a b s t r a c t

Introduction: The Emergency Department (ED) is a critical setting for the treatment of acute violence-related complaints and violent victimization is associated with numerous long-term negative health outcomes. A trauma-informed care framework can prevent re-traumatization of victims within the healthcare setting, but currently there are insufficient mechanisms to detect previous exposures to community violence within the ED. The current study sought to determine the prevalence of community violence and characterize the types of Violence exposures among adult ED patients without trauma-related complaints to determine if there may be a need for expanded screening for previous exposure to violence for ED patients.

Methods: This was a prospective cross-sectional observational study of adult ED patients without a trauma- related chief complaint at an urban public hospital. Adult patients were approached by trained Research staff and answered questions adapted from the Survey of Exposure to Community Violence (SECV), which measures lifetime exposure to community violence, including both witnessing and victimization. The SECV was modified for clarity, brevity, and to assess exposure to violence within the previous 3 months and 3 years from enrollment, in addition to lifetime exposure. Enrollment occurred from June 2019 to September 2022 with a 19-month gap due to the COVID-19 pandemic. Demographics and results within SECV domains were analyzed using descriptive statistics. Comparisons between Males and females in Types of violence experienced during one’s lifetime were made by fitting logistic regression models adjusting for age.

Results: A total of 222 respondents completed some or all of the modified SECV. Ages ranged from 19 to 88, with

47.7% of respondents identifying as female and 50.9% as male. Of all respondents, 43.7% reported directly witnessing violence during their lifetime, 69.4% being personally victimized by violence, and 55.4% personally knowing someone killed by a violent act. Of those personally victimized, 47.4% occurred within the preceding 3 years and 20.1% within 3 months. Among all respondents, lifetime victimization was reported in the following domains: slapping, hitting, or punching (45.9%); robbings or muggings (33.8%); physical threats (28.8%); verbal or emotional abuse (27.5%); being shot at (18.0%); uncomfortable physical touch (15.3%); forced entry while home (14.4%); sexual assault, molestation, or rape (13.5%); or being attacked with a knife (13.5%). Comparing male and female respondents, 63.5% of females and 76.6% of males reported any violent victimization over their lifetime (aOR 1.88; 95% CI 1.04-3.43). Additionally, 31.7% of females and 56.3% of males reported witnessing violence (aOR 2.86; 95% CI 1.64-5.06). Males were more commonly exposed to Physical violence, violence with weapons, and threats while females more commonly reported sexual assault, molestation, and rape.

Conclusion: Both lifetime and recent exposure to community violence was common among adult ED patients without trauma-related complaints. Broader adoption of a trauma-informed care framework and the develop- ment of efficient ED Screening tools for previous exposure to trauma is reasonable in areas where community violence exposure is highly prevalent.

(C) 2023

1. Introduction

* Corresponding author at: University of Illinois at Chicago, Department of Emergency Medicine, 808 S Wood street, 4^th Floor, Chicago, IL 60612, United States of America.

E-mail address: [email protected] (N. Chhabra).

Violence is a public health epidemic in the United States, the effects of which can be long-lasting and affect persons beyond those directly involved in a violent act [1]. Extensive evidence has established links be- tween repeated exposures to violence and negative mental and physical

https://doi.org/10.1016/j.ajem.2023.03.010

0735-6757/(C) 2023

health outcomes, including those from behavioral disorders, psychiatric disorders, cardiovascular disease, diabetes, and Substance use disorders [2-6]. Emergency Departments (EDs) are uniquely situated to both rec- ognize the burden of violence in communities and initiate interventions to address the effects of violence. There are approximately 1,200,000 ED encounters for assault annually in the United States and homicide rates in the US far exceed those of similar high-income nations [7,8].

Negative health consequences for individuals within communities experiencing a high incidence of violent crimes have been described, mostly in younger patients [9-11]. It is postulated that these negative health outcomes are due to chronic psychological stress, physiologic responses to stress, adoption of harmful coping behaviors, and associa- tions between violence and other correlates for poor health such as social disadvantage [5,12]. Although no consensus definition exists, community violence is broadly characterized as direct or indirect expe- riences of public violence, including exposure to the use of guns, knives, and other random violence [13]. Literature evaluating the effects of community violence in children and adolescents is growing, but evalu- ations among the adult population is comparatively limited [13]. The ED has emerged as an important venue for screening and implementation of interventions designed to address public health emergencies given the high rate of ED utilization especially among marginalized and vul- nerable populations. ED-based screenings and interventions have been successfully implemented for multiple Public health concerns including Substance misuse, HIV, and Elder abuse [14-16].

Currently, it is not known if ED-based screening and interventions in adults are needed to combat the negative health consequences of com- munity violence in an adult population. If exposure to community violence is highly prevalent, the ED may represent a unique and critical setting to combat the negative health consequences of such exposures. The objective of this study is to determine the prevalence of exposure to community violence and violent crime in adult Emergency Department patients without trauma-related complaints. We hypothesize that a substantial proportion of adult ED patients would report exposure to community violence, suggesting a role for both screening and targeted intervention in the ED setting.

1. Methods
   1. Study design and setting

This was a prospective cross-sectional observational study of adult ED patients presenting with a chief complaint unrelated to violence or trauma at an urban public hospital. Enrollment occurred from June 2019 to March 2020 and from September 2021 to September 2022 with a temporal gap in enrollment due to a pause of in-person research activities by the primary institution due to the Covid-19 pandemic. The study hospital is part of a large health system in Chicago, IL with an ED which provides care for more than 120,000 unique patients annually. Additionally, it is a level 1 trauma center and employs ED social workers during most hours of the day. The city of Chicago has a violent crime rate substantially higher than the national average and higher than similarly large U.S. cities, ideally situating the hospital for the current analysis [17,18].

• 1. Participants

A convenience sample of ED patients were recruited by trained research assistants from Monday to Friday between the hours of 9 am and 5 pm. Subjects were considered for enrollment if they were 18 years of age or older and had a chief complaint unrelated to physical violence as determined by review of the nursing triage note in the elec- tronic health record (Appendix A). Exclusion criteria included patients deemed medically unstable, in police custody, or intoxicated. All subjects provided verbal informed consent for participation. Given the sensitive nature of the study topic, all subjects were offered resources

including an in-person social worker consultation and local resource list regardless of responses.

• 1. Measurements and analysis

Study subjects were queried about personal and close-contact expo- sure to community violence. Questions were adapted from the Survey of Exposure to Community Violence (SECV). [19] The SECV measures life- time exposure to community violence, including both victimization and witnessing of violence. Though initially developed for use in children, the SECV and modified SECV represent the most commonly used tool in published research for assessing community violence exposure in adults [13]. It has demonstrated acceptable to excellent internal consis- tency across diverse patient populations and modified versions with a limited item bank for administration in an abbreviated time frame have also demonstrated favorable psychometric properties [13,20]. For the purposes of the study, the SECV was modified for clarity, brevity, and to assess exposures both within the previous 3 months and 3 years from enrollment (Appendix B). During the pilot phase of the study, patient feedback indicated that two additional items should be included to reflect potential incidents of verbal/emotional abuse, as well as physical contact which some respondents did not consider to fall under the previous category of “sexual assault, molestation, or rape.” Verbal and emotional abuse has been recognized to cause endur- ing effects which can be as severe as those associated with physical violence [21,22]. These items were thus added to the SECV measure rather than incorporated into the SECV to prevent augmenting the reli- ability and validity within the existing measure’s framework. Both English and Spanish-language versions of the questionnaire were available.

Study data were collected by trained research assistants and man-

aged using REDCap electronic data capture tools hosted at Cook County Health [23,24]. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing: 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export proce- dures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.

Subject demographics and results were analyzed using descriptive statistics. Comparisons were made between male and female respon- dents using odds ratios and 95% confidence intervals in the domains represented on the initial survey as well as the added categories of emo- tional/verbal abuse and physical contact. Odds ratios were determined using logistic regression while adjusting for age as older age provides an increased opportunity for lifetime exposure to violent acts. All anal- yses were performed using R (v4.0.3, R Core Team 2021). The study was approved by the institutional review board of the study hospital. This study conforms, where applicable, to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) state- ment guidelines (Appendix C) [25].

1. Results

A total of 222 respondents out of 323 (68.7%) approached subjects completed some or all of the questionnaire. Demographics of study par- ticipants are shown in Table 1. Representation was noted across all age ranges with a similar distribution of males and females. Subjects that identified as Black accounted for a little over half of all respondents. While over a third of respondents identified their race as ‘other’ or ‘unknown’, 81% of those identified as ‘other’ in the race category identi- fied as ethnically Hispanic.

Of all respondents, 43.7% reported directly witnessing violence during their lifetime, 69.4% being personally victimized by violence, and 55.4% personally knowing someone killed by a violent act. Of those who reported personal victimization, 47.4% reported

Table 1

Demographic characteristics.

Characteristic n = 222 (%)

64); verbal or emotional abuse (27.5%, 61); being shot at (18.0%, 40); uncomfortable physical touch (15.3%, 34); forced entry while home (14.4%, 32); sexual assault, molestation, or rape (13.5%, 30); or being

Age, n (%) 18-24	18 (8.1%)	attacked with a knife (13.5%, 30). Personal victimization by type and time period preceding ED encounter are shown in Fig. 1. Of respondents
25-34	34 (15.3%)	reporting serious physical threat, only 10.9% reported filing for an order
35-44	38 (17.1%)	of protection or restraining order. Similarly, 20.6% of those reporting

45-54 45 (20.3%)

55-64 48 (21.6%)

65+ 39 (17.6%)

Sex, n(%)

Female 106 (47.7%)

Male 113 (50.9%)

Other/Unknown 3 (1.4%)

Race

Black 116 (52.3%)

White 21 (9.5%)

Asian 14 (6.3%)

Other/Unknown 76 (34.2%)

Ethnicity

Not Hispanic 158 (71.2%)

Hispanic 62 (27.9%)

Insurance

Public 135 (60.8%)

Private 17 (7.7%)

no insurance 70 (31.5%)

triage acuity by ESI

1 0 (0%)

slapping, hitting, or punching presented to an ED for evaluation follow- ing the attack. Of those who reported witnessing violence, 94.8% re- ported witnessing an attack with a weapon and 43.3% reported witnessing a person being killed by another person.

Comparing male and female respondents, 63.5% of females and 76.6% of males reported any violent victimization over their lifetime (aOR 1.88; 95% CI 1.04-3.43). Additionally, 31.7% of females and 56.3% of males reported witnessing violence (aOR 2.86; 95% CI 1.64-5.06). Lifetime exposure to community violence, while common in both sexes, showed differences in the types of violence experienced. Males were more commonly exposed to physical violence, violence with weapons, and threats while females more commonly reported sexual assault, molestation, and rape. Adjusting for age, odds ratios with 95% CIs for violence exposure categories between males and females are shown in Fig. 2.

2	46 (20.7%)	4. Discussion
3	152 (68.5%)
4	20 (9.0%)	Exposure to community violence, either through direct victimization
5	4 (1.8%)	or as a witness, were common in this study of adult ED patients present-
ESI = emergency severity index.		ing without trauma-related complaints. Almost 7 of 10 patients re-

victimization within the preceding 3 years and 20.1% within the preced- ing 3 months. Of all respondents, lifetime victimization was reported within the following domains: slapping, hitting, or punching (45.9%, n = 102); robbings or muggings (33.8%, 75); physical threats (28.8%,

ported direct victimization from violence within their lifetime and over half of knowing someone killed by a violent act. Of those reporting direct victimization, approximately half occurred within the three years preceding the ED encounter and one in five reported it within the pre- ceding 3 months. Although exposure to community violence was

Fig. 1. Reported Victimization by Type and Time Interval Preceding ED Encounter.

Fig. 2. Odds for Lifetime Exposure to Violence by Sex.

Odds Ratios adjusted for age; female used as reference category.

common among both sexes, the types of violence experienced varied, with females at greater odds of sexual assault, molestation, or rape and males at greater odds of attacks with a weapon and witnessing attacks with a weapon.

ED encounters for acute trauma due to violence are common and well described, but there is comparatively little literature on lifetime and recent exposure to community violence especially among adult patients [26-28]. The ED represents a common entry point for patients into the broader healthcare system. As such, a trauma-informed care framework has been increasingly adopted within this setting as a way to prevent re-traumatization within the healthcare setting [26]. As the current study indicates the majority of those exposed to violent acts did not present to the ED for evaluation as a result of violence, this framework should not be limited solely to patients presenting with ob- vious trauma-related complaints. The patients analyzed in the current study did not present for trauma-related complaints. ED staff are under- standably unaware of all the traumatizing experiences that patients may have had in their lifetime. Therefore, a consistent approach respect- ing patients’ bodily autonomy and working to compassionately build trust during an encounter should be pursued by all Healthcare staff.

Patients with previous exposures to community violence are at an increased risk for worse health outcomes [3,5,6]. It is therefore impor- tant for health systems to accurately identify patients at risk for worse

health outcomes as a result of previous trauma and provide appropriate interventions. As many of these interventions necessitate collaboration with staff that traditionally practice outside of the ED setting and build- ing connections with appropriate follow-up resources, an intentionally planned approach for patients with previous or current trauma exposure is critical [29]. The current study provides an argument for the development of an efficient and effective ED-specific screening tool for exposure to community violence and further evaluation of inter- ventions to prevent the negative health consequences of exposure to such violence. Bridges should be built from the ED setting to multidisci- plinary resources for these patients including therapy services, trauma social workers, psychiatric services, and law enforcement, where applicable.

The potential benefits of any community violence interventions of- fered within the emergency department setting must be weighed against potential harms including retraumatization and prolonging lengths of stays for both the individual patient and any others waiting to be seen. This is especially true as EDs become busier and care for an increasing number of patients nationally. There is little literature exam- ining health outcomes from violence screening in the ED setting. Screening for intimate partner violence, to date, has not shown im- provements in long term patient outcomes [30,31]. This is potentially due to lack of access to or effectiveness of interventions available in

the ED. Screening for other conditions which may not be emergent or related to patients’ chief complaints, including substance use disorders, have resulted in improved health outcomes, likely do to access to well- researched interventions beyond simple referrals [32-34]. It is therefore critical that any planned resources or interventions undergo evaluations of effectiveness and be provided in a timely manner to minimize disrup- tions to a typical ED workflow. Further research is needed to identify which specific interventions are effective and ED-appropriate in caring for patients with previous violence exposure.

Differences in the types of community violence experienced be- tween sexes was noteworthy. Despite the limited sample size and power, some important differences were noted. Sexual assault, molesta- tion, and rape were more commonly reported by female respondents, reflecting research conducted in other clinical settings [35,36]. While not queried in the current study, sexual violence is predominantly per- petrated by men. All clinicians, but especially male clinicians, should be aware of the risk of re-traumatization that may occur during the admin- istration of even routine clinical care. Additionally, resources specifically designated for victims of sexual violence should be accessible in a timely manner in ED settings. As male respondents were at greater odds for exposure to physical violence involving weapons, the ED represents an opportunity to address potential health consequences from previous violence exposure and for interjection to prevent the propagation of further violence. It is interesting that of patients reporting physical threat, only 1 in 10 sought an order of protection or restraining order. Barriers to involving the legal system are well-described as is the lack of trust between many Vulnerable patient populations and societal insti- tutions, including law enforcement [37-39]. For patients that desire to seek an order of protection, these services should be accessible and health systems should develop protocols to assist patients in this process. For those that do not seek legal system involvement, further exploration of how to best serve patients suffering physical threats are needed to prevent potential violent trauma resulting from threats.

There are several limitations to the current study. As a single center analysis, these results may not be generalizable to other practice set- tings. Approximately one-third of potential subjects did not consent to participation. Therefore, results may be skewed. As research assistants were only available during limited hours, the sample may not be reflective of the entire population of emergency department patients. Additionally, given the sensitive nature of questions, there is a risk re- spondents may have underreported exposures in certain domains. As with any analysis querying subjects of prior exposures, there is an inher- ent risk for recall bias. Furthermore, the current study design did not allow for the collection of data for long-term health outcomes in patients reporting exposure to community violence.

5. Conclusion

Among adult patients without trauma-related complaints present- ing to the ED, lifetime and recent exposure to community violence was common. These results indicate a need for effective screening mechanisms for ED patients, expanded adoption of a trauma-informed care framework, and advanced planning for accessible trauma-specific resources for patients in locations where community violence exposure is prevalent.

Previous presentation of findings

Illinois College of Emergency Physicians, Spring Symposium 2020, Chicago IL.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Neeraj Chhabra: Writing - original draft, Visualization, Supervision, Resources, Methodology, Formal analysis, Data curation, Conceptualiza- tion. Samantha Hernandez: Writing - review & editing, Project administration, Investigation, Data curation. Errick Christian: Writing - review & editing, Validation, Resources, Methodology, Conceptualiza- tion. Lum Rizvanolli: Writing - review & editing, Resources, Project administration, Data curation, Conceptualization.

Declaration of Competing Interest

none.

Acknowledgements

The authors would like to acknowledge Samhitha Rai, Susan E. Panek, and the Academic Associates Program of the Department of Emergency Medicine of Cook County Health for their assistance in conducting this study.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.03.010.

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