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Emerging Disability
NIDRR Research Results

Report from the Center on Emergent Disability

University of Illinois at Chicago
Institute on Disability and Human Development
1640 West Roosevelt Road
Chicago, IL 60608
(312) 413-1977

The Problem - Report from the Center on Emergent Disability (Part 4)

Violence

Violence in our generation continues to be the grist of daily media and the subject of a growing scholarly base in public health (e.g.., Rosenberg & Mercy, 1991). As a leading cause of death in America, and its preeminence as a public health crisis among sub constituencies of Americans, our basis of surveillance is substantial. Federal sources include FBI uniform crime reports, the National Crime Survey, Vital Statistics, and criminal justice agencies at the state and local level.

The sheer magnitude of violent crime victimization in the nation suggests the potential magnitude of long-term health, mental health, and disability implications. The National Crime Victimization Survey (NCVS), a stratified, multi-stage cluster survey of American households, estimated a total of 11 million criminal victimizations in 1994; of these, 2.7 million events resulted in injury to the victim. Rates of violent crimes are up sharply from the mid-1980's but have been stable since 1992. The ratio of violent crimes to crimes of property continue to increase. Despite recent declines in rates of violent crimes, the absolute numbers remain compelling.
Source: National Crime Victimization Survey, U.S. Bureau of Justice Statistics.

A series of syntheses and exploratory studies are underway in a broad-based inquiry on the role of violence as an emerging etiology of disability. As briefly summarized in this report, our initial review of research and synthesis of extant data indicates a research base that is preciously limited and badly fragmented across discipline, condition, and variations on the basic theme of violence.

The extant literature on the link of violence to injury is considerable and only briefly summated here. The violence-injury link can be crudely classified into three core domains: (1) victims and special contexts of violence-based injury, (2) vectors for violence-based injury, and (3) the outcomes. The underlying trends indicate the greater vulnerability of some groups over others, with disproportionate impact on minorities and the poor, with rates against the poor twice that of high income groups (U.S. Department of Justice, 1997). Since 1991, violence has been ranked as one of the ten leading causes of injury and death among Americans and is expected to surpass motor vehicle crashes as the leading cause of mortality for youths.

Encompassed within the larger theme of violence and injury are trends of special concern: domestic violence against women and children, abuse of the elderly, abuse and neglect of those with a disability. While precise measures of the scale of domestic violence are unavailable, imputations based on available indices suggest a problem of considerable magnitude -- approximately half of all homicides involve individuals known to each other (Reiss & Roth, 1993) and abuse is the leading cause of death among infants and children (Peterson & Brown, 1994). According to the National Crime Victimization survey, approximately three-fourths of all violent events (rapes, robberies, and assaults) involve an intimate or relative. Injury was more likely to be sustained when the assault involved an intimate, underscoring the belief that domestic battery may be the major vector for injury among women.

However, while mortality data is well represented we know very little about the consequences of non-lethal violence and of the limited research conducted on violence-based injury, the emphasis is almost wholly on acute conditions.

Five core themes characterize the literature of violence research:

• There is an overwhelming emphasis on mortality as opposed to injury;
• Risk is shared disproportionately across socio-economic groups and gender;
• Domestic victimization of women and children appears to be on the rise though the data are notoriously unreliable;
• Very little research has been devoted to the analysis of injury on a population basis;
• Long-term consequence of injury -- that is, disability -- have rarely been addressed.

Our evaluation of the national data sets for the study of violence and disability outcomes has shown:

• Data sets capable of reliably identifying long-term do not provide etiological information (NHIS, SIPP);
• Data sets on violence and criminal victimization either do not query injury outcomes or restrict queries to acute health events;
• Health care services data provide some (albeit) limited condition information from which crude "disability could be developed (for example, ICD-9 codes) and etiological queries are available. This was the rationale for our pilot analysis of the National Hospital Discharge Survey and the National Hospital Ambulatory Care Survey.
• However, the E-codes (External Cause of Injury) were notoriously unreliable (National Hospital Discharge Survey, National Hospital Ambulatory Care Survey).
• Alternatively one can assess impact on a condition-specific basis. The etiological basis of spinal cord injury (SCI) and traumatic brain injury (TBI) provides insights into the violence-disability linkage in part because of the more well developed systems of surveillance (Spinal Cord Injury Care System). The magnitude of the problem on a population-wide basis, however, remains a matter of conjecture.

The central challenge for the study of the violence-disability link is the absence of information on the nature and magnitude of the problem. Mortality statistics tend to represent the most reliable source of data. The research agenda is very basic: (a) to synthesize currently available data in order to elevate the visibility of the long-term non-fatal consequences of violence in the public-health dialogue, and of violence in disability forums; (b) to review and evaluate state and local injury surveillance systems for information on violence and disability, as well as their capacity for future data collection; and (c) to propose recommendations on surveillance and research needs.

Surveillance

Clearly, a central research need in understanding the changing etiology of disability is a better grasp of surveillance needs. While the character of health surveillance systems varies both in terms of focus, depth, quality, and range, the stated purpose is universal -- to monitor the status of populations, to identify problems, to assist in planning, and to inform policy-making.

It is apparent that the large national data sets, in their current form, provide only a very gross portrait of population-based trends. State and local public health surveillance systems may represent the greatest potential and weakest link in the evaluation of trends in disability.

While much of the statistical basis for understanding disability comes from federally-sponsored national data initiatives and a limited number of Federal data systems, it is the state and local government that is the principal entity responsible for services and support. Unfortunately, public health surveillance systems are fragmented both across and within states -- inconsistent in content, and uncoordinated in coverage, administration, and monitoring. Thus, the probability of developing a reliable national portrait on emerging disability from state and local systems is approximately nil.

National Institute on Disability and Rehabilitation Research (NIDRR) ©1997 Southwest Educational Development Laboratory (SEDL)

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