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    Can hospitals help to reduce violence?

    Hospital-based violence intervention programs steer victims to safer, productive lives. Research shows challenges to reducing assaults on a broad scale.

    Police crime scene yellow tape

    Taking two bullets to the belly and two to the back has a way of making a person open to suggestions about how to avoid getting shot again. Thus Paul Gregroy was willing to listen when staffers from the Violence Intervention Advocacy Program (VIAP) approached his bedside as he recovered from gunshot wounds at Boston Medical Center (BMC) in 2015, when he was 28.

    “Someone from the program was coming up and checking on me every day, seeing if I was being treated okay,” Gregory recalls. “Making sure I was eating, just letting me know that I’m not alone.”

    The VIAP helped Gregory through his recovery in the hospital and at home, by connecting him to medical, financial, and family support. Today, not only does he feel secure, but he works full-time as an advocate at VIAP to help other victims.

    The VIAP is among dozens of hospital-based violence intervention programs (HVIPs) that have sprouted over the past two decades, reflecting a growing determination in health care to move beyond treating the physical wounds of violence to addressing its underlying causes. Some 1.2 million violent crimes were reported to the FBI last year — and studies show that “one of the strongest predictors of future [violent] injury is previous violent injury.”

    HVIPs use treatment of those injuries as opportunities to change the trajectory of victims’ lives, steering them to services and resources that can reduce their risk of future violence and help them thrive in their relationships, careers, and health.

    “We know pretending that it’s a simple physical injury that we patch up, then people will move on with their lives, doesn’t work” to protect them from more violence, says Kyle Fischer, MD, MPH, policy director at the Health Alliance for Violence Intervention (HAVI), a membership network of HVIPs that focuses on assisting and improving the programs.

    The question is, what impact can HVIPs reasonably be expected to achieve? Dozens of studies, and the experiences of program staff, have spotlighted their potential; the programs have improved the lives of countless people, often in areas of their lives that extend beyond the direct risk of violence. Their aggregate impact remains to be determined. They have not yet been shown, through large-scale clinical research studies, to reduce violence among people enrolled in the programs. What’s more, experts caution that HVIPs cannot be expected to overcome on their own all the factors that contribute to violence their communities.

    “A single hospital-based violence intervention program is not going to change, on its own, the level of violence in the community,” says Patrick Carter, MD, associate professor of medicine at the University of Michigan School of Medicine, who oversees several clinical studies on the efficacy of HVIPs. “It’s going to change the risk” for people in the program. “By no means is the intervention the panacea, but it is one part of a larger puzzle that needs multiple solutions.”

    One conclusion that is clear from staff and studies: HVIPs need to work in significant, intertwined collaboration with other community-based organizations (CBOs) so that they can collectively address the myriad social factors that contribute to violence.

    Building relationships

    The interventions start at what HVIP practitioners often call the “teachable moment”: those hours or days after a victim of violence has been treated at a hospital and before their release (from either an emergency department or in-patient care). In the immediate aftermath of the trauma, many victims are particularly receptive to assistance in changing their lives in ways that can keep them and their families safer, says Ali Rowhani-Rahbar, MD, director of the Firearm Injury and Policy Research Program at the University of Washington School of Medicine, in Seattle, and co-author of a study on HVIPs.

    While HVIPs are typically staffed by social workers and health care providers, the initial connection with a victim ideally comes from a messenger with credibility born of experience with violence — such as Gregory.

    “I’ve been there,” says Gregory, who was shot because he resembled the target of someone’s ire. “When I tell them [patients] about my incident, their jaws drop. They’re like, ‘You’re the perfect person to be doing this kind of work.’”

    “It’s about relationship-building, hiring the right people to work bedside to increase the level of engagement,” says Justin Graves, MS, RN, director of trauma programs at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center (UMMC), home of a Violence Intervention Program.

    Program staff introduce victims to a plethora of behavioral health and social services to stabilize their lives, such as mental health and family counseling, addiction treatment, income and food assistance, finding homes in safer neighborhoods, employment referrals and training, and transportation assistance. Some programs, such as the University of Michigan Injury Prevention Center’s HVIP for young people, include cognitive behavioral therapy to help victims recognize risky behaviors and manage their decisions in order to avoid potentially violent situations.

    Often, seemingly small supports have significant impact. Gregory says that one of his main duties is driving clients to court hearings, lawyer and doctor appointments, and grocery shopping. Another gunshot victim, Jamie, who went through the same program as Gregory at BMC (and asked that his last name not be shared), says one of the biggest assists came when the program got him a pair of non-slip shoes that he needed for a housekeeping job at the BMC. Through its connection with other CBOs, the program also helped Jamie cover housing costs for more than a year, provided food from a local pantry, and got him passes for the Boston transit system.

    While each form of assistance helps with specific needs, collectively they build that essential element as defined by Graves at UMMC: a continuously engaged relationship.

    “At my apartment, they [program staff] kept coming, checking on me and seeing where I stand” with regard to his plans for success, Jamie recalls. At BMC, “I had multiple counselors who I could talk to about anything.”

    The HVIP in Boston has helped to guide Jamie and Gregory to safe, happy lives. But figuring out how to make these programs work for most participants can be tricky, partly because of what the programs set out to do and how they are assessed. This is complicated social work that addresses a public health crisis — violence — that governments, corporations, and foundations have been unable to solve.

    Impacts and challenges

    HVIPs help many victims of violence avoid repeats of violence. An early study of the UMMC program found that compared with program participants, those in a control group were three times more likely to be arrested for a violent crime and two times more likely to be convicted of any crime. A study of HVIP participants over a decade at the University of California at San Francisco (UCSF) found a 4% violent reinjury rate, which was half the rate in a control group.

    But a recently published literature review that searched through hundreds of HVIP studies found very few that met the highest scientific standards. “We were able to identify only 14 studies published in peer-reviewed journals that included a control group and measured injuries due to violence, acts of violence, or crimes committed,” says Daniel Webster, ScD, MPH, director of the Johns Hopkins Center for Gun Policy and Research, in Baltimore, who led the literature review.

    Among those that did meet that criteria, according to the study, “the most robust HVIPs showed some evidence of protective effects, but overall evidence of reduced risks for violence was mixed.”

    That doesn’t mean the programs don’t improve people’s lives. The findings of HVIP studies reflect challenges in how the programs are designed and assessed.

    Start with that teachable moment. While many victims are ready to embrace social services to change their life paths, others are not. They might be wary of being case managed by institutions, and might be invested in a lifestyle in their communities that carries a risk of violence.

    “Your teachable moments might be very, very different than mine, based on lived experiences,” Rowhani-Rahbar says. “A teachable moment for a 17-year-old who has been exposed to violence since he was 4 might be very different from a teachable moment for a 35-year-old who had never experienced violence and just got shot.”

    That tamps down initial enrollment. Then, many who enroll in the programs drift away. They lose interest, get busy, move to different homes, get new phone numbers, drift back to the conditions that put them at risk for violence.

    At BMC, Gregory says his biggest frustration is people who enroll in the program but stop responding to his calls and texts. “But I get their lifestyle,” he says. “They’re still trying to figure things out” about their daily lives, relationships, and priorities.

    Losing touch can make tracking someone’s involvement in violence difficult. Even among those who remain engaged, their violent incidents can lead them to any hospitals in their community, or can go unreported.

    As for the studies, many of the most significant findings do not directly involve violence. Some of the studies measured “future offending,” which could involve “shoplifting, selling drugs,” Webster notes. Other measures included engaging in mental health services, and reduction in substance abuse and carrying weapons.

    Nevertheless, those are important indicators of health and safety, even though they don’t pin down whether a person was involved in violent incidents. That raises the question of what outcomes the evaluations should measure. The study of the program at UCSF, for example, found “success in addressing client needs” around such areas as housing, education, mental health care, and employment. People who run HVIPs stress that meeting such needs can vastly improve someone’s life and make them less likely to be in environments where the chances of violence are high.

    “You can’t just look at one outcome” such as violent injuries, Rowhani-Rahbar says. He believes HVIPs should highlight their impact on life improvements like perception of personal safety, progress toward personal goals, job stability, relationships with family and peers, declines in substance abuse, and increases in mental health treatment.

    Community partners

    To strengthen their impact, many HVIPs work closely with other community organizations that provide the array of social and human services for which those organizations are designed.

    “Many of our patients were struggling with housing and employment,” Rowhani-Rahbar says of the program in Seattle. “One of the things we were striving to do is to try to find them transitional, stable housing” through local organizations.

    “It’s incredibly important to get plugged into what’s going on in the community and for a hospital-based violence intervention program to fit within the context of that community,” Carter says.

    At UMMC, the HVIP partners include a legal representation program at the University of Maryland School of Law (UMB ROAR) and an intensive service program (ROCA) in Baltimore for youth and young adults at risk of violence. “We have weekly calls with ROCA” to talk about specific clients, Graves says.

    In Boston, the VIAP meets on a scheduled basis with the public school system, the city health commission, and the district attorney's office, among others, says Clinical Director Elizabeth Dugan, LICSW. “The majority of our work is done in the community,” she says.

    HVIPs also are evolving in the way that they operate and how they assess their effectiveness. Perhaps, as Rowhani-Rahbar explains, “individual-level interventions can’t change things systemwide” even as they help individuals.

    “We are helping to advance the standard of care for violently injured patients,” says Fischer, the policy director at HAVI. “We cannot afford not to do this.”