Violence is a critical public health problem in the United States (US). Each year, more than 16,000 people are victims of homicide – approximately 45 victims every day. Homicide disproportionately impacts young people. Among those aged 15 to 24 years in the US, homicide is the second leading cause of death and is responsible for more deaths in this age group than cancer, heart disease, birth defects, influenza, diabetes, and HIV, combined (CDC, 2010).

Consequences of violence extend beyond the physical and mental suffering of victims and their families to impact schools, neighborhoods, businesses, and the legal and health care systems. Homicides are the tip of the iceberg in terms of the public health burden of violence. In 2011, more than 1.75 million people were treated in U.S. emergency departments for nonfatal injuries resulting from assaults, and over 120,000 of these victims of assault were admitted to the hospital. Consequences of violence extend beyond the physical and mental suffering of victims and their families to impact schools, neighborhoods, businesses, and the legal and health care systems. For example, the healthcare and lost productivity costs associated with homicides and assault-related injuries each year are estimated to exceed $51 billion (CDC, 2012). This estimate does not include the substantial costs to the legal system to arrest, prosecute, and incarcerate perpetrators of violence. It also does not reflect potential consequences from fear of violence, such as willingness to live, work, play, or exercise in certain areas, or other changes to behavior. For example, in a survey of youth risk behaviors, 6% of high school students reported missing at least one day of school in the past 30 days because they felt too unsafe to go (CDC, 2011).

In addition to the risk for violence in the community and at home, there is evidence that nurses are also victims of violence while doing their jobs. An online survey of members of the Emergency Nurse Association found that 1 in 4 respondents reported experiencing frequent (more than 20 times in the past three years) physical violence while working (Gacki-Smith et al., 2010). Nurses are also on the front lines caring for victims. These cases are often particularly challenging because of the nature of the injuries, the young age of the victims, the devastation to families, and the nurse’s potential personal history with violence. These types of exposures to violence can result in vicarious trauma for nurses who provide care for victims (Hartman, 1995).

The public health approach complements the work of the healthcare and legal systems by focusing on prevention and stopping violence before it starts. While the healthcare system must continue to care for injured victims of violence to help them to fully recover physically and emotionally, our legal system must continue to hold perpetrators of violence accountable; proactive steps are warranted to reduce the likelihood that violence will occur in the first place. The public health approach complements the work of the healthcare and legal systems by focusing on prevention and stopping violence before it starts. This article provides a brief overview of the United States Department of Health and Human Services (U.S. DHHS) initiative, Healthy People 2020 (U.S. DHHS, 2013b), summarizes the Healthy People 2020 national violence prevention objectives (U.S. DHHS, 2013c; 2013h), and highlights resources that can help nurses and others to take a proactive approach to violence prevention.

Public Health Approach to Violence Prevention

Prevention at the population level requires input from and coordination across sectors, including health, education, social services, justice, and policy. The goal of public health is prevention at the population level to improve the health of the entire community or society. Prevention at the population level requires input from and coordination across sectors, including health, education, social services, justice, and policy. The model used by public health is multidisciplinary, incorporating science from healthcare, epidemiology, sociology, psychology, criminology, education, and economics. The public health approach includes four interrelated steps (Dahlberg & Krug, 2002). The first step is to define and monitor the problem. This step allows communities to answer basic questions about the type of violence occurring, the groups most impacted, consequences, and changes in prevalence over time. It requires the use of valid data, such as emergency department or law enforcement records, information from surveys or interviews with residents, and mortality data.

The second step is to identify risk and protective factors. The goal is to understand the factors that can be modified to reduce risk for violent behavior and factors that support prevention of violence episodes. This information can then be used to inform the third step, which is to develop and evaluate prevention strategies. This step involves using data from a variety of sources to determine which existing evidence-based prevention strategies are most suitable to address needs in communities or determine if modifications or new approaches are appropriate. Once implemented, it is critical for prevention strategies to be evaluated and monitored to determine whether or not they are having the intended effects.

The final step in the public health approach is to assure widespread implementation of evidence-based approaches. This step is critical for maximizing the preventive benefits of an approach. It consists of training and networking to enhance capacity and to promote expansion and sustained effort so that all of those who can benefit from the preventive approach have the ability to participate (Dahlberg & Krug, 2002)).

Background on Healthy People 2020

Healthy People 2020 (U.S. DHHS, 2013b) reflects the public health approach to prevention. To create this initiative, the U.S. DHHS uses the latest epidemiological data to develop 10-year national objectives for improving the health of Americans. It also provides resources to promote an understanding of risk and protective factors and evidence-based approaches to prevention. Healthy People 2020 provides tools developed for use in communities to increase adoption of prevention strategies.

Healthy People started in 1979 with the release of the U.S. Surgeon General’s first national prevention agenda (U.S. DHHS, 2011). Since then, national objectives with targets have been set for 1990, 2000, 2010, and currently for 2020. Each iteration of Healthy People is intended to:

• Encourage collaborations across communities and sectors.
• Empower individuals toward making informed health decisions.
• Measure the impact of prevention activities.(U.S. DHHS, 2012, para. 1)

The latest iteration, Healthy People 2020, reflects the culmination of a systematic process that incorporated feedback from an array of individuals and organizations who sought to identify objectives that are ambitious, but attainable, by the year 2020. The objectives in Healthy People 2020 are more comprehensive than in the past. Additional web-based tools are provided to facilitate prevention efforts. Healthy People 2020 includes 42 topic areas and more than 1,200 objectives (U.S. DHHS, 2013c). The topic areas are diverse, ranging from Cancer and HIV to Physical Activity, Environmental Health, and Social Determinants of Health. Each topic area includes multiple objectives with baseline data and targets for 2020. The Healthy People 2020 website includes a “DATA2020” application that allows users to query the data by available demographic and background characteristics, including sex, age, race/ethnicity, geographic location, and marital status (U.S. DHHS, 2013d).

The Injury and Violence Prevention topic area (U.S. DHHS, 2013h) includes objectives specific to unintentional injury prevention, such as those related to increasing seat belt use or reducing deaths from drowning or falls. Other objectives, such as increasing access to trauma care in the U.S. and reducing traumatic brain injuries, apply regardless of whether the injury was intentionally or unintentionally inflicted.

Specific Violence Prevention Objectives in Healthy People 2020

There are 20 objectives in the Injury and Violence Prevention topic area that are focused specifically on reducing violence. There are 20 objectives in the Injury and Violence Prevention topic area that are focused specifically on reducing violence (U.S. DHHS, 2013h). These include broad objectives, such as reducing the homicide rate and reducing physical assaults. They also include objectives about specific types of violence, such as bullying and child maltreatment. The 13 measurable objectives all use a national data source to provide the baseline estimate and to set the national target for 2020 (see Table). These data sources include information from health and law enforcement records, such as death certificates gathered by the National Vital Statistics System (CDC, 2013c), data on emergency department visits compiled by the National Electronic Injury Surveillance System – All Injury Program (U.S. Consumer Product Safety Commission, n.d.), and self-reports of violent crime victimization collected by the National Crime Victimization Survey (Office of Justice Programs, 2013). Most objectives use the target setting method of 10% improvement (i.e., reduction), while one objective’s (IVP-36) target is based on projection/trend analysis and another (IVP-43) is based on total coverage. Healthy People 2020 targets are meant to be aspirational yet achievable. For example, data from CDC’s 2009 Youth Risk Behavior Surveillance System indicated that 31.5% of high schools students nationwide reported being in at least one physical fight in the past 12 months (CDC, 2011). The target for 2020 is thus 28.4%, based on a 10% relative reduction.

Table. Healthy People 2020 Violence Prevention Objectives [view full pdf]

*Denotes that the objective is a Leading Health Indicator.

Healthy People objectives reflect national aims for reducing violence-related behaviors and fatal and nonfatal injuries. Healthy People objectives reflect national aims for reducing violence-related behaviors and fatal and nonfatal injuries. The one exception is an objective to increase the number of states with access to integrated data on violent deaths from death certificates, law enforcement, and coroner and medical examiner reports. Starting in 2010, integrated data were collected for 18 states that participated in the CDC-funded National Violent Death Reporting System (NVDRS; CDC, 2013b). By linking these various sources of data on violent deaths, the NVDRS provides previously unavailable information on the circumstances of violence, including major life stresses such as relationship or financial problems; information about the relationship between the perpetrator and the victim; and whether the homicide occurred as part of another crime. Because the system is incident-based rather than victim-based, it includes information about each victim killed in an incident, including multiple homicides and homicides followed by suicides. NVDRS is used by funded states to better understand the prevalence, trends, and characteristics of violence to guide decisions about prevention strategies and to monitor progress over time.

In addition to the 13 measurable violence prevention objectives listed in the Table, the Injury and Violence Prevention topic (U.S. DHHS, 2013h) includes seven developmental objectives specific to violence prevention efforts. These are classified as “developmental” because at the time they were developed, baseline data were not available. These objectives focus on preventing sexual violence across the lifespan by any perpetrator and preventing the different forms of partner violence (including physical and sexual violence, and emotional abuse and stalking by a current or former intimate partner). The CDC is implementing an ongoing surveillance system, the National Intimate Partner and Sexual Violence Survey (NISVS; CDC, 2013a) to collect the latest information on these forms of violence. NISVS data from 2010 underscore how pervasive and widespread sexual violence and intimate partner violence are in the US. The results indicated that nearly 1 in 5 women (18%) and 1 in 71 men (1%) have been raped in their lifetime, and about 1 in 4 women and 1 in 7 men have been the victim of severe physical violence by an intimate partner (e.g., hit with a fist or something hard, beaten, slammed against something) in their lifetime (Black et al., 2011). NISVS data will be used to estimate the baseline prevalence and to set targets for Healthy People 2020.

While most of the violence objectives focus on interpersonal violence, there is one objective to reduce self-directed violence. This objective tracks nonfatal injuries treated in emergency departments for violence against oneself regardless of the intent to die and encompasses self-harming behaviors (e.g., cutting) as well as suicidal behaviors and behaviors where the suicidal intent is unclear. Additional Healthy People objectives to reduce suicidal behavior are included in the Mental Health and Mental Disorders topic area (U.S. DHHS, 2013i).

Healthy People 2020 Resources for Prevention

...the Healthy People 2020 website includes considerable resources for those who want to advance prevention efforts. Healthy People 2020 is being used around the country in a variety of ways, including as a source for national data; for planning and setting research and prevention agendas; to build community partnerships; to provide justification for funding requests through grants; and by states to create health objectives specific to their populations. To promote progress on the objectives, the Healthy People 2020 website includes considerable resources for those who want to advance prevention efforts (U.S. DHHS, 2013e). For example, users can search by topic area for evidence-based resources, such as systematic reviews and descriptions of interventions. The results can be sorted by characteristics of the intended recipients, such as sex, age, the delivery setting, or intervention groups (e.g., businesses, employers, law enforcement, or health care).

Some examples of helpful violence prevention resources include descriptions of prevention programs and strategies that have been rigorously evaluated. For example, Healthy People 2020 maintains a close partnership with the Guide to Community Preventive Services (Community Guide), and several Community Guide reviews are included as evidence-based resources. These resources present the results from the Community Preventive Services Task Force's (2013b; Task Force) review of the evidence for specific prevention strategies and their recommendations for federal, state, and local health departments and agencies. The Task Force has completed systematic reviews of the evidence for 6 violence prevention strategies. Some strategies, such as universal school-based programs to prevent youth violence that average a 15% relative reduction in violent behavior (Community Preventive Services Task Force, 2013a), are supported by evidence and are “recommended.” Other strategies, such as transferring youth to the adult criminal justice system are “recommended against” because they have been shown to be harmful (e.g., 34% increase in rearrests for transferred youth).

One Task Force recommended prevention strategy particularly relevant to nurses is home visitation to prevent child maltreatment. One Task Force recommended prevention strategy particularly relevant to nurses is home visitation to prevent child maltreatment. This strategy involves training nurses or other professionals to provide education and support to parents of infants during regular visits prenatally and during the child’s first years of life (Community Preventive Services Task Force, 2013c). Home visitation programs are often used with high risk mothers, such as low income teen mothers delivering their first child. Nurses can help the mother to understand how to care for her child, how to keep the home environment safe, and what to expect developmentally. They can provide support (e.g., emotional support and direct care) and increase the mother’s skills, confidence, and access to resources. Visitation programs can be voluntary or court mandated. The Task Force review found that evaluations of home visitation programs consistently showed significant reductions in child maltreatment, including an average 39% reduction in reported child maltreatment among participating families, particularly if the visitation program was sustained for more than two years (Bilukha et al., 2005; Guide to Community Preventive Services, 2002). Cost effectiveness analyses have demonstrated that although the program can be expensive to implement (e.g., approximately $9,600 per child), the benefits are substantially greater (e.g., $22,781 per child), so that each participant results in a net savings of over $13,000 (Lee, Aos, Drake, Pennucci, Miller, & Anderson, 2012).

The Healthy People 2020 (2013k) website also provides webinars and information for those interested in learning more about specific topics. These resources feature content specific to violence and injury prevention, including a webinar on bullying prevention. The website also provides an archive of Progress Review webinars, including a review on violence prevention that describes the burden associated with violence across the lifespan, the progress made in reaching the Healthy People 2020 goals, and examples of current activities in place to help achieve the violence-related objectives.

Injury and Violence has been selected as a Leading Health Indicators Topic... Inclusion in this select group of indicators reflects the impact of violence on the health of the Nation. The website includes specific information about the Healthy People 2020 Leading Health Indicators (U.S. DHHS, 2013g), a subset of Healthy People 2020 objectives selected to communicate high-priority health issues and actions that can be taken to address them. Injury and Violence has been selected as a Leading Health Indicators Topic. The objective to reduce homicides has been selected as a Leading Health Indicator. Inclusion in this select group of indicators reflects the impact of violence on the health of the Nation.

The HealthyPeople.gov website also provides an implementation framework, called MAP-IT, which describes key steps and resources to help users Mobilize, Assess, Plan, Implement, and Track progress (U.S. DHHS, 2013f). This framework is a helpful resource for planning and evaluating public health interventions to achieve Healthy People 2020 objectives. Healthy People 2020 provides resources, tools, and “field notes” describing an example from a specific location for each of these steps in the MAP-IT framework.

Additional resources on the Healthy People 2020 website include “Healthy People in Action,” which highlights approaches that communities and states are using to implement Healthy People 2020. The Sharing Library (U.S. DHHS, 2013j) is an online repository of real world accounts designed to promote learning between health professionals; the tool also allows them to submit their own stories of activities and interventions that contribute to the attainment of Healthy People 2020 objectives. Users can also review state and territorial plans to further their understanding of ways in which Healthy People is being used as a guide at the state and local levels. Additionally, many states have identified Healthy People coordinators who are responsible for developing state (or territorial) plans that are consistent with and support the national objectives (U.S. DHHS, 2013a).

Conclusion: Moving Violence Prevention Forward in Communities

Nurses have the skills, professional experience, and perspective to be an important part of comprehensive violence prevention efforts in communities. Nurse home visitation programs are one example of direct services to high risk groups, but other creative strategies involving nurses have also been found to be important. The Cardiff Violence Prevention Programme (CVPP; World Health Organization, 2013) is one example. Law enforcement data provide an incomplete perspective on the scope of violence occurring in communities because many victims of violence do not report the incident to police. CVPP is designed to address this gap. Recent research on the model has shown that nurses in emergency departments can collect information from victims of assault, including when and where the incident occurred. This data can be aggregated and shared with a violence prevention partnership consisting of representation from local government, law enforcement, the emergency department, and licensing regulators to fill gaps and to inform prevention strategies. This data sharing model has been used to adjust policing strategies, guide strategic use of closed circuit television, target problematic alcohol outlets, require use of plastic barware, and modify public transportation to reduce late night crowding, among other prevention strategies. Use of the CVPP data sharing model has resulted in significant and sustained reductions in violence related injuries in Cardiff, Wales relative to comparison cities (Florence, Shepherd, Brennan, & Simon, 2011). The model has also been found to result in savings to both the health and law enforcement systems, with benefit-cost ratios of 14.8 and 19.1, respectively (Florence, Shepherd, Brennan, & Simon, 2013).

Nurses are routinely involved in responses to violence after it occurs, but there are also creative, evidence-based approaches that nurses can use to help prevent violence before it happens. In conclusion, violence is a preventable public health problem. Healthy People 2020 provides national violence prevention objectives to be achieved by the year 2020 and resources to help communities reach these goals. The public health approach to violence prevention works with multiple sectors to use science and data to understand patterns in violence and implement effective prevention strategies to reduce risk for violence at the population level. Nurses are routinely involved in responses to violence after it occurs, but there are also creative, evidence-based approaches that nurses can use to help prevent violence before it happens. The resources available on the Healthy People 2020 website can help nurses and other users to better describe the public health burden of violence, the evidence for prevention strategies, and the resources that can be brought to bear in the work of violence prevention.

Note: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Authors

Thomas R. Simon, PhD
Email: tgs9@cdc.gov

Thomas R. Simon is the Deputy Associate Director for Science within the Division of Violence Prevention in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC). Dr. Simon provides consultation on the violence related content in Healthy People 2020. He has worked for the Division of Violence Prevention for the past 17 years and has published extensively on the topics of youth violence and suicide prevention. Dr. Simon has served as a scientific advisor on multiple etiologic studies examining risk and protective factors for aggressive and suicidal behavior and longitudinal evaluations of violence and suicide prevention programs.

Kimberly Hurvitz, MHS
Email: ifo7@cdc.gov

Kimberly A. Hurvitz is an Epidemiologist within the Office of Analysis and Epidemiology in the National Center for Health Statistics at the Centers for Disease Control and Prevention. She serves as the lead statistical analyst and consultant for five Healthy People 2020 Topic Areas: Injury and Violence Prevention, Heart Disease and Stroke, Nutrition and Weight Status, Respiratory Diseases, and Sleep Health. She coordinates the Healthy People metadata standards for all Topic Areas. In addition, she oversees the content review for and updates of the NCHS FastStats website that was developed to provide researchers and the general public with quick access to statistics on over 80 topics of public health importance. She conducts research on a wide variety of health topics ranging from hypertension to homicide and suicide. Ms. Hurvitz holds a BS in Biomedical and Chemical Engineering and an MHS in Epidemiology, both from Johns Hopkins in Baltimore, MD.

© 2014 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2014