Introduction
Firearm violence is a persistent public health issue in the United States. In 2024, 48,204 individuals died from firearm homicide nationwide, and each year, hundreds of thousands more suffer non-fatal firearm injuries, which carry adverse consequences for physical and psychological health [1–Reference Kaufman, Song, Xiong, Seamon and Delgado4]. Firearms have been the leading cause of death among children ages 1–17 from 2019 to 2022, with particularly elevated harm experienced by youth ages 10–16 years [Reference Villarreal, Kim, Wagner, Somayaji, Davis and Crifasi5]. Beyond the health implications, fatal and non-fatal firearm violence is estimated to carry an economic burden of approximately $557 billion annually in the United States – with $51.3 billion to Texas specifically – and the median medical costs are reported at over $27,000 per injury [Reference Miller, Barnett, Florence, McDavid Harrison, Dahlberg and Mercy6,Reference Miller, Downing, Wheeler and Fischer7]. While firearm-related injuries are primarily present in the health care systems for treatment – with estimates showing that emergency departments receive a firearm injury patient every 30 minutes in the United States [Reference Rowh, Zwald, Sumner, George, Sheppard and Holland8] – prevention of firearm violence has to be entrenched in the community. Thus, community-level interventions integrated with the health care system can be a promising approach for reducing the risk of re-injury and promoting health equity and access to vital services for victims of firearm violence.
Hospital-Based Violence Intervention Programs (HVIPs) are multidisciplinary programs that combine the efforts of medical staff with trusted community-based partners to provide safety planning, services, and trauma-informed care to violently injured people, many of whom are male and men of color [9]. Programs like HVIPs aim to reduce violent re-injury by capitalizing on the opportunity to intervene while a victim of violence is recovering from injury in the hospital [Reference Bell, Gilyan and Moore10]. HVIPs involve a multidisciplinary approach to coordinate the engagement of community-based intervention specialists with the hospital-based teams, integrating patients into intensive community-based service programs prior to discharge to address a multifaceted response to violence. HVIPs ideally incorporate the voice of those who have experienced firearm violence directly [Reference Jang, Thomas and Slocum11,Reference Ranjan, Shah, Strange and Stillman12] and vicariously from multiple perspectives throughout the local community, including both victims of violence, as well as violence perpetrators.
Identifying communities prime for the development of an HVIP is critical for the reduction of firearm violence. The University of Texas Health Science Center at Houston School of Public Health and McGovern Medical School identified this need within its primary teaching hospital and Level-I trauma center (Memorial Hermann – Texas Medical Center) in Houston and partnered with city leaders and community organizations to implement and evaluate the Houston Hospital-Based Violence Intervention Program (Houston-HVIP). Texas, and more specifically, Houston (the largest city in Texas and the fourth most populous city in the United States), is an environment that is ripe for an HVIP. In 2022, Texas experienced 4,630 firearm homicides, a 44% increase from the prior year. In Houston, the region of the newly proposed HVIP, African Americans made up 52% of the firearm homicides from 2009 to 2021, despite being approximately 20% of the population. Furthermore, youth firearm-related offenses increased by 37% from 2016 to 2021 [13].
Given that Houston is the fourth most populous city in the United States, has a high incidence of firearm injury [Reference Levine, Cain, Pompeii, Oluyomi and Naik-Mathuria14] and lacks an established HVIP, the location of Memorial Hermann Hospital-TMC as the Houston-HVIP study site holds potential for positive change. TMC has a wide breadth and reach as the largest medical complex in the world, serving a region of over seven million in the Greater Houston area [Reference Brannen15]. Within Memorial Hermann Hospital-TMC’s patient population, there are significant racial disparities related to the impact of firearm violence, with Black and Hispanic persons disproportionately facing firearm violence injuries [Reference Levine, Cain, Pompeii, Oluyomi and Naik-Mathuria14]. Despite Houston’s vast population, high firearm violence incidence, and racial inequities of firearm violence impact, the city has only two Level-I trauma centers and no active citywide HVIPs. Thus, the Houston-HVIP program fills a critical gap in services.
The primary objectives of this National Institutes of Health-funded research study are to (1) develop a community advisory board (CAB) of stakeholders to advise the formation and oversee the implementation of the new HVIP program. The CAB will inform and foster a receptive climate for the HVIP by developing an interprofessional, trauma-informed care educational platform with a health equity lens and (2) implement and evaluate the new HVIP program utilizing a large randomized controlled trial.
Equitable community and stakeholder engagement within research can expand stakeholder networks, achieve a governance of shared power among investigators and stakeholders from health-disparate communities, improve the rigor of research through higher participation rates, elevate insightful interpretation of findings, develop and implement culturally relevant interventions, ensure valid and reliable assessment, and identify new engagement strategies – all of which can accelerate health equity [Reference Brockman, Balls-Berry and West16,Reference Matthews, Anderson, Willis, Castillo and Choure17]. Our paper outlines the framework, development, and implementation of the HVIP CAB. Using this framework, a structured process and support will allow for equitable and meaningful engagement with the community to strengthen the new HVIP for firearm violence prevention.
Materials and methods
Conceptual framework
The HVIP CAB uses a Community and Stakeholder Engagement Studio (CSES) as the framework for this project [Reference Joosten, Israel and Williams18]. Instituted at the UTHealth Houston Center for Health Equity, the CSES offers researchers a consultative service, assisting in effective study design, intervention planning, impactful implementation, evaluation, and sustainability to support health equity for researchers and their partners. Figure 1 presents the framework of the Center for Health Equity CSES [Reference Joosten, Israel and Head19]. Broadly speaking, from left to right, as outlined in Figure 1, the researcher initiates the request across the research continuum of design, implementation, analysis, dissemination, training, etc. Subsequently, the CSES lead researcher and staff (SVS and AMVT) design the approach to engage stakeholders while concurrently training the research team in the CSES process. Once the goals, questions, and activities of the CSES are established, recruitment is complete, and the studio team prepares both the participating community members and researchers for the logistics, operations, and flow of the meetings. CSES staff facilitates the discussion at the meetings, documents feedback, and summarizes input for researchers.
Community and Stakeholder Engagement Studio (CSES) process. CSES = Community and stakeholder engagement studio.
Source: Adapted from Joosten et.al., Journal of Clinical and Translational Science, 2018 Reference Joosten, Israel and Head19 .
Using the CSES’ structured process and team, the research study brought together the CAB to provide tangible expertise to this HVIP research project, create an important link to the community, and foster cooperation between study researchers and community partners. CAB members’ diverse backgrounds, various connections to the community, and individual lived experiences allow for unique insights from multiple perspectives. These community experts who comprise the CAB have a shared interest in leveraging research to benefit their community; they are truly the key to the success of the CSES model [Reference Joosten, Israel and Williams18,Reference Arnos, Kroll, Jaromin, Daly and Falkenburger20–Reference Michener, Cook, Ahmed, Yonas, Coyne-Beasley and Aguilar-Gaxiola22].
The goals of the HVIP CAB are to:
-
1. Strengthen partnerships and develop a shared agenda for firearm violence prevention in the local community
-
2. Expand knowledge of new HVIP and firearm violence prevention at the regional, state, and national level
-
3. Inform an education and evaluation platform for the HVIP
-
4. Provide insight into the design and development of the HVIP
CAB eligibility criteria and sampling
The eligibility criteria to participate in the HVIP CAB were to (1) live in Houston, the city of the HVIP intervention, and (2) be identified as a (a) firearm violence expert, (b) member of the firearm violence prevention community, or (c) community member who has been a victim or perpetrator of firearm violence. CAB members were external to the project staff. However, study staff, including study principal investigators, co-investigators, case managers, program managers, and other support staff, participated in CAB meetings as facilitators.
The CAB was composed to provide diverse and comprehensive perspectives on the causes and consequences of violence. In order to get a broad perspective, we sought to include those with lived experiences of violence – including those with both firearm violence victimization and firearm violence perpetration – to gather a comprehensive understanding of the root causes of firearm violence and how the Houston-HVIP could address those root causes. In addition, it is important to note that due to the victim-offender overlap (i.e., most perpetrators of violence are also victims of violence) [Reference Berg and Schreck23,Reference Jennings, Piquero and Reingle24], all those categorized as offenders on our CAB had also experienced violent victimization directly or vicariously at some point during their lives. At no point did the inclusion of violent perpetrators lead to any conflict during CAB meetings. All “perpetrators” were recruited successfully through our community partner, a credible messenger organization, The Forgotten Third.
Beginning in the fall of 2023, a convenience sample of CAB members was developed using recommendations from the research team to ensure representation across these sectors: community organizations and religious, political, and civil rights leaders actively engaged in firearm violence prevention and/or advocacy/policy efforts; community members, including youth advocates/credible messengers, who have been victims or perpetrators of firearm violence and/or live in a community with high firearm violence; law enforcement professionals; health systems; and researchers engaged in regional firearm violence research. In December 2023, CSES staff (AMVT) conducted personalized outreach using a formal email inviting each recommended individual, along with an offer to follow up via phone, if needed, for further clarification. The email invitation letter outlined the CAB invitation to participate, the goals of the CAB, the time commitment, and the compensation to be received for their time. Up to three email invitations were sent to each CAB invitee. Subsequently, at least two weeks prior to each CAB meeting, CSES staff sent reminder emails with calendar invites and meeting agenda items and any pre-reading as appropriate. CSES staff also followed up via email or phone for any questions that may have arisen for CAB members between meetings.
Fifteen individuals were invited to be part of the CAB; 13 accepted, one declined due to work commitments, and one could not participate due to health reasons. The invitee who could not participate was a faith-based leader with declining health; he recommended a colleague and fellow faith-based leader who joined the CAB in his place. Additionally, one of the participants (a community advocate and student) accepted the invitation, attended one CAB meeting, and then had to resign from the CAB due to health reasons. In the end, the CAB consisted of 13 members with the following makeup: religious leaders, community advocates for firearm violence prevention, law enforcement professionals, firearm violence prevention academic researchers, and youth advocates/credible messengers from our community partner (The Forgotten Third) with lived experience of firearm violence victimization and perpetration.
At weekly meetings of the research team, the CSES staff developed the agenda, objectives, and activities for each meeting and outlined the run of show. Table 1 outlines agenda items, objectives, and related activities covered in each CAB meeting conducted from January 2024 to March 2025.
Community advisory board meeting agenda items, objectives, related activities and discussion questions
Abbreviations: Houston-HVIP = Houston – Hospital-Based Violence Intervention Program; PI = principal investigator; CAB = community advisory board; Memorial Hermann Hospital-TMC = Memorial Hermann Hospital-Texas Medical Center; HPD = Houston Police Department; SB30 = Senate Bill 30.
Meeting design
Each CAB meeting was developed through the lens of a modified Intervention Mapping (IM)TM approach and lasted two hours in duration [Reference Fernandez, Ruiter, Markham and Kok25–Reference Kok, Gottlieb and Peters27]. In IM, the goals are to utilize a community-based approach to convene consensus on the research problem and design. To leverage the expertise of the CAB, we focused on steps 1–3 of IM, which include problem definition and description, theory of change, and program design. As part of step 1, we reviewed with the CAB a needs assessment of firearm violence in the region. In this setting, we reviewed a comprehensive epidemiological analysis of the firearm injury data obtained from the hospital to estimate the prevalence and incidence of firearm injuries, with a specific focus on firearm assault in the region. We used group facilitation techniques with the CAB members and promoted active participation to generate feedback on the perceived neighborhood-level accuracy of the data and any missingness.
As part of step 2, to identify who and what will change due to the efforts of the intervention, the CAB engaged actively in an exercise to identify change agents due to the efforts of this program at different ecological levels, including the impact at the individual, community, and societal levels. To complete this assessment, the CAB collectively completed a Haddon Matrix. The Haddon Matrix [Reference Lett, Kobusingye and Sethi28], which was developed as a validated tool to assess injury prevention research and intervention techniques, is a grid with four columns and three rows. The rows represent each phase of injury, while the columns represent the factors influencing the injury. Applying the Haddon Matrix to the local community of firearm violence was an opportunity to comprehensively engage the CAB in a targeted manner to assess their perspective of firearm violence from a community perspective.
As part of IM Step 3, to confirm the scope and objective of the intervention, the CAB provided feedback on steps in recruitment scripts, engagement with external referral organizations, and partnerships with law enforcement agencies. The modified IM approach is outlined in Table 1.
To obtain input on how the CAB is functioning, we conducted a midpoint evaluation of the CAB member experience using a self-reported electronic survey administered using REDCapTM by the study team. Survey questions included CAB member sociodemographic information, satisfaction with the overall work of the CAB, clarity on role, responsibilities, and expectations of CAB members, trust building between the CAB member and research team, quality of communication between the research team and CAB members, and the quality of experience of the CAB meetings and various components of the meetings. Response options were largely on a Likert-type scale (scale of 1 to 5, with 1 indicating “very unsatisfied” or “strongly disagree” and 5 indicating “very satisfied” or “strongly agree”). Descriptive analysis was conducted on the results. This study has been approved by the Institutional Review Board at the UTHealth Houston, with review number HSC-MS-23-0904. Written informed consent was obtained by participants at the time of participation.
Results
A total of 16 stakeholders representing academia, law enforcement, community members who have been victims or perpetrators of firearm violence, and community organizations consented to participate in the CAB survey. Of the 16 respondents, 11 were male and five were female, with half between the ages of 15–18, three in each the 40–49 and 50–59 age range and one in each the 30–39 and over 60 age range. Two of the study participants reported having less than a high school diploma/GED, seven a high school diploma/GED, three a bachelor’s degree, one a master’s degree, and three a doctoral degree. At the time of the survey, there had been four CAB meetings.
In regard to their participation in the CAB, members reported high satisfaction (Mean: 4.31 on a scale of 1 to 5, with 1 indicating “very unsatisfied” and 5 indicating “very satisfied,” with a similar scale used throughout) with the meetings, and 15/16 members (15, 94%) reported that they desired to continue participation. One CAB member declined to continue due to health concerns. Overall, CAB members reported that their role (4.29/5) and responsibilities (4.29/5) were clearly defined (Likert scale with 1 indicating “strongly disagree” and 5 indicating “strongly agree”), it was clear what was expected of them (4.19/5), and they felt that their participation was worth their time (4.44/5). Furthermore, CAB members reported a high sense of knowledge about CAB activities (4.38/5), being prepared for meetings (felt the relevant experts were at the meetings (4.44/5)), and the researchers’ presentations provided them with enough information to provide appropriate feedback (4.5/5).
In regard to the engagement and connectedness of the CAB, members reported a high sense of unity and cohesion (4.56/5) and trust (4.56/5). CAB members reported that they felt close to each other (4.25/5) and that their voice was heard within the CAB (4.31/5). They reported feeling comfortable asking questions at meetings (4.5/5) and that they had an opportunity to influence the decision and directions of the CAB (4.06/5). Overall, CAB members indicated they agreed that their feedback would improve the research project (4.63/5). See Table 2 for results.
Community advisory board satisfaction survey questions and results
Abbreviations: CAB = community advisory board; y/n = yes/no.
Discussion
HVIPs are designed to disrupt cycles of violence by providing trauma-informed care, safety planning, and connections to critical services that address the non-medical drivers of health [Reference Arientyl, Castater, Hart and Smith29]. What distinguishes HVIPs is their integration into the hospital setting, initiating intervention during the patient’s recovery from violent injury and extending support through discharge into community-based programming. Our community-centered model reflects an understanding that violence is a public health issue rooted in structural inequities – including poverty, lack of access to healthcare, safe housing, and quality education. These social and economic conditions shape an individual’s ability to achieve health and well-being and are drivers of preventable disparities in injury and recovery [Reference Jang, Thomas and Slocum11] Advancing health equity requires a structural response: one that brings together public health agencies, healthcare providers, social service organizations, and policymakers in a coordinated, community-centered effort. Engaging those most impacted by violence in the design and implementation of these interventions is not only a matter of equity but also a practical necessity for success. This new HVIP model leverages this collaborative approach through the creation of a CAB using a structured approach [Reference Joosten, Israel and Williams18], ensuring that the perspectives and lived experiences of community members directly inform program development, delivery, and refinement.
Equitable community and stakeholder engagement within research can (1) expand stakeholder networks; (2) achieve a governance of shared power among investigators and stakeholders from health-disparate communities; (3) improve the rigor of research through higher participation rates; (4) elevate insightful interpretation of findings; (5) develop and implement culturally relevant interventions; (6) ensure valid and reliable assessment; and (7) identify new engagement strategies – all of which can accelerate health equity. The CSES at the Center for Health Equity offers researchers a structured process and support to achieve these goals, including the goals for their research project through equitable and meaningful engagement with the community. The studio allows for effective study design, intervention planning, impactful implementation, evaluation, sustainability, and dissemination of health equity for community organizations and their research partners. This process has proven to be effective in the convening of this new HVIP CAB by demonstrating a sense of cohesion, unity, and trust. The CAB was able to actively participate in a series of essential tasks to inform the building of the HVIP, ensuring a community-informed approach to the program development. Most importantly, the CAB felt that their participation would improve the project.
The unitization of CABs is not unique in addressing community violence, as this has been used in other programs. The development of digital media to address violence and substance abuse among black men in Chicago utilized a steering committee to inform the development of their existing HVIP with a technology-based intervention [Reference Emezue, Karnik and Reeder30]. In New York, an advisory board was convened to guide the creation of a universal screening tool for firearm violence in the emergency department and subsequent referral to firearm injury prevention programs [Reference Sathya, Harrison, Dauber and Kapoor31]. What is unique about this new HVIP is the approach in the creation, as well as the approach to the CAB meetings, using an intervention mapping approach. This allowed for a framework to promote a collaborative discussion to inform the development of the HVIP in a cohesive manner.
Ultimately, the CAB played a central role in shaping the program’s design and priorities. Based on its input, the project team was able to identify key root causes of violence and determine essential service domains to which participants should be connected, including housing, financial support, employment training, education, and transportation. The CAB also emphasized the importance of trauma-informed care, which directly informed the development of a hospital-based trauma-informed care training module. In addition, the CAB reviewed preliminary findings from the pilot study and provided actionable recommendations to strengthen both recruitment and retention. These recommendations included refining language to build rapport during recruitment and implementing targeted retention strategies, such as identifying optimal times to send reminder text messages, emails, and phone calls to sustain participant engagement throughout the program.
Limitations
There are a few limitations with the current study that should be considered when interpreting the findings. First, the CAB was implemented with voluntary participation from the CAB members. As a result, there were some CAB members who did not participate in every meeting. However, this is not unusual with CABs and is to be expected. To incentivize participation at each meeting, we provided CAB members with lunch and a $50 gift card for their time. Even so, variations in attendance may have led to inconsistent input and reduced the diversity of perspectives during some sessions. Second, surveys were limited as these were self-reported data, and responses may be subject to social desirability bias. To minimize this, we administered the surveys anonymously and also used groupings in the demographics so as to minimize the chance of identification of the members. Third, while we included a large and diverse stakeholder group, there may have been segments and perspectives in the community that were missing. Fourth, the study also took place at a single academic health center in Houston, in a large metropolitan city. Thus, the findings from this experience may not generalize to other contexts. Finally, aside from the satisfaction survey, there was no additional evaluation of the CAB activities. As the CAB will remain engaged throughout the duration of the project (through 2028), future research will involve subsequent survey evaluations, as well as semi-structured interviews to understand CAB perspectives about their satisfaction with the advisory board and perspectives on contributions to the program.
Conclusions
In addressing firearm violence, it is essential to take a community-led approach in the creation of a hospital-based intervention program. Through equitable community and stakeholder engagement, the research team can collaborate to enhance the intervention to best meet the needs of the population that they intend to serve. It is through effective facilitation, evaluation, and shared participation that this new HVIP was developed. Future plans include ongoing evaluation of the program and the engagement from the community partners.
Acknowledgements
We acknowledge the invaluable contributions of the Community Advisory Board (CAB) members as well as the youth advocates/credible messengers from The Forgotten Third. These community experts’ insights and experiences shaped the formation and implementation of the Houston-HVIP. We also extend our gratitude to Hersila Gopal from Memorial Hermann Hospital – TMC and Wes Gibson, Naomi Tice, and Deepali Ernest from UTHealth Houston School of Public Health who supported the engagement processes for this project. The collaboration of the above participants ensured community-driven research as the cornerstone and guide for the development of an equitable and effective HVIP intervention.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request. Data collected within this publication will be stored in DEPUT (the Data Ecosystem Portal for UTHealth Houston).
Author contributions
Anne Marie Vollero Thompson: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Visualization, Writing-original draft, Writing-review & editing; Sandra McKay: Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing-original draft, Writing-review & editing; Alexander Testa: Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing-original draft, Writing-review & editing; Eresha F. Bluth: Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Writing-review & editing; Karlton Harris: Project administration, Resources, Supervision, Writing-review & editing; Asa Singleton: Project administration, Resources, Writing-review & editing; Heidi M. Hagen McPherson: Conceptualization, Project administration, Resources, Supervision, Writing-review & editing; Mary E. Aitken: Supervision, Writing-review & editing; Sarah Beth Abbott: Data curation, Resources, Writing-review & editing; Marisol Nieves: Resources, Writing-review & editing; Latanya S. Monroe: Resources, Writing-review & editing; Carlie Stratemann: Data curation, Methodology, Writing-review & editing; Hema Sarvani Jalaparthi: Data curation, Methodology, Writing-review & editing; Shreela Sharma: Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing-original draft, Writing-review & editing.
Funding statement
Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number UG3NR021232. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health. This work was also supported by the Center for Health Equity at the UTHealth Houston School of Public Health in Houston, Texas, and funding from Kaiser Permanente Center for Gun Violence Research and Education.
Competing interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval and informed consent statement
This study has been approved by the Institutional Review Board at the University of Texas, with review number HSC-MS-23-0904. Written informed consent was obtained by participants at the time of the study.
Open access
