Sanne Oostermeijer1, Matthew Dwyer2, Poni Tongun1. 1. The Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia. 2. H2o Architects, Melbourne, Australia.
Abstract
BACKGROUND: Constructive relationships between staff and young people in custody are a vital component of a therapeutic youth justice approach, which extends to the maintenance of a safe and secure environment (i.e., relational security). Despite the growing recognition that the physical environment of a facility impacts the procedures within a youth justice environment, as well as the relationships between staff and young people, there is a dearth of research in this area. AIMS: We investigated youth custodial staffs' views on, and approaches to, establishing relationships with young people while maintaining safety and security. The current study reports on the impacts and challenges highlighted by staff relating to the design of the facility. METHODS: We interviewed a total of 26 custodial staff members working at a Youth Justice facility in Melbourne, Australia. The semi-structured interviews were audio recorded and transcribed. NVivo 12 was used for thematic analysis. Two researchers (SO and PT) coded one transcript independently, iteratively creating a coding template using a thematic analysis approach. Once the final set of broad themes was constructed, the transcripts were re-examined, and narrower themes were identified. RESULTS: Thematic analysis revealed that a total of 14 staff (53.8%) identified the design of the custodial facility as impacting upon their ability to practice relational security. Identified design aspects included: unit size, quiet and private spaces, communal areas, green and outside spaces, ambience and spatial characteristics, spatial differentiation, facility and unit lay-out. CONCLUSION: Youth custodial staff identified design aspects of a youth custodial facility that either promoted or impeded the ability to practice relational security approaches. The current study highlights the importance of carefully considering facility design given its impact upon staff-young people relationships, procedures and ways of working within these custodial facilities.
BACKGROUND: Constructive relationships between staff and young people in custody are a vital component of a therapeutic youth justice approach, which extends to the maintenance of a safe and secure environment (i.e., relational security). Despite the growing recognition that the physical environment of a facility impacts the procedures within a youth justice environment, as well as the relationships between staff and young people, there is a dearth of research in this area. AIMS: We investigated youth custodial staffs' views on, and approaches to, establishing relationships with young people while maintaining safety and security. The current study reports on the impacts and challenges highlighted by staff relating to the design of the facility. METHODS: We interviewed a total of 26 custodial staff members working at a Youth Justice facility in Melbourne, Australia. The semi-structured interviews were audio recorded and transcribed. NVivo 12 was used for thematic analysis. Two researchers (SO and PT) coded one transcript independently, iteratively creating a coding template using a thematic analysis approach. Once the final set of broad themes was constructed, the transcripts were re-examined, and narrower themes were identified. RESULTS: Thematic analysis revealed that a total of 14 staff (53.8%) identified the design of the custodial facility as impacting upon their ability to practice relational security. Identified design aspects included: unit size, quiet and private spaces, communal areas, green and outside spaces, ambience and spatial characteristics, spatial differentiation, facility and unit lay-out. CONCLUSION: Youth custodial staff identified design aspects of a youth custodial facility that either promoted or impeded the ability to practice relational security approaches. The current study highlights the importance of carefully considering facility design given its impact upon staff-young people relationships, procedures and ways of working within these custodial facilities.
Juvenile justice institutions have the stated aim of providing a safe, secure and structured environment for justice‐involved people in need of secure placement. Security in such institutional settings is offered through distinct but interrelated aspects of security: physical, procedural and relational security (Kennedy, 2002; RC Psych Quality Network for Forensic Mental Health Services, 2015; Tighe & Gudjonsson, 2012). Physical security involves the physically designed environment which includes perimeter walls, fences, spatial boundaries, the lay‐out, locks and closed‐circuit television (CCTV) systems. Procedural security refers to the policies, rules, protocols and procedures in place to maintain safety and security (e.g., searches, phone access and leave). Relational security is more complex and less well‐defined, despite being recognised as a highly effective security measure within an institutional environment (Armytage & Ogloff, 2017; Crichton, 2009; Kennedy, 2002). Generally speaking, it refers to the knowledge and detailed understanding that staff have of the people in their custody and how this informs the management and de‐escalation of incidents (Collins & Davies, 2005; Tighe & Gudjonsson, 2012). Others have considered it to be consistent of a trusting relationship between staff and residents, affected by the staff‐to‐resident ratio and time spent in face‐to‐face contact (Kennedy, 2002). The various definitions share in common the importance of in‐depth and constructive relationships between staff and young people contributing to the maintenance of security in a facility. These relationships are defined by professional boundaries and occur within, and contribute towards, the broader context of an institutional environment and culture. Examples of conditions which may influence such relationships include staff's ability to maintain boundaries and flexibility, group dynamics with other residents, visitors and connections with support network (e.g., family and friends), consideration of personal history and emotional triggers, and the impact of the physical environment on residents (RC Psych Quality Network for Forensic Mental Health Services, 2015).A constructive relationship between staff and young people in custody forms the basis of a therapeutic and ‘open’ custodial environment (van der Helm et al., 2011; van der Helm et al., 2014). An open climate provides a safe, structured and therapeutic environment, counteracting the use of repressive measures (van der Helm et al., 2011). It involves social support, opportunities for personal growth and flexibility in care and control (van der Helm et al., 2014). Whereas a repressive environment is characterised by a lack of respect, major power imbalances, greater dependency on staff, lack of mutual respect and an emphasis on incremental and haphazard rules and punishment. An ‘open’ institutional climate has been associated with higher treatment motivation and lower aggression in incarcerated youth (van der Helm et al., 2012; van der Helm et al., 2014). More positive perceptions of the institutional climate by youth has also been related to lower victimisation and fewer mental health symptoms experienced by young people in custody (Gonçalves et al., 2016; Kupchik & Snyder, 2009). Furthermore, a positive institutional climate is likely to contribute to more effective treatment and ultimately lower the risk of reoffending (Auty & Liebling, 2020; Harding, 2014). Broader youth justice work is recognised to be most effective when grounded in a relational approach; building trusting relationships over time, (re)building positive social interactions and developing a young person's positive identity and sense of self (Johns et al., 2017).
YOUTH JUSTICE FACILITY DESIGN
It is well‐recognised that the built environment can have profound effect on the physical and mental wellbeing of residents in institutional settings. Youth justice stakeholders have repeatedly highlighted the detrimental impacts of the built custodial environment on young people's wellbeing, as well as their prospects of rehabilitation and reintegration (Armytage & Ogloff, 2017; Royal Commission into the Protection and Detention of Children in the Northern Territory, 2017; Victorian Auditor‐General's Office, 2018).In the mental health care sector, certain aspects of facility design have been associated with aggressive behaviours, stress levels, use of restraint and seclusion, length of stay, mental health outcomes and resident and staff wellbeing (Connellan et al., 2013; Oostermeijer et al., 2021; Ulrich et al., 2018). The notion of therapeutic design refers to design that is conducive to the mental health, wellbeing and rehabilitation of its residents. Common design elements that have been related to mental health outcomes include: access to daylight, natural lighting and glare; reduced noise levels; adequate privacy, ‘home‐like’ (as opposed to institutional) features; and access to gardens and nature (Connellan et al., 2013). Similar design features were identified by the Wellbeing in Prison Design project, that sought to develop an evidence base for improving prison design through the application of environmental psychology (Bernheimer et al., 2017). There are similarities between secure mental health care facilities and custodial spaces, both being secure institutions where residents are admitted involuntarily. It is also worth acknowledging the high incidence of young people presenting with mental health issues, including trauma‐related issues and neuro‐disabilities, within custodial systems (Borschmann et al., 2020; Hughes et al., 2020). Recognising the similarities between mental health care institutions and prisons, it has been noted that the physical design of custodial facilities could be a vital component in supporting rehabilitation and desistance from crime (Jewkes, 2018).Further, prison design is thought to impact and define the identities and behaviours of its detainees, partly by shaping daily activities and the social interactions that take place inside (Jewkes, 2018; Oostermeijer & Dwyer, 2019). Beijersbergen et al. (2016) investigated the relationship between prison lay‐outs and the perceptions of detained adults on their relationships with staff across 32 prisons in the Netherlands. Detainees housed in prisons with lay‐outs that were more conducive to social interaction (i.e., campus and high‐rise facilities) experienced a more positive relationship with staff. Liebling (2008) has described evidence from a Norwegian study that indicated that smaller prisons are better equipped to provide a tailored and relational approach for adult detainees.Despite the recognition that the physical environment of a youth justice facility is likely to impact on the wellbeing of, and relationships between, staff and young people—there is a dearth of research in this area. This article explores how the physical design of a Youth Justice facility in Victoria affected the ability to practice relational security approaches, as described by its staff members.
METHODS
Ethics approval for this study was obtained from the Justice and Community Safety Human Research Ethics Committee (CF/20/4136). The study was also registered with the Human Ethics Sub‐Committee at the University of Melbourne (2021‐14003‐19571‐1).
Setting
In Australia, each state and territory has its own youth justice legislation, policies and practices by which young people are charged and detained. Young people can be charged with a criminal offence if they are aged 10 or over. Recently, the Australian Capital Territory (ACT) has announced plans to raise the age of criminal responsibility from 10 to 14 within a year. The upper age limit of the youth system is generally 17, however Victoria's dual track system allows young people aged under 21 to be sentenced to detention in a youth justice facility. Focusing on Victoria, in 2017, responsibility for custodial youth justice services shifted to the Department of Justice and Community Safety who assumed responsibility for maintaining the safety and security of youth justice facilities. At the time of this study there were two Youth Justice facilities in Victoria. Staff from one of these facilities participated in the current study. These Youth Justice staff members were responsible for the care and supervision of the young people on their unit. Each unit houses approximately 15 young people, is managed by a unit manager and has up to nine staff rostered on during the daytime hours. During this study there were six operational units, with one additional intake unit where young people underwent their COVID isolation period before moving on to one of the other units. The facility site and its units are surrounded by a secure perimeter wall and accessible by a single‐entry point. It operates with a central CCTV control room to monitor cameras and undertake checks throughout the facility. Victoria's youth justice facilities are considered a highly restrictive environment, with high movement control during the daily operations (Armytage & Ogloff, 2017).
Staff interviews
Youth Justice Workers received a project flyer via email inviting them to take part voluntarily, which was sent out by the general manager of the youth justice facility. Staff members were then able to contact the research team via email or phone to schedule a time and date for an individual interview. All participants were provided with a plain language statement, an informed consent form and a set of demographic questions.Semi‐structured one‐on‐one interviews were conducted by a research team member (PT). All interviews took place between January 2021 and March 2021 and were conducted face‐to‐face. The pre‐determined questions asked about: their views on, and approaches to, relationship building with young people; their main approaches and strategies for maintaining a safe environment; the main barriers and facilitators to maintaining a safe environment; and how their relationship with young people influences their ability to maintain a safe environment. For an overview of the questions see Appendix 1.
DATA ANALYSIS
All recordings were audio‐recorded and professionally transcribed verbatim, which were used for data‐analysis. Transcripts were coded using the software programme NVIVO12. Using a framework analysis approach (Gale et al., 2013), two members of our team independently coded one transcript (PT, SO), iteratively creating a coding template. Once the final set of broad themes was constructed, transcripts were re‐examined, and narrower themes were identified where appropriate. The two team members compared and revised the coding template until consensus was reached. The final template with the complete set of broad and narrow themes was applied across all transcripts.
RESULTS
A total of 26 participated in the interviews. Participants were aged between 25 and 58 years (M = 39.2, SD = 10.4) and almost half (46.2%) were female. The length of service at the current facility ranged from 8 months to 28 years (M = 7.2 years, SD = 8.2 years).In addition to information gathered regarding the key focus area of the study (i.e., staff‐young person relationship building), a total of 14 youth custodial staff members (53.8%) mentioned at least one physical environmental aspect (or lack thereof) of the facility that impacted upon their daily interactions with young people. These aspects included: unit size, quiet and private spaces, communal areas, green and outside spaces, ambience and spatial characteristics, spatial differentiation and facility and unit lay‐out. These factors are discussed in more detail below.
Unit size
A total of seven staff members mentioned that having smaller units would be preferable. Staff members described how the current units in the facility consist of a total of 15 beds and all seven staff members agreed this is too many. One staff member specifically noted that the ‘ideal’ number would be four or five beds, while another mentioned three or four beds would be best. Staff described how having too many young people on the unit prevents them from attending to the individual needs of each young person, or engaging in meaningful activities with young people. It was noted that large units contribute to young people's behaviours escalating more frequently, whereas smaller units facilitate more constructive relationships between staff and young people, contributing to a feeling of safety and making the space more ‘manageable’ for staff.‘Main barrier is I think there needs to be smaller units. So, at the moment you've got units that house up to like 15 young people, but I think we all know that young people when they're in a cohort, the behaviours are more likely to escalate’.—Staff member #3.‘Where if it's in a smaller group and all of them sort of know each other, and get along, and there's none of that you know conflict with each other, that goes a long way. […] So having a smaller unit does take out the young people having to watch their back all the time type of dynamic’.—Staff member #7.
Quiet and private spaces
Four staff members suggested that the current design of the facility does not include enough space for them to engage with individual young people while on the unit. One staff member pointed out that the busyness within the facility forms a barrier to building rapport with young people. The other three staff members described a lack of (private) space on the unit, with one staff member noting how they will use their managers' office when in need of a private, quiet space to engage with young people.‘You know we have units that they really have no areas, if you can't get off a unit for whatever reason, there's no areas to do much on the unit’.—Staff member #13.
Communal areas
Three staff members commented that areas which facilitate communal activities contributed to a more positive environment and opportunities for relationships building. All three staff members noted the need for a shared kitchen area, which allows young people to cook their own meals. One staff member also noted that having young people do activities together creates opportunity for teaching and building their social skills.‘If you had units that had 6, 8 kids on them only, and you were doing stuff on the unit, a bit more kind of independently in terms of cooking and meals on that unit, you know those kinds of things, I think that kind of helps’.—Staff member #13.‘There'd be times where we'd have dinners on the unit and invite the boys and the girls would have dinner together. Or we'd play mixed basketball games together [..]. We do activities together [..]. But we don't do it anymore. And it's a shame, because it's about you know kind of social, teaching people social skills and how to interact with each other’.—Staff member #13.
Green and outside spaces
Seven staff members discussed the need and/or impact of having access to an outside space and being able to move around, including the gardens and courtyards. Staff described how taking young people out for some ‘fresh air’, sitting in the garden, or having a walk outside helps young people to calm down and allows staff to have a conversation away from other people on the unit. Having the literal space to allow young people to breathe, and being able to interact privately with young people outside, creates an opportunity for de‐escalation and rapport building.‘But if you're in tune, you know the kids, it's like wow, this one needs some space, so yeah get them off the floor, go for a walk, go outside on the courtyard, go in the back courtyard and sit down there outside away from the rest’.—Staff member #10.However, two staff members pointed out that not all units currently have access to a private outside area or how it can be difficult to get clearance to utilise the outside areas. Staff highlighted that this can cause frustration among young people, especially when being outside is a way of regulating their emotions at times of distress, anxiety or anger. One staff member pointed out they had difficulty getting access to the outside area, because this was shared with another unit. Another staff member described a specific example of how prolonged restriction from access to outside areas caused self‐harming behaviour.‘So you know like this environment sometimes isn't all that helpful in ways to de‐escalate. Like a simple go outside and have a walk, you know go outside and get some fresh air, on some of the units that's not as simple as just being able to do that’.—Staff member #2.
Ambience and spatial characteristics
Two staff members pointed out that the current facility buildings were generally outdated, with one staff member noting it resembled an adult facility. Another staff member pointed out that the environment with its low ceilings creates an enclosed feeling, which affects staff and young people's wellbeing, especially for young people as they reside there 24/7. They noted that having more space and access to natural daylight would be more conducive to a positive and rehabilitative youth justice environment.‘So obviously that's going to affect the staff but also the young people's sense of wellbeing as well. […] Where you look at some of the other units, higher ceilings, it doesn't have to be the biggest rooms, but just that feeling of space, windows, natural light, all that sort of stuff makes a big difference’.—Staff member #6.
Spatial differentiation
Five staff members discussed the need for, or lack of, an ability to differentiate between different types of young people and their individual needs, including mental health‐, developmental‐ and security needs. Staff described how these needs were related to spatial characteristics or amenities available for use by young people. One staff member noted that some of the general safety measures, such as not being able to cook your own meals or open your own room, are not appropriate for all young people and that in fact such a ‘one‐size fits all’ approach fuels frustration and incidents, contributing to an unsafe environment. They pointed out that what is needed instead is a ‘gradated system’ from a more restrictive, secure environment on one end, to a more autonomous and open environment on the other—a facility able to cater for young people with different security needs.‘We can't control the young people that come in at the moment, because structurally we don't have enough space to be able to divide it depending on their needs and their trauma, traumatic backgrounds’—Staff member #1.‘I think that's an issue that we are trying to give everyone the same thing. […] trying to shove down the throat everything to everyone—and that affects the safety because you're trying to give someone something they don't need, and you're forcing it [..]. We have to have a gradated system that will fit everyone’—Staff member #4.Three staff members specifically pointed out that this inability to differentiate can be problematic when trying to navigate and deal with young people from opposing street groups (referred to as gangs by staff) who end up being placed on the same unit. This can cause tension and incidents, creating an unsafe environment for both staff and young people.
Facility and unit lay‐out
Three staff members commented on the lay‐out of the units and the facility. Two staff members described how the current facility lay‐out results in a lot of movement across the facility, from and to different areas and units. They noted that when an incident happens in the facility, all movement ceases which creates frustration with both staff and young people and can cause further incidents.‘Because there's so much movement across the site, I might be over at [unit], the girls are waiting to go to a program, and then a code happens on another unit across the other side, code happens, all movement ceases. […] which you know like I said can cause incidents in itself and that you're waiting all the time […] young people and staff both get frustrated with it’.—Staff member #13.One staff member described how the lay‐out of one of the units is spread out in such a way that it makes it more difficult for staff to manage young people across the different unit sections. They also noted that in one area the bedrooms all face into the lounge room, which they feel is not ideal when managing the unit.
DISCUSSION
The current study sought to gain knowledge from youth custodial staff in relation to their views on, and approaches to, relational security. Staff members identified a range of factors that either aided or impeded the formation of in‐depth and constructive relationships with young people, and highlighted how these factors related to the establishment of a safe environment. These included various factors such as interpersonal skills of staff, staff training, teamwork and cohesion, staff turnover and high workloads. An overview of these factors will be described elsewhere. Over half of the staff members identified aspects of the physical environment and facility design that impacted upon their ability to practice relational security. The current study highlights the importance of carefully considering youth justice facility design, given its apparent impact upon procedures and ways of working within these facilities. It should be noted that none of the interview questions specifically prompted staff to talk about design elements of the facility. This may partly explain why each sub‐theme was discussed by only a few staff members. The design elements highlighted by staff included: unit size, quiet and private spaces, communal areas, green spaces and ‘fresh air’, ambience and spatial characteristics, spatial differentiation, facility and unit lay‐out.Staff noted that the size of the unit impacted on their ability to attend to young people's individual needs, engage in meaningful activities, and build relationships with young people. Interestingly, staff also related unit size directly to safety by noting that large units contributed to young peoples' behaviours escalating more frequently. This is in line with previous research indicating smaller prison facilities are better equipped to provide a relational and tailored approach (Liebling, 2008). Given that the interviews focused upon staff's ability to develop constructive relationships between staff and young people, it is worth considering the relationship between escalation of behaviours and unit size. This might be due to the inability to manage and respond to individual needs and as such large units may impede relational security approaches (Oostermeijer & Dwyer, 2019).It is recognised that relational security within a facility is interrelated with the physical and procedural security, and it has been said to be essential that one aspect should never substantially compensate for the absence or ineffectiveness of another (RC Psych Quality Network for Forensic Mental Health Services, 2015). The current results emerging from the interviews substantiate this interrelationship, with staff highlighting both physical and procedural security measures that affected their ability to employ a relational security approach. The interview results also tell us something about how these different aspects of security are related. The absence or lack of access to quiet and private spaces, a shared kitchen and opportunities to cook one's own meals, and outside spaces—spaces and spatial characteristics sometimes restricted in the name of safety or security—were all absences reported to impede the building of constructive relationships between staff and young people. Conversely, staff indicated that, when provided, communal areas such as a basketball court or a kitchen area for cooking, were amenities that actively promoted constructive relationships between staff and young people. Youth Justice facilities are environments where physical and procedural security measures often involve privation of access. Beyond failing to be compensatory, if physical and procedural security measures reduce access to relational security assets, it appears likely that these measures could adversely affect the ability to practice relational security approaches. This may potentially be counterproductive towards a safe environment. Relational security approaches seem to require both the (physical and figurative) space and time to de‐escalate and engage in meaningful and constructive interactions.Furthermore, relational security is thought to enable care to be delivered in an environment where levels of restriction and supervision can be varied according to individual needs (Collins & Davies, 2005). This effectively requires staff to be able to practice flexibility in both physical and procedural measures within a facility. This is consistent with the notion of detaining young people in the least restrictive environment possible and differentiating security based on individual risks and needs (Brogan et al., 2015). Previous research in Victorian Youth Justice facilities described how staff reported that the general safety measures increased in response to incidents at the units (e.g., more security staff and higher fences) did not necessarily make the units safer (van Miert et al., 2021). In the current study staff described how the inability to differentiate between young people based on individual needs contributed to an unsafe environment. This indicates that a ‘one‐size fits all’ approach to physical and procedural measures prevents the ability to vary levels of restriction and supervision according to individual needs. Alternatively, constructive and knowledgeable relationships (a core element of relational security) might safely allow for more flexibility in the levels of restriction and supervision (Collins & Davies, 2005). Youth justice spaces that work flexibly and provide for different patterns of use, including aspects of security, may be an important element in relationship building between staff and young people (Oostermeijer & Dwyer, 2019).Notably, several elements of relational security align with the core principles of trauma‐informed care (TIC), an approach which is receiving growing recognition within youth justice settings and services (Levenson & Willis, 2019). Similarly to relational security, TIC requires constructive and respectful relationships between staff and young people, as well as flexible and individualised approaches (Levenson & Willis, 2019). As over‐bearing physical and procedural security and authoritative approaches may re‐traumatise young people (e.g., through the use of restraint and seclusion), instead centralising relational security approaches and facilitating an ‘open’ and supportive environment—is likely to be conducive to a TIC approach within youth justice settings. Furthermore, Jewkes et al. (2019) have previously argued that design considerations are crucial to the successful implementation TIC approaches within a prison. Several of the suggestions for designing trauma‐informed prisons clearly align with the design features related to relational security including private spaces, communal cooking facilities and access to nature.As relational security has been labelled as the most important security measure in any youth custodial environment (Armytage & Ogloff, 2017), it will be essential to further investigate how this measure can be successfully implemented and operationalised within a youth justice setting. The current study highlights the need to carefully consider the design of a facility, along with its impacts upon procedure, as part of realising a relational security approach. It is evident that the physical design of a facility impacts on the relationships between staff and young people, procedures and ways of working within these custodial facilities.These findings should be interpreted considering some limitations. Firstly, the interviews took place during the COVID pandemic which had significant immediate impacts on both staff and young people within the Youth Justice facility. Due to COVID safety procedures, young people had to undergo a 14‐day COVID isolation period after which they are relocated to one of the other units. The COVID pandemic and associated safety procedures may have impacted on staff workload, staff and youth wellbeing, and access to young people's social support network. As such, this may have impacted staff's current views on, and approaches to, a relational security approach. Secondly, staff participating in the study may not have been a representative sample of the broader youth custodial staff member cohort in Victoria. Thirdly, staff participating in the interviews may have been subject to socially desirable answers which could have led to less critical reflections on relational security approaches. Fourthly, as mentioned previously, none of the interview questions specifically prompted staff to talk about design elements of the facility. To fully understand the impacts of facility design and the impact upon procedures and ways of working within youth justice facilities, future research should include a specific focus on design and environmental features. Furthermore, we did not involve any young people in our study. It is critical to investigate young people's views in the approaches to building and maintaining constructive relationships with staff, being the recipients of the Youth Justice interventions. Future research will need to study the perspectives of young people in custody on relational security approaches, as well as facility design.
CONFLICT OF INTEREST
The authors report no conflict of interests.
ETHICS APPROVAL STATEMENT
Ethics approval for this study was obtained from the Justice and Community Safety Human Research Ethics Committee (CF/20/4136). The study was also registered with the Human Ethics Sub‐Committee at the University of Melbourne (2021‐14003‐19571‐1).
PATIENT CONSENT STATEMENT
All participants were provided with a plain language statement and an informed consent form. Written informed consent was obtained from each participant prior to participation.Supporting Information S1Click here for additional data file.
Authors: Rohan Borschmann; Emilia Janca; Annie Carter; Melissa Willoughby; Nathan Hughes; Kathryn Snow; Emily Stockings; Nicole T M Hill; Jane Hocking; Alexander Love; George C Patton; Susan M Sawyer; Seena Fazel; Cheneal Puljević; Jo Robinson; Stuart A Kinner Journal: Lancet Public Health Date: 2020-01-16