Social and Structural Determinants of Health and Youth Violence: Shifting the Paradigm of Youth Violence Prevention

Violence against non-Hispanic Black youths continues to be a significant public health issue for many communities in the United States. For more than two decades, homicide has been the leading cause of death among non-Hispanic Black youths aged 10 to 24 years (http://bit.ly/2N3lXko). Also, the burden of exposure to community violence is disproportionately carried by people of color and people living in economically disadvantaged neighborhoods.¹ Public health and allied disciplines have played a key role in raising awareness about the system of individual, interpersonal, and social factors that contribute to the development of youth violence and have conducted several decades of research seeking to understand youth violence and develop youth violence–prevention strategies. These efforts have resulted in an array of evidence-based interventions designed to promote a variety of positive outcomes, including promoting positive relationships, developing problem solving, and diffusing interpersonal conflict. However, these interventions have focused heavily on the individual and interpersonal factors while failing to address broader social and structural factors associated with violence.

STRUCTURAL DETERMINANTS OF VIOLENCE

The World Health Organization’s (WHO’s) social determinants of health framework has implicated longstanding social and structural problems—including poverty, racism, discrimination, and poor access to health care and education—as root causes of poor health outcomes. The social ecological theory similarly emphasizes social and structural factors that influence youths’ social and developmental outcomes.^2,3 Subsequent research has empirically supported the association between these variables and violence.² The WHO framework² includes values, policies, and community practices as social determinants of health that contribute to the development and perpetuation of inequities—by marginalizing groups, determining who has the greatest exposure to social problems, and deciding who will receive access to resources that mitigate the effects of social problems.

In the United States, laws, policies, and practices have been systematically used to marginalize people of color to ensure that economic, social, and political power is retained by Americans of European descent.⁴ These policies and practices have evolved; however, their intent—maintaining the current social order and power differentials—remains constant. The insidiousness of this process is apparent in policies related to many of the social structures critical to youth violence prevention. For Black youths and communities, this has included housing policies that evolved from Blacks not being allowed to own property to policies that determined the neighborhoods in which Blacks could obtain mortgages for home purchases and covenants that determined which properties could be sold to Blacks.⁵ Similarly, criminal justice policies, to inequitably target and penalize Black citizens,⁶ evolved from subjecting Blacks to extrajudicial punishments (e.g., lynchings) to increasing surveillance and criminal penalties for crimes more likely to be associated with Blacks and other minorities.⁷

With the call for approaching violence as a public health crisis, the social determinants of health framework provides a helpful conceptualization of youth violence and highlights this gap between theory and practice. Specifically, the framework identifies and emphasizes numerous social and structural determinants of youth violence, whereas youth violence–prevention strategies have primarily focused on individual and interpersonal factors.⁸ We do not point this out to diminish previous work, because public health theory and practice have played important roles in developing violence-prevention initiatives now recognized as evidence based. Despite the success of these strategies, the field has limited success in demonstrating population-level effects and even less success diminishing race and class inequities in violence-related outcomes.⁹ Therefore, we highlight this gap to suggest the need for a paradigm shift to supplement individual and interpersonal interventions with research and practice that addresses social and structural causes of youth violence.

YOUTH VIOLENCE PREVENTION RESEARCH

Part of the charge for the Centers for Disease Control and Prevention’s National Centers of Excellence in Youth Violence Prevention (YVPCs) is to address this gap by developing, implementing, and evaluating strategies designed to have community-level effects on violence (https://bit.ly/2YBOYqx). All neighborhoods served by YVPCs are contending with social and structural challenges associated with racism and other forms of systemic marginalization. Each YVPC has attempted to address these challenges by directing part of their intervention to counteract some of the social and structural factors associated with youth violence, and each has partnered with communities to tailor strategies responsive to local context. Although these strategies cannot comprehensively eliminate the structural problems, they do address structural factors by engaging community members in empowerment processes to identify or challenge the sources and consequences of structural marginalization.

The latter approach is reflected in the University of Michigan YVPC’s focus on local efforts to empower communities by improving neighborhood physical environment. One of the most consistent consequences of structural marginalization is abandoned homes and vacant overgrown lots. The Michigan YVPC has worked with community partners to evaluate the effects of residents involved in cleaning and maintaining vacant properties to create safe spaces for positive youth development and violence prevention. Three YVPCs have implemented enhanced versions of Communities that Care (CTC), an empirically grounded prevention system that helps communities use data to select and implement evidence-based interventions. Importantly, each site has enhanced the CTC model to highlight the contribution of social and structural factors that have marginalized community residents.

The University of Colorado YVPC used CTC with its neighborhood partners to develop youth-driven media campaigns that promote neighborhood pride and identity among youths and counter negative neighborhood perceptions.

The University of Chicago YVPC used CTC with its community partners to create a comprehensive community action plan that included workforce development and school reform to create greater access to education and economic opportunities.

The Virginia Commonwealth University YVPC supplemented CTC with the Walker-Talker and Plain Talk intervention, in which community outreach workers become interveners to promote prevention messages and build social capital through resident-centered conversations, initiatives, and connections to resources that addressed parenting strengths and employment, school, and neighborhood issues.

Finally, the University of Louisville YVPC worked with community partners to develop a social-norming campaign that challenged discriminatory narratives and policies and promoted positive racial identity and sociopolitical development among youths. The youths used this knowledge to educate and inform key decision makers, peers, and others, which activated sociostructural change efforts in their community. The impact of these strategies being implemented in the YVPCs is currently being evaluated (https://bit.ly/3fnzfl3).

The YVPC strategies are novel, promising ways of using public health theories and strategies to target social and structural factors to prevent youth violence. However, there are several limitations of this work. First, the scale of the work is small, as it currently focused on only five communities, with different strategies being used across the communities. This limits the ability to determine the robustness and replicability of the interventions. Also, although the interventions do move upstream from individual and interpersonal interventions, they remain focused on relatively proximal manifestations of structural inequities and are not designed or scaled to eliminate social and structural inequities.

Thus, community residents still bear much of the burden of the interventions to promote social change even though they have had little influence in creating the structural inequities. There are questions about sustainability and scalability that the YVPCs must address with their communities to ensure that the work does not stop with the funding. Also, our description of this framework does not explicate the implications of structure in relation to gender. The risks of violence perpetration and victimization must be understood in the context of how systemic marginalization differs by gender. Finally, and most of all, the extant YVPC work has focused on Black youths because the focal neighborhoods are majority Black. It is important to expand this work to understand the social and structural factors that affect Latinx youths and other marginalized groups and identify similarities and distinctions in how we might affect the experience of violence among these youths.

Importantly, these strategies highlight just how much work is left to do and how many questions remain unanswered regarding how to improve our understanding of the impact of social and structural factors on youth violence.⁸ The extant research has established relations between social structure and youth violence, but there is little research on the mediators and moderators of the relationship. Numerous studies have used census data to provide descriptions of community structure, frequently noting that poverty, racial segregation, and social immobility are often concentrated in particular neighborhoods with high violence rates.¹ Also, research has examined neighborhood social processes (e.g., social norms and collective efficacy) that occur in marginalized communities (https://bit.ly/3hGSKFs; http://bit.ly/3v8biWN).

Yet, these studies provide little information on how resources, policies, practices, and people act or interact to create and perpetuate or disrupt these structures. Fewer studies include metrics to describe how power or its distribution influences specific manifestations of policies and practices, or the lenses through which they are analyzed. One benefit of the YVPC network is a growing understanding that the demography of youth violence might be similar, but the history and lived experiences of these neighborhoods are distinct. We must develop better metrics to capture the salient characteristics that describe the similarities and distinctions.

The predominant definitions of and risk factors for youth violence described in the extant research limit the discussion of structural problems. WHO defines violence as:

the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood resulting in injury, death, psychological harm.^10(p4)

By this definition, many policies and practices used to create and maintain social and structural inequities constitute violence directed toward youths of color and the neighborhoods in which they live. Yet, most operationalizations of violence fail to consider structural indicators such as racial/ethnic disparities in policing practices, disproportionate incarceration of Black youths and men, and the proliferation of the prison industrial complex (https://bit.ly/30aAmyN; https://bit.ly/30ZyMip).

All of these practices have been used in ways consistent with the WHO definition of violence, suggesting that they are as salient to understanding violence as homicide or violent injury rates. Additionally, we know that issues are framed by the language used to name them, and illustratively “youth violence prevention” centers youths as the issue. Based on the current discussion, more responsive phrasing would emphasize structural factors (i.e., “structural violence prevention”) and shift the focus to structural reforms that prevent violence affecting youths. It is time to start considering risk and promotive factors that extend beyond individuals and families and take into account structural causes of disparities as well as to start identifying the policies and intervention strategies that would help overcome the underlying factors that have created disparities in the first place.