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Open Access Publications from the University of California

Volume 14, Issue 4, 2013

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Violence Assessment and Prevention

Prevalence of Exposure to Risk Factors for Violence among Young Adults Seen in an Inner-City Emergency Department

Introduction: To assess the prevalence of risk factors for violent injury among young adults treated at an urban emergency department (ED).

Methods: This study is a cross-sectional analysis of data collected as part of a longitudinal study. Enrollment took place in an urban ED in a Level 1 trauma center, June through December 2010. All patients aged 18–24 years were eligible. Patients were excluded if they were incarcerated, critically ill, or unable to read English. Study participants completed a 10-minute multiple-choice questionnaire using previously validated scales: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, and e) community exposure to violence.

Results: 403 eligible patients were approached, of whom 365 (90.1%) consented to participate. Average age was 21.1 (95% confidence interval: 20.9, 21.3) years, and participants were 57.2% female, 85.7% African American, and 82.2% were educated at the high school level or beyond. Among study participants, rates of high-risk exposure to individual risk factors ranged from 7.4% (recent violent behavior) to 24.5% (exposure to community violence), with 32.3% of patients showing high exposure to at least one risk factor. When comparing participants by ethnicity, no significant differences were found between White, African-American, and Hispanic participants. Males and females differed significantly only on 1 of the scales – community violence, (20.4% of males vs. 30.3% of females, p¼0.03). Selfreported hostile/aggressive feelings were independently associated with initial presentation for injury associated complaint after controlling for age, sex, and race (odds ratio 3.48 (1.49-8.13).

Conclusion: Over 30% of young adults presenting to an urban ED reported high exposure to risk factors for violent injury. The high prevalence of these risk factors among ED patients highlights the potential benefit of a survey instrument to identify youth who might benefit from a targeted, ED-based violence prevention program. [West J Emerg Med. 2013;14(4):303–308.]

Screening for Elder Mistreatment among Older Adults Seeking Legal Assistance Services

Introduction: The aging population is a rapidly growing demographic in the United States. Isolation, limited autonomy, and declining physical and mental health render many older adults vulnerable to elder mistreatment (EM). The purpose of this study was to assess the prevalence and correlates of EM among a sample of older adults using legal assistance services in Atlanta, Georgia.

Methods: Researchers administered surveys to consenting older adults (aged 60þ) in 5 metro Atlanta community centers that hosted legal assistance information sessions as part of the Elderly Legal Assistance Program. The surveys screened for risk factors and prevalence of EM risk using valid and reliable measures and included additional questions regarding demographics characteristics and healthcare use behaviors.

Results: Surveys were completed by 112 participants. Findings reveal that 32 (28.6%) respondents met the criteria for elder abuse / neglect risk; 17 (15.2%) respondents met criteria for depression; and 105 (93.7%) had visited a healthcare provider during the past 6 months.

Conclusion: The rates of EM risk in this sample were higher than those previously reported in research. Findings support continued examination of unique risks that may be present among older adults who may be possibly facing legal issues. Additionally, the reported frequency of healthcare visits among participants reveals a promising opportunity to examine development of a more widespread EM screening approach to be conducted in non-emergency settings. Interdisciplinary collaboration is required to inform screening approaches that account for complexities that EM cases present. [West J Emerg Med. 2013;14(4):309–315.]

Dyadic, Partner, and Social Network Influences on Intimate Partner Violence among Male-Male Couples

Introduction: Despite a recent focus on intimate partner violence (IPV) among men who have sex with men (MSM), the male-male couple is largely absent from the IPV literature. Specifically, research on dyadic factors shaping IPV in male-male couples is lacking.

Methods: We took a subsample of 403 gay/bisexual men with main partners from a 2011 survey of approximately 1,000 gay and bisexual men from Atlanta. Logistic regression models of recent (,12 month) experience and perpetration of physical and sexual IPV examined dyadic factors, including racial differences, age differences, and social network characteristics of couples as key covariates shaping the reporting of IPV.

Results: Findings indicate that men were more likely to report perpetration of physical violence if they were a different race to their main partner, whereas main partner age was associated with decreased reporting of physical violence. Having social networks that contained more gay friends was associated with significant reductions in the reporting of IPV, whereas having social networks comprised of sex partners or closeted gay friends was associated with increased reporting of IPV victimization and perpetration.

Conclusion: The results point to several unique factors shaping the reporting of IPV within male-male couples and highlight the need for intervention efforts and prevention programs that focus on male couples, a group largely absent from both research and prevention efforts. [West J Emerg Med. 2013;14(4):316–323.]

An Examination of Bullying in Georgia Schools: Demographic and School Climate Factors Associated with Willingness to Intervene in Bullying Situations

Introduction: Research dedicated to identification of precursors to cases of aggravated bullying in schools has led to enhanced knowledge of risk factors for both victimization and perpetration. However, characteristics among those who are more likely to intervene in such situations are less understood. The purpose of this study is to examine the associations between demographic characteristics, school climate and psychosocial factors, and willingness to intervene in a bullying situation among middle and high school students in Georgia.

Methods: We computed analyses using cross-sectional data from the Georgia Student Health Survey II (GSHS 2006) administered to public school students in grades 6, 8, 10, and 12 (n=175,311). We used logistic regression analyses to determine the demographic, school climate and psychosocial factors associated with a willingness to intervene in a bullying situation.

Results: Students who were white and who were girls were most likely to report willingness to intervene in bullying situations. Several school-climate factors, such as feeling safe at school, liking school, feeling successful at school and perceiving clear rules at school, were associated with willingness to intervene, while youth who reported binge drinking were less willing to intervene.

Conclusion: These findings, while preliminary, indicate that girls, students who are white, and students who experience a relatively positive school climate and adaptive psychosocial factors are more likely to report that they would intervene in bullying situations. These findings may guide how bullying is addressed in schools and underscore the importance of safe school climates. [West J Emerg Med. 2013;14(4):324–328.]

Sexual Violence Perpetration by Adolescents in Dating versus Same-Sex Peer Relationships: Differences in Associated Risk and Protective Factors

Introduction: Little is known about the risk and protective factors for youth sexual violence (SV) perpetration across different types of relationships. This study examined factors associated with perpetrating SV against a dating partner and a same-sex peer.Methods: Analyses were based on data from a survey conducted in 2004 with public school boys and girls in grades 7, 9, 11, and 12 (N=4,131) in a high-risk, urban school district in the United States. SV perpetration was defined broadly to include forcing someone, about the same age and of the same or opposite sex as the respondent, to have sex or to do something sexual that they did not want to do. Analyses examined the associations between risk and protective factors and SV perpetration, adjusting for SV victimization and demographic characteristics.Results: Findings revealed that 2.1% of respondents reported perpetration against a same-sex peer and 3.2% reported perpetration against a date during the past 12 months. Victims of SV for each relationship type were more likely than non-victims to perpetrate SV. A combination of factors across the individual, relationship, and community level were significantly associated with SV perpetration and there were both shared and unique factors across the relationship types.Conclusion: Data suggest that programs to prevent SV perpetration for both relationship types should start when students are young, with particular focus on middle school boys. Prevention efforts should have slightly different foci to address these 2 types of SV perpetration. [West J Emerg Med. 2013;14(4):329–340.]

Co-Occurring Physical Fighting and Suicide Attempts among U.S. High School Students: Examining Patterns of Early Alcohol Use Initiation and Current Binge Drinking

Introduction: A growing body of empirical research documents a significant co-occurrence of suicide attempts and interpersonal violence among youth. However, the potential role of early alcohol use initiation and current heavy alcohol use as correlates of this comorbidity has not been examined in a nationally representative sample of high school students.

Methods: We based our analyses on cross-sectional data from the 2009 Youth Risk Behavior Survey, which includes a nationally representative sample (n=16,410) of high school students in grades 9 through 12 in the United States. Multinomial logistic regression analyses were conducted to test the associations between measures of alcohol use (early alcohol use initiation and heavy drinking) and comorbid suicidal and violent behavior while controlling for potential confounders.

Results: Among high school students, 3.6% reported comorbid physical fighting and suicide attempt in the past year. Early alcohol use (prior to age 13) and heavy drinking (5 or more drinks in a row) were strongly associated with comorbid reports of physical fighting and suicide attempts (Adj. odds ratio [OR]=3.12; 95% confidence interval [CI]:2.49-3.89) and (Adj. OR=3.45; 95%CI:2.63-4.52).

Conclusion: These findings underscore the importance of both early alcohol use initiation and heavy drinking as statistically significant correlates of comorbid fighting and suicide attempts among youth. While future research is needed to determine the temporal ordering between problem drinking and violent or suicidal behaviors, existing prevention programs may benefit from including components aimed at reducing and delaying alcohol use. [West J Emerg Med. 2013;14(4):341–346.]

The Economic Burden of Intimate Partner Violence in Ecuador: Setting the Agenda for Future Research and Violence Prevention Policies

Introduction: Intimate partner violence (IPV) is a widespread social structural problem that affects a great proportion of Ecuadorian women. IPV is a sexually, psychologically, or physically coercive act against an adult or adolescent woman by a current or former intimate partner. Not-for-profit groups in Ecuador report that 70% of women experience 1 of the forms of IPV sometime during their lifetime, but population-based surveys suggest that 41% of Ecuadorian women are exposed to emotional violence, 31% physical violence, and 12% sexual violence by their spouse or partner over their lifetime. Despite the high prevalence, the response of the Ecuadorian government has been insufficient to reduce the number of victims and to provide adequate legal and health services for the prevention and treatment of IPV. Given the power of economic data to influence policy making, the goal of this study is to produce the first estimate of the economic impact of IPV in Ecuador and to identify the policy paths in which these estimates would have the greatest impact for Ecuador.

Methods: Using a bottom-up method for estimating the economic burden of IPV and a national prevalence of IPV based on a population-based survey in the 2003–2004 year, the total economic burden is estimated at approximately $109 million adjusted to the 2012 United States (U.S.) currency rate. Results: Based on a prevalence of 255,267 women who were victims of IPV in the 2003–2004 year, the total economic burden is estimated at approximately $109 million adjusted to the 2012 the U.S. currency rate. The largest cost category contributing to the economic burden was the costs of healthcare services to treat injuries associated with IPV events.

Conclusion: The asymmetry between the economic burden of IPV and the amount of government resources devoted to IPV prevention efforts suggests the need for a greater role to be played by the government and other factors in society in the area of IPV prevention. [West J Emerg Med. 2013;14(4):347–353.]

Gay and Bisexual Men’s Perceptions of Police Helpfulness in Response to Male-Male Intimate Partner Violence

Introduction Despite several recent studies documenting high rates of intimate partner violence (IPV) among gay and bisexual men (GBM), the literature is silent regarding GBM’s perceptions of IPV within their community. We examine GBM’s perceptions of same-sex IPV: its commonness, its severity, and the helpfulness of a hypothetical police response to a GBM experiencing IPV.

Methods: We drew data from a 2011 survey of venue-recruited GBM (n¼989). Respondents were asked to describe the commonness of IPV, severity of IPV, and helpfulness of a hypothetical police response to IPV among GBM and among heterosexual women. We fitted a logistic model for the outcome of viewing the police response to a gay/bisexual IPV victim as less helpful than for a female heterosexual IPV victim. The regression model controlled for age, race/ethnicity, education, sexual orientation, employment status, and recent receipt of physical, emotional, and sexual IPV, with key covariates being internalized homophobia and experiences of homophobic discrimination.

Results: The majority of respondents viewed IPV among GBM as common (54.9%) and problematic(63.8%). While most respondents had identical perceptions of the commonness (82.7%) and severity (84.1%) of IPV in GBM compared to heterosexual women, the majority of the sample (59.1%) reported perceiving that contacting the police would be less helpful for a GBM IPV victim than for a heterosexual female IPV victim. In regression, respondents who reported more lifetime experiences of homophobic discrimination were more likely to have this comparatively negative perception (odds ratio: 1.11, 95% confidence interval: 1.06, 1.17).

Conclusion: The results support a minority stress hypothesis to understand GBM’s perceptions of police helpfulness in response to IPV. While IPV was viewed as both common and problematic among GBM, their previous experiences of homophobia were correlated with a learned anticipation of rejection and stigma from law enforcement. As the response to same-sex IPV grows, legal and health practitioners should ensure that laws and policies afford all protections to GBM IPV victims that are afforded to female IPV victims, and should consider methods to minimize the negative impact that homophobic stigma has upon GBM’s access of police assistance. [West J Emerg Med. 2013;14(4):354–362.]

Who Sends the Email? Using Electronic Surveys in Violence Research

Introduction: Students aged 16–24 years are at greatest risk for interpersonal violence and the resulting short and long-term health consequences. Electronic survey methodology is well suited for research related to interpersonal violence. Yet methodological questions remain about best practices in using electronic surveys. While researchers often indicate that potential participants receive multiple emails as reminders to complete the survey, little mention is made of the sender of the recruitment email. The purpose of this analysis is to describe the response rates from three violence-focused research studies when the recruitment emails are sent from a campus office, researcher or survey sampling firm.


Methods: Three violence-focused studies were conducted about interpersonal violence among college students in the United States. Seven universities and a survey sampling firm were used to recruit potential participants to complete an electronic survey. The sender of the recruitment emails varied within and across the each of the studies depending on institutional review boards and university protocols.

Results: An overall response rate of 30% was noted for the 3 studies. Universities in which researcher initiated recruitment emails were used had higher response rates compared to universities where campus officials sent the recruitment emails. Researchers found lower response rates to electronic surveys at Historically Black Colleges or Universities and that other methods were needed to improve response rates.

Conclusion: The sender of recruitment emails for electronic surveys may be an important factor in response rates for violence-focused research. For researchers identification of best practices for survey methodology is needed to promote accurate disclosure and increase response rates. [West J Emerg Med. 2013;14(4):363–369.]

Sexualized and Dangerous Relationships: Listening to the Voices of Low-Income African American Girls Placed at Risk for Sexual Exploitation

Introduction: Youth from low-income, urban backgrounds face significant challenges to maintaining a positive developmental trajectory. Dangerous neighborhoods and stressed relationships are common in these settings and threaten adaptation by weakening the natural assets that undergird resilience. African American girls in these contexts face specific, multiple risks, including gender stereotyping, violence, and sexual exploitation. The commercial sexual exploitation of children (CSEC) is a multibillion-dollar industry victimizing over 1 million children around the globe.1 The typical victim in 1 city in the southeastern United States is an African American girl 12-14 years old. There has been little research investigating the characteristics of girls placed at risk for CSEC and even less research on the personal perspectives of these girls. Methods: Over 3 school terms we provided preventive intervention groups for 36 African American middle school girls who were placed at risk because they lived in neighborhoods with high rates of interpersonal violence and CSEC. Two group leaders and a process recorder took detailed notes on each group session. Our focus on group conversations over a period of weeks increased the probability of recording spontaneous, open comments by the children and is a promising method with this population. The data were analyzed qualitatively and resulted in an account of the girls’ own views of the environmental challenges and personal experiences that may influence their development.Results: The girls’ language during the group sessions contained 4 themes: difficulty forming trusting relationships, frequent peer aggression, familiarity with adult prostitution, and sexuality as a commodity.Conclusion: Our research shows how girls placed at risk for CSEC view their own lives. These children described violence and sexual exploitation and cited limited supports to protect them from these risks. Understanding the perspectives of these girls should generate future research and intervention strategies to support their coping and resilience. [West J Emerg Med. 2013;14(4):370–376.]

Metrics for Local Community Planning and Evaluation: The Case for Observational Measurement of High Risk Rural Sub-Populations in Occupant Safety

Introduction: The purpose of this study is to examine the relevance of non-specific safety belt use data for interventions to rural teens and to pilot a data collection project to provide more specific data to traffic safety stakeholders and educators in rural areas.Methods: Twelve high schools in Southeast Georgia were used for observed safety belt data collection over a 16 month period. Observational surveys were conducted at the entrance to student parking lots of the studied schools in the morning or afternoon. Observers were trained and survey methods were standardized to maintain comparability between results.Results: Observational surveys revealed a safety belt usage rate of 38.6% among high schools teens at the studied high schools. Safety belt usage rates ranged from 9.5% to 66.9%. Observed safety belt use for female vehicle occupants was 48.4% compared to 35.6% for males.Conclusion: The observational survey results from this study support research showing that rural teens have lower safety belt usage rates than adults or urban teens. Despite efforts to target rural areas, programs must specifically target sub populations, especially rural male teens, in order to hold any traction. Because of the wide gap between measured safety belt use in rural Georgia (79.9%) and the studied rural high schools (38.6%), local program planners must assess actual safety belt usage in their high risk rural teen population in order to use accurate metrics for intervention and education efforts. [West J Emerg Med. 2013;14(4):380–383.]

Surveillance of Middle and High School Mental Health Risk by Student Self-Report Screener

Introduction: A 2009 National Academies of Sciences report on child mental health prevention and treatment concluded that screening for mental health risk is an essential component of service delivery. To date, however, there are few practical assessments available or practices in place that measure individual child risk, or risk aggregated at the school or community level. This study examined the utility of a 30-item paper and pencil student self-report screener of behavioral and emotional risk (BER) for surveying community risk among 7 schools. Methods: In 2010, 2,222 students in 3 middle and 4 high schools in a medium-sized school district in Georgia were administered the Behavioral and Emotional Screening System Self-Report Child/Adolescent form (BESS Student). The BESS is designed to measure 4 sub-syndromal BER factors for developing mental health disorders: inattention/hyperactivity, internalizing, school problems, and personal adjustment. Analysis of Variance and Chi Square analyses were used to assess the association between adolescent self-reported BER as an indicator of school BER, grade level, child ethnic identification and gender, socioeconomic status, and special education placement status.Results: BESS scores differentiated well between schools for overall BER and special education status, as well as between grade levels, ethnicity, and gender groups. One high school, known by the school administration to have numerous incidents of student behavior problems, had the most deviant 4 BER domain scores of all 7 schools. Girls rated themselves as having a higher prevalence of BER (14%) than boys (12%); middle school students reported fewer difficulties than high school students.Conclusion: Middle and high school students were capable of identifying significant differences in their own BER across schools, suggesting that universal mental health risk screening viastudent self-report is potentially useful for identifying aggregated community risk in a given school that may warrant differential deployment of mental health prevention and intervention strategies. BESS results reliably identified individual mental health risk associated with special education placement, which is documented to lead to poor school outcomes such as school dropout and lack of enrollment in post-secondary education. [West J Emerg Med. 2013;14(4):384–390.]

Towards the Development of an Intimate Partner Violence Screening Tool for Gay and Bisexual Men

Introduction: Recent research suggests that gay and bisexual men experience intimate partner violence (IPV) at rates comparable to heterosexual women. However, current screening tools used to identify persons experiencing IPV were largely created for use with heterosexual women. Given the high prevalence of IPV among gay and bisexual men in the United States, the lack of IPV screening tools that reflect the lived realities of gay and bisexual men is problematic. This paper describes the development of a short-form IPV screening tool intended to be used with gay and bisexual men.

Methods: A novel definition of IPV, informed by formative Focus Group Discussions, was derived from a quantitative survey of approximately 1,100 venue-recruited gay and bisexual men. From this new definition, a draft IPV screening tool was created. After expert review (n=13) and cognitive interviews with gay and bisexual men (n=47), a screening tool of six questions was finalized. A national, online-recruited sample (n=822) was used to compare rates of IPV identified by the novel tool and current standard tools.

Results: The six-item, short-form tool created through the six-stage research process captured a significantly higher prevalence of recent experience of IPV compared to a current and commonly used screening tool (30.7% versus 7.5%, p<0.05). The novel short-form tool described additional domains of IPV not currently found in screening tools, including monitoring behaviors, controlling behaviors, and HIV-related IPV. The screener takes less than five minutes to complete and is 6th grade reading level.

Conclusion: Gay and bisexual men experiencing IPV must first be identified before services can reach them. Given emergent literature that demonstrates the high prevalence of IPV among gay and bisexual men and the known adverse health sequela of experiencing IPV, this novel screening tool may allow for the quick identification of men experiencing IPV and the opportunity for referrals for the synergistic management of IPV. Future work should focus on implementing this tool in primary or acute care settings in order to determine its acceptability and its feasibility of use more broadly. [West J Emerg Med. 2013;14(4):391–401.]

Child Maltreatment and Disaster Prevention: Qualitative Study of Community Agency Perspectives

Introduction: Child maltreatment (CM) is a significant public health problem that increases following natural disasters. Ecological approaches have been used to study these complex phenomena, and the current research fits within this perspective by conducting qualitative interviews with disaster response and family-serving community agencies. The purpose of the study was to identify whether or not community agencies identified CM as an issue that is relevant for disaster planning and response and their perspectives on risk and protective factors for CM risk following disaster.  Methods: Agencies (n=16) from 2 geographical areas participated - one that recently experienced a natural disaster (Louisiana (LA), n=7) and one that had not (Georgia (GA), n=9). Agency representatives completed semi-structured telephone interviews (n=16) and follow up in person focus groups (n=14).  Theory-driven, thematic analyses were completed.  Results: Results suggested that community agencies agree that post-disaster environments increase the risk for CM and that CM prevention has a role in disaster response planning.  Risk and protective factors were identified according to Bronfenbrenner’ s ecological framework.  Conclusion: Study results support the need to include CM prevention efforts within disaster planning and provide guidance for future research to inform such efforts. [West J Emerg Med. 2013;14(4):402–408]

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