VIOLENCE PREVENTION the Western Cape Burden of Disease Reduction Project

1. 1 Professor Craig Househam Head of the Western Cape Department of Health South Africa VIOLENCE PREVENTION the Western Cape Burden of Disease Reduction Project

2. 2 The Western Cape One of nine provinces of South Africa Population: 4 - 4½ million Climate: Mediterranean, semi-desert Economy: tourism, manufacturing, agriculture SA’s highest per capita GDP SA’s highest Gini coefficient (>0.6 & increasing)

3. 3 Western Cape premature mortality (YLL) in 2000 Source: Bradshaw et al. 2004, SANBD Study 2000: estimates of provincial mortality. Combined Injury Burden > 22% More than MID (HIV/AIDS andTB) • Second leading cause of premature mortality in WC

4. 5 Key challengesEvidence based approach • Most studies demonstrating effectiveness originate from HIC’s and are not necessarily replicable in LMIC’s where there is limited capacity for local research • Available evidence resides primarily at the biological and behavioural level and this prompts a programmatic rather than an upstream focus • Conversely the largest number and potentially far reaching interventions are at the societal and structural levels • Need to recognize macro-structural, economic and political realms that foment many of the factors we seek to address

5. 6 Homicide rates (2000) Provincial vs National vs Global Source: (1) Norman et al. 2007. The high burden of injuries in South Africa. WHO Bulletin. (2) Bradshaw et al. 2004, SANBD Study 2000: estimates of provincial mortality. . • Higher than national average for males and females • 10x higher than world average for males, 7x for females

6. 7 Inequality • apartheid legacy of • social exclusion • multiple deprivation • urbanization and migration Source: Groenewald et al. in press. Cause of death and premature mortality in Cape Town, 2001-2006 Homicide by area in Cape Town

7. 8 Elsies River Community Health Center (CHC) November 2010 (n=257)Non-fatal injuries Violence > 60% Resulting in 33% of deaths

8. 9 Elsies River CHC, November 2010 (n=164)Alcohol and drug use Victims of violence Alcohol the drug of abuse in > 90% of intoxicated cases

9. 10 Approach to reducing alcohol-related violence 1. Reduce alcohol consumption i) Reduce demand for alcohol ii) Reduce access to alcohol 2. Invest in safer drinking environments 3. Address upstream causes of violence 4. Research, monitoring and evaluation 5. Establish an transversal structure to address issues related to alcohol

10. 11 Reduce alcohol consumption • Reduce demand for alcohol • TV mass media and community campaigns • Brief Motivational Interviewing • Restriction and regulation of alcohol advertising Most options have political support although varied Effectiveness - ranges from untested to moderate effectiveness

11. 12 Reduce alcohol consumption ii) Reduce access to alcohol: • Reduce trading hours • Prohibit outlets in residential areas Potentially politically controversial and all controversial options have not been fully explored (e.g. targeted reduction in trading hours) Potentially the most cost-effective option which could reduce violence by nearly 50% in the very short term (e.g. introduction of a limit on opening hours in Diadema Brazil reduced the murder rate by 44%)

12. REDUCE AVAILABILITY Population level • Legislation - Western Cape Liquor Act • Reduced trading hours • No liquor outlets in residential areas • Many other aspects of strengthening the act to reduce access to liquor SUCCESS : SAB reports reduced sales SUCCESS : BoD team part of Liquor Act Task Team

13. REDUCE DEMANDEducation and persuasion Source: Babor 2005. Alcohol no ordinary commodity. .

14. Reduce demandRegulate promotion Source: Babor 2005. Alcohol no ordinary commodity. .

15. Create safer drinking environments Measures proposed such as: • Obligation to serve food with alcohol sales • Improved street lighting • Improved security using CCTV cameras Politically more popular Effectiveness is moderate and closely linked with ability to enforce or implement

16. Other actions Address upstream causes such as • Income inequality and Early Childhood Development (ECD) • Long-term investments for sustainable prevention Research, Monitoring and Evaluation • Need for systematic data collection on alcohol-related indicators across sectors Urgent need for inter-sectoralstructure that design and implements multi-sectoralinterventions

17. Role of media and media advocacy 1. Stimulate social mobilisation 2. Place alcohol issues on political agenda 3. Gain popular support for effective interventions e.g. legislation to reduce access Importance of social mobilization and education highlighted by WHO, Lancet Reviews, Global Alcohol Policy Experts

18. Booza TV Project • Booza TV= collection of edited documentary, animation and fictional material on drinking developed by the Western Cape Department of Health • Various product formats possible: • 6 part TV/DVD series (broadcast, captive audiences, stakeholder groups) • Tailor made products e.g. Selected episodes such as the violence related episode for police services • Workbook component for educational purposes • Web presence through website, Facebook and Twitter

19. Surveillance • Provincial Injury Mortality Surveillance • institutionalized within provincial government • improved geo-spatial variables • linkage with vital registration • place of residence and place of death • Health service-based surveillance (Morbidity) • Rich source of risk factor information • GIS analysis • Integrated information systems that measure exposure • liquor outlet densities • multiple deprivation

20. Prevention – long-term • Continue to lobby provincial and municipalities • Comprehensive approach across departments • Promote documentation, monitoring and evaluation • Collaboration to instill “culture of evaluation” • Partnership with academic and research initiatives • Multi-country collaboration with Scotland, Lithuania and others

21. Key challenges Realities of government • Structure of government • Difficulty in delivering transversal projects • Silo-based approach within tiers – lead agencies • Fragmentation – national, provincial, metro/local • Short timeframes – typically five years of a political term • Provincial Transversal Management System as the counter • Politicization of violence and crime prevention • Over-reliance on criminal justice system • Lack of continuity with changes in government. • Both threaten the required long-term, holistic approach

22. Injury Prevention Working Group All injuries Interpersonal violence & Road Traffic injuries Largest contributors to injury BoD Alcohol-related Interpersonal violence and road injuries Groundwork for broader interventions Largest contributing risk factor to injury BoD Vision: To reduce injuries in the Western Cape

23. Aims of injury workgroup • Reduce alcohol-related injury • Establish foundations for broader violence prevention policy • Provide a framework for monitoring and evaluation of injury reduction programs

24. Two immediate priorities • High 5 A focus on 5 high risk areas to deliver intersectoral and holistic alcohol-related violence reduction interventions 2. Violence prevention policy A violence prevention policy founded on best practice guiding principles to optimize effectiveness and sustainability

25. MURDER OUT OF 149 STATIONS IN PROVINCE 50 % OF PRIORITY CRIME COMES FROM 5 STATIONS MITCHELL PLAIN KHAYELITSHA NYANGA KUILSRIVIER GUGULETU ATTEMPTED MURDER ROBBERY AGGR(TRIO) RAPE ASSAULT GBH ASSAULT COMMON Source: SAPS Western Cape 2010

26. The “High 5” approach Violence is CONCENTRATED Approx. 50% of alcohol-related violence occurs in 5 areas Source: PIMMS (DoP analysis)

27. Brief Interventions for trauma patients The teachable moment Screening and brief interventions – trauma-units victims/perpetrators (teachable moments) Screen for drugs and alcohol Randomized controlled trial (3 groups) Cost-effectiveness component Researchers from MRC, UCT STATUS: PILOTING IN KHAYELITSHA AND ELSIES RIVER PLANNED- FUNDING OBTAINED

28. Social Mobilization campaign Pilot study results:Booza TV is effective in • challenging normative views about drinking; and • successfully mobilised support for evidence-based interventions including the Liquor Act, most notably amongst BINGE DRINKING YOUTH AIMS: • Challenge binge-drinking culture and behaviour • Mobilisation for evidence-based interventions to reduce alcohol abuse • Promote action for safer drinking practices and environments Target Groups: 1. Drinkers 2. Intervention agents (e.g. Govt, NGOs, CBOs) 3. Public Messengers (media) STATUS: Proposal developed and will be discussed with PGWC communication

29. Violence Prevention PolicyTwo key requirements 1. Sound guiding principles 2. Sustained action/institutionalisation • PGWC draft guiding principles include the following key concepts: • Complexity - violence prevention and safety promotion require multiple solutions across sectors and these should be underpinned by sound evidence • Safety is a human right • Individual and collective action is required • Underscores PGWCs long-term commitment to effective action

30. Acknowledgements • BoD Project Task Team • BoD Surveillance Working Group • BoD Injury Prevention Working Group • WHO Violence and Injury Prevention • The South African Police Service

31. THANK YOU