1.www.SlideShare.net/AhmedRefatViolence: A Community HealthProblemSelected Topics from "World report on violence" WHO-2002http://www.who.int/violence_injury_prevention/violence/world_report/en/ Dr. Ahmed-Refat A.G Refat (2013)1

2. www.SlideShare.net/AhmedRefat Contents Definition of Violence Typology of violence The nature of violent acts Types of data and data sources The roots of violence: an ecological model How can violence be prevented? Multifaceted responses Public health Approach Haddons Matrix2 3. www.SlideShare.net/AhmedRefat3 4. www.SlideShare.net/AhmedRefatWHO Defining violence as"The intentional use of physical force or power, threatened or actual, against oneself, another person, or against agroup or community,that either results in or has a high likelihood ofresulting in injury, death, psychological harm,maldevelopment or deprivation". 4 5. www.SlideShare.net/AhmedRefatThe definition used by the World HealthOrganization associates intentionality with thecommitting of the act itself, irrespective of theoutcome it produces. Excluded from the definitionare unintentional incidents such as most roadtraffic injuries and burns.5 6. www.SlideShare.net/AhmedRefatThe inclusion of the word power, in additionto the phrase use of physical force, broadens thenature of a violent act and expands the conventionalunderstanding of violence to include those acts thatresult from a power relationship, including threatsand intimidation. The use of power also serves toinclude neglect or acts of omission, in addition tothe more obvious violent acts of commission. Thus,6 7. www.SlideShare.net/AhmedRefatthe use of physical force or power should beunderstood to include neglect and all types ofphysical, sexual and psychological abuse, as well assuicide and other self-abusive acts.This definition covers a broad range of outcomes including psychological harm, deprivation and maldevelopment. 7 8. www.SlideShare.net/AhmedRefatTypology of violenceIn its 1996 resolution WHA49.25, declaringviolence a leading public health problem, theWorld Health Assembly called on the World HealthOrganization to develop a typology of violence thatcharacterized the different types of violence and thelinks between them.8 9. www.SlideShare.net/AhmedRefat Types of violenceThe typology proposed here divides violence intothree broad categories according to characteristicsof those committing the violent act: 1. self-directed violence; 2. interpersonal violence; 3. collective violence. 9 10. www.SlideShare.net/AhmedRefat11 11. www.SlideShare.net/AhmedRefat1- Self-directed violenceSelf-directed violence is subdivided into suicidalbehaviour and self-abuse.The suicidal behaviour includessuicidal thoughts, attempted suicides also calledparasuicide or deliberate self-injury in somecountries and completed suicides.Self-abuse, in contrast, includes acts such as self-mutilation.11 12. www.SlideShare.net/AhmedRefat2- Interpersonal violenceInterpersonal violence is divided into:. Family and intimate partner violence that is,violence between family members and intimatepartners, usually, taking place in the home.Includes forms of violence such as child abuse,intimate partner violence and abuse of the elderly.12 13. www.SlideShare.net/AhmedRefat. Community violence violence between individualswho are unrelated, and who may or may not knoweach other, generally taking place outside the home.Community violence includes youth violence,random acts of violence, rape or sexual assault bystrangers, and violence in institutional settings suchas schools, workplaces, prisons and nursing homes. 13 14. www.SlideShare.net/AhmedRefat3- Collective violenceCollective violence is subdivided into: social,political and economic violence.Unlike the other two broad categories, thesubcategories of collective violence suggestpossible motives for violence committed by largergroups of individuals or by states.14 15. www.SlideShare.net/AhmedRefatCollective violence that is committed to advance aparticular social agenda includes, for example,crimes of hate committed by organized groups,terrorist acts and mob violence.Political violence includes war and related violentconflicts, state violence and similar acts carried outby larger groups. 15 16. www.SlideShare.net/AhmedRefatEconomic violenceincludes attacks by larger groups motivated byeconomic gain such as attacks carried out with thepurpose of disrupting economic activity, denyingaccess to essential services, or creating economicdivision and fragmentation. Clearly, acts committedby larger groups can have multiple motives.16 17. www.SlideShare.net/AhmedRefat The nature of violent actsThe nature of violent acts can be: 1. physical; 2. sexual; 3. psychological; 4. involving deprivation or neglect.The horizontal array in Figure shows who isaffected, and the vertical array describes how theyare affected.17 18. www.SlideShare.net/AhmedRefatTypes of data and potential sources for collecting informationThese types of data include: health data on diseases, injuries and otherhealth conditions; self-reported data on attitudes, beliefs,behaviours, cultural practices, victimization andexposure to violence; community data on population characteristics18 19. www.SlideShare.net/AhmedRefatand levels of income, education and unemployment; crime data on the characteristics andcircumstances of violent events and violentoffenders; economic data related to the costs oftreatment and social services; data describing the economic burden onhealth care systems and possible savingsrealized from prevention programmes; data on policy and legislation.19 20. www.SlideShare.net/AhmedRefat Sources of dataSources of the various types of information include: individuals; agency or institutional records; local programmes; community and government records; population-based and other surveys; special studies 21 21. www.SlideShare.net/AhmedRefatEstimates of mortalityIn 2000, an estimated 1.6 million people worldwidedied as a result of self-inflicted, interpersonal orcollective violence, for an overall age-adjusted rateof 28.8 per 100 000 population21 22. www.SlideShare.net/AhmedRefatThe vast majority of these deaths occurred in low- tomiddle-income countries. Less than 10% of allviolence-related deaths occurred in high-incomecountries.Nearly half of these 1.6 million violence-relateddeaths were suicides, almost one-third werehomicides and about one-fifth were war-related.22 23. www.SlideShare.net/AhmedRefatEstimates of non-fatal violenceThe above-mentioned mortality figures are almostcertainly underestimates of the true burden ofviolence. In all parts of the world, deaths representthe tip of the iceberg as far as violence is concerned.23 24. www.SlideShare.net/AhmedRefatExamining the roots of violence: an ecological model No single factor explains why some individualsbehave violently toward others or why violence ismore prevalent in some communities than in others. Violence is the result of the complex interplay of individual, relationship, social, cultural and environmental factors.24 25. www.SlideShare.net/AhmedRefat Multiple levelsConsidering the ecological model help understandthe multifaceted nature of violence.Ecological model first introduced in the late 1970s, this ecological model was initially applied tochild abuse and subsequently to youthviolence . More recently, researchers haveused it to understand intimate partner violence and abuse of the elderly .25 26. www.SlideShare.net/AhmedRefat The model explores the relationship betweenindividual and contextual factors and considersviolence as the product of multiple levels of influence on behavior26 27. www.SlideShare.net/AhmedRefat 1- IndividualThe first level of the ecological model seeks toidentify the biological and personal history factorsthat an individual brings to his or her behaviour. Inaddition to biological and demographic factors,factors such as impulsivity, low educationalattainment, substance abuse, and prior history ofaggression and abuse are considered. This level offocuses on the characteristics of the individual thatincrease the likelihood of being a victim or aperpetrator of violence.27 28. www.SlideShare.net/AhmedRefat2- Relationship The second level explores how proximal social relationships for example, relations with peers, intimate partners and family members increasethe risk for violent victimization and perpetration ofviolence. In the cases of partner violence and childmaltreatment, for instance, interacting on an almost daily basis or sharing a common domicile with anabuser may increase the opportunity for violentencounters. 28 29. www.SlideShare.net/AhmedRefatBecause individuals are bound together in a continuing relationship, it is likely in these casesthat the victim will be repeatedly abused by theoffenderIn the case of interpersonal violence among youths, research shows that young people are much morelikely to engage in negative activities when those behaviours are encouraged and approved by theirfriends . Peers, intimate partners and familymembers all have the potential to shape anindividuals behaviour and range of experience.29 30. www.SlideShare.net/AhmedRefat 3- CommunityThe third level of the ecological model examines thecommunity contexts in which social relationshipsare embedded such as schools, workplaces andneighbourhoods and seeks to identify thecharacteristics of these settings that are associatedwith being victims or perpetrators of violence.31 31. www.SlideShare.net/AhmedRefatA high level of residential mobility (where people donot stay for a long time in a particular dwelling, butmove many times), heterogeneity (highly diversepopulation, with little of the social glue thatbinds communities together) and high populationdensity are all examples of such characteristics andeach has been associated with violence. 31 32. www.SlideShare.net/AhmedRefat4- SocietalThe fourth and final level of the ecological modelexamines the larger societal factors that influencerates of violence. Included here are those factorsthat create an acceptable climate for violence, thosethat reduce inhibitions against violence, and thosethat create and sustain gaps between differentsegments of society or tensions between different32 33. www.SlideShare.net/AhmedRefatgroups or countries. Larger societal factors include: cultural norms that support violence as anacceptable way to resolve conflicts; attitudes that regard suicide as a matter ofindividual choice instead of a preventable actof violence; norms that give priority to parental rightsover child welfare;33 34. www.SlideShare.net/AhmedRefat norms that entrench male dominance overwomen and children; norms that support the use of excessive forceby police against citizens; norms that support political conflict.Larger societal factors also include the health,educational, economic and social policies thatmaintain high levels of economic or social inequalitybetween groups in society34 35. www.SlideShare.net/AhmedRefatHow can violence be prevented?The first two steps of the public health modelprovide important information about populationsrequiring preventive interventions, as well as on therisk and protective factors that need addressing.Putting this knowledge into practice is a central goalof public health.35 36. www.SlideShare.net/AhmedRefat Types of preventionPublic health interventions are traditionallycharacterized in terms of three levels of prevention:. Primary prevention approaches that aim toprevent violence before it occurs.. Secondary prevention approaches that focuson the more immediate responses to violence,such as pre-hospital care, emergency services36 37. www.SlideShare.net/AhmedRefator treatment for sexually transmitted diseasesfollowing a rape.. Tertiary prevention approaches that focus onlong-term care in the wake of violence, such asrehabilitation and reintegration, and attemptsto lessen trauma or reduce the long-termdisability associated with violence. 37 38. www.SlideShare.net/AhmedRefatThese three levels of prevention are defined bytheir temporal aspect whether prevention takesplace before violence occurs, immediatelyafterwards or over the longer term. Althoughtraditionally they are applied to victims of violenceand within health care settings, secondary andtertiary prevention efforts have also been regardedas having relevance to the perpetrators of violence,and applied in judicial settings in response toviolence.38 39. www.SlideShare.net/AhmedRefatResearchers in the field of violence preventionhave increasingly turned to a definition of preventionthat focuses on the target group of interest. Thisdefinition groups interventions as follows 1. . Universal interventions 2. . Selected interventions 3. . Indicated interventions 39 40. www.SlideShare.net/AhmedRefat. Universal interventions approaches aimed atgroups or the general population without regard to individual risk; examples includeviolence prevention curricula delivered to allstudents in a school or children of a particularage and community-wide media campaigns. 41 41. www.SlideShare.net/AhmedRefat. Selected interventions approaches aimed atthose considered at heightened risk forviolence (having one or more risk factors for violence); an example of such an intervention is training in parenting provided to lowincome, single parents. 41 42. www.SlideShare.net/AhmedRefat. Indicated interventions approaches aimed at those who have already demonstrated violentbehaviour, such as treatment for perpetrators of domestic violence.42 43. www.SlideShare.net/AhmedRefat Multifaceted responsesBecause violence is a multifaceted problem withbiological, psychological, social and environmentalroots, it needs to be confronted on several differentlevels at once. The ecological model serves a dualpurpose in this regard: each level in the modelrepresents a level of risk and each level can also bethought of as a key point for intervention.43 44. www.SlideShare.net/AhmedRefatDealing with violence on a range of levelsinvolves addressing all of the following:. Addressing individual risk factors and takingsteps to modify individual risk behaviours.. Influencing close personal relationships andworking to create healthy family environments,as well as providing professional help andsupport for dysfunctional families.44 45. www.SlideShare.net/AhmedRefat. Monitoring public places such as schools,workplaces and neighbourhoods and takingsteps to address problems that might lead toviolence.. Addressing gender inequality, and adversecultural attitudes and practices.. Addressing the larger cultural, social andeconomic factors that contribute to violence45 46. www.SlideShare.net/AhmedRefatand taking steps to change them, includingmeasures to close the gap between the rich andpoor and to ensure equitable access to goods,services and opportunities. 46 47. www.SlideShare.net/AhmedRefatActions against violence at all levelsLong-term successes in the prevention of violencewill increasingly depend on comprehensiveapproaches at all levels. 1. Local 2. National 3. Global47 48. www.SlideShare.net/AhmedRefat1- Local levelAt the local level, partners may include health careproviders, police, educators, social workers,employers and government officials. Much can bedone here to promote violence prevention. Smallscale pilot programmes and research projects canprovide a means for ideas to be tried out and perhaps as important for a range of partners to 48 49. www.SlideShare.net/AhmedRefatbecome used to working together. Structures suchas working groups or commissions that drawtogether the different sectors and maintain bothformal and informal contacts are essential for thesuccess of this type of collaboration. 49 50. www.SlideShare.net/AhmedRefat2- National levelMultisectoral partnerships are highly desirable atthe national level as much as at the local level. Avariety of government ministries and not onlythose concerned with law enforcement, socialservices and health have important contributionsto make in preventing violence.51 51. www.SlideShare.net/AhmedRefatEducation ministriesare obvious partners, given the importance ofintervening in schools. Ministries of labour can domuch to reduce violence in the workplace,especially in collaboration with trade unions andemployers .51 52. www.SlideShare.net/AhmedRefatDefence ministries can positively shape theattitudes towards violence of large numbers ofyoung men under their control, by encouragingdiscipline, promoting codes of honour, andimpressing a strong awareness of the lethalness ofweapons. 52 53. www.SlideShare.net/AhmedRefatReligious leaders and organizations have a role toplay in their pastoral work and, in appropriate cases,by offering their good offices to mediate in specificproblems.53 54. www.SlideShare.net/AhmedRefat 3- Global levelAs has been shown, for instance, in the internationalresponse to AIDS and in the field of disaster relief,cooperation and exchange of information betweenorganizations globally can produce significantbenefits in the same way as partnerships at thenational and local levels. The World HealthOrganization clearly has an important global role54 55. www.SlideShare.net/AhmedRefatto play in this respect as the United Nations agencyresponsible for health. Other international agencies,though, also have a considerable amount to offer intheir specialized fields. These include the Office ofthe United Nations High Commissioner for HumanRights (in relation to human rights), the Office ofthe United Nations High Commissioner for Refugees55 56. www.SlideShare.net/AhmedRefatRefugees (refugees), the United Nations ChildrensFund (childrens well-being), the United NationsDevelopment Fund for Women and the UnitedNations Population Fund (womens health), theUnited Nations Development Programme (humandevelopment), the United Nations InterregionalCrime and Justice Research Institute (crime) andthe World Bank (financing and governance), to 56 57. www.SlideShare.net/AhmedRefatname just a few. A variety of international donors,bilateral programmes, nongovernmentalorganizations and religious organizations arealready involved in violence prevention activitiesaround the world57 58. www.SlideShare.net/AhmedRefatPublic health ApproachThe principles of public health provide a usefulframework for both continuing to investigate andunderstand the causes and consequences ofviolence and for preventing violence from occurringthrough primary prevention programmes, policyinterventions and advocacy.58 59. www.SlideShare.net/AhmedRefatThe activities of VPA are guided by the scientifically-tested and proven principles and recommendationsdescribed in the World report on violence andhealth.This public health approach to violence preventionseeks to improve the health and safety of allindividuals by addressing underlying risk factors thatincrease the likelihood that an individual will becomea victim or a perpetrator of violence.59 60. www.SlideShare.net/AhmedRefatThe approach consists of four steps: 1. To define the problem through the systematiccollection of information about the magnitude,scope, characteristics and consequences ofviolence. 2. To establish why violence occurs usingresearch to determine the causes and correlatesof violence, the factors that increase or decreasethe risk for violence, and the factors that could bemodified through interventions. 61 61. www.SlideShare.net/AhmedRefat3. To find out what works to prevent violence by designing, implementing and evaluating interventions.4. To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.61 62. www.SlideShare.net/AhmedRefatPublic Health Approach1. Define the health problem.2. Identify risk factors associated with the problem.3. Develop and test community-level interventions to control or prevent the cause or the problem.4. Implement interventions to improve the health of the population.5. Monitor those interventions to assess their effectiveness. 62 63. www.SlideShare.net/AhmedRefat63 64. www.SlideShare.net/AhmedRefatHaddon MatrixHaddons Matrix is a brainstorming tool that combinesthe epidemiology triangle (host, agent, environment)and levels of prevention.64 65. www.SlideShare.net/AhmedRefatStructureHaddons Matrix consists of the following fourcolumns and three rows.Columns 1. The Host refers to the person at risk . 2. The Agent . 3. The Physical Environment includes all the characteristics of the setting in which the injury event takes place .65 66. www.SlideShare.net/AhmedRefat4. The Social Environment refers to the social and legalnorms and practices in the culture and society at the timeRows1. Pre-injury event phase / Primary prevention..2. Injury event phase / Secondary prevention..3. Post injury event phase / Tertiary prevention(Treatment and Rehabilitation).. 66 67. www.SlideShare.net/AhmedRefat67 68. www.SlideShare.net/AhmedRefat Host /AgentPhysicalSocial person ffectedor vehicle environmentenvironmentReliance onCar design & Driving skill; private, ratherPre-event handling; Time pressures than publicAnti-lockRoad design;( primary (in a rush to get brakes, etc;Speed limitstransportationprevention)home?);raises traffic load; Maintenance of Inebriated? Compliance with car seatbelt lawsDuring the Quality of Air bagsWeather emergencyevent Wearingworking? conditions;assistance;( secondaryseatbelt?Size of car &ice on road? Assistance from crash resistanceprevention) bystandersAbility to callPost-event for helpEmergencyContinued funding Tendency of car( tertiary (phone to catch on firevehicle access to for emergencyprevention)available?); collision siteservices Knows first aid? 68 69. www.SlideShare.net/AhmedRefat Haddons CountermeasuresHaddon also proposed a generic sequence of 10 countermeasuresto reduce the risk of injuries. This can be applied to many types ofevents or injuries, and it also covers prevention in general. 69 70. www.SlideShare.net/AhmedRefatHere we have applied it to smoking:Example (reducing smoking-Countermeasurerelated diseases)1. Prevent the creation of the Eliminate cigaretteshazard2. Reduce the amount of hazard Reduce tobacco growing bybrought into beingchanging agricultural policies3. Prevent the release of theForbid tobacco sales to minorshazard4. Modify rate of release of the Develop cigarette that burnshazardslowly5. Separate hazard from personLimit times that vending machinesbeing protected by time and spaceare open 71 71. www.SlideShare.net/AhmedRefat6. Separate hazard from personbeing protected by a physicalFilters on cigarettesbarrier7. Modify basic qualities of the Reduce nicotine content ofhazard cigarettesLimit exposure to synergistic8. Make what is to be protected causes (e.g., environmentalmore resistant to hazardcarcinogens)Screening program to detect early9. Counter damage done by hazardcancersProvide good health care for10. Stabilize, and repair damage cancer patients71 72. www.SlideShare.net/AhmedRefat72 73. www.SlideShare.net/AhmedRefatCited References http://www.health.qld.gov.au/chipp/what_is/e_of_injury.asphttp://www.health.qld.gov.au/chipp/what_is/matrix.asphttp://www.med.uottawa.ca/sim/data/Injury_Prevention_Haddon_e.htmhttp://www.who.int/violence_injury_prevention/violence/world_report/en/73