Violence

1. Violence Review of risk factors and interventions

2. Aim and objectives • describe risk factors for violent, aggressive behaviour • prevalence of risk factors in SA and WC • evidence for prevention strategies

3. 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

4. Background Premature mortality in Western Cape (YLL) in 2000 • 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.

5. Violence by age and sex, Cape Town, 2003 (n=2111)

6. Background Mortality rate / 100, 000 population Western Cape vs. National • Higher than national average for males and females Source: Bradshaw et al. 2004, SANBD Study 2000: estimates of provincial mortality.

7. Background Mortality rate / 100, 000 population Western Cape vs. World average • 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. .

8. 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 .

9. 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

10. Typology of violence Violence Self-directed Interpersonal Collective Source: TEACH VIP www.who.int/violence_injury_prevention/publications/violence/en/index.html

11. Typology of violence Interpersonal Family/partner Community Child Partner Elder Acquaintance Stranger Nature of violence Physical Sexual Psychological Deprivation or neglect Source: TEACH VIP www.who.int/violence_injury_prevention/publications/violence/en/index.html

12. Approaches • Crime prevention • Human rights approach • Developmental science • Public health approach

13. 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?

14. Risk factors - ecological model • Behavioural • Structural • Societal • Biological • Examples: • Inequalities • Norms that support violence • Availability of means • Weak police/criminal justice • Examples: • Concentration of poverty • High residential mobility • High unemployment • Social isolation • Local illicit drug trade • Examples: • Poor parenting • Marital conflict • Friends who engage in violence • History of violent behaviour • Experienced abuse • Examples • Demographic factors • Psychological and • personality disorders Source: TEACH VIP www.who.int/violence_injury_prevention/publications/violence/en/index.html

15. Interventions - ecological model • Structural • Societal • Behavioural • Biological • Examples • Public information • Strengthen police and judicial systems • Reduce poverty and inequality • Educational reform • Reduce access to means • Job creation programmes • Examples • Reducing alcohol availability • Changing institutional settings • Identify and refer people at risk for violence • Improving trauma care and health care • access • Examples • Parenting programmes • Home visitation • Family therapy • Mentoring programmes • Examples • Social development progs. • Vocational training • Victim care and support Source: TEACH VIP www.who.int/violence_injury_prevention/publications/violence/en/index.html

16. 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

17. 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

18. 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.

19. 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;

20. 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

21. 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.

22. 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

23. 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)

24. 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

25. Case study – Colombia • Cali 126 to 90/100,000 • Bogota 82 to 26/100,000 • Mayor institutionalises prog. • 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

26. Violence mortality rates in Cape Town 2001 to 2004 Source: Matzopoulos 2005. Sixth annual report of the NIMSS

27. Change in age std’d homicide rates, Cape Town 2001 - 2004 Source: Groenewald et al. Local level mortality surveillance: utility for evaluation of intersectoral interventions to reduce violence.

28. 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