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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary 5 What Is Working Around the World in Violence Prevention? Linda Dahlberg, the moderator of this panel, remarked on the multiple presentations noting that violence is a global public health problem that is linked to many other health problems and disease outcomes. Before the World Report on Violence and Health (WHO, 2002a) and recent United Nations’ studies on violence against women and children challenged the notion that violence is not predictable and preventable, many people perceived it as an inevitable part of the human condition—a fact of life to respond to rather than prevent. Part of making the case that violence is preventable, she argued, rests in demonstrating that violence prevention programs work. However, funds supporting this research are scarce. Matzopoulos et al. (see Appendix C, 2007) state that of the $73 billion invested annually toward global public health research, less than 10 percent is devoted to research into the health problems that account for 90 percent of the global disease burden. Dahlberg mentioned that this phenomenon is known as the “10/90” gap and that violence is one of those health problems. Dahlberg noted that despite limited funding, the current state of science in violence prevention reveals progress, promise, and a number of remaining challenges. Promising and effective activities include interventions in early childhood; efforts to improve social, emotional, and behavioral competencies; efforts to improve family functioning and parenting practices so as to change social norms; and some effective approaches in terms of reducing concentrated disadvantage and access to lethal means. She pointed out that the majority of the evidence base comes from high-income countries, but there are violence prevention programs in many countries throughout the world. Unfortunately, many of these programs have not been systematically
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary and rigorously evaluated, and without this, there is the potential to actually do harm. Developing effective programs is a continuous and iterative process that requires sustained commitment and resources. It involves identifying the nature of the problem through good epidemiologic work; specifying and clarifying risk factors and, more importantly, trying to figure out how to translate those risk factors into prevention programs; and then the arduous task of testing and refining those programs and determining how best to facilitate their diffusion. This public health approach, she stated, can really make a difference in helping governments increase their knowledge of and confidence in workable interventions while providing them with alternative options to policing and public security to address violence. From her experiences in high-income countries and in a few low- and middle-income countries, she acknowledged that the process is doable. There are, however, some challenges, including empowering stakeholders with the tools for planning, developing, implementing, and evaluating programs—building infrastructure capacity in the countries. She asserted that this is a question not only for those who are involved in prevention work, but also for donors and decision makers in terms of where their investments could and should be made. Another challenge she identified is seeking economies of scale wherever possible and whenever feasible—that is, making the most of existing prevention infrastructures and expertise. She reiterated what was said earlier in the day about the tendency to work in silos and the need for more effective methods that call for really looking at the intersection of different types of violence, breaking down those silos, and determining how prevention efforts can be integrated so that we are not only changing one outcome but potentially changing many outcomes or reducing many types of violence. She also encouraged examining the intersection with other health outcomes and other health areas—for example, HIV infection or maternal and child health—to tap into existing prevention structures and expertise, acting accordingly, and possibly reducing multiple health problems. Her closing remark identified the challenge of really bridging science and practice. It is insufficient, she argued, just to identify effective programs. Determining how to disseminate those programs and policies and get them adopted in different settings and with different populations is critical—in other words, finding ways to accelerate what we do know that works. This is important not only for those who do this kind of work, but also for governments and the development community—everyone is a partner in making sure this is a reality. David Hawkins, Rodrigo Guerrero, Elizabeth Ward, and Charlotte Watts gave presentations to summarize what is known about the effectiveness of different interventions, the importance of data collection in guiding prevention efforts, the types of interventions and their outcomes, the
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary characteristics or components that support effectiveness, and challenges for effective programming and research. ADVANCES IN THE IDENTIFICATION OF EFFECTIVE POLICIES AND INTERVENTIONS David Hawkins’ presentation focused mainly on what is known about youth violence prevention in the United States, the evidence base that supports it, and what elements of effective interventions might be exportable to developing countries for implementation in their epidemiological contexts. The advances in youth violence prevention in the United States and other developed countries have occurred only during the last 27 years; prior to that, there had been only nine true experimental studies for delinquency prevention—and none of them were shown to be effective. The basic premise of the science-based, public health approach to violence prevention is that if you want to prevent a problem before it happens, you need to identify the predictors of that problem. Longitudinal studies that have followed children forward from birth or a bit older have identified factors that, when present in earlier childhood development, predict negative outcomes. Some of these individual, family, and community risk factors include early and persistent antisocial behavior, friends who engage in problem behaviors, alcohol and substance use, and constitutional factors which are individual characteristics carried forward over time and can be induced by the environment (ingestion of lead paint often leads to increased violent behavior) or be genetically determined; family conflict or management problems (failure to monitor children or set clear behavioral expectations; caregivers’ engaging in child maltreatment) and extreme economic deprivation; availability of drugs and firearms, community norms that are permissive of violence, and media portrayal of violence, respectively. Risk factors were also identified in schools, such as academic failure. These studies have identified not only risk factors, but also protective or promotive factors that appear to promote healthy, crime- and violence-free child development. These protective factors include high intelligence, resilient temperament, and competencies and skills in individuals. In the social domains of family, school, peer groups, and neighborhoods, they include prosocial opportunities; reinforcement for prosocial involvement; social bonding in family, schools, or neighborhoods; and healthy beliefs and clear standards of behavior. Hawkins stressed that even though there is consistency across samples from developed nations for these risk factors, none of them is a single cause of the adverse outcomes they can often predict in youth—such as substance abuse, teen pregnancy and paternity, dropping out of school, depression and anxiety, delinquency, and violence. They do, however, provide a convenient catalogue of risk factors that are potential
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary targets for prevention intervention. Multiple risk factors may appear in a number of environments, as well as in the individual, and these factors are also predictive of violence—the more factors that are present, the greater is the likelihood of violence instead of successful or healthier outcomes. He stated that this reinforces the need for multidisciplinary efforts to address the same risk factors if the goal is to prevent youth violence. EVIDENCE FOR EFFECTIVE AND INEFFECTIVE PREVENTION INTERVENTIONS Hawkins reviewed data from a number of controlled studies that have identified both effective and ineffective youth development policies and approaches. Some examples of ineffective approaches, also mentioned earlier by Irvin Waller, are Scared Straight, waivers to adult criminal courts, and gun buyback programs, which were associated with increased violent behavior after the supposed preventive or rehabilitative intervention. Hawkins asserted that we should not replicate these programs in developing countries if we are trying to profit from what has been learned in developed countries. However, in the United States and other developed nations, there have been well-controlled, randomized trials that have shown policies or intervention strategies in 12 different areas (e.g., parental and infancy programs, early childhood education, see Box 5-1) to be effective in reducing youth BOX 5-1 Effective Policies and Programs Identified for Youth Violence Prevention Prenatal and Infancy Programs Early Childhood Education Parent Training After-School Recreation Mentoring with Contingent Reinforcement Youth Employment with Education Organizational Change in Schools Community Mobilization School Behavior Management Strategies Community and School Policies Curricula for Social Competence Promotion Classroom Organization, Management, and Instructional Strategies SOURCE: Hawkins (2007).
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary violence or known risk or protective factors for youth violence. The Center for the Study and Prevention on Violence of the Institute of Behavioral Science at the University of Colorado at Boulder designed, launched and maintains the Blueprints for Violence Prevention Initiative, which identifies available programs that have been developed, tested, and shown to be effective. Their list of programs is available at http://www.colorado.edu/cspv/blueprints/. The Communities That Care® Prevention Strategies Guide produced by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), also lists programs that have been tested and shown to be effective in well-controlled trials; it is available at http://preventionplatform.samhsa.gov/. For effective strategies, the nurse-family partnership intervention has shown real evidence of long-lasting effects from a public health nurse visit during the second and third trimesters of pregnancy and the first two years of infancy, including reductions in prenatal health problems; maternal and child arrests and convictions; child abuse, neglect, and injuries; and welfare and food stamp use. Promoting Alternative Thinking Strategies (PATHS) is a school curriculum that is really involved in cognitive restructuring and in behavioral rehearsal—two potential pathways of intervention discussed by Dr. Garbarino—and can be implemented in the elementary grades for a cost of $82 per student in the first year, and half of that in the second year. Evidence for the effect of this program included improved self-control, improved understanding and recognition of emotions, improved conflict resolution strategies, and decreased conduct problems such as aggression. A minimal-cost program to prevent bullying in elementary and middle schools had the effects of reducing bullying by half, improving the school climate, and reducing antisocial behavior. Additional information on the costs and benefits of prevention programs is available at www.wa.gov/wsipp. One of Hawkins’ longitudinal studies in public schools of the Pacific Northwest has shown that creating opportunities for active involvement of children and reinforcing this involvement (from feeding classroom pets to working on team projects in schools or beautification projects in neighborhoods) reinforces social bonding, which subsequently reinforces positive norms and standards of behavior by which the child is likely to live. He stated that in America, the focus is on the standards that prohibit undesirable behavior but less on the process of promoting social bonding. By training everyday teachers and offering parenting workshops on emotional and skills development, they were able to see in six years, broad-ranging effects not only on lifetime violence, but also on alcohol use and sexual behaviors. Data from following the children to age 21 continued to show significant effects on those broad-ranging outcomes with the promotion of protective factors in high-risk environments.
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary In conclusion, Hawkins stated that investment in early childhood education, especially for low-income children, produces more benefits over the life of a child than it costs—with similar cost-benefit ratios seen in the nurse-family partnership interventions. Data collection to create epidemiological profiles of risk and protective factors to plan effective, multidisciplinary interventions, as well as data to document effective and ineffective programs, and dissemination at the community level to facilitate effective prevention planning, prioritization, and ownership are critically important. He also stated that efforts need to be made to reverse the trend, especially in the United States, of implementing programs that have been shown to be ineffective. Programs and policies that have been tested and shown to be effective can be used in developing countries, but they need to be adapted to the appropriate cultural context, and they have to be monitored and rigorously evaluated. INTERVENTION WITH MICROFINANCE FOR AIDS AND GENDER EQUITY (IMAGE) STUDY Charlotte Watts discussed the Intervention with Microfinance for AIDS and Gender Equity study—a community, randomized controlled trial in eight villages in South Africa—designed in two phases and intended to address two social risk factors for women’s vulnerability to violence and HIV: poverty and gender inequity. It was a collaborative effort between the London School of Tropical Medicine and Hygiene and the University of Witswatersrand’s School of Public Health in South Africa. The study targeted community mobilization, as well changes in economic sufficiency for individuals that could reduce their risk of exposure to HIV and violence. Their community partnerships were with a local microfinance group that made small business loans to women in the poorest rural areas, as well as a local women’s organization that addressed social and health issues facing women in the area. Participant selection was based on the usual selection processes of microfinance groups, which try to identify the poorest women in a community—more than half of whom had had to beg for their food the previous year. A total of 860 women were enrolled in the study. Their evaluation assessed the impact of this combination of microfinance and participatory activities around gender and violence on the women’s economic and social empowerment as this related to the outcome of a woman’s past-year exposure to physical or sexual partner violence. They also assessed any benefits to their households and other community members, especially adolescents in the household, by way of effect on knowledge, communication, voluntary counseling and testing, social mobilization, and sexual behavior as it related to the outcome of HIV infection. She stated that at the end of their study, the control groups also received the intervention.
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary She reported that in the first phase, they used their linkage with the microfinance program by adding a total of 10 educational sessions to their compulsory loan meetings, which prevented the participants from “opting out.” The topics included gender issues, domestic violence, sexuality and HIV, and skill building for communication, conflict resolution, solidarity, and leadership. The second phase focused on helping participants take their concerns to the broader community using what is known as a natural opinion leader model. By offering additional training to a woman selected as a natural leader for her group after the initial 10-week session, they facilitated her ability to work with her loan group to identify and prioritize the concerns they would take to the community with the goals of developing an action plan and engaging men and youth. The investigators’ use of a community participatory model disclosed that their preconceived ideas about prioritizing HIV and violence as the primary concerns for these women were altered when the women identified potable water, alcohol abuse, and a number of other issues for action. Although Watts acknowledged the limited statistical power of their study, she did note that they were really attempting a proof of concept and trying to assess what effect size they could achieve around some of their indicators, given their limited statistical power. She also stated that the supplemental use of qualitative data helped them understand and explain some of the effect that could not be measured quantitatively. Their findings showed a significant impact on several of the different economic indicators of well-being, with improvement in household assets that may be suggestive of improvement in savings and expenditures. They did not see an effect on food security and school enrollments, but she explained that this may have been due to the broader contextual changes that were occurring in South Africa at the time and may have affected both their intervention and the control communities. For broader measures of empowerment, they found positive trends in all of the indicators including self-confidence, challenging gender roles, communication with household members and partners, progressive attitudes toward violence, and autonomy in household decision making. The impact on women’s past-year experience of physical and sexual violence was a reduction in levels of violence (pushing, hitting, forced sex, and fear to refuse) by 55 percent, a significant result, she stated, due to such an effect size. Qualitative data collection and analysis helped explain the reductions in violence by identifying changes in the women’s relationships, a shift in women’s attitudes toward violence, and an increased self-confidence attributed to their ability to earn income, as well as an elevated household status that may have facilitated their ability to challenge their experience of violence, including confidence in the option of leaving their abusive partners because of their newfound financial freedom. They also found fewer
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary conflicts over finances, greater confidence to resolve conflict by improved communication with their partners, and evidence of group solidarity and influence that resulted from their participation in activities linked to their loan groups that enabled them to challenge what was happening in their individual lives, households, and communities in terms of violence. For community mobilization, they were able to measure an increase in the number of marches including one to a local police station to protest the way cases of rape were being handled, meetings with local leaders, village workshops, new village committees targeting and monitoring rape and crime, and new partnerships among local organizations—all to raise community awareness, engage young men, provide assistance and advice to women in the community, and intervene individually when witnessing abuse. All are examples of diffusion that could not really be captured by their impact measures but were captured by their qualitative data collection and analysis. The cost-effectiveness of interventions is a concern for everyone involved in the research on violence prevention and its translation. The IMAGE study was evaluated for cost-effectiveness by examining the costs of the research, the intervention, the trial, and the scaling-up of the intervention. Since the microfinance component was self-sustaining, the analysis really determined the incremental cost of adding the women’s empowerment component with the local women’s organization. In the trial, the cost (U.S. 2004 dollars) was found to be $24 per client, with a decrease to a final cost of $7 per person when scaled up to implementation, which exemplifies the economies of scale that can be obtained when increasing the coverage of this type of intervention. An important finding of this study was that interventions can address the issue of gender-based violence, with all of its associated cultural issues, over relatively short time frames if the intervention is designed properly. Traditionally, Watts stated, it is assumed that interventions targeting cultural norms can bring about change over generations. She noted that other participatory interventions in South Africa and Brazil targeting issues around gender are showing evidence of impact by reducing male perpetration of intimate partner violence and other behaviors that are associated with norms that support gender inequities. Watts echoed the need for long-term funding. For the IMAGE study, she explained that because violence did not fall clearly into the health objectives of many funders, they ended up “piecing together” funding from nine different donors. If funders want evidence on which to base their decisions, she implored them to prioritize funding rigorous research and evaluations. While she did not believe that randomized controlled trials could be conducted for all interventions, she said that there is no shortage of promising and innovative violence prevention interventions in develop-
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary ing countries that should be considered seriously for strategic evaluation to help build the evidence base. She gave two examples—Raising Voices, initiated in Tanzania and later replicated in Uganda and several other East African communities, and the Safer Schools intervention implemented in several countries and funded by the U.S. Agency for International Development. Her final observation was that not only rigorous evaluation, but also methodological work is needed to help conceptualize what these interventions are trying to achieve, to identify the process of change that will be promoted, and to define and measure key impacts and outcomes that are being assessed as part of the evaluation initiative. THE IMPORTANCE OF EPIDEMIOLOGICAL DATA FOR GUIDING PREVENTION Rodrigo Guerrero and Elizabeth Ward discussed the use of epidemiological data in violence prevention planning in Colombia and the Caribbean. In Colombia, Guerrero stated that the public health approach to violence prevention has proven to be of crucial importance in interpersonal violence prevention efforts in the country, and also in the dissemination of their efforts in Cali, Colombia. Sharing data and their meaning was shown to be a very powerful tool for communities in bringing pressure to bear on policy makers and elected officials to engender continued support for the intervention. While serving as mayor of Cali, he stated that all crime 15 years ago was attributable solely to drugs and drug barons, but as they began data collection, they learned that 80 percent was due to firearms—with two-thirds occurring during the weekend. Data also indicated that alcohol intoxication played a role in the occurrence of crime. They instituted restrictions on carrying guns on weekends and actually banned gun carrying for local and national celebrations that permitted alcohol use to address these two risk factors, as well as restricting the sale of alcohol after 1:00 AM in public places. His policies were not without political risk because the gun restriction put his administration at odds with the Colombian army, which manufactures and sells guns in the country. Evaluation of the intervention showed that on the weekends for which the gun ban was in place, there was a 14 percent decrease in homicides compared to weekends that permitted gun possession. The gun ban combined with the restrictions on alcohol sales yielded a 35 percent reduction in homicides, which represented a reduction of nearly 700 homicides. Anecdotally, the mayor of Bogotá decided to implement the same ban on firearms in 1996 and, based on evaluation, saw similar reductions in firearm homicides in the city. From April to November of that same year, a legal battle ensued that questioned the authority of the mayors to institute such bans. The ban was not implemented in Bogotá during this time. As a result, an increase
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary in firearms deaths occurred. Winning a ruling in the Colombian Supreme Court, the mayors were permitted the authority to institute such bans, and when they were reinstituted, the firearm and homicide rates once again declined. According to Guerrero, this type of policy making and implementation requires reliable and opportune information, addressing multiple risk factors, political will and leadership, continuity, multisectoral efforts, and monitoring to make necessary corrections along the way. THE CARIBBEAN Elizabeth Ward focused her comments on violence prevention efforts in Jamaica. She stated that Jamaica’s rate of 54 homicides per 100,000 people surpassed that of the rest of the Caribbean as described by Bernice Bronkhorst. In addition, she acknowledged that the rate is affected by high rates of migration—both legal and illegal, including deportees—with people moving between the United States and the Caribbean, moving between the islands, and moving from South America. She spoke of the collaboration between the Jamaican Ministry of Health and the Centers for Disease Control and Prevention (CDC) to improve their surveillance and data collection and how the Ministry was eventually able to incorporate its computer-based system into nine of the largest hospitals, which cover 70 percent of hospital admissions. By collecting data such as the date of the violence-related injury, the place of occurrence and circumstances, method of injury, victim-perpetrator relationship, and geographic location, they have been able to prepare street-level “hot-spot” maps of Kingston and use this information to target their interventions. Their collaboration with a World Bank project enabled them to engage in a mapping of community assets that can be layered with violence mapping data and homicide data. Again, this mapping ability gave them valuable information for intervention planning, including where interventions were likely to have the greatest impact. Ward stated that by using these tools in a public health approach, they have successfully engaged communities to participate in their research and have validated the conclusions drawn from the data for multisectoral, community interventions. She noted that the Ministry of Health is an active participant in the Violence Prevention Alliance-Jamaica, which is modeled after that of the Violence Prevention Alliance spearheaded by the World Health Organisation (WHO). Examples of Interventions The Peace Initiative is a community-based initiative housed in the Jamaican Ministry of National Security and is a collaboration between
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary social workers and law enforcement. Another example is a U.S.-supported initiative that placed community workers in a specific community to address violence prevention and saw a significant reduction in the homicide rate from 11 percent to zero. Other community-based programs that Ward mentioned focus on violence prevention, including community policing, gang interventions, environmental improvements for safety, mediation and counseling, small-arms control, and domestic violence (including United Nations Development Fund for Women-supported activities). Some youth-focused programs that showed promise include programs at the YMCA, computer-based literacy projects (which she identified as a surprising protective factor against violence), and skills development linked with job opportunities. Some of these programs also utilize the entertainment media, photography, and sports programs as vehicles for effective and efficient communication and implementation. School-based programs in the region are utilizing some innovative cross-cultural activities, as well as some of the social-bonding techniques described by David Hawkins using interschool peer circles. A collaboration with the United Kingdom addressed drug trafficking between the two countries. This UK-Jamaica collaboration also targeted providing economic assistance to the families of offenders and has yielded an 80 percent reduction in the number of “drug mules” who are carrying drugs to the United Kingdom. The private sector is also supporting some innovative strategies with matching donation campaigns, where employers make 2:1 donations for every employee-donated dollar to prevention programs, coupled with community-based interventions that include homework and scholarship programs. Wards stated that randomized, controlled trials of parenting programs that targeted home visits with toy play have even shown unintended positive effects such as improvements in self-esteem, fewer attention problems, and lower incidence of depression in both the intervention and the control groups. Other population-level interventions have shown promise, but they need to be properly evaluated. CHARACTERISTICS OF EFFECTIVE INTERVENTIONS For Jamaica, Ward identified several characteristics of their successful and promising programs for sustainability including good organization, a holistic and comprehensive approach, good leadership, and community-based participation and assistance. Watts made similar observations about the importance of dissemination and community participation and mobilization in her discussion about the IMAGE project in South Africa, including the importance of linkages with other activities and organizations addressing economic development with an emphasis on choosing good partners and maximizing their comparative advantages. The synergy of
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary linking participatory activities focused on gender with the microfinance program enabled them to take advantage of poverty alleviation strategies and processes that were already successful in the communities. She stressed the importance of taking the time to address the concerns of collaborators and other issues that might affect the study design. The microfinance organizations were concerned that collaborating with the researchers not only would affect their financial stability, but also might discourage the women from seeking loans if they were going to address sensitive issues such as intimate partner violence. This led to the linkage with local women’s organizations to facilitate support and empowerment. They found that the collaboration did not jeopardize microfinance, but rather was enhancing, with improvements in various indicators of vulnerability of loan groups that microfinance organizations use for monitoring compared to interventions that offered microfinance only. The study also found a loan repayment rate of nearly 100 percent among the women enrolled as participants. The rigorous evaluation of the IMAGE study and wide dissemination of its findings showed the potential influence of their findings because the South African National AIDS Plan now explicitly incorporates elements about addressing women’s vulnerability to violence as part of the national AIDS strategy. Watts suggested that the participatory nature of the IMAGE study in challenging issues of gender and relationship took time and could not be done superficially and that researchers needed to think critically about intervention modalities that allow them to spend time with participants and really engage them in the issues of interest. The community mobilization component was also identified as important, but she cautioned it can be difficult because it could impact monitoring the effects of the study if the community chooses to mobilize around something that cannot be captured or measured. CHALLENGES FOR EFFECTIVE PROGRAMMING AND RESEARCH In Jamaica, Ward identified the need for increased overall training, as well as community policing, health education for the importance of literacy and healthier lifestyles, strengthening information and monitoring systems, and some forms of income generation such as small business loans. Additional challenges identified include the need for sustained funding for long-term interventions, the need to translate small but effective programs to population-level interventions that are supported by community-based workers, the need to address social factors that affect families and communities, the need for widespread literacy and job skills training, the need to address political issues, and ensuring that efforts are multisectoral and geographically target areas with the highest incidence and prevalence of violence. Lastly, she stated the need for programmatic requirements to
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Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda - Workshop Summary fund rigorous impact evaluation to help understand what interventions are making a difference. Replicability and scaling up to a larger program are also of great concern to researchers, policy makers, funders, and implementers. The IMAGE study was a small intervention, but when it received additional funding, it was able to scale up to 1,800 clients—nearly double the original enrollment. Watts identified several issues for consideration when scaling up from a small research intervention to a much larger implementation including operational and organizational issues, whether there is programmatic compromise when scaling up occurs, whether any revisions have to be made, and whether there are health, social, and economic development mechanisms or vehicles for synergistic linkages and integration other than microfinance—such as literacy, HIV/AIDS, or malaria. QUESTIONS AND ANSWERS The highlights of the discussion with participants focused on examples of the participatory approach in research coupled with epidemiological data from a specific program in El Salvador. The intervention was implemented by a former guerrilla, and while it targeted the entire community, it also targeted those at highest risk (18-25 years) for violence by focusing on job skill development, employment, and other structured activities that address alcohol and drug use to reduce the risk for this population. The community used data from the hospital injury surveillance system to monitor the violence-related injuries that occurred in the city.