Abstract and Introduction
Abstract
Substantial evidence suggests that economic hardship causes violence. However, a large majority of this research relies on observational studies that use traditional violence surveillance systems that suffer from selection bias and over-represent vulnerable populations, such as people of color. To overcome limitations of prior work, we employed a quasi-experimental design to assess the impact of the Great Recession on explicit violence diagnoses (injuries identified to be caused by a violent event) and proxy violence diagnoses (injuries highly correlated with violence) for child maltreatment, intimate partner violence, elder abuse, and their combination. We used Minnesota hospital data (2004–2014), conducting a difference-in-differences analysis at the county level (n = 86) using linear regression to compare changes in violence rates from before the recession (2004–2007) to after the recession (2008–2014) in counties most affected by the recession, versus changes over the same time period in counties less affected by the recession. The findings suggested that the Great Recession had little or no impact on explicitly identified violence; however, it affected proxy-identified violence. Counties that were more highly affected by the Great Recession saw a greater increase in the average rate of proxy-identified child abuse, elder abuse, intimate partner violence, and combined violence when compared with less-affected counties.
Introduction
Violence is defined by the World Health Organization as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation".[1] ,p. 5 Different types of violence are all highly correlated, with victims of one type of violence being likely to be victims of another type of violence in their lifetime.[2–6] Different types of violence also appear to have shared risk factors, which suggests they may arise from similar causes.[4] One risk factor for all types of violence appears to be economic hardship.[1]
One major source of economic hardship is an economic recession, which results in widespread deprivation. An economic recession is defined as a significant decline in a variety of economic indicators but typically gauged in the gross domestic product.[7,8] In the United States, the "Great Recession"—the longest recession since World War II—began in December 2007 and ended in June 2009.[7] There is limited research specifically examining the association of economic crises such as the Great Recession with violence, despite evidence that personal or community level economic hardship is associated with violence.[9–11] The Great Recession was characterized by 3 main components, and then resulted in the stock market crash: 1) the collapse of the housing market; 2) high unemployment in the labor market; and 3) the fall of several financial services such as Lehman Brothers. In the first quarter of the Great Recession alone, approximately $7 trillion dollars in home equity were lost and approximately 1 in every 4 homeowners had an outstanding mortgage balance that exceeded the value of their home.[12] Outstanding mortgages and inability to pay led to a foreclosure rate that increased 4-fold during the recession.[12] Many families lost their homes and were displaced.
Foreclosures were a central feature of the Great Recession, and evidence suggests they may affect violence rates.[10,13] Generally, studies that examine the association between foreclosure, such as those that occurred during the Great Recession, and health find that foreclosure predicts worse health outcomes.[14–16] Theoretical understanding of violence suggests that there is a link between the Great Recession and violent victimization. On the macro level, there are multiple pathways by which foreclosures could have an impact on health. For example, economic spillovers such as a drop in local property values, physical environmental impacts such as neglected properties, or social environmental impacts such as residential turnover can elicit stress and create frustration-aggression.[14,17] More specifically, the economic spillovers may create structurally disadvantaged neighborhoods that inhibit relationships via high population turnover and thus lead to low levels of informal social control and high levels of crime.[18] Further, the role of future economic uncertainty leads to strain and conflict such as increased aggression.[19] Understanding the social links that drive violence is useful for informing violence prevention programs and policy.
Existing studies on links between the Great Recession and violence have several methodological limitations. These studies have separately examined child maltreatment;[20–26] intimate partner violence/domestic violence;[27,28] and serious violent-crime victimization, which includes attempted or completed sexual violence, robberies, and aggravated assaults.[29] First, these studies exclude elder abuse. Second, most studies have relied on national surveys with self-reported violence perpetration and/or victimization, which may suffer from social desirability bias leading to underreporting of violent perpetration or victimization.[30] Other studies use official records of violence, which may be underreported and underinvestigated because of reduced staffing of Child Protective Services workers during recession-related cuts in public funding.[30–32] Further, there is evidence that official records are biased toward identification of violence in more highly scrutinized communities, such as those that are poor or have marginalized racial/ethnic identities.[33] Third, existing research on the associations between economic hardship and violence has been vulnerable to confounding, which limits causal inference. Specifically, it is possible that the factors that make someone poor (e.g., limited emotional regulation skills) may also make them more likely to commit or be victims of violence.[34,35] A quasi-experimental design with a tool such as the difference-in-differences estimator uses exogenous shocks to delink this relationship. To our knowledge, only one study has used quasi-experimental design to examine the association between child abuse and the Great Recession.[26]
One possible alternative data source for surveillance and research of violence is hospital discharge data on injuries. Injuries in hospital discharge data can be identified as violence-related with explicit International Classification of Diseases (ICD) codes. However, these codes rely on patient disclosure, or provider subjective assessment, that the cause of the injury was violence, leading to underutilization and potential bias.[36] One way to supplement this violence identification is through proxy ICD codes.[37] Proxy codes are used to identify instances where someone experienced an injury previously demonstrated to be highly correlated with violence. Using these proxy codes for violence identification, in combination with explicit codes, could help better describe the true burden and distribution of violence.
In light of the limitations of the existing literature, and to improve rigor and causal inference over past research, this study used a quasi-experimental design to achieve improved causal inference of the impact of foreclosures during the Great Recession on county-level violence victimization rates. For the main analyses, explicit codes were used to identify child abuse, elder abuse, and intimate partner violence in the hospital discharge data. However, prior research[37–55] supported using proxy codes in addition to explicit codes to improve measurement of violence cases. We, therefore, also included additional analyses of child abuse, elder abuse, and intimate partner violence identified by proxy codes. We hypothesized that the impact of the Great Recession as measured by county-level foreclosure rate change would be positively associated with all types of violence.
Am J Epidemiol. 2022;191(11):1847-1855. © 2022 Oxford University Press
