Proceedings of a Workshop

Public Policy Approaches to Violence Prevention

Proceedings of a Workshop—in Brief

According to the World Health Organization’s (WHO’s) World Report on Violence and Health, and as described by Alexander Butchart from WHO in his presentation, in 2002 there were an estimated 1.4 million deaths due to violence globally, accounting for 2.5 percent of global mortality, and among those violent deaths are approximately 470,000 lives lost annually to homicide (Krug et al., 2002). For this report, the definition of violence includes self-directed violence (i.e., suicide or self-abuse), interpersonal violence (within a family, with an intimate partner, or against an acquaintance or stranger), and collective violence by larger groups of individuals. In 2014 WHO, the United Nations Development Programme, and the United Nations Office on Drugs and Crime jointly published the Global Status Report on Violence Prevention, which reported that one-quarter of all adults report having been physically abused as a child, one in five women report being sexually abused as a child, one in three women report having been a victim of physical or sexual violence by an intimate partner, and one in 17 older adults report having experienced abuse in the past month (WHO/UNODC/UNDP, 2014). In the United States, suicide rates increased 24 percent from 1999 to 2014, going from 10.5 to 13.0 suicides per 100,000 people (Curtin et al., 2016). There are human and economic costs of violence, with suicide in the United States alone costing $93.5 billion (Shepard et al., 2015). The Institute for Economics and Peace has estimated the economic impact of violence on the global economy to be $14.3 trillion in purchasing power parity (IEP, 2017).

Because of the societal impacts and costs of violence, the National Academies of Sciences, Engineering, and Medicine held a workshop on December 1–2, 2016, with the aim of illuminating the ways in which violence prevention practitioners can effectively share their evidenced-based research findings with policy makers in order to positively affect and amplify violence prevention efforts. The workshop explored this topic through three lenses: (1) economics and costing, (2) research and evidence, and (3) effective communications and messaging. This approach underscored the fact that violence prevention is a complex and multi-faceted issue that requires an “all hands on deck” interdisciplinary approach. This 2-day workshop brought together a diverse group of experts from various domains and backgrounds to foster multi-sectoral dialogues on the topic.¹ Additional information and resources from the meeting can be found on the forum’s webpage.

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ECONOMICS AND COSTING IN PUBLIC POLICY AND VIOLENCE PREVENTION

Andrés Villaveces of the World Bank spoke about a global strategy for violence prevention. It has been challenging, he said, to justify violence prevention from an economic perspective because the indirect costs of violence are defined in disparate ways, and there are varying methods used to measure violence that are not standardized. The combination of these factors results in data that are difficult to compile and compare. Villaveces stressed the importance of having data that demonstrate the costs of violence as well as more standard public health data. He also emphasized that understanding how and when to deploy data to effectively frame a particular message is crucial for justifying and substantiating the need for global violence prevention. In the context of economics and costs, Villaveces emphasized how failing to address violence hampers development, while addressing violence can improve revenues by strengthening the environment to support a more productive society and by preventing the diversion of funds to pay for the costs of violence in a given country or community. In addition, Villaveces spoke about the competing economic interests of addressing violence versus addressing various political or societal interests. Villaveces noted that when there are competing agenda items, policy makers will often make decisions based on which solutions they believe will produce outcomes and deliverables better or faster.

Villaveces mentioned the importance of knowing where the resources are coming from and who is providing them, and to consider the political, legal, and social relevance of what these donors or institutions are trying to accomplish in order to ensure that violence prevention efforts are not only effective but also are sustainable. There is evidence, Villaveces said, that investing in violence prevention earlier in life using a human capital approach can lead to greater returns over time.

Offering a different perspective on economics, Saugato Datta of Ideas 42 spoke about the ways that behavioral economics as a discipline could be used to reframe the way researchers, practitioners, and policy makers think about violence. The decision whether to commit violence results from a series of decisions and actions on the part of a person, Datta said; therefore, to mitigate or prevent violence, it might be helpful to use behavioral economics, which seeks to explain why people act and choose in the ways they do, to design more effective interventions.

According to Datta, the context in which humans make decisions can influence what choices they make. In general, humans believe that they make decisions based on a weighing of benefits versus costs, but behavioral economics takes a much more nuanced approach, which, Datta said, is more realistic and not so linear. One useful concept from behavioral economics is the idea of a default option. When a person does not actively make a choice, he or she may still be affected by what happens in the case of doing nothing—i.e., something is going to happen even if the person does not actively do anything. Datta said that the “default option” occurs a lot more than other options. In terms of violence prevention, Datta said that some proportion of a person’s actions and behavior may not result from fully thought-out active decisions; rather, the person’s actions and behavior may reflect automatic responses to the environment. He explained that violence prevention researchers and practitioners can use this knowledge to change the way that people make decisions regarding perpetrating further violence.

Incorporating Costing into Prevention Strategies

Judith McFarlane of Texas Woman’s University spoke about incorporating costing into a child-based gender violence prevention program, Right to Play, in Pakistan. McFarlane discussed the importance of building cost-effectiveness and cost–benefit analyses into programming at the outset, rather than at the end, so that practitioners and researchers can provide cost-effectiveness and cost–benefit information when the results are disseminated on a wider scale and discussions about scaling-up are undertaken. This critical step, she explained, can help build a case more easily and more effectively to policy makers and stakeholders alike.

Furthering these initial comments from McFarlane, Meg Gardinier of the Child Fund Alliance spoke about costing and economics in the context of violence against children. According to Gardinier, a key for the Child Fund Alliance has been identifying the right stakeholders and champions as well as constantly highlighting issues focused on violence against children. Gardinier cited grim statistics—more than half of the world’s children are exposed to violence each year, which causes long-term negative outcomes across the life course. Furthermore, these consequences are often intergenerational, with those who have faced violence as a child being more likely to become violent adults. Gardinier said that enforcing the rights of children to live free from violence and exploitation will require investments in child protection.

Gardinier said that when in competition for resources, it is necessary to make the right case that resonates with the sponsor and demonstrates a return on their investment. According to Gardinier, in the case of violence against children, the right case includes discussing the fact that the most significant indirect costs are the productivity losses arising from the ways violence can impede child development. In very young children, Gardinier said, violence is known to inhibit brain development, and adults who were exposed to violence in childhood have been found to have lower levels of education, employment, earnings, and assets. The impact of lower-educational attainment, Gardinier said, in turn has a

continuing and lifelong negative impact on employment. Thus, violence against children can, over time, have a significant economic cost to society.

Gardinier said that the Child Fund Alliance commissioned the Overseas Development Institute to conduct a study of the prevalence and consequences of different types of violence, including the types of costs resulting from violence and exploitation against children globally. This study looked at global costs as well as the most effective ways to prevent and respond to violence and exploitation against children. The report looked at four types of violence against children: physical violence, psychological violence, sexual violence, and the violence of the worst forms of child labor. Gardinier said that the researchers used a productivity loss approach because they felt it was the most effective way to estimate the global cost of physical, psychological, and sexual violence. Using the global number of children who suffer from violence, and previous research on the cost of violence against children, she reported that they calculated the cost in terms of lost productivity to be as much as $7 trillion U.S. dollars over the children’s lifetimes, without accounting for health care and criminal justice costs.

Using Research and the Evidence Base in Public Policy and Violence Prevention

Costing studies are only one part of the narrative. Butchart spoke about developing a strong research and evidence base for violence prevention to help form comprehensive solutions to violence.

Butchart stressed that while researchers know the violence statistics, it is critical for them to emphasize the health consequences of violence when talking to policy makers, especially in the context of non-fatal violence. Death, he said, is only the “famous tip of the iceberg,” and lifelong health consequences, including various forms of injuries and the resulting disabilities, often precede death. According to Butchart, interpersonal violence often results in increased risk behaviors such as smoking and alcohol and drug abuse, which can then lead to various non-communicable diseases. Additional health consequences of violence include HIV/AIDS, maternal and child health problems (including unintended and adolescent pregnancy), pregnancy complications, and mental health problems.

Besides the health consequences, Butchart spoke about the compounding nature of violence, where victimization or exposure to violence can put one at greater risk of becoming a victim or a perpetrator of assaultive violence in later life. Butchart touched upon the growing evidence base in global violence prevention and discussed the public health–based framework for dealing with violence, which includes defining the problem using descriptive statistics, identifying underlying causes and risk factors, using outcome evaluation studies to establish effective approaches to preventing violence, and scaling up those policies and programs that are effective.

In terms of defining the problem through data, Butchart said that there is a strong evidence base and understanding of violence in this context; however, there is a need for more evidence from low- and middle-income countries, which share a disproportionate burden of global violence, as well as a need for more research focused on men and boys, who are the primary perpetrators of interpersonal violence and who are at a much higher risk of being victims of homicide. Butchart also said that there is a need for stronger evidence concerning prevention strategies, while commenting that the evidence that does exist concerning prevention strategies indicates that community-based interventions are more promising for reducing multiple forms of violence than individual-level or family-level interventions. The community-based interventions also seem to be more cost-effective, he said.

Concerning scaling up and deploying effective strategies, Butchart again emphasized the need for more evaluation studies while noting the incredible growth of information in the field since the early 2000s, which, he said, is a promising trajectory. Butchart mentioned four new platforms for implementation action: the Sustainable Development Goals, the Global Partnership to End Violence against Children, the INSPIRE technical package for ending violence against children, and WHO’s new Global Plan of Action on violence prevention. These platforms and tools, he said, can and should be used to advocate for increased resources from policy makers to increase our knowledge and understanding of what works to prevent violence.

Leveraging the Evidence Base: Child Labor and Forced Labor

Tina Faulkner of the U.S. Department of Labor, Bureau of International Labor Affairs (ILAB), spoke on leveraging evidence for policy making in the context of child labor and forced labor. Faulkner said that the relationship between research and policy can be bi-directional, with each influencing the other. For instance, she explained, the International Labor Organization and United Nations conventions set forth research goals and standards that governments follow in their efforts to protect children and others from exploitation and violence.

Concerning the ways in which research can influence policy, Faulkner mentioned that as a result of the Trade and Development Act (passed in 2000), the U.S. Department of Labor is now charged with developing an annual report on the worst forms of child labor in countries that receive trade benefits from the United States—approximately 130 countries.

The report contains information about each country, including a narrative describing labor-related issues and the country’s efforts to address that problem; Faulkner said that the report also contains an assessment of those efforts. Ultimately, she said, the report can have tremendous impacts on trade negotiations between the United States and countries covered by the reports, in turn having a direct impact on international and U.S. trade policies.

Another ILAB report is the List of Goods Produced by Child Labor or Forced Labor, whose creation is required under the Trafficking Victims Protection Reauthorization Act. Faulkner said that there are approximately 139 goods from 75 countries currently on the list, which can also affect trade policy.

Faulkner also talked about the role that research performed by ILAB plays in its technical assistance programming. In essence, ILAB focuses its technical assistance on countries that show a willingness to develop and implement Country Level Engagement and Assistance to Reduce (CLEAR) child labor program projects—i.e., those that come directly from recommendations produced as byproducts of ILAB’s research. Faulkner also mentioned that ILAB is more willing to work with countries that have implemented CLEAR and thereby have committed themselves to evidence-based practices. In closing, Faulkner said that just as in general violence prevention, there is a need for more impact evaluations of intervention programming in order to better ascertain and advocate for what works in the fields of prevention of child labor and forced labor.

Leveraging the Evidence Base: Violence Against Children

M. Catherine Maternowska of UNICEF spoke about using the evidence base for policy making in the context of violence against children. Maternowska focused her talk on data from studies performed in Italy, Peru, Vietnam, and Zimbabwe. These countries, she explained, were selected because each of the governments had an interest in preventing violence, had strong UNICEF ties, had accessible data, and they represented different regions and income-economies, which allowed for interesting comparisons.

Maternowska said that working with these countries first entailed an exploration of existing data, including meta-analyses and in-country data. She noted, as did other speakers, that within the data, evaluations of interventions were extremely scarce. Thereafter, it became the role of Maternowska and her UNICEF-based team to support the in-country governments and stakeholders as they made decisions regarding priority areas, began to untangle the complex nature of violence within each country (as it co-occurs with risk factors across all levels of the ecological model), and helped to develop a research infrastructure within each country. Maternowska commented that governments’ unwillingness to acknowledge violence presents additional challenges. Maternowska said that it is important to support in-country data collection and analysis done through the newly established research infrastructures. She explained that it is often the case that large multilaterals like UNICEF will take data to their home offices, run complex analyses, and then send the results back to their in-country partners while wishing them the best on their future prevention and intervention efforts. This process, she said, was purposefully different and was designed to establish a roadmap of sorts for other countries to follow.

Maternowska said that her team’s approach of countries actively using, analyzing, and disseminating their data instead of waiting for reports resulted in rapid uptake of research results by governments in all four countries (Italy, Peru, Vietnam, and Zimbabwe), which led to positive changes in laws, policies, and funding streams related to violence prevention in each country. Furthermore, the approach has developed a sustainable research infrastructure in each location. She also said that scientists within the research infrastructures have begun to assist other countries in their respective regions, which is leading to promising south-south partnerships. This growing trend of in-country/regional ownership and accountability is a positive outcome that Maternowska and her team hope to replicate elsewhere through the development of resource guides and toolkits for building research capacity and identifying and responding to violence.

Leveraging the Evidence Base: Self-Directed Violence and Suicide

Holly Wilcox of the Johns Hopkins Bloomberg School of Public Health spoke on building the evidence base in the context of suicide and self-directed violence. Wilcox explained that suicide is very complex, with social, psychological, genetic, and biological risk factors all contributing to the burden of self-directed violence; however, there are effective approaches to intervening along the pathways toward self-harm. Wilcox said that the most successful—and expensive—suicide prevention efforts are those that are comprehensive and coordinated with built-in evaluation and quality improvement mechanisms in place. These efforts become more refined over time in response to constant input and feedback into the prevention program.

Concerning policy approaches, Wilcox said that the evidence supports providing access to high-quality health care, restricting access to lethal means (pesticides, firearms, etc.), and reducing the misuse of alcohol and over-the-counter drugs. She continued by saying that there are multiple examples of gun law changes leading to a reduction in suicide—in

the United States and in other countries—with both the Israeli Army and the Swiss Army being particularly good examples. Wilcox mentioned how polarizing the topic of guns is in the United States, which has led to a hesitancy among politicians to take on the subject. Another example of policy change involves taxes and related restrictions on alcohol, both of which can influence suicide rates. Wilcox mentioned Russia as a prime example of the relationship between these policies and suicide rates.

According to Wilcox, the areas that still need to be addressed include media coverage of suicide (as certain forms of reporting can lead to copycat attempts) and providing support to families and communities affected by suicide. Dealing effectively with the latter issue, she said, will require a response to the global shortage of mental health workers.

In addition to these overarching areas of focus, Wilcox discussed some of the policy-based barriers that researchers and practitioners in the mental health field can face. For instance, she said, because suicide is illegal in many countries, individuals who survive an attempt can face incarceration instead of receiving the help they need. In addition, there may also be penalties levied against grieving family members. Furthermore, Wilcox said, suicide prevention has not received the same level of financial investment as other areas of violence prevention, and more funding will be necessary to produce measurable impacts. Wilcox also said that as with other areas of violence, the need for program evaluation is pressing.

Wilcox concluded her remarks by reminding the audience that suicide prevention approaches work, and she pointed to the promise of national suicide prevention strategies that can increase funding and resources as well as data collection and political support.

COMMUNICATIONS AND MESSAGING OF RESEARCH FINDINGS TO POLICY MAKERS FOR POLICY CHANGE

Georges Benjamin of the American Public Health Association spoke about messaging and communicating in a public policy context, including strategies for how researchers with the intent to change policy can effectively communicate their findings to policy makers. Benjamin began his talk by defining politics as the practice and theory of influencing other people as well as the study or practice of the distribution of power and resources within a given community. Benjamin noted that policy makers regularly make decisions that may entail tradeoffs among resources.

Concerning policy change, Benjamin offered several basic observations: all politics are local, people can change policy, and advocates bring the front line to policy makers. According to Benjamin, even in national organizations it is important to recognize a policy maker’s accountability on a local level as policy makers are much more likely to pay attention to someone who is in their district or local community. Benjamin explained that policy makers may not feel comfortable supporting a position unless they have a good understanding of the political support they have for what is being presented. Benjamin also said that engaging with policy makers requires making a strategy that defines where stakeholders want to go and the problem they want to address, taking the initiative, being an active collaborator, and bringing solutions to the table. In addition, he stressed the importance of understanding the power, influence, and authority one has, with the goal being to strive for all three. Benjamin emphasized the importance of knowing the U.S. Code of Laws, as it is an important tool to understand what is already on the books for health and what power and authorities one might already have. He stressed the importance of making relationships long before they are needed so that an established trust is already there.

After this overview, Benjamin discussed a number of steps for engaging policy makers, which included: identifying policy makers who support the cause; using the policymakers’ language and making it relevant to them; always telling the truth and using the best evidence and science available; knowing the opponent’s positions and arguments and planning responses to them; and communicating one’s position in a brief, consistent, and articulate manner. He stressed that media advocacy is an essential tool; for example, news stories that help define the problem are helpful, as are public briefings and social media. Benjamin said that one powerful advocate is the “unanticipated messenger”—someone (a community member, or a celebrity, for example) whom the policy maker is not expecting to hear from but who can talk about the problem and articulate the message effectively. Finding the right unanticipated messenger “can make all the difference in the world” in moving a policy agenda forward, he said.

Communicating in the Context of Suicide

Jerry Reed of the Education Development Center furthered the commentary provided by Georges Benjamin about suicide. Reed began his talk by speaking about the importance of the personal story. He mentioned how Senator Harry Reid’s sharing his personal story about the loss of a loved one to suicide was groundbreaking and how it led to countless others sharing their experiences with suicide—which ultimately triggered the beginning of the national response to suicide prevention.

Reed stressed that government cannot do it all, and that participation and solutions from both the public and private sectors are critical. Moreover, Reed emphasized that it is not just one best practice that will fix a problem, but rather “bundled best practices” that will allow for a comprehensive intervention. He mentioned that in using public–private partnerships, one can benefit by getting the synergy and energy of many people from various sectors to do what they are best able to do. According to Reed, the suicide prevention field is “flying in formation” in using its national strategy as a roadmap for meeting its objectives with the goal of reducing suicide by 20 percent by 2025. He said that the field has moved from awareness to setting quantifiable goals and to identifying the areas with the highest burden. Reed spoke about how valuable prevention is for saving lives. He emphasized the importance of knowledge, social strategy, and political will to mobilize legislators to respond. He also said that both engaging the voice of lived experience and having a comprehensive approach can make a huge difference.

Developing a Global Communications Strategy

Joe Wagner of Fenton Communications spoke about the process of developing a global communications strategy to advance the Bernard van Leer Foundation’s work on reducing violence in the lives of young children. In this case, Fenton Communications wanted to reach elite opinion leaders, influencers, and policy makers, with the goal of mobilizing greater, more sustained public and political engagement by raising the visibility of this issue through a compelling, urgent, evidence-based, tested, and actionable narrative. The company’s process included a training and interview guide in which eighteen influencers from various fields were interviewed on their knowledge about violence in the lives of children, how they talked about it, and what could move them to action. The results showed that people knew very little about the issue or its solution. In addition, there was little understanding of the effects of such violence on brain development or physical health. Furthermore, most people had strong, often personal reactions to the issue and tended to find it overwhelming and triggering. The research also showed that few could name a successful violence prevention initiative and that people generally did not know that meaningful change was achievable within 2 years (e.g., most people thought it would take 10 years or more before a real difference would be seen). Moreover, Wagner said, keeping things positive, interactive, and focused on the children was highly effective, as was bringing in children’s voices live or via video.

Wagner said that giving solutions a name helped enormously. For example, participants in the study were slightly overwhelmed by the seven WHO strategies (INSPIRE, as mentioned by Butchart), but they responded very well to “Ring the Bell” and violence interrupters from Cure Violence. As part of the process, Wagner’s group came up with key messages to emphasize, including that violence affects children, whether felt directly or witnessed, in communities, schools, and homes, and in rich and poor families.

Wagner stressed that violence is preventable and that key messaging should emphasize this as well as that major reductions in violence can happen in a short period of time. He said that there are proven solutions and highlighted two key strategies: changing cultural norms and supporting parents. He mentioned a number of other arguments for tackling the problem, including how upfront investments in violence prevention save money in the long term and are more effective, such investments are good for adult health, breaking the cycle of violence decreases the likelihood of individuals being a perpetrator or victim of violence, addressing violence will have positive impacts on economic inequality, and physical discipline does not work and may cause harm. Concerning messaging, he suggested that it is important to make sure the issue is defined, without spending too much time persuading an audience as to why it is a problem, and to make the point that violence can be prevented, sometimes in a relatively short period of time. Wagner suggested linking the problem and its solutions to what audiences care about or work on; for example, violence against women is closely linked to violence against children. He further explained the importance of helping members of the audience understand that they can do something about violence against children by continuing or amplifying the work they already do on other issues and, as a result, can get more resources for their work by making that connection.

Communicating in the Context of Youth Violence

Jorja Leap from the Luskin School of Public Affairs at the University of California, Los Angeles, who is also the director of the Health and Social Justice Partnership and an adjunct professor of social welfare, conducted her talk on youth violence and using communication and messaging research to change policy. Leap emphasized how to talk about research effectively, and she stressed that communications must be authentic and avoid sensationalism. Leap also warned the audience that researchers should avoid providing too much data, while at the same time keeping reports engaging in order to maximize the chances that they are read by Congressional representatives and their staffers. Sensationalism humanizes the information, Leap said, and policy makers are drawn to such sensationalism.

Communicating in the Context of Anti-Trafficking

Hanni Stoklosa of Brigham and Women’s Hospital at the Harvard School of Medicine and executive director of HEALTH Trafficking discussed the measurable public health impacts made by HEAL Trafficking in its efforts to abate the effects of human trafficking.

Stoklosa, an emergency medicine physician, emphasized how health care is uniquely positioned to intervene in the cycle of violence, as doctors and nurses interface with trafficking survivors every day; however, the health care workers are often unaware of the circumstances. This message was echoed by a trafficking survivor, Fainess Lipenga, who listed key warning signs that practitioners should be aware of, including inappropriate dress for the season, lack of eye contact, no identification, and not knowing their home address. Lipenga further urged practitioners to be prepared with interpreters, as a victim may not speak English, and to be ready to contact the authorities or appropriate hotlines as needed if they suspect that they are interacting with a victim of trafficking. Stoklosa predicted that the number of victims identified will rise dramatically as practitioners become more aware of trafficking.

Concerning advocacy, Stoklosa emphasized the need for systems of care that are able to address the stated needs of survivors, including the provision of care during non-banking hours. She said that it is critical to provide both acute resources and more long-term health needs, such as mental health treatment (including treatment for substance use disorders, especially given the connections between trafficking and the opioid epidemic). Protocol development and the updating of medical codes, she explained, are also crucial in ensuring that care is standardized, systematic, holistic, and of good quality.

PRACTICES AND INTERVENTIONS

Case Studies of Policy Making and Violence Prevention: Baltimore, Maryland

Leana Wen, an emergency physician and a health commissioner in Baltimore, Maryland, spoke about the case of policy making and violence prevention in Baltimore City. Wen challenged the audience to not see youth just as being the perpetrators of violence without also recognizing the deep trauma that they are facing in their communities every day. She mentioned that there are neighborhoods in Baltimore City where a child born today can expect to live 20 years less than if that child were born a couple miles away. Wen described three strategies being used in Baltimore City to address violence: understanding the effects of trauma on individual behavior and expanding mental health services, choosing to invest early and differently, and discussing the cost of doing nothing versus how much an intervention would cost. For example, she said, one gunshot wound can cost a city $100,000, and a single life lost can lead to a $1 million loss in economic productivity, which is likely more than what a violence prevention intervention would cost. In her discussions with youth ages 8 to 15, she said that the number one issue of concern was mental health disorders due to trauma. Wen said that she thinks that it is important to recognize the cycle of violence and trauma that exists and that “hurt people hurt people.” These ideas lead to a renewed focus on trauma-informed care, rehabilitation in place of incarceration, and solutions that focus on ethical and just remedies while confronting the interrelated issues of structural racism and discrimination. Wen ended her talk by saying that stopping violence is the “baseline” and that the end goals to which one should aspire are quality of life, safe neighborhoods, and healthy lifestyles.

Case Studies of Policy Making and Violence Prevention: Cali, Colombia

Rodrigo Guerrero, a former mayor of Cali, Colombia, spoke about the case of policy making and violence prevention in Cali. Guerrero said that during his time as mayor, he knew that homicides were the most important health problem of the city; as such, he made reducing interpersonal violence a focus of his tenure as mayor. Because he was trained as an epidemiologist, Guerrero used the epidemiological method, acquiring knowledge by observation.

Guerrero mentioned the theoretical model of risk factors, noting that complex social problems, such as violence, tend to have multiple risk factors. Examples of risk factors for the violence found in Cali include alcohol consumption, access to firearms, cultural behavior, ineffective police and judicial systems, organized crime, inequity, modern poverty, and biological factors. Guerrero said that once one has identified the relevant factors, the next step is to define the problem that is to be solved. Violence in Cali, he explained, was defined as the use of physical force with the intention to inflict injury; it is important to specify “intentional,” he said, because otherwise one might include accidents as well. After defining the problem and identifying where within the city or region it is occurring, Guerrero said, one should then have some hypothesis and planned interventions, followed by evaluation and reformulation. This is the cycle that most people do, he said. Based on their observations and data, Guerrero and his colleagues determined that the key risk factors associated with violence in Cali were firearms and alcohol consumption. Based on this knowledge, Guerrero said, they implemented

policies that restricted the sale of alcohol past 2 a.m. on weekdays and forbid carrying firearms in Cali unless manufactured, administered, and sold by the army. Evaluations showed a 35 percent reduction in homicides. In those areas in which only firearms were forbidden, there was a 14 percent reduction in homicides.

Mobilizing a Community to Action After Tragedy: Lessons from Sandy Hook Promise

Lauren Alfred of Sandy Hook Promise, spoke about mobilizing the community to action after tragedy. Sandy Hook Promise, founded shortly after the shooting tragedy at Sandy Hook Elementary School on December 14, 2012, works to prevent gun violence by working with Congress, states, and communities. Alfred said that gun violence in the United States is significant, and the level of gun violence has not changed in the last 10 years, with approximately a half-million acts each year.

Alfred said that when Sandy Hook Promise researchers examined the levers used by the gun violence prevention community, they saw a concentration in policy and politics rather than in other levers of social change, such as programs, local activism, and legal levers. In addition, they saw that the conversations about violence prevention were not happening in the right groups of people; rather than talking to responsible gun owners, a necessary target population when com-batting the political framework around issues with guns and gun violence, approaches mostly focused on talking to those affected by violence in the past. Furthermore, there was a majority of Americans who supported Second Amendment rights but who had never been engaged to talk about how they could contribute to the cause of gun violence prevention in their own communities and nationally.

Alfred mentioned that time and time again with mass shootings, in particular, missing the signs is easy. According to Alfred, the vast majority of gun (and all) violence is caused by a lack of mental wellness, not mental illness (4 to 8 percent of gun violence is committed by someone with a diagnosed mental illness, whereas the remaining 92 to 96 percent is committed by someone without a diagnosed mental illness but with problems of coping, anger management, empathy, social development, or problem solving). According to Alfred, the majority of firearms used in school shootings, threats, and suicides come from inside the home where the firearm was left unsecured, and firearms used in crimes are primarily purchased illegally or stolen. As a result of this information, Sandy Hook Promise’s interventions focus on engagement, organizing, programs, and policy in order to try to pull different levers than had traditionally been the case. The Sandy Hook Promise team was hoping to do this in an effort to change attitudes and behaviors and prevent gun violence, i.e., to shift the focus, engage everyone, and not lead with the word “gun.”

According to Alfred, Sandy Hook Promise has created a base of more than 800,000 supporters who are able to mobilize quickly by bringing the organization’s programs into schools or its policies to bear on Capitol Hill by making phone calls and lobbying, signing petitions, or organizing in their communities. In addition, Sandy Hook Promise has four programs that it is bringing to schools. The programs are mental health first aid (and youth mental health first aid), Say Something, Safety Assessment and Intervention, and Start with Hello. Alfred said that these programs not only work on the traditional gun violence prevention policies, but they also focus on mental health reform, criminal justice reform, and education reform. Over 1 million students and adults have been trained in these four programs. Furthermore, Alfred said, Sandy Hook Promise has built a base of “Promise Makers” and “Promise Leaders.” Moreover, Alfred said, the organization has also worked on ballot initiatives in many states. The results of Sandy Hook Promise’s programs have already delivered “chilling results” in schools, where they have reduced the rates of bullying and improved the environments for students to be more inclusive. Students have also learned of violence that has been averted, including stopping a school shooting from happening in Cincinnati. She said that she believes the success of Sandy Hook Promise stems from giving people options and from the inclusive nature of their policies and programs.

CLOSING DISCUSSION

In the open discussion that concluded the workshop, Peggy Murray from the National Institutes of Health and Brigid McCaw from Kaiser Permanente brought up differentiating between risk factors and warning signs for violent behavior, since labeling people, especially children, with the latter can increase stigmatization. Thomas Abt from Harvard University summarized the problem of competing resources and how primary prevention is often presented as the most effective solution to reducing violence, but data usually show, he said, that secondary and tertiary interventions have the greatest effect. He stressed that the future of violence prevention lies in a collaborative relationship between public safety and public health. In particular, Abt said, those in the public health sector need to push evidence-based strategies and work closely with members of the public safety community and not view them as a competitor for resources.♦♦♦

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Krug, E. G., L. L. Dahlberg, J. A. Mercy, A. B. Zwi, and R. Lozano. 2002. World violence report on health. Geneva, Switzerland: World Health Organization.

Shepard, D. S, D. Gurewich, A. K. Lwin, G. A. Reed, and M. M. Silverman. 2015. Suicide and suicidal attempts in the United States: Costs and policy implications. Suicide and Life Threatening Behavior 46:352–362.

WHO/UNODC/UNDP (World Health Organization, United Nations Office on Drug and Crime, and United Nations Development Programme). 2014. Global status report on violence prevention 2014. Geneva, Switzerland: World Health Organization.

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Louise Flavahan and Joan Romaine as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

PLANNING COMMITTEE FOR EFFECTIVE PUBLIC POLICY SOLUTIONS FOR GLOBAL VIOLENCE PREVENTION: A WORKSHOP*

Thomas Abt, Harvard University; Sheldon Greenberg, Johns Hopkins University; Rodrigo V. Guerrero, Cali, Colombia; Jorja Leap, University of California, Los Angeles; Judith McFarlane, Texas Woman’s University; and Gerald Reed, Center for the Study and Prevention of Injury, Violence and Suicide Education Development Center.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteurs and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Sheldon Greenberg, Johns Hopkins University; Arturo Cervantes Trejo, Anáhuac University México; and Jacquelyn Campbell, Johns Hopkins University School of Nursing. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSOR: This workshop was partially supported by AB InBev; Administration for Community Living; Archstone; Avon Foundation; Becton, Dickinson and Company; Catholic Health Initiative; Felix Foundation; JSI Research & Training Institute, Inc. (USAID); Kaiser Permanente; Leading Age; National Institute for the Evaluation of Education; National Institutes of Health; New Venture Fund; Oak Foundation; Robert Wood Johnson Foundation; and the U.S. Department of Labor.

For additional information regarding the workshop, visit http://nationalacademies.org/hmd/Activities/Global/ViolenceForum/2016-DEC-01.aspx.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Public policy approaches to violence prevention: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25031.

Health and Medicine Division

Copyright 2018 by the National Academy of Sciences. All rights reserved.