attacked the sheep and ate one of their buddies. So, all the sheep pulled out their own teeth because they saw the teeth in the wolf as the problem. They got rid of all the teeth. That’s the problem that I see . . . that everybody is talking about the gun being the problem and not addressing the issue of mental health and addressing it. People are going to have guns. That’s America. How can we help the people? By addressing their mental health. But the stigma of seeking help for mental health, mental illness is so strong. In my community you can’t tell somebody you’re in counseling. That’s not cool. Your kids can’t go to school and, you know, be cool about it. We have to be better about that as a community. (Participant 6)
Key Concept 1.2: Fear of Unknown Intent and Punitive Consequences
Most participants who were not comfortable talking to healthcare professionals about firearm safety expressed fears that disclosing information about being a firearm owner would be documented or used in punitive ways. Specifically, without clear explanations for why clinicians were asking about firearms, they worried that information shared in clinical settings could be recorded, shared, or interpreted in ways that might infringe on their rights as firearm owners; affect their employment and ability to provide for their families; or even trigger unwarranted involvement from child protective services simply for possessing a firearm in the home: Fear of what may be documented or publicized. That becomes a real concern. I think if there’s a level of confidentiality – I mean there has to be a level of confidentiality – but I think if there is some type of reasonable assurance that revealing that information won’t be detrimental to us in terms of our livelihood. Meaning that, if I tell this doctor, they’re not going tell police that I got a gun, or they’re not going to tell a social worker that I have a gun in a home and I got kids. If there are reasonable assurances that those things won’t come to bear, it may be possible. But at the moment, I really don’t see discussing [firearms with healthcare professionals] as a net positive. (Participant 11)
Another participant echoed similar concerns: For someone to just randomly ask me about my firearm as a patient during a visit, that could be dangerous, in a way, because I feel like that’s targeting our community. Is that information accessible to other agencies? Like, if I’m just in for a visit, and that’s one of the questions, I would be thinking what does that have to do with the reason why I’m here? (Participant 14)
Several participants recognized the link between lethal means accessibility and suicide risk, but fear of how their disclosures might be interpreted made them hesitant to even acknowledge firearm ownership – much less discuss firearm safety – if they happened to be having a bad day during a healthcare visit. They feared that routine stress or emotional strain could be misread as suicide risk, potentially jeopardizing their ability to keep their firearms, for example: Firearms are a passion for me, you know? What if I’m having a bad day? If I’m having a bad day and not talking about suicide, but, like, if I’m having a bad day and I disclose that to a health professional. I wouldn’t want that to be like, “We’re gonna, we’re gonna notify the authorities.” Obviously not, like I said, not anything dangerous like hurting somebody or killing myself, but you take that passion away from me. I mean, if it’s between saving a life, saving my life, I’d gladly give up the firearms. But it’s that fear of not knowing, you know, how my information would be taken or how it would be used by another person. (Participant 13)
One participant drew on their understanding of public policy, noting that these concerns may be amplified by living in a state with regulations like extreme risk protection orders, which, depending on the jurisdiction, may allow family members, law enforcement, or, in some cases, healthcare professionals, to petition a court for a temporary order to remove firearms from someone deemed a danger to themselves. Expressing their frustration with such policies, the participant shared their concern that these policies could have an unintended effect of deterring Black firearm owners from talking about firearm safety with their clinicians, even if they were at risk of suicide: The way the law works, at least to my understanding, is that they’ll take your guns, and then you have to kind of prove that you’re not crazy and you’re not having some sort of crisis. And it could be like . . . the doctor could be like, “He seemed a little sad today,” you know? Then, they say something to someone else. And it kind of just snowballs into this whole thing. But maybe I really was just sad that day, and it wasn’t that big of a deal. But now you’ve come to my home, taken my firearms, and now I’m really mad. I wasn’t mad before. Now, I’m really pissed off. It just turns into this huge thing. Now, I have to hire an attorney. Take time from work. Go in front of a judge. Who knows how long it’s going to take to basically prove that I’m not a danger to myself. I think it’s kind of sad too because I think that people who are having some sort of crisis, who have firearms, they’re probably a bit nervous to say something. Because if you’re going through a crisis and you reach out for help, you could possibly be penalized or something. So, I think some people probably suffer in silence. (Participant 15)
Key Concept 1.3: Lack of Comfort Driven by Mistrust
Participants also focused on mistrust specifically as a barrier to being comfortable with discussing firearm safety with healthcare professionals, regardless of the fear of experiencing specific consequences for doing so. Taking a broader historical perspective, several participants described a generational “trust deficit” in Black communities, comparing their mistrust of healthcare professionals to their mistrust of other societal institutions, which they perceive have failed to protect Black community members’ interests, despite their professional duties: You have to kind of think through a historical lens, particularly a racial historical lens, of the history of healthcare systems and Black people. Of the trust deficit between healthcare professionals and the African American community. It’s not too different from law enforcement and the African American community, the type of trust deficit that exists, because of that history and that past. Working, you know, against that as a backdrop, I don’t know yet that healthcare would be considered a quote-unquote “safe space” to have conversations about firearms for African Americans. It certainly could be provided that there are some measures that kind of reduce the trust gap. . . . Because of that mistrust, I think that you’ll find that, typically, for African Americans, unless it’s an African American healthcare professional, it is typically going to be one of those things where the less I reveal, the better. (Participant 11)
Other participants described that they were uncomfortable discussing their firearm ownership with anyone, let alone healthcare professionals, due to mistrust of people’s reactions to firearm ownership. Two participants elaborated that they refrain from talking about firearms with people who are not interested in firearms or people they do not know or trust because they have experienced negative misconceptions and stereotypes about firearm ownership – and even altercations – when they have done so previously.
Topic 2: Comfort With Talking to Other Community Professionals About Firearm Safety
Key Concept 2.1: Comfort Rooted in Familiar Community Spaces and Shared Experiences
Participants expressed the most comfort with people and settings involved in their daily lives, noting that everyday familiarity, cultural connection, and shared experiences with other Black community members were key reasons these settings felt appropriate for discussing firearm safety, for example: I feel like I can talk to people about firearm safety if it’s a community of people that look like me. Just people who kind of experience what I’ve already experienced. (Participant 2)
Another participant added: People will be comfortable with people they’ve probably known since they were little, seeing them grow up. Those people probably have some kind of sway. They are familiar with them. (Participant 1)
This included family, friends, community leaders, panhellenic/Divine 9 fraternity and sorority members, firearm safety professionals, and community-based mental health advocates in settings like local recreation centers, community centers, festivals, town hall meetings (especially when community safety is on the agenda), barbershops, libraries, and gun stores/clubs. For some participants, feelings of comfort extended to law enforcement officers, particularly when they had preexisting relationships with police officers, though other participants acknowledged that many people in Black communities find it difficult to trust law enforcement enough to have conversations about firearms, especially if their firearms were not acquired legally. One participant noted that they would never feel comfortable talking to law enforcement about firearms. Participants also added that their comfort would be enhanced if the person initiating the firearm-related conversation began by explaining the purpose of the conversation and how any information shared would be used.
Participants repeatedly emphasized faith leaders and church settings as comfortable and trusted people and spaces, suggesting that faith-based organizations may be appropriate for private firearm safety conversations (eg, with clergy) or for publicly disseminating information about safe firearm storage (eg, in church offices). Clergy were described as key sources of comfort, counsel, and support for people who are struggling in Black communities, potentially including those at risk of mental ill-health or suicide, for example: A church, you know, those are places people will go to seek help, to seek comfort, to seek safety. So, why are we not talking about this, too? (Participant 10)
One participant asserted that, while talking about firearms can be viewed as taboo, the reality in their community is that firearms are commonplace even in churches. This may position faith-based settings as appropriate venues for firearm-related conversations, especially when family safety is a concern and clergy are already looked upon for guidance and wellbeing: In a Black church, to be honest with you, especially [where I live], you have pastors and deacons in the pulpit that actually have concealed carry licenses. Their security, in the church, they’re carrying now. To me, that’s actually a good base for these conversations to happen, because the church will pull in the family, the mother, the father, the kids, and that’s something that they can learn together. (Participant 7)
Key Concept 2.2: Comfort With Firearm Safety Education in Trusted Youth Settings
Multiple participants suggested that they would be comfortable with schools or other child-education-focused organizations – such as parent-teacher associations – sharing appropriate firearm safety information. Participants discussed increasing concerns about school safety and how to communicate with children about the risks of accessing firearms, for example: At the end of the day, not everyone wants to be a firearm owner. But am I able to properly know what to do if my child, you know, talks to me about someone brought a gun to school? Nowadays, schools are not off-limits. Just when it comes to like active shooters and, you know, historically what we’ve been seeing in the United States. (Participant 3)
Building on this idea, 1 participant acknowledged that offering firearm safety information or having firearm safety conversations in schools would require sensitivity, as discussions of firearms in school settings may evoke fear or distress in the context of school-related firearm violence in the U.S. Neverthless, the participant expressed comfort with age-appropriate materials and discussion delivered through voluntary school or after-school programs. The participant described how such approaches may allow children to receive reliable safety information and ask questions in familiar settings where they already learn from trusted adults: Some sort of a program at schools. But that’s touchy, especially with all the stuff that’s been going on lately. Or, you know, maybe some voluntary after-school type programs to where firearm safety gets talked about. Not teaching the kids how to handle firearms per se but, you know, just understanding, some of the dos and don’ts of basic safety and storage. Being able to adapt to that information to their age range, you know? (Participant 13)
Noting similar concerns, 1 participant reflected on their comfort with non-school youth settings, such as Scouting America (formerly Boy Scouts of America), which offers a variety of range and target activities (eg, BB guns, archery, and firearms chambered in 0.22 LR) and guidelines for teaching firearm safety and storage. They explained that Scouting programs, like schools, are often familiar environments led by trusted adults, whose mission is to promote youth responsibility, confidence, and character – and may provide opportunities to address firearm safety and suicide prevention.
Discussion
This study addressed an important knowledge gap by gathering feedback from Black adults with access to firearms in their homes on their comfort with talking to healthcare professionals about firearm safety. This study also explored participants’ comfort with discussing firearm safety with community professionals, recognizing that limited comfort in clinical settings may influence where such conversations are perceived to be acceptable. Given the urgency of the recent increase in firearm-involved suicide deaths among Black Americans,1,19 we conducted RQA to expeditiously generate and disseminate new insights locally and beyond. Our findings reflect participants’ perceptions and anticipated behaviors rather than direct observations in clinical settings. Nevertheless, Black adults who participated in this study revealed that their comfort with talking to healthcare professionals about firearm safety was shaped by longstanding trust with clinicians (typically primary care providers), legal firearm ownership, and transparency about why firearm-related questions are being asked. Discomfort was driven by fears of punitive consequences, historical mistrust of healthcare and other institutions in Black communities (ie, the “trust deficit”), and stigma surrounding mental health. At the same time, participants described substantial comfort discussing firearm safety within familiar community spaces, particularly with trusted faith leaders, community figures, and individuals who share cultural experiences. They also expressed support for youth-focused settings, such as schools and Scouting programs, as potentially appropriate venues for age-appropriate firearm safety information. These findings suggest a need for trust-building approaches in clinical settings that prioritize clear communication about the intent and use of information, alongside community-based strategies that leverage trusted relationships and familiar spaces, as potential pathways to improving safe firearm storage and reducing firearm-related suicide deaths among Black adults in the U.S.
Comfort appears to be an important mechanism shaping motivation to engage in firearm safety conversations. Within the COM-B model, 30 motivation includes both reflective processes (eg, intentions, beliefs about consequences) and automatic processes driven by affective states. Comfort and discomfort are particularly salient for automatic motivation, shaping behavior through emotional responses that either facilitate openness and engagement or avoidance and withdrawal. Notably, 1 previous study found that adult participants with depressive symptoms viewed questions about firearm access as appropriate in clinical care for mental health and suicide prevention. 31 From the perspective of motivation, discomfort in clinical settings may undermine motivation to participate in firearm safety discussion or LMC, even when individuals recognize its potential benefits. Addressing this barrier with Black adult patients will likely require strategies that prioritize emotional safety and attend to perceived racial discrimination, 32 rather than relying solely on generalized messaging on safe firearm storage or standardized clinical protocols that dictate the timing/initiation of firearm-related questions without regard for patients’ cultural context or prior relationships. As suggested in recent studies conducted with other populations, 33 tailoring firearm-related discussions to individuals’ values and concerns may help facilitate firearm safety counseling. 34 Participants in this study indicated that firearm-related discussion may activate fears of surveillance, stereotyping, or differential treatment, which can heighten discomfort and suppress engagement. Thus, clinicians may help mitigate these effects by preemptively acknowledging Black adult patients’ concerns, clearly explaining the purpose of firearm-related questions, and proactively communicating the preventive – rather than punitive – intent of firearm safety counseling. Continuity of care may further enhance comfort, strengthening motivation to engage in firearm safety discussions.
Additionally, clinical screening protocols may benefit from incorporating more explicit attention to how firearm-related questions are introduced and contextualized. For example, clinicians might frame questions by emphasizing their role in supporting patient safety and suicide prevention (eg, “I ask all my patients about safety, including access to firearms, because it can help us think together about ways to stay safe during stressful times”), rather than in ways that may be perceived as regulatory or punitive. Prior research suggests that some patients may experience apprehension when encountering firearm-related questions without context – such as on forms or screening tools – particularly when the purpose and use of the information are unclear. 31 Embedding firearm-related questions within broader safety discussions (eg, substance use and seatbelt behavior) and normalizing them as part of routine care may further reduce defensiveness and increase acceptability.35,36 Transparency about how firearm-related information will be documented may further address the concerns described by the participants in this study. For instance, healthcare professionals can briefly explain what is recorded in the electronic health record (EHR) and who has access to that information. Additionally, documentation practices within the EHR may benefit from prioritizing clinically relevant safety information yet minimizing language that could be perceived as stigmatizing or surveillant. Rather than relying solely on standardized approaches, allowing flexibility in how firearm-related discussions are conducted and documented may better support individualized, 34 patient-centered care and build trust with Black patients.
The participants’ strong comfort with familiar community settings points to opportunities for extending firearm safety counseling beyond clinical settings in Black communities. Spaces characterized by shared identity, longstanding relationships, and cultural familiarity may promote emotional safety, trust, and motivation to engage in firearm safety conversations in ways that clinical settings often do not for Black adults. 32 In practice, our findings suggest there is value in pursuing a community-engaged approach through which clinicians collaborate with trusted community leaders and organizations – such as clergy and faith-based organizations, panhellenic fraternity and sorority networks, community festivals, and local recreation centers – to support safe firearm storage behavior and suicide prevention education. Notably, community-engaged strategies have been associated with improved intervention acceptability, participation, and health-related outcomes: These approaches work by aligning prevention efforts with community priorities and leveraging trusted social structures, particularly in underserved and racial/ethnic minority communities.32,37,38 As such, clinician involvement in these community settings, whether through consultation, co-facilitated programming, or referral pathways embedded within community spaces, may help bridge the aforementioned “trust deficit” with Black communities by extending clinical expertise into trusted environments while preserving cultural familiarity and emotional safety. Moreover, these approaches may complement clinical care and expand access to prevention strategies for Black adults and families who may otherwise disengage from clinic-based counseling.
Churches and faith-based settings are longtime partners in the effort to reduce health disparities.32,39 Over the past century, Black churches have been involved in health-related programming and contribute to their congregants’ socio-economic wellbeing32,40 and mental health. 41 More recently, Black churches have demonstrated feasibility as venues for health promotion and have been examined as potential settings for mental health interventions.32,42 At the same time, prior research suggests that African American adults with higher levels of organizational and subjective religiosity may be less likely to utilize professional mental health services, underscoring the importance of integrating prevention pathways within faith-based contexts rather than relying on clinic-based care alone. 43 In particular, clergy may be able to serve as trusted intermediaries who can facilitate engagement and linkage to care among Black adults through strategies such as safe firearm storage messaging in church bulletins, church-sponsored firearm safety and suicide prevention events, LMC delivered in church settings, and lay health advisors trained to provide safe firearm storage education and motivational interviewing. 44
Limitations
This study had several limitations. First, key concepts in this study were identified as preliminary or emerging through structured summaries in matrix format rather than comprehensive line-by-line coding of full transcripts and therefore may not fully capture the nuance or range of participant perspectives, including less dominant or contradictory narratives that may be underrepresented using RQA methods.
Second, as it is not only the firearm owner who may be at risk if a firearm is stored unsafely, but also anyone who may have potential access to it in the household, we intentionally sought to encourage broader input from Black adults who have access to firearms in their homes. Two participants did not identify as firearm owners themselves but had direct access to – and knowledge of handling – firearms in their homes. No notable differences emerged in the responses of these 2 participants compared to those who identified as firearm owners. Prior research has shown that there may be different perceptions of safe firearm storage practices, personal firearm injury risk, and the acceptability of interventions like firearm safety counseling between owners and non-owners.45-47 However, our study was not designed to investigate such differences. To build on this work and further focus on the safety of all household members in homes with firearms in Black communities, future studies should investigate differences in perceptions of firearm safety and risk among Black adults who live in homes with access to firearms but do not own firearms themselves.
Third, although positivist concepts like generalizability were not a goal of this exploratory study, readers should be attentive when considering the transferability of the insights generated through this study to the experiences of other Black adults. This may be due to our small sample size or sampling strategy (eg, word-of-mouth referrals from likeminded participants leading to a limited scope of insights), the limited information collected from the participants by which to compare to other individuals, or the fact that the insights the participants shared reflected their lived realities and no one else’s. Notably, we attempted to mitigate transferability concerns by providing the reader with a detailed description of the participants’ experiences and perceptions relevant to the study objective 48 (including the use of detailed illustrative quotes) and by incorporating relatively wide geographic variation in the sample. 20 As is expected in qualitative inquiry, other studies or individuals from varying geographic contexts may yield different insights. Nevertheless, the information shared by participants in this study complement the existing literature by offering depth and nuance regarding the experiences of Black adults who have access to firearms in their homes, as well as informing future studies that examine variation in perceptions and experiences across demographic characteristics.
Fourth, and consistent with the previous limitation, participants who chose to take part in this study were willing to discuss firearm safety and mental health with a researcher; perspectives of Black adults living in homes with access to firearms who have greater mistrust or deeper legal concerns may be underrepresented.
Fifth, the differences in racial identity between the interviewer and participants may have influenced participants’ comfort or responses despite reflexive efforts to mitigate power dynamics and bias.
Conclusions
Firearms account for more than half of all suicide deaths among Black adults in the U.S. This study gathered feedback from Black adults with access to firearms in their homes on their comfort discussing firearm safety with healthcare professionals and explored their comfort engaging in these conversations with community professionals. Participants described that comfort with talking to healthcare professionals was shaped by trust, continuity of care, legal firearm ownership, and clear communication about the purpose and preventive intent of firearm-related questions. Discomfort was driven by fears of punitive consequences, historical mistrust of institutions, and mental health stigma. Many participants reported greater comfort with discussing firearm safety in familiar community settings – particularly with trusted faith leaders, community figures, and culturally aligned spaces. Ideally, this work will begin to improve the cultural humility of existing initiatives and enhance their effectiveness for firearm safety screening and LMC in Black communities. These findings suggest a need for trust-building approaches in clinical settings that prioritize clear communication about the intent and use of firearm-related information, alongside community-based strategies that leverage trusted relationships and familiar spaces, as potential pathways to improving safe firearm storage and reducing firearm-related suicide deaths among Black adults in the U.S.
Footnotes
Ethical Considerations
The University of Utah Institutional Review Board (IRB) approved the study protocol (IRB_00169397).
Consent to Participate
All participants received a consent cover letter and verbally consented to participate. A waiver of documentation of consent was approved by the University of Utah IRB (IRB_00169397).
Author Contributions
EG: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Visualization, and Writing – original draft. AS: Formal Analysis, Validation, and Visualization. JH: Conceptualization, Methodology, and Writing – review & editing.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number K18MD019159. The funding source had no involvement in the study design, data analysis and interpretation, writing of the report, or in the decision to submit the article for publication. Additionally, the research reported in this publication was supported in part by the Community Collaboration and Engagement Team (CCET) of the Utah Clinical & Translational Science Institute (CTSI). Utah CTSI is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number(s) UM1TR00409. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.