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Background In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood).Methods We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates.Findings The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90middot0% (95% CrI 89middot7-90middot4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76middot5% (95% CrI 76middot3-76middot7) of children were paternal orphans, whereas 23middot5% (23middot3-23middot7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood.Interpretation Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5middot0 million COVID-19 deaths meant that 5middot2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally.Funding UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.Copyright (c) 2022 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY NC ND 3.0 IGO license which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is properly cited. This article shall not be used or reproduced in association with the promotion of commercial products, services or any entity.There should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

Summary Background The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation. Methods We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60–84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection–fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers. Findings Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000–1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000–1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15–50 years. Between two and five times more children had deceased fathers than deceased mothers. Interpretation Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children. Funding UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Ending all violence against children by 2030 is a core part of Sustainable Development Goals 5 and 16. A number of promising violence reduction strategies have been identified in research studies. However, we lack an understanding of the implementation and impact of these programs in respect to their delivery at a large scale or within existing service systems, particularly in low- and middle-income countries (LMICs). We advocate for greater collaboration between researchers, policymakers, donors, governments, non-governmental organizations, and program managers and staff to study how violence prevention programs operate on a large scale. We describe a new initiative aiming to foster such collaborations in the field of family strengthening programs.

CITATION: Cluver, L. et al. 2020. Parenting in a time of COVID-19. Lancet, 395:e64, doi:10.1016/S0140-6736(20)30736-4.

Interpersonal violence affects millions of people worldwide, often has lifelong consequences, and is gaining recognition as an important global public health problem. There has been no assessment of measures countries are taking to address it. This report aims to assess such measures and provide a baseline against which to track future progress.In each country, with help from a government-appointed National Data Coordinator, representatives from six to ten sectors completed a questionnaire before convening in a consensus meeting to decide on final country data; 133 of 194 (69%) WHO Member States participated. The questionnaire covered data, plans, prevention measures, and victim services. Data were collected between November 2012 and June 2014, and analyzed between June and October 2014. Global and country-level homicides for 2000-2012 were also calculated for all 194 Members.Worldwide, 475,000 people were homicide victims in 2012 and homicide rates declined by 16% from 2000 to 2012. Data on fatal and, in particular, non-fatal forms of violence are lacking in many countries. Each of the 18 types of surveyed prevention programs was reported to be implemented in a third of the 133 participating countries; each law was reported to exist in 80% of countries, but fully enforced in just 57%; and each victim service was reported to be in place in just more than half of the countries.Although many countries have begun to tackle violence, serious gaps remain, and public health researchers have a critical role to play in addressing them.

© 2014 The Authors. Published by Elsevier Ltd. Through a global review, we identified gaps in the geographical distribution of violence prevention evidence outcome evaluation studies and the types of violence addressed. Systematic literature searches identified 355 articles published between 2007 and 2013 that evaluated programs to prevent interpersonal or self-directed violence; focused on universal or selected populations; and reported outcomes measuring violence or closely related risk factors. The number of studies identified increased annually from 2008 (n = 37), reaching 64 in 2013. Over half (n = 203) of all studies focused on youth violence yet only one on elder maltreatment. Study characteristics varied by year and violence type. Only 9.3% of all studies had been conducted in LMICs. These studies were less likely than those in high income countries (HICs) to have tested established interventions yet more likely to involve international collaboration. Evaluation studies successfully established in LMIC had often capitalized on other major regional priorities (e.g. HIV). Relationships between violence and social determinants, communicable and non-communicable diseases, and even economic prosperity should be explored as mechanisms to increase the global reach of violence prevention research. Results should inform future research strategies and provide a baseline for measuring progress in developing the violence prevention evidence-base, especially in LMICs.

Background A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. Methods In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. Findings Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I 2 of > 75%) between estimates for almost half of the outcomes. Interpretation To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. Funding Public Health Wales. © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

Injury and violence rank among the leading causes of death worldwide, with more than 5 million deaths annually, representing a significant portion of the global burden of disease. This article examines how injury and violence relate to global health using recent global burden of disease data and selected key studies and databases, and further explores risk factors and intervention initiatives that address unintentional and intentional injuries. The article serves as a call to action to enhance understanding of the growing burden of injury and violence, especially in low-income and middle-income countries, where more than 90% of injuries occur.

Objective To synthesize recent evidence from systematic and comprehensive reviews on the effectiveness of universal and selective child maltreatment prevention interventions, evaluate the methodological quality of the reviews and outcome evaluation studies they are based on, and map the geographical distribution of the evidence. Methods A systematic review of reviews was conducted. The quality of the systematic reviews was evaluated with a tool for the assessment of multiple systematic reviews (AMSTAR), and the quality of the outcome evaluations was assessed using indicators of internal validity and of the construct validity of outcome measures. Findings The review focused on seven main types of interventions: home visiting, parent education, child sex abuse prevention, abusive head trauma prevention, multi-component interventions, media-based interventions, and support and mutual aid groups. Four of the seven – home-visiting, parent education, abusive head trauma prevention and multi-component interventions – show promise in preventing actual child maltreatment. Three of them – home visiting, parent education and child sexual abuse prevention – appear effective in reducing risk factors for child maltreatment, although these conclusions are tentative due to the methodological shortcomings of the reviews and outcome evaluation studies they draw on. An analysis of the geographical distribution of the evidence shows that outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low- and middle-income countries and make up only 0.6% of the total evidence base. Conclusion Evidence for the effectiveness of four of the seven main types of interventions for preventing child maltreatment is promising, although it is weakened by methodological problems and paucity of outcome evaluations from low- and middle-income countries.

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. System- atic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child mal- treatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region’s per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region’s GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child mal- treatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

Developments in the global violence prevention field and the surrounding international policy context over the last four to five years have created new windows of opportunity to strengthen science-based approaches to understanding and preventing violence. With a focus on interpersonal violence (i.e. child maltreatment, youth violence, intimate partner violence, sexual violence and elder abuse), this presentation explores the new horizons for global violence prevention that these developments represent. Within the global violence prevention field, there has been a substantial increase in the number and geographical distribution of nationally representative surveys that document the prevalence, risk factors, and consequences of interpersonal violence, and in particular violence against children and women. Research too has increased, both concerning how exposure to violence can lead to lifelong behavioural, physical and mental health consequences, and by way of outcome evaluation studies into the effectiveness of prevention programmes and victim services. Together, this has resulted in strong convergence between the violence prevention recommendations made by key international and national violence prevention players, and more powerful arguments for investment in evidence-based prevention and response. Key developments in the international policy context include inclusion in the Sustainable Development Goals of several targets that directly aim at violence prevention, and others that address many of the major underlying causes of violence. Within the health sector, adoption by the May 2016 World Health Assembly of a resolution endorsing the first ever WHO Global plan of action to strengthen the role of the health system in addressing interpersonal violence provides a powerful new incentive for increased health sector involvement in preventing and responding to violence. In combination, these developments suggest that the next big advances in global violence prevention will entail a stronger emphasis on implementing evidence-based prevention programming and policy at the national and local levels, coupled with a new drive to better measure the nature, reach and quality of evidence-based policies and programmes at national and local levels. Recent examples of initiatives to move global violence prevention efforts in this new direction include the development by WHO and other international agencies of the INSPIRE technical package for ending violence against children, and the new Global Partnership to End Violence Against Children. While welcome, these new violence prevention opportunities do not come without threats, in particular the danger that violence among and against men and boys may risk being marginalised unless better efforts are made to balance the current focus on women and girls with an equally strong focus on males of all ages.

The almost exclusive media focus on political violence in South Africa has deflected attention from the high levels of interpersonal violence in areas of socioeconomic deprivation. In order to explore the tension between an at-risk community's perspective and the current reality of violence against women, imaginary constructions of their own violent death produced by 45 African female interview respondents were examined in conjunction with forensic data relating to 73 African female homicide victims in Cape Town, South Africa. The prototypical account of an imagined homicide involved a female commuter being approached by a group of men, taunted and assaulted, raped and then killed. The majority of actual homicides occurred at or in the vicinity of the residence of the victim, with the attacker being known to the deceased. Whilst only 1 of the imagined homicide narratives depicted the use of alcohol by the victim, over half the actual homicides had elevated postmortem blood alcohol levels. These and other disjunctions and convergencies between lay and forensic constructions of violent female death should be viewed in the wider context of enmeshment in social circumstance, and could provide some understanding of how at-risk communities perceive violence against women, thereby providing a foundation for appropriate prevention programmes.

Intentional and unintentional injuries represent approximately 11% of the global mortality and 13% of all disability adjusted life years lost every year. Recognising the magnitude of the problem, the World Health Organization (WHO) has recently taken important steps to increase its injury prevention activities. In March 2000, a Department for Injuries and Violence Prevention (VIP) was created. For the first time, in 50 years, injuries and violence prevention now has a place on the WHO organizational chart. The department is located in the Cluster for Non-Communicable Diseases and Mental Health. Injuries and violence prevention is not a new area of work in WHO. WHO has conducted activities in this area for more than two decades. However, the human resources and attention devoted to the topic have recently increased dramatically. The mission of VIP is to spearhead global action to prevent violence and unintentional injuries as major threats to public health. Its goals are to: To date, most injury prevention efforts have occurred in high income countries. And yet, low and middle income countries have higher injury mortality rates than high income countries in all regions of the world. Therefore it is urgent to develop strategies that are appropriate, cost efficient, and effective in low and middle income countries, taking into account the complexity of the problem in these countries and the experience from what works in other countries. Developing strategies …

OBJECTIVE: To examine associations between exposure to physical violence (PV) or sexual violence (SV) and adverse health behaviours among a sample of children in five African countries. METHODS: In a cross-sectional analysis of data from Namibia, Swaziland, Uganda, Zambia and Zimbabwe - countries that participated in the Global School-based Student Health Survey in 2003 or 2004 - we compared the relative frequency of several adverse health behaviours among children (primarily students 13-15 years of age) who did and who did not report exposure to PV or SV. We estimated odds ratios (ORs) for such behaviours and their 95% confidence intervals (CIs) after adjusting for age and sex. FINDINGS: Exposure to PV during the 12 months preceding the survey was reported by 27-50% (average: 42%) of the children studied in the five countries, and lifetime exposure to SV was reported by 9-33% (average: 23%). Moderate to strong associations were observed between exposure to PV or SV and measures of mental health, suicidal ideation, current cigarette use, current alcohol use, lifetime drug use, multiple sex partners and a history of sexually transmitted infection (P < 0.05 for all associations). For example, the odds of being a current cigarette smoker were higher in children involved in one fight (OR: 2.20; 95% CI: 1.77-2.75), 2-5 fights (OR: 3.43; 95% CI: 2.54-4.63), or 6 fights or more (OR: 5.95; 95% CI: 4.37-8.11) (P for trend < 0.001) during the 12 months preceding the survey than in children unexposed to PV. CONCLUSION: Childhood exposure to PV and SV is common among African children in some countries and is associated with multiple adverse health behaviours. In developing countries, increased awareness of the frequency of exposure to violence among children and its potential health consequences may lead to heightened attention to the need for health promotion and preventive programmes that address the problem.

Injuries and violence are a significant and growing cause of child death and disability, as well as having other health consequences including mental health, behavioural and reproductive health problems. Every year injuries and violence kill approximately 875 000 children (aged less than 18 years of age) and injure or disable tens of millions more. Injury-related causes account for 3 of the top 15 killers of children aged 0–4 years and for 6 of the top 15 killers of children aged 5–14 years. Child maltreatment has been associated with significantly increased risk of alcoholism, drug abuse, depression, suicide attempt, smoking and sexually transmitted disease. The burden from child injury is most felt in low- and middle-income countries, where 95% of all child-injury deaths occur, and where recorded rates of child maltreatment are substantially higher than in high-income countries. This huge public health problem is all that much more tragic because it is avoidable. Through combinations of prevention and care, most high-income countries have considerably reduced rates of child-injury death and child maltreatment. Consequently, there are huge inequities globally, with annual child-injury mortality of 8.6/100 000 in high-income countries compared with 41.8/100 000 in low- and middle-income countries.1 In other words, rates of child-injury death are more than four times higher in low- and middle-income countries. A large burden of death and morbidity could be avoided by bringing violence and injury rates in low- and middle-income countries down to levels similar to those in high-income countries. Such public health benefits could be achieved by use of proven prevention methods, such as implementing and enforcing safety legislation and standards; promoting home and transport safety; modifying products or the environment; and improving care and rehabilitation of injured children. Programmes to promote safe, sustainable and nurturing relationships between children and their parents or caregivers can substantially reduce child maltreatment, and youth violence prevention programmes can significantly reduce violence-related death and injury in adolescents. These strategies, most of which are affordable and sustainable in all countries, need to be better applied globally. Child injury and violence need to be better incorporated into broader child survival strategies. Child injury and violence have been only minimally addressed thus far by the global health community and by most governments. Likewise, these topics have been inadequately addressed in the scientific literature. An upcoming theme issue of the Bulletin (May 2009) on child injury and violence will seek to address these shortcomings, to promote greater attention to these significant public health problems, to promote greater uptake of known effective prevention and treatment interventions globally, and to stimulate more research on low-cost and sustainable ways to confront these problems especially in low- and middle-income countries where most children live. The Bulletin theme issue will examine the spectrum of child injury and violence prevention and control including epidemiology, prevention, care and rehabilitation. It will contain papers in the categories of Perspectives, Policy and practice, Research, and Lessons from the field. Several papers will be commissioned. In addition, submissions from interested authors are highly encouraged. We welcome papers for all sections of the Bulletin that focus on any of the following topics: surveillance and data collection; evaluation of methods to prevent unintentional injury and violence; health systems strengthening or financing for child injury and violence prevention interventions; or methods for strengthening emergency care and/or rehabilitation of injured and maltreated children. We would especially encourage papers that go beyond the health perspective to address the cross-sectoral nature of the problem. For example, papers on transport safety could encompass the multi-sectoral nature of road traffic injury, including human behaviour, roadway infrastructure and vehicle design, and broader issues of urban design. Papers on violence could include coverage of the multi-dimensional determinants of violence, including parenting, childhood exposures and subsequent health and social consequences, and societal-level factors such as socio-economic disparities. Likewise, papers examining responses to violence could discuss actions involving the educational, welfare and criminal justice sectors, as well as the health sector. Papers discussing how child injury and violence issues can be better addressed in the broader child survival and global health agendas are encouraged. These could include discussions of the relationship of child injury and violence and Millennium Development Goals such as Goal 4 (reducing child mortality). Papers from authors in developing countries are especially encouraged. It is hoped that the papers in this issue will contribute important information that will assist public health practitioners, clinicians, researchers and policy-makers to better confront the eminently preventable problem of child injury and violence. The deadline for submissions is 1 September 2008. Manuscripts should be submitted to: http://submit.bwho.org respecting the Guidelines for Contributors and accompanied by a cover letter mentioning this call for papers. All submissions will go through the Bulletin’s peer review process. ■

In addition to its specific focus on self-directed violence, the paper by Eddleston et al. in this issue of the Bulletin highlights how intersectoral collaboration can be crucial to furthering the cause of public health. (1) With nearly 900 000 deaths from suicide every year, worldwide, (2) suicide takes more lives than homicides and wars combined; it is commonly acknowledged that this figure is an underestimation and that the real magnitude can barely be guessed. Added to these deaths are the many non-fatal suicide attempts, some of which are addressed by Eddleston et al. In the absence of national registries or reliable hospital-based systems for recording suicide attempts, a large-scale study was conducted by the WHO Regional Office for Europe to estimate the number of suicide attempts in several European cities of various sizes. (3) The findings were compared with corresponding national rates for completed suicides, and showed suicide attempt rates to be 10-40 times higher than rates for completed suicides. Projecting these figures to the global total of completed suicides would give the mind-boggling worldwide estimate of between 9-36 million suicide attempts every year. Whatever the real numbers, self-directed violence clearly constitutes a major public health challenge that health planners, policy-makers and practitioners simply cannot afford to ignore. Imprecision in recording efforts does not only affect the figures for suicide. For every real case of suicide that is misrecorded as something else (e.g. accident, stroke or cardiac arrest), another mortality category will be unduly inflated, thus distorting the entire system of mortality records. Individual studies on the reliability of suicide mortality recording have indicated that numbers of deaths may be underestimated by 30-200%. (W4) Reliable information on suicide mortality and suicide attempts is therefore not only useful for better planning and delivery of suicide prevention programmes, but will also help to provide a clearer picture of the mortality attributable to other causes, particularly those indicated above. Perhaps even less well understood is the specific link between suicide and pesticides, which is significant in rural areas generally and in Asian countries in particular. It is estimated that in the last 10 years between 60-90% of suicides in China, Malaysia, Sri Lanka, and Trinidad and Tobago were by pesticide ingestion. (W5) This led Gunnell & Eddleston to estimate that there are as many as 300 000 deaths each year from intentional pesticide poisoning in those parts of the world. (W6) More recently, WHO has received reports of a growing number of suicides due to pesticide ingestion in many other Asian countries and in Central and South American countries (e.g. Brazil, El Salvador, Guatemala, Guyana, Nicaragua and Paraguay). This may well mean that the global number of suicide deaths is considerably higher than currently estimated, and clearly makes pesticide ingestion the most common method of suicide on a worldwide basis. This new information provides clear indications of directions for action. …

From its modest beginnings based on the analysis of death certificates, the National Violent Death Reporting System represents what can be achieved through sustained investment in efforts to measure violence related mortality The US National Violent Death Reporting System (NVDRS) is a major innovation in violent death surveillance. The NVDRS links data for individual cases from multiple sources, and, where more than one death is associated with an incident, links records for all deaths that occurred in the incident. The NVDRS thus makes it possible to answer questions that are critical for the development of effective violence prevention strategies. What are the risk factors for multiple homicides? What proportion of people who commit homicide go on to kill themselves? How frequently are homicides associated with child maltreatment? Is the national level of violent death in schools increasing or decreasing? What proportion of homicides is associated with illicit drug deals? By having trained coders extract data from death certificates, medical examiner, coroner, and law enforcement records, the NVDRS provides the information sooner than vital statistics data, which are available only two years after a death. As the articles in this special issue illustrate, the combination of comprehensiveness and timeliness mean that NVDRS data are in high demand by violence prevention practitioners. As such, the NVDRS is the new gold standard for violent death surveillance systems elsewhere. Widespread dissemination about how the NVDRS works and its benefit for violence prevention will hopefully lead other countries that already have the elements of such a system in place to emulate the NVDRS. In a global perspective, however, only a small …

WHO, along with other United Nations organisations and international agencies working to strengthen violence prevention at national and local levels, advocates an evidence-based approach to prevent the problem of violence. The case for evidence-based approaches is an ethical one—to do as much good as possible with available resources. Without using an evidence-based approach, well-intentioned policymakers and practitioners can squander scare resources on policies and programmes that are at best ineffective and in some instances actively harmful. Drawing on reviews of the scientific literature, and using the Liverpool John Moores University—WHO online violence prevention database as an indicator of all published violence prevention outcome evaluation studies, this presentation has three aims. The first aim is to map the distribution of outcome evaluation studies by type of violence (ie, child maltreatment; youth violence; intimate partner violence; sexual violence; elder maltreatment, and self-directed violence); level of intervention (ie, individual, family, community, societal), and WHO geographical region. The second aim is to map progress in implementing the four stages of the public health approach to violence prevention (ie, problem description, risk factor identification, intervention evaluation, and scaling up) by country income level and type of violence. The third aim is to suggest priority actions for generating and using scientific evidence for the prevention of violence.

Injuries and violence are a significant cause of child death and physical and psychological disability. Every year injuries and violence kill approximately 950 000 children (aged less than 18 years) and injure or disable tens of millions more as discussed in the recent World report on child injury prevention.1 This burden is particularly tragic because much of it is avoidable. Known, effective prevention and treatment strategies remain greatly underutilized, especially in low- and middle-income countries where 95% of child injury deaths occur. This month’s Bulletin theme issue seeks to promote greater attention to this significant public health problem and to explore ways in which this burden can be lowered. Several strategic directions are addressed. There is a need to increase the knowledge base on the extent and outcome of injury, as well as risk factors that should be targeted with prevention efforts. Celko et al. (374–381) identify risk factors for burns in the Czech Republic as a basis for subsequent prevention efforts. Rozenfeld & Peleg (362–368) determine the extent of violence-related injury in Israel, including identifying risk factors using the National Trauma Registry, a tool that has facilitated injury research in that country. Bordin et al. (336–344) show that severe punishment is related to mental health problems in poor urban Brazilian children and identify potential interventions, such as efforts to support parents emotionally that may help them adopt better child-rearing practices. Mikton & Butchart (353–361) undertake a systematic review of what works in child maltreatment prevention, pointing out evidence for promising interventions such as home visitation and parental education. These four articles demonstrate the scientific foundation of injury control, as emphasized by Haddon in the public health classic, here reviewed by Ruyan & Baker (402–403). Injury control must be better addressed in health policy and integrated into other major agendas. Harvey et al. (390–394) emphasize that there are many proven interventions that need to be put into action. To do so, injury prevention must be integrated into child health and survival initiatives and also into the broader development agenda. In terms of trauma care, Mock et al. (382–389) review several local success stories, point out early efforts to implement system-wide improvements and emphasize that existing global trauma care efforts should better address the special needs of injured children. To be able to influence policy, there must be stronger advocacy in injury control. This point is brought home in the round table discussion in which Pless (395–401) emphasizes the need to convince health departments that injury is a health problem and is therefore part of their role. He advises child safety advocates to push for more government action and to “be prepared to operate at the political level”. To undertake sustainable injury control work, there must be sufficient individual and institutional capacity. Hyder et al. (345–352) emphasize this point in their efforts to improve local ability to gather and handle injury data in a multicountry study. This study has helped to develop the injury knowledge base and has led to better injury surveillance capabilities in the countries involved. At this stage, what is needed more than anything else in injury control are model country programmes. One of the most compelling arguments to bring to the attention of policy-makers is the documentation of successful programmes in similar countries. Pervin et al. (369–373) evaluate the effectiveness of Viet Nam’s recent mandatory motorcycle helmet law and show high compliance with the law among adults. However, compliance is lower for children (although improved since the new law) due to parental misperceptions that children face a higher risk of neck injuries with helmet use as well as a loophole in the law for children not wearing helmets. This study demonstrates the overall success of a helmet law, identifies specific challenges and provides valuable information for other countries to use in their own efforts to promote universal motorcycle helmet use. The increased attention that this Bulletin issue brings to the field of injury control is timely and will be followed closely by several important events: the release of the Global status report on road safety (June 2009); the Violence Prevention Alliance’s fourth milestones meeting (September 2009); and the first global ministerial conference on road safety in Moscow (November 2009). We hope that this special Bulletin issue convinces those in child health and development that child injury and violence should be on their agendas. We also hope that the issue stimulates more research on what works to prevent and treat injuries, especially in low- and middle-income countries, as well as increased advocacy and partnerships to confront child injury. We especially hope that this issue will encourage countries and governments to implement injury control policies and programmes that will actually lower the currently unacceptable toll of child injury. ■

A prospective, hospital based sampling procedure conducted between June 8th, 1989 and August 24th, 1990 identified 1592 victims of interpersonal violence in six state and five private hospitals serving the Johannesburg magisterial district (which includes Soweto). For the 1282 victims resident in the area, this corresponded to crude annualised incidence rates per 100 000 population of 3821 for coloureds, 1527 for blacks, 467 for whites, 433 for asians and 1380 for all residents. Males, most of whom were aged 20–24 years, constituted 83.9% of all victims and were most often attacked on the streets. The majority of females were attacked at home by a spouse or lover, and most incidents occurred between dusk and midnight on weekends. Sharp violence was the most frequent type, involving 52.2% of the male and 51.4% of the female victims. Analysis by racial classification of the overall findings for mechanism of injury and relationship to aggressor showed dramatic differences. Limitations of the findings are discussed. After comparison with similar data for two United States cities and Copenhagen, Denmark, it is hypothesised that the racial differences in the present findings reflect the interplay of universal structural determinants and a specific colonial factor rooted in the sociology and psychology of oppression. Some implications of these findings and hypothesised determinants for violence prevention initiatives are mentioned.

Scientific information on violence can be difficult to compile and understand. It is scattered across websites, databases, technical reports and academic journals, and rarely addresses all types of violence. In response, in October 2017 WHO released the Violence Prevention Information System or Violence Info, an online interactive collection of scientific information about the prevalence, consequences, risk factors and preventability of all forms of interpersonal violence. It covers homicide, child maltreatment, youth violence, intimate partner violence, elder abuse and sexual violence.