Youth violence and substance use co-occur as a public health double threat. Youth violence encompasses a range of behaviors, including dating violence, actual or threatened violence, physical fighting, web-based and school bullying, threats and assault with weapons, homicide, and firearm-related and gang-related violence [1,2]. Similarly, substance use is linked to violent incidents, even as persistent substance use (of marijuana and alcohol) is associated with youth violence perpetration and victimization [3,4]. Although the evidence is conflicting [4,5], youth violence and substance use share transdiagnostic risk and protective factors [4,6] and underlying mechanisms that cross-cutting preventative measures can address. Moreover, these socially costly issues are linked to multiple adverse physical, social, and health effects, such as low quality of life, subpar academic and social functioning, mental health disorders, and suicide risk [4].

Young Black men and boys from disinvested communities are disproportionately survivors, perpetrators, and witnesses of youth violence and homicide [7-9]. Recent Centers for Disease Control and Prevention data reports homicide as the primary cause of death for Black boys and men (aged 10-24 years), and firearms were involved in 94% of these incidents [9-11]. During the pandemic, firearm homicide rates in the United States rose to its highest level since its peak in 1994 [12]. Black boys and men aged 10 to 44 years saw the largest increase in these adjusted rates from 2019 to 2020, followed by Native American individuals, aged 25 to 44 years [7,12]. Consequently, Black youth are 14 times more likely and Hispanic youth are 3 times more likely than White youth to die from firearm-related violence [12].

More than 700,000 urban youths (aged 10-24 years) present to emergency departments (EDs) each year with nonfatal assault-related injuries [4,13,14]. Approximately 20% of these youths report substance use within 3 hours of an assault-related injury [3,14,15]. Despite this, service gaps continue to hamper violence and substance use prevention efforts for underserved, urban, and low-income youth. Outside the juvenile and criminal justice systems, racial and ethnic minority youth report critical barriers to obtaining behavioral health services across the continuum of prevention, treatment, and recovery. These barriers include but are not limited to neighborhood disadvantage, racism, homelessness or temporary housing, unemployment, discrimination, peer and gang pressures, transportation issues, program fees, the lack of culturally relevant services, and competing demands on time to attend clinic or group-based rehabilitation sessions [16-18].

Similarly, violence prevention programs in hospital EDs, schools, juvenile justice facilities, child welfare systems, faith-based and street outreach initiatives continue to have substantial wraparound effects in reducing violence [19,20]. However, in resource-limited communities, these programs lack 24/7 staff coverage, follow-up services, and trauma-informed training and report high employee turnover [16-18,21]. Furthermore, injured young Black men perceive hospital violence intervention programs—and other formal institutions—as places of interface with law enforcement and thus avoid using these services [16,22-24], even though EDs are increasingly recognized as a critical intervention venue for youth at risk for future violent injury [4].

Similar to contexts where these services exist, sociostructural barriers can also impede youth willingness to use them. These barriers include and are exacerbated by experiences of police bias and violence, treatment stigma [16,17,25-27], racial trauma, and a historic mistrust of legal and medical systems linked to the systemic discrimination and overt criminalization of Black men and boys [16,28-30]. In addition, the language (and culture) of formal therapy centering on Western-centric curricula [31] and gender norms that frame help-seeking as a weakness have also been identified by young Black men as impediments to service use despite the high prevalence rates of trauma exposure among these underserved groups [32,33].

These barriers have created substantial service gaps [17]. In addition, they have exacerbated treatment inequities, leaving young Black men involved in violence in underserved communities to adopt ineffective coping techniques, such as service avoidance or opting out [22]. Service avoidance takes the form of deliberate attempts to avoid or disengage from formal treatment or rehabilitation programs perceived to be associated with feds or that place them in the system [22], whereas opting out from preventative programs can manifest as early dropouts, noncompliance, nonparticipation, tardiness, and absenteeism even when the court system mandates program completion. Consequently, persistent service-avoidant behaviors contribute to violence recidivism, substance use relapse, and a revolving-door approach to prevention. Therefore, improving youth access to and trust in existing violence and substance use prevention interventions is critical.

Technology-enhanced interventions can empower underserved and low-income youth to overcome some of these barriers [18]. Studies show that young Black men favor digital interventions as digital natives in a tech-saturated world [34-37]. Even after controlling for age, parent education, and family composition (single vs 2-parent households), Black youth have higher cell phone ownership rates and internet use (ie, hours per day) than Hispanic and White adolescents [36]. Therefore, technology-enhanced interventions can simultaneously mitigate these barriers and broaden the access to trauma-focused therapies. From a prevention science standpoint, engaging at-risk young Black men in this digital landscape—by meeting them where they are—is a promising and pragmatic approach to early prevention of substance-related violence [37-39]. This strategy can potentially reduce service avoidance while boosting the availability, accessibility, and personalization of evidence-based interventions [37-39]. Notably, technology-enhanced interventions can serve the “treatment curious” (those at early risk who have not sought out formal services but who can benefit from a low-stakes digital tool that highlights the risks and consequences of youth violence) and the “treatment veterans” (or returning citizens who are chronically involved in the system and familiar with violence and substance use services). Innovative public health and equity-focused interventions promoting health equity and positive service engagement for at-risk and underserved young Black men are needed to address the gaps and barriers identified previously.

This study aimed to systematically adapt and pilot-test Boosting Violence-Related Outcomes Using Technology for Empowerment, Risk Reduction, and Life Skills Preparation in Youth Based on Acceptance and Commitment Therapy (BrotherlyACT), a culturally congruent, trauma-focused digital intervention tailored to Black boys and men aged 15 to 24 years. BrotherlyACT will incorporate microlearning modules, interactive safety planning tools for risk assessment, goal-setting, mindfulness practice, and a service-engagement conversational agent or chatbot to connect young Black men to relevant services.

To address these gaps and barriers, we developed a protocol for adapting and pilot-testing BrotherlyACT. It is envisioned as a multilevel, multicomponent, web-delivered, and app-delivered intervention to promote psychoeducation, safety planning, and service-engagement self-efficacy to reduce the risk and effects of co-occurring youth violence and substance use among low-income Black boys and men (aged 15-24 years). BrotherlyACT will comprise three main components (as depicted in Figure 1): (1) microlearning psychoeducational modules (or brief lessons framed as learnable life skills in an interactive curriculum) organized around the 6 fundamental acceptance and commitment therapy (ACT) principles (intrapersonal focus); (2) a safety planning tools library with resources to facilitate risk assessment, goal-setting and tracking, and mindfulness practice (interpersonal focus); and (3) an SMS text messaging–styled service-engagement chatbot or conversational agent to promote help-seeking, self-advocacy, and access to a curated list of national and local violence and substance use prevention programs and services (interactional focus). The need for these three components emerged out of interest from young Black men and service providers working with teens involved in violence to help them (1) develop self-efficacy to practice help-seeking while accessing trusted services on their own, (2) create a supportive motivational climate for underserved youth to feel comfortable seeking help, and (3) identify safe people and resources in their communities.

BrotherlyACT is based on several theoretical and conceptual models. The intervention’s psychoeducational modules will adapt an existing theory-driven and skills-based manualized intervention (Achieving Change Through Values-Based Behavior [ACTV]) with motivational, informational, and behavioral activation strategies [40-45]. These brief or microlearning psychoeducational modules will cover topics on help-seeking, substance use, conflict resolution, nonretaliation, healthy relationships, gun and gang refusal skills, mindfulness (putting a brake on emotional reactivity), and positive future orientation and coping.

The original ACTV curriculum comprises 5 modules designed for violence reduction with incarcerated men and women using group sessions [38-44]. In addition to feedback from young Black men and service providers, the other components of BrotherlyACT were informed by the Capability, Opportunity, and Motivation to Change Behavior model [46], which proposes 3 elements that are vital to sustainable behavior change: capability, opportunity, and motivation [46]. Capability refers to an individual’s abilities and skills, such as physical, cognitive, or technical skills, and considers situational and background risk factors that precipitate youth violence. Opportunity refers to the presence or availability of resources and opportunities that enable the individual to engage in a particular behavior, such as access to information, social support, or resources, and practice self-direction and decision-making. Motivation refers to the individual’s desire or willingness to engage in the behavior, which may be influenced by factors such as attitudes, beliefs, values, or goals. Capability and opportunity jointly influence motivation [46], contributing to lasting behavior change. Taken together, the Capability, Opportunity, and Motivation to Change Behavior model helped to clarify individual, community, and structural risk factors (eg, service avoidance and emotional avoidance) that may be targeted by BrotherlyACT.

We hypothesize that through improved behavioral and cognitive skills and service-engagement self-efficacies, BrotherlyACT can reduce key psychological avoidant mechanisms (emotional avoidance and service avoidance) and increase motivation, capability (eg, self-efficacy to create and use a safety plan), and opportunity (eg, knowledge about service options). These improved conditions will, in turn, reduce the risk and effects of violence and co-occurring substance use among low-income young Black men involved in violence.

ACTV is an evidence-based psychotherapy based on ACT [47-52]. ACT is a third-generation cognitive behavioral therapy (CBT) based on the philosophy of functional contextualism and Relational Frame Theory [53]. ACT differs from other CBT-based approaches because it is based on a unified model of human behavior change and psychological growth. It is focused on helping individuals develop a different relationship with their thoughts and emotions instead of trying to change them directly. For example, CBT aims to help individuals identify and change negative or irrational thoughts, whereas ACT holds that pain and discomfort are a fact of life—something we must become comfortable with if we wish to live a happy, fulfilled life. ACT aims to increase psychological flexibility or “the process of contacting the present-moment fully as a conscious human being and persisting or changing behavior in the service of chosen values” and reduce emotional avoidance (unwillingness or perceived inability to remain in contact with difficult internal experiences and efforts to delay gratification and live a value-based lifestyle) [47-52]. Therefore, ACT encourages flexibly responding with openness and acceptance of our thoughts and emotions rather than trying to directly change their form or frequency and then shifting our attention (with practice) to what is most important in our lives. Of note, >20 meta-analyses and >900 randomized trials, with 12,477 participants, have shown that ACT is effective for a wide range of target conditions, with effect sizes ranging from small to medium for depression, anxiety, substance abuse, and chronic pain and small to large effects for increasing psychological flexibility in general [53,54].

ACTV was developed by a coauthor (AZ) and has been rigorously tested in multiple randomized effectiveness trials, feasibility studies, and pilot studies in collaboration with the Iowa Department of Corrections [38-44]. A series of effectiveness trials compared ACTV with the traditional Duluth or CBT model. A 1-year postintervention comparison of community-based ACTV vs the Duluth and CBT models (widely used globally in rehabilitation programs for abusive men) found that ACTV significantly reduced new charges, domestic assault charges, and violent charges for men who were mandated to complete a domestic violence intervention program (N=3474) at 12 months after treatment [42]. In addition, this effect was maintained for both program completers and dropouts [40]. A recent 5-year survival analysis of ACTV participants corroborated a previous study with 1-year outcomes, showing ACTV participants being less likely to acquire new violent or domestic abuse charges at year 5 (χ²₁=6.8, P=.009) but with no difference in general criminal charges between ACTV and Duluth or CBT participants (χ²₁=0.3, P=.60) [40]. In addition, control participants acquired new charges faster than intervention participants [40]. Although effective for reducing partner and criminal violence, ACT (and ACTV) has not been adapted for cross-cutting violence and substance use prevention with at-risk youth or for digitally enhanced delivery.

However, trauma-focused therapies, such as ACTV, remain inaccessible to youth who are economically disadvantaged and belong to a racial and ethnic minority group (eg, Black and Latinx youth) [54]. These interventions are typically developed, adapted, and evaluated with White, high-income populations [55-57]. In addition, White youth who are involved in violence are more likely than their non-White counterparts to be diverted to rehabilitative therapy [58]. In comparison, young Black men who are involved in violence are substantially more likely to be transferred to more punitive alternatives (eg, transferred to adult court) or other forms of detention [58]. Interventions addressing these issues similarly use Western-centric theories for individualistic violence prevention and emphasize racial and socioeconomic distinctions between treatment facilitators, program curricula, and men referred to these programs, resulting in a therapeutic mismatch [31].

User-centered design (UCD) is a general term for design methodologies in which end users are involved in the iterative process to shape the design of an intervention and contexts for its implementation [59-61]. UCD strategies can be put into practice quite fast, enabling us to swiftly determine user needs and create appropriate interventions to address these needs.

UCD methods are important, as they can uncover new information that is not revealed by conventional techniques, improve user experience, and ensure that we obtain representative participant response to match a predetermined usability requirement. In addition, users develop a sense of ownership for the product [59]. Contextual interviews, think-aloud protocols, cognitive walk-throughs, semistructured cognitive interviews, and acceptability or feasibility surveys are some of the UCD techniques we will use with key stakeholders as we develop BrotherlyACT.

The development of BrotherlyACT using UCD principles reimplements the design and adaptation methodologies from our previous studies with young men who are involved in violence and affected by trauma [34,62]. In more recent studies, we have used UCD methods in the design of a mobile clinical decision support app for urinary tract infection in long-term care [63,64] and in understanding the usability and function of consumer-grade wearable devices [65].

Several iterations of BrotherlyACT will be produced and tested for usability. Early studies indicate a need for cross-cutting interventions for violence co-occurring with other risky behaviors. Young men in these studies confirmed the suitability of, and the potential to explore further, the use of digital methodologies as a primary prevention tool [34]. Participants listed the following as intervention must-haves: individualized feedback, compelling firearm injury testimonials, inspiring tales of other young men who have successfully avoided violence and substance use, humanlike chat capabilities, actual stories and violence-related testimonials, pictures and videos of people similar to them, and mechanisms to monitor behavior change. This feedback substantially informed the proposed BrotherlyACT intervention [34].

The development of BrotherlyACT will occur in 3 phases. In phase 1, we will collaborate with Black boys and men (aged 15-24 years) and service providers (aged >18 years; any gender) to identify social and structural barriers and motivators influencing youth violence and substance use prevention. Black boys and men (aged 15-24 years; n=25-30) and their service providers (n=10) will be recruited from clinical (pediatric ED) and community-based settings in the West and South sides of Chicago—2 areas with historically high violence burden and persistent economic disadvantages, but with much promise and a wealth of community-based programs [66-69]. Sessions will include participatory focus groups, in-depth one-to-one interviews, and wish listing activities (ie, listing intervention must-haves).

In phase 2, we will use content and cultural adaptations of the ACTV curriculum using the 8-stage Assessment, Decision, Administration, Production, Topical, Experts, Integration, Training, and Testing (ADAPT-ITT) framework [70,71]. Finally, in phase 3, we will assess the feasibility and acceptability of BrotherlyACT. Overall, 60 young Black men (not part of phase 1 or 2) will remotely pilot-test BrotherlyACT for 10 weeks to determine feasibility and implementation outcomes. An outline of the study stages is shown in Figure 2.

All study phases have been approved by the Rush University Medical Center institutional review board (IRB; Office of Research Affairs number 21122902-IRB01). In addition, we have received recruitment-only IRB approval from the Stroger Cook County Hospital (study 22-087R). Each participant will provide informed consent before recruitment into the study and receive a copy of the signed form as a PDF. They will also be informed that their participation is voluntary and that they may withdraw from the study at any time. Furthermore, permission will be sought to audio-record and take notes during the interviews. All study data will be deidentified and kept confidential according to IRB protocols at designated study sites, with Rush IRB being the primary study site.

Using a mixed methods study format, subjective and objective feasibility and acceptability data will be compared. This will ensure that survey data can be quantified and contribute to our qualitative understanding of the curriculum’s practicality and acceptability.

Few antiviolence technology-enhanced interventions exist, and even fewer studies have studied the acceptability, usability, and engagement of a life skills and mindfulness coaching intervention for co-occurring youth violence and substance use among young Black men. The extent to which existing technology-enhanced interventions are used for violence prevention has been limited to supporting the work of street outreach workers [86]. We expect that BrotherlyACT will prove to be acceptable and usable by young Black men affected by violence. Furthermore, findings from the development of BrotherlyACT will be useful for a future definitive trial. This trial will validate an expanded version of BrotherlyACT across clinical and community-based settings for young Black men in Chicago and other cities with a high prevalence of youth violence. Clinical outcomes will be determined after we evaluate how well BrotherlyACT works (ie, reduction in violence and substance use, perceived likelihood of involvement in violence and problematic behaviors, self-efficacies to plan for a positive future, use of ACT and life skills, and likelihood of using service options). The success of this intervention in different deployment contexts (eg, in a hospital vs a community setting or web-based vs face-to-face setting) will be evaluated as part of the implementation analysis. BrotherlyACT will be tested (1) with referred (vs recruited) young Black men, (2) with an organic deployment by service providers (vs research staff), and (3) in comparison with conventional care in future effectiveness trials.

On the basis of previous application of qualitative methods [34] and UCD [34,59,62], we anticipate that our study will highlight the benefits of technology-enhanced modalities for addressing motivation and self-efficacy to reduce and prevent co-occurring violence and substance use among at-risk young Black men. Studies so far support an association between substance use and violence [4,5], with a consensus that substance use can increase both the frequency and severity of violence [4-6]. A common substance implicated in violent experiences when misused is alcohol, with the suggestion that eliminating hazardous drinking would reduce general violence by 44% [5]. Such findings have led many researchers to focus on developing integrated intimate partner violence and substance use interventions [4-6].

However, this study is the first stage in developing and evaluating a technology-enhanced intervention for reducing co-occurring violence and substance use among Black boys and men aged 15 to 24 years in a high-violence setting. We are using an existing theory-driven and evidence-based intervention (ie, ACTV) that has been proven to reduce violence. This approach eliminates the need for expensive additional investments in developing a new intervention from other data sources, which may face significant feasibility issues and require considerable time. Extending ACTV to noninstitutionalized juvenile samples exposed to youth violence is a logical next step. Addressing our research objectives squarely will drive innovation in violence prevention and identify settings, conditions, and limitations for situations where digital solutions are inapplicable or even detrimental.

Furthermore, crime prediction technologies, digital surveillance tactics, and facial recognition software have all been known to target and penalize Blackness [86]. Therefore, we approach this study through a transformative justice lens, mindful of how technology affects Black communities. We hold ourselves and our team accountable in our quest for ethical and dignified technology-enhanced interventions. We remain responsible to young Black men, who will support this process and, eventually, use BrotherlyACT.

This study and our approach have some limitations. As our study only includes young Black men, we cannot generalize our results to other groups of young men (such as Hispanic; tribal; and lesbian, gay, bisexual, transgender, queer, and more youth) who are disproportionately affected by violence and substance use. Furthermore, using a single sample group for pretest and posttest will not infer causative relationships and will limit the causal attribution related to the proposed intervention. However, our goal at this stage is to develop and pilot-test BrotherlyACT for preliminary feasibility and acceptability. We have evaluated the power of our sample size using suggestions and guidelines for conducting pilot studies contained in the existing literature.

Nevertheless, it is possible that our sample size is very small, which could influence the results we receive. Regarding cultural adaptation of the intervention to young Black men, it can be challenging to present diverse groups with a unified view of culture. Some participants may find that traditional values conflict with their convictions or that generic cultural values may not adequately capture the particulars of their own cultural experience. Therefore, we intend to develop BrotherlyACT’s architecture to be adaptable to user requirements and capable of rapid, iterative adjustments. Moreover, young Black men who have perpetrated violence and use illicit substances are a self-selecting population that may not feel comfortable reporting their substance use and histories of violence, thus necessitating the use of novel recruitment tactics.

At the individual level, studies show that life skills are a vital tool and coping strategy for adolescents in high-trauma contexts. Life skills have been used for decades to prevent violence and aggression in adolescents, particularly those in their early to middle adolescence. However, there is compelling evidence that low-income urban youth have few opportunities to observe, learn, or practice the actionable skills required to deal with the heightened levels and severity of the stressors they face. Accordingly, there is a need for combining multilevel strategies, such as psychoeducation and safety planning (at the individual level), with service engagement at the community level. There is also a dire need for easily accessible and youth-endorsed interventions that allow young people to acquire and practice these abilities as they plan for a values-based life. Improving Black adolescents’ access to skill-building resources and connecting them to already existing and trusted services is a critical and urgent public health need, the absence of which has resulted in a revolving-door approach to youth violence and substance use prevention.