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6 Papers on Research in Preventing Violence Against Women and Children The science behind preventing violence against women and children has evolved greatly over the past several decades. Several speakers offered overviews of the research and described the growing awareness of the com- plexities of the causes, risk factors, and adverse effects of such violence. They also explored potential intervention points that were illuminated by this discussion. The first paper is a reprint from the World Health Organization pub- lication Preventing Intimate Partner and Sexual Violence Against Women (WHO and LSHTM, 2010b). The full report provides an overview of the magnitude of the issue; this workshop summary includes Chapter 3, which is an in-depth analysis of preventive interventions in low- and middle- income countries and was the basis for Claudia García-Moreno’s presenta- tion at the workshop. The second paper is adapted from the International Men and Gender Equality Survey (IMAGES), a multi-country study that explored men’s per- spectives on gender norms and violence. The survey examined the evolving views of men on gender equality as well as whether these views affected men’s sense of well-being and their commitment to reducing violence. The third paper, by Claire Crooks from the University of Western Ontario and the Centre for Addiction and Mental Health, provides an overview of the intergenerational transmission of violence. It also explores the ways in which violence against children can have long-term impacts as well as what considerations are valuable in designing interventions to prevent child maltreatment. 49

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50 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN The final two papers, from Roger Fallot and Julian Ford, explore secondary and tertiary prevention of the long-term effects of violence and associated trauma by including the “trauma lens” in the provision of social services as well as through the empowerment of individuals who are ex- posed to violence. Trauma-informed care and psychosocial empowerment are two means by which survivors of violence can overcome potential ad- verse outcomes and prevent the recurrence of violence. PREVENTING INTIMATE PARTNER AND SEXUAL VIOLENCE AGAINST WOMEN: PRIMARY PREVENTION STRATEGIES1 Intimate partner and sexual violence are not inevitable—their levels vary over time and between places because of a variety of social, cultural, economic, and other factors. This can result in substantial differences between and within countries in the prevalence of intimate partner and sexual violence (WHO and LSHTM, 2010a). Most importantly, this varia- tion shows that such violence can be reduced through well-designed and effective programs and policies. There are important factors related to both perpetration and victimization—such as exposure to child maltreatment, witnessing parental violence, attitudes that are accepting of violence, and the harmful use of alcohol—that can be addressed (WHO and LSHTM, 2010c). At present, evidence on the effectiveness of primary prevention strate- gies for intimate partner and sexual violence is limited, with the overwhelm- ing majority of data derived from high-income countries (HICs)—primarily the United States. Consequently, current high priorities in this field include adapting effective programs from high-income to lower-income settings; further evaluating and refining those for which evidence is emerging; and developing and testing strategies that appear to have potential, especially for use in low-resource settings, with rigorous evaluation of their effective- ness. At the same time, the dearth of evidence in all countries means that the generating of evidence and the incorporation of well-designed outcome evaluation procedures into primary prevention programs are top priorities everywhere. This will help to ensure that the efforts made in this area are founded upon a solid evidence base. Furthermore, program developers should be encouraged to explicitly base programs on existing theoretical frameworks and models of behavior change to allow underlying mecha- nisms to be identified and to make replication easier. Most of the evaluated strategies aimed at preventing intimate partner and sexual violence have 1 Reprinted from World Health Organization and London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: World Health Organization.

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51 PAPERS ON RESEARCH targeted proximal risk factors—primarily at the individual and relationship levels of the ecological model. The Need for Upstream Action In the public health framework, primary prevention means reducing the number of new instances of intimate partner and sexual violence by addressing the factors that make the first-time perpetration of such violence more likely to occur. Primary prevention therefore relies on identifying the “upstream” determinants and then taking action to address these. The impact of widespread, comprehensive programs can then be measured at the population level by comparing the rates at which such violence is either experienced or perpetrated. Given the lifetime prevalence of intimate partner and sexual violence, the hundreds of millions of women worldwide in need of services would outstrip the capacity of even the best-resourced countries (WHO and LSHTM, 2010a). A problem on this scale requires a major focus on primary prevention. Upstream actions can target risk factors across all four levels of the ecological model. To decrease intimate partner and sexual violence at the population level, it is particularly important to address the societal or outer level of the model. Such measures include national legislation and supportive policies aimed at social and economic factors—such as income levels, poverty and economic deprivation, patterns of male and female employment, and women’s access to health care, property, education, and political participa- tion and representation. It is sometimes even argued that programs that aim to reduce intimate partner and sexual violence against women without increasing male–female equity will ultimately not succeed in reducing vio- lence against women. However, while many strategies involving legal and educational reform and employment opportunities are being implemented to increase gender equality, few have been assessed for their impact on inti- mate partner and sexual violence, making the evaluation of such strategies a priority. Any comprehensive intimate partner and sexual violence preven- tion strategy must address these sociocultural and economic factors through legislative and policy changes and by implementing related programs. Creating a Climate of Non-Tolerance Addressing risk factors at the societal level may increase the likelihood of successful and sustainable reductions of intimate partner and sexual violence. For example, when the law allows husbands to physically disci- pline wives, implementing a program to prevent intimate partner violence may have little impact. National legislation and supportive policies should

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52 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN therefore be put in place to ensure that women have equal rights to political participation, education, work, social security, and an adequate standard of living. They should also be able to enter freely into a marriage or to leave it, to obtain financial credit, and to own and administer property. Laws and policies that discriminate against women should be changed, and any new legislation and policies should be examined for their impact upon women and men. Legislation and policies that address wider socioeconomic in- equalities are likely to reduce other forms of interpersonal violence, which will in turn help to reduce intimate partner and sexual violence. Legislation and policies that address wider socioeconomic inequalities can make a vital contribution to empowering women and improving their status in society; to creating cultural shifts by changing the norms, attitudes, and beliefs that support intimate partner and sexual violence; and to creat- ing a climate of non-tolerance for such violence. The human rights of girls and women need to be respected, protected, and fulfilled as part of ensuring the well-being and rights of everyone in society. As a first step toward this, governments should honor their commit- ments in implementing the following international legislation and human- rights instruments: • Convention on the Elimination of All Forms of Discrimination Against Women (1979); • The Convention on the Rights of the Child (1991); • The Declaration on the Elimination of Violence Against Women (1993); • The Beijing Declaration and Platform for Action (1995); • The Millennium Declaration (2000); and • The Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women (Convention of Belem do Para, 1994). Legislation and criminal justice systems must also be in place to deal with cases of intimate partner and sexual violence after the event. These systems should aim to help prevent further violence, facilitate recovery, and ensure access to justice—for example, through the provision of specialized police units, restraining orders, and multi-agency sexual assault response teams. Potentially, legal protection against intimate partner and sexual vio- lence helps to reinforce non-violent social norms by sending the message that such acts will not be tolerated. Measures to criminalize abuse by intimate partners and to broaden the definition of rape have been instrumental in bringing these issues out into the open and dispelling the notion that such violence is a private family matter. In this regard, they have been very im- portant in shifting social norms (Heise and García-Moreno, 2002; Jewkes et

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53 PAPERS ON RESEARCH al., 2002). However, the evidence surrounding the deterrent value of arrest in cases of intimate partner violence shows that it may be no more effective in reducing violence than other police responses, such as issuing warnings or citations, providing counseling, or separating couples (Fagan and Browne, 1994; Garner et al., 1995). Some studies have also shown increased abuse following arrest, particularly for unemployed men and those living in im- poverished areas (Fagan and Browne, 1994; Garner et al., 1995). Protec- tive orders can be useful, but enforcement is uneven, and there is evidence that they have little effect on men with serious criminal records (Heise and García-Moreno, 2002). In cases of rape, reforms related to the admissibility of evidence and removing the requirement for victims’ accounts to be cor- roborated have also been useful but are ignored in many courts throughout the world (Du Mont and Parnis, 2000; Jewkes et al., 2002). Currently, on the whole, sufficient evidence of the deterrent effect of criminal justice system responses on intimate partner and sexual violence is still lacking (Dahlberg and Butchart, 2005). Dismantling hierarchical constructions of masculinity and femininity predicated on the control of women and eliminating the structural factors that support inequalities are likely to make a significant contribution to preventing intimate partner and sexual violence. However, these are long-term goals. Strategies aimed at achieving these long-term objectives should be complemented by mea- sures with more immediate effects that are informed by the evidence base presented in this paper. ASSESSING THE EVIDENCE FOR DIFFERENT PREVENTION APPROACHES From the perspective of public health, a fundamental question is, “Do intimate partner and sexual violence prevention programs work?” That is to say, are there certain programs or strategies that are effective in prevent- ing or reducing intimate partner and sexual violence? Effectiveness can only be demonstrated using rigorous research designs, such as randomized controlled trials or quasi-experimental designs. These typically compare the outcomes of an experimental group (which receives the program) with a control or comparison group (which is as equivalent as possible to the experimental group but which does not receive the program). 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 program and not some other factor. Although “testimonials” are not a sound basis for evaluating the ef- fectiveness of a program, they can provide insights into its running and on whether participants find it worthwhile. However, approaches that are based upon testimonials might expend significant resources and capacity on

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54 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN programs that may be ineffective or may even make things worse (Dahlberg and Butchart, 2005). Various criteria have now been proposed to more systematically evaluate the effectiveness of different programs. The most stringent criteria involve program evaluation using experimental or quasi- experimental designs; evidence of significant preventive effects; evidence of sustained effects; and the independent replication of outcomes. In spite of the emphasis on and visibility of efforts to promote gender equality and prevent intimate partner and sexual violence, very few of the programs reviewed in this paper meet all of these criteria, while others have not been subjected to any kind of scientific evaluation. Rigorous scientific evaluation of programs for preventing intimate partner and sexual violence are even rarer in low- and middle-income countries (LMICs). The field of intimate partner and sexual violence prevention must therefore be consid- ered to be at its earliest stages in terms of having an established evidence base for primary prevention strategies, programs, and policies. The limited evidence base for intimate partner and sexual violence prevention has three important implications for this paper. First, the paper extrapolates, when relevant, from the stronger evidence base for child maltreatment and youth violence prevention but clearly signals that these extrapolations remain speculative. Much, however, can be learned from the literature on youth violence and child maltreatment prevention. Second, the paper describes those primary prevention programs that have the potential to be effective either on the grounds of theory or knowledge of risk factors—even if there is currently little or no evidence to support them or where, in certain cases, they have not yet been widely implemented. In the process, an attempt is made to draw attention to the underlying theories, principles, and mechanisms on which the pro- grams are based. However, it is noted that a firm theoretical base and consistency with identified risk factors do not guarantee the success of a program. Third, the paper includes programs developed in LMIC settings on condition that they have some supporting evidence (even if it is weak) or are currently in the process of being evaluated, that they appear to have potential on theoretical grounds, or that they address known risk factors. The inclusion criteria are designed on the one hand to avoid setting the bar of methodological standards too high—which would lead to the exclu- sion of many of the programs developed in low-resource settings on the grounds that they have no or low-quality evidence supporting them. On the other hand, setting the bar too low would run the risk of appearing to endorse programs unsupported by evidence. However, the limitations of the evidence presented are clearly spelt out and the need for rigorous outcome evaluation studies emphasized.

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55 PAPERS ON RESEARCH Although still in its early stages, there are sound reasons to believe that this field is poised to expand rapidly in coming years. Some programs have been demonstrated to be effective following rigorous outcome evaluations, evidence is beginning to emerge to support the effectiveness of many more, and suggestions for potential strategies have proliferated. Furthermore, tried and tested methods for developing effective evidence-based primary prevention programs and policies for other forms of interpersonal violence have been reported. The field of evidence-based intimate partner and sexual violence prevention now requires an open mind to promising approaches and to innovative new ideas at all stages of the life cycle. SUMMARY TABLES OF PRIMARY PREVENTION STRATEGIES AND PROGRAMS Table 6-1 summarizes the strength of evidence for the effectiveness of those strategies to prevent intimate partner violence and sexual violence for which some evidence is available. Strategies are grouped according to life stage. An important distinction must be drawn between a strategy and a specific program. Although specific programs may have been demonstrated to be effective, this in no way implies that all other programs categorized under the same strategy are also effective. For example, the Nurse Family Partnership, developed in the United States, is a home-visitation program that has been demonstrated to be effective in preventing child maltreatment. Nevertheless, it is the only program within the broader strategy of home visitation (which includes a multitude of different programs) that is sup- ported by solid evidence of its effectiveness (MacMillan et al., 2009). The outcome measures of effectiveness are described in Box 6-1. Strategies are ranked for their effectiveness in preventing intimate part- ner violence and sexual violence as follows: • Effective: strategies that include one or more programs demon- strated to be effective. Effective refers to being supported by mul- tiple well-designed studies showing prevention of perpetration and/ or experience of intimate partner and/or sexual violence. • Emerging evidence: strategies that include one or more programs for which evidence of effectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing pre- vention of perpetration and/or experience of intimate partner and/ or sexual violence or studies showing positive changes in knowl- edge, attitudes, and beliefs related to intimate partner violence and/ or sexual violence. • Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence.

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56 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN • Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging. Emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence. • Ineffective: strategies that include one or more programs shown to be ineffective. Ineffective refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experience of intimate partner and/or sexual violence. • Probably harmful: strategies that include at least one well-designed study showing an increase in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/ or sexual violence. As shown in Table 6-1, there is currently only one strategy for the prevention of intimate partner violence that can be classified “effective” at preventing actual violence. This is the use of school-based programs to prevent violence within dating relationships. However, only three such programs—described below—have been demonstrated to be effec- tive, and these findings cannot be extrapolated to other school-based programs using a different approach, content, or intensity. At present, there are no correspondingly evaluated effective programs against sexual violence. TABLE 6-1 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence for Which Some Evidence Is Available Strategy Intimate Partner Violence Sexual Violence During Infancy, Childhood, and Early Adolescence Interventions for children and adolescents 2 3 subjected to child maltreatment and/or exposed to intimate partner violence School-based training to help children 3 2 recognize and avoid potentially sexually abusive situations During Adolescence and Early Adulthood School-based programs to prevent dating 1 N/A violence Sexual violence prevention programs for N/A 3 school and college populations

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57 PAPERS ON RESEARCH TABLE 6-1 Continued Strategy Intimate Partner Violence Sexual Violence Rape-awareness and knowledge programs N/A 4 for school and college populations Education (as opposed to skills training) N/A 5 on self-defense strategies for school and college populations Confrontational rape prevention programs N/A 6 During Adulthood Empowerment and participatory approaches 2 3 for addressing gender inequality: Microfinance and gender-equality training Empowerment and participatory approaches 2 3 for addressing gender inequality: Communication and relationship skills training (e.g., Stepping Stones) Home-visitation programs with an intimate 3 3 partner violence component All Life Stages Reduce access to and harmful use of alcohol 2 3 Change social and cultural gender norms 3 2 through the use of social norms theory Change social and cultural gender norms 2 3 through media awareness campaigns Change social and cultural gender norms 2 3 through working with men and boys 1—Effective: strategies that include one or more programs demonstrated to be effective; effective refers to being supported by multiple well-designed studies showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence; 2—Emerging evidence of effectiveness: strategies that include one or more programs for which evidence of effectiveness is emerging; emerging evidence refers to being supported by one well- designed study showing prevention of perpetration and/or experiencing of intimate partner and/or sexual violence or studies showing positive changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence; 3—Effectiveness unclear: strategies that include one or more programs of unclear effectiveness due to insufficient or mixed evidence; 4—Emerging evidence of ineffectiveness: strategies that include one or more programs for which evidence of ineffectiveness is emerging; emerging evidence refers to being supported by one well-designed study showing lack of prevention of perpetration and/or experience of inti- mate partner and/or sexual violence or studies showing an absence of changes in knowledge, attitudes, and beliefs related to intimate partner violence and/or sexual violence; 5—Ineffective: strategies that include one or more programs shown to be ineffective; ineffec- tive refers to being supported by multiple well-designed studies showing lack of prevention of perpetration and/or experiencing of intimate partner and/or sexual violence; 6—Probably harmful: strategies that include at least one well-designed study showing an in- crease in perpetration and/or experience of intimate partner and/or sexual violence or negative changes in knowledge, attitudes, and beliefs related to intimate partner and/or sexual violence; N/A—Not applicable.

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58 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN BOX 6-1 Outcome Measures of Effectiveness The effectiveness of a program can be evaluated in terms of three different types of outcome—each of which can be measured at different intervals after the program: 1. Changes in knowledge, attitudes, and beliefs regarding intimate partner and sexual violence. This is the weakest of the three outcomes because changes in knowledge, attitudes, and beliefs do not necessarily lead to changes in violent behavior. In this respect, even successful programs in this area cannot be assumed to be effective at preventing actual inti- mate partner or sexual violence without further research demonstrating corresponding reductions in violent behavior. 2. Reductions in the perpetration of intimate partner or sexual violence. 3. Reductions in the experience of intimate partner or sexual violence. Intimate partner violence is not a unitary construct and can take different forms, including physical, sexual, and psychological violence. Despite this, out- come evaluations generally do not examine effectiveness in relation to these different types of violence—nor are programs generally designed to address specific types of intimate partner violence in particular. It is possible that programs considered to be effective or promising may only be so for certain forms of intimate partner violence (Whitaker et al., 2007a). Table 6-2 lists those strategies for which there is currently no evidence or very weak evidence but that appear to have potential on the grounds of theory, known risk factors, or outcome evaluations that are methodologi- cally of lower quality; it also includes some promising strategies that are currently undergoing evaluation. All the strategies reviewed have been organized according to the main life stages. When strategies are relevant to more than one life stage, they have been categorized under the stage at which they are most often de- livered. Strategies relevant to all life stages are described last. Because of the way programs are organized, intimate partner violence is considered here to include instances of sexual violence that occur within an intimate partnership, while sexual violence is used here to refer to sexual violence occurring outside intimate partnerships (i.e., perpetrated by friends, ac- quaintances, or strangers). Dating violence can be considered to incorporate both possibilities because dating partners can range from being little more than acquaintances to more intimate partners. However, in Table 6-1 and Table 6-2 dating violence is classified for the sake of convenience under intimate partner violence.

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59 PAPERS ON RESEARCH TABLE 6-2 Primary Prevention Strategies for Intimate Partner Violence and Sexual Violence with Potential STRATEGY During Infancy, Childhood, and Early Adolescence Home-visitation programs to prevent child maltreatment Parent education to prevent child maltreatment Parent education to prevent child maltreatment Improve maternal mental health Identify and treat conduct and emotional disorders School-based social and emotional skills development Bullying prevention programs During Adolescence and Early Adulthood School-based multi-component violence prevention programs During Adulthood U.S. Air Force multi-component program to prevent suicide During Infancy, Childhood, and Early Adolescence Home-Visitation and Parent-Education Programs to Prevent Child Maltreatment As noted in earlier sections of this document, a history of child mal- treatment substantially increases the risk of an individual becoming either a perpetrator or victim of intimate partner violence and of sexual violence. It is therefore reasonable to assume that preventing child maltreatment has the potential to reduce subsequent intimate partner and sexual violence (Foshee et al., 2009). However, direct evidence of the effect of such pro- grams on the levels of intimate partner violence is currently still lacking. In general, however, reducing the risk of the different forms of child maltreatment reviewed in Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence (WHO and International Society for Pre- vention of Child Abuse and Neglect, 2006) can contribute to reducing the intergenerational transmission of violence and abuse. The most promis- ing strategies for preventing child maltreatment in this area include home- visitation and parent-education programs (Mikton and Butchart, 2009). However, neither type of program has been evaluated for its long-term effects on the prevention of intimate partner and sexual violence among the grown- up children of parents who were involved in such programs. Improve Maternal Mental Health Maternal depression (which affects at least 1 in 10 new mothers) can interfere with good bonding and attachment processes. This in turn

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106 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN TARGET has been evaluated in a series of real-world effectiveness stud- ies as a group therapy for women and men in substance abuse treatment as well as for incarcerated women, as a one-to-one therapy for low-income women with complex trauma histories and girls involved in delinquency, and as a combined group and milieu intervention for girls and boys placed in juvenile detention centers (Frisman et al., 2008, Ford et al., in press-b, in preparation; Ford and Hawke, in review). Group and milieu interventions enable participants to provide one another with peer modeling, support, and guidance as well as potentially enabling the program or community in which they take place to become “trauma informed” (Fallot and Harris, 2008). Consistent with this view, TARGET was found to enable women and men recovering from substance abuse to maintain a sense of realis- tic confidence and optimism (“sobriety self-efficacy”), where others who received substance abuse treatment as usual showed a marked decline in this important resilience factor (Frisman et al., 2008). The benefits to the entire setting were evident in findings from the evaluation of TARGET in youth detention centers, in which every session of TARGET received by a girl or boy was associated with a reduction in the number of behavioral incidents and punitive sanctions imposed by staff during the first two weeks of youths’ stay in the facilities (Ford and Hawke, in review). On the other hand, many girls or women who have experienced violence may prefer the privacy of a one-to-one therapy intervention, and TARGET showed evidence of helping both underserved women and girls to not only reduce their PTSD symptoms but also to increase their ability to regulate emotions (Ford et al., in press-a, in press-b). Implications of a Psychological Empowerment Approach for Violence Survivors To the extent that knowledge is power, providing women and children who have experienced violence with de-stigmatizing explanations of why they are struggling with persistent emotional distress and how they can draw upon their inherent personal strengths to regain their emotional bal- ance is a very direct and essential form of psychological empowerment. Equally, if not more, important is bringing this same knowledge to the many professionals, advocates, policy makers, funders, jurists, and regula- tors who determine how scarce societal resources will be allocated both to prevent violence and to restore the lives and well-being of survivors of violence. If violence changes how survivors’ bodies respond to subsequent stressors (non-violent as well as violent), then traumatic stress disorders such as PTSD and its more complex variants are simply extreme versions of the out-of-balance emotional states that everyone experiences. Therefore, if recovery from the aftereffects of violence involves regaining or restoring

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107 PAPERS ON RESEARCH innate capacities for re-setting the body’s stress reaction systems—and, in so doing, regaining or restoring the innate ability to regulate emotions and maintain a generally healthy balanced emotional state despite expectable perturbations—it is essential that not only violence survivors but also the public at large (including those key determiners and providers of services) are informed about why and how emotion regulation is essential not only for survivors of violence but also on a larger scale to prevent violence. With this perspective, it becomes possible to understand not only the aftereffects of violence but also violence itself as resulting at least in part from emotion dysregulation on a broad scale (e.g., uncivil discourse in politics or extreme economic and social disparities). Knowledge and skills regarding emotion regulation are essential not just for violence survivors, but for everyone. REFERENCES Adegoke, T. G., and D. Oladeji. 2008. Community norms and cultural attitudes and beliefs factors influencing violence against women of reproductive age in Nigeria. European Journal of Scientific Research 20:265-273. Adi, Y., A. Killoran, K. Janmohamed, and S. Stewart-Brown. 2007. Systematic review of the effectiveness of interventions to promote mental wellbeing in children in primary educa- tion. Report 1: Universal approaches: non-violence related outcomes. London: National Institute for Health and Clinical Excellence. Ahmed, S. M. 2005. Intimate partner violence against women: Experiences from a woman- focused development programme in Matlab, Bangladesh. Journal of Health, Population and Nutrition 23(1):95-101. Amaro, H. 2011. The Boston Consortium Model: Treatment of trauma among women with substance use disorders. Paper presented at Workshop on Preventing Violence against Women and Children, Institute of Medicine, Washington, DC. January 28. Amoakohene, M. I. 2004. Violence against women in Ghana: A look at women’s perceptions and review of policy and social responses. Social Science and Medicine 59:2373-2385. Anderson, L. A., and S. C. Whiston. 2005. Sexual assault education programs: A meta-analytic examination of their effectiveness. Psychology of Women Quarterly 29:374-388. Anderson, P., D. Chisholm, and D. C. Fuhr. 2009. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. The Lancet 373(9682):2234-2246. APA (American Psychiatric Association). 1997. Diagnostic and statistical manual of mental disorders (DSM), fourth edition. Washington, DC: American Psychiatric Association. APA. 2004. Practice guideline for the treatment of patients with acute stress disorder and post- traumatic stress disorder. Washington, DC: American Psychiatric Association. Australian Centre for Posttraumatic Mental Health. 2007. Australian guidelines for the treat- ment of adults with acute stress disorder and posttraumatic stress disorder. Melbourne, Australia: Australian Centre for Posttraumatic Mental Health. Bacon, H., and S. Richardson. 2001. Attachment theory and child abuse: An overview of the literature for practitioners. Child Abuse Review 10:377-397. Bair-Merritt, M. H., J. M. Jennings, R. Chen, L. Burrell, E. MacFarlane, L. Fuddy, and A. K. Duggan. 2010. Reducing maternal intimate partner violence after the birth of a child: A randomized controlled trial of the Hawaii Healthy Start home visitation program. Archives of Pediatrics & Adolescent Medicine 164(1):16-23.

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