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"There is an often quoted parable that tells of a man and woman fishing downstream. Suddenly a person comes down the river struggling for life. The fisherfolk pull her out. Then another comes who again must be rescued. This happens all afternoon and the fisherfolk are getting very tired from constantly pulling people from the river.
When they go upstream, they find that people are drawn to the edge to look at the river, but there is no safe way to do this. Many of them fall. The fisherfolk go to the community leaders and report the number of people who have fallen into the river. They also report that this is due to the lack of a protective barrier on the cliff. Community leaders build a wall behind which people may safely view the water. Some still fall, but there are many fewer victims to rescue."(CDC, 2004; PREVENT, 2005a)
The community above employed a primary prevention strategy to stop the problem from happening in the first place, instead of expending all resources and energy on rescuing people who have fallen into the river (PREVENT, 2005a). In addition to the barrier, the community might also place a warning sign near the cliff and publicize related safety tips. A primary prevention approach typically employs a variety of strategies to counteract the root causes of a specific problem (PREVENT, 2005a), addressing related risk factors and promoting protective factors. A risk factor is a behavior or condition that increases vulnerability to a specific condition. A protective factor is a behavior, social influence or policy that reduces vulnerability to a specific condition or other behaviors.
The correlation of the fisherfolk story to sexual violence prevention is clear: focusing solely on increasing services to sexual assault victims and developing sexual assault response teams are critical 'rescue' or intervention programs. But society needs to address sexual violence as a public health issue and increase its focus on preventing sexual violence, thus preventing it from happening in the first place.
From a public health perspective, there are three levels on the prevention continuum that focus on WHEN an intervention has an effect on a specific problem (PREVENT, 2005a). These three levels of prevention are primary, secondary and tertiary. On the issue of sexual violence, each level has a different focus (PREVENT, 2005a).
The Association of Schools of Public Health (n.d.) describes public health as "the science of protecting and improving the health of communities through education, promotion of healthy lifestyles and research for disease and injury prevention." Rather than focusing on one individual at a time, it addresses the health of the whole population (PREVENT, 2005b). Public health involves an organized effort to "prevent, identify and counter threats to the health and safety of the public" (Turnock, 1997). Unquestionably, sexual violence is one of those threats.
From the public health perspective, sexual violence is viewed as a preventable problem. Data indicates it is caused by the interplay of multiple factors, rather than due to a single factor. Notably, this approach does not identify actions of victims as a cause of sexual violence.
Because sexual violence is a multi-faceted problem, the public health approach to sexual violence emphasizes an equally multi-faceted response involving many sectors of society (World Health Organization & London School of Hygiene and Tropical Medicine, 2010). Today, many communities are moving toward multidisciplinary collaboration to not only intervene when sexual violence occurs, but to collectively consider how to best prevent it from occurring in the first place. Key players in this response include community-based organizations, criminal and civil justice systems, state and local health departments, schools, health care systems, social services, media, policy-making bodies and workplaces (PREVENT, 2005b).
Sexual violence prevention activities are often confused with awareness/outreach activities and risk reduction efforts. But using a public health model, they clearly are different.
To prevent sexual violence, it is critical to understand WHAT factors influence its occurrence (CDC, 2004). The public health approach is driven by a socio-ecological model that outlines how the health status of an individual is influenced not just by that individual's attitudes and practices, but also by personal relationships and community and larger societal factors (PREVENT, 2005c). The World Health Organization (WHO), in World Report on Violence and Health (Krug et al., 2002), used a variation of this model to discuss violence prevention. See the diagram below for a graphic illustration of this model, as found in Chapter 1 (p. 12) of the WHO report.
The Centers for Disease Control, based on the discussion in Krug et al. (2002), used this socio-ecological model to delineate specific risk factors for perpetration of sexual violence. Levels include (CDC, 2004):
In this "nested" model as discussed and illustrated above, risk factors work together to influence culture and behaviors related to sexual violence (CDC, 2004). The model highlights the pivotal role that societal factors play in influencing behaviors and interactions between people and entities (PREVENT, 2005c).
Ideally, multiple prevention strategies/activities simultaneously occur at the different levels of the socio-ecological model. For example, a six-week bullying-prevention program in the elementary school focusing on bystander behavior (individual level) could occur at the same time the local rape crisis center is sponsoring an anti-bullying awareness week that promotes recognizing positive behaviors (societal level). The key is to understand how different levels can reinforce different aspects of a prevention message and to utilize multiple levels in prevention efforts.
Curtis and Love (n.d.) offer another way to look at the socio-ecological model that involves mapping the risk factors for perpetration of sexual violence onto a tree:
"Tree roots distribute nourishment to the trunk, branches and leaves. The societal level issues of oppression and norms that support inequality correspond to the roots because they influence every other level. In this case, the roots send information and expectations to the other parts of the tree. Additionally, these norms hold in place factors and behaviors at the other levels, just as roots anchor a tree. The other levels of the ecological model correspond to the different pieces of the tree as follows: the community level to the trunk, the relationship level to the branches and the individual level to the leaves of the tree. If we think about the process of creating lasting change, we can see how treating the whole system through the roots is more effective than focusing on the leaves or branches. If only the leaves, branches or trunk are treated, then the tree may still be unhealthy. We must become prevention gardeners and tend to the roots of the tree. We can work for change at the root level by addressing issues of oppression and creating equity across all groups. If we make the roots healthy, the tree will take care of the trunk, branches and leaves."
Historically, the belief that awareness programs and prevention programs were one in the same enabled many time-strapped, grassroots professionals to be somewhat complacent in presenting programs only as time and opportunities permitted. We now know that prevention programs have varying degrees of success depending on certain components. Critical to the planning process must be an understanding of what elements can maximize behavioral change. Nine principles of effective prevention programs were identified in What Works in Prevention: Principles of Effective Prevention Programs (Nation et al 2003). This insightful document outlines key issues for any educator to consider when planning a prevention program. Effective prevention programs should include:
Thoughtful, well-planned prevention programs that are intentional in both addressing factors to maximize their effectiveness as well as target multiple levels on the socio-ecological models will enable us to reach our ultimate goal: no more victims of sexual violence.
Note: Audio-slide presentations on this topic by PREVENT of the University of North Carolina Injury Prevention Research Center are available at www.prevent.unc.edu. They include:
Module 1: Orientation To Violence Prevention (2005)
Module 2: Scope Of the Problem (2007)
Association of Schools of Public Health (n.d.). What is public health? Washington, D.C. Through www.whatispublichealth.org.
Centers for Disease Control and Prevention (2004). Sexual violence prevention: Beginning the dialogue. Atlanta, GA. Through www.cdc.gov/violenceprevention/.
Curtis, M. & Love, T. (n.d.). Tools for change: An introduction to the primary prevention of sexual assault. Austin, TX: Texas Association Against Sexual Assault. Through www.mincava.umn.edu/.
Krug, E., Dahlberg, L., Mercy, J., Zwi, A. & Lozano, R. (Eds.) (2002), World report on violence and health. Geneva, Switzerland: World Health Organization, 3-21 (Chapter 1. Violence—a global public health problem). Through www.who.int/violence_injury_prevention/en/.
Nation, M., Crusto, C., Wandersman, A., Kumpfer, K.L., Seybolt, D., Morrissey-Kane. E., & Davino, K. (2003). What works in prevention: principles of effective prevention programs. American Psychologist, 58, 449-456, Prepared for the Centers for Disease Control and Prevention, Division of Violence Prevention.
PREVENT (2005a). Orientation to violence prevention. Moving upstream: The story of prevention. Raleigh, NC: University of North Carolina Injury Prevention Research Center. Through www.prevent.unc.edu.
PREVENT (2005b). Orientation to violence prevention. The public health approach to violence prevention. Raleigh, NC: University of North Carolina Injury Prevention Research Center. Through www.prevent.unc.edu.
PREVENT (2005c). Orientation to violence prevention. The socio-ecological model: A pathway to prevention. Raleigh, NC: University of North Carolina Injury Prevention Research Center. Through www.prevent.unc.edu.
Turnock, B. (1997). Public health: What it is and how it works. Baltimore, MD: Aspen.
Valle, L., Hunat, D., Costa, M., Shively, M., Townsend, M., Kuck, S., Rhoads, W. & Baer, K. (2007). Sexual and intimate partner violence prevention programs evaluation guidebook. Atlanta, GA: Centers for Disease Control and Prevention. www.cdc.gov/pubs/ncipc.aspx.
World Health Organization (2002). Sexual violence facts. Data from Krug et al. Through www.who.int/violence_injury_prevention/en/.
World Health Organization/London School of Hygiene and Tropical Medicine (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: World Health Organization. Through www.who.int/reproductivehealth/en/.