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PREVENTING VIOLENCE IN DEVELOPING COUNTRIES: A FRAMEWORK FOR ACTION

James A. Mercy1,4

Alex Butchart2

Mark L. Rosenberg3

Linda Dahlberg1,4

Alison Harvey2

Introduction

In the year 2002, there were an estimated 1.6 million deaths due to violence throughout the world. This was around half the number of deaths due to HIV/AIDS, roughly equal to deaths due to tuberculosis, somewhat greater than the number of road traffic deaths, and 1.5 times the number of deaths due to malaria.1 The largest number of violent deaths was due to suicide: 870,000 cases or 54 percent. Homicide accounted for 560,000 deaths or 35 percent. There were 170,000 deaths directly due to war.1 Less than 10 percent of all violence-related deaths occur in high-income countries.2 For every death, nonfatal injuries due to violence lead to dozens of people hospitalized, hundreds of emergency department visits, and thousands of doctor appointments. Over and above these deaths and injuries, some highly prevalent forms of violence (such as child maltreatment and intimate

1

James A. Mercy and Linda Dahlberg are with the Division of Violence Prevention National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA.

2

Alex Butchart and Allison Harvey are with the Department of Injuries and Violence Prevention of the World Health Organization, Geneva, Switzerland.

3

Mark L. Rosenberg is Executive Director of the Task Force for Child Survival and Development, Decatur, Georgia, USA.

4

The findings and conclusions of this paper are those of the authors and do not necessarily represent the views of the CDC.

NOTE: The papers in this appendix contain the views and opinions of the author(s) and do not necessarily reflect those of the Institute of Medicine.



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2 APPENDIX C PREVENTING VIOLENCE IN DEVELOPING COUNTRIES: A FRAMEWORK FOR ACTION James A. Mercy1, 4 Alex Butchart2 Mark L. Rosenberg3 Linda Dahlberg1, 4 Alison Harvey2 Introduction In the year 2002, there were an estimated 1.6 million deaths due to violence throughout the world. This was around half the number of deaths due to HIV/AIDS, roughly equal to deaths due to tuberculosis, somewhat greater than the number of road traffic deaths, and 1.5 times the number of deaths due to malaria.1 The largest number of violent deaths was due to sui- cide: 870,000 cases or 54 percent. Homicide accounted for 560,000 deaths or 35 percent. There were 170,000 deaths directly due to war.1 Less than 10 percent of all violence-related deaths occur in high-income countries.2 For every death, nonfatal injuries due to violence lead to dozens of people hospitalized, hundreds of emergency department visits, and thousands of doctor appointments. Over and above these deaths and injuries, some highly prevalent forms of violence (such as child maltreatment and intimate 1James A. Mercy and Linda Dahlberg are with the Division of Violence Prevention National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Preven- tion (CDC), Atlanta, Georgia, USA. 2Alex Butchart and Allison Harvey are with the Department of Injuries and Violence Preven- tion of the World Health Organization, Geneva, Switzerland. 3Mark L. Rosenberg is Executive Director of the Task Force for Child Survival and Develop- ment, Decatur, Georgia, USA. 4The findings and conclusions of this paper are those of the authors and do not necessarily represent the views of the CDC. NOTE: The papers in this appendix contain the views and opinions of the author(s) and do not necessarily reflect those of the Institute of Medicine.

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2 APPENDIX C partner violence) have been shown to have numerous noninjury health consequences, including high-risk behaviors such as alcohol and substance misuse, smoking, unsafe sex, eating disorders, and the perpetration of violence, and via these risk behaviors contribute to such leading causes of death as cardiovascular disorders, cancers, depression, diabetes, and HIV/ AIDS.3 Although the negative effects of violence are felt by all, violence also disproportionately affects the development of low- and middle-income countries. In poorer countries the economic and social impacts of violence can be very severe in terms of slowing economic growth, undermining personal and collective security, and impeding social development. Devel- opment agencies, therefore, have a major stake in preventing violence so as to ensure that their investments are not undermined by the economic and social costs of violence. There are no simple solutions for preventing violence. Violence is, however, a public health problem that can be understood and changed. We have learned a great deal about violence prevention in recent decades, but it has become clear that violence prevention will not be achieved through a vaccination or a single piece of legislation. Rather, preventing violence will require a sustained commitment to the application of good science and the implementation of effective programs in a rapidly changing world. We define violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or com- munity that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.2 Three general types of violence are encompassed by this definition: interpersonal, self- directed, and collective. Interpersonal violence includes forms perpetrated by an individual or small group of individuals, such as child abuse and neglect by caregivers, youth violence, intimate partner violence, sexual violence, and elder abuse.2 Self-directed violence includes suicidal behavior as well as acts of self-abuse, where the intent may not be to take one’s own life.4 Collective violence is the use of violence by groups or individuals who identify themselves as members of a group, against another group or set of individuals, to achieve political, social, or economic objectives. It includes war, terrorism, and state-sponsored violence toward its own citizens.5 This paper articulates a framework for violence prevention that is grounded in the wealth of knowledge we have gained in recent decades from research and programmatic efforts in both rich and poor countries of the world. The framework content draws on carefully considered rec- ommendations that have been presented in major international reports on violence over the past decade. These include the World Report on Violence and Health, the World Report on Violence Against Children, the Secretary General’s In-depth Study of All Forms of Violence Against Women, and the chapter on interpersonal violence in the second edition of Disease Control

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27 APPENDIX C Priorities in Developing Countries.3, 6-8 This framework can be used by both developing countries and funding agencies as a guide for the types of processes and actions that are most likely to be successful in building strong foundations for ongoing violence prevention efforts, and for identifying those violence prevention strategies that are most likely to be effective. This framework is divided into two parts. The first part addresses the processes required to develop and support effective violence prevention interventions, programs, and policies. The second part identifies broad strategies for pre- venting violence. Strategies for preventing violence from occurring in the first place (primary prevention) are discussed as well as those for preventing violence from reoccurring and mitigating its consequences. Ideally we would like to provide a short list of specific interventions or “best buys” that have been proven to be effective and are ready for applica- tion in developing countries now. Unfortunately, few violence prevention interventions have been implemented in developing countries with the capacity to evaluate the outcomes over a sustained period of time and col- lect the data needed to measure cost-effectiveness. We know that we need cost-effectiveness data to market this public health approach to violence prevention; we know that we are marketing to an increasingly sophisticated set of decision makers, and this is a good thing. Unfortunately, however, we are in a vicious circle. We have a good idea about the extensive toll that violence takes in developing countries and we have very good data to show that interventions to prevent interpersonal and self-directed violence are effective in developed countries. But we don’t have the resources necessary to develop the capacity for implementing and evaluating these interventions in developing countries, where we believe they would do the most good. For this reason, we need to make the strongest case possible for investing in building the capacity to take interventions that are proven effective in developed countries and systematically implement and evaluate them in the developing world. Building the Foundation for Violence Prevention To succeed in preventing violence requires building a foundation that supports the development, implementation, maintenance, and monitoring of interventions, programs, and policies. This foundation draws on many of the same skills and capacities that are needed and, in some cases, have been developed for other public health problems. Therefore, wherever possible and reasonable, efforts should be made to build upon the infrastructure that has been developed to address other public health problems to also address violence prevention. The following elements are critical for building this solid foundation (see Box C-1).

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2 APPENDIX C BOX C-1 Key Elements in Building a Strong Foundation for Violence Prevention • Develop a national action plan and identify a lead agency • Enhance the capacity for collecting data • Increase collaboration and the exchange of information • Implement and evaluate specific actions to prevent violence • Strengthen care and support systems for victims Develop a National Action Plan and Identify a Lead Agency Developing a national plan is a key step toward effective violence pre- vention. A national plan should include objectives, priorities, strategies, and assigned responsibilities, as well as a timetable and mechanism for evalu- ation.3, 9 It should be based on input from a wide range of governmental and nongovernmental actors.10 It should also be coordinated by an agency with the capacity to involve multiple sectors in a broad-based implementa- tion strategy.10 Enhance the Capacity for Collecting Data Data are necessary to set priorities, guide the development of inter- ventions, programs, and policies, and monitor progress.3, 6-8 A basic goal of enhancing data collection should be to create a system that routinely obtains descriptive information on a number of key indicators that can be accurately and reliably measured.9 The contributions of violence to other public health problems (e.g., HIV, mental health) should be documented and the baseline measurements for violence and its consequences should be routinely measured along with other health problems. Increase Collaboration and the Exchange of Information The work of violence prevention engages many different societal sec- tors. In particular, health, criminal justice, and social service institutions play a critical role in addressing the needs of victims and formulating and implementing prevention strategies. The success of violence prevention efforts depends to a substantial degree on the ability of these sectors to work together and, in many cases, integrate their efforts. Violence preven-

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2 APPENDIX C tion efforts in developing countries should give dedicated attention to ways to enhance effective collaboration between these sectors.3, 7 Much has been learned about violence prevention in both rich and poor countries over the past several decades. Working relations and communica- tions between international agencies, governmental and nongovernmental agencies, researchers, and practitioners engaged in violence prevention should be improved so that valuable lessons can be shared.3 Systems and processes for collaboration and exchange of information are critical both inter- and intranationally. Implement and Evaluate Specific Actions to Prevent Violence The development of information that assesses and evaluates what pro- grams and policies are most effective is critical.3, 6-8 While there are no simple solutions to the problem of violence, there are a number of effective and promising strategies that can be adapted and implemented in develop- ing countries.3, 6-8 It is critical that such efforts be carefully evaluated in order to ensure that they are working and to build the prevention knowl- edge base. Strengthen Care and Support Systems for Victims Health, social, and legal support systems for victims of violence are critical for treating and mitigating the psychological, medical, and social consequences of violence.3, 6-8 These systems can help to prevent future acts of violence, reduce short- and long-term disabilities, and help victims cope with the impact of violence on their lives.9 Violence prevention efforts should be integrated into the health systems that are developed for the diag- nosis, treatment, and evaluation of interventions and treatments for other health problems. Strengthening integrated health systems should include strengthening the capacity to do violence prevention. Key Strategies for Violence Prevention Based on the scientific literature on the epidemiology, etiology, and prevention of violence, several strategic foci for violence prevention have emerged that are important for developing countries and funding agencies to consider as they decide where to invest limited resources. Strategic Foci for Primary Prevention Ultimately the goal of public health is to prevent violence from occur- ring in the first place. While moving toward that end it is important to

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0 APPENDIX C remember that interpersonal, self-directed, and collective violence are related to one another in several ways.11 These types of violence share com- mon risk factors, often occur together, and one may cause the other (e.g., child maltreatment is a risk factor for suicide). Common underlying risk factors for these different forms of violence include, for example, certain cultural norms, social isolation, substance abuse, income inequality, and access to lethal methods.2 Prevention efforts addressing common underlying risk factors have the potential to simultaneously decrease different forms of violence. The following primary prevention strategies are scientifically credible, can potentially impact multiple forms of violence, and represent areas where developing countries and funding agencies can make reason- able investments (see Box C-2). Increase Safe, Stable, and Nurturing Relationships Between Children and Their Parents and Caretakers Decades of research in the neurobiological, behavioral, and social sci- ences clearly indicate that exposure to maltreatment and other forms of vio- lence during childhood negatively impacts brain development and increases subsequent vulnerability to a broad range of mental and physical health problems, ranging from anxiety disorders and depression to cardiovascular BOX C-2 Key Strategies for Violence Prevention Primary Prevention Strategies: • Change cultural norms that support violence • Promote gender equality and empower women • Reduce economic inequality and concentrated poverty • Increase safe, stable, and nurturing relationships between children and their parents and caretakers • Reduce access to lethal means • Reduce availability and misuse of alcohol • Improve the criminal justice and social welfare systems • Reduce social distance between conflicting groups Secondary and Tertiary Strategies: • Engage the health sector in violence prevention • Provide mental health and social service services for victims of violence • Improve emergency response to injuries from violence • Reduce recidivism among perpetrators

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 APPENDIX C disease and diabetes.12-15 Young children experience their world through their relationships with parents and other caregivers.16, 17 These relation- ships are fundamental to healthy brain development and consequently our physical, emotional, social, behavioral, and intellectual capacities.16 From a public health perspective the promotion of safe, stable, and nurturing rela- tionships is therefore strategic in that, if done successfully, it can benefit a broad range of health problems and contribute to the development of skills that will enhance the acquisition of healthy habits and lifestyles. Moreover, evidence for the effectiveness of targeting violence prevention programs toward children or people who influence children in the early stages of the developmental cycle is greater than for interventions targeting adults. Early interventions have the potential to shape the attitudes, knowledge, and behavior of children while they are more open to positive influences and also to affect their behavior over the course of their lifetimes.18 Three general approaches to increasing safe, stable, and nurturing relationships are parenting training, provision of social support for parents and families, and the creation of social environments that support and protect children (e.g., policies that protect children from victimization at school). The most basic approach to facilitating safe, stable, and nurtur- ing relationships is through the education of parents in child-rearing and management strategies. There is good evidence that these types of programs are effective at influencing the child-rearing practices of families as well as, in the cases of early child home visitation and hospital-based shaken baby prevention programs, reducing maltreatment.12, 19-22 Early child home visi- tation programs include, to varying degrees, training of parents on child care, development, and discipline.22 They may also provide support by facilitating parent group meetings or in the form of daycare, transportation, and family planning services. These programs are typically targeted at low- income families, but not exclusively. These programs, however, are rela- tively expensive and have not yet been rigorously evaluated in developing countries. Hospital-based shaken baby prevention programs disseminate information about the detrimental impact of violent infant shaking to both parents before an infant is discharged following birth.21 These programs are relatively inexpensive to implement; however, there is only limited evidence for their effectiveness. An important dimension of safe, stable, and nurturing relationships is parental monitoring and supervision. Inadequate monitoring and supervi- sion and lack of parental involvement in the activities of children and ado- lescents are well-established risk factors for youth violence.22 There is also evidence that a warm, supportive relationship with parents or other adults is protective against antisocial behavior.22 Given these factors an increase in youth violence would be expected where families have been disintegrated through wars or epidemics, or because of rapid social change.23 Mentoring

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2 APPENDIX C programs that match high-risk children and youth with a positive adult role model are a potentially effective antidote to family disintegration. Although not widely evaluated, there is limited evidence that they can be effective in reducing youth violence.24, 25 In general efforts to increase positive adult involvement in the lives of children and youth appears to be an important element in the primary prevention of violence. Reduce Availability and Misuse of Alcohol Although levels of alcohol consumption, patterns of drinking, and rates of interpersonal violence vary widely between countries, across all cultures there are strong links between the two. Each exacerbates the effects of the other with a strong association between alcohol consumption and an indi- vidual’s risk of being either a perpetrator or a victim of violence. Harmful alcohol use directly affects physical and cognitive function.26 Reduced self- control and ability to process incoming information makes drinkers more likely to resort to violence in confrontations,27 while reduced ability to recognize warning signs in potentially violent situations makes them appear easy targets for perpetrators.28, 29 Individual and societal beliefs that alcohol causes aggressive behavior can lead to the use of alcohol as preparation for involvement in violence, or as a way of excusing violent acts.30, 31 Depen- dence on alcohol can mean individuals fail to fulfill care responsibilities or coerce relatives into giving them money to purchase alcohol or cover associ- ated costs.32, 33 Experiencing or witnessing violence can lead to the harmful use of alcohol as a way of coping or self-medicating.34, 35 Uncomfortable, crowded, and poorly managed drinking settings contribute to increased violence among drinkers.36, 37 Alcohol and violence may be related through common risk factors (e.g., antisocial personality disorder) that contribute to the risk of both heavy drinking and violent behavior.38 Prenatal alcohol exposure resulting in fetal alcohol syndrome or fetal alcohol effects are associated in infants with increased risk of their maltreatment, and with delinquent and sometimes violent behavior in later life, including delinquent behavior, sexual violence, and suicide.39 Central to preventing alcohol-related violence is to create societies and environments that discourage risky drinking behaviors and do not allow alcohol to be used as an excuse for violence. The evidence base for the effective prevention of alcohol-related violence is mainly from high-income countries. Much less is known about the effectiveness of interventions elsewhere with differences in drinking cultures, societal attitudes toward violence, and laws surrounding the sale and consumption of alcohol being important considerations. Increased alcohol prices through higher taxation can reduce levels of violence.40 In the United States, it has been estimated that a 1 percent increase in the price of alcohol will decrease the prob-

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 APPENDIX C ability of wife abuse by about 5 percent, while a 10 percent increase in the excise tax on beer will reduce the likelihood of severe child abuse by around 2 percent.41, 42 Locally, minimum price policies can reduce access to cheap alcohol in licensed premises if adhered to by all vendors.43 Reduc- ing the availability of alcohol can reduce consumption levels and related violence. In Diadema, Brazil, prohibiting the sale of alcohol after 23:00 helped prevent an estimated 273 murders over 24 months;44 conversely, removal of the government control of off-license beer sales in Finland led to a 46 percent increase in consumption and increased alcohol problems.45 Drinking venues that are poorly managed are associated with higher levels of violence.46 Interventions to improve management practice include train- ing programs for managers and staff, use of licensing legislation to enforce change (e.g., door supervisor training), and implementation of codes of practice.47 In Australia, a community-based initiative to improve manage- ment practice of drinking venues in North Queensland led to a reduction in arguments (by 28 percent), verbal abuse (by 60 percent), and challenges or threats (by 41 percent) within those premises.48 Reduce Access to Lethal Means The lethality of interpersonal, self-directed, and collective violence is affected by the means people use to carry out this violence. Reducing access to these lethal means may help to minimize the health consequences of violence. For example, a primary means of attempting and completing suicide in many developing countries is self-poisoning by use of pesticides. In Samoa, the introduction of paraquat was associated with a 367 percent increase in suicide rates between 1972 and 1981.49 Efforts to control access to paraquat began in 1981 and the suicide rate dropped by more than two- thirds by 1988. Similarly, controlling access to lethal doses of sedatives such as barbiturates has also been found to help reduce suicide.50 Firearms are another common means for committing homicide and suicide. A wide variety of strategies have been employed to restrict access to firearms, such as mandating waiting periods before purchase, promoting safe storage, and limiting where firearms can and cannot be carried. In the mid 1990s, Colombian officials in Bogotá and Cali, noting that homicide rates increased during weekends following paydays and national holidays and near elections, implemented a ban on carrying handguns during these times, resulting in an almost 14 percent reduction in homicide rates.51 In the Australian state of Victoria, firearm-related suicides, assaults, and unintentional deaths decreased following two periods of legislative reform: the 1988 implementation of legislation requiring the registration of all fire- arms and the 1996 strengthening of licensing regulations and addition of a mandatory waiting period.52 However, the evidence to determine whether

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 APPENDIX C or not such strategies are effective in reducing firearm-related homicides is currently insufficient,53 although several policies hold promise.54, 55 There is some evidence that homicide rates tend to increase after wars.56 One factor contributing to this may be that weapons remaining in war- stricken regions contribute to mortality and injuries even after wars are over.57 Many of the weapons used during the wars in Mozambique, Angola, and Namibia, for example, are now in the hands of criminals.58 The rela- tionship between collective and interpersonal violence may help explain why in regions like sub-Saharan Africa rates of both homicide and war-related deaths are high.11 Efforts to disarm former combatants may help to reduce the lethality of violence that often occurs in the aftermath of wars. Promote Gender Equality Inequality with respect to gender is strongly associated with interper- sonal and self-directed violence.7, 59, 60 Gender inequality has many faces. For example, cultural traditions that favor male over female children, early marriage for girls, male sexual entitlement, and female “purity” place women and girls in a subordinate position relative to men and make them highly vulnerable to violent victimization.61, 62 More subtle cultural attitudes and beliefs about female roles may also contribute to violence and exist, to varying degrees, in every part of the world.63 An ethnographic study of wife-beating in 90 societies concluded that it occurs most often in societies where men hold the household economic and decision-making power, where divorce is difficult for women to obtain, and where violence is a common conflict resolution tactic.64 Rape is also more common in societ- ies where cultural traditions favoring male superiority are strong.65 Maintaining the sexual purity of girls is a powerful cultural value that is associated with violence in many parts of the world. Female genital muti- lation, for example, is a practice usually performed on girls before puberty in many parts of Africa, some Middle Eastern countries, and immigrant communities around the world.66 An estimated 80 to 135 million women and girls worldwide have undergone female genital mutilation.66, 67 “Honor killings,” another extreme outcome of cultural traditions found mainly in Middle Eastern and South Asian countries, occur when a female is killed by her own family after her virginity or faithfulness has been brought into question because of, for example, infidelity or rape.64, 68 Data on this phe- nomenon are limited, but a study of homicides in Alexandria, Egypt, found that 47 percent of female victims were killed by a relative after they had been raped by another person.69 The cultural preference for male children is associated with high levels of female infanticide in China, Middle Eastern countries, and India.11 In China, the preference for sons is particularly strong in rural areas, where

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 APPENDIX C traditional cultural beliefs have their strongest hold.68 It has also been sug- gested that the “one couple, one child” policy in China may have exacer- bated the problem of female infanticide.68, 70 Suicidal behavior can be both a direct and an indirect consequence of cultural traditions that support male dominance. As an indirect con- sequence, women exposed to intimate partner violence are at greater risk of suicidal behavior.59 The subordination of women has also been more directly linked to high rates of suicidal behavior, particularly among women in their childbearing years.59 In India and Nepal, for example, culturally related phenomena like dowry disputes and arranged marriages have been linked with suicidal behavior among young women.64, 71 In China young rural women are at particularly high risk of suicide; their rates are 66 percent higher than rates among young rural men.72 Low status, limited opportunities, and exposure to various forms of domestic violence may partially explain their elevated rates.73 Examples of effective programs to prevent violence against women by promoting gender equality are limited, but there are some promising approaches. For example, in South Africa, Stepping Stones is an HIV prevention program that aims to improve sexual health through building stronger, more gender-equitable relationships with better communication and less violence between partners.74 A randomized controlled trial of the program found that, in addition to reducing HIV infection, the men in the program disclosed lower rates of perpetrating severe intimate partner violence at 12 and 24 months post-intervention.75 In a 3-year random- ized study involving women from the Sekhukhuneland District of South Africa’s Limpopo Province, the Intervention with Microfinance for AIDS and Gender Equity Study examined whether the provision of a microfinance program combined with education on gender and HIV/AIDS could socially and economically empower women and reduce intimate partner violence and HIV infection.76 The study was a joint initiative of the University of the Witwatersrand (Johannesburg), the London School of Hygiene and Tropi- cal Medicine, and the Small Enterprise Foundation in South Africa with funding from South Africa’s Ministry of Health and the United Kingdom’s Department for International Development. The intervention consisted of providing small loans (500 to 1,000 Rand) to help women start up businesses (e.g., dressmaking, fruit and vegetable sales) and involving the women in training sessions at loan repayment meetings over 6 months that explored issues such as gender roles, culture, sexuality, communication, relationships, violence, and HIV/AIDS. Results showed that experiences of physical and sexual violence were reduced by half among women partici- pating in the intervention compared to a control group of women.76 Levels of economic well-being improved and social changes were observed with evidence of changes in women’s empowerment.

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 APPENDIX C the creation and maintenance of formal mechanisms of association between social groups, otherwise at odds with one another, may be a useful tool in the prevention of collective violence, particularly where conflicting groups are in close geographic proximity. Reduce Economic Inequality and Concentrated Poverty Poverty is consistently found to have a strong and positive correlation with interpersonal violence, especially homicide.90 However, when other community factors distinct from, but related to, poverty are controlled, this association is substantially weakened, suggesting that the effect of poverty on interpersonal violence may be conditional on other factors. These fac- tors include community change associated with high residential mobility, concentrations of poverty, family disruption, high population density, and community disorganization as reflected in weak intergenerational family and community ties, weak control of peer groups, and low participation in community organizations.91, 92 The juxtaposition of extreme poverty with extreme wealth appears to be an important ingredient in the recipe for violence as well. Income inequality, for example, has been found to be strongly linked with homicide rates in both industrialized and developing countries.93-95 Furthermore, the high geographic concentration and social isolation of poor people, typically associated with high levels of economic inequality, compounds many problems that contribute to interpersonal and collective violence.50 Interventions and policies that seek to deconcentrate poverty by dispersing poor people within more economically and socially heterogeneous communities may help to reduce their isolation from jobs, positive role models, marriage partners, and good schools.96 For example, one evaluation of a housing voucher program (i.e., where residents of public housing are given vouchers that can be used to rent housing in the private market in any location) in the United States found that enabling families to move from public housing complexes into neighborhoods with lower levels of poverty substantially reduced violence by adolescents.97 A systematic review of evaluations of the effects of housing voucher programs found them to also be effective in reducing violent victimization and prop- erty crime.98 Economic programs or policies to reduce the inequalities and extreme concentrations of poverty that exacerbate these inequalities may be among the most powerful strategies for preventing violence, although the evidence base for such interventions needs to be more firmly established. Strategic Foci for Secondary and Tertiary Prevention While an emphasis on primary prevention is essential for reducing the health burden associated with violence in the long term, secondary and

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 APPENDIX C tertiary prevention programs and services are necessary for addressing some of its more immediate consequences. In addition to their value for treat- ing and reducing the severity of the physical and psychological sequelae of interpersonal, self-directed, and collective violence, these types of interven- tions are important for intervening in the cycle of violence. Violence in families and other intimate relationships is often repetitive and can occur repeatedly over long periods of time. In many cases of youth violence and hate violence, retaliation for prior acts of violence is an important motive. Moreover, children may learn to engage in violent behavior as a result of observing the use of such behavior by other important persons in their lives. Several strategic foci for the secondary and tertiary prevention of violence have emerged from our existing knowledge base that are important consid- erations in violence prevention planning. Engage the Health Sector in Violence Prevention Physicians and other health professionals are key gatekeepers in efforts to monitor, identify, treat, and intervene in cases of interpersonal and self-directed violence. In fact, some studies show that more cases of inter- personal violence come to the attention of health care providers than to police.99 The potential role of health care providers in these efforts is not widely understood or embraced and there are many institutional and edu- cational barriers limiting the effectiveness of even committed providers.100 Programs to educate health care providers are an essential first step in this process and a variety of such efforts are under way around the world.12, 49, 101 Screening programs to identify victims of intimate partner violence, child maltreatment, sexual violence, elder abuse, or suicidal behavior are also being used in many emergency departments, doctor’s offices, and clinic settings around the world, although the effectiveness of these interventions in reducing subsequent violence is not well understood.12, 49 Despite our limited understanding of the effectiveness of various strategies for engaging the health care sector in violence prevention, activities in this area should be carefully considered as potentially important components of comprehensive efforts to prevent interpersonal violence. Provide Mental Health and Social Service Services for Victims of Violence The health and social consequences of violence are much broader than death and injury. They include very serious consequences for the physical and mental health and development of victims.12, 49, 101, 102 Studies indicate that exposure to violence can lead to risk factors and risk-taking behav- iors later in life (depression, smoking, obesity, high-risk sexual behaviors, unintended pregnancy, alcohol and drug use) as well as some of the leading

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0 APPENDIX C causes of death, disease, and disability (heart disease, cancer, suicide, sexu- ally transmitted diseases).12, 49 Violence also begets violence. Suicidal behav- ior, for example, is a well-documented consequence of intimate partner violence, child maltreatment, and sexual violence.4, 12, 49 Given the poten- tial for violence to impact upon a broad range of costly health outcomes, mental health and social services to intervene and reduce these costs should be considered an important component of secondary and tertiary preven- tion efforts. Mental health services, for example, are provided to victims in many parts of the world; however, while there is research that suggests these types of interventions can improve the mental health of victims, there is less information available on their other benefits.12, 103 Improve Emergency Response to Injuries from Violence Unless death occurs immediately, the outcome of an injury from inter- personal violence depends not only on its severity but also on the speed and appropriateness of treatment.104 Acute treatment of the injured requires a special approach. The establishment of trauma systems designed to more efficiently and effectively treat and manage injured victims, including those injured in violence, is an important factor in reducing the health bur- den of violence that does occur. Research has suggested that reductions in the lethality of criminal assault in the United States, for example, is largely explained by the application of developments in medical technology and medical support services to the treatment of victims of interpersonal violence.105 Reduce Recidivism Among Perpetrators Data from the United States have indicated that a minority of serious violent offenders are responsible for a majority of serious violent crime.106 Whether this is also true in developing countries has yet to be deter- mined, but it suggests that strategies that reduce the risk that an offender will repeat acts of violence are a potentially important part of addressing this problem. Meta-analyses of treatment programs designed to reduce recidivism, particularly among delinquent and violent youth, suggest that effective treatment programs can divert a significant proportion of violent youth from future violence.107 Those programs that have been found to be most effective in developed countries include multimodal, behavioral, and skills-oriented interventions, family clinical interventions such as Family Functional Therapy and Multisystemic Therapy, therapeutic foster care, and wraparound services used by justice systems to intensively supervise and provide tailored services to delinquent youth.106-108

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 APPENDIX C Conclusion As developing countries seek to improve the health of their citizens, the impact of violence on health can no longer be ignored. In 1996 the World Health Assembly adopted a resolution declaring violence as a major and growing public health problem across the world. A framework for approaching violence prevention was first put forth in the World Report on Violence and Health and has been further refined and expanded in sub- sequent reports including the World Report on Violence Against Children, the Secretary General’s Study of All Forms of Violence Against Women, and the chapter on interpersonal violence in the Second Edition of Disease Control Priorities in Developing Countries. The 1996 World Health Assem- bly resolution was cosponsored by a developing country, South Africa, and a developed country, the United States; both recognized the importance of making violence prevention a global public health priority even before evidence of effectiveness could be collected. Eleven years after the resolu- tion, both developing and developed countries have applauded and adopted many recommendations included in this series of reports, signaling the beginning of an exciting, new agenda for public health. A great deal of progress has been made in violence prevention. There is strong reason to believe that the interventions under way and the capac- ity to implement violence prevention will make a difference.8 The lessons learned to date during public health’s short experience with violence pre- vention are consistent with the lessons from public health’s much longer experience with the prevention of infectious and chronic diseases. Violence can be prevented in developing countries if their governments, their citizens, and the global community start now, act wisely, and work together.8 References 1. WHO Global Burden of Disease (GBD) mortality database for 2002 (Version 5), Geneva, Switzerland. 2. Dahlberg LL, Krug EG. Violence—a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002; 3-21. 3. Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002. 4. Deleo D, Bertolote J, Lester D. Self-directed violence. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002; 185-212. 5. Zwi AB, Garfield R, Loretti A. Collective violence. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002; 213-239. 6. Pinheiro PS. World Report on Violence Against Children. Geneva, Switzerland: United Nations, 2006.

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