National Family Safety Program, NGHA January 28th and 29th 2013 Presentation 6. Step 3 of the Public Health Approach to Child Maltreatment Prevention: Prevention Strategies Presented by Alaa Sebeh, MD Ph.D. Independent International Consultant, Child Protection & Disability. alaa1234@gmail.com

Objectives The core learning objective of this module is to provide an understanding of the evidence base for effective child maltreatment prevention strategies and the importance of rigorously evaluating the effectiveness of such strategies.

Outline Two Main Ways of Classifying Prevention Programmes Evidence-Based Prevention and Programme Effectiveness Prevention Strategies by Development Stage and Levels of Ecological Model Summary and Conclusion

Classifying Prevention Programmes

The Public Health Approach Goal 1.Define & describe What is the Problem? 2.Identify risk What are the risk factors and causes? Step 3 of the public health approach to child maltreatment concerns selecting or developing, implementing, and rigorously evaluating programmes to prevent child maltreatment. 4. Scaling up and cost-effectiveness Implement on large scale & cost 3.Develop and evaluate interventions What works and for whom?

Classifying Prevention Programmes  Public health prevention programmes are traditionally classified in one of two ways:   1. According to the time of the programme:  Primary prevention – Approaches that aim to prevent violence before it occurs Secondary prevention – Approaches that focus on the more immediate responses to violence Tertiary prevention – Approaches that focus on long-term care in the wake of violence 2. According to the level of risk of those receiving the programme: Universal programmes – Aimed at the general population without regard to risk Selective programmes – Aimed at people at higher risk Indicated programmes – Those carried out once child maltreatment has already occurred

Strengthening Primary Prevention Many efforts in the field of child maltreatment to date, in both industrialized and developing countries, have focused on secondary and tertiary responses to violence. Such responses should be accompanied by a greater investment in primary prevention. There are two main reasons for this: 1. Child maltreatment affects an important proportion of children. 2. Evidence strongly suggests that treating and trying to remedy the effects of child maltreatment are both less effective and more costly than preventing it in the first place.

Evidence-Based Prevention and Programme Effectiveness

Defining Evidence-Based Prevention Evidence-based prevention is the selection, design, and implementation of prevention programmes with reference to findings from quantitative scientific studies of what works to reduce the frequency of child maltreatment. Effectiveness can only be demonstrated through outcome evaluation studies using rigorous research designs. One major concern is to be able to rule out alternative explanations for any observed changes in outcome in order to be confident that the changes really were due to the intervention and not some other factor.

Criteria to Systematically Evaluate the Effectiveness of Different Programmes Approaches that are based upon testimonials might expend significant resources and capacity on programmes that may be ineffective or that may even make things worse. The most stringent criteria involve programme evaluation using: Randomized-controlled trials Evidence of significant preventive effects Evidence of sustained effects Independent replication of outcomes To design rigorous outcome evaluations, partnership with an academic or research institution with the relevant expertise is necessary.

Levels of Evidence for Effectiveness An effective prevention programme is one that reduces the incidence of child maltreatment in the intervention population A promising prevention programme is one that has been evaluated with a strong design, showing some evidence of a preventive effect but requiring more testing. An unclear prevention programme is one for which the evidence of effectiveness is insufficient or the findings are contradictory. An ineffective prevention programme is one for which evidence using a strong research design shows that the programme has no preventive effect. An harmful prevention programme is one for which the evidence using a strong research design shows that the incidence of child maltreatment in fact increased due to the programme.

Effectiveness of Child Maltreatment Prevention Programmes Promising Unclear Not effective Source: Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization. 87, 353–361

Systematic Review of the Effectiveness of Child Maltreatment Programmes The best source of evidence for the effectiveness of child maltreatment prevention programmes are systematic reviews: Systematic reviews help us tell the difference between real and assumed knowledge. The main aims of systematic reviews are to: Provide an authoritative overview of current evidence Establish “what works” or clear up uncertainty, when previous research on a question has been conducted Identify gaps in existing research and plan new research agendas Make the knowledge base on a particular subject more accessible Inform practice and policy  

Evidence of Effectiveness According to Systematic Review 1 = harmful 2 = not effective 3 = insufficient, weak, or mixed evidence 4 = promising 5 = effective - No programme effective for actual CM - 4 types promising for actual CM Source: Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health Organization.

Evidence of Effectiveness According to a Recent Review in the Lancet In a special series on child maltreatment, the Lancet, found the following: • Home-visiting programmes are not uniformly effective in reducing child physical abuse; those that have shown benefits are the Nurse Family Partnership and Early Start. • The Triple P—Positive Parenting Program—has shown positive effects on maltreatment and associated outcomes. • Hospital-based educational programmes to prevent abusive head trauma and provide care for families of children at risk of physical abuse and neglect show promise but require further assessment. • School-based educational programmes improve children’s knowledge and protective behaviours; whether they prevent sexual abuse is unknown. (MacMillan et al., 2009)

The Evidence Base is Almost Exclusively from High-Income Countries Source: Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health Organization.

Strategies by Developmental Stages and Levels of the Ecological Model

Strategies by Developmental Stages and Levels of the Ecological Model Because violence is a multifaceted problem with biological, psychological, social, and environmental roots, it needs to be confronted on several different levels at once. The ecological model serves a dual purpose in this regard: Each level in the model represents a level of risk, and each level can also be thought of as a key point for intervention.

Strategies that Cut Across Developmental Stages at the Societal and Community Levels: Beneficial Social and Economic Policies One strategy that cuts across developmental stages at the societal and community levels is to introduce beneficial economic and social policies. Good social and economic policies can most likely help prevent child maltreatment Social and economic policies that can probably help prevent child maltreatment include: • The provision of early childhood education and care • Universal primary and secondary education • Measures against unemployment • Good social protection systems

Strategies that Cut Across Developmental Stages at the Societal and Community Levels: Changing Social and Cultural Norms Another strategy that cuts across developmental stages at the societal and community levels is to change social and cultural norms. Social and cultural norms are powerful contributing factors to child maltreatment. They are frequently used to justify violence against children. To help change social and cultural norms, public awareness and media campaigns can likely play a role. These can highlight the extent and nature of child maltreatment and encourage the provision of services to children and families.

Summary and Conclusion

Summary and Conclusion This module reviewed: The Two Main Ways of Classifying Prevention Programmes Evidence-Based Prevention and Programme Effectiveness Strategies by Developmental Stages and Levels of the Ecological Model Creating a strong evidence base for the effectiveness of child maltreatment prevention strategies requires carrying out rigorous outcome evaluation studies. Currently, there are many promising child maltreatment programmes, but almost none have proven to be effective. Outcome evaluation studies should be a priority, especially in low- and middle-income countries. At this stage of the development of the field, it is vital to take action while generating evidence.

References Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teach-vip.edc.org/course/view.php?id=23 Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14. The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 169-194. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. MacMillan, H. Wathen, C. Barlow, J. Fergusson, D. Leventhal, J. Taussig, H. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet, Volume 373, Issue 9659, Pages 250-266 Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health Organization. Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization. 87, 353–361 Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.

Activity: Analysing Methods and Results of Systematic Reviews Break into small groups of 3–5 people. Each group will be assigned either Article 1 or Article 2. Summarize the method used in and the main results of the systematic review on the effectiveness of child maltreatment prevention in the article you were assigned. Discuss how these findings might potentially be applied to your area of work.