Injury, Int. J.

Care Injured 41 (2010) 110–115

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

An analysis of inner-city students’ attitudes towards violence before and

after participation in the ‘‘Cradle to Grave’’ programme
Amy J. Goldberg b, Julia M. Toto b,*, Heather R. Kulp b, Michael E. Lloyd b, John P. Gaughan a,
Mark J. Seamon b, Scott P. Charles b
a
Department of Biostatistics, Temple University Hospital and School of Medicine, Philadelphia, PA, USA
b
Department of Surgery, Temple University Hospital and School of Medicine, Philadelphia, PA, USA

A R T I C L E I N F O A B S T R A C T

Article history: Background: Cradle to Grave (C2G), a hospital-based violence prevention programme, brings inner-city
Accepted 14 September 2009 youth into an urban Level I trauma centre to follow the path of an adolescent gunshot victim from trauma
bay to morgue. We hypothesised that C2G alters student attitudes towards gun violence.
Keywords: Methods: Eighty-eight adolescents were prospectively enrolled. With parental and student consent,
Trauma students completed the Attitudes Towards Guns and Violence Questionnaire (AGVQ), a previously
Gunshot injury validated and reliable social science assessment tool. Two weeks later, the students participated in C2G.
Violence
The survey was re-administered four weeks after C2G participation. AGVQ results are reported both as a
Youth violence
Urban violence
total score and as a breakdown of the four component subscales. Higher AGVQ scores indicate proclivity
Violence prevention towards violence. ANOVA compared scores with respect to demographics and type of school (public vs.
Injury prevention charter).
Hospital-based Results: C2G altered student’s attitudes towards guns and violence. Of 43 public school students, total
Adolescent scores decreased following C2G (p = 0.02). The greatest attitudinal change occurred in subscale 1,
Youth ‘‘Aggressive Response to Shame’’ (p < 0.01). C2G failed to produce significant changes AGVQ scores in the
45 students attending a city charter school. The two groups were found to have baseline differences, with
public school students showing higher baseline tendencies towards violence.
Conclusions: Our hospital-based programme is capable of positively impacting adolescents’ attitudes
towards guns and violence. This effect is most pronounced in subjects who already display increased
tendencies towards violence. These results suggest that hospitals offer a unique opportunity to address
the public health crisis posed by inner-city firearm violence.
ß 2009 Elsevier Ltd. All rights reserved.

Introduction the strict province of social scientists to gain increasing attention

Violence perpetrated by and against young people has been
alternately referred to as ‘‘an epidemic,’’7 ‘‘a public health crisis,’’3
and ‘‘a social contagion.’’14 Nearly three quarters of a million young
people (ages 10–24) are treated in America’s emergency rooms
each year for violence-related injuries.4 It is estimated that
anywhere between 70% and 95% of America’s inner-city youth
have witnessed some form of violent assault.2,19 Considering the
direct medical costs that derive from these violent acts – as well as
the transmittable tendency of violence to beget more violence16,18
– it is easy to understand how youth violence has moved beyond
* Corresponding author at: Temple University Hospital, Department of Surgery,
3401 N. Broad Street, 4th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA.
Tel.: +1 267 971 6512.
E-mail address: jtoto@temple.edu (J.M. Toto).
within the sphere of medicine.
It is possible that no American city better epitomises this public
health crisis than Philadelphia.20 While nationally homicide
represents the second leading cause of death among individuals
ages 15–19,5 it represents the leading cause of death for young
Philadelphians within this same demographic.25 In 2006, the
number of homicides (179) committed against youth ages 7–24
increased 20% over the previous year.25 Shootings caused nearly all
of these deaths.25 Not only are juveniles more often the victims of
gunshot injuries, they are more often the perpetrators, as well. As
recently as 2006, roughly two-thirds of shooting offenders in
Philadelphia were between the ages of 14 and 24.24 As young
gunshot wound victims have become increasingly common in
emergency rooms, Trauma Centres have developed hospital-based
violence prevention programmes in an effort to address this trend.
Despite limited scientific evaluation of their programmes’
efficacy, hospital-based ‘‘impact tours’’ have emerged in recent

0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2009.09.024
 A.J. Goldberg et al. / Injury, Int. J. Care Injured 41 (2010) 110–115
years offering a promising response to community violence. An
internal evaluation of one such programme in St. Paul, Minnesota
suggested that following a visit to a hospital – in which hospital
staff and actors dramatised the resuscitation of a gunshot patient –
youth demonstrated a reduction in their Comfort with Aggression
as measured by the Attitudes Towards Guns and Violence
Questionnaire (AGVQß 2000).23,27,28 Another hospital-based pro-
gramme in Baltimore, Maryland has reported that at-risk youth
scored lower on a survey measuring aggression after viewing
graphic images of gunshot injuries.6
Importantly, an impressive body of research suggests that
interventions directed at unhealthy life choices – behaviours such
as poor nutrition, cigarette smoking and lack of exercise – can be
effective even when offered in limited measure.21 Erlich et al.13
demonstrated that a brief intervention regarding high-risk
behaviours given to families of paediatric patients persisted three
months after the intervention.
Temple University Hospital’s hospital-based violence preven-
tion programme, Cradle to Grave (C2G), recreates the experience of
one unfortunate adolescent gunshot wound victim who died from
his injuries. We hypothesised that C2G would improve student
attitudes towards gun violence and that this effect would remain
when measured four weeks after the intervention. Our primary
objective was to compare students’ attitudes towards violence
before and after participating in the C2G programme. This study
was reviewed and received approval from Temple University’s
Institutional Review Board.
Methods
In 2006, Temple University Hospital – a busy Level I trauma
centre in one of Philadelphia’s most disadvantaged and violent
communities – developed a hospital-based prevention programme
intended to improve juvenile attitudes about the use of violence.
That year the number of paediatric gunshot wound (GSW) patients
age 18 and under treated at TUH had doubled over the previous
two years. Developed by the hospital’s Trauma Programme, Cradle
to Grave has used the hospital setting to educate more than 2000
at-risk youth about the physical and emotional realities of gun
violence.
In an attempt to bring young people as close as possible to the
devastations of gun violence, the two-hour programme guides
participants through the final moments of a young patient who
died at TUH in 2004 after sustaining multiple GSWs. Cradle to
Grave begins in the trauma bay where the 16-year-old boy was
brought by police. He was intubated, resuscitated, and had an
emergency room thoracotomy performed in an attempt to save his
life, all of which ultimately failed. Each of these procedures is
‘‘demonstrated’’ on a volunteer who is asked to represent the
patient.
From the trauma bay, the students proceed to a classroom
setting where both an educational and introspective component
occurs. The issue of inner-city violence, specifically gun violence, is
framed. Pictures illustrating the destructive results of firearm
injury are displayed. The students are also asked ‘‘who would you
die for?’’ and ‘‘how much is your life worth?’’ After much
discussion and contemplation, the programme concludes in the
hospital’s morgue, our patient’s last stop. Participants are asked to
list on toe tags the names of people who would miss them if they
were to become the victims of violence, as well.
Eighth and ninth grade students from low income and working
class backgrounds provided a convenience sample for our pilot
study. They were predominantly African American and attended
either a public or charter school with established relationships
with the Cradle to Grave programme. The charter school
represented in this study is located in a more affluent section of
111
the city and draws from a more geographically diverse area.
Students who attend the charter school are required to complete a
more selective admission process than that required to be
completed by students of the city’s public schools. By comparison,
the primary admissions criterion met by the public school students
represented in this study is only that they live in the neighbour-
hood where their school is situated.
Forty-three urban public school students were prospectively
enrolled to participate in the C2G programme during 2006–2007.
After obtaining parental and student consent, students completed
the Attitudes Towards Guns and Violence Questionnaire. AGVQ
was developed by the Western Psychological Services as a tool that
measures proclivity towards violence (Fig. 1). This questionnaire
has been validated and used in a variety of evaluations of violence
prevention programmes.27 It is a 26 question, self-report ques-
tionnaire that is scored on a 3-point Likert-scale with anchors of 0
(disagree), 1 (not sure), and 2 (agree). Anti-violence statements are
reverse scored so that a proclivity towards violence would always
be indicated by a high score. The questionnaire reports total score
as well as separate scores across four distinct subscales. Subscales
are categorised as ‘‘Aggressive Response to Shame’’, ‘‘Comfort with
Aggression’’, ‘‘Excitement’’, and ‘‘Power/Safety’’ (Table 1). The
‘‘Aggressive Response to Shame’’ subscale assesses sensitivity to
disrespect by others and the belief that violence would heal that
disrespect. The ‘‘Comfort with Aggression’’ subscale evaluates
acceptance of violence in everyday life. The ‘‘Excitement’’ subscale
measures the feeling that guns are fun and exciting, and the
‘‘Power/Safety’’ subscale assesses the feeling of personal safety and
power that may be associated with guns. Scores on this instrument
have been shown to correlate with teacher reports of aggressive
behaviour.28 Respondents are asked if they agree, disagree, or have
no opinion regarding statements such as ‘‘You’ve got to fight to
show people you’re not a wimp,’’ ‘‘I wish there weren’t any guns in
my neighbourhood,’’ ‘‘I bet it would be real cool to walk down the
street with a gun in my pocket,’’ and ‘‘I’d like to have a gun so that
people would look up to me.’’26
Two weeks after the questionnaires were completed, the
students participated in C2G. Four students who completed the
pre-intervention questionnaire were absent from school on the
day of the C2G programme and were subsequently eliminated
from this study. Post-intervention questionnaires were filled out
approximately four weeks after C2G participation (Fig. 2). In 2007 a
second group of students were prospectively enrolled in our C2G
study. However, these students were predominantly from a
charter school. As before, the students filled out the AGVQ,
attended C2G two weeks later, and approximately four weeks later
completed the post-intervention AGVQ.
Data analysed included demographics and AGVQ scores.
Demographic information included age, sex, grade, school, race,
and zip code of residence. All surveys were scored to calculate
both a total score as well as the four subscale raw scores. Higher
scores on the survey indicate a proclivity towards violence based
on the respondents’ attitudes. Analysis of Variance was used to
detect differences in AGVQ scores across all groups, with p-
values of <0.05 considered statistically significant. Data was
analysed using the SAS v.9.1 software system (SAS Institute,
Cary, NC).
Results
Eighty-eight students attended Cradle to Grave and completed
both surveys. Of these participants, 48% were male and 52% were
female; 61% were African American, 19% were Caucasian, 8% were
Hispanic, 3% were Asian, and 9% were self-designated as ‘‘Other.’’
The majority of the students were 8th and 9th graders (95%), with a
mean age of 14.11 years old (Table 2).
112 A.J. Goldberg et al. / Injury, Int. J. Care Injured 41 (2010) 110–115

Fig. 1. Sample AGVQ questions. Sample questions from the AGVQ.

Of all the students who participated in the study, 45 attended a sex (42% vs. 53% males, p = 0.4), however they differed with respect
public school and 43 attended a charter school. A comparison of the to race (African American 69% vs. 53%, p = 0.02), age (13.77  0.71
students’ demographic data showed that the public and charter vs. 14.46  0.91, p < 0.01), and grade (7.90  0.30 vs. 9.10  0.45,
school participants were not statistically different with respect to p < 0.01) (Table 2). Overall, more of the public school students were
 A.J. Goldberg et al. / Injury, Int. J. Care Injured 41 (2010) 110–115 113

Table 1 Table 4
AGVQ subscales. Combined data: AGVQ survey responses before and after C2G.
Subscale 1 Aggressive Response to Shame Combined public and charter school
Subscale 2 Comfort with Aggression
Subscale 3 Excitement to guns and violence Pre-C2G Post-C2G p
Subscale 4 Power and Safety Subscale 1 5.58  3.79 4.64  3.71 <0.01
AGVQ results are reported both as a total score and as a breakdown of the four Subscale 2 3.40  3.08 3.27  2.92 0.63
component subscales. Higher AGVQ scores indicate increased proclivity towards Subscale 3 0.58  1.42 0.75  1.64 0.49
violence. Subscale 4 4.83  2.22 5.00  2.54 0.34

Total 14.81  7.48 14.11  7.66 0.26

When data from public and charter schools were combined, a statistically
significant difference between total AGVQ scores before and after C2G was not
detected (14.81  7.48 vs. 14.11  7.66, p = 0.26). However, there was a statistically
significant decrease in scores on subscale 1: Aggressive Response to Shame (5.58  3.79
vs. 4.46  3.71, p < 0.01). (ANOVA, mean  SD).
Fig. 2. Timeline. Upon study entry, students were required to complete the AGVQ.
Two weeks later, they participated in C2G. Four weeks later they repeated the
AGVQ. A total of 88 students successfully completed all three parts of the study.
Table 5
Public school: AGVQ survey responses before and after C2G.
Table 2 Public school only
Demographics.
Pre-C2G Post-C2G p
Total Public Charter p public
(n = 88) school school vs. charter Subscale 1 6.67  3.52 5.07  3.47 <0.01
(n = 45) (n = 43) Subscale 2 3.14  2.62 2.93  2.62 0.54
Subscale 3 0.81  1.80 0.93  1.88 0.61
Sex (male) 42 (48%) 19 (42%) 23 (53%) 0.40 Subscale 4 5.45  2.06 5.05  2.68 0.25

Race 0.02 Total 16.63  8.19 14.47  8.22 0.02

African American 54 (61%) 31 (69%) 23 (53%)
Caucasian 17 (19%) 3 (7%) 14 (33%) Public school students showed a significant decrease (16.63  8.19 vs. 14.47  8.22,
Hispanic/Latino 6 (8%) 4 (9%) 2 (7%) p = 0.02) in total AGVQ scores, which was most pronounced in the decrease reported in
Other 11 (12%) 7 (16%) 4 (9%) subscale 1: Aggressive Response to Shame (6.67  3.52 vs. 5.07  3.47, p < 0.01).
(ANOVA, mean  SD).
Average age (year) 14.11  0.88 13.77  0.71 14.46  0.91 <0.01
Average grade 8.50  0.69 7.90  0.30 9.10  0.45 <0.01

Participants were not statistically different with respect to sex, however they Table 6
differed with respect to race, age, and grade. Charter school: AGVQ survey responses before and after C2G.

Charter school only

African American than those students enrolled in the charter school. Pre-C2G Post-C2G p
They were also younger than the charter school students.
Subscale 1 4.53  3.78 4.22  3.93 0.27
Comparison of baseline scores on the AGVQ between the public Subscale 2 3.64  3.47 3.60  3.17 0.94
and charter school students showed that there was a significant Subscale 3 0.35  0.88 0.58  1.37 0.45
difference in the pre-C2G scores between these groups. Public Subscale 4 4.20  2.21 4.96  2.43 0.03
school students had higher total scores than charter school Total 13.08  6.36 13.78  7.16 0.47
students (16.62  8.19 vs.13.09, p = 0.04) (Table 3). Baseline
C2G resulted in no statistically significant decrease in AGVQ scores in the charter
differences were also seen in the Aggressive Response to Shame
school group.
subscale (6.67  3.52 vs. 4.53  3.79, p < 0.01) and the Power and
Safety subscale (5.49  2.06 vs. 4.20  2.21, p < 0.01) (Table 3).
Overall, female students from both public and charter schools had a decrease in students’ Aggressive Response to Shame was significant
higher baseline AGVQ scores and demonstrated a statistically (5.58  3.79 vs. 4.64  3.71, p < 0.01) (Table 4).
significant decrease in these scores following their C2G participation. Examination of the public school respondents’ scores revealed
When AGVQ scores from all students (n = 88) were compared that there was a statistically significant decrease in total AGVQ
(pre- and post-C2G), we were unable to detect a statistically score after Cradle to Grave participation (16.63  8.19
significant difference in total score (14.81  7.48 vs.14.11  7.66, vs.14.57  8.22, p = 0.02) (Table 5). The decrease in score was most
p = 0.26) (Table 4). However, when the data was analysed by subscale, pronounced in the Aggressive Response to Shame subscale
(6.67  3.52 vs. 5.07  3.47, p < 0.01) (Table 5). Data obtained from
the charter school participants alone showed that C2G caused no
Table 3 statistically significant decrease in AGVQ scores (13.08  6.36
Baseline differences between public and charter school participants.
vs.13.78  7.16, p = 0.47) (Table 6).
Pre–C2G

Public Charter p Discussion

Subscale 1 6.67  3.52 4.53  3.79 <0.01
Subscale 2 3.14  2.62 3.64  3.47 0.73 This study demonstrates the effectiveness of the Cradle to Grave
Subscale 3 0.81  1.80 0.36  0.88 0.19 programme in producing a significant improvement in at-risk
Subscale 4 5.49  2.06 4.20  2.21 <0.01 youth’s beliefs about the use of violence. A statistically significant
Total 16.62  8.18 13.09  6.36 0.04 reduction in violent beliefs was observed after providing
participants a brief hospital-based intervention that included a
There were baseline differences in AGVQ scores between public and charter school
students. Public school students had higher overall scores when compared to
realistic representation of the treatment of a gunshot wound
charter school students (16.62  8.18 vs. 13.09  6.36, p = 0.04). Public school students patient in the trauma bay, graphic video and slide presentations
also had significantly higher scores in subscales 1 and 4. (ANOVA, mean  SD). depicting the realities of gunshot injuries, and reflective exercises
114 A.J. Goldberg et al. / Injury, Int. J. Care Injured 41 (2010) 110–115
that encouraged participants to consider the consequences of their
actions. Moreover this effect was seen four weeks after participa-
tion in the programme. These results are particularly encouraging,
as attitudes about aggression among youth have been shown to
serve as reliable predictors for future violent behaviour.8,29
The scores that the participants in our study achieved on the
AGVQ can be placed within the context of other students who have
taken the survey. The average overall pre-intervention raw score
for our study group was 14.81  7.48 (Table 4). Shapiro et al.27 found
that students with overall raw scores ranging from 0 to 7 had a
likelihood of owning a gun of only 1 in 125, while the likelihood that a
student with a higher overall score (ranging from 8 to 19) would own
a gun was one in 17. The average baseline T-score achieved by our
participants on the AGVQ overall score was 49.33  9.52, which
places them within the 40th to 60th percentile of young people who
have taken the survey. According to Shapiro,26 scores in the lower end
of this range ‘‘should be considered normal and typical, but not
optimal’’, while scores at the higher end ‘‘constitute mild but notable
elevations suggesting the existence of some problems in the domain
assessed and a possible need for intervention.’’ To date, there have not
been any studies performed which correlate scores on the AGVQ with
the performance of future violent acts.
However, there have been several longitudinal studies which
have examined the correlation between attitudes and behaviour.
One study of 1517 North American boys found that their attitudes
influenced future delinquent behaviour.31 Another study of 11–17-
year-old found that their illegal behaviour was preceded by a
decline in the belief that illegal behaviour is wrong.22 A study
which interviewed 550 adolescents over a six-year period found
that it was mainly attitudes that influenced behaviour, particularly
among teens who were just beginning their delinquency.12
A primary limitation of our study involves the sample size.
Many of C2G’s 2000 participants were involved in both home and
group detention programmes, which created a number of logistical
challenges for collecting data on these individuals. These
adolescents were either released to their homes in geographically
varied communities or sentenced to terms of incarceration before a
post-programme survey could be administered. This fact, in
combination with limited programme resources, necessitated a
convenience sample of participants who would be available for
survey re-administration 30 days after their programme participa-
tion. Despite these limitations, our sample of 88 participants
provided us with enough power to detect statistically significant
changes in attitude on the AGVQ.
While this pilot study is not without methodological problems,
we feel that the results are nonetheless compelling and warrant
more in-depth investigation. Future research around C2G will
utilise control groups and more detailed demographic collection
methods in order to account for the potential influence of variables
such as age, juvenile delinquency, and exposure to community
violence and poverty. Further evaluation of the programme should
also seek to determine the roles that race and gender play in
violence-related attitudes. With the expansion of programme
resources, we also intend to lengthen the follow-up period so that
we might measure the endurance of the effects we have reported
here while tracking participants for future violent victimisation or
perpetration.
While the aim of the study presented here was simply to
establish the ability of a hospital-based programme to alter the
attitudes of inner-city youth towards guns and violence – the
potential gateway to violent behaviour – the results provide a key
direction for future longitudinal research examining the persis-
tence of such attitude changes.
One possible explanation for Cradle to Grave’s effectiveness is
its ability to successfully simulate the physical and emotional
realities of gun violence that often lead to a change in attitudes
among traumatically injured patients. According to Erlich et al., the
time following an injury can provide a teachable moment or a
‘‘unique opportunity during which a person may be particularly
susceptible to interventions that prevent future injuries.’’13 The
vicarious experiences the programme provides succeeds in
creating these ‘‘teachable moments’’ that are comparable to those
awakened in actual trauma patients. It has been shown that
Philadelphia gunshot patients rarely experience subsequent gun-
shot incidents following their initial injuries.
An examination of firearm injury trends conducted by the
Philadelphia Adult Probation and Parole Department reveals that
between January 1, 2002 and December 31, 2006, 8686 city
residents were shot.24 Only 4% of these victims would be shot again
during the five years of the study’s span. Not surprisingly, research
on gangs has shown that the experience of violence – either direct
or indirect – is a consistent factor that leads members to leave the
gang.10 Thus it stands to reason that so aversive are the realities of
violence-related injury that they serve as a particularly potent
catalyst for altering both attitudes and behaviours. This explana-
tion is important, as the ideal would be to confer the relative
benefits that come with exposure to gunshot injury without
passing along its costs.
A decrease in scores from the Aggressive Response to Shame
subscale after participation in C2G is especially encouraging. This
subscale measures respondents’ belief that violence is the only
effective means of repairing self-esteem when it is damaged by the
disrespect of others.28 In America’s inner-cities, this belief is
ubiquitous.30 Lacking more traditional means for bolstering their
sense of self-respect, violence is commonly seen as a tactical
remedy by poor urban youth seeking identity maintenance in the
face of shame.1 As such, the gun becomes an effectual symbol of
both power and status.17 In one large study of juvenile arrestees,
nearly 40% supported the belief that ‘‘it is okay to shoot someone
who has disrespected you.’’9
In an environment where respect is a commodity which is ‘‘hard
won and easily lost,’’12 it is not surprising that poverty and violence
are such co-morbid social diseases. Harvard Medical School
psychiatrist James Gilligan contends that ‘‘shame [is] the pathogen
that causes violence just as specifically as the tubercle bacillus
causes tuberculosis.’’15 Thus the potential for Cradle to Grave to
improve inner-city youth’s beliefs about the value of responding
aggressively to shame has important implications for hospital-
based prevention programmes.
The question of why the programme had a significant impact on
public school participants without affecting their charter school
counterparts requires further examination. One explanation for
this effect might exist in the differences in the groups’ day-to-day
experiences. It is possible that violence is a more salient feature in
the lives of public school students and as a result the students
responded more strongly to the programme’s messages. The public
school was located in a neighbourhood where the incidence of
aggravated assaults with a gun was over seven times that of the
charter school neighbourhood. Baseline attitude differences
between the public and charter schools students emerged upon
review of pre-test scores with public school students scoring
higher on the Aggressive Response to Shame subscale (p < 0.01).
This result is consistent with the findings of a previous study that
administered the AGVQ to 1619 youth in order to examine
demographic variables and violence-related exposure, attitudes
and behaviours.27,28 This study also found that public school
students had higher AGVQ scores and that these higher scores were
associated with trauma-related forms of exposure to gun violence.
A disparity in exposure to guns and gun-related violence might
also account for higher scores among charter school students on
the Power and Safety subscale following C2G participation
(4.20  2.21 vs. 4.96  2.43, p = 0.03, Table 6). As gun violence is a
 A.J. Goldberg et al. / Injury, Int. J. Care Injured 41 (2010) 110–115
much rarer occurrence in their communities as compared to the
neighbourhoods from which the public school students derive, we
postulate that the charter school students’ increased score in this
domain potentially reflects a novelty effect that is an unintended
consequence of C2G’s emphasis on the lethality of handguns. Future
research on C2G will employ demographic data and analysis of
participant experiences to further examine differences in participant
groups.
An unanticipated finding from this study involves the higher
baseline AGVQ scores among females from the sample compared
to their male counterparts as well as the significant decrease in
scores exhibited following their participation in the programme.
While the differences in violence-related attitudes between male
and female adolescents are beyond the initial focus of our study,
these findings raise important questions that certainly merit
further investigation. One potential clue may be found in the
respective ages at which male and female violent offending peaks.
For males, the rate of violent offending peaks at age 17; for females,
the rate peaks at 15–16.11 As the average age for all participants in
the study was 14.11 years, higher baseline scores among females
may owe in part to their having participated nearest the violent
offending peak for their gender group.
Realistic in its aims, the Cradle to Grave programme follows the
tradition of other public health efforts that employ education in
order to modify health-compromising behaviour. That the effects
of the programme persisted several weeks following the inter-
vention offers evidence that the students for whom violence is
most normative walked away with more than the initial ‘‘shock
and awe’’ of the experience. An informal poll of the participants
revealed that nearly all of the public school students knew
someone who had been shot. However, none of the participants,
despite their previous exposure to gun violence, had actually been
shot themselves or seen the physical aftermath of a shooting as
depicted during their visit to the programme (A. Goldberg, MD,
unpublished data, 2008).
Undoubtedly, the students’ memories of the graphic images
from the programme faded with time. It is possible, however, that
taken in total, the authentic human experiences that are
represented during the programme – the devastating physical
harm done the shooting victim, the tremendous emotional damage
done to surviving families, and the irreversible harm done to
communities – served as cogent factors that outbalanced the
influences that support aggressive attitudes.
In conclusion, our study demonstrated a reduction in violent
beliefs one month after participation in the Cradle to Grave
programme. The efficacy of the programme was most notable in
students exposed to the greatest levels of violence. Importantly,
this reduction was most pronounced in the Aggressive Response to
Shame subscale, a subscale that directly measures how adolescents
are likely to respond to confrontation in their community.
Conflict of interest
The authors do not have any conflicts of interest, including
employment, consultancies, stock ownership, honoraria, paid
expert testimony, patent applications/registrations, or sources of
funding/grants, to disclose.
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