Understanding Crime, Violence as a Social Determinant of Health

April 12, 2023 - As the US healthcare system comes to understand the numerous non-clinical factors that influence health and well-being, it can begin to acknowledge exposure to crime and violence as a social determinant of health.

Violence can be varied, Healthy People 2030 says on its website. Typically, when healthcare professionals reference violence, they are referencing:

• Child abuse and neglect
• Gun violence
• Intimate partner violence
• Teen dating violence
• Sexual violence
• Crime
• Police-involved violence
• Hate crimes
• Terrorism
• Suicide
• Elder abuse

Different kinds of violence may impact individuals at different points of their lifespans; cyberbullying is a common form of violence among youths and adolescents, while intimate partner violence may be more common in young adults and adults, per Healthy People 2030.

The pathology of violence can be extremely clear; an act of violence can have physical health impacts. But even if an individual is not a direct victim of violence, violence and crime can still have consequences for health and well-being.

“In addition to the potential for death, disability, and other injuries, people who survive violent crime endure physical pain and suffering and may also experience mental distress and reduced quality of life,” Healthy People 2030 says. “Specific examples of detrimental health effects from exposure to violence and crime include asthma, hypertension, cancer, stroke, and mental disorders.”

In kids, experiences of violence are key adverse childhood experiences (ACEs), the impacts of which are many. For example, in 2022, data from the National Institutes of Health and Eunice Kennedy Shriver National Institute of Child Health and Human Development showed that kids who experienced parental harshness and neglect saw a 16 percent higher risk for premature death.

A focus on firearms, violence, and SDOH

In recent years, the healthcare community has particularly zeroed in on the impact of firearm use and gun violence on public health. According to the CDC, the firearm homicide rate increased by 35 percent between 2019 and 2020, with key disparities emerging for Black populations.

And, per the American Academy of Pediatrics (AAP), gun violence is the number one killer of children. Gun homicides of kids have increased by 14 percent in the last decade, while gun suicides have increased by 39 percent, AAP said.

Gun violence is a public health crisis and social determinant of health, according to leading physician groups, including the American Medical Association (AMA).

“We cannot continue to live this way,” Jack Resneck, Jr., MD, AMA president, said at the organization’s 2022 Interim Meeting of the House of Delegates.

“Our children spend portions of school days running active shooter drills, knowing full well their classroom could be next. In movie theaters, houses of worship, hospitals, big cities and small towns, firearm violence has shattered any sense of security and taken lives. As physicians and healers, we are committed to ending firearm violence by advocating for common-sense, evidence-based solutions, and this task force will be key to that ongoing effort.”

AAP likewise has taken on an advocacy role in the prevention of gun violence, particularly sharing how pediatricians can address this social determinant of health.

"This is not a simple problem and it cannot be fixed with a simple solution," Lois K. Lee, MD, MPH, FACEP, FAAP, chair of the AAP Council on Injury, Violence, and Poison Prevention, the lead author of AAP’s latest guidance on gun violence prevention, said in a statement.

"Pediatricians as a start can offer families guidance and education on more safely storing guns. AAP also calls for supporting legislation that, much like the common-sense requirements for obtaining a driver's license, would improve gun ownership safety."

In addition to advocacy, healthcare providers should also look into how they can screen patients for issues with violence.

Screening for exposure to violence

Like other social determinants of health, there are some screening models for exposure to violence.

The American Academy of Family Physicians (AAFP) has cited a US Preventive Services Task Force (USPSTF) recommendation for screening women of reproductive age and older or vulnerable adults for intimate partner violence. USPSTF suggested using the following screenings for women of reproductive age:

• Humiliation, Afraid, Rape, Kick (HARK)
• Hurt/Insult/Threaten/Scream (HITS)
• Extended-Hurt/Insult/Threaten/Scream (E-HITS)
• Partner Violence Screen (PVS)
• Woman Abuse Screening Tool (WAST)

However, USPSTF acknowledged there are scant validated tools for older or vulnerable adults in primary care settings.

There are also a handful of screenings for neighborhood violence:

• HealthBegins Upstream Risk Screening Tool: This screening tool asks whether patients have concerns about safety in their neighborhood.
• PRAPARE: This screening asks if patients feel physically and emotionally safe where they currently live.
• Structural Vulnerability Assessment Tool: This screening asks multiple questions, including about perceived safety, exposure to violence, exposure to drug use or criminal activity, comfort walking around at night, and experiences being attacked or mugged.
• WellRx Toolkit: This screening asks whether patients feel unsafe in their daily lives.
• Kaiser Permanente’s Your Current Life Situation Survey: This screening asks whether patients have any concerns about their current living situation, including housing safety and costs.

That said, these kinds of screenings don’t always happen. For example, April 2023 data from the Kaiser Family Foundation showed that only 14 percent of adults said a clinician has asked if they own a gun or if guns are in their home; only around a quarter of parents with kids said their pediatrician has asked about guns at home.

Screening for exposure to violence can be tricky because there are not always clear-cut interventions that can solve the problem. While patients screening positive for food insecurity can get a referral to a food voucher program, no such fix exists for exposure to violence.

Nevertheless, industry groups are trying to offer a remedy. For example, in the case of firearm exposure, many industry groups have advocated for clinicians to counsel individuals and families on gun safety. Still, the KFF data showed that only 5 percent of adults have had this type of conversation with their providers.

Other groups have recommended other forms of support for individuals experiencing other forms of violence. For individuals screening positive for intimate partner violence, AAFP said ongoing support services, counseling, and home visits may be effective. However, AAFP acknowledged that there is no evidence base for the most effective interventions for intimate partner violence.

How crime, violence connect to other SDOH

Exposure to crime and violence certainly can be social determinants of health in a vacuum—exposure to gun violence, for example, can determine an individual’s health outcomes if that individual is physically injured.

But, notably, exposure to violence is also interconnected with other social determinants of health.

According to Healthy People 2030, crime and violence can impact anyone, but certain racial and income groups are more likely to experience it.

“For example, the national homicide rate is consistently higher for Black adolescents and young adults than their White counterparts,” they wrote. “Low-income neighborhoods are more likely to be affected by crime and property crime than high-income neighborhoods.”

Those disparities might be due to differences in neighborhood support and structure, separate research has indicated. In 2021, researchers from the CDC wrote a paper outlining the structural and social forces that are linked to violence, including:

• Socioeconomic structures and income inequality
• Community disadvantage and area deprivation
• Social and physical environments, social disorganization
• Bridging of community dynamics, neighborhood social support

“The fact that communities are structurally marginalized by race and experience concentrated disadvantage has historically made it difficult to separate violence causes from these individual-level determinants of health, especially when the measurement of disadvantage includes race and ethnicity as indicators,” the CDC authors said.