JAMA Health Forum. 2026 Nov 6;7(11):e263990. doi: 10.1001/jamahealthforum.2026.3990.
ABSTRACT
IMPORTANCE: Firearm injury is the leading cause of death for adolescents in the US. Few adolescent firearm injury prevention interventions exist that center partnership with firearm-owning communities.
OBJECTIVE: To measure the impact of the Guardians 4 Health shooting sports firearm injury prevention bystander intervention among youth in 4-H Shooting Sports (4HSS).
DESIGN, SETTING, AND PARTICIPANTS: This parallel cluster randomized clinical trial enrolled youth in the US at 4HSS clubs with 6 or more adolescents and the ability to use video conferencing technology. Sites were enrolled from June 2022 to July 2024; they were block randomized and stratified by rurality and state-level child access prevention laws. Intervention sites received the shooting sports firearm injury prevention curriculum, and wait-listed control sites continued standard 4-H programming. Outcome data were collected by survey and aggregated across 5 hypothetical scenarios at baseline, 3 months, and 6 months. Analyses followed intention-to-treat principles. Complete-case analyses used linear mixed models adjusting for baseline and randomization variables; multilevel multiple imputations were adjusted for baseline covariates.
INTERVENTION: A 3-session novel adolescent firearm injury prevention bystander intervention curriculum, previously developed in conjunction with 4HSS.
MAIN OUTCOMES AND MEASURES: The primary outcome was behavioral intention to use bystander intervention. Secondary outcomes were knowledge, subjective norms, attitudes, and perceived behavioral control.
RESULTS: A total of 61 sites from 28 states were randomized (32 to intervention and 29 to control); 50 sites (intervention, 26 sites of 250 youth; control, 24 sites of 174 youth) completed baseline data collection. Of 424 participants, the median (IQR) age was 14 (13-16) years; 226 were male (53.3%). Among 333 participants with nonmissing family firearm ownership data, 291 reported ownership (87.4%). Linear mixed-model analyses showed a small difference in behavioral intention between groups at 3 months (Β = 0.10; 95% CI, 0.003-0.19) but not at 6 months; multiple imputation results were similar. Significant positive intervention effects on firearm injury risk knowledge were observed at both time points in both analyses and on perceived behavioral control at 3 months.
CONCLUSIONS AND RELEVANCE: Results of this nationwide cluster randomized clinical trial of a codeveloped adolescent firearm injury bystander intervention curriculum demonstrated a small short-term positive effect on intention to use bystander interventions and a durable effect on firearm injury risk knowledge. Findings support partnership between shooting sports organizations and public health researchers and the value of the firearm injury prevention bystander intervention within 4HSS. Consideration of boosters and larger-scale evaluation is warranted.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04804189.
PMID:42993539 | PMC:PMC13744018 | DOI:10.1001/jamahealthforum.2026.3990