Accident and emergency navigators work in hospitals to support patients with a violence-related injury with the aim of reducing future involvement in violence.
Focus of the intervention
In the review, accident and emergency (A&E) navigator schemes are referred to as emergency department-based violence intervention programmes EVIPs). These target victims of community violence receiving hospital care for violent injuries and aim to reduce violent reinjury, death and arrest due to violence perpetration. Community violence is defined as violence taking place between unrelated individuals who may or may not know each other and generally occurs outside of the home.
A&E navigators support patients with a violence-related injury by addressing changeable risk factors and promoting protective factors for violence involvement. A&E navigators use techniques such as counselling, mentoring and/or referrals to community services to address psychosocial challenges, such as substance abuse or mental health concerns, and to support attitude and behaviour change.
This narrative is based on one systematic review covering 10 studies, nine from the USA and one from both the USA and Canada. The studies examined the effect of A&E navigators on crime outcomes including:
- rates of arrest
- violent revictimisation
- death
High-risk behaviours were also explored. These included:
- fighting
- delinquency
- weapon carrying
- substance use
Non-crime outcome measures included attitude change and rates of service use, such as education, employment preparation and treatments for substance abuse and mental health.
The review summarised here covered studies that mainly focused on children and young people (under 25 years).
Effect – how effective is it?
There is some evidence from single studies that A&E navigators have reduced crime. As the review did not include a meta-analysis to combine the data from the single studies, we cannot report an overall effect.
The studies examined several different crime reduction-related outcome measures. Two out of the six studies that assessed violent revictimisation and one out of the three studies measuring arrest and imprisonment rates for violent crime, reported statistically significant reductions after receiving support from a navigator in A&E compared to the control group.
Four of the eight studies assessing behaviour considered high risk for violent injury also reported a reduction. None of the studies reported an increase in crime, arrest or violent behaviours following the intervention.
In terms of non-crime outcomes, positive change was reported in two out of three studies assessing community psychosocial service use and three out of four studies assessing attitude changes.
Mechanism – how does it work?
A&E navigator schemes are assumed to reduce involvement in future violence by increasing a participant’s motivation to change high-risk behaviours and promoting the skills and conditions required to do so.
Implementation following injury could capitalise on a 'teachable moment', a period following a traumatic experience where individuals are more receptive to attitudinal and behavioural change.
Specific methods used as part of navigator schemes can include:
- mental health treatment
- substance use rehabilitation
- motivational interviewing
- education and employment preparation
- improving conflict resolution and anger management skills
The findings from the review suggest that A&E navigator schemes may support changes in high-risk behaviours, attitudes and use of appropriate services. However, the impact of these potential mechanisms on violent revictimisation and arrest was not tested.
Moderators – in which contexts does it work best?
The review notes that schemes involving family may be more effective than those involving individuals alone, perhaps due to improvements in family practices and increasing parental involvement.
Individual intervention may be more effective than group-based schemes where there might be a risk of increased problem behaviour. However, the review did not analyse or test these moderating variables.
Implementation – what can be said about implementing this initiative?
The review authors identified the following factors as potentially aiding the successful implementation of A&E navigator schemes.
- A combination of brief intervention (BI) and case management (CM) intervention types may be more effective than either intervention type alone.
- BI takes up to 35 minutes and occurs in the emergency department, delivered by a therapist or computer. BIs can include a review of goals, tailored feedback, decision balance exercises often used in motivational interviewing, role plays, and referrals.
- CM involves meetings with a case manager for months to years after discharge from hospital. This results in individual and family CM plans and provides access to services that address their psychological and social needs.
However, these facilitating factors were not empirically tested and so should be treated with caution.
Economic considerations – how much might it cost?
While the review did not undertake an economic analysis, there is some mention of other studies supporting the cost-effectiveness of A&E navigator schemes in the USA.
General considerations
- All primary studies were based in the USA or Canada so caution should be taken when applying to other countries with different levels, types and causes of violence.
- The primary studies used different outcome measures, control conditions and follow-up periods making it impossible to accurately compare findings produced by different types of interventions.
- Only one author assessed the full-text articles which may contribute to the risk of bias.
Summary
There is some evidence that A&E navigator schemes may reduce crime. However, no meta-analysis was performed.
A&E navigator schemes are assumed to reduce victims’ involvement in future violence through increasing a participant’s motivation to change high-risk behaviours and promoting the skills and conditions required to do so.
Combining immediate and long-term support, addressing unemployment and education, involving family but avoiding group intervention with delinquent peers, were all thought to increase potential effectiveness, but were not empirically tested.
The review focuses on evidence from the USA. Additional evidence is required to identify the moderating factors and costs involved with implementing these schemes in the UK.
Reviews
Review one
Reference
Brice JM and Boyle AA. (2020). ‘Are ED-based violence intervention programmes effective in reducing revictimisation and perpetration in victims of violence? A systematic review’ Emergency Medicine Journal, 37(8), pp. 489-495.
Summary prepared by
This narrative was prepared by the College of Policing and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.