US hospitals stepping up to end violence among youth: Interventions addressing gun traumas
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* Mark Barna

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Farji Shaheer, center, and D'Andre Alexander, right, talk to shooting victim Deyontae Thorpe at Hennepin County Medical Center in Minneapolis in 2017. The hospital’s Next Step Program supports gun violence victims and works to reduce re-injury.

Photo by Evan Frost, courtesy Minnesota Public Radio/AP Images

A car filled with teenagers screeches to a stop outside an emergency department in Philadelphia. In the back seat, a scared young man is slouched and bleeding from a gunshot wound.

This was one of many arrivals of injured youth during Kyle Fischer’s residency at Drexel University College of Medicine. What especially disturbed Fischer, MD, MPH, was that after getting patched up and released, sometimes after a brief hospital stay, the same youth was many times back in the emergency department in weeks or months with another injury from violent trauma.

The frequency motivated him to explore hospital-based violence prevention programs, in which patients are given support and resources to escape the cycle of violence.

“Violence is a preventative health issue that we can treat with the traditional health system and public health approaches,” Fischer, now policy director for the Health Alliance for Violence Intervention, told *The Nation’s Health.*

Hospital-based violence intervention programs work to interrupt the cycle of violence among high-risk youth. They partner with community organizations with experience working with adolescents in disadvantaged neighborhoods where shootings and other violent acts routinely take place. The programs are an effective way to prevent gun violence, research shows. In fact, they were cited as one of the policies that work by APHA and the Bloomberg American Health Initiative at the Johns Hopkins Bloomberg School of Public Health during a September forum on gun violence prevention.

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Photo courtesy Adam Calaitzis, iStockphoto

The hospital-based programs are important because of the high rates of injury recidivism among adolescents in disadvantaged neighborhoods. Injured youth are 25% to 60% more likely to suffer another assault-related trauma, according to a 2018 study in *Annals of Emergency Medicine.* In a study in *JAMA Pediatrics* in 2015, patients between ages 10 and 24 who were treated at a Flint, Michigan, emergency department for violent injury were twice as likely to experience another assault within two years. Studies in other urban centers, such as Detroit and Oakland, California, show similar data, with black victims accounting for over half of the re-injured.

Besides physical danger, victims are at risk of chronic mental and emotional problems from injury trauma, the *JAMA Pediatrics* study found, including post-traumatic stress disorder. PTSD can impair judgment and behavior, leading to retaliation that keeps victims in a cycle of violence.

Adolescents in disadvantaged urban neighborhoods are most at risk of experiencing intentional violence, according to a 2019 study in the *Journal of Surgical Research.* Contributing to the violence are social determinants, such as poverty, a failing school system, housing issues and lack of adequate health care. Home violence and child abuse also contribute, the study said.

Over the last decade, the impact of social determinants on health and well-being have received greater acceptance in public health and medicine, energizing the conversation about violence prevention.

“We realized that violence doesn’t just start in the streets,” Joel Fein, MD, MPH, co-director of the Children’s Hospital of Philadelphia Violence Prevention Initiative, told *The Nation’s Health.* “It starts in the homes and schools and everywhere else kids encounter people.”

Exploring social determinants and ways to prevent youth violence led to rapid growth of hospital-based intervention programs. In 1995, only two programs existed. Today there are over 40 in the U.S., with more than a dozen preparing to launch, Fatimah Loren Muhammad, executive director of the Health Alliance for Violence Intervention, told *The Nation’s Health.*

## Opportunity window opens at hospitals

While violence intervention programs vary in specifics and organization, they all involve interventionists who seek buy-in from traumatized patients to change their lives and take part in intensive, months-long community-based case management services.

After an assault-related injury, intervention specialists take advantage of the window of opportunity in which patients are self-reflective and responsive to services promoting behavioral change, said Adriana Reyes, violence prevention coordinator for Beyond Violence at John Muir Health, the trauma center for Contra Costa County in Northern California.

When a patient injured by interpersonal violence arrives in the emergency department, nurses contact an intervention specialist, who meets the patient there or in a hospital room. Interventionists typically are from the same community as victims and are sometimes program alumni. They have street credibility, Reyes said, but are also trained professionals who understand how to talk to victims persuasively.

“The interventionist forms a relationship that fosters healing and growth in these young people,” Reyes told *The Nation’s Health.*

Between 2014 and 2018, Beyond Violence identified 468 patients with assault-related injuries, of whom 308 — or 66% — agreed to intervention, according to the hospital.

Beyond Violence partners with community organizations that help inter- vention participants. A participant might receive home visits; group counseling; support sessions; health care and mental health assistance; education, housing and conflict resolution services; family interventions; housing assistance; and legal advocacy.

During five years of the program, at least 95% of participants avoided re-injury, arrest and did not seek retaliation, hospital records show. Average age of participants was 20 years old, 80% had been injured by gun violence and half were black.

Beyond Violence also helps people unlikely to enter a circle of violence, such as Jewelie Perez, a Contra Costa County resident and single parent in a household that includes her mother and two sisters. Several years ago, when she was 24 and living in Richmond, a disadvantaged city in the Bay Area, Perez was shot twice in a drive-by shooting while standing in her driveway. One bullet struck her head.

When Perez awoke in the hospital after surgery, an intervention specialist was there to talk, Reyes said. During recovery, various community service partners supplied Perez with victim compensation support, hotel vouchers for her family, and gift cards for food and clothing. Safer housing was found in another neighborhood and the family was relocated.

> **“We realized that violence doesn’t just start in the streets. It starts in the homes and schools and everywhere else kids encounter people.”**
> 
> **— Joel Fein**

Partnering with community organizations trusted by residents is the most important factor for success, Beyond Violence organizers said.

“We hold quarterly partners meetings, bringing all of our partners to the same table,” Jamie Elmasu, MPH, community health improvement manager at John Muir Health, told *The Nation’s Health.* “We work side by side with them.”

Patience is important when forming a community services network. Over a decade, Beyond Violence built its program to the point where it now covers the whole county, with mental health therapists at multiple locations.

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Project Ujima at Children’s Wisconsin hospital in Milwaukee offers a summer camp to victims of interpersonal violence that includes sports, fine arts, music and individual mental health therapy. U.S. hospitals are using intervention programs to help prevent youth from becoming repeat victims of violence.

Photo by Barbara Bell, courtesy Project Ujima

“Some may want to grow too quickly, but to do it right takes time,” Reyes said.

Generous funding is also needed because of the many partners involved. In December 2018, the program received a grant from the Carestar Foundation for $1 million, enabling expansion of services.

Project Ujima in Milwaukee has also benefited from strong funding sources, including federal money allocated to states from the Victims of Crime Act Fund, created in 1984 to support crime victim programs.

Founded in 1995 at Children’s Wisconsin hospital in Milwaukee, Project Ujima was one of the first hospital-based violence intervention programs in the country. It conducts about 300 interventions each year.

An unpublished one-year study of 100 adolescents in the program showed that only one returned to the emergency department with a violent re-injury, Marlene Melzer-Lange, MD, medical director of the project, told *The Nation’s Health.*

Because of such findings, some state and federal lawmakers are taking hospital-based intervention programs more seriously.

Under a package of gun safety laws, New Jersey will require the programs to be in place at hospitals certified as level 1 and 2 trauma centers, which are more likely to treat shooting victims. Other states such as Connecticut are considering similar laws.

Meanwhile, in December, a new federal law was passed that will provide $12.5 million each to the Centers for Disease Control and Prevention and the National Institutes of Health for gun violence research.

Though more funding and programs for gun violence prevention are needed, the growth in hospital-based intervention is encouraging, advocates say. But more work is needed to get hospital leaders on board, Melzer-Lange said. Many of them still think hospital participation ends after mending the physical wounds.

“We need to get all health care providers to think past the initial wound and think about the whole person,” Melzer-Lange said.

For more information on hospital-based violence intervention, visit [www.thehavi.org](http://www.thehavi.org).

For information on gun violence, including a recording of APHA’s 2019 gun violence forum, visit [www.apha.org/gun-violence](http://www.apha.org/gun-violence).

*   Copyright The Nation’s Health, American Public Health Association