Violence in the United States: Status, Challenges, and Opportunities.

IMPORTANCE: Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence. OBJECTIVES: To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities. DATA SOURCES: We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigation's Uniform Crime Reports, the US Justice Department's National Crime Victimization Survey, the National Survey of Children's Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System-All Injury Program. RESULTS: Homicide rates have decreased from a peak of 10.7 per 100,000 persons in 1980 to 5.1 per 100,000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100,000 in 1992 to 242 per 100,000 in 2012. Nevertheless, annually, there are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE: Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.

Effect of face-to-face interview versus computer-assisted self-interview on disclosure of intimate partner violence among African American women in WIC clinics.

African American women in the United States report intimate partner violence (IPV) more often than the general population of women. Overall, women underreport IPV because of shame, embarrassment, fear of retribution, or low expectation of legal support. African American women may be especially unlikely to report IPV because of poverty, low social support, and past experiences of discrimination. The purpose of this article is to determine the context in which low-income African American women disclose IPV. Consenting African American women receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services in WIC clinics were randomized to complete an IPV screening (Revised Conflict Tactics Scales-Short Form) via computer-assisted self-interview (CASI) or face-to-face interview (FTFI). Women (n = 368) reported high rates of lifetime and prior-year verbal (48%, 34%), physical (12%, 7%), sexual (10%, 7%), and any (49%, 36%) IPV, as well as IPV-related injury (13%, 7%). Mode of screening, but not interviewer race, affected disclosure. Women screened via FTFI reported significantly more lifetime and prior-year negotiation (adjusted odds ratio [aOR] = 10.54, 3.97) and more prior-year verbal (aOR = 2.10), sexual (aOR = 4.31), and any (aOR = 2.02) IPV than CASI-screened women. African American women in a WIC setting disclosed IPV more often in face-to-face than computer screening, and race-matching of client and interviewer did not affect disclosure. Findings highlight the potential value of face-to-face screening to identify women at risk of IPV. Programs should weigh the costs and benefits of training staff versus using computer-based technologies to screen for IPV in WIC settings.

Intimate partner violence and functional health status: associations with severity, danger, and self-advocacy behaviors.

OBJECTIVE: To assess physical and mental functional health status as associated with the severity of intimate partner violence (IPV) and perceived danger. METHODS: Prospective cross-sectional survey of all patients aged 18-55 in an urban emergency department during a convenience sample of shifts. Instruments included the George Washington Universal Violence Prevention Screening protocol, administered by computer during the initial visit, the Short-Form 12 Health Survey (SF-12), the Conflict Tactics Scale (CTS2), and the Revised Danger Assessment (DA), administered by interview at 1 week follow-up. RESULTS: In total, 548 (20%) participants screened disclosed IPV victimization. Of those, 216 (40%) completed the follow-up assessment 1 week later. This cohort was 91% African American, 70% single, and 63% female, with a mean age of 35 (SD 10.41). Both physical and mental health functioning scores were lower than normative levels (50) compared with national averages: Physical Component Summary (PCS) scale 43.64 (SD 10.86) and Mental Component Summary (MCS) scale 37.46 (SD 12.29). As physical assault, psychological aggression, and reported injury increased on the CTS2, mental health functioning diminished (p < 0.01). Increased physical assault and psychological aggression were also associated with diminished physical health functioning (p < 0.05). As victim-perceived danger increased on the DA, both physical and mental health functioning decreased (p < 0.01, p < 0.001, respectively). Greater self-advocacy activities were associated with lower mental (but not physical) health functioning as well. Females experienced worsening mental health functioning as both physical assault and psychological aggression increased, whereas male victims experienced worsening mental health functioning only as psychological aggression increased. CONCLUSIONS: These findings suggest that IPV takes a greater mental than physical toll (for both sexes) and that as IPV severity increases, mental health functioning diminishes and self-advocacy behaviors increase. Additionally, as perceived danger increases, both physical and mental health status worsens. This has important implications for clinicians to assess and consider IPV victims' perceptions of their situations relative to danger, not just the levels of abuse they are experiencing.

Nomenclature and definitions for emergency department human immunodeficiency virus (HIV) testing: report from the 2007 conference of the National Emergency Department HIV Testing Consortium.

Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.

Characteristics of victims coarrested for intimate partner violence.

This study evaluated the frequency of coarrest in female victims who utilized 911 for intimate partner violence (IPV) and any patterns or circumstances that increased the likelihood of coarrest. All cases of police-documented IPV where a female IPV victim was arrested in conjunction with the perpetrator were included. Each incident report was reviewed to determine demographic characteristics of the victim, weapon and substance involvement, presence of children, and violence severity. Of IPV victims, 9% (131 of 1,489) were arrested. Having a weapon, alcohol use, not being married, and older age were associated with increased likelihood of arrest (p < .001). The presence of a child decreased the likelihood of victim arrest (p < .001). Race, prior incidents of IPV, offender restraining order, and incident severity were not significantly associated with coarrest. Although coarrest occurred in a minority of cases, it may deter victims from contacting police for future incidents of police.

Emergency contraception: what do our patients know?

STUDY OBJECTIVE: Unintended pregnancy is a major medical, social, and public health problem. Emergency contraceptive pills can prevent 75% to 85% of unintended pregnancies if administered within 72 hours of intercourse. We perform this study to measure knowledge, attitudes, practices, and perceived needs about emergency contraception in a sample of women seeking emergency department (ED) care. METHODS: This was a prospective survey of women presenting to an inner-city ED during an 8-week study period. Women who were aged 18 to 45 years, English speaking, and not critically ill and who presented during 56 randomly generated 4-hour time blocks were eligible. Trained research assistants administered a 20-question survey that included questions on current sexual and contraceptive practices and knowledge, acceptance, and preferences about postcoital contraception. RESULTS: Two hundred thirty-two women met eligibility criteria; 158 (68%) women agreed to participate. Participants and nonparticipants were similar in age, race, ethnicity, and insurance status. The participants' mean age was 30 years. Twenty-five percent were married, whereas 49% had never married and 25% were separated or divorced. Fifty-two percent (95% confidence interval [CI] 44% to 60%) reported at least 1 previous unintended pregnancy; 28% (95% CI 21% to 35%) had 1 or more previous elective abortions. Of women who had been sexually active in the past month, half (47%) reported unprotected intercourse during that time. Among all respondents, 122 (77%; 95% CI 71% to 84%) had heard of emergency contraception as a way of preventing pregnancy after unprotected intercourse. Of these respondents, one fourth to one half did not have enough knowledge to use emergency contraceptive pills effectively. Fifty-seven percent of women were willing to use emergency contraceptive pills in the future, and 16 women said they would consider a change in regular contraception to emergency contraceptive pills if widely available. CONCLUSION: Sexually active women seeking ED care have high rates of unintended pregnancy and abortion. There is broad acceptance of emergency contraceptive pills to prevent pregnancy, but knowledge of availability, timing, and proper use is limited. Emergency contraceptive pills are a safe, effective, and low-cost primary preventive and emergency care intervention, and information about their use should be made available to ED patients. Patients should be advised not to abandon their use of barrier or other traditional contraceptives.

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

BACKGROUND: To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. MATERIAL/METHODS: Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. RESULTS: Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. CONCLUSIONS: This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.