Violence is taking a toll on the health of our country. Major events, like school shootings, bomb attacks and allegations of unnecessary police brutality, captivate our attention. But violence occurs every day — sometimes in public, but more often in private between people who know each other. Violence comes in many forms — physical, sexual, emotional and psychological — and among families, gangs, elders, youth and spouses or domestic partners. Of course, the effects are devastating. Victims of violence may experience not only physical injury but also post-traumatic stress disorder, depression and anxiety, difficulties in school, and problems with substance abuse and delinquency.
Every year, about 56,000 violent deaths occur in the United States, 17,000 of which are homicides (www.cdc.gov/violenceprevention). Homicide is the leading cause of death for African-Americans, Asians and Pacific Islanders, and for American Indians and Alaska Natives between the ages of 10 and 24; it is the second-leading cause of death for Hispanics of the same age. More than three women a day are murdered by their husbands or boyfriends in the United States. About 15.5 million children live in families in which partner violence occurred at least once in the past year, and 7 million children live in families in which severe partner violence occurred. Episodes of violence take a toll on our health care system, costing the United States $107 billion in medical care and lost productivity.
Interrupting the Cycle of Violence
Violence, no matter its source, is a serious community health issue in the United States, but it is preventable if the cycle can be broken. Hospitals are where victims go after physical violence. As a point of contact with the victim, hospitals and health care systems are uniquely positioned to help disrupt the cycle of violence and prevent re-injury.
Violence prevention is outside the scope of services that hospitals traditionally provide, but some recognize it as a pressing community health need. A project team from the Health Research & Educational Trust recently reviewed a stratified random sample of community health needs assessments from around the country to identify needs prioritized by hospitals and health care systems. (Methodology and results can be found at www.hpoe.org/cultureofhealth.) This review revealed that 12 percent of hospitals identify violence as a community health need. Though this number is relatively low, it is noteworthy that hospitals and health care systems are starting to recognize community violence as a priority health need in their communities.
Hospital-Based Approaches to Violence Prevention
Violence prevention fits into a population health framework, where it is the hospital or health care system's goal to optimize the health of its population. Some hospitals are reaching outside their walls to address violence in their communities. Organizations such as the National Network of Hospital-based Violence Intervention Programs (http://nnhvip.org/) provide resources and guidance for hospitals engaging in violence prevention. Last year, Community Connections, an initiative of the AHA, (www.ahacommunityconnections.org/) highlighted hospitals' outstanding work to reduce violence in their communities. Other examples include:
- Children's Hospital of Philadelphia Violence Prevention Initiative. This is a hospitalwide effort to interrupt the cycle of violence by addressing bullying, assault re-injury and domestic violence. CHOP translates prevention research into policy, community engagement and violence prevention and treatment interventions.
- San Francisco Wraparound Project. Based on the public health model for injury prevention, San Francisco General Hospital and Trauma Center serves as a vital point of entry, provides mentorship and links clients to essential risk-reduction resources to reduce violent injury recidivism (repeat behaviors) and criminal recidivism for young people representing the most vulnerable populations in San Francisco. The Wraparound Project operates on the belief that when a trauma occurs, it provides a "teachable moment," and an individual is more likely to change his or her life direction to secure better health and welfare for the future. Case managers work with victims of violence to establish trust and provide mentoring. Then, they shepherd clients to risk-reduction resources based on a needs assessment and provide long-term follow-up from six months to one year.
Linking Violence to Behavioral Health
Violence is inextricably intertwined with two other pressing community health concerns: behavioral health and substance abuse. Exposure to violence is correlated with behavioral health and substance abuse issues, and people with behavioral health issues are more likely to commit violence against others. In HRET's review of community health needs assessments, behavioral health and substance abuse were prioritized by 64 and 44 percent of hospitals, respectively. Effectively addressing violence will require addressing correlates and antecedents, including behavioral health — a community health need prioritized by a majority of hospitals.
Not all hospitals have the capacity to address the social determinants of violence outside their walls. But by addressing behavioral health needs in their patient population, hospitals may help to prevent community violence. With the appropriate resources and staffing to capitalize on the window of time when a victim of violence is a patient, hospitals can (1) provide care that is sensitive to the trauma the patient has experienced and (2) coordinate follow-up care to address the psychological and physical consequences of violence.
Such an approach can be applied in the clinical setting through practicing trauma-informed care, delivered by clinicians who recognize that traumatic experiences affect how people respond to outreach and services, and designed to reduce the incidence and impact of violence on children and families. Key components of trauma-informed care include:
- Safety. Patients learn to recognize how they view and experience safety, create a safety plan to reduce threats, and plan how they can become physically and psychologically safer.
- Emotional management. Patients work to become less reactive, develop trust and devise adaptive coping strategies.
- Loss. Patients learn to recognize the loss they have experienced throughout their lives.
- Future. Patients envision their future and develop a plan to move beyond the status quo.
Trauma-informed care, paired with integrated, community-based behavioral health services, has the potential to improve the personal safety of individuals and families in the community.
Reducing violence is challenging work, and hospitals cannot do it alone. Hospitals and health care systems will have to partner with community organizations and stakeholders to foster real changes that improve the physical and social environment in their communities. Violence is one of the pressing issues of our time: Hospitals and health care systems should capitalize on their unique window during the cycle of violence as they work toward transforming the overall health of their community.
The Association for Community Health Improvement, a personal membership group of the AHA, will be discussing violence prevention and intervention at its national conference, March 4–6, 2015, in Dallas. Visit www.healthycommunities.org/2015achi for more information.
Julia Resnick, M.P.H., is a program manager with the Association for Community Health Improvement and the Health Research & Educational Trust.