Violence

1
Violence

• Review of risk factors and interventions

2
Aim and objectives

• describe risk factors for violent, aggressive
  behaviour
• prevalence of risk factors in SA and WC
• evidence for prevention strategies

3
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

4
Background
Premature mortality in Western Cape (YLL) in 2000

• Second leading cause of premature mortality in WC
• 12.9 vs. 6.9 for traffic - ratio gt most other
  provinces

Source Bradshaw et al. 2004, SANBD Study 2000
estimates of provincial mortality.
5
Violence by age and sex, Cape Town, 2003 (n2111)
6
Background
Mortality rate / 100, 000 population Western
Cape vs. National

• Higher than national average for males and females

Source Bradshaw et al. 2004, SANBD Study 2000
estimates of provincial mortality.
7
Background
Mortality rate / 100, 000 population Western
Cape vs. World average

• 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. .
8
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 .
9
The different faces of violence
Source TEACH VIP www.who.int/violence_injury_prev
ention/publications/violence/en/index.html
10
Typology of violence
Source TEACH VIP www.who.int/violence_injury_prev
ention/publications/violence/en/index.html
11
Typology of violence
Source TEACH VIP www.who.int/violence_injury_prev
ention/publications/violence/en/index.html
12
Approaches

• Crime prevention
• Human rights approach
• Developmental science
• Public health approach

13
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?
14
Risk factors - ecological model
Biological
Behavioural
Societal
Structural

• Examples
• Inequalities
• Norms that support violence
• Availability of means
• Weak police/criminal justice

• Examples
• Demographic factors
• Psychological and
• personality disorders

• Examples
• Poor parenting
• Marital conflict
• Friends who engage in violence
• History of violent behaviour
• Experienced abuse

• Examples
• Concentration of poverty
• High residential mobility
• High unemployment
• Social isolation
• Local illicit drug trade

Source TEACH VIP www.who.int/violence_injury_prev
ention/publications/violence/en/index.html
15
Interventions - ecological model
Biological
Behavioural
Societal
Structural

• Examples
• Public information
• Strengthen police and judicial systems
• Reduce poverty and inequality
• Educational reform
• Reduce access to means
• Job creation programmes

• Examples
• Reducing alcohol availability
• Changing institutional settings
• Identify and refer people at risk for violence
• Improving trauma care and health care
• access

• Examples
• Social development progs.
• Vocational training
• Victim care and support

• Examples
• Parenting programmes
• Home visitation
• Family therapy
• Mentoring programmes

Source TEACH VIP www.who.int/violence_injury_prev
ention/publications/violence/en/index.html
16
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

17
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

18
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.

19
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

20
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
  
• Womens networks to challenge norms and beliefs
  re violence
• Change young mens attitudes, behaviours
• Reducing unintended pregnancies
• Peer mediation or peer counselling for children
• Life skills training programmes
• Recreational programmes for children

21
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.

22
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

23
Limitations of the evidence

• Behavioural and proximal societal bias (esp at
  the relationship level)
• More common, cheaper, easier to design, implement
  and evaluate
• Intuitively distal societal and structural
  interventions may be more effective
• Paucity of interventions from LMICs
• Do not discount the promising interventions (yet)

24
Case study Colombia

• Bogota, Cali succeed in reducing homicide rates
• Similar guiding principles
• 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
• 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

25
Case study Colombia

• Cali 126 to 90/100,000
• Bogota 82 to 26/100,000

• Mayor institutionalises prog.
• 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
26
Violence mortality rates in Cape Town 2001 to 2004
Source Matzopoulos 2005. Sixth annual report of
the NIMSS
27
Change in age stdd homicide rates, Cape Town
2001 - 2004
Source Groenewald et al. Local level mortality
surveillance utility for evaluation of
intersectoral interventions to reduce violence.
28
Research priorities for local community
interventions

• 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