“It is nice, but it can’t keep me safe”: perspectives on the effectiveness of hospital-based violence intervention programs

Abstract

Background

Hospital-based violence intervention programs (HVIPs) have been identified as an important intervention to reduce the likelihood that people who are violently injured return to the hospital for a similar injury. However, these programs often struggle with the recruitment and retention of participants.

Methods

Drawing on long-term multisited ethnographic research at the programs associated with the two busiest trauma centers in the state of Maryland, we examine how survivors of violent injury, their loved ones, and program staff evaluate the effectiveness of HVIPs.

Results

In centering the perspectives of these stakeholders, our analysis shows a clear disconnect between the goals of HVIPs and the realities survivors face. Thematic analysis included the inability of program services to increase participant safety, the limited impact of HVIP services on reducing retaliatory violence, and the need for community-engaged collaboration.

Conclusions

These insights suggest a need for HVIP models that prioritize long-term care and social change.

Level of Evidence

Level IV, Economic & Value-based Evaluations.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Hospital-based violence intervention programs (HVIPs) are a promising intervention to decrease rates of repeat violent injury. However, there has been mixed evidence on their effectiveness, and little is known about how participants in these programs conceptualize meaningful intervention.

WHAT THIS STUDY ADDS

• This study considers the perspectives of black men who survived a violent injury and participated in an HVIP, loved ones of survivors, and program staff to understand their views on the effectiveness of current violence intervention approaches and opportunities for improvement. Our research found that there was a shared sense of program services not increasing participant safety, severe limitations of services in reducing retaliatory violence, and the significant need for community-engaged collaboration.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings from this research have significant implications for practice, as they emphasize the importance of strong relationships between institutions and communities, opportunities for those at the highest risk of violent injury to contribute to designing intervention models, and broader support for structural solutions to community violence.

Background

In the USA, there are marked racial disparities in non-fatal violent firearm injuries, with black Americans being over 21 times more likely to be the victim of a non-fatal shooting than their white peers.¹ The consequences of surviving a gunshot wound include disability, chronic pain, loss of employment, unstable housing, and mental illness (eg, acute stress disorder, post-traumatic stress disorder, substance use disorder, and depression).^2–6 Critically, many black men who survive gunshot wounds are discharged from the hospital and return to the neighborhood where they were injured.^{4 7} A lack of access to safe housing and comprehensive support contributes to high rates of repeat violent injury.^{8 9} Rowhani-Rahbar and colleagues found that, in fact, those who had a history of violent firearm injury were over 21 times more likely to be hospitalized a second time for a gunshot wound compared with those who were hospitalized for non-injury reasons.¹⁰

Recognizing that high levels of violence and barriers to healing are shaped by structural and social factors—including racial segregation, mass incarceration, concentrated poverty, and poor access to healthcare—public health interventions have sought to address health inequalities through a comprehensive approach.^11–14 Hospital-based violence intervention programs (HVIPs) have been identified as an important intervention to reduce the likelihood that people who are violently injured return to the hospital for a similar injury.^15–17 These programs are designed to reduce repeat violent injury by providing psychosocial services to people who survive a gunshot wound and other violent injuries. Although there is not a standardized model of practice, HVIPs may provide outpatient psychotherapy, mentoring, transportation assistance, peer groups, referrals to community-based resources, educational opportunities, and housing services.^{16 18–21} However, programmatic evaluations (randomized-control trials or observational studies) have yielded mixed results on the effectiveness of HVIPs in reducing the likelihood of repeat violent injury and ability to improve the health outcomes of participants.^22–24 Further, even those programs which have been operating for over two decades struggle with recruitment and retention of participants, including a failure to provide services to over 95% of those eligible at one of the busiest trauma centers in the country.²⁵

Recent scholarship has sought to acknowledge the importance of qualitatively examining the barriers to successful intervention, participant experiences of trauma, challenges to recovery, and the healthcare needs of participants.^{4 6 26 27} However, there has been little research examining how Black men who survive a gunshot wound conceptualize effective violence intervention and the kinds of support they desire to reduce the likelihood of re-injury. This lack of engagement, including with the experiences of those at the highest risk for re-injury, precludes a comprehensive understanding of the health and social goals of the men who engage with HVIPs. To our knowledge, this is the first qualitative study to examine how black men who survived a gunshot wound and received supportive services from an HVIP conceptualize the effectiveness of these programs in reducing repeat injury and meeting their psychological and social needs. Our analysis shows a clear disconnect between the goals of HVIPs and the realities survivors face. These insights suggest a need for HVIP models that prioritize long-term care, support, and social change.

Methods

Participants and procedures

Long-term multisited ethnographic work was conducted from December 2021 to January 2023 at the HVIPs associated with the two busiest trauma centers in the state of Maryland, USA—one located on the western side of Baltimore and the other near the border of Washington, DC, in Prince George’s County. In 2022, Baltimore and Washington, DC, had the fourth and fifth highest homicide rates in the country, respectively (Centers for Disease Control and Prevention 2022). Both hospitals treat a large number of patients for violent injury, with the program in Baltimore (University Hospital, pseudonym) seeing approximately 1600 patients each year and the program in Prince George’s County (County Hospital Center, pseudonym) seeing approximately 750 patients each year. The University Hospital’s HVIP is one of the oldest in the country. Throughout the program’s tenure, it had offered, at various points, an inperson peer group, financial assistance with rent, food, and personal care items, and individual therapists. However, in the years prior to the beginning of the pandemic, they radically restricted the services they were able to offer due to high rates of staff turnover and limited financial resources. Similarly, in previous years, County Hospital Center offered individual therapy, long-term case management, transportation, pro bono legal advice, and mentorship to participants. With changes in program leadership and grant funding (and lack of institutional support for financing the program), these services had been cut other than assistance with transportation.

Institution review board approval was obtained from the University of Maryland, College Park, Maryland, USA. This article draws primarily from semi-structured interviews (62 interviews, n=43 participants), which were completed as part of a larger ethnographic study focusing on the emotional experiences of black men who survived a gunshot wound and received care from an HVIP (see Wical for complete detailing of all methods used in the larger study).⁶ Three groups of interlocutors—HVIP participants, their loved ones, and HVIP staff—completed interviews. Inclusion criteria for program participants were: (a) black man, (b) age 18 years or older, (c) survived a gunshot wound, and (d) engaged with one of the research sites. Study participants also had to live in Washington, DC, Maryland, or Virginia at the time of injury and at the time of the interview. Both programs had participants with similar demographics (age, time since injury, participants with multiple injuries, housing status, and length of participation in an HVIP). The individuals in this sample are reflective of these demographics.

Two interviews were conducted with each program participant; they occurred at least 3 months apart and lasted approximately 60 min each (n=23 for the first interview, n=19 for the second interview). These interviews focused on their experiences with an HVIP, perspectives on violence and interventions, recovery and healing, trauma, coping, and the social impacts of surviving a gunshot wound (eg, disability, changed relationships with family, stigma, and loss of employment). Program participants had the option to have an interview conducted with a loved one; all family or friends were over the age of 18 years (n=12) (of the interviews with loved ones, 75% (n=8) were with people who were a primary caregiver at some point). Family and friends were asked about the health and social changes experienced by both their loved ones and themselves. One wave of interviews was completed with all program staff who had been employed by the hospital for over 6 months (n=8). Staff included program managers, caseworkers, and an outreach coordinator. These interviews included questions about how each staff member viewed the causes and consequences of gun violence, what constitutes effective intervention and prevention, and the psychosocial needs of participants.

Recruitment for HVIP participants was completed using a two-step process that included a case worker introducing the study to individuals who met the eligibility criteria to gage their interest and comfort prior to being put in contact with the researcher (William Wical). Subsequently, for those interested, the researcher answered any questions about the project prior to completing informed consent. In some cases, participants were recruited at the weekly virtual peer group at County Hospital Center where the researcher would discuss preliminary findings and observe the group. In total, 10 participants who were treated for their gunshot wound at University Hospital and 13 who were seen at County Hospital Center enrolled in the study. Family and friends were recruited if the program participant felt comfortable with their participation.

This study was conducted during the COVID-19 pandemic. Therefore, a hybrid approach was used to accommodate changing restrictions on human subjects research and participant comfort with meeting in person. Participant observation and interviews were conducted both through Zoom and in person. Both programs underwent significant changes related to the pandemic (see Wical et al), as the HVIPs stopped inperson services and halted most direct service provision. Both programs primarily relied on referrals to community-based organizations (many of which were closed or had limited available services). Despite these changes, staff reported that their ability to meet the needs of violently injured black men was similar to before the pandemic. For much of the research, each program had one primary case manager who was responsible for meeting the needs of all participants (University Hospital had an approximately 2-month period where there were no HVIP staff). Unlike previous years, the programs did not have a clinical counselor or a violence intervention specialist.

Data analysis

All interviews were recorded and transcribed verbatim. All potentially identifiable information was removed to protect the privacy of participants. Data analysis included an iterative coding strategy using the qualitative data analysis software MAXQDA.²⁸ All codes and themes were discussed and unanimously agreed on by all members of the analysis team (WW, TG, TW); two members of this team (TG and TW) have lived experience with surviving a gunshot wound. Only themes that were saturated are presented in this article (ie, salient across the entire sample). Saturation was agreed on when no new information was garnered from analyzing additional interviews. Prior research has demonstrated that the analysis of the experiences of at least six participants provides a robust enough sample to establish most codes on a given topic, with 12 participants yielding over 90% of all codes.²⁹ Pseudonyms are used throughout this article to protect the privacy of both staff and participants.

Results

HVIP participants, their loved ones, and program staff overwhelmingly rejected the notion that the services offered by the programs prevented incidents of violent re-injury, promoted safety, or addressed the causes of violence. Thematic analysis resulted in three themes: (a) a failure of services to meet concerns about safety, (b) lack of programmatic impact on someone’s willingness to retaliate or likelihood of re-injury, and (c) the need to center structural causes of gun violence in prevention and intervention efforts.

“It’s nice, but it can’t keep me safe”

Participants at both programs reported feeling appreciative of the support they received from the HVIP staff. This support included receiving holiday gift baskets (which included toys for their children, gift cards, and food), connections to community-based organizations, bus tokens, and occasional rides to and from hospital appointments through a mobile transportation service (eg, Lyft or Uber). Additionally, many participants emphasized that they had a strong relationship with the primary caseworker, even when they could not provide any support because of limited resources. As Victor, a self-described “on again, off again” participant at County Hospital Center explained:

When my daughter was born, [the program had something] around Christmas time where I can go down to the hospital and they put a lot of toys out for the kids and I was able to get something for her. I’ve had times where I've run out of food and I can call Peter (the caseworker) and see if he can help me get some type of food. He came through every time.

However, participants highlighted that HVIP services did little to reduce the likelihood of being violently injured again. Ray, who was shot a second time just months after he started participating in the HVIP at County Hospital Center, expressed that this resulted in conflicting feelings toward the program. Although he appreciated the connection he had with the primary caseworker, like others, he emphasized that none of the services assisted in navigating the changes in his life after being shot and did not help him avoid being shot again. Ray described:

[The program is] definitely not something that you think you’re going to be looking forward to [attending], but Peter definitely went above and beyond. Anything you do, I'm just going to appreciate it… it’s nice (the virtual peer group, referrals to community-based organizations, and occasional ride to a medical appointment) but it can’t keep me safe.

Michelle, whose son was shot prior to the pandemic and who remained on the ‘active participant’ list at University Hospital HVIP in 2022, explained that she thought the most significant benefit of the program was the space for her son to “verbalize what actually happened, opposed to just keeping it in, in hopes that someone would care.” When asked if she felt as though the services helped prevent violence, she remarked, “I would say not necessarily prevent, but [it can] help with the aftercare as aspect of it.” For Michelle, like other family members and friends, the fact that the program did not actively decrease the likelihood of their loved one being re-injured or promote feelings of safety did not diminish the value of the supportive services that were offered.

When asked what services would promote safety and reduce the likelihood of re-injury, participants, their loved ones, and staff noted that access to temporary housing away from the neighborhood where they were injured and comprehensive financial support were essential. Christine, the girlfriend of a longtime participant at the University Hospital program, felt as though her boyfriend would have benefited from temporary housing after his injury and during moments of acute mental illness. She lamented, “I know that they [helped] put him on a few housing lists… but any [progress] with the housing authority and all that is because of himself.” When waiting on the housing list for a voucher, her boyfriend was homeless for over a year, during which his mental and physical health significantly declined. Early during fieldwork, Christine’s boyfriend, Max, emphasized that although he had been injured on multiple occasions, “it would be homelessness that [would] kill [him],” suggesting the need to prioritize promoting safety from factors beyond re-injury alone.

Mark, the caseworker at the University Hospital program, detailed how when he approached patients at bedside, they often requested assistance with finding a safe place to go after discharge. He explained, “One of the main things they want is housing. Those resources are really slim, especially for men. When they get discharged, they [want to] have somewhere to go that is safe. And that is really hard.” Mark often described how he understood his true work as diverging from the HVIP model, with his primary goal being to “meet the basic needs of survivors”—not intervening on or preventing violence. However, he noted that these services were not priorities for the hospital, and thus, the HVIP often faced barriers in being able to complete them. Both caseworkers and participants underscored that the inability of HVIPs to meet the basic needs of men after they survived a gunshot wound—including housing, financial support, access to food, and access to medical supplies—served as a primary barrier in sustaining long-term participation and effective service provision. Peter, the County Hospital Center caseworker, detailed that although meeting the pressing needs of survivors of violent injury was vitally important for participant satisfaction, it remained a very low priority for the hospital (and was cut prior to the pandemic):

We used to pay for certain small stuff. Back in the day, the one kid had a fine for $75 (for a parking citation) that was causing him to not get this job [he applied to]. So we were able to pay the fine, I got reimbursed and everything was cool. But that is not a high priority [for the hospital], meeting people’s needs.

“They are not stopping shit”: rethinking the effectiveness of intervention on retaliation

The primary caseworker at each program did not think that the limited care they were able to offer reduced the likelihood of participants engaging in retaliatory violence. Peter repeatedly clarified that the County Hospital Center HVIP failed to engage in any meaningful prevention or intervention at a time when levels of violence were rapidly increasing. Although the pandemic had made it significantly harder to provide care to the men who engaged with the program, Peter fully rejected the notion that the services they provided or previously had offered were able to decrease the likelihood of someone getting injured or engaging in retaliatory violence. He stated, “There is no prevention. We are just a program on paper. We are promising all this stuff, we can’t do none of it.” He detailed that because of a lack of staffing, resources, and support from the hospital to do community-focused work, he was restricted to only aiding with navigating the hospital system, offering referrals, and leading the virtual peer group.

Similarly, participants and their loved ones also felt as though the services offered by the HVIP failed to prevent retaliation. The lack of intervention was particularly troubling, as neither HVIP had any connection with community-based violence intervention programs. Thus, when someone was discharged, they were not connected with a street outreach worker residing in their neighborhood who could facilitate conflict mediation or address safety concerns. Terri, the former girlfriend of one of the participants at University Hospital, explained:

I don’t understand what the program is for. I felt like it was just to help a person financially [by assisting with filling out the Victims of Crime Act paperwork] because it don’t provide no kind of relief or help with violence itself.

In contrast to the HVIP model, which emphasizes the need to engage people at bedside when they are supposedly most willing to change their behavior (ie, willingness to engage in retaliatory violence), participants challenged the notion that this interaction reduced the likelihood of further violence. Rather than a ‘teachable moment’, men described the time they were hospitalized as an intense period of social and emotional upheaval when they needed psychological and physical stabilization. Like the caseworkers, Rich, a participant in the University Hospital program, poignantly described his frustration with the program:

[If they call themselves a prevention program], they got to prevent something. You got to go to the violence [our emphasis]. If you can’t go to the violence, bring the people like us, we’re the people who been shot, we’ve been in the violence… I’m just saying you’ve got to really stand on that word. Violence, that’s strong word.

Similarly, Bri, whose boyfriend had been shot during the pandemic, rejected the notion that the HVIP was reducing the likelihood of repeat injury for participants in any capacity. She explained, “No, it doesn’t prevent, at this day and age, I don’t think it can… the violence is so high. I don’t think it can be stopped.” Michael, the father of a gunshot wound survivor, echoed Bri’s feelings of hopelessness. He felt as though nothing could have been done prior to or after his son’s injury to decrease the likelihood of his injury or potential re-injury. Michael noted:

It’s sad to say, but I think [it’s] a possibility just based off the environment alone… No parent wants to be in a position where these are the circumstances, but this is what I can afford right now, so I have to worry about my child going outside.

An acknowledgment of the challenging social contexts to which participants are discharged from the hospital troubles using repeat injury as a primary diagnostic for programmatic impact. John, a long-term participant at the University Hospital program who was seen as a ‘success’, rejected the notion that the HVIP was responsible for his decision not to retaliate after discharge:

I could tell you personally right now, Mark [caseworker] didn’t stop me from wanting to fucking [kill] certain people. That was never even my option [because of the physical disability I had after being shot]… It was like, ‘Oh, okay, [the program is] just some people to talk to, but they're not stopping shit.’

Rather, participants cited many different reasons for not retaliating, such as not knowing who had injured them, physical inability to retaliate because of firearm-acquired disability, the desire to not ruin their life with a homicide charge, love for their mother, and need to provide for their family. Even when men made conscious decisions not to retaliate, both they and their families were worried about future violence related to them still being alive. Sylvia, John’s mother, recalled:

We live in fear of retaliation, live in fear that you will be labeled as a snitch, live in fear that you may lose your life by speaking up for something… [I was] praying that he didn’t try to retaliate, which I know that’s not his character but after going through what he went through, I was just scared of what he might try to do to try to make himself feel better.

John, and other men at both programs, cautioned against using a failure to retaliate as a primary metric for programmatic success. In contrast, they described the circumstances surrounding being re-injured or engaging in violence as being fundamentally related to the structural contexts in which they lived.

“It’s so deep”: the need for community-engaged work and collaboration

Survivors, their loved ones, and program staff agreed that effective intervention and prevention were contingent on accurately determining the causes and consequences of gun violence. However, there was a significant disconnect between the design of HVIPs (eg, programmatic framing of the causes of violence, available staff, and services) and participant views of how to best reduce levels of gun violence. Although black men who survived a gunshot wound did highlight the importance of retaliation in high levels of violence in their neighborhoods, they underscored the need to address the structural conditions which contribute to steep gradients of social inequality, and in turn, violence. Like others, John expressed frustration with the overwhelming focus on individual interventions in HVIPs:

What they talk about [retaliation, decision making, behavioral change] is not even touching [the problem]. It’s not even touching the surface of the problem. [They] really don’t even know what to try and grasp at because it’s so deep. So, to understand it, you would really have to dive into it… you got to [look at the history and] take all that and [see its] impact.

Participants and their loved ones cited residential segregation, over-policing, concentrated poverty, and the elimination of public resources as core issues that require comprehensive solutions. Rejecting the notion that a weekly peer group or referrals meaningfully addressed the complex health and social needs of the men who engaged with HVIPs, program participants and their loved ones described the need for broader efforts to support the goals of black men who survived a gunshot wound. Carl, an occasional participant in the virtual peer group at County Hospital Center, emphasized that no program without direct connections to the community could meaningfully disrupt or prevent violence. He explained that the HVIP model needed “more community uplifting, more people coming into the community and showing love and people giving back to the community… and it has to be consistent.”

Both caseworkers noted that in previous years their HVIPs had done some form of community-focused work, including visiting schools to talk about violence and prevention, collaborating with community partners, basketball games with law enforcement and neighborhood residents, and yoga classes. However, these initiatives did not align with the perspectives of program managers and hospital administration about appropriate services and goals for HVIPs and were stopped. Peter recalled how his efforts to engage the community, which had been stopped:

[In the past], we had gone to the houses [of participants], now it is completely discouraged [a change that happened before the pandemic]… We did a blood drive before, we had all the guys go up to [the Children’s Hospital] and donate blood. Community service stuff, that is something I would like to incorporate more into the program. They get so much out of that, and it helps the community.

He lamented the stopping of these program activities and the elimination of providing groceries to participants who lived in the poor wards of Washington, DC, which did not have any markets. Peter exclaimed, “When poor leadership occurs, that is what kills the program.”

Mothers, fathers, cousins, and romantic partners of program participants felt as though HVIPs should do more in terms of engaging people before they are injured. Like survivors—who often described that the requirements in getting support “shouldn’t be damn near dying”—family and friends noted that partnerships between HVIPs and community-based organizations (both those focusing on violence prevention and social inequality) offered an important avenue for contributing to the well-being of those at risk for injury and re-injury. Kevon, whose cousin was shot twice and who had been participating at County Hospital Center since his first injury, detailed that he did not think the current iteration of how HVIPs provided service could prevent violence because of the decades of systemic disinvestment—limited opportunities for community members, closures of resources for youth, and poor treatment by social institutions. Kevon outlined his vision to decrease firearm violence in his neighborhood and that of his cousin:

There has to be a groundswell. I see it as building rapport. Being hands-on to the point where you start to build up the trust. You build up the trust between the communities and the police department, other communities, and the hospitals. Because [right now] the people don’t trust them. They don’t want to go to these hospitals… You have to actually going in to these groups of people and make them think that we can help them, and let that actually be a fact.

The men who survived a violent injury themselves noted that they were interested in volunteering and working to prevent violence; in some cases, they already were engaged in doing this work informally in their neighborhoods. Cam, who stopped attending the County Hospital Center HVIP altogether because he felt he was not getting anything out of it, explained:

I want people to see that [black men who survive gunshot wounds] really care out here, the real ones really care. [We] really want to see change. I say that shit every day. I want to see change… I know I’m not the only one.

Black men who were injured as well as their loved ones did not expect HVIPs to address structural determinants of health and risk for injury on their own. Rather, they underscored the value in fostering long-term connections and relationships with people and community-led institutions both in terms of promoting health and well-being and acknowledging that violence is not solely contingent on individual behavior.

Discussion and conclusion

It is imperative that approaches to gun violence prevention center the perspectives of those who are most impacted, including their beliefs about the causes of violence, assessments of current intervention strategies, and insights on new directions for supportive services. Although HVIPs may increase access to important resources for black men who survive a gunshot wound, both programs included in this study had little means of addressing participant concerns around safety. The inability to meet these needs is not surprising given the tenuous position of grant-funded programs within the hospital system and the structural causes of repeat violent injury.⁶ However, our analysis of the narratives of program participants, their loved ones, and program staff offers key insights into how HVIPs may best be able to support the physical, social, and psychological needs of those who are injured. These contributions are in alignment with the stated goal for HVIPs as defined by the Health Alliance for Violence Intervention—to “alter risk trajectories by operating at multiple levels of social ecology.”³⁰ We underscore the need for HVIPs to be engaged at all levels of social ecology, not just the micro and meso levels.³¹ Critically, this can be achieved when HVIPs engage in direct service provision, advocacy, and community empowerment.

The HVIPs in this research undoubtedly faced significant challenges related to both the COVID-19 pandemic and the dramatic spike in rates of firearm violence during the pandemic; these challenges included low institutional support, understaffing, and restrictions on inperson programming (see Wical et al for further detailing of these challenges).³² Although these barriers to adequate service provision did alter the daily practices of both programs, the assertion from participants, their loved ones, and HVIP staff that the available services did not promote safety cannot be simply dismissed as an artifact of the unprecedented moment in which the research was conducted. Rather, as all three groups of participants noted, effective violence intervention is reliant on deep familiarity with the lives and structural contexts in which survivors of violent injury live, seek to recover, and attempt to avoid repeat injury and strong relationships with the community. This need for understanding underscores that services must be sensitive to the unique challenges individual participants face, and relatedly, the address the differing factors which contribute to participants’ safety.

Although the disconnection that survivors (as well as their loved ones) expressed may have been exacerbated by the pandemic, their perspectives highlight a key difference in determining the appropriate site of intervention—the mental health of survivors or in neighborhoods where they live. Rich’s contention that “you got to go to the violence” provides clear insight on how engagement in communities impacted by violence may foster higher levels of satisfaction as well as provide additional opportunities to meet the health and social needs of survivors. Additionally, although services like temporary financial support, access to food, and medical supplies may not necessarily translate into feelings of increased safety, they reflect the social needs of black men who survive a gunshot wound and remain a vital means of improving health outcomes. Lastly, since community violence is fundamentally driven by structural drivers of health inequality, the findings from this study regarding the need for more effective community-engaged and collaborative work to address these challenges extend well beyond the restrictions to care related to COVID-19.

In contrast to simplistic definitions of safety which assert that individuals are primarily responsible for risk, participants described safety as a complex social phenomenon rooted in access to resources, historical patterns of neglect and abandonment, and personal experiences of victimization. Program staff must prioritize developing a plan that acknowledges these barriers to avoiding re-injury—these plans may leverage municipal and state resources for temporary relocation, provide temporary unrestricted cash aid, or foster relationships with community-based violence intervention programs as key strategies for improving health and social outcomes. Efforts to promote safety should prioritize engaging loved ones when developing a plan, as family members often provide physical and emotional care during and after discharge from the hospital. Although the HVIP model positions disrupting retaliatory violence as a core avenue to reduce the likelihood of repeat injury or violent perpetration, participants rejected the notion that the care they received accomplished this goal. Further, they noted when someone did not return for a similar injury or engage in retaliation it was not necessarily because of the services provided by an HVIP. This reflection bolsters the call for broader metrics of success for HVIPs and the men they serve.^{8 26 33}

Paying close attention to the experiences and perspectives of Black men who survive a gunshot wound, the views of their family and friends, and the knowledge of frontline staff in HVIPs challenges conventional understandings of how to most effectively interrupt violence. Although leading HVIP scholars and organizations suggest a public health approach to gun violence prevention “recognizes that many risk factors can be modified by the individuals at risk to create a social determinants profile that is less risky”, (Bonne and Dicker 2020 pg. 24)^34–38 this framing fails to adequately acknowledge how those who are injured experience the racialized social systems of exclusion which harm them (eg, housing, healthcare, criminal legal, and educational systems). Further, in rehearsing the dominant politics of responsibility, this discourse is easily co-opted to unduly blame individuals for the structural causes which impinge on their ability to meet their basic daily needs. In contrast, those most impacted by firearm violence emphasize the need for interventions to be firmly rooted within the community—what Rich from the University Hospital program described as “going to the violence.” This shift underscores the need for HVIPs to partner with community-based organizations focusing on changing the structural factors which harm black men who survive a gunshot wound.

Although the findings from this research cannot be generalized to all HVIPs across the USA because of the significant impact of local context (eg, institutional support from the hospital, connections between program and community-based organizations, rates of firearm violence, and specific institutional responses to the COVID-19 pandemic), it provides tangible avenues for promoting safety for HVIP participants after discharge from the hospital. Additional research on how programs have met the durational challenges related to the instability faced during the pandemic (and the following years) may offer critical insight into new avenues for aligning survivors’ visions of effective programming with those available to them in HVIPs. Although both HVIPs in this study did not have formal connections with community-based violence intervention programs, fostering a collaborative relationship with those organizations working in the neighborhoods where men live may provide a continuity of support otherwise impossible. These partnerships would offer greater access to people who are experienced in conflict mediation, have shared lived experience, and are familiar with the social context that someone is returning to after discharge. In doing so, violent firearm injury is framed as a complex social phenomenon requiring comprehensive support rather than as something best addressed through augmenting individual behavior. This framing is in line with the knowledge and experiences of black men who survive violent firearm injury—insight which must serve as a moral guidepost to creating equitable systems of support and care.

Data availability statement

No data are available.