Adapting Safety Check as a Universal Suicide Prevention Strategy in Pediatric Primary Care

Davis, M., Johnson, C., Pettit, A. R., Barkin, S., Hoffman, B. D., Jager-Hyman, S., King, C.A., Leiberman, A., Massey, L., Rivara, F.P., Sigel, E., Walton, M., Wolk, C.B. & Beidas, R. S. (2021). Adapting safety check as a universal suicide prevention strategy in pediatric primary care. Academic pediatrics, 21(7), 1161-1170.


Objective: The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care.

Methods: We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo.

Results: Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm.

Conclusions: Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

Keywords: firearm safety; pediatric primary care; suicide prevention.