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					                    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
                    HIV/AIDS                               14.1
          Homicide/violence                              12.9
                Tuberculosis                       7.9
         Road traffic injuries                 6.9
   Ischaemic heart disease                   5.9
                      Stroke           4.6
   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

                   400
Number of deaths




                   350
                   300
                   250

                   200
                   150

                   100
                   50

                    0




                                         +
                     <1

                             4

                                    9

                                        4

                                        9

                                        4

                                        9

                                        4

                                        9

                                        4

                                        9

                                        4

                                        9

                                        4
                                      65
                          1-

                                 5-

                                      -1

                                      -1

                                      -2

                                      -2

                                      -3

                                      -3

                                      -4

                                      -4

                                      -5

                                      -5

                                      -6
                                    10

                                    15

                                    20

                                    25

                                    30

                                    35

                                    40

                                    45

                                    50

                                    55

                                    60
                                        Age in years
              Background
                  Mortality rate / 100, 000 population
                  Western Cape vs. National
               140
               120
               100
                 80
                 60
                 40
                 20
                  0
                            Males                 Females

                            National         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                  Females

                             World            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                 Community

                         Child   Partner   Elder   Acquaintance    Stranger
Nature of violence
      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      2) Risk Factor
    What is the         Identification
    Problem?             What are the
                           causes?




4)Implementation     3) Develop and
   How is it done?         Evaluate
                        interventions
                         What works?
            Risk factors - ecological model




       Structural         Societal         Behavioural       Biological
Examples:            Examples:                Examples
                                         Examples:
   • Inequalities                              PoorDemographic factors
                        • Concentration of•poverty• parenting
                        • violence
   • Norms that supportHigh residential mobility conflict
                                                  • Psychological and
                                             • Marital
   • Availability of means unemployment personality disorders
                        • High               • Friends who engage in
   • Weak police/criminal justice
                        • Social isolation violence
                                             trade
                        • Local illicit drug • History of violent
                                             behaviour
 Source: TEACH VIP                           • Experienced abuse
 www.who.int/violence_injury_prevention/publications/violence/en/index.html
              Interventions - ecological model




       Structural          Societal         Behavioural        Biological

Examples Examples                                  Examples
                                                Examples
   • Public information alcohol availability
                • Reducing                             • Social development
                                                   • Parenting programmes progs.
                  Changing judicial systems
   • Strengthen• police and institutional settings • Home visitation
                                                       • Vocational training
                • Identify inequality
   • Reduce poverty andand refer people at risk forFamily therapy and support
                                                   • violence care
                                                       • Victim
                • reform
   • EducationalImproving trauma care and health care
                                                   • 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

   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)
        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
            Case study – Colombia
                                                                                                140




                                       Age standardised mortality rate per 100,000 population
                                                                                                120

                                                                                                100
   Cali 126 to 90/100,000
                                                                                                 80
   Bogota 82 to 26/100,000
                                                                                                 60

                                                                                                 40

                                                                                                 20

                                                                                                  0


                                                                                                  91

                                                                                                       92

                                                                                                            93

                                                                                                                 94

                                                                                                                      95

                                                                                                                           96

                                                                                                                                97

                                                                                                                                     98

                                                                                                                                          99

                                                                                                                                               00

                                                                                                                                                    01

                                                                                                                                                         02

                                                                                                                                                              03

                                                                                                                                                                   04
                                                                                                 19

                                                                                                      19

                                                                                                           19

                                                                                                                19

                                                                                                                     19

                                                                                                                          19

                                                                                                                               19

                                                                                                                                    19

                                                                                                                                         19

                                                                                                                                              20

                                                                                                                                                   20

                                                                                                                                                        20

                                                                                                                                                             20

                                                                                                                                                                  20
   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
                                                       Firearm     Non-firearm     All homicide
     Age standardised mortality rate per




                                           80
                                           70
            100,000 population




                                           60
                                           50
                                           40
                                           30
                                           20
                                           10
                                           0
                                                2001             2002            2003         2004

Source: Matzopoulos 2005. Sixth annual report of the NIMSS
                    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
                                           -21.7                          -20.3

  -30.0
                                 -31.7
  -40.0                                              -36.1

                                                                                               -44.1
  -50.0                                                         -47.5                -47.7
           -49.0

  -60.0                                                                                                             -57.0


  -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

   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

				
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