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Public Health Policy for Preventing Violence

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Abstract and Figures

The current epidemic of violence in America threatens not only our physical health but also the integrity of basic social institutions such as the family, the communities in which we live, and our health care system. Public health brings a new vision of how Americans can work together to prevent violence. This new vision places emphasis on preventing violence before it occurs, making science integral to identifying effective policies and programs, and integrating the efforts of diverse scientific disciplines, organizations, and communities. A sustained effort at all levels of society will be required to successfully address this complex and deeply rooted problem. PIP Violence is a major contribution to premature death, disability, and injury. In America, there is an epidemic of violence, which threatens not only the physical health, but also the integrity of basic social institutions such as the family, the communities, and the health care system of the public. In this paper, the new vision for violence prevention embodied in the public health approach is discussed. It shifts the focus of the society in the way violence is addressed, from reacting to the problem to changing the social, behavioral, and environmental factors that cause violence. The emphasis is on preventing violence before it occurs, making science integral in identifying effective policies and programs, and integrating the efforts of diverse scientific disciplines, organizations, and communities. A sustained and coordinated effort to prevent violence will be necessary at all levels of society to address this complex and deeply rooted problem.
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Policy
At the Intersection of Health, Health Care and
doi: 10.1377/hlthaff.12.4.7
, 12, no.4 (1993):7-29Health Affairs
Public health policy for preventing violence
Broome and W L Roper
J A Mercy, M L Rosenberg, K E Powell, C V
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PUBLIC HEALTH
POLICY FOR
PREVENTING
VIOLENCE
by James A. Mercy, Mark L. Rosenberg, Kenneth E.
Powell, Claire V. Broome, and William L. Roper
Prologue: In October 1985 Surgeon General C . Everett Koop
convened his Workshop on Violence and Public Health, which
signaled public health’s entry into the field of violence preven-
tion. Koop culled on public health professionals to “repond con-
structively to the ugly facts of interpersona1 violence. During
the past decade the involvement of the Department of Health
and Human Services in violence prevention research and pro-
grams has expanded, culminating in the formation of the Na-
tional Center for Injury Prevention and Control in 1991 as
part of the Centers for Disease Control and Prevention
(CDC). Despite much progress, however, stark reminders sur-
face daily in the news media that much remains to be done.
President Clinton, introducing his health reform plan to Con-
gress 22 September 1992, invoked “the outrageous costs of vio-
lence in this country” as an urea his administration is commit-
ted to addressing. “The problem of violence in America did not
appear overnight, this paper states, “nor will it disappear sud-
denly. A sustained and coordinated effort . . . will be necessary
at all levels of society to address this complex and deeply rooted
problem.” The authors either are or have been affiliated with
the new National Center for Injury Prevention and Control in
Atlanta. James Mercy is acting director of the center’s Division
of Violence Prevention. Murk Rosenberg is acting associate di-
rector for public health practice at the center. Ken Powell is act-
ing associate director for science in the Division of Violence Pre-
vention and leads the division’s Youth Violence Prevention
Team. At the time this paper was written, Claire Broome was
acting director of the center. William Roper, who was director
of the CDC when the violence prevention program achieved na-
tional prominence, is now president of the Prudential Center
for Health care Research.
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8 HEALTH AFFAIRS | Winter 1993
Abstract: The current epidemic of violence in America threatens not only our physical health bu t
also the integrity of basic social institutions such as the family, the communities in which we live,
and our health care system. Public health brings a new vision of how Americans can work together
to prevent violence. This new vision places emphasis on preventing violence before it occurs, making
science integral to identifying effective policies and programs, and integrating the efforts of diverse
scientific disciplines, organizations, and communities. A sustained effort at all levels of society will
be required to successfully address this complex and deeply rooted problem.
Anew vision for how Americans can work together to prevent the
epidemic of violence now raging in our society has emerged from
the public health community. This vision arises from the recogni-
tion that, by any measure, violence is a major contributor to premature
death, disability, and injury. Fundamental to this vision is a shift in the way
our society addresses violence, from a focus limited to reacting to violence
to a focus on changing the social, behavioral, and environmental factors that
cause violence. From a public health perspective, effective policies for
preventing violence must be firmly grounded in science and attentive to
unique community perceptions and conditions. Scientific research provides
information essential to developing such policies and prevention strategies
and methods for testing their effectiveness. Equally critical is the full
participation of communities to engender a sense of ownership of this
problem and its solutions. Public health seeks to empower people and their
communities to see violence not as an inevitable consequence of modern
life but as a problem that can be understood and changed.
In this paper we discuss the new vision for violence prevention embodied
in the public health approach. We begin by presenting epidemiologic
documentation of the full scope of this health problem and its impact on
specific subgroups in our society. Next we discuss public health contribu-
tions to violence prevention that address deficits in our society’s current
response to this problem. We then present priorities for public health
analysis and action. We conclude by advancing some principles, based on
the public health vision, that are intended to serve as guidelines for forming
and implementing public policy.
Impact Of Interpersonal Violence On The Public’s Health
Interpersonal violence can be defined as threatened or actual use of
physical force against a person or a group that either results or is likely to
result in injury or death. Public health approaches violence as a health issue
and consequently uses injuries-both fatal and nonfatal, psychological and
physical–to quantify the impact of violence.
On an average day in the United States, sixty-five people die from and
more than 6,000 people are physically injured by interpersonal violence.1
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PREVENTING VIOLENCE 9
The violent acts appear to be occurring with greater frequency and severity
in our society. In fact, the 1980s were arguably the most violent decade of
this century, if not in U.S. history. More than 215,000 people died and
twenty million more suffered nonfatal physical injuries from violence.2
Violence also exacts a huge economic toll. The average annual financial
costs of medical and mental health treatment, emergency response, produc-
tivity losses, and administration of health insurance and disability payments
for the victims of assaultive injuries occurring from 1987 to 1990 were
estimated at $34 billion, with lost quality of life costing another $145
billion.3 These grim statistics obscure the disproportionate impact of vio-
lence on specific subgroups within our society-most notably, young men,
women and children, and the poor.
Youth and violence. Young people are disproportionately represented
among the perpetrators of violence. Arrest rates for homicide, rape, rob-
bery, and aggravated assault in the United States peak among older adoles-
cents and young adults.4 During the 1980s more than 48,000 people were
murdered by youths ages twelve to twenty-four.5 Interviews with assault
victims indicate that offenders in this age range committed almost half of
the estimated 6.4 million nonfatal crimes of violence in 1991.6
Adolescents and young adults also face an extraordinarily high risk of
death and injury from violence. Homicide is the second leading cause of
death for Americans ages fifteen to thirty-four and is the leading cause of
death for young African Americans.7 Homicide rates among young Ameri-
can men are vastly higher than in other Western industrialized nations
(Exhibit 1).8 In addition, persons ages twelve to twenty-four face the
highest risk of nonfatal assault of any age group in our society.9 The average
age of both violent offenders and victims has been growing younger and
younger in recent years.10
Violence against women and children. Women are frequent targets of
physical and sexual assault by partners and acquaintances. Many of these
assaults are fatal. In 1990, 5,328 women died as the result of homicide.11Six
of every ten of these women were murdered by someone they knew, about
half of them by a spouse or an intimate acquaintance.12 In addition, homi-
cide is the leading cause of death for women in the workplace, accounting
for 41 percent of all occupational injury deaths among women during the
1980s.13 More than 99 percent of assaults on women, however, result not in
death but rather in physical injury and severe emotional distress. In 1985 an
estimated 1.8 million women were physically assaulted by male partners or
cohabitants.14 In addition, it has been estimated that 1,871 women are
forcibly raped each day in the United States.15 The consequences for
women include an increased risk of attempted suicide, abusing alcohol and
other drugs, depression, and abusing their own children.16
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10 HEALTH AFFAIRS | Winter 1993
Exhibit 1
International Variation In Homicide Rates For Males Ages Fifteen To Twenty-Four,
1988-1991
United States
Italy
New Zealand
Israel
Australia
Finland
Scotland
Portugal
Poland
Ireland
Austria
Sp ai n
Swe d en
Norway
Netherlands
Denmark
Greece
Switzerland
Germany
Fr an ce
Canada
England/Wales
Ja p an
0
5
10
15
20 2 5 30 35 4 0
Homicides per 100,000 population
Sources: National Center for Health Statistics, Vital Statistics, 1990; and World Health Organization Statistics
Annuals, 1990 and 1991.
Children also are all too frequently the targets of abuse in our society. In
1988 an estimated 1,016 to 2,026 children died from abuse and neglect in
the United States.17 In 1986 a minimum of 1.6 million children experi-
enced some form of nonfatal abuse or neglect.18 The long-term conse-
quences for abused children include an increased likelihood of depression,
poor self-esteem, alcohol and substance abuse, self-destructive behavior,
and aggression.19 These patterns often persist through adolescence and into
adulthood. Some, but not all, adults who were abused as children are more
likely than other adults to abuse their children and intimate partners and to
be arrested for violent crime.20
The impact of violence on the poor. The evidence is consistent and
compelling that poor people bear a disproportionate share of the public
health burden of violence in our society. Homicide victimization rates
consistently have been found to be highest in those parts of cities where
poverty is most prevalent.21 In 1991 the risk of becoming a victim of a
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12 HEALTH AFFAIRS | Winter 1993
hold our own, or search for additional preventive methods. Even within the
criminal justice community there is a movement toward looking for new
approaches through community- or problem-oriented policing.30
Underlying the public health approach is the strong conviction that
violence can be prevented. The wide variation in the homicide rate among
developed nations supports this stance. The rate of homicide among males
ages fifteen to twenty-four living in developed nations with accurate vital
statistics data was more than eight times higher in the United States than
in the next-highest country, Italy (37.2 versus 4.3 homicides per 100,000
population in 1988-1991). Even the rate for young white males in the
United States-a group more comparable with young Italian males-was
more than three times the rate in Italy.31 The relatively high rates of
violence in the United States, therefore, are not an inevitable consequence
of economic development. The potential for much lower rates of violence
than we are now experiencing also is evident in our own history. Within
the United States the homicide rate has varied more than twofold since
1950, ranging from a high of 10.7 per 100,000 in 1980 to a low of 4.5 in
1956 (Exhibit 2).32
Perhaps most importantly, although most violence prevention efforts
have not been adequately evaluated, at least a few show promise of being
successful. Regular visits to the homes of unmarried, poor, teenage mothers
by health practitioners have been shown to reduce the incidence of child
abuse in a controlled random trial.33 Providing training in communication,
negotiation, and problem solving to middle school youth with behavioral
Exhibit 2
Homicide Rate By Year, United States, 1900-1991
Homicide rate per 100,000
19 00 19 10 1 92 0 1930 1940 1950 19 60 19 70 19 80 19 90
Source: National Center for Health Statistics, National Vital Statistics System.
Note: Homicide rate for 1991 is a provisional estimate.
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PREVENTING VIOLENCE 13
problems has reduced the number of suspensions attributed to violence.34
The Perry Preschool Project, an educational program directed at the intel-
lectual and social development of preschool children, has been credited
with reducing the cost of delinquency and crime, including violence, by
approximately $2,400 per child.35 Laws that prohibit carrying guns in public
and that impose a mandatory sentence for crimes perpetrated with a firearm
have been found to have small but positive effects on reducing firearm
homicides.36 After passage of the 1977 Washington, D.C., restrictive licens-
ing law that prohibited handgun ownership by everyone but police officers,
security guards, and previous gun owners, firearm suicides and homicides
declined by 25 percent.37 Homicide rates remain high and have increased in
Washington, D.C., however, indicating that other actions besides restrict-
ing handgun ownership are necessary. Thus, despite the fact that we have a
great deal more to learn about how to prevent violence, epidemiologic
patterns and preliminary evaluation research clearly indicate that it can be
prevented.
There exists a broad array of potentially effective intervention strategies
through which violence might be prevented. Exhibit 3 presents a listing of
examples of these interventions grouped by whether their primary goal is to
change knowledge, skills, or attitudes; the social environment; or the
physical environment. The efficacy of most of these interventions has not
been demonstrated. Nevertheless, they are among the many options to be
considered as part of a broad-based, sustained strategy to prevent violence.
Among these options, strong emphasis must be placed on addressing the
role of social and economic deprivation in causing violence. Recent re-
search points to numerous dimensions of poverty that are related to high
community rates of violence: high concentrations of poverty, transiency of
the population, family disruption, crowded housing, weak local social struc-
ture (for example, low organizational participation in community life, weak
intergenerational ties in families and communities, and low density of
friends and acquaintances), and the presence of dangerous commodities or
opportunities associated with violence (for example, gun availability and
drug distribution networks).38 If we are to be successful in preventing
violence, these fundamental social and economic factors must be addressed.
Public health science in action. Although many scientific disciplines
have advanced our understanding of violence, the scientific basis for devel-
oping effective prevention policies and programs remains rudimentary.
Public health brings something that has been missing from this field: a
multidisciplinary scientific approach that is explicitly directed toward iden-
tifying effective approaches to prevention.
This approach starts with defining the problem and progresses to identi-
fying associated risk factors and causes, developing and evaluating interven-
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14 HEALTH AFFARIS | Winter 1993
Exhibit 3
Strategies For Preventing Violence And Its Consequences
Strategy type Description Intervention examples
Change individual Deliver information to individuals to Conflict resolution education
knowledge, skills, or Develop prosocial attitudes and Social skills training
attitudes beliefs Job skills training
Increase knowledge Public information and education
Impart social, markcrable, or campaigns
professional skills Training of health care
Deter criminal actions professionals in identification
and referral of family violence
victims
Parenting education
Mandatory sentences for crimes
with guns
Change social
environment
Alter the way people interact
by improving their social or
economic circumstances
Adult mentoring of youth
Job creation programs
Respite day care
Battered women’s shelters
Economic incentives for family
stability
Antidiscrimination laws enforced
Deconcentrated lower-income
housing
Change physical
environment
Modify the design, use, or
availability of
Dangerous commodities
Structures or space we move
through
Restrictive licensing of handguns
Prohibition or control of alcohol
sales at events
Increased visibility of high-risk
areas
Disruption of illegal gun markets
Metal detectors in schools
Note: See E xhibit 5 for a detailed description of stntegics for preventing firearm injuries.
tions, and implementing interventions in programs (Exhibit 4). Although
the exhibit suggests a linear progression from the first step to the last, in
reality many of these steps are likely to occur simultaneously. Information
systems used to define the problem also may be useful in evaluating pro-
grams. Similarly, information gained in program evaluation and implemen-
tation may lead to new and promising interventions.
The first step, defining the problem, includes delineating related mortal-
ity and morbidity and goes beyond simply counting cases. This step includes
obtaining information on the demographic characteristics of the persons
involved, the temporal and geographic characteristics of the incident, the
victim/ perpetrator relationship, and the severity and cost of the injury.
These additional variables may be important in defining discrete subsets of
injuries for which different interventions may be appropriate. For example,
prevention of violence between intimate acquaintances is likely to require
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PREVENTING VIOLENCE 15
Exhibit 4
Public Health Model Of A Scientific Approach To Prevention
Problem Response
a different approach than prevention of violence among strangers.
The second step in the public health approach involves identifying risk
factors for and causes of injuries. Whereas the first step looks at “who,
when, where, what, and how,” the second step looks at why.” This step
also may be used to define populations at high risk for injury and to suggest
specific interventions. Risk factors can be identified by a variety of
epidemiologic studies, including rate calculations, cohort studies, and case-
control studies.
The next step is to develop interventions based in large part upon
information obtained from the previous steps and to test these interven-
tions. Methods for testing include prospective randomized controlled trials,
controlled comparisons of populations for occurrence of health outcomes,
time series analyses of trends in multiple areas, and observational studies
such as case-control studies.
The final stage is to implement interventions that have been proved or
are highly likely to be effective. In both instances it is important that data
be collected to evaluate the program’s effectiveness, particularly since an
intervention that has been found effective in a clinical trial or an academic
study may perform differently at the community or state level. Another
important component is determining the cost-effectiveness of such pro-
grams. Balancing the costs of a program against the cases prevented by the
intervention can be helpful to policymakers in determining optimal public
health practices.
The public health model for a scientific approach to prevention has been
applied to a wide range of noninfectious as well as infectious public health
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16 HEALTH AFFAIRS | Winter 1993
problems, with a remarkable record of success. Smallpox has been eradi-
cated, smoking rates have been drastically reduced, and the number of
people who die in car crashes has been reduced by tens of thousands. We
believe that this time-tested, goal-oriented approach will yield similar
benefits in the area of violence prevention.
Integrating the efforts of diverse disciplines, organizations, and
communities. Public health brings a tradition of integrative leadership, by
which we can organize a broad array of scientific disciplines, organizations,
and communities to work together creatively on solving the problem of
violence. This approach is in direct contrast with our society’s traditional
response to violence, which has been fragmented along disciplinary lines
and narrowly focused in the criminal justice sector. In addition, communi-
ties have not been given a voice in fashioning and implementing preven-
tion policies and programs. We have, in effect, severely limited our ability
to address violence.
These problems are solvable, but we need to combine our diverse per-
spectives and resources to be successful. First, by unifying the various
scientific disciplines pertinent to violence prevention, public health can
provide policymakers with comprehensive knowledge that will be more
helpful to them than the separate, discipline-specific parcels of information
they now receive.39 Second, public health is establishing links with each of
the sectors that figures in violence prevention: education, labor, public
housing, media, business, medicine, and criminal justice. They are being
encouraged to organize and coordinate their involvement in federal, state,
and local prevention programs. Finally, public health is working hard to
fully involve communities in policy and program development as well as to
stimulate a greater sense of community ownership for this problem.40
A further concern is that our response to violence has been fragmented
along racial and ethnic lines, a problem that is demonstrated by the widely
held belief that violence is just a minority problem. This notion is wrong
and impedes an effective response to violence in several ways. First, it
stigmatizes minority groups by lending support to the false stereotype that
minorities are inherently violent. In fact, there is no scientific evidence of
a genetic link between race or ethnicity and violence.41 The preponderance
of existing research indicates that race or ethnic status per se has little to do
with an individual’s propensity for violence. Rather, racial or ethnic status
is associated with many other factors, such as poverty, that do influence
violent behavior.42 Second, this belief allows the majority of our population
to deny their own problems of violence and dissociate themselves from
solving the problem. Violence should be characterized as an American
problem; to maximize our effectiveness, we must convince the public that
all Americans must work together for a solution.
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PREVENTING VIOLENCE 17
Priorities For Public Health Analysis And Action
Public health priorities for violence prevention include preventing inju-
ries from firearms, interrupting the “cycle of violence,” developing and
evaluating community approaches to violence prevention, and changing
public attitudes and beliefs toward violence. It is believed that attention to
these areas offers the greatest chance of saving lives, preventing injuries,
and reducing the overall impact of violence on our society.
Preventing firearm injuries. Public health has come to see the need for
preventing firearm injuries as central to preventing violence, for several
reasons. First, firearms are involved in a high proportion of deaths associ-
ated with interpersonal violence. In 1990, 65 percent of the more than
24,000 homicides that occurred involved firearms. Further, firearms are
involved in approximately 20,000 deaths associated with suicide and unin-
tentional injury each year.43 Second, studies indicate that firearms have
played a key role in the increasing rates of violent death, particularly among
youth. For example, recent increases in youth homicide and suicide are
almost entirely attributable to increases in homicides and suicides involv-
ing firearms.44 Third, scientific evidence clearly indicates that the presence
of a gun in a violent interaction dramatically increases the likelihood that
one or more of the participants will be killed; the implication here is that
guns are more lethal than other weapons.45 Fourth, scientific evidence is
mounting that access to firearms poses significant risks to owners and their
families. For example, in a well-designed study that controlled for other
known risk factors, the presence of a gun in a household was found to
increase the risk of suicide almost fivefold and the risk of homicide almost
threefold.46 Finally, as previously noted, evaluation research suggests that
certain regulatory approaches can prevent deaths involving firearms.
Public health’s major contribution in this area has been to advance the
scientific understanding of ways in which firearm injuries can be prevented.
In fact, public health scientists have been credited with bringing about a
“sea-change” in firearm injury research over the past ten years.47 This
scientific approach has spanned the first three stages of the public health
model outlined in Exhibit 4. To define the problem, public health scientists
have used existing surveillance data to assess the magnitude, characteristics,
and impact of the problem on a national, state, and local basis.48 They are
exploring ways to improve the national surveillance of fatal and nonfatal
firearm injuries and the monitoring of risky behavior associated with fire-
arm injuries, such as weapon carrying among youth.49 State and local public
health agencies also are developing city- and statewide systems for collect-
ing data on firearm injuries. Public health scientists have helped to identify
risk factors by quantifying the risks of gun ownership, looking not only at
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18 HEALTH AFFAIRS | Winter 1993
the risks from guns in the hands of criminals, but also at the risks to gun
owners and their families. This research has shown, for example, that for
every time a gun kept in the home is used to kill someone in self-defense, it
is used forty-three times to kill someone in a criminal homicide, suicide, or
unintentional shooting; and if a gun is used in an incident of domestic
violence, then the likelihood of one of the two disputants’ being murdered
is twelve times greater than if another type of weapon were used.50
Public health scientists also have been involved in carrying out the third
stage of the public health model: testing the effectiveness of interventions.
For example, a Detroit ordinance prohibiting the carrying of firearms in
public was evaluated and found to have a dampening effect on increases in
firearm homicides occurring outside the home.51 In another example, re-
searchers examining the impact of more restrictive policies toward handgun
ownership in Canada found that between 1980 and 1986 the rate of
homicide in Seattle, Washington, was 65 percent higher than in Vancou-
ver, British Columbia, and that virtually all of this difference was due to an
almost fivefold higher rate of handgun homicide in Seattle. They con-
cluded that a regulatory policy that restricts access to handguns may reduce
the rate of homicide in a community.52
Although our understanding of the role of firearms in violence has
advanced substantially, many questions remain: How frequently are guns
used to successfully ward off potentially violent attacks? Do the risks and
benefits of firearm possession vary, depending on whether one lives in a rich
or poor neighborhood or whether one has children? How do adolescents get
guns, and why do they want them? In addition, few interventions to
prevent firearm injuries have been evaluated. There is a critical need to
assess the value of the numerous intervention strategies that can be, and in
some cases are being, adopted. Exhibit 5 lists interventions that focus solely
on firearms, grouped by four major prevention strategies.
Addressing firearm-related injuries from a public health perspective
helps to reshape the public discussion on firearms in several ways. First,
with a firm scientific understanding of the role of firearms in violence,
public discussion shifts from a criminal justice debate on “gun control” to a
public health discussion of preventing firearm injuries.” The gun-control
debate has become so polarized that neither side really seeks to understand
the other. As a result, there is no middle ground and very little constructive
dialogue. By reframing the debate, public health can help to engage many
more people in this critically important issue. Second, if scientific informa-
tion on the health risks of firearms is developed and disseminated, people
are empowered to take responsibility and make decisions to reduce the risks
for themselves, their families, and their communities.
A third element in reframing the issue of firearm injuries is shifting the
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PREVENTING VIOLENCE 19
Exhibit 5
Strategies For Preventing Firearm Injuries
Strategy Intervention
Change how guns are used/ stored Restriction of gun carrying in public
Mandatory sentences for gun use in crimes
Owner liability for damage by guns
Metal detectors in vulnerable places
Safety education
Affect who has guns Permissive licensing (for example, all but felons,
minors. mentally ill, and so on)
W
aiting periods
Forbid sales to high-risk purchasers
Disrupt illegal gun markets
Combination/electronic Locks on guns
Reduce lethality of guns Protective clothing
Reduce barrel length/bore size
Reduce magazine size
Ban dangerous ammunition
Reduce number of guns Restrictive licensing (for example, only police,
military, guards, and so on)
Buy back guns
Increase taxes on guns
Restrict imports
Prohibit ownership
Source: Adapted from A.J. Reiss Jr. and J.A. Roth, eds., Understanding and Preventing Violence (Washington:
National Academy Press, 1993), 272-273.
focus from an all-or-none” solution to a broad array of diverse strategies
and policies. The remarkable success of public health in preventing motor
vehicle injuries exemplifies this approach. Over the past thirty years the
United States has invested more than $250 million to discover ways to
create safer cars, safer roadways, and safer drivers. Because of this effort cars
now have steering wheels that protect the driver, front ends that crush to
absorb impact, safety belts, and air bags; also, many highway systems have
eliminated unsafe intersections. All drivers must pass licensing examina-
tions, and we have made great progress in removing drunken drivers from
the roads. As a result, the highway driving death rate has decreased mark-
edly, saving more than 243,000 lives.53 Firearm injuries can be reduced
similarly without banning all guns. As with motor vehicle safety, progress
can be made by using a variety of approaches that include changes in
behavior and environmental modification.
Interrupting the cycle of violence. It is clear that violence is a learned
behavior and that older generations influence the knowledge, attitudes,
and behavior of younger generations. Thus we should be able to intervene
at various points in the cycle to change knowledge, attitudes, and behavior
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20 HEALTH AFFAIRS | Winter 1993
conducive to violence.
Several points follow from this notion of a cycle of violence. First,
interventions might be targeted at a variety of ages and groups to reduce
violence in future generations. For example, programs targeted to parents
can affect children through parents’ teaching and shaping their children’s
behavior, and programs targeted at very young children can have a lifelong
impact. Second, because persons are susceptible to a wide range of influ-
ences over their lifetime, efforts to promote prosocial knowledge, attitudes,
and behavior must be sustained and reinforced over time. This mainte-
nance may require new and changing input at various points. Third, inter-
vention early in life may prevent many different types of violence. The
same principles of nonviolence that may keep persons from resorting to
violence when they are young may prevent domestic violence after they
marry, child abuse after the birth of their children, and elder abuse when
their parents become old.
Research into the cycle of violence within the family has shown that
children who are physically abused or neglected are more likely than others
to grow up to abuse their own children.54 Abused children as well as
children who witness parental violence also are more likely to use physical
violence against others when they get older.55 As interpersonal violence
becomes more prevalent, increasingly larger numbers of children are likely
to witness violence firsthand in public. This exposure also may increase the
likelihood of violent behavior.
The importance of early intervention to interrupt the cycle of violence is
clear, and the potential effectiveness of these interventions has been dem-
onstrated for prototype Head Start and home visitation programs.56 How-
ever, early interventions such as these take a long time to demonstrate
effectiveness because they target children who will not enter the periods of
highest risk for violent behavior for many years. These programs are the
hardest to initiate, support, and evaluate, but they may ultimately be the
most effective. Long-term institutional support for such programs clearly is
needed.
Because exposure to violence in the family is a pivotal influence on the
transmission of violence across generations, public health is giving high
priority to the prevention of violence among family members and inti-
mates. In particular, the Centers for Disease Control and Prevention
(CDC) is implementing an initiative to prevent violence against women.
This initiative has five broad goals: (1) to improve the ability to describe
and monitor the problem systematically and on a continuing basis at the
national, state, and local levels; (2) to increase our knowledge of modifiable
factors associated with violence against women and the consequences of
such violence; (3) to demonstrate and evaluate ways to prevent violence
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PREVENTING VIOLENCE 2 1
against women that can be implemented in communities, workplaces,
schools, and other settings; (4) to conduct a national communications
effort to change attitudes and beliefs that condone violence against women
and to train health care providers and social service professionals; and (5)
to develop a nationwide network of prevention and support services, with
the aim of strengthening and coordinating the system for delivering pre-
vention programs and giving direction to a national prevention effort.
The American Medical Association (AMA) has undertaken another
important initiative to prevent family violence. The primary goal of this
initiative is to mobilize physicians by heightening their awareness and
knowledge regarding the diagnosis, treatment, and prevention of child,
partner, and elder abuse. Toward this end, the AMA has launched a major
media campaign, a national coalition of physicians against violence, and a
medical resource center to collect, evaluate, and disseminate information
about family violence. Given that physicians are on the front lines in
dealing with the consequences of violence, this initiative holds great prom-
ise for improving their ability to prevent family violence.57
Developing and evaluating community approaches. The prevention
of violence will require the work of a broad spectrum of community leaders
and organizations, including governmental, business, and grass-roots or-
ganizations. The communities that these leaders and organizations serve
should determine and be responsible for local violence prevention efforts.
This approach is justified and necessitated by several factors. First, the
complexity of violent behavior defies a single simple solution. Multiple
complementary activities are required, and they will demand the involve-
ment of a broad spectrum of participants, including local citizens, officials,
businesses, and a variety of governmental agencies, including justice, edu-
cation, and health. Second, the approach has been successful in other
health promotion efforts to change individual behavior. Community-based
health promotion programs have reduced teenage pregnancy rates, reduced
smoking among adolescents, and improved dietary habits.58 Third, pro-
grams administered above the community level are meeting with increasing
suspicion and resistance, particularly within minority communities. Fourth,
the uniqueness of communities precludes a blanket prescription for all
locales. Finally, in the end, the community must assume responsibility for
ongoing activities. To do so, residents must have the desire and the skills to
continue the program, which is much more likely if the community is
committed to the program from the beginning.
The urgency of the problem, the absence of ready solutions, and the
requirement for community participation create a dilemma. Ideally, com-
munities should be able to select from an array of proven interventions
those activities best suited to them. Unfortunately, of the many seemingly
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22 HEALTH AFFAIRS | Winter 1993
good ideas about how to prevent violence, several of which are being widely
advocated and implemented, few have been scientifically proven to work.59
Cost-effectiveness information is available for none. The tension between
the demand at all levels to act now and the absence of proven interventions
is a critical aspect of the challenge facing public health. We must be aware
of this constant tension and develop programs from which we can learn as
we go.6 0
The CDC is moving ahead on three fronts simultaneously. First, we are
compiling and disseminating descriptions of exemplary violence preven-
tion programs together with information on how to start a violence preven-
tion program at the community level.61 Second, we are rigorously evaluat-
ing discrete interventions. Third, we are supporting community-based dem-
onstration projects to see which combinations of interventions are most
effective in reducing violence and to learn how best to deliver programs at
the community level. A variety of interventions is needed including inter-
ventions to change individual knowledge, skills, and attitudes and to
change the social and physicial environments in which we live (Exhibit 3).
Many different organizations are supporting the development, imple-
mentation, and evaluation of community-based violence prevention pro-
grams. Within the Department of Health and Human Services (HHS), the
CDC, the National Institutes of Health, the Health Resources and Services
Administration, the Substance Abuse and Mental Health Services Ad-
ministration, the Indian Health Service, the Public Health Service Office
of Minority Health, and the Administration on Children and Families each
support community-based violence prevention projects or projects that
have direct relevance to violence prevention in communities (for example,
substance abuse prevention programs). The Departments of Justice, Educa-
tion, and Housing and Urban Development also have a strong interest in
this area and in some cases support community-based projects. Outside of
government, some foundations have become actively involved. For exam-
ple, The California Wellness Foundation has launched a five-year, $24
million violence prevention initiative that focuses on decreasing youth
violence through community health promotion. To learn from and fully
capitalize on these ongoing prevention experiences, federal agencies, foun-
dations, and communities will need to significantly improve their ability to
share information and coordinate activities.
Changing public attitudes and beliefs. Recent experience with public
health information and education campaigns for reducing smoking and
cardiovascular disease and preventing acquired immunodeficiency syn-
drome (AIDS) suggests that similar efforts can be important parts of the
public health approach to preventing violence. Within the field of injury
control, there has been a long-standing debate over the effectiveness of
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PREVENTING VIOLENCE 23
educational efforts to prevent injuries. Early in the history of injury control,
many people felt that injuries could be prevented just by telling people to
“be careful.” Soon, however, critics showed that it was much more effective
to change the environment than it was to try to change individual behav-
ior. As a result, many injury-control advocates felt that behavioral change
was an ineffective way to prevent injuries. It is clear now, however, that
effective injury-control programs-and preventing injuries from violence is
no excep tion-take advantage of both behavioral changes and changes in
the environment. For example, to realize the benefits of child safety seats,
parents must purchase them and use them correctly.
Public health has now become much more sophisticated in the use of
marketing techniques to bring about change. We know that we need to
formulate precise objectives, identify target audiences, carefully develop
culturally competent messages, and then measure the impact of these
marketing efforts on the outcomes of interest. Public health information
campaigns for violence prevention must achieve a number of goals. First,
they must make people aware of the magnitude and characteristics of the
problem of violence today. Second, they must give hope to individuals and
communities, informing them that there are things that work and things
that people and communities can do to prevent violence. Third, they must
mobilize individuals, organizations, and communities to act. Fourth, they
must provide information about what works and how to conduct effective
prevention programs. And fifth, they must be designed so that we can
measure their effectiveness and use that information to constantly improve
them.
Most recent attention to violence and the media has been limited to the
negative impact of violence in the movies and on television. This has had
at least two adverse results. First, opportunities to develop positive uses of
the media through social marketing have not been adequately considered.
Second, false expectations have been raised about the potential of reducing
violence in life by reducing violence in the media.
Popular movies and television contain high levels of violence, and large
organizations such as the American Psychological Association and the
American Academy of Pediatrics have publicly stated their conviction that
violence in the media causes acts of violence in real life.62 Research has
shown that viewing violence on television or in the movies can make
children more aggressive and irritable.63 Researchers have suggested that
children today see so much violence on television that they are desensitized
to it and may even be encouraged to commit violent acts because of their
viewing.64 There seems little doubt that violence in the media contributes
to violence in society. Violence in the media, however, is but one segment,
of uncertain size, of the full scope of influences that produce violence in our
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24 HEALTH AFFAIRS | Winter 1993
society. Efforts to reduce media violence should be part of a larger effort to
change the many factors contributing to frequent violent behavior in
American society.
Im pli cations Of The P ublic Health Ap pro ach
The public health vision for violence prevention has important implica-
tions for policy development. Based on this vision, we advance the follow-
ing principles as guidance for the development of a national policy to
prevent violence.
Invest in prevention. The history of public health has shown repeatedly
that the search for prevention policies and programs pays off. For example,
Americans suffer far less now than in the past from infectious diseases,
motor vehicle injuries, and chronic diseases associated with smoking be-
cause of substantial investments in and commitments to prevention in each
of these areas. A similar commitment to and investment in the prevention
of violence is absolutely necessary if we are to make measurable progress.
Special emphasis should be placed on primary prevention, which aims to
prevent violence from occurring rather than trying to identify people who
have already perpetrated violence or been victimized by it. This means that
the target audience for injury prevention programs is much broader than
just the group of already victimized persons. Primary prevention efforts
likely will have an impact on preventing all forms of violence and will help
to generate a larger constituency than will programs that deliver services to
victims. Primary prevention aims to save the lives of potential perpetrators
as well as potential victims.
Address the root causes. Economic and social problems such as pov-
erty, joblessness, and racism are inextricably linked to violence in our
society. In the final analysis, if violence is to be prevented, these fundamen-
tal societal issues must be addressed at the same time that we take whatever
immediate actions possible to prevent violence. This parallel approach
offers the best opportunity for both short- and long-term success in reducing
the toll of violence.65
Adopt a learn-as-we-go approach. We must act now to prevent vio-
lence, but we must learn from these actions to refine and shape future
public policies. Progress in learning what works depends on rigorous evalu-
ation of specific policy innovations. An approach that emphasizes sound
evaluations of violence interventions, policies, and programs will advance
not only our understanding of prevention but also our basic understanding
of the etiology of violence.66 We are an experimenting society; we must be
sure to learn from our experiments and be willing to alter our course as our
scientific understanding of violence and its prevention evolves.
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PREVENTING VIOLENCE 25
Emp hasize coordinated action. Interest in violence prevention has
grown dramatically in recent years. This interest is shared by a broad range
of federal departments, state agencies, foundations, and organizations. New
prevention initiatives and programs will be emerging from almost every
sector of society. We must attempt to coordinate these activities for two
reasons. First, we should take advantage of the synergistic benefits of
cooperation across the various entities sponsoring these activities. For
example, community-based efforts that draw on the combined resources
and perspectives of public health, criminal justice, education, labor, and
housing agencies will have a great advantage in tackling this problem.
Second, we need to learn from these diverse prevention efforts and share
that knowledge broadly. The more coordinated these disparate initiatives
and programs are, the easier it will be to ensure adequate evaluation and to
derive and share prevention knowledge from those activities.
Intervene early. The most effective interventions in the long run may
well be those that begin with very young children, to shape attitudes,
knowledge, and behavior while the subjects are still open to positive influ-
ences. The impact of early intervention may be felt over the course of a
lifetime and be passed on to successive generations.
Work with the community. We must listen to the communities that
are affected and understand what they consider to be the best approaches to
preventing violence among their residents, given their resources and the
patterns of violence that occur. The success of a program is likely to hinge
as much on the community environment and the connection of a program
to the community as on the nature of the program itself.
The development and implementation of public policies that lead to
violence prevention is a formidable challenge. The problem of violence in
America did not appear overnight; nor will it disappear suddenly. A sus-
tained and coordinated effort to prevent violence will be necessary at all
levels of society to address this complex and deeply rooted problem. We
believe, however, that the new vision for violence prevention put forth by
the public health community provides reason for optimism.
The authors gratefully acknowledge the many individuals, both within and outside of the Centers
for Disease Control and Prevention, who have contributed to the public health vision for preventing
violence. This vision truly is the product of the hard work and dedication of many people and
organizations. We also acknowledge the editorial assistance of Gwen Ingraham in the preparation
of this manuscript.
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PREVENTING VIOLENCE 27
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... (4) Ejecución de acciones que en diversas circunstancias resulten efectivas, acompañadas de una difusión amplia de información y de una evaluación de la eficacia en relación con los costos de los programas. (oms, 2003 p. 5) Estos pasos se traducen en lo que Mercy et al. (1993) comprenden como los elementos centrales de la perspectiva que explican su efectividad superior: el enfoque en la prevención; la base científica para la acción (acción basada en evidencia); y, por último, la integración de soluciones provenientes de diferentes disciplinas, organizaciones y comunidades (carácter interdisciplinario). Dahlberg y Krug (2007) apuntan en este sentido: ...
... (p. 1164) Así, como explican Mercy et al. (1993), la perspectiva propone comprender la violencia como un problema de salud pública y, en términos más generales, como un problema de salud cuyos impactos deben ser cuantificados en relación con las lesiones -fatales y no fatales, psicológicas y físicas-que genera. Según estos autores, el abordaje de la violencia desde la perspectiva de la salud pública constituye un giro en la forma como la sociedad aborda la violencia, substituyendo un abordaje reactivo por uno que se propone atacar los factores sociales, comportamentales y ambientales que causan la violencia (Mercy et al., 1993, p. 8). ...
... Partiendo de una crítica del encarcelamiento como ejemplo de estrategias reactivas a la violencia, los autores hacen referencia a una serie de proyectos del sector educacional y a políticas de prohibición de venta de armas de fuego que parten de la convicción, y aportan evidencia para hacerlo, de que es posible prevenir la violencia en los tres niveles de prevención (primaria, secundaria y terciaria) (Mercy et al., 1993;Dahlberg y Krug, 2007;Rutherford et al., 2007aRutherford et al., , 2007b. ...
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Es imperativo buscar nuevas formas de abordar e indagar las violencias en ciudades latinoamericanas desde la Salud Pública. Este libro responde a esa necesidad, estudiando la violencia urbana como una expresión o un síntoma de la conflictividad social, cuyos procesos malsanos muchas veces implican y producen muerte, multiplicando la violencia (homicida). Para dicho análisis se examinan los malestares y los procesos salud-enfermedad y muerte que se derivan de lo que se conoce como violencia urbana. Los (des)ordenamientos territoriales, la fragmentación y la polarización urbana son características del “neoliberalismo realmente existente” en ciudades del Sur global. Por tanto, esta obra los examina como referentes centrales para entender el fenómeno de la violencia urbana. Además, esta obra se alimenta teóricamente de conceptos propuestos por la Medicina Social y Salud Colectiva Latinoamericana y por la Geografía Crítica Latinoamericana. Para un análisis empírico, se examinan los casos del barrio San Bernardo en Bogotá y el complejo de favelas de La Maré en Río de Janeiro, barrios azotados por (des)ordenamientos territoriales, donde confluyen violencias, se produce muerte, pero también se articulan resistencias.
... There are two different approaches for developing programmatic interventions that have been described: the research to practice model, and the community-centered model (Wandersman et al., 2008). Research to practice interventions generally include research from the onset (Wandersman et al., 2008) and follow predefined stages for program development (Mercy et al., 1993;Mrazek and Haggerty, 1994). There have been some great successes of such models such as Nurse Family Partnerships (Olds, 2006), Perry Preschool Program (Heckman et al., 2010) and the Incredible Years (Menting et al., 2013). ...
... In their seminal work, the Institute of Medicine published a five-stage model to develop successful interventions (Mrazek and Haggerty, 1994). Another pioneering model is the Center for Disease Control model developed by Mercy and colleagues (Mercy et al., 1993), which outlines four stages of program development: defining the problem, identifying risk factors, developing and testing interventions, ensuring widespread use. For the purpose of engaging in scientific accompaniment, we define a four-stage model of program development. ...
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Purpose Calls for the development and dissemination of evidence-based programs to support children and families have been increasing for decades, but progress has been slow. This paper aims to argue that a singular focus on evaluation has limited the ways in which science and research is incorporated into program development, and advocate instead for the use of a new concept, “scientific accompaniment,” to expand and guide program development and testing. Design/methodology/approach A heuristic is provided to guide research–practice teams in assessing the program’s developmental stage and level of evidence. Findings In an idealized pathway, scientific accompaniment begins early in program development, with ongoing input from both practitioners and researchers, resulting in programs that are both effective and scalable. The heuristic also provides guidance for how to “catch up” on evidence when program development and science utilization are out of sync. Originality/value While implementation models provide ideas on improving the use of evidence-based practices, social service programs suffer from a significant lack of research and evaluation. Evaluation resources are typically not used by social service program developers and collaboration with researchers happens late in program development, if at all. There are few resources or models that encourage and guide the use of science and evaluation across program development.
... (2) the socio-ecological model, which expands on Step 2 of the public health approach on risk and protective factors ( Figure 2); and (3) the distinction between preventing, detecting and responding to elder abuse, which expands on Step 3 of the public health approach on interventions ( Figure 3) (Krug et al., 2002;Mercy et al., 1993;Satcher & Higginbotham, 2008). ...
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This is the protocol for a Campbell systematic review. The objectives are as follows: to produce a mega-map which identifies, maps and provides a visual interactive display, based on systematic reviews on all the main aspects of elder abuse in both the community and in institutions, such as residential and long-term care institutions.
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Within the criminal justice system, one of the most prominent justifications for legal punishment is retributivism. The retributive justification of legal punishment maintains that wrongdoers are morally responsible for their actions and deserve to be punished in proportion to their wrongdoing. This book argues against retributivism and develops a viable alternative that is both ethically defensible and practical. Introducing six distinct reasons for rejecting retributivism, Gregg D. Caruso contends that it is unclear that agents possess the kind of free will and moral responsibility needed to justify this view of punishment. While a number of alternatives to retributivism exist - including consequentialist deterrence, educational, and communicative theories - they have ethical problems of their own. Moving beyond existing theories, Caruso presents a new non-retributive approach called the public health-quarantine model. In stark contrast to retributivism, the public health-quarantine model provides a more human, holistic, and effective approach to dealing with criminal behavior.
Chapter
Mental illness accounts directly for 14% of the global burden of disease and significantly more indirectly, and recent reports recognise the need to expand and improve mental health delivery on a global basis, especially in low and middle income countries. This text defines an approach to mental healthcare focused on the provision of evidence-based, cost-effective treatments, founded on the principles of sharing the best information about common problems and achieving international equity in coverage, options and outcomes. The coverage spans a diverse range of topics and defines five priority areas for the field. These embrace the domains of global advocacy, systems of development, research progress, capacity building, and monitoring. The book concludes by defining the steps to achieving equality of care globally. This is essential reading for policy makers, administrators, economists and mental health care professionals, and those from the allied professions of sociology, anthropology, international politics and foreign policy.
Chapter
Mental illness accounts directly for 14% of the global burden of disease and significantly more indirectly, and recent reports recognise the need to expand and improve mental health delivery on a global basis, especially in low and middle income countries. This text defines an approach to mental healthcare focused on the provision of evidence-based, cost-effective treatments, founded on the principles of sharing the best information about common problems and achieving international equity in coverage, options and outcomes. The coverage spans a diverse range of topics and defines five priority areas for the field. These embrace the domains of global advocacy, systems of development, research progress, capacity building, and monitoring. The book concludes by defining the steps to achieving equality of care globally. This is essential reading for policy makers, administrators, economists and mental health care professionals, and those from the allied professions of sociology, anthropology, international politics and foreign policy.
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In a synopsis of the current state of research regarding NSSI, there are two key findings of this thesis: Firstly, there is a severe scarcity of studies and currently no evidence base for effective universal prevention of NSSI in youth. Secondly, not only the number but also quality of those few studies found was considered too low to draw wide-ranging conclusions and no meta-analysis could be conducted. This conclusion based – among other factors listed in chapter six – on the application of the EPHPP quality assessment tool (Evans, Lasen et al. 2015), which revealed distinct deficiencies and a weak overall study quality for all seven studies. Even if the high prevalence of NSSI among adolescents and the importance of this field of research is increasingly emphasized in contemporary literature (Muehlenkamp, Walsh et al. 2010, Wasserman, Carli et al. 2010, Brunner, Kaess et al. 2014, Plener, Schumacher et al. 2015), the shortage of concrete programs addressing the issue is manifest. The potential to tackle NSSI via prevention is underlined in view of the fact that many recent studies prove the high potential of primary prevention regarding NSSI incidences (Evans, Hawton et al. 2005, Fortune, Sinclair et al. 2008). From the studies included for this review, it can be concluded that most interventions show positive effects in raising awareness, knowledge, understanding of risk factors and help-seeking attitudes among school staff or students, particularly when starting with low knowledge at baseline (Robinson, Gook et al. 2008). Yet, most studies focus on training of gatekeepers and only two programmes address students directly and primarily measure actual NSSI behaviour. This finding highlights the importance of more investigation into concrete NSSI measurement targeting mainly the group of youth. There is a severe lack of literature on primary prevention with suitable contexts and target groups, while reviews on secondary targeted prevention deliver much more potential in the quantity of research (Kothgassner, Robinson et al. 2020, Kothgassner, Goreis et al. 2021). Until that changes, secondary prevention approaches of NSSI should be relied upon first. Looking into the future, several considerations may help advance universal approaches to NSSI. Regarding study planning, it is crucial for future research to pursue a thorough background research, examine the feasibility of interventions, and evaluate the appropriateness of study samples chosen. Moreover, research groups are expected to ensure a close observation of participants in cases of adverse events, in order to offer support, but also detect potential deficiencies in the study organisation. Additionally – in accordance with other research in this field (Plener, Brunner et al. 2010) – findings of this review highlight the necessity to expand fundamental research on functions of NSSI and its (neurobiological) mechanism of formation in order to enhance the knowledge of correlations and improve effective preventive approaches. As psychoeducational methods have shown risks of iatrogenic effects (e.g. in patients with eating disorders) (Stice, 2007 #10063), it might be worthwhile to focus on improving emotion regulation in order to strengthen protective factors and improve adolescents’ management of their everyday lives rather than on merely mitigating possible risk factors. Regarding intervention costs, it appears indispensable to include more cost calculations in the study planning of future research. In contrast to therapeutic interventions of NSSI, which are usually conducted in an in-patient setting and entail high measurable expenses as compared to preventive interventions, preventive approaches may in case of success result in a reduction of clinical presentation (O’Connell, Boat et al. 2009). A promising outlook is entailed by study protocol presenting a skills-based universal prevention program of NSSI “DUDE”, a cluster randomized controlled trial scheduled for 16 German schools with a total of 3.200 adolescents (Buerger, Emser et al. 2022). The program is tailored to decrease the incidence of NSSI and avert potential and associated long-term consequences like suicidality among adolescents. It is aimed to provide easy access for adolescents due to its implementation during lesson time at school and is declared cost-effective. Furthermore, DUDE is a promising approach to effective NSSI prevention, as it is intended to improve mental health through the pathway of emotion regulation. It remains to await the implementation of the protocol, which is currently delayed due to the SARS-CoV-19 pandemic. In sum, initial research is promising and suggests that the approach to tackle NSSI via prevention is meaningful. Yet, high-quality studies on the development and evaluation of universal NSSI prevention in adolescents are urgently needed.
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Despite their importance to fall prevention research, little is known about the details of real-world fall events experienced by lower limb prosthesis users. This gap can be attributed to the lack of a structured, population-specific fall survey to document these adverse health events. The objective of this project was to develop a survey capable of characterizing the circumstances and consequences of fall events in lower limb prosthesis users. Best practices in survey development, including focus groups and cognitive interviews with diverse samples of lower limb prosthesis users, were used to solicit input and feedback from target respondents, so survey content would be meaningful, clear, and applicable to lower limb prosthesis users. Focus group data were used to develop fall event definitions and construct a conceptual fall framework that guided the creation of potential survey questions and response options. Survey questions focused on the activity, surroundings, situation, mechanics, and consequences of fall events. Cognitive interviews revealed that with minor revisions, survey definitions, questions, and response options were clear, comprehensive, and applicable to the experiences of lower limb prosthesis users. Administration of the fall survey to a national sample of 235 lower limb prosthesis users in a cross-sectional preliminary validation study, found survey questions to function as intended. Revisions to the survey were made at each stage of development based on analysis of participant feedback and data. The structured, 37-question lower limb prosthesis user fall event survey developed in this study offers clinicians and researchers the means to document, monitor, and compare fall details that are meaningful and relevant to lower limb prosthesis users in a standardized and consistent manner. Data that can be collected with the developed survey are essential to establishing specific goals for fall prevention initiatives in lower limb prosthesis users.
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This article has no abstract; the first 100 words appear below. Benneyan — Robert Noel Benneyan, M.D., of Greenfield, died on February 22. He was 56. Dr. Benneyan received his degree from Cornell University Medical College in 1958. He was a member of the American Medical Association and a fellow of the American College of Surgeons. Borenstein — Morris V. Borenstein, M.D., formerly of Springfield, died on March 4 at the age of 82. Dr. Borenstein received his degree from Universitaet Wien, Medizinische Fakultaet in 1936. He was a member of the American Physicians Fellowship, Inc., the American Psychiatric Association, and the American Society of Law and Medicine. Delisle — Antonio . . .
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The public health impact of firearm-related deaths and injuries in the United States is enormous. During 1989, almost 35,000 people died from firearm-related injuries. Fifty-two percent of these deaths were due to suicide, 42% to homicide, and 4% to unintentional circumstances. Estimates indicate that for every firearm-related fatality more than seven nonfatal injuries occur. The lifetime cost of firearm-related injuries occurring in 1985 is estimated to be $14.4 billion. Demographic groups at greatest risk of a firearm-related death include males, adolescents, young adults, and blacks. The number and rate of firearm-related deaths in the United States has remained fairly steady through the 1980s. However, firearm-related death rates for females, male teenagers, and young adults are higher now than at any time previously. Action to lessen the impact of this public health problem is urgently needed, but this action must be guided by science.
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Objective. —To compare the risk of death and the risk of nonfatal injury during firearm-associated family and intimate assaults (FIAs) with the risks during non-firearm-associated FIAs.Design. —Records review of police incident reports of FIAs that occurred in 1984. Victim outcomes (death, nonfatal injury, no injury) and weapon involvement were examined for incidents involving only one perpetrator.Setting. —City of Atlanta, Ga, within Fulton County.Participants. —Stratified sample (n=142) of victims of nonfatal FIAs, drawn from seven nonfatal crime categories, plus all fatal victims (n=23) of FIAs.Main Outcome Measures. —Risk of death (vs nonfatal injury or no injury) during FIAs involving firearms, relative to other types of weapons; risk of nonfatal injury (vs all other outcomes, including death) during FIAs involving firearms, relative to other types of weapons.Results. —Firearm-associated FIAs were 3.0 times (95% confidence interval, 0.9 to 10.0) more likely to result in death than FIAs involving knives or other cutting instruments and 23.4 times (95% confidence interval, 7.0 to 78.6) more likely to result in death than FIAs involving other weapons or bodily force. Overall, firearmassociated FIAs were 12.0 times (95% confidence interval, 4.6 to 31.5) more likely to result in death than non-firearm-associated FIAs.Conclusions. —Strategies for limiting the number of deaths and injuries resulting from FIAs include reducing the access of potential FIA assailants to firearms, modifying firearm lethality through redesign, and establishing programs for primary prevention of violence among intimates.(JAMA. 1992;267:3043-3047)
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The homicide rate for males 15 through 24 years of age in the United States was compared with the rates in 21 other developed countries. The US homicide rate, 21.9 per 100 000, was more than four times higher than the next highest rate in Scotland (5.0). Most countries had rates that were between 1 and 3 per 100 000. The lowest rates were in Japan and Austria, each with rates below 0.6 per 100 000 males 15 through 24 years of age. Three quarters of the homicides in the United States resulted from the use of firearms contrasted with less than a quarter of all homicides in the comparison countries. The US homicide rate for black males 15 through 24 years of age (85.6) was more than seven times the rate for white males (11.2). In 1987 there were only four states that had homicide rates among white males that were as low as the rates among males in the comparison countries. The lowest state rate among young black males was still seven times the highest rate abroad. There are about 4000 homicides per year among young males in the United States. If the US homicide rate could be reduced to that in the country with the next highest rate, more than 3000 lives would be saved. (JAMA. 1990;263:3292-3295)
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A meta-analysis is performed on studies pertaining to the effect of television violence on aggressive behavior. Partitioning by research design, viewer attributes, treatment and exposure variables, and type of antisocial behavior, allows one to interpret computed effect sizes for each of the variables in the partitions. We find a positive and significant correlation between television violence and aggressive behavior, albeit to varying degrees depending on the particular research question. According to research design, we find ZFisher values ranging from .19 for survey to .40 for laboratory experiments. Erotica emerges as a strong factor even when it is not accompanied by portrayal of violence. Additionally, the effect of television violence on the antisocial behavior of boys and girls is found to be marginally equal in surveys. A host of tests are performed to solidify these, and further results. Substantive interpretation is provided as well.