Assault Injury and Community Violence

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

Hospital-Based Violence Intervention Programs to Reduce Firearm Injuries in Children: A Scoping Review

INTRODUCTION

Hospital-based violence intervention programs (HVIPs) have shown promise in preventing reinjury and enhancing recovery from violent injuries, including those related to firearms. Historically, HVIPs have primarily focused on at-risk adolescents and young adults. The aim of this study is to perform a scoping review of HVIPs targeting children under the age of 18, describe the evidence supporting these programs, and deduce the potential impact of expanding HVIPs to younger children.

METHODS

A scoping review was performed utilizing PubMed database with search terms "violence intervention program" and pediatric, or children, or youth. Articles were screened for youth-inclusive violence programs, and the literature was analyzed for program descriptions, evidence supporting interventions, and barriers to evaluation.

RESULTS

36 studies (covering 23 programs) were identified that met criteria (including patients ≤18 years old), with only 4 programs including children under 10. Many HVIPs utilize brief hospital interventions with longitudinal wraparound outpatient services. Despite heterogeneity in programs and studied outcomes, many HVIPs demonstrated positive outcomes, such as reduction of risk factors, decreased reinjury, decreased violent behaviors, decreased criminal justice involvement, and positive attitude or behavioral changes. Only a few studies reported increased odds of enrollment and positive impact in younger patients specifically.

CONCLUSIONS

Children are an impressionable population in which HVIPs may have significant impact; however, there remains a gap in targeted programs. Given that firearm injuries are the leading cause of death in children and adolescents, priority should be given to piloting, implementing, and evaluating HVIPs among younger age groups.

LEVEL OF EVIDENCE

Level IV.

Utilization of mental health services in pediatric patients surviving penetrating trauma resulting from interpersonal violence

BACKGROUND

Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma.

METHODS

Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization.

RESULTS

There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation.

CONCLUSION

Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.

Staying Out of the Way: Perceptions of Digital Non-Emergency Medical Transportation Services, Barriers, and Access to Care Among Young Black Male Survivors of Firearm Violence

With a reduction in primary barriers to healthcare access as a result of the Affordable Care Act, there is an increased need to address secondary barriers faced by low-income young Black male survivors of violent injury. While transportation is often characterized as a barrier for individuals with chronic disease and disability, it also acts as a significant barrier in accessing cognitive behavioral therapy and mentoring services through hospital-based violence intervention programs (HVIPs). These services address the traumatic stress associated with surviving gun violence. Although there are many challenges associated with the current practices of non-emergency medical transportation, participants in HVIPs face additional risk factors. We highlight the application of a digital transportation intervention to increase the use of psychosocial services among low-income young Black male survivors of violent injury participating in an HVIP. Digital non-emergency medical transportation services (DNEMT) address issues concerning financial barriers, personal safety, program credibility, and program participation. We conducted qualitative interviews and a focus group with this population to assess the impact of Uber Health, a DNEMT service, on their participation in an HVIP located in a suburban Maryland hospital immediately outside of Washington, D.C. Survivors identified the use of Uber Health as essential to addressing the multifaceted and interconnected barriers to treatment. These barriers included reluctance to use alternative forms of transportation services (i.e., bus or subway) due to potential encounters with rivals, increased risk of repeat violent victimization, the need to carry a weapon for protection, stigmatization, and symptoms associated with traumatic stress. We found that integrating digital transportation services into the standard practices of HVIPs, as a part of a patient-centered outcomes framework, contributes to a reduction in violent injury and re-traumatization by addressing the multi-layered risks experienced by survivors of gun violence.

Unpacking the Causes of Post-Traumatic Stress Disorder in Violently Injured Patients

BACKGROUND

Violence is a public health problem that disproportionately affects urban communities. The root causes of PTSD and effects on quality of life, substance abuse, and mental health are unclear. The purpose of this study was to evaluate the prevalence of PTSD and its root causes to direct services to be provided in a hospital-based violence intervention program.

METHODS

Victims of Violence (VOVs) at University Hospital were approached from December 2017 to June 2019. They completed several validated patient-reported outcome surveys, including the Traumatic Life Events Questionnaire, the Peritraumatic Dissociative Experiences Questionnaire, Peritraumatic Dissociative Inventory, Positive and Negative Affect Scale, and the Alcohol Use Disorders Identification Test and the Drug Abuse Screening Test. Responses were recorded in Research Electronic Data Capture and were analyzed using Microsoft Excel.

RESULTS

Fifty-four individuals completed the surveys; 94% were men, 88% black, and 100% victims of interpersonal violence. 85% screened positive for PTSD. VOVs experienced many traumatic events throughout their life. Reported alcohol and drug abuse were low, with 91% at low risk for alcohol use disorders and 92% at low risk for drug abuse disorders (Figure 1). Positive affect remained high, indicating the possibility of resiliency in this population.

CONCLUSIONS

PTSD is high in VOVs in urban trauma centers. Understanding the root causes of PTSD can help direct interventions to support individuals with services that meet their individual needs. Simple screening tools can help hospital-based violence intervention programs and trauma social workers identify individual needs and assess risk for mental health and substance abuse disorders.

Risk factors for recurrent violent injury among black men

BACKGROUND

Black men are disproportionately overrepresented among victims of repeat violent injury. However, little is known about the risk factors that influence violent trauma recidivism among black men. We hypothesize that the following risk factors would be significant among black male victims of repeat violent injury: disrespect; being under the influence; being in a fight and using a weapon in the past year; and previous incarceration when comparing trauma recidivists versus nonrecidivists.

METHODS

Using secondary data analysis, we identified a sample of 191 (n = 191) urban low-income black men treated by a level I trauma unit in Baltimore for violent injury (e.g., gunshot wound, stabbing, or assault) who participated in a hospital-based violence intervention program from 1998 to 2011. Participants in the program completed a risk factor for violent injury questionnaire to assess: exposure to chronic violence, criminal justice involvement, substance abuse, and disrespect (code of the street).

RESULTS

We found that 58% of the sample is characterized as trauma recidivists (defined as hospitalization two or more times for violent injury). Black male patients of violent injury who engage in the following: substance abuse; had previously been in a fight or used a weapon in the past year; perceived disrespect as a precursor to violence; and experienced a previous incarceration were more likely to have multiple hospitalizations for violent injury.

CONCLUSIONS

Trauma recidivism among urban black male victims of violent injury is a major public health issue. Hospital-based violence intervention programs should be engaged in reducing trauma recidivism among this population.

Hospital-centered violence intervention programs: a cost-effectiveness analysis

BACKGROUND

Hospital-centered violence intervention programs (HVIPs) reduce violent injury recidivism. However, dedicated cost analyses of such programs have not yet been published. We hypothesized that the HVIP at our urban trauma center is a cost-effective means for reducing violent injury recidivism.

METHODS

We conducted a cost-utility analysis using a state-transition (Markov) decision model, comparing participation in our HVIP with standard risk reduction for patients injured because of firearm violence. Model inputs were derived from our trauma registry and published literature.

RESULTS

The 1-year recidivism rate for participants in our HVIP was 2.5%, compared with 4% for those receiving standard risk reduction resources. Total per-person costs of each violence prevention arm were similar: $3,574 for our HVIP and $3,515 for standard referrals. The incremental cost effectiveness ratio for our HVIP was $2,941.

CONCLUSION

Our HVIP is a cost-effective means of preventing recurrent episodes of violent injury in patients hurt by firearms.

The psychological sequelae of violent injury in a pediatric intervention

PURPOSE

Pediatric trauma centers have unique potential to prevent violent injury and its psychological sequelae. Hospital-based violence intervention programs (HVIPs) are proliferating across the U.S., but little is known about the psychological needs of pediatric patients who participate in them. The purpose of this study was to describe the prevalence of symptoms of posttraumatic stress and exposure to community violence among pediatric HVIP participants.

METHODS

We conducted a cross-sectional analysis of psychosocial needs assessment data that were collected for 48 participants. The Child Trauma Screening Questionnaire (CTSQ) and modified Survey of Children's Exposure to Community Violence were used to assess primary outcomes.

RESULTS

The sample was 62.5% male and had a mean age of 14.5 years. Twenty-three percent reported previously sustaining a violent injury resulting in medical care, and 47.8% had witnessed a shooting. The majority (66.0%) had a CTSQ score at/above the threshold for probable PTSD diagnosis. The mean CTSQ score was 5.9 and hyperarousal (3.3) symptoms were more common than re-experiencing symptoms (2.6).

CONCLUSION

Pediatric HVIPs and trauma centers should consider integrating PTSD screening and trauma-focused psychoeducation into the practice and protocols. Future research should evaluate the impacts of these interventions.