Cash Transfers and After-School Programs: A Randomized Controlled Trial for Young Men at Risk of Violence Exposure in Wilmington, Delaware.

We conducted a randomized controlled trial to determine whether an after-school program paired with a cash transfer (a conditional cash transfer) or a cash transfer alone (an unconditional cash transfer) can help improve health and economic outcomes for young men between the ages of 14 and 17 whose parents have low incomes and who live in neighborhoods with high crime rates. We find that receiving the cash transfer alone was associated with an increase in healthy behaviors (one of our primary outcome composite measures) and that the cash transfer paired with after-school programming was associated with an improvement in the financial health of participants (one of our secondary outcome composite measures). We find no differences in spending on alcohol, marijuana, cigarettes, or other drugs between either the treatment group and the control group. Neither the cash transfer alone nor the programming plus cash transfer had statistically significant effects on our other primary composite measures (physical and mental health or school attendance and disciplinary actions), or our other secondary composite measures (criminal justice engagement or social supports) but in most cases, confidence intervals were too large to rule out meaningful effects. Results suggest that cash transfers hold promise to improve the health of youth without any indication of any adverse effects.

The Mentors in Violence Prevention programme: impact on students' knowledge and attitudes related to violence, prejudice, and abuse, and willingness to intervene as a bystander in secondary schools in England.

BACKGROUND: Violence is a leading cause of death and disability for young people and has serious impacts on prospects across the lifecourse. The education sector is a crucial setting for preventing youth violence through incorporating programmes that address attitudes and behaviours. The Mentors in Violence Prevention (MVP) programme aims to change harmful attitudes and norms, and increase non-violent bystander intervention, through a peer mentoring approach. To date there is limited evidence on the effectiveness of the intervention in UK school settings. The aim of the current study was to evaluate the impact of the programme on students' attitudes and knowledge related to violence prevention. METHODS: The study employed a mixed methods design. Pre and post surveys measured changes in students' (aged 11-18) attitudes and knowledge related to violence prevention and bystander behaviour, gender stereotyping, acceptability of violence, and perceptions of others' willingness to intervene. Interviews/focus groups with programme delivers and students, and anonymised programme data were used to explore and supplement survey findings. RESULTS: Overall, perceptions of the programme content and delivery were positive. Several beneficial impacts of the programme were found for mentors (students delivering the programme), including significant positive changes on measures of knowledge and attitudes towards violence prevention and the bystander approach, acceptability of violence perpetration, and perceptions of other students' willingness to intervene (effect sizes were small-medium). However, the study found no significant change on any of the outcomes amongst mentees (younger students receiving the programme from mentors). Despite this, qualitative evidence suggested mentees enjoyed the content of the programme and the peer-led delivery, and this built relationships with older students. Qualitative evidence also identified additional benefits of the programme for mentors, including leadership and communication skills, and increased confidence and supportive relationships. CONCLUSIONS: Evidence from this study suggests MVP is effective as a targeted programme for mentors, but no significant evidence was found to demonstrate its effectiveness as a universal bystander and violence prevention programme for mentees. Whilst further research with more robust study design is needed, developing mentors as leaders in violence prevention is a valuable impact of the programme in its own right.

The Influence of Routine Health care on Reoffending in a Sample of Gun Involved Youths.

In the wake of heightened concerns about gun violence and its impacts on youth, "what works" in gun violence prevention remains a critical public health concern. Gun violence prevention in the U.S. is increasingly interdisciplinary, involving both the criminal legal system and the health care system in developing an evidence base for promising programs and policies. The current study contributes to the literature by examining recidivism outcomes (i.e., rearrest) for a cohort of n = 409 Indianapolis youth involved in gun violence who were court-ordered to complete a health education-based prevention program called Project Life. The youth in our sample were predominantly from marginalized communities, all had been charged with a gun-involved or violence offense, 96% were detained by the juvenile justice system for some time, and 64% received at least one routine well check within five years prior to Project Life. Survival analyses of merged juvenile court records and health records show that routine health care (i.e., well visits) and completing the Project Life program were protective against recidivism, whereas time spent in detention increased risk. The findings provide evidence for the value of interdisciplinary approaches that include the health system in disrupting cycles of gun violence, while reducing the carceral footprint on youth.

Too sensitive or not sensitive enough? Sensitivity to context and justice-involved youths' response to violence exposure.

With high rates of violence exposure among justice-involved youth, it is critical to identify factors that might impact the likelihood of youth engaging in violence themselves. One such factor is sensitivity to context, which describes how sensitive youth are to experiences in their environment. Using an ethnically diverse sample of justice-involved male adolescents (47% Latino, 38% Black/African American, 15% White) aged 13-17 at the time of their first arrest, the results of this study indicate that exposure to violence was related to increased violent behavior six months later, and this effect was strongest among youth who were low in sensitivity to context. These findings may help practitioners identify which youth are at greatest risk for violence in a policy-relevant population.

Challenges in Evaluating a Community-Level Intervention to Address Root Causes of Youth Violence.

Violence disproportionately impacts Black American youth, representing a major health disparity. Addressing the possible root causes of structural inequities to reduce violence may increase the impact of prevention strategies. However, efforts to evaluate the impact of such interventions pose numerous methodological challenges, particularly around selecting an effective evaluation design to detect change at the community level, with adequate power and sampling, and appropriate constructs and measurement strategies. We propose a multiple baseline experimental design to evaluate the impact of a community-level youth violence and suicidality prevention strategy. A multiple baseline experimental design with multiple community units balances the need for scientific rigor with practical and values-based considerations. It includes randomization and plausible counterfactuals without requiring large samples or placing some communities in the position of not receiving the intervention. Considerations related to the conceptualization of the logic model, mechanisms of change, and health disparity outcomes informed the development of the measurement strategy. The strengths and weaknesses of a multiple baseline experimental design are discussed in comparison to versions of randomized clinical trials. Future health disparity intervention evaluation research will benefit from (1) building a shared sense of urgent public need to promote health; (2) respecting the validity of values- and partnership-based decision-making; and (3) promoting community-based and systems-level partnerships in scientific grant funding. The described study has been registered prospectively at clinicaltrials.gov, Protocol Record 21-454.

Evaluating the function and psychometric properties of a violence risk screening tool in a community sample of adolescents.

Youth violence continues to be widespread. Despite numerous evidence-based programs that reduce youth violence, objective ways to identify youth in need of services is lacking. Few screening tools are available that enables practitioners or community organizations to predict who may perpetrate serious violence. The Violence Injury Protection and Risk Screen (VIPRS) is a previously validated screening tool providing a framework to address youth violence. The purpose of this study is to evaluate the psychometric properties of the VIPRS in a community sample for use in multiple settings. Youth participating in a community-focused youth violence prevention intervention served as the study subjects. Households with youth ages 10-17 were eligible to participate. Study personnel verbally asked youth survey questions and recorded answers on a laptop. Multiple measures-including risk factors for violent behavior as well as, violence and delinquency scales, were asked. Eleven hundred youth participated. Mean age was 13.3; 53% female, 26% Black, 58% Hispanic, 11% more than 1 race. Twenty percent screened positive on the VIPRS-28% male versus 13% female (p = .000). Violence-related behaviors were common: 33% were in a physical fight, 27% experienced cyberbullying victimization, and 9% perpetrated a minor assault. The VIPRS demonstrated robust criterion validity with significant correlation to multiple violence measures (0.3-0.6). Scoring positive on the VIPRS conveyed increased odds of reporting other violent behaviors, such as perpetrating physical aggression (OR: 7 [95% CI: 5.1-11.5]). Overall, the VIPRS performed well in a community sample of youth further validating its psychometric functioning while demonstrating the potential for use in settings beyond healthcare.

Would Caring Teachers Buffer the Link Between Violence Victimization and Early Sexual Initiation? Comparing Heterosexual and Non-Heterosexual African American Youth.

This study investigated the relationship between youth violence exposures (i.e., peer and neighborhood) and early sexual initiation. It also explored whether caring relationships with teachers might moderate this relationship and whether results differed for heterosexual versus non-heterosexual African American youth. The study sample (N = 580) comprised 475 heterosexual and 105 non-heterosexual youths, 319 female and 261 male, ages 13 to 24 years (M age = 15.8). Students were assessed for peer and neighborhood violence, relationship with teachers, early sexual initiation, sexual orientation, and socioeconomic status. Major results indicated a positive relationship between exposure to peer and neighborhood violence and early sexual initiation for heterosexual youth but not those who identified as non-heterosexual. Further, identifying as female (vs. male) was significantly associated with later sexual initiation for both heterosexual and non-heterosexual youth. In addition, caring teachers moderated the relationship between exposure to peer violence and age of sexual initiation among non-heterosexual youth. Programs and interventions to curtail violence sequelae would need to consider the unique effects of various types of youth violence exposures and the significance of sexual orientation.

Associations between land bank ownership and stewardship of vacant properties and crime, violence, and youth victimization in Flint, MI.

Land banks across the United States are managing expanding vacant property inventories. By maintaining vacant properties and engaging residents in the process, land banks facilitate processes integral to building safe neighborhoods and may play a role in violence prevention. Using generalized additive mixed model regression, adjusted for spatial and temporal dependencies, we examined whether land bank ownership and stewardship of vacant properties in Flint, Michigan were associated with trends in serious, violent, and firearm-involved crime, between 2015 and 2018. We tested for differences in trends in crime density between properties owned by the Genesee County Land Bank Authority (GCLBA; n = 7151) and comparison properties not owned by the land bank (n = 6,245). In addition, we tested for differences in crime density trends between vacant properties that received different levels of land bank stewardship, including biannual mowing, GCLBA standard stewardship, and GCLBA-sponsored community-engaged stewardship. We found that GCLBA ownership was associated with net declines in densities of all types of crime and violence, over time, relative to properties not owned by the GCLBA. When we distinguished between levels of stewardship, we found that GCLBA stewardship, both with and without community engagement, was associated with net declines in serious and violent crime relative to comparison properties. Only community-engaged GCLBA stewardship was associated with declines in firearm-involved crime and firearm-involved crime with a youth victim over time, relative to comparison properties. Land bank stewardship of vacant properties may be protective against crime, violence, and youth victimization in legacy cities like Flint, MI that experience high rates of vacant properties and violent crime.

Earned Income Tax Credit and Youth Violence: Findings from the Youth Risk Behavior Surveillance System.

Family- and neighborhood-level poverty are associated with youth violence. Economic policies may address this risk factor by reducing parental stress and increasing opportunities. The federal Earned Income Tax Credit (EITC) is the largest cash transfer program in the US providing support to low-income working families. Many states have additional EITCs that vary in structure and generosity. To estimate the association between state EITC and youth violence, we conducted a repeated cross-sectional analysis using the variation in state EITC generosity over time by state and self-reported data in the Youth Risk Behavior Surveillance System (YRBSS) from 2005 to 2019. We estimated the association for all youth and then stratified by sex and race and ethnicity. A 10-percentage point greater state EITC was significantly associated with 3.8% lower prevalence of physical fighting among youth, overall (PR: 0.96; 95% CI 0.94-0.99), and for male students, 149 fewer (95% CI: -243, -55) students per 10,000 experiencing physical fighting. A 10-percentage point greater state EITC was significantly associated with 118 fewer (95% CI: -184, -52) White students per 10,000 experiencing physical fighting in the past 12 months while reductions among Black students (75 fewer; 95% CI: -176, 26) and Hispanic/Latino students (14 fewer; 95% CI: -93, 65) were not statistically significant. State EITC generosity was not significantly associated with measures of violence at school. Economic policies that increase financial security and provide financial resources may reduce the burden of youth violence; further attention to their differential benefits among specific population subgroups is warranted.

Adaptation of the Communities That Care Youth Survey for use in Brazil: A pilot study.

Substance use and violence are serious problems affecting Brazilian youth, prompting local authorities to invest in adapting and implementing evidence-based prevention programs developed abroad. To ensure that interventions are effective, valid and reliable measures of risk factors for substance use and violence are needed. We conducted a pilot examination of the measurement properties of risk factors in the Communities That Care Youth Survey (CTCYS), a school-based survey developed in the United States. The Brazilian-adapted CTCYS included 25 risk factors as well as measures of substance use and antisocial behaviors. The survey was translated into Brazilian Portuguese and adapted for use in Brazil, incorporating suggestions from local experts. The survey was administered to 926 students in one Brazilian community. Results indicate that scale internal consistency was acceptable for all but two scales: (i) Academic Failure and (ii) Rebelliousness. Confirmatory factor analyses suggested good model fit for most measurement models albeit with minor modifications for most scales. Findings from this pilot study provide a foundation for the use of the CTCYS in Brazil to assess community levels of adolescent risk and evaluate prevention programs.

Translating Violence Prevention Programs from Research to Practice: SafERteens Implementation in an Urban Emergency Department.

BACKGROUND: Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care. OBJECTIVES: To examine the translation of the SafERteens program into clinical care. METHODS: Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework. RESULTS: SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes. CONCLUSIONS: Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation.

What makes young people get involved with street gangs in London? A study of the perceived risk factors.

This study examined the perceived determinants of street gang-related antisocial behavior (ASB) and crime of young people (YP) in a deprived and ethnically diverse community in London. Twenty-six participants were recruited from two youth centers (one sport and one art-based program) from the borough of Tower Hamlets. Participants took part in four focus groups (FGs) organized into two youth (N = 14) and two adults (N = 12) subgroups. The FG questions explored participants' understanding of their community and social environment, their social interaction with the local YP and youth gangs. Data were analyzed using a thematic approach and key factors associated with youth gang membership, ASB, and crime were identified. Participants highlighted a series of determinants, which were centered on social predispositions and psychological factors. Associated risk factors were heavily embedded in the racial and religious tensions within the borough. Therefore, context-specific to the individual communities' risk factors should be identified before the development and implementation of intervention strategies to enhance their potential for impact.

Generating youth dialogue through the literary arts: A citywide youth health collaboration in the U.S.

A process and outcomes evaluation was conducted of a citywide literary-arts initiative designed to reduce stigma, amplify underrepresented narratives, and generate dialogue about violence. Over 4 months, students in 85 middle schools read a novel addressing mental health and violence-related themes. As a collaboration between a public school district and public library system, the program's classroom activities emphasized dialogue, while coordinated library events supported community engagement. Students completed pre/postsurveys (total n = 1487); school program leaders (n = 39) and public librarians (n = 14) completed postsurveys. Half of student respondents reported personal encounters with violence. Most said the novel influenced their thinking; students with personal experiences of violence reported greater influence than those without. Highest rates of dialogue were seen among students who read the novel in full, and over half of postsurvey respondents wanted more dialogue opportunities. Leaders and librarians indicated that the program was smoothly integrated with existing curricula, but also offered recommendations for improved processes. Findings suggest that this intervention was effective at stimulating dialogue while providing assets-based opportunities for youth to share experiences and concerns. Current program processes indicate promise for further engagement and impact, with some modifications. To this end, authors draw upon evaluation findings and youth development literature to offer recommendations for program development and replication in other regions.

The Intersection of Alcohol Use, Gender Based Violence and HIV: Empirical Findings among Disadvantaged Service-Seeking Youth in Kampala, Uganda.

The SAVA syndemic is frequently used to describe the co-occurrence of HIV, gender-based violence (GBV), and substance use. In this study we determine the extent to which the typologies of the SAVA syndemic can be described and utilized for intervention strategies among youth living in the slums of Kampala, Uganda. We analyzed the "Kampala Youth Survey 2014," a cross-sectional survey conducted in the spring of 2014, consisting of a convenience sample (N = 1134) of urban youth (12-18 years of age). Descriptive statistics were computed for hypothesized risk factors and demographic variables among the 8 typologies of GBV, HIV, and alcohol use. Multinomial logistic regression was conducted to determine statistically significant correlates with each typology. The overall prevalence of GBV was 31.7%, whereas the overall prevalence of alcohol use in the past 12 months was 31.2%. HIV-Positive youth comprised 10.5% of the total sample. Females comprised the majority of the typology with no SAVA components compared to males (55% vs. 45%, respectively), as well as the SAVA syndemic typology (GBV + HIV + ALC +) (58% vs. 42%, respectively). Engaging in commercial sex work (36%), witnessing parental abuse (61%), and depression/suicidality (81%) were all highly prevalent among youth in the SAVA syndemic typology (GBV, HIV, and alcohol use). Sex work and observing parental abuse were associated with the SAVA syndemic typology in the multivariable model. In our study, alcohol rarely coexisted without GBV among the typologies. Therefore, prevention efforts including structural interventions may be particularly warranted in vulnerable populations to address alcohol use, which may directly or indirectly impact GBV and HIV.

Groups of Sexual Violence Perpetration in a National Sample of Youth 13-25 Years of Age.

Little is known about how specific forms of sexual violence (SV) perpetration group together and how youth transition between these groups over time. Between 2011 and 2016, four waves of data were collected online nationally from 1129 13-25-year-olds. Six forms of SV perpetration were assessed: sexual harassment, online sexual harassment, sexual assault, coercive sex, attempted rape, and rape. We used latent class analysis to examine how different types of SV perpetration behaviors clustered together in each of the four waves. Latent transition analysis was used to examine stability and instability in group membership between the first and fourth waves assessed. Three groups were identified in each of the four waves of data collection: (1) a "non-perpetrators" group, ranging from 69 to 81% (n: 775-912) across waves, (2) a "sexual harassment" group, ranging from 17 to 29% (n: 191-327), and (3) a "multiple perpetration" group that engaged in all types of SV perpetration, ranging from 1 to 3% (n: 12-28). Most youth persisted in their behavior over time, which was true for each of the three groups (ranging between 60 and 72%). Desistence was less common, ranging from 35% of those who transitioned from sexual harassment to non-perpetration to 20% for those who transitioned from multiple perpetration to sexual harassment, and from multiple perpetration to non-perpetration. Escalation was least common, ranging from 2% who transitioned from non-perpetration to multiple perpetration to 26% who transitioned from non-perpetration to sexual harassment. Youth who perpetrate SV are heterogeneous; SV perpetration is not persistent for all youth.

Evaluation of the Olweus Bullying Prevention Program in US Urban Middle Schools Using a Multiple Baseline Experimental Design.

We evaluated the impact of the Olweus Bullying Prevention Program (OBPP) in an 8-year study in urban middle schools that served primarily African American students living in low-income areas. Participants included 2755 students and 242 teachers. We evaluated the OBPP with a multiple-baseline experimental design where the order and intervention start time was randomly assigned for each school. We assessed the frequency of bullying behaviors and experiences including physical, relational, and verbal aggression and victimization using teacher ratings of student behavior and student-reported data, as well as cyber aggression and victimization and school climate measures using student-reported data. For teacher ratings of student behavior, we found significant main effects across all subtypes of aggression and victimization, with some variability in the timing of effects. The pattern of findings showed delayed intervention effects for boys and a weaker impact of the OBPP on 6th graders. We found main effects for student-reported cyber aggression and victimization, relational aggression, and a composite of physical, verbal, and relational victimization. Decreases in victimization emerged in the 1st or 2nd year of intervention, and reductions in aggression emerged during the 3rd year. Across all findings, once intervention effects emerged, they remained significant in subsequent intervention years. The OBPP resulted in significant decreases in student- and teacher-reported aggression and victimization. However, this intervention had limited impact on general areas of school climate including teacher support, positive peer interactions, and school safety. Overall, the findings offer important prevention and research implications.

Dating Matters and the Future of Teen Dating Violence Prevention.

Despite increased focus and research on violence prevention, rates of teen dating violence (TDV) victimization have remained stable for the last two decades. In response to this major public health concern, the Centers for Disease Control and Prevention developed and evaluated a multicomponent school-based program, Dating Matters, with the goal of reducing teen dating violence perpetration and victimization. This commentary discusses themes from the results of Dating Matters studies included in this special section of Prevention Science. We review the challenges in implementing multicomponent violence prevention programs across the social ecology as well as the promise of success in communities with elevated rates of TDV. Finally, we summarize the implications of these findings for violence prevention research and offer emerging areas where more research is needed.

Middle School Effects of the Dating Matters® Comprehensive Teen Dating Violence Prevention Model on Physical Violence, Bullying, and Cyberbullying: a Cluster-Randomized Controlled Trial.

Few comprehensive primary prevention approaches for youth have been evaluated for effects on multiple types of violence. Dating Matters®: Strategies to Promote Healthy Teen Relationships (Dating Matters) is a comprehensive teen dating violence (TDV) prevention model designed by the Centers for Disease Control and Prevention and evaluated using a longitudinal stratified cluster-randomized controlled trial to determine effectiveness for preventing TDV and promoting healthy relationship behaviors among middle school students. In this study, we examine the prevention effects on secondary outcomes, including victimization and perpetration of physical violence, bullying, and cyberbullying. This study examined the effectiveness of Dating Matters compared to a standard-of-care TDV prevention program in 46 middle schools in four high-risk urban communities across the USA. The analytic sample (N = 3301; 53% female; 50% Black, non-Hispanic; and 31% Hispanic) consisted of 6th-8th grade students who had an opportunity for exposure to Dating Matters in all three grades or the standard-of-care in 8th grade only. Results demonstrated that both male and female students attending schools implementing Dating Matters reported 11% less bullying perpetration and 11% less physical violence perpetration than students in comparison schools. Female Dating Matters students reported 9% less cyberbullying victimization and 10% less cyberbullying perpetration relative to the standard-of-care. When compared to an existing evidence-based intervention for TDV, Dating Matters demonstrated protective effects on physical violence, bullying, and cyberbullying for most groups of students. The Dating Matters comprehensive prevention model holds promise for reducing multiple forms of violence among middle school-aged youth. ClinicalTrials.gov Identifier: NCT01672541.

Factors associated with successful mentor matching in an intervention study of youth violence.

One challenge of conducting intervention studies is ensuring that study participants are exposed to the intervention. For example, in our randomized controlled trial of Take Charge!, a mentor-implemented and research-informed violence prevention program that partners with one-on-one community-based mentoring agencies, only 50% of intervention youth with fight-related injuries were successfully matched with a mentor. We examined the differences between matched (n = 49) and unmatched (n = 49) youth with regard to demographics, time from injury to study enrollment, perceived seriousness of injury, belief that future injury can be avoided, and household chaos. Youth who were successfully matched with a mentor were more likely to perceive the injury as very serious or somewhat serious compared with unmatched youth (95.9% vs. 79.6%, p = .028). All other factors were not significantly associated with successful mentor matching. Future violence prevention interventions should consider youth perceptions as a factor that may influence the completion of desired interventions.

A community-specific framework of risk factors for youth violence: A qualitative comparison of community stakeholder perspectives in a low-income, urban community.

This study offers a qualitative comparison of risk factors for youth violence from the perspectives of community stakeholders in a low-income, urban community experiencing elevated rates of violence. One-on-one interviews were conducted with 36 community stakeholders across three key categories: 10 community residents who cared for youth living in the community, 15 program or service providers, and 11 leaders in community agencies and organizations. A grounded theory approach was used for data collection and analysis to extract themes that emerged from the question, "What are the things in the community that lead to youth violence?" While there was significant overlap in stakeholders' beliefs about precursors to youth violence, important differences also emerged. In order for youth violence prevention strategies to be successful, they must consider and address risk factors identified by community stakeholders involved in the implementation and sustainability.