Violence Prevention The Evidence

1. Violence PreventionThe Evidence Karen Hughes Centre for Public Health, Liverpool John Moores University WHO Collaborating Centre for Violence Prevention

2. 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

3. 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

4. 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_preventionwww.cph.org.uk

6. 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

7. Childhood Violence and Adult Health 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 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 Felitti et al, 1998; Anda et al, 2006

8. Safe, stable & nurturing relationships Early, primary prevention to teach parenting skills and support healthy child development • 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 Some strong evidence that parenting programmes and parent and child programmes can reduce child maltreatment and problem/aggressive behaviours in youth

9. 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: • Health behaviours (mother/child) • Child care skills • Maternal 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

11. Developing life skills in children & adolescents • “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 • 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

12. Developing life skills in children & adolescents Provide cognitive, emotional, interpersonal & social skills to enable youth to deal with the challenges of life • 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 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

13. 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

14. Social Development Programmes • Emotional & social skills • Self-control • Positive self-esteem • Relationship skills • Problem solving skills Bigfoot Arts Education Ltd • 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

16. 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

17. 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… • Australia (VIC), spatial analysis • Increasing accelerating effect for density of pub licences on violence • Dramatic increase in liquor licenses • Currently capped Livingston, 2008 • 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

18. Targeting alcohol sales in Brazil 44% reduction over 3 years Average 9 per month • 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 Homicide rate Closing time regulation Rate of assaults against women Closing time regulation Dualibi S et al., The effect of restricting opening hours on alcohol-related violence. Am J Public Health. 2007

20. 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

21. Reducing access to lethal means Removing the means to lethal violence 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

22. Preventing Access to Lethal Means • 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 New Zealand Reductions in firearm suicides following legislative changes particularly seen in under 25s • Associated with: • Reduced license demand • Reduced gun homicides • Reduced suicides • not substituted with increases in suicides using other means Kapusta et al, 2007; Beautrais et al, 2006

23. Preventing and reducing armed violence • 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

24. www.euro.who.int www.cph.org.uk

26. 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

27. Promoting gender equality to prevent violence against women • 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 Good evidence for school-based programmes. Some evidence for community-based interventions, although further research is needed

28. IMAGE: Microfinance in South Africa • 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 Pronyk et al 2006; Kim and Watts 2007

30. 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

31. Changing cultural and social norms that support violence • 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. Limited evidence for most types of interventions in this area. Further rigorous evaluations are needed.

32. Changing social norms in South Africa • Soul City • Social and behavioural change • Edutainment: • Soap opera, radio, information booklets • Address social issues • Violence against women • 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 Usdin et al, 2005

34. 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

35. Victim identification, care and support programmes • 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 Good evidence for the use of advocacy support programmes. Promising evidence for screening and referral, psychosocial interventions and protection orders

36. 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

37. 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 trials • Long term follow up • Cost effectiveness • Promising evidence elsewhere, need greater research • Outcome evaluations • Geographical spread of evidence is poor • Need for research in low- and middle-income countries

38. Gaps in the Evidence Base www.preventviolence.info

39. Gaps in the Evidence Base www.preventviolence.info One of 11 reviews on injury and violence prevention UK Focal Point for VIP

40. 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

41. Thank You And special thanks to: Mark A Bellis Sara Wood Chris Mikton Alex Butchart Zara Quigg k.e.hughes@ljmu.ac.uk www.cph.org.uk www.who.int/violence_injury_prevention