Violence takes many forms, including intimate partner violence, sexual violence, child abuse and neglect, youth violence, bullying, suicide, and elder abuse and neglect. These forms of violence are interconnected and often share the same root causes. They can occur together in families and communities and can happen at the same time or at different stages of life. While various forms of violence are often interconnected, separate, or “siloed” approaches, are often used to address each form of violence.

What was happening:

The Maryland Department of Health and Mental Hygiene and the Colorado Department of Public Health and Environment have begun applying a more integrated approach to violence prevention focused on addressing overlapping root causes of violence (risk and protective factors).

Maryland initiated its shared risk and protective factor approach after the 2015 United Healthcare Foundation’s state rankings on health indicators were released. This report highlighted Maryland’s progress in many health areas. It also stressed violence as an area with little improvement over the previous ten years. This report, combined with the Centers for Disease Control and Prevention’s (CDC) Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence, prompted Maryland to conduct a scan of violence prevention programming, data sources, partners, and funding that existed across the state. They wanted to identify opportunities for coordination. The environmental scan included interviews with representatives from 16 state agencies and 24 local health departments. They asked each representative these four questions:

1. What violence prevention programming, data sources, or other initiatives does the agency lead?
2. Who is the target population for the agency’s programs, data sources, or initiatives?
3. What funding resources are harnessed to implement the agency’s programs, data sources, or initiatives?
4. What partners, state or otherwise, does the agency work with on these programs, data sources, or initiatives?

Colorado’s shared risk and protective factor approach began in 2004. The health department formed a violence prevention advisory council with national violence prevention experts, state agency leaders, and members of statewide prevention groups. This council completed a state assessment of child and adolescent violence efforts and identified risk and protective factors associated with multiple forms of violence based on available research. Colorado used this information to publish a statewide violence prevention strategic plan, Bold Steps Toward Child and Adolescent Health, A Plan for Youth Violence Prevention in Colorado. The plan’s goals are to improve the overall health and safety of Colorado’s children and youth. They recommended “bold steps” toward decreasing risk and increasing protective factors that are shared across multiple forms of violence.

Colorado also successfully secured and leveraged additional funds from CDC and other funders. They used this money to begin a number of prevention strategies addressing shared risk and protective factors identified within their plan. For example, Colorado leveraged CDC Rape Prevention and Education funds, and state funding from the Colorado Office of Suicide Prevention and the Colorado Child Fatality Prevention System, to support implementation of Sources of Strength, an evidence-based youth suicide prevention program. The program is being implemented in 24 schools across Colorado. The health department is evaluating the effects on shared protective factors (youth-adult connectedness and school connectedness), and the impact on violence outcomes (sexual violence, suicide, and bullying).

What we learned:

Maryland’s environmental scan revealed that

• State agencies’ efforts often do not have violence as their primary outcome. They focus on outcomes like health, housing, reentry, and parks and recreation. However, many of these agencies serve the same people, including youth, older adults, and veterans. Their programs often address common shared risk and protective factors such as substance abuse, economic stress, and community support/connectedness.
  • For example, the health department’s program focusing on decreasing suicide among veterans and the Department of Aging’s program for minimizing financial fraud among the elderly were programs that seem unrelated. Yet both serve people over the age of 65 and address economic stress and family connectedness, which are shared risk and protective factors for many types of violence.
• Identifying shared risk and protective factors for violence in different programs across state agencies provides an opportunity to address violence outcomes through better collaborations.

Colorado funded five, two-year local pilot projects to implement strategies focused on shared risk and protective factors after developing the Bold Steps Toward Child and Adolescent Health, A Plan for Youth Violence Prevention in Colorado. These successful pilot projects were critical in a number of ways:

• The health department recognized that applying a shared risk and protective factor approach at the local level to address violence prevention was possible in practice.
• New opportunities developed for building partnerships and leveraging funding sources to have a larger impact.
• They laid the groundwork for the shared risk and protective factor work the health department has engaged in since that time. This includes a new statewide violence and injury prevention strategic plan that expands the shared risk and protective factor approach beyond violence prevention to also include unintentional injury prevention. It now includes topics such as opioid overdose, motor vehicle injury, older adult falls, and traumatic brain injury.

What action can be taken:

• Identify Opportunities for Coordination: You can interview state agencies, like Maryland, or create an advisory council of national and state prevention leaders to assess current state violence prevention efforts, like Colorado.
• Invest Time in Partnership Development: You can reach out to partners with similar audiences or who have a vested interest in addressing shared risk and protective factors to identify opportunities for collaboration and coordination. Maryland convened a statewide Violence Prevention Summit to facilitate conversations and connections between state agencies across Maryland.
• Demonstrate Early Applications and Successes: You can demonstrate early “wins” by creating buy-in on a shared risk and protective factor approach from key partners and decision makers. For example, Colorado implemented two early local level pilot projects addressing shared risk and protective factors to demonstrate that this approach to violence prevention was possible in practice.
• Measure Impact on Multiple Outcomes: You can measure the impact of shared risk and protective factor approaches on multiple outcomes. This ensures that all partners are able to demonstrate impact of the collaborative work on their outcome of interest. Colorado partnered with Colorado State University to evaluate the impact of their work not only on shared risk and protective factors, but also on multiple forms of violence such as sexual violence, suicide, and bullying.
• Engage in Strategic Planning: You can incorporate and prioritize shared risk and protective factors in strategic planning efforts to lay a strong foundation for integrated state injury and violence prevention work. Colorado developed a statewide violence and injury prevention strategic plan that prioritizes common risk and protective factors associated with multiple forms of injury and violence, identifies connections across injury and violence prevention programs, and outlines leverage points for coordination and achieving impact on multiple injury and violence outcomes.

Resources

• Connecting the Dots: Understanding the Links between Multiple Forms of Violence. This brief, developed by CDC’s Division of Violence Prevention and Prevention Institute, shares research on connections between different forms of violence and describes how these connections affect communities.
• Connecting the Dots on Veto Violence. This website offers resources, including: 1) a guided training about using shared risk and protective factors to prevent multiple forms of violence; and 2) an interactive map highlighting examples from states that are using a shared risk and protective factor approach to their violence prevention efforts.
• 

  Injury and Violence Prevention

  Colorado Violence and Injury Prevention- Mental Health Promotion Strategic Plan 2016-2020. The Colorado Department of Public Health and Environment developed this strategic plan that expands the shared risk and protective factor approach beyond violence prevention to include unintentional injury prevention. This five-year plan prioritizes common risk and protective factors associated with suicide, prescription drug overdose, older adult falls, motor vehicle crashes, interpersonal violence, child maltreatment, and traumatic brain injury, and identifies the connections across injury and violence prevention programs and leverage points.

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

Read the full issue of our special supplement Catalyzing State Public Health Agency Actions to Prevent Injury and Violence.

Natalie Wilkins

Natalie Wilkins is a behavioral scientist at the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (NCIPC) in the Division of Analysis, Research, and Practice Integration (DARPI). She joined NCIPC in 2008 and her work has focused primarily on translation and systems research, program evaluation, technical assistance and capacity building with partners at the state and local level, and knowledge translation for bridging research and practice within the context of injury and violence prevention. She has worked on numerous child maltreatment, youth violence, suicide prevention, and prescription drug overdose projects, as well as efforts to identify links between multiple forms of violence, injury, and other public health outcomes. She received a BA in Psychology and Sociology from the University of Richmond and an MA and PhD in Community Psychology from Georgia State University.

Lindsey Myers

Lindsey Myers is the Violence and Injury Prevention-Mental Health Promotion Branch Chief at the Colorado Department of Public Health and Environment. In this role, Ms. Myers leads 36 talented staff to address the primary prevention of injury, suicide, and violence, as well as mental health promotion and substance abuse prevention. She has over 15 years of experience developing, implementing, and evaluating prevention programs and policies at the state and local levels. Ms. Myers has bachelor degrees in Biochemistry and English from the University of Colorado and a Master’s in Public Health with a concentration in Epidemiology from Yale University.

Tomei Kuehl

Tomei Kuehl is the Interpersonal Violence Prevention Unit Supervisor at the Colorado Department of Public Health and Environment (CDPHE). Ms. Kuehl oversees the Rape Prevention and Education (RPE) Program, the Essentials for Childhood (EfC) Project, and the Maternal and Child Health (MCH) priorities bullying and suicide prevention. Ms. Kuehl serves as a co-investigator on the CDC research grant, The Impact of Sources of Strength: A Primary Prevention Youth Suicide Program on Sexual Violence Perpetration Among Colorado High School Students. Her expertise includes applying a shared risk and protective factor approach, building coalitions, and the implementation of evaluation and performance management plans. She is passionate about finding the connections between multiple and shared forms of violence and implementing and evaluating strategies at the community and societal levels. Ms. Kuehl has bachelor degrees in History and English from the University of Wisconsin Madison, and a Master’s degree in Public Administration from the University of Colorado Denver.

Alice Bauman

Alice Bauman is Masters trained from the Johns Hopkins Bloomberg School of Public Health where she focused on health communication and education. She has significant experience in strategic planning for population health, health policy, and systems thinking with a nuanced understanding of the intersection of clinical and public health. Previously she worked at the Maryland Department of Health as a policy analyst, where she analyzed and drafted legislation for the Public Health Services unit and oversaw the initiation of an interagency effort to educate, communicate, and coordinate on violence prevention initiatives across the state. Additionally, she served as Deputy Director of the Office of Population Health Improvement, working on local health financing, health improvement processes, and strategic direction on the integration of public health programming into healthcare transformation. Currently, she works at Johns Hopkins HealthCare LLC on population health initiatives with a focus on bridging the gap between research and implementation for positive population health outcomes through integrating innovative tools, focusing on equity, the linkage between the clinical and public health care systems, and facilitating sustainable partnerships.

Marci Hertz

Since 2003, Marci Hertz has worked for the Centers for Disease Control and Prevention (CDC) as a Lead Health Scientist in various positions in the National Center for Injury Prevention and Control (NCIPC) and in the Division of Adolescent and School Health. Since 2014, she has served as the Evaluation and Integration team lead in the Division of Analysis, Research, and Practice Integration in NCIPC, where she manages the evaluation of the Core State Violence and Injury Prevention Program (Core SVIPP) and a large, longitudinal cohort study of Medication Assisted Treatment. Her work at CDC has focused on preventing unintentional injuries and all forms of violence, with a focus on preventing youth violence and bullying. Prior to her work at CDC, Ms. Hertz was the Associate Director of Violence Prevention Programs at the Harvard School of Public Health. In this capacity, she worked with community nonprofit and governmental organizations to prevent youth violence in Boston neighborhoods and co-wrote a curriculum, the PeaceZone, to foster social skills among children exposed to violence. She received her BA in Psychology from Emory University and a Master’s degree in Psychological Services from the University of Pennsylvania.

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