- Email: [email protected]
Implementation of violence prevention education in clinical settings
pATiENTEChJCATioN md Cmibuc, Patient Education and Counseling 25 (1995) 205-210
Implementation of violence prevention education in clinical settings Alice J. Hausman*a, Deborah Prothrow-Stithb, Howard Spivakc aDepartment of Health Education, 304 Seltzer Hall Temple University, Philadelphia, PA 19122, USA bGovernment and Community Programs, Harvard School of Public Health, Boston, MA, USA ‘Division of Pediatrics, New England Medical Center, Boston, MA, USA Received 27 July 1994; revision received 14 March 1995; accepted 22 March 1995
Abstract Clinical settings provide excellent opportunities for educating adolescent patients about violence prevention. This paper reports on the experience of the Violence Prevention Project of Boston in implementing comprehensive violence prevention activities in different clinical settings. The project’s evaluation revealed that staff training, specializededucational materials and staff commitment are required for both initial and sustained implementation of the education. Waiting room brochures and videos-are inadequate to address the problem. Conversely, clinical settings can host a variety of educational experiencesthat generate significant response from patients, families and friends. Clinical settings can also be integrated into broader community-based efforts. Keywordr:
Violence; Adolescents; Evaluation
efforts to introduce youth violence prevention ac-
1. Introduction
Violence continues to be a major source of death and disability among youth today. Once the responsibility of the criminal justice system and youth workers, now the task of violence prevention education has devolved to medical care providers in different clinical settings in addition to their more traditional
curative roles [ 1,2].
tivities into clinical settings and to integrate these settings into a broad community-based educa-
tional approach to the problem. Quantitative data regarding the implementation of the project have been reported elsewhere [3]. Here, we provide qualitative assessment of factors that impeded or promoted the project’s process of implementing violence prevention education in clinical settings.
This paper presents the experience of the Violence Prevention Project of Boston, MA, in its
2. The Violence Prevention Project
*Corresponding 204 1455.
The Violence Prevention Project (VPP) is a community-based outreach and education project
author, Tel.: (215) 204 5112; Fax: (215)
0738-3991/95/$09.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0738-3991(95)00779-Y
206
A.J.
Hausman
et al. /Patient
Education
directed at the primary prevention of youth violence. The VPP was formally implemented and evaluated from 1987 to 1989. More than a curriculum, the project mounted a full scale social change effort through community level organization and education, providing multiple, reinforcing educational messages about violence prevention. Through community saturation and message reinforcement, the project sought to generate a new community ethos around the unacceptability of violent behavior [4]. Many sites within the two intervention, neighborhoods, selected on the basis of the high rates of homicide, low socio-economic and racial diversity (one was indicators, predominantly Black, the other White), were targeted. Providers within organizations that contacted youth were trained to deliver an adapted version of the Violence Prevention Curriculum for Adolescents [5]. Evaluated separately, [6] the curriculum combines factual information with situational and cost-benefit analyses of violent behavior. Community users were encouraged to modify the format of the curriculum to suit their setting, resulting in a variety of presentations from the full curriculum, to some curriculum sessions, to one-on-one discussions about violence [3]. A media campaign, comprised of tee shirts, posters, brochures, television public service announcements, as well as other audio-visual products, was developed to broadly reinforce the prevention message. Technical assistance for development and implementation of other violence prevention educational activities was also provided to community providers. Because medical clinics offer different opportunities for prevention education than other community sites, neighborhood health centers and the hospital serving the two communities were targeted for staff training. The implementation objectives for health centers included encouraging providers to engage in diagnostic and anticipatory guidance procedures for violence, to refer appropriate cases to counseling services, and to establish and maintain links with other community agencies. Nurses, counselors and mental health providers from neighborhood health centers were trained in the curriculum and received technical assistance. Training for health care providers was tailored to focus more on immediate intervention
and Counseling
25 (1995)
205-210
and referral rather than teaching strategies. Rather than giving new skills, the trainings served to raise awareness and encourage the addition of violence to the rest of the diagnostic and referral protocols
HI. Implementation objectives for the hospital included the creation of new mental health services specific for youthful victims of interpersonal ‘street’ violence. The VPP designated a staff person to develop and administer clinical treatment and referral services. This clinical counselor attended the pediatric floor to counsel adolescent intentional injury patients and recruit them for a regularly meeting counseling group. 3. Methods The data presented here reflect the implementation experience of the VPP project in six clinical sites: five multi-service community health centers and one pediatric inpatient ward of the public ho& pita1 serving the target area. Information was derived from several sources. The VPP staff and researchers from the health department who made up the evaluation team kept detailed records of the implementation process that were organized into client tiles. In addition, VPP staff were interviewed by the evaluation team to till in missing details or clarify historical aspects of the implementation process in particular agencies. Structured, openended interviews with the clinical staff participating in the project were conducted by the evaluation team. Data from all sources were compiled and reviewed for major themes and inspected for specific experiences and factors that influenced the implementation process in clinical settings. A randomly selected 10% sample of all adolescent patients (aged 10-19) attending each of two health centers (one in each community) during the pilot year (5188-4189) was reviewed to provide an objective measure of recorded patient-provider interactions regarding violence. 4. Implementation results 4.1. Community health centers Anticipatory guidance. The review of the medical records revealed that only lOoh of the approx-
A.J.
Hauwnan
et al. /Patient
Education
imately 350 reviewed adolescent visits occurring during the time of VPP implementation included any written reference of a discussion related to violence prevention. Notations were generally simple references to discussion with the patient and contained little content information. These numbers reflect a general failure of providers to engage with their patients on the subject, and/or their failure to record any violence-related interactions in the medical record. The interviews with the providers indicated that they had some confusion about their new function as violence prevention educators, and that they needed more assistance in developing skills to both raise and adequately address the issue of violence with their adolescent patients. While training conducted with the clinical staff attempted to build their educational or teaching skills, it did not use or offer a formal teaching tool with recommended dialogues or procedures. The lack of helpful material and the brevity of the training in educational technique contributed to a condition where anticipatory guidance activity never became a regular part of the adolescent visits. Counseling. Incorporating discussions of conflict resolution strategies into individual and family counseling sessions was a way to implement violence prevention in primary care settings that was more obvious to workers in clinical settings, and at least one health center was successful in this effort. This center started a weekly l-h group counseling session for high school boys identified in the neighborhood school or at the local youth club as in need of more intensive attention for the prevention of future serious violence. As with all mental health services, such groups were difficult to get up and running due to thin resources, appropriate counseling personnel, money and time. The greater difficulty, however, was establishing the inter-personal relationships between provider and patient required to successfully engage the youth to the point of regular attendance to the counseling sessions. As discussed below, there was greater success in engaging youth in the inpatient ward. Inter-agency linkages. Clinical settings do not lend themselves to group educational activities. However, training clinical staff to deliver the prevention curriculum proved to be an important
and Counseling
25 (1995)
205-210
201
component of the larger community effort. One result of participation in the VPP was that neighborhood clinic staff reached out to other community organizations and collaborated in a range of prevention activities. In one case, a health center nurse connected with the youth education director at a local boy’s and girl’s club who had started a special club focusing on violence prevention and where the curriculum was taught. The nurse provided a stable educational resource for the youth club, helping to maintain the effort over time and in the face of staff turn-over. She also recruited club members through the health center. This collaboration supported the violence prevention activities in both sites and provided the kind of inter-agency linkage the VPP viewed as critical for the generation of community-wide consensus around the issue of violence prevention. Another example of inter-agency linkages involving clinics came from the efforts of one health center in training teachers and incorporating violence prevention activities into the curriculum of a local school program (a ‘life skills’ program) administered by staff from the health center. Additionally, the clinic staff offered a ‘death and dying’ seminar in response to a series of student homicides in a neighborhood high school. 4.2. Inpatient settings
The implementation experience for the inpatient ward was very different. The VPP was unable to maintain the clinical treatment services because of the administrative and logistical problems of generating a new service. These included difficulties finding regularly available spaceand transporting students to and from the hospital..Students were also unhappy about coming to the hospital when they weren’t ‘sick’. While this attempt to generate group educational/treatment services .failed, other new educational opportunities arose in the hospital. Participation with the VPP’s clinical counselor stimulated one nurse to develop a means by which the issue of violence prevention could be addressed with the patients she encountered. Based on her efforts, a group of pediatric nurses was trained by the VPP, and a VPP staff-person resumed counseling with injured patients on the floor. Through these efforts, the issue of violence became more a
208
A.J. Hausman et al. /Patient Education and Counseling 2.5 (1995) 205-210
part of the service agenda and nurses’ activities expanded to include direct patient education. For example, the nurses organized showings of a high-quality video, portraying a young man permanently disabled by a bullet, to groups of interested patients and their visitors, who included friends and peers. The presentations were followed by a facilitated discussion period. The nurses reported that their evaluation of the sessions revealed that the experience was powerful for many of the teens. The session served as a catalyst for a majority of these patients to consider violence prevention in a group setting. The hospital’s successful use of a video piece was likely due to applicability of the video’s content to the lives of the viewers, the presentation of the video as a special, facilitated event and the presence of a provider to follow up and help viewers process the video. 5. Factors influencing implementation It is increasingly the case that medical settings are appropriate points of intervention for both primary and secondary prevention of behaviors that have serious health outcomes. While medical personnel are more familiar with the role of screening and referral, even for difficult behaviors such as violence [7], the role of prevention education is still difficult [2]. The experience of the Boston Violence Prevention Project revealed several factors that can be manipulated to facilitate the implementation of violence prevention activities in clinical settings. These are related to staff awareness, administrative factors, key personnel and specialized materials. 5.1. Awareness of the problerrf During the implementation of the project, a new, unanticipated objective emerged: in order for providers to successfully engage in violence prevention, they needed to be aware of the extent of the problem among their own service population. While this phenomenon held for providers of all types, the extent to which even health care personnel needed education became evident. For example, in an effort to measure the extent of fighting behavior among the adolescent patients in the health centers serving each of the target
neighborhoods, nurses were asked to query patients with three questions: had they fought within the past 2 weeks, had they been hurt, and had they sought medical care? As a data source, the system failed. Consistency of asking questions could not be maintained, and it was difficult to establish the relevant population denominators from clinic records. However, the questions did serve to increase the clinic staffs awareness of the extent of violence exposure among their patients, particularly girls. Providers also recognized the utility of the questions in broaching the subject of violence with their patients and continued to use them as part of their usual visit routine. A similar situation occurred in the hospital emergency room, where the evaluation attempted to institute an intentional injury surveillance system, under which triage nurses and nurse managers were to fill out a short form gathering information about the injury-causing event from all intentionally injured patients. Here too, consistency and reliability of application of the questionnaires could not be maintained, and the system failed to generate epidemiologically useful data. However, discussions with the nurses about problems with the data collection protocol revealed that it was more difficult to ask patients questions about violence than we had anticipated. Their responses indicated that their personal concerns about violence, personal safety, and the lack of services for victims of violence that was not sexual assault or child abuse, contributed to their avoidance of asking questions. They felt there was nothing they could do for that patient after revealing the nature of the injury-causing event, so it seemed pointless to ask. 5.2. Commitment by arlministration As with all special programs, commitment for support by the administration is critical. The VPP found that centers that were similar in terms of organization, resource base and commitment to the community, were very different in their willingness to adopt and maintain violence prevention as a major part of their agenda. With the same amount of technical support, one health center moved forward and took great initiative and another failed to fully integrate violence prevention into its agen-
A.J.
Hausnum
et al. /Patient
Education
da. In times of fiscal crisis, such adjunct programs will be particularly vulnerable to streamlining or elimination. Conversely, in. the new environment of medical care reform, there may be even greater opportunity for these initiatives. 5.3. Personnel
As with many educational programs that deal with sensitive subjects, it is critical to provide training and support for personnel. Individuals with previous experience should be sought out and engaged fully in the implementation of any prevention initiative. Their comfort and skill will serve both to model and support the efforts of less experienced staff. Although the VPP shied away from formal trainings for clinical staff out of respect for time constraints, it appears that such trainings would have been appropriate and should have been pursued. As was the experience in other community sites, training was the main tool by which staff increased their comfort and ability to address the topic with their clients. Indeed, increasing the emphasis on prevention for clinical staff during their professional training years (e.g. medical or nursing school) is an important part of implementation for any prevention initiative [2].
and Counseling
25 (1995)
205-210
209
As noted above, health care providers indicated that written guidelines would help them engage violence assessment and guidance interactions with their patients as a regular part of their medical appointments. In response, the VPP and Education Development Center, Inc. developed a protocol for clinical settings [8]. The booklet and training slide presentation guide the provider through the interview and counseling process. It includes a special sticker for the medical record to assist in recording the content of the preventive interaction for future intervention with the patient. The protocol has been field tested in a total of five clinical sites and has been well received. 6. Conclusion In summary, a comparison of the two healthcare settings, neighborhood health centers and hospitals, reveals strengths and weaknesses of both settings for involvement in violence prevention (Table 1). In the hospital setting, the longer period of contact, the intimacy and potential for forging personal bonds between provider and patient, and the opportunity to contact and involve a wide circle of acquaintances, can make this an unusually fruitful place into which to introduce
5.4. Specialized material
Video materials can be useful in promoting violence prevention in the health center environment. However, as the hospital experience demonstrated, attention needs to be given to their content and to the context in which these videos are being presented. While this study does not address the impact of media education on outcomes such as knowledge and attitudes, we can say that the format of presentation clearly affects implementation of the education. Messages are more likely to be heard if high quality materials are delivered in structured settings with time for discussion and commentary. In the Boston experience, simply playing videos in the waiting room did not appear to have any impact nor was it perceived as a positive activity by the health center staff. However, the use of a high quality video with facilitated discussion seemed to be rewarding to both patients and staff.
Table 1 Table of practical implications 1. 2.
3.
4.
5.
Traditional waiting room educational materials such as brochures and videos are inadequate to address the prevention of violence among youthful patients. Anticipatory guidance around violence prevention can be routinely implemented during primary care visits with the provision of specialized written materials and provider training. Group educational experiences using high quality videos and facilitated discussions can be successfully implemented and used as a basis for follow-up education and/or counseling with injured youths and their families. Mental health services specific for adolescent patients injured by interpersonal conflicts are requited to both address the problem fully for those youths and to support the prevention efforts conducted by the clinical staff. Clinical settings can be successfully linked with other community agencies to support and facilitate violence prevention efforts.
210
A.J.
Hausman
et al. /Patient
Education
prevention. On the other hand, many more adolescents can be contacted during primary care visits, and the message of concern about the well-being of the youth can provide a long-term positive influence on risk avoidance. Clearly, there is a role for each setting in the prevention of youth violence. Acknowledgements This work was funded by the Henry J. Kaiser Family Foundation. The authors would like to thank James Roeber and Howard Jacobson for their help in preparing this manuscript. References (11 Spivak H, Prothrow-Stith D, Hausman AJ. Dying is no accident. Pediatr Clin North Am 1988; 35(6): 1339-1347.
and Counseling
25 (1995)
205-210
[2] Prothrow-Stith D. Can physicians help curb adolescent violence? Hosp Pratt June 15, 1992; 193-207. [3] Hausman AJ, Spivak H, Prothrow-Stith D, Roe&r J. Patterns of teen exposure to a community-based violence prevention project. J Adolescent Health 1992; 13: 668-675. [4] Prothrow-Stith D, Spivak H, Hausman AJ. The violence prevention proiect: a uublic health aomoach. Science. Technol Hum Values i987; 12: 67-69: [5] Prothrow-Stith D. Violence Prevention Curriculum for Adolescents. Newton, MA: Education Development Center, Inc., 1987. [6] Education Development Center, Inc. Preventing interpersonal violence among teens: field test and evaluation. (Unpublished manuscript). Newton, MA: EDC, 1989. 171 Copoulos E, Hein K. Delinquency and the pediatrician. Pediatrics in Review 1982; 4(5): 156-162. [8] Violence Prevention Project. Identification and Prevention of Youth Violence: a protocol package for health care providers. With Education Development Center and funded by the Maternal and Child Health Bureau, USDHHS, 1992.
Implementation of violence prevention education in clinical settings Alice J. Hausman*a, Deborah Prothrow-Stithb, Howard Spivakc aDepartment of Health Education, 304 Seltzer Hall Temple University, Philadelphia, PA 19122, USA bGovernment and Community Programs, Harvard School of Public Health, Boston, MA, USA ‘Division of Pediatrics, New England Medical Center, Boston, MA, USA Received 27 July 1994; revision received 14 March 1995; accepted 22 March 1995
Abstract Clinical settings provide excellent opportunities for educating adolescent patients about violence prevention. This paper reports on the experience of the Violence Prevention Project of Boston in implementing comprehensive violence prevention activities in different clinical settings. The project’s evaluation revealed that staff training, specializededucational materials and staff commitment are required for both initial and sustained implementation of the education. Waiting room brochures and videos-are inadequate to address the problem. Conversely, clinical settings can host a variety of educational experiencesthat generate significant response from patients, families and friends. Clinical settings can also be integrated into broader community-based efforts. Keywordr:
Violence; Adolescents; Evaluation
efforts to introduce youth violence prevention ac-
1. Introduction
Violence continues to be a major source of death and disability among youth today. Once the responsibility of the criminal justice system and youth workers, now the task of violence prevention education has devolved to medical care providers in different clinical settings in addition to their more traditional
curative roles [ 1,2].
tivities into clinical settings and to integrate these settings into a broad community-based educa-
tional approach to the problem. Quantitative data regarding the implementation of the project have been reported elsewhere [3]. Here, we provide qualitative assessment of factors that impeded or promoted the project’s process of implementing violence prevention education in clinical settings.
This paper presents the experience of the Violence Prevention Project of Boston, MA, in its
2. The Violence Prevention Project
*Corresponding 204 1455.
The Violence Prevention Project (VPP) is a community-based outreach and education project
author, Tel.: (215) 204 5112; Fax: (215)
0738-3991/95/$09.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0738-3991(95)00779-Y
206
A.J.
Hausman
et al. /Patient
Education
directed at the primary prevention of youth violence. The VPP was formally implemented and evaluated from 1987 to 1989. More than a curriculum, the project mounted a full scale social change effort through community level organization and education, providing multiple, reinforcing educational messages about violence prevention. Through community saturation and message reinforcement, the project sought to generate a new community ethos around the unacceptability of violent behavior [4]. Many sites within the two intervention, neighborhoods, selected on the basis of the high rates of homicide, low socio-economic and racial diversity (one was indicators, predominantly Black, the other White), were targeted. Providers within organizations that contacted youth were trained to deliver an adapted version of the Violence Prevention Curriculum for Adolescents [5]. Evaluated separately, [6] the curriculum combines factual information with situational and cost-benefit analyses of violent behavior. Community users were encouraged to modify the format of the curriculum to suit their setting, resulting in a variety of presentations from the full curriculum, to some curriculum sessions, to one-on-one discussions about violence [3]. A media campaign, comprised of tee shirts, posters, brochures, television public service announcements, as well as other audio-visual products, was developed to broadly reinforce the prevention message. Technical assistance for development and implementation of other violence prevention educational activities was also provided to community providers. Because medical clinics offer different opportunities for prevention education than other community sites, neighborhood health centers and the hospital serving the two communities were targeted for staff training. The implementation objectives for health centers included encouraging providers to engage in diagnostic and anticipatory guidance procedures for violence, to refer appropriate cases to counseling services, and to establish and maintain links with other community agencies. Nurses, counselors and mental health providers from neighborhood health centers were trained in the curriculum and received technical assistance. Training for health care providers was tailored to focus more on immediate intervention
and Counseling
25 (1995)
205-210
and referral rather than teaching strategies. Rather than giving new skills, the trainings served to raise awareness and encourage the addition of violence to the rest of the diagnostic and referral protocols
HI. Implementation objectives for the hospital included the creation of new mental health services specific for youthful victims of interpersonal ‘street’ violence. The VPP designated a staff person to develop and administer clinical treatment and referral services. This clinical counselor attended the pediatric floor to counsel adolescent intentional injury patients and recruit them for a regularly meeting counseling group. 3. Methods The data presented here reflect the implementation experience of the VPP project in six clinical sites: five multi-service community health centers and one pediatric inpatient ward of the public ho& pita1 serving the target area. Information was derived from several sources. The VPP staff and researchers from the health department who made up the evaluation team kept detailed records of the implementation process that were organized into client tiles. In addition, VPP staff were interviewed by the evaluation team to till in missing details or clarify historical aspects of the implementation process in particular agencies. Structured, openended interviews with the clinical staff participating in the project were conducted by the evaluation team. Data from all sources were compiled and reviewed for major themes and inspected for specific experiences and factors that influenced the implementation process in clinical settings. A randomly selected 10% sample of all adolescent patients (aged 10-19) attending each of two health centers (one in each community) during the pilot year (5188-4189) was reviewed to provide an objective measure of recorded patient-provider interactions regarding violence. 4. Implementation results 4.1. Community health centers Anticipatory guidance. The review of the medical records revealed that only lOoh of the approx-
A.J.
Hauwnan
et al. /Patient
Education
imately 350 reviewed adolescent visits occurring during the time of VPP implementation included any written reference of a discussion related to violence prevention. Notations were generally simple references to discussion with the patient and contained little content information. These numbers reflect a general failure of providers to engage with their patients on the subject, and/or their failure to record any violence-related interactions in the medical record. The interviews with the providers indicated that they had some confusion about their new function as violence prevention educators, and that they needed more assistance in developing skills to both raise and adequately address the issue of violence with their adolescent patients. While training conducted with the clinical staff attempted to build their educational or teaching skills, it did not use or offer a formal teaching tool with recommended dialogues or procedures. The lack of helpful material and the brevity of the training in educational technique contributed to a condition where anticipatory guidance activity never became a regular part of the adolescent visits. Counseling. Incorporating discussions of conflict resolution strategies into individual and family counseling sessions was a way to implement violence prevention in primary care settings that was more obvious to workers in clinical settings, and at least one health center was successful in this effort. This center started a weekly l-h group counseling session for high school boys identified in the neighborhood school or at the local youth club as in need of more intensive attention for the prevention of future serious violence. As with all mental health services, such groups were difficult to get up and running due to thin resources, appropriate counseling personnel, money and time. The greater difficulty, however, was establishing the inter-personal relationships between provider and patient required to successfully engage the youth to the point of regular attendance to the counseling sessions. As discussed below, there was greater success in engaging youth in the inpatient ward. Inter-agency linkages. Clinical settings do not lend themselves to group educational activities. However, training clinical staff to deliver the prevention curriculum proved to be an important
and Counseling
25 (1995)
205-210
201
component of the larger community effort. One result of participation in the VPP was that neighborhood clinic staff reached out to other community organizations and collaborated in a range of prevention activities. In one case, a health center nurse connected with the youth education director at a local boy’s and girl’s club who had started a special club focusing on violence prevention and where the curriculum was taught. The nurse provided a stable educational resource for the youth club, helping to maintain the effort over time and in the face of staff turn-over. She also recruited club members through the health center. This collaboration supported the violence prevention activities in both sites and provided the kind of inter-agency linkage the VPP viewed as critical for the generation of community-wide consensus around the issue of violence prevention. Another example of inter-agency linkages involving clinics came from the efforts of one health center in training teachers and incorporating violence prevention activities into the curriculum of a local school program (a ‘life skills’ program) administered by staff from the health center. Additionally, the clinic staff offered a ‘death and dying’ seminar in response to a series of student homicides in a neighborhood high school. 4.2. Inpatient settings
The implementation experience for the inpatient ward was very different. The VPP was unable to maintain the clinical treatment services because of the administrative and logistical problems of generating a new service. These included difficulties finding regularly available spaceand transporting students to and from the hospital..Students were also unhappy about coming to the hospital when they weren’t ‘sick’. While this attempt to generate group educational/treatment services .failed, other new educational opportunities arose in the hospital. Participation with the VPP’s clinical counselor stimulated one nurse to develop a means by which the issue of violence prevention could be addressed with the patients she encountered. Based on her efforts, a group of pediatric nurses was trained by the VPP, and a VPP staff-person resumed counseling with injured patients on the floor. Through these efforts, the issue of violence became more a
208
A.J. Hausman et al. /Patient Education and Counseling 2.5 (1995) 205-210
part of the service agenda and nurses’ activities expanded to include direct patient education. For example, the nurses organized showings of a high-quality video, portraying a young man permanently disabled by a bullet, to groups of interested patients and their visitors, who included friends and peers. The presentations were followed by a facilitated discussion period. The nurses reported that their evaluation of the sessions revealed that the experience was powerful for many of the teens. The session served as a catalyst for a majority of these patients to consider violence prevention in a group setting. The hospital’s successful use of a video piece was likely due to applicability of the video’s content to the lives of the viewers, the presentation of the video as a special, facilitated event and the presence of a provider to follow up and help viewers process the video. 5. Factors influencing implementation It is increasingly the case that medical settings are appropriate points of intervention for both primary and secondary prevention of behaviors that have serious health outcomes. While medical personnel are more familiar with the role of screening and referral, even for difficult behaviors such as violence [7], the role of prevention education is still difficult [2]. The experience of the Boston Violence Prevention Project revealed several factors that can be manipulated to facilitate the implementation of violence prevention activities in clinical settings. These are related to staff awareness, administrative factors, key personnel and specialized materials. 5.1. Awareness of the problerrf During the implementation of the project, a new, unanticipated objective emerged: in order for providers to successfully engage in violence prevention, they needed to be aware of the extent of the problem among their own service population. While this phenomenon held for providers of all types, the extent to which even health care personnel needed education became evident. For example, in an effort to measure the extent of fighting behavior among the adolescent patients in the health centers serving each of the target
neighborhoods, nurses were asked to query patients with three questions: had they fought within the past 2 weeks, had they been hurt, and had they sought medical care? As a data source, the system failed. Consistency of asking questions could not be maintained, and it was difficult to establish the relevant population denominators from clinic records. However, the questions did serve to increase the clinic staffs awareness of the extent of violence exposure among their patients, particularly girls. Providers also recognized the utility of the questions in broaching the subject of violence with their patients and continued to use them as part of their usual visit routine. A similar situation occurred in the hospital emergency room, where the evaluation attempted to institute an intentional injury surveillance system, under which triage nurses and nurse managers were to fill out a short form gathering information about the injury-causing event from all intentionally injured patients. Here too, consistency and reliability of application of the questionnaires could not be maintained, and the system failed to generate epidemiologically useful data. However, discussions with the nurses about problems with the data collection protocol revealed that it was more difficult to ask patients questions about violence than we had anticipated. Their responses indicated that their personal concerns about violence, personal safety, and the lack of services for victims of violence that was not sexual assault or child abuse, contributed to their avoidance of asking questions. They felt there was nothing they could do for that patient after revealing the nature of the injury-causing event, so it seemed pointless to ask. 5.2. Commitment by arlministration As with all special programs, commitment for support by the administration is critical. The VPP found that centers that were similar in terms of organization, resource base and commitment to the community, were very different in their willingness to adopt and maintain violence prevention as a major part of their agenda. With the same amount of technical support, one health center moved forward and took great initiative and another failed to fully integrate violence prevention into its agen-
A.J.
Hausnum
et al. /Patient
Education
da. In times of fiscal crisis, such adjunct programs will be particularly vulnerable to streamlining or elimination. Conversely, in. the new environment of medical care reform, there may be even greater opportunity for these initiatives. 5.3. Personnel
As with many educational programs that deal with sensitive subjects, it is critical to provide training and support for personnel. Individuals with previous experience should be sought out and engaged fully in the implementation of any prevention initiative. Their comfort and skill will serve both to model and support the efforts of less experienced staff. Although the VPP shied away from formal trainings for clinical staff out of respect for time constraints, it appears that such trainings would have been appropriate and should have been pursued. As was the experience in other community sites, training was the main tool by which staff increased their comfort and ability to address the topic with their clients. Indeed, increasing the emphasis on prevention for clinical staff during their professional training years (e.g. medical or nursing school) is an important part of implementation for any prevention initiative [2].
and Counseling
25 (1995)
205-210
209
As noted above, health care providers indicated that written guidelines would help them engage violence assessment and guidance interactions with their patients as a regular part of their medical appointments. In response, the VPP and Education Development Center, Inc. developed a protocol for clinical settings [8]. The booklet and training slide presentation guide the provider through the interview and counseling process. It includes a special sticker for the medical record to assist in recording the content of the preventive interaction for future intervention with the patient. The protocol has been field tested in a total of five clinical sites and has been well received. 6. Conclusion In summary, a comparison of the two healthcare settings, neighborhood health centers and hospitals, reveals strengths and weaknesses of both settings for involvement in violence prevention (Table 1). In the hospital setting, the longer period of contact, the intimacy and potential for forging personal bonds between provider and patient, and the opportunity to contact and involve a wide circle of acquaintances, can make this an unusually fruitful place into which to introduce
5.4. Specialized material
Video materials can be useful in promoting violence prevention in the health center environment. However, as the hospital experience demonstrated, attention needs to be given to their content and to the context in which these videos are being presented. While this study does not address the impact of media education on outcomes such as knowledge and attitudes, we can say that the format of presentation clearly affects implementation of the education. Messages are more likely to be heard if high quality materials are delivered in structured settings with time for discussion and commentary. In the Boston experience, simply playing videos in the waiting room did not appear to have any impact nor was it perceived as a positive activity by the health center staff. However, the use of a high quality video with facilitated discussion seemed to be rewarding to both patients and staff.
Table 1 Table of practical implications 1. 2.
3.
4.
5.
Traditional waiting room educational materials such as brochures and videos are inadequate to address the prevention of violence among youthful patients. Anticipatory guidance around violence prevention can be routinely implemented during primary care visits with the provision of specialized written materials and provider training. Group educational experiences using high quality videos and facilitated discussions can be successfully implemented and used as a basis for follow-up education and/or counseling with injured youths and their families. Mental health services specific for adolescent patients injured by interpersonal conflicts are requited to both address the problem fully for those youths and to support the prevention efforts conducted by the clinical staff. Clinical settings can be successfully linked with other community agencies to support and facilitate violence prevention efforts.
210
A.J.
Hausman
et al. /Patient
Education
prevention. On the other hand, many more adolescents can be contacted during primary care visits, and the message of concern about the well-being of the youth can provide a long-term positive influence on risk avoidance. Clearly, there is a role for each setting in the prevention of youth violence. Acknowledgements This work was funded by the Henry J. Kaiser Family Foundation. The authors would like to thank James Roeber and Howard Jacobson for their help in preparing this manuscript. References (11 Spivak H, Prothrow-Stith D, Hausman AJ. Dying is no accident. Pediatr Clin North Am 1988; 35(6): 1339-1347.
and Counseling
25 (1995)
205-210
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