Building Community: Community Engagement Models for Violence Prevention

Introduction

The American Association for the Surgery of Trauma (AAST) hosted its 82^nd annual meeting in Anaheim, California in 2023. Dr. Eileen M. Bulger, the presiding AAST President, declared ‘Building Community” as the overarching theme of the conference. Due to the increasing burden of gun violence across the United States and an urgent need for sustainable solutions, one priority of the conference was to explore existing violence prevention and intervention strategies. These strategic models demonstrate a spectrum of existing programs including a hospital-based violence intervention program (HVIP), community-linked coalition, early intervention youth mentorship program, and a community-based and culturally adapted skills training program (table 1). Moderated by Dr. Rochelle Dicker, the panel discussion entitled Community Engagement Models for Violence Prevention highlighted the natural fit for trauma surgeons to champion strategies outside the operating room, aimed at mitigating firearm injuries and deaths by focusing on root causes of violence and the social drivers of health. Four distinct programs were discussed. Each program highlighted the fact that trauma surgeons are uniquely positioned to work with community stakeholders to develop actionable hospital- and community-based programs that work to ultimately prevent injury and reinjury from firearms.

Engaging Networks within the Community of Omaha to Maintain and Promote A Safe Society

ENCOMPASS Omaha (Engaging Networks within the Community of Omaha to Maintain and Promote A Safe Society) was the first program presented during the panel by CE, the program’s medical director and Professor of Surgery, and Chief of the Division of Acute Care Surgery at the University of Nebraska Medical Center (UNMC)/Nebraska Medicine.

ENCOMPASS Omaha is the only hospital-based violence intervention program (HVIP) in Nebraska. HVIPs are multidisciplinary programs that combine the efforts of the hospital trauma team with community-based partners to provide trauma-informed care to violently injured patients. Omaha is home to just over 500 000 citizens, and in 2022, the city endured 29 homicides. While some cities in the USA see this number of homicides in 1 week, each death is devastating for the victim’s family and friends. CE discussed how gun violence is not just a ‘big city’ problem, it is an ‘our city’ problem, which requires a city-wide response. The hospital serves as an entry point for victims of violence and therefore hospitals have a unique opportunity to interact and intervene with said patients.

In addition to 29 homicides, Omaha endured 121 non-fatal shootings in 2022, of which 83 were treated at UNMC/Nebraska Medicine. These gun violence survivors live with a daily reminder of their trauma, and ENCOMPASS Omaha’s hospital-based team works to provide trauma-informed care within and beyond the hospital. All ENCOMPASS Omaha staff are hospital employees, and includes a medical director, supervisor, two social workers, one licensed independent mental health practitioner, two violence intervention specialists (also known as credible messengers or violence prevention professionals (VPP)) and a statistician. This team helps victims of violence heal from physical and emotional trauma by empowering them with skills, services, and opportunities for recovery. The goal is to ensure victims return to their communities, make positive changes in their lives, and strengthen others affected by violence. ENCOMPASS Omaha optimizes the ‘teachable moment’ at the bedside during hospitalization through interaction with culturally competent VPPs embedded within the trauma team. After a thorough needs assessment, ENCOMPASS Omaha provides intense case management services after discharge that address the barriers for victims to be safe on returning home and guidance to improve social and mental well-being. The program addresses the social drivers of health, including education, job training and job skills, housing and relocation resources, food security, primary healthcare, mental healthcare, substance abuse counseling, and medical and legal aid. For ENCOMPASS Omaha participants, top categories for needs and referrals include permanent housing, obtaining mental health services, establishing a primary care physician, and establishing health insurance. CE discussed documenting activities performed by the ENCOMPASS team that allows them to understand how staff time is being used and the resulting impact. In 2023, staff documented 4880 individual activities performed to support victims enrolled in the program. These activities included 1548 instances of individual advocacy (employment assistance, Department of Motor Vehicles services, birth certificate copies), 931 instances of emotional support (emotional support at funerals, discussions about lifestyle changes resulting from their violent injury, and actively listening to participants’ stories and emotions), 646 instances of medical follow-up (attending medical appointments with participants and facilitating primary care visits, coordinating physical therapy and occupational therapy follow-up, and creating general appointment reminders), 488 instances of individual counseling (discussing mental health options, apprehension of traditional behavioral health services, and mentoring sessions) and 250 instances of referrals to other organizations to meet the needs of participants (food pantries, employment programs, and housing programs). These metrics provide evidence of the impact HVIPs have on individuals and the community beyond rates of reinjury and rehospitalizations.

Building a regional coalition

The second presentation was given by DN, Associate Professor of Surgery at the University of Washington and Medical Director of the Harborview Medical Center Violence Intervention and Prevention Program. DN highlighted the fact that firearm-related violence disproportionately affects young men of color impacted by socioeconomic vulnerability, and it is often concentrated in historically marginalized and disadvantaged communities. This can have a profound impact on people residing in these communities, making it critical that violence intervention programs are deeply rooted in the localities they serve.

Harborview Medical Center is faced with the challenge of being a high-volume center (>7000 injured patients and approximately 600 firearm-related injuries annually) serving a wide geographic area as the only level 1 trauma center in Washington state. In developing and implementing a violence intervention program, this challenge was addressed by partnering closely with several community-based organizations. The hospital became a partner in a regional coalition, led by the community, that brought several community-based organizations together with the goal of addressing gun violence using a public health approach. This has proven to be a powerful way to create a broader sense of community and purpose while increasing the visibility of the group and ability to effectively advocate for the cause.

In practice, each organization has their own area(s) of focus, which contributes to the coalition’s collective goals and efforts. The coalition collects and reviews data during a weekly ‘shots fired’ meeting, where the group discusses incidents and plans needed actions. There is a critical incident response team that addresses hotspots and responds to diffuse conflict and decrease retaliatory violence. Through the work of the community-based organizations in the collective, efforts are made to identify youth at high risk for violence and to connect them with a care team to address root causes of violence with support, life coaching and mentorship. Importantly, the collective also organizes critical community healing and restoration activities.

The violence intervention and prevention program at Harborview Medical Center is deeply connected to these coalition activities and aims to provide holistic support for survivors of violence and their families throughout their hospitalization and after discharge. The hospital-based program includes two VPPs who are credible messengers and the heart of the program, three social workers, a resource navigator, and a trauma mental health therapist. Services provided include peer support, identifying and ameliorating some of underlying social determinants of health, mental health support, assistance with navigating a complex system (medical, crime victims compensation, etc), and working to ensure personal safety at discharge. Understanding that the peridischarge period is a particularly vulnerable time, the hospital-based team connects patients with outreach workers in the community who aim to walk alongside individuals in their recovery and reintegration, and to address immediate needs while working toward long-term goals.

Ultimately, the goal of the coalition is to decrease gun violence in the community by creating sustainable conditions that allow people to live and be healthy, happy, hopeful and thriving. This type of community-based healing and restoration requires a long-term and sustained commitment to some of the most historically disadvantaged communities, and it is critical for programs to find ways to share positive individual stories along the way. There are a number of challenges with the successful implementation of this type of regional coalition that often revolve around difficulty with operationalizing and coordinating efforts across multiple entities. These issues can be eased with time, building trust and understanding, and working toward a common goal. This coalition highlights the importance of bringing entities such as city governments, trauma centers and community-based organizations together as violence prevention ecosystems; each entity has distinct responsibilities, and their violence prevention efforts are greatly enhanced collectively.

Project Inspire: a youth empowerment model

AW, the third presenter, founded and directs a unique youth empowerment program: Project Inspire. AW also serves as an assistant professor in the Department of Surgery at the University of South Alabama (USA) and as the director of the USA Health Center for Healthy Communities in Mobile, Alabama. Through partnership with the Mobile County Juvenile Justice Center, Mobile Police Department, and the City of Mobile, Project Inspire held its inaugural class in 2018.

The goal of this program is to empower youth with non-violent gun-related offenses to realize their full potential through education, exposure, and mentorship. AW emphasized that Project Inspire is a primary prevention strategy that aims to curb gun violence by engaging at-risk youth and addressing their educational and social needs in effort to prevent further victimization and/or gun violence perpetration. Equipping participants with the tools they need to be successful is a priority of the program.

Prior to the COVID-19 pandemic, the program was held during the summer over the course of 3 weeks. After the COVID-19 pandemic, Project Inspire transitioned into a semester-based program with classes taking place every Monday afternoon from 12:00 to 16:00 hours, following the public school system calendar. The curriculum comprised the following five pillars: confidence building and trauma-informed care training, educational and professional development, financial literacy, entrepreneurship, and mentorship. Adjuncts to the curriculum include community service projects, social events, and a formal graduation ceremony. Activities included in the core and adjunct curricula include certifications in Stop the Bleed and Basic Life Support, practice and actual job interviews, resume creation, cooking classes, and one-on-one and group discussions on various topics including mental health and trauma. Social activities include bowling, pickleball, basketball, and educational tours. Community service projects have included teaching police cadets Stop the Bleed, sorting food at a local distribution center, and building and painting wooden gifts for hospitalized children.

As of September 2023, the program has graduated four classes, with the fifth in session. Of the four graduating classes, 17 of 20 enrolled students have successfully completed the program which requires attendees to participate in 80% of the sessions. Of the 17 graduates, one reoffended as an adult. Therefore, the rate of recidivism at this time is 5.9%, compared with 42% among youth in the county, as reported by the Mobile County Juvenile Justice Center. AW mentioned that the rate of recidivism, though important, is only a part of the impact of the program. She described one student who called her just before his job interview to reinforce what he had learned that week during practice interviews and how that student ultimately got the job. This was one of many examples that illustrate the impact of Project Inspire beyond its positive effect on recidivism.

After summarizing the program, AW discussed the limitations. Transportation for participants and funding for a dedicated staff were the top needs that would allow for scaling of the program to reach more youth. Future steps for Project Inspire include launching its first satellite location in January 2024 in neighboring Mississippi at a rural level 3 trauma center. Research efforts related to Project Inspire will also begin prioritizing quantitative data through surveys, interviews, and focus groups. Lastly, Project Inspire seeks to expand by integrating its curriculum into the school-based setting to reach a greater number of students. Project Inspire serves as an example that trauma surgeons and trauma centers have the capacity to build partnerships, invest in community, and empower youth to prevent death and injury secondary to gun violence. Details related to Project Inspire have been published.1

Working for Equity: WE Stop the Bleed

The final program discussed during the 2023 American Association for the Surgery of Trauma (AAST) panel on firearm injury prevention was Working for Equity: WE Stop the Bleed. KMS, founder and director of the program, presented an overview of the program development, theory of change, implementation, and evaluation results. KMS is an Assistant Professor of Surgery in the Division of Trauma, Acute Care Surgery, and Surgical Critical Care at the University of California Davis Medical Center.

WE Stop the Bleed was developed in partnership with the Seattle Somali Health Board after a community needs assessment with Somali community stakeholders identified concerns about distrust of first responders (both emergency medical service and law enforcement) and lack of knowledge of bystander interventions among members of the Somali community. Focus groups with King County/Puget Sound region firefighters and paramedics also identified perceived distrust from patients and cultural differences as barriers to providing optimal care for patients with limited English proficiency, which includes much of the Somali community. WE Stop the Bleed was developed to help address these issues. Details of the program and its results have been published elsewhere.2 3

The primary aims of the WE Stop the Bleed program were to: (1) increase knowledge, self-efficacy, and willingness of individuals living in communities most impacted by gun violence to perform bystander bleeding control; and (2) build trust and familiarity between the community and first responders. To achieve these aims, the program consisted of two main components: (1) semistructured, bidirectional small group discussion and cultural exchange, and (2) American College of Surgeons Stop the Bleed course. A conceptual model illustrating the program theory of change was displayed (figure 1), as KMS described the programmatic implementation and a brief overview of the evaluation results. A total of 122 community members and 42 first responders participated in the program over four sessions, between 2018 and 2022. An evaluation was conducted with presurveys and postsurveys. Bleeding control knowledge improved from 42% precourse to 63% postcourse, though KMS noted that the knowledge of the participants may have been higher than the combined survey results reflected as there were several challenges with translation of the surveys into Somali that may have impacted this measurement during early sessions. Self-efficacy (one’s belief in their capacity to complete a task or goal) to perform bleeding control maneuvers also improved from 74% to 95%. Almost all community participants (97%) and first responders (96%) indicated they would recommend the program to a friend or colleague.

Request permission

KMS relayed that, while these results are encouraging and important, she felt the impact of the program was best demonstrated by participant responses to open-ended questions on the postcourse survey. As an illustrative example of increased trust and familiarity, she displayed two quotes. One quote from a first responder read, ‘[caring for Somali patients] was less intimidating after getting to know them.’ A second quote, from a Somali participant, relayed this message: ‘I am not scared of them anymore.’ Over the four sessions, several adaptations and iterative changes were made to the program based on feedback from participants and the Somali Health Board. The most substantive changes included shifting much of the content from lecture-style delivery to small groups and creating time for the semistructured small group discussions at the beginning of the sessions rather than the end. KMS is now working with three other sites to adapt and implement WE Stop the Bleed for diverse communities across the country.

Question and answer session

Several questions and comments from the audience highlighted the complexity of gun violence in America as it relates to many underlying issues such as the social drivers of health and structural racism. One important point of discussion centered around the fact that the individual programs discussed cannot, and should not be expected to, comprehensively address all underlying contributors to gun violence. The panelists agreed that no single program will be the ‘cure’ for gun violence, but rather that the role of these programs is to address root causes of violence, including social and mental drivers of health, through prevention and intervention efforts. This work should be done in partnership with the local community and efforts should be made to compile thoughtful patient-centered data in parallel with program implementation. Partnering with community organizations and employing credible messengers, including adapting any program and/or model to the local community context, is key to success of any program. The AAST president, EMB, commented that all trauma centers should advocate for an HVIP within their trauma program, reinforcing that we as surgeons need to be part of the solution to this growing public health crisis in addition to treating traumatic injuries.

Undoubtedly, the convoluted nature of the problem requires a complex set of strategic solutions. Trauma surgeons and trauma centers are poised to lead and collaborate with the communities they serve in the creation and implementation of best practices and evidence-informed violence intervention programs that meet the needs of patients, families, and communities with the goal of preventing violence-related injury and reinjury online supplemental figure 1.