Interventions
The evidence base of ways to prevent violence is expanding rapidly, but huge gaps remain in relation to effective strategies for reducing the health burden associated with interpersonal violence. The greatest strides have come in the areas of youth violence and child abuse, and almost all the prevention knowledge has been developed in high-income countries. Despite those limitations, an understanding of the epidemiology and etiology of violence and prevention provides important insights into the spectrum of policies and interventions that can be drawn on to prevent violence in LMICs.
Violence Prevention Strategies
The many commonalities among the various forms of violence in relation to their epidemiology and etiology suggest that common pathways to prevention may be available (Reza, Mercy, and Krug 2001). A typology of prevention strategies is useful in sorting through the complexities and commonalities of this problem to identify the range of strategies that might be incorporated into effective violence prevention plans. We propose a typology of prevention based on two key dimensions: the stages of human development and the ecological model mentioned earlier.
The epidemiology of violence, including its onset, desistance, and continuity, is closely related to the stages of human development (Williams, Guerra, and Elliott 1997). Increasing evidence points to the existence of discrete developmental pathways to violent behavior (Loeber and others 1993; Tolan and Gorman-Smith 1998; U.S. Department of Health and Human Services 2001; additional sources online). Thus, intervening at early developmental stages may reduce the likelihood that violence is expressed during later developmental stages.
The ecological model is also an important dimension of the typology, because violence is the product of multiple and overlapping levels of influence on behavior. The ecological model assumes that violent behavior is influenced by social contexts and the individual attributes brought to these contexts. Intervention may therefore attempt to influence aspects or risk factors at any or all of the model's four levels (Dahlberg and Krug 2002; Mercy and Hammond 1999).
Table 40.4 presents our typology of prevention strategies. The examples presented are not exhaustive, nor have all the strategies proven effective. Rather, they illustrate the breadth of potential solutions and emphasize the need to consider addressing the problem simultaneously at different stages of human development and through different social contexts. In many cases, an intervention might have an effect on multiple forms of violence. At this time, data to prove or disprove the effectiveness of most of these interventions are insufficient, and in those cases in which sufficient data are available, they are almost always from high-income countries.
[Table .]
Strategic Focuses for Prevention
A simple understanding of the approaches illustrated in table 40.4 is insufficient for developing a comprehensive violence prevention strategy. A public health approach to violence prevention concentrates on identifying ways to keep people from committing violent acts. Interventions may eliminate or reduce the underlying risk factors and shore up protective factors. Interventions are typically classified in terms of three levels of prevention: primary, secondary, and tertiary (Dahlberg and Krug 2002).
Primary Prevention
Primary prevention interventions focus on preventing violence before it occurs. The literature has given rise to several strategic focuses for the primary prevention of violence that are important considerations in violence prevention planning. Some have been successfully implemented at the community level in LMICs.
The cultural context plays an important role in violent behavior. Cultural traditions are sometimes used to justify such social practices as female genital mutilation and severe physical punishment of children (Mercy and others 2003). Conversely, cultural norms can be a source of protection against violence, such as traditions that promote the equality of women or respect for the elderly. Although evidence-based approaches for changing cultural traditions as a violence prevention strategy are not yet available, some countries have adopted this strategy. In South Africa, the Soul City health promotion campaign makes residents aware of the extent and consequences of violence and encourages better parenting through role models and improved communication among family members. Evaluations have found shifts in attitudes and social norms concerning intimate partner violence and domestic relations. Willingness to change behavior and take action to stop violence has increased in urban and rural areas among both men and women (Krug and others 2002b, box 9.1). In the Kapchorwa district of Uganda, a community health program has enlisted the support of elders in adopting alternative practices to female genital mutilation that are consistent with their cultural traditions (United Nations Population Fund 1998).
The lethality of interpersonal violence is affected by the means people use to carry out this violence. Reducing access to lethal means, such as firearms, may help minimize the health consequences of violence. A wide variety of strategies have been used to restrict access to firearms, such as mandating waiting periods before purchase, promoting safe storage of firearms, and limiting where firearms can and cannot be carried. In the mid 1990s, Colombian officials in Bogota and Cali, noting that homicide rates increased during weekends following paydays, on national holidays, and near elections, implemented a ban on carrying handguns during those times, which resulted in a 13 to 14 percent reduction in homicide rates (Villaveces and others 2000). In the Australian state of Victoria, firearm-related suicides, assaults, and unintentional deaths decreased following the 1988 implementation of legislation that required the registration of all firearms and strengthened licensing regulations; a mandatory waiting period was added in 1996 (Ozanne-Smith and others 2004). However, the evidence to determine whether such strategies are effective in reducing firearm-related homicides is currently insufficient (Hahn and others 2003), although several policies hold promise (Hemenway 2004; Ludwig and Cook 2003).
Inadequate parental involvement in children's and adolescents' activities and lack of supervision are well-established risk factors for youth violence (U.S. Department of Health and Human Services 2001). Evidence indicates that a supportive relationship with parents or other adults is protective against antisocial behavior. Although not widely evaluated, some mentoring programs that match high-risk youths with a positive adult role model appear to be effective in reducing youth violence (Grossman and Garry 1997; Thornton and others 2002); however, negative findings have also been reported for mentoring, particularly when mentors receive little training and when the relationships between adults and youths break down. The design of mentoring programs varies considerably, and participation by both mentors and youths can be uneven.
Programs that target those who influence children are more effective than interventions that target all adults. For example, preschool enrichment, home visitation, and parenting programs have been found to have both short- and long-term effects on preventing violence (Farrington 2003; Mercy and others 2002; Utting 2003; additional sources online). Early intervention can help shape attitudes, knowledge, and behavior of children at a time when they are more open to positive influences and can affect their behavior over their lifetime (Mercy and others 1993).
Income inequality is a risk factor universally associated with interpersonal and collective violence (Butchart and Engstrom 2002; Zwi, Garfield, and Loretti 2002; additional sources online). Poverty itself does not appear to be consistently associated with violence, but the juxtaposition of extreme poverty with extreme wealth appears to be a key ingredient in recipes for violence. Economic programs or policies that reduce or minimize the effects of income inequality may be strategic in violence prevention, although the evidence base for such interventions has not been established.
Secondary and Tertiary Prevention
Although an emphasis on primary prevention is essential for reducing the health burden associated with violence, secondary prevention programs and services are necessary for addressing the immediate consequences of violent actions and behaviors, and tertiary programs focus on long-term care. Efforts targeted at victims of violence are extremely important for mitigating the physical and psychological consequences of the various forms of violence and abuse and for reducing victims' risks for future violence (National Center for Injury Prevention and Control 2002).
Physicians and other health professionals are gatekeepers in efforts to monitor, identify, treat, and intervene in cases of interpersonal violence. As previously noted, more cases of interpersonal violence come to the attention of health care providers than of police. The role of health care providers in prevention efforts is neither widely understood nor embraced, and many institutional and educational barriers limit their effectiveness (Cohen, De Vos, and Newberger 1997). Programs to educate health care providers are under way worldwide. Many hospital emergency departments, doctors' offices, and clinic settings use screening programs to identify victims of intimate partner violence, child abuse, or elder abuse, although the effectiveness of those interventions in reducing subsequent violence is not well understood (Heise and Garcia-Moreno 2002; Runyan and others 2002; Wolf, Daichman, and Bennett 2002).
Therapeutic approaches have been implemented in many parts of the world to reduce child abuse. Though some research suggests that these interventions can improve the mental health of victims, less information is available on other benefits (Runyan and others 2002; additional sources online). One approach to preventing child sexual abuse in the United States challenges social norms by offering help to those at risk of offending and by encouraging adults to watch for and act on warnings of child sexual abuse before an offense is committed (CDC 2001). Under such programs, individuals voluntarily turn themselves in for treatment and thereby prevent potential future violence.
The outcome of injury from interpersonal violence depends not only on its severity, but also on the speed and appropriateness of treatment (Committee on Trauma Research 1985). Establishment of trauma systems designed to treat and manage injured victims efficiently and effectively is an important factor in reducing the health burden of violence. Research suggests that reductions in criminal assaults resulting in death in the United States are partly explained by the increased survival of victims. Developments in medical technology and trauma services may be reducing the number of interpersonal violence fatalities (Harris and others 2002). Hospital emergency departments may also provide an opportunity to intervene with victims who might otherwise seek revenge against their attackers or victims who are at greater risk for revictimization (Muelleman and others 1996).
