National Family Safety Program, NGHA January 28 th and 29 th 2013

1. National Family Safety Program, NGHA January 28th and 29th 2013 Presentation 1. Public Health Approach to Child Maltreatment Prevention Presented by Alaa Sebeh, MD Ph.D. Independent International Consultant, Child Protection & Disability. alaa1234@gmail.com

2. Objectives The core learning objectives of this module are as follows: • Clarify the distinction between child maltreatment prevention and child protection • Introduce the evidence-based public health approach to child maltreatment prevention

3. Outline • Classifying types of prevention • Child maltreatment prevention vs. child protection • Characteristics of the public health approach to child maltreatment prevention: • Population-based • Interdisciplinary and multisectoral • Based on the ecological model • Proceeds in four steps • Evidence-based approach

4. The Public Health Approach to Child Maltreatment Prevention

5. Classifying Types of Prevention According to Temporality and Risk Public health interventions are traditionally characterized in two ways: 1. According to the time of the intervention: • Primary prevention • Secondary prevention • Tertiary prevention 2. According to the level of risk of those receiving the intervention: • Universal interventions • Selective interventions • Indicated interventions

6. Child Maltreatment Prevention: Primary Prevention Child maltreatment prevention means to reduce the frequency of new cases through direct efforts to remove or reduce the causes and risk factors. Effective child maltreatment prevention programmes usually address specific sub-types of child maltreatment such as: • Inflicted traumatic brain injury • Physical abuse • Sexual abuse

7. Child Protection: Secondary and Tertiary Prevention Child protection refers to providing support and treatment after child maltreatment has already occurred and protecting children from further maltreatment.

8. Child Maltreatment Prevention vs. Child Protection Child maltreatment prevention designates measures taken to prevent child maltreatment occurring in the first place. Child protection refers to measures taken after child maltreatment has occurred to reduce its consequences and prevent it from re-occurring.

9. Characteristics of the Public Health Approach to Child Maltreatment Prevention: Population-Based Public health is not about individual patients. The focus of public health is to prevent health problems and to extend better care and safety to entire populations.

10. Public Health Approach: Interdisciplinary and Multisectoral The public health approach to any problem is interdisciplinary and science-based. Because violence is a multi-faceted problem, the public health approach also emphasizes a multi-sectoral response to it. Each sector has an important role to play in addressing the problem of violence: • Health • Education • Social services • Justice • Policy Collectively, the approaches taken by each have the potential to produce important reductions in violence.

11. Public Health Approach: The Ecological Model

12. The Ecological Model Source: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.

13. The Ecological Model: Determinants of Child Maltreatment • Lack of adequate legislation • Social, economic and health policies that lead to poor living standards or socio-economic inequality • Social and cultural norms that diminish the status of the child in parent-child relationships • Tolerance of violence • Lack of services to support families • High levels of unemployment • Lack of parent-child attachment • Family breakdown • Breakdown in support in child rearing from extended family • Parent was maltreated as child • Parent misuses drugs or alcohol • Child was unwanted as a baby Taken from: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.

14. The Ecological Model: Programmes to Prevent Child Maltreatment • Implementing legal reform and human rights • Introducing beneficial social and economic policies • Reducing economic inequalities • Changing community norms • Increasing family support • Implementing community job creation schemes • Training in parenting • Implementing home visitation programmes • Reducing unintended pregnancies • Increasing access to prenatal and postnatal services Taken from: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.

15. Shared Risk Factors It is not unusual for individuals at risk of violence to experience more than one type of violence. Risk factors for more than one type of violence include: • Prevailing cultural norms • Poverty • Social isolation • Alcohol abuse • Substance abuse • Access to firearms Addressing risk factors across the levels of the ecological model may contribute to decreases in more than one type of violence. Understanding how these factors are related to violence is one of the important steps in the public health approach to preventing violence.

16. 1.Define & describe What is the Problem? 2.Identify risk What are the risk factors and causes? 4. Scaling up and cost-effectiveness Implement on large scale & cost 3.Develop and evaluate interventions What works and for whom? The Four Steps of the Public Health Approach • Systematic, evidence-based approach with 4 steps: • 1.Define and Describe • 2.Identify Risk • 3.Develop and Evaluate Prevention Programmes • 4. Scaling Up and Cost-Effectiveness

17. An Evidence-Based Scientific Approach It is critical to emphasize that the public health approach is an evidence-based scientific approach. By evidence-based we mean, “The development, implementation, and evaluation of effective programmes and policies in public health through application of principles of scientific reasoning …” (Brownson et al, 2003). Evidence-based prevention is the selection, design, and implementation of prevention programmes with reference to findings from quantitative scientific studies of what works to reduce the frequency of child maltreatment.

18. Systematic Reviews An important source of evidence for all four steps of the public health approach, but especially for step 3 is systematic reviews. A systematic review (SR) is a literature review that applies strategies that limit bias in the search for and synthesis of all relevant studies on a specific topic (Chalmers et al. 1994). SRs help us tell the difference between real and assumed knowledge. An SR is a research method that is transparent, explicit, and set out in advance for limiting bias in the production of knowledge and with the overall aim of summing up knowledge in an area. SRs are a form of secondary research: a method to accumulate findings of primary research.

19. Types of Questions That Can be Answered by Systematic Reviews • Treatment effectiveness, “what works” • Accuracy of screening and diagnostic tests • Exploring risk and protective factors • Questions about prevalence • Questions about meanings, perceptions, and processes of treatments, as well as how treatments were implemented. • Gauging the empirical support for theories • Synthesizing models and theories • Methodological questions • Cost-effectiveness and cost-benefit analyses The findings of these reviews are disseminated to decision-makers who can then develop programmes that work effectively.

20. Evidence and the Four Steps of the Public Health Approach In step 1, the magnitude and distribution of child maltreatment is estimated using evidence from population-based epidemiological studies based on representative samples. In step 2, risk factors and causes are identified using evidence, including systematic reviews, derived from a variety of research designs, including cross-sectional, case-control, and longitudinal studies. In step 3, the effectiveness of prevention programmes is evaluated using evidence, including systematic reviews, from experimental or high quality quasi-experimental research designs. In step 4, costs and cost-effectiveness can be determined using techniques from health economics.

21. Summary and Conclusion

22. Summary and Conclusion This module reviewed: • The two main types of classifications of prevention strategies • The distinction between child maltreatment prevention and child protection • The main characteristics of the public health approach to child maltreatment prevention which are as follows: • Population-based • Interdisciplinary and multisectoral • Based on the ecological model • Proceeds in four steps • An evidence-based approach

23. References Brownson, R. Kelly, C. Eyler, A. Carnoske, C. Grost, L. Handy, S. et al. (2003). Evidence-Based Public Health. New York, Oxford University Press. Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Chalmers, I. Haynes, B. (1994). Systematic Reviews: Reporting, updating, and correcting systematic reviews of the effects of health care. BMJ. 309 862-865. Dahlberg, L. Butchart, A. (2005). State of the science: Violence prevention efforts in developing and developed countries. International Journal of Injury Control and Safety Promotion. 12(2) 93-104. The Future of Children. (2009) Preventing Child Maltreatment. 119(2) 3-21. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.

24. Discussion: Child Maltreatment Prevention Programmes at Each Level of the Ecological Model As a large group, identify possible risk factors and child maltreatment prevention programmes which target these risk factors at each level of the ecological model. Taken from: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.