Supplement: Family Safety Net: Developing an upstream suicide prevention approach to encourage safe firearm storage in rural and remote Alaskan homes

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Summary: Suicide is a major and rising public health problem in the United States.1 In Alaska, suicide rates are consistently triple the national rate8,10 and fully 60% of the suicide fatalities are due to firearms.11,12 In rural Alaska Native (AN) communities, virtually all homes have multiple guns, which increases suicide risk significantly.13,14 In the AN study region, youth suicide rates are 18 times that of other American teens.15,16 This context presents an important opportunity to enhance safety and prevent suicide deaths by restricting access to firearms in the people's homes. Restricting `lethal means' for suicide prevention is one of the most effective strategies to date.17-19 Key challenges are widespread uptake, particularly within high-risk and hard-to-reach populations.17,18, 20-22 The proposed research will inform the development of the Family Safety Net (FSN), a public health approach that builds on the collectivist, family-centric orientation of AN people by universally engaging adult family members of youth in increasing their home safety. Our central hypothesis is that by supporting adult family members in locking and unloading all household firearms, we can reduce a key environmental risk factor that contributes to youth suicide in rural AN communities. Using a community-based participatory approach, the study will integrate important culturally-specific considerations to support, encourage, and assess safe firearm storage practices relevant to AN families. The formative research will result in a feasible and acceptable FSN intervention that will undergo preliminary efficacy testing. Our aims are to: (1) Characterize AN household firearm storage practices to inform intervention development; (2) Iteratively develop and focus test the Family Safety Net (FSN) intervention; and (3) Conduct a pilot randomized control trial (n=70, 35/group) to assess feasibility, acceptability, and fidelity of the Family Safety Net (FSN) intervention, as well as examine preliminary efficacy at increasing safe storage practices and expected mechanisms of change based on our theoretical model. The proposed research is significant because effective safe storage interventions are needed to address: 1) elevated rates of U.S. adolescent firearm suicides; and 2) disparities in AN youth suicide rates. Key innovations include: 1) an upstream focus on universal youth suicide prevention and family safe storage practices in a firearm-owning population; 2) addressing collectivist cultural norms, as compared to individualistic norms, which can be an important for other populations; and 3) a focus on tailoring intervention content to address the role of the family member, both gun owners and others, in controlling firearm access. This formative research sets the stage for a larger fully powered randomized trial to evaluate FSN efficacy to increase safe household firearm storage of people who have multiple firearms, and whose youth are at extremely high risk for suicide.