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CHAPITRE 7 • CHAPTER 7 PRÉVENTION DE LA VIOLENCE / VIOLENCE PREVENTION BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 769

Intervenir efficacement face à la violence conjugale Intervening Effectively to Reduce Intimate Partner Violence

THE EFFECTIVENESS OF PUBLIC HEALTH INTERVENTIONS TO REDUCE OR PREVENT SPOUSAL ABUSE TOWARD WOMEN

DAINA MUELLER,HELEN THOMAS Hamilton Social and Public Health Services, Youth and Mental Health Branch Hamilton, Ontario, Canada

PROBLEM UNDER STUDY: Spousal abuse toward women is a serious public health issue experienced by a significant number of women in Canada. A random sample survey of women 18 years of age and over in 1993 found that 29% had been physically or sexually assaulted at leas once by their spouse or common-law partner (Rogers, 1993). The majority of women who were assaulted also experience emotional abuse. Three-quarters of all women who reported physical or sexual abuse also reported emotional abuse while 18% reported experiencing emotional abuse only. Definitions of spousal abuse are wide ranging. For the purpose of this review, spousal abuse is defined as “An attempt to control the behaviour of a wife, common-law partner or girlfriend. It is a misuse of power that uses the bonds of intimacy, trust and dependency to make the woman unequal, powerless and unsafe. Wife abuse can include some or all of the following: physical abuse, psychological abuse, verbal abuse, sexual abuse, financial abuse and spiritual abuse (national Clearinghouse on Family Violence, 2001). Prevention of violence toward women in spousal relationships is a complex issue requiring multiple interventions at multiple levels (King, 1993; White, 1994; Wolfe, Jaffe, 1999). There has been a growing recognition of the need for a public health approach to reduce the incidence of intimate partner violence. Community coactions such as the Task Force on the Health Effects of Woman Abuse, London, ON calls for universal screening of all women for abuse. Others (Jaffe, Wolfe, 1999; Cohen, 1996) reiterate the need for multiple strategies i.e. strengthening individual knowledge and skills, educating the community; provider training; coalition building; changing organizational practices, and influencing policy and legislation.

OBJECTIVES: A Systematic review of the literature was conducted to summarize the evidence about the effectiveness of public health interventions to prevent or reduce abuse of women in spousal relationships. The review will answer the following questions: What is the current evidence about the effectiveness of public health interventions to prevent or reduce abuse of women in spousal relationships? What are the recommendations for public health practice and research?

METHOD OR APPROACH: Four search strategies were utilized to identify published articles for this review: on-line computer searches, hand searches of selected journals, searches of ref- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 770

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erence lists as well as contact with key information. Medline, CINAHL, SocAbst, Embase (1996-2001) and Dissertation Abstracts databases were searched from 1975-2001 using a combination of search terms. All articles retrieved were relevance tested by two independent reviewers. Studies were also quality rated. Only the strong and moderately rated articles are included in this review.

RESULTS: Studies that implemented a screening protocol reported significantly improved identification of pregnant women who were abuse. Public health should consider implementing such screening in partnership with community agencies ensuring sufficient community resources exist for referral and management.

CONCLUSION: Interventions using an empowerment/advocacy framework show promise and should be used in program development. Outreach interventions through advocacy are effective in reducing physical violence.

LIMITS: Women in these studies were primarily pregnant, low socio-economic backgrounds and were living in urban area. Screening interventions should be implemented with a general cohort of women and any further research should be methodologically sound.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This research will outline recommendations for public health practice in the field of spousal abuse reduction, particularly in program development. Recommendations for research in this area will also be presented.

EFFICACY OF AN EMERGENCY DEPARTMENT INTIMATE PARTNER VIOLENCE ADVOCACY: A RANDOMIZED, LONGITUDINAL INVESTIGATION

KELLY B. HYMAN,GREGORY L. LARKIN Boston VA Medical Centre Boston, Ma, USA

PROBLEM UNDER STUDY: Intimate partner violence (IPV) is the largest contributor of injury to women in the world. However, strategies for optimally treating victims are still in their infancy. Much money, time and effort are currently being funnelled into Emergency Department (ED)-based victim advocacy services as one possible approach. However, no studies to date have prospectively examined the impact of these programs. While most providers and policy-makers believe these programs benefit IPV victims, this fundamental approach has not been evaluated.

OBJECTIVES: This study was designed to evaluate the impact of an award winning, model ED-based advocacy program for victims of IPV. Outcome measures included engagement in safety, use of community resources, experience with abuse, PTSD symptomatology, and general distress.

METHOD OR APPROACH: Female patients (ages 18-65; final sample n=53) who presented for treatment at an inner-city, Level I, Trauma and Burn Centre and who screened positive for current IPV exposure (<3 months) were randomized to either advocacy or standard social service. Women were enrolled during their hospital visit and completed follow-up at three- four months. Women were included if they endorsed at least two experiences/types of abuse BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 771

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(i.e., physical, sexual and/or emotional on more than one occasion) and excluded if they could not speak English, had less than a 7th grade education, were unable to answer questions while in the ED, were intoxicated, or were already in shelter at the time of enrolment. Self-report measures were completed at both time points. Data were analyzed using multivariate linear and logistic regression in SPSS.

RESULTS: Significant differences between treatment groups were not observed for any outcome measure. In general, women moved in the hypothesized direction over time. That is, they reported decreased experience with abuse and general distress. An interaction between time and actual treatment received was observed for PTSD symptoms (p=.06), with symptoms decreasing more from enrolment to completion for women who received advocacy compared to those who received social service. Reported use of community resources at enrolment was high with 80% of participants reporting engaging in at least one behaviour in the previous three months. Use of community resources regressed towards the mean over time.

CONCLUSION: This study suggests that, in this sample, an advocacy intervention program provides little benefit over standard social service intervention. While few meaningful group differences were observed, the majority of the women who completed the study reported making strides towards ending the abuse in their lives.

LIMITS: There are a number of limitations with the present study including sample size, possible service saturation or ceiling effect, challenges with program implementation and delivery, lack of a “no treatment” control, and difficulties inherent with self-report data.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is the first to use a prospective, randomized trial to evaluate the impact of an ED-based IPV advocacy program. The program evaluated is considered by many to be foremost in the field and is currently being widely replicated. The findings provide valuable information for program providers, policy makers, and evaluators alike.

SHIFTING PARADIGMS IN EVALUATING DOMESTIC VIOLENCE INTERVENTIONS: CASE STUDY PAIIRS

MARIA ELENA VILLAR,SHERRY AARON,ISLEM PARDINAS,SILVIA TORRES Partnership for the Prevention of Violence, University of Miami Miami, Fl, USA

PROBLEM UNDER STUDY: Traditionally, interventions with victims of domestic violence are considered successful if they result in removal of the batter, transfer of the victim to a safe shelter and/or legal actions such as restraining orders, divorce, child custody agreements. Advocates working with victims of domestic violence are finding that many clients feel that the menu of options currently available to them are not appropriate, and thus choose to stay in the abusive relationship.

OBJECTIVES: To discuss desirable and attainable outcomes of domestic violence intervention programs and propose alternative “interim” outcomes to determine program success. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 772

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METHOD OR APPROACH: We conducted a qualitative assessment of an intensive case management model for victims of domestic violence enrolled in PAIIRS (Preventing Abuse in Intimate Relationships) advocacy program in the neighbourhood of Liberty City in Miami, Florida. We analyzed anonymous data collected from program participants exposed to domestic violence referred to PAIIRS by the police, the hospital or a community health clinic. We assessed process variables such as proportion of women who consented to receive case management services; those who refused case management but accepted support services such as safety planning and resource information; women who initiated contact after receiving a letter or telephone call from the advocate; and women who accepted no services but agreed to further communication with the advocates. We also observed the type of services requested by clients referred from different sources and in different levels of crisis.

RESULTS: Women who face domestic violence vary in their level of self-awareness and identification as victims. Women referred to services from different agencies may arrive with different levels of readiness, and require different types of services. For some women, assistance in resolving an immediate financial need is needed before addressing their own safety, which they perceive as a secondary need. Women who were referred by the police may have mistrust, because they do not want their partners to go to jail. Women who initially present resistance, but agree to be contacted by the advocate, show improved safety and awareness.

CONCLUSION: There is a need for further dialogue between domestic violence survivors, service providers and researchers to identify new ways to measure the success of violence prevention and mitigation programs. The “traditional” outcome measures may not be appropriate when addressing women who do not consider themselves in crisis or at risk for serious injury. Clients may only begin to self identify as victims during the course of the program. We need to document intermediate outcome measures that lead to increased awareness, knowledge of resources and safety. Service providers may need to stratify victims by level of risk, and to determine treatment and referral for services. The goal of intensive case management for battered women is not to force women to get services, but meet them where they are and let the services be led by the client. Appropriate protocols would need to incorporate family and cultural assessments, attitudes towards family separation, law enforcement, women’s shelters, mental health services, etc. so that we are not only offering a limited menu of services and possible outcomes, none of which may be of interest to certain clients.

LIMITS: Further research is needed to support the need for interim outcomes and validate possible outcome measures that may be collected across sites for comparison. The findings presented here are based on the experience of one program in one location. Different outcomes may apply for different populations.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Identified the need capture intermediate outcomes of reaching out to bettered women to increase safety and reduce physical and emotional injury. This framework may translate to the community level. Communities may also be at different levels of readiness or resistance to address domestic violence. In high-risk urban communities, social priorities change frequently. For both individuals and communities, violence is not an issue to be highlighted, feeling that it further stigmatizes an already stig- matized individual/community. As with the individual victims, progress with community organizations may be measured in terms of sustained contact and communication, increased awareness as evidenced by more questions being asked, more cases referred, etc. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 773

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LES PRATIQUES DES INTERVENANTS SOCIAUX DANS LES SITUATIONS DE VIOLENCE CONJUGALE À HAUT RISQUE DE LÉTALITÉ

GILLES RONDEAU,NORMAND BRODEUR,JOCELYN LINDSAY, SERGE BROCHU,GUY LEMIRE École de service social - Université de Montréal Montréal, Québec, Canada Chaque année, 130 000 Canadiennes craignent que leur conjoint les tue. Cette peur se concrétise malheureusement annuellement pour près de 75 d’entre elles. Plusieurs intervenants des milieux pénaux et sociaux ont à composer avec les situations de violence conjugale à haut risque de létalité. Cependant, le personnel des organismes rencontre plusieurs obstacles à une intervention efficace et concertée dans ces situations. Aucune recherche empirique n’a encore analysé la façon dont les intervenants réagissent concrètement lorsque confrontés à des situations de violence conjugale à haut risque de létalité. La présente recherche s’inscrit dans un projet qui porte sur les interventions effectuées par les acteurs pénaux et sociaux québécois dans les situations à haut risque de létalité. Cette communication se concentre sur les intervenants sociaux uniquement. Elle a pour but de documenter les actions des intervenants sociaux québécois des Centres locaux de services communautaires (CLSC), des maisons d’hébergement pour femmes victimes de violence, des ressources pour conjoints violents et des centres de crise afin d’identifier les stratégies d’action efficaces et concertées qu’ils utilisent pour protéger la vie de la victime et mettre fin à la situation de violence. Le devis de recherche retenu est de type qualitatif et repose sur la technique de l’incident critique (TIC) développée par Flanagan (1954). Un total de 45 incidents critiques recueillis auprès de 25 intervenants sociaux, auxquels s’ajoute le récit de 10 femmes exposées à des risques de létalité, a fait l’objet d’une classification et d’une analyse poussée. La présentation fera état du matériel recueilli sur les incidents classés en fonction de l’immédiateté du danger de mort appréhendé. Les résultats feront aussi état des interventions effectuées auprès des victimes et des agresseurs. Ils rendront compte des stratégies d’intervention utilisées et du rationnel sous-jacent aux prises de décision et aux actions qui ont été entreprises. Les situations à haut risque de létalité mobilisent beaucoup les ressources des intervenants et sont celles qui soulèvent le plus de questions et d’anxiété. Certaines des pratiques identifiées seront proposées comme pistes d’action pour rendre l’intervention et la concertation plus efficaces. Les résultats d’une enquête qualitative faite à partir d’un échantillon non probabiliste ne sont pas générali- sables. Les incidents rapportés par les intervenants et les victimes ne sont pas les mêmes et certains remontent à cinq ans. La charge émotionnelle ressentie lors des situations à haut risque de létalité peut avoir affecté la décision de participer à l’étude et le récit des incidents. La recherche permet de présenter aux intervenants des stratégies d’intervention s’appli- quant aux situations à haut risque de létalité; voir de façon concrète comment la concertation s’opérationnalise et enfin de mieux comprendre le point de vue des différents acteurs à partir de leurs rôles et fonctions dans le système. Il s’inscrit, conséquemment, tout à fait dans la perspective de la prévention et du contrôle des traumatismes. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 774

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LES PERCEPTIONS DES VICTIMES DE VIOLENCE CONJUGALE, DES INTERVENANTES SOCIALES DE LA COUR ET DES PROCUREURS DE LA POURSUITE, À PROPOS DE L’ABANDON DES POURSUITES EN MATIÈRE DE VIOLENCE CONJUGALE

SONIA GAUTHIER,PIERRE LANDREVILLE,GILLES RONDEAU,ANNIE GAIL SAUVÉ Université de Montréal, Montréal, Québec, Canada

PROBLÉMATIQUE : L’importante proportion de causes de violence conjugale qui ne se terminent pas par un verdict de culpabilité, un plaidoyer de culpabilité ou un acquittement en préoc- cupe plusieurs. On craint l’impact négatif, sur la population et sur les victimes, de cet apparent manque de succès des tribunaux dans leur capacité à atteindre les objectifs de dissua- sion générale et spécifique, de répression des actes violents et de protection des victimes. Le refus des victimes de s’impliquer dans les procédures judiciaires contribue largement à expliquer le taux d’attrition des causes de violence conjugale. Diverses stratégies peuvent être déployées pour rendre ces causes à terme. Certains tribunaux ou districts judiciaires ont même adopté des politiques de non-retrait de plaintes (no-drop policies), qui se traduisent parfois par des mesures judiciaires visant à contraindre la victime à rendre son témoignage. Certains des moyens pour contrer l’attrition des causes peuvent ainsi alourdir considéra- blement une situation déjà pénible pour la victime. Ils peuvent même la revictimiser de nouveau.

OBJECTIFS : Une recension des écrits a permis de constater que plusieurs dimensions de l’abandon des poursuites judiciaires concernant des événements de violence conjugale sont laissées dans l’ombre. Ainsi, la recherche a pour objectif de développer les connaissances relatives à l’attrition de ces causes : 1. Au plan des pratiques visant à réduire l’abandon des poursuites; 2. Au plan de la perception des acteurs à propos des facteurs et conséquences asso- ciés à ce phénomène.

MÉTHODE OU APPROCHE : Cette communication porte sur les résultats préliminaires d’une recherche qualitative entreprise en 2001 dans deux tribunaux montréalais. La recherche est menée auprès de victimes, de procureurs de la poursuite et d’intervenantes sociales offrant un service d’intervention psychosociale dans ces tribunaux. Les données présentées proviennent de l’analyse de 60 dossiers (30 dossiers dans chaque cour) dans lesquels il y a eu abandon des poursuites. Les trois types d’acteurs présentés plus haut et impliqués dans ces dossiers ont été interviewés, afin de recueillir leurs perceptions à propos de diverses facettes liées à l’événement judiciarisé et à l’abandon de la poursuite. Ce sont les convergences et les divergences entre ces diverses perceptions qui seront présentées.

RÉSULTATS : Nous verrons d’abord quelles raisons sont évoquées pour expliquer l’abandon de la poursuite. Nous parlerons ensuite de ce que ces personnes ont rapporté à propos des effets positifs et négatifs de la poursuite judiciaire, tant pour la victime que pour l’agresseur, compte tenu du retrait de la plainte. Nous verrons également quels auraient été, selon les acteurs interviewés, les bénéfices supplémentaires pour la victime, si la poursuite n’avait pas été BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 775

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abandonnée. Nous terminerons la présentation par une discussion à propos de l’implication de ces résultats sur les pratiques visant à réduire le taux d’attrition des poursuites judiciaires.

LIMITES : La méthodologie utilisée ne nous permet pas de quantifier le phénomène de l’attrition. Par contre, elle permet de tracer un portrait riche et nuancé de l’abandon des poursuites.

VIOLENCE CONJUGALE : ÉVALUATION DE L’APPLICATION D’UN PROTOCOLE D’AIDE ET DE RÉFÉRENCE À L’ENDROIT DES VICTIMES, EN MONTÉRÉGIE, AU QUÉBEC (CANADA)

JOHANNE GROULX,CÉLINE FARLEY Direction de la Santé Publique, RRSSS Montérégie Longueuil, Québec, Canada

PROBLÉMATIQUE : La violence conjugale à l’endroit des femmes est de plus en plus connue et sa gravité reconnue. Au Canada, c’est 25 % des Québécoises (Statistique Canada, 1993) qui ont subi un acte de violence (selon la définition criminelle) de la part d’un conjoint. Les conséquences sur la vie des femmes sont de plus en plus documentées et nombreuses : il peut s’agir de problèmes de santé physique ou mentale, de conséquences familiales (besoins de protection, procédures de séparation ou judiciaires), etc. Les services publics et communautaires de santé et de services sociaux et le système de la justice offrent une aide nécessaire aux victimes. Mais l’organisation de ces services et les mécanismes de coordination peuvent varier d’une région à l’autre, ce qui peut créer des obstacles en matière d’aide ou de réfé- rence. Le gouvernement québécois a reconnu cette situation, et l’une des mesures prescrites en santé publique au sujet de la violence conjugale est le développement de protocoles de référence inter-organismes afin d’intervenir rapidement et de façon concertée auprès des victimes. La Direction de la santé publique de la Montérégie a développé en 1997 un protocole cadre d’aide (suivis psychosociaux, accompagnements socio-judiciaires) et de référence et a recherché depuis 1998 l’adhésion des sous-régions de son territoire au protocole; l’éva- luation de la démarche a suivi.

OBJECTIFS : L’évaluation de la mise en oeuvre des protocoles repose sur deux objectifs : 1. Décrire le développement et l’application des dix protocoles en tenant compte du protocole cadre; 2. Rendre compte de l’appréciation des acteurs au sujet de la concertation. Ces objectifs permettent de mieux comprendre la mise en oeuvre des protocoles avant d’aborder les effets auprès des victimes.

MÉTHODE OU APPROCHE : La démarche évaluative repose sur une collecte de données quanti- tatives et qualitatives selon quatre méthodes : 1. Un questionnaire d’appréciation (choix multiples) au sujet de la concertation à remplir par les représentants des organismes signataires; 2. Une entrevue de groupe auprès des représentants; 3. Un formulaire de suivi de la personne pour la compilation des résultats; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 776

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4. Une analyse documentaire (protocoles, procès-verbaux, rapports d’activités, statistiques générales sur les services d’aide aux victimes et sur les événements de violence signalés aux services policiers).

RÉSULTATS : Les dix sous-régions de la Montérégie (74 % du territoire géographique) ont signé un protocole avec les principaux partenaires identifiés (justice, santé, services sociaux, services communautaires auprès des femmes et des familles). Les facteurs contribuant à la qualité de la concertation sont surtout le leadership et plusieurs rencontres pour préciser les objectifs et les mandats avec les comités. Sans leadership, la collaboration et les mécanismes de référence ou d’aide peuvent être déficients. Le fait d’être issu d’une structure de concertation préexistante n’a pas constitué, pour plusieurs sous-régions, un facteur déterminant de la concertation; cependant, le fait que les partenaires se connaissaient sur le plan local est apparu comme un facteur favorable. Selon les sous-régions, c’est entre 25 et 55 femmes, au cours des 12 premiers mois, qui ont accepté l’offre de services d’aide ou de référence. L’évaluation des besoins des victimes, après un événement de violence conjugale, a été réa- lisée pour la plupart dans un délai de trois heures ou moins. Cependant, peu de femmes ont maintenu leur demande d’aide à ce moment-là. Les suivis psychosociaux ou les accompagnements socio-judiciaires ont été réalisés sur de très courtes périodes.

CONCLUSION : L’identification des conditions nécessaires à la concertation permet de mieux comprendre les exigences de l’application du protocole. Les résultats montrent que plusieurs femmes ont accepté l’offre de services ou de référence; en ce sens, l’intervention rapide est très appropriée.

LIMITES : Nous n’avons pas examiné comment chacun des organismes a organisé ses ressources pour appliquer le protocole ni vérifié l’appréciation des victimes concernant l’offre de services d’aide et de référence, l’évaluation des besoins ou les suivis.

CONTRIBUTION DU PROJET AU DOMAINE : L’évaluation globale élargit nos connaissances sur l’intervention concertée en violence conjugale et la mobilisation des communautés.

LES INTERVENTIONS DES ACTEURS PÉNAUX LORS DE SITUATIONS DE VIOLENCE CONJUGALE À HAUT RISQUE DE LÉTALITÉ

CHRISTINE DROUIN,GILLES RONDEAU,GUY LEMIRE CRI-VIFF,Université de Montréal Montréal, Québec, Canada

PROBLÉMATIQUE : Au Canada, au cours des dix dernières années, une moyenne annuelle de 97 personnes ont été tuées par un conjoint ou un ex-conjoint et 75% de ces victimes étaient des femmes. Chaque année, 13% des canadiennes ayant subi de la violence de la part de leur conjoint craignent pour leur vie. Plusieurs intervenants pénaux ont à composer avec des situations de violence conjugale à haut risque de létalité. Toutefois, aucune étude n’a été menée jusqu’à maintenant sur les méthodes d’intervention des acteurs pénaux lorsqu’ils sont impliqués dans ce genre de situation. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 777

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OBJECTIFS : Le mémoire qui fait l’objet de la présente communication s’inscrit dans un projet portant sur les interventions effectuées par les intervenants sociaux et pénaux québécois lors de situations de violence conjugale à haut risque de létalité. Cette communication se concentre sur les pratiques des acteurs pénaux. Il s’agit des interventions effectuées par ceux-ci afin de diminuer le risque d’homicide et de protéger la vie des personnes impli- quées dans la situation.

MÉTHODE OU APPROCHE : La méthode choisie pour la recherche est de type qualitatif. La cueillette et l’analyse des données ont été effectuées à partir de la technique des incidents critiques (TIC) élaborée par Flanagan (1954). Un total de 30 incidents critiques a été recueilli auprès de 19 intervenants pénaux, soit 10 policiers, 3 procureurs et 6 intervenants correc- tionnels. En plus, s’ajoute le récit de 10 femmes victimes de situation de violence conjugale à haut risque de létalité qui a été analysé.

RÉSULTATS : L’analyse des incidents critiques rapportés par les intervenants pénaux fait ressortir trois catégories de situation qui sont développées selon le niveau d’urgence évalué: 1. Situation où un le risque est présent; 2. Situation où le risque est imminent dans les prochaines 48 heures; 3. Situation où le danger est à plus long terme. Les résultats rendent aussi compte de la prise de décision relative aux interventions effectuées par les intervenants pénaux.

CONCLUSION : Les intervenants pénaux préconisent certaines pratiques lors de situations de violence conjugale qui se distinguent de celles effectuées lors de situations de violence conjugale habituelles.

LIMITES : Les données de l’étude ont été recueillies de façon rétrospective, le récit des participants peut donc s’être modifié avec le temps. De plus, la charge émotionnelle ressentie lors des situations à haut risque de létalité peut avoir affecté le récit et le choix des participants de l’étude. Les incidents rapportés par les intervenants et les victimes ne sont pas les mêmes.

CONTRIBUTION DU PROJET AU PROGRAMME : La recherche permet de mieux comprendre les stra- tégies utilisées par les intervenants pénaux lors de situations de violence conjugale à haut risque de létalité. Elle permet donc de présenter aux intervenants pénaux des pistes d’actions efficaces afin de diminuer le degré de dangerosité de la situation et ainsi de prévenir l’homicide conjugal. La présente étude s’inscrit, donc, parfaitement dans l’optique de la pré- vention et du contrôle des traumatismes.

EVALUATION OF A BATTERED WOMEN’S SHELTER: OUTCOMES TO MEASURE EFFECTIVENESS

MARY A. GARZA,ANDREA C. GIELEN,JACQUELINE C. CAMPBELL Johns Hopkins University School of Hygiene and Public Health Baltimore, Md, USA

PROBLEM UNDER STUDY: Worldwide, domestic violence is considered “a public health priority.”International population-based studies have estimated a lifetime prevalence, of physical BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 778

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violence by an intimate partner, ranging from 10% to more than 50%. The first-line of protection, and in most cases the first contact point for victims of domestic violence to break free of the abuse and to prevent further abuse, is the community-based shelter. The majority of evaluation-related data collected by individual shelters are primarily for monitoring and quality assurance purposes. Only one shelter evaluation study met the scientific criteria of the National Research Council and Institute of Medicine. This study looked at only one outcome measure - new violence - as an indicator of shelter effectiveness, and did not examine specific programs offered in the shelters. Other outcomes need to be examined, given the array of needs that women present with when coming into a shelter. The present study looks at shelter programs and their effects on multiple outcomes (e.g., self sufficiency, empowerment, satisfaction with services, violence). With the demand for accountability and restricted resources, shelters are searching for ways to improve and maximize service delivery programs in order to meet the needs of victims of domestic violence.

OBJECTIVES: This research addresses the following specific aims: 1. Describe the intra- and interpersonal characteristics of women in the shelter that are associated with their participation of different types and levels of program services; 2. Describe the outcomes experienced by women and their children when they exit a battered women’s shelter; 3. Determine the extent to which outcomes change in relation to the type, level, and satisfaction of program services received at the shelter.

METHOD OR APPROACH: Project WE (Women Empowered) is a longitudinal pre-post study of 80 women who resided in a shelter for battered women and children. Women were interviewed at entry into the shelter, at exit, and one month after leaving the shelter. The interview conducted was a combination of both quantitative and qualitative questions. Measures included the following standard instruments: Conflict Tactics Scale measured four domains of violence, Self-Esteem, Quality of Life MOS-SF36, CESD2 measured depression, Social Support Scale measured both emotional and instrumental support, Spirituality/Religiosity measured support and coping, and Empowerment. Moreover, two measures were developed for this study, Self-Sufficiency and Satisfaction with Services. In addition, four focus groups will be held to assess the needs and perceptions women have four to six months after leaving the shelter.

RESULTS: Data being entered and analyses are underway. The presentation will present data on relationships between program services and the following outcomes: level of violence, relationship characteristics, satisfaction with services, empowerment, and self-sufficiency of women who reside in a shelter. Baseline and follow-up interviews with shelter residents and record reviews will be presented. Moreover, focus group data on women’s needs, perceptions of their shelter stay, and effectiveness of services received as to how it impacts their present situation will be addressed. Multivariate analyses that address the specific aims listed above will be discussed.

CONCLUSION: There is a dearth of evaluation research on shelter services. Findings from our study will assist shelters in understanding the complex needs women are confronted with when they try to end an abusive relationship. Worldwide, shelters are limited in resources and are searching for effective ways to respond to the needs of battered women and children. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 779

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Empowering women to become self-sufficient by addressing their specific needs will break the cycle of violence.

LIMITS: Using only a single shelter limits the study and the findings can only be generalized to the population from which the sample was obtained. However, I will carefully describe the shelter’s context and study participants so that other shelters can better draw inferences from the findings.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is the first to my knowledge to systematically examine the impact of shelter services on women’s self-sufficiency status, relationship characteristics, and the level of violence, after leaving the shelter. Findings from this study will assist shelters in understanding the complex social, economic, and cultural issues and needs women face when they enter and when they leave the shelter; and will also provide shelters with the information necessary to make the delivery of service programs more effective in addressing the unmet needs of battered women.

OPERATION KVINNOFRID (PEACE FOR WOMEN): FIVE YEARS AND THREE POSTER CAMPAIGNS

KAREN LEANDER Karolinska institutet; Stockholm County Council Stockholm, Sweden

PROBLEM UNDER STUDY: The most visible prong of the Stockholm County multisectoral initiative, Operation Kvinnofrid, is that consisting of poster campaigns targeting various aspects of men’s domestic violence against women. Under recurring slogans such as “the worst scars are on the inside”,men’s violence against women is a crime, and domestic violence is everyone’s concern, the three public campaigns have focused on women, men, and children in families where a woman is beaten by a man. While the posters were aimed at raising the awareness of the general public, the initiative was founded for the purpose of improving the manner in which public authorities respond to (primarily) battered women and their children.

OBJECTIVES: The campaigns have served various purposes. The efforts within the key public authorities – the police, the social service, the medical and health care sector – have been facilitated by the visibility of the initiative and the widespread dissemination of various concepts, not least of all “kvinnofrid”,roughly translated as “peace for women”.These two strategies – poster campaigns and training programs for personnel – can also be seen as intermediary goals, steps towards achieving the overall objective of this initiative, that of reducing the occurrence and consequences of men’s violence against women. This review of the five years and three poster campaigns of Operation Kvinnofrid will focus on the development of the content of the campaigns (including printed material), the responses in the general public and public authorities, and the various evaluations made of the initiative.

METHOD OR APPROACH: A historical description will be given of the organization and originally articulated goals; a content analysis will be made of the pictures, slogans, and printed material of the poster campaigns; highlights will be identified of the public response (and polar- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 780

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ization) to the third campaign in November 2000 on the theme of “battering their mothers is abusing the children”.

RESULTS: The juxtaposition of systematic and consensus-building training and educational programs with the more politicized and confront public campaigns has resulted in certain unintended consequences and contradictions that have resulted in both stimuli and hin- drances for further Operation Kvinnofrid endeavours.

CONCLUSION: While formally an official priority area of public policy on the national, regional, and local governmental levels, the field of domestic violence – and general public as well as public agency responses to it – is still highly volatile. There is evidence that “behind the scenes” efforts conducted simultaneously with “in-your-face” tactics may serve as a motor for achieving some of the goals of such initiatives.

LIMITS: The limits are those of all so-called “campaigns”: their effectiveness beyond visibility and recognition measurements is extremely difficult to estimate; without stable and reliable base-line data, the prevention of certain behaviour, attitudes, or responses is impossible to capture.

CONTRIBUTION OF THE PROJECT TO THE FIELD: There are certain relatively unique aspects of Operation Kvinnofrid that make it relevant for an international audience: the campaigns have been directed at raising public awareness and debate rather than at modifying individual behaviour; that the initiative was founded and led by the heads of several public authorities in multi-agency cooperation; that the original goals, time-frames, strategies have been constructed while “in progress”; the reactions to the initiative have intensified rather than weak- ened over time and due to the evolution of the “messages” conveyed in the campaign posters and educational material produced under the auspices of Operation Kvinnofrid.

PORTRAIT DES PLAINTES POUR DES INFRACTIONS CRIMINELLES COMMISES DANS UN CONTEXTE CONJUGAL : DE L’OUVERTURE DU DOSSIER JUSQU’À L’ARRÊT DES PROCÉDURES

LOUISE MARIE BOUCHARD,LILIANE CÔTÉ,RENÉE LEVAQUE,JUDITH PAQUET EN COLLABORATION AVEC LA SÛRETÉ MUNICIPALE DE QUÉBEC Institut national de santé publique du Québec Québec, Québec, Canada En 1986, la mise en vigueur au Québec de la Politique d’intervention judiciaire en matière de violence conjugale a entraîné une modification dans les pratiques d’intervention policière et judiciaire, amenant une judiciarisation presque systématique des cas signalés à la police. En 1995, la Politique d’intervention en matière de violence conjugale : Prévenir, dépister, contrer la violence conjugale est venu renforcer cette pratique et confirmer le caractère criminel de la violence dans un contexte conjugal. Entre temps, nous avons assisté à la mise en œuvre de nouvelles initiatives visant à accompagner les femmes victimes de violence conjugale. Or, les organismes concernés ne disposaient pas de données détaillées sur le nombre de vic- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 781

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times susceptibles de faire une demande d’aide ou sur le cheminement des dossiers dans le système judiciaire de leur présumé agresseur.

OBJECTIFS : Décrire le cheminement des dossiers dans le système judiciaire pour des infractions criminelles commises dans un contexte conjugal sur le territoire desservi par la Sûreté municipale de Québec.

MÉTHODE OU APPROCHE : Afin de satisfaire nos besoins de collecte d’information, la Sûreté municipale de Québec (SMQ) a mis à notre disposition deux enquêteurs de la section Délits contre la personne, unité de la famille, qui ont fourni l’information requise sur l’ensemble des dossiers traités au cours de l’année 1996. Le type de dossiers traités par ces deux enquê- teurs est le reflet des plaintes généralement formulées et portées à l’attention de ce service de police au cours d’une année. Les dossiers retenus pour la collecte d’information représen- taient 35 % (275/787) de l’ensemble des dossiers traités par les enquêteurs de cette section.

RÉSULTATS :

Comparabilité de l’échantillon. Puisque les dossiers à l’étude n’ont pas été assignés au hasard, nous avons comparé, à l’aide d’un test de Chi-carré, les proportions observées de certaines variables dans l’échantillon à la proportion théorique ou attendue que représentaient la population des dossiers de la SMQ. Bien que du point de vue statistique on ait observé certaines différences statistiquement significatives, il appert que du point de vue pratique, l’échantillon n’est pas très différent de la population d’où il provient.

Les acteurs en présence. Dans la très grande majorité des situations que nous avons observées (88,7 %), c’est la victime qui a lance l’appel au 911 ou qui s’est présentée à la cen- trale de police pour y signaler une situation de violence conjugale. Les victimes ont en moyenne 33 ans et se situent pour la très grande majorité d’entre elles, dans les catégories d’âge entre 30 et 49 ans (54,6 %), suivi de près par les 18 à 29 ans (36,7 %). Les auteurs pré- sumés ont 35 ans en moyenne et à l’instar des victimes, se regroupent principalement dans les catégories d’âge entre 30 et 49 ans (58 %) suivi de près par les 18 à 29 ans (30,6 %). Les victimes sont des femmes dans 79,3 % des situations et les prévenus sont de sexe masculin dans 84 % des cas.

Cheminement des dossiers dans le système judiciaire. Près de la moitié des dossiers ouverts pour une infraction commise dans un contexte conjugal font l’objet de mise en accusation (49,3 %, n=74), par contre, près de quatre dossiers sur cinq se rendent jusqu’à l’étape du procès (59/74, 79,7 %). Parmi les dossiers qui se sont rendus à cette étape, une sen- tence a été rendue (50/59) dans 85 % des cas.

CONCLUSION : Nous concluons sur le fait que 50 % des dossiers de notre échantillon ne font pas l’objet d’une mise en accusation. Il importe de comprendre que les victimes sont souvent les seuls témoins des actes qu’elles subissent. Dans ces cas, lorsque la victime ne veut pas qu’une plainte soit portée bien qu’il y ait matière à poursuite, il est difficile pour le substitut du Procureur général d’autoriser une mise en accusation d’autant qu’il sait que son seul témoin est la victime et qu’elle risque de refuser de témoigner.

LIMITES: Bien que nous ayons toutes les raisons de croire que la situation mise en lumière dans cette étude n’est pas exceptionnelle, il serait intéressant de reproduire cet exercice auprès d’organisation policière présentant des caractéristiques différentes et de faire d’autres BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 782

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recherches exploratoires afin de mieux comprendre les besoins des victimes dans les moments les plus critiques du cheminement judiciaire.

ASSESSING THE SUCCESS OF THE WOMANKIND PROGRAM: AN INTEGRATED MODEL OF 24-HOUR HEALTH CARE RESPONSE TO INTIMATE PARTNER VIOLENCE

LYNN M. SHORT,SUSAN M. HADLEY Analytic Systems Associates, Inc. Lithonia, Ga, USA

PROBLEM UNDER STUDY: The Womankind program, a non-profit health care based program for victims of domestic/intimate partner violence (IPV), seeks to enable and motivate health care providers to identify victims of such violence and refer them to Womankind’s in-house services. A two-year evaluation of this comprehensive program was conducted to assess client referral to Womankind services and the impact of health care provider training.

OBJECTIVES: The evaluation was conducted to determine the extent to which the Womankind program increases health care providers’ capacity and motivation to identify cases of intimate partner violence and initiate a course of positive change through referral to Womankind in-house services. It was hypothesized that providers at the intervention sites would be more involved with IPV prevention activities than staff at the comparison hospitals in terms of: 1. Response on a survey measuring knowledge, attitudes, beliefs, and self-reported behaviours (KABB); 2. Documentation of IPV-related issues in patient charts; and 3. Patient referral to Womankind for services.

METHOD OR APPROACH: KABB data were collected at three intervals over a 2-year period at 3 intervention and 2 comparison hospitals located in Minneapolis, MN. Hospital staff and volunteer advocate training programs were evaluated as they occurred. Chart reviews were conducted and client referrals assessed.

RESULTS: Providers at Womankind hospitals demonstrated significantly higher knowledge, attitudes, beliefs and behaviours than those at comparison hospitals throughout the study. During the data collection period, 1719 IPV victims were identified and referred to the Womankind program, while only 27 IPV victims were referred to trained social workers at the comparison hospitals. Chart reviews indicated that emergency staff at the intervention sites provides documentation of IPV in patient records twice as frequently as emergency staff at the comparison sites.

CONCLUSION: This study underscores the efficacy of a well-structured, multi-disciplinary effort to deliver services to IPV victims. The results demonstrate that specialized training and on-site client services create a significant positive impact on the KABB of health care providers. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 783

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LIMITS: The project did not provide extensive follow-up with the women referred to Womankind services to determine the effects of Womankind services.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Evaluation results of most researched health care provider training programs in this area have indicated that they are ineffective in producing the intended results of provider screening and referral of IPV victims. In contrast, this study reveals that a comprehensive, on-site training and intervention program can be effective in developing health care provider’s understanding, capacity, and interest in IPV, and increasing their screening, charting, and referral of victims of intimate partner violence.

LA MÉDIATION DANS LE SYSTÈME LÉGAL ET LES VICTIMES DE VIOLENCE

RICARDO ANGEL BASILICO Pouvoir judiciaire Trelew, Chubut, Argentine

PROBLÉMATIQUE : Les motifs qui ont amené à la création et à la mise en place de cette expé- rience pilote ont émané du besoin de donner des solutions concrètes, en accord avec le Droit et avec la réalité quotidienne. Son but général : résoudre les cas de légères lésions physiques qui se règlent en instance pri- vée, de non-accomplissement des engagements d’assistance familiale (loi 13.944), et d’in- terdiction ou de limitation des contacts des mineurs avec leurs parents séparés (loi 24.270). Les cas présentés ont besoin d’une solution comme la médiation-conciliation positive étant donné les risques de désintégration familiale, les dépressions et les tentatives de suicide qui peuvent surgir pendant le procès. Ces problèmes peuvent être prévenus et éliminés par les équipes multidisciplinaires (le juge, le travailleur social, le Centre d’Assistance aux victimes).

OBJECTIFS : Les principaux objectifs recherchés sont : 1. Mettre en valeur le rôle de la victime pendant le procès; 2. Ne pas stigmatiser le présumé suspect et appuyer les parties dans la recherche d’une solution pacifique du conflit; 3. Activer des mécanismes pour une participation positive de la victime (adulte ou enfant); 4. Prévenir des situations plus graves, en tenant compte de la personne blessée, en donnant la possibilité de solutionner les conflits de droit pénal dont on parle pré- cédemment et où l’intégrité familiale est en cause.

MÉTHODE OU APPROCHE : Brièvement, il faut d’abord supposer que l’acte commis fait partie des cas légaux dont on parle plus haut. S’il n’y a pas d’autre magistrat nommé pour régler le conflit, c’est le juge d’office lui-même et à la demande des parties, qui mettra à leur disposition les mécanismes de médiation et qui travaillera avec les équipes multidisciplinaires existantes dans la province (Services Sociaux, Centres d’assistance aux victimes, etc.).

CONTRIBUTION ET UTILITÉ DE LA MÉDIATION : En tenant compte de l’expérience judiciaire passée, je me rends compte que la punition dans plusieurs cas n’agit que comme châtiment, mais BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 784

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ne résout pas le conflit en question. Au contraire, elle crée de nouveaux problèmes : perte des attributions familiales de chacun, désintégration de la famille, désorganisation psychologique du groupe et parfois, dysfonction définitive du noyau essentiel qu’est la famille. Actuellement, l’Institut de la Médiation a été incorporé dans l’avant-projet de loi du Ministère Public fiscal de la province de Chubut que prendra effet le 10 décembre prochain.

RÉSULTATS STATISTIQUES : L’année dernière (novembre 2000- novembre 2001), 25 cas ont été analysés par le Tribunal d’Instruction Numéro 1 de Trelew, province de Chubut. La média- tion a été le moyen de solution des conflits; le Bureau de la Défense Publique, le Ministère Fiscal, le Bureau (Asesoría) de la Famille et des Mineurs sont aussi intervenus. Le Service Social des Tribunaux a fait l’évaluation et le suivi des cas de médiations; les résultats sont les suivants : 16 cas résolus positivement, 4 cas où la médiation n’a pas influencé positivement ou négativement dans la solution du conflit principal, mais où le dialogue a été rétabli par les acteurs, et 5 cas où le résultat a été négatif et où le procès a continué avec le suivi et le traitement apportés par les services sociaux et les cabinets spécialisés. Dans les cas évalués comme positifs, on a noté des améliorations dans deux situations par- ticulières : 1. Là où la violence existait, elle a disparu; 2. Là où la relation était brisée, elle s’est soit rétablie, soit améliorée de façon remar- quable, et dans certains cas, la vie en commun a repris son cours.

CONCLUSION : Dans le but de tendre vers un système juridique légal plus humain adapté à la réalité, la création de l’Institut de la Médiation apparaît pleinement justifiée. En effet, ici non seulement on règle les conflits de façon dynamique et particulière, surtout ceux où l’in- tégrité familiale est en cause, mais en même temps on tente de corriger des institutions qui paradoxalement, vont à l’encontre de l’exercice du droit de tutelle. Comme on sait que dans bien des cas, les enfants sont en cause, et les parties collaborent à la solution, la médiation devient un moyen plus rationnel et plus adéquat pour aborder et résoudre les conflits de violence qu’une poursuite judiciaire semée d’intrigues, de différends et de reproches que fina- lement vont détruire plutôt que protéger. La médiation vise clairement la réconciliation et la solution du cas de manière non conflictuelle et tend à ne pas nuire aux liens familiaux ou communautaires; elle devient de cette façon un outil précieux dans l’amélioration du sys- tème légal d’une société. Ce texte a été traduit de l’espagnol par Jose Hector Paz. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 785

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La violence en milieu scolaire : l’identifier et la prévenir Violence in School Settings: Identification and Prevention

SCHOOL-BASED VIOLENCE PREVENTION PROGRAMMES: SYSTEMATIC REVIEW

CAROLYN DIGUISEPPI,JULIE MYTTON,DAVID GOUGH,ROD TAYLOR University of Colorado Health Sciences Centre Denver, Co, USA

PROBLEM UNDER STUDY: Once viewed as an adult problem, violence is now identified in all age groups. Even murder and violent assault are now witnessed, and sometimes performed, by school children. School based experiences have been shown to influence behaviour. Numerous violence prevention programmes have therefore been established in schools, a frequent site of juvenile violence. School based violence prevention programmes have been evaluated by randomized controlled trials, but the extent of benefit from such programmes is unclear.

OBJECTIVES: A systematic review was conducted to explore and quantify the effects of school based violence prevention programmes for: 1. Children at increased risk of aggressive and violent behaviour, and 2. All children regardless of risk.

METHOD OR APPROACH: We conducted a systematic review and meta-analysis of randomized controlled trials that evaluated violence prevention programmes in primary or secondary schools. Electronic databases and bibliographies were systematically searched, and authors and organisations were contacted, to identify eligible trials. The main outcome measures were violent injuries, observed or reported aggressive or violent behaviours, and school or agency responses to acts of aggression (e.g., expulsion from school). Weighted mean effect sizes were assessed by meta-analysis.

RESULTS: High-risk children: Of 44 trials identified, none reported data on violent injuries. Among 28 trials that assessed aggressive behaviours, the pooled effect size was -0.36 (95% confidence interval -0.54 to -0.19) in favour of reduced aggression with violence prevention programmes. Among nine trials that reported data on school or agency responses to aggression, the pooled effect size was -0.59 (-1.18 to 0.01), in favour of a reduced need for school and agency responses. The results showed significant heterogeneity. Results were similar whether the programmes focused on training in conflict resolution, anger control, and other skills of non-response, or on training in relationship or social skills or social context changes. Subgroup analyses suggested that effects were similar for primary and secondary school programmes, but that effects were greater when administered to mixed gender groups than to boys alone. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 786

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All-risk children: Data collection and analysis are on going. At the conference we will report the effects of school-based violence prevention programmes targeting all children regardless of risk.

CONCLUSION: School based violence prevention programmes produce modest reductions in aggressive and violent behaviours in children already exhibiting such behaviour, and may reduce the need for school and agency responses to aggression in high-risk children. Effects on aggressive behaviour are similar regardless of the programmes’ primary training focus or the age at which it is delivered. However, trials varied substantially in their size, quality, execution and reporting. Therefore, results should be confirmed in larger, high quality trials. These results for programmes targeting high-risk children will be discussed in relation to results from programmes delivered to all children regardless of risk.

LIMITS: Because of inadequate reporting of data, results from several trials could not be included in the meta-analyses and detailed exploration of heterogeneity was not possible. Funnel plot analysis suggests that negative studies may exist that were not retrieved and included.

CONTRIBUTION OF THE PROJECT TO THE FIELD: School based violence prevention programmes for high-risk children appear to modestly reduce both aggressive behaviours and school/agency actions in response to such behaviours. The benefits of violence prevention programmes appear to be at least as great for programmes introduced in secondary schools as for those introduced in primary schools, suggesting that aggressive secondary school children remain an appropriate target for intervention. However, given evidence of possible publication bias and genuine differences among trials, the true effect of such programmes may be smaller than that indicated. Larger, better-controlled trials appear warranted to determine whether the apparent benefit is real. In addition, unexpected results emerged regarding differential effects by gender, which warrant further research.

VIOLENT BEHAVIOUR AMONG URBAN YOUTH ATTENDING ALTERNATIVE SCHOOLS

SOLEDAD LILIANA ESCOBAR-CHAVES,SUSAN TORTOLERO, CHRISTINE MARKHAM,STEVEN KELDER University of Texas Houston, Texas, USA

PROBLEM UNDER STUDY: Youth attending alternative high schools are more likely to engage in violent behaviour than regular high school youth. Results from the 1998 Alternative Youth Risk Behaviour Survey (ALT-YRBS-98) showed that approximately 32.9% of alternative school students nationwide had carried a weapon (i.e., a gun, knife, or club) and 13.8% had carried a gun, on 1 or more days of the 30 days preceding the survey.

OBJECTIVES: Because few studies have documented the prevalence of violent behaviour and its determinants among alternative school youth, we conducted this study to describe violent behaviours and aggression among youth attending alternative schools and to examine socio-demographic factors associated with violence. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 787

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METHOD OR APPROACH: This study involved 494 students attending 10 alternative schools in Southwest Texas. Alternative education serves youth, who are at risk of dropping out of high school. Approximately 280,000 students nationwide attend alternative high schools. Students are admitted to these alternative programs for a variety of reasons including poor academic performance, poor school attendance, disruptive behaviour, substance use, pregnancy, and having contact with the juvenile justice system. Data were collected between November 2000 and February 2001 via audio-enabled laptop computers equipped with headphones. The self-administered survey included questions related to demographics, self- reported aggressive behaviour, and other forms of aggressive behaviour. Statistical analyses include descriptive statistics such as frequencies, means, and standard deviations. The association between gender, race, and age and violent behaviours (weapon carrying, gun carrying, knife or club carrying, fighting, and had been injured in a fight) was examined. Chi- square tests, ANOVA and t-test were used to calculate significant differences. Logistic regression was used to conduct bivariate and multivariate analysis. Students were divided into four mutually exclusive violence-related categories to examine socio-demographic factors associated with violence. The categories were: 1. Students who were not involved in a physical fight during the last 12 months and who did not carry a weapon during the past 30 days (referent group); 2. Students who carried a weapon (gun, knife, or club) during the past 30 days at least once but were not involved in a physical fight during the last 12 months; 3. Students who were involved in a physical fight at least once during last 12 months but did not carry a weapon during the past 30 days; and 4. Students who both carried a weapon during the past 30 days and were involved in a physical fight during the last 12 months.

Students reported an average of 11.8 aggressive acts during the week prior to the survey. Violence related variables indicated 30-day weapon carrying prevalence of 22.7%; 30-day gun carrying prevalence, 11.1%; 30-day knife or club prevalence, 17.2%; 12-month fighting prevalence, 50.6%; and 12-month prevalence of injuries due to fighting, 6.5%. The association between demographic variables and each violence-related behaviour was described using multinomial logistic regression. Demographic variables included: gender, race, anger (the aggression scale), age, and grades in schools. Results showed that aggression is associated and significant at every level of the violence-related categories (OR 1.1 per unit of increase, 95% CI 1.0-1.1; p<0.000) and in presence of the covariates (race, gender, age, and grades in school). Gender was significantly associated with weapon-carrying (OR 2.5, 95% CI 1.1-5.6; p=0.02.

CONCLUSION: Overall the data indicate that youth in alternative schools are at urgent need for prevention and treatment programs to help them live in a safer environment.

LIMITS: Alternative students in the current study were sampled from one county in Texas. This study should be replicated across the country to examine the extent to which alternative school students are involved in violent behaviours such as carrying weapons and fighting.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Examining the prevalence and determinants of violent behaviour among undeserved populations. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 788

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VIOLENCE CHEZ LES JEUNES D’ÂGE SCOLAIRE : CARACTÉRISTIQUES ÉPIDÉMIOLOGIQUES ET ESSAI DE PRISE EN CHARGE

ZOUGHAILECH DJAMEL,BOUSSOUF NADIR,BOUNECER HOCINE, DEKKAR NOUREDINE ORS Constantine, Algérie

PROBLÉMATIQUE : La violence a été reconnue comme problème de santé publique dans le monde et en Algérie. Comment la surveiller et la prévenir. La connaissance de ses caracté- ristiques épidémiologiques et de ses formes d’expression à l’age scolaire permet d’intervenir précocement et de réduire la gravité de ses conséquences. Le milieu scolaire nous semble un passage déterminant car il offre certaines spécificités : 1. Par sa démographie, la population d’âge scolaire constitue plus de la moitié de notre population; 2. L’école n’est pas toujours le lieu de l’épanouissement mais fréquemment celui de l’échec, faute d’une adaptation aux caractéristiques actuelles de développement des sociétés modernes, le système scolaire reste rigide et incohérent provocant un transfert d’agressivité du milieu familial vers le milieu scolaire; 3. Par ses capacités et ses moyens d’intervention à travers l’activité d’apprentissage et la densité et la qualité de la couverture sanitaire à travers le réseau de santé scolaire.

OBJECTIFS : 1. Élaborer des données épidémiologiques sur la violence en milieu scolaire; 2. Proposer une stratégies multidisciplinaires pour la surveillance et la prise en charge de la violence chez les enfants d’âge scolaire.

MÉTHODE OU APPROCHE : Il s’agit d’une étude transversale portant sur un échantillon de la population scolarisée (12-18 ans ) des collèges et lycées représentative de deux wilayas de l’Est algérien et une du centre. On envisage d’élaborer non seulement les indicateurs des traumatismes et leurs conséquences mais aussi les indicateurs d’expositions qui entrent dans le cadre habituel des enquêtes transversales (indicateurs collectifs et individuels ainsi que les indicateurs psychologiques et sociologiques ). Le recueil d’information se fait par inter- rogatoire complétant la description clinique et psychologique du traumatisme. Les autres données proviennent d’études rétrospectives nationales et de l’exploitation de registres de santé scolaires, des urgences des hôpitaux et des services médico-légaux.

RÉSULTATS : L’étude préliminaire faite au niveau du Service d’Épidémiologie et de Médecine Préventive du Centre Hospitalier et Universitaire de Constantine sur 334 actes d’agression avec traumatisme, représentants 19% de l’échantillon d’étude, 69% sont intentionnels. Parmi les traumatismes, la forme physique est la plus fréquente avec 91%, la tranche d’âge la plus touchée est 14-17 ans. L’ensemble des données n’étant pas disponibles, l’analyse reste parcellaire, les autres indicateurs sont en cours de validation. Une formation en communication sociale a été organisée pour 30 jeunes leaders durant 10 jours, elle sera suivi d’un séminaire atelier pour l’élaboration d’un plan de communication annuelle au niveau des lycées et collèges. Proposer la mise en place d’un programme d’échanges de savoir et de pra- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 789

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tiques en matière d’actions d’éducation pour la santé mettant les jeunes en position d’acteurs/sujets. Un site de surveillance a été identifié au niveau de l’Observatoire Régional de la Santé.

CONCLUSION: Cette étude permettra de mieux définir le problème notamment en appréciant sur la base de données objectives l’ampleur, la gravité et l’évolution dans le temps des diffé- rentes formes de violence et particulièrement en mettant au point des mesures et programmes destinés à prévenir la violence à en atténuer les effets il reste à en évaluer l’effica- cité par une recherche approfondie sur les facteurs de risques.

LIMITES : Étude descriptive. Problème d’évaluation de l’essai d’intervention par la communication sociale.

CONTRIBUTION DU PROJET AU DOMAINE : Notre étude, qui est une contribution au développe- ment des activités retenue dans la stratégie conjointe CICR-OMS pour la prévention, les soins et la réhabilitation des victimes, a été approuvée au niveau international par les États, les agences des Nations unies et les ONG; ses axes sont : 1. La surveillance épidémiologique; 2. La recherche des facteurs de risque et des déterminants; 3. L’intervention sanitaire et la politique de santé.

PRINCIPAUX FACTEURS DE VIOLENCE ET RISQUE DE VIOLENCE ASSOCIÉS AU MILIEU SCOLAIRE EN RÉPUBLIQUE DÉMOCRATIQUE DU CONGO

DEDI-ODEKO OSANGO Ministère de l’Éducation Kinshasa 1, République Démocratique du Congo

PROBLÉMATIQUE : Dégager un ensemble des phénomènes liés à l’émergence de la violence en R.D. du Congo; cas de la ville de Kinshasa.

OBJECTIFS : 1. Contribuer dans l’amélioration ou l’assainissement dans l’environnement scolaire; 2. Proposer des pistes de solution pour diminuer les risques de violence dans le milieu scolaire.

MÉTHODE OU APPROCHE : Analyse du système scolaire, établissement de l’échantillonnage et l’observation participative.

RÉSULTATS : 1. Développer les outils de gestion de conflits (violence ou risques de violence); 2. Établir un programme de formation de formateurs envie de la prévention des incidences de violence dans le milieu scolaire.

CONCLUSION : Présentation de l’environnement scolaire et des facteurs de violence. Proposition des pistes de diminution de la violence. Partage d’expérience et de connaissance. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 790

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LIMITES : Nous nous sommes limités dans la Ville de Kinshasa, compte tenu de sa relative stabilité sur le plan politique, économique et social par rapport à d’autres provinces.

CONTRIBUTION DU PROJET AU DOMAINE : Nous avons isolé et analysé les types de violence obser- vée dans les écoles de la capitale de la R.D. du Congo.

TEMPORAL VARIATIONS IN SCHOOL-ASSOCIATED STUDENT HOMICIDE AND SUICIDE EVENTS – USA, 1992-1999

MARK ANDERSON,SCOTT KEGLER,THOMAS SIMON,JOANNE KAUFMAN, LISA BARRIOS,WILLIAM MODZELESKI,THOMAS FEUCHT National Centre for Injury Prevention and Control Atlanta, Ga, USA

PROBLEM UNDER STUDY: Recent, widely reported violent deaths associated with schools in the USA have led many adults to believe that a school shooting could occur in their community and many children to express increasing concern about their own safety at school. The Centres for Disease Control and Prevention (CDC), in collaboration with the U. S. Education and Justice departments, has been tracking school-associated violent deaths since the 1992- 1993 school year.

OBJECTIVES: To evaluate whether the risk for school-associated violent death varies during the school year, CDC analyzed monthly counts of school-associated homicide and suicide events that occurred among students in elementary and secondary (middle, junior high, and senior high) schools in USA.

METHOD OR APPROACH: For these analyses, a school-associated violent death event was defined as a homicide or suicide of a student in which the fatal injury occurred: 1. On the campus of a functioning public or private elementary or secondary school in USA; 2. While the victim was on the way to or from regular sessions at such a school; or 3. While the victim was attending or traveling to or from an official school sponsored event. School-associated violent deaths were identified by study collaborators and through 2 online databases. Each case was confirmed by contacting school or police officials. Police reports, and interviews with police and school officials provided detailed information about each case. For each event type, the number of events per school day was calculated for each month in the school calendar. Poisson rate models were used to evaluate the trends over the school year.

RESULTS: For the seven school years during September 1, 1992 - June 30, 1999, 209 school- associated violent death events occurred that involved either the homicide or the suicide of a student. An average of 0.14 school-associated homicide events occurred each day (one event every seven school days). For homicide events, rates decreased during the semester (monthly change in log rate: -0.2; p=0.0002) and increased markedly in association with the transition between the fall and spring semesters (increase in log rate: 0.98; p=0.001). An average of 0.03 suicide events occurred each school day (one event every 31 school days). The BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 791

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estimated Poisson rate models for suicide events involved a non-significant time-trend variable. However, a simplified model, which included only the semester transition variable, suggested a suicide event rate that was higher during the spring semester than during the fall semester (increase in log rate: 1.0; p=0.0103).

CONCLUSION: These findings suggest significant systematic temporal variations in school- associated student homicide and suicide events. Student homicide event rates were highest near the start of the semester and then declined over the following months. In comparison, suicide event rates did not show any significant variation within semesters, but the overall rate was significantly higher in the spring semester than in the fall semester.

LIMITS: The findings in this report are subject to at least two limitations. First, because events were identified from news media reports, any event not reported in the media would not have been included in the study. However, if underreporting did occur and some events were missed, coverage probably did not vary by the time of year and would not account for the temporal variations observed. Second, because suicide event trend analysis is based on a small number of reported events, result should be interpreted with caution.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Prevention programs can be effective in preventing youth violence. Effective programs often focus on both individual risk factors and environmental conditions that may predispose young persons toward violent behaviour. By describing temporal variations in school-associated student homicide and suicide events, this study provides information that can assist school administrators and faculty in planning the timing and focus of violence prevention programs.

SURVEILLANCE OF DISRUPTIVE BEHAVIOURS IN ELEMENTARY SCHOOL SETTING

JOHN C. LEBLANC,DANIEL WASCHBUSCH,NORMAND CARREY, RICK TULLY,HETTY VAN GURP Dalhousie University Halifax, NS, Canada

OBJECTIVES: Disruptive behaviours in elementary school student are common, have negative impact on individuals and the school environment and are a risk factor for later conduct disorder and serious or violent offences. We implemented a tracking system for disruptive behaviours in 5 elementary schools (kindergarten to 6) in Halifax, Nova Scotia, Canada. Our long-term goals are to monitor disruptive behaviours continuously and at low cost and to identify students with chronic or serious patterns of disruptive behaviours. This presentation will: 1. Outline the types of behaviour by age, sex, and school; 2. Describe responses by school officials to these behaviours.

METHOD OR APPROACH: The system includes a standardized teacher-to-school office referral form, usage policies, and a database for data entry and report generation. The form uses closed and open-ended items to describe the incident and interventions undertaken by the teacher and office. Disruptive behaviour incidents are currently being coded for analysis. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 792

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RESULTS: From September 1999 to June 2000, 3,570 incidents were reported for 1,177 students. Seventy percent of students were never referred to the office and 5% were referred from 5 - 100 times. The proportion of students with at least one referral ranged from 27 - 62% percent among the schools with an overall proportion of 38%. The proportions for males and females respectively were 49% and 24%. Detailed descriptions of physical, verbal and non-verbal incidents will be presented as well as responses by school officials including counselling, referral, discussion with parents and suspension.

CONCLUSION: School-based surveillance of disruptive behaviours is feasible, sustainable and allows schools to monitor changes in behaviour over time and responses by school officials to disruptive behaviour. The systematic approach of the SITS has the potential to streamline the referral process, and to prioritize children who require specialized programming or resources inside or outside of the public education system.

LIMITS: Teachers differ in considering which behaviours to manage in the classroom and which behaviours to refer to the office. interpretation of cross-sectional data (e.g., comparison of rates of disruptive behaviour by class) must account for these differences.

CONTRIBUTION OF THE PROJECT TO THE FIELD: the few studies that describe the epidemiology of disruptive behaviours in the school setting are cross-sectional. A low-cost continuous surveillance system will provide longitudinal data of sufficient quality to assess temporal changes in incidence and type of disruptive behaviours and will allow linkage to other student-specific data.

G.R.E.A.T. SCHOOLS AND FAMILIES PROJECT: VIOLENCE PREVENTION IN MIDDLE SCHOOLS

ARTHUR M. HORNE,PAMELA ORPINAS,WILLIAM QUINN The University of Georgia Athens, Ga, USA

PROBLEM UNDER STUDY: Violence is a persistent public health problem. Increased frequency of school violence and heightened teacher and parent concerns about school safety has become tantamount. The need to intervene with early adolescents is increasingly clear for a number of reasons. First, the rates of violent victimization and perpetration are highest among adolescents. Second, violent behaviour evolves over long periods of time, becoming more difficult to change as children enter adolescence and behaviour patterns become more firmly established. Finally, many of the risk factors associated with the development of violence are present at a young age, such as poor parental monitoring and weak student norms that tac- itly permit aggression. In an effort to address the alarming levels of school violence, prevention programs and policies have been implemented throughout the USA. However, despite the increased number of violence prevention programs in schools, few have been rig- orously evaluated for effectiveness or tested in different locations.

OBJECTIVES: This presentation describes the G.R.E.A.T. Schools and Families Project, a large multi-site violence prevention project for middle schools, which is currently being implemented in the USA. The presentation will include three sections: BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 793

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1. Description of the two universal violence prevention interventions (student curriculum and skills-training program for teachers) and the targeted intervention (family program for high risk children). All interventions have been developed based on the effectiveness of several promising middle school and family-based interventions; 2. Examination of the methodology of this complex study; 3. Discussion of preliminary pilot and baseline data.

METHOD OR APPROACH: The G.R.E.A.T. Schools and Families Project, which is funded by the Centres for Disease Control and Prevention from the USA, is a collaborative project The University of Georgia (Northeast Georgia), Duke University (Durham, NC), Virginia Commonwealth University (Richmond, VA), and University of Illinois (Chicago). All four sites are implementing the same intervention and evaluation procedures. Nine middle schools in Northeast Georgia, eight in Durham, NC, eight in Richmond, VA, and twelve in Chicago have been randomly assigned to one of four conditions: 1. A student violence-prevention curriculum for all sixth graders and a skill development program for their teachers (universal intervention); 2. Family intervention for high risk children (targeted intervention); 3. Student curriculum, teacher skill development program, and family intervention; or 4. Assessment only. All measurement instruments and interventions were pilot tested during the spring of 2001.

The full intervention will be conducted between October 2001 and May 2002. From each school, 100 randomly selected students and 20 high-risk students and their parents will be assessed before and after the intervention.

RESULTS: Interventions of the G.R.E.A.T. Schools and Families Project were developed based on previous research and evaluation (Family Solutions, MACS, RIPP Curriculum, Bully Busters). In the pilot study, during the month prior to the evaluation, students reported on average 13 acts of physical aggression, 16 acts of verbal aggression, and 9 acts of relational aggression. Almost half of the students reported that it is a moderate to serious problem that teachers ignore it when students threat or tease other students. Variables under study include: school norms on violence; frequency of aggression, victimization, drug use, and delinquency; referrals to school office; academic progress; teacher classroom management; and family changes in parenting/supervision/home-school partnerships.

CONCLUSION: The G.R.E.A.T. Schools and Families Project is one of the largest violence prevention studies being implemented and evaluated in the USA in middle schools. Initial evaluations showed high overall levels of aggression and a school climate supportive of aggression.

LIMITS: Post and follow-up data will not be available for this presentation.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study will answer the question whether a universal intervention, a targeted intervention or both are necessary to reduce aggression in middle schools. The effectiveness of the program will be evaluated in multiple sites using a systematic random design to ensure that the results can be successfully replicated in other BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 794

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communities in the USA. This study will influence decision-making by school districts and local communities in the USA regarding effective violence prevention programs.

CREATING PEACEFUL SCHOOLS AND COMMUNITIES WITH PEACEBUILDERS

GAYRE CHRISTIE Heartsprings Brisbane, Queensland, Australia This paper will describe traditional school-based violence intervention and prevention strategies, and demonstrate their shortcomings. It will then describe multiple features of partially successful programs. Next, it will describe the development and implementation of the PeaceBuilders program in a number of Australian, Scottish and American school and community settings. Finally, it will report on empirical findings from these locations that demonstrate a range of outcome measures leading to reduced violence and other anti-social acts in both the short, medium and long term.

PROBLEM UNDER STUDY: The failure of traditional piecemeal violence prevention approaches. To create a sustainable intervention and prevention strategy which would have empirically demonstrable outcomes. The creation of a new prevention program firmly based on forty years of replicable findings from long-term intervention strategies. Multiple short and long- term outcomes including widespread program uptake, widespread program adherence and demonstrable decreases in violence, bullying and other anti-social behaviours within target groups.

CONCLUSION: Programs can be developed and implemented which have sustainable results. Cost of program implementation and the limits of public funding based upon short-term political expediency. This program provides a blueprint that can be replicated in any cultural setting. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 795

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Identification des facteurs associés aux morts violentes et aux blessures Identification of Factors Associated with Injuries and Deaths from Violence

HOMIC,IDE AND FACTORS THAT DETERMINE FATALITY FROM ASSAULT IN THE U.S. ELDERLY POPULATION

LAWRENCE D. CHU,JESS F. K RAUS Southern California Injury Prevention Research Centre, UCLA, University of California Los Angeles, Ca, USA

PROBLEM UNDER STUDY: Homicide and assault against the elderly is a serious, but largely unrec- ognized public health problem in the USA and affects all persons regardless of sex, race, ethnicity, or socio-economic status. There are, on average, close to 1,000 persons 65 or older killed each year in the U.S. at the hands of another and an additional 120,000 per year are assaulted. Homicides and injuries from assault can exact a large toll on individuals in terms of costs for hospitalizations, lost time away from work, long-term care for disabilities, and loss of independent living, as well as a financial burden to society for care of the disadvantaged.

OBJECTIVES: The primary objectives of this research were to determine the magnitude of homicide in the U.S. elderly population, to assess differences between survivors and non-survivors of serious assault, and to develop preventive measures to reduce these deaths.

METHOD OR APPROACH: Two Federal Bureau of Investigation data sources using national law enforcement reports were analyzed to address the objectives. All non-negligent homicides of persons 65 and older from 1980 to 1998 were extracted from the Supplemental Homicide Reports. Rates and rate ratios were calculated for victims and offenders, and interpersonal factors were assessed for this population. The National Incident-Based Reporting System database for 1998 was used to obtain information on survivors and non-survivors of serious assault from the same base population. Weighted logistic models for all victims and elderly victims were examined for possible predictive factors of fatal assault.

RESULTS: From 1980-1998, there were 21,319 elderly homicides involving 22,705 perpetrators in the USA. Similar to younger-aged victims, males and African Americans had the highest rates for elderly homicide by sex and race, respectively. Offending rates of elderly homicide were highest among men, African Americans, and 15-24 year olds. However, a noticeable pattern in same-age homicides exists, indicating possible domestic violence concerns among the elderly. Felony-related assaults were the strongest predictors for fatality risk following assault among the elderly.

CONCLUSION: Violence against the elderly is a largely preventable problem; efforts can involve multidisciplinary approaches in criminology, psychology, sociology, political science, and BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 796

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public health. Results suggest that reducing the risk of crime victimization and increasing resistance to fatal outcomes for the elderly can be improved through education, proper health maintenance, and mandatory reporting of elder abuse by health care and law enforcement personnel.

LIMITS: The databases are comprised of voluntary reporting by law enforcement agencies. Not all agencies may report data completely and consistently so an undercount of homicides and assaults exists. Hence, these findings have limited external validity because the characteristics of the USA are not the same as the characteristics for specific states or other countries. Generalizability of these results should only be limited to the regions involved.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study addressed the limited research in the elderly population regarding predictive factors for fatal assault, offenders of elderly homicide, and different interpersonal and situational variables. By identifying high-risk groups for homicide, we can generate new hypotheses on risk factors, and subsequently target prevention and intervention efforts at the individual and community level.

NONFATAL ASSAULT-RELATED INJURIES TREATED IN HOSPITAL EMERGENCY DEPARTMENTS, USA, 2000

THOMAS SIMON,JOSEPH L. ANNEST,PATRICIA HOLMGREEN,EBEN INGRAM, RESHMA MAHENDRA,JAMES MERCY,LINDA SALTZMAN Centres for Disease Control and Prevention Atlanta, Ga, USA

PROBLEM UNDER STUDY: As a result of collaboration between the Consumer Product Safety Commission (CPSC) and the Centres for Disease Control and Prevention, the CPSC’s National Electronic Injury Surveillance System (NEISS) was expanded in July, 2000 to include all types of nonfatal injuries treated in US hospital emergency departments (EDs). This ongoing surveillance system provides an opportunity to calculate national estimates for recent patterns in nonfatal assault-related injuries treated in ED’s. These data also permit an analysis of the subgroups of victims most affected by these injuries.

OBJECTIVES: A recent CDC report on violence-related and unintentional injuries seen during the first 3 months of the expanded NEISS All Injury Program indicated that 5.3% of all injuries treated in the ED were due to non-sexual assaults and 0.2% were due to sexual assaults. This presentation will extend that report by providing national, annualized, weighted estimates of non-sexual assault-related injuries treated in US hospital EDs and descriptive information by sex, age, race/ethnicity, injury cause, diagnosis, primary body part injured, and outcome, using the first 6 months of data.

METHOD OR APPROACH: Data are from the US Consumer Product Safety Commission’s NEISS All Injury Program. Nonfatal injuries and poisonings were defined as bodily harm resulting from acute exposure to an external force or substance and near drowning, including unintentional and violence-related causes. All injuries were classified for intent of injury (i.e., unintentional, assault, self-harm, and legal intervention). Suspected and confirmed cases of interpersonal violence were coded as assaults. Assault injuries included those to victims, bystanders, police, and perpetrators. Our analysis is limited to those injuries classified as BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 797

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non-sexual assaults, which were treated in the ED during July through December 2000. Data regarding injury cause, diagnosis, primary body part, and disposition were collected.

RESULTS: A total of 13,148 patients with injuries from non-sexual assault were treated in hospital EDs during the study period, representing an annualized weighted estimate of 1,608,133 injuries. Of these patients, 63% were males and nearly half (47%) were younger than age 25. The injury rate among blacks (1,390/100,000) was approximately 4.9 times higher than the rate among white non-Hispanics (286/100,000). Most injuries were caused by being hit with an object or by another person (81%) or being cut/pierced with a sharp instrument (8%). The majority of injuries were contusions (31%) or lacerations (23%), followed by fractures (10%), internal injuries (7%), punctures (7%), and strains or sprains (7%). The parts of the body most affected were the head (54%), arms/hands (19%), and the upper trunk (10%). Most of the patients were treated and released (93%), only 6% required hospitalization.

CONCLUSION: These data indicate that more than 1.6 million people were treated for injuries stemming from nonfatal assaults. These injuries were disproportionately seen among males, adolescents and young adults, and blacks of both sexes. Most of the injuries were contusions, lacerations, or fractures and relatively few resulted in hospitalization.

LIMITS: These findings are from data collected for a 6-month period, and may not reflect seasonal differences in the number of assault-related injuries. Data for the NEISS system are based solely on information contained in the ED records and are not linked or supple- mented with other sources of data. Finally, the outcomes described here are specific to the ED visit and do not include subsequent outcomes or injuries resulting in deaths.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This analysis highlights the utility of the NEISS for providing a national estimate of the number of non-sexual assault-related injuries treated in US hospital EDs and descriptive information about those injuries. These NEISS data increase our understanding of the magnitude and characteristics of assault-related injuries and can provide the basis for monitoring trends, facilitating additional research on the costs and consequences of assault injuries, and for evaluating prevention programs and policies.

EPIDEMIOLOGY OF HOMICIDES IN CALI, 1993-1998. SIX YEARS OF A POPULATION-BASED SURVEILLANCE SYSTEM

CONCHA-EASTMAN ALBERTO,VICTORIA E. ESPITIA, RAFAEL ESPINOSA,RODRIGO GUERRERO Pan American Health Organisation Washington, DC, USA

PROBLEM UNDER STUDY: In the 90’s the city of Cali, Colombia, faced a great burden of violence. Homicide’s rate reached as high as 124 per 100,000 inhabitants in 1994. In 1992 the mayor decided to launch a violence preventive program, based on the following guiding principles: is its Multi-causal, Research is needed to know more about its causes and characteristics, Prevention strategies should be implemented, Community empowerment is required for its success. A task group composed by representatives of all institutions involved in one way or BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 798

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another with the control, care of victims, and prevention was created with the purpose of collecting and monitor the occurrence of violent events in the city. The results of their work on homicides are presented here for the first six years of its implementation.

OBJECTIVES: 1. To implement a reliable and timely homicides surveillance system for the city; 2. To analyze the information and make recommendations to the mayor and other local authorities.

METHOD OR APPROACH: the task group gathers weekly to review every case and bring about a unique report for the Mayor’s Office. Their members are from the Police, the Prosecutor Office, the Secretariat of Health, the Forensic Institute and the Human Rights Advocate office. Each representative brings to their weekly meetings the information collected on the cases that happened the previous week. They share it with the others, under the coordination of an epidemiologist from the City Hall. A unique report containing data for 14 variables is prepared and sent to the mayor. It is worth to say that before this task force was established each institution’s reports varied a great deal from the others.

RESULTS: Between 1993 and 1998 there were 11457 homicides in Cali. Homicide rates in Cali increased five fold from 23 in 1983 to 124/100.000 inhabitants in 1994, and have declined in the following three years to 112 in 1995, 102 in 1996 and 86.1/100.000 in 1997. In 1998, the rate increased to 88/100.000. Male in the age-groups 24-34 years had homicide rates between three and four fold higher than the city average every year; however, all age groups are affected, 44 children under five included. The ratio male/female has been in the range 14.3 to 17.8. People from the lower socio-economic strata had the highest number, proportion and rates but also those of the upper class had high rates, around 160/100.000. Handguns and other firearms were used in more than 80% of the cases. Two out of three homicides occurred overnight and during weekends, mainly on Sundays, when 25% cases happened. In only 8-21% of the cases there has been a perpetrator syndicated of the crime. A bivariate analysis was conducted to look for possible associations between variables, such as: alcohol consumption by the victim was positively associated with use of firearm by the perpetrator (OR: 3.1 95% CI 2.6-3.6), if the homicide happened on the occasion of an interpersonal fighting, it was statistically significant when the perpetrator used a knife or sharp object and the victim was consuming alcohol (OR: 1.9 IC 95% 1.4-2.6). A map by homicide neighbourhood of occurrence is included.

CONCLUSION: This system has proved to be a powerful tool for decision making. Local authorities use its data on a routine basis. The information it produces is reliable, timely, and simple and has low cost. It has been operating without interruption since established.

LIMITS: There are variables from which the information still is not complete.

CONTRIBUTION OF THE PROJECT TO THE FIELD: • Based on this surveillance system report local authorities have made decisions to lower crime and homicides in the city; • Researchers use the DESEPAZ reports for better understanding on the causes of violence at city level; • Local communities, the media and academicians also use its reports; • It has been adapted in other cities of Colombia. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 799

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THE RELATIONSHIP OF EDUCATIONAL ATTAINMENT TO HOMICIDE RATES: TRENDS IN THE USA 1991-1998

LE’ROY REESE,ALEXANDER CROSBY Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control Atlanta, Ga, USA Injury prevention is an important area of public health as examinations of age-adjusted mortality rates indicate that injury is the leading cause of death in the USA. Injury in public health is classified as either unintentional or intentional injury although the focus of this research is on intentional injuries, specifically homicide. Homicide has been the third leading cause of death among young people age 15-24 for the last decade and the leading cause of death for African American and Hispanic American youth during this same period. Violence has exacted a tremendous toll on minorities within the USA as young African American males in particular have accounted for over half of all homicide victims among 15-24 years olds for the last several years. A significant number of these victims lived in impoverished communities which recent census data indicates there is a disproportionate representation of ethnic and racial minorities among the poor in the US. Poverty has been linked to the quality of and number of years of formal schooling that may youth complete and is considered a factor in youth violence although empirical investigations of this relationship have been limited. Empirical efforts to study risk factors for violent behaviour and victimization have largely focused on examinations of individual, familial, and to lesser extent community factors. In the present study, we seek to understand the relationship of educational attainment on homicidal victimization among different ethnic groups in the US and among males and females.

OBJECTIVES: 1. Is there a relationship between educational attainment and homicide?; specifically, does an individual’s risk for homicide decrease as the number of years of formal education completed increases?; 2. Do statistically significant differences exist among males and females as the number of years of education increases for victimization by homicide?; 3. Do statistically significant differences exist among different ethnic groups and by gender as the number of years of education increases for victimization by homicide?.

METHOD OR APPROACH: We use data from the Current Population Survey (CPS) of the US Census Bureau for the years 1991-1998 on individuals age 25 and older to measure educational attainment. We identified homicides using final mortality data from the National Centre for Health Statistics at the CDC. Using the CPS data, three discrete categories of formal educational attainment were created; 0-11 years, 12-16 years, and 16 or more years of education completed. Using the mortality data, we calculated rates of homicidal victimization by each of the aforementioned categories.

RESULTS: Our preliminary results (1991-1995) indicate that homicide rates decreased significantly overall across all demographic groups as the years of education completed BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 800

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increased. These decreases were most evident among African Americans. These initial analyses that among Hispanic with between 12-15 years of education there was an increase in homicides. We will have completed all of our analyses by the time of the conference and will present rates for each demographic groups from 1991-1998.

LIMITS: One limitation of this study is that not all states reported educational attainment data with mortality data, which meant that several states were excluded from our initial analyses. This problem has been addressed however as all except for two of those states now include this data on death certificates.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The implications of this research are broad. In the USA, public health officials are actively engaged in efforts to prevent intentional injuries, particularly among ethnic minorities where the burden has been disproportionate to their representation in the population. These results suggest that educational attainment (i.e. high school completion) has important prophylactic functions in preventing homicides in a manner perhaps different the specific violence prevention efforts that often take place in schools. That the decreases of homicidal risk are most evident among African American is encouraging given their pronounced victimization by homicide and lower high school graduation rates when compared to other minorities except Hispanic Americans. Lastly, these results speak to the need for additional research focused on enhancing school engagement and achievement among all young people in the US.

VIOLENT INJURY SURVEILLANCE IN DEVELOPING COUNTRIES: CASE STUDY, JAMAICA

GLENDENE LEMARD University of Miami Plantation, Fl, USA

PROBLEM UNDER STUDY: The first step in the public health approach to injury prevention is epidemiological surveillance to document trends and identify preventable factors. Within Latin America and the Caribbean, injuries related to violence have been on the rise due to political conflicts, civil instability, increased crime and a high social tolerance for violence. Jamaica has a disproportionately high rate of violence, which has considerably risen over the years. Much of this violence is associated with political warfare, drugs and gang-related activities. However, in the last 20 years Jamaica has witnessed a wave of violence that supersedes the clearly defined realms of politics and drugs, with a marked increase in interpersonal and social violence such as domestic violence and sexual assault. Injuries have been one of the leading causes of curative visits to health care facilities, but only recently have injuries been identified as intentional versus unintentional. Thus, until sufficient data on intentional injuries is available from the health care sector, we must rely on police reporting of violent crime in order to study historical trends in violent injury.

OBJECTIVES: The aim of this presentation is: 1. To track the rate of violent crime in Jamaica from 1970-2000; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 801

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2. To identify the major cases of violent crimes and injuries and to disaggregate such data by region (urban/rural), age, gender, motive and type of weapon used.

METHOD OR APPROACH: • Examination of reports and data provided by the Jamaican Ministry of Health Injury Surveillance System; • Review of available statistics on major crimes provided by the Jamaica Constabulary Force; • Qualitative interviews with police officers and health professionals who deal with violent crimes and injuries on a daily basis.

RESULTS: Trauma and injuries caused by motor vehicle accidents and acts of violence are among the leading causes of death among persons between age 20 and 44 years in Jamaica. Between 1999-2000 50.6% of injuries seen by three major hospitals were caused by stabbing using a knife or other sharp instrument. In 2000, 24% of patients seen for stab wounds, 16.5% seen for gun shot wounds and 57.8% seen for sexual assault were between 10-19 years old. Rape and carnal abuse (sexual abuse of a minor) are among the highest rates of violent crimes. The most common motives for murder include gang-related (23%), domestic violence (27%), and reprisals (avenging a wrong) (29%). Domestic violence is equally prevalent as gang-related violence. The gun is the most popular instrument used in murders (65%) and robbery (68%). Urban centres have the highest rates of reported murders (79%), shootings (76%), rapes (65%) while the rural areas have the higher rate of carnal abuse (56%).

CONCLUSION: While intentional injury surveillance in Jamaica is relatively new, the data that is recorded illustrates the increasing importance of injury prevention initiatives and a need for an intensive focus on injuries as it relates to health and development. Local surveillance is extremely important in developing countries such as Jamaica where cultural issues bear great weight in the definition of violent crimes. In many instances there is cultural support of violence witnessed though the lyrics of popular songs, which endorse rape, child abuse and reprisals.

LIMITS: The data is limited to only crimes that were reported or injuries seen at hospitals. Unreported incidents of assault, rape, domestic abuse and other violent acts would not be included in police statistics and cases were injuries were slight and dressed at home would not be included in the hospital statistics. There might be instances of misclassification bias since the definition used by the police force for domestic violence includes violence among persons who are not related but who may be acquaintances with each other. For example, if a violent act occurred in a home, but the parties were unrelated, this is viewed as domestic violence. The term domestic encompasses instances of social violence, and this must be considered when interpreting the data.

CONTRIBUTION OF THE PROJECT TO THE FIELD: While it is difficult it is for developing countries to do surveillance at the same scale as what is done in the US, by examining existing data that is routinely collected by health and law enforcement we can make the first steps towards establishing preventive mechanisms for violent injuries. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 802

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ROUNDTABLE ON DEVELOPING A SURVEILLANCE SYSTEM FOR VIOLENT DEATHS

DAVID HEMENWAY Harvard Injury Prevention Research Centre, Harvard University Boston, USA

PROBLEM UNDER STUDY: Suicide and homicide are the second and third leading causes of death among 15-34 year-olds in the United States. While a detailed reporting system exists at the federal and state level to collect data on every motor vehicle-related death, little information is collected on violent deaths to guide prevention efforts.

OBJECTIVES: An effort is underway to pilot test and implement a national reporting system for violent deaths.

METHOD OR APPROACH: A group of injury research centres, health departments, and universities in the United States have been developing and pilot testing a reporting system to collect in-depth data on homicides, suicides, firearm-related deaths, and other violent deaths. Information is gathered at the local level from death certificates, coroner/medical examiner reports, police reports, and crime labs. When guns are involved, some pilot sites gather information from the federal Bureau of Alcohol, Tobacco and Firearms about the source of guns used in the incident. Information is maintained in a relational database.

RESULTS: Because of the multi-source nature of the reporting system, important new information is being learned, for example, about the incidence of murder-suicides, the presence of drugs and alcohol among victims, the high proportion of shooting deaths in which a second victim or more are wounded, the prevalence of relationship break-ups and criminal activities as a precipitating factor in suicides, characteristics of guns involved in fatalities, and the prevalence of same-day crises as a precipitating factor in suicides.

CONCLUSION: The system is proving feasible in 13 states and metropolitan areas around the US. Plans are underway for the federal Centres for Disease Control and Prevention to implement the system should funding become available through a Congressional appropriation. The purpose of the roundtable is to receive an informal update from participants in the pilot and to hear about comparable efforts in other countries.

LIMITS: The quality of the reporting system and the utility of the data it collects are being evaluated throughout the pilot. Because the system relies on linking existing data sources such as medical examiner reports and police reports, its quality and timeliness are dependent on the accuracy and completeness of the original data sources and on how rapidly these data sources are made available for linkage.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The reporting system will supply vital new information about the nature of our suicide and homicide problem and give communities and policy makers tools to better evaluate which programs and policies are effective in preventing violent deaths. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 803

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UNDETERMINED VIOLENT DEATHS IN SWEDEN – A CROSS-CULTURAL ANALYSIS

MARCELLO FERRADA-NOLI,LEIF SVANSTRÖM Karolinska Institute, Dept. Public Health Sciences, Div. of Social Medicine Stockholm, Sweden

PROBLEM UNDER STUDY: Deaths occasioned by self-inflicted injures are categorised as accident or suicide, depending on whether lethal intention is or not concomitant. Thus, undetermined cases on the mode of death are those in which it cannot be inferred with a rea- sonable degree of certainty that the injury ultimately responsible for the person’s death was not only intentionally self-inflicted, but also intended to bring about that person’s demise. In Sweden, the incidence of such undetermined cases on the mode of death that can be either suicide or accident (UMSA) is high, and earlier estimates (seven undetermined cases per 100 000 pop.) placed Sweden among the highest rankings among 16 European countries.

OBJECTIVES: To analyse updated epidemiological data on the incidence of undetermined cases (UMSA) in Sweden in a cross-cultural breakdown.

METHOD OR APPROACH: The study presents epidemiological data based in vital statistics and forensic reports. Databases were compiled from classified data obtained at the Unit of Health and Social Services Statistics, Statistics Sweden (SCB), the National Board of Health and Welfare, and WHO publications. Complementary forensic data was obtained at the Department of Forensic Medicine in Stockholm. Chi-square tests were used to test the relationships between the variables and the levels of statistical significance.

RESULTS: The main finding of the study is the overrepresentation of foreign-born victims among the undetermined cases in Sweden.

CONCLUSION: Diagnostic factors regarding UMSA, as well as cross-cultural factors possibly related to violent-death vulnerability are discussed as contributory to the high representation of immigrants in the diagnoses of undetermined cases, which can be either suicide or accident.

LIMITS: In the main, unavailability of psychological autopsies which could help to asses lethal intention among the victims of “uncertain violent deaths”.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Diagnostic procedures, updated epidemiological data, cross-cultural factors.

DEVELOPMENT OF INTIMATE PARTNER VIOLENCE SURVEILLANCE SYSTEMS IN TWO U.S. STATES

MELISSA O’TOOLE,PATRICIA K. SMITH,MARILYN SITAKER Kentucky Injury Prevention & Research Centre Lexington, Ky, USA

PROBLEM UNDER STUDY: Systematic collection, analysis and interpretation of data are fundamental elements of the public health approach to prevention and control of any health BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 804

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problem, including Intimate Partner Violence (IPV). Recently, the USA Department of Justice and the Centres for Disease Control and Prevention (CDC) developed a set of uniform definitions and recommended data elements for IPV surveillance and funded several states to pilot test these recommendations. In addition, CDC funded the development of statewide IPV surveillance systems (IPVSS) based on accessing and linking hospital discharge and emergency room data, police data, victim advocacy centres, and court data systems.

OBJECTIVES: To describe how state-wide IPVSS were developed in two states within the USA. To compare and contrast approaches to building the system, sources of data used, and usefulness of data generated by the surveillance system.

METHOD OR APPROACH: The Michigan Department of Community Health received a CDC Cooperative Agreement to pilot test collection of recommended data elements and develop and IPVSS in 1994. The IPVSS was based on a compilation of prosecuting attorney (PA) data and emergency department (ED) data from a representative sample of counties in Michigan. In addition, a population-based survey on violence against women in 1996 was conducted to establish baseline data. The Kentucky Injury Prevention and Research Centre received a CDC Cooperative Agreement to develop a state-wide IPVSS in 1999. The Kentucky system is based on linkage of several statewide data collection systems, including vital statistics, hospital discharge, trauma registry, protective order and adult protective services. In addition, an annual population based survey is conducted to provide complementary data on the nature and prevalence of IPV in Kentucky.

RESULTS: Although identified IPV-related assaults against women constitute<1% of ED cases involving women age >16 years, pooled data from the sampled EDs in Michigan has yielded useful information on victim-perpetrator relationship, cohabitation status, injuries, police involvement, and temporal trends. However, the perpetrator is not identified in one quarter of the ED assault cases with female victims. The pooled PA data provided similar information, but also includes information on the perpetrator, case status and disposition. In Kentucky, individual datasets from the Administrative Office of the Courts (AOC) and Adult Protective Services (APS) were found to have fields with missing data for many records. Although all AOC cases are to be reported to the APS, linkage based on common variables was successful for less than a third of the 1999 records.

CONCLUSION: Development of a useful surveillance system for Intimate Partner Violence requires several years of patient work, and includes both technical and political challenges. The benefit of the experience of setting up an IPVSS goes beyond estimating the magnitude of the problem. By examining the hospital, judicial, and human services system databases that were obtained for these surveillance systems, problems with the accuracy and completeness of data were identified. Linking data also provided an indication of whether systems operated as planned. Finally, working with representatives of community agencies helped to build partnerships and led to better understanding of the approaches and tools that public health professionals have to offer communities who wish to address IPV.

LIMITS: Anyone wishing to set up a state-wide surveillance system for IPV will face a unique set of challenges, which depend in part upon the accuracy and completeness of data in each component data system and the degree to which collaborative relationships can be established with potential providers and users of surveillance system data. As with any public BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 805

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health surveillance system, an IPV system will require several years to evolve before data are truly useful, as relationships are built and data quality is improved.

CONTRIBUTION OF THE PROJECT TO THE FIELD: There is currently great interest globally in the prevention of IPV. The first step in any good public health approach to prevention is surveillance. The lessons learned by programs currently working on IPVSS development should help pave the way for future programs.

INTERNATIONAL COMPARISON OF VIOLENCE VICTIMISATION SITUATIONS AND THE IMPACT OF VICTIMISATION ON VICTIMS

MARKKU HEISKANEN Statistics Finland Helsinki, Finland

PROBLEM UNDER STUDY: During the last two decades victimisation surveys (i.e. interview studies focused to a sample of the adult population of the country, in which questions of crime experiences are asked) have become popular in different countries. The International Crime Victims Survey (ICVS) makes it possible to do comparisons between different countries.

OBJECTIVES: To expose the extent and the content of women’s an men’s victimisation to violence and it’s consequences to the victims in different areas.

METHOD OR APPROACH: The presentation focuses on the detailed information collected of the last victimisation event. The victimisation situation is constructed of the variables describing the relationship between the perpetrator and the victim, and the place of occurrence of the incidence. Men’s and women’s victimisation to violence differ of each other. Thus analyses of the victimisation in different areas (Northern Europe, Central Europe, Catholic Europe, The New World, the Former socialist countries and in the Developing countries) are done by gender. In developing the victimisation surveys more stress has been laid on the consequences of violence to the victim. The presentation also exposes the subjective consequences, injuries and received help from agencies specialized in helping the victims.

RESULTS & DISCUSSION: Results compare areas victimisation and it’s consequences by gender.(Statistical analyses will be completed during the autumn 2001).

CONTRIBUTION OF THE PROJECT TO THE FIELD: Descriptive comparative information of the extent, content and consequences of intentional violence in different areas of the world. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 806

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SAN FRANCISCO VIOLENT INJURY REPORTING SYSTEM: LINKAGE OF VICTIM-SUSPECT DATA FOR FATAL AND NON-FATAL ASSAULTS

MARY VASSAR,CAROLYN KLASSEN University of California, San Francisco, SF Injury Centre San Francisco, Ca, USA

PROBLEM UNDER STUDY: Each year in San Francisco (SF) nearly 1,000 persons suffer violence- related injuries leading to death or hospitalization and several thousand more victims are treated by paramedics and emergency departments. Efforts to identify risk factors and analyze trends were hindered by disparate and redundant data collection systems used by the police, emergency medical services, trauma centre, medical examiner, and district attorney.

OBJECTIVES: The SF Violent Injury Reporting System was established to link data from multiple agencies in an effort to: 1. Facilitate timely and accurate reporting of data; 2. Provide a centralized system to assist program officials and policy makers with decisions about resource needs for violence prevention programs; 3. Analyze trends and conduct prospective research aimed at examining the impact of prevention efforts and laws on rates of violent injuries and deaths; and 4. Serve as a grant site for pilot testing of the Harvard National Violent Death Reporting System (NVDRS).

METHOD OR APPROACH: Retrospective incident-based data for over 800 violence-related deaths and injuries during 1999-2000 were linked from the police reports, emergency department registry, hospital trauma registry, and medical examiner reports. More than 200 data elements were collected. This included nearly 100 data elements from the NVDRS for firearm- related fatalities combined with additional elements created for our local reporting system which included all incidents of non-fatal firearm and non-firearm related violence. The local data collection included information from police reports with current and historical details of prior police contacts in SF County. The study was approved by the Institutional Review Board. This preliminary analysis is focused on 176 incidents involving 177 victims of firearm homicides and assaults, which accounted for 81% of all the firearm injury-related incidents.

RESULTS: Of the 80 incidents where suspects were identified, 55% of the victims knew the alleged assailant. Sixty-six percent of the victims were shot in the street and eleven percent were shot in their homes. No shootings occurred in schools. The victims resided at the same address as the suspect in 24% of the incidents. Another 36% of the victims resided within 1 mile of the incident location. Prior contacts with police in SF County were reported for 67% of the victims and 95% of the known suspects. Of these, 64% of victims and 84% of known suspects had records for felony police contacts. For the 106 surviving victims, with prior police contacts, 62% had re-offended in SF County within the next calendar year. Based on the high incidence of police contacts among the surviving victims, a review of hospital records was undertaken to determine how frequently referrals were made to recidivism reduction, victim assistance or other appropriate social service programs. Overall, 25% BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 807

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of victims had documentation mentioning these types of referrals. For those victims with histories of police contacts, only 23% had mention of referrals. We were unable to document how frequently the victims followed through with participation in these programs and services.

LIMITS: These results represent a preliminary analysis of data for firearm-related injuries. Additional analysis for several hundred incidents of non-firearm assaults is underway and these findings will be presented at the conference.

CONCLUSION: In the first year of the data linkage effort we have shown that multi-agency sharing of data fulfilled the objective of identifying risk factors that can be incorporated into the development of strategies for prevention programs for survivors of violence. It is clear from these data that there is a need for resources to provide more hospital-based referrals for high-risk victims to recidivism reduction programs.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The establishment of multi-agency reporting systems that include data for survivors, fatalities and perpetrators will advance the development of prevention program strategies and the ability to evaluate the outcomes of efforts to inter- rupt the cycle of violence in our communities.

OBSERVATOIRE DE VIOLENCE ET DE DÉLINQUANCE DE BOGOTÁ : UNE STRATÉGIE POUR LA COEXISTENCE ET LA SÉCURITÉ DES CITOYENS

SONIA CARDONA Sistema Unificado De Información De Violencia Y Delincuencia Bogotá, Colombia

PROBLÉMATIQUE : Le bureau chargé de la gestion politique de la mairie de Bogotá se charge de formuler des politiques en matière de sécurité, justice, protection et promotion des droits et des libertés publiques, dans le but de fortifier et de garantir aux habitants la coexistence et l’égalité, dans un cadre juridique démocratique, décentralisé et de participation. En ce sens, l’Observatoire de Violence et Délinquance de Bogotá, comme filiale dudit bureau, cherche à renforcer la connaissance de la ville, en ce qui concerne les différentes manifestations de violence et de délinquance, à travers l’analyse des données et la recherche en permanence.

OBJECTIFS : Approfondir la connaissance de la ville en ce qui concerne les différentes manifestations de violence et de délinquance, par le biais des stratégies de recherches spécifiques, afin de détecter les variations, qui indiquent la nécessité, soit des interventions spéciales de la part des autorités compétentes, soir par l’adoption de nouvelles stratégies de contrôle, et en même temps, offrir des informations pour la définition des politiques.

MÉTHODE OU APPROCHE : L’Observatoire travaille à partir de cinq composantes : 1. Coordination inter-institutionnelle; 2. Système unifié d’information sur la violence et la délinquance; 3. Projets de recherche; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 808

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4. Divulgation et communications; 5. Création des observatoires locaux de la sécurité.

Coordination inter-institutionnelle : Une des fonctions principales de l’Observatoire de Violence et de Délinquance dans la ville, est celle d’apporter des analyses de l’information en rapport avec les comportements de la délinquance dans la ville et d’effectuer des recherches pour l’analyse des données, dans des espaces créés a ce sujet. Ces espaces ont comme fondement la prise de décisions à caractère stratégique, ce qui est possible quand l’on dispose, d’une part, d’un instrument agile et approprié qui fournit de l’information et, d’autre part, quand on réussit à atteindre des niveaux de coordination inter-institutionnelle pour le maniement des donnés et la définition d’actions spécialisées, pour faire face aux différentes problématiques qui affectent, autant la sécurité que la coexistence des citoyens.

Système unifié d’information sur la violence et la délinquance ( SUIVD) : Le SUIVD s’oc- cupe de la mise en oeuvre d’un système unifié d’information, avec l’interconnexion en réseau, d’organismes tels que la Police Métropolitaine, l’Institut National de Médecine Légale et le bureau chargé de la gestion politique de la ville, afin de disposer et d’améliorer l’information, pour la formulation de politiques et la prise de décisions tendant à la prévention, l’attention et le traitement de la violence et du délit.

Recherches : L’Observatoire développe une stratégie de recherche, laquelle a comme défi d’intégrer des nouvelles connaissances, en s’appropriant des savoirs en rapport avec la quo- tidienneté, l’observation permanente, l’évaluation et le suivi d’actions institutionnelles, en faveur de la sécurité. La recherche permettra à l’Observatoire d’approfondir des sujets spécifiques, de sorte qu’on puisse réunir de l’information variée et contextualisée, sur l’impact social des délits en aler- tant la population sur les nouvelles façons par lesquelles pourrait être affectée la vie des citoyens.

Divulgation et communications : L’analyse et le suivi systématique des zones périlleuses de la ville permettent autant aux citoyens qu’aux autorités de prendre des décisions, du point de vue tant politique qu’organisationnel, pour l’action et la prévention. En ce sens, il dispose d’une page Web (www.suivd.gov.co) et de publications sur les thèmes spécifiques de la sécurité et de la coexistence à Bogotá.

Observatoires locaux de sécurité : La décentralisation dans la prise de décisions passe par les thèmes de la sécurité, lesquels demandent de l’information adéquate et analysée.

RÉSULTATS : L’Observatoire produit à intervalles plus ou moins réguliers, des documents relatifs à l’analyse de I’information sur la violence et la délinquance; ces produits peuvent être hebdomadaires, mensuels, aux quatre mois et semestriels. De plus, l’Observatoire a comme responsabilité de faire le suivi des données en rapport avec les objectifs du programme «Vie sacrée» (réduction des morts violentes et réduction des autres délits à impact social). Ce texte a été traduit de l’espagnol par Jose Hector Paz. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 809

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Tendances internationales dans la compréhension et la prévention des mauvais traitements envers les enfants International Trends in Understanding and Preventing Child Abuse and Neglect

THE DEVELOPMENT OF A COMPREHENSIVE PLAN FOR THE PREVENTION OF CHILD MALTREATMENT

GENE SHELLEY Division of Violence Prevention, Centres for Disease Control and Prevention Atlanta, Ga, USA

PROBLEM UNDER STUDY: Child Maltreatment Prevention.

OBJECTIVES: To develop a comprehensive plan for child maltreatment prevention that can be used by the Division of Violence Prevention, Centres for Disease Control and Prevention, USA and others interested in the prevention of child maltreatment.

METHOD OR APPROACH: The Centres for Disease Control and Prevention (CDC), National Centre for Injury Prevention and Control (NCIPC), Division of Violence Prevention (DVP) has for several years been in the process of developing its activities in the area of child maltreatment prevention. This process has involved the consultation of approximately 100 child maltreatment experts, including individuals from the following groups: 1. Child maltreatment researchers from a variety of academic disciplines; 2. Service providers from health care, criminal justice and social work fields; and 3. Representatives from other federal agencies engaged in the area of child maltreatment prevention (e.g. Office of Child Abuse and Neglect, National Institutes of Health, National Institutes of Justice). Experts were convened for two meetings; additional input was also obtained through email and by phone. The experts were asked to develop a comprehensive plan that would be the blueprint for future action with regard to child maltreatment prevention activities at CDC.

RESULTS: The first meeting of experts produced a plan consisting of 70 prioritized activities for the prevention of child maltreatment. The items were organized into the four areas of the public health model: Surveillance, Research, Evaluation and Implementation/ Dissemination. Based on this plan, the CDC received funds for the prevention of child maltreatment. The second meeting of experts developed the plan in more detail. The experts were given the 70 prioritized activities and were also provided with information on recent research agenda setting activities in NCIPC related to child maltreatment. The resulting plan will be presented and discussed. In addition, the activities in which CDC is currently engaged in the area of child maltreatment will also be briefly presented. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 810

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CONCLUSION: Child maltreatment prevention requires collaboration and consultation with others in order to create a comprehensive set of prevention activities that are valid and useful for the prevention of child maltreatment. The contributions and backgrounds of a variety of individuals are invaluable in creating such a multi-dimensional plan.

LIMITS: This is not a research study, but it does have implications for research, intervention, evaluation, surveillance, strategies for prevention and policy making.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The comprehensive plan for the prevention of child maltreatment will be very useful to CDC in its activities. However, the plan encompasses more than what CDC might be able to accomplish alone. Other individuals or agencies may be able to use parts of this plan in their child maltreatment activities.

CORPORAL PUNISHMENT IN LATIN AMERICA AND SPAIN

PAMELA ORPINAS,DEUKHEE GONG The University of Georgia Athens, Ga, USA

PROBLEM UNDER STUDY: Corporal punishment is defined as the infliction of physical pain on children or adolescents by their caretakers, with the purpose of modifying a behaviour that the caretaker perceives as undesirable. Corporal punishment by parents and caretakers is of concern. The prevalence is high, and a few studies have shown long-lasting, deleterious effects. Theory and prior research suggest that corporal punishment models aggressive behaviour and that it may destroy the bond between parents and children and may increase the likelihood of antisocial behaviour.

OBJECTIVES: This presentation has three objectives. First, to describe the prevalence of aggressive behaviours from parents or caretakers toward their children, including: shouting with anger, spanking, and hitting other than the buttocks with an object such as a strap or a stick, in eight metropolitan areas in Latin America and Spain. Second, to describe the prevalence of corporal punishment on the caretakers when they were children. Third, to discuss the association between the parents’ victimization and their aggression toward their children, partner, or non family members.

METHOD OR APPROACH: Project ACTIVA, which was sponsored by the Pan-American Health Organization, used a cross-sectional design to survey a sample of the population aged between 18 and 70 years, living in the metropolitan areas of selected cities. A survey was administered person-to-person in the participant’s residence. The survey was administered to a random, probabilistic sample, stratified by socio-economic status, of adults of eight cities: El Salvador-Bahia (n=1384) and Rio de Janeiro (n=1114), Brazil; Santiago, Chile (n=1212); Cali, Colombia (n=2529); San José, Costa Rica (n=1131); San Salvador, El Salvador (n=1290); Madrid, Spain (n=1105); and Caracas, Venezuela (n=1297).

RESULTS: Overall, 29% of the parents reported spanking their children and 11% hit them with an object during the month prior to the survey. Prevalence of spanking ranged between BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 811

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20% in San José, Costa Rica, and 36% in Cali, Colombia. Prevalence of hitting with an object ranged between 3% in Santiago, Chile, and Madrid, Spain, and 20% in Cali. Most parents (77%) reported having been spanked at least occasionally during childhood and a few (13%) reported being spanked almost every day. Prevalence varied greatly among sites. Parents who had been spanked as a child were significantly more likely to spank their children (OR=2.6), hit their children with an object (OR=3.5), slap their partner (OR=2.9), hit their partner with an object (OR=3.6), and hit a non family member (OR=2.8).

CONCLUSION: Prevalence of corporal punishment was generally high, with large differences among countries. However, the prevalence was lower than what has been reported in other studies in the USA. Corporal punishment during childhood was strongly associated with current violence toward children, the partner, and non family members.

LIMITS: The cross-sectional nature of the study does not allow for establishing a causative relation between corporal punishment during childhood and current aggressive behaviours. The household interview methodology employed in this study may have increased socially desirable responses. Thus, the prevalence of corporal punishment may be underreported. Prevalence may also be artificially lower than actual levels due to non random refusal to respond, where the most aggressive persons may be the least likely to participate in this type of survey. Finally, this study only looked at one aspect of the determinants of aggression.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Since corporal punishment perpetuates the cycle of violence and may increase antisocial behaviour, reducing corporal punishment may be an important venue for prevention of violence. This study highlights differences and similarities in different countries in Latin America and Spain.

CHILD ABUSE PREVENTION IN THE EUROPEAN COUNTRIES

PAOLA FACCHIN,SILVIA MANEA,FRANCESCO ZAMBON,ANNA FERRANTE, ANDREA VIANELLO,LAURA SALMASO,CRISTINA RANZATO Epidemiology and Community Medicine Unit, Paediatrics Departments, University of Padua Padova, Padova, Italy

PROBLEM UNDER STUDY: Among the wide spectrum of violence, child abuse and neglect (CAN) represents one of the most relevant aspects. Although single-case approach has been evaluated through many studies, lack of information exists about national policy strategies, public health actions and their efficacy.

OBJECTIVES: Legal, organisational and cultural aspects towards child protection of the 51 countries of the World health Organization (WHO) European Region have been evaluated in order to assess if any relationship between general and background conditions and specific strategies or public health activities about CAN exists.

METHOD OR APPROACH: For each country, pre-existing descriptive information sources have been consulted and a five-sections questionnaire has been produced ad hoc. The question- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 812

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naire was given to referees of each country having expertise in child abuse and neglect issue. The obtained data were elaborated in order to have two outcomes: 1. A description of the state of the art on child protection and a comparison of the different countries; 2. An assessment of the existence of relationships between background elements and some crucial aspects of child protection; logistic models were created in order to assess if some of them can predict the existence and type of CAN monitoring system in each country and if they influence, together with the country awareness about CAN, professional training and updating.

RESULTS: Current statistics or continuous monitoring about CAN exist just for less than fifty percent of analysed countries. When they exist, they are produced mainly by legal system. It brings an underestimation of CAN. In 64% of the examined countries there are not specific registers on CAN, while the existing registers are seldom updated. Epidemiological data collection about CAN is mostly fragmented, partial and inhomogeneous. The juridi- cal approach presents, instead, a formal homogeneity among the different countries, whereas the services’ network and the implemented activities show a substantial fragmentation. Structured preventive interventions lack, especially at a national level. The logistic models predict with a very low error the kind of statistics and monitoring carried out by every country, considering only some background determinants. Another result is that the presence of health statistics depends both on country wealth and on its fertility-population growth rates. On the other side, a country with high fertility rate, even if rich, is unlikely to produce CAN statistics, particularly by health system. In this way, the direct role of fertility is reiterated, in terms of considering CAN as a priority health problem and of monitoring it systematically. Other logistic models, analysing the influence of background elements on CAN professional training and updating, show the clear role of fertility and the presence of health statistics, while country wealth seem to have any predictive value. These models predict very accurately the existence of training and updating for health professionals, such as physicians, nurses and psychologists. Furthermore, there is a clear link between the presence of preventive programmes, their institutional organization and their relationship to national fertility rates, the publication of health statistics and professionals’ training.

CONCLUSION: These considerations demonstrate, in analytical and quantitative terms, the strong relationship between background macro-element and specific strategies carried out on child protection in the considered countries. The public attitude towards CAN and the specific culture of professionals towards this issue appear to be particularly relevant, both for their direct role and for their impact on sectoral policies.

LIMITS: This analysis is at a macro level. The complex and specific conditions within each country are not possible to detail. This method could seem crude, considering the inner variability of each specific situation. However, it allows to point out the more sensible elements among the different alternative methods of approach to the problem.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Produced models indicate that health monitoring can trigger positive reactions, including a direct influence on professional training. Training is crucial if appropriate measures, particularly preventive ones, are carried out. According to this analysis, monitoring and training come out to be the two fields in which resources can be properly allocated in order to implement effective child protection strategies. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 813

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EPIDEMIOLOGICAL SURVEILLANCE OF CHILD MALTREATMENT IN CALI: AN INTER-INSTITUTIONAL ALTERNATIVE TO ADDRESS THE PROBLEM

RAFAEL ESPINOSA,VICTORIA ESPITIA,NIBIA GUARDELA, GUTIERREZ MARIA,CONCHA-EASTMAN ALBERTO CISALVA Institute University of Valle Cali, Valle Del Cauca, Colombia

PROBLEM UNDER STUDY: In 1999, Colombia’s National Institute of Legal Medicine and Forensic Sciences (IMLCF) reported 62.123 domestic violence injuries at country level. From those 9.896 (15.9%) affected children; besides 12.485 (20.1%) were sexual abused, 85% of these were under 18 years old. In Colombia, child maltreatment rate per 100.000 increased from 126 in 1996 to 149 in 1999. One study in Cali, carried out in the second semester of 1999, found 1.245 cases of child maltreatment, affecting girls a great deal in (60%). As a consequence of the magnitude of the problem Cali’s Secretariat of Public Health created a post to deal with child maltreatment. One of the activities carried out in this office is the implementation of a Child Maltreatment Surveillance System, involving different institutions. This paper focuses on the methodology and performance of this working group.

OBJECTIVES: To determine the magnitude of child maltreatment as well as its characteristics and circumstances.

METHOD OR APPROACH: Previously designed and validated ordinary forms that collect information at regional offices such as IMLCF, Attorney General, and National Institute for Family and Child Welfare (ICBF) are weekly sent to the City’s Secretariat of Health where they are submitted to a general data base system. Every month, a member of each institution participates on a meeting where reports are discussed and information is shared and completed. A three months report is produced and serves as a main source to Local Health Promotion Office and other government entities in decision making and action development.

RESULTS: In the year 2000, 1.726 maltreatment cases were detected by this system. Children between 5 to 9 years old, were the most affected, 31% of all cases. Girls were more affected than boys, in 56.8% of the cases. In regard to type of maltreatment, physical (32,4%) and sexual abuse (17,8%) appears as main identified. Parents were the more common aggressors, in 28.7% of the cases, and 29.5% were strangers. No information about the aggressor was provided in 22.2% of the cases. Forthcoming actions are related to the role each entity plays to address different aspects of maltreated children. In that regard, IMLCF is in charge of physical exams, ICBF protects children and deals with aggressors, Family Stations play a conciliatory role, and promote multidisciplinary interventions, and General Attorney Office leads legal investigations for further judicial decisions. Besides the Secretariat of health leads and develops different protection and promotion programs for the affected children.

CONCLUSION: Different type of resources from the involved institutions had been relocated to address child maltreatment. The surveillance system is effective in bringing about useful and timely information. It works with few variables and has a low cost performance, in addition the institutions have identified and corrected gaps on how each of them handles the BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 814

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problem. Based on this information a special committee representing all the required institutions, is working on the design and implementation of child maltreatment prevention and care interventions. This committee is city’s largest inter-institutional organization addressing a multi-cause problem that requires approaches from different perspectives.

LIMITS: The main limitation of this approach is the lack of information from those who gather more qualitative data. Efforts are underway for further joint activities.

CONTRIBUTION OF THE PROJECT TO THE FIELD: For the first time in city’s institutional history, different sources of information have agreed to work together, share their knowledge and information, and joint efforts for a better and complete panorama of child maltreatment situation. Most of the involved institutions did not have formal and organized record systems but, as a result of this work, they have modified their own data forms in order to feed the “new” system.

ÉTUDE COMPARATIVE DE FILICIDES MATERNELS ET PATERNELS MAL TRAITANTS

MYRIAM DUBÉ CRI-VIFF de l’Université Laval et de l’Université de Montréal Montréal, Québec, Canada

PROBLÉMATIQUE : Tenter de rapprocher la notion de passage à l’acte chez des parents qui cau- sent le décès de leur(s) enfant(s) à la notion de passage à l’acte chez le délinquant serait emprunter une voie bien étroite de connaissances pour tenter de comprendre la probléma- tique du filicide; tout autant, d’ailleurs, que de l’assimiler ipso facto à celle des individus souffrant d’un trouble psychotique. Afin d’arriver à saisir le sens de cette réalité complexe, il serait donc opportun d’en avoir une vision globale en tentant de se figurer les raisons qui ont poussé des parents à commettre un geste d’une violence aussi extrême. Ces raisons, les chercheurs en épidémiologie les nomment facteurs de risque. À la fois multiples, distincts et similaires d’un parent à l’autre, ce sont eux qui, en ce moment, nous permettent le mieux de comprendre le filicide et par le fait même d’aider à le prévenir.

OBJECTIFS : Le protocole de la présente étude étant basé sur un échantillon épidémiologique de parents filicides, il a, par conséquent, permis, dans un premier temps, de comparer les facteurs de risque et les indices comportementaux précurseurs de filicide des hommes et des femmes mal traitants et dans un second temps, de faire l’examen de ces résultats à la lueur des données obtenues de la comparaison des facteurs de risque et des indices comportementaux des hommes et des femmes filicides non mal traitants.

MÉTHODE OU APPROCHE : Nous avons retranscrit à l’aide de la grille multifactorielle du filicide parental, créée pour les besoins de cette étude, toutes les informations pertinentes que nous avons pu retracer dans des rapports de coroners, d’enquêtes policières et d’enquêtes préliminaires et dans des copies de dossiers psychiatriques et médicaux qui faisaient partie de ces derniers, et nous nous sommes procurées aussi des copies de dossiers de la Direction de la Protection de la Jeunesse (D.P.J.) et de la Commission de la Protection de la Protection de la Jeunesse (C.P.J.). BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 815

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RÉSULTATS : Ainsi, au Québec, entre janvier 1986 et mars 1994, 75 parents (36 hommes et 39 femmes) ont commis au total 105 filicides. De ce nombre, 27 parents (12 femmes et 15 hommes) avaient maltraité leur(s) enfant(s) une fois ou plus avant la commission du filicide. Ainsi, en ce qui a trait à ce sous-type de parents filicides, nous avons trouvé par exemple que plus d’hommes que de femmes ont tué leur enfant lors d’un abus physique fatal ou par mesure de représailles envers leur conjoint-e. Par contre, aucun homme n’a perpétré un filicide par «altruisme» envers son ou ses enfant-s, cette motivation étant asso- ciée au filicide commis par des femmes.

CONCLUSION : Ce qui précède nous semble être une avancée majeure dans le domaine des connaissances relatives au phénomène du filicide. Ainsi, le fait que nous ayons comparé les différences de genre obtenues chez les filicides mal traitants à celles trouvées chez les filicides non mal traitants, nous aura permis de mettre en contraste les différences qui existent entre ces différents types.

LIMITES : Néanmoins, plusieurs variables, rendant compte de toute la complexité de la co- morbidité existant entre le filicide et les mauvais traitements, doivent encore être étudiées de façon rigoureuse pour en arriver à une meilleure compréhension et une prévention plus efficace de cette double problématique. Ainsi, parmi les facteurs permettant de donner un éclairage important à celle-ci, on peut noter, entre autres, une meilleure compréhension de la relation d’attachement des parents filicides mal traitants avec leurs propres parents dans l’enfance et à l’adolescence et l’étude des traits de personnalité et du réseau social de ces parents en utilisant des instruments de mesure fiables. Enfin, en ce qui concerne le groupe des parents filicides non mal traitants, la violence conjugale est une information importante à recueillir de façon valide puisqu’elle semble caractérisée davantage ce sous-groupe.

CONTRIBUTION DU PROJET AU DOMAINE : En tentant de redonner à chacune des catégories de cette problématique un sens, au nom du respect à porter à l’inimaginable souffrance inscrite dans l’histoire de chacune des familles ayant vécu pareille tragédie, et, par cette confrontation patiente et minutieuse de ce modèle théorique en regard des faits, nous nous serons appliquées à placer cette souffrance à l’ordre des enjeux majeurs de la recherche clinique et sociale actuelle en santé mentale.

CHILD ABUSE AND NEGLECT SITUATION IN GEORGIA

GEORGE BAKHTURIDZE IAYD Tbilisi, Georgia

PROBLEM UNDER STUDY AND OBJECTIVES: The problems addressed in the study are to identify the prevalence of child abuse/violence from adults, to undertake a comparative analysis of prevalence of violence among boys and girls. The object of the study–child abuse/violence, physical or psychological, on the part of adults in families, institutions (schools, study groups, sport groups, etc.), neighbourhoods.

METHOD OR APPROACH: Quantitative research structured interviews. A group of interviews was used for this purpose, their training and selection were conducted. The group’s profes- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 816

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sional composition: sociologists, psychologists, teachers. Anonymity of all interviews was guaranteed. Geographic coverage: all Georgia. Survey population: children in the age range 6-17 - 4382 in total, 2235 (53.2%) girls, 2147 (46.8%) boys. Age: 5-8 - 29% 9-11 - 32.5% 13 - 23.3% 14 and older - 15.2%.

RESULTS: Neglect in the family The research shows no significant differences between the girls and the boys who mentioned some form of neglect in the family. The first two items are obviously the leading ones, the others have an approximately equal percent, except the item “family members do not always remember your birthday”.61% of the girls and 64% of the boys reporting “neglect of their opinion” know the reason for that–more often “the adults do not think it necessary” and “the adults neglect my opinion because of financial difficulties”. Three quarters said such maltreatment occurred rather rarely. Child abuse/violence in schools and at the place of residence (in the neighbourhood/street) Noteworthy is that besides secondary school classes, sport groups are attended by 4.4% of the girls and 23.3% of the boys; music-schools and music study groups are attended by 19.4% of the girls and 6.4% of the boys; dance groups and dance schools are attended by 5.5% of girls and 4.5% of the boys. 62% of the girls and 4.5% of the boys do not attend groups, schools, circles. The research shows that in the entire survey population the forms of verbal non-contact violence (from 1 to 2) significantly prevail over the contact forms (from 3 to 4) –73% vs. 27% in the sub-group of the girls, 66% vs. 34% in the sub-group of the boys. Sexual abuse Boys are obviously more often joked with and told anecdotes with sexual meaning than girls, with male adults joking with and telling anecdotes to boys and females to girls. For instance, 25.5% of the girls and 7.2% of the boys indicated a female neighbour using such “humour”, 8.2% of the girls and 28.7% of the boys mentioned an adult male neighbour. However, it is done mostly by children of the respondents’ age and older children. 24.5% of the girls and 9.6% of the boys are afraid of such treatment. As to showing erotic films and pictures, boys become victims of such “violence” more often. In this case most active are children of the same age as the surveyed boys and girls (50% for the entire category of the respondents) and adult male neighbours with respect to boys (31.6%). 27.8% of the girls and 13.2% of the boys indicating the existence of such facts are afraid of such treatment.

CONCLUSION AND LIMITS: Maltreatment is more obvious in the families, than in schools, then in the neighbourhoods. In the vast majority of cases mothers are perpetrators of abuse, fathers even less cruel than the older sisters and brothers. As it was mentioned above, the share of violence in the neighbourhood and sexual abuse is not significant and its perpetrators are often children of the respondents, age, sometimes “the oldest boy”,etc. In this case the focus of the problem is shifted form relationships between age groups to internal group sub-cultural violence. In this case girls show more fear than the boys–27.8% of the surveyed girls and 13.2% of the boys feel fear when they are shown erotic drawings.

CONTRIBUTION OF THE PROJECT TO THE FIELD: For purposes of an improvement in the situation it is necessary to include in these processes such international financial institutes such as World Bank, etc., which will finance programs on overcoming of poverty, since precisely poverty and heavy social and economic situation are main reasons for the forced children’s labour, unhealthy life style and so forth the implementation of similar programs will become the basis of the solution of many problems, which are directly connected with social, educational, medical, creative and other rights of children. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 817

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L’ABUS SEXUEL CHEZ LES ENFANTS LIBANAIS : RÉALITÉS ET MODALITÉS D’ACCOMPAGNEMENT

NATHALIE CHEMALY,BERNARD GERBAKA,HYAM KAHI,JAMILÉ KHOURY École libanaise de Formation Sociale Beyrouth, Liban

PROBLÉMATIQUE : Cette étude exploratoire descriptive des abus sexuels d’enfants dans les municipalités de la banlieue de Beyrouth tentera de déterminer l’incidence des abus, le processus de dévoilement et les modalités éventuelles d’accompagnement. Au Liban, les droits de l’enfant sont ratifiés depuis 1990; cependant, des chiffres alarmants sont publiés par le ministère de la Justice : «62 plaintes pour viols de mineurs au mois d’octobre 1996», «222 cas de viols déclarés en 1994, 265 en 1995», «31 jeunes filles molestées présentent des troubles de santé et du comportement».

MÉTHODE OU APPROCHE : L’échantillon est défini par quatre catégories : les personnes impli- quées dans l’accompagnement social, le personnel de la protection juridique, les instances d’hébergement ou de placement et les services d’accompagnement spécialisé. Un questionnaire, comprenant des questions ouvertes et fermées, est divisé en quatre parties : l’enfant abusée et le contexte, le dévoilement, l’accompagnement et les mesures préconisées. 33 contacts sont établis, 23 questionnaires remplis dont 22 retenus.

RÉSULTATS : L’analyse est quantitative et qualitative. Deux à six pour cent uniquement des enfants abusés de la population identifiée dévoilent. Les intervenant ont rencontré 176 enfants des deux sexes et travaillé avec 119 enfants, dont 80 % sont de sexe féminin. Les premières agressions se concentrent autour de l’enfance (40 % entre 6 et 10 ans) et de la puberté (30 %), contre 15 % lors de la petite enfance. Les acteurs sociaux ont pu cerner la situation sociale de 77 % des enfants lors de la période de l’abus, dont 58 % d’enfants sco- larisés, 14 % au travail et 5 % à domicile. Les acteurs sociaux soulignent la présence de séquelles psychologiques, relationnelles et physiques chez les enfants à court terme et à long terme. La famille de la victime, libanaise dans 63 % des situations, bi-parental dans 50 % des situations, reste l’une des figures les plus recherchées et la moins connue de la part des intervenants. Les catégories socioprofessionnelles sont diversifiées. Les plus identifiables sont les ouvriers (35 %), les employés (10 %), les patrons d’industrie et de commerce (7 %). L’agresseur est dans 68 % des cas d’origine libanaise et dans 97 % connu de l’enfant. Dans 46 % des situations, il est membre de la famille directe (dans 54 % c’est une personne extra- familiale). Dans 80 % des cas, l’agresseur est adulte, masculin ou féminin. Ces individus ne diffèrent pas de manière significative des autres par leur niveau éducatif, intellectuel ou rela- tionnel, leurs occupations ou leur physique. Les rencontres entre agresseurs et abusés se font dans le cadre intime de l’enfant, dans le lieu de travail, l’établissement scolaire, dans le cadre de l’agresseur ou dans des lieux isolés. Les facteurs susceptibles d’avoir favorisé l’abus sexuel des enfants couvrent les plans familial et environnemental. Le dévoilement a lieu chez 65 % des enfants au bout de plusieurs années, contre 20 % après plusieurs mois, tandis que 13 % d’entre eux l’ont fait immédiatement. Une personne a parlé d’une thérapie chez un des agresseurs, les autres vont vers des tentatives de réparations juridiques. Certaines familles sont accompagnées surtout de la part des aidants naturels. Des intervenants sociaux et du corps juridique, surtout si la famille est sous l’emprise de l’agresseur et que les théra- pies familiales sont inexistantes. Les difficultés exprimées par les acteurs sociaux se reflè- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 818

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tent sur plusieurs niveaux : personnel (50 % les intervenants reflètent un vécu d’isolement dans l’action), familial (14 % des acteurs soulignent des obstacles familiaux), social (les valeurs sociétales sur la sexualité et la virginité, loi sur le crime d’honneur) et juridique.

CONCLUSION : Les résultats obtenus recoupent ceux de certaines études faites en d’autres pays, surtout quant au sexe des enfants abusés, à la nature de l’agression, aux séquelles et à certains facteurs de risque. Cependant, quelques indices socioculturels spécifiques au contexte libanais sont importants à souligner : le support familial, la législation libanaise, le sujet de la sexualité qui reste tabou (décret loi sur l’honneur), la protection et la responsabilité des enfants, l’action des personnes qui opèrent auprès des enfants abusés, la formation des acteurs sociaux à la réalité de l’abus sexuel.

LONG TERM OUTCOMES OF CAN: HOW DO THEY REACH ADOLESCENCE?

PAOLA FACCHIN,CRISTINA RANZATO,FRANCESCO ZAMBON,SIMONA SFORZIN, MONICA MAZZUCATO,LAURA VISONÀ,DALLA POZZA,SILVIA MANEA Epidemiology and Community Medicine Unit, Paediatrics Department, University of Padua Padova, Padova, Italy

PROBLEM UNDER STUDY: It is of common knowledge that violence produces various kinds of harms to health, and among them, physical injuries constitute only a part. Even if it has been shared that psychical and moral harms associated are really remarkable, it has been a general widespread opinion that physical injuries constitute the leading condition and the greater impact on current and future health of individuals and communities. As a matter of fact there are few studies evaluating in perspective way the natural history of victims of different kinds of violence and comparing medium and long term health outcomes.

OBJECTIVES: The aim of the present study is to describe the follow-up in adolescence of children victims of different kinds of violence, a part physical abuse victims and a part emotional abuse and negligent treatment victims (without the association with physical abuse).

METHOD OR APPROACH: A population of 700.000 inhabitants (116.307 under 15 years of age) living in North East of Italy has been monitored. Gathering records from registers or case- histories of primary health services, hospitals, municipalities, Juvenile Court, help-lines and educational departments, all the subjects presenting health and/or social problems have been selected, during 3 years of monitoring. For the pointed out subjects data regarding their families and themselves have been collected. Crude and specific incidence and prevalence rates of each problem have been estimated. 210 abused and neglected children have been followed to adolescence (15-18 yrs). At the end of follow-up period, disabilities, social maladjustment comprehending early delinquency and drug addiction, psycho and behavioural pathologies, learning problems and scholastic’ abandonment have been detected. Moreover familial structure and background has been described in relation to the presence of psychical pathology, deviance and crime, drug addiction and alcoholism, problematic behavioural and extreme poverty. Moreover for each child removing experience from origin family has been considered. More logistic models have been created to evaluate the role BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 819

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of physical abuse vs. emotional one and negligent treatment in determining adolescence problem profile. Finally it has been planned a case-control study: cases (adolescents with emotional abuse and neglect experiences in infancy) were compared to 2 different typologies of controls, 440 cases of problematic adolescents, without abuse experiences, and adolescents victims of physical abuse during childhood. Data have been processed using Breslow logistic stratified analysis.

RESULTS: The prevalence rate of abused and neglected children is 5‰, approximately the 80% of these cases are neglect. Age distribution shows peaks in the first and in the 6th year, corresponding to the first schooling. Abused and neglected children stretch to add an increasing number of health problems reaching preadolescence and show, nearly constantly, serious deficit of scholastic performance and a fall of the ability to establish competent relations with the peers. 21% of all infancy’ neglected children show disabilities during adolescence, 31% maladjustment, 4% juvenile crime, 33% psychical pathologies, 57% serious learning deficits, and 17% early drug addictions. All these rates are constantly higher than those showed by other problematic adolescents without abuse experiences, and, considering drug-addiction and delinquency, their rats are higher than those showed by physical abused children.

CONCLUSION: Among all generated models, for the same origin families conditions, personal history and problematic nature of subjects, negligent treatment assumes a more important role than physical abuse in determining psychical pathology and learning defects. Physical abuse experience seems to play an essential role in determining violent behaviours during adolescence.

LIMITS: The classification of cases could show bias: some children classified as neglected could have been also physically abused. Indeed, different typologies of misclassification could determine both under or overestimation of risk, due to neglect condition, estimation. Nevertheless, obtained results show a so relevant link between neglect experience and unfavourable outcome during adolescence that it seems to be really existing.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Our work is one of the few cohort study on long- term outcomes of children suffering of different typologies of CAN, and it proves the key role of emotional abuse and negligent treatment in determining multi-problematic profile of problems.

OUTIL DE PRÉVENTION AUPRÈS DES FAMILLES À RISQUE : INTERVENTION FAMILIALE PRÉCOCE SUITE À LA NAISSANCE D’UN ENFANT AVEC UNE DÉFICIENCE

DIANE PELCHAT,HÉLÈNE LEFEBVRE Université de Montréal Montréal, Québec, Canada

PROBLÉMATIQUE : La naissance d’un enfant ayant une déficience provoque un stress familial et est susceptible d’avoir des implications importantes pour l’avenir de l’enfant et pour celle de la famille. Certains parents évoluent relativement bien dans cette situation difficile en développant des stratégies adaptatives pour s’ajuster et répondre aux besoins particuliers de BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 820

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l’enfant. Cependant, pour d’autres, l’intensité du stress perçu dépasse les ressources adaptatives et se traduit par des difficultés ayant des répercussions plus ou moins graves pour tous les membres de la famille immédiate et élargie. Les parents présentent davantage de pro- blèmes de santé physique, ont une plus grande incidence de dépression, d’anxiété et de détresse émotionnelle, une moins bonne estime de soi et vivent davantage de stress comparativement aux parents d’enfants sans atteinte. Ils peuvent développer des problèmes rela- tionnels et de communication qui mènent souvent à la séparation ou au divorce. Ces diffi- cultés peuvent avoir un impact sur la qualité de l’interaction entre l’enfant avec une déficience et les membres de la famille. Cette situation difficile les rend plus à risque de violence familiale et de maltraitance de l’enfant. Cette situation est aussi cause de stress pour les intervenants qui se sentent démunis face aux besoins de ces familles et conservent plusieurs préju- gés, mythes et tabous à l’égard des personnes ayant une déficience et de leur famille. Pour répondre aux besoins des professionnels et aider les familles à s’adapter à leur situation, Pelchat a développé un Programme d’intervention familiale interdisciplinaire (PRIFAM) appliqué dès la naissance d’un enfant ayant une déficience jusqu’à six mois et impliquant les deux parents. Fondé sur une philosophie de soins à la famille qui met l’emphase sur les forces et les capacités adaptatives de la famille et de ses membres, il vise l’autonomie des familles et l’appropriation de leurs compétences parentales. Le principe sur lequel s’appuie le PRIFAM et qui guide l’intervention est le partenariat.

OBJECTIFS : Une étude visant à évaluer l’efficacité du PRIFAM à favoriser l’adaptation des familles d’enfants ayant une déficience (trisomie 21 et fissure labiale et/ou palatine) a été menée. Celle-ci vise aussi à évaluer les variations dans les effets de l’intervention sur l’adaptation familiale selon le temps de mesure, le type de déficience de l’enfant et le sexe du parent.

MÉTHODE OU APPROCHE : Deux groupes de parents ont participé à l’étude: un groupe expéri- mental (n=46) qui ont bénéficié du programme d’intervention, et un groupe de comparaison (n= 53), constitué de familles d’enfants avec les mêmes déficiences qui ont bénéficié des services habituels. Trois dimensions de l’adaptation sont évaluées : le stress parental, la détresse émotionnelle et le soutien conjugal. Ces dimensions sont évaluées à trois reprises : quand les enfants ont 6 mois (au terme de la participation des familles à l’intervention), 12 mois et 18 mois.

RÉSULTATS ET CONCLUSION : Globalement, les résultats de l’étude démontrent une meilleure adaptation chez les parents qui ont participé à l’intervention comparativement aux parents qui n’y ont pas participé. Ces résultats confirment l’efficacité du programme d’intervention à favoriser de façon significative l’adaptation des familles. Les parents sont plus autonome et mieux adaptés à leur situation, ils vivent moins de stress et de détresse, ont des perceptions et des attitudes plus positives et constructives face à la déficience de leur enfant et de leur situation parentale. Ils sont mieux préparés à faire face aux éventuelles exigences de leur situation particulière.

LIMITES : Le fait de ne pas avoir sélectionné les familles participant à l’intervention d’une façon aléatoire, mais plutôt sur une base de la période de recrutement, limite l’interprétation de la causalité entre l’intervention et la plus grande adaptation des parents et la taille relativement petite de l’échantillon.

CONTRIBUTION DU PROJET AU DOMAINE : Bien qu’il reste encore beaucoup à apprendre sur les facteurs qui favorisent une intervention familiale efficace, ces résultats représentent un jalon BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 821

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essentiel pour répondre à l’importante question du «Pour qui, à quel niveau et dans quelles conditions les interventions auprès de parents vivant avec un enfant ayant une déficience sont les plus efficaces ?». La poursuite des efforts de recherche en ce sens permettra de mieux comprendre la dynamique des processus adaptatifs des familles d’enfants ayant une défi- cience, de mieux identifier les problèmes présents et à venir pour ces familles et de cibler les interventions pouvant mieux aider ces parents.

CHILD ABUSE AND VIOLENCE SITUATION IN GEORGIA

GEORGE BAKHTURIDZE IAYD Tbilisi, Georgia Our report concerns the state of the children rights precisely beginning from this period and on now. From 1991 many misfortunes happened in Georgia. As a result of the military conflict in Abkhaziya of approximately 250.000 people were forced to leave its houses, of them about 60.000 children. But after conflict into Samachablo refugees became about 150.000 citizens, of them about 40.000 children. During these conflicts perished about 2.000 innocent children. Children refugees are today forced to work somewhere and so to contain themselves and their relatives, because state grants are insufficient and comprise not more than 15 % consumer basket. Greatly increased a quantity of homeless children, who were forced to work because of the difficult social and economic position. An increase in the bad habits among the children and the adolescents is noted in the last 5 years. Namely by 30 % grew the consumption of tobacco among the young people, especially among the girls. 32 % children are toxicomany, and dependence to the narcotic substances manifest 10 % adolescents. 70-75 % of children do not reject the consumption of alcoholic beverages. Were increased in frequency the cases of the infection of children by AIDS, in essence as a result of using of non-sterile injections and pouring of the infected blood. The low level of prostitution among the children in Georgia is caused by the mentality of people. As a result of social and economic problems, in the families were increased the cases of the slaughter of children. Officially the Georgian Government guarantees free medical insurance to children of up to 12 years, but this actually in practice does not act and 90 % of families are forced to pay for the medical service. Actually, free of charge it is carried out only immunization programs, financed by UNICEF. On the basis of all above mentioned, the situation regarding the state of children in Georgia is very heavy and requires special attention and financial support from the international society and financial institutes. Because of grow heavy by economic situation in Georgia they are barely satisfied preventive programs. The State Department in the matters of young people of the Georgia prepared bill “About the protection of children and adolescents from the bad influence of the surrounding factors”, but this bill already two years lies at the Parliament of Georgia waiting until examination. The only organization, which by all forces attempts to solve the problems of children in Georgia, appears the Caucasian representation of UNICEF, whose office is located in Tbilisi. With the support of UNICEF are conducted BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 822

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immunization programs, it was published Convention on the rights of children in the Georgian language, educational programs in the schools and in the mass media are conducted. For purposes of an improvement in the situation it is necessary to include in these processes such international financial institutes such as World Bank, etc., which will finance programs on overcoming of poverty, since precisely poverty and heavy social and economic situation are main reasons for the forced children’s labour, unhealthy life style and so forth the implementation of similar programs will become the basis of the solution of many problems, which are directly connected with social, educational, medical, creative and other rights of children.

Blessures et homicides causés par les armes à feu: connaissances nécessaires à la mise en place de politiques de prévention Injuries and Homicides Caused by Firearms: What We Need to Know About Implementing Prevention Policies

FIREARM AVAILABILITY AND FEMALE HOMICIDE ACROSS HIGH INCOME COUNTRIES

DAVID HEMENWAY Harvard School of Public Health, Harvard Injury Control Research Centre Boston, Ma, USA

PROBLEM UNDER STUDY: Cross-national studies suggest that countries with higher levels of household firearm ownership have higher homicide rates, but none have focused on females. Compared to males, females have much lower rates of homicide victimization, so the data in these analyses are dominated by male deaths. We examine whether females in countries with more firearms are also at higher risk of homicide victimization. Our study analyzes contemporaneous data from the late 1990s among countries with more than 2 million inhabitants defined by the World Bank as high-income nations.

OBJECTIVES: To explore the relationship between firearm availability and homicide rates among women across 25 populous high income countries.

MATERIALS AND METHODS: Data were assembled for the most recent year for which data were available (1994-1999) from the official reports of the Ministries of Health for those countries with more than 2 million inhabitants that are classified as high-income by the World BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 823

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Bank. Twenty-five nations provided sufficient information for the analysis. For females, rates of victimization from homicide, firearm homicide and non-firearm homicide were compared to a validated proxy for household firearm ownership levels, the percentage of total national suicides that are committed with a firearm. Analyses are conducted using both the (female firearm, non-firearm and overall) homicide victimization rate and the natural log of the homicide victimization rate, the latter better approximating a normal distribution. Analyses are also conducted both using un-weighted data, and data weighted by each country’s female population.

RESULTS: For the 25 populous high-income countries, the female homicide rate per 100,000 varied from 0.20 (Israel) to 3.21 (US). Female homicide victimization rates are significantly associated with firearm availability, due largely to the USA, which has the highest level of household firearm ownership and the highest homicide rate. The U.S. accounted for 32% of the female population in these high-income countries, but 70% of all female homicides and 84% of all female firearm homicides.

CONCLUSION: Across high-income countries, where firearms are more available, more females are homicide victims, particularly firearm homicide victims. These results are driven largely by the USA. Females in the US are at far higher risk than females in any other high- income country for homicide victimization.

LIMITS: First, the regressions contain only one independent variable, a proxy of household gun ownership. It is possible that the associations could be explained by other variables. However, by looking exclusively at high-income nations, we control, in part, for some social and economic variables. Second, measures of homicide may vary from country to country because of differences in the specificity and sensitivity of the surveillance systems. Such problems with data comparability and accuracy are particularly acute for non-industrialized nations. Including only high-income countries in our analysis reduces the problem. Third, cross- sectional studies like ours do not provide information about causality. It is possible that high rates of lethal violence cause some households in the US to acquire firearms. For women, this does not generally appear to be a beneficial strategy, since many murders of females are perpetrated by intimates. Furthermore, since men are typically the owner of the household firearm, and obtain guns for self-protection primarily against perceived external threats, reverse causation is not likely to be a problem in this study.

CONTRIBUTION OF THE PROJECT TO THE FIELD: A few studies have examined the relationship across high-income countries between gun availability and homicide, but none have focused on females. Our study suggests that women living in developed nations where there are more firearms are more likely to become homicide victims, a relationship between firearms and homicide previously noted only for the population as a whole. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 824

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FIREARM STORAGE METHOD AND RISK OF HOMICIDE IN THE HOME

DOUGLAS J. WIEBE,SUSAN B. SORENSON UCLA School of Public Health Los Angeles, Ca, USA

PROBLEM UNDER STUDY: A firearm in the home is a risk factor for household members to die by gun-related homicide. If a gun is in the home, it is important to know whether risk is reduced when the firearm is stored in a way that makes it less accessible.

OBJECTIVES: To investigate how gun storage method varied between victims of homicide in the home and living controls. In addition, to describe national data sources in the U.S., particularly, factors that make it difficult to examine firearm storage methods.

METHOD OR APPROACH: A case-control study was conducted using victims of homicide in the home and living controls. Subjects were 18 years or older. The cases were drawn from the 1993 National Mortality Follow-back Survey; the controls were drawn from the 1994 National Health Interview Survey. These surveys provide comparable gun-storage information for subjects who lived in a household where one gun was present. Cases and controls were drawn from these data sources if they lived in a home: 1. Where a firearm was present; and 2. The storage method was known. The controls were matched to the cases by sex, race, and age group. The data yielded 33 homicide cases and 1,984 controls with one firearm in the home. Each subject was classified according to two general gun storage methods: not recommended (loaded and unlocked) or recommended (unloaded and/or locked or disassembled). Conditional logistic regression was used to compare cases and controls with regard to the method used to store the gun.

RESULTS: Twenty-six (26) of the 33 cases (79%) died from a gunshot wound. Fifty-eight percent (58%) of the cases lived in a home where a gun was kept in a non-recommended manner, compared to 14% of the controls. The estimated odds ratio for homicide, comparing adults living in a home where a gun was kept in a non-recommended versus recommended manner, was 10.4 (95% confidence interval=4.9 to 22.0).

CONCLUSION: Using national data we found an association between gun storage method and homicide in the home. The finding warrants further study of whether strategies to prevent in-home homicide can focus on gun storage methods. We suggest how survey questions regarding gun ownership can be revised. Doing so may provide more comprehensive data for the study of this important public health issue.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We provide evidence that the method used to store a firearm is a risk factor for homicide in the home. We also suggest how revisions to national surveys may yield data that improve the ability of researchers to study this issue. The issue cannot be fully addressed with current data. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 825

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EPIDEMIC OF GUN VIOLENCE IN CAPE TOWN, SOUTH AFRICA

MEGAN RENAY PRINSLOO,RICHARD MATZOPOULOS South African Medical Research Council Cape Town, Western Cape, South Africa

PROBLEM UNDER STUDY: Firearms are one of the leading causes of non-natural death in South Africa. Firearm-related injuries among under 19-year olds almost trebled between 1992 and 1996 from 142 to 421, while the number of firearm deaths for this age group increased from 32 to 87 over the same period. Preliminary analysis of National Injury Mortality Surveillance System (NIMSS) data indicates that this is also a national trend. The epidemic of gun violence has prompted the introduction of a new firearms control act, which will include an updated firearms register and stricter controls for the issuing of firearms.

OBJECTIVES: To assess the utility of current injury surveillance systems to evaluate the effectiveness of the gun legislation.

METHOD OR APPROACH: We reviewed two current injury surveillance systems in South Africa, namely NIMSS and the National Non-Fatal Injury Surveillance System (NANFISS) and assessed whether they would provide detailed and accurate information on firearm injury trends. The NIMSS has been implemented at 37 of the 265 state mortuaries, and includes mortuaries in several major urban centres. The NANFISS has been implemented at two of the 41 sentinel facilities that were selected to provide a representative sample of non-fatal injury. Both surveillance systems collate and disseminate descriptive epidemiological information for deaths and injuries due to non-natural causes and describe the “who, what, where, when and how” of fatal injuries in participating facilities. We reviewed firearm injury data from the two surveillance systems for the period 1 January to 31 December 2000 to assess the quality of reporting and to identify variables that could be used to describe changes in the incidence of firearm violence.

RESULTS: In the NIMSS, the following variables were accurately recorded: age, gender, manner of death (homicide, suicide or unintentional), the city and suburb of injury and blood alcohol concentration. Scene of injury data and date and time of injury were poorly recorded. The manner of death data enabled the calculation of age and gender-specific rates for annual and inter-city comparison for firearm homicides, suicides and accidents. For example, the crude suicide rate for Cape Town in 1999 was nine per 100 000 population in 1999 compared to 12 per 100 000 in 2000. Similarly Cape Town’s firearm homicide rate increased from 37 per 100 000 population in 1999 to 39 per 100 000 in 2000. Cape Town’s firearm homicide rate was considerably higher than Port Elizabeth’s (29 per 100 000), although the total homicide rate for Port Elizabeth (107 per 100 000) was higher than Cape Town’s (91 per 100 000). City and suburb specific data enabled Geographical Information System (GIS) mapping, depicting high risk areas, although the information was inadequate for pinpointing high risk streets and firearm violence “hot-spots”.Blood alcohol concentration (BAC) information, measured in g/100 ml, was available for all firearm homicide victims. The NANFISS data had similar quality of data pertaining to age, gender, manner of death, town/city and suburb of injury. Only observational data on BAC and drug usage were recorded, but information on scene, date and time of injury were well reported. As the data were recorded BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 826

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from non-fatal victims, information about the perpetrators of firearm violence was also available, including the number and sex of the perpetrators, the victim perpetrator relationship, and the type of violence (e.g. gang/syndicate, interpersonal).

CONCLUSION: The current surveillance systems routinely collect information to monitor firearm injury and mortality trends, which can be used to assess the effectiveness of the new gun legislation in reducing firearm injuries.

LIMITS: The NIMSS currently only provides full coverage in Cape Town, Port Elizabeth and Pretoria. Once implemented, the NANFISS will enable the monitoring of provincial and national trends but not the calculation of suburb or city specific rates.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The study demonstrates the utility of information that can be extracted from the two surveillance systems. This should motivate hospital and mortuary staff to improve their data collection activities.

BRIDGING THE GAP BETWEEN RESEARCH AND ADVOCACY: HOW SURVEILLANCE DATA WAS USED TO MOBILIZE FIREARM INJURY PREVENTION POLICIES IN SOUTH AFRICA

CLAIRE JANET TAYLOR,STEPHANIE BURROWS Gun Free South Africa Braamfontein, Gauteng, South Africa

PROBLEM UNDER STUDY: Violence and the resulting trauma pose a serious public health threat in South Africa (SA). The most recent figures indicate that firearms overshadow all other causes of death, even when all transport-related deaths are combined. Since the majority of those injured or killed are economically active young males, firearm injuries are a financial burden in terms of the direct expenditure on health care, as well as lost productivity because of temporary / permanent disability or premature death. A previous lack of sound epidemiological data made it difficult to grasp the size and profile of the problem and to argue for appropriate safety measures. However, with the advent of a national injury surveillance system, data which show the patterning of firearm-related injuries are available to be used in prevention-orientated policies.

OBJECTIVES: To describe how firearm-related data from a national injury surveillance system was used to advocate for stricter firearm legislation.

METHOD OR APPROACH: Action to improve methods to monitor and prevent injuries in SA began in 1998 when funding was received to develop a national violence and injury surveillance system. The system collects data for both fatal and non-fatal injuries, including information on victim demographic details, temporal and spatial data related to the injury event, the external cause and manner of death, the involvement of alcohol, the type of violence and the victim-perpetrator relationship. Findings from the system have been fed to various agencies including government departments and NGOs). Gun Free South Africa (GFSA) is one agency that has received the data. GFSA is a national NGO aimed at making BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 827

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SA more secure by reducing the number of firearms in circulation. Since its inception in 1994, GFSA has recognised that this entails both reducing the supply of, and demand for firearms. In attempting to reduce the supply of firearms, GFSA has strongly advocated for new firearm legislation. GFSA’s advocacy work was significantly boosted by the findings of the national injury surveillance system.

RESULTS: The most significant result of the surveillance system’s data was that it allowed GFSA to place the debate about why SA needs stricter gun control within a public safety context. This greatly facilitated GFSA’s advocacy work, which was consistently challenged by an organised and well-resourced gun lobby. The surveillance system’s data also facilitated specific policy recommendations, particularly: +Increasing the age limit for gun ownership, as the data showed that young men are the most likely victims of gun violence; +Declaring places in which alcohol is sold firearm-free zones because of the close link between blood- alcohol levels and fatal injury; and +Strictly screening firearm licence applicants, including interviewing the applicant’s spouse or partner as the majority of women are killed in the home, almost certainly in domestic violence disputes.

CONCLUSION: The surveillance data was extremely useful and necessary for lobbying. Collaboration between researchers and advocacy groups is important, though decisions need to be made about how closely each work together, as aligning themselves too closely with advocacy organisations could compromise the independence of research institutes.

LIMITS: Surveillance data for the whole of SA are not yet available and therefore the present analyses represent only selected areas within the country.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This work shows how surveillance data can be used for prevention-orientated strategies. In addition, continued surveillance will be able to evaluate the effectiveness of interventions, such as policy changes, so highlighting the need for sound epidemiological data and future funding of surveillance systems. Finally, it creates space for debate about the role research institutes should play in advocating for injury prevention policies, particularly regarding controversial issues such as gun control.

SMALL ARMS AND GLOBAL HEALTH

ANDRÉS VILLAVECES,ALEXANDER BUTCHART, ETIENNE KRUG,GYANENDRA SHARMA Department of Injuries and Violence Prevention, World Health Organization, Geneva 27, Switzerland

PROBLEM UNDER STUDY: The impact of Small Arms on Global Health.

OBJECTIVES: To describe the magnitude and characteristics of small arms injuries and mortality at the global level.

METHOD OR APPROACH: Using the WHO mortality database, information on firearm deaths were obtained from 52 countries and descriptive statistics were calculated. The study also BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 828

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reviews the current situation and knowledge on small arms in the world in terms of magnitude, populations at risk, costs to the health system and advocacy and policy activities.

RESULTS: It is estimated that 2.3 million people died worldwide due to violent events in 1998; (mortality rate of 38.4 per 100 000 person-years). Approximately 42% of all deaths were suicides, 32% were homicides, and 26% were war-related. Among persons aged 15-44 years, the categories of interpersonal violence, self-inflicted injuries and war injuries all ranked in the top ten leading causes of death world wide. Due to the lack of reliable global data, it is not yet known how many of the estimated 2.3 million violent deaths world wide involve small arms. Best estimates indicate that at least several hundred thousand people are killed each year as a result of gun-inflicted homicides, suicides and armed conflict. Using the WHO mortality data it has been estimated that more than 115,000 people died from firearm injuries in a one-year period in the mid-1990s in 52 countries, representing a combined population of over 1400 million. Among all firearm-related deaths, approximately 79,000 (or 69%) were homicides. Suicide accounted for almost 29,000 deaths, with undetermined causes and unintentional injuries accounting for the remaining 5,000 and 3,000 deaths, respectively According to WHO’s global burden of disease data for 1998, the rate of violent death in low- and middle-income countries (42.2 per 100 000 persons) is more than double that in high-income countries (17.3 per 100 000 persons). In high-income countries, suicide using firearms tends to be more frequent than homicides. Social and physical consequences due to firearm-related injuries substantially increase health costs and over-burden health systems thus diverting resources from other areas of health. Factors that influence the use of small arms and those that determine the occurrence of violence, suicide or collective violence should be tackled in a coordinated way. Increased surveillance activities especially in lower-income countries are crucial to understand the magnitude of the problem and to identify populations at risk, as well as other individual and social factors that might increase the likelihood of victimization or act in a protective manner. Such actions aimed at acquiring more reliable information should inform policy makers so that effective preventive activities can be developed.

CONCLUSION: This is a comprehensive review of the situation and state of the art of knowledge on the impact of small arms on health in the world. It shows measures that can be applied to prevent violence with small arms as well as pointing out areas where more information is needed in order to have a more representative view of the global problem.

LIMITS: Information on small arms is based on 52 mainly high and middle income countries and is therefore not representative of societies with lower income levels where violent events are more predominant.

CONTRIBUTION OF THE PROJECT TO THE FIELD: : Our study informs the public health community and relevant policy-makers about the most important areas where resources and preventive activities should be aimed in order to better understand and reduce the problem of small arms and health in the world. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 829

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SUICIDE, HOMICIDE AND UNINTENTIONAL INJURIES: PREVENTING GUN VIOLENCE

MARIELLE HAYWOOD-POSEY,ALICIA HORTON Brady Centre to Prevent Gun Violence Washington, DC, USA

PROBLEM UNDER STUDY: Gun violence and gun violence prevention in America.

OBJECTIVES: These objectives apply to the STOP 2 workshop (not intended as a scientific paper) which includes gun violence prevention as a public health issue, firearm homicide, suicide, unintentional shootings, domestic violence, and counselling on firearm violence prevention. The workshop seeks: to provide participants with a primary source of information on the issue of gun violence and the prevention of gun injury and death; to assist health care providers and health educators in including firearm violence prevention counselling in routine injury prevention counselling; and to increase the skill level of participants in counselling clients/patients. Participants will be able to: identify and discuss the risks of keeping a gun in the home and its implications for the community, and society; identify and discuss the three means of injury and injury-death associated with firearms; and broach the subject of firearm-related prevention counselling to patients/clients in their routine safety counselling.

METHOD OR APPROACH: The Steps To Prevent Firearm Injury In The Home (STOP 2) program is a counselling tool that prepares health care providers to talk with patients/clients and their families about the dangers of guns in the home during their injury prevention counselling routine. STOP 2 was designed in response to health care providers across a broad range that requested print materials to assist them in firearm violence prevention with their patients and clients. It is based on the premise that gun-related injuries and deaths are preventable! The broad range of health care providers includes physicians, medical care providers, counsellors, psychologists, nurses and nurse practitioners, mental health providers, health educators, midwives, therapists, school counsellors and staff, and other professions that educate clients and patients about injury prevention. This program was developed in concert with organizations that serve diverse populations to be inclusive and to insure sensitivity of all populations. The STOP 2 program provides print materials, Internet activities, and gun violence prevention workshops at national conferences, universities, hospitals, and for organizations. Print materials are delivered in the form of a kit that includes: A reference manual designed for health care providers that provides facts about gun violence (homicide, suicide, and unintentional shootings) and prevention; and a bibliography; a family brochures provides facts, prevention steps, a family quiz, and resource numbers; and posters encourage patients and clients to ask their health care provider for more information about preventing gun violence in the home. World wide web activities at www.bradycentre.org provide the following activities: an interactive parent quiz; an interactive children’s game; kit request forms; and firearm violence facts and information.

RESULTS: The Steps To Prevent Firearm Injury In The Home (STOP 2) program was launched in June of 1998. Since that time, nearly 5,000 kits and over 150, 000 family education brochures have been disseminated nationwide. Along with health care providers and health educators, clergy, law enforcement, schools, and community centres use the materials in BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 830

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their firearm violence prevention efforts. The STOP 2 workshop has been well received at national conferences, and universities (Schools of Public Health and Medicine).

CONCLUSION: Material evaluation results indicate that they are effective tools to teach firearm violence prevention steps. These materials and activities poise the educator and patient to broach the subject of guns in the home with each other, family, friends and places where children visit and play. Nearly 5,000 health care providers across the country are currently implementing the STOP 2 program.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The STOP 2 materials and workshops teach health care providers to infuse gun violence prevention into their routine injury prevention counselling. The tool is empowering to both the health care provider and the client. It encourages parents and guardians to ask if there is a gun in the home and how it is stored at the places their children visit and play. Empowering both health care providers and families to initiate a crucial and life saving conversation with their clients, friends, neighbours, and relatives, will ultimately make homes and communities safer for everyone.

GUN STORAGE AND CHILD ACCESS

JUDY SCHAECHTER,MARIA ELENA VILLAR Partnership For The Study And Prevention Of Violence, University of Miami School of Medicine Miami, Fl, USA

PROBLEM UNDER STUDY: It is estimated that 40% of US households in which children live have guns. The additional access in homes where children visit has not been assessed.

OBJECTIVES: to quantify child access to firearms in Miami-Dade County and to compare demographics and household composition of gun-owners and non-gun owners.

METHOD OR APPROACH: A random digit dial telephone survey was conducted in Miami-Dade County between September 2000 and February 2001. The sample included 285 persons who reported having a gun in the house (gun owners), and 243 who reported having no guns (non-gun owners). Gun owners were asked questions about their demographic characteristics, number of children living and visiting their home, number and types of guns in the house and locking/storage practices. Non-gun owners were asked about demographics and children in the household.

RESULTS: Fourteen percent of respondents reported keeping a gun, and 36% of these agreed to respond to the survey. Gun owners were older, better educated, more likely to be male, white, and had a higher household income than non gun-owners. In both groups, about 40% of respondents had children living with them. An additional 20% of gun owners reported that children visit their home regularly. More than half of the respondents had more than one gun in the home. Only 56% had purchased the gun at a store (the only source always that always requires a background check). Over half of the respondents said they keep a gun for the protection of self, home or family (57%). Storage practices differ slightly when comparing homes with and with out children. 52% of the respondents that live with children, and 44% of those in homes with guns where children visit, use gunlocks, compared to those BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 831

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that do not live with children (31%) and those where children do not visit (35%). Gun owners without children were twice as likely as gun-owners with children to keep guns loaded. (OR=2.3)

CONCLUSION: While only forty percent of surveyed gun-owners have children living in their homes, an additional 20% have children regularly visit their home. Prevention and education efforts should include this additional exposure of children to unlocked firearms. It is encouraging to see that homes in which children live or visit report higher use of locking devises. This indicates that the gun-owning population with close child contact may be more open to education about alternatives to unsafe gun storage in the home. However, even among those with children living in the home, almost half of respondents did not securely lock their gun(s). Clearly, more is needed in education and prevention efforts, as well as research that may overcome the barriers to lock usage.

LIMITS: Overall, the proportion of respondents reporting gun ownership was significantly lower than national averages. Given the anonymous nature of the survey, there is no way to characterize potential participants who declined to respond. The controversial subject may have impacted respondent refusal rates and/or resulted in responses biased to what is considered socially desirable. New legislation was recently passed requiring that guns are locked when not in the owner’s immediate control. This may have inflated the number of gun- owners with children who reported using gunlocks. Finally, previous studies have shown that women may be less likely to have accurate information about gun ownership and storage in the household. This may explain the small proportion of women who responded the survey as gun-owners (27% compared to 59% among non-gun owners).

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is unique in that in assessing child exposure to guns, it asked not only whether children live in the home, but also whether children visit. The findings can help advance prevention efforts encouraging parents to ask even temporary caretakers about gun storage prior to allowing their children to visit another home. The finding that gun owners may practice safer storage when children are in the home is important to prevention planners to continue to target gun safety education to gun owners that have children living in their home and to expand efforts targeting gun-owners who have child visitors.

HOMICIDE IN THE AMERICAS OVER THE PAST DECADE

ANGELA GARNER,ALBERTO CONCHA-EASTMAN Pan American Health Organization Washington, DC, USA

PROBLEM UNDER STUDY: In the region of the Americas, injuries account for 13.2% of all deaths. Injuries are divided into 2 categories intentional and unintentional injuries. This study primarily focuses on intentional injuries in the Americas, specifically homicide. Violence is a large problem that encompasses many different areas from domestic violence to homicide and suicide. Homicide is a particularly difficult situation in the Americas. More than 12 countries in Latin America and the Caribbean have homicide rates above 10 per 100,000. Many factors BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 832

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contribute to homicide and violence such as family structure, alcohol and or drug abuse, cultural values, witnessing violent acts or being part of a violent act, lack of quality education, lack of self efficacy, lack of trust of governmental officials and availability of firearms.

OBJECTIVES: This study will demonstrate the magnitude of violence in the region of the Americas by illustrating the homicide trends over the past decade. Showing the trends in Latin America and the Caribbean will allow officials to see the severity of the problem and hopefully, devote more time and research to careful surveillance of the problem in order to help correct it the way the community deems necessary.

METHOD OR APPROACH: Data was collected from the Technology Information System (TIS) the Pan American Health Organization’s central database of whose member countries, report pertinent information and other sources via the internet including a forensic database in Colombia and other statistical pages from different countries. Age specific mortality rates due to homicide were placed into a graph in order to illustrate a trend analysis.

RESULTS: According to the data, Colombia has the highest homicide rate in the Northern part of South America. The data collected from 1992-1995 was from TIS and the data from 1996-2000 was from the Instituto Nacional de Medicina Legal y Ciencias Forenses. The trend shows that homicides rates in Colombia were 71.4/100,000 people in 1992, 60.8/100,000 people in 1995 and 65/100,000 people in 2000. Ecuador had the lowest homicide rate, 14.8 per 100,000 in 1999, of Northern South America among the countries with data. However, there was a 51% increase in the homicide rate in Ecuador from 1990-1999. Among data within 3 countries in the Andean sub-region Brazil has the highest homicide rate 25/100,000 people in 1999. There was a 36% increase from 1990-1999 and a 30% increase from 1995-1999. Among the 4 countries evaluated in Central America, El Salvador has the highest homicide rate. No data was available for 1993 however, there was a tremendous shift in the homicide rate from 1990-1994. In fact, there was a 400% increase (1990- 27.6/100,000 and 1994- 138.2/100,000.) Perhaps this is due to the Chaputepec Peace Accord in 1992 ending the war and in 1994 the new Civilian Police was deployed therefore, rein- stating the recording of mortality data. There was a decrease in 1998 and 1999 due to missing data from both May and June. Honduras had a 35% decrease from 1994-1999. Data from 3 countries in the Caribbean showed that Jamaica has the highest homicide rate in the Caribbean and it is increasing. There was a 48% increase in homicide rates from 1994- 1997. (Graphs are available.)

CONCLUSION: Showing the percent change in homicide rates demonstrates the importance of devoting more time and research to violence prevention programs related to homicide. Perhaps, implementing more surveillance systems in order to create proper homicide prevention programs and working with the communities on implementing the programs can do this.

LIMITS: The main limitation of this study was the lack of data. However, the information collected reflects the reality of homicides in the Americas.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study contributes to the field of injury by catching policy maker’s attention and demonstrating the necessity of allocating funds for homicide prevention programs in the Americas. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 833

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INITIAL EFFORTS FOR PREVENTION OF SMALL ARM INJURIES AND LETHALITIES IN RUSSIA

VYACHESLAV SHAROV Ural State Medical Academy for Additional Education Chelyabinsk, Chelyabinsk Region, Russia

In order to develop preventive measures to reduce small-arm injuries and lethality, there is a need for information on numbers and patterns of deaths and environment in each case. Besides, examination of each injury event, including agents and instruments, human factors involving the victims are necessary to set up a database for working up prevention policy. Although in the former USSR preventive health care was the priority, gunshot wounds were not considered a subject for prevention. At present, the problem of gun violence in Russia is understudied due to the fact that in the former USSR small arm injuries and deaths were quite seldom. Together with the ruin- ing of Soviet Union most arsenals of small arms in new republics went out of strict control and rapid dissemination of small arms took place all over NIS causing destabilization in many regions. During last 10 years small arms became easily available for civilians and that resulted in the significant jumping of injury and deaths and crime with the use of firearms. In clinical practice physicians more and more often have to come across consequences of the use of small arms and combat weapons while some 15 years ago gunshot wounds were quite seldom and only due to hunting weapons. Because of the poor economic situation in Russia and destruction of health care system most of those injured by small arms have no access to in-time and adequate treatment. At present there is a lack of almost everything for the treatment of gunshot wound at hospitals–sometimes it is hard to even perform diagnostic procedures because of absence of X-ray film. Besides there are no supplies, pharmaceuticals, surgical instruments and sutures at the hospitals and that results in the jump of a number of handicapped people. The inability of the state to support handicapped people and professionals (militiamen) who have been wounded in the struggle with organized crime or armed criminals has created one more problem. There is no system for rehabilitation of them and they experience deep psychological crisis and depression and there are hardly quite a few organizations that are dealing with these problems. That dictates the necessity to build up a system of prevention small arm trauma to avoid huge extra expenses in the future. All health care problems are associated with social and legal ones. In their turn, legal structures are unable to defend citizens and that is why they officially call them to arm now (Elena Arbuzova HELLO WEAPONS (Security).-Novosti.-N92 (93).-Thursday, May, 24, 2001). Only joint efforts of legal structures, health care professionals could create a strong prevention policy. Regional department of statistics have no data concerning firearm injury–all gunshot wounds are registered as a trauma cases and small arm deaths–as a violent death. It is hard to get any reliable statistics concerning gun violence and gun injury not only at the hospital but in the city, region, country. that is why the purpose of the first stage of the study of gun violence in Russia should be a standardization of statistical indices. As far as it is hard to get any reliable statistics concerning gun violence and gun injury in Russia we have undertaken a study on gunshot wounds at the Chelyabinsk Municipal BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 834

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Hospital No. 9 (665 beds). The population of the city is 1,2 million and the Chelyabinsk Municipal Hospital No.9 is one of the 8 hospitals in the city of Chelyabinsk which is dealing with gunshot wounds. The hospital provides health care service for a district with 30276 inhabitants. Results of the survey in the trauma department (75 beds) where all patients with gunshot wounds underwent treatment have shown that the small arm injury involved all age groups of population but more often occurred in males aged 20-39 (60% of all cases), which is in correspondence to the world statistics. Also, there is obvious prevalence of gunshot wounds of extremities (65%), still wounds of the head and body constitutes about 35% of all gunshot wounds. Nevertheless, there are still opportunities to start setting up the system for the prevention of the firearm injury and deaths by means of the study of all reasons and the environment of the use of small arms, education in all communities, increase of the living standards, elimination of aggression, improvement of health care, responsibility of legal structures. In consider of the present economic situation on Russia it is obvious that these problems could be solved only with the aid of the world community.

USE OF MEDIEVAL WEAPONS IN HOMICIDAL INJURIES IN VILLAGE POPULATION OF A LARGELY RURAL, DEVELOPING COUNTRY (INDIA): SPECTRUM AND CAUSES

PANKAJ KUMAR LAKHTAKIA Department Of Orthopaedic Surgery, Shyam Shah Medical College, Awadhesh Pratap Singh University Rewa, M.P., India India, a large developing country has a predominant 65 % of its more than a billion population living in about half a million villages. Such a large village population with some peculiar socio-economico-culturo-political conditions has witnessed an increased incidence of homicidal injuries involving the use of medieval weapons. The increased use of medieval weapons in this jet age of firearms may be surprising and unexpected. It may be worth studying the spectrum and causes of the use of medieval weapons in homicidal injuries for purposes of violence prevention especially in the back drop of the prevalent socio-economico- culturo-political environment and criminal legislation. The profile of injuries caused may be worthy of analysis too from the viewpoint of trauma care. A year long prospective study was conducted in Gandhi Memorial Hospital, Shyam Shah Medical College, Awadhesh Pratap Singh University, Rewa, M.P.,India in the millennium year, involving all homicidal injuries. Details of the nature and circumstances of the use of medieval weapons and the profiles of injuries sustained were noted. Analysis of the spectrum and causes of the use of medieval weapons was undertaken in the light of the socio-economico-culturo-political attributes. 314 homicidal injuries were studied from amongst 1394 cases of unnatural causality. 280 (89.1 %) were males and 130 (42.0%) belonged to the 13-30 yrs. age group. In 267 (85.0%) cases medieval weapons were used. Lathes (wooden rod) constituted the homicidal weapon in 213 (67.8 %) cases, while sharp medieval weapons were used in 44 (14 %) incidents and iron rods in 10 (3.1 %) cases. Injuries profile showed fracture of BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 835

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both bones of forearm, single bone of forearm, tibia- fibula and dislocations of elbow and upper radio-ulnaar joints to be the commonest. Analysis revealed that ready availability, easy usage, low costs, minimal maintenance, lack of high-tech knowledge and expertise as well as medico-legal considerations of criminal legislation were the main causes for the rampant use of medieval weapons in homicidal injuries in village population in India. It may be concluded that various socio-economico-culturo- political attributes are responsible for the surprising incidence of the use of medieval weapons in homicidal injuries in rural India and need to be corrected to ensure violence prevention. The study is a hospital based one year prospective study with the limitations inherent in such a study design and protocol. It has both disadvantages as well as advantages to its credit. Homicidal intentional trauma with the ready use of easily available, household medieval weapons in a rural society of a developing country causes serious law and order problems besides much mortality and morbidity. Trauma load on poorly infrastructure and already financially stretched medical services causes immense burden reflected by overall unsatis- factory quantitative and qualitative treatment care. Study of the spectrum and causes of the common use of medieval weapons and the injury’ profile may help law enforcing agencies with better insights for violence prevention strategies and medical services to optimize the meagre health care resources.

MAGNITUDE AND DISTRIBUTION OF DIFFERENT TYPES OF VIOLENCE IN A LATIN AMERICA CAPITAL CITY: BOGOTÁ, COLOMBIA

LUIS F DUQUE,JOANNE KLEVENS,CLEMENCIA RAMIREZ ASSALUD and School of Public Health, University of Antioquia Medellin, Colombia

PROBLEM UNDER STUDY: Intentional injuries cause 2.7% of the number of years from premature death and disability in the world. This burden is even greater among the poorer nations and is projected to increase. The increasing importance of violence as a cause of morbidity and mortality along with its great social and economic costs has lead the World Health Assembly to adopt a resolution declaring it a worldwide public health problem. To approach violence from a public health perspective, relevant epidemiological information must be collected as a basis for developing programs for its prevention and control. Colombia ranks as one of the most violent countries in the world with a rate of 96 homicides per 100,000. Bogotá (6 million inhabitants) is the capital city of Colombia and has a homicide rate of 44 per 100,000. In Colombia, violence is the leading cause of death and contributes to 25% of the burden of disease. However, data on the magnitude and distribution of violence in Colombia are limited and based on mortality statistics, injuries treated by the health services or police crime reports. These sources most likely underestimate the real magnitude of the problem because of unreported events. In addition, because there are no standardized definitions and records, they might be subject to errors in recording, classification and interpretation.

OBJECTIVES: To establish the prevalence and distribution of witnesses, victims and perpetrators of different types of violence in the general population and the proportion of victims consulting health services or reporting the incident to authorities. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 836

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METHOD OR APPROACH: Cross-sectional survey of a random sample of 3007 inhabitants between the ages of 15 and 60 in the city of Bogotá, Colombia, based on a face-to-face interview. This is the first study of this kind oriented to establishing population based rates of witnesses, victims and perpetrators of violence in Bogotá, Colombia. (1997-98).

RESULTS: Results are presented age adjusted using WHO reference population. Age adjusted prevalence per 100 persons (95% confidence interval).

Past year prevalence rates are: 1. Verbal aggression: witness 87.0 (85.7-88.3), victim: 68.4 (66.6-70.1), aggressor: 56.5 (54.6-58.3); 2. Mild physical aggression: witness: 60.7 (58.8-62.5), victim: 27.2 (25.6-28.8), aggressor: 26.9 (25.2-28.5); 3. Assault with a weapon: victim: 5.9 (5.0-6.8), aggressor: 0.3 (0.1-0.5); 4. Sexual aggression: victim: 0.5 (0.3-0.7), aggressor: 0.04 (0–0.1).

Lifetime prevalence rates are: 1. Verbal aggression: witness: 80.2 (78.7-81.7), victim: 59.4 (57.5-61.2), aggressor: 41.0 (39.0-42.8); 2. Stolen something of value: witness: 63.3 (61.5-65.2), victim: 51.0 (49.1-52.9), aggressor: 6.1 (5.2-6.9); 3. Assault with a weapon: witness: 70.1 (68.3-71.8), victim: 55.0 (53.1-56.9), aggressor: 5.8 (4.9-6.7); 4. Sexual aggression: witness: 8.7 (7.7-9.7), victim: 4.6 (3.9-5.4), aggressor: 0.3 (0.1- 0.5). Different types of aggression were studied by gender, age, socio-economic class, education, place of living, marital status and employment status. Those involved in most types of physical violence tended to be young, male, from lower middle social classes, with some degree of secondary education, and single or divorced. Between 11% and 67% of the victims consulted a health service and less than 32% reported the incident to an authority.

CONCLUSION: Prevalence of witnesses and victims of violence in this sample appears to be high, while perpetrators of serious violence constitute a small proportion. Violence is not equally distributed throughout the population suggesting the possibility of identifying a population at higher risk for the development of intervention programs. There is a high proportion of unreported incidents to authorities.

LIMITS: Those derived from a cross sectional study conclusion can be extrapolated to 15-60 years persons not institutionalized ( for instance, not in jails, convents, etc).

CONTRIBUTION OF THE PROJECT TO THE FIELD: Authorities can target their violence prevention and control actions to the high risk population groups identified in these data. CREDITS. Colombian Institute for the Advancement of Science and Technology (Colciencias) and the Colombian Association for Health (ASSALUD) supported this study. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 837

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SUICIDE, HOMICIDE, AND UNINTENTIONAL INJURIES: PREVENTING GUN VIOLENCE

MARIELLE HAYWOOD-POSEY,ALICIA HORTON Brady Centre to Prevent Gun Violence Washington, DC, USA

PROBLEM UNDER STUDY: Gun violence and gun violence prevention in America.

The poster session seeks: 1. To provide participants with a primary source of information on the issue of gun violence and the prevention of gun injury and death; 2. To assist health care providers and health educators in including firearm violence prevention counselling in routine injury prevention counselling; and 3. To increase the skill level of participants in counselling clients/patients.

Participants will be able: 1. To identify and discuss the risks of keeping a gun in the home and its implications for the community, and society; 2. To identify and discuss the three means of injury and injury-death associated with firearms; and 3. To broach the subject of firearm-related prevention counselling to patients/clients in their routine safety counselling.

METHOD OR APPROACH: The Steps to Prevent Firearm Injury In The Home (STOP 2) program is a counselling tool that prepares health care providers to talk with patients/clients and their families about the dangers of guns in the home during their injury prevention counselling routine. STOP 2 was designed in response to health care providers across a broad range that requested print materials to assist them in firearm violence prevention with their patients and clients. It is based on the premise that gun-related injuries and deaths are preventable! The broad range of health care providers includes physicians, medical care providers, counsellors, psychologists, nurses and nurse practitioners, mental health providers, health educators, midwives, therapists, school counsellors and staff, and other professions that educate clients and patients about injury prevention. This program was developed in concert with organizations that serve diverse populations to be inclusive and to insure sensitivity of all populations. The STOP 2 program provides print materials, Internet activities, and gun violence prevention workshops at national conferences, universities, hospitals, and for organizations. Print materials are delivered in the form of a kit that includes: a reference manual designed for health care providers that provides facts about gun violence (homicide, suicide, and unintentional shootings) and prevention; and a bibliography; a family brochures provides facts, prevention steps, a family quiz, and resource numbers; and posters encourage patients and clients to ask their health care provider for more information about preventing gun violence in the home. World wide web activities at www.bradycneter.org pro- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 838

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vide the following activities: an interactive parent quiz “Is My Family Safe?”; an interactive children’s game; kit request forms and firearm violence facts.

STAYING SAFE AROUND GUNS, FIREARM SAFETY FOR PREADOLESCENTS

RHONDA SIEGEL,ELAINE FRANK Injury Prevention Program, Division of Disease Prevention and Health Promotion, Office of Community Concord, NH, USA

INTRODUCTION: “Staying Safe Around Guns” was produced by the New Hampshire Firearm Safety Coalition, a group of individuals and organizations with diverse opinions around the possession and use of firearms. Despite their differences, Coalition members share a commitment to keep all children safe and to prevent deaths and injuries from the misuse of firearms.

PROBLEM UNDER STUDY: At least half the homes in the USA are estimated to have firearms. Whether or not a family chooses to own or use firearms, children can easily find themselves in a situation where a firearm is present. In addition, children are exposed to media images of firearms that are unrealistic and often fail to show the real life consequences of firearm use and misuse. When children find themselves in a situation where firearms are present, their understanding of the potential dangers of firearms and quick thinking may help them stay safe.

OBJECTIVES: The Coalition wished to develop an educational tool that would address these issues for children between nine and twelve years old, when they begin to be left home alone and start making important decisions on their own. The Coalition determined that there was BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 839

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a lack of educational information available for this age group. A video was chosen in order to present a consistent message, an important factor given the controversial nature of the material being presented. Based on focus groups held with children in the target age range and with adults from a wide range of organizations and perspectives, the following objectives were selected: 1. Show the real consequences of firearm use and misuse; 2. Give children practical strategies to use if they find a firearm or if a friend is misusing or threatening to misuse a firearm; 3. Provide basic firearm safety guidelines; 4. Show how real firearms behave as compared to media images.

METHOD OR APPROACH: The Coalition hired a company with experience in producing videos “by kids, for kids” to produce the program. A final draft was pilot tested with youth in several towns around the state representing diverse populations and attitudes towards firearms. To ensure that children were attentive to the video and that the main messages were com- municated, the final version was pilot tested in six additional communities.

RESULTS: Based on pilot tests and subsequent evaluations, the response to the video has been very positive. Despite the controversial topic, the video has been well accepted by schools and community groups. Both children and adults give it high marks for interest and clarity of message.

CONCLUSION: A coalition, composed of individuals or groups with widely divergent philoso- phies on a controversial topic, can collaborate and find common ground from which to produce an effective educational tool.

LIMITS: Any one-time educational strategy is of limited effectiveness.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This video demonstrates the strength of a committed coalition in focusing on shared values to develop an effective educational tool. It’s positive reception demonstrates the value of including young people in all aspects of the development of a project like this.

TRENDS IN BB/PELLET GUN INJURY RATES AND FIREARM INJURY AND DEATH RATES AMONG CHILDREN AND TEENAGERS: USA, 1985-1999

JOSEPH L. ANNEST,MARY H. NGUYEN,LOIS A. FINGERHUT,JAMES A. MERCY Centers for Disease Control and Prevention Atlanta, Ga, USA

PROBLEM UNDER STUDY: Gun-related injuries and deaths in children and teenagers in the USA.

OBJECTIVES: To characterize gun-related injuries and deaths in the USA for persons aged 19 years and younger, including gun shot wounds associated with BB/pellet guns and firearms.

METHOD OR APPROACH: Numbers and rates of nonfatal BB and pellet gun injuries and fatal and nonfatal firearm injuries are presented by age, year, and intent of injury. Nonfatal injury data were obtained from hospital emergency department (ED) records for all BB/pellet gun BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 840

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injury cases reported from 1985 through 1999, and all firearm injury cases reported from 1993 through 1999 using the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Product Safety Commission. Fatal injury data from 1985 through 1999 were obtained from death certificates using the National Vital Statistics System (NVSS) of the National Centre for Health Statistics, CDC. NEISS comprises approximately 100 hospitals that are a stratified probability sample of all U.S. hospitals with at least 6 beds and that provide 24-hour emergency service.

RESULTS: National trends in gun-related injury and death rates were examined by age and by year. BB/pellet gun-related injury rates increased from age 1 to age 13 and declined thereafter. Firearm-related injury and death rates increased gradually until age 13 and then increased sharply until age 18. For persons aged 19 years and younger, BB/pellet gun-related injury rates increased from the late 1980s until the early 1990s and then declined up to 1999 (rates per 100,000 population were 24.0 in 1988, 32.8 in 1992, and 18.3 in 1999). This trend was similar to those for fatal and nonfatal firearm-related injury rates (death rates per 100,000 were 4.5 in 1985, 7.8 in 1993, and 4.9 in 1998 (latest year of data now available) and nonfatal rates per 100,000 were 38.5 in 1993 and 16.3 in 1999). In spite of these declines, gun-related injuries remain a public health concern. For children and teenagers in 1999, an estimated 14,313 (95% C.I., 12,025-16,601) cases with nonfatal BB/pellet gun injuries and an estimated 12,748 (95% C.I., 7,881-17,615) cases with nonfatal firearm-related injuries were treated in U.S. hospital EDs. Also, firearm-related injuries (3,792 deaths in 1998) remain the second leading cause of death behind motor vehicle traffic-related injuries (7,641 deaths in 1998) in the USA. BB/pellet gun-related injuries were predominantly unintentional, while firearm-related injuries and deaths were mostly violence-related. However, the percentage of cases that were violence-related increased with age for both BB/pellet gun- related injuries and firearm-related injuries and deaths.

CONCLUSION: Despite substantial declines in BB/pellet gun-related and firearm-related injury rates since the early 1990s, prevention efforts to further reduce these rates should continue to be emphasized. These efforts should consider the role of preventing unsupervised access to both BB/pellet guns and firearms by children. Also, reducing gun violence should help reduce BB/pellet gun-related injuries and firearm-related injuries and deaths among children and teenagers.

LIMITS : Nonfatal gun-related injury rates are based on data from a nationally representative sample of approximately 100 U.S. hospitals with emergency departments and are therefore subject to sampling error.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study suggests that efforts to reduce gun- related injuries among children and teenagers need to consider those associated with BB/pellet guns as well as firearms. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 841

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Mobiliser les communautés pour prévenir la violence Community Mobilization to Prevent Violence

WALKING THE PREVENTION CIRCLE: UNDERSTANDING CHILD/YOUTH MALTREATMENT FOR ABORIGINAL COMMUNITIES

SHELLEY CARDINAL Canadian Red Cross RespectED: Violence & Abuse Prevention Victoria, BC, Canada

PROBLEM UNDER STUDY: From a cultural, societal and familial framework, Walking the Prevention Circle explores the effects of Indian Residential Schools, family violence and child maltreatment on our indigenous peoples. A significant legacy of the emotional, physical and sexual abuse experienced in residential schools has been child/youth maltreatment and family violence in all its forms. This project was designed to provide prevention education based on current adult learning principles. Through using a culturally specific, interactive workshop format, this project seeks to shine a light on a painful topic. By providing a safe learning environment where the types of abuse can be named and examined, participants are free to discuss their issues and develop protection strategies for themselves, their young people and the community as a whole.

OBJECTIVES: Walking the Prevention Circle is about giving a language and facilitating change that will identify and start to reverse the lasting effects abuse has had on Aboriginal lives. Using award winning curricula and videos, this project establishes a baseline of information on all types of abuse and neglect. From there, participants are able to formulate healthy community strategies.

METHOD OR APPROACH: In 1989, RespectED developed its first partnership with an Aboriginal community. An 80 hour training program was delivered to band members of the StoLo Tribal Council. Over the next 6 years various Aboriginal communities collaborated and participated in RespectED training programs. In 1997, Walking the Prevention Circle was developed. By defining the events that have shaped Aboriginal lives, sharing peoples’ stories of who they are and using the process of the circle, healing continues. In 4 years Walking the Prevention Circle has been facilitated over 50 times to bands and tribal councils, Aboriginal organizations and educational institutions. Each aspect, from program development to workshops has been evaluated.

RESULTS: The learning curve has been substantial. RespectED has grown from one training program with the StoLo Nation to Walking the Prevention Circle being facilitated to Aboriginal communities across Canada. The ongoing process of evaluation has driven the following learning: -the program needs to be Aboriginal driven, developed and facilitated -a capacity building model must be followed -the ownership of program development and BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 842

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delivery lies within the community -flexibility is needed within service delivery models - communities need assistance to add RespectED to their prevention plans -Aboriginal prevention educators are needed -it is important to identify challenges within the community such as: language; traditional vs. euro-Canadian belief systems; fear of the issues this type of program raises; limited support systems.

CONCLUSION: Aboriginal people and communities across Canada are in an incredible healing process. Within that process there is recognition of the need for primary prevention within their prevention plans. Walking the Prevention Circle is about understanding the cycles of violence, acknowledging all aspects of the experience and letting it go. In doing so, the circle of healing is completed and the full potential of Aboriginal people is realized. Through the circle healing continues; through this program the prevention circle is travelled.

LIMITS: The results of this program are based on experiential evidence, participant numbers, feedback and focus groups. Further study is needed to test knowledge retention and attitude change within participants.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Walking the Prevention Circle is the only national Aboriginal primary prevention program in Canada. The growing number of Aboriginal communities incorporating RespectED into their prevention plans defines a successful multi-dimensional approach and the process of safety promotion.

THE LEARNING CURVE: SEVENTEEN YEARS OF PROMOTING SAFETY THROUGH “RESPECTED: VIOLENCE & ABUSE PREVENTION” EDUCATION

JUDI FAIRHOLM Canadian Red Cross ResepectED: Violence & Abuse Prevention Vancouver, BC, Canada

PROBLEM UNDER STUDY: Child and youth maltreatment is a complex and devastating problem. Effective prevention needs to address causes, manifestations, contributing factors and populations affected by violence. Prevention efforts must be as multifaceted as the problem itself. A significant factor in prevention is education, which must be developed within a framework of community ownership, policies, support systems, standards, training, service delivery models and evaluation.

OBJECTIVES: To identify the components needed to promote safe communities for children and youth through violence and abuse prevention education.

METHOD OR APPROACH: During the past 17 years, the Canadian Red Cross, RespectED: Violence & Abuse Prevention has delivered education to over 780,000 youth and 65,000 adults. Reaching across the country RespectED has trained and certified over 1000 community members as Prevention Educators. Building on the U.N. Convention on the Rights of the Child, these people in turn, educate their communities about abuse, violence, neglect and harassment. Evaluation at each delivery point, drives the evolving development of RespectED and identifies the changes needed to decrease intentional injury and promote safe communities. By continually assessing the evaluation, RespectED has learned many lessons. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 843

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RESULTS: The learning curve has been substantial. From starting as a grass roots program in one Canadian city, RespectED is now delivered within all provinces and territories, including two national initiatives. Other countries such as Sweden, Denmark, Norway, Britain, Greece and Australia have expressed interest in RespectED programs. The ongoing process of evaluation has driven the following learning: • The ownership of program development and delivery within communities; • The challenges of working in collaboration with diverse and geographically scat- tered communities; • The flexibility needed within service delivery models; • The importance of developing and communicating policies and laws that support safe environments; • The screening process to ensure that young people are not at risk from the adults in their lives; • The barriers and benefits to preventing violence and abuse in communities; • The needs of Prevention Educators; • The maintenance of training and delivery standards; • Evaluation and research methods

CONCLUSION: RespectED is a primary prevention program that collaborates with communities in naming a problem, identifying resources and promoting health for individuals, families, communities and societies. It works towards reducing risk factors and preventing violence from becoming a reality in the lives of youth. By looking retrospectively and learning from participants, RespectED plays a significant role in establishing principles of risk reduction and promoting safe environments.

LIMITS: The learnings are based on evaluations, assessments, a four month longitudinal study on students’ knowledge and skills, and experience. Further study is needed to test knowledge retention and attitude change within participants.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This analysis underscores the important learning in not only expanding a program nationally but in also maintaining consistency and standards while honouring flexibility and community ownership.

BUILDING COMMU,NITY ENGAGEMENT TO PREVENT SEXUAL VIOLENCE

AMY OKAYA Minnesota Department of Health St. Paul, Mn, USA

PROBLEM UNDER STUDY: National and state data show that sexual violence is a problem of serious public health concern. Nearly 18% of women and 3% of men in the USA report having been victims of completed or attempted rape during their lifetimes (Tjaden and BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 844

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Thoennes, 1998). Other studies have found that at least 20% of U.S. women and 5% to 10% of U.S. men have experienced sexual abuse as children. In Minnesota, 8.8% of ninth graders report having been sexually abused (Minnesota Student Survey, 1998). The health effects of sexual victimization can be far-reaching, and may include pregnancy, physical injury, STDs/HIV infection, post-traumatic stress disorder, depression, chemical abuse, and suicidal behaviour. While services for victims, and treatment and correctional interventions for perpetrators, have expanded over the last 30 years, recognition of sexual violence as a public health problem is relatively recent. Public health offers a population-based approach, with an emphasis on primary prevention. As a problem reflecting the confluence of multiple risk factors, it is clear that the prevention of sexual violence must involve diverse segments of the community, working simultaneously and in concert to prevent the incidence of sexual violence. Currently many barriers exist to fully addressing sexual assault, including ignorance, embarrassment, shame, fear, silence, and the isolation of those concerned about the problem. A successful public health approach must seek to reduce these barriers so that the problem can be effectively addressed.

OBJECTIVES: 1. To provide vehicles for the sharing of community experience, knowledge and expertise related to sexual violence prevention; 2. To promote community engagement in the prevention of sexual violence.

METHOD OR APPROACH: Several methods have been used to increase public understanding of and engagement in the prevention of sexual violence. These methods are consistent with a public health approach to prevention. A comprehensive resource kit was developed to provide strategies, examples and tools for sexual violence prevention within specific segments of the community (i.e. faith communities, the arts, education, sports and recreation, etc.). Content for the kit was drawn from community and national experts and practitioners in sexual assault and violence prevention. A state-wide town meeting was held to engage a diverse group of citizens in a discussion about prevention. The town meeting illustrated the multifaceted nature of the issue, and was taped and broadcast on public television stations in Minnesota, as well as other states across the U.S. A Sexual Violence Prevention Network has been formed to promote information-sharing, networking and collaboration across disciplines. The Network serves as a regular venue for individuals and organizations to learn from one another and enhance their prevention work.

RESULTS: ‘A Place to Start: A Resource Kit for Preventing Sexual Violence’ is being widely used across Minnesota by sexual assault programs, educators, and others. The kit is available online and receives hundreds of visits daily. Analysis of the strengths and limitations of the kit will be presented. The town meeting set the stage for further community-based discussion, and helped to model new ways of sharing responsibility and resources for prevention among service providers, other professionals, and the general public. Videotapes of the town meeting are being used with adult and youth groups to stimulate further local discussion about the issue. The Sexual Violence Prevention Network now includes approximately 400 members from diverse professions and organizations. Results of a survey of Network members will be presented, describing outcomes and factors that influence the success of this approach. Each of these activities and resources represent venues for broader community participation and involvement in the prevention of sexual violence. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 845

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CONCLUSION: Resources that provide forums for the sharing of information, the building of relationships, and the development of prevention practice are sought after by community members. The methods described have produced outcomes that contribute to broader community engagement and improved capacity to prevent sexual violence.

LIMITS: Strategies have been tailored to needs and resources present in Minnesota, and may or may not be appropriate or feasible in other regions.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This project describes unique community-based strategies to support the prevention of sexual violence, grounded in a public health approach.

CARE: COMMUNITIES AGAINST RAPE INITIATIVE

FREDERICA KRAMER,MICHAEL BROSNAN Indiana State University Terre Haute, In, USA

PROBLEM UNDER STUDY: Girls under 18 are the victims of more than half of the rapes reported to police, and the younger the victim, the more likely the attacker is a relative or an acquaintance. Fifty-seven percent (57%) of all sexual assaults occur during a date. It is estimated that 70 to 90% of rapes are not officially reported.

OBJECTIVES: In response to these statistics, CARe was formed to reduce the incidence of sexual assault and rape to school age children and youth in Indiana. Now in its sixth year, the initiative continues to be implemented by a state-wide partnership including the Indiana State Department of Health, Purdue University Cooperative Extension Service, Indiana Coalition Against Sexual Assault, Indiana State University, Indiana Youth Institute, Purdue University Centre for Families, Purdue University Student Health Centre, Purdue University 4-H Youth Department, and communities throughout Indiana.

METHOD OR APPROACH: To target the young audience noted above, a curriculum to educate students about rape/sexual assault was developed and tested by classroom teachers and presented to over 650 Indiana middle, junior high, and secondary teachers attending sixteen in- service workshops. Over 137 teachers who implemented the curriculum assessed their students’ attitudes and knowledge about rape using the pre-test instrument. After implementing the curriculum, post-test results were obtained to measure improvement.

RESULTS AND CONCLUSION: Data from over 4400 students, from 57 schools, 137 teachers, from 34 different subject matter areas on knowledge and attitudes regarding rape have been gathered before and after the use of the curriculum. Multivariate analysis of variance was performed examining gender, age, size of school, geographical setting (urban, rural, suburban population) and gender of teachers as factors. Comparison of pre and post-test scores revealed: 1. Positive changes in students’ knowledge and attitudes about rape following instruction using the CARe curriculum; 2. Persistent sex differences regarding beliefs and attitudes; and 3. Youth at grades 6-8 are most likely to have mistaken ideas and inappropriate attitudes, signifying the greatest need for educational intervention. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 846

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LIMITS: Participation was voluntary and thus no random sampling characterized this study. Indiana may not be typical of the USA. No measure of behaviour was obtained, limiting these data to paper and pencil format.

IMPLICATIONS: Future implications include: 1. Continued improvement through grade 12 indicates broad range suitability of the curriculum; 2. Greater involvement by male teachers/coaches is needed for maximum impact; 3. Success of interdisciplinary programming will provide encouragement for total- school involvement; and 4. Improvement in knowledge and attitude should be reflected in reduced rate of rape/sexual assault. The CARe partnership is the largest rape and sexual assault prevention project in the state and in 1999, received national recognition,“Outstanding Community Service Award” from the USA Department of Agriculture and Cooperative Extension Service. Also, the Indiana Rural Health Association recognized the project with the “Distinguished Community Service Award.

IT’S MORE THAN JUST A GAME

JUDI FAIRHOLM Canadian Red Cross Vancouver, BC, Canada

PROBLEM UNDER STUDY: In January, 1997, former NHL hockey player Sheldon Kennedy dis- closed publicly that for numerous years he had been sexually abused by Graham James, his junior hockey coach. This courageous act revealed a significant problem: the vulnerability of young athletes and the gaps within policies and procedures, prevention education and risk management. The sporting world was thrown into a crisis as they realized there was an expanded definition, both legally and morally, to “safe environments”.

OBJECTIVES: To examine the risk elements within sport and a proactive plan that is moving the sport world from denial into promoting and providing safety for participants, staff and volunteers.

METHOD OR APPROACH: Building on successful prevention programs throughout Canada, the Red Cross’ RespectED: Violence & Abuse Prevention responded to this crisis by developing an innovative program “It’s More Than Just A Game”. This comprehensive program has worked closely with Canadian Hockey Association, Western Hockey League, provincial hockey associations, Sport BC, Sask Sport, Sport NB, Sport Manitoba, Alberta Gymnastics Federation, Little League Alberta and Sport Canada. Each aspect, from policy development to workshops has been evaluated; this case study demonstrates successful practice.

RESULTS: In 1997, the Canadian sporting world had very limited knowledge about abuse, harassment, child protection acts and their legal and moral responsibility to provide safe environments for young Canadians. Four years later: BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 847

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• All hockey associations and numerous other sports have adopted policies and procedures to deal with abuse and harassment; • Over 100,000 sport personnel have participated in a screening process; • Over 20,000 coaches and administrators have participated in It’s More Than Just A Game workshop; • 220 Hockey Facilitators have been trained to deliver Speak Out: It’s More Than Just A Game to hockey coaches; Canadian Hockey Association has mandated that all 58,000 coaches will participate in this workshop by Dec. 2002; • Men are increasingly becoming involved with the prevention of abuse and harassment; • Manuals, brochures, booklets, posters, public service announcements and newslet- ters have been produced to increase knowledge and public awareness; • The understanding of “safe environments” has moved past physical safety to include emotional safety and care

CONCLUSION: Sporting organizations and adults have begun to realize that they are responsible for the safety of Canada’s young people in their care. A need was identified, Red Cross RespectED was able to respond; in the last four years many sport organizations have committed their resources and time to a comprehensive prevention plan that promotes safety. This multi-dimensional approach is fundamental to bring about this depth of change.

LIMITS: The results of this program are based on experiential evidence, participant numbers and feedback, focus groups and satisfaction surveys.

CONTRIBUTION OF THE PROJECT TO THE FIELD: A national initiative led by two national organizations–Canadian Red Cross and Canadian Hockey Association–has resulted in significant changes throughout the sporting world across Canada. This contribution defines a successful multi-dimensional approach and the process of safety promotion.

VIOLENCE WITHIN INUIT COMMUNITIES OF CANADA: A CALL TO PUT NORTHERN CANADIAN HEALTH POLICY INTO CONTEXT

TRACY O’HEARN,VERONICA DEWAR Pauktuutit Inuit Women’s Association Ottawa, On, Canada

PROBLEM UNDER STUDY: Health policies and programming to date are limited in their influence on violence as an injury prevention issue due to the lack of a culturally and contextu- ally relevant framework. The intricacies of intentional and unintentional injury within Inuit communities are consistently overlooked as policy development is often removed from Inuit reality. Culture, gender, geography, and isolation, neo-colonialism and language are some of the many variables identified as significant to an effective amelioration of this problem. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 848

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A commitment from all levels of health and social services to relevant, community based policy development and implementation is needed.

OBJECTIVES: 1. To identify the unique context of Inuit women, children and communities; 2. To identify the influencing factors that contribute to the reality of violence; 3. To identify appropriate approaches to design, intervention and prevention.

METHOD OR APPROACH: Review of literature, research and interviews with Inuit women.

RESULTS: A thorough collection of recommendations on approaches to policy design and program implementation that is grounded in an awareness of Inuit women’s lives.

CONCLUSION: Community based approaches to policy development tend to embed policy into the reality of community. Culture, language and geographic specific knowledge are inherent in community based processes that naturally result in relevant policy and program initiatives. Addressing violence issues in health care will have a positive impact on men, women, children and the overall community.

LIMITS: There is a lack of current, accurate statistical information that is Inuit specific.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This paper serves to educate the public and influence all levels of government on policy development and implementation in order to meet the needs of Inuit communities in Canada.

INUIT HELPING INUIT: REDUCING FAMILY VIOLENCE

BEVERLY ILLAUQ,REPIKA IQALUKJUAK,DAISY ASHEVAK,SARAH KILLIKTEE, NINGEORAPIK AMAKAK,RAYGEE ATSIQTAK,IGAH PALLUQ,PIA PANEAK, ONALEE RANDELL Inuit Tapirisat of Canada Ottawa, On, Canada

PROBLEM UNDER STUDY: Family violence is a problem in our community.

OBJECTIVES: 1. To support and strengthen families, couples, parents, and individuals within the context of our own community; 2. To address family violence issues with counselling, education and awareness; 3. To manage and design our own programs.

METHOD OR APPROACH: Friending, interaction, information sharing and counselling. The centre is location of a variety of cultural and social development programs that tends to invite the community into the building.

RESULTS: Families that have been abusive are demonstrating healthy and appropriate involvement with each other. Recently a survey revealed that the centre is seen as a help to com- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 849

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munity members who are searching for healthier functioning. Generally, the community as a whole reveal a shift in attitude towards abusive situations. For example, members are more willing to acknowledge family violence as a reality rather than hide these facts, as has been the case in the past. In turn, the respondents also reveal an educated condemnation of family violence. Further, as a result of this centre and approach, people are seeking safety and starting to take responsibility for inappropriate actions.

CONCLUSION: If an organization supports victims, it will propagate victims of family violence. If an organization supports healthy and functional lifestyles, it will encourage appropriate individual and family development. For each person that experiences community support and self growth, this has a positive impact on the whole community.

LIMITS: The program is mostly limited in its youth and scarce resources. Staff training and salary costs are difficult to retain. Most of the funding is annually based, which means that the coordinator often is writing proposals. Currently, this person works for free.

CONTRIBUTION OF THE PROJECT TO THE FIELD: It is a valuable example of Inuit helping Inuit in a community based manner. The centre has produced 35 titles written in Inuktitut that are on personal development topics. These materials are widely distributed in the immediate area. They are now developing a website which will make these publications available to the wider public.

FIRST STEPS: TAKING ACTION EARLY TO PREVENT VIOLENCE

LARRY COHEN Prevention Institute Oakland, Ca, USA

PROBLEM UNDER STUDY: Violence occurs at an alarmingly high rate in our society, and affects young children deeply. Children who are exposed to violence are at increased risk for dis- rupted physical, emotional and cognitive development, as well as long-term deleterious effects such as school failure, difficulty maintaining healthy relationships, being re-victimized, and perpetrating violent acts later in life. Traditionally, most of violence prevention attention has been paid to adult and adolescent delinquents and perpetrators of crime. However, youth violence prevention practitioners have long urged that we “start earlier,”and a great amount of emerging research shows the importance of positive early childhood experiences and healthy environments in preventing children’s later involvement in violence.

OBJECTIVES: First Steps focuses on the intersection between violence prevention and child development. The project demonstrates the association between healthy early childhood development and violence prevention; synthesizes the existing information on best practices, programs, and policies addressing violence prevention in early childhood; delineates a series of concrete strategies that policy makers, practitioners, and parents can implement to ensure a safe and healthy childhood.

METHOD OR APPROACH: First Steps is a partnership between Prevention Institute, Action Alliance for Children, Fight Crime, Invest In Kids, and the Crime and Violence Prevention Centre of the California Attorney General’s Office. The research approach involves a synthesis BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 850

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of current findings from the child development and violence prevention fields, interviews with practitioners and experts, and a survey of Children and Family Commissioners and other policy makers. The research focuses on identifying areas of overlap between the two fields, and proven and promising strategies to reduce risks and build individual, family, community, and system strengths.

RESULTS: First Steps highlights key risk and resiliency factors, outlines a comprehensive framework for action, and delineates key areas for action. Recommendations include the need to integrate content and training on violence prevention into child development programs; ensure that early child care and education support healthy child development; enhance effective functioning within families and foster family self-sufficiency and empowerment; train providers to work in multidisciplinary collaborative; expand treatment services to reduce parental substance abuse; foster community strengths and networks, and increase local participation in decision-making; strengthen positive mental functioning within the family, and recognize poverty as a significant risk factor for violent involvement, and act to minimize its impact. Additional findings include the need to build strengths as well as reduce risks, work collaboratively across disciplines, and address broader, system-level issues, in addition to individual and family concerns.

CONCLUSION: It is important that policy makers and practitioners understand the linkages between the fields of violence prevention and child development, and be familiar with violence prevention strategies for young children. Legislators who are well educated about this issue can ensure that strategies and policies that promote healthy child development and prevent involvement in violence are supported, well funded, and institutionalized in local and state policy.

LIMITS: The main limitation of this project is that, instead of simply highlighting a single program, it delineates a comprehensive set of recommendations that necessitates action by a broad, multidisciplinary partnership. However, because violence is a complex problem, the solutions must be comprehensive.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Violence is not something that affects an occasional child. It is something that has its foundation in the communities that children grow up in and the norms that they are inculcated with. As such, people and organizations currently doing child development work need to rethink how they are using their resources so that violence prevention becomes an integral part of all their work, instead of a marginal or tangential issue. While First Steps was initially intended as a resource for state and local Children and Families Commissions, it is of value to all interested in these issues, both nationally in the USA, and internationally. It presents a series of concrete recommendations that, together, serve as a violence prevention roadmap to support children under five, their families and communities. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 851

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LA PRÉVENTION DE LA VIOLENCE ET DES AGRESSIONS SEXUELLES DANS LES SPORTS ET LES LOISIRS DES JEUNES

RUTH PILOTE DSP- Régie régionale de la Montérégie Longueuil, Québec, Canada

PROBLÉMATIQUE : Parmi les clientèles vulnérables à la violence et aux agressions sexuelles, on retrouve celle des mineurs. Actuellement, en matière de prévention de la violence et des agressions sexuelles, on a davantage mis l’accent sur le développement des habiletés des jeunes à se protéger et ce, malgré le fait que certaines recherches démontrent que l’enfant peut difficilement se défendre seul dans des situations d’abus (Kosky, 1987) et que le dévoi- lement d’une agression sexuelle par la victime est très difficile (Tourigny et Lavigne, 1985). Par ailleurs, on commence à voir l’importance d’impliquer les adultes et les organismes qui oeuvrent auprès d’eux dans le développement de milieux de vie plus sécuritaires. Les résul- tats d’un sondage auprès de 69 municipalités de la Montérégie (Demers et al., 1998) indi- quaient l’absence presque généralisée de mesures de prévention des agressions sexuelles envers les mineurs au sein de leurs activités. Cependant, cette étude révélait une grande pré- occupation des autorités locales au regard de la prévention des agressions sexuelles envers les mineurs et mettait en lumière leurs besoins spécifiques de soutien technique et de moyens concrets pour instaurer des mesures efficaces de prévention dans leur milieu.

OBJECTIFS : Le projet a comme objectif principal de prévenir la violence et les agressions sexuelles à l’égard des jeunes dans les activités sportives et de loisir. Dans une perspective de collaboration intersectorielle (municipal, milieu associatif, éducation, judiciaire, santé), le but est de développer un environnement sécuritaire et de renforcer les mesures de protection pour les groupes vulnérables.

MÉTHODE OU APPROCHE : La collecte d’informations a été effectuée à partir de 3 types de sources: 1. Les sources documentaires (littérature, documents d’orientation, autres politiques, outils d’information et de sensibilisation déjà existante); 2. L’expertise de personnes-ressources (experts en prévention des traumatismes, intervenants communautaires, policiers, avocats, etc.); 3. La validation auprès des milieux concernés (consultations régionales et provin- ciales auprès d’organismes du milieu, comité aviseur intersectoriel responsable de la réalisation du projet).

RÉSULTATS : Une politique comportant plusieurs volets dont, un code d’éthique et des outils concrets de filtrage pour réduire l’intrusion d’agresseurs dans les activités des jeunes. Elle propose des règles, des mesures, des procédures, des outils d’information et de formation. Un guide d’implantation accompagne le document. Les municipalités, les associations béné- voles de sport et de loisir ainsi que le milieu scolaire sont ciblés dans une stratégie d’implantation bien définie.

CONCLUSION : Les lois et les politiques gouvernementales sont claires en ce qui a trait à la res- ponsabilité morale et légale des organismes de protéger les mineurs contre les crimes et les BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 852

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menaces à leur intégrité. Cette politique continue, pour les établissements et les associations, un moyen concret pour mobiliser la communauté en ce sens.

LIMITES : Une recherche évaluative est prévue pour connaître le degré d’implantation de la politique dans les milieux ciblés et les facteurs facilitant son intégration.

CONTRIBUTION DU PROJET AU DOMAINE : La contribution de cette politique dans le domaine de l’intervention repose sur 2 plans: 1. La mobilisation intersectorielle réunissant des partenaires provenant de plusieurs disciplines et secteurs lesquels ont des modèles d’intervention différents mais qui doivent collaborer à l’atteinte d’un objectif commun, soit l’amélioration de la sécurité de la population; 2. La politique met l’accent sur le rôle des adultes en tant que responsables de la sécurité des mineurs. On multiplie ainsi le nombre de personnes responsables de la sécurité et du bien-être des jeunes et les chances d’éliminer les risques de violence et d’agressions sexuelles à leur égard. Cependant, cette approche présente de grands défis en termes de sensibilisation, d’adhésion et de participation de la com- munauté.

SAFER BARS

COLLEEN TESSIER,CHRISTINE BOIS Centre for Addiction and Mental Health Toronto, On, Canada

PROBLEM UNDER STUDY: Drinking in bars is often associated with aggressive behaviour and high levels of consumption and contributes disproportionately to certain types of alcohol related problems such as injuries, death and impaired driving. Those between the ages of 20 and 24 are particularly at risk since drinking in these settings accounts for 37% of their total alcohol consumption. In a 1999 general population survey of Ontario adults aged 18-60, 30% of those who reported being involved in an incident of physical aggression during the previous 12 months said that their most recent incident occurred in or near a licensed premise. This proportion was higher for men (39%) than for women (18%), and especially high for men aged 18-24 (44%) and 25-34 (59%). (Graham & Wells, In Press)

OBJECTIVES: The Safer bars program was developed for bar owners and staff to prevent and minimize violence. The program is comprised of various components targeting bar owners, managers and staff to help prevent and successfully manage aggression in their bars, therefore making the bars safer for staff and customers and reducing the risks of liability as well.

METHOD OR APPROACH: The Safer Bars program is an important component in an overall community effort to reduce violence and injury. The program was developed by CAMH with the help of a variety of community partners including licensed establishments. The program is comprised of the following components: 1. Assessing and Reducing Risks of Violence–a booklet that helps managers and owners assess the risks of violence in their bars, with suggestions for making improvements; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 853

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2. Trainer’s Guide–a step-by-step guide to train bar staff in the prevention and management of aggressive behaviour; 3. Just Another Night–a video story about Ray’s experience as a doorman; comple- ments the Trainer’s Guide; 4. Participant Workbook–a summary of material and activities covered in the training; 5. Legal Brochure–a brochure that explains legal issues related to aggression in bars.

RESULTS: Working in partnership with licensed establishments was a unique experience for CAMH staff. We experienced challenges and successes working with the bar industry, who are not a sector of the community typically involved in activities dealing with injury prevention or health promotion. Licensed establishments helped us develop the program, ensuring it was relevant to their needs and was a format that fit their unique circumstances. All our approaches to implementing the program gave us new and interesting insights into the bar industry and the other community partners with whom we worked. We learned how important it is to understand and accept bar culture. As members of the health sector, we have no history of working with bars, night clubs or taverns as community partners and regardless of the strategy used to engage them, it is important to learn and appreciate the nature of this industry in order to engage them effectively and implement the program. We will share with you our understanding of the bar culture and the challenges we face as health professionals in working with this industry. In fact some of the realities of working with this industry will go directly against the very values we try to promote and instil in the public as health professionals. Our lessons learned can be applied to prevention activities with other sectors. We will also describe strategies in working with other community partners in seeking their support and involvement to bring the program to the community.

CONCLUSION: The Safer Bars program is a useful tool available for communities to use to help reduce violence in and around licensed establishments. It is also a way for those working in the field of health to initiate and develop partnerships with the licensed establishments in their communities. Often licensed establishments are not seen as positive partners who can contribute to the community.

LIMITS: The long term evaluation of the effectiveness of the program is not yet available.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The Safer Bars program has a role to play in making communities safer for their residents by reducing aggression and the resulting injuries to people, damage to private and public properties and reduction in the use of the health and police services. This paper will contribute knowledge to the effective development and dissemination strategies of violence prevention. CAMH is presently conducting a long term evaluation of the effectiveness of the program. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 854

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UNE APPROCHE COMMUNAUTAIRE EN PRÉVENTION DE LA CRIMINALITÉ

PATRICE ALLARD Ville de Montréal Montréal, Québec, Canada

PROBLÉMATIQUE : Le visage varié de la criminalité et ses causes multiples interpellent une foule d’acteurs tout aussi indispensables les uns que les autres. Parmi ceux-ci, la municipa- lité est au cœur des interventions, comme le concluait la conférence internationale de Montréal de 1989: «C’est au niveau de la cité que doit avant tout se mener une politique de prévention». C’est ainsi que la Ville de Montréal a mis sur pied, il y aura 20 ans en 2002, un programme de prévention de la criminalité, Tandem Montréal. S’appuyant sur une répon- se adaptée aux besoins locaux, l’approche communautaire du programme, bien que plusieurs projets aient été primés, demeure peu connue des intervenants en prévention de la crimi- nalité (corps policiers, gouvernements, instances publiques, chercheurs, etc.). L’affiche pré- sente de façon schématique les éléments constitutifs.

OBJECTIFS : De l’approche communautaire en prévention de la criminalité : 1. Réaliser le programme Tandem Montréal avec des organismes locaux aptes à comprendre les besoins de la population et à développer les réponses judicieuses à ceux-ci; 2. Inscrire les projets dans une dynamique locale où plusieurs intervenants ont à cœur la prévention de la criminalité; 3. Impliquer les citoyens dans une démarche visant à contrer les comportements criminels; 4. Augmenter le sentiment de sécurité dans la population montréalaise; 5. Assurer un rôle de leader et d’expert engagé dans son milieu; 6. Informer les citoyens des moyens individuels et collectifs qu’ils peuvent prendre pour améliorer leur sécurité; 7. Offrir un soutien aux citoyens et organismes préoccupés par la sécurité.

MÉTHODE OU APPROCHE : L’approche communautaire de Tandem Montréal est caractérisée par un processus comprenant : 1. Identification des préoccupations et des cibles; Analyse des éléments de comportement criminel ou un sentiment d’insécurité; 2. Mise en place de stratégies locales (information, éducation, mobilisation); 3. Développement de liens de collaboration entre individus, instances communautaires et services publics et para-publics; 4. Élaboration d’un plan prévoyant une série d’interventions et de vérifications afin d’assurer la prise d’action. Cette méthode s’applique selon des approches situationelles et de développement social. «Des évaluations scientifiques de plus en plus nombreuses font la preuve que l’application méthodique, complémentaire et intégrée de mesures de développement social, de réduc- tion des occasions de délits et de mobilisation communautaire donne des résultats positifs et durables» (Normandeau, 1998). BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 855

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RÉSULTATS : 1. Réduction des situations favorisant la criminalité dans les quartiers; 2. Changement, lorsque requis, des attitudes et comportements des résidants, des instances communautaires publiques et para-publiques; 3. Gains individuels : a Diminution de pertes matérielles; b Meilleur contrôle de sa sécurité; c Appropriation des lieux publics; d Jouissance de la propriété; e Augmentation du sentiment de sécurité; f Milieu sécuritaire pour la famille. 4. Gains collectifs : a Réduction des coûts de la criminalité; b Quartier paisible pour tous; c Meilleure connaissance des ressources du quartier; d Soutien direct au développement économique de la ville; e Contribution à la création d’emplois locaux; f Intégration sociale de citoyens marginalisés; g Développement des valeurs sociales d’entraide et de solidarité.

CONCLUSION : Cette approche communautaire permet d’informer, de sensibiliser et d’intervenir de façon structurée. Ce renforcement de la sécurité et du sentiment de sécurité constitue un acquis indéniable pour la qualité de vie, personnelle et communautaire, des citoyens.

LIMITES : Les contingences financières et matérielles freinent la réalisation d’ actions ou leur inscription dans la durée. L’absence de liens entre chercheurs et intervenants privent les uns et les autres d’une riche expérience.

CONTRIBUTION DU PROJET AU DOMAINE : L’affiche sur l’approche communautaire présente un modèle schématisé d’intervention pour assurer la sécurité des personnes dans leurs milieux de vie et augmenter le sentiment de sécurité. Cette modélisation se vit en complémentari- té des autres types d’interventions (judiciaires, policières. sociales, etc.) en prévention de la violence.

URUGUAYAN INNOVATOR SUICIDE AND VIOLENCE PREVENTION BOOK

DANIEL CLAUDIO MALTZMAN PELTA National Children Institute, The National Delinquency Prevention Centre Montevideo, Uruguay This special book is the result of a team work of professionals from different disciplines, which put their long term experience to bring to the community how it is possible to prevent this tremendous situation. This publication titled: “Violence, dangerously in the day by BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 856

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day society...”,treats about the different point of view of large experience Uruguayan professionals that expose in detail their thinking about their experiences. Those professionals are from the following fields: legal, criminology, medical–forensic, educative and pedagogic, psychosocial and human rights, and each article treats a specific aspects to prevent this difficult problem. The Presentation of it was made by the Former President of the Inter-American Institute of Human Rights, Prof. Dra. Jacinta Balbela, and its Prologue is written by the President of the Uruguayan Supreme Court of Justice, Prof. Dr. Milton Cairoli and also Professor of Penal Justice. The Editor and co-author is Dr. Daniel Maltzman, is actually a Member of the National Executive Committee for the ONU 2001 Volunteer Year, and he has being working as a volunteer for different organizations for the last 20 years, for the rights of people in need in his country (Uruguay) and in other countries as Germany, Spain, France and U.S.A. The important article that Dr. Maltzman exposes in this publication is a recent 3 years Program made with youth trough 14 to 29 years old to prevent depression and suicide in the Project named: “To bet on life” (“Apostando a la Vida”) as the Responsible of the Quality of life and Mental Health Area in the National Youth Institute that belonged to the Ministry of Culture and Education. It’s Project made by several workshops with youth, their family, their community and the mass media (and how it makes an important impact on the people affective disorders) making an important impact on the prevention aspects through all the country and also its small communities. That gave Dr. Maltzman a recognition of his work as a Coordinator of this new prevention process to be declare his Program as a Ministry Interest Project. After that, the Inter-American Developing Bank (IDB) brings him a scholarship to express his experience working with thousands of people in the prevention of suicide in the Uruguayan population, starting his labour with the youth. Maybe, as an example to be mul- tiply this kind of work in the region or international level.

SHIFTING THE FOCUS: ADVANCING AN INTERDISCIPLINARY APPROACH TO VIOLENCE PREVENTION

LARRY COHEN Prevention Institute Oakland, Ca, USA

PROBLEM UNDER STUDY: Over the years, as public concern about violence has grown, numerous projects and independent sources of funding have been established in the State of California, as in other locales. Too often, these varied sources of funding and information are uncoordinated and/or duplicative. Shifting the Focus is a voluntary interagency violence prevention partnership that seeks to reengineer State government away from isolated efforts to a broader emphasis on serving communities.

OBJECTIVES: The objectives of this initiative are to: ·Reengineer State government away from isolated efforts to a broader service-orientation for communities ·Enable locales to focus BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 857

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on strengthening individuals, families, and communities rather than responding to State bureaucracies ·Shift current government practices to be more responsive to local concerns and facilitate local solutions to issues of violence prevention.

METHOD OR APPROACH: Leaders from over 30 departments in California’s state government agencies, as well as representatives from local violence prevention agencies, state commissions, and state organizations, recognize that violence prevention in communities can be strengthened by crafting an integrated, interdisciplinary approach to the State’s violence prevention goals. Shifting the Focus advances ways in which State practices can better support and maximize local violence prevention initiatives. It accomplishes this through addressing the barriers to interagency and interdepartmental collaboration and forging working partnerships and improved communication in State government.

RESULTS: Success can be gauged in the short term by monitoring the success of activities that aim to improve service to communities in California. Shifting the Focus recently completed a series of 10 community hearings across the State of California to identify the strengths and barriers of State support for local violence prevention efforts. Building on these findings, Shifting the Focus is advancing several key recommendations outlined in its strategic plan, including developing a common Request for Proposal (RFP), promoting flexible funding for communities, improving access to multiple data sources, and creating a set of Common Prevention Principles for use in legislative bill analysis, funding reviews, program development, and budget changes.

CONCLUSION: Violence is a complex issue that crosses the boundaries between criminal justice, health and human services, and education. Effective violence prevention requires collaboration across these disciplines to most effectively support local efforts. Shifting the Focus is pursuing a strategy to improve State government support for local violence prevention efforts through advancing interdisciplinary collaboration and strategic partnership.

LIMITS: One major challenge facing Shifting the Focus is the size and complexity of California’s state government, and so institutionalization of these efforts takes time. In addition, each of the many departments and agencies working on violence prevention brings with it its own language, mandates, conceptualization of the problem and solutions, funding sources, and training. Successful collaboration requires the achievement of a common language and an understanding of what each partner contributes and the value of that contribution to the whole collaboration. While there may be elements of this initiative specific to the nature of California’s state bureaucracy and political climate, there are lessons to be learned about levers of change within government entities working to improve violence prevention.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Shifting the Focus is a model for effective interdisciplinary collaboration in government. Lessons learned from the Shifting the Focus initiative can help shape future efforts and direct the development of new violence prevention projects at county, state, and national levels. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 858

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TOWN MEETING: A COMMUNITY RESPONSE TO SEXUAL VIOLENCE

AMY OKAYA Minnesota Department of Health St. Paul, Mn, USA

PROBLEM UNDER STUDY: National and state data show that sexual violence is a problem of serious public health concern. Nearly 18% of women and 3% of men in the United States report having been victims of completed or attempted rape during their lifetimes (Tjaden and Thoennes, 1998). Other studies have found that at least 20% of U.S. women and 5% to 10% of U.S. men have experienced sexual abuse as children. In Minnesota, 8.8% of ninth graders report having been sexually abused by either a family member or by someone outside the family (Minnesota Student Survey, 1998). The health effects of sexual victimization can be far-reaching, and may include pregnancy, physical injury, STDs/HIV infection, post- traumatic stress disorder, depression, chemical abuse, and suicidal behaviour. Because sexual violence is typically related to multiple risk factors, it is clear that the prevention of sexual violence must involve diverse segments of the community, working simultaneously and in concert for prevention. Currently many barriers exist to fully addressing sexual violence, including ignorance, embarrassment, shame, fear, silence, and the isolation of those concerned about the problem. A successful public health approach must seek to reduce these barriers so that the problem can be effectively addressed.

METHOD OR APPROACH:

Town Meeting: A Community Response to Sexual Violence’ was an event held in May 1998 in the rural town of Appleton, Minnesota, to provide a unique forum for community dialogue about the need for sexual violence prevention. Produced by the Minnesota Department of Health in partnership with Pioneer Public Television, the event was captured on video- tape and broadcast on Minnesota public television stations. Since its original broadcast, it has also been shown on at least 70 other public television stations in the United States. Among the thirty-one diverse participants in the Town Meeting are parents and Boy Scout leader, local and state policy makers, a police officer, sexual assault advocates, high school and college students, a paediatrician, a faith community leader, and many others. Discussion during the Town Meeting is wide-ranging, provocative and absorbing, and illustrates the multifaceted nature of the issue. The Town Meeting also includes pre-recorded feature segments highlighting individual and community dimensions of the problem. Videotapes of the Town Meeting have been created in an educational format for use in the group setting, and in a shorter presentation format (9 minutes) designed to introduce the topic and stimulate discussion. Both versions of the Town Meeting include facilitator’s guides.

RESULTS: Publicity for the Town Meeting led to increased media attention to the problem of sexual violence and the need for prevention. This media attention was qualitatively differ- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 859

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ent from more common stories about sexual predators and stranger sexual assaults. Statements about sexual violence as a public health problem from the Minnesota Commissioner of Health were disseminated through print and broadcast media. Participants in the town meeting reported gaining new knowledge and a broader appreciation for the problem, developing new ideas, and creating new relationships. The Town Meeting set the stage for further community-based discussion, and helped to model new ways of sharing responsibility and resources for prevention among service providers, other professionals, and the general public. Videotapes of the Town Meeting are being used across Minnesota to educate about the problem of sexual violence and its prevention.

CONCLUSION: The Town Meeting provided a forum for the sharing of information, the building of relationships, and the modeling of community dialogue about the problem of sexual violence and the need for prevention. The Town Meeting event, the Town Meeting broadcast, and associated videotapes support broader community engagement and improved community capacity to prevent sexual violence.

LIMITS: Ideas and opinions of Town Meeting participants are diverse, however they are not and cannot be as diverse as the general population. For this reason, providing opportunities for discussion in conjunction with the Town Meeting are encouraged.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This project describes a unique community-based strategy to support the prevention of sexual violence, grounded in a public health approach

WORKING FOR CHANGE, A SAFER COMMUNITY

SHARON TAYLOR, Wolseley Family Place Inc Winnipeg, Mb, Canada

PROBLEM UNDER STUDY: Most safety audits and crime in the community focuses on property crime and ignore the gender difference and the crimes that occur inside the home such as domestic abuse, sexual assault “the hidden crimes”.

OBJECTIVES: 1. To provide the women the opportunity to have a voice about crime and safety in their Community. 2. To have women recognize factors that put their children at risk of being victims of crime and factors that put their children at risk of being involved in criminal behaviour. 3. To provide training on the use of a safety audit as a community development tool and becoming more involved in local decision making processes. 4. To develop and produce an accessible workbook.

METHOD OR APPROACH: Women will participate in identifying and contributing to the content of the workbook and in sharing their knowledge about safety and crime from their perspective with the broader community. The project uses a participatory approach. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 860

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RESULTS: The Workbook provides an opportunity to value the women’s knowledge and experience at the same time, as it is a tool for learning. Two researchers will produce an evaluation tool to collect written feedback of participants and the community regarding their experience and the value of the information. It is to mobilize communities to take on greater responsibility in addressing women’s local safety needs and crime prevention.

CONCLUSION: Women have a strong voice about crime and safety. It is to foster community development and crime reduction.

LIMITS: It is a twelve-month project.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Having women’s voices heard and recognized and valued. Empowerment.

Violence dans la vie des femmes Violence in the Lives of Women

PHYSICAL ABUSE DURING PREGNANCY AMONG RURAL POPULATION AND URBAN SLUM

FAZLUR AKM FAZLUR RAHMAN,PRAVAT CHANDRA BARUA, AMINUR RAHMAN,SAMEENA CHOWDHURY Institute of Child and Mother Health Dhaka, Bangladesh

PROBLEM UNDER STUDY: Violence during pregnancy is an unrecognised health and social problem in Bangladesh. This family violence poses particular risks to the women and her foetus. Studies have shown that physical abuse during pregnancy increases the risk of miscarriage, abruption placenta, pre-term labour and delivery. This is an important cause of high maternal mortality in Bangladesh. But, magnitude and risk groups of this problem are yet to be explored in this country. For preventive and control of this physical abuse during pregnancy, it is important for the policy makers, and obstetricians to be aware of the extent of the problem.

OBJECTIVES: The objective of the study was to estimate the prevalence of physical abuse during pregnancy among rural population and urban slum dwellers in Bangladesh. This study was also aimed to explore the factors associated with the physical abuse during pregnancy.

METHOD OR APPROACH: 750 pregnant women of 12 to 20 weeks of gestation from rural population and 250 such women from slum dwellers of Dhaka city were recruited for the study. Multistage cluster sampling method was applied during selection of study subjects. The recruited pregnant women were interviewed thrice- one during recruitment, another after 12 weeks of recruitment and finally at term to record any physical abuses during their pregnancy period. Female health and family welfare workers and female university graduates BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 861

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were extensively trained and involved in data collection in rural and urban areas respectively. Two structured pre-tested questionnaires were used to record information on socio- demographic characteristics of pregnant women and their husbands, and promoting, orig- inating and facilitating factors of violence against women. The study has been conducted during July 2000 to June 2001.

RESULTS: Of all 1000 recruited pregnant women, 876 were interviewed at term. The drop out rate was 12.4%, which in rural area was 10.1% and in urban slum was 19.2%. In all 876, 133 (15.2%) of women reported experiencing physical abuse during their current pregnancy. Of the 133 women 105 (78.9%) reported that the perpetrator was her husband. Dowry was the main reported cause of physical abuse. The illiterate women were at greater risk than literate women (OR 2.70; 95% CI 1.77-4.14). Women whose husbands had drinking habit were 2.85 times (95% CI 1.39-5.80) more likely to have been abused than women whose husbands did not have drinking habit. Women whose husbands received dowry was 1.5 times greater risk (95% CI 1.02-2.20) to be abused.

CONCLUSION: Physical abuse during pregnancy is a major public health problem in Bangladesh. Physical abuse affects significantly low socio-economic group of pregnant women. Dowry was the main cause of physical abuse during pregnancy in Bangladeshi women.

LIMITS: Samples might not be representative of whole Bangladesh as study was limited only on the rural population and slum dwellers.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The findings of the study will provide an insight to the policy makers and obstetricians to take necessary steps to address this problem.

PREVALENCE AND FACTORS ASSOCIATED WITH PHYSICAL AND EMOTIONAL ABUSE AGAINST PREGNANT WOMEN IN CENTRAL TRINIDAD

LAURA MCDOUGALL,NADIA LEEPOW,SUNIL PATEL, SANKAR SASHA,MOHESS DENISE,KAWAL RAVI Caribbean Epidemiology Centre Federation Park, Trinidad

PROBLEM UNDER STUDY: Domestic violence rates in Trinidad have not been published. In other settings, pregnant women are at increased risk of abuse and the antenatal setting provides an opportunity for intervention.

OBJECTIVES: To determine the prevalence and risk factors for physical and emotional abuse during pregnancy in central Trinidad, and to determine the acceptability of screening for abuse in the antenatal clinic.

METHOD OR APPROACH: A consecutive sample of 347 women attending five antenatal clinics in central Trinidad was invited to participate. Inclusion was limited to women of at least 20 weeks’ gestation. Participants underwent a 10-minute interview based on a 25-item questionnaire adapted from the Abuse Assessment Screen and other published surveys. Of the 338 women who consented to be interviewed (97.4% response rate), 9.2% (95% CI: 6.4,12.9) BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 862

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reported physical abuse during their current pregnancy. The face was most commonly injured, and 3% of women were sexually abused. A significantly higher proportion of abused women lived in households with more than three children (22.6% versus 10.6%), had partners who reportedly abused alcohol (35.7% versus 9.2%), and had partners who had been physically abusive before the current pregnancy (46.4% versus 7.6%). Only 22.6% of the abused women reported the abuse to their physicians. Seventy-two women (21.7%) were emotionally abused during pregnancy. Only 36.4% of women in the study were able to identify at least one social service available for abused women, and awareness was not associated with abuse status. Almost all women (94.6%) felt that physicians should question all pregnant women about abuse.

CONCLUSION: Domestic abuse during pregnancy is common, and physicians are rarely informed. A universal screening programme is needed to identify and assist abused pregnant women. Routine questioning about abuse is acceptable to antenatal patients in central Trinidad.

LIMITS: This study was conducted in primary health centres in central Trinidad. Women of East Indian origin were over-represented compared with census data, as were women in lower income groups. Reported rates of domestic abuse during pregnancy were likely under- estimates for the following reasons: 1. Some women would be reluctant to divulge sensitive information to researchers; 2. The women’s pregnancies were not yet completed so opportunities for abuse remained.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This is one of the first studies of domestic abuse rates in the Caribbean and the first to focus on pregnancy. The findings indicate the breadth of opportunity for intervention and the cultural acceptability of universal screening in the antenatal setting.

PREGNANCY-ASSOCIATED ASSAULT HOSPITALIZATIONS

HAROLD B. WEISS,BRUCE LAWRENCE,TED MILLER Centre for Injury Research and Control Pittsburgh, Pa, USA

PROBLEM UNDER STUDY: Violence against women during pregnancy is an issue that stirs broad interest. From either the foetal or maternal perspective or both, it is disturbing to even imag- ine that violence can intrude upon this poignant period in a women’s life, and but the start of the life of the unborn. But if violence exists in a relationship prior to pregnancy, it does not always stop because a woman becomes pregnant. And the answers to whether it is more likely to begin increase, or decrease during this period, and how these changes are expressed in different populations, have remained elusive.

OBJECTIVES: To estimate the prevalence of pregnancy-associated hospitalized assaults and compare assault injury rates between pregnant women and all women of reproductive age with appropriate age and severity adjustments. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 863

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METHOD OR APPROACH: Using 1997 acute-care hospital discharge data from 19 states representing 52% of the U.S. population of women 15-49 years of age, records were classified as assault-related with and without coexistent pregnancy-associated diagnoses. The 19 states represented the hospitalization experience of 36 million women aged 15-49 that were residents of those states and 1.9 million resident births covering over 2,000 hospitals. Pregnant women were compared to all women focusing on serious assaults adjusted for age and severity.

RESULTS: There were 7,402 assaults identified among 137,887 acutely injured women ages 15-49 (5.4%), of these, 745 (10%) were pregnancy-associated. Only 812 (11%) of the assaults specified the perpetrator relationship. Among the cases that were perpetrator coded, 88.0% and 83.7% were spouse or partner related among pregnancy-associated versus all assaults, respectively. The prevalence of assaults was 65 per 100,000 person-years for pregnant women vs. 21 for all women ages 15-49 (rate ratio=3.13, 95% CI=2.91, 3.38). The prevalence of assaults was 178 per 100,000 person-years for non-white pregnant women vs. 26 for whites (rate ratio=3.34, 95% CI=2.55, 3.69 for non-white and 2.65, 95% CI=1.41, 3.03 for whites). Pregnant women were younger, their median length of stay was shorter, and their mean injury severity score and the median charge per stay was lower than all women. Unadjusted rate ratios for assaults were higher for the youngest mothers 15-19 (rate ratio=7.22, 95% CI=4.81, 8.38), elevated among both whites and non-whites. The median charge per visit was $3,351 for pregnancy-associated women and $6,775 for all women. The total for charges, lifetime medical loss sum and lifetime monetized QALY (rounded) was $4,926,000, $6,296,162, and $71,620,000 versus $89,245,000, $111,545,000, $1,689,194,000 for pregnancy-associated versus all assaults respectively. When adjusted for severity by excluding cases with minor injury (injury severity score< 4) most significant differences in rate ratios disappeared except for in the youngest age group and for firearm related assaults.

CONCLUSION: Much of the apparent risk is due to a lower hospital admission threshold for pregnant women, implying that they should be considered a “sensitive” population. While the rate of serious assaults may be moderately increased during pregnancy among the youngest mothers, pregnancy alone may not necessarily explain the observed remaining difference. The reported rate of assault by race needs to be addressed, perhaps more than the modest rate increase during pregnancy in the youngest ages.

LIMITS: Limitations include concerns about the quality/completeness of intent and perpetrator coding and possible duplicate counts. We did not follow or interview individual women, thus, the data cannot elucidate patterns of violence before or after pregnancy. It does not address the relationship of violence to factors not discernible from discharge records such as pregnancy intendedness, sexual assault, previous births, parity, pregnancy outcome, marital status or relationship of the foetus to the assailant.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This is the first study to address the prevalence and risk of pregnancy-associated hospitalized assaults in a multi-state population. It describes a significant increase in the rate ratio for pregnancy-associated assaults, but shows that age-specific rate ratios are markedly reduced once adjusted for injury severity. These findings can be applied to better prioritize and target effective injury prevention efforts aimed toward young women for the benefit of the mother and the foetus. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 864

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EXPERIENCES OF INTIMATE AND STRANGER RAPE: IMPLICATIONS FOR PREVENTION AND CONTROL

SHAHNAAZ SUFFLA Institute for Social and Health Sciences Cape Town, South Africa

PROBLEM UNDER STUDY: The concern with sexual violence against women continues to receive considerable attention worldwide. Accordingly, there is an increasing focus on the impera- tive to promote knowledge, develop best practices and formulate policies to address its prevention and control. In South Africa, the prevalence and incidence of rape has been the subject of many contemporary research investigations. South Africa’s rape statistics, which rate as amongst the highest in the world, suggest that in general almost half of South African women are raped by men known to them, with rapes often occurring inside the home. Furthermore, statistics from first world countries indicate that at least 50% of rapes are committed by men familiar to their victims. However, despite the increasing focus on sexual violence against women, there appears to be minimal research evidence that compares and contrasts the experiences of intimate and stranger rape among South African rape survivors. Against this backdrop, an exploratory study was undertaken to explore and illuminate the specific trends, risk profiles, experiences and post-rape sequelae associated with incidents of both intimate and stranger rape.

OBJECTIVES: The study aims to explore the pre-event, event and post-event experiences of intimate and stranger rape among a group of South African women. This study represents one component of a broader South African research initiative focusing on sexual violence and the after-care of rape survivors.

METHOD OR APPROACH: A qualitative research approach has been utilized to gather relevant data. In-depth individuals interviews are currently underway to collect data from 10 women who were raped by their intimate partners, and 10 who were raped by strangers. The data will be analysed using thematic analytic procedures.

RESULTS: The precise findings of the study will be detailed in the oral presentation. The findings will be located and discussed within a framework that includes a focus on the rape survivors’ pre-event, event and post-event experiences.

CONCLUSION: It is anticipated that the study will illuminate factors and processes associated with experiences of intimate and stranger rape among a group of South African rape survivors.

LIMITS: The exploratory nature of the study will limit the generalisability of findings.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The findings of the study, and the implications thereof are likely to contribute to the development of women’s safety promotion initiatives, and sexual violence prevention and control strategies in low- to middle-income contexts. It is anticipated that the study will hold important implications for social policy formulations to address more responsively the problem of sexual violence in South Africa, and possibly elsewhere. Furthermore, the study may yield important lessons for health and related systems of service delivery in other similar contexts. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 865

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ACID VIOLENCE AGAINST WOMEN IN BANGLADESH

NURUL ISLAM,GOLAM RASUL ARMAN District Council Road Manikgonj, Bangladesh

PROBLEM UNDER STUDY: Violence against women is a common picture in our country like Bangladesh. It has different forms. Acid violence is one of the worst forms. It brings unend- ing sufferings and deplorable condition in the life of victims of this crime. Though this violence is not uncommon to males, it occurs mostly against women in our country.

OBJECTIVES: To sensitize the policy makers for taking appropriate measure to prevent violence against women especially acid violence.

METHOD OR APPROACH: • Literature review; • Daily newspaper review; • Case study. Review of existing laws.

RESULTS: Acid is a corrosive substance that causes the skin tissue to melt. Many of the victims lose their sight forever. Even one may lose his/her hearing ability if the ears are exposed to acid. In our country, we have a law that provides for death penalty or rigorous life imprisonment with one fine not exceeding Taka one lac in the event of crimes like acid throwing. Although we have such an act, this form of violence is increasing in an extreme form in the society. There is hardly any day when some people do not become victims of acid violence. The reasons are the loopholes of cases, lack of evidence, unavailability of witnesses, lack of proper implementation of law and negligence of law enforcing agencies. Moreover, unrest, unemployment, dowry, drug addiction, lack of awareness, degradation in mental attitude of people etc. are also responsible for this crime. About 590 women belonging to different age groups have become victims of acid attacks in last five years across the country while only 31 accused have so far been convicted in the case filed under the Women and Children protection Act 2000. Women aged between 13 and 24 years are particularly vulnerable to acid attacks because of family disputes, refusal to get into a relationship or marriage, dowry, attempted rape, kidnapping and trafficking etc.

CONCLUSION: In conclusion we can say that only laws will not be sufficient to stop acid violence. We need something more to stop such a barbarous practice. The government needs to adopt some extra efforts to bring a proper step in this connection. We need strict law and its proper implementation so as to prevent this form of violence.

LIMITS: The study is confined within the reported cases. Data were collected from the secondary sources. Did not consider other violence except acid violence.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The study will be helpful in designing project on: • Violence Prevention; • Human rights; • Women rights; • Women Empowerment; • Acid violence, etc. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 866

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DOMESTIC VIOLENCE-PREVENTION AND SAFETY MEASURES UNDERTAKEN BY THE BATTERED WOMEN OF JHARHAND, INDIA

MEERA JAYASMAL Ranchi University Ranchi, Jharkhand, India

PROBLEM UNDER STUDY: Despite safety provided by low, majority of the Indian women are exposed to domestic violence. It cuts across age, literacy level, rural-urban place of residence and income levels. The battered women are abused physically, psychologically, economically and sexually. This is a hurdle in the empowerment of women. The women are at risk of homicide, suicide, unwanted pregnancies, reproductive morbidity, stress, humiliation and insecurity. In order to empower women to combat domestic violence it is prerequisite to learn the preventive and safety measures taken by the women leading to empower women for combating the social evil.

OBJECTIVES: 1. To know the preventive measures adopted by the women, to learn the safety measures at the time of domestic violence; 2. To examine the post-violence strategies aimed at lessening the incidence in next time and to see the impact of age, place of residence and educational levels on safety and preventive measures adopted by the battered women. 3. The sample was selects in two tiers. In the first tier, the questionnaire to identify barters was given to 300 women age range 20-45 years. Only those women were included in the sample that scored 50 % or more scores on the Abuser Identification Questionnaire. Such women were 223.

METHOD OR APPROACH: The following tools were used to collect data in the present study: the first one is a personal data questionnaire; to elicit information of the sample, e.g., age, name, place of residence, level of education and the second one is a participatory methods; Focussed Groups Discussion, Case Study, Criteria Scoring, Chapati Diagram, Seasonality were used to know the incidence of violence, severity of violence, the preventive and safety measures taken by battered women.

RESULTS: Most of the women did not adopt any preventive measures aimed at preventing the incidence of domestic violence. During the incidence, less than 10 % battered women react to the violence-aggression, counter attack, throwing household materials but none of the women complain to police. The post-incidence effort is also negligible. The effect of age has been visible. Younger women (less than 20 years) are more inclined to seek safety measures after the incidence. The effect of education and place of residence was also nor visible on the pre, during and post measures adopted by the women.

CONTRIBUTION OF THE PRESENT STUDY: Focused on the various attempts by the battered women, whose role to combat the social evil is crucial. It is urgent to make women strong and assertive so that they can take pre, during and post preventive and security measures to combat the incidence of domestic violence. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 867

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NATIONAL PLATFORM FOR ACTION ON VIOLENCE AGAINST WOMEN IN DEVELOPING COUNTRIES – MALAWI GOVERNMENT STRATEGY

NOEL J. MKHUMBA Ministry of Labour Lilongwe, Malawi

PROBLEM UNDER STUDY: The Malawi National Platform for action (NPFA) is a declaration of the commitment of the government of Malawi to improve the status of woman with the log- term objective of achieving equality and equity between women and men in the 21st century. This as a result of input by politician, policy makers, chiefs, traditional leaders and men and women from the grassroots level. This programme mainly focuses on four priority areas, namely; Poverty alleviation and empowerment, violence against women, the girl child and peace.

OBJECTIVES: To achieve maximum equality and equity between women and men in Malawi in the 21st century through two strategic objectives: 1. To prevent and eliminate violence against women in public places, institutions and domestic arena; and 2. To determine the extend and nature of violence against women.

METHOD OR APPROACH: Responsibility for implementation, monitoring and following up of the Platform for Action is placed on the government in partnership with agencies, non- governmental organizations and the private sector. All the stakeholders have a role to play in drawing plans of operation and resource mobilization to encourage discussion on violence in legislative and judicial services and to ensure the effective implementation and advancement of women.

RESULTS: Implementation of a National Platform for action on violence against women, enact laws on violence against women and more people aware of the true activities of violence against women.

CONCLUSION: Women would recognise that their rights are being thwarted by men. Legal action to be taken on those not complying.

LIMITS: No limits. All the country to be reached by any means of media and communication available.

CONTRIBUTION OF THE PRESENT STUDY: Expected violence against women cases in Malawi to be reduced by 70 % by the end of the year 2004. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 868

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INCIDENCE AND LOCATION OF GENITAL INJURY AFTER SEXUAL ASSAULT

MARILYN SOMMERS,JOHN SCHAFER,THERESE ZINK,MISCHELLE HILL University of Cincinnati Cincinnati, Oh, USA

PROBLEM UNDER STUDY: Of the estimated 6.8 million rapes and physical assaults that occur each year against U.S. women, 2.6 million will result in injury and 792,200 will require health care. The reported incidence of genital injury resulting from sexual assault ranges from 32% on direct visualization to 87% with colposcopy. Physiologic theory suggests that consensual sex is associated with lower rates of genital injury than that of non-consensual sex because of the lack of lubrication that occurs during non-consensual sex.

OBJECTIVES: Primary purpose of the presentation is to determine the epidemiology of genital injury associated with sexual assault against women. The secondary purpose is to report preliminary findings from a study investigating injury patterns in women who engage in consensual sex.

METHOD OR APPROACH: Retrospective study: We reviewed the medical records of 576 women who were examined following sexual assault to determine the location and severity of genital injury. Approximately 200 of the women received a colposcopic exam, while the others were examined with direct visualization only. Prospective study: We also conducted a prospective study using colposcopy technique to determine the location and number of genital injuries in 10 women following consensual sex. Female volunteers were recruited to have a colposcopy examination 4 to 8 hours after consensual sexual intercourse with a male partner. Injuries were identified by expert review of the colposcopic photographs following the examination.

RESULTS:

Retrospective study: Following sexual assault, the cervix was the location most frequently injured, followed by the labia minora, posterior fourchette, vagina, and mouth. The rate of genital injury was 42%. Mode number of injuries was 1.

Prospective study: Female subjects (N=10) in the prospective study investigating injury following consensual sex had a mean age of 35.2 years (range 26-26). Five described themselves as African American/Black and five described themselves as Caucasian/White. The mode number of different sexual partners over the lifetime was 6-10. One subject experienced one injury at the location of the posterior fourchette (10% genital injury rate).

CONCLUSION: Our findings supported the theory that rates of genital injury following consensual are lower than rates following non-consensual sex. In addition, our preliminary findings point to the cervix as the most frequently injured location following sexual assault.

LIMITS:

Retrospective study: The data were collected from patient information that was documented for clinical rather than research purposes.

Prospective study: The study was preliminary work with a small sample. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 869

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CONTRIBUTION OF THE PROJECT TO THE FIELD: Little is known about genital injury rates in women who are sexually assaulted as compared to women who have consensual sex. If differences exist in the incidence, severity, and location of genital injury in these two groups of women, the forensic examination can be used with increasing confidence to predict the nature of the encounter.

PRESENCE OF BENZODIAZEPINS ON INJURED PERSONS WHO WERE EXAMINED BY THE FORENSIC SURGEON OF THE NATIONAL INSTITUTE OF LEGAL MEDICINE AND FORENSIC SCIENCES IN BOGOTÁ 2000-2001

MONICA GARCIA RUIZ,MAURICIO SILVA National Institute Of Legal Medicine Bogotá, Colombia

PROBLEM UNDER STUDY: A significant number of injured person who were victims of illicit events that were attendance at Forensic Clinic of the National Institute of Legal Medicine and Forensic Sciences in Bogotá presented some level of Benzodiazepins, sedative and hypnot- ic drugs, when in mixed with ethanol, the sedative effects are enhanced.

OBJECTIVES: To identify the illicit events associate factors of the persons who were attendance at Forensic Clinic of the National Institute of Legal Medicine and Foresic Sciences in Bogotá, to whom were detected the presence of Benzodiazepins.

METHOD OR APPROACH: Exploratory retrospective study of the judgment injured person that arrives to the medical-forensic exam remitted by the authority in spite of illicit event. The authority solicited to Toxicology Laboratory a judgment of Benzodiazepinins, during November and December of 2000 and the first six months of 2001.

RESULTS: The techniques utilized by the Toxicology Laboratory of the National Institute of Legal Medicine and Forensic Sciences in Bogotá detect just four (4) types of Benzodiazepins. In the organism of the people examined was detected Lorazepan in a high percentage than others Benzodiazepins. Lorazepan was found in almost all the women examined who were raped and sexual assaulted. Was found an average value of 60 ng/ml in women and average value of 150 ng/ml in men. The illicit events more common associated to the supply of Benzodiazepins was the sexual assault, rape and rob.

CONCLUSION: In needed the implementation of the new different techniques from the actual HPLC in order to detect others Benzodiazepins that has been used by criminals. Victims of the illicit events (rape, sexual assault, rob) who supplied Benzodiazepins, were vulnerable because they didn’t have known neither of its effects and its mechanism of administration.

LIMITS:. The techniques utilized by the Toxicology Laboratory of the National Institute of Legal Medicine and Forensic Sciences in Bogotá didn’t detect all types of Benzodiazepins. An important percentage of judgement didn’t describe the happening of illicit event, it didn’t permit to establish the association between the supply of Benzodiazepins and the illicit. Toxicology Laboratory detection techniques presents a cut off 50 ng/ml, the low value to this, didn’t detected by the Laboratory because of the event occurred long time ago. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 870

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CONTRIBUTION OF THE PROJECT TO THE FIELD: The results indicate us the necessity of implemented more control for the sale of Benzodiazepins in order to put in guard population, prevent illicit event in the future, contribute to detect the illegal sale of the person involved and diffuse the cares of how to avoid the rob, rape and sexual assault.

CIRCUMSTANCES OF HOMICIDE AGAINST WOMEN IN CALI–COLOMBIA

VICTORIA ESPITIA,MARIA I. GUTIERREZ CISALVA Institutet, Universidad de Valle Cali, Valle Del Cauca, Colombia

PROBLEM UNDER STUDY: In Colombia occur near to 2.000 homicides per year against women. In Cali, a city with 2 million inhabitants- in a period of 9 years (1993- 2001 (09/16)) occurred 1.109 homicides against women. In this same period died for motor vehicle 856 women, in suicide 155 and in accidental deaths 232. The homicides are the first cause of death in women from 15 to 44 years. and represent 6.6% of the total. The strategies of prevention implemented by the local government are directed toward the reduction of the homicides against men by being the higher number.

OBJECTIVES: To identify the circumstances in the which the homicides against women occur in Cali, in order to contribute in prevention strategies.

METHOD OR APPROACH: The source of data are the institutions that attend the cases of homicides in the city; District Attorney, Police Department, Forensis Medicine and Health and Transportation departments. The information was collected by weekly meetings to confront and complement the data. The homicides against women in a period of 9 years were analyzed. The motives were collected with greater detail in the two last years (2000 and 2001). Variables related to the victim were: age and sex; place of occurrence as time of the fact (month, day and hour), circumstances as, type of weapon and the motive registered by security agencies. Rates and averages were calculated to permit a comparison with the homicides against men in the period.

RESULTS: The rate average/year in this period was 12 by each 100.000 women. For this same period the rate for men was 207. In average there was 11 homicides against women by month. For men the average was 152. The rates for the group from 35 to 39 years went the highest in all the period (24 for 100.000 women). During the weekend occurred 50% of the cases and near 20% the days Sundays. In the night they occurred 45% of the cases. The offender was identified 27% of the times. For men this average was 16%.(p=0.000). 79% of homicide were perpetrated with firearm, as compared with 83% for men (p=0.000) and 5.4% (59) were caused by strangulation, bludgeon and other different from handgun and cutting instrument, as compared with 2.8% (435) for men (p=0.000). In poor neighbourhoods occurred 87.2% of homicides against women. The circumstances of homicide against women were identify for the last 2 years (2000-2001) thus: in relation with the offender, 14.4% (28) of women were killed by their husbands and intimate acquaintance; delinquency-related homicide were 7.2% (14); gang- related homicides 1.5% (3); by assault 11.8% (23); in revenges BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 871

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8.7% (17); related with physical fights 7.2% (14); in 28.7% (53) the circumstance was not determinable. One woman was pregnant at the moment of the murder.

CONCLUSION: The findings of this study have important implications for research efforts directed towards prevention. We have identify four areas of inquiry that should be pursued by researchers and police-makers: domestic violence, firearm use, delinquency-related homicide and by assault. The occurrence of homicide in weekend suggest a relationship with alcohol use. More attention must be paid to evaluation in developing and implementing programs intended to prevent domestic violence.

LIMITS: Although the offender was known at nearly a third part of the cases, the information about the circumstances is difficult to obtain. The data related with alcohol use and residential status were not available in this study.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Homicides against women involving husbands and intimate acquaintance as offender, are an important dimension of the homicide problem in Cali, particularly in poor neighbourhoods. However, research in the area of domestic violence has been constrained by certain definitional and methodological problems. Attention to the following findings may help clarify understanding of domestic violence.

THE IMPACT OF VICTIMIZATION ON WOMEN IN NIGERIA

GLORIA EGBUJI Crivifon Lagos, Nigeria Studies in social Psychology have yielded considerable understanding on the nature and dynamics of socio cultural Behaviour. Deriving from that context, this paper examines the nature of victimization forces as it affects women within Nigeria socio cultural environment. Among the factors highlighted include the paucity of genuine social awareness, the seeming inability to extricate herself from the core for correctional and motivational orientation of victimized women, through the enforcement and adoption of the United Nation International Human Rights treaties on women. Psychological distortions created by negative attitudes, values, norms, mislabelling, stigma, misperception, alienation, stereotypes and its concomitant cognitive implications, problems associated with clearly sustained inability to make a clean break from the primitive cultural cocoon necessary to exercise full social emancipation. Additionally, there are problems arising from obvious ineptitude and negligence towards mobilizing and setting up of a virile agenda that would check of understanding of the psychosocial demands and ingre- dients of victimization on gender basis. Finally, some possible psychological readjustment, re-orienting and coping strategies are discussed which will form the bedrock of Behavioural Adjustment mechanism of victimized women in Nigeria. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 872

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FOCUS GROUP DISCUSSION BASED VIDEO DOCUMENTARY REFLECTS VIOLENCE EXPERIENCED BY THE COMMERCIAL SEX WORKERS IN BANGLADESH

SK.NAZMUL HUDA,SACHOY K. CHANDA,KAZI HASIBUL AHASHAN, ABU NASSER FARUK Colt Foundation Fellow Dhaka, Bangladesh

PROBLEM UNDER STUDY: Several hundred thousand commercial sex workers in Bangladesh carry on their business in different ways including providing brothel based sexual services. There is no reliable data about the number of CSWs in Bangladesh. In most of the cities in country, there is one or more brothels. Print Media reports very often about the violence against the commercial sex workers in Bangladesh.

OBJECTIVES: The Video documentary title “Noise in the Nova” has been made with the objective to communicate the public at large about the types of violent activities experienced by the CSWs, and to aware the public at large about the safety concerns of the brothel based commercial sex workers.

METHOD OR APPROACH: During August 2001, two Focus Group Discussion session were organized in two urban brothels attended 27 commercial sex workers in total. A trained FGD moderator conducted both the FGDs with the objectives to see how and how often the commercial sex workers experience violence in their business. The FGD findings are shown in a 7 minutes real life video documentary titled “Noise in the Nova”.

RESULTS: Out of 27 CSWs in two FDGs, 22 CSWs report that they have experienced at least one episode of violence in the last seven days. Four CSWs have experienced more than one episode of violence in this period. CSWs are physically assaulted by the lady pimps, their Clients and the Police. The causes of violent behaviour are unwillingness of the CSWs to do work on any particular time or day due to physical sickness (in case of lady pimps), failure to satisfy the customer (in case of lady pimps), unwillingness to comply with the customer mostly about the demand of anal intercourse and oral sex. The concern for payments is another cause of violence. A number of CSWs are beaten by police demanding bribe and free service. Violence acts including, burning with cigarette fire, cutting by knives and punch and kicks.

CONCLUSION: Violence is very common in the life of Commercial Sex workers in the brothels in Bangladesh. To promote the safety of the several thousands CSWs in Bangladesh immediate program should taken.

LIMITS: The video documentary is based on limited FGDs. To understand the situation in depth comprehensive study should be done.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The study and the video production on the basis of the study would be very sensitizing for the policy makers of the country as it is the first of its kind in Bangladesh. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 873

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Traumatismes chez les enfants victimes d’abus et de négligence Injuries Among Victims of Child Abuse and Neglect

DOES SOCIAL CAPITAL PROTECT AGAINST THE ADVERSE OUTCOMES OF CHILD MALTREATMENT?

JONATHAN KOTCH,JON HUSSEY,LI-CHING LEE,GITANJALI SALUJA University of North Carolina at Chapel Hill Chapel Hill, NC, USA

PROBLEM UNDER STUDY: Social capital has been identified as one possible explanation of differences in crude death rates and infant mortality rates between countries and between states within the US (Kennedy, Kawachi, Wilkinson, Prothrow-Stith, etc.). Most studies of social capital and health have used secondary analysis of large, cross-sectional data sets to demonstrate an association. In this paper we use data from an on-going, longitudinal study of children at risk of maltreatment to assess the possible protective role of social capital in moderating the adverse emotional and behavioural outcomes of child abuse and neglect.

OBJECTIVES: 1. Create an index of social capital; 2. Examine the moderating role of social capital in the relationship between child maltreatment and depression/anxiety and aggression in children.

METHOD OR APPROACH: Survey questionnaire items from caregivers of 6 year old children and from the children themselves (N=220) are used to create the outcome variables and the index of social capital. Outcome variables will be measured using the Child Behaviour Check List. Measures of social capital will be selected from among several variables including maternal church attendance, group memberships, and responses to such questions as, “I could get help from a neighbour,”“We watch out for each other’s children in our neighbourhood,”and “People trust each other in my neighbourhood.”The independent variable, child maltreatment, is based upon official reports to the Central Registry of Child Abuse and Neglect filed with the state Division of Social Services prior to age 6. Results of bivariate analyses are presented here. The final analysis will use linear regression to model the relationship between maltreatment and the emotional/behavioural outcomes. A limited number of potential confounders, such as number of siblings, SES, maternal depression and maternal age, will be used as controls. A social capital index will be created using factor analysis, and this will be used in interaction terms with maltreatment and other significant predictors.

RESULTS: The child population is 65% African American, 54% female and predominantly poor (46% on welfare). 41% had been reported for child maltreatment before the age 6 interview. Aggression is significantly predicted by maltreatment, poverty, and caregiver BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 874

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depression. Depression/anxiety is significantly predicted by male gender, poverty and caregiver depression. Maltreatment as a predictor of depression/anxiety is nearly significant (p=0.052). Indicators of social capital, such as the items “People care what happens to me,” “I could get help from a neighbour,”and “People trust each other in my neighbourhood,”significantly predict both depression/anxiety and aggression. Final models using a social capital index will determine whether social capital reduces or eliminates the relationship between maltreatment and other predictors on the one hand and aggression and depression/anxiety on the other.

CONCLUSION: Individual variables which have been used in the literature to represent social capital and prior maltreatment report predict adverse behavioural and emotional outcomes in 6 year old children in a longitudinal study of children at risk of abuse and neglect. The final analysis will answer the question of whether social capital is a protective factor moderating between maltreatment and depression/anxiety and aggression.

LIMITS: The sample is not representative of the general population but is a systematic sample of children at risk. Social capital, while well known in political science, is new to the health field, and what measures may be used to indicate social capital are still being debated.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Most of the health literature about social capital is secondary analysis of large data sets. The researchers have been criticized for over-interpreting their results. This study reports a primary analysis of data from a longitudinal study, and uses social capital in a unique way, as an effect moderator rather than a primary predictor. The results may have implications for preventing the consequences of abuse and neglect, which are ubiquitous problems in both the developed and the developing worlds.

CHILD NEGLECT AND PHYSICAL INJURY IN CANADA: RESULTS FROM THE CANADIAN INCIDENCE STUDY OF REPORTED CHILD ABUSE AND NEGLECT

RICHARD DE MARCO,GORDON PHANEUF Health Canada Ottawa, Ontario, Canada

PROBLEM UNDER STUDY: The neglect of children by their caregivers is an important issue in family violence and child maltreatment research. However, up until recently we did not have estimates of the incidence of this problem across Canada. The Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) is the first major attempt to present the scope of neglect and its potential injury consequences among Canadian children. There are significant consequences of neglect revolving around physical harm and injury. For example, the CIS suggests that some form of physical injury occurs in 10% of all substantiated and suspected investigations of child maltreatment where the primary form of abuse is neglect. This translates into an estimated 3561 investigations of child neglect in Canada in 1998 where injury was identified. While these data show that caregiver neglect may play a part in child injury and physical harm, questions arise regarding the basis of child injuries that are considered “accidents”. Though unintentional injuries are common, child maltreatment BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 875

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researchers question the part played by caregiver neglect, including a lack of supervision and the inability to provide a child with a safe home environment.

OBJECTIVES: This research will examine investigations of child neglect in which the child suffered a physical injury. Specific forms of neglect will be compared in terms of the proportion of physical harm noted within each form. The study will also examine contextual variables such as the age and sex of the child victim and the alleged perpetrator, the relationship of the perpetrator to the child, and the socio-economic context of the child’s family. The aim is to understand which specific forms of neglect are more likely to be associated with injury and what type of injury is most likely given a specific form of neglect and other contextual variables.

METHOD OR APPROACH: Data are derived from the Canadian Incidence Study of Reported Child Abuse and Neglect. Using both substantiated and suspected cases of child neglect, the analysis presents both bivariate cross tabulations and multivariate results. Neglect is classified into several forms which include failure to supervise resulting in physical harm or sexual harm, physical, medical, or educational neglect, abandonment, failure to provide treatment for mental health problems, and permitting criminal or maladaptive behaviour. Physical injury is measured in terms of head trauma, bruises/cuts/scrapes, burns/scalds, and broken bones. Analyses begin with a global measure of physical harm as the outcome variable and then move to the specific types of physical injury.

RESULTS: Results suggest a significantly higher percentage of children experience physical harm from medical neglect and failure to provide treatment for mental, emotional, or developmental problems. That said, neglect in the form of abandonment, educational neglect, and failure to supervise leading to physical harm is each associated with a lower percentage of physically harmed children. Specific types of injury showed varying relationships with the neglect measures. Of particular interest is that these specific measures of injury sometimes demonstrate a reverse relationship with neglect–the presence of neglect is associated with significantly fewer injured children. Possible reasons for this are discussed.

CONCLUSION: The relationship between child neglect and physical injury is complex. Some forms of neglect are related to injury and some are not. Thus, a clear understanding of the effects of the former on the latter must take into consideration specific behaviours and specific outcomes.

LIMITS: 1. Child welfare based study examining only known cases of neglect 2. Physical harm measures are non-standardized 3. Forms of maltreatment within the category of neglect are specific to the study and are intended to reflect current child welfare practice.

CONTRIBUTIONS OF THE PROJECT TO THE FIELD: This research provides a better understanding of the relationship between child neglect, as revealed by child welfare, and physical injury. In addition, it presents the first analyses of these two variables using data that includes all provinces and territories. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 876

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L’ABUS ET LA NÉGLIGENCE VÉCUS PAR LES ENFANTS ET LES TRAUMATISMES : UNE COEXISTENCE RÉELLE AU QUÉBEC

DANIELLE GUAY,HÉLÈNE RIBERDY,MARC TOURIGNY,MICHELINE MAYER Direction de la santé publique, RRSSS de Montréal-Centre Montréal, Québec, Canada

PROBLÉMATIQUE : La mort d’un enfant étouffé par un parent désespéré nous interpelle tous. Ces drames font facilement la première page des journaux. Mais que savons-nous des blessures et autres atteintes subies par les enfants abusés ou négligés. Les données d’enquêtes poli- cières et d’hospitalisation nous informent sur une très faible proportion de ces situations, alors que les fichiers administratifs des Centres jeunesse, bien que couvrant l’ensemble des signalements reçus par leurs services, ne contiennent aucune information sur la présence de traumatismes. Une enquête récente, l’ÉIQ–l’Étude sur l’incidence et les caractéristiques des situations d’abus, de négligence, d’abandon et de troubles de comportement sérieux signa- lés à la direction de la protection de la jeunesse (DPJ) au Québec, permet de tracer un premier portrait de la coexistence des traumatismes et des mauvais traitements au Québec.

OBJECTIFS : 1. Décrire l’ampleur et les caractéristiques des blessures et autres atteintes à la santé identifiées chez les enfants reconnus abusés ou négligés par les services de protection; 2. Identifier les principales différences entre la situation de Montréal et celle du reste du Québec.

MÉTHODE OU APPROCHE : L’ÉIQ couvre tous les signalements reçus par les Centres Jeunesse (CJ) du Québec entre le 1er octobre 1998 et le 31 décembre 1998. Ainsi près de 10 000 signalements ont été documentés par les intervenants des DPJ. Pour les signalements retenus, des informations inédites ont pu être recueillies sur le milieu de vie de l’enfant, les adultes jouant le rôle de parents, les faits en cause et les décisions rendues lors du cheminement du signalement au CJ. Les analyses portent plus spécifiquement sur les quelques 3 000 enfants dont les faits rapportés ont été jugés fondés. Les principales informations utilisées sont celles portant sur l’analyse des faits en cause : type de blessure et autre atteintes, nécessité d’un traitement médical et les personnes dont les comportements sont mis en cause.

RÉSULTATS : Une proportion non négligeable d’enfants victimes d’abus et de négligence avaient une blessure ou une autre atteinte physique au moment du signalement ou lors de l’évaluation. Ces traumatismes s’étalent sur un large spectre : des ecchymoses, des coupures ou des éraflures; des brûlures; des fractures; des traumatismes crâniens ainsi que d’autres pro- blèmes de santé. Par ailleurs, pour une forte proportion des enfants abusés ou négligés, l’intervenant pouvait identifier une atteinte à leur santé mentale ou des troubles émotionnels. Pour plusieurs de ces enfants, les blessures et atteintes étaient assez sérieuses pour requérir un traitement médical ou spécialisé. Ces résultats varient selon la forme de mauvais traitement, sa durée, l’âge des enfants ainsi que la région de provenance du signalement (Montréal versus le reste du Québec).

CONCLUSION : Les intervenants des CJ ont observé des blessures et autres atteintes chez un bon nombre d’enfants abusés et négligés. C’est donc une source de traumatismes à ne pas négli- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 877

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ger dans nos efforts de prévention, d’autant plus que ces problèmes risquent de se répercu- ter tout au long de leur vie.

LIMITES : Le portrait ainsi obtenu des traumatismes reliés à l’abus et la négligence n’est pas représentatif de l’ensemble des enfants abusés et négligés puisqu’une partie seulement de ces enfants sont signalés aux CJ. Par ailleurs, il s’agit uniquement des traumatismes observés entre le moment du signalement et la fin de la période d’évaluation, ce qui ne nous ren- seigne aucunement sur les traumatismes antérieurs ou à plus long terme, et probablement peu sur les atteintes moins visibles.

CONTRIBUTION DU PROJET AU DOMAINE : Cette analyse des données de l’ÉIQ permet d’obtenir un premier estimé de l’ampleur des traumatismes associés aux mauvais traitements au Québec, d’en décrire les caractéristiques et de vérifier l’association avec certaines variables.

BLUNT ABDOMINAL TRAUMA UNDER 5 YEARS OF AGE: ABUSE VS UNINTENTIONAL INJURY

MATTHEW TROKEL,RICHARD SEGE,CARLA DISCALA New England Medical Centre Boston, Ma, USA

PROBLEM UNDER STUDY: Child abuse is a significant source of serious childhood injury. In 1998, child abuse was the third leading cause of death in one to four year olds. Abdominal trauma is an uncommon but serious injury caused by abuse. No multi-centre studies of the outcomes of abdominal trauma associated with child abuse have yet been reported.

OBJECTIVES: To characterize abdominal injuries to children under age 5 resulting from child abuse.

METHOD OR APPROACH: Retrospective analysis of data on children 0-5 years old hospitalized with blunt abdominal trauma caused by child abuse or unintentional injury. Data were obtained from the National Paediatric Trauma Registry (NPTR), October 1995-April 2001, which contains information concerning over 43,000 cases of childhood injury treated at paediatric trauma centres in the USA. Comparisons of patient characteristics, cause of injury, nature and severity of injury, interventions required, and outcomes at discharge were performed.

RESULTS: Of a total of 927 cases of abdominal injury, 146 (15.7%) were caused by child abuse (CA), and 781 (84.3%) by unintentional injuries (U), including the 656 (70.8%) whose injuries involved motor vehicles.. Boys accounted for approximately 53% in both groups. The CA children were significantly younger (t-test: p<.01) with a mean age in months of 19.9 versus 34.4 in the U group. In the U group, the 3 most frequent causes were being injured as motor vehicle occupant (44.2%), pedestrian (26.6%), or in a fall (16.1%). The Injury Severity Score was significantly higher (t-test: p<.05) in the CA than in the U group (mean: 15.8 versus 13.3). The admission to the Intensive Care Unit was approximately the same for both groups (~65%), so was the frequency of surgical intervention (~32%). The length of stay was significantly longer (t-test: p<.05) for the CA children with a mean of 9.7 days versus 7.2 days. The in-hospital death rate was significantly higher (chi-square: p<.01) for the CA chil- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 878

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dren: 21.9% versus 7.4%. In fact, CA children accounted for 15.7% of all the children but for 36.6% of all the deaths.

CONCLUSION: Child abuse has many adverse consequences. In the sub population of abdominal trauma, child abuse is associated with increased severity on presentation, increased morbidity and mortality. Child abuse accounts for the majority of all serious abdominal injuries not related to motor vehicles in children under 5 years old. The death rate of abused children with abdominal trauma was almost triple the death rate due to unintentional abdominal. Further investigation is needed to determine if the increased mortality rate is due to delays in seeking care for abused children.

LIMITS:. Misdiagnosis of child abuse as the cause of injuries has been reported, and may confound the data reported here. Only seriously injured children treated at specialized paediatric trauma centres are reported here, and these children may not be representative of all injured children in the USA.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Abdominal trauma is a rare but serious form of injury, especially when due to child abuse. Recognition of the potential for abuse in children with serious abdominal injury may increase the ability of health care workers to protect injured children and their family members.

APPROCHE NEUROPSYCHOLOGIQUE ET ÉTUDE DE LA VIOLENCE PHYSIQUE CHEZ L’ENFANT

PIERRE NOLIN,ANNIE STIPANICIC Université du Québec à Trois-Rivières Trois-Rivières, Québec, Canada Malgré les indicateurs d’un effet certain de la maltraitance sur les fonctions cognitives, le fonctionnement intellectuel et le comportement, peu de recherches neuropsychologiques ont été réalisées de façon systématique auprès de cette clientèle. La présente étude vise deux objectifs : 1. Vérifier si la violence physique envers les enfants influence l’ensemble des fonctions cognitives couvertes de façon traditionnelle par l’approche neuropsychologique ou si, au contraire, seulement certaines fonctions sont plus susceptibles d’être altérées par cette condition; 2. Comparer le profil neuropsychologique d’enfants qui sont dans un contexte de violence physique à celui d’enfants témoins. 13 enfants de 5 à 12 ans, en contexte de mauvais traitements physiques composent le groupe expérimental. Ils ont été appariés à 13 autres enfants formant le groupe témoin (sans maltraitance) selon le sexe, l’âge, le niveau scolaire et le milieu socio-économique. L’évaluation neuropsychologique couvre l’ensemble des fonctions couvertes par cette approche : la motricité, l’attention, la mémoire, l’apprentissage, le langage et les fonctions exé- cutives. Les résultats vont dans le sens des hypothèses et démontrent que les enfants en situation de violence physique ont des rendements significativement inférieurs à ceux des BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 879

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enfants témoins aux tests neuropsychologiques. Ainsi, les enfants en situation de violence physique obtiennent des résultats significativement inférieurs à ceux des enfants témoins aux mesures de motricité, d’attention, du langage et des fonctions exécutives. Les résultats seront discutés à la lumière des dysfonctionnements cérébraux possiblement imputables aux conditions de la violence physique et des aspects développementaux de la cognition. Cette étude démontre la pertinence de l’approche neuropsychologique dans l’étu- de de la problématique de la maltraitance. La portée des résultats de notre étude est cependant très limitée puisqu’il s’agit d’une étude pilote réalisée avec un échantillon très restreint. Des résultats supplémentaires seront cependant disponibles au moment du congrès. Parmi ceux-ci, un groupe d’enfants porteurs du diagnostic «Shaken Baby Syndrome; Shaken Impact Syndrome» feront l’objet d’une évaluation similaire au groupe d’enfants en contexte de mauvais traitements physiques. Ces résultats préliminaires seront donc présentés. Ils permettront une première réflexion sur la spécificité de ce type de sévices au plan des séquelles cognitives. Selon la taille de l’échantillon, une approche quantitative ou qualitative sera privilégiée. Cette étude revêt selon nous trois contributions particulières par rapport au domaine. D’abord, nos travaux démontrent que la neuropsychologie apporte une lumière nouvelle dans la compréhension de la violence physique et s’ajoute ainsi aux perspectives médicales et sociales déjà implantées. Par ailleurs, le fait de démontrer la présence de séquelles neuropsychologiques chez ces enfants contribue à souligner les effets dévastateurs de la violence physique sur le développement des enfants et, par extrapolation, ajoute de l’importance à la prévention de ces actes portés envers les enfants. Enfin, les résultats des évaluations neuropsychologiques pourront servir de guide à l’élaboration de plans d’intervention visant à améliorer le fonctionnement de ces enfants.

THE EPIDEMIOLOGY OF SHAKEN BABY SYNDROME RELATED TRAUMATIC BRAIN INJURY

MALINDA DOUGLAS,PAM ARCHER Oklahoma State Department of Health Oklahoma City, Ok, USA

PROBLEM UNDER STUDY: Named for the mechanism of injury, shaken baby syndrome is a term that describes a variety of signs and symptoms that result from violent shaking or a combination of shaking and impact of the head of an infant or small child. An estimated 600 to 1500 cases of shaken baby syndrome occur each year in the USA. Approximately one-third of the cases are misdiagnosed, especially if the symptoms are of mild head injuries. Caregivers may interpret lethargy or a decreased level of consciousness as compliance. Caregivers and medical personnel may associate the head injury related nausea, emesis, feeding difficulties, or diarrhoea with illness. Approximately 15% to 35% of the cases are fatal with most survivors having significant impairments.

OBJECTIVES: There are several research studies on shaken baby syndrome, but very few with state-wide population basis with multiple years of study. The most well known shaken baby BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 880

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syndrome campaigns provide the message of never shake a baby. Many informational materials, designed with pictures of mothers and infants, are distributed to mothers. Our objectives were to determine the epidemiology of shaken baby syndrome-related traumatic brain injury in Oklahoma; determine the characteristics of those injured; determine the percentage of case that had evidence of other forms of abuse; determine, if possible, the characteristics of the alleged perpetrators; and determine implications for new approaches for prevention campaigns and materials.

METHOD OR APPROACH: Hospitalized and fatal traumatic brain injury (TBI) became a reportable condition by public health mandate in 1991. Systematic data collection began in 1992 at all of the state’s acute care hospitals and the Medical Examiner’s Office. Data collection was limited to state residents. Hospitalized TBI cases were identified as those dis- charged with at least one primary or associated ICD-9 code of 800.0-801.9, 803.0-804.9, 850.0-854.1, or 959.01. Non-hospitalized, fatal cases were identified by a description of a head injury on their medical examiner report. Demographic, medical, and epidemiological data were collected. Beginning in 1999, full data collection was completed for only a random sample of TBI cases. Therefore, this study was limited to 1992-1998. The Centres for Disease Control and Prevention fund the TBI surveillance system. Shaken baby syndrome-related TBI was defined for this study as TBI cases coded with the ICD-9 code for shaken baby syndrome (since 1996) or mentioned shaking as the mechanism of injury among children 0-4 years of age. RESULTS During the 7-year study period, 84 of the 1,385 TBI cases among children 0-4 years were identified as shaken baby syndrome. Two-thirds of the cases were among males. Nearly 80% of the cases were among infants less than one year of age, peak- ing at three months of age. Among the cases that survived, injury severity as calculated by the Abbreviated Injury Scale (AIS) was high with 90% with a severe, life threatening or critical injury. Eighteen percent of the cases were fatal. Females were more likely to die from shaken baby syndrome than males. Birth fathers were most often identified as the alleged perpetrators, followed by boyfriends of the mothers. Nearly 40% of the records mentioned other forms of physical abuse also being present. One-fifth of the records had mention of multiple episodes or chronic shaking. Only 70% of eligible cases were coded with the appropriate ICD-9 code at discharge.

CONCLUSION: Shaken baby syndrome-related TBI is often misdiagnosed and under reported. Males are most often the perpetrators of the shaking. Signs of chronic shaking or other physical abuse were found in a substantial number of the cases.

LIMITS: Limitations of this study are that the study is limited to Oklahoma residents who died or were hospitalized within the State of Oklahoma and exclude cases that may have been treated in other states. Other limitations include some of the circumstantial information was collected in a non-standardized memo field format and only cases with relatively severe TBI were identified.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study contributes to the field of injury prevention by acknowledging that shaken baby syndrome is a form of child abuse that can be identified and studied through the use of existing injury surveillance. Through the study of the epidemiology of shaken baby syndrome, appropriately-targeted and therefore, effective prevention can be accomplished. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 881

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TRACKING PAEDIATRIC VIOLENT INJURY

JUDY SCHAECHTER,MEG HATE,MARIELENA VILLAR University of Miami Miami, Fl, USA

PROBLEM UNDER STUDY: Paediatric violent injury is not a reportable diagnosis and insufficient surveillance exists to reliably describe it. The design of a system to track nonfatal intentional injury requires an understanding of the incidence of violent injury and examination of the utility of currently available hospital data sources.

OBJECTIVES: Characterize paediatric violent injuries presenting to a large urban trauma centre, and examine whether data elements such as E-codes and zip codes are sufficiently available to describe this population.

METHOD OR APPROACH: We reviewed all cases of children< 18 years old seen at Ryder Trauma Centre (RTC) for violence-related injuries from January 1994–December 2000. RTC accepts only severe injuries; more mild cases are served by nearby emergency rooms. Data reviewed includes patient demographics, date and length of admission, disposition, E-codes, and limited provider comments. Data was analyzed for frequencies and E-codes were compared to provider notations for accuracy.

RESULTS: During the 7 years under study 757 children 0-17 years were seen at RTC for violent injury. The majority (83%) of cases were adolescents 13-17 years. 89(12%) cases were 5-12 year olds and 39(5%) cases were 0-4 year olds. 593(78%) patients were male, 84% of which were 15-17 years old. The ration of male to female patients increased with age (1.4:1 for 0-5 y/o; 5:1 for 15-17 y/o). At least 518(68%) of patients were black and 131(23%) were white; remaining cases were entered as “latin.” More than half (407) of patients were dis- charged within 24 hours, though a quarter was hospitalized for a week or more. A quarter of patients (183) were sent directly to the OR, ten percent (74) admitted directly to the ICU and a third (219) were admitted to the floor. 86(11%) expired. The seven years of data revealed that the frequency of violent injuries generally fell from 1994 to 1999, but then rose by 15% in 2000. More than half (412, 54%) of all cases involved firearms. Cutting and stabbings accounted for 213 (28%) cases. The remainder comprised BB guns (21), child abuse (10), burns (5), and non-specified assaults (89). Concerning data availability: 43% of cases did not have an entered E-code, 42% of cases had no zip code. At least 150(46%) of the cases without E-codes involved gunshot wounds and 114(35%) stabbing wounds. In most cases were zip codes were absent, no other address information was documented. Were zip codes were noted, cases were mapped to recognized high crime, underserved neighbourhoods.

CONCLUSION: Paediatric violent injury presenting to RTC is frequent and severe. The majority (86%) of cases involved weapons, two thirds required hospitalization and more than one in five went to the OR, ICU or died. The typical patient was an older black male adolescent. Though it is too early to predict a trend, the incidence of paediatric violent injury may be rising again. Large gaps exist in data availability when violent injury tracking relies on E codes and zip codes.

CONCLUSION: from either may be inaccurate, as over 40% of the cases are without sufficient information. For example, in our study, the cases involving firearms are twenty percent BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 882

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higher than that detected by E-codes alone. Further, mapping based on zip codes in hospital records may miss additional areas quite in need of prevention efforts. Additionally, we found that notation of race is not well standardized. Improved collection and coding techniques are needed. Additionally, first responder (police or rescue) information regarding area of incident may help fill mapping gaps.

LIMITS: The study does not detail more mild injury from nearby emergency rooms in the county. Further, by using a readily available database we might miss information available in a review of the full medical record.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The use of E-codes has been proposed as a way to track the causes of nonfatal injury. However, in this study, we found E-codes and zip codes to be insufficiently documented. The study can be used to encourage medical centres to improve the quality of their documentation for research purposes. Alternatively, nonfatal intentional injury surveillance will require additional means of data inquiry. The study further indicates that in this urban setting, firearms remain the predominant cause of severe paediatric violent injury, and that adolescent black males are disproportionally its victims.

IDENTIFYING CHILD ABUSE AND ITS ASSOCIATED MEDICAL COSTS; IMPLICATIONS FOR PRACTICE

THOMAS J. SONGER,LORRAINE ETTARO,KAREN ZURI University of Pittsburgh-Centre for Injury and Research & Control Pittsburgh, Pa, USA

PROBLEM UNDER STUDY: Child abuse is a well known problem to social and judicial practitioners. Little is known, however, about the relative public health burden of child maltreatment. Injuries from maltreatment are thought to be meaningful, particularly in the very young, but there are no established surveillance systems for identifying their frequency and cost. Current efforts to monitor child maltreatment are focusing on identifying cases through various sources, including medical examiner, child protective services, and hospital records. The strengths and limitations of these sources are not yet known from a case-identification and injury point of view.

OBJECTIVES: We are conducting a review of hospital records from all 22 institutions in Allegheny County, Pennsylvania to identify the number of reported cases of child abuse, associated injuries, and estimated medical charges.

METHOD OR APPROACH: Child abuse events are being identified from the hospital institutions on the basis of diagnosis and E-codes. Each hospital is asked to pull records with any of the following codes: 995.5x, E904.0, E967.x, E968.4, V61.2x over a 5 year time frame (1995- 1999). Both inpatient and emergency department (ED) visits are being assessed. The records are reviewed and abstracted to note the reported case history, and the related injuries and charges for medical treatment. A child abuse event is defined as one in which a report was filed to the child protection authorities.

RESULTS: At this time, more than 600 inpatient and outpatient records have been abstracted from 7 hospitals. Several observations have been noted from this continuing work regard- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 883

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ing the value of diagnostic codes as a surveillance tool, the injury patterns in identified cases, and the medical charges of child maltreatment. First, diagnostic codes work best for inpatient data. All 22 institutions can identify admissions with the related codes. However, 3 of the hospitals cannot identify ED visits related to abuse with these codes. We are searching an alternate source in the hospital (social work records) to identify cases in these institutions. Second, fatal maltreatment events are often contained on microfilm only. Examining only paper medical records may miss fatal events. Third, for inpatient admissions, associated child protection reports were found for 98% of the events identified through the noted diagnostic codes. Fourth, head trauma is more frequent in the very young (under age 1) than in older cases. Fifth, medical charges are significantly higher for admissions related to neglect ($15,786 per stay) than those from physical abuse ($7,979 per stay).

CONCLUSION: Our assessment of child maltreatment in Allegheny County suggests that surveillance activities using electronic databases and associated diagnostic codes are likely to find most inpatient events, but may miss a meaningful number of ED visits. Abusive head trauma is highest in the young. Neglect is associated with significant medical treatment charges. Surveillance systems that focus only on physical abuse may under-represent the financial burden of maltreatment.

LIMITS: This work focuses only on one potential data source for child abuse surveillance systems. The reporting and recording practices for maltreatment may differ in Allegheny County than in other parts of the country.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This work provides some of the first evidence to outline the advantages and disadvantages of hospital-based surveillance of child abuse.

CHILD ABUSE IN PENNSYLVANIA: ELEVEN YEARS OF DATA

BONNIE J. CLEMENCE,MARRY ANN SPOTT,LISA BERNARDO Pennsylvania Trauma Systems Foundation Mechanicsburg, Pa, USA

PROBLEM UNDER STUDY: Child abuse in Pennsylvania. The number of children over an 11 year period (1990-2000) who were admitted to trauma centres in Pennsylvania with the diagnosis of child abuse.

OBJECTIVES: 1. Identify the number of children who suffered child abuse in Pennsylvania from 1990-2000; 2. Identify the characteristics (month and time of day of injury, Injury Severity Score [ISS], ICD-9-CM codes) and circumstances (description of injury event and environment) of the injuries; 3. Identify the demographics ( age, sex, total length of stay in the intensive care unit and hospital and hospital discharge status) of the children who were abused in Pennsylvania. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 884

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METHOD OR APPROACH: A descriptive, retrospective analysis was performed on data obtained from the registry of the Pennsylvania Trauma Outcome Study(PTOS), a product of the Pennsylvania Trauma Systems Foundation. This registry consists of records from all trauma patients admitted to the 26 accredited trauma centres in Pennsylvania since October 1, 1986. Registrars from each of the trauma centres are trained in the PTOS data-collecting process, in abstracting the medical record data and completing computerized registry forms. Trauma patients are eligible fro inclusion into the PTOS if they have,“...severe multi-system or major unisystem injury, the extent of which has the potential of producing mortality or major disability.”Patients are included in the registry if they are admitted for traumatic injuries with in 48 hours from the time of arrival to the Emergency Department, transfer in or transfers out of the trauma centre, any stay in the Intensive Care Unit, all trauma deaths, all dead on arrivals or pronounced dead after arrival and burns. Injuries are classified by the International Classification of Disease, 9th Revision, Clinical Manual (ICD-9-CM) codes. The computerized registries are sent to the PTSF for inclusion into the PTOS registry, where they are evaluated for completeness. The subjects for this study were individuals from 15 years of age or younger who had been entered into the registry during January 1, 1990 through December 31, 2000 and who injuries were associated with child abuse. The records were abstracted for: 1. Patient demographics (age, sex, total length of stay in the intensive care unit and hospital, and hospital discharge status); 2. Characteristics of injury ( month and time of day of injury, Injury Severity Score [ISS], ICD-9-CM codes); and 3. Circumstances of the child abuse (description of injury event).

RESULTS: The following are the results of the study to date (not all of the data has been analysed completely). During the study period 687 children were admitted to Pennsylvania trauma centres with some form of child abuse. Most of the patients (n=511, 74%) were less than a year old. In 1990 there were 38 children admitted to trauma centres that had been abused compared to 100 children admitted in the year 2000. The average length of stay for the Intensive Care Unit for child abuse in 1990 was 17.8 days compared to 2000 with 7.0 days.

LIMITS: The usefulness of the PTOS registry would be increased if more specific information was included regarding child abuse, such as better description of the incident. These data may not be collected at the time of initial treatment and therefore are omitted form the patient’s medical record and subsequent registry entry. The PTOS registry includes data from the initial treatment period.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Because this study deals with child abuse, it will pinpoint the types/kind of abuse that are most often seen in Pennsylvania. With this information preventive education can be developed to make not only health care personnel aware of the patterns of injury but also ways to provide education to the public. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 885

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Des réalités politiques, sociales et culturelles génératrices de violence interpersonnelle The Political, Social and Cultural Realities Leading to Interpersonal Violence

FACTORS CORRELATED WITH DIFFERENT TYPES OF AGGRESSION AMONG ADULTS IN BOGOTÁ, COLOMBIA

LUIS F. D UQUE,JOANNE KLEVENS,CLEMENCIA RAMIREZ ASSALUD and School of Public Health, University of Antioquia Medellin, Colombia

PROBLEM UNDER STUDY: In the last 15 years, violence has become the main cause of death in Colombia generating about 25% of the health burden. In contrast, it generates only 3.3% of the health burden in Latin America and 1.9% in industrialized nations. Colombia has one of the highest reported violence rates in Latin America (65 homicides per 100,000 inhabitants). Bogotá, Colombia’s capital with 6 million inhabitants, has a rate of 44 x 100,000. As in other cities in the Americas, Bogotá experienced a marked increase in homicide rates during the latter half of the 1980s, reaching its peak (93 x 100,000) in 1993 and descending thereafter. The majority of reported violent deaths and injuries in Bogotá is related to common and organized delinquency and interpersonal conflicts. Most research on violence in Latin American has centred on victimization, and thus little is known on perpetrators. Knowledge on characteristics of perpetrators can be useful in designing preventive interventions.

OBJECTIVES: To identify factors associated with different types of aggression and the overlap among different forms of aggressors in Bogotá, Colombia.

METHOD OR APPROACH: Cross-sectional household survey with face to face interviews of a random sample (n=3007) of the general population between the ages of 15 and 60. Verbal and mild physical aggression, assault with an object, and assault with a weapon were measured with a behaviour inventory as well as the following potential correlates: parental affect, communication, supervision, clarity of norms and use of physical aggression; separations from mother; beliefs justifying the use of violence in response to violence and in defence of family and honour; generalized beliefs of distrust; family involvement in crime or street brawls, family history of verbal aggression in the home; alcohol consumption; and gun ownership and carrying.

RESULTS: In this population the more severe forms of aggression (assault) tend to appear concurrently with the less severe forms, but persons who assault with an object and those who assault with a weapon tend not to overlap. Multivariate analyses of the data show that a family history of crime, and physical aggression among family members are the main correlates of verbal aggression. A family history of crime and street brawls, physical aggression BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 886

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among family members, and beliefs justifying violence in response to aggression are correlated to mild physical aggression. Family history of crime and street brawls, beliefs justifying violence as response to violence or in defence of family or honour, and carrying a gun are associated with assault with a weapon. These associations are independent of age, gender and social class.

CONCLUSION:. Among all analyzed factors, only a few of them are associated to less severe aggression forms, and a few also are associated to more severe forms of aggression. Antecedents of family crime and aggression, beliefs justifying violence in response to violence are common correlates for verbal and mild physical aggression and assault with a weapon.

LIMITS: Although the findings are limited by the cross-sectional design, exclusion of the institutionalized population and reliance on retrospective self-reports, they provide support for known correlates of aggression in a Latin American context.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Authorities and social organizations can use these data in order to built their prevention and control programs among aggressors.

A QUALITATIVE STUDY OF INJURIES IN REFUGEE AND HOST POPULATIONS IN NORTHERN UGANDA

DINESH SETHI,MARGARET LAMUNU,EDNA JURUGO,ANTHONY ZWI Lecturer in International Public Health London, UK

PROBLEM UNDER STUDY: Injuries are a leading cause of death in sub-Saharan Africa. Despite this, little attention has been devoted to their prevention or management. This lack of attention is even more apparent when one focuses on refugee populations in Africa. Whereas injuries resulting from war have been well described, little is known in the aftermath of conflict, where there is social disruption, and the ready availability of weapons. This is also the case in Northern Uganda, where there are refugees displaced because of the chronic conflict in Sudan.

OBJECTIVES: The objectives of the study was to undertake a qualitative investigation of injury in order to better understand the knowledge and attitudes towards injuries and violence of the refugee and host communities so as to develop preventive strategies.

METHOD OR APPROACH: The setting was Adjumani district, in Northern Uganda among the Madi speaking refugees from southern Sudan and the Madi speaking host population. There were three components: 1. Questionnaires as part of a community household survey carried out in December 1999 which involved 1609 households in the refugee and 1430 households in the host populations; 2. 53 Key informant interviews of community and refugee leaders, government, district and NGO workers and officials; 3. 14 focus group discussions with members from the two communities. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 887

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Subjects were asked to talk about the causes and solutions for intentional and unintentional injuries. Responses from the survey and key informant interviews were hand written on respective questionnaires and the focus group discussions were recorded and then tran- scribed. A thematic analysis was carried out to highlight the findings and prevention implications for each main category of injury cause.

RESULTS: The leading causes of injuries in the home as perceived were in decreasing order: 1. Refugees: falls, poisoning, assaults, cuts/stabs and burns; 2. Locals: poisoning, falls, cuts, assaults and burns. About half the refugees and locals felt unsafe in their neighbourhoods at night. Both communities stated that alcohol was the leading cause of violence (70% refugees and 82% of the locals). Solutions for the problem of violence reported by the two populations were: enforcement /legal interventions (about 50%), elder advice (35%) and refraining from alcohol/brewing (15%). More refugees thought that poverty alleviation was a solution (10% vs. 2%). In contrast, the key informants thought that the three leading causes of injuries in the district for the under 10 year olds were falls, burns and poisoning, and for the 20-30 year olds this was violence, falls and poisoning. Focus group discussions violence and poisoning were the main causes of concern. Solutions to the former included income generation activities as an alternative to alcohol brewing.

CONCLUSION: This study suggests that there was a slight mismatch between priorities perceived by the communities in contrast to the key informants. It emphasises the importance of involving communities in assessing needs and planning preventive strategies. Community based views on the causes and solutions to injuries need to be taken on board to enhance the likelihood of safety promotion programmes being successful.

LIMITS: The representativeness of the study sample and the generalisabilty of the study results need to be considered.

CONTRIBUTION OF THE PROJECT TO THE FIELD: An increased understanding of the importance of incorporating population based views in assessing community needs and planning preventive programmes.

CIRCUMSTANCES OF HOMICIDE AGAINST WOMEN IN CALI–COLOMBIA. 1993-2001

VICTORIA ESPITIA,GUTIERREZ MARIA I. Research member CISALVA Institute. Universidad del Valle Cali, Valle Del Cauca, Colombia

PROBLEM UNDER STUDY: In Colombia occurs near to 2.000 homicides per year against women. In Cali–a city with 2 million inhabitants– in a period of 9 years (1993- 2001 (09/16)) occurred 1.109 homicides against women. In this same period died for motor vehicle 856 women, in suicide 155 and in accidental deaths 232. The homicides are the first cause of death in women from 15 to 44 years. and represent 6.6% of the total. The strategies of prevention implemented by the local government are directed toward the reduction of the homicides against men by being the higher number. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 888

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OBJECTIVES: To identify the circumstances in the which the homicides against women occur in Cali, in order to contribute in prevention strategies.

RESULTS: The rate average/year in this period was 12 by each 100.000 women. For this same period the rate for men was 207. In average there was 11 homicides against women by month. For men the average was 152. The rates for the group from 35 to 39 years went the highest in all the period (24 for 100.000 women). During the weekend occurred 50% of the cases and near 20% the days Sundays. In the night they occurred 45% of the cases. The offender was identified 27% of the times. For men this average was 16%.(p=0.000). 79% of homicide were perpetrated with firearm, as compared with 83% for men (p=0.000) and 5.4% (59) were caused by strangulation, bludgeon and other different from handgun and cutting instrument, as compared with 2.8% (435) for men (p=0.000). In poor neighbourhoods, occurred 87.2% of homicides against women. The circumstances of homicide against women were identify for the last 2 years (2000-2001) thus: in relation with the offender, 14.4% (28) of women were killed by their husbands and intimate acquaintance; delinquency-related homicide were 7.2% (14); gang- related homicides 1.5% (3); by assault 11.8% (23); in revenges 8.7% (17); related with physical fights 7.2% (14); in 28.7% (53) the circumstance was not determinable. One woman was pregnant at the moment of the murder.

CONCLUSION: The findings of this study have important implications for research efforts directed towards prevention. We have identify four areas of inquiry that should be pursued by researchers and police makers: domestic violence, firearm use, delinquency-related homicide and by assault. The occurrence of homicide in weekend suggests a relationship with alcohol use. More attention must be paid to evaluation in developing and implementing programs intended to prevent domestic violence.

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MULTI-LEVEL ANALYSIS

ANTHONY FABIO,WEI LI,STEPHAN STROTMEYER University of Pittsburgh, Centre for Injury Research and Control Pittsburgh, Pa, USA

PROBLEM UNDER STUDY: The majority of epidemiological studies of the association of race and intentional injury have been conducted at the individual level. These studies have found that minorities are significantly over represented in arrest and victimization data. However, by only looking at the individual-level factors, you assume that the risk of victimization due to an individuals race is the same across all communities. In fact, the racial makeup of individual communities has also been found to be related to intentional injury of a community. It is likely that the effects of race are influenced by community-level factors, and it is possible that minorities respond to racial segregation differently than whites.

OBJECTIVES: This analysis extends epidemiological estimates of the risk of violent victimization beyond the traditional individual-level risk factors. We quantify the individual- and community-level contributions to violence, and their interactions, in a novel way, by applying hierarchical estimation. The objective is to assess the role of racial segregation as an independent and interactive risk factor for violent victimization; Hypothesis: The degree of racial segregation in a county contributes both independently and in interaction with individual attributes to violent injury. All else equal, individuals who reside in counties with higher levels of segregation will experience higher risk of violent victimization. In addition, we hypothesize that the effect of racial segregation will be stronger for other races compared to whites.

METHOD OR APPROACH: Hospital Discharge (1997-1999) and Census data were used for the analysis. An intentional injury hospital discharge was defined as a case having an ICD-9-CM code in the range of E960-E969. County-level indicators were extracted from US census data, including: overall population size, racial composition, racial segregation, poverty (percentage below poverty level), unemployment (percentage unemployed), and education (percentage with high school diploma or higher).

Dependent variable: intentional versus non-intentional injury. Independent measures: the dissimilarity index (DI) developed by Duncan and Duncan (1955) was used to measure racial segregation. It was calculated for each county using the census tract level distribu- tions of population for white and other races. The highest index value of 100 occurs when the two groups are totally segregated.

Statistical Analysis: Hierarchical logistic modeling was used to assess the independent contribution of racial segregation on the risk of violent injury. The model at the individual level specifies the outcomes for individuals as a function of individual-level attributes. The model at the county level of the estimates the county-specific beta coefficients, expressed as a function of county-level attributes for the individual attribute and the county-level factor. This model estimates the individual- and county-level effects jointly, to allow for interaction between individual and county attributes by permitting county-level factors to differen- tially influence the effects of individual attributes.

RESULTS: An increase in DI increased the risk for intentional injury (P< 0.000) for other races compared to whites after adjusting for county-level (injury rate, education, population BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 890

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density, household income, unemployment, income rate) and individual level (age, length of stay, sex, race) variables. In other words, minorities were more sensitive to the effects of segregation than were whites.

CONCLUSION: The proposed study contributes to an emerging research literature that inte- grates the perspectives of what in the past have been separate bodies of research on either the individual-level impacts of race on individual offending or victimization risks, and community-level analyses of impacts of racial composition on community crime rates. After adjusting for known individual- and community-level correlates, increased segregation was associated with increased intentional injury. Furthermore, this association existed for minorities compared to whites.

LIMITS: This study uses unintentional injury discharges as controls, which may influence the results. In addition, the analysis is cross-sectional in nature.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This represents an important step in understanding the nature of observed race/violence links, and may help direct efforts to develop effective prevention strategies that target community organization and interaction not usually addressed in violence prevention efforts.

HEALTH AND PEACE FOR A COUNTRY IN WAR: COLOMBIA

SAUL FRANCO Universidad Nacional de Colombia Bogotá, Colombia

PROBLEM UNDER STUDY: The impact of violence on health in Colombia.

OBJECTIVES: 1. To point out the main forms of violence in Colombia; 2. To analyze the impact of the above on health; 3. To make a contribution from the health sector to the confrontation of violence and the construction of peace

METHOD OR APPROACH: 1. Data collection on the different forms of violence in Colombia; 2. Analysis of the different ways in which the above forms of violence have an impact on the quality of life and health situation of Colombians; 3. Elaboration and discussion of proposals, according with the main findings and analysis.

RESULTS: Annual homicide rate: 60/100.000 inhabitants (12 times greater than the world average). 25.655 homicides in the year 2000. Almost 500,000 homicides in the past 25 years. Victims predominantly young males (15–35 years of age). High levels of cruelty and frequent collective murders. Over 2.000.000 people forcefully displaced, 300.000 of them on the year 2000. High rates of kidnappings and other forms of violence. Common violations of BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 891

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Humanitarian International Rights, direct interference with healthcare services at all levels and threats to the life and freedom of healthcare personnel.

CONCLUSION: Violence is the main public health problem in Colombia today. This is so because of the overall number of fatalities, the resulting damage to the physical and mental health of the population and the negative impact on healthcare services and personnel.

LIMITS: There are limitations on the access to reliable and systematic sources of information. It is also difficult to perform an objective and durable analysis in the middle of such an intense and continuously degrading conflict situation.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The work has contributed to a better understanding of the problem and to an improved collective awareness of its implications. It has also helped in the formulation of a number of actions in the fields of prevention, health promotion, and health education.

KOSOVO: INTERPERSONAL VIOLENCE IN A POST-CONFLICT SETTING

MAGDALENA CERDA,NADINE FRANCE, KIDIST BARTOLOMEOS,GANI DEHMOLI World Health Organization Geneva, Switzerland

PROBLEM UNDER STUDY: Between 1998 and 1999, conflict occurred in Kosovo. In the aftermath of the conflict, the population was faced with the need to reconstruct the social and physical fabric of their communities. Focus groups were carried out to better understand the health and violence concerns of the population. The results would serve as the basis for the design of violence prevention programmes.

OBJECTIVES: The focus groups were used to: Understand the health concerns of the population during and after the war Assess attitudes to violence and coping mechanisms Identify existing community support for victims of violence Define the gaps, the needs and priority actions.

METHOD OR APPROACH: The study used the focus group technique to obtain a general overview of the types of health and violence concerns experienced by the Kosovar population. The question guide was developed over a period of 1 1/2 months by the WHO research team in Kosovo, WHO Kosovo and WHO Geneva. Following the training of moderators and note- takers, the question guide was pilot tested in four focus groups and revised accordingly. The focus groups were run over eight weeks between February and March 2000. Participants were identified with the help of local NGOs and health professionals. 14 focus groups were held: seven female and seven male groups, each ranging between 5-10 people in size. In total 90 people participated in the focus groups: 42 females and 48 males, divided by marriage status. The age range was 17-55 years of age: married groups had a mean age of 35, while the unmarried groups had a mean age of 21. All participants were Kosovo-Albanians and came from seven regions of Kosovo: Suhareke, Rahovac, Maliseva, Skenderaj, Kamenica, Decan and Dragash. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 892

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RESULTS: Major social and structural changes took place due to the war. Destruction of public infrastructure, rupture of the family structure, loss of family members and increased unemployment were reported. Gender roles also shifted: women seemed to acquire an increased public role, and males felt more pressure to understand the experiences of women and to support the family. Respondents stated that people showed optimism and collective perseverance to improve the future, but also had difficulty dealing with human loss. Focus groups reported that rape, disappearances and torture predominated during the war, and were perpetrated by enemy forces. The nature of violence changed after the war: respondents indicated that domestic/family violence and community violence were currently present in their communities. Respondents blamed the socio-economic conditions, the increased use of alcohol, and the ensuing feelings of helplessness and aggression among the men for the post-conflict violence. Women and children were reported as high-risk groups in the war and post-war period. However, in the post-war period women were also reported to perpetrate child abuse. Victims of sexual violence were generally blamed and victims of all types of violence generally received little family and community support. Respondents expressed the need for improved services to manage the consequences of violence, such as psychosocial support and health care, support and protection services, and services to prevent further violence, such as social meeting places, investment in education, media campaigns, and support for infrastructure reconstruction.

CONCLUSION: Kosovars were faced with the need to reconstruct their communities and to cope with the experiences of human loss. Violence shifted from collective to interpersonal, and moved into the family sphere. A need may exist to invest in community development, particularly infrastructure reconstruction, promotion of employment opportunities, violence prevention, and education. Services are needed for victims to work through their experiences and to prevent the perpetuation of the social trauma.

LIMITS: Focus groups include the opinions of a small convenience sample of people. The results are not statistically applicable to the population as a whole. Consequently, focus group research is regarded as exploratory and preliminary rather than conclusive. Focus groups should be complemented with epidemiological data on the actual patterns of violent victimization.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study illustrated the social and health concerns present in a post-conflict society, the cycle of violence that passes from conflict to post-conflict settings. Public health practitioners can use the results to identify priority actions to promote the safe reconstruction of a post-conflict society.

CHILDREN’S EXPOSURE TO VIOLENCE IN COLOMBIA

NELSON ARBOLEDA Partnership For The Study And Prevention Of Violence Miami, Fl, USA

PROBLEM UNDER STUDY: Colombia has the fourth largest displaced population in the world due to violence. Exposure of children to social and political violence results in serious physical and emotional trauma, the extent of which has yet to be seen. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 893

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OBJECTIVES: 1. Present a descriptive analysis of the degree of social and political violence in Colombia; 2. Identify factors that contribute to violence against children; 3. Discuss the needs of children affected by violence.

METHOD OR APPROACH: A literature review of the most current incidence and prevalence data on violence in Colombia. Sources include reports from the US Dept of State, UN High Commission Refugees, UN Commission on Human Rights, UNICEF, US Campaign to Ban Landmines, The Coalition to Stop the Use of Child Soldiers and the International Save the Children alliance. Additioanl sources include CISALVA–Violence Investigative Centre at La Universidad del Valle in Cali-Colombia and several Colombian International Newspapers.

RESULTS: Colombia ranks as one of the countries with the highest homicide rates in the world, with approximately 25,000 violence-related deaths per year and a homicide rate of 68 per 100,000. Four Colombians are killed daily in combat in the undeclared guerrilla war. According to the US Dept of State, out of 128 terrorist acts in Latin America, 107 took place in Colombia. Colombia is the country with the largest number of planted landmines in Latin America and the only country at this time, in which these artifacts are still being planted, although Colombia has signed the International treaty that bans them. (UNICEF) According to the US committee for refugees, Colombia has the fourth largest displaced population in the world, only after Sudan and Angola. Five million Colombians were forcefully displaced from their homes in just the last 10 years, the majority of these being women and children. Between 1995 and 1998, 835,000 persons were displaced; more than half (542,000) were children. This number is far greater than that totalled for Kosovo, during the conflict in 1999-2000. Colombia is considered the kidnapping capital of the world. There have been 20,000 reported kidnappings since 1998. Three out of four go unreported. Just in the year 2000 there were 3,096 kidnappings, including 264 children. In Colombia a child is kid- napped every 36 hours. At this time 250 children are being held under siege.

CONCLUSION: Colombia is experiencing an undeclared war that results in physical and emotional injury to children. The long-term health effects of social and political violence to children are yet to be fully understood. Many young soldiers have deformed backs and shoulders from carrying heavy loads. Malnutrition, respiratory, skin infections and other pathologies are frequent, as are sexually transmitted diseases, including HIV/AIDS. Children from displaced communities and refugees in camps are at particular risk of being exploited by armed entities. When families are torn apart, children are often left to their own devices in profound social and economic uncertainty. The full extent of the impact on society and the psychological consequences of active participation in hostilities with children witnessing and at times committing atrocities is just beginning to be understood. By elucidat- ing the tragic and violent situation of these children in Colombia we can hope to find strategies to decrease the sequelae of violence on these children. Strategies that focus on reducing social and political violence require political will and commitment of resources. These strategies must include:

• Care for children that are victims of violent injury, witnessing violence, kidnapping or displacement due to war; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 894

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• Interventions to decrease the amount of violent acts and implementing international standards to protect children from violence; • Political and humanitarian efforts to protect children caught in the web of war and conflict; • The support of international organisms such as the UN, OAE, World Bank and IADB to confront this humanitarian emergency and enforce international standards to protect children.

LIMITS: This presentation is only a descriptive analysis that illustrates Colombia’s current situation and only briefly focuses on treatment or intervention.

CONTRIBUTION OF THE PROJECT TO THE FIELD: To raise awareness on the alarming rate of violence against children; the impact of violence on child-health and well-being; and to support intervention and prevention programming aimed at this population.

BOMB BLAST INJURIES & POLITICAL VIOLENCE IN BANGLADESH

SHAH SHAH ALAM,MUSSARRAT HAQUE Dhaka University Dhaka, Bangladesh

PROBLEM UNDER STUDY: Bangladesh is one of the 3rd World countries, political unrest always present. Bomb blast explosive is one of the important & strong weapons of the political parties. Due to lot of internal causes and influences from Donor & developed countries violence’s are increasing day by day. General people loosing their lives, loosing their nearest relations and people becoming cripple by becoming permanently blind and disable. That is why sometimes actual data’s are hidden by the influences of Govt. and political parties. So the data are recorded when the helpless patients attend the hospital seeking help. Dhaka Medical College Hospital & NITOR (National Institute of Traumatology & Orthopaedic Rehabilitation) former R.I.H.D have some data on this issue.

OBJECTIVES: Bomb blast injuries are only expected in War field not in any civil cases. But in our country not only in Bangladesh, India, Pakistan, Nepal & other 3rd world countries are really facing challenging problems. Main target to focus these problems to minimize the injuries, collection & analysis of the real data and to increase the public awareness and to highlight this great problem in international level to get any solution.

METHOD OR APPROACH: All patients attended in Dhaka Medical College Hospital & NITOR with bomb blast injuries during the period of January 1998 to December 2000 were analyzed irrespective of their age & sex. Male were main victims but female victims also were not very less in number. New born children to 80 years are included in this study. Main issue of the bomb blast were political but other than this hijacking, loitering & for dacoiting. Weak enforcement of law and force, illiteracy, unemployment, student politics, poverty and political influences are the main causes detected in this study. Maximum incidences found before, during and within 2 years after national election and during 2 Eid festival. Maximum accused were at the age of 20-35 years and their education level was not very high. A few became vic- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 895

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tims during preparation of the bomb. They lost their lives, became permanently blind & disable in different degrees. Main age of victims was 15-45 years.

In this study we have observed that few Institutes, district areas and few political party members have their maximum involvement.

RESULTS: A total 1500 patient of bomb blast injuries were studied. Among them about 45 cases (3%) were brought dead. Male female ratios were 15:1. Among the affected people, a significant number of patients become injured during making this explosive. 35 (2.3%) people became permanently blind. 100 patients (15%) had to be amputated their either single or both limbs. 175 (11.66%) patients lost their both hand functions also permanently and 55 patients lost 25% their right hand functions. All other patients became disable in different degrees.

CONCLUSION: No anti social activities are accepted & expected at any cost. human & Humanity issue can’t be compromised. So we should be careful enough to reduce this sort of violence’s. Influence of political party & donor countries should be very careful to take any steps for humanity ground to reduce this type of brutal activities.

LIMITS: Under reporting & eludes of actual data is a common phenomenon due to above- mentioned influence.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We are trauma surgeon. We are dealing these type of injures almost daily. So proper data collection & analysis system can increase the public awareness and reduce the mortality & morbidity. If I can present & publish this paper in this international conference then lot of developed countries would be able to know the real problems of 3rd world countries and by exchange of their knowledge and by applying their experience upon our helpless people would benefited.

VIOLENCE AND CRIMINAL JUSTICE

JORGE NILSON MORALES MANZUR,MARÌA ALEJANDRA FERNANDEZ Universidad del Zulia Maracaibo, Zulia, Venezuela

PROBLEM UNDER STUDY: The venezuelan bolivarian republic congress produced a processal reform where it was adopted the accusatory, oral and public system of justice administration, based on an in force procedimental code called penal processal organic code. This radical reform changes the old fashioned penal process focuses on the summary secret and the use of prison as an investigation and punishment tool, same as an in advance penalty. These days, the penal system is alike other systems used in the developed countries in which citizen participation is guaranteed through the jury and public and public roles; the respect of the legal rights and all the processal aspects protecting humans rights. In despite of what is positive in the previous panorama, the reality indicates since the promulgation of this code in June 1999, the criminal and institutional violence indicators have amazingly increased. That is why it has to be asked: why if the expected results of the oral trial were a faster and trans- parent justice; citizen participation, better understanding of the penal justice procedures; the diminution of the judicial corruption and specially the diminution of the violence indicators BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 896

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as a consequence of a better justice administration; so why if there were the goals, the results have been the opposite? The consequences of the transition from an inquisitive system to an accusing one has been an all society actors resistance for considering themselves affected by the application of this code that touched vested interests due to a long term illegal practice which, obviously, is resistant to these changes, no matter how positive they can be.

OBJECTIVES: The main objective to show how the application of a new justice administration code is necessary for the improvement of the judiciary, although it is used to amplify the increment of the institutional and criminal violence due to its supposed bad performance an the incapacity of the State to make it efficient.

METHOD OR APPROACH: This research is part of a greater project that mainly focuses on the application of the criminal justice code by all organizations related to justice.

RESULTS: To show who the application of this new code is not really responsible for the increment of the violence indicators.

CONCLUSION: The necessity of making a new criminal code along with the new reality that Venezuela lives among deep changes in the political, economic and social scene, has justi- fied the change of all the aspects of national life, as the increase of the violence and the appear- ance of new kinds of criminal behaviours and the feelings of insecurity in the population, jus- tified the necessity of a new criminal instrument. It is no easy to make a new criminal code in the very special situation Venezuela is going through. We must bear in mind the principles of justice that must follow the notion of a state of justice, in others words, the notions of criminalization and decriminalization of criminal behaviours, the review of the basic concepts of the alternative control about the alternative penalty of the privative liberty, among others.

MACRO AND MICRO LINKS BETWEEN VIOLENCE IN BROADER SOCIETY AND INTERPERSONAL VIOLENCE – AN INTEGRATED ETIOLOGICAL PERSPECTIVE

ROBERT PEACOCK Midrand University, South Africa Halfway House, Gauteng, South Africa Traditional etiological perspectives on violence focused mainly on factors within the individual (intra-psychic), or external factors (milieu-oriented perspectives). The main objective of this study was to develop an integrated etiological perspective, incorporating thereby, macro and micro links between violence in broader society and interpersonal violence. Frustration was deemed to be the fundamental theoretical building block, and violence was constructed amid social strain, as a self-preserving and egocentric defence mechanism. Literature survey Norm enforcement and self-image defending variables were central to the cyclical nature of violence. Recommendations for further research were made towards violence prevention as with regard to the empirical -analytical, interpretive and emancipatory research paradigms. In order to conduct an integrated study on the causes and prevention of violence, triangulation would serve to enhance both research design coherence, and the fusion of quantitative and qualitative research paradigms. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 897

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As the main objective of the study was to develop an integrated theoretical perspective on macro and micro links of violence, no empirical study was conducted. Theory and research development.

CHANGING SPIRITUAL PERCEPTIONS OF THE MARRIAGE RELATIONSHIP TO PREVENT DOMESTIC VIOLENCE

JULIE A. MCCOURT University of Medicine and Dentistry of New Jersey School of Nursing Newark, NJ, USA

PROBLEM UNDER STUDY: Traditionally, Christian religious leadership has been slow to address Domestic Violence as a violation of the marriage covenant. Coupled with the cultural norm of male dominance in the African-American culture, African-American victims find little support from religious leaders. The Hearts of Compassion program assists religious leaders in broaching the divide between religious marital doctrine and domestic violence.

OBJECTIVES: 1. Provide religious leaders with essential historical information about domestic violence; 2. Cultivate attitudinal change about victims held by religious leaders; 3. quip religious leaders with fundamental assessment and intervention skills.

METHOD OR APPROACH: Based on the information theory that information is valued as a tool to reduce risks and shape decisions promoting safety, Christian African-American leaders attended 40 hours of domestic violence training, which included assessment, referral and intervention skills promotion. The training placed domestic violence as a violation of the marriage covenant. Data collection occurred both quantatively through pre/post test knowledge, skill and attitudinal measures as well as qualitatively through focus group and follow- up group sessions. Finally, religious leaders were asked to describe the impact of the training on their personal lives and intimate relationships in personalized interviews that are part of a videography of African-American Domestic Violence documentary.

RESULTS: 1. Religious leaders demonstrated improved and accurate understanding of domestic violence; 2. Religious leaders were able to assess domestic violence victims without placing blame or doubting the validity of the victims experience; 3. Religious leaders were able to implement interventions with congregation members under either the priest-penitent confidentiality protection of the law or the counsellor-victim confidentiality protection of the law; 4. Religious leaders were able to identify personal attitudinal changes towards victims and about domestic violence as a significant issue facing the African-American community as a whole. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 898

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CONCLUSION: 1. Religious leaders are well positioned to assist victims and address domestic violence close if not directly in the abusive environment; 2. Religious leaders understand the value and appropriateness of addressing the victims immediate safety needs prior to the victims spiritual needs; 3. Religious leaders are able to use their status as respected individuals to encourage behaviour change in batters.

LIMITS: The Hearts of Compassion Program and this abstract address domestic violence in the context of urban African-American culture as well as confront long held Christian religious doctrinal beliefs about the covenant of marriage.

CONTRIBUTION OF THE PROJECT TO THE FIELD: 1. Begins to breakdown barriers between victims and their religious leadership; 2. Cultivates understanding of victimization experience by religious leaders; 3. Serves as a model program for duplication in other religious communities; 4. Demonstrates to the domestic violence professional community that religious leaders are inculcating their work.

THE ROLE OF URBAN RENEWAL AND DESIGN IN THE REDUCTION OF VIOLENT CRIME

INGRID PALMARY Centre for the Study of Violence and Reconciliation Johannesburg, Gauteng, South Africa A great deal of research has been done internationally on the relationship between crime and grime. The ‘tipping point’ and ‘broken windows’ theories have indicated that the reduction of incivilities and urban decay can themselves lead to a reduction in serious violent crime. In South African cities, these theories are present in many of the urban violence reduction strategies of both national and local government. In his most recent election speech, the South African president identified a number of ‘urban renewal’ sites. These were the sites with the highest levels of violent crime and the renewal of these sites is intended to reduce violence in the area. This research aims to test the relationship between urban decay and levels of violence in the South African context and compare this to research findings in other countries. It also to investigates the impact of urban renewal on residents’ fear of violence. The research makes use of three primary methodologies: 1. Key informant interviews with government officials responsible for the design, implementation and management of the renewal programmes; 2. An analysis of the number and nature of crimes reported to the South African Police Services in the urban renewal sites before and after the implementation of the renewal programme; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 899

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3. A survey of residents fear of violence and the impact that urban renewal has on these levels of fear. The results will determine the extent to which violence has or has not reduced in areas where urban renewal programmes have been implemented and the extent to which any reductions in violence may be attributable to urban renewal. They will also determine the impact that urban renewal has on residents fear of serious violent crime. The conclusion will focus on the extent to which urban renewal programmes are an effective way to reduce urban violence in cities in developing countries and the implications for expanding such programmes. This research is limited by the difficulty of obtaining crime statistics in South Africa given that there has been a moratorium on all crime statistics. Access to these statistics has, however, been negotiated with the relevant authorities. In addition, there is evidence to suggest that certain crimes (particularly crimes such as rape and domestic violence) are seriously under-reported in South Africa. This will need to be taken into consideration when drawing conclusion about the research findings. In spite of these limitations, this research makes an important contribution to understanding and preventing urban violence in developing countries. In South Africa, urban design and renewal has been flagged as an important part of the reduction of violence. However, there has been no evaluation of the effectiveness of these programmes as yet. This research therefore shows the effectiveness of these strategies as well as allowing for international comparisons of the relationship between urban decay and violence.

MESURES POUR COMBATTRE LE TRAFIC DE MIGRANTS : L’IMPACT ET LES CONSÉQUENCES POUR LES VICTIMES

ESTIBALITZ JIMENEZ Université De Montréal, École de criminologie Montréal, Québec, Canada

PROBLÉMATIQUE : Les médias nous montrent souvent des images d’individus arrivant de façon clandestine, comme les Chinois à Douvres ou à Vancouver, les Kurdes en France, les Cubains aux États-Unis, les Afghans en Australie, etc. Ce sont toujours des images scandaleuses qui reflètent une misère intolérable. Par contre, on ferme régulièrement les yeux devant la misè- re humaine et les injustices qui existent quotidiennement dans les pays d’où provient l’immigration. Dans un contexte de vie intolérable où ils n’ont rien à perdre, les migrants ten- tent une vie ailleurs. Les pays riches ferment leurs portes aux flux de migrants, rendant l’accès légal aux pays de plus en plus limité. À leur tour, pour pouvoir atteindre un niveau de vie digne et acceptable, les migrants sont forcés d’utiliser des moyens illégaux, comme faire appel aux filières de passeurs. Dans certains cas, ceux qui font affaire aux passeurs peuvent souffrir de traitements inhumains ou dégradants de la part de ces derniers; violence physique, psychologique, verbale, sexuelle ou économique, sans oublier de nombreux incidents où certains d’entre eux ont perdu la vie. Dans tous ces cas, nous considérerons les migrants comme des victimes qui ont besoin de support et dont le véritable statut doit être reconnu. Par conséquent, il y a une évidente nécessité de mettre en place des mécanismes de protec- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 900

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tion et d’assistance, toujours en tenant compte des besoins, réalités et points de vue des victimes. Toutefois, dans un but de sécurité nationale et publique, face à ce flux de migrants non documentés, les États ont décidé d’augmenter les contrôles migratoires et de renforcer leurs politiques d’immigration sans tenir compte de la réalité, des besoins et du point de vue des migrants. Ces textes juridiques ne visent généralement pas la protection des migrants et peuvent même les victimiser.

OBJECTIFS : Analyser les mesures pour combattre le trafic de migrants, vérifier si elles res- pectent un équilibre entre les droits des États à l’égard de la sécurité nationale et de l’immigration versus ceux des migrants et en ressortir les lacunes et des pistes de solutions.

MÉTHODE OU APPROCHE : 1. Examiner les programmes et politiques internationaux de lutte contre le trafic de migrants : le cadre législatif, les structures organisationnelles, les modèles d’échan- ge d’information, les outils d’application de la loi; 2. Analyser le contenu du Protocole contre le trafic illicite de migrants par terre, air et mer additionnel à la Convention de Nations Unies contre la criminalité transnationale organisée; 3. Analyser les mesures de protection prises ou qui sont en voie de l’être, tant au niveau national que bilatéral ou multilatéral; 4. Préciser les manifestations du trafic de migrants actuellement couvertes dans la législation canadienne, plus particulièrement dans la Loi canadienne sur l’immigration et la protection des réfugiés; 5. Analyser les textes adoptés par les organisations internationales et ONG relatifs à l’assistance et la protection des victimes de trafic de migrants.

LIMITES : Les instruments juridiques pour combattre le trafic de migrants sont très récents. Donc, il est trop tôt plus examiner dans la pratique l’impact et les conséquences du Protocole sur les migrants.

CONTRIBUTION À LA SCIENCE : Il existe encore très peu de littérature sur le trafic de migrants, les migrants clandestins, le contrôle migratoire...alors que l’attentat au World Trade Centre le met à l’avant-plan avec la proposition du Président George W. Bush de créer un Périmètre nord-américain de sécurité. Toute la question de l’équilibre entre la protection des droits et les mesures visant à assurer la sécurité nationale et publique sera extrêmement importante dans les années à venir. La question du trafic de migrants remette à jour les agendas de la communauté internationale. Ainsi, le 15 novembre de l’année 2000, l’Assemblée générale a adopté le Protocole contre le trafic illicite de migrants par terre, air et mer additionnel à la Convention des Nations Unies contre la criminalité transnationale organisée. Même si le protocole n’est pas encore entré en vigueur, il est impératif de l’analyser et de connaître son véritable objectif afin d’identifier les aspects qui semblent poser problème du point de vue victimologique et qui menacent de porter atteinte aux droits des réfugiés tels qu’exprimés dans la Convention de 1951 relative au statut de réfugiés. Comment revoir le cadre juridi- co-politique des contrôles migratoires étatiques aux frontières de manière à ce qu’ils ne vic- timisent plus les migrants et ne bafouent plus leurs droits? BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 901

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LOCAL EXPRESSIONS OF HOMICIDE, COLOMBIA YEAR 2000

LUZ JANETH FORERO Centre for National Reference on Violence of National Institute of Legal Medicine and Forensic Science Bogotá, Cundinamarca, Colombia

PROBLEM UNDER STUDY: What factors characterize the homicide in Colombia ?

OBJECTIVES: Characterizing the homicide in Colombia in year 2000, whit emphasis in local expressions.

METHOD OR APPROACH: This descriptive study focused on criminal homicide. Determination that a death was criminal homicide was based on the results of investigation by forensic doctor. Demographics characteristics of victims and situational characteristics of de homicide were obtained from confidential National Institute of Legal Medicine and Forensic Sciences file, of Colombia.

RESULTS: The National Institute of Legal Medicine and Forensic Sciences registers 25.681 fatally injuries due to homicide in Colombia, showing an 11% increase in the cases (p=0.2), compared to that of 1.999. Rate of 61 homicide per 100.000 inhabitants. Apartadó in the department of Antioquia show the higher rate of homicide in the country (269 homicide per 100.000 inhabitants). The 93% of de cases corresponded to the male gender. The most exposed group was young. A very few cases know motives. The principal criminal motives was the vengeance 30%, criminal actor was unknown 87% and the instrument or means was firearms 85,1%.

CONCLUSION: The profile of homicidal violence, described trough variables collected by the National Institute of Legal Medicine and Forensic Sciences, shows particular dynamics belonging to each geographic scenario. Nevertheless, the global pattern describes a major commitment by individuals of the male gender in economically active ages, mainly killed by firearm projectile, in public spaces and by unknown authors as well as unknown motives. Homicide in Colombia, in terms of rate, is centred in a few townships presenting low population density. It is not possible then to state that it is an eminently urban phenomenon. The detracting arguments for Colombian violence as a “normalized” situation find in the time- space distribution of homicides, according to the participants and presumed motivations, their strongest support. There is clear historic coincidences between townships that bear the higher violence rates, which are associated to clearly defined social dynamics, be them a product of the martial conflict, the culmination of norco-traffic or other illegal economies, migration and colonization processes or others. It is worthwhile to emphasize that scenarios with a lower intensity in homicidal violence can be related to higher rates in other forms of violence, hence indicators that relate to different manifestations of violence are suitable and necessary for the global comprehension of the phenomenon.

LIMITS: This study can not establish causal relation, but if explored associate factors homicide for its understanding.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The purposes of this study are to encourage may- ors and general community to evaluate associate factors homicide, in the local context and BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 902

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implement protective measures and encourage researchers to gather more detailed information about homicide and to develop and evaluate protective measures.

SELF-SUFFERED FRACTURES – A FOUR YEAR STUDY

JAGDISH GARGI Government Medical College Amritsar, India

PROBLEM UNDER STUDY: Self-suffered fractures are commonly caused to blame the other party, misusing the law whereby punishment for the injury gets enhanced and is a non-bailable offence as per the Indian Penal Code (IPC). A study pertaining to alleged self-suffered fractures in injury cases was carried outin the emergency wing of the Guru Nanak Dev Hospital and Sri Gury Teg Bahadur Hospital attached to Government Medical College, Amritsar from 20.5.1997 to 19.5.2001.

OBJECTIVES: To determine the incidence of self-suffered fractures in different age groups, sex, religions, literacy level, occupation, anatomical area of the body, type of injury, total number of injuries in an individual, direction, accessibility of the part, weapon used, nature of injury, and to establish the parameter for declaring the fracture as self-suffered fractures and provision of justice to the society.

METHOD OR APPROACH: All medico-legal injury reports from 20.5.1997 to 19.5.2001 were studied in detail along with the radiological findings and the data were tabulated and analysed. A total of 2998 cases were studied out of which 484 (16.1%) had self suffered fractures. The commonest age groups were 20-29 years and 30-39 years in males–244 cases (50.4%) and 40-49 and 50-59 years in females–20 cases (4%)

RESULTS: Rural population showed the commonest involvement–340 cases (70.2%). Sikhs, the local ethnic community were involved in 315 cases (65%). Literate subjects outnumbered the illiterates and farming was the most common occupation of those involved–178 cases (36.7%). The leg, especially the shin of tibia was the most frequently selected site–179 cases (37%). Non-vital parts, arms, forearm, hands, fingers, legs, feet and toes constituted 76% of the cases. The head and face including the forehead was involved in 24% cases. The most common injury corresponding to the site of fracture was an incised bound–4444 cases (91.7%), in the rest lacerated wounds were present. The total number of injuries in alleged self-suffered fractures varied from 1 to more than 3. Direction of injury was either horizontal of oblique–202 cases (4.7%) and 214 cases (44.2%) respectively. Vertical injury was observed on the skull in 68 cases (14.15). Fractures were caused on accessible parts in 306 cases (63.2%). A sharp edged weapon was used in 444 cases (91.7%) and blunt force was responsible for the injury in 40 cases (8.3%), sharp-edged weapons caused the fracture in lacerated wounds. Majority of the cases reported within 12-24 hours for medico-legal examination. The nature of injury in all the 484 cases was grievous.

CONCLUSION: Self-suffered fractures were more common in males in the age group of 20-39 years. Rural subjects outnumbered the urban population. Sikhs, the ethnic community and farmers were more often involved. It was a surprise finding that literate people were more BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 903

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often involved than the illiterate ones (those who were unable to read or write any language). Non-vital parts, the legs and forearms were most often involved. A peculiar finding was the fact that people were not hesitant to undergo self-suffered fractures on the head and face, including the forehead. Incised wounds were the commonest injury associated with the fracture. The direction of injury was either horizontal or oblique. Fractures were mostly caused on accessible parts. Fractures on non-accessible parts included the head, face, chest, back of chest and right upper limb in right-handed subjects. Sharp edged weapon was used in most cases and all injuries were of grievous nature.

LIMITS: The study of the clothing has been omitted which is vital finding for defining the parameters of self-suffered fractures. Clothes were usually spared as observed by the inves- tigators even if the clothes covered the injured part. This is a pointer to the self-suffered nature of the injuries.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The study will help in establishing norms for determining parameters for study of self-suffered fractures. Photographic presentation of the study would prove useful in highlighting salient features of such cases.

IMPLEMENTATION OF CORRIDORS OF SECURITY, IN THE DEPARTMENT OF THE VALLEY OF THE CAUCA

CAMILO ARTURO MONTENEGRO Government of the Valley of the Cauca Santiago De Cali, Valley of the Cauca, Colombia

PROBLEM UNDER STUDY: The criminal increment for armed groups to the margin of the law, in festival times, they took to the Departmental government, directed by the Doctor Germßn Villegas, to plate integral politicians of security to protect the inhabitants and tourists of the Valley of the Cauca, implementing corridors of security. In front of the current state of violence and insecurity, there are bewilderment, fear and perplexity. It is urgent to insist in the formulation of alternative scenarios where fades the psychological effect sought by the generating groups of violence. We have confronted deaths, humiliations and offences, but we should have in mind the statement Holderlin, where the danger grows, there we find the sal- vation. The affected area understands the highways of the Department of the Valley of the Cauca, located this to the Colombian south-occident, its problem generates continuous kidnappings in times of festivities in the highways, theft of vehicles, homicides, decrease of the tourism.

OBJECTIVES: 1. To strengthen, to support and to coordinate the combined forces of the state, guaranteeing their presence in the highways of the Department of the Valley of the Cauca; 2. To guarantee the tranquility of the residents y/o citizenship in the roads in festival times, to diminish the index of crimes made in these times.

METHOD OR APPROACH: First that everything, to guarantee security to the inhabitants of the region that move to the defined places where the Corridor is implemented; selected because BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 904

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they take place parties, encounters of character academic, cultural religious anniversary y/o, achieving with it to reactivate the tourism, the economy, the family integration and the health esparcimiento of the Vallecaucanos. It programs that it involves the effort common of the Departmental Government’s Administrative Entities, the force of the Order like soldiers, Policemen Colombian air forces, navy forces, Administrative department of security and the citizenship in general. Achieving the goal: the Valley of the Cauca doesn’t unite jail but a paradise to enjoy it free, sure and in peace.

RESULTS:: To the date we have carried out nine (9) corridors of security, tourist and of coexistence this way: • Cali-Calima Darien; • Buenvaventura-Palyas of the pacific-buga; • Seville-Caicedonia; • Cali-El Cerrito; • Tula-Ginebra; • Buenvaventura-the bocana -juanchaco-ladrilleros; • Florida-Zarzal; • Vijes-Buga; • Cali-the cumber-Ansermanuevo-Cartago. The results can be observed in the squares statistical annexes.

CONCLUSION: It programs healthy, reactivador of the economy and security. The Valley of the Cauca should be framed inside the socio-economic Politicians with approaches of security, generating alternative that give solutions of rest, recreation and tranquility to the families. These corridors of security are executing in tracts that unite to two towns where it is trafficked without danger.

LIMITS: They are tourists corridors, framed inside the geography Vallecaucana, with the interest of protecting the citizens in development of the Constitutional execution of guaranteeing the fundamental rights and prevention of the crime.

CONTRIBUTIONS OF THE PROJECT TO THE FIELD: Employment generation and revenues, reactiva- tion=n of small companies, security and civic coexistence, psychological tranquility, eco- turismo, recovery of civic spaces reduces in the index delincuenciales like thefts, homicides, control and non intentional lesion in accident of I traffic, kidnappings, personal lesions and family integration. The tourists have gone massively to the corridors programmed in an approximate number of 2 049 000 people. BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 905

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Violence exercée et subie par les jeunes : étendue du problème, facteurs associés et prévention Youth as Perpetrators and Victims of Violence: Breadth of the Problem, Associated Factors and Prevention

UNDERSTANDING THE INTERSECTION OF RACISM AND INTENTIONAL INJURIES

RICHARD WRIGHT Children’s Safety Network, Education Development Centre Newton, Ma, USA

PROBLEM UNDER STUDY: There is substantial evidence documenting severe racial disparities in intentional injuries, yet there is not widespread understanding of the causes and contexts in which African-American communities experience and understand violent victimization.

OBJECTIVES: 1. To provide empirical data on the racial disparities of fatal and non-fatal intentional injuries; 2. To discuss the context and social, psychological impacts of violence in African- American communities.

METHOD OR APPROACH: A literature review was conducted examining key national studies of violence and race. Literature was also reviewed examining African-American responses to violent victimization.

RESULTS: African-American adolescents and young men are killed at a rate 8 times greater than that of white adolescent males. One out of every four African-American males will go to prison at some point in their lifetime compared to one out of every 23 white males. Seven percent of all black children have at least 1 parent in prison. Nearly 60% of the juveniles who were incarcerated in adult state prisons were black. According to one national study, African-American children have the highest rate of child maltreatment than any race.

CONCLUSION: These statistics frame how African-American boys understand, experience, respond to and in some cases commit violent victimization. This presentation will illustrate how vulnerable African-American males are to victimization and will discuss how racism contributes to the violent traumatic event. The presentation will present models that African-American boys may respond to when they are victimized. An examination of Black hyper-masculinity in the form of “street” or “gangsta” rappers will be discussed. Additionally the presentation will discuss barriers for African-American male victims in disclosing victimization, seeking help and accepting their vulnerability. The role of institutions (e.g., res- BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 906

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idential homes, DYS, prisons, etc.) in dealing with black male victimization (and perpetration) will be discussed.

LIMITS: This is not a meta-analytic nor other type of quantitative study. There is very little research in understanding the interaction of racism and intentional injuries, therefore exploratory research is an appropriate but limited methodology.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This presentation and discussion will enhance both clinical and non-clinicians’ understanding of African-American violence and victimization and intervention strategies designed to enhance skills and cognitive development. Additionally, the presentation will clarify, how the Children’s Safety Network can and will provide assistance in addressing issues of black male victimization.

IMPACT OF DRUG USE AND ABUSE AND OTHERS FACTORS

TORRES DE GALVIS YOLANDA,MAYA MEJIA JOSE MARIA,MURRELLE LENN CES University Medellin, Antioquia, Colombia

PROBLEM UNDER STUDY: Several decades of research have revealed that the aetiology of juvenile violence behaviour comprises a complex network of interactive social, biologic, and genetic factors. There are several excellent studies on risk factors for drug use but far less is known about the risk and protective factors for violent behaviour. The recent social history of Colombia, South America has been influenced markedly by drug trafficking and violent crimes making adolescents from that country a unique population in which to study the complex relationships between the dual threats of drug abuse and others factors and violent behaviour.

Colombia Violence Indicators: 1. Rate of Homicides /100.000–1999. 2. 5–14 years 7/100.000; 3. 15–24 years 240/100.000 Medellin homicides in < 18 years old: January To February 1997; 15–24 years 48.8%. 1998; 15–24 years 56.6% of the total of homicides. Gender: 94.1% males.

Juvenile Delinquency: 19.498, 12 to 17 years: 1. Personal injury and homicide 18%; 2. Illegal carrying of firearms 8.5%.

OBJECTIVES: The goal of this study was to examine the prevalence of antisocial behaviours among Colombian adolescents and the relationship between behaviour disorder and risk and protective factors. To ask the following questions: • Which risk factors interact in the development of antisocial and violent behaviour?; • Which protective factors reduce the impact of risk or change the way a persons responds to them?; BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 907

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• Which is the frequency of these factors in the Medellin’s young?; • Which factors occurs more frequently in group who are “exposed” cases than the “no exposed” controls?; • Which are the factors with most strongly association with juvenile violence?.

METHOD OR APPROACH: This was a case-control study representative young 11 to 18 years old, it was conducted to examine risk and protective factors for juvenile violence. Using data from a study of 1,113 Colombian adolescents (mean age=15.6±2.0 years) at high and low risk of aggressive and violent behaviours, the links between violence and a number of individual, family and interpersonal risk factors were examined.

RESULTS: The variables included, poor parent-child communication and parental monitoring, problem peers, self-esteem, social attitudes regarding violence, impulsivity, neuroti- cism, and school aptitude. With the exception of an indicator of self-esteem, all variables tested were statistically significantly (p=0.05) associated with lifetime risk of violent or antisocial conduct. Age of onset, recency and frequency of use, and problems with licit and illicit psy- choactive substances were found to increase significantly with increasing involvement with violent or antisocial behaviours. The mitigating effects of positive family and teacher relations on the association between anti-sociality and drug involvement was examined.

CONCLUSION: Our findings confirm the cross-cultural consistency of risk factors for violent, antisocial, and drug use behaviours among a large population of Latin American adolescents, replicate the robust relationship between anti-sociality, drug abuse and the others risk and protective factors in this group, and identify potential targets for primary and secondary intervention.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The goal of the prevention science is to prevent, delay the onset, or moderate problems such aggressive and violent behaviours. The research has identified a number of risk factors associated with initiation of violent behaviour, additionally, the results indicates that protective family factors can moderate the effects of the risk factors. This outcomes are very important in the contest for potential targets for primary and secondary intervention prevention programs.

LA VIOLENCE : FACTEUR DE RISQUE DE L’ITINÉRANCE DES JEUNES

MARIE ROBERT,ROBERT PAUZÉ,LOUISE FOURNIER, GILLES FORGET,MICHELLE CÔTÉ Direction de la santé publique de Montréal-Centre; Institut national de santé publique du Québec Montréal, Québec, Canada

PROBLÉMATIQUE : L’itinérance chez les jeunes est un phénomène dont l’intérêt en matière de santé publique est incontestable. Les jeunes sans domicile fixe (SDF) souffrent de problèmes de santé mentale, de problèmes de consommation liés aux drogues et à l’alcool et sont à haut risque de contracter le sida et d’attenter à leur vie. De plus, ils manifestent des comportements de violence qui augmentent le risque de judiciarisation et de victimisation. La BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 908

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prévention du phénomène de l’itinérance des jeunes s’inscrit donc comme une préoccu- pation de santé publique et de sécurité publique. Nos travaux de recherche s’inscrivent dans l’optique de la prévention de l’itinérance, par- ticulièrement chez les jeunes mineurs. Plusieurs études se sont penchées sur le problème des adolescent(e)s SDF mais les facteurs de risque demeurent mal connus en raison des dif- ficultés d’accès que pose cette population. Ces jeunes vivent rarement littéralement dans la rue et utilisent peu les services d’hébergement qui leur sont dédiés de peur d’être dénon- cés aux autorités policières et aux agences de protection de l’enfance. Ainsi, la plupart vivent une forme d’itinérance cachée qui consiste à faire appel à leur réseau social (amis, connaissances, parenté, etc.) pour pallier leur instabilité résidentielle. Or, la majorité des études utilisent un échantillon constitué de jeunes mineurs qui fréquentent les refuges. Par ailleurs, peu d’études utilisent un groupe comparatif adéquat afin d’identifier les facteurs de risque liés à l’itinérance des mineurs.

OBJECTIFS : Nous présentons les résultats d’une étude visant à développer des connaissances sur les facteurs spécifiques de risque liés à l’itinérance des adolescent(e)s.

MÉTHODE OU APPROCHE Nous avons constitué un échantillon de 216 adolescent(e)s, âgés de 12 à 17 ans, pris en charge par 4 centres jeunesse du Québec (Montréal, Québec, Côte-nord, Estrie). Ces jeunes présentent alors un ensemble de difficultés familiales qui sont recon- nues, dans les écrits scientifiques, comme un type de facteur de risque important de l’itiné- rance. Cet échantillon se divise en deux groupes de 108 jeunes chacun, l’un ayant vécu des épisodes SDF au cours de l’année écoulée et l’autre n’ayant jamais vécu ce type d’expérien- ce. Les deux groupes sont le résultat d’un pairage établi selon le sexe, l’âge et la région de provenance. Ceux ayant connu des expériences de SDF sont des fugueurs (80%) répétitifs (71,6%) dont les épisodes SDF sont de moins de 2 semaines (78,4%) et la majorité (59,1%) ont dormi chez des connaissances, des amis ou de la parenté. Nous avons comparé ces deux groupes selon : leur profil clinique, leur consommation de drogues et d’alcool, le fonctionnement familial, les pratiques éducatives des parents, la relation parent-adolescent et enfin, la maltraitance parentale subie. Des analyses de régression logistique ont été réalisées afin de mettre au jour les facteurs déterminants liés à l’itinérance des jeunes de notre échantillon.

RÉSULTATS : Nos résultats montrent que seulement 4 facteurs de risque sont associés à l’ex- périence d’itinérance : 1. Les troubles des conduites chez le jeune augmentent le risque de 3,22; 2. Les relations parent-adolescent détériorées augmentent le risque de 2,31; 3. La violence subie par le jeune augmente le risque de 2,05; et enfin 4. Les placements antécédents du jeune en milieu substitut augmentent le risque de 2,01. Si chacun de ces facteurs contribue d’une manière directe et indépendante à augmenter les risques d’itinérance, on peut toutefois les regrouper en deux grandes catégories distinctes. La première catégorie renvoie à la «violence subie» par le jeune (placement en milieu substitut, conflits familiaux, violence parentale); la seconde, au contraire, fait référence à la «violence exercée» par les jeunes (troubles des conduites). Contrairement à plusieurs études, nos résultats montrent que la consommation de drogue/alcool ainsi que les problèmes intériorisés (troubles anxieux et affectifs) de santé BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 909

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mentale ne sont pas des facteurs de risque de l’itinérance. La violence, subie et exercée, par le jeune devrait être au centre des préoccupations de prévention de l’itinérance des jeunes.

LIMITES : L’expérience d’itinérance tend à augmenter l’effet des facteurs de risques. Cependant, puisque l’expérience SDF des jeunes à l’étude est de courte durée, la contamination est peu probable. Nos résultats ne peuvent être généralisés à tous les jeunes de la rue, notamment à ceux qui ne vivent pas de situations familiales adverses.

GUNS, GANGS AND GOSSIP: A QUALITATIVE ANALYSIS OF STUDENT ESSAYS ON YOUTH VIOLENCE

SUSAN MORREL-SAMUELS,MARC ZIMMERMAN,DARIAN TARVER, SHARRICE WHITE,SHANIT BUCHANAN,DEANA RABIAH University of Michigan Ann Arbor, Mi, USA

PROBLEM UNDER STUDY: Youth violence has been the subject of countless research efforts, however the perspectives of young people most affected by this problem are seldom heard. This study examines 391 essays on youth violence written by middle school students in Flint, Michigan. A qualitative analysis examines the students’perceptions of the causes of youth violence.

OBJECTIVES: The objectives of the study are to: 1. Describe, in students’ own words, perceived causes of youth violence; 2. Identify broad themes and sub-themes of causes expressed by students; 3. Examine theses themes in the context of the larger research literature; and 4. Identify areas for further study and possible implications for youth violence interventions.

METHOD OR APPROACH: Three hundred and ninety one essays were written by seventh and eighth grade students from five Flint, Michigan middle schools as part of the “Do the Write Thing” national essay contest. The sample included 133 males, 256 females and 2 participants whose gender was not specified. Students were instructed to answer three questions: 1. How has youth violence affected my life?; 2. What are the causes of youth violence?; 3. What can I do about youth violence?. A coding outline was developed based on a literature review and a preliminary reading of the essays. Each member of the research team coded common essays in order to discuss issues and develop consistent coding. The essays were chunked and coded and placed into a mas- ter outline for analysis. Themes and sub-themes were identified and representative quotes extracted. For the purposes of this study, only statements about causes were examined.

RESULTS: The causes of violence identified by students were broadly categorized into individual factors, peer relationships, family relationships and social factors. Among individual BONNE_MAQUETTE.QXD 4/17/02 11:53 AM Page 910

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factors, commonly cited causes of violence included poor problem solving and anger management skills, depression, low self-esteem, greed and jealousy. Predominant peer factors included gang membership, peer pressure, gossip and rumours. Many essays also discussed lack of parental involvement and negative parental role modeling as contributors to youth violence. Media violence, easy access to guns and drugs, racial prejudice and social acceptance of violence were among the social factors most frequently described.

CONCLUSION: The seventh and eighth grade students were able to articulate theories and observations about the specific causes of youth violence. Some of the factors identified in the essays are consistent with commonly held theories about the aetiology of youth violence, however, the students raised several topics that have received less attention. These include the role of gossip and jealousy in the initiation of youth violence and the effects of specific genres of media violence. These issues and others merit further consideration.

LIMITS: Participation in the essay contest was voluntary and the sample included more females than males; so the views expressed by the students are not representative of the entire middle school population. Nevertheless, a large number of essays were studied and can provide useful insights about youths’perceptions.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study gives voice to twelve to fourteen year old boys and girls who frequently experience the effects of violence, but have had limited opportunities to contribute to a greater understanding of its causes and consequences. These insights can be helpful for defining new directions for research and topics to cover in preventive interventions.

LA VIOLENCE ENTRE LES ÉLÈVES À L’ÉCOLE SECONDAIRE : CE QU’ON EN SAIT À MONTRÉAL

HÉLÈNE RIBERBY,MICHEL JANOSZ,JEAN BÉLANGER Direction de la santé publique, RRSSS de Montréal-Centre Montréal, Québec, Canada

PROBLÉMATIQUE : Les vols, les menaces et les attaques entre élèves à l’école secondaire ne datent pas d’hier. Toutefois, les médias nous laissent à penser qu’il s’agit de phénomènes bien plus présents qu’on le croit. Les statistiques officielles nous renseignent sur les événe- ments criminels et le nombre de jeunes pris en charge par les services sociaux à cause d’actes délinquants, mais qu’en est-il des victimes ? L’enquête sur l’environnement socio-éducatif de l’école (EESE) réalisée auprès d’écoles désireuses de lever le voile sur la situation nous permet d’avoir quelques éléments de réponse.

OBJECTIFS : Décrire l’ampleur et la fréquence des victimes de violence de la part d’autres élèves de leur école au secondaire.

MÉTHODE OU APPROCHE : L’EESE a été réalisée entre février et avril 2000 auprès d’écoles secondaires désirant obtenir un portrait de leur école dans une perspective d’action. La présente étude est basée sur un échantillon plus de 20 000 élèves de 37 écoles secondaires publiques francophones montréalaises volontaires (sur une possibilité de 65 écoles). Le questionnai- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 911

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re s’adressait aux élèves des classes régulières et des classes d’adaptation scolaire de la pre- mière à la cinquième année du secondaire. Il s’agit d’un questionnaire auto-administré par les élèves préservant l’anonymat et rempli sous supervision d’un membre du personnel de l’école. On y recueillait des informations sur le climat de l’école, les pratiques socio-éduca- tives, quelques renseignements socio-démographiques et les problèmes rencontrés ou vécus. Les analyses descriptives effectuées pour cette présentation portent essentiellement sur les questions de victimisation entre élèves.

RÉSULTATS : Une proportion importante des élèves qui ont répondu, ont été victimes d’au moins une situation de violence de la part d’autres élèves depuis le début de l’année dans leur école. Les proportions varient selon le sexe, le niveau scolaire et le type de classe (régulière versus adaptation scolaire). De ceux qui ont été victimes de violence, une proportion non négligeable ont été victimes à plusieurs reprises (4 fois et plus) et ont été victimes de plus d’un genre de situation (vol, menace, attaque).

CONCLUSION : La violence entre élèves semble une réalité bien présente dans les écoles secondaires qui ont bien voulu participer à l’enquête : les informations provenant des statistiques officielles ne représentent que les cas les plus grave. Cette violence existe sous plusieurs formes et touche autant les élèves des classes régulières que ceux des classes d’adaptation. Devant cet état de fait, il n’est que plus certain qu’il serait bénéfique de pouvoir mesurer les mêmes éléments dans l’ensemble des écoles de Montréal et d’adapter l’intervention selon le sexe et le type de classe.

LIMITES : Le portrait ainsi obtenu de la violence à l’école secondaire n’est pas représentatif de l’ensemble des élèves de l’Île de Montréal puisqu’il s’agit uniquement d’écoles publiques francophones. De plus, il ne s’agit pas d’un échantillon aléatoire mais bien d’écoles dési- reuses de participer.

CONTRIBUTION DU PROJET AU DOMAINE : Cette analyse des données de l’EESE permet d’obtenir un premier estimé de l’ampleur de la violence vécue par les élèves dans certaines écoles publiques secondaires montréalaises et de vérifier l’association entre certains genres de violence et leur fréquence. Il s’agit donc de données inusitées pour la région de Montréal.

TEENAGER’S MEANING OF VIOLENCE IN CARACAS, VENEZUELA

ROBERTO BRICEÑO-LEÓN,VERÓNICA ZUBILLAGA Laboratorio de Ciencias Sociales, LACSO Caracas, Df, Venezuela The homicide rate increased more than three times between 1988 (9/100000) and 2000 (32.6/100000) in Venezuela, but in Caracas the increase was even higher. Victims and perpetrators of such a violence are mainly young men living in city shantytowns. This paper reports an investigation carried out among young men involved in violent crime. The objective has been tried to understand their subjective approach to violence as a way of living and surviving in the poor neighbourhoods were they live in. This research was carried out on both young inmates imprisoned in underage jails centres and young involved in BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 912

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crime and violence but free. The data collection techniques were in-depth interviews and life stories. Interviews were applied in the reclusion centres and the homes of individuals or their friends between 1998 and 2000. The content analysis was used for data analysis. The results showed a trivial approach to violence. Violence infringed or suffered was considered not relevant. Violence was understood as a legitimize self-defence practice in everyday life and a way of building up their male self-identity based on respect. The role of violence in the construction of the masculinity was considered more important that their functional use either for economic purposes as robbery or drug trade, or as a way for solving problems (culebras) with rival individuals or gangs. This subjective meaning of violence is considered essential in order to improve violence prevention and control strategies by State and NGO institutions.

APPROACH TO THE CAUSES OF THE MORTALITY BY HOMICIDES OF YOUNGS IN CALI. 1993-2001

VICTORIA ESPITIA,RAFAEL ESPINOSA,GUTIERREZ MARIA I., CONCHA-EASTMAN ALBERTO CISALVA Institute, Universidad del Valle Cali, Valle Del Cauca, Colombia

PROBLEM UNDER STUDY: Among 1993 and 2001 (09/16) in Cali, Colombia, a city of 2 million inhabitants, died by homicide 6.099 young from 15 to 24 years, becoming in the first cause of death in this human group. The rates of homicide for 100.000 inhabitants, in the group from 15 to 19 years oscillated among 250 and 389, and from 20 to 24 years they went among 325 and 475. These rates are higher than either the total for men and for men and women joined.

OBJECTIVES: To describe the magnitude, characteristic and motive in which the homicides of young among 15 and 24 years old, occur, in order to help in the development of new strategies for homicide prevention.

METHOD OR APPROACH: The data are analyzed and consolidated for a working group con- formed by the institutions that have responsibility in the attention and control of these facts: Police Department, District Attorney, Forensis Medicine, Health and Transportation Departments, who contribute with information related to the facts, the victim and motive that could have caused the death. In the present study the information upon homicides of young from 15 to 24 years is analyzed, including the variables of age, sex, date, place and hour of the fact, class of weapon and motive of the fact.

RESULTS: The homicides in this group of age represent more than one third part of the homicides in Cali (35%). The homicides average rate for men of 15-19 was 326 and of 20-24 was 405 by each 100.000 men. In the women the rates were 15.3 and 16.7 respectively. In under age, 15 -17 years, occurred 19.8% of the homicides. In Sundays and nocturnal hours happened 45% of the cases. Near 90% of the murders went perpetrated with firearm. In the poorest neighbourhoods the biggest proportion of deaths was presented, 90%. In some sectors of the city the rates went as high as 897 for 100.000 inhabitants. The motive was determined with greater accuracy in the last three years thus: delinquency-related homicide were 24.1%; 15.9% by confronting among gang members; 7.5% related to drug trafficking; 11.7% BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 913

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by assault and 5.0% by stealing the slippers. Among the motive identified is emphasized that 11.4% were murdered for delinquency organized (such as “militias”,“hired assassin”); 3.3% of homicides were related to domestic violence; related with physical fights occurred 4.9%; by belonging to a group of risk 4.4% (“homeless”,“police”); in 37.7% the circumstances were not determinable.

CONCLUSION: A working group as the mentioned, permits to approach the reality of the homicides against young. In this study the situation of violence against the youths is shown in its serious dimension in Cali. In spite of not arranged of data upon the motive in the 100% of the cases, if is cause of worry the high proportion of deaths occurred during the commission of a crime (24%) and in confronting among gang members (14%). This information calls the attention of rulers, academic, and the communities where these facts occur, who claim prompt solutions. Other motive as the assault and robbery of slippers imported deserves special attention, to possess them generates leadership in the groups and who cannot buy is prompted to steal or including to kill -if is the case- to obtain them. Finally the deaths by execution that involves so much to bands of crime organized, as to civil, suggests studies of greater depth and measured of control on the part of the state.

LIMITS: We focused on homicide victims because legal constraints make data on homicide offenders much more difficult to obtain. Still should be done efforts to have data upon the motive of those homicides by specific studies that complement the information here analyzed.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We hope that characteristics described in this study will help in the development of new strategies for homicides prevention and that this study will serve as a model for analyzing social and public health implications of homicide in other communities.

CHILDREN’S EXPOSURE TO WEAPONS AND EXPLOSIVE DEVICES DURING THE WAR IN CROATIA

AIDA MUJKIT,GORKA VULETIC University of Zagreb - School of Public Health Zagreb, Croatia

PROBLEM UNDER STUDY: During the war period civilian access to weapons and other explosive devices are much greater than in the peace time. It is particularly true for children. War in Croatia suddenly exposed civilians to great amount of weapons and different explosive devices.

OBJECTIVES: The aim of the study was to find which kind of weapons were the children exposed to and were the parents aware of it. The study was part of the project “Prevention of War Injuries among Children in Croatia”.

METHOD OR APPROACH: Two cross sectional surveys were conducted during war years 1994 and 1995 in the countries on the front line. War directly affected 11 countries, four of these were selected for the survey: Dubrovnik, Karlovac, Lika and Sisak. Two surveys sites were selected in each country; the largest town and additional town selected at random. In each site one primary and secondary school were selected at random. The sample consisted of par- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 914

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ents from each school grade in the primary school and first two grades from secondary school and children from higher grades from primary school (5-8) and all grades from secondary school. Anonymous questionnaires were used for parents and children. The children’s questionnaire was given to the children at the beginning of class and completed during the class period. The parents’ questionnaire was distributed to children at school, completed at home and returned to school. The respond rate was 98%.

RESULTS: Results showed that children were in majority exposed to weapons and other explosive devices at their own home and surroundings. According to the type there were mainly hand guns, ammunition, bombs and explosives. Quite opposite parents were mostly afraid of grenades, explosive toys and landmines. As a cause of injuries and death (out of direct attacks) on the first places were means which children put on the first places. Counties which had additional community based intervention had significantly lower exposition of children to the means which were the main cause of injuries and deaths. Boys and girls are exposed differently to various kind of weapons and explosive devices.

CONCLUSION: During the war children are exposed to different kind of weapons and explosive devices dispersed in their environment. The operations of war are the main cause of injuries and death but excessive amount of weapons represent long term danger not only during the war but for years later. The most known example are landmines. Among the children in Croatia large proportion were killed and injured unrelated to the operations of war. This survey showed that children were exposed to handguns, ammunition, hand bombs and explosive much more than to grenades and landmines. Parents were not completely aware of the danger from different type of weapons and explosive devices.

LIMITS: The large number of confounding factors are limitation to such survey.

CONTRIBUTION OF THE PROJECT TO THE FIELD: National intervention was modified towards results of survey and more attention was paid on weapons disposal from homes.

USING GIS AND THE AMERICAN COMMUNITY SURVEY IN UNDERSTANDING YOUTH VIOLENCE

AMY PASINI Baystate Medical Centre- Tufts University Springfield, Ma, USA

PROBLEM UNDER STUDY: We describe a police-hospital collaboration to better understand youth violence in Springfield Massachusetts, USA using a geographic information system (GIS).

OBJECTIVES: To combine police data on violent incidents involving youth with spatial and socio-demographic data from the US Census Bureau’s American Community Survey utilizing GIS.

METHOD OR APPROACH: Police data on youths were combined with spatial data and socio- demographic data from the American Community Survey using GIS. We examined the geographic distribution of incidents and identified police sectors at increased risk of youth violence. We performed spatial regression to determine factors related to location of incidents and youths’ home location. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 915

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OBJECTIVES: To promote a better understanding of youth violence, we identified police sectors within Springfield, MA with excessively high rates of youth violence occurring during the after-school hours.–Utilized ACS data to identify demographic and socio-economic factors that increase the risk of violent crimes and identify population subgroups at whom intervention and prevention programs will be targeted.–Compared the rates of youth violence during in-school and vacation time-periods to determine if there is an increase during vacation weeks, necessitating additional programs.

METHOD OR APPROACH: The study population consist of all violent criminal arrests committed by persons aged 17 and under between the hours of 2 pm-7 pm, Monday–Friday from September 1999 through August 2000. Data from the following sources were utilized: American Community Survey (by Police Sector), Demographic Age groups, Race, Sex Primary language spoken, Socio-economic Status, Percent of families living in poverty, Percent of families receiving food stamps, Percent of boarded-up buildings, Percent of high and low income households, Percent of one-parent households, Percent of persons 25 and over whom did not graduate high school, City Sources, Youth arrests (both incident and residence), Schools, Youth and community centres, Open spaces, Parks/Playgrounds, Bus stops, Analytic Approach, Distribution of arrest location. We utilized GIS to visualize the distribution of youth crime throughout the city. Spatial analysis determined whether there was a significant spatial (geographical) component to crime and identify police sectors at high- risk for violent youth crime (clusters) where more police presence is needed. Characteristics of resident location Spatial regression analysis was conducted using ACS estimates of the prevalence of various attributes (e.g. racial, age, economic groups) in each police sector to identify significant risk factors for crime in police sectors where the youth offenders live.

RESULTS: The sector with the highest number of incidents also was the home of the highest number of youth offenders. 70% of all incidents occurred in the youth’s home sector. Race and several economic indicators of the offender’s residence were significantly related to vol- ume of incidents in regression analysis. Median Household income and black race were significantly related to incident location. The lower the median household income for a sector, the higher the number of incidents in that sector. The higher the total population (all ages) or black rate per thousand, the higher the number of incidents in a sector. Race, public assistance and median house value were significantly related to home location. The higher the rate (black or white), or total public assistance dollars, the higher the number of incidents. Incidents tended to occur in sectors with lower rates of 10-17 year olds. Targeting high-risk police sectors We used the attributes of area of residence identified in the regression analysis as significantly contributing to the risk of violent youth crime to form a “violence risk index” for each police sector. The risk index computed according to the methods of the OJJDD2. Police sectors with a high risk index will be identified as primary targets for intervention. To test the validity of the risk index for predicting the rate of violent youth arrests, we will compare, for each police sector, the predicted ranking using the risk index with the actual ranking based data from a new six-month time period from September 2000 through March 2000. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 916

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ON YOUTH AND VIOLENCE: GANGS, VICTIMIZATION AND CRIMINAL VIOLENCE IN EL SALVADOR

MARÍA SANTACRUZ-GIRALT,JOSÉ CRUZ,ALBERTO CONCHA-EASTMAN University Institute of Public Opinion IUDOP-UCA San Salvador, El Salvador

PROBLEM UNDER STUDY: During the last decade, there has been a considerable increase in the level of violence and victimization among street gangs in El Salvador. According to the Salvadorian Institute of Legal Medicine (1999), the highest mortality rates due to homicide occur in young men aged 15 to 24; 41% of which were committed with a firearm. Many people around this age are currently joining a street gang or are already members of it. Although gang membership is not new for Salvadorian society, there is a great deal of concern because it constitutes one of the major reasons of premature death of hundreds of young people, of insecurity in an increasingly number of areas in the country, and of bloody fights between rival groups which usually end up tragically. Thus, the relevance of the situation is not only related to the fact that gang membership is becoming one of the options preferred by an increasingly number of adolescents, but also to the fact that the dynamic of violence that dis- tinguishes these groups puts them at risk of violence both as victims and as perpetrators.

OBJECTIVES: 1. To provide and update information on the situation of hundreds of young Salvadorian gang members. 2. To propose an approach to identify predictors of gang criminal violence and victimization. 3. The information must be useful for decision makers addressed to violence prevention.

METHOD OR APPROACH: A 5 sections questionnaire was applied to 938 gang members, most of whom belong to two of the biggest gangs in the country (18th Street and Mara Salvatrucha). In total, there were 75 questions that assessed: 1. Demographic information; 2. Process and characteristics of gang membership; 3. Consumption of alcohol and drugs; 4. Type and frequency of violent acts carried out and received; and 5. History and characteristics of early victimization and exposure to violence at home and in their environment. A probability sampling was not possible in this survey due to the inherent difficulty of interviewing a street gang member and to the non-existence of a registry that can give an accurate idea of the number of people involved in gangs. Trained former gang members were the interviewers.

RESULTS: The number of youth involved in gang activities has increased compared to another study in 1996. A multiple linear regression model was used to identify those factors more strongly correlated with criminal violence and victimization. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 917

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The variables detected as more robust for aggression were: 1. Being an active gang member; 2. Having been in prison; 3. Use and abuse of alcohol and drugs; 4. Being male; and 5. History of domestic violence. For victimization the variables were: 1. Being female in the gang 2. High consumption of illegal drugs; 3. Being an active gang member; 4. Being employed, and; 5. Having been victim of violence at home. Many other information is included in the final report.

CONCLUSION: The problem of gang violence–witnessed and perpetrated within the group and toward others–as well as excessive consumption of alcohol and drugs have worsened in comparison to previous studies. This has happened, among other things, because the leading factors–both personal and socio-economic–have not been effectively addressed. Hence, primary prevention becomes an important tool to reduce gang membership and violent activities.

LIMITS: Although a survey like this is a good method for getting reliable information, it is not the only way to get more in depth information.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is a valuable source of information for policy making. Although gang violence is quite complex, it can be understood and poten- tially prevented using good and reliable information of its risk factors. This research gives us concrete guidelines of factors that increase the likelihood of a person to join gangs, to commit acts of criminal violence and to become one more victim of the cycle of violence.

THE FLINT YOUTH VIOLENCE PREVENTION CENTRE: COMMUNITY-ACADEMIC COLLABORATION IN ACTION

MARC A. ZIMMERMAN,SUSAN MORREL-SAMUELS,LEE BELL,THOMAS REISCHL U-M School of Public Health Ann Arbor, Mi, USA

PROBLEM UNDER STUDY: This presentation will focus on the development and organization of the Youth Violence Prevention Centre (YVPC) in Flint, Michigan. The mission of the Centre is to develop, implement, and monitor comprehensive strategies that help prevent youth violence and promote healthy development through collaboration among community, university and health department partners in ways that focus on interdisciplinary, ecological- ly and culturally relevant and community-based approaches.

OBJECTIVES: The objectives of the Centre are to: BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 918

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1. Establish of a collaborative group in Flint to plan an overall strategy for youth violence prevention; 2. Involve youth in this process; 3. Develop community awareness and acceptance of the Centre’s activities; 4. Create a surveillance system and evaluation plan; 5. Implement and evaluate three pilot projects; and, 6. Develop a broad range of training activities for health professionals and community partners.

METHOD OR APPROACH: The YVPC involves an interdisciplinary team of university faculty, in partnership with community organizations, to address youth violence in multiple ways across all levels of analysis. The Centre utilizes quantitative and qualitative methods to study the determinants of youth violence, identify factors that reduce youth violence and evaluate preventive interventions.

RESULTS: In its first year of operation, the Flint Youth Violence Prevention Centre has grown from a proposed idea to a fully functioning organization. The YVPC Steering Committee, composed of representatives from the schools, law enforcement, health care, social services, and community organizations, meets monthly to guide the activities of the centre. A separate youth advisory committee has formed and its members are participating in a photo- voice project and community service activities. Members from the youth committee attend Steering Committee meetings and report on youth activities. Three YVPC pilot projects have been initiated: 1. The Safe Passage Project uses neighbourhood crime watch groups to provide adult supervision children walking to and from school; 2. The Personal Growth Project provides a curriculum for elementary students emphasizing cultural identity and alternatives to violence; and 3. The Emergency Department Violence Intervention Project is developing an interactive computer program designed for use by adolescent ER patients. Progress is being made in the development a youth violence surveillance system in Flint. E-code data are being collected from all three hospitals serving Flint patients in their emergency departments. The Flint Schools provided access to disciplinary data for all schools in the district and the Centre is working with the Flint Police Department to extract crime report data for all areas of the city.

CONCLUSION: YVPC has helped create a setting for local community organizations and university partners to work together on an issue in a mutually respectful and collaborative fashion. YVPC has also provided resources at the University of Michigan School of Public Health to develop research and teaching opportunities that focus on youth violence. Our community and university efforts are designed to identify assets as well as risks, and to promote healthy development as well as prevent youth violence.

LIMITS: The Centre has only been in operation for one year so the conclusions that can be drawn about its effects on youth violence in the community are limited.

CONTRIBUTION OF THE PROJECT TO THE FIELD: YVPC provides a model for the development of a community-academic partnership to prevent youth violence and promote healthy development. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 919

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PROMOTING GENDER SPECIFIC CONFLICT RESOLUTION: THE SWISS NATIONAL NETWORK

DORIS SUMMERMATTER Head of Division Adolescence and Health Bern, Switzerland

PROBLEM UNDER STUDY: The Swiss Health Study “Health and Health Behaviour in Switzerland 1997 showed clearly, that in comparison to other countries a considerable percentage of adolescents feel mentally quite unwell (only 1/3 are feeling mentally well). Because of these findings and due to the fact that more cases of violence among young people are occurring, the Swiss Health Promotion Foundation initiates a programme with a new approach. So far programmes addressing violence and suicide in adolescents focused on singular sectors of youthful activities and few projects have orienting themselves along health promotion concepts. It is therefore even more important to coordinate, to network and to support activities which would contribute to the development of young people so that they themselves are empowered to overcome tensions, crisis, the daily frustration and the constraints of life.

OBJECTIVES: This project builds on the resources of adolescents and will focus on establishing competences in conflict resolution as an integral element of health promotion. We actively foster the creation of a network of institutions and individuals and promote models of best practice by using resource oriented concepts of conflict resolution. This is realized by focusing on gender specific issues and social capacity building among boys and girls.

METHOD OR APPROACH: Integrating in a gender specific manner the concept of conflict resolution into practical health promotion programmes, the Swiss Health Promotion Foundation did the unique step of mandating Pro Juventute Foundation to establish a national network of institutions and individuals addressing the topics of violence and suicide in young people. This network will create synergies between the partners and catalyze the exchange of knowledge and best practices. A fund will provide incentives for ongoing activities and support innovative pilot projects.

Source of data (a selection): A study on population health in two Swiss cantons by Graz B et al, (1999), analyzing the relative importance of various health problems, allows to set priorities in preventive activities. A study by Coggan C et al, (1997) on qualitative data through interviews with youth illustrated the use of focus groups with young people to enhance knowledge of ways to address and prevent youth suicide. Saewyc EM et al, (1999) explored gender differences in the health and risk behaviours. The study suggests that health care providers should incorporate gender-specific approaches to health promotion and risk reduction into mental health promotion programmes. Kolip P.and Helfferich C. both suggest that healthy risk behaviour fulfills also a specific function to symbolize sexual identity. Kolip pleads for a reconciliation of gender specific behaviour in the field of prevention and health promotion. Wyn J et al, (2000), reported in a national mental health promotion program in Australian schools the effectiveness of the promotion of whole-school approaches to mental health promotion through conflict resolution. Waring T et al, (2000), conclude that innovative health promotion programmes (basing on the Ottawa Charta of Health Promotion) should be an integral part of mental health education and training.

RESULTS: Less cases of violence in schools and communities. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 920

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CONCLUSION: Subjects as suicide, violence and health promotion do go very well together, if adapting a health promotional approach, which is quite new. This network is an important instrument to achieve the defined goals of the division of adolescence and health from the Swiss Health Promotion Foundation. The recent defined focus of this division is to establish competences in conflict resolution with young people and children as an integral element of health promotion, giving particular attention to gender aspects and providing the chance for adolescents to develop an individual way of living, deriving from the tensions of the dangers which are surrounding each growing up personas and salutogenic opportunities. The programme of this division wishes to encourage the “testing” of life styles, and–if necessary–to provide an enabling environment for the adolescent to revise their choices, based on their individual experiences. They should become conscious about their abilities and learn to use those. The environment of young people should be structured in a way, which would allow reference persons and adolescents to understand and appreciate societal support factors.

LIMITS: Difficulties as any other health promotion project focusing on developing social competences to prove their effectiveness.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Enhance the capacities of social institutions and individuals in the filed of prevention to concentrate the efforts on conflict resolution and competence building of adolescents and children.

CORPORAL PUNISHMENT IN ISRAEL: THE POPULATION’S OPINION

ROSA GOFIN,ITZHAK LEVAV,ROBERT KOHN Department of Social Medicine, Hadassah Medical Organization and the Braun School of Public Health Jerusalem, Israel

PROBLEM UNDER STUDY: Corporal punishment of children constitutes a human rights violation, yet, it is frequently practiced in many countries of the world. Despite the almost universal norm of using corporal punishment as a means to control undesirable behaviour in a child, countries are becoming more aware that such a violation is no longer admissible. As of today, no less than 12 countries have legislated its prohibition at home, following the example of Sweden from 1979. Of late, the Supreme Court of Israel has ruled that the prohibition to use violence against a child includes that used by a parent or any other adult for the sake of education. Whether or not parents will comply with the high court ruling, and whether society will support such a measure, will not solely be due to measures adopted to oversee the ruling. There is evidence on effective methods that parents or surrogates could use to enforce discipline yet spare the rod. However, there are barriers to the implementation of educational programs for the responsible adults to learn about these methods. Therefore, the successful implementation of a program requires that information on these obstacles be available to public health practitioners in order to better design intervention strategies.

OBJECTIVES: To determine attitudes and beliefs in regards to corporal punishment among an urban Jewish Israeli population. Corporal punishment was defined as the means to discipline children by the use of physical force. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 921

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METHOD OR APPROACH: The sample consisted of 1,000 Jewish Israeli respondents 18 years and older residing in urban areas. The sampling error was 3.1% within a 95% confidence interval. A short battery of questions (vignettes) exploring attitudes and beliefs on the use of corporal punishment of children was administered. Respondents were also asked about their own experience with corporal punishment as a child and the readiness of the public to comply with the Supreme Court ruling.

RESULTS: The majority of the respondents did not endorse this method of discipline. Factors associated with a positive attitude to corporal punishment were: being married or widowed, having only primary education, having children older than 5 years of age, and having a positive history of corporal punishment as a child. When confronted with a question tapping the readiness of the public to comply with a recent ruling by the Supreme Court that pro- hibits the use of physical punishment at home, most respondents (71%) expressed scepti- cism that the ruling will be followed. Fifty seven percent of the respondents experienced physical discipline when growing up, this variable was present in all the responses favour- ing its use for the children. A sizeable minority of the sample, 40%, thought that most parents would agree to undergo training in the use of alternative means of discipline.

CONCLUSION: The results of the study give sufficient grounds to initiate programs purport- ed to offer training on alternative methods of discipline. Training, however, was unwelcome by the majority of the sample; strategies to overcome the barriers will need to be designed.

LIMITS: The study is representative of the urban Jewish population of Israel and does not include other sectors of the population.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study examines the general population pre- paredness to comply with a new ruling against corporal punishment of children and the potential barriers in the implementation of programs addressing this issue.

THE GROWTH OF CONDUCT PROBLEMS IN EARLY ADOLESCENCE: DOES NEIGHBORHOOD REALLY MATTER?

MARIA ISABEL GUTIERREZ M., NICHOLAS IALONGO, SHEPPARD KELLAM,JAMES C. ANTHONY CISALVA- Universidad del Valle Cali, Valle, Colombia

PROBLEM UNDER STUDY: It is estimated that approximately 50% of individuals with conduct disorder develop subsequent psychiatric problems of different degrees. Some authors identify aggressive behaviour and conduct problems as being a precursor of conduct disorder. Patterson in 1989 published a model of Development of Antisocial Behaviour and Substance Abuse. This has been used to give theoretical support for interventions that target early risky behaviours predictive of future conduct problems. Patterson noted that deficiencies in the quality of parental monitoring in early childhood are associated with conduct problems in middle childhood among boys. Although, Patterson believes that the interaction effect between parenting styles and neighbourhood environment determines the outcome of the conduct problem, the importance of the neighbourhood environment was not fully BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 922

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included in his model. This study evaluates whether the neighbourhood component may enhance the Patterson model and to assess whether a modified model might be integrated with other community models. This approach could open research opportunities that affect the macro social dimension.

OBJECTIVES: This study examined the effects of Neighbourhood Environment on the growth of Conduct Problems in late childhood and early adolescence.

METHOD OR APPROACH: A secondary data analysis was performed to accomplish these goals. Nineteen public elementary schools in east Baltimore City participated during 1985-1986 in a developmental epidemiological based randomized preventive trial in first and second graders (n=2,311). Teacher’s evaluations and child self reported data were obtained. Neighbourhood disadvantage, age, gender, peer affiliation and parent monitoring were some of the variables evaluated. Exploratory analyses and initial characterization of the over-time association between Neighbourhood Disadvantage (ND) and Conduct Problems (CP) were performed separately for each year. Generalized Estimating Equations (GEE) methodology was used to produce a single summary estimate through summary estimates of the ND-CP cross-sectional and longitudinal relationship.

RESULTS: Prevalence of conduct problems was over 22 % each time- point (1990-1992). The mean of CP scores for the total sample ranged from 22.6 to 22.2 for 1990 to 1993 (SD=11.4- 10.6). As in the total sample, Conduct Problems scores did not appear to vary much over the 5-year period, even among boys or girls. Mean ND scores for the total sample also remained stable 8.8 (SD=2.6 to 2.3) across the five time points. In the final GEE model, it was possible to discern independent relationships when CP has been regressed ND. As in the cross-sectional analyses, results from the longitudinal analyzed data provide evidence of a main effect between ND and CP, even when statistical adjustments were made for multiple covariates (OR= 1.3, 1.10-1.16 95% C.I., p= 0.0001 ). The magnitude of the ND-CP relationship was observed to be stable in the longitudinal analyses as compared with the cross-sectional analyses.

CONCLUSION: High levels of Neighbourhood Disadvantage predicted an increase of Conduct Problems in early adolescence. The findings from the cross-sectional and longitudinal time- series analyses provide evidence that the longitudinal relationship between ND and CP is not affected by variables described by Patterson in 1989. Parent Monitoring and Deviant Peer Affiliation did not confound or interact with this direct relationship.

LIMITS: As in any longitudinal analysis, sample attrition was a concern. The majority of the attrition resulted from movement of families out of the Baltimore City Public School catch- ments area. External validity of the results as children from study comes from inner city.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study provides evidence that neighbourhood environment affects children’s social performance and their mental health. For over 20 years, followers of the Patterson model have studied family risk factors associated with raising children with Conduct Problems. This study provides evidence that there is macro-community factors which may also influence youth through out their lives. This is not solely a health sector responsibility but must also be a high priority for the government plans. This plans may prove to be difficult requiring commitment from public and private sectors. Major social investments will need to be initiated to protect neighbourhoods for the sake of our future generations. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 923

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CHILD LABOUR AND “VICIOUS CIRCLE OF VIOLENCE”

KOUSTUV DALAL Head Dept. of Economics & Statistics, Howrah Akshaya Sikshayatan Calcutta, West Bengal, India

PROBLEM UNDER STUDY: The unorganized employment sectors in India are still depend on child labours. Due to physical and mental exploitation, these children are dangerously violent. Through they are engaged in various discipline and come from different family backgrounds (up to their age of 15 years) but generally they exhibit more or less same category of violence and destructive attitude. The boys are engaged in various road side hotels, food stalls, hawking, carpet weaving, garages, helper of trucks, mail/express rail-coach floor clean- ing, collection of plastic/paper waste from garbage dumps and vats and in other thousands of unorganized jobs. The girls are generally engaged as made servant in various families, street singing and dancing, own household jobs, carpet weaving and in other several unorganized jobs. Here, this paper will discuss why they are so violent.

OBJECTIVES: A major part of these boy labours are significantly engaged in illicit trades and underworld operations. Particularly, just after leaving the jobs they immediately get engaged in criminal activities. The girls are mostly got married and rest are vicariously engaged in all sorts of notorious crimes. But in nature all most all of them are highly violent. If we find out the causes behind their such violent and destructive attitude and accordingly proceed to the problem then in long run it must have a significant positive impact on the society.

METHOD OR APPROACH: In and around four major metro cities and suburbs in India, viz. Delhi, Mumbai, Chennai and Calcutta we have conducted our study on 160 boys and 100 girls for nearly six months with a twice/thrice observation per week. We have considered their peripheral attitude, their whole day activities and the persons to whom they are acquainted with by questioning their employers, parents (if found) and colleagues to have more appropriate information. The boy’s age is ranging from 9-15 years whereas for girls it is from 7-15 years. Above these age bar generally they leave their job in search of new and better one or marriage. Though 38% of them return back to their previous job but we had not considered them as they exhibit miraculous change with less violent attitude. These sorts of boys and girls have significantly helped us towards our problems.

RESULTS: The boys face multi-various types of persons: from nether bob tag and rag tail to top class razzmatazz people, which psychologically contaminate them. Self comparison with the other same age group boys (of students, richer section) with their playful jovial hassle free life, they from the very beginning become highly greedy on money, arrogant and violent in nature. To earn more money in short run eventually they get involved in criminal activities and from haunting insecure feelings they always exhibit violent attitude even in future life also. The girls are got easily physically abused and socially exploited. From shame- fulness and haunting money crisis they become disgusted the society and psychologically they become violent. These situations can easily be defined by the “vicious circle of violence” (figure on paper version)

CONCLUSION: “Vicious Circle of Violence” is a long run phenomenon. To cope up from it we need drastic social and economic thrust with mass awareness and moral suasion. The employer should have to bear a ethical view so that these child labour not only be used as BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 924

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labour also should be deterred from any errant attitude as a sympathetic treatment like employer’s own relatives one.

LIMITS: Some child labour are really lucky to have employer like their own family with almost care and sympathy. Here this “vicious circle of violence” is just inappropriate to them.

CONTRIBUTION OF THE PROJECT TO THE FIELD: With this identification of “vicious circle of violence” for the child labour we can easily understand the source and background of their violence. It’ll help us to prevent their violence and to protect them with their talent.

TAPP-C: A BRIEF INTERVENTION PROGRAM FOR JUVENILE FIRE SETTERS

SHERRI MACKAY,JOANNA HENDERSON,BEV GILBERT,STEPHEN WELOWSZKY Centre for Addiction and Mental Health/University of Toronto Toronto, Ontario, Canada

PROBLEM UNDER STUDY: Fire-setting and other fire-related behaviours by children and adolescents.

OBJECTIVES: Ten years ago, the Office of the Fire Marshal of Ontario, the City of Toronto Fire Department and the Clarke Institute of Psychiatry (now the Centre for Addiction and Mental Health) collaborated to develop and disseminate the TAPP-C program, a provincial intervention program for children and adolescents involved in fire play or fire-setting. TAPP- C utilizes the joint expertise of fire service and mental health specialists to assist families dealing with children involved with fire. Burn injury remains a significant killer of children and many of the children burned or killed in fires have started these fires themselves. The present study reports data on two hundred families who have participated in TAPP-C.

METHOD OR APPROACH: A standardized battery that included multiple measures of child and family psychosocial functioning was administered at CAMH on entry into the intervention program and at follow-up 1-4 years subsequent to completion of the TAPP-C program.

RESULTS: The assessment data show that for the majority of children and adolescents, fire involvement was occurring in the context of broader-based child and family psychopathology. More importantly, many of the youth had substantial histories of fire involvement that included burns to self or others as well as property damage. Despite the high risk status of the sample, fully 80% had no further unsanctioned fire involvement at follow-up. Several risk factors including measures of the severity of fire involvement at program entry were predictive of fire-setting recidivism.

CONCLUSION: The TAPP-C brief intervention provided collaboratively by fire service and mental health specialists is effective in reducing further fire involvement by children and adolescents.

LIMITS: The data were collected in an university affiliated teaching hospital so generalizability to the approximately 40 TAPP-C sites across the province of Ontario remains to be determined. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 925

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CONTRIBUTION OF THE PROJECT TO THE FIELD: TAPP-C is the first evidence-based intervention program for juveniles involved with fire-setting and other fire-related behaviours in Ontario. Data from this program have relevance for burn-related injury prevention at the national level.

A REVIEW OF ADOLESCENT VIOLENCE ADMISSIONS TO A PAEDIATRIC EMERGENCY DEPARTMENT

IRIS MELTZER,MARGUERITE ERME,GERALD POWELL Children’s Hospital Medical Centre of Akron Akron, Oh, USA The development of violence intervention for young people requires identifying those most at risk of engaging in violence. Prior involvement in violence and child abuse victimization have previously been identified as indicators of at-risk status. Determining the most appropriate target audience for intervention in a paediatric emergency department is necessary in order to expend available resources most effectively and appropriately: 1. Participants will gain knowledge of the demographic profile of youth seeking emergency department care to a violent injury from a non-domestic violence, non-child abuse incident; 2. Participants will be able to identify the predictive power of previous violent injuries on subsequent involvement in violence during adolescence; 3. Participants will be able to discuss the predictive value of previous incidents of child abuse on adolescent violence victimization. All emergency department charts of adolescents age 13 to 22 who had visited the emergency department as the result of a violent incident involving at least one other person in 1999, were reviewed if they had any other emergency department visit after 1987 (the year hospital data was computerized). Demographic information, cause and diagnosis of previous visits, social work consults, and child abuse were collected. Black males comprised 39% of the targeted visits, 30% were white males, 18% were black females, and 13% were white females. 16.5% had experienced interpersonal violence prior to age 13, while 8.6% were victims of child abuse. There is an interesting race-gender disparity between those who had emergency department prior to age 12 due to interpersonal violence and the overall visits after age 12 to the department. While black males were the most frequent patients due to interpersonal violence, white males were almost twice as likely to have suffered a prior incident to violence requiring an emergency department visit. They were also more likely to be a victim of child abuse: 1. The total N is small and based on only one mid-sized city’s paediatric hospital emergency department; 2. If the only visit to the emergency department (prior to 1999) was before 1988, the chart was not reviewed; BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 926

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3. Previous interpersonal violence that did not need emergency department care was missed. The project adds to the body of knowledge regarding those adolescents most at risk of being involved in interpersonal violence. Those most appropriate for targeting of violence prevention/intervention programs, particularly in the paediatric emergency department setting are described.

RISK FACTORS FOR YOUTH AGGRESSION IN AN INPATIENT SAMPLE

MICHELE KNOX Medical College of Ohio Toledo, Oh, USA

PROBLEM UNDER STUDY: The identification of predictors of youth aggression is needed to guide prevention and intervention efforts designed to reduce the incidence of youth violence. Although past research has indicated that males demonstrate more frequent and persistent aggressive behaviour than females, results of recent research (e.g., Howell, 1998, Knox, 2000) has challenged these conclusion.

OBJECTIVES: The present study examines gender differences in aggressive behaviour in a clinical sample of adolescents, and identifies predictors of aggression in this population. It was hypothesized that aggression in males and females will not differ, and that both violence exposure and attitudes toward violence will predict aggressive behaviour.

METHOD OR APPROACH: Participants were 116 adolescents, aged 13 to 17 years. Exclusion criteria were moderate or more severe forms of mental retardation, psychosis (other than major depressive disorder with psychotic features), and pervasive developmental disorders. The sample is largely (88%) Caucasian. The remaining 12% of the participants were from various racial backgrounds. Participants were inpatients at a psychiatric hospital for children and adolescents. The Adolescent Aggressive Incidents Interview (AAII) was adapted from the Brown-Goodwin Assessment for Lifetime History of Aggression (Brown et al, 1979) to assess aggressive behaviour in adolescents. The Buss Durkee Hostility Inventory (BD; Irritability, Verbal Aggression, and Physical Aggression subscales) also was used to measure aggressive behaviour. These scales demonstrate sound psychometric properties (Knox, King, Hanna, Logan, & Ghaziuddin, 1999). The Screen for Adolescent Violence Exposure (SAVE) was used to assess adolescents’ exposure to violence in the home, school, and community. Reliability and validity of the scale have been well-established (Hastings & Kelley, 1997). The Attitudes Toward Violence Scale (ATVS; Funk, Elliott, Urman, Flores, & Mock, 1999) was used to evaluate adolescents’ attitudes toward the use of aggressive and violent behaviour. The scale demonstrates good internal consistency reliability (Cronbach’s Alpha=0.86), and scores on the measure correlate with violent victimization.

RESULTS: Multivariate analyses of variance revealed no significant effects of gender in verbal aggression, physical aggression, or irritability (scores on BD subscales). There was no gender effect on aggression in the home or school or aggression related to legal involvement BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 927

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(scores on AAII subscales). Independent samples t-tests revealed no gender differences in attitudes toward violence or exposure to violence. Because there were no associations between gender and these variables, multiple regression analysis was completed using the total sample, rather than by gender. Violence exposure and attitudes toward violence contributed significantly to the prediction of aggression (scores on the Buss Durkee Verbal and Physical Aggression scales), accounting for 36% of the variance in aggressive behaviour (F=31.32, p<.001) for the total sample. Attitudes toward violence contributed significantly to the prediction of aggression, above and beyond the prediction made by violence exposure.

CONCLUSION: Despite widespread beliefs about the prevalence of male aggression, results of the present study indicate no gender differences in several aspects of aggression in a clinical sample of adolescents. The risk for aggressive behaviour appears to be equivocal for male and female treatment-seeking adolescents. Violence exposure and attitudes toward violence were significant predictors of aggressive behaviour.

LIMITS: This sample is made up of adolescents seeking inpatient treatment and results may be generalized primarily to youth with severe psychopathology, or youth who are at serious risk for self-harm or harm to others. Further, the data presented are cross-sectional; longitudinal data will be gathered to address prospectively the influence of violence exposure, attitudes toward violence, and other variables, on changes in aggressive behaviour.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The present study identifies risk factors for aggressive behaviour in treatment-seeking youth. These factors may be used in prevention and intervention efforts aimed at youth violence. Attitudes toward violence may be an appropriate target for prevention and intervention programs addressing youth aggression. Cognitive techniques may be useful in challenging and replacing distorted beliefs support- ing the use of future violence. Further, efforts to prevent youths’ exposure to violence, or to reduce the impact of such exposure, will be critical to youth violence prevention efforts.

LA RELATION ENTRE LA VIOLENCE, LES TROUBLES DU COMPORTEMENT, LA COMPÉTENCE SOCIALE ET LA PRATIQUE D’ACTIVITÉS PHYSIQUES CHEZ LES ADOLESCENTS

MARTIN GENDRON,ÉGIDE ROYER,PIERRE POTVIN,RICHARD BERTRAND Université Laval Sillery, Québec, Canada

PROBLÉMATIQUE : Plusieurs études rapportent que les élèves en trouble du comportement (TC) démontrent de façon générale des comportements agressifs et violents ainsi que de faibles habiletés sociales (Goldstein, 1999; Kauffman, 1993). L’entraînement aux habiletés sociales et divers programmes d’intervention basés sur la théorie de l’apprentissage social (Bandura, 1986) ont été développés pour répondre aux besoins de ces élèves en TC (Powell et al., 1996). Malgré le potentiel de ces programmes, le niveau de compétence sociale ne s’améliore pas suite aux interventions. Face à ce problème, il faut tenter de revoir et d’actualiser nos stratégies d’intervention. Les initiatives d’intervention démontrent des limites importantes: BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 928

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a) Peu d’effets; b) Faible transfert des acquis vers l’adoption de comportements pro-sociaux; c) Faible généralisation (Beelman, 1994). Devant le constat, les auteurs suggèrent d’explorer de nouveaux moyens pour actualiser les stratégies d’enseignement des habiletés sociales: ajout d’un volet de jeux coopératifs aux autres moyens déjà inclus dans divers programmes afin de mieux prévenir la violence et les TC chez les jeunes.

OBJECTIFS : L’objectif de cette étude est d’évaluer dans quelle mesure la pratique d’activités physiques a un impact sur la compétence sociale et le développement des habiletés sociales chez les adolescents. Cette étude utilise un échantillon d’élèves (12 à 14 ans) de la région de Québec identifiés TC (n=77) et d’élèves non TC (n=108). Des résultats préliminaires indiquent l’existence de relations entre certaines caractéristiques de la pratique d’activités physiques et les TC chez les adolescents. À titre d’exemple, les élèves TC pratiquent plus des sports libres tandis que la pratique des élèves non TC est beaucoup plus axée sur des sports organisés.

MÉTHODE OU APPROCHE : L’échantillon utilisé est formé d’élèves de 12 à 14 ans de trois écoles de la région de Québec identifiés TC (n=77). Le dépistage des élèves en TC par des ensei- gnants s’est fait à partir de deux instruments de mesure : le SSBD (Walker & Severson, 1994) (identification des TC) et l’EDC (Bullock & Wilson, 1997) (évaluation de l’intensité des TC). Un échantillon d’élèves non TC (n=108) est utilisé pour fins de comparaisons. Les instruments sont : Enquête sur la pratique des activités physiques au secondaire (Desharnais & Godin, 1995); Social skills rating system (Gresham & Elliott, 1990); Generalyzed self-efficacy scale (Schwarzer, 1993).

RÉSULTATS : Les résultats préliminaires nous permettent d’appuyer des études antérieures qui ont trouvé des relations significatives entre les élèves TC et de faibles niveaux d’estime de soi, d’auto-efficacité et de rendement scolaire (Barnett, 1991; Butki, 1998). L’examen des résultats permet aussi de noter des liens entre les élèves non TC et les sports organisés. L’élève en TC serait plus enclin à pratiquer des sports non organisés. Ces résultats appuient des hypothèses initiales de l’étude dont celle que le jeune en TC pratiquerait moins de sports organisés, dû aux contraintes perçues face à la supervision et à la discipline demandée. Une analyse plus poussée des résultats est prévue.

CONCLUSION : Les premiers résultats de cette étude démontrent une relation significative entre les TC et la pratique d’activités physiques chez les adolescents. De plus, l’étude cherche à valider l’idée d’introduire le jeu coopératif (activité physique) à titre de stratégie pour mettre en pratique les habiletés sociales à l’intérieur d’une démarche d’intervention en milieu scolaire. Une analyse des données sur la compétence sociale permettra d’évaluer les liens avec la pratique d’activités physiques chez les jeunes.

LIMITES : Cette étude est présentement dans une phase d’analyse plus poussée des données. D’ici la présentation au congrès en mai prochain, ce projet d’études sera terminé et des limites auront été identifiées.

CONTRIBUTION DU PROJET AU DOMAINE : Les résultats de cette étude, ainsi que le projet de recherche et d’intervention du Programme PEC, permettront de publier durant la pro- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 929

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chaine année des outils pédagogiques pour les milieux scolaires et communautaires qui désirent enseigner des habiletés sociales (guides d’animation et vidéocassette). Un volet d’intervention axé sur le jeu coopératif (en cours d’expérimentation) sera évalué afin d’en mesurer l’impact sur le transfert, le maintien et la généralisation des acquis suivant un programme d’entraînement aux habiletés sociales pour des jeunes ayant des problèmes liés à la violence et aux TC.

THE P.A.R.T.Y.VIDEO – PRODUCING AN ORIGINAL INJURY PREVENTION VIDEO RESOURCE

LAURA WILDING The Ottawa Hospital Ottawa, Ontario, Canada

PROBLEM UNDER STUDY: The issues, challenges and obstacles associated with the production of a video resource for Injury Prevention. The audio-visual presentation used by the P.A.R.T.Y.(Prevent Alcohol and Risk-Related Trauma in Youth) program was out-of-date and lacked impact. In this presentation, we will discuss the steps we took to produce our own Injury Prevention video resource. This presentation will cover the details of our pursuit, the shoot day, and the post-production sessions. We will guide participants from the very early planning stages, through script writing, and rewriting, professional consultation, sto- ryboards, and site selection. We will share what we learned about the finer points of producing a video on a very limited budget. Through open and informal discussion, we will discuss what went well, what could have been improved upon.

OBJECTIVES: The P.A.R.T.Y. program targets teens aged 15-18 and seeks to provide useful, relevant information which enables them to; recognize injury producing situations, make informed prevention oriented choices, and adopt behaviours and actions that minimize risk. In order to completely involve the teens in the experience of injury and recovery, the group observes a re-enactment of the typical course of injury and treatment for a person involved in a motor vehicle collision. The intent is to have the teens appreciate the experience of a trauma injury and the possible permanent affects to their health/future. The first portion of the day is the pre-hospital experience of a trauma victim. The existing presentation consisted of a slide show accompanied by an audiotape. A group of students were depicted drinking, driving, and crashing their vehicle. The purpose of this section of the day is to show the realities of trauma, extrication from a vehicle, and subsequent transfer to a trauma centre. This audio-visual program was identified as requiring a more relevant presentation medium to be effective with this age group. A project (which vastly under- estimated the ultimate scope) was initiated with the objective to replace the dated presentation with a video.

METHOD OR APPROACH: The videos were produced using the resources of a local community college, and students studying in the Corporate Video Production Program. The students were able to direct, record and edit a video. However, the production aspects of the film were our responsibility. Production covers script development, funding, casting, and coordination of the shoot location and other resources required. It was decided that we would BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 930

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produce two videos, one depicting the crash scene, and another showing the Emergency room resuscitation of a trauma patient.

RESULTS: We accomplished our goal of the production of two dramatic videos, “Crashing the PARTY (running time 15 minutes), and “After the PARTY” (running time 12 minutes). We are currently in the process of seeking copyrights to these two videos, and are exploring different ways to market our success. As well, an assessment tool is being developed to evaluate the student response to the “Crashing the PARTY” video. This is to be completed and administered to students viewing the video during the fall 2001.

CONCLUSION: We are pleased with the results of our first endeavour. However, there are many factors that we have learned through the process of video production that we would attempt to change if we were to repeat such a project. As well, we would incorporate suggestions taken from the results of our student evaluation into any future revision.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We feel that our videos have contributed to the educational resources available for the promotion of Injury Prevention. By sharing our experience, we hope to encourage and guide others interested in such a project.

Initiatives des milieux de soins pour dépister la violence physique et sexuelle Health Sector Initiatives in Identifying Physical and Sexual Violence

THE TASK FORCE ON THE HEALTH EFFECTS OF WOMAN ABUSE – A COMMUNITY RESPONSE

GRAHAM POLLETT,MARION BOYD Middlesex-London Health Unit London, On, Canada

PROBLEM UNDER STUDY: In the fall of 1999, Dr. Graham Pollett, Medical Officer of Health in London and Middlesex County, Ontario declared woman abuse an urgent public health issue. He called together a task force of key stakeholders from the health care, justice, community service and private service sectors. Chaired by former Ontario Attorney General Marion Boyd, the primary goal of the Task Force on the Health Effects of Woman Abuse was to explore the design and implementation of a universal screening tool for woman abuse for widespread use in local health care settings.

OBJECTIVES: The major objectives of the Task Force were to clearly define the type of screening tool to be used in the prevention and early identification of woman abuse; to work with key stakeholders to have the tool incorporated into regular health assessments; and to create expectations among all patients/clients that screening is applied universally thereby elim- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 931

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inating stigmatization. The tool would also serve to encourage the assessment and documentation of the extensive health effects of woman abuse, address immediate safety concerns of patients/clients, and strengthen the community’s integrated referral network.

METHOD OR APPROACH: Task Force Community Consultation Report to the Community Extensive Literature Review.

RESULTS: In October of 2000, the Task Force on the Health Effects of Woman Abuse presented its Final Report to the community and unveiled The Routine Universal Comprehensive Screening (RUCS) Protocol along with 29 recommendations and a timeline for their implementation. The RUCS Protocol calls for health care providers to screen all women over the age of 12 for any form of physical, sexual or emotional abuse occurring in childhood, adolescence or adulthood. Since the Final Report, the initiative has gained considerable momentum and numerous recommendations have been addressed. All physicians in London and Middlesex County have received information about how to screen for woman abuse using the RUCS Protocol, and the protocol has since been endorsed by the Canadian College of Family Physicians.

CONCLUSION: Health care professionals have a crucial role to play in the prevention and early identification of woman abuse. Through multi-sectoral collaboration and consultation with key stakeholders, protocols such as the RUCS can move from theory to practice, increasing the chances of women living their lives in good health and safety.

LIMITS: This initiative brings to light a new approach to an age-old problem. Limits acknowledged by the Task Force include the availability of time and resources in the health care sector; the approaches/attitudes present in different practice settings and different health care professions; professional education and skill training in the application of the RUCS Protocol; the need for health care professionals to relinquish the notion of sole responsibility for fixing the problem; and the impact on patient relations.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Woman abuse is happening in epidemic proportions in communities across Canada. While the criminal justice and social service sectors have made great progress in addressing woman abuse, the health care sector has lagged significantly behind. Through community collaboration with key stakeholders the Task Force on the Health Effects of Woman Abuse has expanded on, and provided greater clarity regarding the necessity of engaging health care professionals to routinely screen their patients/clients for present and past abuse.

INVOLVING HEALTH CARE PROVIDERS IN FAMILY VIOLENCE PREVENTION

MARTHA STOWE Injury Prevention Centre of Greater Dallas Dallas, Texas, USA

PROBLEM UNDER STUDY: In the US, the number one cause of injury to women is family violence. The greatest hope of preventing family violence is to observe early stages and bring intervention at that time. Research shows that health care professionals are in positions to BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 932

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observe the signs of family violence and to provide interventions. Most health care providers are not aware of the dynamics or the resources to prevent family violence.

OBJECTIVES: The objective is to organize and educate health care providers to work to prevent family violence. To have ten hospitals develop interdisciplinary teams to create and implement a plan for providing education. policies, and resources to support the prevention of family violence among patients, staff, and the greater community.

METHOD OR APPROACH: Literature searches show that people involved in family violence are likely to pay attention to information received from a physician. Literature showed that interdisciplinary teams have been effective in addressing the issue of family violence.

RESULTS: Ten hospitals were recruited through the hospital CEOs. Each hospital brought an interdisciplinary team to a full day training on family violence. Each domestic violence shelter provided a professional in family violence to work with a hospital for 18 months on the development of the program. Each team was given an assessment tool to judge the interventions presently utilized. The teams then prioritized the work needed to be done to put into place appropriate policies, training and resources. Each team determined the needed membership and meeting times. At the end of 18 months the teams reported the progress achieved. Each of the hospitals had implemented new interventions. Eight hospitals had instituted hospital-wide protocols. Seven instituted screening procedures. Seven instituted policies and procedures on family violence for employees. Nine established on-going working groups on family violence prevention. All ten provided clinical training on family violence for employees. Nine hospitals keep materials displayed for anyone to access. Ten have discharge sheets on domestic violence for patients.

CONCLUSION: The health care system is a viable partner in the prevention of family violence. Many employees expressed interest in knowing how to respond to this issue. Calls to domestic violence hotlines from hospital employees and patients did increase. The community has seen a sharp decline in deaths from domestic violence this year. The hospitals have been a partner in working toward that decline.

LIMITS: The measures of the incidence of family violence are not reliable. The only measure is whether or not deaths have decreased and if the number of people accessing services increases. Therefore it is very difficult to measure impact.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Effective means for involving health care systems in family violence prevention have been established. Hospitals involved in this project can act as models for other hospitals that want to play a meaningful role in family violence prevention.

THE COST OF ABUSIVE HEAD TRAUMA IN YOUNG CHILDREN

LORRAINE ETTARO,THOMAS SONGER,RACHEL BERGER University of Pittsburgh Pittsburgh, Pa, USA

PROBLEM UNDER STUDY: Many believe that child abuse is a major cause of head trauma. We need to assess the characteristics and cost of this head trauma in order to better evaluate BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 933

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interventions for preventing abusive head trauma (AHT). Currently, little is known about these items for victims of AHT.

OBJECTIVES: We examined hospital admissions for head trauma in children under 3 years of age in the local regional paediatric trauma hospital to identify the presenting characteristics and financial charges of these cases and to examine if these factors differ among abused and non-abused cases.

METHOD OR APPROACH: Subjects were identified from the inpatient register of patients admitted to Children’s Hospital of Pittsburgh from January 1, 1995 through December 31, 1999. We focused on head trauma following injury defined as intra-cranial injury and/or skull fracture. Cases of head trauma (n=378) were identified from ICD-9-CM coding. All records with the following diagnostic codes were examined: intra-cranial haemorrhage following injury (852.00 to 852.59, 853.00 to 853.19), skull fracture, excluding fracture of face bones (800.00 to 800.99, 801.00 to 801.99, 803.00 to 803.99, 804.00 to 804.99), intra-cranial injury of other and unspecified nature (854.00 to 854.19), unspecified head injury (959.01) and shaken infant syndrome (995.55). Records were reviewed and injuries were classified as intentional (child abuse) or unintentional based on standard criteria using information about the type of injuries observed, the history provided by the family/caretakers, and physical and radiographic findings. AHT was defined as injuries confirmed by radiographic and physical findings that did not match the stated mechanism of injury. The following data were also abstracted from medical and billing records (UB-92 form) for the hospitalizations: age, sex, race, payer, injuries, stated mechanism of injury, and health care resource use. Only charges associated with the acute event (initial hospitalization) were included. Health care charges were adjusted to 1999 dollars using the Medical Care Component of the Consumer Price Index. Parametric and nonparametric tests were used to evaluate the relationship between these factors and classification of cause of head trauma.

RESULTS: Ninety cases were classified as intentional (abuse) and 288 as unintentional. Cases classified as intentional were more likely to be less than 1 year of age (OR: 8.97; 95% CI 4.67, 17.21), more likely to be covered by Medicaid (vs. commercial insurance) (OR: 3.08; 95% CI 1.80, 5.28), and more likely to have an intensive care unit stay (OR: 3.93; 95% CI 2.39, 6.47) than unintentional cases. No gender or race differences were observed. Admissions related to intentional injuries accounted for 46% ($3.8 million (1999 dollars)) of total charges. Medicaid was the payer for 75% of the abuse-related admissions. Total charges (1999 dollars) (median: $19,321 vs. $4,249; p<.001) and total length of stay (median: 5 days vs. 1 day, p<.001) were significantly greater among cases with intentional vs. unintentional injuries. Logistic regression analysis shows that cases with intentional injuries were more likely than unintentional cases to have a length of stay greater than 1 day (vs. 1 day) after controlling for age, payer type, and ICU stay (p<.001).

CONCLUSION: Our results highlight the significant economic impact of head trauma injuries among abused children, with most of these health care charges payable by public dollars. AHT is a significant injury issue in young children representing 1 out of 4 admissions for head trauma. Moreover, the severity of these admissions is greater and health care charges are higher than those among non-abused head trauma cases.

LIMITS: This work is based on admissions at one large paediatric trauma hospital and may not be representative of head trauma admissions at other hospitals. Also, this study is based on BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 934

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a retrospective review of medical records and thus is limited to the information available in these records.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This work provides some of the first data on health care charges associated with AHT, and can be used for advocacy in child maltreatment prevention. Based on these results, age, payer type, and stated history of trauma (minor vs. major) appear to distinguish intentional from unintentional head trauma and may aid in identifying intent of head trauma in children.

CONDUITES AUTODESTRUCTRICES À L’ADOLESCENCE ET RECHERCHE DES ANTÉCÉDENTS DE MALTRAITANCE DANS LA PRATIQUE PSYCHIATRIQUE EN FRANCE

PHILIPPINE BAER,PASCALE GERBOUIN-RÉROLLE,ANNE TURSZ,MONIQUE CROST INSERM U502/CERMES Paris, France

PROBLÉMATIQUE : En France, comme dans de nombreux autres pays, anglo-saxons notamment, il a été démontré dans divers cadres qu’il existait des filiations entre violence subie dans l’enfance et violence agie ultérieurement. Les mauvais traitements (abus sexuels notamment) n’ont pas toujours été révélés et/ou diagnostiqués. Dans le cadre d’une recherche sur les conséquences graves de la maltraitance méconnue dans l’enfance, une étude a porté plus spécifiquement sur les pratiques professionnelles de psychiatres voyant des adolescents pour anorexie ou au décours de tentatives de suicide, quant à la recherche de tels antécédents.

OBJECTIFS : 1. Analyser les pratiques professionnelles conduisant ou non à la suspicion, puis la reconnaissance de la maltraitance; 2. Lorsqu’il s’agit d’un professionnel qui soulève le problème, voir s’il est possible d’évaluer la prévalence des antécédents de maltraitance à partir des données disponibles; 3. Analyser de façon critique les problèmes méthodologiques rencontrés (biais habituels des enquêtes rétrospectives, difficultés d’obtenir des informations sur les antécédents de maltraitance, même en cas de recherche systématique, et délai parfois important avant leur «révélation».

MÉTHODE OU APPROCHE : Elle repose sur des entretiens semi-directifs auprès d’un échantillon national de psychiatres et pédopsychiatres recevant des adolescents. Le protocole a com- porté les éléments suivants : 1. La constitution d’une base de sondage nationale de psychiatres en vue de procé- der à un tirage au sort; 2. La réalisation, par ce tirage au sort, d’un échantillon de 50 psychiatres travaillant dans les secteurs public et privé, en psychiatrie infanto-juvénile ou générale, dans des cabinets libéraux ou dans des établissements de tous les niveaux dans la hié- rarchie du système de soins en santé mentale; BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 935

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3. La mise au point d’un outil de recueil de données auprès de ces psychiatres; 4. La réalisation d’entretiens avec ces psychiatres; 5. L’analyse de contenu de ces entretiens.

RÉSULTATS : L’étude sera achevée à la fin de l’année 2001. Les premiers résultats indiquent que la majorité des professionnels interrogés étaient des hommes exerçant à la fois en milieu hospitalier et en cabinet privé. Peu d’entre eux ont évoqué d’emblée des situations de maltraitance ou d’abus sexuels. Le malaise souvent retrouvé face à ces thèmes s’est traduit par des hésitations verbales, des évitements, un retrait dans des considérations générales et de l’ir- ritation. Toutefois, la plupart ont reconnu le lien entre violence agie et violence subie, avec un accent mis sur les violences morales, citées spontanément à propos des violences subies. C’est face à des passages à l’acte, à des transgressions (toxicomanie, fugue, tentative de suicide), à des situations inexpliquées, illogiques, à des réactions émotionnelles fortes, des dif- ficultés relationnelles que certains psychiatres recherchent systématiquement une situation de maltraitance, mais plus souvent dans le passé récent que dans la petite enfance. La plupart des praticiens interrogés ne recherchent pas de liens entre l’anorexie et la violence subie dans l’enfance. Si, pour certains il peut exister une très grande complicité entre le père et la fille anorexique, elle reste de l’ordre du fantasme. Le lien entre tentatives de suicide et maltraitance est plus connu et plus facilement admis. Selon les professionnels interrogés, la maltraitance est un sujet dont les patients parlent plus facilement qu’il y a 20 ans car les campagnes de sensibilisation et la recherche ont avancé.

CONCLUSION : Les conclusions ne peuvent actuellement être que temporaires. Il semble bien exister, chez les psychiatres, une réticence à rechercher des antécédents de maltraitance, voire à en parler, malgré une évolution récente.

LIMITES : Celles des études rétrospectives; des études fondées sur des «déclarations»; des dif- ficultés à obtenir une représentativité de l’échantillonnage (nécessité de relances et tirages au sort successifs du fait d’un taux de réponse initial insuffisant).

CONTRIBUTION DU PROJET AU DOMAINE : Une fois l’enquête par entretien achevée, et complétée par une analyse de dossiers médicaux, on tentera de réaliser une évaluation chiffrée de la maltraitance «méconnue» dans la petite enfance, venant s’ajouter à celle déjà déclarée par les adolescents dans d’autres études. Les résultats de cette recherche pourraient alors contribuer à la mise au point d’une information et d’une formation des professionnels de santé recevant des adolescents ayant des conduites autodestructrices. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 936

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IS IT POSSIBLE TO ELIMINATE OR CONFIRM THE DIAGNOSIS OF CHILD ABUSE IN THE CASE OF SUSPECT INFANT DEATHS ? A FRENCH FEASIBILITY STUDY BASED ON MULTIPLE DATA SOURCES

ANNE TURSZ,PASCALE GERBOUIN-RÉROLLE,MONIQUE CROST INSERM U502/CERMES Paris, France

PROBLEM UNDER STUDY: In France, an analysis of national yearly statistics on medical causes of death before one year of age reveals some disturbing facts: for example, the significant number of deaths from “unknown or unspecified causes” (307 cases or 9.1% of all causes of death in 1998), or the very high rate of non-traffic related “accidental” deaths. Moreover, procedures following the death at home of an infant with no known serious pathological condition (malformation, metabolic disease...) depend on the situation (the geographical and social context, or the nature of the person first called to intervene). Finally, since the number of homicides of under-one children declared each year is very low, the cross-checking of various data sources is necessary in order to identify intentional deaths that do not appear as such in official statistics.

OBJECTIVES: 1. Using national statistics, analyse the global distribution, geographically and by sex, of infant deaths from “suspicious” causes, and their trends over time; 2. Identify available sources of information on these deaths; 3. Evaluate the prevalence of suspected child abuse through investigating these sources; 4. For each source, examine professional practices which do or do not lead to suspicion and then acknowledgement of abuse, and decisions taken; 5. Compare data gathered from these sources with national statistics, and attempt to attribute diagnoses to deaths “from unknown causes” and to correct diagnostic errors.

METHOD OR APPROACH: Study population: children under one year of age who died in France between 1-01-1996 and 31-12-2000. Two aspects are developed: a census of cases from several information sources; an examination of professional practices and decisions taken in the case of an infant death. Studies carried out: 1. A national study in medical services receiving deceased infants (30 SIDS reference centres and 60 hospital departments); 2. An additional study among personnel transporting deceased infants; 3. A study in law courts; 4. A cross-checking of these data and those from national statistics. Data analysis with the SAS programme.

RESULTS: 1. In a situation (the discovery outside health services of a deceased infant whose cause of death is unclear) for which a standard legal procedure exists, medical services take a variety of courses of action; BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 937

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2. There are numerous obstacles for establishing an exact diagnosis and ensuring the accuracy of statistics: additional examinations (lumbar puncture, x-rays) are not systematically performed; autopsies either not suggested or refused by the families; no correction of misdiagnoses (generally SIDS) on the death certificates; 3. Access for researchers to information sources is highly variable: whereas access to medical services and to national vital statistics is simple, the judicial system is practically closed and complex negotiations are necessary to obtain the conclusion of medico-legal autopsies; 4. Although it is currently under way, the national study among medical services indicates that: • Criteria of suspicion of child abuse are variable and sometimes subjective. Clinical data are used often or fairly frequently by 55% of those answering, death circumstances by 52%, socio-demographic characteristics by 43%, parents’ behaviour at the time of death by 35%; • Only 23% indicate having frequent recourse to legal notification in case of strong suspicion and 35% inform local medico-social services; • 86% of hospital services systematically suggest psychological support to parents (actually never or sometimes done in 65% of the cases); 89% do not receive feedback from the judicial system; • Among 460 deaths recorded up to now, 8% were considered as deaths with undetermined intent, and for 2% the cause remained unclear.

CONCLUSION: Initial results of this study illustrate the complexity of the work needed to reconstruct reliable statistics on all causes of death among infants, and to identify violent deaths for which the intent remained unclear (deliberately or not). The operational objective of the ministry initiating this project (General Directorate of Social Action), to create an Epidemiological Observatory on the severe consequences of unrecognised abuse in childhood, therefore appears to be somewhat unrealistic if surveillance and data collection are to be performed on a routine basis.

LIMITS: The actual scientific objective of the project (reconstructing cause of death before one year of age) is difficult to reach, principally because of problems in accessing judicial and medico-legal structures, but this is a feasibility study.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This project should lead to: • Identifying the most relevant information sources on infant suspect deaths; • Deciding if a surveillance of these information sources is possible; • Developing training tools for health professionals on the recognition of abuse as a possible cause in certain deaths; • Preparing recommendations aimed at improving tools such as death certificates, or procedures such as those relating to communication between judicial and medical structures and the service of vital statistic. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 938

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VIOLENCE AGAINST WOMEN: CAN A COMPREHENSIVE HOSPITAL SERVICE REDUCE ITS CONSEQUENCES?

SIRIWAN GRISURAPONG Faculty of Social Sciences and Humanities, Mahidol University Salaya, Nakhonpathom, Thailand

PROBLEM UNDER STUDY: Domestic violence is a major problem in Thailand but there is no specific hospital services provided to women victims of violence.

OBJECTIVES: To establish a comprehensive hospital service (which has been called “a one- stop crisis centre”) in a public hospital to be a model for other hospitals under the Ministry of Public Health.

METHOD OR APPROACH: The one-stop crisis centre has been set up in the hospital’s emergency department to provide health care services including prevention, clinical services, rehabilitation, basic social welfare and legal services as well as response to immediate need of survivors of domestic violence by using inter and interagency networking.

RESULTS: Women victims of violence received more effective services due to increase in knowledge and skills of hospital staff in response to their need. The one-stop crisis centre assist in collaboration between hospital staff from different departments as well as among health care system, legal system and other social service system.

CONCLUSION: Training not only in technical content but also in gender issues and power relations is an important component to increase knowledge and skills and change attitude of hospital staff. Selection of key staffs from different departments to be the team members of one-stop crisis centre is also essential for sustainability of the intervention.

LIMITS: The outcome and impact of such kind of interventions may be seen after several years. The immediate success of this project can only be measured by client’s satisfaction

CONTRIBUTION OF THE PROJECT TO THE FIELD: In order to provide adequate and more responsive services to victims of domestic violence; raising awareness on domestic violence, increasing knowledge and change attitude /belief of hospital staff must be included in the intervention plan.

INTENTIONAL INJURIES AND THE EMERGENCY ROOM OF PUBLIC HOSPITALS IN MEXICO

MARTHA HÍJAR National Institute of Public Health of México Cuernavaca, Morelos, Mexico

PROBLEM UNDER STUDY: The relationship between quality of life and urban development is a topic of growing concern because the social and environmental modifications generated by the growth of the large cities have direct consequences on the levels of health of the populations. In Mexico City, as well as in other large cities of Latin America, there is an increase in the violence phenomena that has a negative impact on the quality of life where Intentional BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 939

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injuries have a significant impact in the health system. Domestic violence since 1999 has taken special attention as a policy of the health sector.

OBJECTIVES: To identify and analyze the specific weight of different types of violence in general, and by domestic violence in particular, as a cause of demand by injuries to the emergency room of public hospitals in Mexico City.

METHOD OR APPROACH: A cross-sectional design was used applying interviews of injured people who demand medical care to the emergency room of 4 public hospitals during the months January to march of 2000. Violence was categorized taking into account the relationship between injured and perpetrator, except on the self inflicted injuries, in four categories: interpersonal violence, assault injuries, domestic violence, and self inflicted injuries. The sample size was proportional to the size of demand by injuries in 4 public hospitals in Mexico City. Variables included were: age, sex, external cause (CIE IX Rev.), place of occurrence, alcohol intake, history of injuries, etc. The statistical analysis includes the description, distribution and categorization of variables, risk analysis using odds ratio and confidence intervals (95%) and logistic regression analysis. All analyses were done using Stata 5.0.

RESULTS: The total number of cases was 598, 75% of them where due to interpersonal violence and assault injuries. A description of the results founded among the different types of violence were included, but in general terms, male sex under 30 years old were the most affected group, statistically different P=0.000, and the severity of injuries were statistically different on self inflicted injuries p=0.000. A special analysis was done of injuries due to Domestic violence. This type of violence account only the 19% of cases The adjusted risk factors that were found related with domestic violence were: female sex OR 8.60 CI 4.25-17.40, age 30 years and > OR 2.36 CI 1.13-4.90, history of injuries OR 4.93 CI 2.03-11.95, place of occurrence at home OR 36.25 CI 16.59-79.18 and Scholar degree elementary or less OR 2.33 CI 1.03-5.26.

CONCLUSION: The analysis of the differences among the violence categories give us the possibility to know the specific weight of each one, like motif of demand of emergency room care, severity of injuries, needs of hospital care and like mortality cause of those cases of intentional injuries that may arrive to health services facilities for their medical care.

LIMITS: This study was delimited to a kind of hospitals and do not permit to know what happen with institutions like social security or private hospitals.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The results give us two levels of analysis, the level related with the type of violence event and the other one with the external cause and make possible to define specific health interventions and target groups.

EXPLORING PREDICTORS OF INTIMATE PARTNER VIOLENCE IN INJURY DATA

ANGELA MARTIN,ABBY SCHWARTZ,PATRICIA K. SMITH Michigan Public Health Institute–Centre for Collaborative Research on Health Outcomes and Policy Okemos, Mi, USA

PROBLEM UNDER STUDY: The Centres for Disease Control and Prevention funded the development of a state-wide Intimate Partner Violence (IPV) surveillance system in Michigan, BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 940

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based on existing hospital Emergency Department (ED) data. These data were used to identify possible predictive markers of IPV among female injury patients age 16 or older. Once the key differences between IPV cases and general injury cases were characterized, further analysis was conducted to test whether these differences persisted when IPV cases were compared to non-IPV assault against women cases.

OBJECTIVES: 1. To discover possible indicators of IPV in women with injuries visiting EDs in Michigan; 2. To transform these indicators into practical tools to aid in the identification of potential IPV cases by hospital staff, researchers, and others interested in establishing IPV surveillance systems.

METHOD OR APPROACH: Using a voluntary sample of 23 hospitals in Michigan, a surveillance system of injuries seen in EDs was developed. Potential assault cases against women age 16 or older were identified from the injury cases, and additional variables were collected. Cases recognized as IPV were compared to other assault and injury cases involving women age 16 or older. Chi square tests were used to measure significant differences between sub-samples.

RESULTS: Although less than 2% of ED injury cases involving women age 16 or older were IPV cases, 428 cases were identified from the 1999 data. Statistical comparison of these cases with general injury cases of women 16 or older revealed significant differences in diagnoses, cause of injury, age, payment source, and temporal trends. Far fewer differences were found in statistical comparisons of IPV with non-IPV assault cases. For example, diagnoses among general assault cases and IPV cases were very similar. However, a number of key differences remained. For example, IPV cases were younger than general injury cases, while non-IPV assault cases were younger still.

CONCLUSION: Contrasting the differences found between IPV cases, injury cases, and assault cases showed that female IPV victims are unique, even among female victims of assault. Capturing these differences helps identify possible markers of IPV.A combination of these markers, particularly age, payment source, and cause of injury, may be successfully used by interested persons to identify potential IPV cases in ED visits.

LIMITS: A number of limitations are inherent in using ED data to identify indicators of IPV. These include incomplete hospital E-coding, screening and documentation of victim-perpetrator relationship, and accuracy of data entry. In addition, this analysis is based on early data from a new IPV surveillance system in Michigan. Since all 23 hospitals in the sample had not yet initiated injury case reporting in 1999, results are not yet generalizable to the state.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The combination of IPV indicators identified here may provide valuable insights for use by hospital staff, researchers, and others interested in establishing IPV surveillance systems. The ability to identify potential IPV cases is an important prerequisite to developing and targeting prevention and intervention programs. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 941

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SEXUALLY ABUSED WOMEN IN GYNAECOLOGIC CARE

URSULA M. PESCHERS,KATHARINA JUNDT,MONA PFUERTNER, JANICE DU MONT,GUENTHER KINDERMANN,LUDWIG MAXIMILIANS Department of Obstetrics and Gynaecology Muenchen, Germany

PROBLEM UNDER STUDY: In Germany, gynaecologists are part of the primary health care system. They provide the routine gynaecologic and obstetric care provided by family doc- tors in North America. Sexual abuse is related to a variety of gynaecologic problems such a chronic pelvic pain. There is also research and clinical evidence to suggest that women with a history of sexual abuse may suffer re-traumatism during pelvic examinations, vagi- nal ultrasounds, pregnancy and childbirth. To date, however, it is not known how many women seen by gynaecologists have a history of sexual abuse. Nor it is known whether gynaecologists screen for this problem.

OBJECTIVES: To determine the prevalence of sexual abuse among women seen for gynaecologic care and to examine patient-physician interactions related to this problem.

METHOD OR APPROACH: A short anonymous questionnaire was distributed to women attending a gynaecologic outpatient clinic in a large urban city in Germany. This survey included questions on patient characteristics and sexual abuse. Women who reported that they had been forced to engage in unwanted sexual activities were also asked whether: their physician had screened for abuse, they would have liked their physician to ask them about their experiences of having been abused, they had introduced the topic themselves, they had felt com- fortable raising the issue, and the gynaecologist had responded appropriately.

RESULTS: A total of 1157 questionnaires were distributed, 1075 of which were returned for a response rate of 92.9%. Almost half (n=479, 45.0%) the women surveyed reported that they had been the subject of unwanted sexual attention (e.g., been propositioned, touched). Over one-fifth (n =216, 20.1%) indicated that they had been forced to engage in unwanted sexual activities. Approximately 7% (n=73) of all respondents stated that they had been abused in childhood, 10% (n=111) during adolescence and 6 % (n=69) as adults. Thirty- eight (3.5%) had been abused during more than one stage of their lives. Of those women who had been forced to engage in unwanted sexual activities, only one (0.5%) reported that her gynaecologist had asked about abuse experiences; 67 (31.0%) reported that they would have liked to have been asked about their abuse experiences, and 13 (6.0%) reported raising the topic themselves. Of this group, approximately half (n= 6, 46.2%) described their gynaecologist’s response as uncomprehending, disapproving, indifferent, or incompetent. Reasons given by women for not disclosing their histories of sexual abuse were: afraid to raise the issue (n=66, 30.5%) and information not relevant to care (n=119, 55.1%).

CONCLUSION: Despite the fairly high rate of sexual abuse reported in this study, gynaecologists were not routinely screening for it. A substantial proportion of abused women would have liked to talk about their abuse experiences, but were afraid to raise the issue with their physician.

LIMITS: Results may not be generalizable as the study sample was drawn from a single gynae- cological clinic within a single jurisdiction. As well, patients were recruited while sitting in the waiting room and not from the clinic list. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 942

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CONTRIBUTION OF THE PROJECT TO THE FIELD: Results from this study suggest that in Germany a substantial proportion of women presenting to gynaecologic clinics may have experienced sexual abuse. As women with histories of sexual abuse may suffer re-traumatism during routine gynaecologic care (e.g., pelvic examinations), knowledge about women’s abuse experiences and interactions with their physicians may aid in improving care.

SENTINEL SURVEILLANCE OF EXTERNAL CAUSES OF INJURY IN A PRIMARY CARE HOSPITAL, CALI, COLOMBIA 2000

RAFAEL ESPINOSA,VICTORIA ESPITIA,FERNANDO FIGUEROA, CONCHA-EASTMAN ALBERTO,GUTIERREZ MARIA CISALVA Institute University of Valle Cali, Valle Del Cauca, Colombia

PROBLEM UNDER STUDY: During 1999, The Colombian Institute for Legal Medicine and Forensic Sciences (ICMLF), registered 188.830 non-fatal intentional injuries, which included rape, rape attempts, wounds, lacerations and soft tissue trauma. During this same year there were 23.209 homicides. The ratio of non-fatal injuries to homicide was 8:1. Additionally, for the same year there were 52.346 non-fatal injuries due to motor vehicle accidents. The regional IMLCF office in Cali, a city of 2 million people (5% of the country population), reported 10.804 cases of both intentional and non-intentional injuries during 1999. During this year the local government reported 1,991 homicides (8,6% of the nations homicides). Homicides were the first cause of mortality in Cali (rate 103 per 100.000 person-years). During 1998, the city’s health authority reported 30.177 injuries seen in primary care hospitals. A sentinel surveillance system was therefore established at a primary care hospital.

OBJECTIVES: To identify the magnitude of injuries due to all causes in the City of Cali and propose and evaluate interventions.

METHOD OR APPROACH: The Primitivo Iglesias Hospital was chosen due to its location in an area of high injury occurrence. It serves approximately 400.000 people (1/5 of the city urban population) and is representative of the total population. The case definition used was: patient visiting the E.D. due to any injury in any location of the body. The medical history was completed by the physician in charge. The chart was classified by the Epidemiology office, where the information was coded in a database and every 3 months analyses and reports were disseminated.

RESULTS: Between March and December 2000, the system identified 6.522 injuries, or an average of 21.7 injuries per day, increasing to 27.3 injuries per day during weekends (p<0.001). Unintentional injuries, occurring at home, during sports activities or by falls accounted for 42,5% of the total. The most affected age groups were children below 9 years and elders over 60 years. Motor–vehicle Injuries accounted for 21% of the total injuries; 70% of traffic injuries occurred among motor cycle drivers or passengers and 25% occurred in pedestrians. Intentional injuries accounted for 17% of the total. These injuries occurred BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 943

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mostly in young males between 15 and 34 years (70%). Among males the most common cause was due to brawls or assaults. Among females the most common cause was domestic violence. In 48.6% of the cases the offenders are unknown. In 34.2% of the total cases the aggressor was a known person, a relative or a partner. Regarding weapons used, 69.3% were sharp objects or blunt arms. Firearms accounted for 22% of the total. History of alcohol ingestion, as determined by the physician or stated by patient, was present in 30% of violent injuries and 17% of vehicle accidents.

CONCLUSION: This sentinel surveillance operated by the health authority in this hospital man- aged to identify circumstances and attributes of occurrence of injuries due to external causes. It has helped to program interventions, mostly in women and the young. Results have been sent to other government authorities and affected communities in order to implement preventive measures.

LIMITS: Total coverage of injuries is not possible with this type of surveillance; however greater detail on circumstances of injuries can be obtained.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Implementing this system allows to better define the magnitude and characteristics of the problem, circumstances in which events occur and more accurate typification of events. This model has been extended to 7 other intermediate cities in Colombia. The form used to collection of date is appropriate and used other hospitals.

DYSPLASIA AND SEXUAL OR PHYSICAL ABUSE AMONG MINORITY WOMEN WITH STD

JANE DIMMITT CHAMPION,J.M.PIPER,R.N.SHAIN,S.PERDUE,A.HOLDEN The University of Texas Health Science Centre at San Antonio San Antonio, Texas, USA

PROBLEM UNDER STUDY: Previous studies describe relationships between sexual risk behaviours, health seeking behaviours and sexual or physical abuse among women. These studies have not described the effect these relationships have on occurrence, diagnosis or treatment of cervical dysplasia.

OBJECTIVES: This study examines the relationship between sexual or physical abuse, sexual risk behaviours, health-seeking behaviours, and cervical dysplasia among minority women with STD.

METHOD OR APPROACH: Mexican and Black-American women aged 14-45 years (n=827) with STD underwent questioning regarding sexual or physical abuse, sexual risk behaviours, health seeking behaviour, and cervical dysplasia.

RESULTS: Comparisons indicated sexually or physically abused women (n=531) reported higher sexual risk behaviours including earlier coitus (p=.003), more sex partners at 1, 3, 6, 12 month and lifetime intervals (p<.001), and higher previous incidence of STD (p<.05) and PID (p<.005) than non-abused women. No differences were found for condom use although abused women reported greater use of contraception (p<.001). Fewer abused women report- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 944

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edly had a pap smear within the past 12 months (p<.03) than non-abused although abused women reported more cervical dysplasia (p<.001). More abused women reported experiencing barriers to health care services (p<.01) including transportation, financial, and affective (shame) barriers.

CONCLUSION: Abused women’s reports of relatively higher sexual risk behaviours, previous history of STD and PID, delayed health seeking behaviours and history of cervical dysplasia identify them as women at high risk for cervical cancer. Due to its considerable impact on sexual risk and health seeking behaviours, assessment for sexual or physical abuse is essential in medical management of women with STD and cervical dysplasia.

LIMITS: Limitations of this study include those of self-report data.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study identified sexually or physically abused minority women with STD as at even higher risk for cervical dysplasia than nonabused women with STD. This higher risk may be attributed in part to the higher sexual risk behaviours and delayed health seeking behaviours reported by sexually or physically abused women.

WOMEN AND TRAUMA – ONE COUNTY HOSPITAL EXPERIENCE

MARIE CRANDALL,KIMBERLY NAGY,SUE AVILA Harborview Medical Centre/University of Washington Seattle, Wa, USA

OBJECTIVES: The study of trauma has often excluded women trauma patients. This study begins to identify risk factors for trauma in urban women patients.

METHOD OR APPROACH: This paper looks at the female trauma patients seen at a large Midwestern Level I Trauma Centre from 1989-1995. It categorizes individuals with respect to race, gender, and type of traumatic injury suffered. The results were analyzed with a X2 Fisher’s Exact Test.

RESULTS: It was discovered that African-American (AA) women are much more likely to present to this trauma department with violence-induced injury than their Non-African- American counterparts (53.8% vs. 25.0%; p<0.001). This also held true for their male counterparts (76.4% vs. 56.6%; p<0.001). In addition, both AA and NAA women had a lower incidence of trauma due to violence than their racially matched counterparts (above per- centages p<0.001). Finally, AA women and men who presented with violence-related injury were much more likely to have suffered penetrating trauma than blunt trauma compared to individuals of other races who presented for violence-related trauma.

CONCLUSION: When one compares AA vs. NAA women with respect to incidence of trauma, injury from violent crime (i.e. stabs, gunshot wounds, and blunt trauma/assault) was much more common in AA women for each year studied. These differences may reflect a true increased risk of violent injury among African-Americans, or may reflect differences in socio-economic status, ethnic/cultural differences, or reporting biases. Most likely is a complex interdependence of these factors. More work will be needed to elucidate the strongest BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 945

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risk factors for trauma and violent injury among women. Finally, regardless of aetiology, support of violence prevention programs along with job and education efforts within our communities continues to be a goal.

THE IDENTIFICATION OF DIAGNOSES CONCERNING VIOLENCE AGAINST MINORS ASSISTED

RENATA CRISTINA DA PENHA SILVEIRA,KATIA CRISTIANE ALVES, ANA CLAUDIA LOPES,MARIA LUCIA DO CARMO University of São Paulo at Ribeirão Preto Ribeirão Preto, São Paulo, Brazil Violence against children is understood as any action or omission that hinders children’s global development. It seems to be present in all societies, and appears as a historical and social phenomenon. The types of violence are: physical, psychological, television-related, sexual abuse and abuse due to neglect. These situations may take place in children’s healthcare institutions, schools and workplaces. Indexes of violence against children can sometimes be easily evinced due to the presence of haematomas, bruises and lacerated wounds that are not usually explained by the family, employer and/or child when they seek hospital care. However, as a result of violence, the child’s behaviour, many times, changes and aggressive, passive, depressive, retracted behaviour may occur through the demonstration of fear of one’s parents and employers jointly with learning difficulty, among others. Health care professionals show difficulty in coping with this phenomenon and notifying the cases of mis- treatment and occupational accidents to the legal system as a result of their lack of knowledge, the omission of employers and parents themselves and the fear felt by the children in reporting the violent act that has caused them some type of injury. This study aimed at characterizing the diagnoses attributed by the hospital team when assist- ing children who had been victims of violence. To that end, an assessment of hospital records was requested concerning patients under 18 years old who had been assisted by a university hospital (HE) from January 01, 1995 to December 31, 1996 and whose medical diagnoses were classified in chapters XIX and XX of the International Classification of Diseases–ICD/ 10th revision ( 1993). It was observed that of the 1,785 records selected in this period, 146 referred to children who had been victims of some type of violence. Among them, 22 had suffered occupational accidents. With regard to the 146 victims, it was noticed that there was a larger incidence of children with the following medical diagnoses: 89 (53%) had cutting and bruising injuries, 45 (26.8%) had been beaten up and presented unspecified diagnoses, 3 cases (1.8%) showed sexual violence, among others. Among the children that had been victims of occupational accidents, the following diagnoses were observed: crushing (31.8%), limp amputation (13.6%), car accident (13.6%), cuts and bruises (4.5%), among others. Many times, the parent, minor or employer do not report that the accident took place in the work place since child labour is prohibited according to the Child and Adolescent Statute (Law no. 8,069, dated July 13, 1990–Brazil). In face of this situation, it is noticed that health care professionals need better training concerning the care to be given to minors who have BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 946

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been victims of accidents as to the identification and reporting of the various types of violence, including those related to the workplace. Therefore, this study can contribute to make healthcare professionals more aware of the various types of violence against minors, which will lead them to notify such cases so that appropriate measures can be taken.

CAUSES OF VIOLENCE AGAINST MINORS: PERSPECTIVES FOR NURSING ACTIONS

KATIA CRISTIANE ALVES,RENATA CRISTINA DA PENHA, ANA CLAUDIA CARDOSO,MARIA LUCIA DO CARMO University of São Paulo at Ribeirão Preto Ribeirão Preto, São Paulo, Brazil In Brazil, the phenomenon related to violence against children and adolescents is a reason for concern. Information conveyed by the communication media shows this reality in everyday life, particularly in large Brazilian urban centres. This study was conducted with the purpose to detect cases of violence and their causes among children and adolescents (under 18 years old) assisted in a university hospital (HE). To that end, an assessment was made of the hospital records in a two-year period (from January 01, 1995 to December 31, 1996) whose causes were classified in chapters XIX and XX of the International Classification of Diseases–ICD/ 10th revision (1993). Three thousand, three hundred and one hospital records were selected which referred to 1,785 patients. Therefore, it was verified that a patient, many times, presented more than one cause and more than one medical diagnosis. Among such records, 168 (9.4%) were related to violence against minors. Of these, 146 (86.9%) referred to general violence and 22 (13.1%) concerned violence in work places. Most of the patients, (75.6%) were males. Among the instruments and forms of aggression, the most frequent were: firearms, with 51 cases (30.4%); followed by cutting instruments, 38 cases (22.6%); physical aggression (beating up), 26 cases (15.5%) and stick blows, 19 cases (11.3%) in addition to the Mistreating Syndrome, which was represented by 6 cases (3.6%). In face of this situation and since the most relevant cause is the use of firearms, we can infer that the factors that mostly influence such lesions possibly are: family disintegration, unemployment, use of drugs, uncontrolled dissemination of violence by means of news and films publicized in the communication media and the possibility of easily acquiring a firearm. Most of the aggression cases due to the use of firearms occur intentionally and the involved patients are males aged 10 to 15 years. The problem concerning “mistreating”,understood in a general fashion, requires the intervention of multidisciplinary, inter-institutional and intersectorial teams for which it is necessary to further study this problem and its components in order to explain its origin and analyze possible solutions. There is still a lot to be done in the extent of Brazilian nursing with regard to violence against children and adolescents, which includes academic education on this theme in the country’s under-graduation and nursing programs. Cases are under-notified because they are not reported or identified as such when children require hospital care. Violent attitudes against this unprotected population need to be fur- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 947

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ther studies and understood so that effective recommendations and actions can be pursued by the health care team in general as well as by the nursing team in particular in order to favour the Brazilian society.

VIOLENCE ISSUES & HEALTH PROFESSIONALS: A CROSS-CULTURAL EDUCATION INTERVENTION PROGRAM

LEE ANN HOFF,JOSE ORNELAS,PHILIPPA SULLY,RUTH GALLOP University of Massachusetts Lowell, College of Health Professions Lowell, Ma, USA

PROBLEM UNDER STUDY: National and International survey data reveal that violence-related content on violence issues is addressed only incidentally in curricula preparing future health and social service professionals. These findings suggest limited actualization of health professionals’ significant potential for preventing violence and alleviating the negative sequalae of this global epidemic. Consequently, healthcare agencies must compensate for these curricular deficits through in-service training of health providers to competently assess and treat emotional trauma and potential life-long pathologies resulting from interpersonal violence. This paper describes an interdisciplinary education intervention addressing violence content in health professions curricula.

OBJECTIVES: 1. Present data from U.S. and Canadian surveys and health curricula regarding violence issues. 2. Describe a research-based education intervention project: An international graduate program designed to prepare health, mental health, and social service professionals for teaching, expert practice, and research on violence prevention and care of victim/survivors. 3. Review evaluation outcomes (i.e. graduates’ knowledge base and practice competency) of this educational endeavour in Portugal, and the U.K. from 2000-2002.

METHOD OR APPROACH: This graduate education intervention project was developed from the following sources: 1. National survey data form health science faculties and health professions students in Canada and in the USA; 2. Evaluation data from curriculum development surveys and workshops in five Canadian health sciences faculties; 3. Results of Canadian and U.S. students’ competency assessments regarding violence prevention, detection, and intervention; 4. Assessment of in-service training sessions, special seminars, and graduate education programs in Lisbon, Portugal, London, U.K., and Lowell, Massachusetts, U.S.A.

RESULTS: The following results will be presented via a poster in English, Portuguese, French and Spanish. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 948

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1. Survey outcomes from Canada, USA, and Portugal between 1992 and 2000 consistently revealed that health professions educators do not systematically address violence issues in their curricula. Prominent reasons cited include lack of time; inadequate knowledge and practice skills; and the legacy of interpreting interpersonal violence as a “private” issue. Curricular deficits are strongly associated with health students’ assessment of their knowledge and practice competency around violence issues. 2. U.S., Portuguese, British, and Canadian faculty addressed this issue through an educational intervention: A university consortium offering a graduate certificate program on “Violence, Crisis, and Gender Studies.” The program consisting of eight two-credit in non-traditional arrangements, including distance learning. Course content draws on these disciplines: public health; social, cultural, and health sciences; criminal justice; forensic medicine; trauma theory and rehabilitation sciences; public educational and curriculum development theory. 3. Results of evaluation data from graduate students in Portugal and the U.K. 4. Outcomes of a needs assessment for instituting this certificate program in Canada will also be presented. 5. A plan for evaluating long-term outcomes of this certificate program will be reviewed.

CONCLUSION: Preliminary evaluation data from Portugal and the U.K. suggest that this primary prevention approach to the international epidemic of interpersonal violence across the life span has positively influenced graduate students’ violence-related knowledge and practice skills. We expect that end-of-program evaluation and needs assessment data to be collected between October 2001 and March 2002 will support students’ early enthusiastic response to this program and to provide evidence for refining and expanding the project internationally.

LIMITS: Major limits include inadequate funding and the curriculum development policies of higher education institutions in the U.S., Portugal, and Canada that result in long delays in new program implementation -even when the topic is as urgent as our research findings suggest.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We expect this program to assist health professions educators to systematically include violence content in their curricula, and thereby contribute toward tapping the enormous potential of health providers to positively influence violence preventions, detection, and intervention around interpersonal injuries and their negative health and social sequelae. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 949

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Les conflits armés : quelles en sont les conséquences et comment les prévenir? Armed Conflict: What Are the Consequences and Can It Be Prevented?

VIOLENCE AGAINST WOMEN AND GIRLS IN RWANDA

KAREGEYA DAVIS KASHAKA FACT (Forum des Activités Contre la Torture) Kigali, Rwanda

VIOLENCE RAPTURE BOUNDARIES: It is one form of human rights violation that has contributed to human suffering in our country.

PROTECTION OF WOMEN AGAINST VIOLENCE: Women and girls were the vulnerable group to violence at centre of 1994 conflict/genocide in Rwanda. The vulnerability stems from their gender aspect which has considerable effect on the form of human rights abuses, the circumstances in which the abuse occurs.

METHOD OR APPROACH: The paper will focus on how FACT Rwanda a local human rights organisation that addresses issues of torture and organised violence has made intervention in prevention of violence in women and Girls in Rwanda.

PROBLEM UNDER STUDY: Results of presentation will reflect findings done by FACT on women and girls issues.

CONCLUSION: The author concludes by highlighting on the way violence can be prevented in Rwanda. He further discusses on how FACT has set up projects aimed at prevention of violence in women and girls.

LIMITS: Discussion is limited to one area, which is Rwanda experience.

PROJECTS FACT: has set of project aimed at prevention of torture and violence in Rwanda. The projects in discussion are the vademecum guide on rape in Rwanda and the micro- survey on situation of torture and violence in Rwanda.

CHILDREN’S EXPOSURE TO WEAPONS AND EXPLOSIVE DEVICES DURING THE WAR IN CROATIA (HRVATSKA)

AIDA MUJKIT,GORKA VULETIC University of Zagreb, Medical School-School of Public Health Zagreb, Croatia (Hrvatska)

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Croatia suddenly exposed civilians to great amount of weapons and different explosive devices.

METHOD OR APPROACH: Two cross sectional surveys were conducted during war years 1994 and 1995 in the counties on the front line. War directly affected 11 counties, four of these were selected for the survey: Dubrovnik, Karlovac, Lika and Sisak. Two survey sites were selected in each county: the largest town and additional town selected at random. In each site one primary and secondary school were selected at random. The sample consisted of parents from each school grade in the primary school and first two grades from secondary school and children from higher grades from primary school (5-8) and all grades from secondary school. Anonymous questionnaires were used for parents and children. The children’s questionnaire was given to the children at the beginning of class and completed during the class period. The parents` questionnaire was distributed to children at school, completed at home and returned to school. The respond rate was 98%.

CONCLUSION: During the war children are exposed to different kind of weapons and explosive devices dispersed in their environment. The operations of war are the main cause of injuries and death but excessive amount of weapons represents long term danger not only during the war but for years later. The most known example is landmines. Among the children in Croatia large proportion were killed and injured unrelated to the operations of war. This survey showed that children were exposed to handguns, ammunition, hand bombs and explosive much more than to grenades and landmines. Parents were not completely aware of the danger from different type of weapons and explosive devices.

LIMITS: The large number of confounding factors is limitation to such survey.

CONTRIBUTION OF THE PROJECT TO THE FIELD: National intervention was modified towards results of survey and more attention was paid on weapons disposal from homes. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 951

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PREDICTORS OF MASS VIOLENCE AND DEMOCIDE: THE NEED FOR EARLY WARNING SYSTEM

ELIHU RICHTER,ZIAD ABDEEN,MELISSA TELSHER Hebrew University School of Public Health Jerusalem, Israel

PROBLEM UNDER STUDY: Since 1900, there have been some 170 million victims of mass murder, starvation, forced migrations, and expulsions, as compared with 34 million victims from warfare.

OBJECTIVES: Define the need for Early Warning Systems for Response to Mass Violence and Killing.

METHOD OR APPROACH: Literature review, data review.

RESULTS: “Democide”–organized mass killing and abuse of persons of common or special origins, ethnic status, religion, gender or class, or political affiliation, often starts with incitement and isolated episodes of violence, and then spreads. In the past 100 years, the former Soviet Union (62 million), Nazi Germany (35 million) and China (21 million) have been the big killers. Since WWII, there have been at least 4 million victims of mass murder, mostly from ethnic conflict. Cambodia, Nigeria, Uganda, Angola, Rwanda, Iraq, Yugoslavia, and East Timor have been major sites. By every criterion in epidemiology, we are dealing with propagated epidemics, presenting as protracted civil conflict. Risks for democide include dictatorship, previous war, an ideology of expansion, a pattern of grievance, lack of outside interest, and a pattern of incitement. Incitement is required to carry out democide, since large numbers of persons are needed to carry it out. Organized mass killing usually starts from a point source, starting with a isolated episodes of violence, and then spreads, with rapid increases in the number of persons doing the killing and the number of victims The vocab- ulary of public health and genetics provides rationales for genocide: preventing disease in individuals escalates to getting rid of individuals with disease, and then to getting rid of groups of individuals classified by common racial, ethnic and genetic attributes. Forced starvation, expulsions, political persecution and discrimination either lead to democide or indicate increased risk for its occurrence.

CONCLUSION: We suggest that democide is predictable, and therefore preventable. The sentinel event is incitement, because genocide requires mass political support and manpower for its implementation. There has been insufficient attention to social and political warning signs of impending mass violence and killing, how to stop it before it starts, how to suppress it rapidly before it spreads, and to prevent recurrence. We propose setting up Early Warning Systems, using epidemiological tools and systems to identify predictive markers of mass violence and democide, notably incitement, and to promote preventive measures to prevent mass violence, and genocide. There is a need to establish an international epidemiological network for surveillance and reporting the warning signs of mass violence, murder, and genocide modeled after those for reporting outbreaks of infectious disease. This reporting network needs to be insulated from the political process. Its mission will be to track and report “markers” of increased risk for mass murder and genocide and mandate an organized response. Scope of problem, lack of resources for dealing with it and responding to it. Use of concepts derived from epidemiological surveillance to attack the biggest crowd disease. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 952

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PREVENTING POLITICAL VIOLENCE IN BANGLADESH: SOME POLICY OPTIONS

MOHAMMED BIN KASHEM University of Chittagong Chittagong, Bangladesh

PROBLEM UNDER STUDY: The unprecedented growth of violence in recent years has generated serious concerns for personal safety of populations. In the eve of Parliament Election more than 200 people were killed in Bangladesh during the last two months. All of them are member of two major political parties. Besides, interpersonal violence the successive regime has generated political violence that resulted in numerous deaths and injuries. Thus, in the face of increased level of violence in particular, political violence many claim that the government especially law enforcing agencies are not doing enough to ensure the safety of the general citizen. In an effort to control increased level of violence the government recently passed a major piece of anti-crime legislation called “Public Safety Act 2000”.Evidence suggests that this legislation has had little practical effect in combating crime and disorder.

OBJECTIVES: The purpose of this paper is to examine the state of political violence in Bangladesh. The central focus of the study however, will be on the political violence, its characteristics, causes and controls. Some policy options are suggested in controlling increased level of violence.

METHOD OR APPROACH: Content analysis and in-depth-interviews were the basic strategy for collecting data. Using content analysis data on violence occurred during the last two years were gathered from the newspaper. Two of the highest circulated newspapers of the country, one Bengali and an English were purposively selected. For in depth-interview 30 top leaders of the two major political parties were selected. The respondents were selected on the basis of hierarchy in their respective party. They were chosen as the subject because it is believed that the leaders control the activities of their workers. Besides 20 senior level police officers representing various categories including the chief of the police force were interviewed. In conducting in-depth interviewing an interview schedule was developed which addressed a variety of issues related with the primary thesis of the study.

RESULTS: The preliminary results suggest that in order to establish domination political parties are now engaged in large scale violence that resulted in significant increase in the rates of death and injuries. There is considerable evidence that major political parties in particular, the party in power are connected to violence. In other words, on many occasion violence was promoted by the political parties. It appears that the prevailing socio-political system is largely responsible for interpersonal violence in particular political violence. Data revealed that in the majority of the cases the incident of violence directed against the political opponents. On many occasions, the innocent bystanders are the victims of such violent acts. Several factors such as the proliferation of illicit firearms, the rise of organized criminal groups, increased use of drugs account for the presence of interpersonal violence. Political instability, is another factor that contributes to violence. Interviews with police officers suggest that the politicians heavily influence policing activities. Therefore, in the majority of the cases the acts of violence committed by political criminals cannot be stopped.

CONCLUSION: A convincing argument can be made that organized political violence could not exist without the cooperation and assistance of corrupt police officials and, in many BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 953

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cases, members of the political elite. The risk factors associated with violence such as guns and drugs must be eliminated through coordination with other agencies. It is very difficult to reduce the level of violence when large numbers of criminals are on the streets with guns. Evidence suggests that gun carrying by the high-risk groups contributing to increasing homicides and gun violence in a community. Given the high rates of violent events a strin- gent policy on firearms regulating the ownership, possession, and use is essential. Community involvement especially the cooperation from political parties are needed.

LIMITS: As noted earlier, this research has been based on information published in the newspapers. One of the problems of newspaper data are the reliability because in many instances press reports are motivated.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Hardly any study is done in this area at national level. This study has identified some of the causes of political violence, which in turn, may contribute to policy formulation, and academic understanding of this serious national problem.

THE BURDEN OF INJURY DURING CIVIL CONFLICT: GULU DISTRICT, UGANDA

RONALD LETT,OLIVE KOBUSINGYE,PAUL EKWARU,CHRSITOPER ORACH Canadian Network for International Surgery Vancouver, BC, Canada

OBJECTIVES: The objective of this study was to determine the magnitude, causes, distribution, and risk factors for injury in a population experiencing armed conflict in northern Uganda. The living conditions and access to care for the population were also determined.

METHOD OR APPROACH: Multistaged stratified random sampling of population of Gulu District was performed in August 1999. Trained interviewers administered a previously reported three part questionnaire that was translated into Acholi, to household heads. Quantitative data was analyzed using Epi Info and SAS. Qualitative data will be reported elsewhere.

RESULTS: A total of 1475 households with 8595 people were surveyed. Seventy three per cent of the population lives in temporary housing, 46% are internally displaced persons and >80% of the total population are under 35 years. Fourteen per cent of the population were reported to be injured annually. Gunshots was the lead cause of injury mortality. The annual injury rates were: mortality–7.7/1000, disability–11.3/1000. Only 8.36 percent of the injured were reported to be military combatants. Fifty per cent of the injured received first aid while only 13% of those who died reached hospital.

CONCLUSION AND RECOMMENDATIONS: The injury mortality in Gulu is 7 fold greater than our studies in a rural district and 3.5 greater than an urban district both in Uganda. The mortality rate over the last 5 years is likely an under estimate of the rates occurring for the last 17 years as periods of high intensity were not included in this study. Using the 5 year rate for the past 17 years we conclude that at least 13% of the population has died due to injury during this conflict and that if the war continues we project that the life time risk of an injury death in Gulu is 33%. In Gulu people live in poverty without access to care when injured. Peace building is a legitimate and important means of injury control that requires BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 954

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scientific assessment and intervention by health professionals and social scientists. The political and military approach has failed.

PSYCHOLOGICAL DISTRESS IN LEBANESE PRISONERS OF WAR

BASEM ROBERTO SAAB,MONIQUE CHAAYA,LAILA FAROUD, MYRNA DOUMIT,FEDERICO ALLODI American University of Beirut Beirut, Lebanon

PROBLEM UNDER STUDY: A cross sectional study assessed the prevalence and determinants of psychological distress among prisoners of war in Lebanon.

METHODS: Trained field researchers using standard measurements interviewed 118 Lebanese detainees released from Khiam prison, an Israeli detention centre in Lebanon. Their imprisonment took place between 1990 and 1996 and they were interviewed during 1997 and 1998.

RESULTS: They were in prison an average of over 3,4 years and 86 % reported having been submitted to torture. Psychological distress was present in 42,1 % of sample. Distress was significantly higher for ever-married POWs, having more than two children, with low education. Duration of imprisonment, deprivation of food and water and the experience of torture were significantly associated with distress, whereas exposure to brainwashing techniques was associated with a decrease likelihood of distress. Chronic illness, doctor visits, psy- chotropic medication intake following their release were directly and significantly related with presence of distress.

CONCLUSION: The paper discusses the significance and implications of the factors predicting resistance and vulnerability.

“TRAFFICKING IN WOMEN” GENDER JUSTICE AND SUPPORT FOR WOMEN WHO SEEK SAFETY FROM GENDER MOTIVATION ATTACKS AS REFUGES ARRIVING IN THE LAND & FREE

LIMOTA GOROSO GIWA The Women Institute–IWCC Office Ilorin, Kwara State, Nigeria

PROBLEM UNDER STUDY: Trafficking & Gender Security.

OBJECTIVES: Examine the issue of trafficking prevention and safety on trafficked women.

METHOD OR APPROACH: Case study and human right document. World wide oral presentation and data from Nigeria.

RESULTS: The issue of trafficking in women–human being have been given a serious concerned by researchers, activist, and policy makers. Yet there is an urgent need to resolved BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 955

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this multi dimensional problem facing us as women and children, such as surprisingly considerable number of women and children in Africa continent or developing countries like ours. There is the need for an international support for women safety as cosponsor of an article (s.2787) of UN documents on violence against women act. 2000 For victims or gender based persecution: Women who seeks safety from gender motivated attacks as refuges arriving in land of the free. By confirming the applicability of the gender consideration for all asy- lum cases before immigration courts, in so doing will be extending hopes and freedom from brutal practices or domestic violence, rape, and sexual abuse of female genital mutilation and other types of gender based persecution, as it contain in the universal declaration of human rights an no longer denying this basic right on accounts of persons and gender.

CONCLUSION: It is in a conference like this that these issues of prevention and safety of women as human being will be tabled and discussed, for a lasting solution.

Enquêtes sur la vie des femmes et la violence conjugale Study on Women’ Lives and Domestic Violence

PREVALENCE OF PHYSICAL AND SEXUAL VIOLENCE AGAINST WOMEN BY INTIMATE PARTNERS: RESULTS FROM A FOUR-COUNTRY COMPARISON

CLAUDIA GARCIA-MORENO World Health Organization Geneva 27, Switzerland

PROBLEM UNDER STUDY: There is a lack of reliable population-based data on the prevalence of different forms of violence against women and its health consequences, particularly data from developing countries and that is comparable across settings. Such information is important to understand the consequences of intimate partner violence on women’s health, to raise awareness of the problem among health providers and policy-makers and for the development of interventions in the health sector.

OBJECTIVES: To use population data from 4 countries participating in the WHO multi-country study on women’s health and domestic violence to explore the extent to which a recent or long-term history of intimate partner violence is associated with different indicators of women’s physical, mental and reproductive ill-health and the use of health services. Comparisons will be made between women reporting violence and other women, controlling for a history of previous victimization. To discuss what are the implications of this for preventive and supportive interventions, and identify issues for further research. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 956

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METHOD OR APPROACH: In 2000 and 2001 cross-sectional household surveys were conducted in Brazil, Japan, Peru, and Thailand. In each country approximately 1500 women of reproductive age from each capital city were interviewed in private by trained female interviewers. In Brazil, Peru and Thailand approximately 1500 interviews were also conducted in one other province. In each country comparable questions were included about the respondent’s current and past experiences of different forms of physical and sexual partner violence, and violence during pregnancy. Data was also obtained on various health issues/outcomes (smoking and alcohol consumption, indicators of physical health, of reduced mobility and of psychological distress, suicidal) and health care utilization and use of medication in last month, injury and use of health services as a result of injury. Data collected were double entered using Epi-Info, and cleaned. Analysis was conducted using SPSS V.10.

CONCLUSION: The findings will be used to assess the extent to which violence by intimate partners is associated with various health outcomes, and how this between settings and countries, and to discuss the implications for secondary and tertiary prevention activities.

LIMITS: The interviews involved the use of structured interviews. While it is not possible in a cross-sectional survey to demonstrate causality between violence and different events, the study explores various associations and the extent to which these are found in each of the countries. As such the study is likely to raise issues that warrant further research.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is the first attempt to collect comparable population data about this partners in diverse settings, and to try to identify factors associated with this violence.

SEEKING HELP AND ENDING VIOLENCE; RESULTS FROM A FOUR-COUNTRY COMPARISON OF SOURCES OF HELP, RETALIATION AND LEAVING AMONG WOMEN REPORTING A HISTORY OF PHYSICAL PARTNER VIOLENCE

CLAUDIA GARCIA-MORENO World Health Organization Geneva 27, Switzerland

PROBLEM UNDER STUDY: Most data about the coping strategies used by women experiencing partner violence comes from research involving women utilising domestic violence services. Little is known at the population level about the range of strategies that women experiencing domestic violence utilise to try to minimise the extent of violence or injury, to obtain support, or to end the violence. Such information could be used to advise other women experiencing violence, and to inform policy.

OBJECTIVES: To use population data from 4 countries participating in the WHO multi-country study on women’s health and domestic violence to: 1. Identify what proportion of women seek help from informal and formal sources in each country; BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 957

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2. Explore and compare the strategies used by different women in different settings and countries, and experiencing different levels of severity of partner violence; 3. Identify factors associated with the likelihood of seeking help, the cessation of physical partner violence, or leaving a violent relationship; 4. Discuss the implications of the findings for secondary and tertiary prevention.

METHOD OR APPROACH: In 2000 and 2001 cross-sectional household surveys were conducted in Brazil, Japan, Peru, and Thailand. In each country approximately 1500 women of reproductive age from each capital city were interviewed in private by trained female interviewers. In Brazil, Peru and Thailand approximately 1500 interviews were also conducted in one other province. In each country comparable questions were included about the respondent’s current and past experiences of different forms of physical partner violence. Women reporting abuse were asked whether they had ever left the relationship, sought help from friends or relatives, turned to the police, the health sector, or other support services, and whether there were other people from whom they would like to receive support. Socio-economic data about each respondent and her partner, and the timing of violent episodes was also collected. Data collected were double entered using Epi-Info, and cleaned. Analysis was conducted using SPSS V.10.

CONCLUSION: The findings will be used to assess the similarities and differences between settings and countries, and to discuss the implications for secondary and tertiary prevention activities.

LIMITS: The interviews involved the use of structured interviews. Further insights into women’s coping strategies could be obtained using complementary in-depth interviews with women who have left violent relationships, or who have ended violence within their current relationships.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is the first attempt to collect comparable population data about women’s experiences of and response to physical partner violence in four diverse settings, and to try to identify factors associated with the use of services, the cessation of physical violence or leaving a violent relationship.

PRELIMINARY FINDINGS FROM THE WHO MULTI-COUNTRY STUDY ON WOMEN’S HEALTH AND DOMESTIC VIOLENCE – OVERVIEW PRESENTATION

CLAUDIA GARCIA-MORENO,CHARLOTTE WATTS, MARY ELLSBERG,LORI HEISE,HENRIETTE JANSEN World Health Organization Geneva 27, Switzerland

PROBLEM UNDER STUDY: There is a dearth of reliable information, particularly from developing countries, on the prevalence of different forms of violence against women (vaw), in particular domestic violence; the risk and protective factors that operate in different cultural contexts; and the strategies that women use to deal with this violence. There is also a need to understand the health consequences of vaw and the synergies between them, in order to BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 958

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assess its real “burden”,and to use these data for the development of interventions that are effective, feasible and sustainable in resource poor settings. To fill this gap, WHO developed and implemented in 8 countries a multi-country study on women’s health and domestic violence against women.

OBJECTIVES: The objectives of the round table are to present data from the 4 (possibly 5) countries that have already completed data collection. The roundtable would include the following 4 presentations: 1. An overview of the Study, its characteristics and follow-up in each country; 2. Prevalence of different forms of violence by partners (physical and sexual violence and violence during pregnancy; 3. Health consequences of violence, with an emphasis on mental health; 4. Strategies that women in violent relationships use to deal with the violence.

METHOD OR APPROACH: The study has been carried out in 8 culturally diverse countries (Bangladesh, Brazil, Japan, Namibia, Peru, Tanzania, Thailand, and Samoa). in each country a cross-sectional survey of 3,000 women in both rural and urban areas was used to: 1. Obtain detailed information on the prevalence and frequency of different forms of violence against women; 2. Document the health consequences of domestic violence against women; 3. Identify and compare risk and protective factors for domestic violence against women, within and between settings; and 4. Explore and compare the strategies and services used by women in violent relationships to end or minimize violence. The study was also committed to several corollary outcomes including: 1. Developing and testing new instruments for measuring violence cross-culturally; 2. Increasing national capacity amongst researchers and women’s organizations to address vaw; and, 3. Increasing sensitivity to the subject among researchers, policy makers and health providers. A formative stage of qualitative research was used to help guide the study development, describe the context within which the quantitative findings will be interpreted, and guide the application and use of the research results to inform intervention and policy development.

RESULTS: Data collection has been completed in 4 countries and is currently underway in another two. Data analysis is beginning and will initially focus on : 1. Describing the prevalence, frequency and characteristics of intimate partner violence in the different countries; 2. Analysis of a range of health consequences and their association with different forms of violence. The health issues being analysed include: reproductive health outcomes, use of family planning and condoms, a screening tool for mental distress (the srq-20 or self-reported questionnaire), suicide attempts and ideation, injury and use of health care services; 3. Describing the strategies that women use to deal with or end violence, including which services they use and where do they seek help. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 959

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We will also present the next stages of the study and how the research results will be used for advocacy and policy change and to inform the identification of culturally relevant interventions.

CONCLUSION: There is a need for basic information to understand the magnitude and nature of the problem, its health and other consequences, and to identify factors that can inform the design and implementation of interventions in different cultural contexts. this study provides such information for a range of countries.

LIMITS: The Study relies on self-reporting, but has been designed to maximize possibilities for disclosure. The focus is on intimate partner violence, so while the Study will provide basic information on physical and sexual abuse by other than partners and on sexual abuse before the age of 15, it is not able to address these other forms of vow in depth.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The Study provides much needed data that is comparable across countries. For most of these countries it is the first time to collect data of this nature. The study has been designed to ensure scientifically sound data is obtained, while also ensuring wide ownership at country level and establishing mechanisms to ensure maximum use of the results for advocacy and policy change and to inform the identification of culturally relevant interventions.

HEALTH CONSEQUENCES OF VIOLENCE AGAINST WOMEN BY INTIMATE PARTNERS: RESULTS FROM A FOUR-COUNTY COMPARISON

CLAUDIA GARCIA-MORENO World Health Organization Geneva, Switzerland

OBJECTIVES: 1. To use population data from 4 countries participating in the WHO multi-country study on women’s health and domestic violence to explore the extent to which a recent or long-term history of intimate partner violence is associated with different indicators of women’s physical, mental and reproductive ill-health and the use of health services. Comparisons will be made between women reporting violence and other women, controlling for a history of previous victimization; 2. To discuss what are the implications of this for preventive and supportive interventions, and identify issues for further research.

METHOD OR APPROACH: In 2000 and 2001 cross-sectional household surveys were conducted in Brazil, Japan, Peru, and Thailand. In each country approximately 1500 women of repro- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 960

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ductive age from each capital city were interviewed in private by trained female interviewers. In Brazil, Peru and Thailand approximately 1500 interviews were also conducted in one other province. In each country comparable questions were included about the respondent’s current and past experiences of different forms of physical and sexual partner violence, and violence during pregnancy. Data was also obtained on various health issues/outcomes (smoking and alcohol consumption, indicators of physical health, of reduced mobility and of psychological distress, suicidal) and health care utilization and use of medication in last month, injury and use of health services as a result of injury. Data collected were double entered using Epi-Info, and cleaned. Analysis was conducted using SPSS V.10.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This study is the first attempt to collect comparable population data about these partners in diverse settings, and to try to identify factors associated with this violence.

TOWARD A BETTER UNDERSTANDING OF DOMESTIC VIOLENCE

MARYSE RINFRET-RAYNOR,SOLANGE CANTIN,ARIANE RIOU Université de Montréal & Direction de la santé publique de Montréal-Centre Montreal, Quebec, Canada

PROBLEM UNDER STUDY: During the last decades of the 20th century, violence against women has been transformed from a private to a social problem. The harmful consequences of this violence on victims, their children, the family, and society are such that many practitioners and researchers are seeing it as a public health issue. Domestic violence (DV) has especially attracted the attention of researchers. Quebec has developed, along with other countries and states, policies and services to reduce and prevent DV and to better meet the victims’ needs. More recently, Quebec has conducted studies to asses the problem.

OBJECTIVES: To present the main results of a survey carried out in Quebec in order: 1. To measure the extent (annual prevalence) of violent behaviours towards female partners; 2. To gather information on the relationship between violent behaviours and selected variables (individual, social and family); and 3. To compare the prevalence rates in this study with other national studies.

METHOD OR APPROACH: The “Survey on Violence Against Women in Quebec Couples” was part of the 1998 Health and Social Survey conducted by Santé Québec. This general health BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 961

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and social survey was carried out with 15 330 selected dwellings; 5 955 dwellings were selected within this larger sample. A total of 2 742 women in these dwellings met the following eli- gibility criteria: women 18 years of age and older living with a spouse (married or common law) or having lived with a spouse for at least two months in the year preceding the study. In all, 2 120 women accepted to participate in the survey (weighted response rate: 76.6%). Female interviewers from CATI (Computer Aided Telephone Interviewing) conducted this telephone survey. The questionnaire was developed using different valid and reliable instruments: Verbal Aggression Scale of the CTS; Physical Violence Scale of the CTS-2; questions taken from Statistics Canada’s National Survey on Violence Against Women 1993 and questions from a questionnaire developed in Quebec to measure sexual violence.

RESULTS: We will present the annual prevalence of husband-to-wife violence (verbal, physical, sexual) and of the controlling behaviours as well as the concomitance of the controlling behaviours with different types of violence and the prevalence of violence related to certain characteristics of the women, such as age, marital status, family status, and the family’s economic status. Previous history of violence will be explored, and we will show how violence rates are related to women’s psychological distress level, social support level and loneliness level, and to their perception of their mental health and satisfaction with their social life. The direct effects of violence on women will be presented : physical injuries, fear of being killed, children witnessing violence, and the main effects perceived by the women. We will also highlight the results concerning calls to the police, use of social and health services, use of informal resources, and what the victims considered the most helpful.

CONCLUSION: Those results help us gain a better understanding of domestic violence, confirm the importance of social and family factors linked to DV, and highlight common consequences.

LIMITS: In addition to the methodological limits of this survey, it is important to note that it contains little information about the social setting and situations in which violent behaviours occur. Another limit resides in the difficulty in comparing it to other national surveys, due to the differences in our understanding of domestic violence; it can be seen as conflict, control and domination, or a criminal act.

CONTRIBUTION OF THE PROJECT TO THE FIELD: We hope that this presentation will open new doors to the development of domestic violence prevention strategies, as a result of a clear- er understanding of the manifestations and repercussions of DV and its associated factors. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 962

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Vers une meilleure compréhension de la violence conjugale Toward Better Understanding of Intimate Partner Violence

FEMALE INTIMATE PARTNER HOMICIDE-SUICIDE EVENTS IN VIRGINIA, 1990-1999

KRISTA BIERNATH,SUZANNE J. KELLER,MARK ANDERSON,LEN PAULOZZI National Centre for Injury Prevention and Control/Centres for Disease Control and Prevention (CDC) Atlanta, Ga, USA

PROBLEM UNDER STUDY: In 1998, nearly 1,500 females were killed by an intimate partner (current/separated/former spouse, dating partner, or same-sex partner) in the USA. Many of these deaths were followed by the suicide of the perpetrator. Actual numbers of these deaths, however, are unknown. In Virginia, the Office of the Chief Medical Examiner (OCME) suspected a recent increase in female intimate partner homicide-suicide (IPHS) events, despite a state-wide decrease in the rate of female homicides.

OBJECTIVES: At the request of the OCME, a team from the Centres for Disease Control and Prevention (CDC) assisted with an investigation of IPHS events in Virginia. Objectives for this investigation were: 1. To study and describe IPHS event characteristics in the state of Virginia, 1990- 1999; and 2. To determine if rates of IPHS events in Virginia were changing during the 10 year period.

METHOD OR APPROACH: For this investigation, we defined a female IPHS as an event in which a perpetrator allegedly kills a female intimate partner (12 years of age or older and a resident of Virginia) and then commits suicide within one week. First, we reviewed all female homicide records in Virginia for the years 1990-1999, identifying any suicides that were linked to these female homicides. Once a homicide-suicide link was found, we determined if the victim and the perpetrator were intimate partners. Rates and rate ratios (RR) of event characteristics were calculated by age, race and metropolitan status. Rate trends in female IPHS events were then compared with rate trends in all other female intimate partner homicide (IPH) events and with rate trends in all other female homicide events using Poisson regression. IPH rates and female homicide rates in Virginia during this ten-year period were obtained using mortality data from the National Centre for Health Statistics and from the Federal Bureau of Investigations (FBI), respectively.

RESULTS: Preliminary data showed that from 1990 to 1999, 183 female IPHS events occurred in Virginia. All 183 (100%) perpetrators were male. For 133 (72.7%) of the events, the victim and perpetrator were either married, separated or divorced. Documented separation BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 963

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or impending separation between the victim and perpetrator was noted in 105 (57.4%) of the events. Rates of IPHS victimization were higher among women who were non-white (RR=1.48, 95%CI=1.12-2.07), between the ages of 25 to 34 years (RR=3.80 95%CI=1.73- 8.34), and injured in a non-metropolitan area (RR=1.61 95%CI=1.09-2.06). A significant increase over time in female IPHS rates (p< 0.05) was found despite a significant down- ward trend for IPH rates and for rates of all other female homicides (p<0.01).

CONCLUSION: The reason for this increase in the rate of female IPHS over time is not known. Further investigation is needed to better understand these events and to determine whether or not the rates of these events are increasing in other states and nationwide.

LIMITS: Lack of information in the medical examiner records regarding an intimate relationship between the homicide and suicide victims may have led to undercounting of IPHS events. Our results cannot be generalized either to other localities or to other types of homicide-suicide events because this study is specific to events involving female victims residing in Virginia who were killed by an intimate partner. And finally, the FBI data used are drawn from a voluntary reporting system and therefore are estimates of the true numbers of female intimate partner homicides.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Based on a review of the literature, we believe this study represents the largest investigation of IPHS to date. It demonstrates the importance and feasibility of using a medical examiner system for data collection and surveillance. Replication of this process in other states is needed to determine if similar patterns exist. The data obtained from this study can be used to develop and test a surveillance tool using death certificate data that will allow states without medical examiner systems to determine trends of IPHS events.

INTIMATE PARTNER VIOLENCE SURVEILLANCE: COMPARING TWO COMMON DATA SOURCES

PATRICIA SMITH,THOMAS LARGO,ABBY SCHWARTZ,CHERIBETH TAN-SCHRINER Michigan Department of Community Health Lansing, Mi, USA

PROBLEM UNDER STUDY: Ongoing surveillance of intimate partner violence (IPV) is becoming important as IPV is more frequently highlighted as a significant health issue, especially for women. However, there does not appear to be any one source of data that is ideal for surveillance purposes. The Michigan Department of Community Health is actively examining two common data sources-emergency departments (ED) and county-level prosecuting attorney (PA) offices.

OBJECTIVES: 1. Determine if EDs and PA offices are viable independent sources of data for IPV surveillance; 2. Ascertain if it is necessary to maintain two unique data sources or if one is sufficient. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 964

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METHOD OR APPROACH: Select data items are collected annually from all identified IPV cases seen in a representative sample of EDs in the state of Michigan in the USA. Similar items are also collected on cases with authorized arrest warrants for domestic violence (DV) handled by a representative sample of PA offices. In one county, ED and PA data were linked to examine the overlap of cases seen in the two systems.

RESULTS: In the initial year of data collection (1999), 17 of 23 hospitals submitted IPV data. Thirty-nine percent (n=428) of all identified assault cases with female victims age >16 seen in these EDs were identified as cases of IPV.Victim-perpetrator relationship was not available in one-quarter of the assault cases. Standard medical data, demographics (other than race), and police involvement were available for most IPV cases. Psychosocial and referral data were available for 47%-79% of the cases, depending on the data item. Representative 1999 DV cases from 14 of 15 PA offices in the sample were aggregated for analysis. Within these cases, 69% (n=1,372) with authorized arrest warrants for DV were identified as IPV against women age >16. Victim-defendant relationship was unknown for 1% of DV cases. Case and defendant data are generally excellent for PA cases, while availability of victim data varies widely by data item and office. When ED and PA cases were linked in one county, 42% of 123 IPV cases identified in the county’s EDs also had arrest warrants for DV authorized by the PA office. Conversely, 6% of the women listed as victims in the 856 PA DV cases were identified in the EDs. The two sources had a high level of agreement on victim injury and race, but low agreement on city of occurrence and victim-perpetrator cohabitation status, primarily because ED records often did not contain this information.

CONCLUSION: • Both EDs and PA offices supply substantial numbers of cases for IPV surveillance; • Within each data source, availability and quality of data vary by item; • It is necessary to maintain both data sources since each contributes a significant number of unique cases and critical information to the system; • If data systems are to be linked to obtain additional information on individual cases, a prioritization criteria need to be established for determining which source to use for items that appear in both systems; • Collecting data from more than one system requires significant resources.

The reduced costs of using only one system must be balanced against the greater usefulness of data obtained from multiple systems.

LIMITS: 1. Identification of female assault cases in ED data is limited by the level of external cause of injury coding (E coding) done by the hospital. In this sample, E coding levels varied from 4%-99%; 2. Identification of IPV cases within either system is dependent on victim-perpetrator relationship being available in the record; 3. Availability of individual data items in each system appears to be limited by its usefulness for either medical treatment or prosecution. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 965

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CONTRIBUTION OF THE PROJECT TO THE FIELD: It becomes apparent when looking at these data sources that, while both are likely necessary for IPV surveillance, neither is sufficient in its own right. Others seeking to establish IPV surveillance systems need to be fully cognizant of the limitations of their data sources and examine how multiple data sources may enhance their work.

CONTINUING RISK OF VIOLENCE AGAINST WOMEN AFTER INTIMATE PARTNERSHIPS END

LINDA SALTZMAN,ROBIN IKEDA Centres for Disease Control and Prevention Atlanta, Ga, USA

PROBLEM UNDER STUDY: In recent years, public health practitioners have acknowledged the importance of violence prevention, and have included prevention of violence perpetrated by current and former intimate partners (spouses, cohabiting partners, and boyfriends/girlfriends) as part of that focus. Because of difficulties in obtaining accurate information about the incidence and prevalence of the problem in general, it has been difficult to know what proportion of women in violent relationships also experience violence after the relationship ends. Anecdotal evidence suggests that the risk of violence may increase after a relationship ends.

OBJECTIVES: This study examines the proportion of women who experience rape or physical assault by an intimate partner during the relationship and after it has ended. We also examine whether this differs by race or by whether the perpetrator and victim were married to each other, or cohabiting but unmarried.

METHOD OR APPROACH: Data are from the National Violence Against Women Survey conducted in the USA in 1995-1996. Random digit dial telephone surveys were conducted with 8,000 women age 18 and older. The survey included information about experiences of rape (completed and attempted) and physical assault perpetrated by spouses and cohabiting partners of either sex. Our study focused on whether violence occurred during the relationship or after it ended, thus we limited our analysis to those women with former intimate partners, operationalized here as ex-spouses or ex-cohabiting partners of either sex. We conducted separate analyses for each of these types of former intimate partner. For rape and for physical assault, variables were created to differentiate victims by two abuse patterns including: abuse that occurred during the relationship only, and abuse that occurred both during the relationship and after it ended.

RESULTS: The study sample includes 247 women who reported being raped by an intimate partner, and 972 women reporting being physically assaulted by an intimate partner. Of the rape victims, 77.4% were abused during the relationship only; 22.6% were abused both during the relationship and after it ended. We found no differences when we controlled for race of victim (OR=1.35, 95% CI=0.71-2.53) or type of former intimate partner (OR=0.61, 95% CI=0.26-1.43). Of the physical assault victims, 82.2% were abused during the relationship only; 17.8% were physically assaulted both during the relationship and after it ended. We found no differences when we controlled for race of victim (OR=0.77, 95% CI=0.50-1.18) or type of former intimate partner (OR=0.84, 95% CI=0.54-1.30). BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 966

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CONCLUSION: A relatively small proportion of women who report experiencing rape or physical assault during an intimate partner relationship also report experiencing rape or physical assault after the relationship ends. This does not differ by the race of the victim, or by whether the relationship that ended was a marital one, or one of cohabitation without marriage.

LIMITS: Rape or physical assault occurring when women were planning to end a relationship, but had not yet done so, could not be differentiated from other rape or physical assault that occurred during the relationship. Severity of rape and physical assault could not be addressed, but only whether or not it occurred. Race was the only demographic variable that could be examined, since demographics at the time of the survey interview did not necessarily reflect demographics at the time of the violent relationship(s). We were unable to examine former dating partners who had not cohabited.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Information from this analysis provides descriptive information about what proportion of women in a violent relationship experience abuse after the relationship ends, and whether this differs by race or by whether the partners were married, or cohabiting but unmarried. This information may be useful for consideration by women in (or at risk of) abusive relationships and by service providers who work with them.

THE NATURE AND EXTENT OF RECURRING INTIMATE PARTNER VIOLENCE AGAINST WOMEN

MICHAEL RAND,LINDA SALTZMAN U.S. Bureau of Justice Statistics Washington, DC, USA

PROBLEM UNDER STUDY: The research literature on intimate partner violence (IPV) indicates that many victims are repeatedly victimized over time. While repeat victimization may be a prevalent characteristic of IPV,few studies have analyzed the ongoing victimizations. Many surveys count the number of times a person was victimized but do not collect information about the recurring violence sufficient to characterize the nature of the violence.

OBJECTIVES: This study provides some insight into the nature and characteristics of IPV that is ongoing rather than episodic. The study also reviews methods that have been used to identify and measure recurring violence, and discusses their implications for measuring the extent and characteristics of IPV.

METHOD OR APPROACH: This study uses 1992-99 data from the National Crime Victimization Survey (NCVS) to examine the nature and extent of recurring IPV against women. The NCVS is an ongoing survey conducted by the U.S. Bureau of Justice Statistics to provide information on the frequency, characteristics and consequences of crimes both reported and not reported to police. About 160,000 people age 12 and older are interviewed each year for the survey. The NCVS utilizes a protocol to collect information on victimizations that recur at least 6 times during a 6 month reference period (“series victimization”). The series protocol collects detailed information about the most recent incident and general BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 967

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information about the nature of the entire series of incidents. We examine the NCVS series protocol used to collect data on recurring violence and consider the implications for measuring IPV.

RESULTS: When we count series victimizations as the number of times the person was victimized, NCVS data indicate that nearly one-fourth (28%) of IPV victims were victimized 2 or more times during the 6 months prior to the interview. About 1 in 8 victims (12%) experienced 6 or more such victimizations during the survey’s 6 month reference period. In almost every case of series victimization (99%), the victim reported that she had been victimized by the same person in every event in the series, although in 2% of incidents within a given series, additional persons were also offenders. Nearly two-thirds (62%) of victims of one incident of IPV during the previous 6 months reported the incident to the police; in contrast, almost half (47%) of victims of recurring intimate partner violence reported the most recent incident to the police (p<.05). There was no significant variation in the likelihood of victims of one-time or recurring IPV being injured in the victimization; about half (50% and 48% respectively) of all IPV victims were injured regardless of the number of times victimized.

CONCLUSION: Recurring victimization represents a substantial portion of IPV.Recurring IPV shares some similarities but also differs in some ways from one-time violence. Victims of recurring IPV may be less likely to report their victimization to the police, but appear equally likely to be injured as victims of one-time IPV. Problems exist with the way recurring violence is measured, to which there are no easy solutions. To better understand such violence, it is necessary to develop improved methods for measuring and characterizing it.

LIMITS: This study is a first step in developing improved measures of intimate partner violence. We do not attempt to examine long-term ongoing violence because we utilize the NCVS reference period and thus examine only victimizations that occur during 6 month intervals. People who are victimized once during a given 6 month period are treated as if they are victimized one time, although they may have suffered similar victimizations prior to the survey reference period. Information is not available about whether the victims in the study were in relationships with their offenders for the entire 6 month reference period.

CONTRIBUTION OF THE PROJECT TO THE FIELD: To understand the nature of IPV and develop programs to assist its victims, better understanding must be obtained of the extent and nature of recurring violence. This study contributes to the body of knowledge describing the nature of such violence, and discusses some possible improvements and areas for future study.

THE IMPACT OF INTIMATE PARTNER VIOLENCE ON LOW INCOME WOMEN: IMPLICATIONS FOR INTERVENTION

ANDREA GIELEN,KAREN MCDONNELL,PATRICIA O’CAMPO,JESSICA BURKE Johns Hopkins University Centre for Injury Research and Policy Baltimore, Md, USA

PROBLEM UNDER STUDY: Intimate partner violence (IPV) affects women from all walks of life and in all countries. Of particular concern is its impact on women who are also economi- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 968

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cally disadvantaged because they may be especially vulnerable to its health consequences and least equipped to end the violence.

OBJECTIVES: To describe: 1. Rates of IPV among a large sample of women living in low income inner city neighbourhoods; 2. The impact of IPV on mental health and physical health indicators; and 3. Women’s opinions about the role of health care providers and other services in helping them end the abuse.

METHOD OR APPROACH: Project WAVE (Women, AIDS and the Violence Epidemic) is a cross sectional study of 445 women (half of whom were HIV-positive). Quantitative and qualitative interviews were conducted. Measures included: psychological aggression, physical abuse, and sexual coercion based on the Conflict Tactics Scale-Revised; physical health, cognitive function, social function, mental health, bodily pain, health distress and quality of life based on the MOS-SF36; depression based on the CESD; and injuries. Women were also asked their opinions and policy preferences for IPV screening and reporting by health care providers, and to describe their experiences with help seeking to end the abuse.

RESULTS: 62% of women reported IPV in the year prior to the interview; of these, 32% reported psychological aggression only; 28% reported both psychological and physical abuse; and 40% reported sexual coercion. Injuries were reported by 19% of the total sample, or 29% of the abused women. Results from multivariate analyses will be presented to demonstrate the substantial impact of the abuse (in total and by type of abuse) on the physical and mental health indicators, even after adjusting for women’s HIV status, age and drug use. The majority of women (83%) supported routine screening by health care providers, and they believed it would make getting help easier for women (86%). A slight majority of women (56%) thought that health care providers should be required by law to report the abuse, although 67% thought that women would be less likely to disclose their abuse under conditions of mandatory reporting. The qualitative portions of the interview provide a more in-depth understanding of women’s experiences, and excerpts from women’s own descriptions will be presented. Women often did not seek care for their injuries and they were unlikely to discuss their abuse when they did. Jobs and educational services were identified as services needed to help women end abusive relationships.

CONCLUSION: Low income urban women experience high rates of IPV and its associated negative health effects. Women support screening by health care providers, although there are other services outside of the health care setting that are needed to help abused women end the abuse. Combining both quantitative and qualitative data collection methods enriches our understanding of this complex problem and potential intervention strategies.

LIMITS: Women for this study were recruited from clinic and social service settings and thus our results may not be generalizable to other groups of low income women who do not come in contact with health and social service agencies.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The results of this study can be used to plan interventions that are appropriate for low income urban women living with IPV. These interventions should include a health care provider component, but additional resources that will enable women’s independence appear to be needed. Demonstration projects should be undertaken to identify effective interventions for this population. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 969

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DOWRY DEATHS IN BANGALORE CITY, INDIA

RAMA R. DEVI University Arts College Bangalore, India

PROBLEM UNDER STUDY: “Dowry is as old as India” the Indian religion, tradition, custom and belief play a predominate role in lower middle class families is that the life of a male is more valuable than that of female. Women are raised to be servants to their husbands often arranged by the parents to marry a man that they have never met, but by paying dowry.

OBJECTIVES: The dowry consists of money, merchandise or gold. Women were burn alive for the shake of dowry and then to marry another. The men are not anxious to see this practice to go and religious do not see a need for change, so women groups must fight to get help for a better quality of life.

METHOD OR APPROACH: A deep study was under taken to investigate the humiliation and pain, the women under went in a short married life or at a time of alleged dowry death. A detail description of the incidents was collected from hospital causality departments and Police jurisdiction of Bangalore City for one year from 1-1-2000 to 31-12-2000. Police complaints of the victims kin and kith was noted down and very rarely victims deaths statement was collected from hospitals authorities in Bangalore City.

RESULTS: In the study it is found 38 women have become victims of dowry cases in one year. 23.7% of women were abused and beaten every day by the drunker husband to get more dowry from her parents. 47.4% of victims were tortured and killed by the husband, greedy mother-in-law and sister-in-laws. 10.5% of the victims killed by themselves because thy could neither to tolerate the torture nor get the demanded dowry from the poor parents. 18.4% of them survived from death in the hospitals.

CONCLUSION: Though it is a pressing and burning issue, the society offers very little push to resolve this. The most important solution is that every girl child should be educated and become economically independent with the help of the parents, Government and social supports.

LIMITS: The study is limited to Bangalore City Population, data collected from City Police and Hospital limits for one year from 1-1-2000 to 31-12-2000.

CONTRIBUTION OF THE PROJECT TO THE FIELD: The study will enlighten about one of the serious problem of Bangalore City Women in specific and applicable to Indian Society in general.

THE FAMILY VIOLENCE IN SANTIAGO OF CALI

RUBÉN DARÍO GARZÓN MUÑOZ,ANA INÉS RICAURTE VILLOTA Instituto Nacional de Medicina Legal y Ciencias Forenses Cali, Valle, Colombia The family violence is social and global phenomenon; it is multifactorial. The different factor involve produce and perpetrate the problem. The city of Cali is not exception, daily in BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 970

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the city occur many events like child abuse, sexual abuse and conjugal violence, this events is sending for evaluation to the Legal Medicine by authority.

OBJECTIVES: Our project is about the violence’s relationship between conjugal subsystem, with our forensic work determine the risk factors individual, social familiar and culture; we detect cause of conflict, management of situation by involve persons, language and pieces uses by involve persons. We made a quantitative and qualitative analyze of conjugal violence. We want expound strategic for control and prevention of this big problem. We use the software EPI-INFO 6.04 for the statistics analysis and ethnography for the qualitative analysis.

RESULTS: We determine the risk factors and cause the conflict in the conjugal violence in Cali.

ALCOHOL CONSUMPTION AND IPV – A CROSS SECTION STUDY IN INDIA AMONGST OTHERS AND ABORIGINALS

KOUSTUV DALAL Head Dept. of Economics & Statistics, Howrah Akshaya Sikshayatan Calcutta, West Bengal, India

PROBLEM UNDER STUDY: According to the police report, generally, most of the personal violence had been committed by the drunker. In the rural and urban areas people exhibit violent nature and become errant mostly after taking alcohol which are 25-65% pure. The developed or developing tribal people are relatively violent to a little extent, but the pure primitive tribal people are exclusively violent hater. With the consumption more concentrated country liquor, they exhibit unthinkable forgiveness and become highly introspective. Why it has such a tumbling result, which is our problem.

OBJECTIVES: We examine here the effects of alcohol on violence. It is a common belief that alcohol is one of the primary cause behind inter personal violence (IPV). This cross section study will clarify and segregate whether it has really such effects behind IPV or not, which ultimately help us to prevent it.

METHOD OR APPROACH: Field study and spatial pre and post incidence interrogative observation were made on interpersonal or micro violence for nearly two years. Inhabitants of three pure primitive tribes (PPT): Kondakoddu, Kui and Porja, two scheduled and developed tribes (ST): Santhals and Soura, two remotest rural village: Nimtala and Rasikgange, two small town: Ghatal and Memari, and a cosmopolitan city: Calcutta were observed. The sample size for PPT, ST and villages were 122-405. For towns it considers 400 people and for the city it was 500.

RESULTS: The PPT males regularly take maddikallu (nearly 90% proof indigenous country liquor) 500-700 ml and females 400-750 ml but, become totally violence hater. Even if one’s beloved young wife goes with another male for concubine pleasure for one or two nights the husband puts more physical labour in the field on next couple of days and becomes highly forgiving. The STs with more or less, same mahua or hanria (70-90% proof) avoid violence but who are relatively acquainted with the modern life are violent to exhibit chauvinism. Here, for the above stated case the husband severely beats up the guilty-man and their leader charges him two/three cows as compensation. Only 17% rural people regularly take alcohol (40-50% proof) as most of them belief that liquor consumption is a sinful act. Here, the BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 971

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drunkards habitually beat their wives and children and shout about their grievances. But, in the towns and city the scenario is very gloomy. Most of the young and elderly people (42%) regularly take either country or foreign liquor and always stay under violence stage–beat family members, perform all sorts of illicit trade/trafficking, tease passing by females, murder, snatch i.e. in a nut shell all notorious works. According to socio-economic background the performances may vary but they must have taken liquor at the time of violence. Another interesting observation is that at the pre or dot incidence phase they grumble. Later it found that they have grumbled about their socio-political and/or economic agony and taken liquor to wipe out their normal feelings to become misanthropist.

CONCLUSION: Alcohol consumption is not a source of violence. It may act as a catalyst to tumbling a human being from violent adversary to violent lover. As it decontrols our brain and nervous system it makes violence making easier and violence decision faster but never be treated as cause of violence.

LIMITS: The study was completed in tropical and hot weather and in economically backward region. In cold and developed region it may have a slightly different results but the conclusion hopefully will be unaltered.

CONTRIBUTION OF THE PROJECT TO THE FIELD: This self-propelled, self-guided and self-funded study dethrones alcohol, one of the major suspected element as a cause of violence.

VIOLENCE AGAINST WOMEN (A SILENT EPIDEMIC)

JULIE ANN A. SANTOS Ateneo de Davao University E.Jacinto St. Davao City, Philippines

PROBLEM UNDER STUDY: Domestic Violence has been an issue for the longest time. It is a very sensitive issue that requires not only prompt but also proper handling since the lack of proper handling might lead to inability of the women to file cases if this is not treated as serious. It is an issue that has remained constant all throughout despite the efforts to educate the masses. One main reason is the fact that for some it has become “normal” that the victim has learned to regret it but at the same time has also accepted it as part of life.

OBJECTIVES: The objectives of the study was to determine violence for which women from the rural, urban poor and indigenous community were subjected. It seeks to analyze as well as profile the survivors of violence by understanding their coping mechanisms and understand the triggering factors that lead them to their present situation.

METHOD OR APPROACH: The study employed both the quantitative and qualitative method. A standard interview schedule was given but this was administered on a one-on-one basis and an in-depth interview. In critical areas, aside from the in-depth interview, a focus group discussion was made to protect the survivors. Results gathered from the study was supported further by the review of related literatures.

RESULTS: The women interviewed were between the ages of 20-60 and were basically married with at least one child. The husbands were older than the women and in terms of educational status, the women have at least reached the secondary level. Most of these women are work- BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 972

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ing except among the indigenous groups wherein the women are full-time housewives. The women are basically battered emotionally, economically, verbally, psychologically and most of all physically. Most of the time they experienced all forms at the same time. Reasons for the abuses ranges from alcohol to drugs but there are cases also which states that boredom is a factor. These acts of violence have already affected the health of the women. One woman suffers occasional black-outs and shortness of breath due to being made the punching bag for quite some time now. Women often stayed in a violent situation based on culture that a family must stay together no matter what. This is the logic behind the act.

CONCLUSION: Women do not enjoy their situation but despite the efforts to educate them, they are basically trapped with the cultural beliefs valuing family above all. Thus, the task to eradicate this particular issue is still a long way off.

LIMITS: Due to the sensitiveness of the issue, the number of respondents were relatively small but they have been divided into the three areas, rural, urban and indigenous.

CONTRIBUTION OF THE PROJECT TO THE FIELD: These particular study has helped the researchers analyzed why the campaign against violence has not been successful. By understanding the reasons behind the issue, a better approach is being conceptualized without stepping beyond the cultural limits.

A SURVEY TO ASSESS INTIMATE PARTNER VIOLENCE IN KENTUCKY

MELISSA O’TOOLE,MARILYN SITAKER Kentucky Injury Prevention & Research Centre Lexington, Ky, USA

PROBLEM UNDER STUDY: As part of a project funded by the U.S. Centres for Disease Control and Prevention (CDC) to develop a state-wide surveillance system for Intimate Partner Violence (IPV), the Intimate Partner Violence Surveillance Team conducted a survey of adult women in Kentucky. This survey provides complementary data on the state-wide incidence and prevalence of IPV in current and former relationships.

OBJECTIVES: This survey, conducted in 2001, is the second of 4 annual surveys. It describes the nature and scope of IPV among adult, non-institutionalized women in Kentucky. State- wide rates of lifetime prevalence and annual incidence were estimated based on survey responses.

METHOD OR APPROACH: A survey of 2000 adult, non-institutionalized women in Kentucky was conducted using computer-assisted telephone interviewing (Waksberg Random Digit Dialling method). A proportionate sampling scheme was used to ensure representation of poorer rural counties that have a low phone service density. The survey included questions about childhood risk factors, annual incidence and lifetime prevalence of physical, emotional and sexual abuse, injuries resulting from partner violence, weapon use, abuse during pregnancy, utilization of medical, legal, shelter, counselling, and other services. The possible health impact of IPV was investigated. Questions used in the survey were selected from the Conflict Tactics Scale II, and the Michigan Department for Public Health IPV survey (1996), the Abusive Behaviour Inventory and Violence Against Women scales, and the Project BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 973

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for Research on Welfare to Work. CDC’s Uniform Definitions and Recommended Data Elements for Intimate Partner Violence were used as a guideline to determine which elements to include in the survey.

RESULTS: About half a million adult women in Kentucky report that they have experienced intimate partner violence at some point in their lives. Emotional abuse, mainly in the form of insults, was the most frequently reported type of abuse. Physical violence was reported less frequently, with severe forms reported only rarely. About half of all women who reported intimate partner physical abuse said that they were injured as a result of partner violence. Women who suffered intimate partner violence as adults were more likely to report exposure to partner violence or abuse in childhood, and were more likely to be less healthy as adults than women who had never experienced IPV.Less than one in five women sought help for IPV through traditional sources, most frequently they turned to family and friends. Less than one-quarter of women in a current abusive relationship were asked about IPV by a health professional. Survey estimates are compared to reported abuse from the Kentucky IPVS system, and to the results of the National Violence Against Women and the National Crime Victimization Surveys.

CONCLUSION: Intimate partner violence against women is a significant problem in Kentucky. Despite potential biases that would lead to underestimation, a large number of women were found to have experienced IPV in their lifetimes. The costs of IPV in terms of poorer health, lost productivity and injury alone are sizable. Yet few women seek and/or receive appropriate help to alleviate current abuse. Despite mandatory reporting in Kentucky, few abused women are asked by health professionals about the abuse.

LIMITS: Telephone surveys are limited in their representativeness, because the characteristics of those who choose not to respond are unknown. Surveys on sensitive topics such as intimate partner violence may suffer form disclosure bias. For example, a respondent may not have described her intimate relationship as “abusive” due to denial, shame or fear of repercussions. In this survey, “emotional abuse” and “physical abuse” were defined by certain specific behaviours. These definitions should be reviewed before making any comparisons with other surveys.

CONTRIBUTIONS OF THE PROJECT TO THE FIELD: Only a few states have undertaken population- based surveys to estimate the incidence and prevalence of intimate partner violence in their communities. Thus, the results of this survey will not only have local relevance and usefulness for advocates, law enforcement officials and policy makers, but will also contribute to the body of knowledge regarding state surveys for IPV.

TROUSSE DE FORMATION SUR LE DÉPISTAGE DE LA VIOLENCE CONJUGALE

LUCIE JOYAL,RICHARD MARTIN CLIPP Montréal, Québec, Canada Une récente production de deux vidéos, dont un documentaire et un vidéo de modélisation de l’activité de dépistage. Cette trousse s’adresse aux établissements du réseau de la santé afin BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 974

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de sensibiliser tous les professionnels à la pertinence et au savoir-faire en matière de dépis- tage de la violence conjugale auprès de leur clientèle féminine. Le documentaire de 36 minutes rassemble à la fois les propos scientifiques, les expériences professionnelles ainsi que le vécu de femmes victimes qui consultent le réseau de la santé. Le second vidéo de 30 minutes démontre l’activité de dépistage exercée par un médecin lors d’une consultation clinique, une travailleuse sociale, et une infirmière lors d’une visite à domicile. Les clien- tèles et problématiques présentées sont: une femme enceinte qui consulte pour sa grosses- se, une femme qui consulte pour les problèmes de comportements de son jeune enfant et une femme handicapée qui reçoit des services post-opératoires à son domicile. Les formes de violence décrites sont la domination, le contrôle, la violence psychologique ou symbolique, violence physique et sexuelle. La méconnaissance des conséquences de la victimisation de la violence conjugale chez les différents professionnels du réseau de la santé fait en sorte que les services offerts ne tiennent pas compte de l’existence de ce problème. L’absence du dépis- tage peut mener dans certains cas à une aggravation du problème ou détérioration ou encore à un traitement sans succès. Les femmes gardent le silence, ne savent pas qu’elles sont victimes et s’isolent. Les professionnels, pour leur part ne reconnaissent pas toujours les signes ou les symptômes, ne savent pas comment aborder le sujet ou encore comment réagir lors de dévoilement. Le dépistage de la violence conjugale vise à améliorer l’état de santé de la femme et par conséquent, à améliorer le services professionnels rendus ou requis. Deux projets de recherche sont directement en lien avec le dépistage et un mode d’application reposant sur une instrumentation spécifiquement développée et évaluée dans un établisse- ment de la santé. D’autres sources scientifiques justifient la pertinence du dépistage de cette problématique et une plus grande sensibilisation auprès des professionnels. Rapports de recherche: Développement et évaluation d’un protocole de dépistage systéma- tique de la violence conjugale au CLSC St-Hubert. L’évaluation de l’implantation du protocole systématique de dépistage de la violence conjugale dans les CLSC du Québec. La dif- fusion de cette trousse se veut un support aux activités de formation réalisées dans les milieux de pratique du réseau de la santé ainsi que dans les milieux universitaires dans le cadre de la formation des futurs professionnels de la santé. Dans le domaine de la prévention de la violence conjugale et de l’intervention.

VIOLENCE! PRÉVENIR DE TOUTE URGENCE

PIERRE H. TREMBLAY,RICHARD MARTIN Direction de la santé publique de Montréal-Centre Montréal, Québec, Canada

PROBLÉMATIQUE : La violence est un problème social qui a un impact majeur sur la santé mentale et physique et sur le bien-être des individus. Les principaux facteurs de risque de la violence sont liés à l’individu (impulsivité, contrôle de la colère), à la famille (méthodes d’éducation, tolérance), au milieu de vie (influence des pairs, exclusion...), et à la société (média, modèles, pauvreté, accès aux substances...). Il s’agit d’un problème de santé publique pour lequel des actions de prévention peuvent et doivent être mises en oeuvre, dès le plus bas âge. Parmi celles-ci, des programmes de développement de l’estime de soi, de développement des habiletés sociales ou de résolution de conflits implantés en milieu scolaire primaire. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 975

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L’école est un milieu privilégié pour intervenir parce qu’elle a une mission éducative et le principal lieu d’influence après la famille.

OBJECTIFS : 1. Décrire la violence est un problème de santé publique, aux causes multiples, pour lequel des actions de prévention peuvent être mises en place; 2. Informer sur l’existence de programmes efficaces de prévention en milieu scolaire primaire; 3. Montrer quelques exemples de prévention afin de motiver les milieux à entreprendre une démarche.

RÉSULTATS : De Paris à Montréal en passant par Béziers, Roubaix et Genève, le film aborde la question de la violence et de sa prévention en donnant la parole tout d’abord à des jeunes d’une banlieue parisienne, victimes, témoins et parfois acteurs de violence. Puis, des spé- cialistes résument les principaux facteurs de risque, les moyens d’intervention et les lieux pri- vilégiés pour agir. Puis, quatre expériences de prévention de la violence en milieu scolaire provenant de Suisse, de France et du Québec sont montrées : quatre témoignages enthou- siastes de programmes éducatifs.

CONCLUSION : On sait que la violence se produit souvent dans un contexte de relations inter- personnelles et que des programmes de prévention implantés en milieu scolaire démon- trent des résultats efficaces, notamment les programmes de développement des habiletés sociales, de l’estime de soi et d’apprentissages à la résolution de conflits. Le film espère donner aux milieux scolaires le goût d’entreprendre à leur rythme, une démarche de prévention dont ils pourront observer à brève échéance d’heureux résultats.

LIMITES : Même si certains programmes en milieu scolaire ont été évalués et ont démontré des résultats efficaces, les actions isolées sont en général vouées à l’échec. Il faut donc com- biner les stratégies et agir non seulement au niveau individuel mais aussi au niveau de la famille, du milieu scolaire, du quartier et dans la société en général. De plus certaines conditions doivent être remplies si on veut implanter un programme de façon efficace. : engagement des intervenants, leadership, financement, participation des parents...

CONTRIBUTION DU PROJET AU DOMAINE : Ce projet international place pour la première fois le problème de la violence comme un problème de santé publique ce qui semble relativement évident en Amérique mais nouveau en Europe. L’enthousiasme des co-producteurs et leur motivation à le diffuser le plus largement possible feront de ce film un formidable outil de sensibilisation à la mise sur pied un peu partout d’actions de prévention de la violence.

PROJET DE PRÉVENTION DE LA VIOLENCE

MARIE-CHANTALE PARENT OSA–Anjou Anjou, Québec, Canada

RÉSUMÉ DU PROJET : Objectif Sécurité Action s’associe aux Productions Mas vidéo pour vous proposer un projet de prévention de la violence sous forme de production vidéo. Ce projet a consisté d’abord à regrouper une quinzaine de jeunes (à risques) et à les impliquer dans BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 976

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un processus actif de réflexion sur la violence qui leur permit de faire une prise de conscien- ce, d’articuler et d’exprimer leur point de vue sur le sujet. Ces jeunes ont fait partie intégrante de toutes les étapes de l’élaboration et de la production du document audio-visuel. Conséquemment, le fruit de leur réflexion est un outil de sensibilisation et de travail pour un vaste auditoire à travers le Canada. Le but est de répondre à des besoins nationaux en diffusant dans différents milieux francophones (institutionnels, scolaires, réadaptation, etc.) un document original et à la portée des jeunes. Nous croyons que le processus d’influence s’effectue parmi les pairs et c’est pourquoi les protagonistes du document sont du même âge que ceux qui le visionneront. Le projet a impliqué la concertation et le partenariat de plusieurs instances et leur contribution y est largement représentée.

LE CONCEPT : Tout au long de ce document, on suit un groupe de jeunes qui, armés d’une caméra vidéo, font une réflexion sur le phénomène social de la violence, plus particulière- ment chez les adolescents. Ils discutent et posent des questions, se remettent en question et scrutent l’opinion des gens qui les entourent (amis, professeurs, parents, etc.). Ils invitent le spectateur à participer à cette réflexion qui prendra diverses formes se chevauchant tout au long de la vidéo. Les parties du document sont construites comme des collages, juxtaposant de courtes capsules, fictions ou documentation, de façon à garder un rythme rapide qui convient tout à fait à la dynamique des participants et à l’auditoire principal qui est visé.

LE GUIDE D’UTILISATION : Un guide d’utilisation est fourni avec le document vidéo; cet outil supplémentaire, où on suggère aux utilisateurs et animateurs de groupes, des thèmes et des questions clés pour alimenter la discussion, permet de cerner rapidement différentes pistes de réflexion. Synopsis Cinq jeunes, La violence vécue au quotidien, Famille, École, Justice, Aujourd’hui, Partout, Tout le temps, le Mur, Prisonniers du passé, Du présent, De l’avenir, Briser le mur du silence, Prendre la parole, Dire tout haut ce que les autres pensent tout bas ou ne pensent pas, Regarder ce qu’ils ne voient pas, Écouter ce qu’ils n’entendent pas, Filmer la vraie vie, Tracer les portraits, Suivre la trace de la réalité, Témoignages, Vox-pop, Performances, La caméra recueille les confidences, Pourquoi toute cette violence, Violence, dans la rue, Dans la tête, Dans les mots, Dans les gestes, Violence pour faire mal, Ou sans y penser, Violence d’Hommes et de Femmes, De passé et d’avenir, D’individus et de société, Violence d’ignorance, D’indifférence, D’intolérance, Violence pour rester ou pour changer. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 977

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Surmonter l’héritage de la violence Forgiving the Legacy of Violence

FORGIVING THE LEGACY OF VIOLENCE

GHISLAIN DEVROEDE,DAN BAR ON,ANNE ANCELIN, BORIS CYRULNIK,ED BROADBENT Université de Sherbrooke Sherbrooke, Quebec, Canada Wars, as can be seen today, in different parts of the world, leave major sequelae, which can transcend generations, because the urge of vengeance triggered by this kind of trauma calls to be followed by another trauma, in a tempo of crescendo. For instance, Milosevic brought on June 28, 1989, to Pristina, Kosovo, the remnants of Prince Lothar beheaded by the Turks on June 28, 1389, and this triggered the Kosovo war. In contrast, the bereavement process permits to overcome the need for vengeance and to stop the iterative process of traumatizing out of vengeance. Projective identification is also at play, leading some from the trauma inflicted upon the Jewish people by the nazi perpetrators, to that inflicted upon Palestinians by a fraction of people living today in Israel. Yet,it has been shown that descendants of perpetrators suffer just as much as descendants of the victims, and that they can be brought to work together, as a group, in a process of bereavement and reconciliation. Finally, there is the question of what constitutes resiliency, how it occurs, how it is effective, on a relative or absolute basis, and whether the fact that it rests on a fundamental trauma, can influence future generations. These issues will be explored and discussed by a number of experts in these areas. Professor Dan Bar On has written “The legacy of silence”,and a number of other books. He discovered the hurt of the descendants of nazi perpetrators, just as well as he knew that of the descendants of the victims of the Holocaust, and succeeded to put together descendants from both sides. He later inspired groups composed of black and white South Africans, people from Israel and the Palestine, and people from North and South Ireland. Professor Anne Ancelin Schntzenberger has written,“Aie, mes aieux”,showing how we are acted out by history. Now published over 100000, this book has been translated in different languages, among them English (“The ancestors syndrome “).She will show how wars leaves traces beyond the traumatized generation. She will also show clinical evidence for an “anniversary syndrome “ encompassing several generations. Boris Cyrulnik has written and talked extensively on resiliency, and is the author of popular recent books, such as “Un mer- veilleux malheur”,“Les vilains petits canards”,et “Les nourritures affectives”.The presentations of the following topics will be done: 1. About the resilient nature of some individuals which allows them to go through hardship; 2. About the transmission of past traumas that act out unconsciously future generations, in a compulsive behaviour, with the added on drama of simplistic venge- ful behaviour; 3. About the bereavement process and true forgiveness, apart from any kind of denial or repression. BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 978

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These presentations will be followed by a group discussion to find ways to have more peace on earth, and less reactional violence in an endless spiral. Working through forgiveness is a difficult process, full of pitfalls, and still largely not practiced. Forgiveness is the essence of the subject of this round table.

A FEASIBILITY STUDY TO ESTIMATE GLOBAL PREVALENCE OF INTENTIONAL INJURIES IMPACT ON HUMAN COMMUNITIES

PAOLA FACCHIN,FRANCESCO ZAMBON,ALBERTO DANI,CRISTINA RANZATO, SILVIA MANEA,CAROL DJEDDAH,CLAUDE ROMER Epidemiology and Community Medicine Unit, Paediatrics Department, University of Padua Padova, Padova, Italy

PROBLEM UNDER STUDY: The lack of epidemiological data on the whole impact of intentional injuries on human communities health.

LIMITS: The possibility to compare the result of actions of community protection and its safety promotion to other public health activities in order to select macro priorities of intervention. Moreover, several objective difficulties make quite impossible a direct survey of the phenomenon in most world countries.

OBJECTIVES: The aim of the study is to test the hypothesis to produce an indirect estimation of violence impact on community health starting from available unspecific data describing the different countries.

METHOD OR APPROACH: The preliminary results of the feasibility study based on the sequen- tial use of two complex methods of data processing, are reported. The first method is based on clusters obtained from Self-Organizing Map (SOM), a neural network model based on unsupervised learning extremely powerful in determining complex units aggregations through multivariate vector matrices that shows high robustness also in case of many lacking data. The second method consists in multivariate regression models. The feasibility study is based on 22 Countries (Algeria, Ethiopia, Nigeria, South Africa, Uganda, Brazil, Colombia, USA of America, Egypt, Jordan, Pakistan, Somalia, Italy, Kazakhstan, Russian Federation, UK, India, Thailand, Australia, China, Japan, Philippines), selected in order to represent the World whole complexity and the 60% of the world-wide population. For each country all data available comprehending demographic, economic, social, cultural, political, medical and health organization data, have been collected using international databases from reliable international sources. It has been determined 172 indicators and more than 120 variables sufficiently available for almost all the countries have been collected for each one of them: after the screening of the overflowing information utilizing correlation matrices, data have been processed through the following analytical steps: 1. Cluster identification of homogeneous countries by SOM; 2. In case of lacking data, input of the central value of the cluster which the country belongs to; BONNE_MAQUETTE.QXD 4/17/02 11:54 AM Page 979

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3. Check of countries clusters homogeneity through variance analysis as regards outcome variables, indirect estimation or proxy of social violence (i.e. homicides rate, suicides rate, etc.); 4. Generation of regression models, utilizing the same variables that generated countries clusters and values input for lacking data, useful to violence phenomenon estimation and general health status description for countries whose data were not available; 5. Double validation of the generated models utilizing data of three countries (Canada, France, Mozambique) whose values were not used to build the models.

RESULTS: Fine prediction results were obtained by the created model, showing r=0.98 for infant mortality rate and r=0.93 for mortality rate violence related. The double validation confirmed method’s goodness and robustness.

CONCLUSION: Following this method it seems possible to reach good estimation useful to health policy at macro-level avoiding global direct monitoring of each aspect of the phenomenon.

LIMITS: The method explained in the present study was validated, so far, only for outcomes of extreme expressions of violence, such as homicides and suicides. It will be necessary to generate multivariate vectors that should be utilized as dependent variables for outcomes understated and of strong complexity such as psychological and social damages related to violence.

CONTRIBUTION OF THE PROJECT TO THE FIELD: Although these limit exist, new assumptions can be defined utilizing this method and its results: 1. It is possible to get crude estimation of violence and injuries impact, quickly and at very low costs, immediately available for health policies by countries and international organizations; 2. There are strong associations between a restricted number of background variables and intentional injuries magnitude, that highlight the existence of direct causal relations; 3. It is possible to generate Countries homogeneous clusters that show analogous trend as regards the most relevant health indicators (i.e. specific mortality rates).