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Applying Behavioral Economics to Enhance Safe Firearm Storage Applying Behavioral Economics to Enhance Safe Firearm Storage Katelin Hoskins, MSN, MBE,a,b Unmesha Roy Paladhi, MPH,d Caitlin McDonald, MPH,d Alison Buttenheim, PhD, MBAa,b,c Behavioral economics applies key principles from psychology and economics abstract to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ∼4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation aDepartment of Family and Community Health, School of Nursing, bLeonard Davis Institute of Health Economics, prompts, in-group messengers, and increased salience as behaviorally cCenter for Health Incentives and Behavioral Economics, and informed strategies that may counter these biases and subsequently enhance dPerelman School of Medicine, University of Pennsylvania, safe firearm storage. We also describe other opportunities to leverage the Philadelphia, Pennsylvania behavioral economic tool kit. By better understanding the individual Ms Hoskins, Ms Roy Paladhi, and Ms McDonald behavioral levers that may impact decision-making around firearm storage, drafted the initial manuscript and reviewed and revised the manuscript; Dr Buttenheim revised the behavioral scientists, pediatric providers, and public health practitioners can manuscript critically for important intellectual partner to design and test tailored interventions aimed at decreasing content; and all authors conceptualized and pediatric firearm injuries. Further empirical study is warranted to identify the designed the manuscript, approved the final fi manuscript as submitted, and agree to be presence of speci c biases and heuristics and determine the most effective accountable for all aspects of the work. behavior change strategies for different subpopulations. DOI: https://doi.org/10.1542/peds.2019-2268 Accepted for publication Dec 9, 2019 Address correspondence to Katelin Hoskins, MSN, BEHAVIORAL ECONOMICS AND FIREARM a cognitive bias that refers to the MBE, School of Nursing, University of Pennsylvania, STORAGE BEHAVIORS “ ” 418 Curie Blvd, Philadelphia, PA 19104. E-mail: tendency to rely heavily ( anchor )on [email protected] 1 value when making decisions; the Behavioral economics applies key PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, principles from psychology and initial, irrelevant starting point then 1098-4275). influences future estimates.1 By economics to address obstacles to Copyright © 2020 by the American Academy of behavior change. Whereas economists addressing the subtle decision errors Pediatrics that occur in everyday life, behavioral describe human beings as logical, FINANCIAL DISCLOSURE: The authors have indicated rational decision-makers, behavioral economics offers insights and tools that they have no financial relationships relevant to this economists recognize that predictable can support better choices. Although article to disclose. and systematic errors in judgment pediatricians and behavioral FUNDING: No external funding. 1,2 characterize human decision-making. economists recently have POTENTIAL CONFLICT OF INTEREST: The authors have To adapt to a complex world, humans collaborated on ideas to support indicated they have no potential conflicts of interest rely on unconscious cognitive biases parental behavior change and boost to disclose. and simplifying heuristics. These clinical effectiveness (notably around – processing aids and mental shortcuts vaccination),3 5 the important topic of To cite: Hoskins K, Roy Paladhi U, McDonald C, can be helpful, but they can also lead to pediatric firearm injuries has not yet et al. Applying Behavioral Economics to Enhance decisions not in one’s best interests. been explored through a behavioral Safe Firearm Storage. Pediatrics. 2020;145(3): e20192268 For example, the anchoring effect is economic lens. Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 145, number 3, March 2020:e20192268 SPECIAL ARTICLE Pediatric firearm-related injuries are stored.19 Shifting patterns of gun We aim to educate pediatricians a significant public health problem in ownership, especially the increase in about behavioral economic concepts the United States, with firearms as the handgun ownership for personal that could inform clinical practice leading mechanism of injury death for protection, amplifies the risk of but are still in need of testing to 10- to 24 year-olds in 2017.11 More pediatric injury given that handguns determine if, and in which groups, than half of child and adolescent are more likely to be stored loaded they are effective. We will explore firearm deaths were homicides and unlocked.14,17,20 Estimates implementation prompts, in-group (59%), followed by suicides (35%) suggest that ∼4.6 million children live messengers, and increased salience as and unintentional injuries (4%).12 in homes with at least 1 loaded and behaviorally informed strategies that From 2007 to 2014, firearm suicides unlocked firearm.14 may enhance safe firearm storage in children trended up, and between practices. We will also describe other Evidence to date for safe storage 2002 and 2014, 60% of the firearm relevant behavioral science interventions is varied. Gun suicides among children were constructs. avoidance programs directed to completed with a handgun.13 The children do not reduce risk,18,21 and majority of both younger and older the effects of child access laws vary DEPLOY IMPLEMENTATION INTENTION children who died by firearm suicide by strength and state.22,23 Firearm PROMPTS TO COUNTER PRESENT BIAS or unintentional firearm injury training in its current form is not received the fatal injury in the Present bias is the tendency of most associated with storing firearms home.13 Firearms are present in individuals to overemphasize the safely.24 In contrast, pediatrician approximately one-third of US present and discount the future. In screening, brief counseling, and households.14 Households, especially health-related decisions, present bias distribution of cable locks to firearm- those with children, with a firearm leads to overweighting the immediate owning parents (bundled with other present are at an increased risk for costs of following through with an violence prevention interventions) intentional and unintentional intention and underweighting led to improvements in parental injury.15,16 potential future benefits.6 Take reports of lock use.25 The physical activity for example: Consistent safe firearm storage may development and evaluation of individuals will overvalue the short- meaningfully reduce both fatal and approaches to engage parents in safe term costs, such as the time, energy, nonfatal pediatric injuries. Safe firearm storage are urgently needed, and financial costs, associated with storage is defined as “practices that especially in light of the Monuteaux exercising as opposed to the long- limit accessibility to guns by et al26 finding that a modest (20%) term benefits, such as weight loss, unauthorized users.”17 The American uptake of a direct safe firearm storage reduced risk of heart disease, and Academy of Pediatrics (AAP) states recommendation among adult overall improvements in health.6 The that the absence of guns in homes and firearm owners in households with future seems uncertain and unknown, communities is the most effective children could result in meaningful leading individuals to put more value way to prevent pediatric firearm- reductions in both unintentional on the present. Although individuals related injuries.18 If firearms are injuries and suicide. may have strong intentions to present in the home, AAP guidelines The problem of unsafe firearm accomplish a particular task, present advise that pediatricians counsel storage reflects broad structural bias may interfere with execution. families that firearms should be challenges but is also an individual Implementation intention prompts stored unloaded, in a locked box or behavior driven by individual are a potential strategy to counter with a locking device, and separate decision-making. By focusing on present bias. One type of an from ammunition.18 Locked boxes individual behavioral levers, the field implementation intention prompt is include gun safes or cabinets, and of behavioral economics offers a commitment contract. Simply locking devices include trigger or insights that may complement asking people to declare, “In situation cable locks. current public health approaches to X, I plan to do Y” can increase Despite these recommendations, increasing safe firearm storage. In achievement of the desired goal.27 approximately one-fifth of gun this article, we use behavioral Developing this intention fosters owners store at least 1 gun loaded economic theory to identify specific a connection between the desired and unlocked.14,16 Strikingly, only cognitive biases that may influence action and a concrete future moment. 46% of US adults who own a firearm parental decision-making,
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