Violence PreventionThe Evidence

Karen HughesCentre for Public Health, Liverpool John Moores University

WHO Collaborating Centre for Violence Prevention

Introduction• 1.6 million people die each year through violence

Estimated economic cost of $151 billion

• Millions more affected as victims and witnesses Physical and mental health Education and employment Relationships and social functioning Cycles of violence

• Preventing violence major priority

• Public health approach Intelligence-led multi-agency evidence-based

• What works to prevent violence

Updating the Evidence

• Lots of new research since 2002

Need to re-review the evidence

• Series of briefings based on 7 scientifically viable strategies

• Provide overview of evidence for their effectiveness

• Easily accessible to non-specialists

• Neither under- nor over-stating the case

• Encourage implementation of these interventions

• Identify main gaps in the current evidence base

The Series• Academic & grey literature

Database searches

e.g. Medline

Systematic reviews

Internet searches

• Balance between high quality evidence and geographical coverage

• Peer review process www.who.int/violence_injury_prevention www.cph.org.uk

Developing safe, stable & nurturing relationships between children & their parents & caregivers

• Children at greater risk of being abused when:

Parents have little understanding of child development, are less affectionate and responsive, use harsh or inconsistent punishment..

• Early relationships are central to a child’s development

Affect brain development

Affect social, emotional and intellectual development

• Lack of safe, stable and nurturing relationships in childhood can have long-lasting effects:

Anxiety, low self-esteem, difficulty forming relationships

Increased risks of violence

Childhood Violence and Adult HealthChildhood Violence and Adult Health

Felitti et al, 1998; Anda et al, 2006

Anxiety x 2.4

Severe obesity x 1.9

Alcoholism x 7.2

Illicit drug use x 4.5

Sexually transmitted infections x 2.5

Current smoker x 1.8

Perpetrating partner violence x 8.8

Any cancer x 1.9

Increased risk of health behaviours and conditions as adults for individuals experiencing four or more Adverse Childhood Experiences in childhood. • Abuse (Physical, sexual, emotional)• Neglect (Physical, emotional)• Household Dysfunction (mother treated violently, substance abuse,

mental illness, parental separation / divorce, incarcerated household member

• Parenting programmes Information & support for parents

• Parent & child programmes Preschool education, family

support, child/health services etc.

• Social support groups e.g. peer support for parents

• Media interventions e.g. raise awareness & knowledge

of child maltreatment

Safe, stable & nurturing relationships

Early, primary prevention to teach parenting skills and support healthy child development

Some strong evidence that parenting

programmes and parent and child programmes can

reduce child maltreatment and

problem/aggressive behaviours in youth

Nurse-Family Partnership, USA• Targets low-income first time mothers

• Pre and post natal nurse home visits (early in pregnancy to age 2)

Develop better parenting and emotional bonding

Promote and teach:o Health behaviours (mother/child)o Child care skillsoMaternal personal development

• Long term evaluation – 15 years

• Lower levels of child abuse/neglect by mothers

• Children born to participating mothers:

Fewer behavioural problems Fewer arrests/convictions Fewer injuries Fewer sexual partners Lower frequency of alcohol consumption

• Most effective for deprived women Olds et al, 1996,1998, 2005

Developing life skills in children & adolescents

Interventions to develop life skills can: Improve social and emotional competence Improve school participation & performance Increase prospects for employment

Addressing risk factors for violence: Poor social competence Low academic achievement and truancy

“Abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life”

Self-awareness (e.g. self-esteem) Self-management (e.g. coping skills) Social awareness (e.g. empathy) Relationships (e.g. conflict management) Decision making (e.g. critical thinking) World Health Organization

• Preschool enrichment Child skills, parent programmes

• Social development training Empathy, relationships, conflict

resolution, anger management..

• Academic enrichment Study & recreation out of school

• Vocational Training Providing skills to find work

Developing life skills in children & adolescents

Provide cognitive, emotional, interpersonal & social skills to enable youth to deal with the challenges of life

Some strong evidence that preschool

enrichment and social development

programmes can reduce aggression and improve social skills, particularly in at-risk

youth

Cost effectiveness

Early childhood education (3-4 year olds)

Average benefit

- $2.35 for every dollar invested

Preschool Enrichment• Preparing children for school• Social, emotional and educational skills• Chicago Child-Parent Center, USA • Children aged 3-9 in deprived areas

Preschool enrichment ongoing support in formal education Intensive parent programme

• By age 20, participants showed (cf controls):• Fewer arrests (including for violent offences; 9% v 15%)• Greater higher school completion (50% v 38.5%)

• Age 24 - lower depressive symptoms, higher employment

• Also associated with lower rates of child maltreatment Reynolds et al, 2001, 2003, 2004

Social Development Programmes• Emotional & social skills

• Self-control• Positive self-esteem• Relationship skills• Problem solving skills

• Promoting Alternative Thinking Strategies (PATHS)• 131 lessons over 5 years; teacher training

• Regular school children•↓ peer-rated aggression, hyperactivity, ↑emotional competence

• Children with behaviour and learning problems•↓conduct problems, depression, anxiety, ↑problem solving

• Successful school programmes •high quality, longer intervention, at-risk groups, positive skills

Greenburg et al, 1997; CPPRG 1997; CSVP Blueprints, 1998; Curtis and Norgate, 2007

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Reducing availability & harmful use of alcohol

• Strong links between alcohol and violence Affects physical and cognitive function

Beliefs that alcohol causes aggression

Used to prepare for/excuse violent acts

Dependence - failure to fulfil care duties

Prenatal exposure - foetal development

Drinking a coping mechanism in victims

Common risk factors

• 30% violent deaths related to alcohol 8% in Middle East and North Africa

56% in Europe and Central Asia

• Reduce violence and other alcohol-related harm

Reducing availability & harmful use of alcohol

Evidence promising, suggesting that alcohol-focused

measures can reduce violence. However, many barriers and

few available studies

Regulating alcohol availability• sales times, outlet density

Raising alcohol prices• e.g taxation, minimum price

Reducing alcohol use in risky drinkers

• e.g. brief interventions, treatment for alcohol dependence;

Improving drinking environments• Community partnerships,

responsible retailing, strict enforcement, physical design…

England, economic modelling• minimum price of 50p/alcohol unit • estimated would save:• 2.1% of all violence

• 10,300 incidents a year Meier et al, 2008

Australia (VIC), spatial analysis

•Increasing accelerating effect for density of pub licences on violence

•Dramatic increase in liquor licenses

•Currently capped Livingston, 2008

Targeting alcohol sales in Brazil

Diadema, Brazil

60% of murders and 45% complaints of violence against women between 23:00 and 06:00

Many linked to alcohol

2002: municipal law banned alcohol sales after 23:00

Public and alcohol retailer information campaign

Strict enforcement of law by multi-agency team

Closing time regulation

Rate of assaults against women

Closing time regulationHomicide rate

44% reduction over 3 yearsAverage 9 per month

Dualibi S et al., The effect of restricting opening hours on alcohol-related violence. Am J Public Health. 2007

Reducing access to lethal means

• Lethality of violence can depend on means used• Three lethal means account for a significant proportion

of homicide and suicide

Guns• 360,000 firearm homicides in non-conflict situations each year• A further 52,000 deaths directly through armed conflict

Knives• Around 40% of homicides in the European Region are due to

knives and sharp implements

Pesticides• Pesticide ingestion accounts for 370,000 suicides each year -

over a third of all suicides

Reducing access to lethal means

Some evidence of success, mainly for firearms legislation. Elsewhere evidence

base poorly developed. More research needed,

particularly in developing countries

• Legislative measures E.g. bans and licensing schemes

• Increased enforcement E.g. test purchasing, stop and search

• Weapons amnesties• Safer storage

E.g. provision of pesticide storage facilities

Removing the means to lethal violence

• Gun law reforms in Austria, 1997 minimum firearm purchase age of 21

valid reason to purchase a firearm

background checks/psychological testing

three day waiting period between firearm licensing and purchasing;

safe firearm storage regulations

Preventing Access to Lethal Means

Kapusta et al, 2007; Beautrais et al, 2006

•Associated with: Reduced license demand

Reduced gun homicides

Reduced suicides

• not substituted with increases in suicides using other means

New Zealand Reductions in firearm

suicides following legislative changes particularly seen in

under 25s

•Direct approaches Measures to reduce access to firearms

Firearm injury prevention programmes

Criminal justice interventions

Community based programmes

• Indirect approaches Parenting programmes

Life skills programmes

Alcohol-targeted measures

Environmental and urban design

Disrupting illegal drug markets

Programmes to reduce inequalities

Preventing and reducing armed violence

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www.cph.org.uk

Promoting gender equality to prevent violence against women

• Relationships between gender and violence are complex

• Different roles and behaviours of males and females are shaped and reinforced by gender norms in society

• Differences in these roles and behaviours can create gender inequalities which can:

Increase the risk of violence by men against women

Hinder victims’ ability to remove themselves from violence and seek support

• Challenging ideas that one sex has more power and control over another; a reason for violence against women

Promoting gender equality to prevent violence against women

Good evidence for school-based

programmes. Some evidence for

community-based interventions,

although further research is needed

• School-based interventions

Addressing gender norms and attitudes, e.g. safer dating

• Community interventions

Microfinance programmes, combined with gender equity training

• Life skills programmes

educate about gender-based violence and develop relationship skills

• Intervention with Microfinance for AIDS and Gender Equity

improve women’s employment opportunities increase influence in household decision making increase ability to resolve marital conflicts strengthen social networks reduce HIV transmission

• Women in poorest rural households Financial services Training & skill building Community participation to engage males

• Two years after programme 55% fewer acts of intimate partner violence Less controlling behaviour by partners Better household communication

IMAGE: Microfinance in South Africa

Pronyk et al 2006; Kim and Watts 2007

Changing cultural and social norms that support violence

• Cultural and social norms strongly influence individual behaviour

• Cultural acceptance of violence is a risk factor for many violence types

• Social tolerance of violence likely learned in childhood, e.g.

Use of corporal punishment

Witnessing violence in the family

Violence in the media

• Interventions challenge rules or behaviour expectations that tolerate violent behaviour

Child maltreatment

Physical punishment is a normal part of rearing a child

Intimate partner violence

A man has a right to discipline female behaviour

Sexual violence

Sexual activity (inc. rape) is a marker of masculinity

Youth violence

Violence is an acceptable way of resolving conflict

Suicide and self-harm

Mental health problems are embarrassing and shameful

Changing cultural and social norms that support violence

Limited evidence for most types of

interventions in this area. Further

rigorous evaluations are needed.

• Mass media campaigns

Providing messages on health behaviour to a wide audience

edutainment

• Social norms / marketing

Targeting specific groups Correcting misperceptions of

cultural norms

• Laws and policies

Implementing laws that make violent behaviour an offence.

Soul City• Social and behavioural change• Edutainment:

Soap opera, radio, information booklets Address social issues

o Violence against womeno Alcohol and violence

• Intimate partner violence (IPV) After 8 months: Less acceptance of IPV Increase in belief that communities can help prevent IPV No measurement of violent behaviour

Changing social norms in South Africa

Usdin et al, 2005

Victim identification, care and support programmes

• Violence often hidden: Child and elder abuse Intimate partner violence

• A women will be assaulted an average of 35 times before reporting to police

Witness and community intimidation

•Violence can lead to: Lifelong physical & mental health

problems Social and occupational impairment Increased risk of further violence

• Identifying and supporting victims critical in breaking cycles of violence and limiting long term impacts

Victim identification, care and support programmes

Good evidence for the use of advocacy

support programmes.

Promising evidence for screening and

referral, psychosocial interventions and protection orders

• Screening and referral Identifying and supporting victims of

violence

• Advocacy support Support and guidance to victims,

e.g. counselling, education, legal aid.

• Psychosocial interventions Treat emotional & behavioural

problems linked to victimisation.

• Protection orders Prohibit perpetrators from further

abusing their victims

Supporting abused pregnant women in China

• Based on US programme (Parker et al, 1999) Empowerment training – enhance women’s independence and control Reduced violence in pregnant abused women

• Hong Kong Pregnant women attending first antenatal appointment Screened for physical, sexual and emotional intimate partner abuse Assigned to intervention or control (standard care)

• Intervention One-to-one session (30 mins) Advise on safety, decision making and problem solving Additional component on empathic understanding Cultural modifications (e.g. ‘shame’ of disclosure outside family)

• After intervention: Less psychological and minor physical violence (but not less sexual or

severe physical violence) Also lower post natal depression

Control: information card

Tiwari et al, 2005

State of the Evidence

• Brief overview of the series• Wide range of interventions can prevent violence

Individual, relationship, community and societal levels Throughout the life course Wide range of agencies involved in their delivery

•Quality of the evidence varies widely•Strongest evidence for early life, primary prevention

Randomised controlled trialsLong term follow upCost effectiveness

•Promising evidence elsewhere, need greater researchOutcome evaluations

•Geographical spread of evidence is poorNeed for research in low- and middle-income countries

Gaps in the Evidence Basewww.preventviolence.info

One of 11 reviews on injury and violence prevention

UK Focal Point for VIP

Gaps in the Evidence Basewww.preventviolence.info

Summary

• Enhance investment in research on violence and violence prevention– especially in low- and middle-income countries

– expanding the number of outcome evaluation studies

• Increase the flow to low- and middle- income countries of financial resources and technical support for violence prevention

• The need to expand the evidence base in no way precludes taking action now and implementing interventions

• Intensify and expand violence prevention awareness among decision makers

Thank YouAnd special thanks to:

Mark A BellisSara Wood

Chris MiktonAlex Butchart

Zara Quigg

k.e.hughes@ljmu.ac.uk

www.cph.org.ukwww.who.int/violence_injury_prevention