california health interview survey sie lao eer California veterans who lived in a household with a firearm reported that at least one firearm was stored without any locking device (e.g., trigger lock or lockbox). INTRODUCTION According to the California Department of Public Health, 583 veterans died by suicide in California in 2020, with 61% of those suicides the result of firearm injuries (62% among males; 25% among females).' Access to a firearm and specific storage practices - such as storing a firearm loaded with ammunition and unlocked - are associated with increased suicide risk.23 Since many policies impacting firearm use and ownership are initiated at the state level, it is important to understand state- specific prevalence of firearm access and firearm storage practices and their intersection with mental health risk factors for suicide. This understanding can inform clinical, public health, and policy efforts to prevent firearm suicides among California's veteran population. Questions that were asked of adolescents and adults in the 2021 California Health Interview Survey' included items assessing sociodemographic and military service UCLA Center for Health Policy Research / 1 characteristics, firearm access, firearm storage practices, health care access, and mental health characteristics relevant to suicide risk. The mental health characteristics include serious psychological distress (Kessler Psychological Distress Scale [K6]),5 past-year suicidal ideation, and lifetime suicidal ideation and suicide attempt. For this fact sheet, we report findings from respondents ages 18 years and older who identified themselves as military veterans and who resided in a household with at least one firearm, such as a pistol, shotgun, or rifle, including those kept in garages, outdoor storage areas, or motor vehicles. Participants were asked not to include "BB guns, starter pistols, or guns that could not fire." We describe firearm access and storage practices among California veterans overall, then stratify these by whether respondents reported any lifetime suicidal ideation - an important Exhibit 1 / Demographic and Military Service Characteristics of Veterans Who Reside in Households With Firearms, California, 2021 Characteristic Prevalence estimate | 95% confidence interval (%) Male 91.4% 88.9-93.8 Age group 18-34 years 8.6% 5.3-11.9 35-54 years 23.5% 18.8-28.2 55-64 years 16.3% 12.5-20.2 65-74 years 21.5% 17.8-25.2 75 and older 30.1% 26.3-33.9 Latino or Hispanic ethnicity 17.0% 13.3-20.8 Race White 80.9% 76.8-84.9 Black or African American 9.8% 6.5-13.2 Asian 5.0% 3.0-7.0 American Indian or Alaska Native 4.0% 2.4-5.6 Other Pacific Islander 0.3%* 0.03-0.6 Native Hawaiian 0.09%* 0.0-0.2 Other 4.8% 2.1-7.6 Marital status Married 71.1% 66.7-75.6 Widowed, separated, divorced, lives w/partner 21.8% 17.4-26.2 Never married 7.1% 4.4-9.7 1+ child in household under age 18 17.3% 13.5-21.0 Educational attainment Less than high school 3.3% 1.4-5.2 High school, some college, vocational 43.3% 38.9-47.7 College or advanced degree 53.4% 48.8-58.0 Work status last week Working at a job/business 41.6% 37.2-46.1 With a job/business, but not at work 2.5%* 1.0-4.0 Looking for work 3.5% 1.7-5.5 Not working 52.4% 47.5-57.3 Any service-connected disability 32.2% 27.9-36.5 Military service erat Iraq War/Operation Iraqi Freedom 23.9% 17.9-29.8 Afghanistan War/Operation Enduring Freedom 18.2% 13.0-23.4 Gulf War/Operation Desert Storm 20.3% 15.9-24.6 Vietnam War 53.6% 47.8-59.4 Korean War 7.6% 4.1-11.1 World War II 0.9%* 0.0-2.1 Notes: *Estimate is statistically unstable. tNot mutually exclusive. Total survey respondents included in study=760 Source: 2021 California Health Interview Survey UCLA Center for Health Policy Research / 2 correlate of future suicide risk.° Estimates are weighted to represent the statewide population of veterans who reside in households with firearms. KEY TAKEAWAYS Home firearms and firearm storage practices According to the 2021 CHIS, 5.8% of California adults identified as veterans, and 38.1% of California veterans reported that they resided in a household with a firearm (see Appendix, Exhibit A1). The mean numbers of firearms and handguns in each veteran household were 4.3 and 2.2, respectively. In comparison, 16.3% of California nonveteran adults resided in a household with a firearm. Sociodemographic and military service characteristics among veterans who resided in households with firearms are shown in Exhibit 1. When asked about firearm storage, approximately one-third (36.0%) of California veterans who lived in a household with a firearm reported that at least one firearm was stored without any locking device (e.g., trigger lock or lockbox), 25.6% reported that at least one was stored loaded with ammunition, and 13.9% reported that at least one was stored loaded with ammunition and without any locking device. Mental health characteristics and health care access Among California veterans who resided in households with firearms in 2021, 6.3% reported symptoms consistent with serious psychological distress in the past year, and nearly 1 in 7 (14.1%) said they had ever seriously thought about dying by suicide. Among those who had ever seriously thought about dying by suicide and resided in a household with firearms, 21.7% reported suicidal ideation in the past year, and 23.3% had ever attempted suicide. One-fourth of California veterans who resided in households with firearms in 2021 had received care for mental health needs within an emergency department setting (24.4%), and 18.0% reported needing professional help for an emotional, mental health, alcohol, or drug problem in the preceding year. Approximately 1 in 10 had received care from a primary care clinician (7.8%) or other professional (11.8%) for an emotional, mental health, alcohol, or drug problem in the preceding year. Mental health and firearm storage practices Of California veterans who resided in households with firearms and reported any lifetime suicidal ideation, 18.4% said that at least one household firearm was currently stored loaded with ammunition and without any locking device (Exhibit 2). Among California veterans who resided in households with firearms in 2021, nearly seriously thought about dying by suicide. UCLA Center for Health Policy Research / 3 Exhibit 2 / Firearm Storage Practices by Presence of Lifetime Suicidal Ideation Among Veterans in Households With Firearms, California, 2021 No loaded and - Loaded and unlocked firearms unlocked firearms in household in household | 86.8% 81.7% 18.4% = 13.2% Any lifetime No lifetime suicide ideation suicide ideation Confidence intervals (in parentheses): 18.4% (9.7-27.0); 81.7% (73.0-90.3); 13.2% (9.7-16.7); 86.8% (83.3-90.3) Source: 2021 California Health Interview Survey IMPLICATIONS AND POLICY RECOMMENDATIONS In 2021, 38.1% of California veterans reported living in a household with a firearm. In comparison, 16.3% of California nonveteran adults reported living in a household with a firearm during the same time period, and in 2015, nearly half of veterans nationally reported living in a household with a firearm." Of California veterans residing in households with firearms, 13.9% reported that at least one firearm was stored loaded with ammunition and unlocked - double the prevalence compared with nonveterans in California (6.8%).8 Programs to educate, encourage, and facilitate secure storage of household firearms - such as providing free or discounted locking devices or reducing barriers to accessing out- of-home storage options - will be important for reducing the risk of suicide or other firearm injuries among both veteran and nonveteran populations. Findings from the 2021 CHIS also demonstrate a substantial need for mental health and substance-related services for veterans: Almost 1 in 5 veterans (18.0%) who resided in households with firearms reported needing professional help in the preceding year for such care, and 14.1% reported having seriously considered dying by suicide at some point in their life. Of the latter group, almost 1 in 5 reported that they lived in a household with at least one firearm that was stored loaded with ammunition and unlocked. Future work is needed to determine how best to align Veterans Affairs (VA) and non-VA clinical care systems to improve access to mental health services and align them with ongoing parallel efforts to promote voluntary, secure firearm storage among at-risk veterans. Disclosures The contents of this work are the authors' sole responsibility and do not necessarily represent the official views of any of the authors' or contributors' funders or employers. UCLA Center for Health Policy Research / 4 california | health interview survey The California Health Interview Survey covers a wide array of health-related topics, including health insurance coverage, health status and behaviors, and access to health care. It is based on interviews conducted continuously throughout the year with respondents from more than 20,000 California households. CHIS interviews were offered in English, Spanish, Chinese (both Mandarin and Cantonese), Vietnamese, Korean, and Tagalog. CHIS is designed with complex survey methods requiring analysts to use complex survey weights in order to provide accurate variance estimates and statistical testing. CHIS is a collaboration of the UCLA Center for Health Policy Research, the California Department of Public Health, the California Department of Health Care Services, and the Public Health Institute. For funders and other information on CHIS, visit chis.ucla.edu. Author Information Joseph Simonetti, MD, MPH, is the director of mentorship and education at the Firearm Injury Prevention Initiative, University of Colorado School of Medicine, and an assistant professor at the University of Colorado School of Medicine. Erin Wright-Kelly, DrPH, MA, is director of research and evaluation at the Firearm Injury Prevention Initiative, University of Colorado School of Medicine. Tiffany Maksimuk, BA, is a medical student at the University of Colorado School of Medicine. Marian Betz, MD, MPH, is director of the Firearm Injury Prevention Initiative, University of Colorado School of Medicine; a research physician at the VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora; and a professor of emergency medicine at the University of Colorado School of Medicine. Funders and Acknowledgments This project was supported by an award from the National Collaborative on Gun Violence Research. The views expressed in this fact sheet are those of the authors and do not necessarily reflect the views of the National Collaborative on Gun Violence Research. Endnotes 1 California Department of Public Health. 2020. Suicide Death Among Veterans in California, 2020. Sacramento, CA: CDPH, Injury and Violence Prevention Branch. https://www.cdph.ca.gov/ Programs/CCDPHP/DCDIC/SACB/CDPH Document Library/CA Violent Death Reporting System (CalVDRS)/SuicidesAmongVeteransCA2020_ DataBrief.pdf 2 Kellermann AL, Rivara FR Somes G, et al. 1992. Suicide in the Home in Relation to Gun Ownership. New England Journal of Medicine 327(7): 467- 472. https://www.nejm.org/doi/full/10.1056/ nejm199208133270705 3 Anglemyer A, Horvath T, Rutherford G. 2014. The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-Analysis. Annals of Internal Medicine 160(2): 101-110. https://pubmed. ncbi.nlm.nih.gov/24592495/ UCLA Center for Health Policy Research / 5 4 California Health Interview Survey. October 2022. CHIS 2021 Adult Survey. Los Angeles, CA: UCLA Center for Health Policy Research. Kessler RC, Barker PR, Colpe LJ, et al. 2003. Screening for Serious Mental Illness in the General Population. Archives of General Psychiatry 60(2): 184-189. https://pubmed.ncbi.nim.nih. gov/12578436/ Nock MK, Borges G, Bromet EJ, et al. 2008. Cross- National Prevalence and Risk Factors for Suicidal Ideation, Plans and Attempts. The British Journal of Psychiatry 192(2): 98-105. htips://pubmed.ncbi.nIm. nih.gov/18245022/ Cleveland EC, Azrael D, Simonetti JA, Miller M. 2017. Firearm Ownership Among American Veterans: Findings From the 2015 National Firearm Survey. Injury Epidemiology 4(1): 33. https://www.ncbi.nim. nih.gov/pmc/articles/PMC5735043/ Banawa R, Tan S. 2022. Despite California's Strong Gun Laws and Regulations, Issues of Gun Safety and Fears of Gun Violence Remain. Fact Sheet. Los Angeles, CA: UCLA Center for Health Policy Research. https://healthpolicy.ucla.edu/publications/ Documents/PDF/2022/Gun-Violence-FactSheet- sep2022. pdf UCLA Center for Health Policy Research / 6 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu The UCLA Center for Health Policy Research is part of the UCLA Fielding School of Public Health. The analyses, interpretations, conclusions, and views expressed in this policy brief are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. FS2023-1 Copyright © 2023 by the Regents of the University of California. All Rights Reserved. Editor-in-Chief: Ninez A. Ponce, PhD Read this publication online 0ODO0 UCLA CENTER FOR ®, HEALTH POLICY RESEARCH healthpolicy.ucla.edu