1
VIOLENCE PREVENTION
the Western Cape Burden of Disease
Reduction Project
Professor Craig Househam
Head of the Western Cape Department of Health
South Africa
2
The Western Cape
One of nine provinces of South Africa
Population: 4 - 4½ million
Climate: Mediterranean, semi-desert
Economy: tourism, manufacturing, agriculture
SA’s highest per capita GDP
SA’s highest Gini coefficient (>0.6 & increasing)
Western Cape premature
mortality (YLL) in 2000
14.1
HIV/AIDS
Homicide/violence
12.9
Tuberculosis
7.9
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
Combined Injury Burden > 22%
More than MID (HIV/AIDS andTB)
 Second leading cause of premature mortality in WC
Source: Bradshaw et al. 2004, SANBD Study 2000: estimates of
provincial mortality.
3
5
Key challenges
Evidence based approach
 Most studies demonstrating effectiveness originate from HIC’s and are not
necessarily replicable in LMIC’s where there is limited capacity for local
research
 Available evidence resides primarily at the biological and behavioural level
and this prompts a programmatic rather than an upstream focus
 Conversely the largest number and potentially far reaching interventions are
at the societal and structural levels
 Need to recognize macro-structural, economic and political realms that
foment many of the factors we seek to address
Source: (1) Norman et al. 2007. The high burden of injuries in South Africa.
WHO Bulletin. (2) Bradshaw et al. 2004, SANBD Study 2000: estimates of
provincial mortality.
6
Homicide rates (2000)
Provincial vs National vs Global
Mortality rates / 100, 000 population
140
120
W orld
100
80
National
60
W estern Cape
40
20
0
Males
Females
 Higher than national average for males and females
 10x higher than world average for males, 7x for females
rber
g
Inequality
 apartheid legacy of
social exclusion
multiple deprivation
 urbanization and migration
Homicide by area in Cape Town
120
100
80
60
40
20
0
Source: Groenewald et al. in press. Cause of death and premature
mortality in Cape Town, 2001-2006
We
ster
n
Tyg
e
Sou
ther
n
No r
ther
n
Kha
yeli
tsha
Pl .
font
ein
Mi t c
hell
s
Klip
Eas
tern
Mortality rates / 100, 000 population
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Elsies River Community Health Center (CHC)
November 2010 (n=257)
Non-fatal injuries
Other
8%
Unknown
4%
Self-harm
11%
Traffic
8%
Violence
69%
Cause of Trauma
Violence > 60%
Resulting in
33% of deaths
8
9
Elsies River CHC, November 2010 (n=164)
Alcohol and drug use
Victims of violence
Alcohol the drug
of abuse in > 90%
of intoxicated
cases
7%
Alcohol & drugs
Alcohol only
41%
Drugs only
None
51%
1%
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Approach to reducing alcohol-related
violence
1. Reduce alcohol consumption
i) Reduce demand for alcohol
ii) Reduce access to alcohol
2. Invest in safer drinking environments
3. Address upstream causes of violence
4. Research, monitoring and evaluation
5. Establish an transversal structure to address
issues related to alcohol
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Reduce alcohol consumption
i)



Reduce demand for alcohol
TV mass media and community campaigns
Brief Motivational Interviewing
Restriction and regulation of alcohol
advertising
Most options have political support although varied
Effectiveness - ranges from untested to moderate
effectiveness
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Reduce alcohol consumption
ii) Reduce access to alcohol:
• Reduce trading hours
• Prohibit outlets in residential areas
Potentially politically controversial and all
controversial options have not been fully explored
(e.g. targeted reduction in trading hours)
Potentially the most cost-effective option which could
reduce violence by nearly 50% in the very short term
(e.g. introduction of a limit on opening hours in
Diadema Brazil reduced the murder rate by 44%)
REDUCE AVAILABILITY
Population level

Legislation - Western Cape Liquor Act
1.
Reduced trading hours
No liquor outlets in residential areas
Many other aspects of strengthening the act to reduce access to liquor
2.
3.
SUCCESS : SAB reports reduced sales
SUCCESS : BoD team part of
Liquor Act Task Team
REDUCE DEMAND
Strategy or
Intervention
Alcohol
education in
schools
College
student
education
Public service
messages
Warning
labels
Effective ness
+/-
Research
Support
+++
CrossCultural
Testing
++
+/-
+
+
High
-
+++
++
Moderate
-
+
+
Low
Cost
High
Source: Babor 2005. Alcohol no ordinary commodity.
.
Education and persuasion
Reduce demand
Strategy or
Intervention
Advertising
bans
Voluntary
controls by
alcohol industry
Effectiveness
+
Research
Support
+
XCultural
Testing
++
-
+
++
Cost
Low
Low
Source: Babor 2005. Alcohol no ordinary commodity.
.
Regulate promotion
Create safer drinking environments
Measures proposed such as:
• Obligation to serve food with alcohol sales
• Improved street lighting
• Improved security using CCTV cameras
Politically more popular
Effectiveness is moderate and closely linked with
ability to enforce or implement
Other actions
Address upstream causes such as
• Income inequality and Early Childhood Development
(ECD)
• Long-term investments for sustainable prevention
Research, Monitoring and Evaluation
• Need for systematic data collection on alcohol-related
indicators across sectors
Urgent need for inter-sectoral structure that design and
implements multi-sectoral interventions
Role of media and media
advocacy
1. Stimulate social mobilisation
2. Place alcohol issues on political agenda
3. Gain popular support for effective interventions e.g.
legislation to reduce access
Importance of social mobilization and education
highlighted by WHO, Lancet Reviews, Global
Alcohol Policy Experts
Booza TV Project


1.
2.
3.
4.
Booza TV= collection of edited documentary,
animation and fictional material on drinking
developed by the Western Cape Department of
Health
Various product formats possible:
6 part TV/DVD series (broadcast, captive audiences, stakeholder
groups)
Tailor made products e.g. Selected episodes such as the violence related
episode for police services
Workbook component for educational purposes
Web presence through website, Facebook and Twitter
Surveillance
 Provincial Injury Mortality Surveillance
 institutionalized within provincial government
 improved geo-spatial variables
 linkage with vital registration

place of residence and place of death
 Health service-based surveillance (Morbidity)
 Rich source of risk factor information
 GIS analysis
 Integrated information systems that measure exposure
 liquor outlet densities
 multiple deprivation
Prevention – long-term
• Continue to lobby provincial and municipalities
– Comprehensive approach across departments
– Promote documentation, monitoring and evaluation
• Collaboration to instill “culture of evaluation”
– Partnership with academic and research initiatives
– Multi-country collaboration with Scotland, Lithuania and
others
Key challenges
Realities of government
• Structure of government
– Difficulty in delivering transversal projects
– Silo-based approach within tiers – lead agencies
– Fragmentation – national, provincial, metro/local
– Short timeframes – typically five years of a political term
• Provincial Transversal Management System as the
counter
• Politicization of violence and crime prevention
– Over-reliance on criminal justice system
– Lack of continuity with changes in government.
• Both threaten the required long-term, holistic
approach
Injury Prevention Working Group
Vision: To reduce injuries in the Western Cape
All injuries
Largest contributors to
injury BoD
Largest contributing
risk factor to
injury BoD
Interpersonal violence &
Road Traffic injuries
Alcohol-related
Interpersonal violence
and road injuries
Groundwork for
broader interventions
Aims of injury workgroup
1. Reduce alcohol-related injury
2. Establish foundations for broader violence
prevention policy
3. Provide a framework for monitoring and
evaluation of injury reduction programs
Two immediate priorities
1.
High 5
A focus on 5 high risk areas to deliver
intersectoral and holistic alcohol-related
violence reduction interventions
2. Violence prevention policy
A violence prevention policy founded on best practice
guiding principles to optimize effectiveness and
sustainability
KHAYELITSHA
MURDER
ATTEMPTED MURDER
ROBBERY AGGR(TRIO)
RAPE
ASSAULT GBH
ASSAULT COMMON
OUT OF 149
STATIONS
IN
PROVINCE
50 % OF
PRIORITY
CRIME
COMES
FROM 5
STATIONS
Source: SAPS Western Cape 2010
NYANGA
KUILSRIVIER
GUGULETU
MITCHELL PLAIN
The “High 5”
approach
Suburbs
Violence is
CONCENTRATED
Zero
Positive
Unknown
Total
Khayelitsha
313 (15%)
527 (21%)
303 (8%)
1143 (13%)
Gugulethu
97 (5%)
169 (7%)
143 (4%)
409 (5%)
Nyanga
121 (6%)
161 (7%)
149 (4%)
431 (5%)
Kraaifontein
73 (3%)
124 (5)
92 (2%)
289 (3%)
Philippi
110 (5%)
125 (5%)
143 (4%)
378 (4%)
.
.
Total
2135 (100%)
.
2460 (100%)
.
.
3902 (100%)
8497 (100%)
Approx. 50% of
alcohol-related
violence occurs
in 5 areas
Source: PIMMS (DoP analysis)
Brief Interventions for trauma patients
Screening and brief interventions –
trauma-units victims/perpetrators
(teachable moments)
Screen for drugs and alcohol
Randomized controlled trial
(3 groups)
Cost-effectiveness component
Researchers from MRC, UCT
STATUS: PILOTING IN
KHAYELITSHA AND ELSIES
RIVER PLANNED- FUNDING
OBTAINED
The teachable
moment
Social Mobilization campaign
Pilot study results: Booza TV is effective in

challenging normative views about drinking; and

successfully mobilised support for evidence-based interventions including
the Liquor Act, most notably amongst BINGE DRINKING YOUTH
AIMS:
1.
Challenge binge-drinking culture and behaviour
2.
Mobilisation for evidence-based interventions to reduce alcohol abuse
3.
Promote action for safer drinking practices and environments
Target Groups: 1. Drinkers
2. Intervention agents (e.g. Govt, NGOs, CBOs)
3. Public Messengers (media)
STATUS: Proposal developed and will be discussed with PGWC communication
Violence Prevention Policy
Two key requirements
1. Sound guiding principles
2. Sustained action/institutionalisation
PGWC draft guiding principles include the following key concepts:
•
Complexity - violence prevention and safety promotion require
multiple solutions across sectors and these should be underpinned
by sound evidence
•
Safety is a human right
•
Individual and collective action is required
•
Underscores PGWC s long-term commitment to effective action
Acknowledgements
 BoD Project Task Team
 BoD Surveillance Working Group
 BoD Injury Prevention Working Group
 WHO Violence and Injury Prevention
 The South African Police Service
THANK YOU