Emma R. Barton*, Lara C. Snowdon*, Bryony Parry*, Alex Walker*
This article is related directly to the First European Conference on Law Enforcement and Public Health (LEPH) held in Umea, Sweden in May 2023.
ABSTRACT
Violence among children and young people (CYP) is a complex societal issue that has detrimental impacts on the health and well-being of children, young people, and adults throughout their lives. Population health research tells us that CYP are adversely at risk of experiencing violence and are at higher risk of experiencing multiple forms of violence. However, evidence suggests that prevention approaches are most effective when implemented with CYP and can have positive health, well-being, and social impacts across the life-course.
This social innovation narrative sets out how the Wales Violence Prevention Unit and Peer Action Collective Cymru coproduced a strategic multi-agency framework for the prevention of violence among CYP in Wales. The first of its kind to be developed in the United Kingdom, this national framework acts as a guide to strategic action on violence prevention, amplifying the voices of CYP, and providing evidence of “what works.”
This evidence-informed, coproduced framework used an innovative participatory design process to listen to the voices of a diverse range of stakeholders, highlighting the voices of CYP. Informed by the views and experiences of over 1,000 people in Wales, and grounded in the lived experiences of CYP, the Framework proposes nine strategies to prevent violence among CYP as part of a public health approach to violence prevention. These strategies represent evidence-based approaches proven to reduce violence among CYP, address the risk factors for youth violence, and build individual, community and societal resilience.
Key Words: Violence prevention, evidence-informed, public health, public health approach, coproduced
What would a Wales Without Violence look like?
“Children and young people wouldn’t be afraid to be themselves and to pursue their dreams.” (Young Person)
Violence among children and young people (CYP) is a complex societal issue that has detrimental impacts on the health and well-being of our population across the life-course. Those experiencing violence can suffer long-term consequences to their physical, mental, and social well-being (Krug et al., 2002). Preventing violence before it occurs and developing effective response strategies can improve the health and well-being of individuals and communities, and have a wider positive impact on the economy and society (World Health Organization, 2021).
Population health research tells us that violence among CYP is widespread, serious and normalized (Wilkins et al., 2014). Additionally, CYP are adversely at risk of experiencing violence and are at higher risk of experiencing multiple forms of violence (Centers for Disease Control and Prevention, 2016). Like other countries worldwide, violence is commonplace in Wales and can cause long-lasting harm and trauma. Fifty per cent of pupils in Wales experience bullying (HBSC Survey, 2018), and for one-third of those, it is recurrent (Moore et al., 2017). For every 10 people admitted to hospital for injuries caused by a knife or other sharp object, four are under 25 years old (Patient Episode Data for Wales, 2023). Across the United Kingdom, 97% of women aged 18 to 24 have experienced sexual harassment (UN Women, 2021); 70% of victims of sexual assault are aged between 16 and 25 (ONS, 2020); and 40% of domestic abuse victims are aged between 16 and 24 (ONS, 2022).
Whilst violence is prevalent, the risk, nature and impact of violence are felt disproportionately. The Equality and Human Rights Commission (2019) found that racial harassment and bullying are still commonplace in UK schools, with CYP from ethnic minority backgrounds more likely to experience such incidents. They report that 71% of Black CYP experience racial harassment in schools, compared with 29% of White CYP. Similarly, a Race Disparity Unit (2021) report found that Black and mixed ethnicity CYP in the United Kingdom were more likely to experience and be victims of violent crime than their White counterparts and, according to the Office of National Statistics (ONS, 2021), are six times more likely to be victims of homicide in England and Wales.
A 2017 UK Survey by Stonewall found that 84% of lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) pupils had experienced homophobic, biphobic, or transphobic abuse, with 35% experiencing physical assault (Stonewall, 2017); and between 2018 and 2020, 52% of sexual assault victims were bisexual (ONS, 2020). Between March 2018 and March 2020, 65% of all sexual assault victims in the United Kingdom were classed as disabled (ONS, 2020). In 2018, CYP living in the poorest areas of the United Kingdom were seven times more likely to be involved in violent crimes as a young adult compared with those living in more affluent areas (Mok et al., 2018).
Despite violence being harmful and pervasive, it is preventable (Krug et al., 2002). Internationally, new evidence of “what works” to prevent violence is emerging at pace, with efforts made to synthesize and advocate for evidence-based violence prevention programming by academics and public health and policy professionals as part of a public health approach (Kovalenko et al, 2020; Quigg et al., 2020).
A public health approach prioritizes the health, safety, and well-being of an entire population. It employs a systematic and multidisciplinary approach to promote health, reduce health inequalities, and prevent violence through epidemiological analysis and scientific evidence. Multi-agency partners work in partnership with local communities to develop a coordinated and comprehensive approach (UK Faculty of Public Health, 2016).
To achieve population-level impact in preventing interpersonal violence, a comprehensive, multi-component approach is necessary. This involves implementing multiple theory and evidence-based interventions across the socio-ecology. Given the range of interrelated risk and protective factors for interpersonal violence, such an approach appears more effective than single-component interventions, as it addresses multiple risk factors. The interventions work together in a whole-system approach to create sustainable conditions for preventing violence (Nation et al., 2003; David-Ferdon et al., 2016).
The Wales Violence Prevention Unit (VPU) and the Peer Action Collective (PAC) Cymru (see Figure 1) have coproduced a strategic multi-agency framework for the prevention of violence among CYP in Wales. This national framework, the first of its kind to be developed within the United Kingdom that focuses specifically on the primary prevention of violence among CYP, is an evidence-informed guide to strategic action on violence prevention, amplifying the voices of CYP, and providing evidence of “what works.”
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FIGURE 1 Framework development partners. CYP = children and young people. |
The Framework draws upon evidence of what works to prevent violence among CYP from two literature reviews (Maxwell & Corliss, 2020; Addis & Snowdon, 2021), commissioned by the VPU and Welsh Government.
In addition, a systematic scoping review was undertaken which explored international public health violence prevention frameworks (Snowdon, 2023). Using this evidence base, the VPU developed an initial model that was presented to CYP for consultation, as well as to professionals across Wales. The VPU also sought technical advice from experts on specific areas. This model was then adapted following feedback. This pragmatic approach means that the Framework is both rooted in the evidence of “what works” and considers the practicalities of implementing violence prevention work in Wales. Most importantly, it is grounded in the lived experiences of CYP.
To ensure the voices of CYP remained at the forefront of the Framework development, the VPU invited the PAC to act as the Advisory Board for this project. The PAC provided leadership, facilitation with children, young people, and professionals, outreach and expert advice to guarantee the views of CYP were embedded into the Framework. The Advisory Board sat throughout the duration of the Framework’s development (January 2022 – February 2023). It was chaired by members of the PAC team and supported by staff from the VPU.
Extensive participatory consultation with children, young people, professionals and members of communities across Wales took place over a 6-month period. The Framework development team held a range of consultation events nationwide, including in-person workshops and online webinars, in-depth online surveys (one designed specifically for CYP and one for professionals); attended school events; ran stalls at community events, such as university freshers’ fayres and Pride events; and created and ran a city centre pop-up shop that provided a safe and interactive space for members of the public, and particularly CYP, to speak to the PAC about their views on violence prevention. The themes considered throughout the consultations can be found in Figure 2.
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FIGURE 2 Consultation themes. CYP = children and young people. |
Sector-specific webinars and workshops were held with police, education, health, and community partners, with separate wider professional consultation events for anyone involved in violence prevention to attend. Over the consultation period, the VPU and PAC engaged with almost 500 CYP and over 550 professionals and volunteers (see Figure 3 for breakdown).
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FIGURE 3 Number of people engaged with during consulation |
The Framework development team coproduced a definition of violence among CYP (see Figure 4) through the PAC advisory group and then consulted on the definition. The CYP involved in developing this definition did not differentiate between different forms of violence in the same ways that professionals might. Instead, results from the consultation revealed that, rather than the type of violence or the characteristics of the victims of violence, violence among CYP should concentrate on the age group of those affected by it. Additionally, no distinction was made between violence that happens in online or offline settings, in community settings, or in public or private spaces.
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FIGURE 4 Definition of “violence among children and young people” used as the focus for the Framework |
The children, young people, and professionals who contributed to this definition were clear that the term “youth violence” was a term that has become outdated, with the potential to lead to stereotyping of CYP.
A whole-system approach describes collective actions that can be taken by multiple partners to address a complex, population-scale issue, such as violence. The Framework outlines nine evidence-informed strategies (Figure 5) that, together, have the potential to prevent multiple forms of violence that impact CYP if a whole-system approach is used.
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FIGURE 5 Nine strategies for preventing violence among children and young people |
The nine strategies are mapped against the socio-ecological model (Krug et al., 2002) and describe areas of intervention for primary prevention and early intervention. These nine strategies are underpinned by nine principles which should inform all violence prevention work in Wales (Figure 6). The nine strategies are described in further detail below (for full details see Snowdon et al., 2023).
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FIGURE 6 Nine violence prevention principles |
This strategy includes promoting supportive, nurturing, and resilient family and caregiving environments, and quality early years and pre-school education, including measures for the prevention of child abuse and other adverse childhood experiences (ACEs). Evidence supports a number of different delivery models as being effective, including home visitation (Bilukha et al., 2005), group-based parenting training, and support in community settings (Knox & Burkhart, 2014; Pierce, El-Banna, et al., 2020; Pierce, Maxwell, & Scourfield, 2020), parenting support as a component of comprehensive interventions (Beets et al., 2009; Kärnä et al., 2011; Washburn et al., 2011; Salmivalli & Poskiparta, 2012), pre-school programmes (Children’s Commissioner, 2019), and measures to prevent harsh parenting and corporal punishment (Knerr et al., 2013).
This strategy focuses on the importance of CYP having access to meaningful and equitable training and employment opportunities to develop a career path and find direction and hope for the future. These are important protective factors for preventing violence and exploitation (David-Ferdon et al., 2016). Evidence suggests that the following have all been used as successful methods of delivery: after-school programs (Goldschmidt et al., 2007), apprenticeship schemes (Goerge et al., 2007), mentoring programs (Tolan et al., 2014), and tailored support to young people not in education, employment, or training, including developing basic skills, employability skills, therapeutic support, and specialized support, such as job searching (Damm et al., 2020).
This strategy describes trauma-informed approaches to encouraging CYP who have experienced violence, or are concerned about violence, to access safe, appropriate, and timely support.
There is good evidence for the value of victim-centred services and therapeutic approaches for reducing the long- and short-term impacts of violence. These approaches include an array of formal and informal services provided by both charities and the public sector, such as helplines and support services for victim-survivors (Campbell, 2006), identification and referral in healthcare settings (Purtle et al., 2015), and safeguarding responses (Bentovim et al., 2009).
Therapeutic treatment, such as group or individual trauma-focused cognitive behavioural therapy or multi-systemic therapy, can mitigate the behavioural and health consequences of witnessing or experiencing violence in the home and community and other ACEs (Cary & McMillen, 2012; Letourneau et al., 2009).
Characteristics of a community’s environment can have a significant influence on how a person acts, creating a context that can have a positive or negative effect on their behaviour. Examples of evidence-based programming include the following: improving the built environment to create appealing, safe, and accessible spaces in communities (Cassidy et al., 2014; Cerdá et al., 2012); interrupting the “spread” of violence using a public health approach to prevent transmission and change community norms to resolve conflicts (Skogan et al., 2009; Webster et al., 2012); identifying violence hotspots within nightlife areas to inform licensing decisions, transport planning or other safety schemes (Braga et al., 2012; Quigg et al., 2020); and using data sharing and analysis (Florence et al., 2011).
Education settings play a crucial role in violence prevention. These are places where CYP are socialized into societal norms, learn about relationships with their peer group and community, develop a sense of belonging, and acquire knowledge, skills, and experiences. Educational engagement is also an important protective factor in preventing violence in childhood and adolescence (World Health Organization, 2016).
There is a wealth of research on evidence-based programs and whole-setting approaches that are proven to be effective in reducing levels of violence. These include school-based life, relationship, social, and emotional skills training (Wilson & Lipsey, 2007; Shek & Ma, 2012), intimate partner violence prevention programs (Foshee et al., 2005; Wolfe et al., 2009), sexual violence prevention programs in universities (Salazar et al., 2014), community based relationship and life skills training (Jewkes, 2007), gender transformative approaches (Banyard et al., 2019), bystander programs (Fenton et al., 2016), and interventions to prevent school exclusions (Timpson, 2019).
Multi-level approaches, including individual, classroom, peer-group, whole-school, and wider community interventions, have also been proven to be effective (Baldry & Farrington, 2007), as have been multi-modal approaches such as programs with online and offline components (Palladino et al., 2016). Overall, whole-school, comprehensive programs, in which multiple modalities reinforce each other with consistent messaging across the types of violence, were the most effective compared with targeted and social skills programs (Cox et al., 2016).
Children and young people’s risk of becoming involved in violence can be buffered through strong connections with caring adults—outside of parents and caregivers—and taking part in activities that encourage skill development, creativity, learning, and growth. These relationships can have a positive influence on CYP’s choices and prevent them from committing crimes and acts of violence, using alcohol and drugs, and engaging in harmful sexual behaviour (David-Ferdon et al., 2016).
Evidence-based interventions include applied theatre (Heard et al., 2020), mentoring programs that focus on supporting positive youth development (Gaffney et al., 2022; O’Connor & Waddell, 2015), and sports-based interventions (Gaffney et al., 2021; Miller at al., 2012).
Reducing poverty and inequality are fundamental to preventing violence (Bourguignon, 2000). Whilst violence can happen to anyone, its adverse impacts are felt most severely in communities with high levels of socio-economic deprivation, so reducing poverty and income inequality are fundamental building blocks in preventing violence and improving community safety. In Wales, people living in the most deprived communities are seven times more likely to attend an Emergency Department as a result of an assault compared with those in the least deprived communities (Violence Prevention Unit, 2021).
Social inequalities relating to socioeconomic status also intersect with race, ethnicity, sexuality, disability, and gender, increasing the likelihood of violence taking place. In turn, violence further ingrains and perpetuates those inequalities, leaving certain populations more vulnerable to violence and its consequences. Specific groups of people, such as those who are LGBTQI+, people with disabilities, people from racially and ethnically minoritized groups, women, and girls, are more likely to experience multiple forms of interpersonal violence (Snowdon et al., 2023).
Evidence suggests that poverty reduction schemes have positive impacts on risk factors for violence, such as child and adolescent mental health (Zaneva et al., 2022). Other programs include those that build confidence, knowledge, and leadership skills, which can in turn lead to improved outcomes in education, employment, community engagement, and political participation (UN Women, 2020).
A robust legislative and policy framework lays the groundwork to prevent violence, address risk factors and legislate for employing a children’s rights approach. It can also provide a structure for protecting, effectively responding to, and supporting victims, witnesses, and children (World Health Organization, 2016). Whilst laws alone cannot reduce violence, effectively implementing and enforcing them strengthens all nine strategies to prevent violence among CYP. This can include laws banning physical punishment of children by parents, teachers, and other caregivers (Roberts, 2000; Österman et al., 2014); laws criminalizing the sexual abuse and exploitation of children (World Health Organization, 2014a); laws that prevent alcohol misuse, including limiting clustering of alcohol outlets (alcohol outlet density), increases in alcohol price, changes to closing times (Fitterer et al., 2015), and minimum age purchase limits (World Health Organization, 2014b); laws limiting access to firearms and other weapons (Xuan & Hemenway, 2015); multi-component legislation that increases funding for victim services, prevention programming, research, evaluation and improves rates of prosecution and penalties associated with gender-based violence (Degue et al., 2014).
This strategy describes programs that challenge harmful attitudes, beliefs, social norms and stereotypes that uphold privilege, inequality and subordination, justify violence and stigmatize survivors. Violence prevention efforts in this area seek to strengthen social norms and values that support nonviolent, respectful, nurturing, positive, and gender-equitable relationships for all CYP (World Health Organization, 2016).
This can include programs that change adherence to restrictive and harmful social and gender norms (Jewkes et al., 2008; Verma et al., 2008; Miller et al., 2012), interventions to prevent child marriage as a risk factor for domestic and sexual violence and abuse (Malhotra et al., 2011), community mobilization programs (Abramsky et al., 2014), bystander interventions (Banyard et al., 2007; Coker et al., 2015; Coker et al., 2016) and long-term, social norms marketing campaigns (Mennicke et al., 2018).
Collaboration is essential to maximize the impact of violence prevention efforts through a public health approach. This involves exchanging information, promoting learning, and developing shared governance and understanding. To prevent violence among CYP, a cross-cutting approach addressing multiple forms of violence is necessary. This requires building on existing partnerships, creating new relationships, and engaging with CYP and communities. To achieve this, violence prevention practitioners need opportunities to develop relationships and learn from one another in a more effective and systematic way. The violence prevention landscape in Wales goes some way to supporting this (Snowdon et al., 2023). This Framework forms part of the violence prevention “toolkit” for Wales. Local areas can take this shared understanding of a whole-system approach and use it to develop their own responses to violence prevention rooted in a public health approach.
Violence among CYP is a public health issue of critical importance which has adverse impacts on the health and wellbeing of our population across the life-course. It is evident from the development of this Framework that there is not a single catch-all solution or one agency that has the answers to violence prevention among CYP. It is a complex issue that requires a coordinated effort from all sectors and stakeholders. Prevention strategies must be evidence-based, inclusive, and intersectional.
This Framework outlines the key elements needed to successfully develop primary prevention and early intervention strategies to end violence among CYP through a public health, whole-system approach.
Working directly with CYP is essential in developing effective strategies to prevent violence through a public health, whole-system approach. Extensive engagement with CYP has facilitated the creation of a shared understanding and approach across Wales, ensuring that the strategies are tailored to meet their specific needs and challenges. Such engagement has been crucial in identifying key areas of concern and ensuring that CYP have a voice in shaping the interventions aimed at promoting their safety and well-being.
This evidence-informed, coproduced Framework used an innovative participatory design process to listen to the voices of a diverse range of stakeholders, centring the voices of CYP to provide such strategies. By working together, we can create a safer and healthier environment for all CYP.
What would a Wales Without Violence look like?
“Peace. My mind would be at peace”. (Young Person)
The greatest of thanks go to the Peer Action Collective Cymru who provided leadership and expert advice throughout the development of the Framework, and to Media Academy Cymru and YMCA Swansea for hosting and providing invaluable support to the Peer Action Collective Cymru. Sincere thanks go to our colleagues in the Wales Violence Prevention Unit and Public Health Wales for facilitating workshops, leading consultation events, providing technical advice, and reviewing drafts of the Framework; and to our range of partners who generously gave their time and expertise to take part in expert interviews, organize events and offer technical advice on specific areas of the Framework. Particular thanks go to Elinor Crouch-Puzey and Jean Lowe from the National Society for the Prevention of Cruelty to Children (NSPCC) for their advice and guidance when developing the online consultation for children and young people; Nancy Lidubwi from BAWSO, Tony O. Ogunsulire from Steps4Change and Yvonne Jardine from Grow Cymru for their help in organising workshops. Lastly, a special thanks to the children and young people who offered their insight and shared their experiences to help develop this Framework; and to the large number of stakeholders across the country who gave their time to take part in our workshops and online consultation. Funding: The Wales Violence Prevention Unit receives support in the form of funding from the UK Home Office, and funding in kind from Public Health Wales, the South Wales Police and Crime Commissioner, Welsh Government, and South Wales Police. The Peer Action Collective Cymru is funded by the Youth Endowment Fund and the Co-Op.
The authors have no conflicts of interest to declare.
*World Health Organization Collaborating Centre for Investment in Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom, and Wales Violence Prevention Unit, Public Health Wales, Cardiff, United Kingdom.
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Journal of CSWB, VOLUME 8, NUMBER 3, September 2023