VIOLENCE AND PUBLIC HEALTH: AN INTEGRATED, EVIDENCE-BASEDAPPROACH TO PREVENTING DOMESTIC VIOLENCE AND CHILD ABUSE
By Alexander Butchart*

I. INTRODUCTION
Domestic violence and child abuse are both serious problems in their own right and highly significant
contributors to the burden of ill health in countries the world over. Along with other types of violence towhich they are causally related - such as youth violence, elder abuse and suicide - child abuse and domestic
violence are therefore challenges for public health. In addition to the massive direct costs of treating injuries
due to violence, most types of violence, but especially child abuse and intimate partner violence, haveenormous non-injury health consequences including alcohol and drug abuse, depression and anxiety
disorders, suicide and suicide attempts, obesity and eating disorders, unsafe sexual behaviour and sexuallytransmitted diseases (including HIV-AIDS) and smoking.
Violence - including child abuse and domestic violence - is, however, preventable. As shown by a growing
body of scientific research, interventions that address the underlying causes of violent behaviour andvictimization are effective in preventing new instances of violence. When applied at the population level toentire communities and societies, such interventions have been shown to be both effective and costeffective.
Although there are relatively few published economic evaluations of interventions targeting interpersonal
violence, available studies show that preventive interventions to stop interpersonal violence occurring costless than the money that they save, in some cases by several orders of magnitude.
For instance, the costs of a USA programme to prevent child abuse equalled 5.0% of the costs of childabuse itself. Also in the USA, interventions that targeted juvenile perpetrators of violence - including
aggression replacement training and foster care treatment - resulted in economic benefits that were morethan 30 times greater than the corresponding costs1.

A. World Report on Violence and Health2
The impacts of violence on public health, the drain on health services of treating the consequences ofviolence, and the fact that violence is preventable are among the main reasons why the World HealthOrganization (WHO) has in recent years scaled up its commitment to promoting the prevention of violence.
In the year 2002, WHO published the World report on violence and health, and this report forms thefoundation of the Organization’s violence and health activities at the global, regional and country levels. The
report represents the first ever comprehensive review of violence on a global scale, and through an
exhaustive review of the best available scientific studies looks at the magnitude and impact of violence, risk
factors, interventions and policy responses, and a set of recommendations for national and international
action, all of which are discussed below.
Violence has many faces, some of which are highly visible and others of which we are only barely aware.
The report addresses all of these, including youth violence occurring among persons aged 10-29 years;* World Health Organization, Department of Injuries and Violence Prevention, Geneva, Switzerland.
1 For a review of the literature on the costs of violence and cost effectiveness of prevention, see Waters H, Hyder A, Rajkotia
Y, Basu S, Rehwinkel JA, Butchart A. The economic dimensions of interpersonal violence. Department of Injuries andViolence Prevention, World Health Organization, Geneva, 2004.
2 Unless otherwise indicated, all statistics and findings cited in this paper are from the World report on violence and health.
Krug EG et al., eds. World report on violence and health. Geneva, World Health Organization, 2002.

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collective violence, particularly armed conflicts; sexual violence, largely against women and girls, but also
men and boys; suicidal behaviour; elder abuse; violence by intimate partners, and child abuse and neglect byparents and caregivers. Also included is a statistical annex with country and regional data from the WHO
Database and Global Burden of Disease project for 2000, and a list of resources for violence prevention.

B. Objectives
This paper has six objectives.
• The first objective is to review the definition and typology of violence developed by WHO and fromthis to highlight the importance of dealing with child abuse and domestic violence in an integrated
way, as part of the larger problem of preventing suicide and interpersonal violence in general.
• The second objective is to describe what is known about the magnitude and impact of different typesof violence, and, as importantly, to highlight how much is not known about this aspect.
• The third objective is to describe what’s known about risk factors and causes, especially those that
underlie multiple types of violence.
• The fourth objective is to review the current status of prevention efforts and describe what is known
about the effectiveness of different approaches – touching upon all types of violence to the extent
possible.
• The fifth objective is to provide a snapshot of WHO’s Global Campaign for Violence Prevention,
focusing upon its recommendations for multi-sectoral prevention programming.
• The sixth and final objective is to highlight some of the implications of the public health approach toviolence prevention for the criminal justice sector’s work on child abuse and domestic violence.
II. DEFINITION AND TYPOLOGY OF VIOLENCE
A. Definition of Violence
The World report on violence and health defines violence as “the intentional use of physical force orpower, threatened or actual, against oneself, another person, or against a group or community, which either
results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or
deprivation”. This definition reflects extensive review of other definitions of violence and thoroughconsultation with international experts. While every word of the definition is important, it is worthhighlighting the fact that the definition identifies violence as including both threatened and actual physicalforce or power and that it does not limit violence to only those acts resulting in physical injuries but also
includes psychological harm, deprivation and maldevelopment.
The report also stresses the importance of using operational definitions for particular forms of violence(such as violence involving firearms, knives and blunt instruments, child sexual abuse and intimate partner
violence) that permit their unambiguous identification for measurement purposes, that are shared between
different sectors, and that permit international comparability. The operational definitions contained in thevarious editions of the International Classification of Diseases3 come closest to meeting these criteria.

B. Typology of Violence
To properly understand the problem of violence in a way that assists in showing where and how we canintervene to prevent it, a typology of violence, such as the WHO typology shown in Figure 1, is useful. At
the first level this typology differentiates between violence people inflict upon themselves, interpersonal
violence inflicted by another individual or small group of individuals, and violence inflicted by larger groups
such as states.

3 International Statistical Classification of Diseases and Related Health Problems 10th Revision. Version for 2003

http://www3.who.int/icd/vol1htm2003/fr-icd.htm.

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Figure 1: Typology of violence from World report on violence and health

Self directed violence is divided into suicidal behaviour and instances of self-abuse. Interpersonal
violence is divided into family and partner violence, and community violence. Collective violence is divided
into social, political and economic violence. For each subtype of violence, the typology also includes thenature of violent acts, which can be physical, sexual, psychological, or involving deprivation or neglect.
While there is conceptual and practical value in distinguishing between these different types of violence,it also important to emphasize that there are many important links between them, and therefore thatpreventing one type of violence may help prevent other kinds of violence. For instance, war is a major risk
factor for suicide and interpersonal violence, while interpersonal violence involving child maltreatment is arisk factor for suicidal behaviour and for becoming a victim or perpetrator of intimate partner violence inlater life.

III. MAGNITUDE AND IMPACT OF VIOLENCE
A. Fatal Violence
Globally, violence is a substantial problem even when measured in terms of the deaths that it causes,
which, as described below, represent only a small fraction of the full burden of its negative social andeconomic consequences. According to WHO burden of disease estimates, in the year 2000 there was a global
total of over 1.6 million deaths due to violence. 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.
In the year 2000, and contrary to the impression created by the massive media coverage of collective
violence, the largest number of violent deaths was due not to war but to suicide: 815,000 cases, or one
suicide every 40 seconds. Interpersonal violence accounted for 520,000 deaths: or one murder per minute.
There were 310,000 deaths directly due to collective violence or one war death every two minutes.
1. Global Homicide Rates
Rates of violent death vary by country and region income levels. For the year 2000, homicide rates werehighest in Africa, Latin America and central and Eastern Europe, and lowest in Western Europe and somecountries in the western Pacific. Studies show a strong relationship between homicide rates, economic
development and economic inequality with poorer countries (especially those with large gaps between therich and poor) tending to have higher rates of homicide than wealthier countries, and poorer communities inhigh inequality societies have higher homicide rates than their wealthier counterparts.
By age and sex there were marked differences in homicide rates. Gender differences were least marked
for the age groups 0-4 and 5-14 years. For the age groups 15-29 and 30-44 male rates were four times ashigh as female rates and for the remaining age groups around 2.5 times as high as female rates. From age 15
onwards female rates showed little difference between age groups while male rates varied substantially.

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2. Global Suicide Rates
Suicide rates show a very different geographical distribution to homicide rates. Except for central andeastern Europe which have high homicide and high suicide rates, the highest suicide rates occur in regions
where homicide is lowest, and, at the country level, wealthier countries tend to have higher levels of suicide
than poorer countries (though, this may also reflect gaps in information; for example, there is little
information on suicide in Africa).
Suicide rates showed a clear trend towards increasing gender differences with age. At 5-14 years rates
for males and females were roughly equal, whereas from age 45 onwards male rates were nearly twice ashigh as female suicide rates.
Owing to the inadequacies of data on collective violence, WHO burden of disease statistics do not include
similar information for war deaths, although the World report on violence and health notes that, likehomicide, war death rates were lowest in high-income countries and highest in low- and middle-income
countries.
Deaths are only the tip of the violence iceberg, and even in terms of knowing the real size of this tip
there is a very long way to go. In over half the world’s countries there is no adequate information about how
many people die by violence.

B. Non-fatal Violence
The violence recorded in routinely available data, such as vital statistics and crime reports, is mainly thatwhich leads to fatalities. By contrast, the much larger burden of violence is non-fatal. To count non-fatal
health outcomes one could begin by looking at cases reported to health agencies or to the police. Only small
proportions present at both the health agencies and the police, and studies from several countries show thatfor every victim reporting to the police at least two more report only to health agencies. The health burden
this represents is illustrated by the fact that for every young person murdered at least 20 to 40 other young
people receive hospital treatment for a violent injury. Given that there are approximately 200,000 youth
homicides each year, this means that globally there are between four and eight million hospital presentations
each year for youth violence alone.
Moving away from health facilities, epidemiological studies show that an even larger proportion ofviolence is reported in household surveys and special studies, and it is here that female victims often
outnumber male victims. These studies have shown, for instance, that up to 70% of women report being a
victim of intimate partner violence at some point in their lives. One in five women versus one in 10 men
report being sexually abused as a child. For 90% of cases involving female victims of child sexual abuse theperpetrators are male, as they are for 70% of male child sexual abuse victims. Up to 40% of first sexual
encounters are forced. About 4% to 6% of the elderly report having been abused in their homes bycaregivers, with elderly males and females equally at risk for being abused by spouses, adult children andother relatives. Many older citizens have also been subjected to abuse in institutions.
Unfortunately, a lot of violence never gets reported – whether due to fear, shame, the acceptance ofviolence as normal and therefore unremarkable, or the inadequacy of reporting and recording systems.

C. Health Consequences and Economic Costs of Violence
Beyond counting the deaths and injuries due to violence, the Report shows that it is of critical importanceto look at the non-injury health consequences of violence, which are especially important for childmaltreatment and intimate partner violence. These non-injury health consequences are many and include:
physical consequences, such as gastrointestinal disorders and chronic pain syndromes; mental healthconsequences, such as depression, anxiety disorders and post-traumatic stress disorder; behaviouralproblems such as alcohol and drug abuse, eating and sleep disorders, unsafe sexual behaviour, smoking andother risk-taking behaviours; reproductive health consequences, such as infertility, gynaecological disorders,sexual dysfunction, unwanted pregnancies or pregnancy complications, and sexually transmitted infections,
including HIV/AIDS.
In the case of collective violence, conflicts also destroy infrastructure and disrupt vital services such as
immunization, medical care, and food production and distribution – contributing to infectious diseases andfamine.

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The human toll is only one dimension. Violence also puts a massive burden on national economies
costing billions in US dollars each year when the direct costs associated with health care, emergency
response services and law enforcement are combined with the many indirect costs such as lost productivity,
quality of life and strains on economic development.

IV. RISK FACTORS FOR VIOLENCE
To prevent violence and reduce its consequences it is necessary to understand the causes of violence. A
major finding of the World report on violence and health is that no single factor explains why one individual,family, community or society is more or less likely to experience violence. Instead, it shows that violence isrooted in the interaction of factors ranging from the biological to the political. The Report captures this in an
ecological model that organizes the risk factors for violence into four interacting levels: the individual, close
relationships, community contexts and societal factors.
Individual-level risks include demographic factors such as age, income and education; psychological andpersonality disorders, alcohol and substance abuse, and a history of engaging in violent behaviour orexperiencing abuse.
The relationship level explores how relationships with families, friends, intimate partners and peers
increase the risk of becoming a victim or perpetrator of violence, and risk factors at this level include poor
parenting practices and family dysfunction, marital conflict around gender roles and resources, andassociating with friends who engage in violent or delinquent behaviour.
The community level refers to the contexts in which social relationships occur such as neighbourhoods,
schools, workplaces and other institutions, and the Report identifies a number of community characteristics
that increase the risk for violence – for example, poverty, high residential mobility and unemployment, social
isolation, the existence of a local drug trade, and weak policies and programmes within institutions.
At the societal level the Report identifies broad factors contributing to a climate that encourages
violence, including economic, social, health, and education polices that maintain or increase economic andsocial inequalities, social and cultural norms supporting the use of violence, the availability of means (suchas firearms) and weak criminal justice systems that leave perpetrators immune to prosecution.

V. THE PUBLIC HEALTH APPROACH TO PREVENTION
Violence is often seen as an inevitable part of the human condition – a fact of life to respond to, rather
than to prevent. By contrast, the notion that violence is preventable is a basic tenet of the public healthapproach. In moving from problem to response, the public health approach has four steps. The first step is tostatistically describe and monitor the extent of the problem; to identify the groups and communities at risk.
The next step is to identify and understand the factors that place people at risk for violence – to assess
which factors may also be amenable to intervention. The third step is to develop and evaluate interventions
to reduce these risks, and the fourth is to implement and apply widely the measures that are found to work.
By linking ongoing statistical description and monitoring of the problem to the fourth step of widespread
implementation, the four steps form a feedback loop through which the effectiveness of violence prevention
programmes can be constantly monitored and improved.
The public health approach is population-based. It emphasizes primary prevention – doing something
about the problem before it occurs. It draws upon a wide range of expertise across many sectors, and it isbased in science. It asserts that everything – from identifying the problem and its causes, to planning,
testing and evaluating responses – should be based on sound research and informed by the best evidence.
To look forward and build a future violence prevention agenda, it is useful to have a sense of where thefield of violence prevention is now. The following sections, mainly based upon analysis of the evidencecollected in the World report on violence and health, therefore show the current status of prevention efforts
in order to highlight what works and what’s promising, and to identify areas where more attention is needed.

A. Public Health Interventions
Public health interventions are traditionally characterized in terms of three levels of prevention: primary68130th INTERNATIONAL TRAINING COURSE
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prevention – approaches that aim to prevent violence before it occurs; secondary prevention – approaches
that focus on the more immediate responses to violence, such as pre-hospital care, emergency medical
services or treatment immediately following a rape or an injury sustained as a result of violence; tertiary
prevention – approaches that focus on long-term care in the wake of violence that has already occurred, suchas rehabilitation and reintegration, attempts to lessen trauma or reduce the long-term disability associatedwith violence. The three levels of prevention are defined by their temporal aspect – whether prevention
takes place before violence even occurs, immediately afterwards or over the longer term. While these levelsof prevention have traditionally been applied to victims of violence and within health care settings, they arealso relevant to perpetrators and have been used to characterize judicial responses.
When we look at where the emphasis of prevention programmes has been placed in terms of timing(before, soon after, or long-term care), there are some differences by type of violence. In youth violence, themajority of efforts have focused on primary prevention. There have been programmes for youth alreadyinvolved in violent and delinquent behaviour and initiatives aimed at “getting tough on crime” – detaining
juveniles, boot camps, shock incarceration programmes, and trying and sentencing youth in adult courts forserious offences – but on balance, there have been many more prevention efforts aimed at curbing violent
behaviour before it occurs. And there has been a growing emphasis on early intervention in childhood – as away of disrupting or changing the developmental trajectories of violence.
With intimate partner violence, sexual violence, child maltreatment and elderly abuse, the majority ofefforts have been focused on secondary/tertiary prevention – that is, identifying victims and providing thenecessary care and services to prevent re-victimization. There have been primary prevention efforts inschools and communities, and efforts aimed at parents and caregivers, but on balance, there have been more
efforts aimed at secondary/tertiary prevention.
It is important to keep in mind that this is not an either/or proposition. As stated in the Report, we must
do what we can to strengthen responses for victims of violence and make sure that offenders are punished,
but we also need to develop and test programmes and strategies aimed at preventing violence fromhappening in the first place.

B. Ecological Model – Systems of Influence
Another way of looking at violence prevention programmes is by their level of influence. The ecologicalmodel was used in the World report to illustrate the complex and multifaceted nature of violence. As
outlined in Section IV above, violence has its roots in the interaction of many factors – biological, social,
cultural, economic and political. It is the outcome of a complex interaction between context and person – notperson alone; and not context alone.
Each level in the ecological model can be thought of as a level of influence and also as a key point forintervention. That is, we can attempt to modify individual behaviour directly; we can modify individual
behaviour by influencing the close, interpersonal relationships of people such as family environments; we
can influence behaviour by modifying the settings people move through – for example, schools, workplacesor neighbourhoods. And we can make more societal, system-wide changes to improve (for example),
educational or economic opportunities or change cultural norms. In short, we can aim to modify individual
behaviour directly, and we can also attempt to change the environments and systems that create the climatesfor violence to occur.
If we look at the emphasis of prevention programmes by their level of influence, we can see that acrossthe different types of violence, there is an imbalance in the focus of prevention programmes – there havebeen far more efforts aimed at changing individual and relationship factors than there have been at changing
community or societal factors. In other words, more emphasis has been placed on changing individual
attitudes, beliefs, and behaviours than on the factors or systems that create the conditions for violence tooccur. It some ways this is not surprising because it is much easier to design these types of programmes andit is also much easier to evaluate them.

C. Types of Outcomes
Outcomes are also very important in violence prevention efforts. We can think of outcomes in terms of acontinuum – with knowledge change at one end and reductions in injuries and deaths at the other end. We

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can also think of these as a causal chain with change in one potentially leading to change in the next one –although this is not always the case. In terms of the outcomes generally studied, there have been more
efforts across the different types of violence geared towards changing knowledge and attitudes than
behaviour. Behaviour change is an important outcome and should be an important goal of prevention efforts.
As one might expect, smaller-scale research efforts have generally not included injuries and deaths. These
are more rare outcomes and it is difficult to see a significant change in these outcomes with a smaller-scale
prevention trial.

VI. EVIDENCE-BASE FOR VIOLENCE PREVENTION PROGRAMMES4
From the perspective of public health, a fundamental question is “Do violence prevention programmes
work?” That is, “Are there certain interventions, programmes or strategies that are effective in preventing
or reducing violence?” To answer this question, this section reviews the evidence base for effective violence
prevention programmes. Before doing so, it is important to note that the evidence-base for prevention
programmes has largely come from developed countries. This is not to say that prevention programmes are
not in place in developing countries, but rather that many have not been systematically and rigorously
evaluated. It is important to keep this in mind when reviewing what is known about the effectiveness ofdifferent approaches.
To begin, it is necessary to define “effective”. Testimonials about a programme are useful because it isimportant to know that a programme is running smoothly and that the participants seem to be getting a lotout of the programme. But testimonials are insufficient when it comes to knowing whether or not the
programme is producing change in behaviour or in the factors that mediate or moderate violence.
Various criteria for effectiveness have been proposed. The most stringent include an evaluation of aprogramme using a strong research design, either experimental or quasi-experimental; evidence of asignificant preventive effect; evidence of sustained effects (that is, they are maintained beyond treatment or
participation in the programme); and replication of the programme with demonstrated preventive effects. As
you might expect, few programmes meet all of these criteria.
In the following sections, the term “effective” refers to programmes that have been evaluated with astrong research design and have evidence of a preventive effect; “promising” to programmes that have been
evaluated with a strong design and have some evidence of a preventive effect, but require more testing; and“unclear” to programmes that have either been poorly evaluated or remain largely untested.
A useful way to review what is currently known about the effectiveness of different interventions is toconsider it according to the different levels of influence mentioned earlier, namely the individual; close
relationships; community and society levels of influence.

A. Individual-Level Interventions
Individual-level interventions are those designed to change an individual’s attitudes, beliefs andbehaviours directly. It does not matter where the intervention takes place, if it is designed to change theattitudes, beliefs, and behaviour of an individual directly it is considered an individual-level intervention.
Programmes designed to prevent unintended pregnancies and to get women to seek adequate prenatal
and postnatal care are believed to be key in ensuring better birth outcomes and reducing the risk for childmaltreatment and the early developmental risk factors for youth violence. Both strategies, however, require
more testing, particularly in terms of these outcomes. Interestingly, a year 2000 study by US economists
John Donohue and Steven Levitt5 attributes the more than 50% decline in the US teenage murder rateduring the 1990s to the impact of legalising abortion 20 years earlier, in 1973. Legalized abortion meant
fewer unwanted children, and fewer unwanted children meant that 20 years later there were fewer
individuals with socialization and substance abuse problems, and less violence.
4 This section is adapted from: Dahlberg LL, Butchart A. State of the Science: Violence Prevention Efforts in Developing andDeveloped Countries. In press, Safety Promotion and Injury Control.
5 Donohue J, Levitt S. The Impact of Legalized Abortion on Crime. The Berkeley Law & Economics Working Papers. Volume

2000, Issue 2, 2001 Article 7.

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Preschool enrichment programmes are designed to strengthen bonds to school and to introduce children
early on to the social and behavioural skills necessary for success in school. Long-term follow-up studies ofprototypes of such programmes have found positive benefits including less involvement in violent and otherdelinquent behaviours (e.g. the Perry preschool programme). This is in the promising category because
there have only been a few long-term studies.
Social development/life-skills training programmes are designed to build social, emotional, cognitive andbehavioural competencies. They are often multi-component programmes that help participants manage
anger, resolve conflicts and develop social and other life-skills. These appear to be an effective strategy for
reducing youth violence and have also yielded positive, although short-term, results for dating violence.
Educational incentives for high risk youth to complete schooling are also among the most effective andcost effective approaches to preventing youth violence. A study by the Rand Corporation6 showed that, in
California USA, graduation incentives for high risk youth were 5-7 times more cost-effective in achieving a
10% reduction in violence and crime than increased incarceration.
The evidence for counselling and therapeutic approaches is mixed. Counselling or psychotherapy is notan effective strategy for reducing youth violence. There is, however, some evidence that cognitivebehavioural therapy administered shortly after a sexual assault can hasten the rate of improvement andlessen trauma, and there is evidence that it may be an effective approach in reducing suicide attempts; inboth cases, while promising, the evidence is not conclusive.
Some programmes provide training to police, health care providers, and employers to make them better
able to identify and respond to the different types of violence. Training police has proved largely ineffective
in changing police behaviour primarily because it has not always been accompanied by or reinforced withefforts to change attitudes and organizational culture. In terms of health care providers, training has led tochanges in knowledge and awareness in the short term, but these changes have not always translated into
behavioural change or changes in practice. And there has been little evaluation of programmes for
employers.
Programmes for men who physically and sexually abuse their partners have helped some men modify
their behaviour, but there is generally a very high drop-out rate and many who are referred to these
programmes never complete them. These programmes work best when they continue for longer rather thanshorter periods; change men’s attitudes enough for them to discuss their behaviour; sustain participation,
and work in tandem with a criminal justice system that acts strictly when there are breaches of theconditions of the programme.

B. Relationship-Level Interventions
Relationship-level interventions focus on changing behaviour by influencing close, interpersonal
relationships and proximal environments, such as the family environment.
The evidence for programmes that focus on family relationships and functioning, particularly on family
management, problem-solving, and parenting practices – is quite strong, consistent, and among the best
evidence we have for reducing child maltreatment and other negative outcomes, including youth violence.
The most successful programmes address both the internal dynamics of the family and the family’s capacity
for dealing with external demands. The earlier these programmes are delivered in the child’s life and thelonger their duration, the greater the benefits. Programmes that simply provide parents with information,
however, are not effective.
For child abuse, evaluations of intensive family preservation services (which are geared towards keeping
the family together and providing intensive services over a short period of time) have been limited and theirfindings inconclusive mainly because these programmes offer a large variety of services (making it difficult
to know which are effective) and relatively few studies have included a control group.

6 Greenwood PW et al. (1996). Diverting children from a life of crime: measuring costs and benefits. Santa Monica, CA, The

Rand Corporation.

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A warm and supportive relationship with a positive adult role model is thought to be a protective factor
for youth violence, and some well-designed studies do suggest that this is the case. However, there is also
substantial variability with respect to mentoring programmes and participation by both the mentors and theyouth can be uneven. Negative effects have been reported particularly where there has been little training
and breakdowns in the relationships with mentors.
Peer interventions emphasize modifying behaviour by changing the nature of peer interactions, changing
peer group norms, or redirecting peer group activities. The latter, for example, have been tried with gangs.
There is little evidence to date that these types of approaches are effective in reducing violent behaviour,
particularly as single component programmes. Some have also led to unintended increases in violent
behaviour. One of the failed ingredients in these types of approaches is the mixing of high-risk youth
together – which has had the unintended consequence of increasing cohesiveness and facilitating
delinquency.

C. Community-Level Interventions
Community-level interventions focus on modifying the characteristics of settings that promote violent
behaviour or create the conditions for violence to occur. Interventions at this level also focus on changes toinstitutional environments by means of appropriate policies, guidelines and protocols.
There have been a number of efforts aimed at improving school settings with policies and programmesthat are designed to promote a consistent, pro-social, non-sexually and physically-violent environment inclassrooms and throughout the school. Attention has been paid to classroom management practices,
promotion of cooperative learning techniques, teacher/staffing practices, student monitoring andsupervision, changes to the physical environment, and efforts to increase student engagement, reducebullying, and involve parents/caregivers. And the evidence to date suggests that these types ofenvironmental change programmes are promising. Several have been evaluated with rigorous designs andhave evidence of a preventive effect. Further evidence of sustained effects and replication will place these in
the effective category.
The evidence-base for other settings, however, is less developed. Active screening for abuse – whether
for intimate partner violence, sexual violence, child maltreatment or elderly abuse – is generally consideredgood practice. Unfortunately, little systematic evaluation has been carried out on whether screening forabuse can improve safety and health-seeking behaviour – and if it does, under what conditions.
Efforts to improve workplace, residential and primary care environments by means of appropriate
policies, guidelines, and protocols for identifying and managing abuse and for promoting healthy and nonviolent behaviour have also not been rigorously and systematically evaluated.
More has been done along the lines of changing community attitudes, beliefs, and norms surrounding
violence with the use of public information campaigns. Multi-component prevention campaigns have beenlaunched to address gang violence, bullying, child maltreatment, and domestic and sexual violence. In
general, these types of campaign have increased knowledge and awareness, as well as shifts in social norms
concerning domestic violence and gender relations, and some have led to increases in disclosure of childabuse and sexual offending, but have not consistently led to changes in behaviour.
Other types of community-level interventions focus on community organizing, coordination of services,
proactive policing, increased cohesion among community residents, the density of housing, and theavailability of alcohol. Most have either been poorly evaluated or remain largely untested. Community
coalitions, coordinating councils or interagency forums, for example, have been used to monitor and improve
responses to intimate partner violence. Their aim is to identify and address problems in the provision ofservices, promote good practice through training, and to promote community awareness and prevention
work. This type of intervention has been popular in the United States, Canada, and the United Kingdom andin parts of Latin America. Coalitions have also been put in place to raise awareness about the problem ofyouth violence, and similar coordinated community interventions have been put in place in parts of Africa toaddress child sexual abuse. These types of intervention have seldom been rigorously evaluated and thelimited findings that do exist suggest that the efficacy of the services provided, particularly in the cases ofpartner violence and child abuse, may be more important than the community organizing per se. Efforts to72

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reduce the availability of alcohol, by, for instance, reducing the number of points of sale, the hours of sale,and the price of alcohol show promise in preventing youth violence.

D. Societal-Level Interventions
Societal interventions focus on the cultural, social and economic factors related to violence – addressing
such issues as access to means, gender, economic or educational inequality – and emphasize changes inlegislation, policies, and the larger social and cultural environment to reduce rates of violence.
Measures for reducing access to means include restricting access to guns (e.g., bans on certain types offirearms, waiting periods, rules on licensing and registration, stricter policing of illegal possession andtrafficking of guns, and rules for storing them safely). With suicide, it also includes fencing in high bridges,
limiting access to roofs and high exteriors of tall buildings, automatic shut-off devices for motor vehicles,
restricting access to pesticides and fertilizers, and measures to make prescription drugs safer (e.g.,
packaging and monitoring size and use).
There is some evidence that restricting access to means is effective in reducing suicide. With
interpersonal violence, there have also been a few studies showing a preventive effect. However, a recent
systematic review of all the measures pertaining to firearms found insufficient evidence to conclude whether
or not such measures are effective – citing inconsistencies in the findings and serious methodological flaws
in the studies themselves.
The evidence for legislative and judicial remedies is also mixed. Measures to criminalize abuse by
intimate partners, to broaden the definition of rape, to criminalize the harsh, physical punishment of children
in various settings, and mandatory reporting laws for child and elderly abuse have been instrumental inbringing these issues out in the open and dispelling the notion that violence is a private family matter. In thisregard, they have been very important in shifting social norms. However, the evidence surrounding thedeterrent value of arrest in cases of domestic violence shows that it may be no more effective in reducing
violence than other police responses such as issuing warnings or citations, providing counselling or
separating couples. Some studies have also shown increased abuse following arrest, particularly for
unemployed men and those living in impoverished areas. Protective orders can be useful, but enforcement isuneven and there is evidence that they have little effect on men with serious criminal records. In cases ofrape, reforms related to the admissibility of evidence and removing the requirement for victims’ accounts tobe corroborated have also been useful, but are also ignored in many courts throughout the world.
As for the other societal approaches, much could be done in the way of educational reforms, policychanges to reduce poverty and inequality, and improve support for families. More could also be done interms of changing social and cultural norms around issues of gender and to address racial and ethnic
discrimination and harmful traditional practices. Unfortunately, although critically important, many remain
largely untested ideas.

E. Multi-sectoral Solutions
From this review of the evidence for what works in preventing violence, it is evident that prevention, as
noted earlier, is a multi-sectoral challenge requiring multi-sectoral solutions, and the involvement, among
others of welfare, education, employment, the police, justice, diplomacy and public health. Within this mix of
sectors, the Report shows that the role of public health should be to add value by assisting with:
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data collection through mortuary, coroner and medical examiner reports, health agency records,
surveys and other surveillance mechanisms;
research into the underlying causes and risk for violence, such as those discussed in this paper;
prevention, by promoting a primary prevention approach and contributing advice on how to design,
implement and disseminate prevention programmes;
evaluation, by applying public health methods to determine the most effective responses;
policy development;
the provision of more effective trauma and health care services for victims of violence; andadvocating for prevention using the information at the health sector’s disposal about the magnitudeof the violence problem and about its preventability.

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VII. GLOBAL CAMPAIGN FOR VIOLENCE PREVENTION
Using data about the magnitude of the violence problem, the public health model for problem
identification, intervention and ongoing monitoring, and the evidence base for prevention described in thepreceding sections, the Global Campaign for Violence Prevention seeks to raise awareness about violence asa major public health problem, including the impact of violence on public health and the role that publichealth can play in the prevention of violence, and to advocate for increased human and financial resources forscience-based violence prevention efforts at local, national and international levels.

A.World Report on Violence and Health Recommendations
At the heart of the campaign are nine recommendations for the prevention of violence made in the World
report on violence and health and taken up in a number of global and regional resolutions and policy papers(see below).
Recommendations one to six focus on country-level actions for prevention and advocate:
1. creating, implementing and monitoring a multi-sectoral national action plan for violence prevention;
2. enhancing capacity for collecting data on violence;
3. defining priorities for and supporting research on the causes, consequences, costs and prevention ofviolence; and4. promoting primary prevention responses;
5. strengthening responses for victims; and6. integrating violence prevention into social and educational policies and thereby promoting genderand social equality.
Recommendations seven to nine promote international prevention actions, advocating:
7. increasing collaboration and exchange of violence prevention information;
8. promoting and monitoring adherence to international treaties, laws and other mechanisms to protect
human rights; and9. seeking practical, internationally-agreed responses to the global drugs trade and the global arms
trade.

B. Country-level Implementation
A major thrust of the campaign is to promote implementation of the recommendations at the countrylevel. To this end, around 60 countries have involved their ministers of health, justice and others sectors innational launches of the report, often in conjunction with policy discussions about how to strengthen
violence prevention activities. Over 70 countries around the world have officially designated senior ministryof health focal points for violence and health; and around 25 countries have or are currently preparing
national reports and plans of action on violence and health.
C. Resolutions and Declarations
These ongoing efforts to secure political commitment by national governments are complemented bywork with global and regional political and professional bodies to encourage the preparation and adoption ofresolutions and declarations that commit signatories to implementing the World report on violence andhealth recommendations. These include resolutions by the World Health Assembly, United Nations
Commission on Human Rights, the African Union, the Council of Europe and the World Medical Association.
D. Visual AwarenessTo assist partners in violence prevention, WHO has published three poster series’ - the “red” series, the“explanations” series, and, launched at the May 2005 World Health Assembly, the “family album” series copies of which are freely available from WHO. For countries interested in customizing the posters bytranslating the text into local languages, WHO will gladly provide the electronic printer files and permission
to adapt and reprint the posters. Currently being edited, WHO has also collaborated with an independent
television producer on production of a 50 minute television documentary on the problem and prevention ofinterpersonal violence.
E. Implementation Tools
The WHO has also prepared a number of documents7 that provide technical guidance on how to
7 All WHO violence prevention documents and posters can be downloaded or ordered, free of charge, from the WHOPrevention of Violence website, at: http://www.who.int/violence_injury_prevention/violence/en/.

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VISITING EXPERTS’ PAPERS

implement the World report on violence and health recommendations, including Preventing violence which
gives step-by-step advice on how to implement the report’s country-level recommendations; a handbook forthe documentation of violence prevention programmes, guidelines for the medico-legal care of sexual
violence victims, and essential trauma care guidelines.

F. Violence Prevention Alliance
The Violence Prevention Alliance is a network of institutions linked by their voluntary adoption of shared
violence prevention principles and policies derived from the World report on violence and health .
Participation is open to WHO Member State governments, nongovernmental and community-basedorganizations, and private, international and intergovernmental agencies working to prevent violence. The
Violence Prevention Alliance activities will expand the number of agencies that apply a public healthapproach to implementing violence prevention programmes and services. It will enhance the impact ofindividual programmes on national and local policy and practice. The Alliance is part of an ongoing effort tointegrate more countries into the Global Campaign for Violence Prevention, while connecting similar groups
at regional and local levels to facilitate better sharing of knowledge.
VIII. CRIMINAL JUSTICE IMPLICATIONSThis final section briefly comments on some of the main implications of the public health approach toviolence prevention for the criminal justice sector’s efforts to deal with violence in general and with childabuse and domestic violence in particular.
First, encyclopaedic reviews of the empirical research on what reduces crime and interpersonal violence
have been completed by a number of governments, intergovernmental agencies and university groups inrecent years. The findings of these reviews are highly convergent and agree with the World report onviolence and health that rates of interpersonal violence can be significantly reduced through well-planned
and multi-sectoral strategies that tackle multiple causes, using frameworks such as the public healthapproach. They are cautious about the extent to which increasing expenditures on policing and corrections
will reduce rates of crime and victimization, particularly because of the costs involved to achieve minimal
returns. The principal conclusions that these reviews draw are that while policing and corrections are an
essential component of prevention, the policing models and types of intervention involved will strongly
determine whether or not they are effective.
Second, the public health approach implies that child abuse and domestic violence are not free standing
problems, but are causally linked to each other and to causes that are shared with other types of violence.
Their prevention is therefore most likely to be achieved through an integrated approach that establishes
information systems, prevention programmes and victim services relevant to all types of violence, andwithin this develops the specialist programmes (e.g. for home visitation and parent training) required toprevent child abuse and domestic violence. The third implication is that primary prevention is only possible
through a multi-sectoral approach. For instance, the health sector has neither the mandate nor theknowledge to implement situational violence prevention measures, such as CCTV monitoring, which must
be the task of the police, and the police are not equipped to design and deliver parent training and home
visitation services, which must be the job of the social welfare sector. The obvious need for different sectors
to deliver the interventions in a coordinated way highlights the need for clear leadership, which, sinceprevention is still new or unknown in many countries, remains critically underdeveloped.
The third and final implication concerns the importance of sharing data and collaborating across sectors inusing data to identify the size and characteristics of the problem, to target interventions, and to provide
ongoing monitoring of the impact of prevention efforts on violence and risk factors for violence. Because
only a partial view of the problem is provided when using data from a single sector (such as the police orhealth services), it is critical to establish an information working group where data from many sectors can bebrought together, analysed and interpreted with a view to informing prevention programming. An
information working group can facilitate the initiation, continuation, and intensification of cross-disciplinary
collaboration on the prevention of interpersonal violence. Once existing sources of data have been identified
and relationships with the responsible agencies fostered through development and limited dissemination of
the initial profile, interested groups can join the multi-sectoral response to the interpersonal violence
problem by participating in the information working group. The information working group must ensure

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widespread dissemination of the information gathered and all reports that are produced. Dissemination can
inform the public about the extent of the problem and the factors affecting it; can raise the political profile ofthe problem within the community; and is essential to ensure that future plans to address it are based on
appropriate evidence. Finally, an ongoing responsibility of the working group will be to critically assess theeffectiveness of the system that has been created, as well as the quality of the data being produced.

IX. CONCLUSION
This paper has reviewed the World report on violence and health’s key finding that violence ispreventable, and has argued that child abuse and domestic violence should be addressed as part of the larger
problem of violence in general. Practical steps to reduce the amount and severity of violence include
preventing unintended pregnancies; strengthening preschool enrichment programmes; providing home
visitation services to high risk parents; training parents in parenting skills; changing community norms
surrounding violence; reducing alcohol availability; enhancing the fairness and efficacy of the criminal justicesystem; improving access to effective emergency medical care and medico-legal services, and reducing
gender, economic and social inequalities.
There are many concrete things that can be done right now to further strengthen national violence
prevention capacity, including appointing a ministerial violence and health focal point; commissioning anational report on violence and health; developing a national plan of action for violence prevention; raisingawareness of the need for violence prevention through a poster campaign, and joining the ViolencePrevention Alliance, whose founding participants include Belgium, Canada, Germany, Jamaica, South Africa,
the US Centres for Disease Control and Prevention and the California Wellness Foundation.
To end, it is useful to recall the words of Nelson Mandela, who in his foreword to the World report onviolence and health, writes: “We must address the root causes of violence. Only then will we transform thepast century’s legacy from a crushing burden into a cautionary lesson”.

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