Description of the condition
Injuries due to interpersonal violence make a significant contribution to morbidity and mortality worldwide. Annually, over 1.6 million people die due to violence with low- and middle-income countries (LMICs) accounting for over 90% of these mortalities (World Health Organization 2008 p. 49). The economically active portion of society is particularly vulnerable. In 2004, interpersonal violence was the sixth largest cause of death and disability globally in the age group 15 to 44 years (World Health Organization 2008 p. 58).
Mortality rates only reflect a small proportion of the problem. In many countries, non-fatal injuries place a considerable strain on the health system. Studies investigating youth violence have estimated that 20 to 40 seriously injured young people require hospital treatment for every one violence-related mortality (Krug 2002 p. 27). Furthermore, the consequences of these injuries are far-reaching and include more than just physical pain and disability.
There are several implications of violence and violence-related injuries. The mental health impact of these injuries can lead to persistent psychiatric disorders. Emotional distress and disorders such as posttraumatic stress disorder (PTSD), substance abuse and major depression have been documented after injuries due to violence, and in some cases, after witnessing violence (Resnick 1997; Golding 1999; Kilpatrick 2003; Ellsberg 2008). Further implications of violence-related injury place victims of violence at risk for poor long-term physical and mental health. For example, victims of violence are more likely to engage in behaviours such as risky sexual behavior, substance use, and unhealthy eating (Resnick 1997; McNutt 2002).
Studies from high-income countries (specifically New Zealand, the United States and Sweden) have shown that patients presenting with injuries due to violence are at increased risk of reinjury due to violence (Sims 1989; Dowd 1996; Ponzer 1996; Brooke 2006; Worrell 2006). In one US study, those with penetrating injuries were more likely to return with further penetrating injuries, than patients who first presented with a blunt injury (Brooke 2006). Data from New Zealand reveal that an assault-injured patient presenting to an emergency centre has a 39.5 times (95% confidence interval (CI): 35.8-43.5) increased risk of presenting with further injuries due to violence, when compared to the general population. Patients presenting with non-assault injuries had a 3.2 times (95% CI: 2.7-3.9) increased risk of subsequently presenting with an injury due to assault (Dowd 1996). These patients represent a high-risk group which could benefit from modification of risk factors for violence-related injury. There is a dearth of evidence from LMICs regarding violence-related injury recurrence, and interventions for victims of violence.
Risk factors such as adverse social conditions and mental health factors have been implicated in conferring vulnerability for violence-related injury (Arseneault 2000; Kessler 2001; Wood 2006; Elbogen 2009). The risk of violence and related injury in participants with a mental disorder is particularly significant when a comorbid substance use disorder is present (Arseneault 2000; Elbogen 2009). Attention to these factors would not only improve the individual's quality of life, but may be instrumental in preventing further mortality and morbidity due to violence.
A sizeable percentage of violence victims will access health care on an outpatient basis only, often being seen in emergency centres for less severe injuries and discharged directly from the emergency centre without formal hospital admission. In many LMICs, physical care (for example, suturing and analgesics) is the only care consistently provided, and systems are not in place to address the psychosocial needs of patients with violence-related injuries. In other words, interactions with the medical team tend to be limited to the primary reason for presentation (i.e. the injury). Consequently, opportunities to address individual risks and the sociocultural context for reinjury are overlooked. The question of, 'how can we prevent this from happening again?' may never be raised. The emergency interaction and setting can offer an opportunity to initiate primary prevention for re-injury.
Description of the intervention
Primary prevention of reinjury includes psychosocial interventions which are offered to patients with violence-related injuries and are performed or initiated in the emergency centre (with a contact session which is not solely for the purpose of acquiring the participants' contact information) for patients with violence-related injuries. One of the objectives of the intervention should be to decrease reinjury due to violence, including: mortality, self-reported reinjury or a repeat visit to an emergency centre for injury. The intervention should have a psychosocial component.
For the purpose of this review, psychosocial interventions in emergency centres will include those that target individual, family and relationship level risk factors for future poor health outcomes by intervening in psychological processes or social circumstances of the participant. Such interventions in the emergency centre may include education regarding risky behaviours, counselling, case management approaches or brief interventions for risky behaviours such as weapon-carrying and substance abuse. These interventions could be described as secondary prevention of violence as they are implemented for at-risk individuals in order to halt a potentially recurrent ‘condition’ or ongoing ‘disease’ process.
How the intervention might work
Patients presenting to an emergency centre with violence-related injuries are at increased risk for reinjury due to violence (Sims 1989; Dowd 1996; Ponzer 1996; Brooke 2006; Worrell 2006), as well as other negative outcomes. Psychosocial factors associated with reinjury due to violence have been identified in patients with violence-related injuries (Zatzick 2004; Cunningham 2009; O'Donnell 2009). Unfortunately, these needs are not always addressed (Zun 2003; Anixt 2012). The modification of these risk factors may be instrumental in protecting individuals from future violent episodes.
Why it is important to do this review
Violence prevention programmes are in use in a variety of settings, including community groups, schools, hospitals and criminal justice settings. Many of the hospital-based interventions target patients admitted with serious injuries due to violence (Snider 2009). The medical literature shows that these patients constitute a smaller proportion of violence victims than those seen only in an emergency centre and discharged (Wadman 2003; Alexandrescu 2009). The emergency centre visit could represent a 'teachable moment' for victims of violence who engage in risky behaviours (Johnson 2007). The visit could also be an opportunity to address other risk factors for repeat violent victimization or perpetration, such as mental health factors.
Some studies have addressed the economic benefits of violence prevention interventions in the emergency centre to reduce reinjury and the numerous consequences associated with violent injuries. Injuries due to violence are costly. In the US, the cost of violent deaths and injuries was estimated to be $37 billion in 2000, including medical care spending and lost productivity (Corso 2007). In light of the considerable cost involved, the potential cost-saving benefits cannot be ignored. Severe injuries are particularly expensive to treat, with medical costs in the US amounting to $24,353 and lost productivity costing a further $57,209 per injured person (Corso 2007). Some studies suggest that repeat victims may experience increasingly severe injuries, increasing their chances of serious injuries and death with each emergency centre visit (Sims 1989; Brooke 2006).
At the present time, it is not clear whether psychosocial interventions delivered in emergency centre settings can reduce reinjury due to violence. Furthermore, of the interventions showing promise, it would be beneficial to determine the specific components or types of interventions that are most effective, and in which group of patients these interventions are the most advantageous. Policymakers, government health departments and clinicians could apply the results of this review in implementing interventions in emergency centres which are most likely to be beneficial for individual patients, communities and national health systems.