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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 14.1 HIV/AIDS 12.9 Homicide/violence 7.9 Tuberculosis 6.9 Road traffic injuries 5.9 Ischaemic heart disease 4.6 Stroke 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 450 350 300 250 200 150 100 50 Age in years 65 + 10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 59 14 0 <1 Number of deaths 400 Background Mortality rate / 100, 000 population Western Cape vs. National 140 120 100 80 60 40 20 0 Males National Females 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 World Females 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 Nature of violence Child Partner Elder Community Acquaintance Stranger 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 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? Risk factors - ecological model Structural Societal Behavioural Biological Examples: Examples: Examples: Examples • Inequalities • Concentration of•poverty Poor • Demographic parenting factors • Norms that support violence • High residential mobility • Marital • Psychological conflict and • Availability of means • High unemployment • Friends personality who engage disorders in • Weak police/criminal justice • Social isolation violence • Local illicit drug •trade History of violent behaviour • Experienced abuse Source: TEACH VIP www.who.int/violence_injury_prevention/publications/violence/en/index.html Interventions - ecological model Structural Societal Behavioural Biological Examples Examples Examples Examples • Public information • Reducing alcohol availability • Parenting • Social programmes development progs. • Strengthen• police and institutional judicial systems Changing settings • Home • Vocational visitationtraining • Reduce poverty andand inequality • Identify refer people at risk for violence • Family • Victim therapy care and support • Educational reform trauma care and health• care • Improving 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 Cali 126 to 90/100,000 Bogota 82 to 26/100,000 Age standardised mortality rate per 100,000 population Case study – Colombia 140 120 100 80 60 40 20 04 03 20 20 02 01 20 00 20 20 99 98 19 19 97 96 19 19 95 94 19 93 19 19 92 19 19 91 0 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 Age standardised mortality rate per 100,000 population Firearm Non-firearm All homicide 80 70 60 50 40 30 20 10 0 2001 2002 2003 Source: Matzopoulos 2005. Sixth annual report of the NIMSS 2004 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 -20.3 -21.7 -30.0 -31.7 -36.1 -40.0 -44.1 -50.0 -47.5 -49.0 -47.7 -57.0 -60.0 -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