Caught in the Crossfire: The Effects of a Peer-based Intervention Program for Violently Injured Youth

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1 JOURNAL OF ADOLESCENT HEALTH 2004;34: ORIGINAL ARTICLE Caught in the Crossfire: The Effets of a Peer-based Intervention Program for Violently Injured Youth MARLA G. BECKER, M.P.H., JEFFERY S. HALL, M.A., CAESAR M. URSIC, M.D., SONIA JAIN, M.P.H., AND DEANE CALHOUN, M.A. Purpose: To assess the effet of a hospital-based peer intervention program serving youth who have been hospitalized for violent injuries on partiipant involvement in the riminal justie system and violent reinjury and death after hospital disharge. Methods: A total of 112 violently injured youth (ages years; 80% male; predominantly Afrian-Amerian [60%] and Latino [26%]) hospitalized in Oakland, California partiipated in a retrospetive ase ontrol study. Clients were mathed by age and injury severity. Treatment and ontrol youth were followed for 6 months after their individual dates of injury. The outome variables of rate of entry/reentry into the riminal justie system, rate of rehospitalization for violent injuries and rate of violene-related deaths were ompared for treatment and ontrol groups using an odds ratio analysis. Results: Intervention youth were 70% less likely to be arrested for any offense (odds ratio [OR] 0.257) and 60% less likely to have any riminal involvement (OR 0.356) when ompared with ontrols. No statistially signifiant differenes were found for rates of reinjury or death. Conlusion: A peer-based program that intervenes immediately after, or very soon after, youth are violently injured an diretly redue at-risk youth involvement in the riminal justie system. Soiety for Adolesent Mediine, 2004 KEY WORDS: Adolesene Community health From the Department of Surgery, University of California San Franiso East Bay, Oakland, California and Youth ALIVE!, Oakland, California. Address orrespondene to: Marla Beker, Youth ALIVE!, 3300 Elm Street, Oakland, CA mbeker@youthalive.org Manusript aepted April 12, Urban health Violene prevention Violene Youth violene prevention Youth violene Violene ontinues to plague our soiety and is a serious publi health problem that results in loss of life, injury, disability, suffering, and expenditure of billions of dollars in treatment of vitims and inareration of perpetrators eah year [1 5]. Young people ontinue to be disproportionately represented as vitims of violent injuries and deaths. In 2000, adolesents aged years were more than twie as likely to be injured in violene-related inidents at a rate of per 100,000 ompared with the overall U.S. population [6]. Homiide is the seond leading ause of death for Amerians aged 15 to 24 years [7]. In 1999, young people in this age ategory died as a result of homiide at a rate of 13.2 per 100,000, more than twie the rate for the general population [8]. Homiide is the leading ause of death for young Afrian-Amerian males aged years, who are murdered at a rate of 85.1 per 100,000 [9]. This rate is eight times higher than the rate for young Cauasian males of the same age [10]. The homiide rate in Oakland, California, at 30 murders per 100,000 people, is the highest in the County of Alameda [11] and is more than five times the nation s average homiide rate [7]. Homiide is the leading ause of death for males aged years in Oakland [11]. Being a vitim of violene during adolesene inreases the odds of being a perpetrator or vitim of violene in adulthood [12]. Furthermore, a reent study suggests that riminal involvement plaes an Soiety for Adolesent Mediine, X/04/$ see front matter Published by Elsevier In., 360 Park Avenue South, New York, NY doi: /j.jadohealth

2 178 BECKER ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 3 individual at inreased risk of subsequent homiide vitimization [13,14]. A number of fators inrease the risk of perpetration of violene during adolesene and young adulthood, inluding negative peer influenes, family disruption, and soial isolation [1,5,15,16]. Effetive long-term violene prevention requires multidisiplinary approahes, involving families and ommunities, that address both the underlying roots of the problem and the day-to-day manifestations [17], and that treat individuals within a omplex of an interonneted system [18]. However, speifi violene prevention efforts an mitigate the effets of some risk fators, at least for the short term [19]. The present evaluation of the Caught in the Crossfire program was onduted from 1998 to 2001 to examine the effet of the program on three key outomes: (a) rate of entry/reentry into the riminal justie system; (b) rate of rehospitalization for violent injuries; and () rate of violene-related deaths. These outomes are diretly related to the primary goals of the program: (a) prevent retaliatory violene; (b) redue entry and reentry into the riminal justie system; () redue the total number of youth injured and killed by interpersonal violene; (d) promote alternatives to violene for youth; and (e) provide positive peer role models. The results of this study may have signifiant impliations for designing future interventions for youth injured by violene in urban areas. Methods Program Desription Caught in the Crossfire is a peer-based violene prevention intervention program serving youth who have been hospitalized in Oakland, California for violent injuries. Established in 1994, Caught in the Crossfire is prediated on the importane of intervening with violently injured youth at the right time and with the right person to maximally ahieve the program s goals. The program employs and trains young adults who are from the same or similar ommunities as the youth whih they serve and who have experiened violene in their own lives; some of these peer staff members have been formerly inarerated or are disabled from a violent injury. These Crisis Intervention Speialists serve as positive peer role models and are partiularly qualified to establish trusting mentoring relationships with highest risk and hardest-to-reah youth. Crisis Intervention Speialists meet with the youth and their family and friends immediately after, or very soon after, the youth have been hospitalized for a violent injury (often for lose to 2 hours), a pivotal period in the young person s life in whih he or she may be most likely to make a lifestyle hange. Caught in the Crossfire Crisis Intervention Speialists ondut initial visits at the hospital bedside whenever possible (for youth who are hospitalized for only a brief period of time these initial visits are onduted at the individual s home postdisharge) and provide ongoing intensive follow-up servies to the youth and their family members, inluding home visits, referrals to ommunity servies, and assistane with job plaement, ourt and probation hearings, shool enrollment, and housing. Staff members work losely with the youth and their families for up to 1 year. Crisis Intervention Speialists reeive training in ounseling skills development, ultural ompeteny, anger management, onflit resolution, effetive ommuniation, resoure identifiation, sexual assault, and the theoretial frameworks of ounseling, asework, ommunity soial work, and youth development. New staff members reeive intensive training in these areas during their first month of employment and all staff partiipates in ongoing in-servie training sessions. Evaluation Design This outome evaluation of the Caught in the Crossfire program is a retrospetive ase ontrol study in whih lients of an intervention were mathed by age and by injury severity to equivalent youth who did not reeive the intervention [20]. Owing to ethial reasons, the intervention was not withheld from any violently injured youth during the intervention period. Controls were overseleted from violently injured youth in 1998 who had not reeived intervention servies from the program and then arefully mathed to members of the treatment group by age and injury severity to minimize seletion bias. The evaluation was designed with the intent of assessing the intervention s overall effets. Members of the treatment and ontrol groups were followed for 6 months after their individual dates of injury. Probation, arrest, violent injury, and violent death data for both groups were olleted, analyzed, and ompared. This study was reviewed and approved by the Alameda County Medial Center Committee for the Protetion of Human Subjets.

3 Marh 2004 PEER INTERVENTION FOR INJURED YOUTH 179 Study Sample Using a ase ontrol study design, youth hospitalized for violent injuries at Alameda County Medial Center/Highland General Hospital in Oakland, California were seleted to partiipate in the study. Youth in both the treatment and ontrol groups had an average hospital stay of 3.39 days and an average injury severity sore of 7.94 out of a 1 36 (minimum to maximum) point sale. All inoming lients were seleted to be part of the treatment group. Initially, ontrols were seleted randomly and 69 ontrols were mathed to 69 treatment ases by age and injury severity. However, 23 treatment group youth were eliminated from the evaluation, given that they did not meet inlusion riteria for the study, and three youth delined to partiipate in the intervention. A final total of 112 youth partiipated in the study. The sample is omprised of 69 ontrols (61.6%) and 43 treated ases (38.4%). Caught in the Crossfire staff approahed 69 youth ages 12 through 20 years hospitalized for a violent injury (i.e., trauma admits ) between January 1999 and May 2000 for partiipation in the intervention program. Of these youth, more than 95% agreed to partiipate in the program. To ensure that eah partiipant met the inlusion riteria, data for 10 partiipants were exluded from the final database, as they were trauma onsults and not trauma admits. Furthermore, in order for lients to be eligible for inlusion in the study, they were required to suessfully omplete the Caught in the Crossfire program. Suessful ompletion of the program was defined as a minimum of three ontats with a Crisis Intervention Speialist within 6 months of injury, at least one of these being an in-person ontat (on average, members of the treatment group had 5.14 in-person ontats and telephone ontats with a Crisis Intervention Speialist during the 6-month period). Out of 56 youth, eight partiipants were exluded based on this riterion. Thus, 86% of eligible lients who joined Caught in the Crossfire suessfully ompleted the program. In addition, data for five youth were exluded owing to signifiant missing data, resulting in a net total of 43 eligible treatment ases. Among the treatment group, 72% (n 31) were referred to Caught in the Crossfire while in the hospital, and 28% (n 12) were referred to the Caught in the Crossfire program after being disharged. Control group partiipants were seleted randomly from youth ages 12 through 20 years who were hospitalized for a violent injury and survived the previous year (January 1998 through Deember 1998). These youth did not reeive servies from Caught in the Crossfire and were arefully mathed by age and injury severity to members of the treatment group. A 17-month reruitment period for members of the treatment group was neessary to ahieve a large enough sample size (n 40) to ondut statistial analyses. Data Colletion and Analysis All lient information was kept stritly onfidential and analysis was onduted on aggregated data. Baseline data, inluding demographis, injury harateristis, and medial information, were olleted from loal hospital trauma enters medial reords. Median household inome information was obtained for all study partiipants using 1990 ensus postal ode data. Youth provided postal ode information at the time of hospital admission. Death, probation, and arrest data were provided by reords from the Alameda County Coroner s Offie, the County Probation Department, and the Oakland Polie Department, respetively. Quality and auray of the olleted data was assured by reonfirming deaths with the oroner s offie, reheking hospital or other reords for questionable data (e.g. high injury severity sores), ompleting missing information whenever possible through ase notes or other soures, and finally, exluding all ases that had signifiant missing information. The age of the youth was alulated based on age at time of hospital admission. All data analysis was double-heked by an epidemiologist at the Alameda County Publi Health Department. Software Pakage for Statistial Signifiane (SPSS) version 10.0 (Chiago, IL: SPSS In., 1998.) was used for statistial analysis. Simple frequenies of events in the treatment and ontrol groups were first alulated. Independent sample Student s t-test or Analyses of Variane (ANOVA) was performed to determine whether the differene in various demographi, soial, injury harateristis was signifiant between the two groups. Mantel-Haenszel Common Odds ratios were alulated, whih estimate the relative risk for members of the treatment group ompared with members of the ontrol group for being arrested during the intervention period, as well as for other outomes [21]. The 95% onfidene limits around the odds ratios, based on a proedure developed by Cornfield and later modified by Gart [22], were alulated to estimate the preision of the relative risk estimates. Owing to the relatively small

4 180 BECKER ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 3 sample size, partiularly among the treatment group (n 43), speifi stratified analysis ould not be onduted and in some ategories multivariate analyses that would take into aount two or more variables were not always feasible. Results Youth Charateristis No signifiant differene in raial/ethni or age omposition exists between treatment and ontrol groups: predominantly Afrian-Amerian (60.0%), followed by Latinos (25.9%), a few Asian/Paifi Islanders (8.0%) and the rest of Other rae/ethniity (6.1%). The average age of partiipants at the time of admission to the hospital was 18.3 years, with a range of 12 to 20 years. In both groups, the majority (61.6%) of partiipants were age 18 years or above and most were male (80%). Youth in the treatment and ontrol groups have similar soioeonomi bakgrounds. Most were residents of Oakland. No statistially signifiant differenes in median household inome were found between ontrol and treatment groups (approximately $27,000). The evaluators examined histories of arrest for general and violene-related offenses before the evaluation period and found no signifiant differene in prior arrests among the treatment versus ontrol groups. In fat, members of the treatment group displayed slightly higher rates of prior arrests than members of the ontrol group (53.5% vs. 52.2%) and more members of the treatment group ompared with ontrols were arrested for a violene-related offense before the evaluation period (35% vs. 26%). Of the treatment group, 67.4% of the members were vitims of firearm violene and one youth suffered from an aidental self-inflited shooting. Controls were one-third less likely to be vitims of firearm violene, with only 47.8% being treated for a gunshot wound. Only 15.2% of youth in both groups were involved in a brawl. Stabbing was the mehanism of injury for more ontrols (21.7%) than for members of the treatment group (9.3%). Use of blunt instrument was also muh more ommon among ontrols (11.6%) than among members of the treatment group (2.3%). Figure 1. Arrest rates prior to 6-month postinjury evaluation period. Odds ratios 1.054; 95% CI 0.492, p value is insignifiant. resulted in redution of youth (re-) entering the riminal justie system as measured by arrest rates. Intervention results were signifiant for this outome. The intervention program demonstrated a protetive effet for members of the treatment group. Youth who partiipated in Caught in the Crossfire were 70% less likely (OR 0.257; 95% CI 0.054, 1.223) to be arrested for any offense 6 months postinjury when ompared with youth in the ontrol group. Almost 12% of the total 112 youth were arrested during this evaluation period, of whih 87% were members of the ontrol group (Figures 1 and 2). The odds of having any riminal outome were also signifiantly redued for members of the treatment group, even after ontrolling for the severity of the injury (Table 1). The evaluation examined the likelihood that study partiipants were plaed on formal or informal probation, violated probation, and/or were arrested during the evaluation period. This also inreased the numbers in the outome variable, enhaning the power of the study and providing a more reliable estimate of the outome in relationship to the risk fators. Of the 112 total youth, 13.4% had at least one riminal outome during the intervention period; 80% of these youth were members of the ontrol Redution in Rate of Entry and Reentry Into the Criminal Justie System One of the outomes measured in this study was whether being treated by Caught in the Crossfire Figure 2. Arrest rates during 6-month postinjury evaluation period. Odds ratios 0.257; 95% CI 0.54, p

5 Marh 2004 PEER INTERVENTION FOR INJURED YOUTH 181 Table 1. Outomes of Treatment by Caught in the Crossfire vs. Control Group During the Evaluation Period a All n 112 Treatment Group n 43 Control Group n 69 Odds Ratio (95% CI) b Arrested during evaluation period (%) ( ) violene-related (%) At least one riminal outome d (%) ( ) Plaed on in/formal probation (%) ( ) Violated probation (%) violene-related offense (%) Hospitalized for violene-related injury (%) Died as a result of violene-related injury (%) a Evaluation period 6 months following date of injury. b Odds Ratio (OR) is based on the Mantel-Haenszel test; it is a (estimate) ratio of the odds of having an adverse outome if a youth is treated by Caught in the Crossfire ompared to the odds of having an adverse outome if not treated by Caught in the Crossfire. OR 1 means that treatment is protetive. Unreliable Odds ratio, numbers in ells less than 5. d Arrested, violated probation, or plaed on in/formal probation during the evaluation period. group. The ontrols had a 60% greater rate of a riminal outome than members of the treatment group (OR 0.356; 95% CI 0.094, 1.345), not ontrolling for severity of injury. The differene between the two groups was signifiant in having at least one riminal outome. Controlling for the severity of injury, the odds of having a riminal outome during the 6-month evaluation period remained greatly redued for members of the treatment group ompared with the ontrols. The redued odds of having a riminal outome during the evaluation period were partiularly signifiant among the less severely injured ases. Among the less severely injured youth (n 69), the ontrol group partiipants are 72% (OR 0.287; 95% CI 0.034, 2.432) more likely to have a riminal outome ompared with members of the treatment group. Among the more severely injured ases (n 40), ontrols are 36% (OR 0.636; 95% CI 0.080, 5.050) more likely to have a riminal outome ompared with members of the treatment group (Figure 3). Results were not signifiant for violene-related arrest rates or probation rates. Whereas none of the youth treated by the Caught in the Crossfire program were arrested for a violene-related offense during the 6-month postinjury evaluation period, only 5.8% of the ontrols were arrested for a violene-related offense. Furthermore, although youth treated by Caught in the Crossfire were 35% less likely than ontrols to be plaed on probation during the evaluation period, the differene in this redution rate between the two groups was not signifiant. Rate of Youth Rehospitalization or Death Owing to Interpersonal Violene A very small proportion (1.8%) of the youth were re-hospitalized for a violent injury during the evaluation period. A total of two youths (one in the treatment group and one in the ontrol group) were rehospitalized owing to another injury. The differene in rehospitalization of the two groups was insignifiant. In addition, no youth died as a result of violene-related injury in either group. Figure 3. Perentage of treatment vs. ontrol group involved with the riminal justie system* during the 6-month postinjury evaluation period. Odds ratio 0.356; 95% CI 0.094, p value *Arrest, violation of probation, or plaement on probation. Disussion This study demonstrates that treatment by the Caught in the Crossfire program of youth hospitalized for a violent injury was assoiated with the redued likelihood of involvement in the riminal justie system (arrest, probation, probation violation) during a 6-month postinjury period. Results for riminal outomes were statistially signifiant. For youth who partiipated in the intervention program, there

6 182 BECKER ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 3 was a 70% redution in arrests for any offense ompared with the ontrol group during a 6-month postinjury period. Moreover, youth who suessfully ompleted the Caught in the Crossfire program were 60% less likely to have any involvement in the riminal justie system ompared with youth who did not partiipate in the program. These results are similar to those ahieved by the best juvenile offender intervention programs reviewed by Lipsey and Wilson [23]. Of the 200 violene intervention program studies reviewed, programs falling into the most effetive ategory redued riminal reidivism by 40% among juvenile offenders and average programs redued it by 12%. Programs that ontained soial skills training and family omponents (Caught in the Crossfire falls into this program ategory) were deemed most suessful, whereas punitive programs suh as boot amps demonstrated little or no effet. Limitations Despite these positive results, the urrent evaluation design was limited by several fators. The strategies used by the program are primarily intended for at-risk youth who are involved in violene either as vitims or perpetrators, not youth in general. Additionally, although evaluators ontrolled for hospital injury severity sores during mathing, mehanism of injury was not ontrolled for in this study. Furthermore, the evaluators measured the overall effets of the program (i.e., riminal involvement, reinjury, and death), not intermediate outomes or the effets of speifi interventions (e.g., shool reenrollment, job prourement). This may have prevented a omplete analysis of important risk or protetive fators, as well as aurately using these fators as possible suess outomes of the program partiipation. Data were olleted on study partiipants for a 6-month postinjury period. Thus, long-term effets of the program ould not be measured within this study. The effets of the program on violent reinjuries and deaths may be demonstrated during a longer follow-up period. A review of the literature reveals that reinjury (i.e., trauma reidivism) may our more than 6 months after the initial injury [24 27]. Results may also have been onfounded by some historial effets. Owing to ethial onerns, the evaluators did not randomly assign violently injured youth to ontrol and treatment groups. To ompare youth that partiipated in the violene prevention program to those that did not reeive any intervention, evaluators ompared the outomes of two groups from slightly different time periods (1998 for ontrols and 1999 and 2000 for treatment). Seular trends in loal politis, eonomis, or major soial events may have affeted the outomes measured. For this reason, the evaluation team olleted loal ommunity data omparing the different time periods and found few signifiant hanges. The only potentially signifiant differene identified was the hange in leadership at the Oakland Polie Department 6 months into the treatment period and after the onlusion of the ontrol period. However, data obtained from the Researh and Planning Division of the Oakland Polie Department demonstrate that this hange had minimal effet on general or juvenile arrest rates. In fat, the number of total arrests (12,576) and juvenile arrests (1959) during the treatment period exeeded both total arrests (11,835) and juvenile arrests (1751) during the ontrol period. Conlusions This evaluation demonstrates that hospital-based peer intervention programs that employ members of the ommunity and intervene immediately or soon after the injury has ourred an diretly redue riminal ativity among youth most at risk for violene. These findings are signifiant in light of reent researh, whih indiates that riminal involvement plaes an individual at inreased risk for subsequent violent vitimization [13,14]. The reation of a hospital-based peer intervention program provides the possibility of reahing those youth most at risk for future violene during the pivotal postinjury period [28]. Additional researh is warranted to determine the sustainability of these findings as well as potential long-term effets on violent reinjury and death. This study was supported under funding from The California Wellness Foundation Violene Prevention Fellowship Program, the Rihard and Rhoda Goldman Fund grant P99-429, and The California Endowment grant number We would like to thank Jessia Sannell, Varsha Vimalananda and Ni Bekaert for their assistane in oneptualizing and implementing the study. We appreiate the assistane of Coraline Journel in data olletion and Cara Torruellas in manusript writing and editing. Finally, we would like to aknowledge the vision and dediation of Sherman Spears, Dr. Vernon Henderson and Karen West who oneptualized and implemented the Caught in the Crossfire program. Referenes 1. Dahlberg LL. Youth violene in the United States: Trends, risk fators, and prevention approahes. Am J Prev Med 1998;14:

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