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5 Violence Prevention Among Multiple Sectors As the field of violence prevention has evolved over the past few de- cades, the lack of coordination between related fields and a hesitation to engage in multisectoral response has posed a major obstacle to the field’s success. Traditionally, various sectors have approached violence and its prevention from their own theoretical bases, without integration or col- laboration, which has often resulted in duplicative work or unsustainable planning. Many workshop speakers felt strongly that collaboration and an integrated response are necessary for successful, long-term prevention pro- grams. David Butler-Jones of the Public Health Agency of Canada described Canada’s approach to public health as “the organized efforts of society to improve health and well being and to reduce inequalities” and said that the efforts include multiple sectors outside of health in order to offer a comprehensive approach. He stressed the important of this perspective in preventing missed opportunities both within and outside the health sector. He also said this perspective is useful in identifying the various roles that different agencies, sectors, and individuals can play. A number of speakers observed that violence prevention, while di- vided into silos, is often its own silo as well. Integrating violence preven- tion interventions into broader programs aimed at improving health and well-being would lead to greater success. Dr. Butler-Jones emphasized the need to address violence as part of addressing health inequities: Two things that can mean the difference between average health and excellent health are a sense of self-determination and a sense of connectivity, and interventions for violence prevention and for health should promote both of these factors. 42

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43 VIOLENCE PREVENTION AMONG MULTIPLE SECTORS Mary Ellsberg cited a World Bank review that found that multisectoral response is a key to successful intervention. “Strategies must improve co- ordination between sector-specific approaches, civil-society initiatives, and government institutions,” she said. “They must also take into account the need for change at all levels of society, from national laws, policies, and in- stitutions to community-level norms and support networks and household and individual attitudes and behaviors.” James Lang from Partners for Prevention listed three key components of any comprehensive strategy: an evidence base, building the capacity of local partners, and communications for social change. Although the public health approach underscores the importance of collaborating across disciplines (particularly as prevention efforts move upstream), some speakers felt that further effort is needed to include such sectors as education, criminal justice, and international aid. For example, Claudia García-Moreno called for the provision of safe spaces in schools, laws that create equitable societal structure, and public education directed at changing norms. Kiersten Stewart said that an important objective of the International Violence Against Women Act is to coordinate violence pre- vention, gender equality, and international aid efforts that all seek similar goals. Ms. Stewart also mentioned the need to include the private sector not only as a partner in funding and programming, but also as an investor in the public good. Mary Ellsberg spoke of the evidence basis behind success- ful programs and said that the more successful programs have integrated efforts, such as home visitations for teaching parental skills. Several speak- ers commented that violence prevention and gender equality efforts need to be coordinated because addressing gender equality alone will not affect the prevalence of violence. Another key element in ensuring the success of multisectoral responses will be to build on a foundation of evidence. Claudia García-Moreno sug- gested that prevention should move from small-scale programs to national and multi-country interventions, but the evidence base concerning such a translation is still weak. She also said that although awareness of the issue is growing, allocation of resources is still lagging for both research and evalu- ation. Dr. Ellsberg noted that political and social will are essential as well. Ms. Widyono urged participants to remember that research in this area drives advocacy and policy and that the interventions that work best are ones based in evidence to show it. She also suggested that increasing the evidence base would result in greater buy-in from implementing partners— and that the buy-in would be even greater if the partners are included in the research and data gathering. In such cases, as demonstrated by Partners for Prevention, community partners are able to assist in the designing of interventions. By developing mutually beneficial best practices, researchers, implementers, and advocates all feel equally invested in the efforts.

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44 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN Despite the will to increase coordination of efforts, however, various barriers persist. Forum member Evelyn Tomaswieski said that identifying relevant partners can be difficult, while forum member Arturo Cervantes questioned whether investing in various sectors would work without a mechanism for integration, which would includes buy-in from all partners. Gail Wyatt said that in addition to using comprehensive approaches, in- terventions must be built on comprehensive theories of complex traumas and multiple types of exposures because sequelae and even interventions can be different. Cheryl Thomas emphasized the need for agreement from the entire group not only on the cost-effectiveness of prevention and in- tervention, but also on the foundational theory of the violence and its risk and protective factors. A few speakers said that mechanisms for delegat- ing responsibility among partners are key but that they can be difficult to implement. James Lang emphasized the lack of ideal integrated models for social change. Speakers also expressed frustration with the existence of silos in re- search and in funding for research. One audience member said that there is a need for increased data sharing and stated that some partners are not always willing to share proprietary or confidential information. Several speakers said that funding for a coordinated and integrated response is rare and that researchers are often limited in these approaches by their funding sources. Dr. Wyatt suggested that researchers should demand integrated funding and design their interventions to facilitate collaborative funding. Models for coordinated and sustainable programs do exist, and several presentations provided examples. One factor in a successful program is the integration of the intervention into pre-existing programs or activities. Judy Langford stressed this observation in her discussion of the Strengthening Families model, which promotes healthy behaviors in pre-existing settings, such as daycare. Such integration makes a model more sustainable and eas- ier to implement for those on the ground. The Fourth R program followed a similar approach, integrating the intervention into physical education or health classes, thereby allowing students to practice what they were learn- ing, much as they would in other classes. Agnes Tiwari’s intervention used obstetricians and midwives in an integral way, which increased penetration into the community because most of the women were already using prenatal care. International Men and Gender Equality Survey (IMAGE) took an integrated approach by using a one-hour participatory group session into which was integrated messaging about gender equality, violence, and HIV; the messaging not only focused on the intersection among the three factors but also discussed how addressing all three together leads to measurable change. Hortensia Amaro and Roger Fallot went a step further to discuss

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45 VIOLENCE PREVENTION AMONG MULTIPLE SECTORS how integrating thinking about trauma into such existing programs would bolster them even further, particularly by providing training to service pro- viders on trauma sensitivity. The trauma-informed context also requires coordination. It is, by its nature, a model of integration as it views health care needs through the trauma lens. Roger Fallot discussed how this approach incorporates ev- erything known about trauma and trauma response into existing systems of care. Such contexts facilitate healing by providing a more hospitable environment, a major result of which is reduced re-victimization. Brigid McCaw described Kaiser Permanente’s existing model of integra- tion into a system of care, which makes it easy to implement system-wide models of change and to coordinate disparate sectors into one program. In particular, chronic care management offers a variety of lessons in this area. Another example is the Boston Consortium Model, an integrated interven- tion that addressed both trauma and substance abuse; when researchers tested whether this approach was more successful than substance abuse programs by themselves, they found that this was the case. Partners for Prevention was able to overcome initial problems caused by a lack of coordination by addressing internal silos. Because United Na- tions efforts are not always coordinated, Partners for Prevention began by bringing together sectors within that agency. In doing so, the program was able to address external issues of lack of coordination because government ministries were already partnered with various UN agencies that were working together. In the same way, the InterCambios Alliance had similar success by bringing together the organizations working on the issues and coordinating with government agencies. Ms. Widyono stated that innova- tive work was happening but not being shared, and InterCambios helped develop the collaboration needed for technical capacity building. Both speakers stressed the need for flexibility and trust in ensuring that all part- ners’ needs are being met. Ms. Thomas mentioned an early model in this field. “I mentioned the Duluth Model of Coordinated Community Response,” she said. “Every- body, I think, is just in agreement how critical it is that this multisectoral approach occurs where people understand. A judge can’t sit up at the bench and issue an order for protection by himself and expect this work to keep a woman safe and hold an offender accountable. People have to be communicating in the system. The police have to know that it exists and how to enforce it. Shelters have to know that it exists. And if people are communicating about that we know now that that is where laws work when there is this coordinated community response, this holistic model, this multisectoral approach.”

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46 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN KEY MESSAGES A holistic, integrated response requires participation from all essential stakeholders, because the ultimate aim is not only the reduction of violence but also the promotion of well-being. Overcoming barriers to successful comprehensive approaches include cooperation amongst partners, a foun- dation of evidence, and community and political will. It will also require addressing the stovepiping of funding and research, not only between sec- tors, but also within the health field, and violence prevention itself.