First European Conference on Injury Prevention and Safety Promotion, 25-27 June 2006, Vienna

Early family violence: from data to action

Dr Dinesh Sethi, Dr Inge Baumgarten, Ms Francesca Racioppi Violence and Injury Prevention ProgrammeWHO European Centre for Environment and HealthRome, Italy

Purpose of presentation to:

• Define family violence

• Frame family violence within the overall problem of injuries and violence in the European Region

• Review data available for family violence

• Highlight East-West differences

• Review risk factors for family violence

• Discuss policy options to convert data to action

Problem definition

• Political and economic transition have increased injuries and violence in the east of the Region.

• Unintentional injuries and violence are a leading cause of death and disability, especially in people under the age 45 years in WHO EUR

• Family violence arises in the family between members and can manifest as child abuse, intimate partner violence and elder abuse.

• Family violence is often hidden but endemic in all societies and the prevalence is high

• Like all forms of violence it is amenable to prevention using the public health approach

• Important to consider family violence because of the intergenerational nature of violence

Interpersonal violence typology

InterpersonalInterpersonal

Family/partnerFamily/partnerFamily/partnerFamily/partner

Nature of violence

PhysicalPhysicalPhysicalPhysical

SexualSexualSexualSexual

PsychologicalPsychologicalPsychologicalPsychological

Deprivation or neglectDeprivation or neglectDeprivation or neglectDeprivation or neglect

SiblingSiblingSiblingSibling AcquainAcquaintancetance

AcquainAcquaintancetance StrangerStrangerStrangerStranger

CommunityCommunityCommunityCommunity

ElderElderElderElderPartnerPartnerPartnerPartnerChildChildChildChild

“Violence is the intentional use of physical force or power, threatened or actual, against oneself (self-harm/suicide), another person (interpersonal violence), or against a group or community (collective violence) that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” World report on violence and health, WHO 2002

Definition of violence

Rank 0-4 years 5-14 years 15-29 years 30-44 years 45-59 years 60+ years TOTAL

Lower respiratory infections

Road traffic injuries Road traffic injuries Ischaemic heart disease Ischaemic heart disease Ischaemic heart disease Ischaemic heart disease 1

31971 4691 37994 52052 253018 2064108 2373141

Low birth weight Lower respiratory

infections Self-inflicted injuries Self-inflicted injuries Cerebrovascular disease Cerebrovascular disease Cerebrovascular disease

2 26707 3793 32327 44830 106943 1309057 1447010

Birth asphyxia and birth trauma

Drownings Violence Poisonings Trachea, bronchus, lung

cancers Trachea, bronchus, lung

cancers Trachea, bronchus, lung

cancers 3 20258 2863 15679 32292 78321 276456 365351

Congenital heart anomalies

Leukaemia Poisonings Road traffic injuries Cirrhosis of the liver Chronic obstructive pulmonary disease

Lower respiratory infections 4

13130 1766 12051 31551 59089 238855 280883

Diarrhoeal diseases Self-inflicted injuries Drownings Violence Self-inflicted injuries Lower respiratory

infections Chronic obstructive pulmonary disease 5

11827 1597 8342 24645 43054 203298 260605

Meningitis* Childhood-cluster

diseases War Cerebrovascular disease Poisonings Colon and rectum cancers Colon and rectum cancers

6 9313 860 7810 24023 41517 193507 229083

Childhood-cluster diseases

Cerebrovascular disease Tuberculosis Cirrhosis of the liver Breast cancer Hypertensive heart

disease Hypertensive heart

disease 7 4913 848 7099 22949 38097 157267 179849

Upper respiratory infections

Poisonings Cerebrovascular disease Tuberculosis Colon and rectum cancers Stomach cancer Cirrhosis of the liver 8

2517 810 5266 22445 29247 123319 170600

Drownings Violence Lower respiratory

infections HIV/AIDS

Lower respiratory infections

Diabetes mellitus Self-inflicted injuries 9

1817 765 4941 18675 27532 122667 163878

Road traffic injuries Epilepsy HIV/AIDS Breast cancer Stomach cancer Alzheimer and other

dementias* Stomach cancer

10 1698 687 4193 11076 26786 101353 157717

Endocrine disorders Congenital heart

anomalies Falls Drownings Road traffic injuries Breast cancer Breast cancer

11 1309 674 3914 10127 23958 100570 150116

Spina bifida Falls Ischaemic heart disease Trachea, bronchus, lung

cancers Tuberculosis Prostate cancer Diabetes mellitus

12 1176 610 3905 10000 21095 89331 141454

Poisonings Lymphomas, multiple

myeloma Leukaemia

Lower respiratory infections

Violence Cirrhosis of the liver Road traffic injuries 13

1024 567 3637 9347 20036 85336 126546

Fires Meningitis* Drug use disorders Inflammatory heart

diseases Inflammatory heart

diseases Pancreas cancer Poisonings

14 976 554 3527 9299 19351 70212 109870

Cerebrovascular disease Fires Cirrhosis of the liver Drug use disorders Hypertensive heart

disease Inflammatory heart

diseases Alzheimer and other

dementias* 15 872 551 2848 8417 18280 68891 105264

Interpersonal violence is among top 15 death causes in European Region, 2002.

The magnitude of interpersonal violence

• In 2002 a registered 73 000 people of all ages and both sexes were killed by interpersonal violence in the WHO European Region

• The difference in the magnitudeof violence in the Region is striking

• More males in the region arevictim to interpersonal violence resulting in death or serious injury

• Males are also more likelyto be the perpetrators of violence - both against menand women

• A significant proportion of the violent deaths are due to family violence

<= 30

<= 24

<= 18

<= 12

<= 6

No data

Min = 0

SDR, Homicide and assault, per 100000

Lastavailable

European Region6.88

(Source: HFA MDB)

1. Infanticide and child abuse in the European Region

0

0.5

1

1.5

2

1980 1985 1990 1995 2000 2005

European RegionEU CIS

SDR(0-14), Homicide and assault, per 100000

1,500 (11%) of 27,900 deaths in children under 15 are due to violence

The likelihood of child homicide in CIS is three times that in the EU

The majority of these deaths are due to child abuse

Child abuse: Prevalence and risk factors

• 5-8% life time prevalence of severe physical punishment• Sexual victimisation 20% in women and 5-10% in men• Child sex trade: 75 000 children in Eastern EuropeRisk factors• Sex abuse more common post puberty• Female perpetrate physical abuse and when males do

this more likely to be fatal• Poor, single parent, low education, substance misuse,

isolation, unemployment• Previous history of abuse• In relationships where there is domestic violence• Poverty, lack of social capital• IN UK homicide is 5.9 times higher in lowest social class

children than in highest

Health and social consequences of adverse childhood experiences 18000 participants, USA

Definition: Experiences that represent medical and social problems of national importance -childhood abuse and neglect, growing up with domestic violence, substance abuse or mental illness in the home, parental loss, or crime

Findings: Psychological by parents 11%, Physical 11%Sexual (anyone) 22%Domestic violence 13%, substance abuse 26%, mental illness 19%

Contribution of the Adverse Childhood Experiences (ACE) Study

Childhood Experiences vs. Adult Alcoholism

0

2

4

6

8

10

12

14

16

18

% A

lco

ho

lic

ACE Score

1

23

4+

0

Associations found between Adverse Childhood Experience and risk factors of behaviour affecting adult health: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, substance misuse, 50+ sexual partners

Child abuse and prevention

• Parent training and home visitation: € 1 spent saves € 19

• Therapeutic treatment of violent parents

• Training of health professionals, teachers, police

• Better laws against violence in the home and physical punishment, mandatory reporting of child abuse

2: Intimate partner violence

GEO

TKM

KGZ

KAZ

BUL

MDAUKR

RUS

BLR

LTU

ISRBEL

EST

ALB

MKDSCGSVN

HUNAUT

SWI

NETLUXUNKFRA

DEU

IRE

FINDENSWE

NOR

ICESPA

MAT

POR

ITA

GRE

CZH

POL

SVK

CRO

ROM

AZE

UZB

LVA

ARM

0

2

4

6

8

10

12

14

16

18

20

SD

R p

er 1

00,0

00 p

opul

atio

n

Nordic West Euro South Euro Central Euro South-East Euro Baltics N-W CIS South CIS

Mortality rates for interpersonal violence in females aged 30–44 by country and sub-region in the WHO European Region, 2002

(Source: HFA-MDB)

5200 deaths from violence in the European Region: 40-70% of murders due to intimate partner

The WHO Multi-country Study on Women’s Health

and Domestic Violence against Women

• First-ever WHO global study on domestic violence against women

• Collecting data from over 24,000 women in ten countries

• Documenting the prevalence of intimate partner violence and its association with women's physical, mental, sexual and reproductive health

• Lifetime prevalence of physical assault is 10-60%

Country example – Serbia and Montenegro

Violence against women is invisible

• 27% of physically abused women told no one about the violence

• 78% of physically abused women had never asked any formal agency for help

• Two thirds of physically abused women did not seek help because they thought such abuse “normal” or not serious enough to seek help

I suffered a long time and

swallowed my pain. That is why I am

constantly visiting doctors and using

medicines. No one should have to do

this.

Woman interviewed in Serbia &

Montenegro

Risk factors and what works for prevention

Risk factors– History of violence, poor parenting, witnessing abuse, harmful

alcohol use and poor educational attainment– Low income, poverty, overcrowding, disagreements about

money– Societies with rigid gender roles, inequalities between men and

women, concentrations of poverty, alcohol and substance misuse

• Prevention– Attitudes and behaviours, anger management– Relationship skills and family therapy– Stimulating community action, providing services and training

professionals– Poverty reduction and alcohol misuse policies

3. Elder abuse• Acts of commission or omission causing

harm– !n 2002, 11090 people over 60 murdered in

Region– Proportion attributed to elder abuse not known– 4-6% older people; higher in institutions

• Risk factors– Alcohol, substance misuse, personality

problems– Strained family relations, financial dependence– Lack of social support networks– Institutions geared to own rather than elderly

interests

How can we prevent elder abuse

– Training of care givers, comprehensive care plans, care environments

– Help lines, shelters, strengthening health, social and volunteer services

– Educational campaigns to change public attitudes

– Training professionals in health, justice, social sectors

– NGOs, self help groups, – Strengthening legal and policy frameworks to

protect elders– More research needed

Sibling violence

Child maltreatment

Intimate partner violence

Elder abuse

Links between types of violence

Shared risk factors (alcohol, substance abuse,

parental loss, social isolation, mental illness, household poverty, crime, norms condoning violence

inequalities)

Life course approach to violence prevention

Risk factors - ecological model Risk factors - ecological model

IndividualRelationshipCommunitySocietal

Examples• Demographic factors• Psychological and personality disorders• History of violent behaviour• Experienced abuse

Examples:• Poor parenting• Marital conflict• Friends who engage in violence

Examples:• Concentration of poverty• High residential mobility• High unemployment• Social isolation• Local illicit drug trade

Examples:• Inequalities• Norms that support violence• Availability of means• Weak police/criminal justice•Alcohol

WHO Violence Prevention Programme

1. National action plan for violence prevention

2. Enhance data collection3. Priorities for research on causes,

consequences, costs and prevention4. Promote primary prevention 5. Strengthen responses for victims 6. Integrate prevention into social and

educational policies7. Increase collaboration and

exchange of information on prevention

8. Adherence to international treaties, laws etc to protect human rights

9. Internationally agreed responses to the global drugs and arms trade

What can we do to decrease the burden of injuries?

•Prevent violence against children to break the cycle of violence •Prioritise programmes aimed at primary prevention:

•parental training/ support programmes, •school based prevention programmes•societal factors as alcohol, poverty

•Shift away from abrogating responsibility to individuals and undertake violence prevention as a societal responsibility•Recognise health sectors’ key role in developing a comprehensive societal response to violence prevention.•Foster multi-sectoral, comprehensive approaches that will enforce human rights, gender equality, and public health concerns to create safer environments for society’s vulnerable

WWW.EURO.WHO.INT/VIOLENCEINJURY

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How do we get there – other international initiatives

WHA and UN resolutions on violence as a public health problem and implementing the WRVHRegional Committee Resolution EUR/RC55/R9 on Prevention of injuries in the WHO European Region•Ministry of Health Focal Points – there is at least one FP in 49 countries. •Global Strategy for Child Injury Prevention 2006•World and European Reports on Child Injury Prevention (2008)•UNICEF - Regional consultations on injuries and violence against children•UN secretary-general’s study on violence against children and violence against women

The Public Health Approach

Problem Response

Describe theproblem

Identify causes

Develop & evaluate

interventions

Implement &Disseminate

• Population-based

• Emphasis primary prevention

• Multidisciplinary and Multi-sectoral

• Science based

0

5

10

15

20

25

0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+

Age group

Males

Females

Rate

s per

10

0,0

00 p

opula

tion

Age- and gender-specific mortality rates from interpersonal violence in European Region, 2002

Deaths are tip of the iceberg: psychological, physical and sexual damage and neglect. Not captured by routine data.