Introduction

Violence is a public health crisis and America’s trauma centers stand on the front lines. Recent literature demonstrates that violence follows similar patterns to infectious disease [1]. Among youth living in urban communities in the USA, the prevalence of experiencing violence is high [2••, 3]. Research has identified populations at risk, and primary interventions have been deployed in some places, but despite this, violent trauma and trauma recidivism leads to the most prevalent cause of death in young African American men and seconds among young Latinos. Exposure to interpersonal violence is a recognized form of trauma with both psychological and physiological effects [4]. Chronic exposure to trauma in the urban population and hospitalization for violent injury are associated with symptoms of PTSD, which can lead to an increase in violence perpetration in affected individuals [5••]. This cycle of violence leads to injury recidivism, adding additional burden to already overwhelmed urban trauma centers and the communities they serve.

At its core, the field of public health is defined by its focus on the health of a population; With nearly 40,000 people dying from violence associated with firearms alone, violence indeed is endangering populations. As with other public health epidemics, violence has risk factors and protective factors. Framing it in this context guides us to study root causes and develop and test strategies to intervene and ultimately mitigate risk.

Structural racism is a construct that describes the governmental, religious, economic, and geographic state of being that puts populations at risk for poor health, lack of wealth, and injury, particularly violence [6]. A striking and tangible example of structural racism and structural violence is the practice of redlining: The Federal Housing Authority practice of redlining denied mortgages to African American and low-income populations. Many of these neighborhoods today have significantly lower life expectancies, experience a paucity of healthy food choices (food desserts), and experience a higher prevalence of chronic diseases at a young age, including violence. Digging deeper into the details of structural violence leads us to modifiable root causes encapsulated in the social determinants of health: These social determinants represent the conditions in which people are born, grow, live, work, and age and are shaped by the distribution of money, power, and resources at global, national, and local levels. They are the major drivers of health and disparate health outcomes across communities and populations. Figure 1, from the CDC, outlines the factors that affect health which include poverty, poor housing, poor education, lack of access to preventive health care, poor nutrition, and unemployment. These factors are prevalent among the urban violently injured population. Both the CDC and the WHO implicate the social determinants of health as the driver of health inequity. Consistent with the public health approach, addressing the social determinants can have the largest impact on well-being.

Fig. 1
figure 1

CDC framework for public health action: the health impact pyramid [7]

It is important to emphasize the deep relationship between health and wealth. Drafting heat maps of a variety of chronic diseases, including violence within impoverished communities, demonstrates an overlapping prevalence of many of these conditions at an age and rate that is far younger and higher than counterparts in wealthy communities. As a result of this state of intergenerational poor health, impoverished communities have a significantly shorter life expectancy and have significant challenges staying well enough to seek higher education or viable employment necessary to build wealth and change their socioeconomic conditions [8••, 9].

Another public health framework is captured in an ecologic model; Fig. 2 outlines the factors that contribute to the public health problem of violence. Factors influencing individual violence start from individual factors and spread out from the individual in increasingly concentric circles, stretching out to the family, community, and society. Some factors are static, or unable to be changed by the individual. These are the factors, like basic demographics, that have typically been used to identify high-risk groups. The use of basic demographics to identify risk groups is, however, sometimes sensitive but nearly never specific. For example, many individuals who are victims of urban violence are young African American males; however, not all young African American males become victims of violence. Therefore, directing time and resource intense prevention resources to all young African American men would be far too resource intense to be practical and would also be directing interventions toward a vast number of individuals who would never need them.

Fig. 2
figure 2

Factors influencing violence

The public health approach, however, is more dynamic, and recognizes that individuals and their risk for violence is far more complex than simple demographics. It also recognizes that many risk factors can be modified by the individuals at risk to create a social determinants profile that is less risky. For example, unemployment is a risk factor for violent injury victimization, but an individual can modify their employment status, if appropriate means to do so are made available. HVIPs set up a framework that assists individuals in modifying their social determinants profile.

Principles of HVIPs

Patients who are victims of violence (VOVs) are offered life-saving medical care and follow up. VOVs are not offered violence prevention services that address the risk factors during this critical time in order to prevent “recurrence,” or repeat episodes of violence. The advent of HVIPs has shown the success of a “teachable” moment that occurs following a traumatic event, in which individuals are more receptive to intervention immediately following an injury. It is thought that during efforts in primary prevention, individuals may not have the context to see themselves as high risk or to understand their social determinants profile, but once injured, people are receptive to tangible opportunities to change their risk profile. This is the “teachable moment.” Other disciplines in medicine have precedent in utilizing this “teachable moment” prior to HVIPs. For example, in the field of Cardiology, a patient experiencing a myocardial infarction demonstrates more capacity to accept changes in diet, exercise, and blood pressure control than prior to the event.

During this crucial time, VOVs may be receptive to the idea that they can change their social determinants profile, but there is little evidence that physicians are the most effective messengers [10]. Much more evidence supports intervention specialist (IS) who are relatable individuals from the community as essential credible messengers for prevention following trauma [11]. Through a relationship-based mentoring and case management model, the IS engage at-risk VOVs while they are hospitalized, and provide them with individualized support. This relationship then continues for a variable period of time, but is typically long term, and can last for years from the time of program enrollment. The ISs continue through this period with intensive contact, mentoring, and case management and are willing to be a highly available, reliable contact to victims of violence. ISs initial actions as mentors include the following: Connect and assist with immediate safety planning, enroll and refer clients to existing community resources serving victims of crime, assist in application for victim of crime compensation funding and provide referral to legal assistance for this application, and connect individuals to victim advocates. The bulk of the work is done post-discharge with the VOV and is based upon an evolving needs assessment.

It is essential that ISs are culturally competent to the communities in which they work, which often requires that they reside in the community and have a working understanding of the key community and cultural factors at play in that environment. These individuals should also have a working knowledge of the resources that are available to victims of violence, and typically continue to develop this knowledge base through their employment in the HVIP. It is recommended that the hiring of these individuals is done with the assistance of a community advisory board or community leaders who can identify individuals who have a working knowledge of the community dynamics.

Key to the HVIP model is the recognition, in a public health model, that risk of violence is rooted in modifiable risk factors that often represent social determinants of health, and that mitigating these risk factors, could reduce future risk for violent re-injury and improve overall well-being. The case management that occurs within the HVIP is focused on addressing social determinants of health through a community-based approach. Examples of appropriate services include assistance with meeting education goals, employment and job training assistance, housing assistance, and the attainment of mental health services. ISs often help process necessary paperwork for patients, such as victims of crime compensation paperwork, or paperwork to help patients obtain government identification. Depending on the needs of the patient, ISs may also help the individual navigate the utilization of other community resources, such as substance abuse clinics, health insurance applications, housing applications, applications for state and federal assistance, or the attainment of services and charity-based donations from faith-based organizations.

Often, HVIPs will employ a coordinator or social worker skilled at developing relationships with service providers, potential employers for VOVs, and community-based organizations. This individual may also serve as a reference for complex cases when the scope of case management falls beyond the capacity of a single individual or the scope of the ISs proficiencies.

In order to understand the flow of how victims of violence are approached, enrolled, and taken through HVIP services, the following is a step-by step guide [12••].

  1. 1)

    A victim of violence is seen at the Trauma Center and resuscitated as per standard protocol

    1. a.

      If an intervention specialist is on site during this time, he or she typically makes contact with family or other next of kin. They may help diffuse anger and frustration over the event, but this is not the main goal of these ISs. Some cities have concomitant violence interrupter programs such as Cure Violence that provides this important service.

  2. 2)

    Once stabilized, the IS will go to the bedside of the injured victim and begin to establish rapport.

    1. a.

      This process may be slow and require several bedside visits. If the patient is discharged, this relationship development may take place outside of the hospital.

  3. 3)

    Once rapport is established, the victim is offered enrollment into the HVIP. If the victim accepts, consent is obtained (maintaining a database is critical) and a needs assessment begins to develop.

    1. a.

      A needs assessment is often dynamic and based upon the victim’s mental and physical state.

    2. b.

      Needs include but are not limited to mental health services, job training, employment, education, tattoo removal, substance abuse treatment, housing, victim of crime assistance, and court advocacy.

    3. c.

      Mental health care is frequently the priority need in this population. They have often been retraumatized (see below for more detail) and a Trauma Informed Approach is essential [13].

  4. 4)

    The victim is discharged from the trauma center and the IS continues to maintain a close relationship, shepherding the victim through risk reduction resources in the city or community based on the needs assessment.

    1. a.

      This process may take months to years but the most intensive period is typically the first 6 months.

    2. b.

      There are many HVIPs that offer in-house services such as resume development or life skills training.

    3. c.

      Sometimes the ISs will simply meet their clients for a meal, just to maintain that special mentoring relationship.

  5. 5)

    Although clients at times “graduate” from the program, the door is never closed to them.

Needs assessments performed by ISs on victims of violence have revealed a great requirement for mental health services. The presence of symptoms associated with PTSD, anxiety, depression, and acute stress response (many of which are preexisting conditions) often render a victim of violence unready to seek stable employment. This makes addressing mental health a priority in our population. Traditionally, our young, injured population has been reluctant to seek out mental health services, but with the facilitation by a IS, this has become possible and acceptable to our population. Once mental health challenges are in the process of being addressed, it is much more likely that a VOV will succeed in other areas such as employment.

Initial reported data from HVIPs has been promising. This data has compelled the national adaptation of this model to programs throughout the USA and internationally. Additionally, in 2009, the National Network of Hospital Based Violence Intervention Programs was formed. This group served to bring together programs to provide technical assistance, best practice guidelines, policy advocacy, data sharing, and support through an organization and an annual conference. In 2019, this group was renamed the Health Alliance for Violence Intervention (HAVI), to reflect the contribution of programs that are community based, hospital linked (in contrast to hospital based), and based out of departments of public health. While these programs vary in their implementation strategies, funding streams, and overseeing bodies, they are uniform in their commitment to the public health approach to violence reduction.

Evidence to Support the HVIP Model

While the focus of HVIPs is on the modification of risk, the quantification of success is still in the process of being codified. The Health Alliance for Violence Intervention’s (HAVI) Research Working Group has undertaken a Delphi process to establish common data elements. These elements will certainly represent a public health approach to programmatic evaluation. This approach includes formative, process, short-term, and long-term measures. Demonstrating the value of programs also requires qualitative studies in order to raise the voice of the programs’ participants, and cost-effectiveness analysis. Program evaluation is absolutely essential for a number of reasons. First and foremost, the population that HVIPs serve often represents a group of vulnerable individuals who have been traumatized, and assuring the fidelity of programs is vital to ensuring that patients are not further traumatized by substandard case management or an inadequate relationship with a case manager. Second, programmatic evaluation is necessary for quality and performance improvement, which is a cornerstone of all facets of a high-quality health care system. Finally, evaluation is often needed to justify continued funding of these programs, whether to philanthropic funding bodies or to municipal or state agencies that provide funding.

In a program that seeks to prevent violent re-injury, it seems natural that the outcome measure of choice would be recidivism, or a second violent injury. In fact, this is the reported outcome for many of the early HVIPs. Recidivism, however, is an imperfect outcome measure for a number of reasons. First, it can be difficult to assess in a large urban environment in which a patient may not present to the same hospital or trauma center the second time they are injured. Second, recidivism does not take into account the ecological factors that may contribute to a second injury. For example, if an individual has changed their social determinant profile and has generally improved their lives as a result of the HVIP, but is victimized a second time as the result of a prior relationship, this is not really a programmatic failure. For this reason, the value in HVIPs should be measured beyond simple recidivism.

To date, most studies have been performed on single centers, with the exception of HAVI’s multi-institutional database analysis. Single-center studies have demonstrated capacity of TOWs to engage and enroll and retain the target population (formative and process evaluation) and conduct a needs assessment and successfully address risk factors associated with violent injury including many social determinants of health (process and short-term outcomes).

Despite the lack of uniform data collection at this time, HVIP programs in the USA have individually demonstrated measurable improvements in quality of life for victims of violence. [14, 15••, 16••] Single-center data thus far has demonstrated that the HVIP model successfully addresses the risk factors associated with violence and is successful at assisting victims in receiving mental health services and obtaining employment. Court advocacy and placement in educational programs have also been touted as successfully addressed in these programs. When victims of violence and their contacts are identified and enrolled in HVIP programs, positive outcomes are reported, such as return to work and school, increased self-esteem, decreased retaliatory violence, decreased substance abuse, and decreased trauma recidivism [14, 15••] Finally, there is some data to support reduction in the recidivism rate in clients enrolled in these programs [14, 15••, 16••, 17,18,19,20,21]. Ultimately, these programs result in decreased health care resource utilization and spending, as overall trauma recidivism and its associated expense is decreased [15••, 16••, 17].

When speaking with certain stakeholders in this HVIP work, a discussion of cost benefit often is necessary. There is health economics data through a Markov analysis that demonstrates that these programs are very cost effective, particularly given that many of the clients receive Medicaid benefits [22, 23••]. The HAVI is currently managing a multi-institutional dataset that seeks to resolve questions about best practices, evaluation parameters that should be most relied upon, and outcome measures that should be captured. The Eastern Association for the Surgery of Trauma recently published an evidence-based review making no strong recommendation regarding implementation of HVIPs. Evidence was based essentially on recidivism rate alone. This review drives home the point that ecologic factors cannot be controlled and our research in the future must go well beyond recording just a recidivism rate in these programs [24]. In particular, there is need for measurement of intermediate outcomes, health outcomes, and qualitative analysis and patient-reported long-term outcomes. It is clear that among this group of experts, they did not believe that HVIPs lack quality, but they do, at this time, lack high-quality evidence and a strong recommendation was made that research into this field be supported.

Next Steps

Based upon positive data that is available on the value of HVIPs, several policy measures have either passed or are being considered that would support the efforts of HVIPs. California Assembly Bill 166 (D-Gabriel) has passed the California Senate and Assembly and at the time of this chapter, preparation is on Governor Gavin Newsom’s desk for consideration. If passed, the bill would allow for established California HVIPs to be reimbursed through MediCal (Medicaid) for services rendered. The Bill assures appropriate training in order to ensure quality control and fidelity of the public health model. In 2019, the State of New Jersey Attorney General’s Office made $20 million in grants available for starting violence intervention programs in nine qualified health care settings. Currently, only the University Hospital in Newark has a hospital-based program. This effort was supported by members of HAVI and the Giffords Law Center. In The State of Virginia, $2.45 million in Victim of Crime (VOCA) grant funds were made available to Virginia Hospital and Health Care Association Foundation to support the implementation of hospital-based violence intervention programming at 7 Virginia hospitals. As a result of these efforts, other states are exploring similar efforts and legislation.

Another forward-leaning step in the arena of HVIP work is the development of partnerships and alliances. The Health Alliance for Violence Intervention has a partnership with the American College of Surgeons Committee on Trauma (COT). Given that the COT sets criteria for trauma centers nationally and is the leadership body for trauma care, this alliance has been important in spreading HAVI’s best practices. This partnership will provide opportunities moving forward in strengthening efforts in research and advocacy for HVIPs. Discussion between the two organizations is directed toward seeing that a best practices model of HVIPs is ultimately expanded to all trauma centers that see a high burden of violent injury. HAVI has also developed a partnership with the American Foundation for Firearm Injury Reduction (AFFIRM). This organization’s commitment to funding research on firearm injury and injury prevention aligns perfectly with HAVI’s vision and mission.

HVIPs traditionally address the upstream causes of violence. Many have begun to look beyond the individual and into the at-risk communities they serve. Trauma Centers can play a unique role in supporting their communities, for example, by offering workforce development and career opportunities. Health and wealth are intimately related and our opportunity to intervene and prevent downstream violence is very much in alignment with our goal of health and wellness.