Prevention is a systematic process that promotes safe, healthy environments and behaviors and reduces the likelihood or frequency of an incident, injury, or condition from occurring. There are three types of prevention: primary, secondary, and tertiary. Primary prevention is taking action before a problem arises. Secondary prevention is the early detection of the problem, relying on physical changes, symptoms, or abnormal tests to determine action. It focuses on responses that take place shortly after the condition has developed or has been recognized. Tertiary prevention slows or prevents deterioration from a condition, focusing on treatment of and rehabilitation from the consequences of the condition. These are usually long-term responses to ameliorate or prevent further negative effects.
Primary prevention strategies can target the individual, relationship, community, or societal levels. Individual strategies address personal or biological factors. Relationship strategies focus on relations with others. Community strategies target the policies and practices of communities and social environments, such as schools, workplaces, and neighborhoods. Societal strategies focus on the macro level, addressing norms, beliefs, or policies. For example, tobacco control used this continuum to frame its work to reduce smoking. Prohibiting smoking in public places changed societal norms. To date, most public health and health care efforts to prevent interpersonal violence have focused on the first two areas (individual and relationship).
Prevention Strategies for the Prenatal and Birth Period
During this time period, primary prevention efforts focus on the individual level, largely with home visits. In addition to violence reduction and child abuse prevention, prenatal and early childhood home visitation has been used for a wide range of health and nonhealth goals. Home visitation programs are common in Europe, where they are most often made available to all childbearing families, regardless of estimated risk of child-related health or social problems. In the United States, home visitation programs are commonly targeted to specific population groups that are at high risk for problems. These include low-income groups; minorities; youth; less-educated groups; first-time mothers; substance abusers; children at risk for abuse or neglect; and low birth weight, premature, disabled, or developmentally compromised infants.
Visitation programs include, but are not limited to, one or more of the following components: training of parent(s) on prenatal and infant care, training on parenting, child abuse and neglect prevention, developmental interaction with infants or toddlers, family planning assistance, development of problem-solving skills and life skills, educational and work opportunities, and linkage with community services. In addition to home visits, programs can include daycare; parent group meetings for support, instruction, or both; advocacy; transportation; and other services. When such services are provided in addition to home visitation, the program is considered multicomponent.
The evaluations of home visitation programs demonstrate that women’s prenatal health-related behaviors improve, child abuse and neglect rates are reduced, maternal welfare dependence is reduced, successive pregnancies are spaced, and maternal criminal behavior as well as behavior problems related to drug and alcohol abuse are also reduced. Early home visits have also impacted antisocial behavior and the use of substances by teens.
In 2003, the Centers for Disease Control and Prevention (CDC) reviewed the scientific evidence concerning the effectiveness of early childhood home visitation in preventing violence by the visited child against others or self (i.e., suicidal behavior), violence against the child (i.e., maltreatment, which is defined as abuse or neglect), violence by the visited parent, and intimate partner violence. They concluded that there was insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited children and between adults. However, this is difficult research to do. Home visitation programs in the United States are diverse, differing in focus, curricula, duration, visitor qualifications, and target populations. Although no single optimal, effective, and cost-effective approach could be defined for the multiplicity of possible outcomes, settings, and target populations, the CDC stated that the findings were robust, suggesting that programs can be effective. Health professionals and policymakers are encouraged to carefully consider the attributes and characteristics of the particular home visitation program to be implemented.
Secondary prevention efforts can occur during routine prenatal care visits when women are assessed for factors that might complicate the pregnancy or impact a healthy outcome. In addition to screening for health problems like anemia, diabetes, or poor weight gain, providers have the opportunity to assess for violence. This is encouraged by the American College of Obstetrics and Gynecology. Screening is recommended for a number of symptoms and problems that have been identified as potential indicators of abuse such as preterm labor, poor weight gain, and depression.
Strategies for Infants And Children
During the infancy and childhood years, parents are encouraged to bring children into a health care office for well-child visits. This time is used to give immunizations preventing childhood diseases and to assess biomedical health, behavior, development, and family functioning, as well as to provide parent education through age-appropriate counseling, referred to as anticipatory guidance. Anticipatory guidance has been part of the well-child check for years and has been integrated into state-supported efforts such as Bright Futures or Child and Teen Check-ups. This is a primary prevention approach that includes topics such as nutrition, sleep, toileting, discipline, childcare, screening for lead exposure, and safety in the home regarding poisons and medications. When a problem is identified, the child and parent are referred for additional assistance.
Recent efforts have summarized the components of anticipatory guidance to prevent violence throughout the child’s life—infancy, toddler, school age, adolescence—and guidance for the parents of adolescents. These components are all included in the program Connected Kids: Safe, Strong, and Secure, which is a complete package of parent and adolescent educational brochures, a clinical guide for pediatricians, and a Web site with supporting literature and supporting training materials from the Internet.
Anticipatory guidance can have several positive outcomes. Used strategically, it can be effective in leading to behavioral change, particularly if the counseling addresses issues of concern to the parent. Verbal counseling accompanied by personalized written information seems to be effective. Supportive materials need to be compelling and written to match the educational level of the parent.
Anticipatory guidance is encouraged by professional medical organizations that focus on the health of children (American Academy of Pediatrics and the American Academy of Family Physicians), but how to best translate the directive into practice is far from simple. Clinics often delegate some of the assessment to a nurse, incorporate questions in the office visit grid, or, with the advent of the electronic medical record, include smart texts with the guidance appropriate to the age of the child. Studies show that anticipatory guidance is provided inadequately in many practices and the format is not always useful to the parent. There are many topics to cover and topics are not equally relevant; priorities need to be set.
Linking prevention strategies to risk and protective factors improves the chance of effectiveness. For example, one of the most consistent risk factors for intimate partner violence (IPV) as an adult is exposure to it as a child. Therefore, secondary and tertiary prevention efforts with victims and perpetrators, such as referrals to shelters and domestic violence support groups for victims, and using the court and batterers programs for perpetrators, may actually be primary prevention for exposed children. In 1998, the American Academy of Pediatrics encouraged physicians to inquire about IPV, since witnessing the abuse between adults in the home is associated with physical and mental health problems in the child. IPV is generally not a mandatory report in most states unless the child is being hurt.
In the realm of secondary and tertiary prevention, watching for signs of child abuse and neglect has been the responsibility of physicians since the mid-1960s. As mandated reporters, physicians are required by law to report a family to the local children’s protective services when there is a concern about abuse or neglect.
Strategies for Adolescents
Relationship health falls on a spectrum that includes healthy, unhealthy, and abusive relationships. Primary prevention focused on the relationship level can be done individually or with a curriculum in a classroom or group setting. This means educating teens about their dating or peer relationships before abuse or violence happens.
Guidelines for Adolescent Preventive Services, developed by the American Medical Association, outlines areas of anticipatory guidance and health assessments that providers should address with teens in the health care setting. Violence prevention recommendations include counseling teens about resolving personal conflicts without violence and avoiding the use of weapons and weapon safety. As previously discussed, the implementation of these recommendations is a challenge.
On the community level, prevention efforts for teens have resulted in a number of curricula on “healthy relationships.” Some examples are the Family Violence Prevention Fund’s Expect Respect: Working with Men and Boys, which focuses on educating males about dating violence; the CDC’s sexual violence prevention program, Beginning the Dialogue, which identifies concepts and strategies that may be used as a foundation for planning, implementing, and evaluating sexual violence prevention activities in a community; and the CDC’s Choose Respect, which focuses on healthy teen relationships.
Strategies for Adults
To date, there has been no deliberate approach for discussing relationship health with adult patients in the health care setting. To achieve this, providers must understand the elements of healthy, unhealthy, and abusive relationships, and also have the skills, comfort level, tools, and time to initiate and follow through on conversations about relationship health. At this point, few health systems or professional health organizations have developed an approach to this issue. Promotion of positive relationship health should lessen individual, financial, and social costs of both intimate partner and employee abuse and violence. However, this requires sustained efforts on the part of health systems, with commitment from leadership, the designation of internal champions, and the implementation and ongoing evaluations of policies and practice.
Most efforts in the health care setting are secondary or tertiary prevention in nature. A number of screening tools and guidelines are available to assist providers in inquiring about IPV during the health care encounter in order to identify individuals in abusive relationships so that they can be referred before long-term consequences begin. Tertiary prevention seeks to identify victims and to limit the disability from the violence by caring for their health issues, both physical and mental, and linking them with resources to address the abuse.
Strategies for Seniors
Assessing elders for the evidence of abuse or neglect by their caregivers has been encouraged for a number of years. U.S. physicians are mandated by law to report cases where they suspect the abuse or neglect of an elderly person or vulnerable adult to local adult protective services. The “vulnerable adult” is defined in law and refers to an adult who is physically or mentally incapacitated, so that he or she is unable to make decisions for himor herself. Efforts to identify older victims of IPV are a more recent development. Meeting the needs of these victims requires the collaboration of domestic violence advocacy and services for the elderly. Identifying elder abuse or older victims of IPV can be both secondary and tertiary prevention. Screening questions and tools are available. Efforts are needed to raise the awareness of physicians so that they understand the signs and symptoms associated with abuse and neglect, take the time to create privacy, and then routinely inquire about abuse when the signs and symptoms are present. Once abuse is identified, then the individual needs to be linked with services.
Community-Focused Efforts
Over the years, public awareness campaigns have addressed interpersonal violence. Messages communicate the norms of nonviolence in relationships and in the family and publicize available community resources for violence and abuse. Outlets for these campaigns have occurred through the media, slogans on buses, billboards, and educational literature distributed at various community locations. Examples include education about shaken baby syndrome or child abuse; about what is appropriate and inappropriate in dating relationships or intimate relationships; and about financial exploitation.
There are many opportunities to prevent interpersonal violence across the lifespan at the individual, relationship, and community levels within the realm of health. These approaches include primary, secondary, and tertiary prevention. The Institute of Medicine, in its report Confronting Chronic Neglect, concludes that additional effort is needed to enhance the education of physicians throughout their careers so that they have the skills to do a better job in identifying and assisting victims of interpersonal violence.
On the relationship and community levels, continued efforts by public health and health systems are needed.
Bibliography:
- American Medical Association. (1997). Guidelines for adolescent preventive services. Retrieved May 27, 2017, from http://www.uptodate.com/contents/guidelines-for-adolescent-preventive-services
- Centers for Disease Control and Prevention. (2003). First reports evaluating the effectiveness of strategies for preventing violence—Early childhood home visitation: Findings from the Task Force on Community Preventive Services. Retrieved May 27, 2017, from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5214a1.htm
- Institute of Medicine. (2002). Confronting chronic neglect: The education and training of health professionals on family violence. Washington, DC: National Academy Press.
- Page-Glascoe, F., Oberklaid, F., Dworkin, P. H., & Trimm, F. (1998). Brief approaches to educating patients and parents in primary care. Retrieved May 27, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/9606252
- Salber, P. R., & Taliaferro, E. (2006). The physician’s guide to intimate partner violence and abuse: A reference for health care professionals. Volcano, CA: Volcano Press.
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