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3
Paradigm Shifts and
Changing Social Norms
in Violence Prevention
An important thread running through the workshop was the sense that
the attitudes and norms concerning violence against women and children
and its prevention are changing. There is a growing awareness of the mag-
nitude of the issue as well as of the potential value of early intervention.
Some of those intervention strategies involve the inclusion of men and boys
as part of the solution instead of seeing them only as perpetrators to be
punished. Speakers also felt that early intervention should include strate-
gies that bolster resilience or mitigate future violence. Finally, speakers
addressed the issue of complex stressors, the intersection of violence with
other inequities, and the importance of addressing violence within a larger
context.
Mary Ellsberg from the International Center for Research on Women
remarked that violence is taking its place not only on the human rights
agenda but also on the health and development agendas. As a result, efforts
to reduce violence against women and children are involving multiple sec-
tors and fields in bringing attention to the issue. Speaker James Lang from
Partners for Prevention thought that communications for social change
were an important part of the puzzle. Speaker Monique Widyono from
PATH agreed with this point and added that these communication tech-
niques can be harnessed to bring momentum to gender equity.
David Butler-Jones, the chief public health officer of Canada, said he
felt that change requires not only ending violence but also making a cultural
shift toward non-acceptance of violence. Dr. Ellsberg agreed, saying that
people should be empowered to stop violence when they see it occurring.
She referred to a program in Papua New Guinea in which women formed
20
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21
PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
a community policing group and created a safe haven for women and chil-
dren experiencing abuse.
Gail Wyatt and Michael Phillips both stated that cultural relativity and
sensitivity require particular attention: Norms and attitudes within cultures
shape issues such as gender equality and the rights of children, but they also
influence response. Rachel Jewkes agreed but added that nuances in what is
accepted versus what is normalized can be important. She highlighted the
importance of conversation with communities to understand what is truly
culturally valued.
On the workshop’s second day, speakers in the afternoon panel delved
into violence and its relationship to trauma and the importance of under-
standing the intersection of these issues. Roger Fallot said that an important
step in addressing violence is understanding trauma and bringing it into the
mainstream of public health.
GROWING ACCEPTANCE OF THE MAGNITUDE OF
VIOLENCE AGAINST WOMEN AND CHILDREN
Many speakers expressed the sense that violence against women and
children has become a mainstream issue over the past few decades. Claudia
García-Moreno of the World Health Organization said that when she first
began working in this field, she was informed that violence was not a health
issue but a social problem. Currently, researchers, particularly in public
health, have begun to recognize and document the magnitude of these types
of violence, though many gaps remain.
Only recently has evidence demonstrated that violence has an accu-
mulated effect, and in many cases it starts early and continues throughout
the lifespan. Little data exist from low- and middle-income countries, but
studies are under way, and preliminary findings show high rates of abuse.
In particular, Claudia García-Moreno mentioned a study in Swaziland con-
ducted by the Centers for Disease Control and Prevention, which found that
33 percent of girls had been victims of childhood sexual abuse. The WHO
Multi-Country Study shows that between 1 and 21 percent of women in
the 10 countries included in the study experienced abuse in childhood,
most commonly perpetrated by a family member (García-Moreno et al.,
2005). She also referred to a study by Jeff Edleson of children’s exposure to
violence; the study found that up to 83 percent of children had overheard
episodes of intimate partner violence (Edleson et al., 2003).
Dr. García-Moreno said that in the past 10 years the amount of data
on magnitude and consequences has increased significantly, although much
information is still missing on different types of violence against women
and children (García-Moreno et al., 2005). According to the current state
of knowledge, the majority of violence perpetrated against women is done
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22 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
by an intimate partner, but the means and methods vary. Denise Wilson
of the Auckland University of Technology mentioned statistics from New
Zealand showing that 50 percent of homicides are related to family vio-
lence, and as many as 1 in 3 women in New Zealand experience some sort
of lifetime physical or sexual abuse. Indigenous populations such as the
- -
Maori are at highest risk; 47 percent of women seeking safety are Maori,
although this group only makes up 15 percent of the population (Wilson,
2011). Agnes Tiwari said that intimate partner violence in Hong Kong is
relatively unrecognized, particularly as it tends to be emotional rather than
physical abuse, which makes it difficult to determine rates of prevalence. Dr.
García-Moreno added that the prevalence of other types of violence, such
as female genital mutilation, does not seem to be lessening.
Finally, Dr. García-Moreno noted that in addition to the increasing
body of knowledge concerning the prevalence of violence, there is also a
growing body of evidence about the long-term effects, with evidence show-
ing that consequences can continue for years after the violence itself.
GROWING ACCEPTANCE OF THE NEED FOR PREVENTION
Speakers generally felt that there was a growing recognition that pre-
vention of violence was useful to multiple sectors in addressing health and
social issues, and that this prevention included systemic changes in health
systems as well as in legal systems. Claudia García-Moreno asked rhe-
torically why those in the health sector should care, as violence prevention
efforts are often seen as competing with other interests. She felt that this
state of affairs indicated the need for system-wide changes. Similarly, Roger
Fallot talked about trauma-informed care as a new culture that has resulted
from a systemic approach to addressing trauma that seeks to provide safety,
address the potential for recurrence, and avoid replicating the violent situ-
ation. In addition, he said that a paradigm shift is needed in health service
organizations and settings that would focus on supporting victims, such
as an effort by health care providers to build trust with patients. Several
speakers reiterated this point and said that addressing issues of violence
and safety in communities and health-care systems would actually improve
health-care providers’ ability to provide services.
A number of speakers also spoke of the need for institutional, legal,
regulatory, and policy changes to address violence. Denise Wilson described
a number of pieces of legislation aimed at protecting women and children
in New Zealand: the Domestic Violence Act of 1995; the Children, Youth,
and Families Act in 1989; and the Care of Children Act in 2004. She also
discussed the New Zealand Health Strategy of 2000, which included reduc-
tion of interpersonal violence as a goal and included family violence as a
health problem.
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PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
Cheryl Thomas discussed the early stages of work performed in Cen-
tral Asia in the early 1990s by a group that she led; in particular, she said,
there were no provisions for domestic violence (no shelters, hotlines, or
service providers, for example) and no research and no political or social
will. In 1993 her group began work in Romania documenting domestic
violence, which opened the door to research in the area. Through this
work, she said, there has been a growing understanding that implement-
ing laws criminalizing violence against women is essential, and many
countries in Eastern Europe and Central Asia have begun to do so. In
particular, Advocates for Human Rights has highlighted the importance
of the role of an “order for protection.” Ms. Thomas also noted that in
Morocco the work of local implementing partners, particularly women’s
groups, has advanced the chances for implementation of a national do-
mestic violence law greatly.
Finally, speakers explored the need for nuanced research into develop-
ing prevention and intervention strategies. David Wolfe pointed out that
in self-reports of violence, girls state they hit as much as, if not more than,
boys do, and the rationalizations they use reflect familiar language from
men and boys from the 1980s (Wolfe et al., 2009). This is troublesome,
he said, because the girls will often still end up the victim because the boy
will often retaliate. Furthermore, the situation of girls-as-victims-only is less
prevalent in adolescent abusive relationships than at the adult level, perhaps
because adolescence is a training ground and teenage violence is somewhat
peer-sanctioned. Thus, he surmised, interventions that address girls solely
as victims miss a major piece of the growing understanding of adolescent
relationships and will not be as successful.
Monique Widyono offered another example with her description of a
tool called In Her Shoes, developed originally in Washington State, which
allows people to “walk in the shoes” of women experiencing violence. The
process allows policy makers, service providers, and others a chance to see
the consequences of such violence and to diminish stereotypes or expecta-
tions of survivors of violence.
ENGAGING MEN AND BOYS
Gender equality and violence against women and children are intri-
cately entwined, and advocates for reducing violence highlight the impor-
tance of increasing gender equality. Conversely, Kiersten Stewart discussed
the reverse, describing how addressing violence can address gender in-
equality. James Lang said that violence is a “constitutive element of gender
inequality” and that Partners for Prevention quickly became involved in
engaging men and boys because they are the “gatekeepers of power” and
primary prevention has to take that into account. However, Mr. Lang
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24 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
warned against sliding into the paternalistic language of men and boys
“saving” women and girls from violence or thinking about males solely as
instruments of change.
Rachel Jewkes delved deeper into the nuances of gender equity, point-
ing out that simply involving more females in government is not enough;
relationships between men and women must be addressed as well. She
demonstrated the existence of a disconnect between gender equality and
a lack of violence by describing a study done in South Africa in which 90
percent of men said women should be treated equally, but 50 percent of
those surveyed admitted to committing physical violence against a female
partner (Gender Links and South African Medical Research Council, 2010).
Dr. García-Moreno also noted that there is a growing body of information
from men about their own perpetration of violence.
Dr. Jewkes explained that gender socialization is a process of learning
social expectations about the goals and practices of men and women as
well as about their experiences of power. Mary Ellsberg highlighted the
importance of social dynamics: Boys are raised to be “tough,” and girls are
raised to be pliant. Gender norms also influence the type of violence that
children experience, with boys more likely to experience bullying and fights
while girls are more likely to experience sexual and psychological violence
and exclusion.
Thus in the process of growing up children discover that going against
the dominant cultural model results in pressure, abuse, and violence. Dr.
Jewkes used the example of the rape of lesbians in South Africa as a “cor-
rective measure” to emphasize this point. Gary Barker agreed and suggested
that changing gender norms should mean not only redefining the roles of
men and women but also making people aware of the diversity of roles that
already exist in various cultures.
Therefore, Dr. Jewkes concluded, addressing violence against women
and children must include gender socialization. Various social institutions,
such as schools, help define gender, but the home and family life are some
of the earliest and strongest influences. If gender balances are unequal in the
home or if partner violence is occurring, boys and girls are at greater risk
of mimicking these models and finding themselves in abusive relationships
again and again. Gary Barker reiterated this, mentioning the stress on men
of being a provider, particularly during economic downturns, and suggested
that perhaps early gender socialization that included alternative roles for
men might reduce this stress. Dr. Jewkes, speaking for Julia Kim, said that
giving women increased roles as providers does not always help, particu-
larly if it is added to women’s responsibilities for taking care of the home,
because it can increase the stress on women. She noted that standards for
feminine behavior in the developing context are often constructed around
acquiescence to men’s demands and that social structures often reward
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25
PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
women who fit into socially acceptable roles despite the increased risk of
violence they must endure.
Dr. Jewkes referred to the hegemonic masculinity theory of Raewyn
Connell, which states that power is not exercised through use of force but
rather through the acquiescence of the powerless. A study in South Africa
found that while the vast majority of men and women believe in equality,
the majority of men and a smaller majority of women believe that a woman
should obey her husband. This was true across races. One of the factors
contributing to this situation is a lack of exposure to other culturally ap-
propriate ways of being a woman. Dr. Jewkes also pointed out that, ac-
cording to one study, women who strongly agree that a husband has a right
to beat his wife are more likely to be beaten and that women who believe
that beating is a sign of affection are also more likely to be beaten (Gender
Links and South African Medical Research Council, 2010).
The International Men and Gender Equality Survey (IMAGES) de-
scribed by Dr. Barker found that men report knowing about laws address-
ing gender-based violence but express sometimes contradicting views on
such laws. One consensus among interviewees across countries was the
feeling that the laws increase a sense of being observed or scrutinized,
which Dr. Barker described as not only a symptom of the gender power
balance being upset but also an indication that additional education might
be needed to explain how these laws are protective and not punitive. Claire
Crooks also expressed a concern about lack of services for men at risk of
perpetrating violence aimed at preventing either violence or the recurrence
of violence; most efforts are punitive instead of preventive.
To explain why some men experience similar risk factors but do not
perpetrate violence, Dr. Barker showed responses from IMAGES suggesting
that men are sensitive to positive cultural and social norms, including the
influence of a respected elder, reflection on past abuse (as victim or per-
petrator), and exposure to community spaces that promote non-violence.
Interventions that take into account these sensitivities often include
involving men in the care of family. Dr. Crooks said that it is important not
to assume that a program that works with mothers will work with fathers
and that more effort should be put into designing programs that include
men more actively.
Agnes Tiwari agreed, citing her work in including men in prevention
efforts as active participants rather than as passive partners. In her Hong
Kong study, men were included in a prenatal education intervention in
which the discussion around parenting skills was used as an entry point to
discussing couple relationships. This was more effective because the cultural
barrier to discussing romantic relationship skills could be overcome. In
particular, it was effective in reaching men and discussing both partner and
father roles in a way that didn’t seem “therapeutic.”
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26 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
INTERSECTION WITH OTHER INEQUITIES
Recent research in the field of violence prevention shows that violence
does not occur in a vacuum; instead, it is highly co-occurring with certain
factors such as poverty, food insecurity, the presence of infectious and
chronic diseases, and lack of education. Addressing violence prevention in a
comprehensive way requires looking at these other issues as well. Dr. Butler-
Jones remarked that “poverty is a constellation” and can entail a lack not
only of economic resources but also of relationships as well. Having stabil-
ity, shelter, and adequate food means the difference between average health
and good health, all of which affect resiliency.
Thus investing in preventing violence against women and children
is not just about ending violence and promoting gender equality. As Dr.
Ellsberg said, “We cannot hope to make significant progress in achieving
the ambitious goals of ending poverty and hunger, achieving universal pri-
mary education, improving maternal and child health, and combating AIDS
and other infectious diseases unless we are able to end violence against
women and children.” Brigid McCaw also said that it is important to iden-
tify co-morbidities and inequities (poverty, substance abuse, and so forth)
because they may be more likely to bring the victim to the attention of the
provider than the violence itself. For example, as Claudia García-Moreno
pointed out, children experiencing violence at home often have difficulties,
such as behavior problems, at school, and understanding this link can lead
service providers to the violence even if no report is ever made.
These intersections are bi-directional: The increased risk of violence
creates a suspicion of legal and medical authorities, while unstable social
conditions can lead to an increased incidence of violence. Dr. Ellsberg
pointed out, for example, that poverty and lack of access to health care
prevent parents from accessing resources for addressing parenting and cop-
ing skills. Furthermore, those who fear the stigma of HIV and its associated
violence—of which women are most at risk—fail to seek screening and care.
Roger Fallot said that while violence increases the risk of homelessness,
incarceration, and substance abuse problems, those outcomes in turn place
people at risk of continued violence.
The context in which violence can occur is a major factor affecting
the risk and severity of violence. Dr. Amaro suggested it might be useful to
look further upstream at issues such as environmental factors and structural
violence, a topic that had been touched upon by an earlier audience member
who suggested that violence prevention efforts need to be incorporated into
social studies curriculum in schools. Dr. Crooks said that the more types
of violence a person experiences, the worse the outcome will be in terms
of both future perpetration and health and psychosocial outcomes. Poverty
and racism increase both the likelihood and the severity of violence and
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PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
also affect the impacts of violence. Denise Wilson underscored this point
-
by bringing up the example of the Maori, who live in the most deprived
neighborhoods in urban centers of New Zealand and who still experience
barriers to access to health care and social services system because of racial
-
discrimination. The Maori are disproportionately victims of violence, and
they account for 50 percent of women and children in shelters. Dr. Wilson
-
also described how the Maori culture has seen huge shifts over the past
several decades, with the loss of traditional social structures that previously
supported women’s equality. Not all women have the same rights, Dr. Wyatt
said, and ethnic and racial differences play a large role in who is exposed
to or victimized by violence.
Promundo’s IMAGES study shows that one major factor in predict-
ing violence is whether men report feeling economic stress (as opposed to
reporting of actual income), which is related to the social norms of men’s
traditional roles as providers. Dr. Jewkes referred to a study from South
Africa in which women who report higher food insecurity report less eq-
uitable views of gender and men who report lower food security report
higher rates of violence against a partner. A similar outcome was found in
a study in India, which found that 49 percent of women who did not own
property reported violence, as compared with 7 percent of women who did
own property. In general, a lower ability to mobilize resources is correlated
with a higher acceptance of violence, greater likelihood of being a victim or
perpetrator, and lower likelihood of leaving a violent situation. This greater
risk of violence leads to a continued cycle of violence in which victims find
themselves re-victimized and sometimes become perpetrators themselves.
The context of violence also affects the severity of the outcomes. Julian
Ford and Claudia García-Moreno paid particular attention to the concept
of toxic stress and how continual exposure to violence both directly and
indirectly creates a climate of chronic stress, which has been shown to have
fundamental effects on cell growth in the brain. This is of particular impor-
tance for children, whose brain development can be significantly altered,
resulting in secondary outcomes throughout their lives. Exposure to chronic
stress affects language and communication ability and places an individual
at increased risk of substance abuse. The development of trauma as a long-
term outcome also has a complex relationship with violence, putting victims
at additional risk of re-victimization as well as at risk of other adverse
health outcomes. Dr. Amaro mentioned the high rates of co-occurrence of
alcohol- and drug-related disorders with trauma and post-traumatic stress
disorder (PTSD). Often the alcohol- and drug-related issues are methods of
self-medicating that are used to deal with trauma, but such use intensifies
the symptoms of PTSD, creating a cycle.
In the Boston Consortium study discussed by Dr. Amaro, an integrated
system was created to address trauma and substance abuse issues in women.
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28 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
This included treatment for the trauma (psychotherapy and skills build-
ing) as well as substance abuse treatment, both clinical and residential.
The intervention involved careful attention to gender and racial linguistic
usage because the population was primarily African-American and Latina
women, and it paid close attention to addressing the roles of women in
society and their relationship to violence. The intervention also included
components to address integration with other services being provided,
because many of the women involved had other issues, such as the loss of
custody of children or a lack of economic empowerment.
Cris Sullivan applied her community advocacy model to discuss how
empowering women has a strong effect on whether abuse recurs and on
how capable women are of escaping the cycle of violence. She found
in her intervention that providing an advocate who would support the
woman with skills transfer and assistance empowered her to take control
of her life.
PREVENTION THROUGH PROMOTION
The speakers also agreed on the importance of primary prevention
and on moving even further upstream to address the environment in which
violence occurs. Researchers felt that promoting resilience and protec -
tive factors provides individuals with skills to deal with the conflict and
instability that breeds violence. Addressing many of the issues mentioned
previously, such as gender equality and co-morbidities and the chronic
stress on children, would be cost-effective and successful in the prevention
of violence against women and children. Speakers felt that mitigating the
climate of violence through social and legal programs often results in the
greatest success.
Some of these legal interventions would involve laws and regulations
that strengthen the rights of women and children, such as the interna-
tional and country-level policies mentioned by Cheryl Thomas and Kiersten
Stewart. Katrina Baum of the National Institute of Justice described the
paradigm shift that occurs when including criminal justice in prevention,
citing a case of a police chief referring to a stalking unit as a “homicide
prevention unit,” and Gary Barker noted that there is good evidence that
community policing can play a role in preventing violence.
Prevention can also be addressed in programs that strengthen individual
skills and family coping mechanisms. Bryan Samuels of the Administration
on Children, Youth, and Families referred to research undertaken to inform
program decision making that showed three important protective factors:
“young people who have the ability to self regulate, young people who
choose a particular way of coping with adversity, and young people who have
a level of self efficacy that leads them to the belief that they can avoid the
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PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
bad things that are going on around them, and that they have got a skill set
or a method for doing so.” Dr. Fallot talked about G-TRIM (Loving Life),
in which girls were given a space to talk about trauma, anger, and how to
move forward.
David Wolfe said that prevention is cheaper and easier than treatment
and noted that the Fourth R is designed around the promotion of healthy
relationships in adolescence. Learning to relate starts early, and adolescents
are curious and experimental, pushing at boundaries and becoming more
exposed to risk factors. The Fourth R addresses management of these
risk factors, strengthening the skills needed to make responsible choices
and teaching students to balance “pro-abuse” messages with healthy mes-
sages. An important component of the program is involving youth in their
own empowerment, particularly having older youth demonstrate the skills
learned through the program in videos or other activities. One major out-
come of the program is that boys who experienced maltreatment outside of
school were less likely to engage in dating violence after this intervention.
Risk factors are most noticeable at the middle school level, so addressing
troubling relationships then makes sense. However, it could potentially be
more effective to begin earlier with general information on the skills needed
to build healthy relationships.
Judy Langford discussed Strengthening Families, which targets all fami-
lies, not just those at risk, and aims to increase resilience and promote
strengths. To easily reach out to families, the program is carried out at
locations that they are likely to frequent. Strengthening Families is designed
to support five essential protective factors that were identified through re-
search and evaluation of successful programs. The first is parental resilience,
which aids a parent’s ability to maintain healthy relationships and handle
individual and parenting challenges. The second is social connections and
the ability to create a social network to prevent the damage caused by iso-
lation as a result of or a precursor to susceptibility to violence. The third
is knowledge of parenting and child development, which encompasses not
only “official” information from parenting guides but also the unofficial
information gleaned from family networks and cultural sources. The fourth
is concrete support in times of need, both the basic needs required to main-
tain a stable household, such as economic stability, and access to services
in crisis. The fifth protective factor is social and emotional development of
children, because children with developmental delays and cognitive disabili-
ties are more vulnerable to maltreatment than those with normal develop-
ment. The importance of this work, Ms. Langford said, is highlighted by the
number of states that expressed interest in learning about this framework,
which in turn resulted in a number of interdisciplinary approaches being
created and used in these states. Strengthening Families has been adopted by
national and international nongovernmental organizations, parent groups,
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30 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
administrators, and state child welfare agencies as a means to reduce vio-
lence and improve family relationships.
Gary Barker discussed an intervention strategy, Program H, designed to
promote alternative masculine identities of non-violent or less violent men
and directed at both men and women. The program ran a campaign includ-
ing radio spots, TV ads, community theatre, and other media that high-
lighted positive aspects of masculinity. In Brazil the campaign resulted in
attitude change; in India, it resulted in lower reported rates of gender-based
violence. Preliminary data in the Balkans are being assessed, but one major
obstacle to success there was the ingrained violence in all-male schools, a
more difficult cultural context to overcome. A second intervention, Program
M, is looking at changing these attitudes within schools, not only among
students, but also among teachers as transmitters of these norms.
In the Intervention with Microfinance for AIDS and Gender Equity
study in South Africa, which was conducted by Julia Kim and described by
Rachel Jewkes, researchers sought to identify whether microfinance pro-
grams with added gender training elements resulted in women feeling more
empowered and in men and women reporting fewer violent events. Women
reported feeling more empowered collectively. There were also increases in
food security and household assets and a reduction in loan defaults. The
program also saw a 55 percent reduction in intimate partner violence two
years after the intervention, through shifts in attitudes, including greater
negotiating status of women, the ability of women to leave abusive relation-
ships, and fewer conflicts over finances. In a comparison group without the
gender training, there was no reduction in violence.
Finally, several speakers addressed the importance of education, given
that higher levels of education correlate to low violence. Dr. Barker referred
to cases in which the dropout rates for girls and boys in secondary school
are high, suggesting that while the focus is mostly on girls, consideration
should be given to addressing the issue with boys in order to keep them in
school, which in turn would increase earning potential, reduce economic
stress, and expose the boys to more positive gender role socialization.
KEY MESSAGES
The stigma of violence against women and children is diminishing, re-
vealing important cultural and contextual elements that could be addressed.
This paradigm shift involves increasing the evidence base, implementing
programs that move further upstream and address contextual factors, and
engaging men and boys, traditionally seen as perpetrators, as part of the
solution. As well, as the violence prevention community produces fur-
ther research and evidence of successful programs, the pervasive nature of
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PARADIGM SHIFTS AND CHANGING SOCIAL NORMS
violence, and its relationship to other health and social inequities, continues
to be illuminated.
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