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Building Public Health Infrastructure for Youth Violence Prevention

Policy Date: 11/10/2009
Policy Number: 200914

Youth violence, perpetrated both by and against young people, results in considerable physical, emotional, social, and economic consequences.
Youth violence refers to harmful behaviors that can start early and continue into young adulthood. Youth violence includes various behaviors. Some violent acts—such as bullying, slapping, or hitting—can cause more emotional harm than physical harm. Others, such as robbery, assault, rape, homicide and suicide can lead to serious injury or even death. The scope of youth violence is broad. Youth can be perpetrators or victims of violent acts. Hence, policies must be designed to distinctively address perpetration of and victimization from acts of violence.
Preventing serious youth violence, which denotes “serious violent crime” involving youth, is the focus of this resolution. The Bureau of Justice Statistics includes rape, robbery, aggravated assault and homicide as serious violent crimes1; and when these acts of violence involve youth, either as a perpetrator or a victim, they indicate serious youth violence.2

Magnitude of the Problem, Societal, and Economic Impact
Homicide is the second leading cause of death for young people between the ages of 15 and 24.3 Among 15–24 year olds, homicide is the leading cause of death among blacks and the second leading cause of death for Hispanics.3 Homicide ranks second for Asian/Pacific Islanders ages 15–19 years and is the third leading cause of death for American Indians/Alaska Natives between the ages of 15–24 years.3 There are substantial racial, ethnic, and socioeconomic disparities in rates of serious youth violence such as homicide.4,5 For each homicide among youth aged 10–24, there may be as many as 1,000 nonfatal violent assaults.6
Recently in the United States, overall homicide levels have fluctuated minimally. However, those involving young people, particularly young black males, have been on the rise. From 2002 to 2007, homicides involving black male juveniles as victims rose by 31% and as perpetrators by 43%.7 The sociocultural and economic contexts of increasing trend are important. There are special circumstances of inner-city communities, border communities and geographically isolated communities such as American Indian/Alaska Native reservations and poor neighborhoods that need to be considered in light of the increasing trend.8–10 Epidemiological studies, for instance, indicate that the disproportionate burden of youth violence among blacks are for the most part explained by reference to racial differences in community contexts such as living in a high-crime neighborhood characterized by gangs, guns, and drugs rather than the intrinsic attribute of race/ethnicity.11 In particular, inner cities and neighborhoods with income inequality and rampant poverty act as environmental stressors to promote hostilities and acts of violence.19
Further, the increasing trend in youth violence is proving to be disruptive to learning, posing a threat to economic growth and development.Youth Risk Behavior Surveillance System data indicated that approximately 6% of high school students reported not going to school on 1 or more days in the 30 days preceding the survey because they felt unsafe at school or on their way to and from school, and approximately 36% reported being in a physical fight 1 or more times during the past 12 months.12
Youth who are victims of violence or who witness violence in their communities suffer many consequences, including physical injuries, posttraumatic stress syndrome, depression, anxiety, and substance abuse; they may also suffer longer term health problems associated with the biopsychosocial effects of such exposure.13 Violence is a factor in the development of chronic disease, including limiting physical activity and healthy eating. Strategies, policies, and programs need to take these links into account.
Much of the serious youth violence is perpetrated by youth outside of home and school settings. As a consequence, the community itself is a key focus for youth violence prevention activities. All members of communities with high rates of youth violence suffer as well through its negative effects on safe mobility, the nature and quality of social relations, business activity, and housing prices.14,15
Serious youth violence also presents a substantial economic cost because of immediate medical costs as well as further losses to productivity.16,17 Such costs include immediate medical costs, lost future earnings, victims’ assistance, and public program costs related to police investigation. In the Year 2000, total medical costs and lost productivity for the 0–24 age groups for fatal and nonfatal assaults was an estimated $15.270 billion.17
Despite the profound detrimental effects of acts of violence on youth and communities, most cities do not have a comprehensive strategy to address youth violence, and public health departments are not generally included in current city strategies.18 Some cities with the greatest coordinated approaches have the lowest rates of violence.18

Prevention Strategies, Countermeasures, and Societal Return
Violence, like all other injuries, is predictable and preventable. Literature cites numerous risk factors and predictors of violence in youth. Evidence from the literature indicates that the strongest categories of predictors for youth violence include individual psychological factors, family factors, school factors, peer-related factors, and community and neighborhood factors.20 Numerous prevention efforts have used this information to tailor successful prevention interventions. In addition, environmental factors that may promote youth violence such as poverty, poor housing, geographic segregation of poor families; inadequate social institutions such as schools, social services and criminal justice; and the role of racism in the treatment of families of color, including youth, need further research to better understand and prevent youth violence.
Interventions that have been documented to be effective must be used by communities, states, and the nation to prevent youth violence. The Centers for Disease Control and Prevention (CDC) released Best Practices of Youth Violence Prevention: A Sourcebook for Community Action, which identified 4 key areas for prevention: parents and families, home visiting, social and conflict resolution skills, and mentoring.21 In addition, Blueprints for Violence Prevention provides a rigorous, ongoing, systematic review of the research evidence for youth violence prevention.22 The Blueprints review has identified 11 model programs that meet strict scientific standards of program effectiveness. The initiative has also identified 18 promising programs that if replicated could potentially become model programs.
Special attention is also needed to ensure that culturally competent interventions are available for racial and ethnic minority populations and communities if study samples are inadequate.23 Recognizing that few evidence-based programs exist for certain racial and ethnic minority populations such as American Indian/Alaska Natives, comprehensive strategies should build on the best available science. Prevention efforts must be comprehensive and address all levels that influence youth violence: individual, relationship, community, and society. Efforts to identify the best combinations of approaches at multiple levels could lead to a better understanding of how programs, policies, or strategies at the community and societal levels interact with individual and relationship-level programs to maximize impact.
School-based prevention programs have shown promise in the prevention of youth violence.24,25 The Community Guide for Preventive Services has identified universal school-based programs as an effective strategy.26 In addition, because much delinquent behavior takes place after school, community-based after-school programs can assist in preventing delinquent activities that take place among youth during unsupervised time.27–29 After-school programs can also mediate the effect of neighborhood factors, such as safety, by providing youth with a safe place to go and inhibiting youth perpetration of delinquent or violent actions.29,30 Participation in a culturally competent, community youth service program can also have an impact on violent behaviors of youth, especially when delivered with classroom instruction.31
There are other approaches that we know do not work, and they may even have serious unintended negative effects. The Surgeon General’s report on youth violence identified 5 popular programs that have been shown to be consistently ineffective.2 The report also described programs as ineffective because of poor implementation. Such ineffective programs are costly and may drain resources that could be better allocated to effective, evidence-based programs.
Collectively, effective programs aimed at preventing youth violence reap the benefits of not only a reduction in violence but also a reduction in economic losses, overall improvements in quality of living in the affected communities, and the inhibition of presently diminishing social capital.10,30,32

Infrastructure Building
Public health is uniquely positioned to convene, collaborate, and coordinate the multidisciplinary teams to work together to prevent youth violence. The public health approach to preventing youth violence includes collecting high-quality data about the problem, with an emphasis on and commitment to identifying policies, programs, and strategies that are effective; disseminating evidence-based strategies to communities to ensure the best science is used; and planning and evaluation to ensure the prevention strategies are comprehensive and have the desired effects.
However, there is limited public health infrastructure to prevent youth violence. We must build the necessary public health infrastructure to support youth violence prevention at the local, state, and national levels. Public health departments must have resources and professionals that focus on youth violence prevention with an infrastructure and capacity that is proportionate to the public health burden in the service areas. The American Public Health Association (APHA) recognizes the need to build a public health infrastructure for youth violence prevention that include academic institutions, local health departments, and community-based organizations to implement more effective youth violence prevention and improve public health.
Effective translation of youth violence prevention research to action requires building and reinforcing the public health infrastructure that (a) synthesize and translate information on effective interventions and communicate it to all stakeholders; (b) build the general skills and motivations of communities and organizations and strengthen their capacity to successfully implement specific interventions; (c) deliver high-quality implementation of specific interventions at the national, state, or local level; and (d) strengthen research and program evaluation to monitor the quality, costs, and continued effects as interventions become more widely diffused. Public health infrastructures founded on these principles could seamlessly add new discoveries as they are made, ensuring that the best available scientific evidence are immediately translated, supported, and delivered to communities.

Action Steps
There is a strong call for action to prevent youth violence. Major urban cities like Chicago, Los Angeles, and Baltimore are experiencing escalation in youth violence threatening social capital. In 2001, the Surgeon General found that the most pressing need was the national resolve to confront the problem systematically, using evidence-based approaches and correcting the myths and stereotypes that impede progress.2 National leadership is needed that includes the CDC, state and local governments, and the APHA to articulate a national, comprehensive strategy to prevent youth violence.
The APHA has a commitment to promote healthy behaviors of youth that could, if coupled with the right social and environmental interventions, prevent youth violence.33 APHA Policy 2000-27, Encourage Healthy Behaviors by Adolescents, calls for congressional and state legislation and funding for comprehensive and integrated programs such as Safe Schools/Healthy Schools Initiative, community schools with after-school programs, health education programs, family resource centers, collaborative research on impact of community schools, and age-appropriate incarceration.33 This proposed policy builds on and advances APHA’s existing policies for the prevention of firearm violence and violence research (Policies 2001-18 and 99-26) as well as policies for health education and promotion, prevention of child abuse, and injury and violence prevention and control (Policies 2004-09, 86-14(PP), 99-27).34–38
Cognizant of the need for public health infrastructure in youth violence prevention, the APHA—
1. Urges the Congress and states to fund comprehensive, culturally based programs based on scientific evidence and using the following guidance from Youth Violence: A Report of the Surgeon General2 and other evidence:
1.1. Continue to build the science base.
1.2. Accelerate the decline in gun use and stabbings by youths in violent encounters.
1.3. Facilitate the entry of youths into effective intervention programs rather than incarcerating them.
1.4. Disseminate model programs with incentives that will ensure fidelity to original program design when taken to scale.
1.5. Provide training and certification programs for intervention personnel.
1.6. Convene youths and families, researchers, and private and public organizations for a periodic youth violence summit.
1.7. Improve federal, state, and local strategies for reporting crime information and violent deaths.
2. Urges support of CDC in the development and implementation of a National Public Health Prevention Strategy to Prevent Youth Violence that aims to create a national movement with the collaboration of partners and stakeholders (e.g., parents and educators), working together to reduce youth violence.
3. Encourages local, state, and federal public health organizations to take a leadership role through coordination and collaboration with justice, education, business, and other partners to develop and implement plans to address youth violence and prevent it before it occurs.
4. Urges Congress and states to enhance the capacity and infrastructure of the public health community at the federal, state, and local levels to address the ongoing public health crisis of violence.
5. Urges Congress, state, and local public health departments in building infrastructure, capacity, and systems to develop adequate data and surveillance systems.
6. Urges federal, state, and local governments to develop coordinated prevention planning, program implementation, and evaluation efforts in the most needed locales, including incentives and opportunities to participate in citywide efforts. Efforts should adopt a comprehensive, culturally based approach, including equitable distribution of interventions and greater collaboration between cities.
7. Urges training for state and local public health departments about the role of public health in preventing violence and effective, evidence-based programs for youth violence prevention. APHA also supports the integration of such training programs in all public health graduate school curricula.
8. Calls for the support of additional research to understand the community and societal factors that can contribute to or prevent youth violence and how these factors can be modified to reduce risk or enhance protection. Research is needed in all communities, including ethnic minority communities.
9. Calls for resources to support dissemination and implementation of evidence-based youth violence prevention programs, strategies, and policies and on-going evaluation to ensure that these efforts are being implemented appropriately and that they are having the intended effects on youth risk for violence.
10. Urges federal, state, and local governments to improve data collection, including supporting nationwide expansion of CDC’s National Violent Death Reporting System.

References

1. US Department of Justice Office of Justice Programs Bureau of Justice Statistics. Key Facts at a Glance. Available at: http://bjsdata.ojp.usdoj.gov/content/glance/cv2.cfm. Accessed December 19, 2009.
2. US Department of Health and Human Services Office of the Surgeon General. Youth Violence: A Report of the Surgeon General. Washington, DC: US Department of Health and Human Services Office of the Surgeon General; 2001. Available at: www.surgeongeneral.gov/library/youthviolence/toc.html. Accessed December 19, 2009.
3. Web-based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention National Center for Injury Prevention and Control, 2009. (www.cdc.gov/ncipc/wisqars).
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22. Blueprints for Violence Prevention. Boulder, Colo: Center for the Study of Prevention of Violence Colorado University–Boulder. Available at: www.colorado.edu/cspv/blueprints. Accessed December 20, 2009.
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33. American Public Health Association. APHA policy statement 2007-27: Encourage healthy behavior by adolescents. Washington, DC: American Public Health Association; 2007. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=234. Accessed December 18, 2009.
34. American Public Health Association. APHA policy statement 86-14(PP): Prevention of child abuse. Washington, DC: American Public Health Association; 1986. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1129. Accessed December 18, 2009.
35. American Public Health Association. APHA policy statement 2004-09: Promoting public health and education goals through coordinated school health programs. Washington, DC: American Public Health Association; 2004. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1292. Accessed December 18, 2009.
36. American Public Health Association. APHA policy statement 1999-26: Support for research on the socioeconomic causes of violence. Washington, DC: American Public Health Association; 1999. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=197. Accessed December 18, 2009.
37. American Public Health Association. APHA policy statement 2001-18: Support for curricula in firearm related violence prevention. Washington, DC: American Public Health Association; 2001. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=257. Accessed December 18, 2009.
38. American Public Health Association. APHA policy statement 99-27: Injury and violence prevention and control programs in state and local health departments. Washington, DC: American Public Health Association; 1999. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=198. Accessed December 18, 2009.