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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 …

In this paper the authors extend the predominantly etic analysis of the Soweto Community Health Centre System's macrostructural and managerial factors presented in Part 1 (Seedat & Nell, this issue), to an emic analysis at the microlevel of interpersonal processes and practices among nursing staff. Content analysis of interviews with 18 nurses one year after they had completed a psychological skills-training programme revealed five key constraints on the development of nurse autonomy and integration of psychological with biomedical treatment modalities: (1) Dichotomization of biomedical and psychosocial treatment modalities; (2) Inadequately explained instructions; (3) Contradictions between official roles and organizationally determined powerlessness; (4) Time-limited effects of psychological skills training on patient referral patterns; and (5) Invasion of nurse-patient boundaries by superiors. Positive effects of training were evident in only two areas: (a) Improved conflict resolution skills in relationships with family and peers; and (b) Attempts at self-initiated application of psychological skills during routine treatment of patients. The findings are discussed in relationship to the wider organization, and in particular the attitudes and actions of matrons toward nursing staff. This suggests that in the absence of organizational changes to reduce the ambiguity of role definitions and power relationships between nurses, matrons, doctors and management, the development of holistic and empowering primary health care cannot prosper. In conclusion, some suggestions are presented as to the nature of these changes at the conceptual and organizational levels of primary health care provision.

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.

Some of the theoretical tenets of family therapy such as emphasis on the activation and utilization of existing family resources and the importance it accords to context appear to have a good fit with primary health care's commitment to empowering individuals in their struggle against ill health and the circumstances in which it occurs. This paper explores the possibility of teaching a problem-solving approach to family therapy to nurses in a South African primary health care system. Training consisted of conceptual, pragmatic, and self-growth exercises, and trainees' conceptual and performance skills were compared to the skills of a group of untrained nurses.

Along with the numerous trauma-related impacts of violence and its effects on other health outcomes, the social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development. A companion piece to a review of the scientific literature describing the nature, magnitude and impact of violence on health (Matzopoulos, Bowman, Butchart & Mercy, 2008) in this issue, this paper reviews the current knowledge base on violence and development with a specific focus on low- to middle-income countries. It describes how violence impacts on all eight goals of the Millennium Development Plan and exerts a considerable economic burden on already stressed state systems and social spending. Violence will become an increasingly important threat to development and is receiving growing recognition among the global health community and within health ministries. The near absence of violence prevention within the global development agenda is, however, cause for concern. There is an urgent need to mobilise the international development community to provide financial and technical support for intersectoral collaboration, multilateral research cooperation and the development of research capacity towards addressing violence as a significant threat to development.

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. …

Violence is an important global public health problem that claims the lives of over 1.6 million people each year and results in numerous other health and social consequences. It is also a preventable health problem. This paper provides an overview of the current status of prevention efforts in developing and developed countries, describes what is known about the effectiveness of different approaches and highlights some of the important challenges in building the evidence-base for violence prevention programmes. Research conducted to date shows an imbalance in the emphasis of prevention programmes across the different types of violence. This imbalance is reflected in the timing of response, the nature and level of influence of interventions and programmes and the outcomes studied. Promising and effective approaches have been identified, but many more still require rigorous testing, particularly in developing countries. The current state of the science in violence prevention reveals both progress and a number of remaining challenges.

This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of interpersonal violence reach 3.3% of GDP. The public sector-and thus society in general-bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic impact in these countries. International comparisons are complicated by the calculation of economic losses based on foregone wages and income, thus undervaluing economic losses in poorer countries.

This study describes the sociodemographic distribution of suicide deaths compared with other injury deaths in South Africa. Cross-sectional data for 26,354 cases were extracted from an injury surveillance database. These included all manners of injury death from 10 mortuaries for 1999-2000 (approximately 18-20% coverage of all injury deaths per year). They were used to examine the distribution of suicide across different sex, race and age groupings, and the relative involvement of alcohol across manners of death. The share of suicide as a cause of death was comparable for males and females, but varied considerably across races and age groups. It was twice as high for Whites as for Asians, and four times as high as for Coloureds and Blacks. For all races except Whites, suicides were concentrated in the younger age groups. Only among Whites was the proportion of alcohol-positive suicides higher or comparable with that for other manners of death. While homicides and unitentional injury deaths outnumbered suicides overall, the relative importance of suicide in some social groups is reason for concern. South Africa is a country undergoing profound transformations, and differences in the distribution of suicide across sociodemographic groups deserve attention.

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 …

Derived from a marxist/liberal humanist view of power, conventional critiques of the South African gold mining industry's medical apparatus see only its power to repress and negate the true bodily attributes and authentic person of the African mine worker. In so doing, they ignore the productive capacity of medical practice as a manifestation of what Foucault termed “disciplinary” power, by which the human body is manufactured and made manageable as an object of medical knowledge and industrial utilization. Accordingly, this paper offers just such a Foucaultian reading of South African mining medicine to demonstrate how it has operated to fabricate the bodies of African miners as visible objects possessed of distinct attributes that provoked particular strategies for their surveillance in health and disease.

Traditional measures of health status such as mortality rates and cause-of-death information give limited insight into the role of caregivers and health care providers in infant illness and death. To the extent that the behaviours of these parties can be accurately mapped, they may reveal important sites for effective community interventions and the improvement of medical care. This possibility is explored in relation to infant mortality in Cape Town, South Africa, by analysing verbal histories provided by the caregivers of 70 infants in the course of obtaining police death certification. From these verbal histories it appears that acute respiratory infection and diarrhoeal disease caused the majority of deaths. Infants with a respiratory condition were likely to have been taken for medical attention prior to death. By contrast, the parents of infants with diarrhoeal disease, while more active towards these infants, were less likely to seek medical care—these infants typically being found dead in bed or dying en route to the hospital or clinic. A story of infant death at home following recent medical care was obtained in over half the cases. This study demonstrates a simple method for the examination of the content and structure of lay accounts of illness and death. The implications for health care of such accounts are discussed in terms of the behavioural antecedents of infant mortality due to acute respiratory infections and diarrhoeal disease.

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.

The WHO, in collaboration with the Education Development Center, has developed two training packages covering child maltreatment and intimate partner and sexual violence to accompany its normative guidance on the prevention of family violence.1 2 The packages will help policymakers and programme planners improve their understanding of an evidence-based public health approach to preventing family violence and develop multisectoral policies and prevention programmes. They are also relevant to agencies that fund family violence prevention programmes. The target audience includes individuals working in sectors such as child protection, criminal justice, education, gender, health, social development and social welfare. The training packages have been field tested in over 10 countries in Asia, Africa, and Central and Latin America over the past year, and will be periodically revised to accommodate new research findings. Intimate partner and sexual 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.

Injuries arising from violence are a major public health problem and a leading cause of death around the world. Globally, violence kills at least 1.6 million people each year. Of these violence-related deaths, 86% are due to interpersonal violence (520 000 deaths each year) and self-directed violence (870 000 deaths each year). For every death, there are numerous hospital admissions and emergency department presentations. For instance, interpersonal violence is estimated to result each year in at least 16 million injuries severe enough to warrant medical attention, and suicide attempts are estimated to be 10–40 times more common than completed suicides. Injuries due to interpersonal and self-directed violence therefore result in large direct expenditures for healthcare and are a major burden for other sectors, such as law enforcement, criminal justice, and welfare. Meeting even these direct costs already diverts many billions of dollars from more constructive societal spending. Far larger still are the indirect costs of violence-related injuries due to lost productivity and inability to continue with the activities of daily life. These massive indirect …

This paper critically analyses the historical embeddedness and ideological functions of the concept of community as it is used in South Africa by representatives of the state and its opponents. The analysis shows that ‘community’ is a key concept in the ideology of separatism through which an apartheid psychology and society is reproduced. This has implications for progressive psychologists who aim to empower oppressed ordinary people through interventions based upon theoretical models of community. Some of these are explored by examining the interplay between political and theoretical images of community and ordinary people's ideas about social ills. This suggests that whilst community psychology can revitalise a sense of community amongst the oppressed, it may also reinforce existing social inequalities by deflecting experts and ordinary people from the reconstruction of individual agency upon which liberating social transformation depends. It is concluded that a central task for South African psychologists is to engage in critical self-reflection with the aim of identifying and eliminating oppressive forms of social and psychological discourse, thereby empowering themselves and contributing to the construction of a coherent counterideology.

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.