Dr Niamh Ní Longáin of the NHS London Violence Reduction Programme explains how you can help support young people at risk of injury and death.
Violence against young people can lead to serious injury and lost lives, but also impacts on the wellbeing of individuals and the wider community. We know that young people affected by serious youth violence attend a variety of healthcare settings, including A&E departments, with lesser injuries before sustaining a life-threatening injury, thus creating the opportunity for prevention.
The NHS London Violence Reduction Programme recognises that violence is preventable, not inevitable, and by working together there is more the NHS can do to empower communities to challenge the attitudes and behaviours that result in violence. London is acting as a testbed for violence reduction programmes in England. The lessons learned and principles gleaned can be utilised in the rest of the UK, taking into account local need, with input from local experts.
Interpersonal violence is the fourth-largest cause of death among those under 30 in Europe (WHO, 2020). It is associated with structural inequalities, adversity and contextual factors and it is important that we acknowledge this complexity, looking beyond simplistic scoring systems and identifying the risk factors.
It is imperative that healthcare professionals are able to identify those affected by violence and exploitation in order to institute early support.
To help with this, the NHS London Violence Reduction Programme worked with NHS professionals across England, third-sector organisations and young people to create a free e-learning tool to equip health and care staff with the knowledge and skills to help support violence reduction in local communities (see Resources).
The context of violence
Adverse childhood experiences (ACEs) and difficulties at home have a significant impact on the likelihood of being impacted by violence. If a person has four or more ACEs, they are 14 times more likely to be a victim of violence and 15 times more likely to inflict serious violence within the past 12 months (Violence Prevention Unit Wales, 2022). ACEs are useful in planning services and on a population level, and they should not be used in a deterministic manner but be seen as part of a wider landscape.
In 2021, a report by City Intelligence for the Mayor’s Office of Policing and Crime, Understanding serious violence among young people in London, highlighted the associations of inequalities with being impacted by violence. During the pandemic, Universal Credit claims increased by 186% in Brent and 177% in Newham – two of the top five boroughs for rates of offending (Mayor of London, 2021). And Black Londoners were three times more likely to be victims of knife injury and five times more likely to be victims of homicide (Greater London Authority, 2021).
Taking contextual factors (see contextualsafeguarding.org.uk) and the impact of extrafamilial harm into account – from the neighbourhood, online, schools and with peers – is critical to understanding risks affecting young people. While considering the role of external environments, young people may also attend healthcare settings with injuries that appear to be a result of ‘random attacks’. However, further investigation can uncover much more complexity, including criminal exploitation or gang involvement. Although many people may assume these activities are more likely to occur in major cities, this may not always be the case. These activities can also occur in rural or suburban areas, particularly as a result of county lines [criminal activity] (NCA, 2022). Scenarios such as these are an example of why the principles of contextual safeguarding have been added to the government’s Working Together to Safeguard Children guidance (HM Government, 2018).
Lessons being learned
In developing the content for our e-learning tool (see Resources), we collaborated with young people who spent a day filming with us, courageously sharing their own experiences of adversity, violence, and health and social care. This allowed us to hear what approaches they found helpful, unhelpful, or indeed re-traumatising.
There are important quotes from these young people throughout the modules, and an animation about unconscious bias, which includes aspects from our conversations with them. Healthcare professionals should be aware of their own unconscious biases and work collaboratively to address barriers that prevent young adults and adolescents from accessing healthcare (Royal College of Physicians, 2015).
To add context to the learning, the modules include real-life anonymised case studies of young people and their interactions with healthcare across a range of settings. We acknowledge current good practice happening across the NHS such as in-hospital violence reduction services (NHS England and Improvement, 2022a) and social prescribing across primary care (NHS England and Improvement, 2022b), which may be useful for staff to help drive change. The e-learning also covers the principles of trauma-informed practice with examples of these principles in action in healthcare settings, including the different levels of prevention (Trauma Informed Care Implementation Resource Center, 2021).
What can CPs do?
Below are four things you can do to support young people at risk of violence in your communities:
- Develop cultural competency. It is vital that healthcare professionals are aware and gain understanding of the key issues relating to culture and how this may influence the uptake of healthcare and treatment options. Developing this knowledge and understanding will influence the way we all deliver care and could have an impact on reducing disparities in healthcare outcomes.
- Taking a trauma-informed approach to delivering care. This means being able to recognise the signs and symptoms of trauma in young people and their families; responding by fully integrating knowledge about trauma into policies, procedures, and practices; and actively resisting re-traumatisation.
- Education and advocacy. Ensuring yourself and others within and outside of the healthcare system are aware of the latest evidence in relation to violence reduction, and taking robust positions on domestic abuse, child exploitation, sexual assault and serious youth violence.
- Use risk indicators to identify vulnerable young people. There are risk indicators and flags to be aware of that allow us to identify troubling behaviours. The earlier we can identify these behaviours, and provide targeted interventions for them, the more chances we have of interrupting patterns of violence.
As community practitioners, you are in a unique position to get involved in prevention at community level – helping to identify the risks and vulnerabilities in young people before they are seriously harmed and supporting them to lead happy healthy lives.
As well as taking the modules in our e-learning tool, you can use them as part of discussion groups or workshops, and support with wider sharing of the resource across your services or social media channels. We recommend exploring the work of your local violence reduction units and how you can get involved.
The training module in our e-learning tool also outlines the use of an expanded biopsychosocial assessment tool – HEEADSSS – which can be used to give young people the opportunity to speak about their lives. All healthcare professionals can use the tool to assess a young person’s wellbeing and identify what further support might be needed.
- Complete the Violence Reduction E-learning Programme at e-lfh.org.uk/programmes/nhs-violence-reduction (currently free for all NHS England staff)
- For more information on the NHS London Violence Reduction Programme, contact [email protected]
- Niamh can be contacted via Twitter @niamhie53
- A social prescribing pathway to support vulnerable youth in the community, NHS England and Improvement, relevant for all the UK bit.ly/supporting_CYP_VR
Greater London Authority. (2022) Understanding serious violence among young people. See: https://data.london.gov.uk/dataset/serious-youth-violence (accessed 22 April 2022).
Mayor of London. (2021) Mayor reveals driving factors behind violence affecting young people. See: london.gov.uk/press-releases/mayoral/driving-factors-behind-violence-affecting-young-pe (accessed 22 April 2022).
NHS England and Improvement. (2022a) In hospital violence reduction services: a guide to effective implementation. See: www.england.nhs.uk/london/wp-content/uploads/sites/8/2022/03/In-Hospital-Violence-Reduction-Services-A-Guide-to-Effective-Implementation-FINAL.pdf (accessed 22 April 2022).
NHS England and Improvement. (2022b) Social prescribing pathway supporting children and young people affected by violence. See: https://mcusercontent.com/ec5dea9536bde16d5a3153530/files/ce706604-1578-1ca4-9b6a-2df5575c9f21/VR_SP_pathway_Paper_FINAL_FOR_PUBLICATION.pdf (accessed 22 April 2022).
National Crime Agency. (2022) County lines. See: nationalcrimeagency.gov.uk/what-we-do/crime-threats/drug-trafficking/county-lines (accessed 22 April 2022).
Public Health Wales. (2016) Adverse childhood experiences and their association with chronic disease and health service use in the Welsh adult population. See: www.wales.nhs.uk/sitesplus/documents/888/ACE%20Chronic%20Disease%20report%20%289%29%20%282%29.pdf (accessed 22 April 2022).
Royal College of Physicians. (2022) Why young adults and adolescents need better healthcare. See: www.rcplondon.ac.uk/projects/outputs/why-young-adults-and-adolescents-need-better-healthcare (accessed 22 April 2022).
Trauma-Informed Care Implementation Resource Center. (2022) What is Trauma-Informed Care?. See: www.traumainformedcare.chcs.org/what-is-trauma-informed-care/ (accessed 22 April 2022).
UK Government. (2018) Working together to safeguard children. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf (accessed 22 April 2022).
Violence Prevention Unit (Wales). (2022) Adverse childhood experiences. See: www.violencepreventionwales.co.uk/research-evidence/adverse-childhood-experiences-aces (accessed 22 April 2022).
WHO. (2020) Violence, health and sustainable development. See: www.euro.who.int/__data/assets/pdf_file/0006/430854/InterpersonalViolenceAcrossTheLife-Course-eng.pdf (accessed 22 April 2022).