The Economics of Violence Prevention Many are aware of the burden of violence on public health, but fewer are aware of the financial burden of violence and the research challenges related to studying population-based interventions. Because of the costs involved with program implementation, we believe that widespread use of violence prevention interventions should be tested for efficacy at some level. Herein, we will discuss the economics of violence prevention and the challenges of conducting population-based violence prevention research on a brief intervention. Please also visit the links at left to learn more about how you can assess, advocate for, and address the need for aggression intervention. In the United States, cost estimates of interpersonal violence are 3.3% of the gross domestic product.* Thus, a population-based intervention that results in a relatively small reduction in the rate of interpersonal violence could result in a large cost savings for the public sector. Potential savings United States gross domestic product in 2005: $12,000,000,000,000 ($12 trillion) Estimated cost of interpersonal violence in US in 2005 (3.3% of GDP): $400,000,000,000 ($400 billion) Potential cost savings of reducing interpersonal violence by 10%: $40,000,000,000 ($40 billion) Potential cost savings of reducing interpersonal violence by 1%: $4,000,000,000 ($4 billion) Potential cost-benefit of a population-based intervention Number of children born in the US every year: 4,000,000 (4 million). The cost of delivering a $20 violence prevention intervention to the parents of every newborn child in the US: $80,000,000 ($80 million=$0.08 billion). Assuming that a $20 population-based intervention could reduce the rate of violence by 10%, the potential cost benefit would be $500 saved for every $1 spent ($40 billion/$0.08 billion). Assuming that a $20 population-based intervention could reduce the rate of violence by 1%, the potential cost benefit would be $50 saved for every $1 spent ($4 billion/$0.08 billion). Violence prevention research challenges Our efforts have focused on assessing the efficacy of a brief educational program, Play Nicely, that addresses one of the strongest risk factors of violence, persistent early childhood aggression. Studying this population-based violence prevention intervention is challenging. Rates of violence It would be best to implement population-based interventions only after randomized controlled trials have demonstrated a reduction in the rate of violence in an intervention group which received the intervention compared with a control group which did not. However, the sample size needed to enroll participants in a randomized control trial designed to assess a small shift in the rate of violence is prohibitively large. The US violent crime rate is 500 violent crimes per 100,000 inhabitants. Assuming that a researcher would like to detect a reduction of 10% in the rate of violent crime in an intervention group compared with a control group, a study would need to enroll 300,000 participants at birth and follow them through early adulthood (alpha = 0.05 and beta = 0.8). Assuming that a researcher would like to detect a reduction of 1% in the rate of violent crime in an intervention group compared with a control group, a study would need to enroll 30,000,000 participants at birth and follow them through early adulthood (alpha = 0.05 and beta = 0.8). Subsequently, decisions to implement population-based interventions that attempt small, but important, reductions in violence by addressing childhood aggression will likely need to be based upon studies that look at outcomes other than rates of violence later in life. Conduct disorder Another excellent outcome to consider is conduct disorder (i.e. persistent childhood aggression) in young children because it is a risk factor for violence later in life. However, enrolling enough participants to detect a small, but important, effect on the rate of conduct disorder will still be challenging. The rate of conduct disorder is higher in boys and varies between 1 and 10%. For this sample size estimate, we will assume a rate of conduct disorder of 5%. Assuming that one would like to be able to detect a reduction of 10% in the rate of conduct disorder in an intervention group compared with a control group, a study would need to enroll 28,000 participants at birth and follow them through early childhood (alpha = 0.05 and beta = 0.8). Other outcomes Sample size requirements limit measuring rates of violence and conduct disorder for brief interventions such as Play Nicely. Until larger studies can be conducted that measure these important outcomes, researchers will need to focus on other research questions related to childhood aggression. Some of these might include: Is the program embraced (i.e. high satisfaction) by those with different backgrounds? Can the program increase comfort level with managing aggression? Can the program increase knowledge of aggression management strategies? Can the program improve the quality of counseling provided to parents by health care professionals? Can the program increase parents' willingness to discuss discipline options and child behavior with health care provider or other counselor? Can the program affect parents' disciplining strategies such as spanking, time-out, redirecting, and promoting empathy. Can the program affect parents' attitudes about disciplining strategies such as spanking? Do parents who view the program report that it helps them manage aggression with their own children? Do parents recommend the program to others? Can the program reduce negative behaviors in young children? In summary, research may never be able to demonstrate that a brief, population-based, violence prevention program can reduce the rate of violence or conduct disorder due to sample size requirements for such a study. Violence prevention programs that have potential for a small, yet important, reduction in the rate violence will likely need to focus on a variety of other outcomes. * The economic dimensions of interpersonal violence. The World Health Organization. Geneva. 2004.