Preventing violence against children: what approaches work?
RW commentary author
First, we need good epidemiological data to see the location and source of the child abuse problem, and to track and monitor its response to our efforts. This is something we currently do not have, at least at the level that would satisfy any even generous public health epidemiologist. Second, we need experimental studies to evaluate new and existing practices, so we can agree on what works. Currently, we have practically none, outside of a couple in regard to home visitation and a couple in regard to sexual abuse treatment. There is more experimental science in the toilet paper we use every day than in what we have to offer abused children or families at risk of abuse.1
Fourteen years later, in 2013, this indictment of the failure to bring science to bear on the problem of preventing violence against children remains largely valid, although there has been some increase in the number of scientific studies that attempt to ascertain what works to prevent violence against children. Accordingly, WHO guidance documents can list the following recommendations for preventing child maltreatment by parents and caregivers in children aged 0-14 years, and violence occurring in community settings among adolescents aged 15-18 years.
Child maltreatment by parents and caregivers can be prevented by:
- reducing alcohol availability during pregnancy and by new parents through the enactment and enforcement of liquor licensing laws, taxation, and pricing;
- providing home visitation services by professional nurses and social workers to families where children are at high-risk of maltreatment, and
- providing training for parents on child development, non-violent discipline and problem-solving skills.
Violence involving adolescents in community settings can be prevented through:
- pre-school enrichment programmes to give young children an educational head start;
- life skills training;
- assisting high-risk adolescents to complete schooling;
- reducing alcohol availability through the enactment and enforcement of liquor licensing laws, taxation and pricing, and - restricting access to firearms.
However, it is recognized that the evidence informing these approaches derives largely from high-income countries (HIC), and that due to a different mix of causes, risk factors, and prevention opportunities, they may not be as effective in low- and middle-income countries (LMIC). Accordingly, the critical question becomes "how can we increase LMIC capacity to obtain good epidemiological data on the location and source of violence against children, and conduct experimental studies to evaluate new and existing prevention practices"? Well-developed, highly standardized evaluation procedures have been available for decades, and are routinely applied to economic, social, and health programmes and policies in HIC and LMIC settings alike. The evolution of evidence follows a typical pattern.
First, a few studies reporting successful outcomes for a handful of unrelated programmes delivering the same or very similar programmes are published. Second, efforts to replicate such successes in many other settings are undertaken, and the number of studies evaluating whether they work increases considerably. Third, assuming that a preponderance of studies show effectiveness, the programme is scaled up and its effectiveness at scale measured by monitoring how one or two key indicators change in the target population. The challenge is therefore to attract enough "big science" and "big money" to violence against children in LMIC to initiate such a process. What are possible barriers to doing so, and how might they be overcome?
Epidemiologists and evaluation scientists are in short supply in LMIC, and this capacity is absorbed in other issues perceived to be of greater importance than violence against children. Addressing the capacity shortage is an issue for the health and human sciences field at large. Altering the perception requires advocacy to raise awareness among relevant decision-makers about the importance of violence against children as a contributor to high-risk behaviours across the life span (such as unsafe sex, smoking, harmful use of alcohol, illicit drug use, delinquency, and crime), and via these a drag on social and economic development. The official development assistance (ODA) agencies from which most LMIC receive support identify violence against children as a human rights and criminal justice concern. Their requests for proposals therefore reach sectors responsible for human rights, criminal justice and child protection, which frame the issue in legal terms and usually are not equipped to undertake research into programme effectiveness.
Advocacy to sensitize ODA agencies about the value of using science in efforts to address violence against children will help create greater receptivity among these key partners. Most practitioners dealing with violence against children are trained to deliver victim services (e.g., counselling, child protection services) and are employed in settings (e.g., child protection units) that require them to meet service delivery quotas. This creates a professional vacuum in the area of science-based approaches to preventing violence against children. Filling this vacuum requires teaching more public health trainees and evaluation scientists about the contributions they can make to understanding and preventing violence against children, and working with relevant government ministries to raise awareness about the needs to invest in policy and programme evaluation and monitoring.2
The last few years have seen some signs that this situation may be improving. The Together for Girls surveys conducted by UNICEF and the United States Centers for Disease Control and Prevention (CDC), and the WHO-CDC Global Schools Based Student Health Survey initiative, are starting to fill the LMIC gap in respect of scientifically reliable, population-based studies that describe the who, what, when, where, and how of violence against children. The UBS Optimus Foundation’s surveys of child sexual abuse and access to services is revealing the chasm between the vast numbers of individuals that experience sexual abuse and the tiny fraction thereof who receive any kind of care.
The Violence Prevention Alliance’s parenting project group is finalizing guidance for project managers on why and how to evaluate child maltreatment prevention programmes, and for donor organizations on how they can more strongly support the generation of evidence about the effectiveness of the programmes they fund. The Children and Violence Outcome Evaluation Challenge Fund uses funding from four international donor organizations to support outcome evaluation studies in LMIC, and to date is supporting nine such initiatives, with a similar number due to come on stream in the second half of 2013.
It is scientifically reasonable to assume that more approaches which work in preventing violence against children actually exist than we are currently aware of or able to detect. These approaches will remain unknown until scientifically informed monitoring systems and evaluation studies are widely deployed in all settings, and especially in LMIC.