Examining Associations between Adverse Childhood Experiences and Posttraumatic Stress Disorder Symptoms among Young Survivors of Urban Violence.

Our study examines the association between Adverse Childhood Experience (ACE) exposure and posttraumatic stress disorder (PTSD) symptoms among survivors of violence. In this cross-sectional study, an ACE questionnaire and PTSD Checklist for DSM-5 (PCL-5) were completed by 147 participants ≤ 3 months after presenting to a Philadelphia, PA emergency department between 2014 and 2019 with a violent injury. This study treated ACEs, both separate and cumulative, as exposures and PTSD symptom severity as the outcome. Most participants (63.3%) met criteria for provisional PTSD, 90% reported experiencing ≥ 1 ACE, and 39% reported experiencing ≥ 6 ACEs. Specific ACEs were associated with increasing PCL-5 scores and increased risk for provisional PTSD. Additionally, as participants' cumulative ACE scores increased, their PCL-5 scores worsened (b = 0.16; p < 0.05), and incremental ACE score increases predicted increased odds for a positive provisional PTSD screen. Results provide further evidence that ACEs exacerbate the development of PTSD in young survivors of violence. Future research should explore targeted interventions to treat PTSD among survivors of interpersonal violence.

How education and racial segregation intersect in neighborhoods with persistently low COVID-19 vaccination rates in Philadelphia.

BACKGROUND: COVID-19 infection has disproportionately affected socially disadvantaged neighborhoods. Despite this disproportionate burden of infection, these neighborhoods have also lagged in COVID-19 vaccinations. To date, we have little understanding of the ways that various types of social conditions intersect to explain the complex causes of lower COVID-19 vaccination rates in neighborhoods. METHODS: We used configurational comparative methods (CCMs) to study COVID-19 vaccination rates in Philadelphia by neighborhood (proxied by zip code tabulation areas). Specifically, we identified neighborhoods where COVID-19 vaccination rates (per 10,000) were persistently low from March 2021 - May 2021. We then assessed how different combinations of social conditions (pathways) uniquely distinguished neighborhoods with persistently low vaccination rates from the other neighborhoods in the city. Social conditions included measures of economic inequities, racial segregation, education, overcrowding, service employment, public transit use, health insurance and limited English proficiency. RESULTS: Two factors consistently distinguished neighborhoods with persistently low COVID-19 vaccination rates from the others: college education and concentrated racial privilege. Two factor values together - low college education AND low/medium concentrated racial privilege - identified persistently low COVID-19 vaccination rates in neighborhoods, with high consistency (0.92) and high coverage (0.86). Different values for education and concentrated racial privilege - medium/high college education OR high concentrated racial privilege - were each sufficient by themselves to explain neighborhoods where COVID-19 vaccination rates were not persistently low, likewise with high consistency (0.93) and high coverage (0.97). CONCLUSIONS: Pairing CCMs with geospatial mapping can help identify complex relationships between social conditions linked to low COVID-19 vaccination rates. Understanding how neighborhood conditions combine to create inequities in communities could inform the design of interventions tailored to address COVID-19 vaccination disparities.

Pathways to Help-Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis.

Many Black men suffer symptoms of traumatic stress in the aftermath of traumatic injury, and they also often carry social concerns, including experiences of discrimination and stigma, and a lack of financial resources. The objective of the present study was to understand how traumatic symptoms and social factors combine in complex ways toward the outcome of psychological help-seeking. We analyzed qualitative and quantitative data from 32 injured Black men admitted to a Level 1 trauma center. Qualitative interviews explored their attitudes toward seeking professional psychological help. We analyzed quantitative data, collected using validated instruments, on posttraumatic stress and depression symptoms, financial worry, and discrimination/stigma. Fuzzy set qualitative comparative analysis (fsQCA) was conducted by calibrating each condition to fuzzy set membership scores based on our knowledge of the causal conditions and the cases. We then constructed truth tables for QCA analysis using fsQCA software. Three causal pathways for psychological help-seeking were identified: Two pathways showed that severe trauma symptoms in the absence of financial worry were sufficient for seeking help, whereas the third showed that financial worry and discrimination in the absence of trauma symptoms were sufficient for help-seeking. We identified two causal pathways for negated help-seeking, in which low posttraumatic symptom severity and low levels of discrimination or financial worry were sufficient for not seeking psychological help. The QCA analysis revealed multiple pathways for psychological help-seeking among Black men who suffer trauma. These findings highlight the need for further research to understand complex pathways toward psychological help-seeking in this population.

Trauma-Informed Care for Violently Injured Patients in the Emergency Department.

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Gender Differences in Posttraumatic Stress Symptoms Among Participants of a Violence Intervention Program at a Pediatric Hospital: A Pilot Study.

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.

The Youth Nonfatal Violent Injury Review Panel: An Innovative Model to Inform Policy and Systems Change.

Among young people in the United States, nonfatal violent injuries outnumber fatal violent injuries by 171 to 1. The Child Fatality Review Team (CFRT) is a well-established model for informing injury prevention planning. The CFRT's restricted focus on fatal injuries, however, limits its ability to identify opportunities to prevent violent reinjury and address issues unique to nonfatal violent injuries. We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel. We convened representatives from 23 agencies (e.g., police, housing, and education) quarterly to share administrative information and confidentially discuss cases of nonfatal violent injury. In this article, we describe the panel model and present preliminary data on participants' perceptions of the process. Although outcomes research is needed to evaluate its impacts, the Youth Nonfatal Violent Injury Review Panel offers an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects.

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 $82,765 (narrowest model) to $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.

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.

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

The Surgeon General's 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.

Intimate partner violence among men having sex with men, women, or both: early-life sexual and physical abuse as antecedents.

Little is known about the prevalence of intimate partner violence (IPV) among men who have sex with men (MSM) or about childhood adversity as a predictor of IPV among MSM. Studies have documented high rates of childhood sexual abuse among MSM. To evaluate associations of early-life sexual and physical abuse with IPV among African American heterosexual men or MSM, prevalence of early-life (≤ 21 years) sexual and physical abuse was measured among 703 nonmonogamous African American men. Men were classified as (1) MSM who disclosed male sex partners; (2) MSM who initially denied male sex partners but subsequently reported oral-genital and anal-genital behaviors with men; (3) non-MSM. MSM who initially disclosed male sex partners reported significantly (P < 0.0001) higher rates of early physical abuse (36%) and lifetime abuse (49%) compared with non-MSM (15 and 22%), respectively. These MSM reported significantly higher rates of sexual abuse by age 11, age 21, and over a lifetime compared with non-MSM (P < 0.0001). Being an MSM who initially disclosed male sex partners (OR: 2.1; 95% CI: 1.2, 3.6) and early-life sexual abuse (OR: 2.8; 95% CI: 1.8, 4.3) was associated with IPV victimization in current relationships. Similarly, being an MSM with early-life physical and sexual abuse was associated (0.0004 ≤ P ≤ 0.07) with IPV perpetration. Early-life physical and sexual abuse was higher among MSM who disclosed male sex partners compared with heterosexual men; however, all MSM who experienced early-life abuse were more likely to be IPV victims or perpetrators.