Violence Prevention in Low- and Middle-Income Countries Finding a Place on the Global Agenda: Workshop Summary (2008) / Chapter Skim
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Preventing Violence in Developing Countries: A Framework for Action--James A. Mercy, Alex Butchart, Mark L. Rosenberg, Linda Dahlberg, Alison Harvey
Preventing Violence in Developing Countries: A Framework for Action--James A. Mercy, Alex Butchart, Mark L. Rosenberg, Linda Dahlberg, Alison Harvey
Pages 125-148
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Rosenberg3 Linda Dahlberg1, 4 Alison Harvey2 Introduction In the year 2002, there were an estimated 1.6 million deaths due to violence throughout the world. This was around half the number of deaths due to HIV/AIDS, roughly equal to deaths due to tuberculosis, somewhat greater than the number of road traffic deaths, and 1.5 times the number of deaths due to malaria.1 The largest number of violent deaths was due to suicide: 870,000 cases or 54 percent.
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We define violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.2 Three general types of violence are encompassed by this definition: interpersonal, selfdirected, and collective. Interpersonal violence includes forms perpetrated by an individual or small group of individuals, such as child abuse and neglect by caregivers, youth violence, intimate partner violence, sexual violence, and elder abuse.2 Self-directed violence includes suicidal behavior as well as acts of self-abuse, where the intent may not be to take one's own life.4 Collective violence is the use of violence by groups or individuals who identify themselves as members of a group, against another group or set of individuals, to achieve political, social, or economic objectives.
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The first part addresses the processes required to develop and support effective violence prevention interventions, programs, and policies. The second part identifies broad strategies for preventing violence.
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In particular, health, criminal justice, and social service institutions play a critical role in addressing the needs of victims and formulating and implementing prevention strategies. The success of violence prevention efforts depends to a substantial degree on the ability of these sectors to work together and, in many cases, integrate their efforts.
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Strategic Foci for Primary Prevention Ultimately the goal of public health is to prevent violence from occurring in the first place. While moving toward that end it is important to
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. Increase Safe, Stable, and Nurturing Relationships Between Children and Their Parents and Caretakers Decades of research in the neurobiological, behavioral, and social sciences clearly indicate that exposure to maltreatment and other forms of violence during childhood negatively impacts brain development and increases subsequent vulnerability to a broad range of mental and physical health problems, ranging from anxiety disorders and depression to cardiovascular BOX C-2 Key Strategies for Violence Prevention Primary Prevention Strategies: • Change cultural norms that support violence • Promote gender equality and empower women • Reduce economic inequality and concentrated poverty • Increase safe, stable, and nurturing relationships between children and their parents and caretakers • Reduce access to lethal means • Reduce availability and misuse of alcohol • Improve the criminal justice and social welfare systems • Reduce social distance between conflicting groups Secondary and Tertiary Strategies: • Engage the health sector in violence prevention • Provide mental health and social service services for victims of violence • Improve emergency response to injuries from violence • Reduce recidivism among perpetrators
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There is good evidence that these types of programs are effective at influencing the child-rearing practices of families as well as, in the cases of early child home visitation and hospital-based shaken baby prevention programs, reducing maltreatment.12, 19-22 Early child home visitation programs include, to varying degrees, training of parents on child care, development, and discipline.22 They may also provide support by facilitating parent group meetings or in the form of daycare, transportation, and family planning services. These programs are typically targeted at lowincome families, but not exclusively.
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Harmful alcohol use directly affects physical and cognitive function.26 Reduced selfcontrol and ability to process incoming information makes drinkers more likely to resort to violence in confrontations,27 while reduced ability to recognize warning signs in potentially violent situations makes them appear easy targets for perpetrators.28, 29 Individual and societal beliefs that alcohol causes aggressive behavior can lead to the use of alcohol as preparation for involvement in violence, or as a way of excusing violent acts.30, 31 Dependence on alcohol can mean individuals fail to fulfill care responsibilities or coerce relatives into giving them money to purchase alcohol or cover associated costs.32, 33 Experiencing or witnessing violence can lead to the harmful use of alcohol as a way of coping or self-medicating.34, 35 Uncomfortable, crowded, and poorly managed drinking settings contribute to increased violence among drinkers.36, 37 Alcohol and violence may be related through common risk factors (e.g., antisocial personality disorder) that contribute to the risk of both heavy drinking and violent behavior.38 Prenatal alcohol exposure resulting in fetal alcohol syndrome or fetal alcohol effects are associated in infants with increased risk of their maltreatment, and with delinquent and sometimes violent behavior in later life, including delinquent behavior, sexual violence, and suicide.39 Central to preventing alcohol-related violence is to create societies and environments that discourage risky drinking behaviors and do not allow alcohol to be used as an excuse for violence.
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, and challenges or threats (by 41 percent) within those premises.48 Reduce Access to Lethal Means The lethality of interpersonal, self-directed, and collective violence is affected by the means people use to carry out this violence.
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For example, cultural traditions that favor male over female children, early marriage for girls, male sexual entitlement, and female "purity" place women and girls in a subordinate position relative to men and make them highly vulnerable to violent victimization.61, 62 More subtle cultural attitudes and beliefs about female roles may also contribute to violence and exist, to varying degrees, in every part of the world.63 An ethnographic study of wife-beating in 90 societies concluded that it occurs most often in societies where men hold the household economic and decision-making power, where divorce is difficult for women to obtain, and where violence is a common conflict resolution tactic.64 Rape is also more common in societies where cultural traditions favoring male superiority are strong.65 Maintaining the sexual purity of girls is a powerful cultural value that is associated with violence in many parts of the world. Female genital mutilation, for example, is a practice usually performed on girls before puberty in many parts of Africa, some Middle Eastern countries, and immigrant communities around the world.66 An estimated 80 to 135 million women and girls worldwide have undergone female genital mutilation.66, 67 "Honor killings," another extreme outcome of cultural traditions found mainly in Middle Eastern and South Asian countries, occur when a female is killed by her own family after her virginity or faithfulness has been brought into question because of, for example, infidelity or rape.64, 68 Data on this phenomenon are limited, but a study of homicides in Alexandria, Egypt, found that 47 percent of female victims were killed by a relative after they had been raped by another person.69 The cultural preference for male children is associated with high levels of female infanticide in China, Middle Eastern countries, and India.11 In China, the preference for sons is particularly strong in rural areas, where
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For example, in South Africa, Stepping Stones is an HIV prevention program that aims to improve sexual health through building stronger, more gender-equitable relationships with better communication and less violence between partners.74 A randomized controlled trial of the program found that, in addition to reducing HIV infection, the men in the program disclosed lower rates of perpetrating severe intimate partner violence at 12 and 24 months post-intervention.75 In a 3-year randomized study involving women from the Sekhukhuneland District of South Africa's Limpopo Province, the Intervention with Microfinance for AIDS and Gender Equity Study examined whether the provision of a microfinance program combined with education on gender and HIV/AIDS could socially and economically empower women and reduce intimate partner violence and HIV infection.76 The study was a joint initiative of the University of the Witwatersrand (Johannesburg) , the London School of Hygiene and Tropical Medicine, and the Small Enterprise Foundation in South Africa with funding from South Africa's Ministry of Health and the United Kingdom's Department for International Development.
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To date, however, the link between public awareness campaigns and intimate partner and sexual violence behavior change is not well established.79 In South Africa, the Institute for Health and Development Communication has won acclaim for using mass media to change attitudes and basic social norms around intimate partner violence through a broadcast series called Soul City.3 A multilevel intervention was launched over 6 months consisting of the broadcast series itself, print materials, a helpline, partnership with a national coalition on intimate partner violence, and an advocacy campaign directed at the national government with the aim of achieving implementation of the Domestic Violence Act of 1998. The strategy aimed for impact at multiple levels: individual knowledge, attitudes, self-efficacy, and behavior; community dialogue; shifting social norms; and creating an enabling legal and social environment for change.
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Attempts were made to measure impact on violent behavior but numbers were not sufficient to determine the impact.80 Improve the Criminal Justice and Social Welfare Systems Cross-national studies show that the efficiency and reliability of a nation's criminal justice institutions and the existence of programs that provide economic safety nets are associated with lower rates of homicide.81, 82 In Bahia, Brazil, one study concluded that dissatisfaction with the police, the justice system, and prisons increased the use of unofficial modes of justice.83 From the perspective of the primary prevention of violence, maintaining a fair and efficient criminal justice system contributes to the general deterrence of violence. Similarly, social welfare institutions provide basic supports for individuals and families in dire economic circumstances and, therefore, may serve to mitigate the effects of income inequality.
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in the United States found that enabling families to move from public housing complexes into neighborhoods with lower levels of poverty substantially reduced violence by adolescents.97 A systematic review of evaluations of the effects of housing voucher programs found them to also be effective in reducing violent victimization and property crime.98 Economic programs or policies to reduce the inequalities and extreme concentrations of poverty that exacerbate these inequalities may be among the most powerful strategies for preventing violence, although the evidence base for such interventions needs to be more firmly established. Strategic Foci for Secondary and Tertiary Prevention While an emphasis on primary prevention is essential for reducing the health burden associated with violence in the long term, secondary and
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Engage the Health Sector in Violence Prevention Physicians and other health professionals are key gatekeepers in efforts to monitor, identify, treat, and intervene in cases of interpersonal and self-directed violence. In fact, some studies show that more cases of interpersonal violence come to the attention of health care providers than to police.99 The potential role of health care providers in these efforts is not widely understood or embraced and there are many institutional and educational barriers limiting the effectiveness of even committed providers.100 Programs to educate health care providers are an essential first step in this process and a variety of such efforts are under way around the world.12, 49, 101 Screening programs to identify victims of intimate partner violence, child maltreatment, sexual violence, elder abuse, or suicidal behavior are also being used in many emergency departments, doctor's offices, and clinic settings around the world, although the effectiveness of these interventions in reducing subsequent violence is not well understood.12, 49 Despite our limited understanding of the effectiveness of various strategies for engaging the health care sector in violence prevention, activities in this area should be carefully considered as potentially important components of comprehensive efforts to prevent interpersonal violence.
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Suicidal behavior, for example, is a well-documented consequence of intimate partner violence, child maltreatment, and sexual violence.4, 12, 49 Given the potential for violence to impact upon a broad range of costly health outcomes, mental health and social services to intervene and reduce these costs should be considered an important component of secondary and tertiary prevention efforts. Mental health services, for example, are provided to victims in many parts of the world; however, while there is research that suggests these types of interventions can improve the mental health of victims, there is less information available on their other benefits.12, 103 Improve Emergency Response to Injuries from Violence Unless death occurs immediately, the outcome of an injury from interpersonal violence depends not only on its severity but also on the speed and appropriateness of treatment.104 Acute treatment of the injured requires a special approach.
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A framework for approaching violence prevention was first put forth in the World Report on Violence and Health and has been further refined and expanded in subsequent reports including the World Report on Violence Against Children, the Secretary General's Study of All Forms of Violence Against Women, and the chapter on interpersonal violence in the Second Edition of Disease Control Priorities in Developing Countries. The 1996 World Health Assembly resolution was cosponsored by a developing country, South Africa, and a developed country, the United States; both recognized the importance of making violence prevention a global public health priority even before evidence of effectiveness could be collected.
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Preventing Violence: A Guide to Imple menting theRrecommendations of the World Report on Violence and Health. Geneva, Switzerland: Department of Injuries and Violence Prevention, World Health Organiza tion, 2004.
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Adverse consequences of intimate partner abuse W among women in non-urban domestic violence shelters. American Journal of Preventative Medicine 2000;19:270-275.
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Violence by intimate partners. In: Krug E, Dahlberg LL, H Mercy JA, Zwi AB, Lozano R, eds.
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A cluster randomized controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behavior amongst youth in the rural Eastern Cape, South Africa: trial design, methods, and base line findings. Tropical Medicine and International Health 2006;11:3-16.
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Why is collective violence collective? Sociological Theory 2001;19:126-144.
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The ef fectiveness of therapeutic foster care for the prevention of violence: a systematic review. American Journal of Preventive Medicine 2005;28(2S1)
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