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Violence Syndemics as a Way of Understanding Sexual Risk Among African-American Adolescents

      See Related Article on p.937
      Violence, namely racism and race-related stress, neighborhood violence, police violence, peer bullying, and family violence and disruptions, remains a significant public health concern in the United States [
      Centers for Disease Control and Prevention (CDC)
      Ten leading Causes of Death and Injury.
      ,
      • DiClemente C.M.
      • Rice C.M.
      • Quimby D.
      • et al.
      Resilience in Urban African American adolescents: The Protective enhancing effects of neighborhood, family, and School Cohesion Following violence Exposure.
      ]. African-American heterosexual adolescents, especially those residing in socioeconomically disadvantaged communities, are particularly vulnerable to experiencing violence (both witness and involvement in) [
      • Sheats K.J.
      • Irving S.M.
      • Mercy J.A.
      • et al.
      Violence-related disparities experienced by Black Youth and young adults: Opportunities for prevention.
      ]. National surveillance data indicate that, relative to the general United States adolescent population, African-American adolescents report similar (e.g., sexually active) or higher (e.g., early sexual debut) prevalence of sexual risk behaviors [
      Centers for Disease Control (CDC)
      1991-2019 High School Youth risk behavior Survey data.
      ]; however, African-American adolescents residing in socioeconomically disadvantaged communities initiate sexual risk behaviors at relatively younger ages [
      • Warner T.D.
      Adolescent sexual risk Taking: The Distribution of Youth behaviors and Perceived peer Attitudes across neighborhood contexts.
      ] and are disproportionately affected by sexual risk behavior-linked disease burden such as sexually transmitted infections, including HIV [
      • Harling G.
      • Subramanian S.
      • Bärnighausen T.
      • Kawachi I.
      Socioeconomic disparities in sexually transmitted infections among young adults in the United States: Examining the interaction between income and race/ethnicity.
      ,
      • Sales J.M.
      • Smearman E.L.
      • Swartzendruber A.
      • et al.
      Socioeconomic-related risk and sexually transmitted infection among African-American adolescent females.
      ]. Indeed, evidence supports the link between violence and sexual risk behaviors among African-American heterosexual adolescents, yet many researchers have examined these links through the use of individual indicators of violence. A violence syndemic, defined as the constellation of violence risk factors that operate in a synergistic, reciprocal, and mutually reinforcing manner, increases sexual risk behavior vulnerability and may provide a fuller understanding and optimal characterization of how a host of interlocking violence risk factors shape African-American heterosexual adolescent sexual risk behaviors [
      • Warner T.D.
      Adolescent sexual risk Taking: The Distribution of Youth behaviors and Perceived peer Attitudes across neighborhood contexts.
      ,
      • Singer M.
      • Clair S.
      Syndemics and public health: Reconceptualizing disease in bio-social context.
      ,
      • Córdova D.
      • Heinze J.E.
      • Hsieh H.F.
      • et al.
      Are trajectories of a syndemic index in adolescence linked to HIV vulnerability in emerging and young adulthood?.
      ].
      Voisin and Takahashi [
      • Voisin D.R.
      • Takahashi L.M.
      The Relationship between violence syndemics and sexual risk behaviors among African American adolescents: Implications for future research.
      ] provide a conceptual framework for a violence syndemic and how this syndemic influences sexual risk behaviors among African-American heterosexual adolescents. Importantly, Voisin and Takahashi [
      • Voisin D.R.
      • Takahashi L.M.
      The Relationship between violence syndemics and sexual risk behaviors among African American adolescents: Implications for future research.
      ] focus only on heterosexual African-American adolescents and underscore the need for conceptual frameworks focused on African-American LGBTQ+ adolescent populations who experience additional acts of violence. The authors conducted a review of the existing literature from 2000 to 2020 that focused on the links of a violence syndemic (i.e., racism and race-related stress, neighborhood and police violence, peer violence, family violence, and disruptions) with African-American adolescent sexual risk behaviors. In addition, the framework consists of potential pathways (i.e., depression, anxiety, aggression, posttraumatic stress disorder) through which a violence syndemic may have an effect on African-American heterosexual adolescent sexual risk behaviors. The conceptual framework advances theory in several important ways. First, several testable hypotheses are derived from the conceptual framework, including the potential to examine how multiple violence risk factors reinforce one another to enhance sexual risk behavior vulnerability. Second, the conceptual framework illustrates how a violence syndemic approach can be used to explain sexual risk behaviors among African-American heterosexual adolescents. Finally, the conceptual framework may help guide the development and testing of preventive interventions to ameliorate the complex disease burden disproportionately experienced by this vulnerable population. To advance the scientific knowledge in violence syndemics and move the conceptual framework to a testable model, several important limitations in the literature will need to be addressed.
      There remains the critical need to develop a fuller understanding of how a violence syndemic evolves over space and time [
      • Tsai A.C.
      • Burns B.F.O.
      Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept.
      ]. In fact, most empirical studies focused on syndemics use statistical approaches that examine additive effects, and not the interlocking nature of epidemics. Therefore, examining how racism and race-related stress, neighborhood violence, police violence, peer bullying, and family violence and disruptions interact and are mutually causal epidemics will be an important future research direction [
      • Tsai A.C.
      • Burns B.F.O.
      Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept.
      ]. Adding to the complexity within the context of syndemics is the central and salient tenet of multilevel processes. Thus, there remains the need to test models that examine how multiple epidemics (e.g., police violence, family violence, and disruptions) and social determinants of health (e.g., socioeconomic disadvantage) interact and are mutually causal to disease burden. Finally, the vast majority of researchers have focused on individual-level outcomes, and a fuller understanding of how a violence syndemic interacts at both individual and population levels is critically needed. Examining violence syndemics at both individual and population levels provides a unique opportunity to examine both proximal and distal syndemic factors which may lead to the development of optimally efficacious, sustainable, and scalable prevention strategies [
      • Tsai A.C.
      • Burns B.F.O.
      Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept.
      ].
      The moral foundation of public health is social justice [
      • Powers M.
      • Faden R.
      Social justice: The moral foundations of public health and health policy.
      ]. From a social justice perspective, there remains the urgent need and social responsibility to address violence syndemics that disproportionately affect African-American communities. Hart [
      • Hart L.
      Viewing addiction as a brain disease promotes social injustice.
      ] asserts that a focus on individual-level factors, and the omission of larger social forces such as the overpolicing and poverty that disproportionately affect black and brown communities, to explain substance use disorders may in fact promote social injustice. Extending this logic to sexual risk behaviors, a focus on distal syndemic forces promotes social justice. In doing so, we have an opportunity to prevent and reduce sexual risk behaviors among African-American heterosexual adolescents, and thereby improve public health.

      Acknowledgments

      This work was supported, in part, by the National Institutes of Health (1R03DA041891-01A1).

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