National Family Safety Program, NGHA
January 28th and 29th 2013
Presentation 6. Step 3 of the Public Health
Approach to Child Maltreatment Prevention:
Prevention Strategies
Presented by
Alaa Sebeh, MD Ph.D.
Independent International Consultant,
Child Protection & Disability.
[email protected]
Violence and Injury Prevention Short Course
Objectives
The core learning objective of this module is to provide an
understanding of the evidence base for effective child
maltreatment prevention strategies and the importance of
rigorously evaluating the effectiveness of such strategies.
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Outline
1. Two Main Ways of Classifying Prevention Programmes
2. Evidence-Based Prevention and Programme Effectiveness
3. Prevention Strategies by Development Stage and Levels of
Ecological Model
4. Summary and Conclusion
Violence and Injury Prevention Short Course
Classifying Prevention Programmes
Violence and Injury Prevention Short Course
The Public Health Approach Goal
Step 3 of the public
health approach to child
maltreatment concerns
selecting or developing,
implementing, and
rigorously evaluating
programmes to prevent
child maltreatment.
1.Define &
describe
What is the
Problem?
2.Identify risk
What are the risk
factors and
causes?
4. Scaling up and
cost-effectiveness
Implement on
large scale & cost
3.Develop and
evaluate
interventions
What works
and for whom?
Violence and Injury Prevention Short Course
Classifying Prevention Programmes
Public health prevention programmes are traditionally classified in one of two ways:
1. According to the time of the programme:
•Primary prevention – Approaches that aim to prevent violence before it occurs
• Secondary prevention – Approaches that focus on the more immediate responses to
violence
• Tertiary prevention – Approaches that focus on long-term care in the wake of violence
2. According to the level of risk of those receiving the programme:
• Universal programmes – Aimed at the general population without regard to risk
• Selective programmes – Aimed at people at higher risk
• Indicated programmes – Those carried out once child maltreatment has already
occurred
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Strengthening Primary Prevention
Many efforts in the field of child maltreatment to date, in both industrialized
and developing countries, have focused on secondary and tertiary responses
to violence.
Such responses should be accompanied by a greater investment in primary
prevention. There are two main reasons for this:
1. Child maltreatment affects an important proportion of children.
2. Evidence strongly suggests that treating and trying to remedy the
effects of child maltreatment are both less effective and more costly than
preventing it in the first place.
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Evidence-Based Prevention and
Programme Effectiveness
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Defining Evidence-Based Prevention
Evidence-based prevention is the selection, design, and implementation of prevention
programmes with reference to findings from quantitative scientific studies of what
works to reduce the frequency of child maltreatment.
Effectiveness can only be demonstrated through outcome evaluation studies using
rigorous research designs.
One major concern is to be able to rule out alternative explanations for any observed
changes in outcome in order to be confident that the changes really were due to the
intervention and not some other factor.
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Criteria to Systematically Evaluate the
Effectiveness of Different Programmes
Approaches that are based upon testimonials might expend significant resources
and capacity on programmes that may be ineffective or that may even make
things worse.
The most stringent criteria involve programme evaluation using:
• Randomized-controlled trials
• Evidence of significant preventive effects
• Evidence of sustained effects
• Independent replication of outcomes
To design rigorous outcome evaluations, partnership with an academic or
research institution with the relevant expertise is necessary.
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Levels of Evidence for Effectiveness
•An effective prevention programme is one that reduces the incidence of child
maltreatment in the intervention population
• A promising prevention programme is one that has been evaluated with a strong
design, showing some evidence of a preventive effect but requiring more testing.
• An unclear prevention programme is one for which the evidence of effectiveness is
insufficient or the findings are contradictory.
• An ineffective prevention programme is one for which evidence using a strong
research design shows that the programme has no preventive effect.
• An harmful prevention programme is one for which the evidence using a strong
research design shows that the incidence of child maltreatment in fact increased due
to the programme.
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Effectiveness of Child Maltreatment
Prevention Programmes
Intervention type
Early home visitation
Parenting education
Child sexual abuse prevention
Prevention of abusive head trauma
Multi-component programmes
Effective
Promising
Unclear
Not effective
Media-based interventions
Support and mutual aid groups
Source: Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health
Organization. 87, 353–361
Violence and Injury Prevention Short Course
Systematic Review of the Effectiveness of Child
Maltreatment Programmes
The best source of evidence for the effectiveness of child maltreatment prevention
programmes are systematic reviews:
Systematic reviews help us tell the difference between real and assumed knowledge.
The main aims of systematic reviews are to:
• Provide an authoritative overview of current evidence
• Establish “what works” or clear up uncertainty, when previous research on a
question has been conducted
• Identify gaps in existing research and plan new research agendas
• Make the knowledge base on a particular subject more accessible
• Inform practice and policy
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Evidence of Effectiveness According to
Systematic Review
1 = harmful
2 = not effective
3 = insufficient, weak, or mixed evidence
4 = promising - No programme effective for actual CM
5 = effective
- 4 types promising for actual CM
Source: Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health Organization.
Violence and Injury Prevention Short Course
Evidence of Effectiveness According to a
Recent Review in the Lancet
In a special series on child maltreatment, the Lancet, found the following:
• Home-visiting programmes are not uniformly effective in reducing child physical
abuse; those that have shown benefits are the Nurse Family Partnership and Early
Start.
• The Triple P—Positive Parenting Program—has shown positive effects on
maltreatment and associated outcomes.
• Hospital-based educational programmes to prevent abusive head trauma and
provide care for families of children at risk of physical abuse and neglect show promise
but require further assessment.
• School-based educational programmes improve children’s knowledge and protective
behaviours; whether they prevent sexual abuse is unknown.
(MacMillan et al., 2009)
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The Evidence Base is Almost Exclusively
from High-Income Countries
Source: Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health
Organization.
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Strategies by Developmental Stages and Levels
of the Ecological Model
Violence and Injury Prevention Short Course
Strategies by Developmental Stages and Levels
of the Ecological Model
Because violence is a multifaceted problem with biological, psychological,
social, and environmental roots, it needs to be confronted on several different
levels at once.
The ecological model serves a dual purpose in this regard: Each level in the
model represents a level of risk, and each level can also be thought of as a key
point for intervention.
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Strategies that Cut Across Developmental Stages at the Societal and
Community Levels: Beneficial Social and Economic Policies
One strategy that cuts across developmental stages at the societal and community
levels is to introduce beneficial economic and social policies.
Good social and economic policies can most likely help prevent child maltreatment
Social and economic policies that can probably help prevent child maltreatment include:
• The provision of early childhood education and care
• Universal primary and secondary education
• Measures against unemployment
• Good social protection systems
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Strategies that Cut Across Developmental Stages at the Societal
and Community Levels: Changing Social and Cultural Norms
Another strategy that cuts across developmental stages at the societal and
community levels is to change social and cultural norms.
Social and cultural norms are powerful contributing factors to child
maltreatment. They are frequently used to justify violence against children.
To help change social and cultural norms, public awareness and media
campaigns can likely play a role.
These can highlight the extent and nature of child maltreatment and encourage
the provision of services to children and families.
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Summary and Conclusion
Violence and Injury Prevention Short Course
Summary and Conclusion
This module reviewed:
• The Two Main Ways of Classifying Prevention Programmes
•Evidence-Based Prevention and Programme Effectiveness
•Strategies by Developmental Stages and Levels of the Ecological Model
Creating a strong evidence base for the effectiveness of child maltreatment prevention
strategies requires carrying out rigorous outcome evaluation studies.
Currently, there are many promising child maltreatment programmes, but almost none
have proven to be effective.
Outcome evaluation studies should be a priority, especially in low- and middle-income
countries. At this stage of the development of the field, it is vital to take action while
generating evidence.
Violence and Injury Prevention Short Course
References
Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action
and generating evidence. Geneva, World Health Organization.
Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teachvip.edc.org/course/view.php?id=23
Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences
of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14.
The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 169-194.
Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.
MacMillan, H. Wathen, C. Barlow, J. Fergusson, D. Leventhal, J. Taussig, H. (2009). Interventions to
prevent child maltreatment and associated impairment. The Lancet, Volume 373, Issue 9659, Pages
250-266
Mickton, C. (2010). Module 6 PowerPoint Presentation. Geneva, World Health Organization.
Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin
of the World Health Organization. 87, 353–361
Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.
Violence and Injury Prevention Short Course
Activity: Analysing Methods and Results
of Systematic Reviews
1.
Break into small groups of 3–5 people. Each group will be assigned either
Article 1 or Article 2.
2.
Summarize the method used in and the main results of the systematic review
on the effectiveness of child maltreatment prevention in the article you were
assigned.
3.
Discuss how these findings might potentially be applied to your area of work.
Violence and Injury Prevention Short Course