Violence Prevention

The Evidence
Karen Hughes
Centre for Public Health, Liverpool John Moores University
WHO Collaborating Centre for Violence Prevention
 Introduction
• 1.6 million people die each year through violence
 Estimated economic cost of $151 billion

• Millions more affected as victims and witnesses

 Physical and mental health
 Education and employment
 Relationships and social functioning
 Cycles of violence

• Preventing violence major priority

• Public health approach
 Intelligence-led
 multi-agency
 evidence-based

• What works to prevent violence

 Updating the Evidence
• Lots of new research since 2002
 Need to re-review the evidence

• Series of briefings based on 7 scientifically viable strategies

• Provide overview of evidence for their effectiveness

• Easily accessible to non-specialists

• Neither under- nor over-stating the case

• Encourage implementation of these interventions

• Identify main gaps in the current evidence base

 The Series
• Academic & grey literature
 Database searches
 e.g. Medline
 Systematic reviews
 Internet searches
• Balance between high quality
evidence and geographical
coverage
• Peer review process

www.who.int/violence_injury_prevention www.cph.org.uk
Developing safe, stable & nurturing relationships
between children & their parents & caregivers

• Children at greater risk of being abused when:

 Parents have little understanding of child development, are less
affectionate and responsive, use harsh or inconsistent
punishment..

• Early relationships are central to a child’s development

 Affect brain development
 Affect social, emotional and intellectual development

• Lack of safe, stable and nurturing relationships in childhood

can have long-lasting effects:
 Anxiety, low self-esteem, difficulty forming relationships
 Increased risks of violence
Childhood Violence and Adult Health
Increased risk of health behaviours and conditions as adults for individuals
experiencing four or more Adverse Childhood Experiences in childhood.

• Abuse (Physical, sexual, emotional)

• Neglect (Physical, emotional)
• Household Dysfunction (mother treated violently, substance abuse,
mental illness, parental separation / divorce, incarcerated household member

Anxiety x 2.4
Severe obesity x 1.9
Alcoholism x 7.2
Illicit drug use x 4.5
Sexually transmitted infections x 2.5
Current smoker x 1.8
Perpetrating partner violence x 8.8
Any cancer x 1.9
Felitti et al, 1998; Anda et al, 2006
Safe, stable & nurturing relationships
Early, primary prevention to teach parenting skills and
support healthy child development
• Parenting programmes Some strong evidence
 Information & support for parents that parenting
• Parent & child programmes programmes and
 Preschool education, family parent and child
support, child/health services etc.
programmes can
• Social support groups
reduce child
 e.g. peer support for parents
maltreatment and
• Media interventions
problem/aggressive
 e.g. raise awareness & knowledge
of child maltreatment behaviours in youth
 Nurse-Family Partnership, USA
• Targets low-income first time mothers
• Pre and post natal nurse home visits (early in pregnancy to age 2)
 Develop better parenting and emotional bonding
 Promote and teach:
o Health behaviours (mother/child)
o Child care skills
o Maternal personal development
• Long term evaluation – 15 years
• Lower levels of child abuse/neglect by mothers
• Children born to participating mothers:
 Fewer behavioural problems
 Fewer arrests/convictions
 Fewer injuries
 Fewer sexual partners
 Lower frequency of alcohol consumption
• Most effective for deprived women Olds et al, 1996,1998, 2005
 Developing life skills in children & adolescents

“Abilities for adaptive and positive behaviour that enable individuals to

deal effectively with the demands and challenges of everyday life”
 Self-awareness (e.g. self-esteem)
 Self-management (e.g. coping skills)
 Social awareness (e.g. empathy)
 Relationships (e.g. conflict management)
 Decision making (e.g. critical thinking) World Health Organization

Interventions to develop life skills can:

 Improve social and emotional competence
 Improve school participation & performance
 Increase prospects for employment
Addressing risk factors for violence:
 Poor social competence
 Low academic achievement and truancy
Developing life skills in children & adolescents
Provide cognitive, emotional, interpersonal & social skills to
enable youth to deal with the challenges of life

• Preschool enrichment
Some strong evidence
 Child skills, parent programmes
that preschool
• Social development training enrichment and social
 Empathy, relationships, conflict development
resolution, anger management..
programmes can
•Cost effectiveness
Academic enrichment
reduce aggression and
 Study
Early childhood education
& recreation out of school
(3-4 year olds)
improve social skills,
•Average
Vocational Training
benefit particularly in at-risk
 Providing
- $2.35 skills dollar
for every to find work
invested youth
 Preschool Enrichment
• Preparing children for school
• Social, emotional and educational skills
• Chicago Child-Parent Center, USA
• Children aged 3-9 in deprived areas
 Preschool enrichment
 ongoing support in formal education
 Intensive parent programme

• By age 20, participants showed (cf controls):

• Fewer arrests (including for violent offences; 9% v 15%)
• Greater higher school completion (50% v 38.5%)

• Age 24 - lower depressive symptoms, higher employment

• Also associated with lower rates of child maltreatment
Reynolds et al, 2001, 2003, 2004
Social Development Programmes

Bigfoot Arts Education Ltd

• Emotional & social skills
• Self-control
• Positive self-esteem
• Relationship skills
• Problem solving skills

• Promoting Alternative Thinking Strategies (PATHS)

• 131 lessons over 5 years; teacher training

• Regular school children

• ↓ peer-rated aggression, hyperactivity, ↑emotional competence
• Children with behaviour and learning problems
• ↓conduct problems, depression, anxiety, ↑problem solving
• Successful school programmes
• high quality, longer intervention, at-risk groups, positive skills
Greenburg et al, 1997; CPPRG 1997; CSVP Blueprints, 1998; Curtis and Norgate, 2007
Reducing availability & harmful use of alcohol
• Strong links between alcohol and violence
 Affects physical and cognitive function
 Beliefs that alcohol causes aggression
 Used to prepare for/excuse violent acts
 Dependence - failure to fulfil care duties
 Prenatal exposure - foetal development
 Drinking a coping mechanism in victims
 Common risk factors

• 30% violent deaths related to alcohol

 8% in Middle East and North Africa
 56% in Europe and Central Asia

• Reduce violence and other alcohol-related harm

 Reducing availability & harmful use of alcohol

 Regulating alcohol availability Evidence promising,

• sales times, outlet density suggesting that
Australia (VIC), spatial
Raising alcohol prices analysis alcohol-focused
• Increasing accelerating
• e.g taxation, effect
minimum for density
price
measures can reduce
of pub licences on violence violence. However,
 Reducing alcohol use in risky
• Dramatic
drinkersincrease in liquor licenses many barriers and
• Currently capped
• e.g. brief Livingston, 2008
interventions, treatment
few available studies
for alcohol dependence;
England, economic modelling
• minimum
Improving drinking
price environments
of 50p/alcohol unit
• estimated wouldpartnerships,
• Community save:
• 2.1%responsible retailing, strict
of all violence
enforcement, physical design…
• 10,300 incidents a year Meier et al, 2008
 Targeting alcohol sales in Brazil
44% reduction over 3 years
 Diadema, Brazil Average 9 per month
 60% of murders and 45% Homicide rate Closing time regulation
complaints of violence
against women between
23:00 and 06:00
 Many linked to alcohol
 2002: municipal law banned
alcohol sales after 23:00 Rate of assaults against women
Closing time regulation
 Public and alcohol retailer
information campaign
 Strict enforcement of law by
multi-agency team

Dualibi S et al., The effect of restricting opening hours

on alcohol-related violence. Am J Public Health. 2007
Reducing access to lethal means
• Lethality of violence can depend on means used
• Three lethal means account for a significant proportion
of homicide and suicide
Guns
• 360,000 firearm homicides in non-conflict situations each year
• A further 52,000 deaths directly through armed conflict

Knives
• Around 40% of homicides in the European Region are due to
knives and sharp implements

Pesticides
• Pesticide ingestion accounts for 370,000 suicides each year -
over a third of all suicides
Reducing access to lethal means

Removing the means to lethal violence

• Legislative measures Some evidence of

 E.g. bans and licensing schemes success, mainly for
• Increased enforcement firearms legislation.
Elsewhere evidence
 E.g. test purchasing, stop and search
base poorly
• Weapons amnesties developed. More
• Safer storage research needed,
 E.g. provision of pesticide storage particularly in
facilities developing countries
 Preventing Access to Lethal Means
• Gun law reforms in Austria, 1997
 minimum firearm purchase age of 21
 valid reason to purchase a firearm
 background checks/psychological testing
 three day waiting period between firearm
licensing and purchasing;
 safe firearm storage regulations New Zealand
Reductions in firearm
•Associated with: suicides following
 Reduced license demand legislative changes
 Reduced gun homicides particularly seen in
under 25s
 Reduced suicides
• not substituted with increases in suicides using other means

Kapusta et al, 2007; Beautrais et al, 2006

Preventing and reducing armed violence
• Direct approaches
 Measures to reduce access to firearms

 Firearm injury prevention programmes

 Criminal justice interventions

 Community based programmes

• Indirect approaches
 Parenting programmes

 Life skills programmes

 Alcohol-targeted measures

 Environmental and urban design

 Disrupting illegal drug markets

 Programmes to reduce inequalities

www.euro.who.int

www.cph.org.uk
Promoting gender equality to prevent violence
against women

• Relationships between gender and violence are complex

• Different roles and behaviours of males and females are
shaped and reinforced by gender norms in society
• Differences in these roles and behaviours can create
gender inequalities which can:
 Increase the risk of violence by men against women
 Hinder victims’ ability to remove themselves from
violence and seek support
• Challenging ideas that one sex has more power and control
over another; a reason for violence against women
Promoting gender equality to prevent violence against
women

• School-based interventions
 Addressing gender norms and Good evidence for
attitudes, e.g. safer dating
school-based
• Community interventions programmes. Some
evidence for
 Microfinance programmes,
combined with gender equity community-based
training interventions,
although further
• Life skills programmes
research is needed
 educate about gender-based
violence and develop relationship
skills
IMAGE: Microfinance in South Africa
• Intervention with Microfinance for AIDS and Gender Equity
 improve women’s employment opportunities
 increase influence in household decision making
 increase ability to resolve marital conflicts
 strengthen social networks
 reduce HIV transmission

• Women in poorest rural households

 Financial services
 Training & skill building
 Community participation to engage males

• Two years after programme

 55% fewer acts of intimate partner violence
 Less controlling behaviour by partners
 Better household communication

Pronyk et al 2006; Kim and Watts 2007

Changing cultural and social norms that support
violence
• Cultural and social norms strongly
influence individual behaviour
• Cultural acceptance of violence is a
risk factor for many violence types
• Social tolerance of violence likely
learned in childhood, e.g.
 Use of corporal punishment
 Witnessing violence in the family
 Violence in the media
• Interventions challenge rules or
behaviour expectations that
tolerate violent behaviour
Child maltreatment
Physical punishment is a
normal part of rearing a child
Intimate partner violence
A man has a right to
discipline female behaviour
Sexual violence
Sexual activity (inc. rape) is a
marker of masculinity
Youth violence
Violence is an acceptable
way of resolving conflict
Suicide and self-harm
Mental health problems are
embarrassing and shameful
Changing cultural and social norms that support
violence

• Mass media campaigns

 Providing messages on health
behaviour to a wide audience Limited evidence for
 edutainment most types of
• Social norms / marketing interventions in this
area. Further
 Targeting specific groups
rigorous evaluations
 Correcting misperceptions of
cultural norms are needed.

• Laws and policies

 Implementing laws that make
violent behaviour an offence.
Changing social norms in South Africa

Soul City
• Social and behavioural change
• Edutainment:
 Soap opera, radio, information booklets
 Address social issues
o Violence against women
o Alcohol and violence
• Intimate partner violence (IPV)
 After 8 months:
 Less acceptance of IPV
 Increase in belief that communities can help prevent IPV
 No measurement of violent behaviour
Usdin et al, 2005
 Victim identification, care and support
programmes
• Violence often hidden:
 Child and elder abuse
 Intimate partner violence
• A women will be assaulted an average
of 35 times before reporting to police
 Witness and community intimidation
• Violence can lead to:
 Lifelong physical & mental health
problems
 Social and occupational impairment
 Increased risk of further violence

• Identifying and supporting victims critical in breaking

cycles of violence and limiting long term impacts
Victim identification, care and support
programmes
• Screening and referral
 Identifying and supporting victims of Good evidence for
violence
the use of advocacy
• Advocacy support support
 Support and guidance to victims, programmes.
e.g. counselling, education, legal aid.
Promising evidence
• Psychosocial interventions for screening and
 Treat emotional & behavioural referral, psychosocial
problems linked to victimisation.
interventions and
• Protection orders protection orders
 Prohibit perpetrators from further
abusing their victims
 Supporting abused pregnant women in China

• Based on US programme (Parker et al, 1999)

 Empowerment training – enhance women’s independence and control
 Reduced violence in pregnant abused women

• Hong Kong
 Pregnant women attending first antenatal appointment
 Screened for physical, sexual and emotional intimate partner abuse
 Assigned to intervention or control (standard care)
• Intervention Control: information card
 One-to-one session (30 mins)
 Advise on safety, decision making and problem solving
 Additional component on empathic understanding
 Cultural modifications (e.g. ‘shame’ of disclosure outside family)
• After intervention:
 Less psychological and minor physical violence (but not less sexual or
severe physical violence)
 Also lower post natal depression Tiwari et al, 2005
State of the Evidence
• Brief overview of the series
• Wide range of interventions can prevent violence
 Individual, relationship, community and societal levels
 Throughout the life course
 Wide range of agencies involved in their delivery
• Quality of the evidence varies widely
• Strongest evidence for early life, primary prevention
 Randomised controlled trials
 Long term follow up
 Cost effectiveness
• Promising evidence elsewhere, need greater research
 Outcome evaluations
• Geographical spread of evidence is poor
 Need for research in low- and middle-income countries
Gaps in the Evidence Base
www.preventviolence.info
Gaps in the Evidence Base
www.preventviolence.info

One of 11 reviews on injury

and violence prevention
UK Focal Point for VIP
 Summary
• Enhance investment in research on violence and violence
prevention
– especially in low- and middle-income countries
– expanding the number of outcome evaluation studies

• Increase the flow to low- and middle- income countries of

financial resources and technical support for violence
prevention
• The need to expand the evidence base in no way precludes
taking action now and implementing interventions
• Intensify and expand violence prevention awareness
among decision makers
 Thank You
And special thanks to:
Mark A Bellis
Sara Wood
Chris Mikton
Alex Butchart
Zara Quigg

k.e.hughes@ljmu.ac.uk
www.cph.org.uk
www.who.int/violence_injury_prevention