The Role of Evidence Based Policy Development in the Prevention of Child Maltreatment Dr Dinesh Sethi
Programme Manager Violence and Injury Prevention Division of Noncommunicable Diseases and Life-Course
Outline • Definition of violence • Links between different types of violence • Life course approach and childhood adversity • Focus on preventing maltreatment and adversity in Europe
Definition of violence 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, maldevelopment or deprivation.
The 4 steps of the public health approach
1.Define & describe What is the Problem?
4. Scaling up and cost-effectiveness Implement on largescale & cost
2.Identify risk What are the risk factors and causes?
3.Develop and evaluate interventions What works and for whom?
Scope and magnitude 160 000 deaths per year Violence
Self-directed
Interpersonal
Collective
78% of deaths
20% of deaths
2% of deaths
Why action needs to be focused on children? •
Childhood and adolescence are periods of vulnerability
•
Childhood is a period of exploration with increased exposure to risks
•
Neurodevelopmental, cognitive and behaviourial changes are happening
•
Exposure to adversity in childhood may result in mental trauma and health harming behaviour
•
Physical, family and social environments need to be modified to ensure safety for children Photo: Bigstockphoto
Consequences: life-long & far-reaching
Child maltreatment is a common and leading public health problem throughout Europe • Worse mental and physical health and social outcomes • Cause of inequity and social injustice • Costs society billions of Euros • Contributes to ‘cycles of violence’ through the life-course • Report offers framework for violence prevention
There is a mortality gap • 850 deaths • Peaked with economic and political transition in eastern Europe • Declining but still higher • 71% deaths in LMIC • Deaths tip of iceberg
Homicide rates children under 15 years
Risk forwithin child maltreatment …andfactors a divide countries
Reliable data are needed
Availablity
High
Low
Child maltreatment is a hidden form of violence in the Region Types of abuse and neglect Sexual abuse Physical abuse Emotional abuse Physical neglect Emotional neglect
Prevalence 9.6% 22.9% 29.1% 16.3% 18.4%
Children maltreated 18 million 44 million 55 million 31 million 35 million
Adverse Childhood Experience Study • Developed in USA
• 17,000 middle-aged adults • Ten ACEs • Examine ACEs, risky behaviours and adult health status
Child Abuse
• Coping strategy for childhood trauma as underlying cause of disease
Physical abuse Sexual abuse Emotional neglect Physical neglect
Family Dysfunction
• Relationship between obesity and child abuse
Emotional abuse
Substance use Mental illness Incarceration Mother treated violently Parental separation/divorce
Consequences are far reaching: long-term effects of ACEs Death ACEs are fundamental risk factors for disease and early death
Early Death Disease, Disability and Social Problems Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment
Conception Source: CDC (2010).
Adverse Childhood Experiences Toxic Stress
Risk factors for child maltreatment • Young/single parents • Mental ill health • Substance abuse • Perpetrator abused • Externalising problems • Child disability
• Socioeconomic disadvantage • Poor social capital • Availability of alcohol and drugs
Societal
Community
Relationship
Individual
• Family conflict
• Norms that support violence
• Weak legislation for abuse • Economic stress • Societal conflict
• Domestic violence • Poor parenting • Large family size • Low socioeconomic • Non-biological parent
Shared risk factors: alcohol, substance abuse, parental loss, crime, mental illness, social isolation, household poverty, norms condoning violence, access to weapons, inequalities,…
Where prevention can work Prevention before occurrence
Prevention of recurrence Physical abuse Sexual abuse Emotional abuse Neglect Exposure to IPV
Prevention of impairment
Long-term outcomes
(Adapted from MacMillan et al., 2009)
What works for prevention? • • • • • • • • • • • •
Nurse Family Partnerships Positive parenting Multi-component pre-school programmes Life skills and vocational training Training for abusive head trauma Changing social norms Reduce availability of alcohol Reduced poverty Preventing exposure to domestic violence Improve school settings Reduce access to lethal means Reduce inequality and job creation programmes
Evidence of effectiveness according to a recent review in the Lancet • Home-visiting programmes are not uniformly effective in reducing child physical abuse; those that have shown benefits are the Nurse Family Partnership and Early Start. • The Triple P—Positive Parenting Program—has shown positive effects on maltreatment and associated outcomes. • Hospital-based educational programmes to prevent abusive head trauma show promise but require further assessment. • School-based educational programmes to prevent child sexual abuse improve children’s knowledge and protective behaviours; whether they prevent sexual abuse is unknown. (MacMillan et al., 2009)
Benefit-cost results for early childhood programmes
The "Triple-P" • Prevention strategies across different levels – media messages on positive parenting – informational resources – short targeted interventions for specific behaviour – more intensive parent training programmes – addressing broader family issues
Protective factors that reduce the risks of child maltreatment •
High levels of social capital and strong social networks
•
Supportive family environment
•
Strong parent-child and parental relationships
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Nurturing parenting skills
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Parental employment
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Higher parental education
•
Parental self-esteem
•
Lack of parental support for corporal punishment
•
Child social competence
Implementation of evidence-based interventions in WHO EURO
Areas for action • Data linkage of routine information from health, social, justice and education • Requirement for training, both for prevention as well as detection and reporting • Need to shift focus from culpability to prevention • How do we address parental problems before they become too severe - Proactive role for GPs, paediatricians, teachers, others • Improve research on what is the best for whom for both out of home care interventions and social welfare interventions
Life Course
• Physical injury • Health problems • Behavioural problems • Poor social development • Poor school performance • Substance use • Delinquency and crime • Violence • Unemployment • Poor mental health • Risky sexual behaviour • Obesity • Diabetes • Heart disease • Cancer • Suicide attempt • Premature mortality
Global and European policy developments • UN Convention on the Rights of the Child 1989 • WHA resolution on implementing the recommendations of the World report on violence and health 2003 • WHA resolution on Strengthening the role of the health system in addressing violence, in particular against women and girls, and children 2014 • WHO Regional Committee for Europe Child Maltreatment Prevention Action Plan for consideration in September 2014
Child maltreatment prevention action plan will be discussed for adoption at the 64th WHO Regional Committee for Europe • Develop multisectoral national policy • Implement prevention programmes • Strengthen health systems’ response • Build capacity & exchange good practice • Improve data collection and research • Advocate for investment in best buys • Address equity Health 2020: opportunities for policy makers to act with prevention
Objective 1 of action plan: Make child maltreatment more visible by setting up information systems • Outcomes – Publish comprehensive reports – Participate in standardised surveys
• Indicators – Countries that routinely measure incidence and prevalence of child maltreatment – Surveys- ICAST, ACE, HBSC, Adult GHS – Number countries with comprehensive reports – Surveys of child mental well being
Objective 2 of action plan: promote governance for preventing child maltreatment and intersectoral action • Outcomes – Prepare and review existing plans – Develop multisectoral plans that are linked to socioeconomic determinants and other policy areas
• Indicators – Countries with comprehensive and inclusive plans
Objective 3 of plan: Reduce risks for child maltreatment and consequences by strengthening health systems • Outcomes – Nurse Family Partnerships – Positive parenting – Training for abusive head trauma – Training of health and other professionals – Changing social norms /Reduce availability of alcohol/ Reduced poverty/ Preventing exposure to domestic violence – Rehabilitation for victims / Early detection and response
• Indicators – Number of countries implementing universal and targeted measures – Number of countries undertaking capacity building
Conclusions • Importance of early life – Health harming and anti-social behaviour – Mental ill health and non-communicable disease – Cost-effective & lifetime benefits – ACE levels are changing • Common risk factors between different types of violence • Widening the evidence base for what works – Midwifery, contraception, education – Mental health & well being – Alcohol & drugs services – Population interventions
Thank you
http://euro.who.int/child-maltreatment-report Photo: Bigstockphoto