Staying Out of the Way: Perceptions of Digital Non-Emergency Medical Transportation Services, Barriers, and Access to Care Among Young Black Male Survivors of Firearm Violence

Abstract

With a reduction in primary barriers to healthcare access as a result of the Affordable Care Act, there is an increased need to address secondary barriers faced by low-income young Black male survivors of violent injury. While transportation is often characterized as a barrier for individuals with chronic disease and disability, it also acts as a significant barrier in accessing cognitive behavioral therapy and mentoring services through hospital-based violence intervention programs (HVIPs). These services address the traumatic stress associated with surviving gun violence. Although there are many challenges associated with the current practices of non-emergency medical transportation, participants in HVIPs face additional risk factors. We highlight the application of a digital transportation intervention to increase the use of psychosocial services among low-income young Black male survivors of violent injury participating in an HVIP. Digital non-emergency medical transportation services (DNEMT) address issues concerning financial barriers, personal safety, program credibility, and program participation. We conducted qualitative interviews and a focus group with this population to assess the impact of Uber Health, a DNEMT service, on their participation in an HVIP located in a suburban Maryland hospital immediately outside of Washington, D.C. Survivors identified the use of Uber Health as essential to addressing the multifaceted and interconnected barriers to treatment. These barriers included reluctance to use alternative forms of transportation services (i.e., bus or subway) due to potential encounters with rivals, increased risk of repeat violent victimization, the need to carry a weapon for protection, stigmatization, and symptoms associated with traumatic stress. We found that integrating digital transportation services into the standard practices of HVIPs, as a part of a patient-centered outcomes framework, contributes to a reduction in violent injury and re-traumatization by addressing the multi-layered risks experienced by survivors of gun violence.

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The Journal of Primary Prevention
https://doi.org/10.1007/s10935-020-00611-2
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ORIGINAL PAPER
Staying Out oftheWay: Perceptions ofDigital
Non‑Emergency Medical Transportation Services, Barriers,
andAccess toCare Among Young Black Male Survivors
ofFirearm Violence
JosephB.RichardsonJr., etal.[full author details at the end of the article]
Accepted: 25 September 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
With a reduction in primary barriers to healthcare access as a result of the Afford-
able Care Act, there is an increased need to address secondary barriers faced by
low-income young Black male survivors of violent injury. While transportation is
often characterized as a barrier for individuals with chronic disease and disability,
it also acts as a significant barrier in accessing cognitive behavioral therapy and
mentoring services through hospital-based violence intervention programs (HVIPs).
These services address the traumatic stress associated with surviving gun violence.
Although there are many challenges associated with the current practices of non-
emergency medical transportation, participants in HVIPs face additional risk fac-
tors. We highlight the application of a digital transportation intervention to increase
the use of psychosocial services among low-income young Black male survivors of
violent injury participating in an HVIP. Digital non-emergency medical transporta-
tion services (DNEMT) address issues concerning financial barriers, personal safety,
program credibility, and program participation. We conducted qualitative inter-
views and a focus group with this population to assess the impact of Uber Health,
a DNEMT service, on their participation in an HVIP located in a suburban Mary-
land hospital immediately outside of Washington, D.C. Survivors identified the
use of Uber Health as essential to addressing the multifaceted and interconnected
barriers to treatment. These barriers included reluctance to use alternative forms of
transportation services (i.e., bus or subway) due to potential encounters with rivals,
increased risk of repeat violent victimization, the need to carry a weapon for protec-
tion, stigmatization, and symptoms associated with traumatic stress. We found that
integrating digital transportation services into the standard practices of HVIPs, as a
part of a patient-centered outcomes framework, contributes to a reduction in violent
injury and re-traumatization by addressing the multi-layered risks experienced by
survivors of gun violence.
Keywords Violent injury· Gun violence· Hospital-based violence intervention
programs· Non-emergency medical transportation· Barriers to care· Post-traumatic
stress disorder· Uber Health· Patient-centered outcomes research

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Introduction
In 2017, homicide was the leading cause of death for Black males ages 15–34,
and the second leading cause of death for Black males aged 1–14 (CDC, 2017).
For each of the 67,299 Americans who died from violence-related injuries, nearly
19 additional emergency department visits were attributed to a non-fatal assault
(CDC, 2017). These survivors of violence face significant trauma-related disrup-
tions to their psychological and social well-being, for which they require health
services (Hanson, Sawyer, Begle, & Hubel, 2010; Wong etal., 2007). Hospital-
based violence intervention programs (HVIPs) have emerged as a promising
wraparound service provider for violently injured young Black men, as they pro-
vide mental health services, resources for housing and jobs, conflict resolution,
and retaliation prevention programming (Rich & Grey, 2005; Richardson, Vil,
Sharpe, Wagner, & Cooper, 2016; St. Vil, Richardson, & Cooper, 2018). These
types of programs have been shown to be successful at reducing both trauma
and criminal justice recidivism (Cooper, Eslinger, Nash, Al Zawahri, & Stolley,
2006; Shibru etal., 2007; Purtle etal., 2013). Despite the increasing availability
of these services for this disproportionately low-income and uninsured popula-
tion, transportation remains an important and understudied barrier to service uti-
lization (Davis etal., 2008; Dixon, Ahles, & Marques, 2016; Solomon, Wing,
Steiner, & Gottlieb, 2020; Valentine, Dixon, Borba, Shtasel, & Marques, 2016).
Transportation is widely cited as one of the most common barriers for treat-
ment (Cristancho, Garces, Peters, & Mueller, 2008; Goins, Williams, Carter,
Spencer, & Solovieva, 2005; Rust et al., 2008; Syed, Gerber, & Sharp, 2013).
Additionally, patients with transportation barriers typically experience an
increased burden of disease, reflecting the interconnections between poverty and
transportation accessibility (Syed etal., 2013). Access to reliable nonemergency
medical transportation to attend medical and mental health appointments is an
important dimension of care provision for urban victims of violent crime (Kelly,
Merrill, Shumway, Alvidrez, & Boccellari, 2010). Rideshare services, such as
Uber and Lyft, may provide opportunities to address barriers to healthcare access
(Powers, Rinefort, & Jain, 2016). Limited research has evaluated whether digi-
tal non-emergency medical transportation services (DNEMT), such as rideshare
apps, improve health service attendance. Among Medicaid beneficiaries treated at
an urban medical center, Chaiyachati etal. (2018a) noted that the implementation
of a no-cost rideshare intervention increased show rates for primary care appoint-
ments. However, these findings are not unanimously supported, as a later study
observed no change in missed appointment rates (Chaiyachati etal., 2018b). No
research regarding DNEMT has been conducted among low-income young Black
male survivors of nonfatal firearm violence, a population that is particularly
adversely affected by transportation barriers and may benefit from transportation
interventions. Furthermore, no research has qualitatively explored how DNEMT
affects this population’s perceived quality of care provided through HVIPs.
Patient-centered approaches provide a framework for improving service provi-
sion to survivors of trauma. Bonne and Dicker (2020) call for further evaluation

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and refinement to service provision by HVIPs to inform best practices. The use
of qualitative research to understand how participants experience transporta-
tion barriers provides nuanced narratives regarding why and how transportation
interventions augment service utilization and offers insights that may improve
program quality and research direction. Few studies have explored the impact of
digital transportation services among socially marginalized populations that often
face the greatest transportation barriers (Blome, Rosenbaum, Lucas, & Schreyer,
2020; Chaiyachati etal., 2018b; Syed etal., 2013). In this study, we qualitatively
explore the unique barriers experienced by young Black male survivors of violent
injury and their perceptions of DNEMT provided by an HVIP. Through their nar-
ratives, survivors emphasized how these services shaped their participation in an
emerging HVIP located in the Washington, D.C. metropolitan area and addressed
their specific needs to achieve successful health outcomes.
Transportation limits access to trauma-focused treatment for Black people in
low-income urban communities, including young men who survive violence (Davis
etal., 2008; Dixon etal., 2016; Solomon etal., 2020; Valentine etal., 2016). Black
males are approximately half as likely as their White counterparts to use profes-
sional mental health services, even after adjusting for socioeconomic and clini-
cal factors (Gonzalez etal., 2010; Hankerson etal., 2011; Motley & Banks, 2018;
Watkins & Neighbors, 2007). In a quantitative study of unmet need for trauma care
among Black people living in low-income urban communities, Davis etal. (2008)
identify that transportation and finances pose significant barriers to service use.
For older, poor, and minority populations in the United States, limited car access
as well as reliance on walking and public transportation are negatively associated
with healthcare utilization and predicts lack of a routine healthcare provider (Flores,
Olivar, & Kastner, 1998; Pesata, Pallija, & Webb, 1999; Rask, Williams, Parker, &
McNagny, 1994; Syed etal., 2013). Syed etal. (2013) note that limited research has
explored the particular details and circumstances that make transportation a barrier
to health service utilization, especially for socially marginalized populations.
Several studies have begun to explore how transportation barriers constitute an
obstacle to postinjury care for Black men who survive violence. Qualitative and
quantitative studies report that many low-income Black people experience compet-
ing obligations for time and money that may reduce their ability to seek care (Davis
et al., 2008; Hines-Martin, Malone, Kim, & Brown-Piper, 2003). Limited vehicle
access, such as the lack of availability of a private car or poor public transportation
infrastructure, may compound the time and financial burden of care for these popu-
lations. Survivors of physical violence often experience trauma-related disruptions
to their well-being which serve as unique barriers to receiving care (Vella et al.,
2020). Physical disability resulting from violence-related injury augments transpor-
tation related challenges and may alter existing barriers for underserved minority
populations (Drainoni etal., 2006; Peterson-Besse, Walsh, Horner-Johnson, Goode,
& Wheeler, 2014; Scheer, Kroll, Neri, & Beatty, 2003). Psychological trauma and
a disturbed sense of safety prevents survivors from using public transportation to
seek care (Liebschutz etal., 2010; Rich & Grey, 2005). In addition to symptoms
associated with traumatic stress such as hypervigilance, survivors of violent injury
also note concerns about retaliatory violence while using public spaces (Liebschutz

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etal., 2010; Rich & Grey, 2005). In addition to the limited literature regarding how
transportation functions as a barrier to post-injury care for Black men, no studies
have explored how wraparound service providers, specifically HVIPs, may improve
access to care through the use of digital transportation services.
Digital rideshare services such as Uber and Lyft may offer new opportunities
to overcome transportation barriers for survivors of violent injury. In 2016, Uber
and Lyft announced Uber Health and Lyft Concierge, which are transportation
services that allow health organizations to schedule and pay for rides on behalf of
their patients (Powers etal., 2016). Organizations subscribing to the transportation
service, such as managed care organizations, request drivers to be dispatched to
patients through a HIPAA-secure application (Powers etal., 2016). Compared with
taxis and livery services, digital transportation companies offer improvement across
dimensions of transportation including cost and user experience (Powers et al.,
2016). Although transportation interventions have attempted to increase social ser-
vice access, no studies have been conducted on providing DNEMT services for low-
income young Black male survivors of nonfatal firearm violence.
A growing number of studies have demonstrated the value of using qualitative
methods to identify the cultural contexts of healthcare experienced by Black men
(Watkins & Neighbors, 2007; Wical, Richardson, & Bullock, 2020). Ravenell, John-
son, and Whitaker (2006) used focus groups to explore Black men’s perceptions of
health, health influences, and definitions of health. Rich and Grey (2005) used in-
depth interviews to explore the social context of traumatic stress, the code of the
street, and substance abuse among violently injured young Black men.
Our study employs qualitative methods, a grounded theory approach, and a
patient-centered outcomes framework to assess an intervention serving young
Black male survivors of violent injury treated through the County General Violence
Intervention Program (CG-VIP), an HVIP in a suburban Maryland hospital. CG is
located less than five miles from the border of the District of Columbia and is the
busiest Level II trauma center in Maryland. It treated an average of 740 victims of
violent injury annually from 2017 to 2019, with approximately 30% of patients being
seen for gunshot wounds. Approximately 98% of the population treated for gunshot
wounds are male, 82% are Black, and 48% are between the ages of 19–30. CG-VIP
provides clinical counseling, intensive case management, and peer mentoring and
support for survivors of violent injury using a trauma-informed care approach that
emphasizes client safety and empowerment (Leitch, 2017).
Methods
We employed a purposive sampling strategy to select participants from the popu-
lation of survivors of gun violence that engaged with CG-VIP during the study
period from August 2018–August 2019. Study participants were low-income
Black males between the ages 18–35 who resided in the Washington, D.C. met-
ropolitan area and were injured via gunshot wounds, and who largely reflected
the demographics of individuals treated in the CG-VIP. Each participant had
been hospitalized for at least one gunshot wound on at least one occasion. All

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participants had a previous history of criminal justice involvement. Our violence
intervention specialist (VIS), who bridges program participants and psychosocial
services by providing peer mentoring and support, is trained in cognitive behav-
ioral therapy (M-TREM: Men’s Trauma Recovery Empowerment Model), trauma
informed care, motivational interviewing, conflict resolution, and human subjects
research (Wical et al., 2020). He recruited the majority of survivors into CG-
VIP at their hospital bedsides during their medical treatment for violent injury.
The VIS called potential study participants who were not recruited at bedside by
phone, briefly described the study, and asked if they were interested in participat-
ing. Those who responded positively received a detailed description of the study
from the VIS and Research Director in a private room at CG hospital. Individuals
who wished to participate gave their informed consent at that time. No eligible
respondent refused participation in interviews or in the focus group; however, one
member dropped out of the study and another was killed.
The Research Director and VIS co-facilitated all 11 qualitative individual inter-
views which focused on the lived experiences of violent victimization, the impact
of criminal justice involvement, experiences of traumatic stress, perspectives of the
program, and barriers to care. Although the same interview guide was used with
each survivor, some participants did not answer all the questions due to the sensitive
nature of their answers. Interviews were conducted in a closed private studio at the
University of Maryland and lasted between 45 and 60min.
Concurrently, the Research Director and the VIS also moderated a focus group
of four of the 11 young Black male survivors of gun violence to explore how CG-
VIP could best empower patients to improve their health outcomes. Recruitment for
the focus group was conducted in the same manner as for the interviews. Conversa-
tion was generated from the moderator’s guide; however, participants were able to
discuss the 10 open-ended questions with little interruption. When appropriate, the
VIS and Research Director asked for clarification of terms, experiences, and reason
for beliefs. The focus group was used to capture the range of survivors’ experiences,
differing needs for services, and dissimilarities in psychological well-being after dis-
charge from the hospital. These participants were a sub-group of the interviewees;
they were chosen to represent variations in age, experiences with the criminal justice
system, and number of times being injured. The moderators guide included ques-
tions centering on how the experience of injury impacted participants physical and
mental health, changes in their ability to accomplish daily goals, and what would
best support their wellbeing. The focus group was conducted in a private conference
room at the University of Maryland and lasted approximately 60min.
After program participant data had been collected, we conducted an interview
with the VIS to assess his perceptions of patient-centered outcomes among pro-
gram participants. All procedures were in accordance with the ethical standards of
the institutional and/or national research committee (University of Maryland Col-
lege Park Institutional Review Board, #938948-6) and with the 1964 Helsinki Dec-
laration and its later amendments or comparable ethical standards. We obtained
informed consent from all individual participants included in the study. We use
pseudonyms in this article to protect the identity, confidentiality, and privacy of
study participants.

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Analysis
All interviews and the focus group were transcribed. We used a grounded theory
approach (Glaser & Strauss, 1967); that is, no a priori codes were used in order to
ensure that participants perspectives were most accurately reflected. This analyti-
cal strategy was chosen as there is no previous research on the use of DNEMT in
this population to suggest possible codes or significant themes. We determined
that topics had to be discussed in at least 30% of the data sources to be considered
thematic. The theme of digital transportation services emerged from both the
interviews and focus group, as CG-VIP participants and researchers discussed the
value of Uber Health as a resource that reduced the likelihood of repeat victimi-
zation and re-traumatization. Using the qualitative analysis software Dedoose, we
utilized a three-staged coding strategy in order to generate themes and patterns
from the interviews. In the first stage, we analyzed transcribed interviews to gen-
erate a codebook based on reoccurring themes. After discussion and consensus,
we assigned codes to transcribed interviews and the codebook was iteratively
modified. This was done to certify that codes were applied in a uniform manner.
In order to confirm reliability of the generated codes, we did not use any codes
that did not have unanimous consensus. The applications of codes were discussed
and agreed upon by the research team in order to ensure that the quotes were rep-
resentative of the perspectives of the participants.
We utilized Lincoln and Guba’s (1986) “four-dimensions criteria” as a means
to establish the trustworthiness of the data; these include credibility, dependabil-
ity, confirmability, and transferability. This approach ensured that the results were
credible from the perspective of the participants, while recognizing and reflect-
ing differences in their opinions. The Research Director and VIS maintained a
detailed study protocol to promote replicability. The iterative coding strategy was
used to increase the likelihood that the findings could be confirmed or corrobo-
rated by other researchers if they were given access to the data. This approach
was used to reach consensus between all members of our research team.
The codes were then analyzed to determine emergent themes including finan-
cial barriers, safety of DNEMT, and program credibility and participation. The
relationships among these codes emphasized the possible range of survivors’ per-
spectives as well as the importance of transportation services for service use.
Results
Financial Barriers
In the focus group and interviews, study participants identified the cost of trans-
portation as a significant barrier to accessing psychosocial services provided
through the HVIP. Participants noted that Uber Health services, provided at no
cost to participants by the program, incentivized service use.

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One participant, Slim (Age 29), mentioned that increasing the program’s Uber
Health budget would improve participant service use and outcomes. He noted that
HVIP services were important and beneficial to him:
[Uber Health]’s big, they just got me right here. I just caught an Uber to
come right here through [CG-VIP], know what I am saying? So, whoever is
giving [funding] for this situation, give them some more, give them some
more money for that. It ain’t going to hurt you, y’all got it. Because that
sh*t helps… if you tell somebody, I got paradise over here and you living
in hell, but I got paradise over here, if you come over I got paradise for you,
but you gotta buy your own ticket over here though to get there. While we
living in hell holes, I am glad you let me know about paradise over here
(program), or I’d have to still be over there while you are eating, drinking,
Grey Poupon and sh*t. I’d still be over there.
Slim also noted that he was willing to overcome the financial barrier of transpor-
tation to participate in the program because of the value psychosocial services
provided him and his daughter. However, he suggested that others with limited
financial resources were unlikely to participate in the HVIP due to the cost of
transportation:
Yeah, I need [CG-VIP] for my daughter. But like, if you asked somebody
else with kids, they would be like, I gotta spend my own money? I ain’t got
no money. Get what I am saying? I don’t have no f*cking money.
Study participants unanimously expressed the importance of free DNEMT ser-
vices as a primary factor for remaining engaged in the program. Multiple par-
ticipants noted that they would not have engaged in the program’s psychosocial
services if free DNEMT services were not available. The removal of financial
barriers offered an important pathway to increase program participation, as Slim
noted:
Say I got the Uber ride for you, who ain’t going to get in the car? They
going to get the f*ck in the car… You are telling me I can go to the Uni-
versity of Maryland program (site for services) or stay where I am at, every
day, all day? For free? Now it would be a different story if you had to say I
had to find my own way. You hear what I am saying, but you aren’t telling
me I have to find my own way. You are telling me that you have the trans-
portation for me. I’m being real, man.
Another survivor, Wall (Age 26), reported telling two of his friends about the
program’s use of DNEMT. His friends, both survivors of nonfatal violent fire-
arm injury, subsequently joined the program: “They get you Ubers, free Ubers,
all that. You can’t say you ain’t got no ride, they give it to you. It’s free. You can
come to the program, it’s a good program.”
Study participants repeatedly assessed the value of the program as related to
their financial constraints. Although participants spoke positively about the pro-
gram, even describing it as “paradise,” they noted that in the absence of free

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DNEMT, they would not have participated due to the financial burden of trans-
portation. This suggests that participation in HVIP services by survivors of vio-
lent injury is related to both perceived service quality and the financial burden of
program access.
Safety ofDNEMT
The threat of re-victimization—perceived and actual—while using public transpor-
tation also serves as a significant barrier to care for many young Black male survi-
vors of violent injury; this barrier may be exacerbated by the symptoms of traumatic
stress. Participants highlight the multiple ways in which a reliance on public trans-
portation decreased their safety, including potential encounters with rivals, criminal
justice prosecution for engaging in violence, and the need to carry a weapon for
protection. Traveling by public transportation via bus or subway was perceived to
increase the likelihood of conflict and re-injury from rivals and law enforcement.
Red (Age 20) discussed safety:
It’s not about being scared, or none of that. Or worrying about what the next
man [is] thinking about you. It’s about you keeping yourself in safety. You
know what I’m saying. Worrying about you safety-wise. Cause you still gotta
be out there…People be trippin on metro (subway system). I’m more safer in
Uber. Uber’s more private.
Nell (Age 24) emphasized the importance of DNEMT:
[Uber]’s quicker and better transportation. It’s safe. The [metro line] that I was
on the other day… that ain’t that safe. [Uber]’s one of the best things about the
program.
For many survivors, it is difficult to maintain personal safety upon discharge from
the hospital because they immediately return to the neighborhood and social context
in which they were injured. The fear of repeat victimization may be intensified by
traumatic stress symptoms such as hypervigilance, avoidance of external reminders,
and increased irritability. The prolonged periods of waiting in a heavily occupied
space may also preclude survivors from taking public transportation. One survivor,
Kane (Age 20), discussed being hypervigilant in public spaces: “If somebody going
in their pocket to get their phone, like, I am on alert. Like I am watching what is
about to come out of your pocket.”
The unpredictability of public spaces is reflected in survivors’ unwillingness to
use these alternate modes of transportation: “Say like a train or a bus, I don’t really,
I don’t get on those for real” and “Never metro, I can’t ever do metro… It ain’t safe
on the metro.”
Some survivors expressed similar reservations regarding the safety of DNEMT.
One survivor, Smokey (Age 22), explained:
You can feel safe, but at the end of the day anything can happen, anything.
So, you can be in that Uber, look out that window, looking whatever, a lot of
people, I notice this a lot, so a lot of people be looking at their phone with their

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The Journal of Primary Prevention
head down. And that one moment you could pop your head up, look to your
left, look to your right, there can be a gun in your face so, you gotta stay on
your pivot (hypervigilant), stay focused or whatever.
Other participants noted that Uber Health reduced their likelihood of carrying fire-
arm due to a perceived sense of safety. One participant, Suge (Age 19), elaborated:
It’s (Uber) comfortable for young people like us that is running the streets,
that is doing whatever we doing. But if you take two, three hours out of your
day to go to a program, you don’t got to, you don’t gotta take heat (gun) to the
program.
He further suggested that Uber reduced the likelihood of engaging in violence on
the Metro which may result in arrest and prosecution: “You going to jail too (if you
engage in violence) on the metro.”
Although some participants noted some safety risks associated with DNEMT,
participants unanimously perceived DNEMT as safer than traditional public trans-
portation. They highlighted that a greater sense of personal safety experienced while
using DNEMT services enabled them to participate in the HVIP, not carry a firearm,
and not engage in violence.
Program Credibility andParticipation
Research indicates that violently injured young Black men are often disconnected
and estranged from the traditional healthcare system (Cooper etal., 2000, Cooper,
Eslinger, & Stolley, 2006; Purtle et al., 2013); this may be especially intense for
those experiencing traumatic stress symptomology. These symptoms increase the
importance of adopting a trauma-informed care approach in addressing transporta-
tion barriers. Survivors emphasized that Uber Health fosters credibility for the pro-
gram. The VIS explained:
[Uber Health] does multiple things. It brings clients transportation to our facil-
ity and back home. It strengthens the relationship with our clients and also
makes us credible. It is safe because our participants naturally feel comfortable
on the way to the hospital because it’s a controlled environment.
This credibility stemmed from survivors’ recognition that the HVIP understood
and took seriously their experiences. One survivor who would not have been able
to attend the program without the use of DNEMT emphasized that itwas a vitally
important factorin improving access to services for program participants: “It has
made it greater, perfect for you. Leave right out your door, the Uber right there…
When you use Uber, that is what makes people come.”
The flexibility in transportation pickup time and available routes enhanced
responsiveness to participant-specific cases, thus empowering their voice. The VIS
stated: “Our guys can also tell the drivers which way to go. Say for instance one of
our guys has a beef on Southern Avenue, he can tell the driver an alternate way to
go.”
This sentiment was echoed by another program participant:

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Most of these dudes ain’t doing no public transportation, no bus, no train.
Like, this program has the Ubers for you, so it’s better for you. Like, ain’t no
way you can say you can’t get up here. Because I have got a ride for you there
and back.
This is particularly important for young Black male survivors that experience trau-
matic stress symptoms, as the need to avoid external reminders and triggers may
impact the use of traditional transportation methods. Young men emphasized that
their participation in the program was bolstered by the use of DNEMT: “Yeah, more
programs should use Uber. Because, when you use Uber, that is what makes people
come. That is what makes them come. They don’t feel as though, okay, boom, they
got the Uber, that is a free ride.”
Participants in the program were also disproportionately involved in the criminal
justice system, approximately 70% of the participants were under community super-
vision (i.e., probation). Uber Health increased their adherence to appointments with
probation officers which bolstered the credibility of the program, here Wall (Age 26)
explained:
Yeah Uber is a good thing. I have never seen a program do that, because most
of these programs will tell you get there how you get there. If you missed it,
you missed it. Your P.O. (probation officer) will try to get you transportation.
I told my friends, it’s a good program. And they are on papers (community
supervision) too. And I am like, man, it’s a good program, and I know the
dude—Mr. Billups (VIS) and he will help you out, man. He will be good for
your P.O. to stay off your line (avoid probation violations), Mr. B is going to
make sure you come to the program. They get you Ubers, free Ubers, all that.
According to both survivors and staff, DNEMT is an important feature of the HVIP
because it enables program staff to build rapport and credibility. In addition to sup-
porting retention and recruiting of HVIP participants, DNEMT helps staff be atten-
tive to the safety, social, and legal needs of survivors.
Discussion
We found that DNEMT can address safety issues regarding travel via public trans-
portation that may result in repeat victimization and re-traumatization, reinforc-
ing similar findings by Liebschutz etal. (2010) and Rich and Grey (2005). Free
DNEMT services also address financial barriers among low-income young Black
men that may prevent access to program services. Finally, DNEMT use bolstered
the credibility of the HVIP with participants involved in the criminal justice system
and increased their participation in program services. These outcomes were likely
strengthened because of participants’ established relationships with their VIS which
were built on mutual respect, trust, and compassion. Research findings on the role
and best practices of the VIS suggests that this relationship plays a critical role in
engaging participants in program services (Wical et al., 2020). The VIS’s cred-
ibility, stemming from his own lived experiences as a survivor of violent assault

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and interactions with the criminal justice system, was influential in introducing
DNEMT services to survivors. This finding suggests the importance of non-clini-
cal staff members in the integration of services into HVIP programming. We found
that DNEMT services were perceived by program participants and staff as a reliable
and efficient form of transportation that increased access to psychosocial services.
These important factors influenced HVIP service use and patient satisfaction and
outcomes.
The implementation of DNEMT into the HVIP reflects a strategy of comprehen-
sive and integrated service provision that is attentive to the needs of program par-
ticipants (Kelly etal., 2010). The perceived importance of DNEMT suggests that
service provision must emphasize safety, convenience, affordability, and utility for
the patient population. Although trauma-informed care is a valued framework used
when working with survivors of violent injury, the literature has not emphasized
DNEMT as part of this approach. Through a patient-centered outcomes approach,
researchers and practitioners worked collaboratively to understand the needs of
patients and used their voices in the decision-making process for the implementa-
tion of program services. This perspective shifted the normative paradigm regarding
how HVIPs address transportation barriers which require participants to utilize pub-
lic transportation as their primary resource to access program service. We argue that
the typical approach is in direct conflict with the principles of safety, convenience,
and affordability. Furthermore, the use of Uber Health by this HVIP promoted the
principles of trauma-informed care by providing clients with a sense of safety, trust-
worthiness and transparency, peer support, empowerment, and voice. DNEMT use
addressed the cultural and gender specific challenges associated with increasing the
participation of low-income violently-injured young Black men who live in structur-
ally marginalized communities; these include difficulty in navigating the healthcare
and criminal justice systems, traumatic stress, and the code of the street (Rich &
Grey, 2005; St. Vil etal., 2018). Our findings suggest that DNEMT should be con-
sidered by HVIPs as an alternative to traditional non-emergency medical services
and public transportation.
In addition to improvements to service provision, DNEMT offered practical
benefits to HVIP administration. While CG-VIP initially utilized Lyft and Uber to
transport participants to services, this process posed several logistical problems.
Although the VIS had daily contact with program participants through his provi-
sion of psychosocial services (i.e., peer mentoring and support), the co-director
of the HVIP was assigned to manage the Uber/Lyft account. This required several
phone calls between the VIS and co-director for scheduling, a cumbersome process
that often resulted in cancellations. Additionally, each trip had to be recorded on
a screenshot using a cell phone because Uber and Lyft did not provide rideshare
reports. Information for each participant from each trip was logged onto an Excel
sheet that included all participants who had used the service; this was an inefficient
process and introduced opportunity for user error.
The utilization of Uber Health made the process much less complicated and pro-
vided a more streamlined process. The VIS arranged the roundtrip transportation
with Uber Health by providing the client’s name, address, and pickup/drop off times.
Uber Health coordinated the transportation services directly with the client via text

The Journal of Primary Prevention
1 3
or call, thus allowing the ability to schedule transportation services in advance.
Uber Health also provided online quarterly statements to the HVIP for services via
an excel spreadsheet documenting the transportation services provided during that
period. The spreadsheet included the client’s name, pickup/drop off address with the
dates, times, cost of trip, and the length of time for each trip. Uber Health is HIPAA
compliant and we found that all communications between drivers, riders, and organ-
izations met the HVIPs standards of confidentiality. The culmination of these factors
motivated the CG-VIP to offer DNEMT services at no cost to program participants.
Over an 18-month period from 2017 to 2019, the HVIP provided psychosocial
services for 116 participants. Of those participants, only one was re-hospitalized
for a violent injury, which translated into a trauma recidivism rate of less than 1
percent. Prior to the implementation of the program, the trauma recidivism rate at
CG for violently injured patients was 32 percent (during a similar time period in
2013–2015). DNEMT may play a significant role in bringing participants to services
that contribute to lowering rates of trauma recidivism. Future studies are needed to
evaluate the contribution of DNEMT in preventing violent re-victimization and re-
traumatization. Future studies should also analyze the cost-effectiveness of using no-
cost-to-patient DNEMT compared to traditional transportation interventions such
as provision of public transportation fare cards. Large scale studies are needed to
evaluate the effectiveness of DNEMT in increasing access to psychosocial services
and reducing barriers and costs of continued care.
We acknowledge some limitations to our study. Generalizations cannot be inferred
due to its small sample size and the fact that it was conducted at one HVIP. Personal
factors, such as individual priorities, aspirations, and values of both program par-
ticipants and heath care practitioners shape successful HVIP engagement. Structural
factors, such as state Medicaid expansion, criminal justice policy, and investment
in social services for marginalized populations also affect the outcomes of Black
men who survive violence. Despite the efforts made by the Research Director to
promote replicability, it is important to acknowledge the significant rapport between
participants and interviewers that may not be fully reproducible. We argue that the
trusting relationship between our VIS and survivors was essential in our ability to
achieve sustained participation and conduct high-quality interviews. Throughout the
duration of the study, we discussed how the social positions of the interviewers—
as Black men with cultural and structural awareness and lived experience—shaped
the research process. Lastly, the purposive sampling strategy was completed with a
goal of being representative of the CG-VIP population; however, the research team
unanimously agreed that the results cannot be generalized to all other contexts due
to local patterns of violence inthe Washington, D.C. metropolitan area and the fact
that this is the first study examining the use of DNEMT in this population.
Our study’s findings suggest that DNEMT may be a viable solution for keeping
violently-injured low-income young Black men engaged in psychosocial services
and “staying out ofthe way” of future harm. The policy and practice implications
for using DNEMT, if realized, may revolutionize how violence prevention and inter-
ventions programs provide a holistic range of services for marginalized populations
of young Black men. In discussions with other HVIPs and violence prevention/inter-
vention programs in the Washington, D.C. metropolitan area, we found that only

1 3
The Journal of Primary Prevention
one additional HVIP used Uber Health and that its program replicated the model
used by CG-VIP. We hope that the findings from this study result in more rigorous
evaluation of the HVIPs in the national network, the Healing Alliance for Violence
Intervention, which is comprised of 35 programs situated in major cities across the
United States. Future research on DNEMT could have important policy implica-
tions on the ways digital transportation services, marginalized populations, and the
healthcare system intersect.
We titled this paper Staying Out ofthe Way to capture a colloquial phrase used in
the everyday language of urban young Black men participating in the CG-VIP. They
routinely used this phrase to describe how they avoid future violence and harm. As
translational research scientists, it is our aim to translate this phrase into holistic pol-
icies and practices of HVIPs that protect survivors from future harm.
Acknowledgements The study was funded through a Center for Victim Research Researcher 2 Prac-
titioner Fellowship (Center for Victim Research) and the University of Maryland PATIENTS Program
(Patient-Centered Outcomes Research) at the UMB School of Pharmacy.
Compliance With Ethical Standards
Conict of Interest The authors declare they have no conflicts of interest.
References
Blome, A., Rosenbaum, J., Lucas, N., & Schreyer, K. (2020). Ridesharing as an alternative to ambulance
transport for voluntary psychiatric patients in the emergency department. Western Journal of Emer-
gency Medicine, 21(3), 618. https ://doi.org/10.5811/westj em.2020.2.45526 .
Bonne, S., & Dicker, R. A. (2020). Hospital-based violence intervention programs to address social
determinants of health and violence. Current Trauma Reports. https ://doi.org/10.1007/s4071 9-020-
00184 -9.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2017).
Web-based Injury Statistics Query and Reporting System (WISQARS) Fatal Injury Data. Accessed
Retrieved 30 September 2019.
Chaiyachati, K. H., Hubbard, R. A., Yeager, A., Mugo, B., Lopez, S., Asch, E., etal. (2018a). Association
of rideshare-based transportation services and missed primary care appointments: A clinical trial.
JAMA Internal Medicine, 178(3), 383–389. https ://doi.org/10.1001/jamai ntern med.2017.8336.
Chaiyachati, K. H., Hubbard, R. A., Yeager, A., Mugo, B., Shea, J. A., Rosin, R., etal. (2018b). Ride-
share-based medical transportation for Medicaid patients and primary care show rates: A difference-
in-difference analysis of a pilot program. Journal of General Internal Medicine, 33(6), 863–868.
https ://doi.org/10.1007/s1160 6-018-4306-0.
Cooper, C., Eslinger, D., Nash, D., Al Zawahri, J., & Stolley, P. (2000). Repeat victims of violence:
Report of a large concurrent case-control study. Archives of Surgery, 135(7), 837–843. https ://doi.
org/10.1001/archs urg.135.7.837.
Cooper, C., Eslinger, D. M., & Stolley, P. D. (2006). Hospital-based violence intervention programs
work. Journal of Trauma and Acute Care Surgery, 61(3), 534–540. https ://doi.org/10.1097/01.
ta.00002 36576 .81860 .8c.
Cristancho, S., Garces, D. M., Peters, K. E., & Mueller, B. C. (2008). Listening to rural Hispanic immi-
grants in the Midwest: A community-based participatory assessment of major barriers to health care
access and use. Qualitative Health Research, 18(5), 633–646. https ://doi.org/10.1177/10497 32308
31666 9.
Davis, R. G., Ressler, K. J., Schwartz, A. C., Stephens, K. J., & Bradley, R. G. (2008). Treatment barriers
for low-income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal

The Journal of Primary Prevention
1 3
of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies,
21(2), 218–222. https ://doi.org/10.1002/jts.20313 .
Dixon, L. E., Ahles, E., & Marques, L. (2016). Treating posttraumatic stress disorder in diverse settings:
Recent advances and challenges for the future. Current psychiatry reports, 18(12), 108. https ://doi.
org/10.1007/s1192 0-016-0748-4.
Drainoni, M. L., Lee-Hood, E., Tobias, C., Bachman, S. S., Andrew, J., & Maisels, L. (2006). Cross-dis-
ability experiences of barriers to health-care access: Consumer perspectives. Journal of Disability
Policy Studies, 17(2), 101–115. https ://doi.org/10.1177/10442 07306 01700 20101 .
Flores, G., Abreu, M., Olivar, M. A., & Kastner, B. (1998). Access barriers to health care for Latino chil-
dren. Archives of Pediatrics and Adolescent Medicine, 152(11), 1119–1125. https ://doi.org/10.1001/
archp edi.152.11.1119.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative
research(Ser. Observations). London: Aldine Publishing.
Goins, R. T., Williams, K. A., Carter, M. W., Spencer, M., & Solovieva, T. (2005). Perceived barriers to
health care access among rural older adults: A qualitative study. The Journal of Rural Health: Offi-
cial Journal of the American Rural Health Association and the National Rural Health Care Asso-
ciation, 21(3), 206–213. https ://doi.org/10.1111/j.1748-0361.2005.tb000 84.x.
González, H. M., Vega, W. A., Williams, D. R., Tarraf, W., West, B. T., & Neighbors, H. W. (2010).
Depression care in the United States: Too little for too few. Archives of General Psychiatry, 67(1),
37–46. https ://doi.org/10.1001/archg enpsy chiat ry.2009.168.
Hankerson, S. H., Fenton, M. C., Geier, T. J., Keyes, K. M., Weissman, M. M., & Hasin, D. S. (2011).
Racial differences in symptoms, comorbidity, and treatment for major depressive disorder among
Black and White adults. Journal of the National Medical Association, 103(7), 576–584. https ://doi.
org/10.1016/s0027 -9684(15)30383 -7.
Hanson, R. F., Sawyer, G. K., Begle, A. M., & Hubel, G. S. (2010). The impact of crime victimization
on quality of life. Journal of Traumatic Stress: Official Publication of The International Society for
Traumatic Stress Studies, 23(2), 189–197. https ://doi.org/10.1002/jts.20508 .
Hines-Martin, V., Malone, M., Kim, S., & Brown-Piper, A. (2003). Barriers to mental health care access
in an African American population. Issues in Mental Health Nursing, 24(3), 237–256. https ://doi.
org/10.1080/01612 84030 5281.
Kelly, V. G., Merrill, G. S., Shumway, M., Alvidrez, J., & Boccellari, A. (2010). Outreach, engagement,
and practical assistance: Essential aspects of PTSD care for urban victims of violent crime. Trauma,
Violence, & Abuse, 11(3), 144–156. https ://doi.org/10.1177/15248 38010 37448 1.
Leitch, L. (2017). Action steps using ACEs and trauma-informed care: A resilience model. Health & Jus-
tice, 5(1), 5. https ://doi.org/10.1186/s4035 2-017-0050-5.
Liebschutz, J., Schwartz, S., Hoyte, J., Conoscenti, L., Christian, A. B., Sr., Muhammad, L., etal. (2010).
A chasm between injury and care: Experiences of Black male victims of violence. The Journal of
Trauma, 69(6), 1372. https ://doi.org/10.1097/ta.0b013 e3181 e74fc f.
Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalis-
tic evaluation. New Directions for Program Evaluation, 1986(30), 73–84. https ://doi.org/10.1002/
ev.1427.
Motley, R., & Banks, A. (2018). Black males, trauma, and mental health service use: A systematic
review. Perspectives on Social Work: The Journal of the Doctoral Students of the University of Hou-
ston Graduate School of Social Work, 14(1), 4.
Pesata, V., Pallija, G., & Webb, A. A. (1999). A descriptive study of missed appointments: Families’
perceptions of barriers to care. Journal of Pediatric Health Care, 13(4), 178–182. https ://doi.
org/10.1016/s0891 -5245(99)90037 -8.
Peterson-Besse, J. J., Walsh, E. S., Horner-Johnson, W., Goode, T. D., & Wheeler, B. (2014). Barriers to
health care among people with disabilities who are members of underserved racial/ethnic groups:
A scoping review of the literature. Medical Care. https ://doi.org/10.1097/mlr.00000 00000 00019 5.
Powers, B. W., Rinefort, S., & Jain, S. H. (2016). Nonemergency medical transportation: Delivering care
in the era of Lyft and Uber. JAMA, 316(9), 921–922. https ://doi.org/10.1001/jama.2016.9970.
Purtle, J., Dicker, R., Cooper, C., Corbin, T., Greene, M. B., Marks, A., et al. (2013). Hospital-based
violence intervention programs save lives and money. Journal of Trauma and Acute Care Surgery,
75(2), 331–333. https ://doi.org/10.1097/ta.0b013 e3182 94f51 8.
Rask, K. J., Williams, M. V., Parker, R. M., & McNagny, S. E. (1994). Obstacles predicting lack of a
regular provider and delays in seeking care for patients at an urban public hospital. JAMA, 271(24),
1931–1933. https ://doi.org/10.1001/jama.1994.03510 48005 5034.

1 3
The Journal of Primary Prevention
Ravenell, J. E., Johnson, W. E., Jr., & Whitaker, E. E. (2006). African-American men’s perceptions of
health: A focus group study. Journal of the National Medical Association, 98(4), 544.
Rich, J. A., & Grey, C. M. (2005). Pathways to recurrent trauma among young Black men: Traumatic
stress, substance use, and the “code of the street”. American Journal of Public Health, 95(5), 816–
824. https ://doi.org/10.2105/AJPH.2004.04456 0.
Richardson, J. B., Vil, C. S., Sharpe, T., Wagner, M., & Cooper, C. (2016). Risk factors for recurrent
violent injury among Black men. Journal of Surgical Research, 204(1), 261–266. https ://doi.
org/10.1016/j.jss.2016.04.027.
Rust, G., Ye, J., Baltrus, P., Daniels, E., Adesunloye, B., & Fryer, G. E. (2008). Practical barriers to
timely primary care access: Impact on adult use of emergency department services. Archives of
Internal Medicine, 168(15), 1705–1710. https ://doi.org/10.1001/archi nte.168.15.1705.
Scheer, J., Kroll, T., Neri, M. T., & Beatty, P. (2003). Access barriers for persons with disabilities:
The consumer’s perspective. Journal of Disability Policy Studies, 13(4), 221–230. https ://doi.
org/10.1177/10442 07303 01300 404.
Shibru, D., Zahnd, E., Becker, M., Bekaert, N., Calhoun, D., & Victorino, G. P. (2007). Benefits of a
hospital-based peer intervention program for violently injured youth. Journal of the American Col-
lege of Surgeons, 205(5), 684–689. https ://doi.org/10.1016/j.jamco llsur g.2007.05.029.
Solomon, E. M., Wing, H., Steiner, J. F., & Gottlieb, L. M. (2020). Impact of transportation interven-
tions on health care outcomes: A systematic review. Medical Care, 58(4), 384–391. https ://doi.
org/10.1097/MLR.00000 00000 00129 2.
Syed, S. T., Gerber, B. S., & Sharp, L. K. (2013). Traveling towards disease: Transportation barriers
to health care access. Journal of Community Health, 38(5), 976–993. https ://doi.org/10.1007/s1090
0-013-9681-1.
Valentine, S. E., Dixon, L., Borba, C. P., Shtasel, D. L., & Marques, L. (2016). Mental illness stigma and
engagement in an implementation trial for Cognitive Processing Therapy at a diverse community
health center: A qualitative investigation. International journal of culture and mental health, 9(2),
139–150. https ://doi.org/10.1080/17542 863.2015.11237 42.
Vella, M. A., Warshauer, A., Tortorello, G., Fernandez-Moure, J., Giacolone, J., Chen, B., etal. (2020).
Long-term functional, psychological, emotional, and social outcomes in survivors of firearm inju-
ries. JAMA Surgery, 155(1), 51–59. https ://doi.org/10.1001/jamas urg.2019.4533.
Vil, C. S., Richardson, J., & Cooper, C. (2018). Methodological considerations for research with Black
male victims of violent injury in an urban trauma unit. Violence and Victims, 33(2), 383–396. https
://doi.org/10.1891/0886-6708.vv-d-17-00065 .
Watkins, D. C., & Neighbors, H. W. (2007). An initial exploration of what ‘mental health’ means to
young Black men. The Journal of Mens Health & Gender, 4(3), 271–282. https ://doi.org/10.1016/j.
jmhg.2007.06.006.
Wical, W., Richardson, J., & Bullock, C. (2020). A credible messenger: The role of the violence interven-
tion specialist in the lives of young Black male survivors of violence. Violence and Gender. https ://
doi.org/10.1089/vio.2019.0026.
Wong, E. C., Marshall, G. N., Shetty, V., Zhou, A., Belzberg, H., & Yamashita, D. D. R. (2007). Survi-
vors of violence-related facial injury: Psychiatric needs and barriers to mental health care. General
Hospital Psychiatry, 29(2), 117–122. https ://doi.org/10.1016/j.genho sppsy ch.2006.10.008.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Aliations
JosephB.RichardsonJr.1· WilliamWical2· NipunKottage2·
NicholasGalloway2· CheBullock3
* Joseph B. Richardson Jr.
jrichar5@umd.edu

The Journal of Primary Prevention
1 3
William Wical
williamwical@gmail.com
Nipun Kottage
nkottage@gmail.com
Nicholas Galloway
nickg596@gmail.com
Che Bullock
chebullockpgparks@gmail.com
1 Department ofAfrican-American Studies andtheDepartment ofAnthropology, College
ofBehavioral andSocial Sciences, University ofMaryland College Park, 1141 Taliaferro
Building, CollegePark, MD20742, USA
2 Department ofAnthropology andtheDepartment ofAfrican-American Studies, Translational
Research andApplied Violence Intervention Lab (TRAVAIL), College ofBehavioral andSocial
Sciences, University ofMaryland College Park, 1141 Taliaferro Building, CollegePark,
MD20742, USA
3 Department ofAfrican-American Studies, Translational Research andApplied Violence
Intervention Lab (TRAVAIL), College ofBehavioral andSocial Sciences, University
ofMaryland College Park, 1141 Taliaferro Building, CollegePark, MD20742, USA