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J Community Psychol. Author manuscript; available in PMC 2011 September 1.
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J Community Psychol. 2010 September ; 38(7): 874–885. doi:10.1002/jcop.20402.

Youth’s Strategies for Staying Safe and Coping with the Stress
of Living in Violent Communities
Anne Teitelman, PhD, CRNP1, Catherine C. McDonald, PhD(c), RN1, Douglas J. Wiebe,
PhD2, Nicole Thomas, MBA2,3, Terry Guerra, MS3,4, Nancy Kassam-Adams, PhD5, and
Therese S. Richmond, PhD, CRNP1
All authors are affiliates of the Philadelphia Collaborative Violence Prevention Center
1 University of Pennsylvania, School of Nursing
2 University of Pennsylvania, School of Medicine
3 Philadelphia Area Research Community Coalition
4 AchieveAbility
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5 Children’s Hospital of Philadelphia, Center for Injury Research & Prevention

Abstract
Youth living in urban environments of pervasive violence are exposed to a variety of violence-
related stressors. This qualitative descriptive study sought to ascertain how community-dwelling
youth perceived exposure to violence and how these youth identified and used available resources.
The intent of this community-based participatory research study was to help inform the design of a
youth violence prevention center intervention. Semi-structured interviews were conducted with a
purposive sample of 18 youth ages 10–16. Youth reported high levels of exposure to
neighborhood violence. A theme of identifying and navigating safe and unsafe places emerged.
Other stressors were more proximal and included interpersonal issues and conflicts. Youth used
neighborhood and individual resources to cope with stressors. Youth maintained a high level of
vigilance and developed clear strategies to safely navigate violent neighborhoods. Implications for
youth due to the constant vigilance and exquisite sensitivity to stressors of chronic neighborhood
violence are discussed.
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Keywords
violence; adolescents; stressors; resources; coping strategies

Exposure to pervasive community violence compounds the developmental challenges of

adolescence. Almost all of urban youth are exposed to some form of community violence in
their lifetime (Farrell & Bruce, 1997; Mazza & Reynolds, 1999; Overstreet & Braun, 2000;
Pastore, Fisher, & Friedman, 1996) and 70% report direct victimization (Duckworth, Hale,
Clair, & Adams, 2000; Howard, Feigelman, Li, Cross, & Rachuba, 2002; Overstreet &
Braun, 2000). Violence does not occur in isolation; it is strongly associated with
concentrated neighborhood disadvantage (Fagan & Davies, 2004). Growing up in violent
neighborhoods can evoke stressful responses with physical, psychological, and social
consequences, such as placing youth at high risk for future victimization and injury and

Corresponding Author: Therese S. Richmond, PhD, CRNP, FAAN, Andrea B. Laporte Endowed Term Associate Professor,
University of Pennsylvania, School of Nursing, Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-6096, Phone:
215-573-7646, Fax: 215-573-7507.
 Teitelman et al. Page 2

interfering with healthy development (Parker & Pruitt, 2000; Powell & Tanz, 1999; Viner et
al., 2006; Wheaton, Roszell, & Hall, 1997). A growing literature regarding urban youth
describes the complex interplay of violence exposure, coping strategies, and outcomes such
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as aggression, victimization, substance use, psychological distress, and academic

functioning (Bass & Lambert, 2004; Crouch, Hanson, Saunders, Kilpatrick, & Resnick,
2000; Prelow, Danoff-Burg, Swenson, & Pulgiano, 2004; Scarpa & Ollendick, 2003;
Wickrama, Noh, & Bryant, 2005). Even youth who are resilient in one domain (e.g.
academics) may suffer consequences in others (e.g. depression, stress) (Luthar, 1991;
Luthar, Cicchetti, & Becker, 2000).

Addressing Youth Violence Prevention Through Community Based Participatory Research

Three neighborhoods in West/Southwest Philadelphia serve as a site for a Centers for
Disease Control (CDC) Urban Partnership-Academic Center of Excellence (UPACE) in
youth violence. In West/Southwest Philadelphia, over 25% of residents live below federal
poverty levels (Cartographic Modeling Laboratory at the University of Pennsylvania,
2006a). Reported robbery rates are nearly 5 times the national average (Cartographic
Modeling Laboratory at the University of Pennsylvania, 2006b). Youth are especially at
risk; 43% of the population is younger than 25 years. The average annual youth homicide
rate (ages 5–24 years) in these neighborhoods is 37/100,000, five times the national rate of
7/100,000 and higher than the city’s rate of 31/100,000 (Center for Disease Control and
Prevention, 2007; Philadelphia Safe and Sound, 2006). The UPACE in these neighborhoods,
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called the Philadelphia Collaborative Violence Prevention Center (PCVPC), uses a

community-based participatory research model on two key beliefs: 1) youth violence is a
complex disorder socially embedded in unique communities, and 2) communities have the
potential to contribute to or mitigate youth violence.

Community residents and leaders identified youth violence as a priority. This priority
directly influenced a PCVPC developed youth violence prevention intervention targeted at
youth ages 10–14. For this intervention, the community desired to approach violence from a
positive, asset-building model rather than a deficit approach. As such, the community
believed there was much to learn from local community-dwelling youth about how they
perceive themselves as doing well, while living in violent neighborhoods. Thus, the purpose
of this qualitative descriptive study was to explore the perceptions and experiences of youth
living in three selected neighborhoods to help unveil patterns and co-occurrences of their
stressors and assets. Through this exploration, we sought to determine the assets that served
to mitigate stressors in pervasively violent neighborhoods according to external data (i.e.
crime rates, youth homicide rates). Findings of this study served to affirm and contribute to
the content of the youth violence prevention intervention being jointly designed by
community and researchers in the PCVPC.
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Methods
Community-Academic Partnerships
This study was conducted by members of the PCVPC. Committed to the core tenets of
community-based participatory research (Israel, Schultz, Parker, & Becker, 1998) the
partnership between the academic and community partners was established in response to a
call for applications from the CDC for a UPACE for youth violence. Community partners
were solicited from the Philadelphia Area Research Community Coalition (PARCC), an
independent group of community residents and leaders committed to designing,
implementing, and sustaining research to improve the health of the community. The
Executive Board of PARCC selected community members to be involved in PCVPC and
negotiated their roles as core co-directors with financial support. To this end, the PCVPC is

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co-directed by researchers and residents and leaders in the community. The study we report
here was designed, implemented, analyzed and interpreted by a community-academic team.
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Data Collection
Data for this study were collected between September 2007 and August 2008. The
qualitative approach was ideally suited to meet the study aims, providing opportunity for
contextual specificity, giving voice to urban youth, and challenging researcher and adult-
centric biases (Ungar, 2004). Community members provided guidance about recruitment
strategies, setting, and the nature and timing of contact with potential participants (Yancey,
Ortega, & Kumanyika, 2006). The interview guide, developed by the research team that
included a child psychologist and two community partners, progressed from less threatening
topics to those of increasing sensitivity. Developmentally appropriate language sensitive to
the cultural and linguistic norms of the community was used. Follow-up probes
accompanied open-ended questions. Topic areas included family and important people in
their lives, violence exposure, perceptions of safety in the neighborhood, and people they
looked up to or who they “thought were doing really well.”

Semi-structured, face-to-face individual interviews were conducted with 18 youth, ages 10–
16 years living in three Philadelphia neighborhoods. Even though the youth violence
prevention intervention at the center of the PCVPC is aimed at 10–14 year olds, the 10–16
age group was purposively chosen for this study, so that 15–16 year olds could ‘reflect back’
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on stressors and assets in the previous years. Recruitment strategies identified by community
members and researchers reflected the focus of the community on a positive, assets-building
approach on youth violence prevention, Therefore, youth were recruited in two ways:
referral by adult members of community organizations or recruitment by community liaison
research assistants from a variety of community sites where parents and youth congregated
(e.g., outside a recreation center). The three neighborhoods from which these youth were
recruited were 95% African American. The sample was stratified by age, gender, and
neighborhood to achieve a balanced representation. The mean age of the youth in this study
was 13 years and included 10 females and 8 males.

Protection of Human Subjects

This study was approved by the human subjects’ review board of each involved institution.
Parental consent and youth assent were first obtained. Interviews lasted about 40 minutes.
Young African American women were used as interviewers at the request of the community
and to enhance the potential for connection with youth. Interviewers underwent intense
training in qualitative interviewing techniques, human subjects’ protection, and the study’s
Child Safety Plan. Interviews were conducted in a variety of locations that constituted a
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private space, including PCVPC offices, a private room in the youth’s home, or a private
area in a mutually selected public location. Youth received a $20 gift card as a thank you for
participation.(Rice & Broome, 2004)

Method of Analysis
Each interview was digitally audio-recorded, downloaded to a password-protected computer,
transcribed verbatim (names or identifiers removed), and checked for accuracy. We used
both content and narrative analyses. Each transcript was read to obtain a sense of the story as
a whole and a narrative summary was created. Descriptive coding involved attaching short
labels (codes) to selected text sections. Transcripts were coded to initially describe people,
places, and actions. Subsequently, coding focused on identifying violence exposure, coping
strategies, and resources. ATLAS.TI was used to organize the coding process (Muhr, 2004).
Two members of the research team read interview transcripts, coded the data separately, and
met to discuss the coding until there was mutual agreement on a code list with definitions.

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The resulting codes and narrative summaries were examined within and across interviews to
identify patterns and themes (Miles & Huberman, 1994). Both community and academic
team members met to discuss analysis. Data collection and analysis were conducted
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concurrently, enabling preliminary findings to inform subsequent interviews.

Results
Youth provided compelling stories confirming exposure to neighborhood violence and their
responses to this exposure. An overarching theme of safe and unsafe places emerged as
youth described people, places, their movement and activities in their neighborhoods.

Identifying and Navigating Safe and Unsafe Places

Youth described their neighborhoods as containing both safe and unsafe areas. Even the
same location was often seen as having elements of both danger and enjoyment. The youths’
descriptions illuminated how they made these distinctions between safe and unsafe spaces
(e.g. time of day, certain activity, etc), as in this quote from a young male pertaining to a
recreation center:
S1: The swimming pool area is fine. Um, in the summertime a lot of kids go there
just to swim, to cool off. Um, the basketball part for the most part is alright. Um,
just late at night, is when the games going on, little fights break out, just a few
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times, a couple shootings happened, um. The playground, it’s fun for the little kids.
… And the football field, it’s just it helps the kids out. That’s where they go to stop
being around the bad people they hang with and everything…It’s pretty good.
This young female’s description of the area near her home reflected a more general
distinction about different locations in the neighborhood being either safe or unsafe.
S7: A little boy got shot around the corner. So, my mom don’t like for us to hang
out cause kids might get caught in the cross fire when somebody is shooting…
usually, my mom is always with me so I don’t feel unsafe. I don’t go out on my
own too much….I just go you know, to the corner store sometimes, but that’s only
right there at the corner of my block. So, I don’t feel unsafe…...
In the neighborhood, youth described exposure to guns, drugs, and unsafe places as
stressors. Exposure to guns included seeing guns, hearing gunshots, hearing about someone
being shot, knowing someone who was shot, and like this young female, seeing cross-fire in
front of her house.
S3: They was like, actually like shooting past me. One was standing down the
street and the other one was standing up the street and they was actually like firing
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back and forth…I was shocked…I was just shocked. I couldn’t move or nothing
‘cause I couldn’t believe that it was happening.
Youth described knowing about drug dealers on certain blocks, and identified drugs as
something that they would change about their neighborhoods. This young female says:
S7: There’s a lot of corners where people hang out and sell drugs and stuff. And
around the corner where the boy got shot, there’s like drug houses around there.
Youth had highly developed and nuanced assessments differentiating safe and unsafe places
and described various strategies to stay physically safe based on these assessments (e.g., go
with someone else, not at night, don’t bump into anybody, avoid certain blocks, avoid
recreation center during certain activities). Navigating the neighborhood took a constant,
conscious effort. Youth were clear about settings that they knew were unsafe and had
strategies to avoid these settings. For example:

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S1: At, usually in [this neighborhood] everything is pretty dangerous so we have to

be careful. Um, especially late at night. You don’t want ever to be outside late at
night in Southwest….That’s why I try not to go out at night. So, when you’re
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around there you want to be as calm as possible. You don’t want to say anything to
anybody. Whoever you want, you want to just talk to them and get where you got
to go. ………Um, usually when I’m walking around my neighborhood I’m kinda
looking around. Cause you have to be careful. What you say to people, you have to
make sure you don’t bump into nobody the wrong way. Or, problems can start.
Many youth would not affirm to feeling unsafe. Yet, upon probing, youth described
avoiding places that they felt were unsafe. This young female at first says she does not feel
unsafe, but then talks about how she moves about her neighborhood to avoid ‘unsafe’
places.
S9: Um, a couple places, not, I mean I never really feel, I never really feel unsafe,
but like I’m always aware that like, certain places are just like, are not, I’m not
supposed to be there, or not good for me. But I never really feel afraid. But I just, I
know like on my way home from school or something like that, I catch the bus
from “#” and “I” Street, and if I’m around there sometimes I don’t feel, sometimes
I don’t feel safe… it’s like a lot of people out and just, people that kinda seem like
they’re like negative individuals. …sometimes I see people fighting or people
cursing or being really loud, so I always, I’m always like aware, that maybe I
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should just hurry up and try to get home, but I never feel scared.
Danger could be contained by identifying the unsafe ‘micro’ environments within
neighborhoods. By using strategies to avoid unsafe places, youth minimized exposure to
physical violence and limited stress associated with fear of violence.

Neighborhood Resources
Youth also identified neighborhood resources, including afterschool programs, sports and
activities, recreation centers, schools, and parks. Afterschool programs are particularly
important to younger youth, providing a place for youth to “stop being around bad people”
as quoted above by S1 and also a place to go with others where they can enjoy activities and
do homework.
S7: After school a lot of times I go to the after school program with my friends, and
sometimes we have different kinds of activities after we get done our homework.
So we like to go there and then I just go home from there.
Youth identified some places as both safe and unsafe. Some youth described school,
recreation centers, and parks as places they enjoyed, while these locations were also sources
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of stress and threatened safety. This duality emerged both across youths and within
individuals. This is not to say that these places were always unsafe or stressful. Many youth
enjoyed school, and found the parks and recreation centers to be a place of freedom and fun
with friends and family. Context was key to distinguishing safe and unsafe and signified
youths’ awareness of their environments.

Interpersonal, Violence-related Stressors

Youth were asked about stressful situations in their lives. They identified several types of
interpersonal conflicts including bullying and threats, disrespect, disagreements, and
physical fighting. In describing disrespect, one young female noted that disrespect was
something she wanted to respond to because it made her angry.
S6: A time when somebody disrespected me was when they called me a “B” and I
tried to avoid it by walking away and trying be a bigger person.

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INT: OK. Did you say anything back to them?

S6: No…I was thinking about going to hit em, and I was feeling mad.
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INT: OK. Um, how did other people expect you to handle that?
S6: They expected me to handle it by hitting her.
INT: Ok. And you didn’t.
S6: No.
This situation exemplifies the decision not to allow the situation to escalate to physical
violence. She indicates the previous preparation by her mother, who said “…not to worry
about them, because words can’t hurt you.”

Disagreements pose a substantial stressor, occurring in school, with friends and others.
Disagreements with family members were particularly stressful.
S6: I was arguing with my, one of my family members cause she thought she was
right and she was not right….it made me felt bad because I was arguing with one of
my family members.
Disagreements with family members may be more salient to youth because these important
relationships often provide a buffer from other sources of stress.
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Interpersonal Resources
Youth identified a variety of family members (father, mother, grandparent, sibling, aunt) and
key non-family members (friends and other adults) as people they could talk to, confide in,
and trust. This ability to identify someone to talk to, trust, and confide in was a key asset for
youth’s daily lives. The strong presence of mothers permeated the interviews with both boys
and girls speaking to the importance of mothers, as someone important in their lives,
someone they admired and looked to for guidance and help. One young male said:
S18: Yes, because I used to have a anger problem and like if it wasn’t for my mom
I would be in the streets and all that, fighting, shooting people, doing drugs, selling
drugs, all that in the streets. But I’m not cause my mom helped me control my
anger and all that and you know showed me different ways I could avoid different
situations. Some people don’t have that and that’s why our society is the way it is
now cause they don’t have good role models.

Strategies for Coping with Neighborhood and Interpersonal Violence

Youth talked about a variety of strategies used to manage stress associated with both
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neighborhood and interpersonal violence. Strategies focused on how youth dealt with
problems, tried to stay safe, or positioned themselves to be successful. Five core sub-themes
emerged pertaining to: disagreements, disrespect, safety, stress, and success. Many of the
strategies for disagreements and disrespect were similar. These strategies included
confronting or fighting back, ignoring a situation or walking away, and talking or saying
something. For example, one girl talked about how she handled disrespect.
S17: Well when I was younger, whenever I got disrespected it always resulted into
fighting and stuff like that but as I got older and matured more I found out that
fighting wasn’t always the answer and I tried talking out the situation with the
person; telling them how I felt and stuff and sometimes it worked and sometimes it
didn’t. Sometimes the person still wanted to fight or still had the problem with me,
so I just walked away and told an adult or something. Or my friends would try to
talk to them.

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The strategies for safety that youth described highlight the duality of safe and unsafe. As
previously described, youth would state that they did not feel unsafe, yet described many
ways they navigate the neighborhood in order to stay safe. For example:
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S2: Cause I know my way around the neighborhood and I know what type of
people live around there and who lives where and all that kind of stuff….See, most
of the time I see my friends every day and I travel with them a lot. And I just feel
safer when I’m with them… there’s not too many places that I go by myself except
over to the park, and I feel pretty safe there ‘cause most of my friends be over
there.
Reframing the meaning of ‘safe’, by using various coping strategies (e.g. knowing who lives
where) allowed these youth to mitigate the stress associated with living in violent
neighborhoods. In addition to identifying and navigating safe and unsafe settings, other
prominent strategies included running, walking away, getting out of the situation fast,
avoidance, knowing your way around the neighborhood, and travelling with others.

Implications and Discussion

This study focused on youth living in three violent urban neighborhoods to better understand
their perceived exposure to violence, and their assets and stressors in this environment. The
community–academic partners were most interested in learning from local community-
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dwelling youth how they perceived exposure to violence and identified and used resources
available to them. Garnering this information from local community-dwelling youth helped
affirm the focus of interventions by the PCVPC to enhance positive outcomes of youth. The
findings indicate that the youth experienced exposure to violence and other neighborhood
stressors on a daily basis, yet they had strategies and resources to help them cope. These
resources and strategies to stay safe are reflected in the youth violence prevention
intervention currently underway that focuses on positive interpersonal interactions, problem-
solving skills, and leadership development.

These interviews indicate that often youth have a finely tuned system of assessing their
neighborhoods that was constantly ‘on.’ This surveillance, coupled with highly nuanced
assessments, helped youth identify places in their neighborhoods as safe or unsafe, and
further, to understand when the same places changed from safe to unsafe. This sample of
community-dwelling youth identified resources available to help successfully cope with
their violent neighborhoods. Our findings support other reports of youths’ exquisite
sensitivity to violence and other stressors (Scott & House, 2005). Despite this apparent
success in navigating the neighborhood, our findings of constant surveillance are
concerning, given the growing literature suggesting that children’s cumulative exposures to
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stressors (such as violence) become biologically embedded and cause significant future
health disorders (Shonkoff, Boyce, & McEwarn, 2009).

Developing strategies to stay safe is an important life skill for youth growing up in violent
urban neighborhoods. Other reports indicate that youth identify fighting as a safety strategy,
in that fighting can generate respect, popularity, and social power (Johnson, Frattaroli,
Wright, Pearson-Fields, & Cheng, 2004). Our findings are distinctly different. This
difference may be linked to the sample characteristics. Youth involved in the interviews
were recruited at community recreation centers or through references from community
members or leaders. Thus, conclusions drawn from this study may not generalize to all
youth in the neighborhood, or youth in other urban neighborhoods. The findings, however,
are important in informing how youth are able to cope successfully in their violent
environments. These skills youth possess might help other youth successfully navigate their
environments.

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Supportive and involved adults were helpful to youth as they developed coping strategies for
living in violent neighborhoods. Several youth identified mothers as role models, guiding
them to make the right choices. Mothers, however, were not the only important adults.
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Aunts, grandmothers, and less often fathers were identified as being a major asset for
guidance and emotional support. Parenting processes play an important role in African
American youth growing up in dangerous inner city environments (Vazsonyi, Pickerin, &
Bolland, 2006). Our findings suggest that it is not just parents who can fill this role, and
other adults in the family can become a focus of potential points of intervention to enhance
health in inner city youth. These findings are reflected in the vantage point of the PCVPC
violence prevention intervention which examines risk and resiliency through relationships
with peers, parents, and professionals in the community (Philadelphia Collaborative
Violence Prevention Center, n.d.). Importantly, the PCVPC intervention targets youth, also
incorporates a parent/caregiver intervention, and community workshops. Our findings
further substantiate the efforts to involve more than just youth in violence prevention efforts
in this community.

We are careful not to overstep the implications of this qualitative study for the broader arena
of health policy or practice. The most important implications are for health education or
community-based practice. Keeping with the tenets of community based participatory
research the preliminary findings of this study were discussed in detail with our community
advisory committee. At this point, the committee indicated the when preparing to
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disseminate the findings of this study to the community, these findings should be linked with
specific actions that could be taken by youth and adults in the community. As a result of this
advice, our team developed vignettes highlighting the themes reported in this paper and
linked each vignette with one or two evidence-based action steps that could be taken. The
evidence-based tips had been co-developed by the academic and community partners as a
center-wide effort to empower the community with action steps to reduce violence. Thus,
linking these tips with the findings from this qualitative study is a powerful strategy for
research dissemination to the community.

These qualitative studies provide guidance to the focus on design of future research of
importance to youth violence. As indicated, the findings were used to inform a larger
intervention trial currently being conducted in the communities from which our youth were
drawn, by informing concepts and instrument selection and supporting the inclusion of a
parenting component into the intervention trial. Future studies are warranted. As described
some youth were reluctant to state that they felt unsafe. With further probing, however,
youth expressed strategies to stay safe. This is intriguing and begets questions for future
research such as: How are safety and fear interpreted by youth? What does expression of
fear mean? Does reluctance to admit to feeling unsafe affect their mental and physical
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health? These questions, though not answered in our study, would be an important area of
future research.

Challenges, Lessons Learned, and Study Limitations

The co-design, implementation, analysis and interpretation of this study between researchers
and community members enhanced the cultural sensitivity, linguistic strength, and strategies
to obtain sensitive information from youth. We learned a critical lesson about the
importance of context during data analysis through the partnership between community and
academic partners. For example, recreation centers were frequently noted to be an asset for
youth; someplace they enjoyed being, where activities, friends, and caring adults surrounded
them. A few youth, though, mentioned recreation centers as being unsafe, places where
fights can break out. Specifically, one youth mentioned a shooting. The context to these
interviews was that a shooting occurred at one of the recreation centers only weeks before
these interviews were conducted. The knowledge of this neighborhood contextual

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information from community members was essential in data analysis and interpretation of
findings.
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Findings were shared with the researcher-community team designing a major intervention
and also helped us learn more about the daily lives of youth in at-risk areas. We first shared
our findings with community members through a PARCC meeting. These findings also
served to inform working sessions with the PCVPC external community advisory committee
to co-design modes of providing research results to the broader community, and
disseminating findings in local neighborhood media and venues.

It is crucial to consider these findings within the context of the community where data were
collected and not to broadly generalize to unlike communities. Since many youth in our
study were engaged in community activities, it is important to understand the results within
this context. These findings, however, may be useful for other communities plagued by
violence. Although we had fairly balanced age groups and gender break-down, we are
unable to draw conclusions about differences based on age or gender because within-group
numbers were too small to indentify meaningful patterns. This is another area that would be
important for future research.

Concluding Remarks
If we are to achieve the CDC’s (2007) overarching health protection goal of “healthy people
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in healthy places,” we must better understand the effect of environments with high levels of
violence on youth. This study reflects the commitment of the community to approach
violence from an assets rather than deficits perspective. The duality of safe and unsafe
places and the constant vigilance of these youth indicate that, even though many youth are
doing well in these violent environments, many youth are able to point out significant
stressors in their lives. In order to help youth better attain optimum health and wellness, we
must understand how to best aid youth in accessing their assets and resources contributing to
positive outcomes.

Acknowledgments
This manuscript was supported by the cooperative agreement number 5 U49 CE001093 from The Centers for
Disease Control and Prevention. Its contents are the sole responsibility of the authors and do not represent the
official position of the Centers for Disease Control and Prevention. This research was also supported by Award
Number F31NR011107 (PI: Catherine C. McDonald) from the National Institute of Nursing Research. The content
is solely the responsibility of the authors and does not necessarily represent the official views of the National
Institute of Nursing Research or the National Institutes of Health. We acknowledge the thoughtful input of Tamara
M. Haegerich, Ph.D during the early phases of study design and implementation.
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