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Taking Action to Prevent Violence Against Adolescents in the Time of COVID-19

      Adolescents are often considered the forgotten demographic in public health and social policy [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. They may be particularly vulnerable to certain types of violence owing to simultaneous risks of violence from caregivers and intimate partners and their unique physiology, particularly the rapid brain development that is a hallmark of adolescence [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Chronic exposure to the toxic stress of violence during youth can have severe consequences across the lifespan such as poor mental health, sexual and reproductive health problems, and chronic disease [
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE).
      ]. While the global burden of violence in youth is high, impacting 1 billion children and adolescents each year, [
      • Hillis S.
      • Mercy J.
      • Amobi A.
      • Kress H.
      Global prevalence of past-year violence against children: A systematic review and minimum estimates.
      ] countries are beginning to prioritize prevention, and many government officials acknowledge the need for scale-up. Of 155 countries assessed, 56% reported some national support for implementing evidence-based violence prevention and response for children and adolescents, but just 25% considered their support adequate to reach all in need [
      World Health Organization
      Global status report on preventing violence against children 2020.
      ].
      In 2016, the World Health Organization and key stakeholders released INSPIRE: Seven strategies for ending violence against children [
      World Health Organization
      Inspire: Seven strategies for ending violence against children.
      ], an evidence-based technical package for preventing and responding to violence against children and adolescents. These strategies include implementation and enforcement of laws; norms and values; safe environments; parent and caregiver support; income and economic strengthening; response and support services, and education and life skills. INSPIRE equips governments and stakeholders to prioritize investment into evidence-based approaches with the potential for the largest impact in fiscally strained environments. Well-designed INSPIRE programs have achieved violence reductions of 20%–50% [
      World Health Organization
      Global status report on preventing violence against children 2020.
      ].
      History provides clear evidence that violence against children, adolescents, and women increases during crises [
      • Peterman A.
      • Potts A.
      • O’Donnell M.
      • et al.
      Pandemics and violence against women and children.
      ]. The COVID-19 pandemic will likely follow this pattern. With communities under lockdown and economic uncertainty increasing family stress, adolescents may be more vulnerable than ever to violence [
      World Health Organization
      Global status report on preventing violence against children 2020.
      ]. It is valuable to look to prepandemic data to provide insights into the dangers adolescents already faced in the places they were supposed to be safest. Across countries with Violence Against Children and Youth Surveys, physical violence by a caregiver before the age of 18 years ranged from 7% to 49%. Furthermore, at least 1 in twenty (5%) and almost 1 in two 13- to 17-year-old adolescents (45%) witnessed physical violence at home in the past 12 months. Among 18- to 24-year-old victims of sexual violence before the age of 18 years, the first incident was most commonly during the age of 16–17 and often occurred at home (16%–43%) [
      Violence against children and youth Surveys.
      ] (Violence Against Children and Youth Surveys with one or more data points represented within these ranges: Botswana, Cambodia, Colombia, El Salvador, Haiti, Honduras, Kenya, Laos PDR, Uganda, Malawi, Nigeria, Rwanda, Zambia, and Zimbabwe.). These data highlight the unique vulnerabilities of adolescents as they remain susceptible to family violence and also face increasing risks sexual violence.
      Violence Against Children and Youth Surveys additionally found that few youths (between 0% and 18%) who experienced sexual or physical violence ever receive professional services [
      Violence against children and youth Surveys.
      ] (Violence Against Children and Youth Surveys with one or more data points represented within these ranges: Botswana, Cambodia, Colombia, El Salvador, Haiti, Honduras, Kenya, Laos PDR, Uganda, Malawi, Nigeria, Rwanda, Zambia, and Zimbabwe.). With COVID-19–related school closures and decreased access to health facilities, children and adolescents' access to the professionals who most often identify and refer victims for critical response services is likely impacted. The need for adaptable, accessible, and youth-friendly violence prevention programming and response services may be more urgent than ever.
      We identify how the INSPIRE strategies can be adapted to guide governments and partners in identifying efficacious programs to prevent and respond to violence among adolescents during this pandemic. Addressing harmful norms and values at a time when community mobilization interventions are difficult with social distancing requirements may require innovative adaptation. For example, we can capitalize on youth online engagement, leveraging virtual platforms including social media to produce efficacious programs to change the harmful norms that facilitate violence. Raising Voices' community mobilization program for norms change, SASA! (SASA! is a Kiswahili word that means “now.” Raising Voices, based in Uganda, named their violence prevention program “SASA!” because “now is the time prevent violence against women and its connection to HIV/AIDS. We all have the power to act now!”), has proposed pioneering adaptations during COVID-19 such as online trainings and text message communication campaigns [
      Raising Voices
      Guidance Note 5: How can SASA!/SASA! Faith/SASA! Together adapt? Series on prevention violence against women during the COVID-19 pandemic.
      ].
      Safe environments generally focuses on community spaces, but with stay at home orders, it is now important to shift focus to maximally safe and nurturing home environments. Relatedly, we can reduce risk of violence by equipping parents and caregivers with the parenting skills and support to cope with the increased stress during COVID-19 owing to quarantining in tight quarters, economic and housing uncertainty, or increased demands of managing schooling. Parenting for Lifelong Health provides a suite of tips and activities [
      COVID-19: 24/7 Parenting
      Parenting for lifelong health.
      ] toward maintaining a healthy and positive family environment when facing stressors. However, creative solutions are needed to address the root causes of stressors, such as economic hardships. Large-scale income and economic strengthening is an important evidence-based strategy to offset the financial damage that COVID-19 has inflicted on families globally. The overwhelming evidence points to the efficacy of cash transfers [
      • Tirivayi N.
      • Richardson D.
      • Gavrilovic M.
      • et al.
      A rapid review of economic policy and social protection responses to health and economic crises and their effects on children: Lessons for the COVID-19 pandemic response.
      ], a straightforward approach to increasing income among vulnerable households. Ensuring high quality and safe response and support services for adolescent victims during COVID-19 likely includes a pivot to telemedicine, provision of first-line support at novel entry points, bolstering hotlines, and innovation to effectively and safely reach youth. Finally, to sustain educational attainment, continue learning, and allow youth to thrive in this time, it is important for governments and stakeholders to focus on education and life skill programs, ensuring equitable access to remote or home learning materials and opportunities and providing programming on coping and problem solving skills.
      A comprehensive approach to COVID-19 could benefit from the integration of violence prevention as a key priority among governments and donors, particularly among adolescents. Although fidelity is critical, innovation may be required when the intended implementation approach may be hampered because of the current context. While adolescents may share a lower burden of direct COVID-19 morbidity and mortality [
      • Ludvigsson J.
      Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.
      ], they might be uniquely vulnerable to its social consequences including violence. Meanwhile, the social protection safety nets that identify and respond may be significantly impeded. To mitigate the severe and lasting impacts of violence for this critical population, we must address not only the immediate crisis of interrupting a dangerous novel pathogen but also the silent epidemic of violence among such vulnerable members of society in the very places that should be safest. Governments and stakeholders can consider INSPIRE as a critical resource, focusing on approaches that can most adeptly be applied to preventing violence in adolescence in the new reality of COVID-19.

      References

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        (Available at:)
        • Raising Voices
        Guidance Note 5: How can SASA!/SASA! Faith/SASA! Together adapt? Series on prevention violence against women during the COVID-19 pandemic.
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        • COVID-19: 24/7 Parenting
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        (Available at:)
        https://www.covid19parenting.com/
        Date accessed: July 21, 2020
        • Tirivayi N.
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        • et al.
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