First European Conference on Injury Prevention and Safety Promotion, 25-27 June 2006, Vienna

1. First European Conference on Injury Prevention and Safety Promotion, 25-27 June 2006, Vienna Early family violence: from data to action Dr Dinesh Sethi, Dr Inge Baumgarten, Ms Francesca Racioppi Violence and Injury Prevention Programme WHO European Centre for Environment and Health Rome, Italy

2. Define family violence Frame family violence within the overall problem of injuries and violence in the European Region Review data available for family violence Highlight East-West differences Review risk factors for family violence Discuss policy options to convert data to action Purpose of presentation to:

3. Political and economic transition have increased injuries and violence in the east of the Region. Unintentional injuries and violence are a leading cause of death and disability, especially in people under the age 45 years in WHO EUR Family violence arises in the family between members and can manifest as child abuse, intimate partner violence and elder abuse. Family violence is often hidden but endemic in all societies and the prevalence is high Like all forms of violence it is amenable to prevention using the public health approach Important to consider family violence because of the intergenerational nature of violence Problem definition

4. Interpersonal violence typology Sibling Acquaintance Stranger Elder Partner Child Interpersonal Family/partner Community Nature of violence Physical Sexual Psychological Deprivation or neglect

5. Definition of violence “Violence is the intentional use of physical force or power, threatened or actual, against oneself (self-harm/suicide), another person (interpersonal violence), or against a group or community (collective violence) that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” World report on violence and health, WHO 2002

6. Interpersonal violence is among top 15 death causes in European Region, 2002.

7. The magnitude of interpersonal violence • In 2002 a registered 73 000 people of all ages and both sexes were killed by interpersonal violence in the WHO European Region • The difference in the magnitude of violence in the Region is striking • More males in the region are victim to interpersonal violence resulting in death or serious injury • Males are also more likely to be the perpetrators of violence - both against men and women • A significant proportion of the violent deaths are due to family violence (Source: HFA MDB)

8. 1. Infanticide and child abuse in the European Region 1,500 (11%) of 27,900 deaths in children under 15 are due to violence The likelihood of child homicide in CIS is three times that in the EU The majority of these deaths are due to child abuse

9. 5-8% life time prevalence of severe physical punishment Sexual victimisation 20% in women and 5-10% in men Child sex trade: 75 000 children in Eastern Europe Risk factors Sex abuse more common post puberty Female perpetrate physical abuse and when males do this more likely to be fatal Poor, single parent, low education, substance misuse, isolation, unemployment Previous history of abuse In relationships where there is domestic violence Poverty, lack of social capital IN UK homicide is 5.9 times higher in lowest social class children than in highest Child abuse: Prevalence and risk factors

10. Contribution of the Adverse Childhood Experiences (ACE) Study • Health and social consequences of adverse childhood experiences 18000 participants, USA • Definition: Experiences that represent medical and social problems of national importance • childhood abuse and neglect, growing up with domestic violence, substance abuse or mental illness in the home, parental loss, or crime • Findings: • Psychological by parents 11%, Physical 11% • Sexual (anyone) 22% • Domestic violence 13%, substance abuse 26%, • mental illness 19%

11. Childhood Experiences vs. Adult Alcoholism 4+ 3 2 1 0 Associations found between Adverse Childhood Experience and risk factors of behaviour affecting adult health: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, substance misuse, 50+ sexual partners

12. Parent training and home visitation: € 1 spent saves € 19 Therapeutic treatment of violent parents Training of health professionals, teachers, police Better laws against violence in the home and physical punishment, mandatory reporting of child abuse Child abuse and prevention

13. 2: Intimate partner violence Mortality rates for interpersonal violence in females aged 30–44 by country and sub-region in the WHO European Region, 2002 (Source: HFA-MDB) 5200 deaths from violence in the European Region: 40-70% of murders due to intimate partner

14. The WHO Multi-country Study on Women’s Health and Domestic Violence against Women • First-ever WHO global study on domestic violence against women • Collecting data from over 24,000 women in ten countries • Documenting the prevalence of intimate partner violence and its association with women's physical, mental, sexual and reproductive health • Lifetime prevalence of physical assault is 10-60%

15. Violence against women is invisible 27% of physically abused women told no one about the violence 78% of physically abused women had never asked any formal agency for help Two thirds of physically abused women did not seek help because they thought such abuse “normal” or not serious enough to seek help Country example – Serbia and Montenegro • I suffered a long time and swallowed my pain. That is why I am constantly visiting doctors and using medicines. No one should have to do this. • Woman interviewed in Serbia & Montenegro

16. Risk factors History of violence, poor parenting, witnessing abuse, harmful alcohol use and poor educational attainment Low income, poverty, overcrowding, disagreements about money Societies with rigid gender roles, inequalities between men and women, concentrations of poverty, alcohol and substance misuse Prevention Attitudes and behaviours, anger management Relationship skills and family therapy Stimulating community action, providing services and training professionals Poverty reduction and alcohol misuse policies Risk factors and what works for prevention

17. Acts of commission or omission causing harm !n 2002, 11090 people over 60 murdered in Region Proportion attributed to elder abuse not known 4-6% older people; higher in institutions Risk factors Alcohol, substance misuse, personality problems Strained family relations, financial dependence Lack of social support networks Institutions geared to own rather than elderly interests 3. Elder abuse

18. Training of care givers, comprehensive care plans, care environments Help lines, shelters, strengthening health, social and volunteer services Educational campaigns to change public attitudes Training professionals in health, justice, social sectors NGOs, self help groups, Strengthening legal and policy frameworks to protect elders More research needed How can we prevent elder abuse

19. Links between types of violence Child maltreatment Intimate partner violence Shared risk factors (alcohol, substance abuse, parental loss, social isolation, mental illness, household poverty, crime, norms condoning violence inequalities) Sibling violence Elderabuse Life course approach to violence prevention

20. Risk factors - ecological model • Societal • Community • Relationship • Individual • Examples: • Inequalities • Norms that support violence • Availability of means • Weak police/criminal justice • Alcohol • Examples: • Concentration of poverty • High residential mobility • High unemployment • Social isolation • Local illicit drug trade • Examples: • Poor parenting • Marital conflict • Friends who engage in • violence • Examples • Demographic factors • Psychological and • personality disorders • History of violent behaviour • Experienced abuse

21. National action plan for violence prevention Enhance data collection Priorities for research on causes, consequences, costs and prevention Promote primary prevention Strengthen responses for victims Integrate prevention into social and educational policies Increase collaboration and exchange of information on prevention Adherence to international treaties, laws etc to protect human rights Internationally agreed responses to the global drugs and arms trade WHO Violence Prevention Programme

22. What can we do to decrease the burden of injuries? • Shift away from abrogating responsibility to individuals and undertake violence prevention as a societal responsibility • Recognise health sectors’ key role in developing a comprehensive societal response to violence prevention. • Foster multi-sectoral, comprehensive approaches that will enforce human rights, gender equality, and public health concerns to create safer environments for society’s vulnerable • Prevent violence against children to break the cycle of violence • Prioritise programmes aimed at primary prevention: • parental training/ support programmes, • school based prevention programmes • societal factors as alcohol, poverty

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24. How do we get there – other international initiatives • WHA and UN resolutions on violence as a public health problem and implementing the WRVH • Regional Committee Resolution EUR/RC55/R9 on Prevention of injuries in the WHO European Region • Ministry of Health Focal Points – there is at least one FP in 49 countries. • Global Strategy for Child Injury Prevention 2006 • World and European Reports on Child Injury Prevention (2008) • UNICEF - Regional consultations on injuries and violence against children • UN secretary-general’s study on violence against children and violence against women

25. Implement & Disseminate Develop & evaluate interventions Identify causes Describe the problem Problem Response The Public Health Approach • Population-based • Emphasis primary prevention • Multidisciplinary and Multi-sectoral • Science based

26. Age- and gender-specific mortality rates from interpersonal violence in European Region, 2002 25 20 15 Males Females 10 5 0 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ Age group Rates per 100,000 population Deaths are tip of the iceberg: psychological, physical and sexual damage and neglect. Not captured by routine data.