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
Felitti et al, 1998; Anda et al, 2006
Any cancer x 1.9
Safe, stable & nurturing relationships
Early, primary prevention to teach parenting skills and
support healthy child development
• Parenting programmes
 Information & support for parents
• Parent & child programmes
 Preschool education, family
support, child/health services etc.
• Social support groups
 e.g. peer support for parents
• Media interventions
 e.g. raise awareness & knowledge
of child maltreatment
Some strong evidence
that parenting
programmes and
parent and child
programmes can
reduce child
maltreatment and
problem/aggressive
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:
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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)
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
World Health Organization
Developing life skills in children & adolescents
Provide cognitive, emotional, interpersonal & social skills to
enable youth to deal with the challenges of life
• Preschool enrichment
 Child skills, parent programmes
• Social development training
 Empathy, relationships, conflict
resolution, anger management..
effectiveness
•Cost
Academic
enrichment
 Study
& recreation
out of school
Early
childhood
education
(3-4 year olds)
•Average
Vocational
Training
benefit
 Providing
skills dollar
to find work
- $2.35
for every
invested
Some strong evidence
that preschool
enrichment and social
development
programmes can
reduce aggression and
improve social skills,
particularly in at-risk
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
• Emotional & social skills
• Self-control
• Positive self-esteem
• Relationship skills
• Problem solving skills
Bigfoot Arts Education Ltd
Social Development Programmes
• 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
• sales times, outlet density
(VIC), spatial
Australia
Raising alcohol
prices analysis
• Increasing
accelerating
effect
for density
• e.g taxation,
minimum
price
of pub licences on violence
 Reducing alcohol use in risky
• Dramatic
drinkersincrease in liquor licenses
• Currently
capped
Livingston, 2008
• e.g. brief
interventions, treatment
for alcohol dependence;
England, economic modelling
• minimum
Improving
drinking
environments
price
of 50p/alcohol
unit
• estimated
wouldpartnerships,
save:
• Community
retailing, strict
• 2.1%responsible
of all violence
enforcement, physical design…
• 10,300 incidents a year
Meier et al, 2008
Evidence promising,
suggesting that
alcohol-focused
measures can reduce
violence. However,
many barriers and
few available studies
Targeting alcohol sales in Brazil
 Diadema, Brazil
 60% of murders and 45%
complaints of violence
against women between
23:00 and 06:00
44% reduction over 3 years
Average 9 per month
Homicide rate
Closing time regulation
 Many linked to alcohol
 2002: municipal law banned
alcohol sales after 23:00
 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
Rate of assaults against women
Closing time regulation
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
 E.g. bans and licensing schemes
• Increased enforcement
 E.g. test purchasing, stop and search
• Weapons amnesties
• Safer storage
 E.g. provision of pesticide storage
facilities
Some evidence of
success, mainly for
firearms legislation.
Elsewhere evidence
base poorly
developed. More
research needed,
particularly in
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
•Associated with:
 Reduced license demand
 Reduced gun homicides
 Reduced suicides
New Zealand
Reductions in firearm
suicides following
legislative changes
particularly seen in
under 25s
• 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
attitudes, e.g. safer dating
• Community interventions
 Microfinance programmes,
combined with gender equity
training
• Life skills programmes
 educate about gender-based
violence and develop relationship
skills
Good evidence for
school-based
programmes. Some
evidence for
community-based
interventions,
although further
research is needed
IMAGE: Microfinance in South Africa
• Intervention with Microfinance for AIDS and Gender Equity
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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
Child maltreatment
• Cultural acceptance of violence is a
risk factor for many violence types
Intimate partner violence
• Social tolerance of violence likely
learned in childhood, e.g.
Physical punishment is a
normal part of rearing a child
A man has a right to
discipline female behaviour
Sexual violence
 Use of corporal punishment
Sexual activity (inc. rape) is a
marker of masculinity
 Witnessing violence in the family
Youth violence
 Violence in the media
Violence is an acceptable
way of resolving conflict
• Interventions challenge rules or
behaviour expectations that
tolerate violent behaviour
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
 edutainment
• Social norms / marketing
 Targeting specific groups
 Correcting misperceptions of
cultural norms
• Laws and policies
 Implementing laws that make
violent behaviour an offence.
Limited evidence for
most types of
interventions in this
area. Further
rigorous evaluations
are needed.
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
violence
• Advocacy support
 Support and guidance to victims,
e.g. counselling, education, legal aid.
• Psychosocial interventions
 Treat emotional & behavioural
problems linked to victimisation.
• Protection orders
 Prohibit perpetrators from further
abusing their victims
Good evidence for
the use of advocacy
support
programmes.
Promising evidence
for screening and
referral, psychosocial
interventions and
protection orders
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
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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