Youth violence is a significant public health problem and is the third leading cause of death for adolescents 15 to 24 years of age in the United States.1 In 2015, a total of 4891 adolescents aged 10 to 24 years were victims of homicide, and exponentially more adolescents are affected physically and mentally as a result of violence.2 Youth violence is characterized by violent acts or behaviors that range from bullying to assault and can result in serious injury or death.3 Exposure to violence can have a lifelong impact, especially on children and adolescents, whether they are the perpetrator, victim, or witness to violence.3
Violence in any form directly affects the health and well-being of communities and increases the risk of additional poor health outcomes.4 The short- and long-term consequences of youth violence are extensive, spanning from psychological trauma to physical injury and death.5 Youth violence also has an ecological influence that affects families and communities and contributes to premature death, disability, and the overall burden of violence.5,6 Moreover, communities that experience youth violence suffer substantial economic impact5,6; youth homicides and assault injuries cost approximately $18.2 billion in health care and productivity loss.2 In addition, the significant economic impact of decreasing property values in areas of high violent crime leads to disinvestment in communities and the disruption of social services.5,6
The unintended consequences and widespread impact of youth violence make it a critical public health issue.7,8 Understanding that violence is preventable sets the foundation for addressing recent increases in community-level violence (eg, homicides, shootings). Advances in public health, such as those documented in the “Ten Great Public Health Achievements in the 20th Century,”9 are an indication that public health has the power to make change, prevent injury, and save the lives of citizens.10 Injuries, such as homicide and suicide, have remained among the top 10 leading causes of death for youth,11 underscoring the need for prevention and early intervention.
Local Health Departments' Role in Violence Prevention
Local health departments (LHDs) have a unique capacity to prevent youth violence. As frontline advocates for public health, LHDs can mobilize and lead communities to implement strategies that prevent and reduce youth violence. According to the National Association of County & City Health Officials' (NACCHO's) 2016 National Profile of Local Health Departments, the only comprehensive survey of LHD infrastructure and practice, 22% of LHDs are engaged in violence prevention activities and 42% are involved in injury prevention activities.12 Although less than half of LHDs reported providing population-based prevention services for violence and injury prevention, 89% reported that violence prevention programs and services are provided by another organization in their community.12 Therefore, LHDs have an opportunity to facilitate community partnerships and engagement in crucial activities to prevent and reduce youth violence in communities.
LHDs' role in coordinating and collaborating with community partners across sectors (eg, public health, health care, education, law enforcement, juvenile justice, mental/behavioral health, social services, community leaders, businesses, faith-based organizations, and organizations that support youth, victims of violence, and their families) can also support development, implementation, and evaluation of programs that address all levels of violence prevention.13 Through surveillance, LHDs have the ability to diagnose and investigate health hazards in the community and identify strategies to address these hazards.14 In addition, LHDs are uniquely positioned to implement comprehensive, evidence-based prevention strategies; advocate for multidisciplinary policies, programs, and strategies; and build the capacity of local communities.13
Youth Violence Prevention in Practice
In April 2015, Baltimore was affected by high levels of violence and civil unrest. In a 30-day period, after the civil unrest began, 98 people were victims of nonfatal shootings and 40 people were victims of homicide in 111 shooting incidents.15 During this time, the Sandtown-Winchester neighborhood experienced heightened hostility and distrust toward the Baltimore City Police Department due to a police-involved death of a local community resident. This incident put additional strain on the community's relationship with Baltimore City Police Department and adversely affected the community's ability to heal from recent events and improve community safety. To reduce violence in this neighborhood, NACCHO, with support from the Centers for Disease Control and Prevention (CDC), funded the Baltimore City Health Department's (BCHD's) expansion of a youth violence interruption strategy, the Safe Streets Baltimore initiative.
Safe Streets Baltimore is a violence prevention initiative designed to reduce shootings and homicides within targeted communities at high risk for violence. The BCHD's Safe Streets Baltimore initiative works to create a network of sites that reduce gun violence and provide a path for residents to achieve individual and community economic development. Safe Streets Baltimore works to shift the discourse toward the view that violence is a disease by placing the emphasis on prevention and finding solutions to end the epidemic. Safe Streets Baltimore aims to prevent violence through a 3-pronged approach:
1. Identifying and detecting violence;
2. Interrupting, intervening, and reducing risk in high-risk neighborhoods; and
3. Changing behaviors and norms in communities.
Safe Streets Baltimore relies on strong community support and resources such as outreach workers, clergy, and community leaders. These community-level supports enhance public health efforts to intervene in conflicts and promote alternatives to violence. The Safe Streets Baltimore initiative uses outreach workers, or violence interrupters, as credible messengers and vehicles for prevention. Outreach workers live in the neighborhoods they serve and receive violence interruption and reduction training, which allows them to mediate conflicts that are very likely to escalate into violence or a shooting.
Safe Streets Baltimore is implemented by partnering with community-based organizations and institutions. Current host organizations are the Associated Catholic Charities, Family Health Centers Baltimore, Living Classrooms, and Park Heights Renaissance. These organizations are critical for providing site management, hiring and overseeing staff, and offering unique resources to support the community. Safe Streets Baltimore has worked to change the thinking on violence at the community level by mobilizing the community through events, public education, and coalition building and by providing referral and mentoring services. These events are additional opportunities to reinforce the messaging that shootings are not normal and violence is not an acceptable way to resolve conflict. Since its implementation, Safe Streets Baltimore staff had 11 233 individual contacts and hosted 60 community events to engage the community in violence prevention.
Since the expansion of Safe Streets Baltimore to the Sandtown-Winchester site in March 2016, the site has engaged all 5 components of the Safe Streets model, including community mobilization, outreach, public education, faith-based leader involvement, and law enforcement participation. The BCHD also gathered detailed data about mediated conflicts to inform its work. Safe Streets Baltimore staff mediated 508 conflicts in the Sandtown-Winchester neighborhood. Fifty-five percent of these mediations occurred before the conflict escalated to violence. Of the individuals engaged in conflicts, 58% were thought to be group/gang members. According to the data, the primary reason for conflicts was personal altercations (61%) and the secondary reason was personal disrespect (41%). Although the site has only been in place for 16 months, the site has demonstrated capacity to prevent community-level violence.
Building on Lessons Learned
Although evaluation of the Safe Streets Baltimore initiative is ongoing, preliminary data and information indicate that the BCHD has been able to implement an effective community-wide strategy to prevent violence, particularly among youth. The initiative has also identified additional areas of need in the community and prompted the health department to expand the program to meet those needs. For instance, through the implementation of the program in Sandtown-Winchester, an increase in violence among young women prompted the BCHD to hire female outreach workers. The BCHD also identified an increased need to expand the violence interruption strategies to both hospitals and schools to engage the community and youth in areas where there is an increased risk for violence.
To address these identified gaps, the BCHD will implement the Hospital-Based Violence Intervention Project (HBVIP) to address retaliation at the bedside of individuals admitted to emergency departments due to violence. This effort will provide an opportunity to increase Safe Streets Baltimore's impact by providing wraparound support to persons affected by violence. HBVIP will also leverage partnerships with nearby hospitals to anchor Safe Streets Baltimore sites to create broader support for communities. In addition to the hospital-based program, the BCHD will partner with Baltimore City Public Schools during the 2017-2018 school year to implement a school-based Safe Streets Baltimore program. The project, funded by the CDC, will focus on implementing a school-based violence prevention strategy to address shared risk and protective factors to prevent and reduce teen dating violence and other forms of youth violence. The Safe Streets Baltimore school-based program will be implemented in 3 neighborhoods and 4 targeted schools in or near Safe Streets Baltimore program sites and will provide training to peer leaders and school staff to address violence through conflict mediation and resolution.
As demonstrated in Baltimore, LHDs can be instrumental in youth violence prevention efforts. The BCHD leveraged partnerships and engaged communities to address community-level violence and reduce homicides. In addition to strategies used in Baltimore, local public health efforts to reduce youth violence should include (1) promoting family environments that support healthy development; (2) providing quality education early in life; (3) strengthening youth skills; (4) connecting youth to caring adults and activities; (5) creating protective community environments; and (6) intervening to lessen harms and prevent future risk of youth.16
NACCHO has worked to strengthen LHD capacity to create safe and healthy communities by providing learning opportunities, developing tools and resources, providing technical support, and facilitating peer exchange. NACCHO's violence prevention approach supports LHD efforts to interrupt violence at critical points across the life span and at all levels of the community. Youth violence prevention is complex and all forms of violence are interconnected, often sharing the same root cause.17 By implementing comprehensive, community-based youth violence prevention strategies, LHDs can be instrumental in protecting youth and strengthening their communities.
1. David-Ferdon C, Simon TR, Spivak H, Gorman-Smith D, Listenbee RL, Iskander J. CDC grand rounds: preventing youth violence. MMWR Morb Mortal Wkly Rep. 2015;64(7):171–174. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6407a2.htm#Fig. Published February 2015. Accessed July 13, 2017.
2. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. https://webappa.cdc.gov/cgi-bin/broker.exe. Published 2015. Accessed July 10, 2017.
3. Centers for Disease Control and Prevention. Violence prevention. https://http://www.cdc.gov
/violenceprevention/youthviolence/index.html. Published 2017. Accessed July 10, 2017.
4. Urban Networks to Increase Thriving Youth through Violence Prevention. A Public Health Approach to Preventing Violence: FAQ. Harvard School of Public Health. https://http://www.preventioninstitute.org
/sites/default/files/publications/FAQ%20preventing%20violence_A_112109-1.pdf. Published 2009. Accessed July 5, 2017.
5. Centers for Disease Control and Prevention. Youth violence: risk and protective factors. https://http://www.cdc.gov
/violenceprevention/youthviolence/riskprotectivefactors.html. Published 2015. Accessed July 10, 2017.
6. World Health Organization. Youth violence. http://http://www.who.int
/mediacentre/factsheets/fs356/en. Accessed July 10, 2017.
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8. Centers for Disease Control and Prevention. Understanding youth violence. https://http://www.cdc.gov
/violenceprevention/pdf/yv-factsheet-a.pdf. Published 2015. Accessed July 4, 2017.
9. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(19):619–623.
10. Wen L, Goodwin K. Violence is a public health issue. J Public Health Manag Pract. 2016;22(6):503–505.
11. Heron M. Deaths: leading causes for 2014. Natl Vital Stat Rep. 2016;65(5):619–623. https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_05.pdf. Accessed July 12, 2017.
12. National Association of County & City Health Officials. National Profile of Local Health Departments. http://nacchoprofilestudy.org/wp-content/uploads/2017/04/ProfileReport_Final3b.pdf. Published 2016. Accessed July 10, 2017.
13. National Association of County & City Health Officials. Statement of policy: youth violence prevention. http://http://www.naccho.org
/uploads/downloadable-resources/14-08-Youth-Violence-Prevention.pdf. Published 2014. Accessed July 17, 2017.
14. Centers for Disease Control and Prevention. The public health system and the 10 Essential Public Health Services. https://http://www.cdc.gov
/nphpsp/essentialservices.html. Published 2013. Accessed July 12, 2017.
15. City of Baltimore. Open Baltimore: BPD part 1 victim based crime data. https://data.baltimorecity.gov/Public-Safety/BPD-Part-1-Victim-Based-Crime-Data/wsfq-mvij/data. Accessed July 26, 2017.
16. David-Ferdon C, Vivolo-Kantor AM, Dahlberg LL, Marshall KJ, Rainford N, Hall JE. A Comprehensive Technical Package for the Prevention of Youth Violence and Associated Risk Behaviors. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://http://www.cdc.gov
/violenceprevention/pdf/yv-technicalpackage.pdf. Accessed July 26, 2017.
17. Wilkins N, Tsao B, Hertz M, Davis R, Klevens J. Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence. Atlanta, GA/Oakland, CA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention/Prevention Institute; 2014.