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SAMJ: South African Medical Journal

versión On-line ISSN 2078-5135

SAMJ, S. Afr. med. j. vol.98 no.9 Cape Town sep. 2008

 

FORUM
ISSUES IN PUBLIC HEALTH

 

Interpersonal violence prevention: Prioritising interventions

 

 

R MatzopoulosI; J E MyersII; B BowmanIII; S MathewsIV

IRichard Matzopoulos is a specialist scientist at the Crime, Violence and Injury Lead Programme, and is affiliated to the Medical Research Council, the UNISA Institute for Social and Health Sciences, and the School of Public Health and Family Medicine of the University of Cape Town
IIJonny Myers is Director of the Occupational and Environmental Health Research Unit, and Professor in the School of Public Health and Family Medicine of the University of Cape Town
IIIBrett Bowman is a Senior Researcher in the Department of Psychology at the University of the Witwatersrand
IVShanaaz Mathews is a Senior Scientist in the Gender and Health Research Unit of the Medical Research Council of South Africa

 

 

Background

The Burden of Disease (BoD) Reduction Project1 of the Western Cape Department of Health reviewed risks for violence-related injury and best practice interventions for potential application.2

Violence claims an estimated 1.6 million lives worldwide, with 90% of these in low- to- middle-income countries.3 This reflects a fraction of the impact of violence on global health and development.4 In South Africa, most violence is interpersonal rather than self-inflicted and homicide rates are 5 - 8 times higher than the global average for females and males respectively.5 In the Western Cape, interpersonal violence accounted for 12.9% of premature mortality and was the second leading cause of years of life lost (YLL) after HIV/ AIDS, which accounted for 14.1% of YLL in 2000. Western Cape mortality rates were higher than national rates for males per hundred thousand (129 v. 115), and females (25 v. 21).6

Data for the Western Cape province and the literature on risk factors for interpersonal violence were reviewed with a view to providing policy makers with an inventory of appropriate interventions.

Violence was defined as 'The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in, injury, death, psychological harm, mal-development or deprivation',7 and the focus of the BoD was interpersonal violence, which is typologically categorised into family and intimate partner violence and community violence.

Risks were conceptualised as biological, behavioural, societal and structural following the ecological approach1 and the relevant literature was reviewed.

The National Injury Mortality Surveillance System (NIMMS) provided all homicides in the City of Cape Town and Stellenbosch8 and the published reports of the Crime, Information and Analysis Centre of the South African Police Services also informed the aggregate data pool for analysis.9 The BoD project prioritised upstream risk factors and interventions, which refer to more upstream societal and structural levels further up the causal chain that typically fall within sectors other than health.

 

Risks for violence

Age and sex are the principal biological risks. Young males are at greater risk for being both perpetrators and victims of violence. In the Western Cape there were 5.2 violent male deaths for every female death,6 compared with the world average of 3.4.3 Males are more frequently victims of physical abuse, and females of sexual abuse. Children constitute a large proportion of victims of violence generally and of sexual abuse in particular. Homicide rates increase sharply from 15 years of age, peaking in the 25 - 29 and 35 - 39 age groups for men and women.10

Behavioural risks include individual personality characteristics and quality of social interactions, which are aggravated by environmental factors. Problems experienced in early childhood development can predispose youth to violent behaviour. Diet and exposure to lead may affect aggressiveness and risk-taking behaviour.11-13

Alcohol and substance abuse impact primarily at the behavioural level. Their association with trauma is well documented. Alcohol accounts for 25 - 50% of intentional injuries,14-17 and is associated with child abuse18-19 and intimate partner violence.20-22 In South Africa, more than half of the patients presenting with injuries from violence tested positive for alcohol use.23 Although testing for other drugs is not routinely performed, urinalysis among arrestees in Cape Town, Durban and Johannesburg found that 46% of murder suspects tested positive for drugs.24

Societal risks begin with early childhood family relationships including large numbers of children, poor family cohesion, single-parent households, young mothers, partner and child abuse and harsh punishment.25-31 The quarter of men from three municipalities in the Western Cape who had witnessed abuse of their mothers were three times more likely than other men to abuse their partner.32 Half of all murdered women were killed by an intimate partner.33

Having violent friends is a risk factor for violent and sexually abusive behaviour and substance abuse among youth.34-35 The Western Cape has a history of social problems associated with street crime and gangs comprising an estimated 90 000 members.36 Gangs, drugs and guns with high violence rates engender violence in residents with negative mental health implications for children.30,37-38

Reduced social capital, manifesting as low social cohesion and interpersonal mistrust, has been linked with higher violence rates.39 A Cape Town study found that 32% of pregnant adolescents and 18% of matched controls had been forced into their first sexual experience.40 In the Lavender Hill and Steenberg area in Cape Town, over 70% of a sample of primary school children reported exposure to violence.41

Traditional gender and social norms are associated with female partner abuse.42 Such abuse is aggravated by the existence of armed conflict where violence is an everyday occurrence.43-44 In the Western Cape, 38% of male and 8% of female learners admitted carrying weapons in the past 6 months45 and a national study on female homicide showed that women were at 10 times greater risk of being killed if their intimate partners owned legal guns (Shanaaz Mathews - unpublished data).

The effectiveness of policing for social protection and crime and violence prevention is a key determinant of violence levels. Effective apprehension of murder suspects and state provision of social protection institutions and welfare have substantial violence-reducing impacts.46-48

Structural risks include major social and demographic changes, e.g. migration, urbanisation or modernisation, which are associated with increased youth violence.27,49-51 Poverty, deprivation and inequality are strong determinants.34,49,51-53 The highest homicide rates in Cape Town are recorded in Nyanga (132/100 000) and Khayelitsha (120) compared with the Southern Suburbs (60).54 Homogeneous, poor populations have lower rates of violence than heterogeneous socio-economically unequal populations.55-56 Urban living with increased population density, degraded environment, overloaded infrastructure, and stretched service delivery is associated with higher injury and homicide rates.57

 

Proven and promising interventions

The hierarchy of anti-violence interventions prioritises sustainable upstream primary preventive interventions (reducing deprivation and inequality and early education), rather than purely downstream interventions (behaviour change via policing and law enforcement); however, the latter remain critically important. Strategies include reducing income inequality and social deprivation; improving criminal justice and social welfare systems resources; changing cultural norms to promote gender equality and respect for the elderly while challenging negative norms associating violence with masculinity, racism or sexism; strengthening communities through reducing alcohol availability and improving child care facilities; investing in early childhood education; and increasing positive adult involvement in the monitoring and supervision of children and adolescents.34 A summary of feasible interventions for the Western Cape is presented in Table 1.

Interventions aimed at individuals and relationships are more prevalent, affordable, feasible and evaluable. The evidence is typically for knowledge and attitude changes rather than injury reduction.58 Community and societal violence prevention strategies are less common with relatively little evidence for their effectiveness, but nevertheless hold great promise. Effectiveness is difficult to measure owing to rarity of outcomes and complexity of causal pathways.

 

The need for an intersectoral approach

In Bogota, Colombia, a violence prevention programme partnering local government and academic institutions included social development, political empowerment, enhanced social cohesion and substantial investments in the enhancement of public spaces, transportation, policing and the criminal justice system, resulting in dramatic decreases in rates of interpersonal violence over a 10-year period. The homicide rate dropped to a quarter of 1994 levels by 2003. A key success factor was the programme's institutionalisation within the municipality and hence its sustainability through changes in government, unlike a similar but failed intervention in another city, Cali.59

Efforts to address the burden of violence in the Western Cape require an inter-sectoral approach that spans the criminal justice, health, and infrastructural domains. There is also a need to balance achievable short-term targets to offset the long-term nature of many of the strategies most needed to affect fundamental shifts in socio-cultural attitudes and the propensity towards aggressive and violent behaviour. Thus, if the typical perpetrator in the Western Cape is a young male dependent on alcohol and living in an area with severe structural and social problems including unemployment, poverty, poor services (schools, health care, transport, etc.) and numerous armed gangs that support a drug trade, the Provincial Government may wish to provide certain 'quick-fix' solutions (for example, through improving the criminal justice system), while investing heavily in those programmes most likely to affect a fundamental and lasting change in the long term. Appropriate investments in programme documentation and evaluation are important factors in driving long-term investment, ensuring effectiveness and enabling replication of successful programmes. Evaluation should, wherever possible, include the measurement of behaviour change and actual changes in injury rates.

 

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