Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Objective: The objectives of this analysis were to: 1) assess the impact of sociodemographic factors, and perceived costs and benefits on engagement in a parenting program designed to prevent child maltreatment, 2) determine if perceived costs and benefits mediated the association between sociodemographic factors and engagement, and 3) assess whether or not race/ethnicity moderated the relationship between sociodemographic factors, perceived costs and benefits, and engagement.

Methods: Perceived costs and benefits of the intervention were assessed from parents providing self-reports, including satisfaction/ usefulness of the program (benefits), and time/difficulty associated with the program (costs). Engagement was defined as attendance at both the mid-point and then the number of visits attended throughout the remainder of the intervention. To investigate the direct and indirect effects (through perceived costs and benefits) of parental sociodemographic factors (education, age, gender, number of children, household income) on program engagement, data were analyzed with structural equation modeling (SEM). To assess the potential moderating effect of race/ethnicity, separate models were tested for White and African-American parents.

Results: Perceived benefits positively impacted attendance for both White (n=227) and African-American (n=141) parents, whereas perceived costs negatively influenced attendance only for White parents. Parent education and age directly impacted attendance for White parents, but no sociodemographic factor directly impacted attendance for African-American parents. The indirect impact of sociodemographic characteristics on attendance through perceived costs and perceived benefits differed by race/ethnicity.

Conclusions: Results suggest that White parents participate in a parenting program designed to prevent child maltreatment differently based upon their perceived benefits and costs of the program, and based on benefits only for African-American parents. Parental perception of costs and/or benefits of a program may threaten the effectiveness of interventions to prevent child maltreatment for certain racial/ethnic groups, as it keeps them from fully engaging in empirically validated programs. Different methods may be required to retain participation in violence prevention programs depending upon race/ethnicity.

Objective: A growing body of literature suggests that IPV occurs within same-sex relationships and that members of the LGBT community face a number of unique challenges in accessing IPV related services. This paper examines the use of an on-line survey, marketed through a popular social networking site, to collect data on the experience and perpetration of IPV among men who have sex with men (MSM) in the US.

Methods: Internet-using MSM were recruited through selective placement of banner advertisements on MySpace.com. Participants were eligible for the baseline survey if they were males ≥ 18 years of age, and reported at least one male sex partner in the last 12 months. In total 16, 597 men responded to the ad, of which 11, 681 were eligible for the study, and 5602 completed the questionnaire: in total 543 men completed the follow-up survey which included questions on the experience and perpetration of IPV. The final analysis sample was 402 MSM.

Results: The prevalence of violence among the sample was relatively high: 11.8% of men reported physical violence from a current male partner, and about 4% reported experiencing coerced sex. Reporting of perpetration of violence against a partner was generally lower, with approximately 7% reporting perpetrating physical violence and less than 1% reporting perpetration of sexual violence.

Conclusion: The results presented here find lower levels of experiencing both physical and sexual IPV than have been shown in previous studies, yet show relatively high levels of reporting of perpetration of IPV. Collecting IPV data through surveys administered through social networking sites is feasible and provides a new opportunity to reach currently over-looked populations in IPV research.

Objective: Poisoning events, including exposures to hazardous materials, can involve multiple victims. Regional poison centers often are contacted in such events involving multiple victims.

Methods: We searched our poison center database over a nine-year time period for all calls involving a poisoning event in which more than two people were exposed to the same substance. We then matched each product to the generic category used by the National Poison Data System. We analyzed this data to find the most frequent substances reported as primary substances in the multiple exposures.

Results: We identified 6,695 calls between 2000 and 2008 that had more than two people exposed to the same substance. In these calls, 25,926 people were exposed (3.6% of the 715,701 human exposure calls for this period). These calls involved 64 of the 67 NPDS substance group codes. Some substances were much more commonly involved than others. The top three categories causing the most exposures were Fumes/Gases/Vapors, Food Products/Food Poisoning and Pesticides. Of the patients exposed, 69.4 % were not followed due to minimal effects possible or judged as nontoxic, 0.3% had major effects, 8.6% had no effects, and 9.3% had minimal to moderate effects. Eight people expired.

Conclusion: Fumes, gases, and vapors make up the majority of multi-exposure calls. The overall mortality from multi-exposures, based on our data, is low. Analysis of these calls can help poison centers better understand these events and direct training. [West J Emerg Med 2010; 11(3): 292-294.]

Objective: To assess rates of substance abuse (including tobacco, alcohol, and drug abuse) as well as rates of intimate partner violence (IPV) among African-American women seen in an urban Emergency Department (ED).

Methods: Eligible participants included all African-American women between the ages of 21-55 years old who were seen in an urban ED for any complaint, and who were triaged to the waiting room. Eligible women who consented to participate were taken to complete a computer-based survey that focused on demographic information and general health questions as well as standardized instruments including the Index of Spouse Abuse (ISA), the Tolerance, Worried, Eye openers, Amnesia, K(C)ut down (TWEAK) screen for alcohol abuse, Drug Abuse Screening Test (DAST20), and Hooked on Nicotine Checklist (HONC). This analysis uses results from a larger study evaluating the effects of providing patients with targeted educational literature based on the results of their screening.

Results: 610 women were surveyed. Among these, 85 women (13.9%) screened positive for IPV. Women who screened positive for IPV were significantly more likely to also screen positive for tobacco abuse (56% vs. 37.5%, p< 0.001), alcohol abuse (47.1% vs. 23.2%, p < 0.001), and drug abuse (44.7% vs. 9.5%, p<0.001). Women who screened positive for IPV were also more likely to screen positive for depression and to report social isolation.

Conclusion: African-American women seen in the ED, who screen positive for IPV, are at significantly higher risk of drug, alcohol, tobacco abuse, depression and social isolation than women who do not screen positive for IPV. These findings have important implications for ED-based and community-based social services for women who are victims of intimate partner violence. [West J Emerg Med. 2010; 11(3): 253-257.]

Purpose: The current study examines the associations between a range of risk factors and reports of suicide attempts, and attempts requiring medical care in a nationally representative study of high school students. The goal is to examine sex differences in the risk factors that are associated with suicide attempts and attempt-related injuries requiring treatment by a health-care provider.

Methods: Data from the 2007 Youth Risk Behavior Survey for students in grades 9-12 were used to assess the prevalence and risk factors for suicidal behavior as well as differences in these for boys and girls. Cross-sectional multivariate logistic regression analyses were computed to determine the most important risk factors for suicide attempts and for suicide attempts requiring medical care for the sample overall and also stratified for boys and for girls.

Results: Overall, 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys). Girls were more likely than boys to report a suicide attempt in the past year (Adj.OR=2.89). Among girls, sadness (Adj.OR=5.74), weapon carrying (Adj.OR=1.48), dating violence (Adj.OR=1.60), forced sex (Adj.OR=1.72), and huffing glue (Adj.OR=2.04) were significantly associated with suicide attempts. Among boys, sadness (Adj.OR=10.96), weapon carrying (Adj.OR=1.66), forced sex (Adj.OR=2.60), huffing glue (OR=1.63), hard drug use (Adj.OR=2.18), and sports involvement (Adj.OR=1.52) were significantly associated with suicide attempts.

Conclusions: These findings demonstrate similarities and differences in terms of the modifiable risk factors that increase risk for suicide attempts among boys and girls. In terms of the differences between boys and girls, hard drug use and sports involvement may be important factors for suicide prevention strategies that are directed specifically towards boys, while dating violence victimization may be an important risk factor to address for girls. Overall, these findings can help guide prevention, clinical practice, and intervention strategies to prevent suicidal behaviors among adolescents. [West J Emerg Med. 2010; 11(3): 258-264.]

Objective: Dating violence is a significant health problem among youth that leads to adverse health outcomes, including injuries. Reciprocal violence (perpetrated by both partners) is associated with increased injury in adults, but very little is known about the prevalence and context for reciprocal violence, as well as injury rates, among youth. We sought to determine the prevalence and scope of reciprocal dating violence and injury occurrence among urban youth in a high-risk community.

Methods: Analyses were based on data from the Youth Violence Survey, conducted in 2004, and administered to over 80% of public school students in grades 7, 9, 11, and 12 (N=4,131) in a high-risk, urban school district. The current analyses were restricted to those who reported dating in the past year and who also reported any dating violence (n=1,158). Dating violence was categorized as reciprocal (the participant reported both violence perpetration and victimization) and non-reciprocal (the participant report either violence perpetration or victimization, but not both). Results: Dating violence reciprocity varied by sex. Girls who reported any dating violence were more likely to report reciprocal dating violence (50.4%) than were boys (38.9%). However, reciprocity did not vary by race/ethnicity or grade level. Reciprocal dating violence was more common among participants who reported more frequent violence experiences. Reciprocal violence was also associated with greater injury occurrences relative to non-reciprocal relationships (10.1% versus 1.2%).

Conclusion: Reciprocal dating violence is common among adolescents and leads more often to injury outcomes. In particular, relationships in which boys report reciprocal violence against their partner appear to lead to more frequent injury occurrences. These findings underscore the importance of addressing dating violence and factors that increase risk for reciprocal violence and therefore exacerbate injury occurrence. [West J Emerg Med. 2010; 11(3): 265-269.]

Objective: This research report examines the feasibility of identifying eligible trauma patients for a study providing an early therapeutic intervention for the prevention of posttraumatic stress disorder (PTSD), and identifies reasons around participation.

Methods: This prospective observational study used a convenience sample of acute trauma victims presenting to a university-affiliated Level One trauma center in a large southeastern city. Patients eligible to participate in the early intervention study were adults (18- 65) who experienced a traumatic event within 72 hours of presentation, feared that they might be killed or seriously injured during the event, and were able to return for follow up appointments. Patients were excluded if they were non-English speaking; experienced a loss of consciousness greater than 5 minutes; had a history of a serious mental illness or were currently suicidal; or endorsed current substance dependence. Descriptive statistics were conducted to determine differences in ineligible, eligible, and consenting trauma patients who enrolled in the intervention study.

Results: Over a six month period, n =1961 patients presented for treatment of a traumatic injury during study hours. Results showed that eligible patients were significantly younger than ineligible patients. Survivors of assaults (physical and sexual), younger patients, and women were generally more likely to participate in a study offering a psychological intervention in the immediate aftermath of a traumatic event.

Conclusion: Fourteen percent of trauma patients were eligible and entered a study offering an early psychological intervention for the prevention of PTSD. Trauma type, age and gender may play a role in determining preference for receiving psychological services immediately after experiencing a traumatic event. [West J Emerg Med. 2010; 11(3): 275-279.]

Objective: To increase teen seat belt use among drivers at a rural high school by implementing the Drive Alive Pilot Program (DAPP), a theory-driven intervention built on highway safety best practices.

Methods: The first component of the program was 20 observational teen seat belt surveys conducted by volunteer students in a high school parking lot over a 38-month period before and after the month-long intervention. The survey results were published in the newspaper. The second component was the use of incentives, such as gift cards, to promote teen seat belt use. The third component involved disincentives, such as increased police patrol and school policies. The fourth component was a programmatic intervention that focused on education and media coverage of the DAPP program.

Results: Eleven pre-intervention surveys and nine post-intervention surveys were conducted before and after the intervention. The pre- and post-intervention seat belt usage showed significant differences (p<0.0001). The average pre-intervention seat belt usage rate was 51.2%, while the average post-intervention rate was 74.5%. This represents a percentage point increase of 23.3 in seat belt use after the DAPP intervention.

Conclusion: Based on seat belt observational surveys, the DAPP was effective in increasing seat belt use among rural high school teenagers. Utilizing a theory-based program that builds on existing best practices can increase the observed seat belt usage among rural high school students. [West J Emerg Med. 2010; 11(3): 280-283.]

Objective: Alcohol is more likely than any other drug to be involved in substance-related violence. In 2000 violence-related and self-directed injuries accounted for an estimated $37 billion and $33 billion in productivity losses and medical treatment, respectively. A review of emergency department data revealed violence and clinically identified trauma-related injuries have the strongest correlation among alcohol-dependent injuries. At the environmental level there is a relationship between alcohol outlet density and violent crime. A limited number of studies have examined the relationship between alcohol outlet type and the components of violent crime. The aim of this study is to examine the relationship between the aggregate components of violent crime and alcohol outlet density by type of outlet.

Methods: For this study we used Washington, D.C. census tract data from the 2000 census to examine neighborhood characteristics. Alcohol outlet, violent crime, and population-level data for Washington, D.C. were drawn from various official yet publicly available sources. We developed an analytic database to examine the relationship between alcohol outlet category and four types of violent crime. After estimating spatial correlation and determining spatial dependence, we used a negative binomial regression analysis to assess the alcohol availability-violent crime association, while controlling for structural correlates of violence.

Results: Independent of alternative structural correlates of violent crime, including the prevalence of weapons and illicit drugs, community-level alcohol outlet density is significantly associated with assaultive violence. Outlets were significantly related to robbery, assault, and sexual offenses. In addition, the relationship among on-premise and off-premise outlets varied across violent crime categories.

Conclusion: In Washington, D.C., alcohol outlet density is significantly associated with the violent crimes. The science regarding alcohol outlet density and alcohol-related harms has clearly identified the use of limiting outlet density to reduce the associated adverse health consequences. Moreover, the disproportionate burden among poor urban and minority communities underscores the urgency to develop context-appropriate policies to regulate the functioning of current alcohol outlet establishments and to prevent the proliferation of future outlets. [West J Emerg Med. 2010; 11(3): 284-291.]

Objectives: Motor vehicle-pedestrian crash is a significant public health concern. The urban campus of Georgia State University poses unique challenges due to a large number of students and university employees. The objectives of this study are twofold: (1) to examine the correlation between specific features of the built environment on and around the University campus and pedestrian crashes; and (2) to identify crash clusters in the study area using network-based geospatial techniques.

Methods: We obtained pedestrian crash data (n=119) from 2003 to 2007 from Georgia Department of Transportation and evaluated environmental features pertaining to the road infrastructure, pedestrian infrastructure and streetscape for each road segment and intersection. Prevalence rate of each feature with pedestrian crashes present was calculated. We used network-based Kernel Density Estimation to identify the high density road segments and intersections, then used network-based K-function to examine the clustering of pedestrian crashes.

Results: Over 50% of the crosswalk signs, pedestrian signals, public transit, and location branding signs (more than three) at intersections involved pedestrian crashes. More than half of wider streets (greater than 29 feet), two-way streets, and streets in good condition had pedestrian crashes present. Crashes occurred more frequently in road segments with strong street compactness and mixed land use present and were significantly (p<0.05) clustered in these high-density zones.

Conclusions: Findings can be used to understand the correlation between built environment and pedestrian safety, to prioritize the high-density zones for intervention efforts, and to formulate research hypotheses for investigating pedestrian crashes. [West J Emerg Med. 2010; 11(3): 295-302.]

Objectives: The purposes of this exploratory study were to a) describe physical health symptoms and diagnoses in abused immigrant Latinas, b) explore the relationships between the women’s physical health and their experiences of intimate partner violence, their history of childhood trauma, and their immigration status, and c) explore the correlations between their physical health, health related quality of life (HRQOL), and mental health, specifically symptoms of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD).

Methods: The convenience sample (n=33) for this cross-sectional descriptive study consisted of Latino women who were receiving emergency shelter and community-based services at a domestic violence services agency in the northeastern U.S. Pearson product-moment correlation coefficients were used to analyze the relationships between physical health variables and IPV type and severity, childhood and adulthood sexual abuse, and HRQOL.

Results: All of the women experienced threatened abuse. More than two-thirds of the women experienced moderate to severe psychological abuse, moderate to severe physical abuse, and/or sexual abuse. Twenty women experienced all three types. Women endorsed one or more items in neuromuscular (69.7%), gastrointestinal (63.6%), and genitourinary/gynecologic (45.5%) groupings. Pain was the most reported symptom: bodily pain in previous month (60%), repeated neck or back pain (54.5%), severe/frequent headaches (54.5%), and pelvic pain (21.2%). Eighty-one percent of women endorsed at least one pain item (mean=2.56) and the same number reported difficulty falling asleep or staying asleep. Pain and sleeping difficulty, the two most frequently reported symptoms, were consistently and highly correlated with PTSD and MDD diagnoses and symptom severity and HRQOL. Childhood sexual abuse was significantly correlated with total pain symptoms (r=0.606; p=0.000) and difficulty sleeping (from the PTSD scale) (r=0.349; p=0.046). Both pain (r=0.400; p=0.023) and sleeping difficulty (r=0.467; p=0.006) were also strongly correlated with undocumented immigration status.

Conclusion: Detailed assessment of patients with pain and sleep disorders can help identify IPV and its mental health sequelae, PTSD and MDD. Accurate identification of the root causes and pathways of the health burden carried by victims and survivors of IPV, who are vulnerable to persisting health problems without adequate healthcare, is critical in both clinical practice and research. [West J Emerg Med. 2010; 11(3): 248-252.]

Objectives: Internet usage has increased in recent years resulting in a growing number of documented reports of cyberbullying. Despite the rise in cyberbullying incidents, there is a dearth of research regarding high school students’ motivations for cyberbullying. The purpose of this study was to investigate high school students' perceptions of the motivations for cyberbullying.

Method: We undertook an exploratory qualitative study with 20 high school students, conducting individual interviews using a semi-structured interview protocol. Data were analyzed using Grounded Theory.

Results: The developed coding hierarchy provides a framework to conceptualize motivations, which can be used to facilitate future research about motivations and to develop preventive interventions designed to thwart the negative effects of cyberbullying. The findings revealed that high school students more often identified internally motivated reasons for cyberbullying (e.g., redirect feelings) than externally motivated (no consequences, non-confrontational, target was different).

Conclusion: Uncovering the motivations for cyberbullying should promote greater understanding of this phenomenon and potentially reduce the interpersonal violence that can result from it. By providing a framework that begins to clarify the internal and external factors motivating the behavior, there is enhanced potential to develop effective preventive interventions to prevent cyberbullying and its negative effects. [West J Emerg Med. 2010; 11(3): 270-274.]