Sexual Violence Prevention:

Beginning the Dialogue
CDC Internal Workgroup Members

Margaret Brome

Janet Saul

Karen Lang

Rebeca Lee-Pethel

Neil Rainford

Jocelyn Wheaton

Acknowledgments

CDC wishes to thank the following people for their expertise and

sound advice on how to present this important information:

Karen Baker, National Sexual Violence Prevention Center

Kathleen Basile, Centers for Disease Control and Prevention

Shelley Bearman, Kansas Department of Health

Gail Burns-Smith, National Alliance to End Sexual Assault; Connecticut Sexual Assault Crisis Services

Larry Cohen, Prevention Institute

Linda Dahlberg, Centers for Disease Control and Prevention

Rachel Davis, Prevention Institute

Marci Diamond, Massachusetts Department of Health

Alisa Klein, Stop It Now

Sally Laskey, National Sexual Violence Resource Center

James Mercy, Centers for Disease Control and Prevention

Delilah Rumberg, Pennsylvania Coalition Against Rape

Wendy Siebold, Michigan State University

Nan Stein, Wellesley College Center for Research on Women

Gayle Stringer, Washington Coalition Against Sexual Assault Program

Suggested Citation: Centers for Disease Control and Prevention. Sexual violence prevention: beginning the dialogue.

Atlanta, GA: Centers for Disease Control and Prevention; 2004.
Prevention: Beginning the Dialogue

One day, a fisherman was fishing from a river bank when he saw someone being swept downstream,

struggling to keep their head above water. The fisherman jumped in, grabbed the person, and helped them

to shore. The survivor thanked the fisherman and left, and the hero dried himself off and continued fishing.

Soon he heard another cry for help and saw someone else being swept downstream. He immediately

jumped into the river again and saved that person as well. This scenario continued all afternoon. As soon

as the fisherman returned to fishing, he would hear another cry for help and would wade in to rescue

another wet and drowning person. Finally, the fisherman said to himself, “I can’t go on like this. I’d better

go upstream and find out what is happening.”

This public health analogy of “moving upstream” to prevent tragedies from occurring downstream is taught

in many public health courses and is relevant for our dialogue on sexual violence prevention. It is presented

as a catalyst for discussion and to convey how important it is to have strong teams along the river building

safe passages.

The Centers for Disease Control and Prevention (CDC) could not begin to address sexual violence

prevention without the years of hard work and dedication of survivors, advocates, prevention educators,

and other professionals. Their efforts ensure the provision of crisis intervention, victim advocacy, and

social and mental health services that are critical to the long-term well being of those affected by sexual

violence. One of the tenets of the public health approach is building partnerships and identifying the

strengths and expertise that partners offer to help frame solutions to a public health problem. CDC’s niche

is to be part of the team working at the top of the river: building safe passages and keeping people from

being pushed into the river. The Rape Prevention and Education (RPE) grant program should be a major

contributor to this effort. We also know that we are working in partnership with others along the river

making sure that anyone who falls in will survive.

Purpose

This document is intended to begin the dialogue about what it means to move upstream. Over the past few

years — since CDC’s Injury Center became the administrator of the RPE program — we have been

asked repeatedly to define what we mean by “prevention.” How does prevention look, and where should

recipients of RPE funds focus their efforts and resources? Our working definition of sexual violence

prevention for the RPE program is population-based and/or environmental and system-level strategies,

policies, and actions that prevent sexual violence from initially occurring. Such prevention efforts work to

modify and/or entirely eliminate the events, conditions, situations, or exposure to influences (risk factors)

that result in the initiation of sexual violence and associated injuries, disabilities, and deaths. Additionally,

sexual violence prevention efforts address perpetration, victimization, and bystander attitudes and behaviors, and seek to identify and enhance protective factors that impede the initiation of sexual violence in atrisk populations and in the community.

CDC convened an internal working group to review theoretical frameworks and to define and describe

prevention concepts and strategies that were compatible with the public health approach and would benefit

entire communities affected by this issue. CDC also solicited input from advocates and others working in

the sexual violence field (see inside front cover for the list of reviewers).

We would like RPE grantees to use these prevention concepts and strategies as a foundation for planning,

implementing, and evaluating activities conducted with RPE funds. In addition, we would like RPE grantees to share this document and discuss its content with traditional and nontraditional partners, particularly

those who work at the local level with communities. Discussions with key stakeholders and community

leaders (including public health agency leadership) will also help build support for prevention activities.

1
The Public Health Approach to Prevention

As a recipient of RPE funds, you have probably heard us talk about the “public health approach” to sexual

violence prevention. Similar to other disciplines, public health promotes specific principles as the foundation

for work within the field. Four public health principles—health of the public, data-informed approaches,

cultural competency, and prevention—are central to this document and to our ongoing discussion of sexual

violence prevention.

Public health is ultimately concerned with approaches that address the health of a population rather than

one individual. This is generally referred to as a population-based approach and is one of the principles that

distinguishes public health from other approaches to health-related issues (e.g., medicine focuses on

helping the individual). Based on this principle, a public health prevention strategy demonstrates benefits

for the largest group of people possible, because the problem is widespread and typically affects the entire

population in some way, either directly or indirectly. The public health approach also depends upon collective action (Krug, Dahlberg, Mercy, et al. 2002). It is a community-oriented approach that takes the onus

from victims and advocates and encourages the entire community (women, men, and youth) to prevent

sexual violence.

Data-informed, evidence-based approaches are also a central concept in the field of public health. According to this principle, all phases of program planning and implementation should be based on the best

information available. Below are some examples of how data can be used in all four steps of the public

health approach.

• Define the Problem. Data can provide answers to questions of how much sexual violence is

happening, where it is happening, and who are the victims and perpetrators. Data sources may

include the criminal justice system, emergency rooms, rape crisis centers, and general public

surveys. These data can be used in many ways such as applying for resources, focusing the

delivery of prevention programs, and tracking the success of various efforts over time.

2

Define the Problem

The Public Health Approach

Identify Risk and

Protective Factors

Develop and Test

Prevention Strategies

Ensure Widespread

Adoption
• Identify Risk and Protective Factors. Findings from research studies can reveal some of the

factors that may put people at risk for sexual violence perpetration and victimization or protect

them from harm. Those who design sexual violence prevention programs can use this information

to plan the content of their program by focusing on activities that address those risk and protective

factors.

• Develop and Test Prevention Strategies. Data gathered from the experiences of practitioners

working with various groups and through community assessments, stakeholder interviews, and

focus groups may be useful for designing prevention programs that increase program acceptability

among the intended audience. In addition, information gathered during program implementation

can be used to document successful and unsuccessful implementation; demonstrate program

accomplishments; and identify areas needing improvement. Promising programs and curricula

should undergo rigorous evaluation before they are widely disseminated.

• Ensure Widespread Adoption. Once data supports an effective prevention strategy, the goal is

to establish the prevention strategy as a standard in the field of sexual violence prevention.

Prevention strategies known to be effective should be adopted and implemented in a variety of

settings, and should replace ineffective strategies. Dissemination techniques that can promote

widespread adoption and implementation of the new standards include training, networking,

technical assistance, and process evaluation to assure fidelity. Dissemination should also include

outcome evaluation to assess the effectiveness of strategies with new populations.

A key principle that cuts across all areas of the public health approach is cultural competency. It is essential that core activities such as collecting and analyzing data, designing and implementing programs, and

determining what works be conducted within the context of the unique aspects of various populations and

communities. Guidance from the population is key in the design, implementation, and evaluation of a

prevention program. Also, simply translating the materials for a given intervention into a different language

does not constitute a culturally-appropriate or relevant strategy as it does not address the different ways

communities talk and think about sexual violence.

The concept of prevention is central to the field of public health. The remainder of this document focuses

on prevention and how these public health principles can be applied to programmatic decision-making in

the field of sexual violence.

Prevention: WHEN do we intervene?

Public health *interventions are often grouped into three prevention categories based on when the intervention occurs. Sexual violence interventions can be divided into the following three categories:

• Primary Prevention: Approaches that take place before sexual violence has occurred to

prevent initial perpetration or victimization.

• Secondary Prevention: Immediate responses after sexual violence has occurred to deal with

the short-term consequences of violence.

• Tertiary Prevention: Long-term responses after sexual violence has occurred to deal with the

lasting consequences of violence and sex offender treatment interventions.

*In this document, “intervention” describes any prevention or service-related activity.

3
While the major purpose of interventions that take place after violence has occurred is to reduce or

ameliorate the negative effects of the violence, some of these approaches may have the advantageous

effect of preventing a reoccurrence of violence. Categorizing prevention by WHEN an intervention occurs

is a less than perfect fit when looking at violence, and therefore we often simplify this discussion by talking

about interventions to prevent violence before it ever occurs and those that take place after violence has

already occurred.

Prevention: WHAT is the focus?

To prevent sexual violence, we have to understand what circumstances and factors influence its occurrence. There are many different theoretical models that attempt to describe the root causes of sexual

violence: biological models, psychological models, cultural models, and grassroots, feminist, power-based

models. Each of these models contributes to a better understanding of sexual violence and helps experts

build programs that sustain protective factors and reduce modifiable risk factors. The CDC working group

(see inside front cover) chose to use an ecological model as part of the framework for our discussion

because it allows us to include risk and protective factors from multiple domains. Thus, if there is evidence

from psychological models about individual risk factors and from feminist models about societal risk

factors, it can all be incorporated in the same ecological model. Building such a model offers a framework

for understanding the complex interplay of individual, relationship, social, political, cultural, and environmental factors that influence sexual violence (Dahlberg and Krug 2002) and also provides key points for

prevention and intervention (Powell, Mercy, Crosby, et al. 1999). We use the four-level ecological model

presented in the World Report on Violence and Health for this discussion (Dahlberg and Krug 2002);

however, there are a variety of ecological models that have been developed (see, for example, Heise

1998).

The examples in Table 1 illustrate the levels of the ecological model. The examples of risk factors are also

taken from the chapter on sexual violence in the World Report on Violence and Health (Jewkes, Sen,

Garcia-Moreno 2002) and are not a comprehensive list of risk factors for sexual violence perpetration.

There is a lack of research on protective factors so no such examples are presented in the model.

• Individual-level influences are biological and include personal history factors that increase the

likelihood that an individual will become a victim or perpetrator of violence. For example, factors

such as alcohol and/or drug use; attitudes and beliefs that support sexual violence; impulsive and

other antisocial tendencies; preference for impersonal sex; hostility towards women; and childhood

history of sexual abuse or witnessing family violence may influence an individual’s behavior

choices that lead to perpetration of sexual violence (Dahlberg and Krug 2002). Interventions for

individual-level influences are often designed to target social and cognitive skills and behavior and

include approaches such as counseling, therapy, and educational training sessions (Powell et al.

1999).

• Interpersonal relationship-level influences are factors that increase risk as a result of

relationships with peers, intimate partners, and family members. A person’s closest social circle—

peers, partners, and family members—can shape the individual’s behavior and range of experience (Dahlberg and Krug 2002). Interventions for interpersonal relationship-level influences could

include family therapy, bystander intervention skill development, and parenting training (Powell et

al. 1999).

4
5

• Community-level influences are factors that increase risk based on community and social

environments and include an individual’s experiences and relationships with schools, workplaces,

and neighborhoods. For example, lack of sexual harassment policies in the workplace can send a

message that sexual harassment is tolerated, and that there may be few or no consequences for

those who harass others. Interventions for community-level influences are typically designed to

impact the climate, systems, and policies in a given setting.

• Societal-level influences are larger, macro-level factors that influence sexual violence such as

gender inequality, religious or cultural belief systems, societal norms, and economic or social

policies that create or sustain gaps and tensions between groups of people. For example, rape is

more common in cultures that promote male sexual entitlement and support an ideology of male

superiority (Dahlberg and Krug 2002). Interventions for societal-level influences typically involve

collaborations by multiple partners to change laws and policies related to sexual violence or

gender inequality. Another intervention would be to determine societal norms that accept violence and to identify strategies for changing those norms (Powell et al. 1999).

The ecological model supports a comprehensive public health approach that not only addresses an

individual’s risk factors, but also the norms, beliefs, and social and economic systems that create the

conditions for the occurrence of sexual violence.

Prevention: Integrating the WHEN and the WHAT

The following matrix provides examples of how interventions to prevent violence before it occurs, and

interventions that take place after violence has happened, can be implemented across all levels of the

ecological model. Distinguishing interventions by “before” and “after” violence has occurred serves to

highlight the salient differences between the two approaches.

Influences: attitudes and beliefs

that support sexual violence;

impulsive and antisocial behavior;

childhood history of sexual abuse

or witnessing violence; alcohol

and drug use

Influences: association

with sexually aggressive

peers; family environment

that is emotionally

unsupportive, physically

violent or strongly

patriarchal

Influences: general tolerance

of sexual assault; lack of

support from police or judicial

system; poverty; lack of

employment opportunities;

weak community sanctions

against perpetrators

Influences: inequalities

based on gender, race,

and sexual orientation,

religious or cultural

beliefs, economic and

social policies

Individual Relationship Community Societal

Table 1. The Ecological Model
Individual Relationship Community Societal

Before

After

Implement and

evaluate discussion

groups among men that

explore prevalent

notions of masculinity

and their relationship

with sexual violence;

healthy and respectful

relationships; and

men’s role in preventing sexual violence.

Provide offender

treatment services for

perpetrators.

Provide crisis intervention services for

sexual assault

survivors.

Implement and

evaluate a discussion

group based intervention with male

peer groups (e.g.,

fraternities, athletic

teams) to change

group norms that

support and condone

sexual harassment

and violence. Men

will learn to hold their

peers accountable for

attitudes and

behaviors that

support sexual

violence.

Provide services to

family members of

sexual assault

survivors to assist

them in resolving the

impact of the assault

and to help them be

sensitive and

supportive of the

survivor.

Engage youth as

agents of change to

affect their school’s

climate of tolerance

for sexualized

bullying by leading

classroom-based

conversations and

school-wide special

events.

Develop police

protocols for responding to and investigating reports of sexual

assaults.

Hold “Take Back the

Night” rallies to raise

community awareness

of the scope, nature,

and impact of sexual

violence.

Assist in educating

legislators about the

importance of

economic and

educational policies

that promote the

economic status of

women and reduce

inequalities in

employment.

Assist in educating

legislators about the

importance of

mandatory legislation

that ensures all

survivors of sexual

assault the provision

of a forensic medical

exam at no charge.

 Table 2. The WHEN and WHAT Matrix

6
Prevention: WHO is it for?

Prevention strategies are often developed based upon the group for whom the intervention is intended.

Using this type of differentiation, sexual violence interventions can again be divided into three categories:

• Approaches that are aimed at groups or the general population regardless of individual risk for

sexual violence perpetration or victimization are called universal interventions. Groups can be

defined geographically (e.g., entire school or school district) or by characteristics (e.g., ethnicity,

age, gender).

• Approaches that are aimed at those who are thought to have a heightened risk for sexual

violence perpetration or victimization are referred to as selected interventions.

• Approaches that are aimed at those who have already perpetrated sexual violence or have been

victimized are called indicated interventions.

Prevention: Integrating the WHAT and the WHO

The following matrix demonstrates how universal, selected, and indicated approaches can be implemented across the ecological model. Comprehensive prevention programs are multifaceted and address

multiple cells within the matrix. CDC acknowledges that some of the programs and services designed for

victims may also prevent reoccurrences of victimization and perpetration. However, we still consider

these activities “indicated” because the primary goal of many of these programs is to address the important need to prevent the short- and long-term negative consequences of the violence. As a primary goal,

the public health community wants to prevent new incidents from occurring, so in keeping with this, we

have provided some examples of strategies and activities for both universal and selected approaches

within the ecological model.

It is important to note that the cells in the matrix are not isolated from one another and may overlap. For

example, women could be defined as an entire population for a universal approach or as a high-risk group

for a selected approach. Either approach could be appropriate, but the course of action taken should be

based on data or other considerations outlined in “How to Make Programmatic Decisions about Prevention Approaches” on page 10.

Because this document is geared toward the RPE program, no examples for indicated approaches were

included.

7
Table 3. The WHAT and WHO Matrix

NOTE: The example strategies in this matrix further describe prevention concepts and strategies.

CDC looks forward to working with grantees to develop innovative and effective ways to prevent

sexual violence that address individual, relationship, community, and societal influences for universal and selected populations.

Individual Relationship Community Societal

Universal

Approaches are aimed at

everyone in the population of interest, regardless

of risk, and are designed

to impact individual

factors that increase the

likelihood of being a

victim or perpetrator of

sexual violence (SV).

Example:

a) Develop, implement,

and evaluate a

comprehensive,

faith-based educational program with

multiple sessions

and clear outcomes

that will teach

people about sexual

violence and dispel

the rape myths,

attitudes, and beliefs

that condone SV.

b) Evaluate and

implement effective

curriculum on dating

and SV that is

delivered to high

school students in

grades 9-12.

Approaches are aimed at

everyone in the population of interest, regardless of risk, and are

designed to impact

factors that increase the

risk of SV as a result of

relationships with

peers, intimate partners,

and family members.

Example:

a) Develop, implement, and evaluate a

program for little

league coaches to

build/develop skills

to interrupt and

address inappropriate comments and

behaviors among

athletes that

promote a climate

condoning bullying,

sexual harassment

and SV.

b) Partner with a local

PTA to develop,

implement, and

evaluate a skillsbuilding program

for parents to help

them address

attitudes and

behaviors in their

children that

promote SV.

Approaches are aimed at

everyone in the population of interest, regardless of risk, and are

designed to impact

community and social

environments that

increase the risk of SV.

Example:

a) Implement and

enforce sexual

harassment policies

in schools, workplaces, and other

institutions.

b) Help communities

implement

environmental

safety measures

such as adequate

lighting and

emergency call

boxes. This

complements

community

education and

enforcement of

policies that

prohibit inappropriate behavior such as

stalking and

threatening or

coercing community

residents.

c) Hold annual

meetings or press

conferences to alert

communities about

the latest statistics

on SV to rally

support for

prevention.

Approaches are aimed at

everyone in the population of interest, regardless of risk, and are

designed to impact the

larger, macro-level

factors that influence SV,

such as gender inequality

and religious, cultural,

social, or economic

factors.

Example:

a) Conduct strategic

planning activities

with partners and

policymakers using

data from a variety

of sources such as

emergency rooms,

crime reports, rape

crisis centers, etc.

to help determine

where, when, and to

whom prevention

activities should be

focused.

b) Promote and

enforce full

implementation of

the Title IX law.

c) Establish and

enforce policies for

colleges and

universities to

accurately report SV

on campus and

provide rape

prevention

programs to

students and staff.

8
9

Individual Relationship Community Societal

Selected

Approaches are aimed at

those in the population at

heightened risk for SV

victimization or

perpetration and are

designed to impact

individual factors that

increase the likelihood of

victimization or perpetration.

Example:

a) Implement and

evaluate a program

for high school boys

to address alcohol/

drug use and the

ability to give and

receive clear consent

for sexual activity.

Multi-session,

classroom-based,

peer-led discussions

with messaging

reminders from peers

or media (posters,

PSAs, etc.) should be

included.

b) In partnership with

an immigration and

refugee center,

develop, implement,

and evaluate a

culturally-appropriate awareness

campaign for

immigrants and

refugees that dispels

rape myths and the

beliefs and attitudes

that condone SV as

they integrate into a

community.

Approaches are aimed at

those in the population

at heightened risk for

SV victimization or

perpetration and are

designed to impact

factors that increase the

risk of SV as a result of

relationships with

peers, intimate partners,

and family members.

Example:

a) Implement and

evaluate a program

that addresses

potentially high risk

components of

“Greek life,”

specifically

fraternities where

male-peer support

for obtaining sex by

facilitating

intoxication

(alcohol/drug) is

acceptable.

b) Implement and

evaluate a skillbuilding program

for parents of youth

convicted of

inappropriate

sexual behavior to

help them address

attitudes and

behaviors that

promote SV.

Approaches are aimed at

those in the population

at heightened risk for

SV victimization or

perpetration and are

designed to impact

community and social

environments that

increase the risk of SV.

Example:

a) Develop, implement, and evaluate a

program in

neighborhoods with

a high density of

alcohol advertising

and advertising that

sexualizes/

objectifies women

to demand the

removal of such

advertising as a

means of changing

the social environment that supports

sexual violence.

b) Establish and

enforce employee

and volunteer

screening and

training policies for

caregivers of

persons with

disabilities.

Approaches are aimed at

those in the population

at heightened risk for

SV victimization or

perpetration and are

designed to impact the

larger, macro-level

factors that influence SV,

such as gender inequality,

and religious, cultural,

social, or economic

factors.

Example:

a) Work through mass

media (PSAs,

editorials, documentaries, insertion

into programming,

etc.) to promote

societal norms that

support prevention,

endorse help

seeking (treatment

and counseling)

behaviors, and

lessen the stigma

for individuals that

identify themselves

as being a potential

perpetrator.

b) Educate

policymakers to

support efforts that

are designed to

address and

ameliorate the

consequences of

children’s exposure

to violence,

including family

violence, school

violence, and youth

violence (as part of

an overall comprehensive sexual

violence prevention

plan).
Making Programmatic Decisions About Prevention Approaches

None of the categories presented within the matrix (i.e., the what and who of prevention) are superior to

the others. In fact, each has its own advantages and disadvantages (Powell et al. 1999). Universal,

selected, and indicated interventions all contribute to a comprehensive prevention strategy. However,

CDC’s strength lies in supporting universal and selected strategies focused on preventing sexual violence

before it occurs. These strategies provide the maximum benefit for the largest number of people and work

to modify and/or entirely eliminate the event, conditions, situations, or exposure to influences (risk factors)

that result in the initiation of sexual violence. Additionally, these prevention efforts identify and enhance

protective factors that may prevent sexual violence in at-risk populations and the community at large.

CDC decisions about the RPE program are guided by this prevention approach.

We all have limited resources and difficult decisions to make about which programs to implement. The

following questions highlight some of the issues to consider when deciding where to focus your RPE

program resources:

What are the mission and goals of the funding agency?

• If you are applying for funds to support prevention activities, certain types of prevention may be

more or less suitable, depending on the mission of the funding agency. For example, criminal

justice sanctions and offender treatment programs that focus on perpetrator accountability may be

more appropriate for funds from an agency with a criminal justice mission. The public health

approach to prevention focuses on improving the health of populations rather than a single individual. Therefore, as a public health agency, CDC is more likely to focus on universal and selected

approaches with an emphasis on preventing sexual violence before it occurs.

Do the mission and goals of your agency support rape prevention and education?

• The compatibility of your organization’s mission and goals with those of various funding agencies

may drive your decisions about the types of grants and cooperative agreements for which you

apply and for the types of prevention activities you plan to conduct.

Individual Relationship Community Societal

Indicated

Approaches are aimed at

those in the population

who are victims or

perpetrators of SV and

are designed to impact

individual factors that

increase the likelihood of

re-victimization or reperpetration.

Approaches are aimed at

those in the population

who are victims or

perpetrators of SV and

are designed to impact

factors that increase risk

of re-victimization or reperpetration as a result

of relationships with

peers, intimate partners,

and family members.

Approaches are aimed at

those in the population

who are victims or

perpetrators of SV and

are designed to impact

community and social

environments that

increase the risk of revictimization or reperpetration.

Approaches are aimed at

those in the population

who are victims or

perpetrators of SV and

are designed to impact

the larger, macro-level

factors that influence the

likelihood of revictimization or reperpetration, such as

gender inequality, and

religious, cultural, social,

or economic factors.

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11

Where are current resources being focused and where are the gaps?

• Resources for all levels of prevention are limited within the field of sexual violence prevention.

Analyzing how federal, state, and local funds are allocated and used can show where the largest

gaps exist within the matrix. At this time, the majority of federal and state funds are designated

for indicated approaches—after the sexual violence has occurred. Funds that allow for universal

and selected (“before”) approaches can provide a unique opportunity to develop a more comprehensive strategy and to focus on the problem “upstream.” (For example, rather than implementing a one time pre/post-tested training session geared towards children in schools, develop a

more comprehensive systems approach to address school environments, policies and procedures, and behaviors and attitudes that support or condone sexual violence). At the current

program level, priority is often given to secondary and tertiary approaches to violence prevention

to provide much needed services to victims and to hold perpetrators accountable (Krug et al.

2002). While this focus is understandable because the human need is so great, it can leave a gap

in primary/universal and selected approaches to prevention.

What do we know about who is at risk for sexual violence perpetration and who is vulnerable to

sexual violence victimization?

• Research in the area of risk and protective factors for sexual violence is still evolving and does

not yet offer specific strategies. However, some approaches are more appropriate than others,

depending on who is at risk (Powell et al. 1999). If everyone is at equal risk, a universal approach is more appropriate. If a certain group has been accurately identified as the source of

many or most new incidents of sexual violence, a selected approach may be more appropriate.

For a synopsis of known risk factors, please refer to the World Report on Violence and Health

(Krug et al. 2002).

What data are available to help you make decisions?

• One of the basic principles of the public health approach is to use data to make programmatic

decisions. Data can come from a variety of sources including public health surveillance, research, and program evaluation.

• Do you have evaluation data for current programs or for those you plan to implement in the

future? Evaluation data are a critical part of the program planning, development, implementation,

and improvement cycle. These types of data ensure that you are accomplishing what you set out

to do and that you know when a part of your program needs some improvement. It is important

for programs to incorporate outcome data to evaluate efforts and to provide evidence that you

are making a difference. Outcome data may also be helpful for garnering additional resources

and support for your efforts.

Who are your partners?

• Sexual violence is a complex and multifaceted issue that requires a broad-based, multisystem

response from a wide array of individuals, groups, and agencies. Because sexual violence

affects all sectors of our communities, many groups and agencies are engaged in prevention

efforts. As you look at the allocation of current resources and identify gaps, look for ways to

partner with other groups and agencies to make limited resources go further, especially among

those groups and organizations that represent and include members of underserved populations.

Many states were able to develop broader, more comprehensive initiatives by partnering and

sharing staff and other resources.
Are the programmatic activities permissible?

• Congress legislated that RPE grant funds may be used for the following seven permitted uses:

1. Educational seminars

2. Hotlines

3. Training programs for professionals

4. Informational materials

5. Training programs for students and campus personnel designed to reduce the incidence

of sexual assault at colleges and universities

6. Education to increase awareness about drugs used to facilitate rape or sexual assault

7. Other efforts to increase awareness in underserved communities and awareness

among individuals with disabilities as defined in Section 3 of the Americans with

Disabilities Act of 1990 (42 U.S.C. 12102).

• Given our discussion about the public health approach to prevention, states are encouraged to think

broadly. They should consider implementing universal or selected interventions across the ecological model that are permissible program activities.

These are just a few of the issues that programs struggle with when making decisions. There are obviously other things to consider such as the cost of various programs; the level of evidence on effective

approaches; the capacity of your organization to carry out various approaches; and your organization’s

access to and experience working with various populations, etc.

Summary

This initial discussion of public health approaches to sexual violence prevention lays the foundation for

future dialogue about ways RPE programs can individually and collectively identify strategies and opportunities for maximizing the effectiveness of limited program funds. This dialogue could not begin without

acknowledging the important and ground-breaking work of survivors, advocates, prevention educators, and

other professionals who have worked tirelessly to bring the issue of sexual violence to the forefront. CDC

places great value in developing partnerships and working creatively to move “upstream.”

We know that prevention works through our experience in addressing other public health issues. The

spectrum of sexual violence prevention is broad and multifaceted, and requires the skills and approaches

from many disciplines and areas of expertise. Through the RPE program, CDC hopes to contribute to

sexual violence prevention by promoting efforts to modify or eliminate the individual, relationship, community, and societal influences that result in perpetration, victimization, and bystander attitudes that allow

sexual violence to occur. In particular, CDC seeks those efforts designed especially for general populations

(universal efforts) or those at heightened risk (selected efforts) to ensure that the greatest number of

people benefit from the prevention of sexual violence.

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References

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Mercy JA, Zwi AB, Lozano R, editors. World Report on Violence and Health. Geneva

(Switzerland): World Health Organization; 2002. p. 3-21.

2. Heise LL Violence against women: an integrated, ecological framework. Violence Against

Women 1998;4(Pt 3), 262-90.

3. Jewkes R, Sen P, Garcia-Moreno C. Sexual violence. In: Krug EG, Dahlberg LL, Mercy JA,

Zwi AB, Lozano R, editors. World Report on Violence and Health. Geneva (Switzerland):

World Health Organization; 2002. p. 149-81.

4. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on Violence and

Health. Geneva (Switzerland): World Health Organization; 2002.

5. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for

preventing violence. Health Affairs 1993; 7-29.

6. Powell KE, Mercy JA, Crosby AE, Dahlberg LL, Simon TR. Public health models of violence

and violence prevention. In: Kurtz LR, editors. Encyclopedia of Violence, Peace, and Conflict. Vol. 3. San Diego (CA): Academic Press;1999:175-87.

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Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Division of Violence Prevention

www.cdc.gov/injury