Introduction

This paper describes the grave problem of violence in the United States (US) and the strategies developed by the UNITY initiative, (Urban Networks to Increase Thriving Youth Through Violence Prevention), a collaborative of large US cities committed to reducing violence. UNITY is facilitated by Prevention Institute, a US NGO initially funded by the US Centers for Disease Control and Prevention. Violence, as defined by the World Health Organization, is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that results in injury, death, psychological harm, or deprivation.1 Injuries and violence are the leading causes of death among children, adolescents, and young adults in the US and disproportionately affect young people of color.2

Fortunately, there is a strong and growing evidence base that confirms that violence is preventable. Preventing violence has tremendous value, through saving lives, saving money, fostering well-being, promoting health equity, and strengthening communities.3 Since 2005, UNITY has built support for effective, sustainable efforts to prevent violence before it occurs, so that urban youth can thrive in safe environments with ample opportunities and supportive relationships. The UNITY City Network openly shares concerns and strategies with one another and Prevention Institute synthesizes learnings, creates tools, and helps cities develop, implement, and evaluate strategies. The group collectively advanced the notion that violence prevention was a critical national concern and that cities needed a coordinated, public health approach to preventing violence.

In 2006, UNITY conducted the Assessment of Youth Violence Prevention Activities in USA. Cities. Researchers conducted interviews with mayors, police chiefs, school superintendents, and public health directors in one third of the largest US cities. The assessment revealed that violence was a major concern; law enforcement and criminal justice were the most prevalent strategies used to address it; responses were not perceived to be highly effective or adequate; most cities lacked a comprehensive strategy; few cities reported using primary prevention to stop violence before it occurs; and informants lacked a shared knowledge of existing youth violence prevention resources available in their cities. Importantly and perhaps surprisingly, the cities with the greatest coordinated approach also had the lowest rates of youth violence.4

In response to these findings, UNITY developed The UNITY RoadMap: A Framework for Effectiveness and Sustainability. 5 UNITY staff developed it in partnership with city representatives and advisors from across the US as a framework for understanding the key elements needed to prevent violence before it occurs and to sustain these efforts in cities. The UNITY RoadMap

  1. 1.

    helps cities understand what is needed locally as well as the current status of their efforts (starting point);

  2. 2.

    describes the core elements necessary to prevent violence before it occurs (milestones); and

  3. 3.

    provides information, resources, and examples to support cities in planning, implementation, and evaluation.

The UNITY RoadMap is most effective when tailored to the needs of a particular city and could be useful for cities in other countries. Cities worldwide can modify it to address local circumstances.

The Role of Community Risk and Resilience Factors

A broad focus on reducing risk and increasing resilience among people and communities can play an important role in reducing violence.6 UNITY advances comprehensive and multidisciplinary efforts for addressing the underlying contributors to violence (risk factors) and for building resilience. This is sometimes called a public health approach to preventing violence. ‘Risk factors’ are detrimental community, family, or individual circumstances that increase the likelihood that violence will occur.7 ‘Resilience factors’ support the healthy development of individuals, families, schools, and communities, and build capacity for positive relationships and interactions, thereby reducing the long-term impact from exposure to violence (see Table 1). All people and communities deserve equal opportunities to be healthy and safe, but opportunities are not distributed evenly across our society. Multiple risk and resilience factors interact to make violence more or less likely in a community or in society.8

Table 1 Key community-level risk and resilience factors
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The Impact of Inequity

Some communities, particularly communities of color and low-income communities, accumulate an overwhelming number of risk factors for violence and at the same time lack adequate compensatory resilience factors to protect against violence.9 Worldwide, as the gap widens between those with more opportunities and those with fewer, the level of violence in a society increases.10 Entire communities, particularly low-income communities and communities of color, experience traumatizing events and conditions.11 Young people in urban neighborhoods often experience persistent or chronic traumatic stress and fear of violence. In the US, homicide is the leading cause of death for African Americans and Asians and Pacific Islanders between the ages of 10 and 24, (grouped as they are in US health statistics) and the second-leading cause of death for Latinos of the same age.12 African American young men, 15- to 19-year old, are six times more likely to be homicide victims as their white peers13 and African American children, age 2–17, are 20 times more likely to witness a murder than white children.14 , 15

The difference in accumulation of community risk or resilience factors is one example of health inequities, the unnecessary, avoidable, and unfair differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. They result from historical and present-day policies, practices, and procedures on the part of government and other institutions.16 For example, inequities in housing, education, healthcare, criminal justice, land use, community design, and workforce and economic development have led to significant differences in community and individual opportunity and resources.17 Whether these actions are deliberate and intentional, inadvertent, or neglectful, individually and cumulatively they have contributed to unjust disparities in health and safety.18 – 20

Violence also worsens other health outcomes, further exacerbating inequities.21 – 23 The presence of and fear of violence causes individuals to be less physically active and influences where people live, work, and shop; whether parents let their children play outside and walk to school; and whether or not a grocery store or workplace will locate in a community, influencing whether people have access to healthy food and livable wages.24 Adverse Childhood Experience (ACE) studies are US studies that assess the extent to which a child is exposed to adverse experiences and evaluates that child’s health and social outcomes more than a generation later. These studies have found that adverse childhood experiences accumulate and people who experienced trauma when they were young—including experiences of neglect or of having witnessed or experienced violence—were at significant risk of experiencing further violence.25 , 26 Strikingly, the studies also found that exposure to violence and other trauma is so destructive as it increases the likelihood of developing virtually every other health problem, from anticipated ones like depression, drug use, alcoholism, and other mental health challenges, to illnesses such as asthma, heart disease, and diabetes.27 – 29 Exposure to trauma also leads to increased risky behavior for children, including early initiation of smoking, sexual activity, and pregnancy; antisocial attitudes; lack of involvement in activities and school, and poor academic performance.30

Intentionally advancing violence prevention and health equity is needed to provide all people with fair opportunities to have the best possible health and safety.31 Resilience factors can be protective against violence even when risk factors are present; like risk, the effects of resilience factors accumulate.32 – 34 The presence of quality schools, health and mental health facilities, libraries, recreational centers and parks buffer against the likelihood of violence and chronic trauma. Children in communities with more of these assets are less likely to engage in violence and other high-risk behaviors and are more likely to have positive attitudes and behaviors such as good health, healthy eating, success in school, healthy relationships, and self-control.22 The specific institutions and sectors that have played roles in producing health inequities now have invaluable roles to play in producing equitable health and safety outcomes.

Frameworks for Changing Community Environments to Prevent Violence

The UNITY City Network has used several related frameworks to develop strategies for addressing the impact of community environment on health and safety.35 – 37 These frameworks build on the World Health Organization’s (WHO) Commission on Social Determinants of Health38 overarching recommendations for addressing environmental impact:

  1. 1.

    Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and age. This includes safe housing and transportation, and other physical aspects of a neighborhood; fair employment opportunities and decent working conditions; and quality early childhood and schooling.

  2. 2.

    Tackle the inequitable distribution of power, money, and resources—the structural drivers of those conditions of daily life—at the global, national, and local levels.39

Two Steps to Prevention (see Figure 1) is a framework developed by Prevention Institute for helping to analyze the underlying causes of illness, injury, and health inequities and for identifying key opportunities for prevention. It helps communities, practitioners, and policymakers to develop community strategies to systematically address violence and inequity.40 The framework shows how the environment sets the stage for behaviors and exposures, which then result in illnesses and injuries.

Figure 1
figure 1

Two steps to prevention framework. Source: Ref. 54. Adapted from Ref. 55

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To get to the actual causes of illness and injury, we must step back from a specific disease or injury (e.g., a gunshot wound or heart disease) to the behavior or exposure (e.g., violence or eating unhealthy food) and then to the underlying community conditions that make such behavior and exposures more likely (e.g., high density of alcohol outlets in low-income communities and lack of access to healthy food). Researchers have identified specific behaviors and exposures and related community conditions (such as poverty, racism, and other forms of oppression) that are strongly linked to injuries, chronic diseases, and major causes of death.41 Prevention Institute has identified 12 specific aspects of the community environment (see Table 2) associated with health, safety, and health equity, called the community determinants of health.

Table 2 Community factors associated with health and safety
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Comprehensive Approaches for Preventing Violence

As UNITY has found, educational efforts and individual programs are not sufficient for addressing the community factors that lead to childhood and youth exposure to violence. The ‘Spectrum of Prevention’42 , 43 is a tool created by Prevention Institute for developing comprehensive strategies to change environments, systems, and norms. The Spectrum can be applied to virtually any preventable concern and Table 3 provides examples of violence prevention strategy.

Table 3 Spectrum of Prevention and its application to violence prevention44
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Violence is Preventable

Violence is a significant health and equity issue that affects communities in every country. Although different countries and cities may face dramatically different circumstances, each community faces similar underlying conditions, such as poverty, inequities, community trauma, proliferation of guns, and the presence of alcohol and drugs, as well as the policies and practices that lead to these factors.

Yet we know that violence is preventable and the UNITY collaborative is one of a growing number of initiatives that work to decrease the likelihood of violence occurring in the first place. An eight-year UNITY evaluation demonstrated that engaged cities have enhanced city-wide strategic planning to address violence.45 The cities rely more on comprehensive prevention strategies across sectors and with communities to address violence before it occurs, moving beyond traditional approaches of intervention, suppression, or enforcement.46 Cities that have developed or are developing strategic plans include Baltimore, Kansas City, New Orleans, Seattle, and Oakland to name a few.

Minneapolis is one UNITY city that has successfully implemented a coordinated, multi-sector, city-wide strategic plan for addressing youth violence. The plan had four goals:

  • to connect every young person to a trusted adult,

  • to intervene at the first sign of at-risk behavior,

  • to restore youth who have gone down the wrong path, and

  • to facilitate everyone to unlearn the culture of violence.

As the Mayor said, “The public health approach means backing up from the emergency room (ER) where you bandage the wound and starting at the beginning, understanding why that person is there in the ER at all.”47 Within 3 years of developing a strategic plan in 2006, homicides of youth decreased by 77 %, and the number of people under 18-year old either suspected of or arrested for violent crime dropped to the lowest in a decade.48 , 49 The state legislature also passed the Youth Violence Prevention Act, which mandated the Minnesota Department of Health to replicate Minneapolis’ success in four other cities.50

The approaches and tools used by UNITY can be tailored and adapted for any city or locality across the world to achieve broad and sustainable impact, including improving equity, shifting norms, collaborating with non-traditional partners to develop comprehensive strategic plans for addressing multiple forms of violence, and increasing the effectiveness of prevention efforts to address the underlying factors and systems that perpetuate violence and injury in the first place. Young people in particular need environments that foster connection, identity, opportunity, and hope, particularly in the most disadvantaged communities. Community members, municipalities, policymakers, and practitioners can work together now to support safe, equitable communities.

Editors’ Note

This article is one of ten papers in a Special Sponsored Issue of the Journal of Public Health Policy in 2016, Violence and Health: Merging Evidence and Implementation.