Defense, Disrespect, and #Deadly: A Qualitative Exploration of Precursors to Youth Violence Informed Through Hospital-Based Violence Prevention Program Follow Up

Youth violence intervention and prevention effects, particularly for gun violence, will be more successful when appropriately informed by the antecedents and context of violence. Youth violence is guided by social and cultural norms that are shifting with the rise of technology. Bullying, gang violence, and self-directed violence is increasingly found to occur in the online space influencing peer groups across contexts. Through focus groups with youth at risk for violence and victimization, this study finds three themes emerge as common precursors to violence: defense of self or others, disrespect of self or family, and threats or disrespect related to social media platforms. Youth violence prevention programs can be more effective through use of a social cognitive intervention framework to address violence through building knowledge, attitudes, and skills needed for violence reduction informed by precursors to violence found in this analysis.

a social cognitive intervention framework to address violence through building knowledge, attitudes, and skills needed for violence reduction informed by precursors to violence found in this analysis.
Homicide rates are the third leading cause of death for young people aged 15-24 (CDC, 2018), disproportionately effecting ethnic and racial minorities in our community.
Thirteen young people are victims of homicide every day, and emergency departments treat 1,300 additional youth for non-fatal violence related injuries. In 2019, 14,414 homicides with firearm occurred in the United States. In addition to a deleterious impact on public health, ongoing violence is costly. The U.S. spends more than $21 billion in combined medical expenses and lost productivity costs due to violent injuries (CDC 2018;David-Ferdon, Vivolo-Kantor, et.al. 2016;Kann, McManus, et.al. 2018).
To reduce and prevent violence related injuries, particularly youth gun violence, researchers underscore that we need to better understand the antecedents of violence and the context within which violence occurs (Teplin et al., 2021). Prior research has established that both individual and community factors influence an individuals' likelihood of experiencing and perpetrating violence, with adverse childhood experiences most robustly influencing violence (Leban & Gibson, 2020). Individual differences that influence involvement in youth delinquency include, but are not limited to substance use, antisocial attitudes, history of victimization, impulsivity, and poor school performance (Farrington, 2003;Farrington, Loeber, & Ttofi, 2012;Herrenkohl, Farrington, Brewer, Catalano, Harachi, & Cothern, 2000). Interpersonal relationships that youth have with peers, parents, and other adults (e.g., teachers) and the nature and quality of those relationships also matter. Youth who have frequent interactions with delinquent peers or belong to gangs are more likely to be victims CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 3 themselves and more likely to victimize others (Farrington et al., 2012;Herrenkohl et al., 2000). Within the community, interactions between individuals in formal institutions such as schools, and informally within neighborhoods, result in varying levels of risk and opportunity for youth engagement in violence (Farrington et al., 2012;Herrenkohl et al., 2000;Sampson, Moreno, & Gannon-Rowley, 2002;Toomey, Erickson, Carlin, Lenk, Quick, Jones, & Harwood, 2012). Dynamics in these various contexts and the potential for youth violence are guided by social and cultural norms regarding violence, but also present violence prevention and intervention opportunities (Herrenkohl et al., 2000;Egerter, Barclay, Grossman-Kahn, & Braveman, 2011;Petrosino, Turner, Hanson, Fronius, & Campie, 2014).
Adding to the complexities that exist in relationship dynamics within these various contexts is the increased use and availability of technology. Communication between youth has changed to include social media platforms that shape interactions and relationships between individuals, within groups as well as between groups. New social and cultural norms inform behavioral expectations in these realms. Violations of normative behavior may be perceived as inappropriate, disrespectful, or even rise to the level of perceptions as bullying or threatening behaviors. When behaviors target specific youth, negative psychological impacts for victimized youth result (Marciano, Schulz & Camerini, 2020) and may lead to retaliatory behavior.
Researchers note the Internet has changed opportunities for crime and deviance, much as it has changed other aspects of social life (Pyrooz, Decker & Moule, 2015).
Social media applications and online platforms originally created for prosocial engagement transcending geographical location, now facilitates urban-based youth violence. Bullying, gang violence, and self-directed violence is increasingly found to occur in the online space influencing peer groups across contexts (Patton, Hong, Ranney, Patel, Kelley, Eschmann, & Washington, 2014). In schools, the prevalence of cyberbullying can range from targeted harassment to threats of violence (Ansary, 2020) with such cyber-victimization, in turn, resulting in retributive violence (Cardwell et al., 2021;Cho et al., 2017). On the streets, youth at risk for engaging in violence include active gang members who use social media to plan and engage in delinquency, incite violence, or support local substance use and distribution (Pyrooz, Decker & Moule, 2015). This use of social media, known as Internet banging (Patton, Eschmann & Butler, 2013;Patton, Eschmann, Elsaesser, & Bocanegra, 2016), led to serious injury and homicide in some instances (Patton, Lane, Leonard, Macbeth, & Smith Lee, 2017). CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 4 Accompanying the movement of offending and victimization to the online environment is the expansion of deviant violence-oriented groups-including youth gangs-in online settings. A relatively new trend among youth living in violent urban neighborhoods is the utilization of social networking sites such as TikTok, Twitter, Instagram, SnapChat and other applications to brag about violence, make threats, and recruit gang members. Further, these same social media platforms are also used to incite violence within communities by taunting rival gangs, posturing and boasting about violent events.
The focus on gang member use of social media is particularly relevant for violence intervention and prevention efforts as these individuals are among the highest risk youth in most communities. Pyrooz and colleagues (2015) gathered social media use data from 585 respondents, including 418 current and former gang members in five cities. They concluded gang members use the Internet and social networking sites as much, if not more, than their non-gang counterparts. Importantly, gang members have a greater overall propensity for online crime and deviance than former and non-gang respondents. Although Pyrooz et al. found the Internet was more commonly used for symbolic purposes than instrumental (i.e., monetary) gain, other researchers disagree. Patton, Patel, Hong, Ranney, Crandall, and Dungy (2017)

A Trauma and Context Informed Approach to Violence Prevention
Programs targeting youth violence prevention are oftentimes reactive, focusing on scaring adolescents out of unwanted antisocial behavior. Yet, examinations of "Scared Straight" programs have found these types of programs to be ineffective and even lead to higher rates of violent and criminal offenses in youth who participate in the program (Dodge, 2001;Petrosino, Turpin-Petrosino, et. al., 2013). One reason these programs are ineffective is they fail to account for the relationship between the youth's contextual environment, their adverse childhood experiences including trauma, and their current behavioral issues (Dodge, 2001;Petrosino, Turpin-Petrosino, et. al. 2013). CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 5 To counteract prevention program deficits, Cradle to Grave (C2G), a hospital-based violence prevention program was implemented at Temple University Hospital and preliminary data found the program was successful in preventing youth violence (Goldberg, Toto, et al., 2010). Temple University Hospital's hospital based C2G violence prevention program recreates the experience of an adolescent who died because of a gunshot. The two-hour long program walks participants through the last moments of a 16-year-old boy's life in a trauma center, combining a classroom and hands-on learning approach that uses participant volunteers to demonstrate procedures experienced by the gunshot victim, asking them to reflect upon the broader implications of youth violence. An evaluation of the program found a reduction in violent beliefs one month following participation in the program and the results were observed most frequently in those participants who were exposed to the greatest levels of violence (Goldberg, Toto, et al., 2010).
Modeled after C2G, Dusk to Dawn (D2D), a hospital-based youth violence prevention program was developed and implemented in a Midwestern city. D2D follows a social cognitive intervention framework by addressing violence at an individual level through knowledge, attitude, and skills needed for violence reduction. This paper uses data and insight gathered from D2D participants to better understand the current context of youth violence and help inform violence prevention program efforts. Several quantitative studies have been published to understand the context of youth violence, yet few qualitative studies have been conducted more recently when factors such as social media and online aggression are increasingly impactful in initiating violence or retributive violence. Violence is a multifactorial issue, with no single factor leading to violent behavior in youth; therefore, a qualitative approach will enhance a deeper understanding of the associated complexities, systems, and contexts to better guide future youth violence prevention efforts.
The focus of this study is to gain an understanding of the perceptions and contextual factors that lead to youth involvement in violence. This research extends prior work on youth violence by incorporating an in-depth examination of themes related to youth violent victimization and perpetration. It is crucial to engage youth from communities experiencing violence as participants in both hospital-based violence prevention activities and as research participants. Their perspectives will strengthen future violence prevention and intervention programming and approaches. CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 6

Method
The present study utilized data collected from a community sample of youth who participated in a hospital-based violence prevention program. Data from five focus groups with D2D participants were analyzed with a goal of determining themes that emerged from the discussions. The priority was to understand the socio-cultural context in which youth violence occurs from the youth perspective. This information could be used to facilitate improvements and long term follow up of youth in violence prevention programs.

Sample
The sample for this study was comprised of youth who participated in the D2D program, and the focus group discussion held on subsequent dates (See Snyder et al. 2020 for discussion of D2D program). All focus group participants were youth from the Boys and Girls Clubs of the Midlands (BGC), lived in an urban area, and were between 12 and 18 years of age. Community-based organizations, probation, or an adult community member who perceived a youth to be at risk for violence perpetration or victimization may refer a youth to the BGC. While we often conceptualize youth violence as a "big city" problem, less populous cities across the nation continue to be

The Dusk to Dawn Program (D2D)
D2D is a 2 ½ hour hospital-based youth violence prevention program developed using evidence-based anti-gang prevention principles. D2D is facilitated by a team comprised of a credible messenger, a trauma surgeon, staff facilitator, BGC team leader (familiar to the kids), and the mother of the victim discussed. Youth participants meet the CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 7 program staff at a local hospital, which is a Level 1 trauma center.

Focus Groups
For the purposes of this study, after the D2D program, focus groups were held at five different BGC in the metropolitan area. Each focus group was comprised of between five and ten youth. Focus group sessions were approximately one hour in length. The research team developed and utilized a semi-structured interview guide to prompt discussion about a variety of topics including general awareness of violence, typical response to violence, and violence risk and protective factors. The focus groups were audio-recorded and transcribed using a professional transcription service.

Analytical Strategy
A thematic analysis using Braun and Clark's (2006) six phase procedure was performed. These phases include familiarization with data, generating initial codes, searching for themes, reviewing themes, defining, and naming themes, and reporting.
Two independent coders reviewed and coded the transcripts. Throughout the analysis, coders discussed and reviewed emerging themes. Although coding disagreements rarely occurred, coders discussed differences and reached consensus before proceeding. Codes, notes, themes, and excerpts were entered and tracked using Dedoose online software version 8.0.35.
As typical with qualitative research methodology, reliability is achieved when the data analysis reaches a saturation point, meaning the analysis reaches a point where the data offers no new information (Dreher, 1994). Themes were identified after the first CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 8 few transcripts were coded and were further confirmed through the analysis of subsequent transcripts. The present analysis was based on data drawn from five independent focus groups held in five distinct areas of Omaha to reduce potential bias and increase overall generalizability of the study.
The present analysis made use of the constructivist framework, which focuses on experience as socially produced (Fahy & Harrison, 2005). The constructivist framework is most appropriate given the socio-cultural context of violence. The first goal of this research was to highlight the voices of the youth living these experiences.
Secondly, to describe the contexts that allow for violent perpetration and victimization among at-risk youth who participated in a hospital-based youth violence prevention program. Finally, to present these findings in a purposeful manner that will support future avenues of focus and expansion for youth violence prevention programming and long term follow up.

Results
Three primary themes emerged from the analysis of focus group discussions including Defense, Disrespect, and #deadly. First, the theme of defense includes concepts related to perpetration of violence as a means of self-defense. Second, disrespect included discussion related to the role of perceived disrespect in situations of violent perpetration. Finally, #deadly included youth perceptions of violence in social media and the role of social media in promoting violent behavior.

Defense
Violence as a means of self-defense emerged as a primary theme in discussions among focus group participants. Many participants reported that engagement in violence with peers was the result of situations in which other youth-initiated fistfights, forcing the participant to self-defend with violence. One participant says, "if they throw the first punch that's when you…that's when you fight." Most participants agreed that violence as a means of self-defense was generally acceptable. As most participants agreed that violence in self-defense was justified, focus group moderators further prompted participants to discuss their views related to any potential positives to violence. A participant responded, "The good one is like defending yourself because like you know you need to do it, but like you're trying to protect yourself from another person, and in the bad way is like doing it to hurt someone." Violence as a defense was perceived in a positive light by this participant as it was a way to stand up for and protect themselves. Further, the sentiment to fight back was so strong that it emerged even CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 9 when the conversation topic was about stepping in while others were fighting. When the moderator questioned the focus group participants if they were scared to break up a fight, one participant replied, "Two people throwing punches? If I get hit, I've got to swing back." This behavior suggests youth are willing to engage in violence even when they were not the initial focus of the fight and perceive this involvement to be defensive violence.
A benefit of the Dedoose software used for the analysis is that it allows researchers to track code co-occurrence, highlighting topics that were often discussed in unison. In our analyses, parental approval of violence in self-defense, specifically mothers were most often brought up when the discussion revolved around violence stemming from then what will your family think?" to which the participant responded, "My dad thought he's soft." This suggests that self-defense is a learned behavior and that interactions with and perspectives of parents, especially mothers, are vital to the process by which youth learn expectations in responding to real or perceived threats of violence. Overall findings that emerged related to the theme of defense, suggest that these youth learned over time that violence is a means of self-defense or defense of another was acceptable, justified, and in many cases, an expected behavioral norm.

Disrespect
Another prevalent theme that emerged was violence used in situations that stemmed from the perceived disrespect of the youth. Youth often named disrespect as a risk factor for violence along with drugs, gang involvement or "gangbanging," and guns.  Youth described feeling exposed to their peers and under pressure to react when others instigated them on social media. A participant says, Findings related to social media, #deadly, suggest that offline violent interactions often begin in an online environment. Threats received via social media are often perceived to be just as legitimate and serious as in person threats, and responses to them are also perceived as necessary and justified. Further, the age gap between youth and the adults in their lives, as it relates to the digital world, leave youth unguided, unsupervised, and often misunderstood.

Discussion
As youth violence is a complex issue influenced by a multitude of factors, the prevention of such violence is an equally complicated problem facing communities. The purpose of this study was to build upon prior research through a more in-depth examination of factors that emerged as relevant for violent perpetration and victimization among focus groups of youth who had previously participated in a hospital-based violence prevention program. Three primary themes, defense, disrespect, and #deadly emerged from discussions with these focus group participants. Youth recalled the relationship between past perpetration in violence and how these related to situations in which they felt compelled to defend themselves or someone else through violent means. As interactions do not occur in a vacuum, situations involving youth violence often arose when a youth perceived they (or a family member) had been disrespected by another. Notions of the necessity to retaliate against disrespect through violent means was often linked by youth to interactions they had with parents, especially with their mothers. Finally, and perhaps most importantly for future youth violence prevention efforts, while these interactions often begin in an online environment, they frequently lead to offline violent behavior. The greater use of social media by an increasingly younger population, combined with a lack of inappropriate supervision, has implications for further escalating rates of youth violence perpetration and victimization when they do not have the skills to diffuse these negative interactions.
Follow-up research with program participants offers the ability to further our understanding of factors that initially lead youth into violence as well as the effects of this type of violence prevention program. Although the latter is beyond the scope of the present study, qualitative examinations of focus group data allow researchers to gain a more in depth understanding of the factors and social context that encourage CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 13 youth violence offers opportunities to improve upon youth violence prevention programs.
This study is not without limitations. As the data for this study were derived from focus groups, participants may have responded to questions differently than they would have if they had been interviewed individually. Another disadvantage of using focus groups relates to observer dependent biases, or the tendency of participants to agree with those moderating the group discussion. Finally, the small sample size and lack of demographic information due to assurance of confidentiality prevents generalizability of results to larger populations of youth.

Implications
The findings of this study have implications for policy and practice regarding youth violence, particularly gun violence. Youth violence is not just a problem for law enforcement, it is also a public health problem that must be studied and intervened from multiple perspectives. Much quantitative work, and some qualitative work has been undertaken to examine perspectives of youth regarding violence and intervention programs. More qualitative work on youth violence through a public health and criminological lens is needed. Here, we examined the hospital-based D2D program that youth attended prior to the focus groups followed a social-cognitive framework for youth violence prevention that are specifically designed for youth. Prior studies find the younger participants are when they begin prevention programming, the better chance of successful prevention (Greene, 1998;Slaby, 1998). Ideally, a prevention program would reach all youth in our communities, rather than restricting it to youth considered at risk for violence. Programs, like D2D, are typically designed to introduce ways for youth to alternative viewpoints on violence and conflict, discuss avenues to that would encourage conflict avoidance and management skills by improving interpersonal and problem-solving skills to work towards mutually beneficial solutions (Greene, 1998;Slaby, 1995). D2D incorporates these considerations into the curriculum as well as in active learning exercises that work towards changing attitudes and beliefs regarding non-violent solutions to conflicts. As prior research was lacking in program follow-up, this study utilizes a qualitative approach to gather focus group data and aimed to give youth a voice with a seat at the table and further explore antecedents to youth violence, particularly regarding incidents stemming from negative social media interactions. Our findings underscore the changing landscape of youth interactions that may lead to violence and the importance of using qualitative approaches to guide policy and practice. Our findings are exploratory given the lack of CrimRxiv Defense, disrespect, and #deadly: A qualitative exploration of precursors to youth violence informed through hospital-based violence prevention program follow up 14 research in this area. Future research should further examine the process by which youth violence perpetration and victimization occur and the importance of themes related to perceptions of disrespect, desire for self-defense, and the influence of social media in these interactions. Further, youth violence prevention and treatment programs should seek to incorporate these themes into treatment strategies.