Emerging research areas and contributions of NIH in violence research across the lifespan and throughout different settings

Abstract

This commentary provides background for NIH’s interest in research designed to better understand the causes and consequences of violence and the development, evaluation, and implementation of preventive and treatment interventions to address the resulting trauma, injuries, and mortality from violence. The manuscript describes the context that contributed to a range of initiatives from the NIH focused on violence research, with a particular emphasis on firearms violence prevention research, and opportunities and gaps for future research.

Existing efforts and opportunities to advance NIH-funded research on the prevention of violence and its resulting injury and trauma across the lifespan are discussed.

Implications.

Practice: Research on the causes and consequences of violence and the development, evaluation, and implementation of preventive and treatment interventions can help inform the type of interventions that will be most effective and scalable for each unique community and population.

Policy: Research on violence can provide information and resources to policymakers to help inform evidence-based decision making regarding the development and implementation of policies to most effectively reduce violence and its impacts on individuals, communities, and populations.

Research: Future research should be aimed at expanding violence interventions across the continuum of care, including community-level interventions, and considering the unique experiences of different populations in order to implement strategies most effectively.

BACKGROUND

Since its founding, the National Institutes of Health (NIH) has supported biomedical and behavioral research that aims to benefit society. Specifically, the NIH mission is to “seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability” [1]. Violence, which is the intentional use of physical force or power to injure a person or group of people, is a critical public health issue [2] with profound impacts on lifelong health, opportunity, and well-being and is one of the leading causes of death and nonfatal injuries in the United States [3], especially for young people [4] and members of NIH-designated health disparity populations [5, 6]. Though not officially represented in any one NIH Institute, Center, or Office (ICO), NIH plays a critical role in supporting rigorous research into the causes and consequences of violence, both interpersonal and self-directed, as well as the development, evaluation, and implementation of preventive and treatment interventions to address the resulting trauma, injuries, health and social consequences, and mortality. Initiatives presented herein represent only a subset of NIH-supported violence research initiatives and efforts.

For decades, NIH has funded research to better understand the epidemiology, risk, and protective factors involved with violent behavior and has made important contributions to interventions that reduce aggression and violent behavior. A variety of NIH ICOs have supported this work through both investigator-initiated applications and Funding Opportunity Announcements (FOAs) published by specific ICOs. Nevertheless, violence remains a significant public health problem and additional research is needed to make existing interventions more available and sustainable in diverse communities. More recently, following the publication of a series of NIH targeted announcements in 2013 [7–9], there was a substantial increase in the number of awards focused on violence research. This coordinated, NIH-wide effort sent a message to the field and acted as a significant driver for additional application submissions and funding of high-quality violence-related research.

NIH’s violence research portfolio is diverse with respect to type of violence and includes child maltreatment, sexual violence, Intimate Partner Violence/Teen Dating Violence (IPV/TDV), community violence, youth violence (including bullying), elder mistreatment, and self-directed violence, including suicide [10]. For the past two decades, violence-related projects funded by the NIH have focused on three main areas of research, with some projects focusing on more than one area: risk factors for violence, consequences and impacts of violence, and prevention and intervention development. Research that examined the etiology, causes, or risks for violence/aggression analyzed both distal and proximal biopsychosocial risk factors that contributed to violence across different levels (e.g., individual, interpersonal, community, structural), sometimes through mechanistic analysis. Studies that analyzed the consequences or sequelae of experiencing violence/aggression examined a range of physical and mental or behavioral health outcomes with some projects examining protective factors that make an individual resilient to the impact of violence exposure. Lastly, grants that focused on the development, implementation, or dissemination of an intervention addressed either treatment or prevention activities, focused on either the initial act of violence or recurrent violence, and targeted either victims and/or perpetrators.

Firearm violence is a particularly salient and deadly form of violence that has been included in a broad range of NIH-funded projects. When firearms are involved with violent events, the risk for injury and mortality in addition to acute or chronic physical/mental/behavioral health conditions increases. In recent years, approximately 40,000 deaths each year in the United States are a result of firearm injuries, 60% of which are attributed to suicide and 37% of which are due to homicide [11]. In 2019, firearm-related injuries were one of the leading causes of death for American children, teens, and adults less than 65 years of age, accounting for three quarters of all homicides and half of all suicides [11]. In 2020, the firearm homicide rate increased 33.4% from 2019, reaching its highest level since 1994, making firearm-related injury the leading cause of death for youth aged 1–19 and widening longstanding health disparities [12, 13]. Over the past decade, the suicide rate by firearm in the United States has increased by 19%, but the rate remained relatively stable from 2019 to 2020 [13]. In addition to firearm deaths, many more Americans experience nonfatal firearm injuries which still has a substantial impact on the lives of surviving victims. Both direct and indirect (e.g., witnessing) violent victimization events are associated with not only physical injury or mortality, but also a range of acute and chronic physical and behavioral health conditions, such as obesity, somatic symptoms, sleep disturbance, alcohol and substance use, anxiety, depression, and impaired socioemotional well-being [14, 15].

Populations that are socially marginalized and/or NIH-designated health disparity populations (Blacks/African Americans, Hispanics/Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders, socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities) [16, 17] are disproportionately impacted by both interpersonal and self-directed violence, including but not limited to firearm violence. Homicide has been the leading cause of death for Black men under the age of 45 for the past three decades and is the second-leading cause of death for Hispanic youth [9]. The gun homicide rate for Black males between the ages of 15 and 24 is more than 21 times higher than White males of the same age group [18].

Disparities in suicide rates are most pronounced in younger age groups. Suicide rates are increasing overall among children aged 5–12, with Black children twice as likely to die by suicide compared to their White counterparts [3]. In 2019, American Indian/Alaska Native individuals aged 15–34, however, had the highest suicide rate—24.8/100,000—[11] and were the only ethnic group to see significant increases in the firearm suicide rate from 2019 to 2020 [13]. Sexual and gender minority (SGM) populations experience higher rates of self-directed violence in adolescence [19] and adulthood [20]. Similarly, risk of violent victimization is about three and a half times more often than those who are not SGM [21].

The disproportionality of violence among health disparity populations is likely the result of a complex interaction of social, structural, and economic stressors, and longstanding inequities. For example, structural racism negatively impacts housing, educational, and economic opportunities in Black and Latino neighborhoods and Native American reservations and has been associated with increased risk for violence and related health conditions [22]. Recent studies demonstrate the impact of structural racism and the downstream socioeconomic and built environment factors that contribute to violence and related health outcomes, opening the opportunity for interventions that seek to facilitate change at levels beyond the individual, such as at the community, organizational, or policy level [23].

RECENT FEDERAL VIOLENCE RESEARCH EFFORTS

Broad violence efforts

Although NIH has supported violence research for decades, recent attention to the public health impact of firearm violence has led to a significant increase in investment in recent years. The Further Consolidated Appropriations Act, 2020 [24], the Consolidated Appropriations Act, 2021 [25], and the Consolidated Appropriations Act, 2022 [26] provided $12.5 million to the NIH each year to support research on firearm injury and mortality prevention by taking a comprehensive approach to studying the underlying causes and evidence-based methods of prevention of firearm injury, including crime prevention. Spending bill language in these Acts noted that research must be ideologically and politically unbiased, funds could not be used to advocate or promote gun control, and grantees were required to fulfill requirements around open data, open code, preregistration of research projects, and open access to research articles.

Following the appropriation of these funds, NIH released two FOAs per year in 2020 and 2021 for the purpose of building upon NIH’s existing violence research portfolio and to address emerging areas in violence research through increasingly larger awards—starting with supplements and small pilot awards [27]. Specifically, these FOAs aimed to solicit applications proposing research to improve understanding of the determinants of firearm injury, the identification of those at risk of firearm injury (including both victims and perpetrators), the development and evaluation of innovative interventions to prevent firearm injury and mortality, and the examination of approaches to improve the implementation of existing, evidence-based interventions to prevent firearm injury and mortality. The FOAs took a broad public health approach to firearm injury and mortality prevention, encouraging research on interventions delivered by healthcare providers/systems and in community settings, as well as research that integrated individual, family, interpersonal, community, and structural or system (e.g., criminal justice, schools, hospital systems) approaches to firearm injury and mortality prevention. A particular focus on NIH-designated health disparity populations, which are disproportionally impacted by firearm violence, was also encouraged. In response to these FOAs, NIH supported 9 awards in 2020 [28] and 10 awards in 2021 [29] for firearm violence prevention research.

Research funded under several awards aim to focus on intervening with high-risk populations at different locations within the continuum of care, such as emergency departments or hospital-based services. Reaching beyond the traditional sites of care, many awardees are also accessing populations outside typical healthcare settings with use of technology or through community violence interventions (CVIs). Some awards propose to investigate novel approaches to preventing community violence such as universal screening procedures or vacant property reuse while others specifically examine barriers to implementing CVI programs by supporting the workforce on the ground. Since violence is influenced by a variety of factors, several awards aim to identify unique risk and protective factors on distinct populations (mothers, people with mental health disorders) or types of violence (intimate partner homicide) across different settings, such as school settings, and in relation to state-specific policies. Other awards aim to develop new tools for suicide prevention, including safe firearm storage, for populations across the lifespan. Importantly, given the significant disparities in violence, several investigator teams are focusing on populations most impacted by firearm violence including young Black men and Alaska Native youth.

In response to the Consolidated Appropriations Act 2022, following a comprehensive review of the existing violence prevention portfolio and identification of existing gaps, a set of FOAs were released to build on the prior year’s investments [30, 31]. These FOAs were intended to seed a research network comprised of several research sites and one coordinating center to develop, implement, and evaluate community-level interventions to prevent firearm and related violence. If funded, the research teams at each site will conduct community-engaged research and include a community representative as a key leader in the project.

This focus on community-driven, structural, and multisectoral interventions is consistent with the increasing recognition that such efforts are necessary in order to effectively and sustainably eliminate health disparities and work towards health equity [32]. Given that social determinants of health (e.g., poverty and structural racism) are drivers of population-level disparities in violence and victimization, there is a clear need for this “third generation” of interventions that go beyond the individual [33]. Such interventions are designed to directly manipulate or impact the social and structural drivers of health disparities (e.g., housing opportunities) instead of simply working to mitigate the impact of these drivers.

The transition away from individual-level interventions, while nascent in behavioral medicine and health, is increasingly being solicited in NIH initiatives. For example, NIH has encouraged the development and testing of various interventions such as community-level interventions to improve minority health and reduce health disparities [34], interventions focused on social determinants of health to prevent opioid misuse and co-occurring conditions [35], and systems-level interventions to reduce suicide and suicidal behaviors among youth [36]. It is slowly being recognized that interventions focused only on individual-level change, even if targeting high-risk individuals as many hospital-based violence prevention programs do, will not ameliorate longstanding systematic disenfranchisement such as structural racism and related discrimination.

Indeed, NIH Common Fund’s ongoing “Transformative Research to Address Health Disparities and Advance Health Equity” initiative is currently performing “ground-breaking” efforts to eliminate health disparities by focusing specifically on structural racism and racial inequities [37]. As one example, researchers funded under this initiative are conducting a randomized controlled trial of “concentrated investment” in Black neighborhoods to address structural racism as a fundamental cause of poor health [38]. Notably, occurrence of violence is included as a primary outcome of the study along with other, more typical, health and wellness measures such as blood pressure and psychosocial distress. In this case, the coordination of the “Transformative Research to Address Health Disparities and Advance Health Equity” initiative through the NIH Common Fund facilitated the targeting of community-level factors that have the potential to impact a range of co-occurring clinical outcomes including violence. An increased focus on supporting community and structural interventions to address social determinants of health, along with coordinated NIH-wide efforts, is likely to increase the overall portfolio of violence prevention work across the NIH.

As stated above, populations that experience health disparities are disproportionately impacted by violence. As such, the National Institute on Minority Health and Health Disparities (NIMHD) considers violence as both a determinant of poor health outcomes as well as a health outcome in itself and has initiated a number of efforts to support violence research. In 2017, NIMHD released a FOA [39] to support research on the development and testing of youth violence preventive interventions that incorporated racism/discrimination prevention targets, such as school disciplinary practices or local media messaging, specific to youth belonging to one or more populations that experience health disparities. In response to this FOA, one NIMHD-funded research team is aiming to examine the effectiveness of a community-based youth violence preventive intervention that directly addresses racism and discrimination [40]. The intervention provides support to participants healing from experiences of trauma by restoring social connections, challenging gender norms that foster violence perpetration, and teaching positive bystander intervention skills to intervene safely with peers’ disrespectful and harmful behaviors. NIMHD also published a Notice in 2018 [41] highlighting general interest in receiving grant applications studying the causes and consequences of violence in health disparity populations, as well as policy, health services, and intervention studies to understand how best to prevent or mitigate the impact of violence in these populations. More recently, a NIMHD-led FOA, with 25 ­participating ICOs, solicited research that sought to understand and address the impact of structural racism and discrimination on minority health and health disparities [42]. This FOA resulted in at least one project with violence as the primary health outcome [43]. Researchers supported by this award are evaluating whether an intervention designed to address structural racism in law enforcement and education can reduce interpersonal and self-directed violence among low-income, African American middle school-aged youth.

In support of these recent efforts, NIH has continued to collaborate with other federal agency partners such as the Center for Disease Control and Prevention (CDC) and the National Institute of Justice (NIJ). Notably, the same amount of funds were also provided through Congressional appropriation in each year to the CDC for research into firearm violence [44]. In addition, the NIJ has funded research on firearm violence for decades. In response to the recent appropriations, NIH has coordinated funding efforts through regular meetings with these federal agencies in order to support broad, rigorous, and impactful mortality and injury prevention research on firearm and related violence.

Efforts related to specific violence types

In addition to the recent initiatives on firearm violence, research on specific types of violence continue to be supported by NIH ICOs when they align with their mission and current priorities. Research on children exposed to violence is an important priority for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). In 2002, the NICHD initiated a formal program of research on children exposed to violence with a multiagency scientific meeting aimed at identifying gaps and setting a research agenda across topics including differentiating exposure to violence and child abuse, measuring violence exposure, and preventing and evaluating impacts of domestic violence, community and school violence, terrorism, and war on childhood health. Services and interventions for children exposed to violence and legal and policy issues were also among the areas deemed in need of further research. Subsequently, the NICHD led a FOA with other ICOs and federal agency co-sponsors calling for projects to develop new knowledge in the areas discussed at the meeting, as well as studies examining the definition, identification, epidemiology, prevention, etiology, effects, early intervention, and mechanisms of violence exposure.

To encourage research that addresses unanswered questions related to childhood maltreatment and pursues understudied lines of inquiry through multidisciplinary approaches, NICHD published a FOA called the CAPSTONE Centers for Multidisciplinary Research in Child Maltreatment [45]. The goal of this program is to support multidisciplinary centers to serve as regional and national resources for child maltreatment researchers, practitioners, and policymakers. In addition to conducting thematic research, the funded Centers are also required have a dissemination and outreach component which translates scientific knowledge and study findings to applications for practitioners and policymakers.

As increasingly more children have become victims of firearm violence, NICHD encourages investigator-initiated research that addresses the science of child and adolescent firearm injury prevention with a goal toward promoting safety, preventing death, and reducing injuries and co-occurring psychological trauma. Additional emerging areas of prioritized research for the Institute include studies that address the associations of intimate partner violence, pregnancy, and pregnancy outcomes as well as the impact on infant and child health. Studies examining the long-term reproductive health consequences of experiences of chronic childhood sexual abuse are also a priority for NICHD.

Research on the intersection of mental illness and violence and the prevention of both interpersonal violence and self-directed violence (e.g., suicide, suicide attempts, suicide ideation) is supported by the National Institute of Mental Health (NIMH). This includes research to identify the mechanisms that give rise to and the developmental and neurobiological trajectories that lead to, mental illness following exposure to violence across the lifespan. Interest also includes the development and testing of preventive and treatment interventions that target putative and confirmed mechanisms that drive psychopathological consequences of violence or that impact treatment adherence. One recent example can be found in three FOAs published in 2019 to address the role of violence on HIV care and viral suppression [46]. NIMH also prioritizes research on factors associated with etiology, risk, and prevention of interpersonal aggression and violence against others in the context of serious mental illness [47].

NIMH continues to prioritize suicide prevention research that will contribute to near-term reductions in the rate of suicide [48] and also strengthen the understanding of proximal and distal mechanisms associated with risk, etiology, maintenance, and course of self-injurious thoughts and behaviors (SITBs), especially among populations at elevated risk, such as youth from underserved populations [36], Black children and adolescents [49], and suicidal individuals recently treated in an acute care setting [50]. For example, NIMH has placed special emphasis on healthcare settings, where most suicide decedents receive care in the year prior to death [51], while also working with the research field to identify the state of the science and key questions related to preteen suicide risk [52]. Looking ahead, research on firearm injury and mortality prevention is needed in the context of crisis care services as the new rollout of the 988-suicide prevention hotline is poised to greatly expand the delivery of services across the crisis continuum of care for individuals at elevated risk for suicide.

The NIMH Division of Services and Intervention Research (DSIR) prioritizes a deployment focus that integrates stakeholder input and setting considerations into study designs to improve implementation and sustainability of preventative, intervention, and services strategies for suicide prevention. Studies in the DSIR suicide prevention portfolio include those where lethal means safety (i.e., firearms, medications) is the primary focus [53] or a component of a comprehensive suicide prevention program [54]. Following the deployment-focused research model, several FOAs provide the opportunity for investigators to refine and pilot test strategies to improve safe storage practices in various medical settings and clinical contexts such as primary care [55–57].

Although all people are at risk of victimization, older populations, including people with impaired cognitive function and Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRDs), are considered particularly vulnerable to mistreatment. As such, the National Institute of Aging (NIA) has long supported research on elder mistreatment, issuing FOAs to initiate the systematic scientific study of elder mistreatment in response to its recognition as a significant public health problem in 2005 [58], and again in 2006 [59]. In response to elder justice being identified as a national priority during the 2015 White House Conference on Aging [60], NIH hosted a 1-day workshop on understanding and preventing elder mistreatment and issued a subsequent FOA in 2017 that solicited research to uncover its causes, contexts, and consequences [61, 62]. In 2021, NIA published a FOA to support research on the development of reliable and accurate primary care-based screening tools and brief and effective point-of-care psychoeducational and behavioral interventions to prevent all types of abuse in at-risk older and vulnerable adults with mild cognitive impairment and AD/ADRD [63]. Funded research will directly address the priority research needs and gaps highlighted in the U.S. Preventive Services Task Force’s 2018 final recommendation statement on screening for IPV, elder abuse, and abuse of vulnerable adults [64].

Strong links have been found between alcohol use and the occurrence of IPV/TDV and sexual assault, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has supported a range of research focused both on understanding the mechanisms involved in and the prevention of such behaviors. NIAAA also contributed to the National Academies of Science, Engineering, and Medicine’s Forum on Global Violence Prevention which allowed for the exchange of information and ideas on violence prevention in low- and middle-income countries, including co-occurrence with alcohol use interventions, and resulted in several consensus reports [65].

EMERGING GAPS AND OPPORTUNITIES FOR VIOLENCE RESEARCH

Violence research is a complex field with intersecting stakeholders (e.g., academia, community partners, schools, justice systems, healthcare), far-reaching impacts, ethical implications, and unique factors that need to be considered throughout different settings and across the lifespan. Several research gaps and opportunities have become evident for violence research. Basic behavioral and social science research findings on factors leading to resilience have not been fully integrated in the development of innovative violence preventive interventions. In addition, since violence can have an impact on a broad range of health and disease outcomes, more research is needed across the continuum of care so that treatment and preventive interventions can be integrated through different settings. This comprehensive approach to violence prevention research at NIH has been somewhat limited by the fact that health outcomes cut across a number of diseases, conditions, and populations, making it hard for any one institute to lead such cross-cutting efforts. Thus, a coordinated NIH-wide approach has been needed to maximize the impact of the work, facilitate broad ICO engagement, and ultimately advance the field.

Lastly, with increasing recognition of the critical impact of broader sociocultural forces and the experiences of structural racism and discrimination on violence, more research is needed on community-based interventions that work across multiple levels of the socioecological model. As detailed above, while efforts to address these macro-level determinants of violence and related health outcomes are increasing, more work is needed to achieve health equity and eliminate the longstanding disparities and disproportionate impact of violence on marginalized populations. Indeed, as noted in a review of such efforts in the mental health field, there has been a strong need for this type of research, but very few published, rigorous studies have demonstrated the impact of such interventions [32].

Integration of basic mechanisms of resiliency into intervention development

With the development of novel and innovative technologies, new methods and tools continue to reveal the underlying biology of aggression and the consequence of violence on the brain and overall health and well-being. Additional basic science research on the underlying mechanism and the impact of aggression could better identify intervention targets and inform the development of effective interventions. For example, research has shown that early adverse childhood experiences (ACEs) may be a risk factor for aggression and other health risk behaviors in adulthood [66]. However, not all children who experience ACEs have been shown to have poor outcomes and not all ACEs correlate with poor outcomes, so it remains unclear whether ACEs should be the target of intervention. Research on the neurobiology of resilience [67], coping, and adaptation in the face of and in the aftermath of adversity could elucidate effective strategies to promote positive health outcomes in adulthood. Findings from this research could be better integrated into programs aimed at preventing and treating the experiences of early adversities such as child maltreatment and exposure to interpersonal and family violence.

Aggression can also take nonphysical forms such as emotional, relational, or verbal aggression. With technology, bullying has transferred online and taken the form of cyberbullying. Bullying is increasingly being recognized as a form of youth violence that has significant negative impacts on health and well-being for both victims and perpetrators. According to the 2019 Youth Risk Behavior Surveillance from the CDC, one in five high school students was bullied at school and one in six was bullied electronically in the last year [68]. Females and SGM youth experienced bullying at much higher rates than their male or heterosexual peers [68]. In response to being exposed to violence or aggression, the impact of these stressors can dysregulate biological stress response systems, impair mental health, and also increase the chance for future victimization. Basic research on resilience can help inform efforts to ameliorate the effects of bullying on health and well-being.

Finally, research on approaches to better integrate violence research across generations and the life course is greatly needed. Explicit development of longitudinal data can be useful to track the impact of violence across the life course and the circumstances that may lead to individuals being most resilient. Relevant data sets that collect violence or victimization-related measures, such as the ongoing NIH-supported Adolescent Brain Cognitive Development (ABCD) Study [69], can also be used for exploration of the etiology of violence and its sequelae across the life course. By examining different developmental stages, such longitudinal research can eliminate silos that currently exist for certain types of violence associated with a certain age range, such as child abuse, intimate partner violence, and elder maltreatment, and allow for advances to be translated to different sectors of violence research.

Preventing and treating firearm-related injury across the care continuum

More people suffer nonfatal firearm-related injuries than are killed by firearms with 7 out of 10 medically treated firearm injuries resulting from an interpersonal assault [70]. Because firearm violence can have an impact on a broad range of health and disease outcomes, interventions should be better integrated across different health settings. Victims of violence may receive care across the care continuum, including emergency departments (EDs), critical care, acute rehab, mobile crisis outreach programs, community health programs, and school-based health settings depending on the nature and severity of injuries sustained from violence exposure. For example, since IPV can often have an impact on oral health, dental settings may be an untapped entry point for health professionals to provide survivors with support and referral services to benefit patients’ overall health [71]. In addition, women experiencing IPV are more likely to present to hospitals for traumatic brain injuries [72] and gynecologic conditions.

More research is also needed to examine the ways in which different entry points offer unique advantages that may increase an individual’s willingness to receive resources to prevent future injuries or engage in an intervention. For example, youth intervention programs sponsored by community centers to promote social activities as alternatives to violence may find more success in intervening on violence than programs promoted by settings that represent the site of care, such as EDs. For survivors, concerns around privacy and repercussions on the perpetrator may also impact the setting by which they prefer to seek care.

With so many settings offering unique services and interventions, a coordinated approach across multiple settings is needed to ensure the efficacy and cost-effective implementation of a designated program. Although provider attitudes/practices and high staff turnover may be a barrier for implementing standardized assessments in primary care settings, development of practitioner training resources, patient assessments, and a streamlined support and referral program for each unique setting can aid in the implementation of interventions across the continuum of care. In addition, precision medicine approaches can be applied to community interventions to help determine which setting is more effective in which communities and with which populations.

Implementation and scale up of community-based violence prevention programs

Most current violence prevention strategies that focus on specific types of violence such as bullying, teen dating violence, and sexual assault tend to be brief, psychoeducational programs that attempt to change individual attitudes and behaviors or are school or group based [73]. While such programs have demonstrated success in changing attitudes and sometimes behaviors, such benefits are often short-lived and require a substantial outlay of resources to implement [74]. With increasing recognition of the critical role of broader sociocultural forces and the relevant experiences of structural racism and discrimination on violence, particular emphasis has been placed on interventions that work across multiple levels of the socioecological model (e.g., individual, relationship/family, community, societal). Indeed, the CDC’s new strategic vision prioritizes community- or societal-level preventive efforts along with identifying root causes that cut across different types of violence and address racial, gender, and economic disparities. Such efforts are critical to achieving health equity.

As such, the current situation calls for structural prevention strategies that can be implemented at the community level that function by modifying the characteristics of community settings such as schools, workplaces, and neighborhoods that may lead to an increased risk for violence victimization and perpetration as well as an exacerbation of health disparities. Importantly, these community-based interventions should represent a comprehensive approach and be integrated across multiple systems (justice, healthcare, community, and housing) in order to shift from individually targeted violence interventions to interventions that target higher-level structural factors. Research on the basic science of aggression can help inform the development of novel approaches, but community-specific factors must also be considered to adapt the intervention to the population of focus.

Given the strong opinions related to firearm ownership and storage practices, partnerships between researchers and key stakeholder groups are imperative to ensure acceptability, utilization, and sustainability of intervention strategies. In particular, programs that invest in and directly engage with communities that have experienced decades of policies and practices formed by structural racism could facilitate advancements in employment, peer/parental support, and educational opportunities [75]. For example, job training for formerly incarcerated individuals or after school programs that target youth may build community resilience and decrease risk for violence perpetration and victimization in the future.

In the case of both preventive and treatment-focused interventions, a broad range of implementation and dissemination strategies (e.g., learning collaborative models) should be examined. While some effective implementation strategies exist, conducting implementation-related research for CVI programs is particularly challenging, given the complexity of coordination across multiple settings as well as the range of stakeholders from diverse and sometimes competing perspectives. Successful programs are often not easy to maintain, are difficult to scale, and do not often translate to other communities, so implementation strategies must be adjusted based on community factors and program goals. Hybrid research designs can be considered to examine implementation factors while concurrently evaluating the effectiveness of an intervention in real-world settings.

To ensure a program is meeting the goals of a community, programs must undergo rigorous evaluation [76] to allow a program to learn from its successes and failures and correct mistakes, demonstrate results, and win public support. To build evidence for a community-based organization intervention, the following types of evaluations may be informative: impact evaluation, performance monitoring, process evaluation, and cost evaluation [77]. The impact on public safety, programs, and practices should be considered when selecting the types of evidence needed for program or policy adoption. Importantly, evaluators must work in partnership with communities to design programs and evaluations to meet the needs of both the researchers and the communities.

Unique experiences of people who are underserved by community resources

As noted above, certain populations bear a disproportionate burden of violent victimization. Recent events including the coronavirus pandemic and events focused on racial and social justice issues have heighted public awareness to the violence, poverty, and racism intertwined with other structural and socioeconomic factors that many marginalized populations face. As a result, there is a need for qualitative research on violence against the subjective experiences of specific populations including children/youth, older populations, SGM populations and persons with disability (among others) with respect to their unique voices and perceptions of violent victimization. New methods and measures may need to be developed and validated to capture the perspectives of these populations more precisely, such as a better understanding of the role of social media in the perpetration and the experience of victimization. Partially responding to this need, the NIH Sexual and Gender Minority Research Office (SGMRO) convened a multiphase scientific workshop [78] to build relevant tools and identify and prioritize key research opportunities in demographics, epidemiology, risk factors, preventative and treatment-focused interventions, and ethical/logistical challenges needed to further understanding of violence within SGM communities.

CONCLUSIONS

NIH continues to play an important role in supporting rigorous research into the causes and consequences of violence and the development, evaluation, and implementation of preventive and treatment interventions to address the resulting trauma, injuries, and mortality from violence. As violence research is a complex field with intersecting stakeholders, emerging areas of research are focused on integrating basic research on protective factors increasing resilience with intervention development, implementing treatment and preventive interventions across different health settings, and developing community-based interventions. By considering the relevant experiences and unique characteristics of the populations that the interventions are targeting, the disproportionate impact of violence on health disparity populations could be minimized in an effort to pursue health equity.

Compliance with Ethical Standards

Conflict of Interest: The authors have no conflict of interest to report.

Primary Data: This manuscript has not and will not be submitted for publication elsewhere until a decision is made regarding its acceptability for publication in the Translational Behavioral Medicine journal. All authors had full access to all aspects of the research and writing process.

Ethical Approval: This article does not contain any studies with human participants or animals performed by any of the authors. This manuscript is a commentary and does not involve original data and thus no transparency or human rights statement is needed.

Informed Consent: This manuscript is a commentary and does not involve original data collection and therefore informed consent was therefore not required.