John A. Rich

The experience of violent injury for young African-American men : The meaning of Being a sucker

OBJECTIVE: To explore the experience of violent injury among young African-American men with gunshot or stab wounds to better understand violent injury.DESIGN: Convenience sample, using open-ended, semistruc-tured interviews.SETTING: An urban, municipal hospital in Boston.PATIENTS: Eighteen African-American men between the ages of 18 and 25, who had been shot or stabbed.RESULTS: Analysis of the interviews revealed that these young men identify with a concept called “being a sucker.” They perceive that a person who fails to retaliate when he is disrespected or injured will be viewed as weak and will be the target of future victimization.CONCLUSIONS: This study reveals an important perception among these young male victims of violence that if they fail to respond violently to injury or the threat of injury, they will be at risk of further victimization. The social environment in which young male victims of violence live and the meaning of being a sucker must be considered in efforts to decrease recurrent interpersonal violence. Providers who care for young men who are victims of or at risk of violence should understand the implications of the social context on individual behaviors.

Developing a trauma-informed, emergency department-based intervention for victims of urban violence.

The Surgeon Generals report on youth violence, the Centers for Disease Control and Prevention, and other national organizations are calling for public health approaches to the issue of youth violence. Hospital-based violence intervention programs have shown promise in reducing recurrent violence and decreasing future involvement in the criminal justice system. These programs seldom address trauma-related symptoms. We describe a conceptual framework for emergency department–based and hospital-based violence intervention programs that intentionally addresses trauma. The intervention described—Healing Hurt People—is a trauma-informed program designed to intervene in the lives of injured patients at the life-changing moment of violent injury. This community-focused program seeks to reduce recurrent violence among 8- to 30-year-olds through opportunities for healing and connection. Healing Hurt People considers the adversity that patients have experienced during their lives and seeks to break the cycle of violence by addressing this trauma.

The Prevalence of Trauma and Childhood Adversity in an Urban, Hospital-Based Violence Intervention Program

Hospitals represent a promising locus for preventing recurrent interpersonal violence and its psychological sequella. We conducted a cross-sectional analysis to assess the prevalence of post-traumatic stress disorder (PTSD) and adverse childhood experiences (ACEs) among victims of interpersonal violence participating in a hospital-based violence intervention program. Participants completed PTSD and ACE screenings four to six weeks after violent injury, and data were exported from a case management database for analysis. Of the 35 program participants who completed the ACE and/or PTSD screenings, 75.0% met full diagnostic criteria for PTSD, with a larger proportion meeting diagnostic criteria for symptom-specific clusters. For the ACE screening, 56.3% reported three or more ACEs, 34.5% reported five or more ACEs, and 18.8% reported seven or more ACEs. The median ACE score was 3.5. These findings underscore the importance of trauma-informed approaches to violence prevention in urban hospitals and have implications for emergency medicine research and policy.

Cost−Benefit Analysis Simulation of a Hospital-Based Violence Intervention Program

BACKGROUND Violent injury is a major cause of disability, premature mortality, and health disparities worldwide. Hospital-based violence intervention programs (HVIPs) show promise in preventing violent injury. Little is known, however, about how the impact of HVIPs may translate into monetary figures. PURPOSE To conduct a cost-benefit analysis simulation to estimate the savings an HVIP might produce in healthcare, criminal justice, and lost productivity costs over 5 years in a hypothetical population of 180 violently injured patients, 90 of whom received HVIP intervention and 90 of whom did not. METHODS Primary data from 2012, analyzed in 2013, on annual HVIP costs/number of clients served and secondary data sources were used to estimate the cost, number, and type of violent reinjury incidents (fatal/nonfatal, resulting in hospitalization/not resulting in hospitalization) and violent perpetration incidents (aggravated assault/homicide) that this population might experience over 5 years. Four different models were constructed and three different estimates of HVIP effect size (20%, 25%, and 30%) were used to calculate a range of estimates for HVIP net savings and cost-benefit ratios from different payer perspectives. All benefits were discounted at 5% to adjust for their net present value. RESULTS Estimates of HVIP cost savings at the base effect estimate of 25% ranged from

Viewing the Future Through the Lens of the Past: A Personal Reflection on Disparities Education in Medicine and Public Health

82,765 (narrowest model) to

‘Sharing things with people that I don’t even know’: help-seeking for psychological symptoms in injured Black men in Philadelphia

4,055,873 (broadest model). CONCLUSIONS HVIPs are likely to produce cost savings. This study provides a systematic framework for the economic evaluation of HVIPs and estimates of HVIP cost savings and cost-benefit ratios that may be useful in informing public policy decisions.

782 Adverse childhood experiences affect psychological outcomes of injury in Urban black men in the US

A s we move into the second decade of the millennium, we face the continuing challenge of educating medical students and health care providers about health disparities. In my recollection, this journey, which has mostly taken shape over the past 25 years, has faced all the challenges that come with an emerging body of knowledge that must be interpreted, synthesized and translated to effective action. This special supplement to the Journal of General Internal Medicine presents promising research and practice to inform how we educate present and future health care providers in this critical field. As context for this issue, I have found it useful to review my history of knowledge about health disparities over the past 25 years, mining my own experience as a medical student, medical residents, attending physician and public health practitioner over that time. Short of an exhaustive review of the history of health disparities, the goal of this personal reflection is to consider the impact of emerging knowledge about disparities on my experience as a learner and as a teacher. My first recollection of evidence of racial disparities in health came when I was a medical resident in 1985. Then Health and Human Services Secretary Margaret Heckler released the groundbreaking Report of the Secretary’s Task Force on Black and Minority Health. This landmark report documented the significant disparities in the burden of illness and mortality experienced by Blacks and other minority groups in the US population. The report was perhaps the first explicit acknowledgment from a government health agency that such disparities existed. Furthermore, the report led to concrete action, specifically the establishment of the Office of Minority Health in the Department of Health and Human Services. While portions of the report might appear obsolete to us now, the document contains relevant information that is applicable today. The report identified exposure to stressors among minority groups as playing a critical role in health outcomes. Not only did the report identify stress itself, but it identified the availability of “resources available to resolve stressful situations” as playing an important role in health. The report carried another important but largely unheeded recommendation: Encourage health professions’ training institutions to develop training programs so that health care providers such as physicians, dentists, nurses, social workers, health educators, lay counselors, allied health professionals, and volunteers may gain increased awareness of and sensitivity to the health problems and health attitudes, beliefs, and concerns of minority populations. By the late 1980s, researchers in medicine and public health had turned their attention to documenting disparities in the delivery of health care, particularly diagnostic technology. In 1987, Wenneker and Epstein published a paper that had a notable influence on my education about disparities. The researchers used Massachusetts’ hospital discharge data to show a higher rate of cardiac catheterization among Whites than Blacks. Their approach, and that of other researchers, moved the focus from stereotypical cultural difference to specific diseases and procedures. This step forward left an unclear role for providers—speculating “patient preference, different levels of disease severity and socioeconomic status not adequately accounted for”—but began an era of wide exploration on disparities in various interventions. The impact of this line of research on disparities education moved us to focus more on disparities in health care and identified important questions about how patients saw health care, including skepticism of medical procedures, refusal of important care due to financial reasons, and most importantly the role of cultural differences and beliefs. In my own experience, this next phase of work and disparities focused on the role of culture. In my education, this phase was most embodied in Anne Fadiman’s 1998 book, The Spirit Catches You and Then You Fall Down. This eloquent narrative work, which became standard curriculum in many medical and public health education curricula, highlighted the cultural disconnect between providers and patients. The book detailed the disastrous consequences of provider ignorance of cultural understandings by describing the fragmented delivery of care to a Hmong child with a severe seizure disorder. This book drew my attention and that of many of my colleagues. As junior faculty, we began to incorporate messages about cultural differences into our medical student and resident teaching. At the level of institutions, this cultural message most often activated seminars and forums where specific cultural and ethnic differences among groups were dissected and examined. While enlightening for many, these forums often divorced the cultural from the sociopolitical or environmental circumstances that led to these differences in communication. More problematic was the fact that these cultural differences were presented as exotic or static mental models of diversity. For me, a critical shift occurred in 2000 when increasingly the health and public health literature began to face the issue

Gender differences in posttraumatic stress symptoms among participants of a violence intervention program at a pediatric hospital: a pilot study

ABSTRACT Objectives: Psychological distress is common in survivors of traumatic injury, yet across United States’ trauma systems, it is rare that standard injury care integrates psychological evaluation and professional mental healthcare. The purpose of this study was to explore help-seeking for psychological symptoms in injured Black men living in Philadelphia. Design: A subset of a cohort of 551 injured Black men admitted to a Trauma Center in Philadelphia participated in qualitative interviews that explored their perceptions of psychological symptoms after injury and the factors that guided their decision to seek professional mental health help. Data from 32 participants were analyzed for narrative and thematic content. Results: Three overarching themes emerged: (1) facilitators of help-seeking, (2) barriers to help-seeking, and (3) factors underlying the decision not to consider professional help. Five participants felt that their injury-related psychological distress was severe enough to merit professional help despite any perceived barriers. Seventeen participants identified systemic and interpersonal obstacles to professional help that prevented them from seeking this kind of care. These included: financial constraints, limited access to mental healthcare services, and fear of the judgments of mental healthcare professionals. Ten participants would not consider professional help; these men perceived a lack of need and sufficiency in their existing social support networks. Conclusions: Research is needed to inform or identify interventions that diminish the impact of barriers to care, and identify from whom, where, and how professional mental health help might be more effectively offered to injured Black men in recovery environments like Philadelphia.

66 The contribution of adverse childhood experiences to post-injury psychological outcomes in urban black men in the US

Background Injury is not evenly distributed across race and class. In the U.S., urban Black men are at high risk for injury and poor outcomes from injury. Our purpose was to examine the contribution of adverse childhood experiences (ACEs) to post traumatic stress disorder (PTSD) and depression after recent serious physical injury in Black men. Methods This prospective, cohort follow-up study consecutively enrolled adult Black men hospitalised for serious injury at a Level I Trauma Centre. Men with head injury or currently receiving medical treatment for PTSD or depression, and those in police custody were excluded. ACES (7) were collected by self-report during the intake interview. The outcomes of PTSD (measured by the PCL-C) and depression (measured by the QID-SR16) were collected during in-person interviews in the men’s homes 3 months after hospital discharge. Results 320 (mean age = 36.8 years) were enrolled. Injury was classified as unintentional (50%) or intentional, i.e. the result of interpersonal violence (50%). The mean number of ACEs did not differ between intentional and unintentional injuries (2.64 vs. 2.35, p = 0.187). 81% reported at least 1 ACE, 45% reported 3 or more ACEs and 34% reported > 4 ACEs. Intentional injuries were associated with higher mean PCL-C scores (42.4 vs. 33.7, p <0.001) and higher mean QID-SR scores (10.0 vs. 7.6, p <0.001). In adjusted multiple regressions, younger age, intentional injury, and number of ACEs were independently associated with higher PCL-C scores. Intentional injury and number of ACEs were independently associated with higher QID-SR scores. Conclusions This sample of urban Black men reported substantial histories of childhood trauma and adversity. Results provide evidence that adverse childhood experiences increase the risk for depression and PTSD after serious injury. (Funded: NIH R01NR013503 to Dr. Richmond)

Pathways to Recurrent Trauma Among Young Black Men: Traumatic Stress, Substance Use, and the “Code of the Street”

Hospital-based violence intervention programs (HVIPs) have emerged as a strategy to address posttraumatic stress (PTS) symptoms among violently injured patients and their families. HVIP research, however, has focused on males and little guidance exists about how HVIPs could be tailored to meet gender-specific needs. We analyzed pediatric HVIP data to assess gender differences in prevalence and type of PTS symptoms. Girls reported more PTS symptoms than boys (6.96 vs 5.21, P = .027), particularly hyperarousal symptoms (4.00 vs 2.82, P = .002) such as feeling upset by reminders of the event (88.9% vs 48.3%, P = .005). Gender-focused research represents a priority area for HVIPs.