Community violence and adolescent mental health in Brazil

In Brazil, child and adolescent mental health problems account for a substantial proportion of its burden of disease. Brazil also has strikingly high levels of community violence, both when compared to high-income countries and to other Latin American low- and middle-income countries, and is home to some of the most violent cities in the world. There is evidence that exposure to community violence is associated with high levels of mental health problems in high-income countries, especially among adolescents. However, very little research exists in Brazil on this and few policies or interventions are in place to specifically manage, reduce, and prevent the resulting mental illness burden.

This project aims to establish a UK-Brazil research network on community violence and mental health, to produce evidence on this under-researched topic of primary importance to LMICs generally, and LMICs in Latin America in particular, and lay the groundwork for future collaborative research. Our long-term goal is to reduce the burden of mental health problems associated with exposure to community violence among adolescents living in Brazil.

The projects will tackle four research activities:
1. Through secondary analysis of two existing longitudinal studies, from Pelotas in the south of Brazil, and Salvador in the northeast of Brazil, we will investigate the association between exposure to different types of community violence and depression, post-traumatic stress disorder (PTSD) and conduct problems among adolescents.
2. We will assess the feasibility of investigating the effect on mental health of violence-reduction policies in Brazil through data linkage of national routine datasets on community violence, mental health, and social policies.
3. We will develop new tools through pilot data collection. We will assess the validity of the International Trauma Questionnaire, a new tool for ICD-11 PTSD and complex PTSD diagnosis, and conduct qualitative work to refine a measure of community violence in Brazil. Primary data will be collected in the State of Sao Paulo, Brazil, in Embu, a violent municipality in the outskirts of Sao Paulo city, and a middle-sized city, Araraquara.
4. The organisation of a workshop in Brazil bringing together Brazilian and UK researchers, governmental officials, NGOs and local stakeholders in order to draft a consensus statement on the policies and interventions necessary to manage, prevent and diminish the mental health consequences of exposure to community violence among adolescents in LMICs. Furthermore, the workshop will represent an opportunity to draft a statement on the research priorities in the field, with a particular attention being paid to the cognitive, emotional-processing and neurological mechanisms underlying the association between violence and mental health.

This funding will represent an opportunity to bring Brazilian and UK researchers from different disciplines together in an "International Community Violence and Mental Health Research Hub", with the common aim of tackling a public health priority for the Brazilian population. The findings will fill an important gap in the literature concerning the impact of exposure to community violence and the development of mental health problems in adolescents, the event-specific consequences of community violence on mental health, as well as enabling the future investigation of the potential effectiveness of different policies to reduce adolescent mental health problems. Furthermore, findings will provide the basis for informed discussions on the future research agenda and policies on community violence and mental health, a major public health priority for the Brazilian population.

Community violence is consistently associated with mental health problems in high-income countries, in particular depression and post-traumatic stress disorder (PTSD). Brazil reports strikingly high levels of community violence - such as homicide, gang and drug-related violence - and adolescents are particularly vulnerable, with 59% of deaths among Brazilian adolescents being due to homicide in 2009. Very little research exists on the association between community violence and adolescent mental health in Brazil nor on the effect of policies or interventions to manage, reduce and prevent the resulting mental illness burden.

The current projects provide preliminary data for future sustainable, large-scale, global mental health research on community violence and mental health and to establish a strong collaboration between Brazilian and UK researchers by building on existing ties and developing new ones through four activities:
1. Secondary analysis of existing longitudinal prospective cohort data from Pelotas and Salvador, on the association, directionality and temporal relationship between different types of community violence and depression, PTSD and conduct problems.
2. Data linkage of national datasets to assess the effect on mental health of violence-reduction policies in future work.
3. Pilot data collection to assess the validity of a new measure for ICD-11 PTSD and complex PTSD diagnoses and qualitative work to refine a community violence measure.
4. A workshop to identify evidence-based policies and research priorities in order to reduce, manage and prevent the mental health burden resulting from community violence among adolescents. Attention will be paid to future research on underlying cognitive and neurological mechanisms and expanding findings to other violent Latin American LMICs.

Understanding how and to what extent community violence impacts mental health and what can be done to tackle this problem represents a public health priority.

This research will impact several areas from policies to research landscapes in global mental health.

1. From the beginning of the research, the advisory board will include not only Brazilian and UK researchers but also regional and national governmental officials, NGOs and community stakeholders. This will allow our results to have a direct pathway into the policy decision making processes.

2. Many of our researchers have a long history of impacting research as much as the social realities to which the research is relevant. Our Brazilian collaborators have strong ties with the Ministry of Health, the Estate and City Council Departments, WHO, UNICEF and the Abrinq foundation in Brazil. Dr. Kiss in particular has a proven track record of collaboration with the public sector on violence prevention, in particular with the Health Network for Violence Prevention and Assistance (linked with the São Paulo City Council), and several regional and national governmental officials in different parts of Brazil. The close ties that our research team holds with the governmental institutions will be an exception value in translating our research findings into evidence-based policies and interventions.

3. Many of our Brazilian collaborators are highly involved in the areas in which we are planning to conduct preliminary data collection. For example, Prof. Bordin has previously conducted research in Embu and is knowledgeable about the different local NGOs, governmental institutions, mental health services and community stakeholders which could use our research findings. This would allow our research to have an impact not only at the level of regional and national policy-making but also at the level of communities and local institutions and make a more direct change in the lives of the adolescents living in those communities. The inclusion of local NGOs, mental health services and community stakeholders will ensure that the research is informed by the needs of the population under study from the very start of the project and that the results will be linearly translated with their help into what they believe is the most useful and locally relevant solution to tackle the issue of mental health and community violence.

4. We will also attempt to engage with the local community of adolescents in the areas we will be collecting data in, i.e. Embu and Araraquara. The five focus groups we will organise will represent an excellent opportunity for raising awareness of the most common mental health problems in adolescence and in order to advertise local mental health services and ways to access them. Adolescent community stakeholders will be part of the advisory board from the start of the project.

5. The involvement of governmental officials from different parts of Brazil within the advisory board and during the workshop will represent an excellent opportunity for sharing evidence-based best-practice interventions and policies between them.

6. The advisory board will allow local NGOs, community stakeholders and mental health service to communicate their needs directly to governmental officials and will ease translation into practice. In addition to the academic local stakeholders, users of this information include national and international organizations and advocacy groups (e.g WHO, Unicef, Fundacao Abrinq, Promundo, Sou da Paz).

7. In terms of the research impact our research will explore an under-researched question (i.e. the association between community violence and mental health), assess the feasibility of new data analysis methods (i.e. linkage of national big data), refine standardise measures for future use in research (the ITQ and a community violence measure) and will collect preliminary data in order to tackle the aetiology, resilience factors and cognitive and neurological mechanisms underpinning the association between exposure to community violence and mental health problems.