1. Violence Prevention The Evidence
Karen Hughes
Centre for Public Health, Liverpool John Moores University
WHO Collaborating Centre for Violence Prevention

2. 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

3. 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

4. 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

6. 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

7. 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

8. 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

9. 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:
Health behaviours (mother/child)
Child care skills
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

11. 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

12. 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..
Academic enrichment
Study & recreation out of school
Vocational Training
Providing skills to find work
Some strong evidence that preschool enrichment and social development programmes can reduce aggression and improve social skills, particularly in at-risk youth
Cost effectiveness
Early childhood education (3-4 year olds)
Average benefit
- $2.35 for every dollar invested

13. 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

14. Social Development Programmes
Emotional & social skills
Self-control
Positive self-esteem
Relationship skills
Problem solving skills
Bigfoot Arts Education Ltd
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

16. 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

17. Reducing availability & harmful use of alcohol
Regulating alcohol availability
sales times, outlet density
Raising alcohol prices
e.g taxation, minimum price
Reducing alcohol use in risky drinkers
e.g. brief interventions, treatment for alcohol dependence;
Improving drinking environments
Community partnerships, responsible retailing, strict enforcement, physical design…
Evidence promising, suggesting that alcohol-focused measures can reduce violence. However, many barriers and few available studies
Australia (VIC), spatial analysis
Increasing accelerating effect for density of pub licences on violence
Dramatic increase in liquor licenses
Currently capped Livingston, 2008
England, economic modelling
minimum price of 50p/alcohol unit
estimated would save:
2.1% of all violence
10,300 incidents a year Meier et al, 2008

18. Targeting alcohol sales in Brazil
44% reduction over 3 years
Average 9 per month
Diadema, Brazil
60% of murders and 45% complaints of violence against women between 23:00 and 06:00
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
Homicide rate
Closing time regulation
Rate of assaults against women
Closing time regulation
Dualibi S et al., The effect of restricting opening hours on alcohol-related violence. Am J Public Health. 2007

20. 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

21. 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

22. 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 suicides following legislative changes particularly seen in under 25s
Associated with:
Reduced license demand
Reduced gun homicides
Reduced suicides
not substituted with increases in suicides using other means
Kapusta et al, 2007; Beautrais et al, 2006

23. 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

26. 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

27. 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

28. 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

30. 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

31. 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.

32. Changing social norms in South Africa
Soul City
Social and behavioural change
Edutainment:
Soap opera, radio, information booklets
Address social issues
Violence against women
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

34. 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

35. 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

36. 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
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
Control: information card
Tiwari et al, 2005

37. 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

38. Gaps in the Evidence Base

39. Gaps in the Evidence Base
Gaps in the Evidence Base
One of 11 reviews on injury and violence prevention
UK Focal Point for VIP

40. 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

41. Thank You And special thanks to: Mark A Bellis Sara Wood Chris Mikton
Alex Butchart
Zara Quigg