Contextual Effects in School-Based Violence Prevention Programs: A Conceptual Framework and Empirical Review

This paper reviews the theoretical and practical importance of studying contextual factors in school-based violence prevention programs and provides a framework for evaluating factors at the classroom, school, and community/district level. Sixty-two published papers describing 38 different programs were reviewed; of these 16 were identified that reported data on contextual effects or discussed possible contextual effects on the intervention. The small number of studies precludes definitive conclusions regarding contextual effects in school-based violence prevention programs, but suggests (a) some evidence for contextual effects on program outcomes, and (b) interdependence of context and implementation factors in influencing outcomes.Editors' Strategic Implications: This review suggests that contextual effects are important to school violence prevention, as context can influence outcomes directly and through interactions with implementation factors. Consequently, characteristics of the classroom, school, and community contexts should be considered by practitioners when implementing prevention programs and measured by researchers studying the processes and outcomes of these programs.     

Cultural Context of School Communities in Rural Hawaii to Inform Youth Violence Prevention*

BACKGROUND: Escalation of youth violence within a large geographic school-complex area in southeastern rural Hawaii became a major problem in 2006. How cultural forces impact the problem was an impetus to examine youth violence from perspectives of adults and children in rural communities. Gathering these data was an essential first step toward school-based youth violence prevention program development. METHODS: Eight focus groups involving 86 community stakeholders included 51 adults (parent, teachers, school staff, community leaders) and 35 children aged 8-15 years old (3rd- to 10-th grade). Qualitative narrative analysis elicited major themes. RESULTS: Five themes emerged: (1) School-community violence takes on many forms that become entrenched in local culture. (2) Disintegration of community resources and a sense of learned helplessness underlie the escalation of youth violence. (3) Inadequate role modeling coupled with behavioral ambivalence among adults has sustained a climate of local cultural acceptance with youth violence. (4) Connection to cultural values has diminished, leading to a sense of loss in cultural identity among students. (5) Cultural values and practices are potential strategies for youth violence prevention. CONCLUSIONS: Cultural and community contextual factors contributed to youth violence in rural Hawaiian communities. Study implications include the need to further investigate the impact of vigilant, community involvement of stakeholders in school-based youth violence prevention program development. Cultural revitalization at family, school, and community levels may be critical success factors of such programs.     

Needs for Youth Substance Abuse and Violence Prevention in Schools and Communities

Substance abuse and violence among today's youth are at an all time high. Numerous prevention programs have been implemented to address these issues. Not all are successful. Research has found that when schools and communities are involved in the planning of prevention programs, youth are more cognizant of risk factors and of behaviors that strengthen risk factors. The purpose of this study was to assess the emerging needs for prevention and health education among youth, and to identify effective approaches for prevention program development and service delivery in schools and communities. This study surveyed 312 youth prevention specialists, school and community health educators and counselors, and parents in a regional sample of ten states. Results indicated that substance abuse and violence are the two most critical and priority issues in need of comprehensive prevention. Multiple prevention service delivery strategies appropriate to youth, including training, technical assistance, conferencing and networking, needs assessment and evaluation, and information requests are discussed in detail. Implications for prevention programming emphasized reducing risk factors and strengthening protective factors, reaching and motivating youth participation.     

Ideology and injury prevention

Data from a recently completed study of head injuries reveal that many of these injuries, and deaths from these injuries, result from interpersonal violence and automobile accidents. Such injuries are normally difficult to prevent. In this study it was found that much of the interpersonal violence involves family members and many of the vehicle accidents, especially those that result in death, happen to pedestrians. Prevention thus becomes even more difficult. Based upon these data and observations, five categories of prevention strategies are generated and evaluated. It is determined that the four strategies usually within the domain of traditional prevention (inaction, education, legislation, and design alterations) are not likely to prevent many head injuries or injuries in general. A fifth category is thus recommended. This category requires meaningful involvement of people into work that impacts on the social and political reality of their lives. The prevailing ideology of prevention offered by the health professions is considered and is found to be in opposition to our fifth prevention category. The implications of this opposition are examined and the search for improved health is considered in this context.     

The association between exposure to interpersonal violence and suicide among women: a systematic review

Objective : To review the association between exposure to interpersonal violence and suicide among women. Methods : In accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses Protocol (PRISMA‐P), this review examined articles identified by using the key terms ‘interpersonal violence’, ‘suicide’ and ‘death’. Of 5,536 articles identified, 38 met the a priori inclusion criteria. These required that studies examined interpersonal violence, included women and completed suicide was a measured outcome. Results : Thirty‐eight studies were identified. These examined suicides among women exposed to interpersonal violence as a victim (n=27) or perpetrator (n=14). A history of interpersonal violence was identified in 3.5–62.5% of female suicides, with many articles finding victims of abuse have an increased risk of death from suicide. Females perpetrating violence may also be at increased the risk of death from suicide. However, several papers have questioned these associations. Further, the contribution of mental illness to this association is unclear. Conclusions : Although the association between suicide and interpersonal violence requires further investigation, being a victim or perpetrator of violence appears to be associated with risk of suicide. Future research should focus on the impact that the type of violence, victim‐perpetrator relationship and proximity of violence has on the risk of death from suicide. Implications for Public Health : There may be significant opportunity for targeted suicide prevention strategies among women who have been victims or perpetrators of interpersonal violence.     

Looking ahead toward community-level strategies to prevent sexual violence

The Division of Violence Prevention within CDC's National Center for Injury Prevention and Control recently undertook a systematic review of primary prevention strategies for sexual violence (SV) perpetration. This review identified the lack of community-level strategies to prevent SV as a critical gap in the literature. Community-level strategies function by modifying the characteristics of settings (e.g., schools, workplaces, neighborhoods) that increase the risk for violence victimization and perpetration. Identification of evidence-based strategies at the community level would allow implementation of ecologic approaches to SV prevention with a greater potential for reducing the prevalence of SV perpetration. The field will face several challenges in identifying and evaluating the effectiveness of promising community-level strategies to prevent SV. These challenges include limited knowledge of community-level and societal-level risk factors for SV, a lack of theoretical or empirical guidance in the SV literature for identification of promising community-level approaches, and challenges in evaluating SV outcomes at the community level. Recognition of these challenges should guide future research and foster dialogue within the SV prevention field. The development and evaluation of community-level approaches to SV prevention represent a vital and logical next step toward the implementation of effective, multilevel prevention efforts and a population-level reduction in the prevalence of SV.     

The role of housing in determining HIV risk among female sex workers in Andhra Pradesh, India: considering women's life contexts

Recent research on HIV prevention, regardless of the population, has increasingly recognized the relevance of contextual factors in determining HIV risk. Investigating such factors among female sex workers (FSW) is especially relevant in the South Indian state of Andhra Pradesh, where HIV rates are among the highest across Indian states and where HIV has largely affected FSW. Stable housing is a particular contextual challenge experienced by female sex workers in this region (as well as elsewhere); however, local studies have not examined the impact of this issue on HIV risk. In this paper, we examine residential instability, defined as a high frequency of reported evictions, among FSW and relation to experiences of violence (as a factor increasing risk for HIV) and sexual risk factors for HIV. Women were recruited through respondent-driven sampling for a survey on HIV risk. Using logistic regression models, we assessed: (1) residential instability and association with HIV sexual risk variables (including unprotected sex, reported STIs, and recent physical and sexual victimization) and (2) whether the association between residential instability and reported STI (as an indicator of HIV risk) was attenuated by individual risk behaviors and violence. In adjusted logistic regression models, FSW who reported residential instability were more likely to report: sexual violence, physical violence, accepting more money for unprotected sex, and a recent STI symptom. Violence associated with residential instability contributed to reported STIs; however, residential instability remained significantly associated with STIs beyond the influence of both violence and unprotected sex with clients. Findings highlight the interrelation among residential instability, violence, and HIV risk. Residential instability appears to be associated with women's HIV risk, above and beyond its association with individual risky sexual behaviors.     

Supportive family contexts: promoting child well-being and resilience

Prevention and intervention programmes for children at risk aim to improve child well-being and resilience. They do so using both direct and indirect strategies, intervening with children but also considering broader contextual factors (such as family dynamics). Children's subjective well-being comprises five main components (physical health, mental health, self-regulation, social competence, and cognitive competence) and is predicted by person, relationship, and contextual factors. Children's resilience, or ability to beat the odds under adverse conditions, is predicted by similar protective factors. Family well-being (FWB) is one of the strongest and most consistent predictors of child well-being and resilience. Aspects of FWB (including adult health and well-being, family self-sufficiency, and family resiliency) have been shown to impact child well-being through positive parent–child interactions. However, risk factors (including poverty and living in geographic locales with limited resources or high levels of neighbourhood violence) can threaten both family and child well-being. Strategies are offered for promoting FWB as a means of supporting resilience and well-being in children at risk for violence, abuse, or neglect.     

The Impact of Contextual Factors on Comprehensive Sexuality Education for Learners with Intellectual Disabilities in South Africa

Adolescents and youth with disabilities in South Africa still lack access to sexual and reproductive health and rights services including comprehensive sexuality education, which may increase their vulnerability to SRHR issues such as HIV and sexual violence. This is exacerbated for learners with intellectual disabilities whose educators often lack skills and tools to accommodate these learners in comprehensive sexuality education lessons. The following paper outlines the findings of a formative evaluation of an innovative sexuality training approach for educators of learners with diverse disabilities (Breaking the Silence approach). This approach was developed and piloted with educators across eight schools for learners with intellectual disabilities in KwaZulu-Natal, South Africa. The paper discusses the educators’ understanding and experiences of using this approach. The findings revealed that although educators were able to implement parts of the approach, contextual factors impacted the degree of implementation. These factors were related to perceptions of socio-cultural norms, interpersonal engagement with peers and management, the structural environment of school settings, and the wider community setting. Educators began to address cultural taboos related to talking about sexuality, but were challenged by untrained staff and the larger socio-cultural context, which includes a heighted risk of sexual violence against their learners. The paper concludes with recommendations for a further investigation of the approach within a whole school setting considering the needs of educators to not only acquire skills and knowledge but also to address their larger socio-cultural context in which they have to implement comprehensive sexuality education.     

Designs for Evaluating the Community-Level Impact of Comprehensive Prevention Programs: Examples from the CDC Centers of Excellence in Youth Violence Prevention

This article discusses the opportunities and challenges of developing research designs to evaluate the impact of community-level prevention efforts. To illustrate examples of evaluation designs, we describe six projects funded by the Centers for Disease Control and Prevention to evaluate multifaceted approaches to reduce youth violence in high-risk communities. Each of these projects was designed to evaluate the community-level impact of multiple intervention strategies to address individual and contextual factors that place youth at risk for violent behavior. Communities differed across projects in their setting, size, and how their boundaries were defined. Each project is using multiple approaches to compare outcomes in one or more intervention communities to those in comparison communities. Five of the projects are using comparative interrupted time-series designs to compare outcomes in an intervention community to matched comparison communities. A sixth project is using a multiple baseline design in which the order and timing of intervention activities is randomized across three communities. All six projects are also using regression point displacement designs to compare outcomes within intervention communities to those within broader sets of similar communities. Projects are using a variety of approaches to assess outcomes including archival records, surveys, and direct observations. We discuss the strengths and weaknesses of the designs of these projects and illustrate the challenges of designing high-quality evaluations of comprehensive prevention approaches implemented at the community level.     

Physical and sexual violence,childhood sexual abuse and HIV/STI risk behaviour among alcohol-using women engaged in sex work in Mongolia

Although the prevalence of human immunodeficiency virus (HIV) in Mongolia is low, it could increase without strategic prevention strategies. Female sex workers (FSWs) often experience barriers to prevention, including interpersonal violence. This study investigated if childhood sexual abuse (CSA) or recent physical or sexual violence was associated with HIV sexual risk behaviours and if CSA modified associations between recent violence and HIV sexual risk behaviours. Two-hundred twenty-two women who (1) were at least 18 years old and clients at the National AIDS Foundation; (2) reported vaginal or anal sex in the past 90 days in exchange for money or goods and (3) met criteria for harmful alcohol use in the past year were enrolled. In-person interviews assessed sexual risk behaviours and violence in childhood and adulthood. Negative binomial regression, ordinary least squares regression and modified Poisson regression were performed. Sexual risk with paying partners was associated with penetrative CSA and sexual violence by paying partners. CSA and recent violence were not associated with sexual risk behaviours with intimate partners. CSA modified the association between recent sexual violence and unprotected sex with intimate partners. Findings highlight the need for integrated violence and sexual risk reduction services to ensure safe and effective prevention for FSWs.     

Context of Risk for HIV and Sexually Transmitted Infections Among Incarcerated Women in the South: Individual,Interpersonal, and Societal Factors

Incarcerated women are disproportionately affected by HIV and sexually transmitted infections (STIs) due to risk factors before, during, and after imprisonment. This study assessed the behavioral, social, and contextual conditions that contribute to continuing sexual risk behaviors among incarcerated women to inform the adaptation of an evidenced-based behavioral intervention for this population. Individual, in-depth interviews were conducted with 25 current and 28 former women prisoners to assess HIV/STI knowledge, perceptions of risk, intimate relationships, and life circumstances. Interviews were independently coded using an iterative process and analyzed using established qualitative analytic methods. Major themes identified in the interviews involved three focal points: individual risk (substance abuse, emotional need, self-worth, perceptions of risk, and safer sex practices); interpersonal risk (partner pressure, betrayal, and violence); and risk environment (economic self-sufficiency and preparation for reentry). These findings highlight the critical components of HIV/STI prevention interventions for incarcerated women.     

Domestic violence in South Australia: a population survey of males and females

Objective: To determine the self‐reported prevalence of domestic violence in South Australian adults and to examine the associated risk factors, demographic factors and related health issues using computer‐aided telephone interviewing (CATI) methodology. Sample: A representative random sample of South Australian adults aged 18 years and over selected from the Electronic White Pages. Overall, 6,004 interviews were completed (73.1% response rate). Results: In total, 17.8% of adults in South Australia reported some form of domestic violence by a current or an ex‐partner. Demographic factors such as low household income, unemployment or part‐time employment and health variables such as poor to fair self‐reported health status and alcohol abuse problems were found to have a significant relationship with domestic violence. Conclusions: Approximately one in five South Australian adults report physical and emotional abuse from current or ex‐partners, of whom the majority are women who are separated, divorced or never married and on lower incomes. Telephone interviewing is a cost‐effective method of identifying prevalence estimates of domestic violence when compared with data collection by way of police reports or hospital emergency statistics. Implications: Domestic violence is a serious public health concern often ‘hidden’ by the lack of appropriate data. This study has shown that domestic violence is frequent and has important social, economic and health consequences.     

Community influences on adolescents' use of home-brewed alcohol in rural South Africa

ABSTRACT: BACKGROUND: Alcohol represents a major public health challenge in South Africa, however little is known about the correlates of alcohol use among rural adolescents. This article examines community influences on adolescents' use of home-brewed alcohol in a rural region of South Africa. METHOD: A total of 1600 high school adolescents between 11 and 16 years of age participated in this study. Seven hundred and forty (46.3 %) were female and 795 (49.7 %) were male. Data on gender were missing for 65 students (4.0 % of the sample). The age range was 11--29 years (mean age 16.4 years; Standard deviation = 2.79).A survey questionnaire on adolescent risk behavior that examined adolescents' use of alcohol and various potential community influences on alcohol use was administered. Factor analysis was used to group community-level variables into factors. Multiple logistic regression techniques were then used to examine associations between these community factors and adolescents' use of home-brewed alcohol. RESULTS: The factor analysis yielded five community-level factors that accounted for almost two-thirds of the variance in home-brewed alcohol use. These factors related to subjective adult norms around substance use in the community, negative opinions about one's neighborhood, perceived levels of adult antisocial behavior in the community, community affirmations of adolescents, and perceived levels of crime and violence in the community (derelict neighborhood). In the logistic regression model, community affirmation was negatively associated with the use of home-brew, whereas higher scores on "derelict neighborhood" and "adult antisocial behavior" were associated with greater odds of drinking home-brew. CONCLUSION: Findings highlight community influences on alcohol use among rural adolescents in South Africa. Feeling affirmed and valued by the broader community appears to protect adolescents against early alcohol use. In contrast, perceptions of high levels of adult anti-social behavior and crime and violence in the community are significant risks for early alcohol initiation. Implications of these findings for the prevention of alcohol use among adolescents in rural communities are discussed.     

Interpersonal violence: an important risk factor for disease and injury in South Africa

Background  

Burden of disease estimates for South Africa have highlighted the particularly high rates of injuries related to interpersonal violence compared with other regions of the world, but these figures tell only part of the story. In addition to direct physical injury, violence survivors are at an increased risk of a wide range of psychological and behavioral problems. This study aimed to comprehensively quantify the excess disease burden attributable to exposure to interpersonal violence as a risk factor for disease and injury in South Africa.     

Understanding the Role of Culture in Domestic Violence: The Ahimsa Project for Safe Families

Domestic violence affects women across all racial, national, social, and economic groups. In particular, immigrant and refugee families are at risk for domestic violence because of their migration history and differences in cultural values and norms. The Ahimsa for Safe Families Project is an innovative collaborative project that addresses domestic violence in immigrant and refugee communities in San Diego. The project is designed to increase awareness of domestic violence among Latino, Somali, and Vietnamese communities and to develop and implement culturally specific programs aimed at each community. Here the authors describe the Project's needs assessment and communitydialogues that guided the development of specific interventions; present the lessons learned; and describe replicable, culturally specific prevention strategies utilized by the Project.     

Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa

Gender-based violence is a key health risk for women globally and in South Africa. The authors analyzed data from 1,395 interviews with women attending antenatal clinics in Soweto, South Africa, between November 2001 and April 2002 to estimate the prevalence of physical/sexual partner violence (55.5%), adult sexual assault by nonpartners (7.9%), child sexual assault (8.0%), and forced first intercourse (7.3%). Age at first experience of each type of violence was modeled by the Kaplan-Meier method, and Cox hazard models with time-varying covariates were used to explore whether child sexual assault and forced first intercourse were associated with risk of violent revictimization in adulthood. Child sexual assault was associated with increased risk of physical and/or sexual partner violence (risk ratio = 2.43, 95% confidence interval: 1.93, 3.06) and with adult sexual assault by a nonpartner (risk ratio = 2.33, 95% confidence interval: 1.40, 3.89). Forced first intercourse was associated with increased risk of physical and/or sexual partner violence (risk ratio = 2.64, 95% confidence interval: 2.07, 3.38) and nonsignificantly with adult sexual assault by a nonpartner (risk ratio = 2.14, 95% confidence interval: 0.92, 4.98). This study confirms the need for increased attention by the public health community to primary and secondary prevention of gender-based violence, with a specific need to reduce risk among South African adolescents.     

An exploration of the understandings of drug use from young drug users’ perspectives in the Western Cape: implications for primary prevention

ABSTRACT

The high rate of substance abuse among youth in South Africa is a clear indication of the level to which this issue has infiltrated the South African society. Drug abuse at an early age has been associated with problems, such as risky sexual behaviours, health problems, depression, crime, and ultimately drug addiction, which often occur at a later stage. There are many interrelated reasons and risk factors for drug use among youth and studies have mostly focussed on familial and other broader social environments such as peer/neighborhood factors for use. Less attention has been focussed on the internal or psychological factors at play in the lives of young users. This study aimed to fill this gap by exploring young drug users’ perceptions of the internal or psychological factors cited as their reasons for drug use. A better understanding of the internal risk factors that influence adolescent drug use is crucial for the development of effective prevention strategies. A qualitative method of inquiry was applied to gather in-depth data from a purposive sample of 41 young (14–19 years of age) drug users, at five drug treatment centres in the Western Cape. The findings of this study revealed that internal factors such as a permissive and/or positive attitude towards drugs, a deficit in social skills; a lack of self-esteem, and poor/maladaptive coping mechanisms were at play in the lives of the adolescents in this study. Implications for primary prevention were considered, as these findings underscore the need to consider these internal risk factors when developing interventions to reduce adolescent drug abuse.     

New levels of understanding: methods for revealing structural links to chronic disease

Research on the etiology and course of illness typically follows a biological model emphasizing the individual as the primary unit of analysis. The result has been a narrowed orientation that focuses a great deal of resources on individual-level interventions and much less attention to underlying factors that contribute to the prevalence of disease. Chronic diseases such as asthma, coronary disease, ulcers, diabetes, and cancers, however, have been found to be affected by multiple factors on various levels of analysis, defying attempts to ‘individualize’ risk and prevention. The study of structural factors that underlie health outcomes can reveal important information that normally remains undetected during clinical and epidemiological research on individual risk factors. Research that incorporates contextual variables of a physical, social, biological, temporal, or economic nature can help identify patterns of illness across space and time and factors that predispose a population to greater health disparities. This article reviews the theoretical basis and methods for improving the validity of ecological studies in addressing contextual variables. In particular, research design incorporating multiple levels of analysis and geographic information systems (GIS) is examined to address some of the challenges to incorporating community information. Community-based studies are described to illustrate this approach to ecological research. Finally, suggestions are offered for the further development of ecological and contextual research strategies in public health interests.     

Interventions Using Regular Activities to Engage High-Risk School-Age Youth: a Review of After-School Programs in Latin America and the Caribbean

In this paper, I review an issue that is an urgent challenge in the development field—the effectiveness of after-school programs for preventing school-age youth violence in vulnerable settings in Latin American and the Caribbean. These programs have proliferated in the region and include sports, recreation, music, tutoring, and other focused activities. Given their popularity and because they target known risk factors for violence (such as drop-out from school, poor academic performance, lack of motivation, too much idle time, low quality and quantity of adult supervision, and social isolation), it is critical to examine empirically whether they can be effective prevention strategies. Unfortunately, most rigorous trials of after-school interventions to prevent youth violence have been conducted in developed countries, with far fewer in Latin America. In this review, a broad range of databases was searched systematically. Only six studies in five Latin American and Caribbean countries were identified. Reported results indicate at least some benefits for youth behavior, although not across all youth. Additional concerns regarding how these programs are implemented and whether specific components can be tied to violence prevention are noted. The need for more rigorous evaluation of these programs is noted.