Reduce Access to and Harmful Use of Alcohol
Harmful use of alcohol is associated with the perpetration of intimate partner and sexual violence (WHO and LSHTM, 2010c). It can therefore be hypothesized that reducing both access to alcohol and its harmful use will lead to reductions in intimate partner and sexual violence. However, the relationship between harmful use of alcohol and violence is complex—not everyone who drinks is at equally increased risk of committing violence, and intimate partner and sexual violence can occur at high rates in cultures where alcohol use is taboo. Furthermore, there is disagreement among experts on whether or not alcohol can be considered to be a “cause” of intimate partner and sexual violence or whether it is better viewed as a moderating or contributory factor. It seems clear, however, that individual and societal beliefs that alcohol causes aggression can lead to violent behavior being expected when individuals are under the influence of alcohol and to alcohol being used to prepare for and excuse such violence. To date, research focusing on the prevention of alcohol-related intimate partner and sexual violence is scarce. There is, however, some emerging evidence suggesting that the following strategies aimed at reducing alcohol consumption may be effective in preventing intimate partner violence:
Reducing alcohol availability: In Australia, a community intervention that included restricting the hours of sale of alcohol in one town reduced the number of domestic violence victims presenting to hospital (Douglas, 1998). In Greenland, a coupon-based alcohol rationing system implemented in the 1980s that entitled adults to alcohol equivalent to 72 beers per month saw a subsequent 58 percent reduction in the number of police call outs for domestic quarrels (Finnish Foundation for Alcohol Studies and World Health Organization, 2003).
Regulating alcohol prices: Increasing the price of alcohol is an effective means of reducing alcohol-related violence in general (Chaloupka et al., 2002). Although research evaluating the effectiveness of this approach in reducing intimate partner violence specifically is scarce, one study using economic modeling estimated that in the United States a 1 percent increase in the price of alcohol may decrease the probability of intimate partner violence toward women by about 5 percent (Markowitz, 2000).
Treatment for alcohol-use disorders: In the United States, treatment for alcohol dependence among males significantly decreased husband-to-wife and wife-to-husband intimate partner violence 6 and 12 months later, suggesting that such treatment may also be an effective primary prevention measure (Stuart et al., 2003).
Intimate partner and sexual violence may also be reduced through primary prevention programs to reduce the more general harms caused by alcohol (Anderson et al., 2009). Approaches for which effectiveness is well supported by evidence include:
Making alcohol less available: This can be achieved by introducing minimum purchase-age policies and reducing the density of alcohol retail outlets and the hours or days alcohol can be sold. Such an approach has been shown to lead to fewer alcohol-related problems, including homicide and assaults (Duailibi et al., 2007).
Banning of alcohol advertising: Alcohol is marketed through increasingly sophisticated advertising in mainstream media; through the linking of alcohol brands to sports and cultural activities; through sponsorships and product placements; and through direct marketing via the Internet, podcasting, and mobile telephones. The strongest evidence for the link between alcohol advertising and consumption comes from longitudinal studies on the effects of various forms of alcohol marketing—including exposure to alcohol advertising in traditional media and promotion in the form of movie content and alcohol-branded merchandise—on the initiation of youth drinking and on riskier patterns of youth drinking (Anderson et al., 2009). However, evidence showing that such measures reduce intimate partner and sexual violence is currently lacking.
Individually directed interventions to drinkers already at risk: These include screening and brief interventions. Alcohol screening and brief interventions in primary health care settings have proven effective in reducing levels and intensity of consumption in LMICs and HICs (Finnish Foundation for Alcohol Studies and World Health Organization, 2003). However, their direct effect on alcohol-related intimate partner violence has not been measured. Evidence indicates that drinkers may reduce their consumption by as much as 20 percent following a brief intervention and that heavy drinkers who receive such an intervention are twice as likely to reduce their alcohol consumption as heavy drinkers who receive no intervention. Brief interventions include the opportune provision of advice and information in health or criminal justice settings (typically during a 5- to 10-minute period) but can also extend to several sessions of motivational interviewing or counseling (FPH, 2008; Sheehan, 2008).
School-based education on alcohol does not appear to reduce harm, but public-information and education programs (while again apparently ineffective at reducing alcohol-related harm) can increase the attention given to alcohol on public and political agendas (Anderson et al., 2009).
As with most primary prevention programs to prevent intimate partner and sexual violence, programs to reduce access to and harmful use of alcohol have mainly been conducted and evaluated in HICs, and little is known of their suitability or effectiveness outside such countries. For many LMICs, programs such as efforts to strengthen and expand the licensing of outlets could be of great value in reducing alcohol-related intimate partner and sexual violence. In many developing societies, a large proportion of alcohol production and sales currently takes place in unregulated informal markets. One study in São Paolo, Brazil, found that just 35 percent of alcohol outlets surveyed had a license of some form, and that alcohol vendors (whether licensed or not) faced few apparent restrictions on trading (Laranjeira and Hinkly, 2002). Furthermore, in many LMICs there are far fewer specialist health facilities, reducing the opportunities for alcohol treatment or screening. In such settings it may instead be beneficial to develop the role of primary health care workers or general practitioners in identifying and alleviating the harmful use of alcohol.
Although evidence for the effectiveness of measures to reduce access to and harmful use of alcohol is only beginning to emerge and high-quality studies showing their impact on intimate partner and sexual violence are still largely lacking, alcohol-related programs for the prevention of intimate partner violence and sexual violence appear promising. The strong association between alcohol and intimate partner and sexual violence suggests that primary prevention interventions to reduce the harm caused by alcohol could potentially be effective. Approaches to preventing alcohol-related intimate partner and sexual violence should also address the social acceptability of excessive drinking as a mitigating factor in violence, while altering normative beliefs about masculinity and heavy drinking. There remains a pressing need for additional research to evaluate the effectiveness of such approaches in reducing intimate partner and sexual violence, especially in LMICs.
Change Social and Cultural Norms Related to Gender That Support Intimate Partner and Sexual Violence
Cultural and social gender norms are the rules or “expectations of behavior” that regulate the roles and relationships of men and women within a specific cultural or social group. Often unspoken, these norms define what is considered appropriate behavior, govern what is and is not acceptable, and shape the interactions between men and women. Individuals are discouraged from violating these norms through the threat of social disapproval or punishment or because of feelings of guilt and shame in contravening internalized norms of conduct. Often traditional social and cultural gender norms make women vulnerable to violence from intimate partners, place women and girls at increased risk of sexual violence, and condone or support the acceptability of violence (Box 6-3).
Examples of Social and Cultural Norms That Support Violence Against Women. A man has a right to assert power over a woman and is considered socially superior. Examples: India (Mitra and Singh, 2007), Nigeria (Ilika, 2005), and Ghana (Amoakohene, 2004). (more...)
Efforts to change social norms that support intimate partner and sexual violence are therefore a key element in the primary prevention of these forms of violence. Approaches have been adopted, although rarely evaluated, throughout the world to break the silence that often surrounds intimate partner and sexual violence, to try to inform and influence social attitudes and social norms on the acceptability of violence, and to build political will to address the problem. The use of research findings for advocacy has been shown to be promising in bringing attention to, and raising awareness of, the problem and in contributing to the shaping of reforms and policies (Ellsberg et al., 1997). Currently the three main approaches for changing social and cultural norms that support intimate partner and sexual violence are social norms theory (i.e., correcting misperceptions that the use of such violence is a highly prevalent normative behavior among peers), media awareness campaigns, and working with men and boys. Often several approaches are used in one program.
Social norms theory assumes that people have mistaken perceptions of other people's attitudes and behaviors. The prevalence of risk behaviors (such as heavy alcohol use or tolerance of violent behavior) is usually overestimated, while protective behaviors are normally underestimated. This affects individual behavior in two ways: (1) by increasing and justifying risk behaviors, and (2) by increasing the likelihood of an individual remaining silent about any discomfort caused by risky behaviors (thereby reinforcing social tolerance). The social norms approach seeks to rectify these misperceptions by generating a more realistic understanding of actual behavioral norms, thereby reducing risky behavior.
In the United States, the social norms approach has been applied to the problem of sexual violence among college students. Among such students, men appeared to underestimate both the importance most men and women place on sexual consent and the willingness of most men to intervene against sexual assault (Fabiano et al., 2003). Although the evidence is limited, some positive results have been reported. In one university in the United States, the A Man Respects a Woman project aimed to reduce the sexual assault of women, increase accurate perceptions of non-coercive sexual behavior norms, and reduce self-reported coercive behaviors by men. The project used a social norms marketing campaign targeting men, a theater presentation addressing socialization issues, and male peer-to-peer education. Evaluation of the campaign two years after its implementation found that men had more accurate perceptions of other men's behavior and improved attitudes and beliefs regarding sexual abuse. For example, a decreased percentage of men believed that the average male student has sex when his partner is intoxicated; will not stop sexual activity when asked to if he is already sexually aroused; and, when wanting to touch someone sexually, tries and sees how they react. However, the percentage of men indicating that they have sex when their partner is intoxicated increased (Bruce, 2002).
Media awareness campaigns are a common approach to the primary prevention of intimate partner and sexual violence. Campaign goals might include raising public awareness (for example, about the extent of the problem, about intimate partner violence, and sexual violence as violations of women's human rights and about men's role in ending violence against women); providing accurate information; dispelling myths and stereotypes about intimate partner violence and sexual violence; and changing public opinion. Such campaigns have the potential to reach large numbers of people. An example of a media-awareness campaign is Soul City in South Africa. This multimedia health promotion and change project examines a variety of health and development issues, imparts information and aims to change social norms, attitudes, and practice. It is directed at individuals, communities, and the socio-political environment. One of its components aims to change the attitudes and norms that support intimate partner and sexual violence. This multi-level intervention was launched over six months and consisted of a series of television and radio broadcasts, print materials, and a helpline. In partnership with a national coalition on preventing intimate partner violence, an advocacy campaign was also directed at the national government with the aim of achieving implementation of the Domestic Violence Act of 1998. The strategy aimed for impact at multiple levels from individual knowledge, attitudes, self-efficacy, and behavior to community dialogue, shifting social norms, and the creating of an enabling legal and social environment for change. An independent evaluation of the program included national surveys before and after the intervention, focus groups, and in-depth interviews with target audience members and stakeholders at various levels. It found that the program had facilitated implementation of the Domestic Violence Act of 1998, had positively impacted on problematic social norms and beliefs (such as that intimate partner violence is a private matter), and had improved levels of knowledge of where to seek help. Attempts were also made to measure its impact on violent behavior, but there were insufficient data to determine this accurately (Usdin et al., 2005).
As the Soul City project indicates, evidence is emerging that media campaigns combined with other educational opportunities can change knowledge, attitudes, and beliefs related to intimate partner and sexual violence. Although good campaigns can increase knowledge and awareness, influence perceptions and attitudes, and foster political will for action, evidence of their effectiveness in changing behavior remains insufficient (Whitaker et al., 2007a).
Working with men and boys—There has been an increasing tendency to focus efforts to change social and cultural norms on adolescent males or younger boys using universal or targeted programs that are delivered through a variety of mechanisms, including school-based initiatives, community mobilization, and public awareness campaigns.
Objectives typically include increasing an individual's knowledge, changing attitudes toward gender norms and violence, and changing social norms around masculinity, power, gender, and violence. Some programs also aim to develop the capacity and confidence of boys and young men to speak up and intervene against violence, with the goal of changing the social climate in which it occurs (Katz, 2006). Failure to engage men and boys in prevention may result in the type of negative effects seen in some settings where cultural shifts and other changes have taken place in the absence of efforts to engage them (Box 6-4).
Nicaraguan Backlash Shows the Need to Engage Men as Well. Since 2000, Nicaragua has pioneered a number of initiatives to protect women against domestic violence. These have included: a network of police stations for women (Comisaria de la Mujer) where (more...)
A review of programs that work with men and boys to prevent violence against women (Barker et al., 2007) included 13 primary prevention programs, 5 of which were implemented in LMICs. Four of these programs were judged by the reviewers to be “effective,” six “promising,” and three “unclear.” For example, one community outreach and mobilization campaign in Nicaragua judged to be effective was called Violence Against Women: A Disaster We Can Prevent as Men (Solórzano et al., 2000). This was aimed at men aged 20-39 years who were affected by Hurricane Mitch. The campaign's main messages addressed men's ability and responsibility to help prevent or reduce violence against their partners. Constructing masculinity without intimate partner violence was a group-education program aimed at men in periurban districts of Managua, Nicaragua (Welsh, 1997). The effect of the program was, however, unclear because of the weakness of the outcome evaluation.
Indeed, the methodological quality of most of the outcome evaluations was very low, and outcome measures consisted mainly of attitude changes and self-reported rates of gender-based violence, often using only small sample sizes. One campaign in New South Wales in Australia—Violence Against Women: It's Against All the Rules—targeted 21- to 29-year-old men and aimed to influence their attitudes. Sports celebrities delivered the message that violence toward women is unacceptable and that a masculine man is not a violent man. It also sought to enhance the community's capacity to challenge and address violence against women. A post-campaign survey indicated that the campaign achieved some positive results: 83 percent of the respondents reported that the message of the campaign was that violence against women is “not on,” and 59 percent of respondents could recall the campaign slogan. However, 91 percent of the target group reported that the issue was not one they would talk about with their peers, irrespective of the campaign.
Similarly, in the United States Men Can Stop Rape runs a public education campaign for men and boys with the message: “My strength is not for hurting.” This campaign runs in conjunction with Men of Strength (MOST) clubs—a primary prevention program that provides high-school-age young men with a structured and supportive space to learn about healthy masculinity and the redefining of male strength.
Although programs to alter cultural and social norms are among the most visible and ubiquitous of all strategies for preventing intimate partner and sexual violence, they remain one of the least evaluated. Even where evaluations have been undertaken, these have typically measured changes in attitudes and beliefs rather than in the occurrence of the violent behaviors themselves, making it difficult to draw firm conclusions on their effectiveness in actually preventing intimate partner and sexual violence. Nonetheless, some evidence is emerging to support the use of the three types of programs reviewed above in changing the social and cultural gender norms that support intimate partner and sexual violence. However, these must now be taken to scale and more rigorously evaluated.
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