In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.
Introduction
Nearly 180 000 people in the USA die every year from injuries and violence related to preventable events such as car crashes, drug overdoses, falls, assaults, drowning, and self-harm, according to numbers from the US Centers for Disease Control and Prevention (CDC).1 This number is equivalent to one injury death every 3 mins. Millions more people survive these events every year and are left with substantial physical, emotional, and financial problems as a result of acts of violence or unintentional injury. No individual is immune from these tragedies—people of all ages, races, and levels of education and income are affected.
Injuries and violence are not accidents and are not inevitable. They can be prevented. Yet, although figures in public health maintain a common understanding for the definition, causes, and solutions to injuries and violence, this recognition might not be widely accepted by other audiences, including policy makers, clinical health professionals, and the public. Injuries and violence can be seen as inevitable and unpredictable.2, 3 Representatives in public health have struggled to change this perception in some key stakeholders such as policy makers and even health professionals. When the need for injury prevention is recognised by individuals in health systems, training, time, and skill are often insufficient to enable a suitable response.
In clinical settings, injury prevention is not integrated fully in practice and patients are not as familiar with ways to prevent injuries as they are with those for other major killers such as heart disease, stroke, and cancer.4 Physicians and other health-care workers have not yet included screening for injury risk into routine standards of care. National estimates are that one in five adults visiting health-care providers receive counselling about injury prevention.5 This absence might be partly due to the increase in demands on practitioners—if primary care physicians were to satisfy fully the clinical recommendations of the US Preventive Services Task Force, then they would need to devote longer than 7 h per day to preventive services alone.6 Managed-care organisations and other health-care institutions have not fully codified injury prevention counselling into clinical workflow and electronic medical records to improve the delivery of injury prevention services.7
Although the USA has achieved some important milestones in injury and violence prevention in the past century, greater improvements are attainable.8 Even in individuals who have awareness of the preventability of injuries and violence, perception of risk is incongruent with actual risk.9 The tendency for optimistic bias, an attitude of self-exception, or an inaccurate perception of the consequences of actions can all disrupt prevention efforts. And similar to other major public health challenges (especially those attached to broad public policy solutions), tension exists between the protections of personal freedom and the sought after benefits for public health. Stated simply, how does the USA achieve the greatest good for the greatest number of people, while also respecting civil liberties?
Key messages
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In the first three decades of life, more people in the USA die from injuries and violence than from any other cause
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Injuries and violence take an enormous economic toll on the USA, including the cost of medical care and lost productivity; they are preventable and have been linked to a wide range of physical, mental health, and reproductive health problems, and chronic diseases
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For all ages, the five largest causes of injury deaths are motor-vehicle crashes, poisoning, falls, firearm suicides, and firearm homicides
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Injury and violence-prevention strategies include education, behavioural changes, policy, engineering, and environmental supports; they have a positive return on investment and can be supported through use of communication framing theory, sharing of success stories, and provision of data to decision makers
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Systems must be in place to allow the widespread adoption of effective strategies for injury and violence prevention and to bridge the gap between research and practice
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Professionals in public health must work in partnership with those in clinical medicine to ensure that health delivery systems are well integrated and perform effectively, efficiently, and equitably to prevent injuries and violence and to improve outcomes
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Continuing investments for research and innovation are needed to achieve further reductions in injury and violence
In a Comment in a 2012 issue of The Lancet, Shakur and colleagues10 stated that “…to reduce the human and economic effect of injury, we need better prevention, effective and affordable treatments, and the tenacity to ensure their universal access”. The viability of attention to public health issues is linked to features of the problem, the way in which stakeholders portray the issue, the policy environment, and the strength of organisations concerned with the issue.11 Using these perspectives, we posit that to advance injury and violence prevention, the communication frame should be enhanced (so that messages increase awareness and change perceptions), success stories be shared, science be translated, data be provided to decision makers, effective interventions be disseminated, and public health be integrated with clinical medicine.
Section snippets
Morbidity, mortality, and the effect of injuries and violence
From age 1 year to age 30 years, more individuals in the USA die from injuries and violence than from any other cause (figure 1).1 In 2010, the ten leading causes of death in this age group were, in order, unintentional injury, suicide, homicide, cancer, heart disease, congenital anomalies, cerebrovascular disease, influenza and pneumonia, diabetes, and chronic low respiratory disease. An alarming 79% (n=41 121) of deaths were due to injuries, whereas 20% were due to chronic diseases and 1%
Choice of focus
Some types of injury, such as homicide, suicide, prescription drug overdose, falls in older adults, traumatic brain injury, and child injury, have received increased recognition because of changing trends, striking disparities, and rising public concern. These topics underscore new pressing demands in the USA and offer compelling reasons to respond swiftly. Other types that we have not expanded on in this article, such as road traffic injuries, have reduced substantially and are considered
Social determinants
Many social and economic factors contribute to disparities in injury risk and outcomes in the USA, including income, education, employment, and community environment. For example, men who are unmarried, have a low-income, are unemployed, or are poorly educated are at increased risk for death by motor-vehicle injury.38 Young people growing up in communities with concentrated disadvantage are more likely to witness violence, attend underperforming schools, and have poor employment opportunities;
Effective interventions
The scientific evidence to support prevention of injury and violence is strong.8, 42, 43 Public health strategies for prevention such as education, behaviour change, policy, engineering, and environmental support are guided by the social-ecological model that informs how strategies should be implemented across individual, relationship, community, and society levels. Interventions that address the social and economic determinants of health and change the context to make individuals' default
Conclusion
Greater success in the USA is possible through public health and medical practice working together to frame injuries and violence as preventable, identify cost-effective and evidence-based interventions, provide evidence to decision makers, and strengthen the capacity of the health-care system.83 Clinical medicine and public health partnerships can help to ensure that life is not stopped by a preventable injury and that thousands are spared the debilitating effects of a car crash, non-fatal
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Community violence is a global public health problem that is associated with mental health disorders. Physical activity can enhance mental health and may play an important role in the relationship between exposure to community violence and mental health. We systematically reviewed the literature to better understand the potential role of physical activity in this relationship. In this review, we searched the databases PubMed, Embase, Web of Science, Cochrane Central, PsycInfo, and SPORTdiscus, and conducted a grey literature search of one clinical trials registry and four organizations’ websites. The review included quantitative observational studies, intervention studies, and qualitative studies published by November 30, 2022 and that involved generally healthy individuals across the lifespan. Eligible studies included measures of community violence, mental health, and physical activity. Five studies met the inclusion criteria for the review. Four studies were conducted in high-income countries, only two minority populations were represented in the studies, and none of the studies included older adults or children. Studies defined and measured community violence, mental health, and physical activity in different ways. In most studies, physical activity was not a primary focus but assessed as one item within a larger construct. The role of physical activity was examined differently across the studies and only one study found a significant role (mediator) of physical activity. This review revealed that few studies have specifically examined physical activity’s role in the relationship between exposure to community violence and mental health. Further research is needed involving low-income countries, diverse minority populations, and children.
This figure is even higher in subjects affected by severe mental disorders (SMD) [4,5]. Thus, a great effort has been made by policy makers and health care providers to develop and implement preventive interventions [6]. To some extent, these approaches have proven successful given the decline in the rate of aggression-associated premature mortality observed during the past 10 years [7].
Aggressive behavior exerts an enormous impact on society remaining among the main causes of worldwide premature death. Effective primary interventions, relying on predictive models of aggression that show adequate sensitivity and specificity are currently lacking. One strategy to increase the accuracy and precision of prediction would be to include biological data in the predictive models. Clearly, to be included in such models, biological markers should be reliably associated with the specific trait under study (i.e., diagnostic biomarkers). Aggression, however, is phenotypically highly heterogeneous, an element that has hindered the identification of reliable biomarkers. However, current research is trying to overcome these challenges by focusing on more homogenous aggression subtypes and/or by studying large sample size of aggressive individuals. Further advance is coming by bioinformatics approaches that are allowing the integration of inter-species biological data as well as the development of predictive algorithms able to discriminate subjects on the basis of the propensity toward aggressive behavior. In this review we first present a brief summary of the available evidence on neuroimaging of aggression. We will then treat extensively the data on genetic determinants, including those from hypothesis-free genome-wide association studies (GWAS) and candidate gene studies. Transcriptomic and neurochemical biomarkers will then be reviewed, and we will dedicate a section on the role of metabolomics in aggression. Finally, we will discuss how biomarkers can inform the development of new pharmacological tools as well as increase the efficacy of preventive strategies.
Although universal suicidal ideation screening has been recommended for patients in all healthcare settings [67], many EDs have yet to implement screening, and many youths deny suicidal thoughts. Our findings suggest that promising psychiatric and social services indicated for adolescent patients presenting with self-harm [68–73] may have benefits if extended to those presenting with mental health problems, substance use, assault or unintentional injury, and a history of residential mobility – perhaps especially if they live in wealthier neighborhoods. Notably, none of the characteristics we examined (novel or traditional) had high specificity for predicting self-harm [74]; however, our results suggest they should be incorporated into the multifactorial risk prediction algorithms that are gaining traction as a method of identifying high-risk adolescents [75–77].
This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm.
Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm.
Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk.
A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.