Incentivizing Lethal Means Safety Among Veterans at Risk for Suicide

Background. Firearm injury accounts for 70% of Veteran suicides, making safer storage of firearms among Veterans at risk for suicide a top VA & HSR&D priority. Although VA providers encourage Veterans to store their firearms more safely during lethal means safety counseling (LMSC), only about half of individuals follow

through on these recommendations. Additionally, little is known about methods for verifying firearm storage practices, which are critical for evaluating LMSC interventions. Research shows that offering financial and social incentives increases behavior change, and the Philadelphia VAMC has led a successful national

program providing incentive-based interventions to Veterans with substance use disorders. The use of financial and social incentives to increase safe storage of firearms, however, has not yet been assessed. Significance/Impact. This proposal aims to leverage financial and social incentives to increase Veterans’ safe

storage of firearms following LMSC, thereby contributing to VA’s suicide prevention efforts. VA’s existing infrastructure supporting the delivery of both LMSC and incentive-based interventions makes it an ideal setting for this work. Operational partners, including the Office of Mental Health and Suicide Prevention, the Rocky

Mountain VA, and the Veterans Rural Health Resource Center support this proposal. Innovation. Financial and social incentives increase behavior change and our pilot work suggests that Veterans and VA clinicians are interested in using incentives to encourage safer storage of firearms. This proposal is the first to examine the use of incentives to change firearm storage behavior. It is also the first to

evaluate methods for verifying firearm storage practices, which will provide critical information to researchers developing lethal means safety interventions and clinical providers delivering these interventions. Specific Aims. 1) Consult with stakeholders to determine the most acceptable and feasible intervention

protocol that offers Veterans at risk for suicide financial and/or social incentives to store their firearms safely. 2) Pilot test the add-on, incentive-based intervention among Veterans receiving LMSC in VA behavioral health. Methodology. Aims will include participants from the VAMCs in Philadelphia and New Orleans, and will be

conducted remotely to facilitate recruitment. Veteran participants will be seen in outpatient behavioral health and have access to firearms; equal numbers will be drawn from urban and rural settings and about a quarter will identify as women and racial/ethnic minorities. Aim 1 will include two steps. First, we will conduct qualitative

interviews with ~20 Veterans with recent suicidal ideation, as well as ~10 VA clinicians/administrators. Interviews will evaluate the acceptability and feasibility of potential incentives, methods of verifying firearm storage practices, and other intervention components. Second, we will develop an advisory board made up of

8 Veterans and 8 other stakeholders (subject matter experts, VA clinicians/administrators). The advisory board will consider findings from qualitative interviews and use online modified Delphi methods to reach consensus on the most acceptable intervention components and best items to include in the pilot trial outcome measures.

The study team will develop an intervention protocol and iteratively modify it to align with study findings. In Aim 2, we will conduct a pilot study with 24 Veterans who have completed LMSC to assess the add-on, incentive- based intervention. We will evaluate the feasibility of recruitment, retainment, provision of incentives, and

methods of verifying changes in firearm storage, the acceptability of the intervention, and methods of individualizing the intervention based on Veterans’ preferences and sociodemographic characteristics. Next Steps/Implementation. We will apply for IIR funding to conduct a multi-site, Hybrid Effectiveness-

Implementation Type 1 Randomized Clinical Trial. This trial will assess the effectiveness of the add-on LMSC intervention and barriers and facilitators to its implementation. If effective, we will disseminate the intervention in VA behavioral health settings to improve safe storage of firearms among Veterans at risk for suicide.