SAN FRANCISCO – An inpatient intervention that used gunshot or stab wounds as "teachable moments" significantly improved some attitudes about violence in a randomized study of 40 hospitalized trauma patients.
The prospective pilot study administered the Attitudes Toward Guns and Violence Questionnaire (AGVQ) before and after the intervention or usual care for patients treated at Temple University Hospital, Philadelphia, from January to June 2012. Their general proclivity toward violence (the overall AGVQ score) decreased by 20% in the intervention group (from a mean score of 15 to 12.1) and held steady in the control group (scores of 11.5 and 11.3).
Courtesy Wikimedia Commons/Francois Polito/Creative Commons
"Non-Violence" sculpture by Carl Fredrik Reutersward.
Two subscales of the AGVQ also produced significant attitudinal changes after the intervention, a four-part program called Turning Point, Dr. Catherine E. Loveland-Jones and her associates reported at the annual meeting of the American Association for the Surgery of Trauma.
Patients’ comfort with aggression (or acceptance of violence as a part of everyday life) decreased from a mean score of 4.2 to 2.8 after the intervention (a 33% reduction) compared with scores of 2.9 and 2.8, respectively, in the control group.
The greatest change was seen in scores for aggressive response to shame. Patients in the intervention group showed a 44% reduction in their sensitivity to disrespect from others and the belief that violence is the best means for preserving one’s damaged self-esteem, said Dr. Loveland-Jones of Temple University. Their mean scores decreased from 3.6 to 2 after the intervention, compared with scores of 3.1 and 2.6 in the control group.
"We believe that attitude change is fundamental and really the first step to behavior change," she said. The ongoing study is nearing its goal of enrolling 80 patients.
Dr. Catherine E. Loveland-Jones
A separate program at her institution to prevent violence in youth also had its greatest impact on attitudes about shame and violence. The findings are encouraging because reaction to shame is thought to be a driver of violence in the study’s population, she said.
All patients in the study received the usual social services care offered at the urban Level 1 trauma center to victims of gunshot and stab wounds, consisting of team care from a trauma outreach coordinator, a case manager, and a social worker. The 21 patients in the Turning Point group also watched a video of their resuscitation in the trauma bay and a reality-based movie about violence. They met with a gunshot wound survivor, were introduced to an outpatient case manager, and received a psychiatric evaluation if the patient or a clinician requested one.
"I think the most important part of our program is our referral to outpatient services," Dr. Loveland-Jones said. Previous data suggest that "meeting mental health needs and finding employment for patients are the most important," and that moderate- to high-intensity case management in the first 3 months after the trauma helps achieve that.
The study enrolled English-speaking adults with gunshot or stab wounds who had a Glasgow Coma Score of 15. The cohort "overwhelmingly" consisted of black males in their 20s, she said. In general, more than half of gunshot victims in Philadelphia are young, she added.
The Turning Point program costs $50,000 per year and subcontracts with an established community group for the outpatient case management.
Two subscales of the AGVQ did not change significantly in either group. Scores were lowest for reported levels of gun-related excitement, "suggesting that guns are viewed as necessary and commonplace rather than exciting," she said. The AGVQ scores before and after the intervention were 0.1 and 0.5 in the control group, respectively, and remained at 0.3 in the Turning Point group.
Scores were highest for feelings of gun-related power and safety, "suggesting that there is a very strong view in our community that guns are a necessary means for preserving personal safety," she said. The AGVQ scores before and after the intervention were 5 and 5.2 in the control group and 6 and 6.4 in the Turning Point group, respectively.
The study excluded 119 (75%) of 159 potential participants, primarily patients who stayed in the hospital less than 48 hours (69%). A total of 9% of patients refused to participate. Other reasons for exclusion were police custody (7%), devastating neurologic injury (4%), severe psychiatric disorder (2%), and unknown reasons (2%). Investigators also excluded 3% who were non-English speakers, 2% who left the hospital against medical advice, and 2% who planned to relocate after discharge.
Patients in the Turning Point group were significantly more likely to be alcohol abusers (26%), compared with the control group (14%), and were significantly younger – an average of 22 years vs. 31 years in the control group.