Transcript Slide 1

Violence
Review of risk factors and
interventions
Aim and objectives

describe risk factors for violent,
aggressive behaviour

prevalence of risk factors in SA and WC

evidence for prevention strategies
Background


Injuries part of a quadruple burden of disease
with HIV/AIDS, infectious diseases, chronic
conditions
Interpersonal violence the major cause of injury
in SA and WC
Background
Premature mortality in Western Cape (YLL) in 2000
14.1
HIV/AIDS
12.9
Homicide/violence
7.9
Tuberculosis
6.9
Road traffic injuries
5.9
Ischaemic heart disease
4.6
Stroke
Trachea/bronchi/lung ca


2.7
Lower resp infects
2.4
Suicide
2.3
Diarrhoeal disease
2.3
Second leading cause of premature mortality in WC
12.9% vs. 6.9% for traffic - ratio > most other provinces
Source: Bradshaw et al. 2004, SANBD Study 2000: estimates of provincial mortality.
Violence by age and sex,
Cape Town, 2003 (n=2111)
Male
Female
450
350
300
250
200
150
100
50
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
+
59
14
0
<1
Number of deaths
400
Age in years
Background
Mortality rate / 100, 000 population
Western Cape vs. National
140
120
100
80
60
40
20
0
Males
National

Females
Western Cape
Higher than national average for males and females
Source: Bradshaw et al. 2004, SANBD Study 2000: estimates of provincial mortality.
Background
Mortality rate / 100, 000 population
Western Cape vs. World average
140
120
100
80
60
40
20
0
Males
World

Females
Western Cape
10x higher than world ave for males, 7x for females
Source: Norman et al. in press. The high burden of injuries in South Africa. WHO Bulletin.
Definition of violence
The intentional use of physical force or
power, threatened or actual, against
oneself, another person or against a
group or community, that either results in
or has a high likelihood of resulting in
injury, death, psychological harm,
maldevelopment or deprivation .
The different faces of violence
Child abuse and
neglect by parents and
other caregivers
Elder abuse and
neglect
Violence by intimate
partners
Sexual violence
Youth violence
Collective violence
Self-directed violence
Source: TEACH VIP
www.who.int/violence_injury_prevention/publications/violence/en/index.html
Typology of violence
Violence
Self-directed
Interpersonal
Collective
Source: TEACH VIP
www.who.int/violence_injury_prevention/publications/violence/en/index.html
Typology of violence
Interpersonal
Family/partner
Nature of violence
Child
Partner
Elder
Community
Acquaintance
Stranger
Physical
Sexual
Psychological
Deprivation or neglect
Source: TEACH VIP
www.who.int/violence_injury_prevention/publications/violence/en/index.html
Approaches
Crime prevention
 Human rights approach
 Developmental science
 Public health approach

The public health approach
1) Surveillance
What is the
Problem?
2) Risk Factor
Identification
What are the
causes?
4)Implementation
How is it done?
3) Develop and
Evaluate
interventions
What works?
Risk factors - ecological model
Structural
Societal
Behavioural
Biological
Examples:
Examples:
Examples:
Examples
• Inequalities
• Concentration of•poverty
Poor
• Demographic
parenting factors
• Norms that support
violence
• High
residential mobility
• Marital
• Psychological
conflict
and
• Availability of means
• High unemployment
• Friends
personality
who engage
disorders
in
• Weak police/criminal
justice
• Social
isolation violence
• Local illicit drug •trade
History of violent
behaviour
• Experienced abuse
Source: TEACH VIP
www.who.int/violence_injury_prevention/publications/violence/en/index.html
Interventions - ecological model
Structural
Societal
Behavioural
Biological
Examples Examples
Examples
Examples
• Public information
• Reducing alcohol availability
• Parenting
• Social programmes
development progs.
• Strengthen• police
and institutional
judicial systems
Changing
settings • Home
• Vocational
visitationtraining
• Reduce poverty
andand
inequality
• Identify
refer people at risk for
violence
• Family
• Victim
therapy
care and support
• Educational
reform trauma care and health• care
• Improving
Mentoring programmes
• Reduce access
to means
access
• Job creation programmes
Source: TEACH VIP
www.who.int/violence_injury_prevention/publications/violence/en/index.html
6 key intervention themes
Investing in early interventions
 Increasing positive adult involvement
 Strengthening communities
 Changing cultural norms
 Reducing income inequality
 Improve criminal justice, social welfare

Violence – Interventions
INVESTING IN EARLY INTERVENTIONS
 Lead monitoring and toxin removal
 Increasing access to pre- and post-natal care
 Multi-context, long-term interventions that impact on
multiple dimensions of a child's environment
 School feeding schemes to ensure adequate nutrition
 Therapeutic foster care for children - 0 to 3 years
 Preschool enrichment programmes
 Mentoring for children aged 3 to 11 years;
 School-based child maltreatment prevention
programmes for children
 Home visitation
 Training in parenting
Violence – Interventions
INCREASING POSITIVE ADULT INVOLVEMENT
 Incentives for young adults and high risk youths
to complete high school and post-secondary
education or vocational training
 Mentoring for children aged 12-19 years
 Family mentoring for children aged 12-19 years
 Home-school partnership programmes
 After-school programmes to extend adult
supervision for children.
Violence – Interventions
STRENGTHENING COMMUNITIES
 Alcohol - see mental health
 Education and childcare
 e.g. programmes which provide youths with
incentives to complete secondary schooling
 e.g. child-protection service programmes
 Social development programmes
 Academic enrichment programmes
 Foster-care programmes for delinquents
 Firearms
 e.g. Longer waiting periods for firearm
purchases;
 e.g. Owner liability for damage by guns;
Violence – Interventions
CHANGING CULTURAL NORMS
 Increase awareness of child maltreatment
 Public shaming of partner violence offenders
 Establish adult recreational programmes
 Prioritise community policing
 Reducing media violence
 Promote pro-social norms - children 3 to 11 years
 Women’s networks to challenge norms and
beliefs re violence
 Change young men’s attitudes, behaviours
 Reducing unintended pregnancies
 Peer mediation or peer counselling for children
 Life skills training programmes
 Recreational programmes for children
Violence – Interventions
REDUCING INCOME INEQUALITY
 Establish job-creation programmes for the
chronically unemployed for ages 20 and older
 Strengthen police and judicial systems for all ages to
ensure more equitable access, protection and legal
recourse.
 Reduce poverty - for all ages;
 Housing density/ residential mobility programmes
 Microfinancing projects for women.
Violence – Interventions
IMPROVE CRIMINAL JUSTICE, SOCIAL WELFARE
 Easier access to social support for women, families
 Criminal justice reforms to criminalise child
maltreatment, intimate partner violence, elder abuse
 Mandatory arrest for intimate-partner violence
 Train health-care professionals to refer battered
women, victims of elder abuse, child maltreatment,
sexual violence and identify high-risk youth
 Improve services for children who witness violence
 Safe havens for children on routes to, from school
 Shelters and crisis centres for battered women and
victims of elder abuse
 Treatment programmes for maltreated children
 Services for adults abused as children
 Treatment for child, intimate partner abuse offenders
Limitations of the evidence
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Behavioural and proximal societal bias (esp at the
relationship level)
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More common, cheaper, easier to design, implement
and evaluate
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Intuitively distal societal and structural interventions
may be more effective
Paucity of interventions from LMICs
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Do not discount the promising interventions (yet)
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Case study – Colombia
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Bogota, Cali succeed in reducing homicide rates
Similar guiding principles
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multiple, comprehensive interventions;
scientific research and surveillance
primary prevention a priority
responsibility shared by govt, police, citizens
tolerance; social development, equity, human rights
Partnership betw local govt. and academic institutes
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reliable information systems to identify risk factors and
inform prevention strategies
strategies to reduce alcohol sales at high risk periods and
carrying of firearms
investment in police and judicial systems
public education campaigns
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Cali 126 to 90/100,000
Bogota 82 to 26/100,000
Age standardised mortality rate per 100,000 population
Case study – Colombia
140
120
100
80
60
40
20
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

04
03
20
20
02
01
20
00
20
20
99
98
19
19
97
96
19
95
19
19
94
93
19
19
92
19
19
91
0
Mayor institutionalises prog.
Bogota Cali
Sustained prog. unaffected by changes in local govt
Substantial investment in public spaces, social infrastructure
Larger budgetary allocation to policing, criminal justice
Source: Guerrero 2006. Violence Prevention through multi-sectoral partnerships
Violence mortality rates in
Cape Town 2001 to 2004
Age standardised mortality rate per
100,000 population
Firearm
Non-firearm
All homicide
80
70
60
50
40
30
20
10
0
2001
2002
2003
Source: Matzopoulos 2005. Sixth annual report of the NIMSS
2004
Change in age std’d homicide
rates, Cape Town 2001 - 2004
% change in age standardised homicide death rates 2001 - 2004 by subdistrict, Cape Town
30.0
22.5
20.0
10.0
0.0
-4.5
-10.0
-20.0
-20.3
-21.7
-30.0
-31.7
-36.1
-40.0
-44.1
-50.0
-47.5
-49.0
-47.7
-57.0
-60.0
-70.0
Athlone
Blaauw
Central
Helder
Khay
M Plain
Nyanga
Oosten
SPD
Tyg East
Tyg Wes
Source: Groenewald et al. Local level mortality surveillance: utility for evaluation of
intersectoral interventions to reduce violence.
Research priorities for local
community interventions
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Need to formally document and evaluate promising interventions
e.g. community safety in Khayelitsha and Nyanga
Enhancing the intervention by identifying most effective aspects
Identifying key variables and information criteria to evaluate
future initiatives
Complement evidence on utility of broad community
interventions to reduce violence, aggressive behaviour, and
associated risk factors e.g. alcohol and substance abuse;
Enable easier replication / repetition of the intervention in other
areas and by other prevention agencies;
Assisting with research capacitation
Highlight / showcase successful local interventions