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Transforming Our World: Implementingthe 2030 Agenda Through SustainableDevelopment Goal Indicators
Bandy X. Leea,*, Finn Kjaerulfb, Shannon Turnerc, Larry Cohend,Peter D. Donnellye, Robert Muggahf, Rachel Davisd, Anna Realinid,Berit Kieselbachg, Lori Snyder MacGregorh, Irvin Walleri,Rebecca Gordonj, Michele Moloney-Kittsj, Grace Leea andJames Gilligank
aLaw and Psychiatry Division, Yale University, 34 Park Street, New Haven, CT 06519,USA
bDIGNITY – Danish Institute Against Torture, Copenhagen, Denmark
cPrevention of Violence Canada-Prevention de la violence, Quebec City, Canada
dPrevention Institute, Oakland, USA
ePublic Health Ontario, Toronto, Canada
fIgarape Institute (Brazil) and the SecDev Foundation (Canada), University of Oxfordand the Graduate Institute of International Studies in Geneva, Geneva, Switzerland
gWorld Health Organization, Geneva, Switzerland
hRegion of Waterloo Public Health and Emergency Services, Waterloo, Canada
iUniversity of Ottawa, Ottawa, Canada
jTogether for Girls, Washington, DC, USA
kNew York University, New York, NY, USA
*Corresponding author. E-mail: [email protected]
Abstract The United Nations’ 2030 Agenda for Sustainable Developmentrecognizes violence as a threat to sustainability. To serve as a context, we providean overview of the Sustainable Development Goals as they relate to violence pr-evention by including a summary of key documents informing violence preventionefforts by the World Health Organization (WHO) and Violence Prevention Alli-ance (VPA) partners. After consultation with the United Nations (UN) Inter-Ag-ency Expert Group on Sustainable Development Goal Indicators (IAEG-SDG), we
� 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31www.palgrave.com/journals
select specific targets and indicators, featuring them in a summary table. Using thediverse expertise of the authors, we assign attributes that characterize the focusand nature of these indicators. We hope that this will serve as a preliminaryframework for understanding these accountability metrics. We include a briefanalysis of the target indicators and how they relate to promising practices inviolence prevention.Journal of Public Health Policy (2016) 37, S13–S31.doi:10.1057/s41271-016-0002-7
Keywords: sustainable development; violence prevention; indicators;accountability measures
What Can and Should be Done to Sustain Momentumand Strategic Direction for Global Violence Prevention?
The 2030 Agenda for Sustainable Development will shape globaldevelopment policy and actions for the next 15 years.1 Ensuringmomentum and strategic direction for global violence prevention willrequire concerted action to kick-start the process in the next 2–5 years.On 22–23 September 2015, in Geneva, the World Health Organization(WHO) hosted the 7th Milestones of a Global Campaign for ViolencePrevention Meeting for violence prevention researchers and practition-ers from all over the world. The conference theme, ‘‘ViolencePrevention and the 2030 Agenda for Sustainable Development,’’encouraged discussion of the need for specific indicators for measure-ment, and about priorities for data collection related to the violencereduction targets. We outline selected conclusions below. The ViolencePrevention Alliance (VPA) is a network of 63 institutions involved inviolence prevention worldwide, bringing together WHO MemberStates, international agencies, civil society organizations, and academicinstitutions. The VPA plays a key role in uniting a vision of effectiveviolence prevention through multi-sectoral collaboration. Because of itsunique forum, which includes sectors at all levels (community,national, regional, and international) the VPA offers an invaluableopportunity for bridging the gap between theory and practice, evidenceand implementation, to identify priority areas for global leadership inviolence research.
Figure 1 provides a timeline and summary of key references designedto support the Global Campaign to Prevent Violence. A Global Plan ofAction to strengthen Health Services is under development and will bean important strategy for achieving SDG’s (Table 1).
Lee et al
S14 � 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31
2002First report on the scope and scale of violence around the globe. Introduced a Typology of Violence and ecological model for understanding violence. Explained the public health approach to addressing and preven�ng violence. Helped to launch the Global Campaign for Violence Preven�on
2008Preven�ng violence and reducing its impact How development agencies can helpA key aim is to s�mulate dialogue on the role of interna�onal development agencies in the preven�on of violence globally, and ul�mately to increase investment in a commonly agreed set of applied violence preven�on strategies.
2009 Violence preven�on: the evidence is a set of briefings on what works to prevent interpersonal violence (including against women and girls), and self-directed violence The Evidence includes: promo�ng safe, stable and nurturing rela�onships between children and their parents and caregivers; developing life skills in children and adolescents; reducing availability and harmful use of alcohol; reducing access to guns, knives and pes�cides; promo�ng gender equality; changing cultural norms that support violence; and vic�m iden�fica�on, care and support.
2012The Global Ac�on Plan calls for countries to: Inrease the priority of evidence-informed violence preven�on as a global public health and development issue . Build the founda�ons for violence preven�on. Implement Violence preven�on strategies
2014 - Jointly published by WHO, UNDP, UNODCData from 133 countries assess na�onal efforts to address interpersonal violence, namely child maltreatment, youth violence, in�mate partner and sexual violence, and elder abuse.Report calls for a scaling up of violence preven�on programmes; stronger legisla�on and enforcement of laws relevant for violence preven�on; and enhanced services for vic�ms of violence.
2015World Health Assembly Resolu�on May 2015 -WHA67.15Calls for the crea�on of a Global Plan of Ac�on to strengthen the role of the health systems to address interpersonal violence, in par�cular against women and girls, and against children
2015• Goal 5: Achieve gender equality and empower all women and girls• Goal 16: promote peaceful and inclusive socie�es for sustainable development, the provision of access to jus�ce for
all, and building effec�ve, accountable ins�tu�ons at all levels.
Targets:5.1 End all forms of discrimina�on of women and girls everywhere5.2 Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and other types of sexual esploita�on5.3 Eliminate all harmful prac�ces , such as child, early and forced marriage, and female genital mu�la�on
TARGETS:16.1 Significantly reduce all forms of violence and related death rates everywhere16.2 End abuse , exploita�on, trafficking and all forms of violence against and torture of children16.7 Ensure responsive, inclusive, par�cipatory and representa�ve decision-making at all levels
Global Campaign for Violence Preven�on
Figure 1: Global violence prevention policy and planning documents.
Source: World Health Organization: http://www.who.int/violence_injury_prevention/violence
https://sustainabledevelopment.un.org/?menu=1300.
Transforming Our World
� 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31 S15
Table
1:
Vio
lence
-rel
ate
dSD
Gin
dic
ato
rsby
tim
efra
me,
gover
nan
ce,
statu
s,and
type
Target
Objective
ProposedIndicator
Tim
eframe:
immediate
medium
term
long(I
ML)
term
Governan
ce:
localregional
national
(LRN)
Status:
Population
service
environment
(PSE
)
Typ
e:structural
driver
behav
iour/
Exposure
medical
condition
(SBM)
Goal5:
Ach
ieve
gen
der
equali
tyand
empow
erall
wom
enand
gir
ls5.2
Eli
min
ate
all
form
sof
vio
lence
again
stall
wom
enand
gir
lsin
the
publi
cand
pri
vate
spher
es,
incl
udin
gtr
affi
ckin
gand
sexual
and
oth
erty
pes
of
explo
itati
on
5.2.1
Pro
port
ion
of
ever
–part
ner
edw
om
enand
gir
ls(a
ged
15-49)
subje
cted
tophysi
cal
and/o
rse
xual
vio
lence
by
acu
rren
tor
form
erin
tim
ate
part
ner
,in
the
last
12m
onth
s
Imm
edia
teL
RN
PB
/E
5.2.2
Pro
port
ion
of
wom
enand
gir
ls(a
ged
15–49
)su
bje
cted
tose
xual
vio
lence
by
per
sons
oth
erth
an
an
inti
mate
part
ner
,si
nce
age15
Imm
edia
teL
RN
PB
/E
5.3
Eli
min
ate
all
harm
ful
pra
ctic
es,
such
as
earl
yand
forc
edm
arr
iage
and
fem
ale
gen
ital
muti
lati
on
5.3.1
Per
centa
ge
of
wom
enaged
20–24
who
wer
em
arr
ied
or
ina
unio
nbef
ore
age18
(i.e
.ch
ild
marr
iage)
med
ium
LR
NPE
B/E
5.3.2
Per
centa
ge
of
gir
lsand
wom
enaged
15–49
yea
rsw
ho
have
under
gone
FG
M/C
by
age
gro
up
(for
rele
vant
countr
ies
only
)
Med
ium
LR
NP
EB
/E
Lee et al
S16 � 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31
Goal16
:Pro
mote
pea
cefu
land
incl
usi
ve
soci
etie
sfo
rsu
stain
able
dev
elopm
ent,
pro
vid
eacc
ess
toju
stic
efo
rall
and
buil
def
fect
ive,
acc
ounta
ble
and
incl
usi
ve
inst
ituti
ons
at
all
level
s16
.1Sig
nifi
cantl
yre
duce
all
form
sof
vio
lence
and
rela
ted
dea
ths
ever
yw
her
e16
.1.1
Num
ber
of
vic
tim
sof
inte
nti
onal
hom
icid
eby
age,
sex,
mec
hanis
mand
wher
eposs
ible
type
of
per
pet
rato
r,per
100,00
0popula
tion
Imm
edia
teL
RN
PB
/E
16.1
.2T
his
indic
ato
ris
stil
lunder
dis
cuss
ion
–G
rey
Conflic
t-re
late
ddea
ths
per
100,00
peo
ple
(dis
aggre
gate
dby
age,
sex,
and
cause
)im
med
iate
LR
NP
ES
B/E
16.2
End
abuse
,ex
plo
itati
ons,
traffi
ckin
gand
all
form
sof
vio
lence
again
stand
tort
ure
of
chil
dre
n16
.2.1
Per
centa
ge
of
chil
dre
naged
1–14
yea
rsw
ho
exper
ience
dany
physi
cal
punis
hm
ent
by
care
giv
ers
inth
epast
month
med
ium
LR
NP
B/E
16.2
.2N
um
ber
of
det
ecte
dand
non-d
etec
ted
vic
tim
sof
hum
an
traffi
ckin
gper
100,00
0;by
sex,
age
and
form
of
explo
itati
on
imm
edia
teL
RN
PE
SB
/E
Addit
ional
This
indic
ato
ris
stil
lunder
dis
cuss
ion-
Gre
y
Per
centa
ge
of
young
wom
enand
men
aged
18–24
yea
rsw
ho
exper
ience
dse
xual
vio
lence
by
age18
Long
Ter
mL
RN
PE
B/E
16.3
Pro
mote
the
rule
of
law
at
the
nati
onaland
inte
rnati
onalle
vel
sand
ensu
reeq
ualacc
ess
toju
stic
efo
rall
16.3
.1T
his
indic
ato
ris
stil
lunder
dis
cuss
ion
-G
rey
Per
centa
ge
of
vic
tim
sof
vio
lence
inth
epre
vio
us12
month
sw
ho
report
edth
eir
vic
tim
izati
on
toco
mpet
ent
auth
ori
ties
or
oth
eroffi
ciall
yre
cogniz
edco
nflic
tre
solu
tion
mec
hanis
ms
(als
oca
lled
crim
ere
port
ing
rate
)
Imm
edia
teL
RN
PSE
SB
/E
16.3
.2U
nse
nte
nce
ddet
ain
ees
as
aper
centa
ge
of
the
over
all
pri
son
popula
tion
Imm
edia
teL
RN
PS E
SB
/E
Transforming Our World
� 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31 S17
Table
1:continued
Target
Objective
ProposedIndicator
Tim
eframe:
immediate
medium
term
long(I
ML)
term
Governan
ce:
localregional
national
(LRN)
Status:
Population
service
environment
(PSE
)
Typ
e:structural
driver
behav
iour/
Exposure
medical
condition
(SBM)
16.4
By20
30,
signifi
cantl
yre
duce
illi
cit
financi
al
and
arm
sflow
s,st
rength
enth
ere
cover
yand
retu
rnof
stole
nass
ets
and
com
bat
all
form
sof
org
aniz
edcr
ime
16.4
.1T
his
indic
ato
ris
stil
lunder
dis
cuss
ion
-G
rey
Tota
lvalu
eof
inw
ard
and
outw
ard
illi
cit
financi
al
flow
s(i
ncu
rren
tU
S$)
Imm
edia
teR
NE
S
16.4
.2T
his
indic
ato
ris
stil
lunder
dis
cuss
ion
-G
reen
Per
centa
ge
of
seiz
edand
coll
ecte
dfire
arm
sth
at
are
reco
rded
and
trace
d,
inacc
ord
ance
wit
hin
tern
ati
onal
standard
sand
legal
inst
rum
ents
Imm
edia
teL
RN
ES
Addit
ional
-G
reen
Per
centa
ge
of
small
arm
sm
ark
edand
reco
rded
at
the
tim
eof
import
inacc
ord
ance
wit
hin
tern
ati
onal
standard
s
Imm
edia
teN
ES
16.7
Ensu
rere
sponsi
ve,
incl
usi
ve,
part
icip
ato
ryand
repre
senta
tive
dec
isio
n-m
akin
gat
all
level
s16
.7.1
Pro
port
ions
of
posi
tions
(by
age
,se
x,
dis
abilit
yand
popula
tion
gro
ups)
inpublic
inst
ituti
ons
(nati
onal
and
loca
lle
gis
latu
res,
public
serv
ice,
and
judic
iary
)co
mpar
edto
nat
ional
dis
trib
uti
ons
Imm
edia
teL
RN
SE
S
Lee et al
S18 � 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31
16.10
Ensu
republi
cacc
ess
toin
form
ati
on
and
pro
tect
fundam
enta
lfr
eedom
s,in
acc
ord
ance
wit
hnati
onal
legis
lati
on
and
inte
rnati
onal
agre
emen
ts16
.10.1
This
indic
ato
ris
stil
lunder
dis
cuss
ion
-G
rey
Num
ber
of
ver
ified
case
sof
kil
ling,
kid
nappin
g,
enfo
rced
dis
appea
rance
,arb
itra
rydet
enti
on
and
tort
ure
of
journ
ali
sts,
ass
oci
ate
dm
edia
per
sonnel
,tr
ade
unio
nis
tsand
hum
an
rights
advoca
tes
inth
epre
vio
us12
month
s
Imm
edia
teL
RN
PE
SB
/E
16.a
.Str
ength
enre
levant
nati
onal
inst
ituti
ons,
incl
udin
gth
rough
inte
rnati
onal
cooper
ati
on,
for
buil
din
gca
paci
tyat
all
level
s,in
part
icula
rin
dev
elopin
gco
untr
ies,
topre
ven
tvio
lence
and
com
bat
terr
ori
smand
crim
e16
.a.1
This
indic
ato
ris
stil
lunder
dis
cuss
ion
-G
rey
Per
centa
ge
of
vic
tim
sw
ho
report
physi
cal
and/o
rse
xual
crim
eto
law
enfo
rcem
ent
agen
cies
duri
ng
the
past
12m
onth
sD
isaggre
gate
dby
age,
sex,
regio
nand
popula
tion
gro
up
med
ium
LR
NP
SB
/E
16.b
.Pro
mote
and
enfo
rce
non-d
iscr
imin
ato
ryla
ws
and
poli
cies
for
sust
ain
able
dev
elopm
ent
16.b
.1Per
centa
ge
of
popula
tion
havin
gper
sonall
yfe
ltdis
crim
inate
dagain
stor
hara
ssed
wit
hin
the
last
12m
onth
son
the
basi
sof
agro
und
of
dis
crim
inati
on
pro
hib
ited
under
inte
rnati
onal
hum
an
rights
law
.D
isaggre
gate
by
age,
sex,
regio
nand
popula
tion
gro
up
Long
Ter
mL
RN
PE
B/E
S
Transforming Our World
� 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31 S19
Next Steps and Specific Recommendations for the Way Forward
It is important to increase our focus on risk and resilience factors thatconcern violence. The three keys to preventing violence are as follows:
(1) Understanding that violence is a complex issue and requires acomprehensive approach.
(2) Addressing risk and resilience factors with attention to increasedvulnerability due to gender inequality, age, etc.
(3) Developing an integrated strategy for action.
While investments in violence prevention and response haveincreased in recent years, overall they have been woefully inadequateand highly disproportionate to the magnitude of the problem. Com-munity and interpersonal violence not only cause immediate health andsafety issues — including injuries, death, and emotional trauma — butalso long-term sequelae affecting the financial and personal capital ofentire communities and societies. Currently, the social welfare, criminaljustice, and health sectors bear the largest burden for dealing with theconsequences of violence, while programs focus on responses afterviolence occurs. However, high levels of violence and conflict are majorobstacles for inclusive socio-economic development, not to mention adrain to resources.2 We now know that violence is preventable withcommitment and sustained attention. A great deal of research nowhighlights key societal, community, familial, and individual risk andresilience factors, and we have a growing understanding of interven-tions that work and are ready for implementation.
The next step, then, requires expanding approaches that preventviolence before it occurs — not only through programs, but throughsystemic changes in environmental factors and a more comprehensiveset of prevention activities, including changes in social norms aroundgender inequality and violence acceptance; improving and enforcinglaws and policies, institutional practices, and public education; andcooperating among multiple partners. Addressing the ‘determinants ofhealth’3 includes prioritizing data collection on a few known, universalrisk factors, such as firearms ownership and access; alcohol use andaccess; illicit drug use and drug-trafficking; exposure to violence; socialdeterminants/inequality measures and institutional legitimacy. It alsorequires looking at the underlying elements that allow these factors to
Lee et al
S20 � 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31
proliferate in the first place. In each of these areas there is strongevidence for interventions that work.
Sustainable violence prevention requires transformation of thesystems and institutions committing and supporting state-sanctionedviolence into systems supporting legitimacy and inclusiveness, amedium- to long-term undertaking that requires additional qualitydata. This will require a better understanding of all forms of violence,including collective and structural violence. A stronger focus oninnovative studies in this area can create new insights and contributeto the development of measurable indicators to guide global develop-ment policies and action toward the sustainable transformation ofinstitutions to promote safety and security.
Recommendations for Capacity Development and InstitutionalReform
Preventing violence entails building on partnerships across global andlocal institutions, identifying and using existing United Nations (UN)instruments, and prioritizing multi-sectoral approaches. We need torefine existing knowledge and, more importantly, to support commu-nities and countries to develop the political will to translate thatknowledge into practice. Local authorities and national governmentsmust be the focus and champions of these changes; we must engage keyactors like police, health professionals, and social workers, who havedirect contact with violence on the ground, and support them to buildcapacity; and we need to work with multiple sectors to developguidelines regarding their roles in addressing and preventing violencewithin their own mandates.
Ensuring the SDGs Account for Violence Prevention:A Preliminary Discussion
The SDG’s present a golden opportunity for achieving far-reaching andcollaborative gains on violence prevention around the world.4 Of note,the United Nations (UN) Statistical Commission created an Inter-Agency and Expert Group on SDG Indicators (IAEG-SDGs) in March2015. It comprises Member States as well as regional and international
Transforming Our World
� 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, S1, S13–S31 S21
agencies as observers. The IAEG-SDGs are expected to provide a globalindicator framework — and associated global and universal indica-tors — for consideration by the Statistical Commission at its 47thsession in March 2016 (See http://unstats.un.org/sdgs/iaeg-sdgs/). Afterconsultation with the United Nations UN IAEG-SDG, we selectedpreliminary indicators to facilitate monitoring of progress on SDGs.5
Although we included indicators on lethal and non-lethal violence, wedid not include key metrics associated with violent conflict mortalitydue to political disagreement and concern over their methodologicalrigor.6,7
Whether measuring violence or other development priorities, indi-cators alone do not fully capture the dynamics of all situations equally.We must interpret indicators in the context from which they arise.Their use in isolation from qualitative and other contextual researchinsufficiently captures the experience of a given setting or theunderlying factors influencing a specific environment. Nevertheless,indicators serve as critical markers toward a goal and will helpilluminate progress or failure to meet objective targets.
Two SDGs directly address violence and can play an important rolein shaping global violence prevention efforts. These are SDG 5(‘‘Achieve Gender equality and empower all women and girls’’) andSDG 16 (‘‘Promote peaceful and inclusive societies for sustainabledevelopment, provide access to justice for all and build effective,accountable and inclusive institutions at all levels’’). There are severalother SDGs that address important underlying risk factors forinterpersonal violence like alcohol and drugs and safety in schoolsand cities. SDG 11, for example, has a potential indicator 11.7.2:‘‘Proportion of women subjected to physical or sexual harassment, byperpetrator and place of occurrence (last 12 months)’’ (SDG 11 on safe,inclusive, resilient and sustainable cities also includes some referencesto the promotion of security, but we have chosen not to discuss itwithin the length of this article). Following these SDGs also helpsilluminate conditions that impact rates of violence.
Tracking global, national, regional, and municipal indicators canallow us to achieve some measurements of progress toward the SDGs.Given that many countries, regions, and cities are on an unequalfooting when it comes to data collection, surveillance, and reporting,the road ahead is challenging.8
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There are other barriers to consider. Standard definitions forcategories of violence and means of validating prevalence are necessarybefore we can analyze and compare the data. Reaching agreement on acore set of indicators among various constituencies is also a contentiousand demanding process. Any final determination of indicators comeswith its own limitations as ‘what gets counted counts’ – and influencesthe comprehensiveness of any assessment. For example, measurementof sexual violence often depends entirely on incident reports. We knowfrom population survey data that many do not report assaults, and thatthe ways in which the law defines sexual violence influence whatappears in reports. When one selects indicators from criminal justice orother systems, it is important to acknowledge that these constituteproxy measures for actual incidence and can vary by a multitude ofsocial and cultural factors, making it likely that we are undercountingtrue incidence. For example, recent analyses of human services datafrom 24 countries suggested that estimates of gender-based violenceprevalence derived from health or police data will result in hugeunderestimates, with at best 9 % of incidents occurring in developingcontexts.9 We also must acknowledge that if violence prevention andresponse are working, rates of violence according to service surveillancemay rise initially, as more people are aware and seek support andservices. One way to address this challenge is to use ancillary data tocontextualize the primary indicators, which the international commit-tee has selected. This helps to make more certain that we understandthe full story surrounding an indicator. For example, ancillary data onthe greater availability of rape kits in emergency rooms in a jurisdictioncould help explain an increase in criminal charges for sexual assaultwithin that jurisdiction; conversely, a lack of access to rape kits couldmean a decrease in criminal charges and investigations regarding sexualassaults.
Metrics can influence the design, implementation, and evaluation ofinterventions. This is a risk in the SDG process of limiting the types andcontext of reporting indicators. The way we frame a ‘problem’ insociety can influence approaches to the solution. For example, whenmeasuring violence and addressing prevention through surveillance,metrics for crime may provide us with some insight. Communitiesaddressing high levels of crime reports can interpret this as a need formore police officers, but a public health approach would indicate theneed to address causal factors through community-based violence
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prevention, while understanding (and possibly transforming) how wedefine ‘crime’ and measure it within society. Solutions to violence callfor a public health approach with a focus on evidence-informedinterventions. (For a more comprehensive discussion of this issue,please see Less Law More Order10,11 and A Manifesto for fragilecities12,13).
The SDG process can benefit from learning from countries and citieswhere violence prevention has generated results. For a case study ofthis, we can look to Latin America. After decades of heavy-handedcrime prevention – ‘mano dura’ in the vernacular – some Latin Amer-ican cities such as Bogota, Medellin, and Mexico are changing theirtactics dramatically. Since the 1990s, elected officials, private businesspeople, and civil society groups started experimenting with newapproaches consisting of ‘‘community-level violence prevention’’ insome of the region’s fragile cities.12 (For more about fragile environ-ments, see also in this Special Issue: Kumar and Willman14).
Such approaches involve strategies that target places, people, andbehaviors. After making some important gains, they are today helpingto reshape the global debate on urban safety. Latin America’s newapproach to urban crime prevention is producing some spectaculardeclines in murder and victimization. Even before investing in urbanrenewal, new forms of policing, at-risk youth programs, or alcoholand firearm restrictions, Latin American leaders focused first onattitudes and values. A first step was to craft a new culture ofcitizenship, encouraging locals to regulate themselves and oneanother. In Bogota, for example, local governments paid street mimes(performers who work in public spaces) to deliver ‘behavior cards’ forthose who broke rules. This allowed for modeling desired behaviorsin an often comedic and expansive way, emphasizing the message orsocial norm the governments wanted communicated through theater.City planners also started up women’s nights, cleaned up publicspaces, created amnesties for collecting firearms, reduced alcohol salesand outlets in hot spots, and created national and metropolitanobservatories to track crime and violence. Over time, they comple-mented these investments in social norm and behavior change withconcrete investments in public security and violence preventionprograms.
On the basis of a careful reading of the evidence, civic leaders in somemajor Latin American cities began investing in data-driven and
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community-based policing and gun collection programs. In some cases,they invested in conditional cash transfer programs (welfare programsthat are conditional upon the receivers’ meeting certain criteria), earlychildhood support for single-headed female households, and after-school activities for at-risk young males. The last has been especiallysuccessful in reducing both violent and property-related crime.
Despite ongoing challenges related to collective violence anddisplacement, and interpersonal violence, these holistic approachesrepresent great strides in violence prevention and response, and manyof these Latin American innovations in violence prevention reflect bestpractices now known to the global public health community. Effectiveuse of data and design of comprehensive approaches often succeedswhere narrowly designed law enforcement measures have failed. TheVPA led discussions in Geneva in 2015 that point to a need forindicators to track progress at three levels:
• Immediate effects (‘quick fix’ indicators measuring short term visiblegains and creating and/or sustaining political will for ongoingviolence prevention actions).
• Medium-term effects (‘proximate’ indicators that can track outcomemetrics and measure the intermediate effects of violence preventionon communities).
• Long-term effects (‘structural’ indicators that can measure sustainedreductions in the underlying risks of violence in institutions, societies,and at-risk population groups).
Researchers can choose several indicators at all three levels ofanalysis. Possible immediate effect indicators could track theprevalence of firearms, alcohol and drugs; increases in trauma-informed care, treatment and intervention for offenders and potentialperpetrators, parenting support, early childhood development pro-grams, life skills training, community-based social norms change;and promotion of peace education in schools. Medium-term effectindicators could measure social norms and behavior change; urbanupgrading and poverty de-concentration programs; reduced commu-nity-level trauma; and increased social protection with an emphasison human dignity. Long-term effect indicators should consist ofsociety-level poverty and inequality reduction, institutional reform,and improved governance.
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SDG Indicators for Sustaining and Directing Momentum:An Outline for Further Action
We will now examine indicators that the IAEG SDG Indicator expertgroup has selected.15 The IAEG-SDG meets periodically to determinewhich indicators researchers will use to measure the SDG targets(accepted indicators are designated as ‘green’) and to guide the efforts ofnational statistical offices. A critical review of the IAEG-SDG processwill support balancing the SDG indicators framework from a publichealth perspective. Such an analysis can facilitate the implementation ofa public health approach to violence prevention and ensure that weemploy an ecological approach to reduce violence globally.16 It mightalso point the way to future research and partnerships with governmentsand nongovernmental organizations (NGOs).
Drawing from the current indicator framework of the IAEG-SDG,we have mapped each indicator to a number of attributes relevant toviolence prevention. As this is a preliminary analysis and the indicatorframework is still in development, further refinement will be necessary.We also accept that creating community-level indicators will depend ondata that one captures at a different level from national aggregate data.One can capture data from a variety of levels of organization and fromsurveys, incidents, encounters, or transactions. Organization of thesesources can occur at many levels of aggregation — for example, thenumber of liquor outlets in a community versus those in a region orcountry. Community-level indicators may not be of interest to nationalreporting systems. In many cases, community-level indicators areoutside of major reporting systems and therefore not visible as part of anational surveillance strategy. Hospital encounters at the local level canbe very helpful for criminal justice, counseling, and other types ofinterventions. At this time, emergency visits relating to violence have noconnection to criminal justice reporting systems.
We find the examination of indicators that work at multiple levels ofaggregation to be useful to this review, as is the characterization ofindicators by type. We derive the indicator by type category from thehealth equity work by the California-based Prevention Institute,17 aVPA partner and leader in community-level interventions for violenceprevention. In addition, a ‘‘status’’ attribute identifies whether theindicator is status of a population, an indication of infrastructure orservice, or an appraisal of the social environment.
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A review of the table, as we shall see, reveals interesting findings.First, there is agreement within the IAEG-SDG on a ‘‘homicide’’ metric,but there is still disagreement on a ‘‘violent conflict deaths’’ indicator.The latter indicator is a significant marker for any effort to manage andreduce violence globally. We cannot know the true intensity of armedconflict and thus the global burden of violence if we exclude conflictmortality from the SDG framework; and to include this, we need ashared understanding of how to measure conflict-related deaths.18
Second, the majority of the selected indicators register the incidenceand prevalence of some form of victimization and harassment. Many ofthe indicators will help establish a baseline for the targets and thustrack the longer term. These are essential indicators for characterizingthe global scope of violence.
We have noted that there is no specific indicator for violence duringpregnancy, a particularly vulnerable time for the health of mothers andchildren. A lifespan approach that acknowledges the reproductive yearsbeginning in preconception highlights the vulnerabilities as well asopportunities to impact health and well-being. Violence duringpregnancy is a major concern for maternal-child health and is a majorpublic health issue. Under 5.2.1, we recommend for consideration anindicator such as ‘‘Proportion of ever-partnered women and girls (aged15–49) subjected to violence during pregnancy’’.
Third, there are relatively few indicators that reflect structural driversor compliance with international standards, norms, and legislation.Finally, many indicators that we recommend will be very difficult tosource (e.g., victims of human trafficking) but should nevertheless be onour radar if we are to generate a better understanding of the trueimplications of violence around the world.
Importantly, the IAEG-SDG indicator framework also focuses on thedisaggregation of key indicators from the global to regional, sub-regional, and city levels. The UN, however, is still deliberating on thefinal shortlist of metrics. It will develop data on the basis of a three-tierapproach based primarily on the availability and existence of anestablished methodology for producing the indicator in question. Aninformal briefing to the UN shared the following approach fordeveloping the framework globally:
The first important step will be the assessment of the status of theindicators proposed. The indicators will be classified into three
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tiers: Tier I: an established methodology exists and data arealready widely available (‘‘green’’); Tier II: a methodology has beenestablished but for which data are not easily available (yellow’’);and Tier III: an internationally agreed methodology has not yetbeen developed (‘‘grey’’).19
The discussion on SDG indicators is evolving. While we are still at apreliminary level, the framework proposes an ambitious high-leveloverview and incentive to measure structural drivers, societal norms,the strengthening of protective factors, and the reduction of risksassociated with violence. What ultimately may be more important forprevention efforts are indicators at the local level that help provide acomprehensive profile of communities, including their social andeconomic characteristics (including employment, education, access tohealthy and nutritious food, social mobility, and wealth distribution),values, norms, and perceptions. A comprehensive approach to mea-suring SDG indicators would benefit from the WHO-recommendedpublic health approach to violence prevention. The overarching focusof sustainability necessitates an engagement at all levels of governanceto establish truly nurturing and thriving human settlements in viableecosystems.
About the Authors
Bandy X. Lee M.D., M.Div., is a faculty member of the Law andPsychiatry Division at Yale University and directs the Violence andHealth Study Group as well as the Academic Collaborators ProjectGroup for the WHO Violence Prevention Alliance.
Finn Kjaerulf M.Sc., is an economist and program manager atPrevention of Urban Violence Theme, DIGNITY – Danish InstituteAgainst Torture, Denmark. Email: [email protected].
Shannon Turner B.A., B.Sc., M.Sc., Ph.Dc., is a Doctoral Fellow at theUniversity of Victoria, British Columbia Canada, National Co-Chair ofPrevention of Violence Canada- Prevention de la violence Canada,Social Innovation Research Lead and Co-Chair of the Global AdvisoryCircle for Bridge For Health. Email: [email protected].
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Larry Cohen M.S.W., is the Founder and Executive Director ofPrevention Institute, a U.S. nonprofit organization dedicated to im-proving community health and equity by taking action to buildresilience and to prevent violence and illness before they occur. Email:[email protected].
Peter Donnelly M.D., is President and CEO of Public Health Ontario.He holds Professorships at the University of Toronto, Queens Univer-sity, and the University of St. Andrews.
Robert Muggah Ph.D., is research director of the Igarape Institute(Brazil) and the SecDev Foundation (Canada) and a fellow at theUniversity of Oxford and the Graduate Institute of InternationalStudies in Geneva, Switzerland. Email: [email protected].
Rachel Davis M.S.W., is Managing Director at Prevention Instituteand Chair of UNITY (Urban Networks to Increate Thriving Youth), anational violence prevention initiative that advances a public healthapproach to violence in the U.S. Email: [email protected]
Anna Realini is the Manager of the Executive Office at PreventionInstitute, a U.S. nonprofit organization dedicated to improving com-munity health and equity by taking action to build resilience and toprevent violence and illness before they occur. Email:[email protected].
Berit Kieselbach M.Sc., is Technical Officer at the World HealthOrganization Department for Management of NoncommunicableDiseases, Disability, Violence and Injury Prevention. Email:[email protected].
Lori Snyder MacGregor R.N., B.Sc.N., M.Ed., is a Public Health Nurseat the Region of Waterloo Public Health and Emergency Servicesand Past Co-Chair and current member of Prevention of ViolenceCanada- Prevention de la violence Canada. Email: [email protected]
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Irvin Waller Ph.D., is Professor of Criminology, University of Ottawa,Canada, and President of the International Organization for VictimAssistance.
Rebecca Gordon M.P.H., is the Senior Program Advisor for Togetherfor Girls, based in Washington, DC. Prior to joining Together for Girls,she coordinated violence prevention and response in South Sudan andThailand.
Michele Moloney-Kitts M.S.N., is the Executive Director of Togetherfor Girls and serves as a Senior Advisor to the Executive Director ofUNAIDS. Previously, she served as the Assistant Global AIDSCoordinator for the U.S. President’s Emergency Plan for AIDS Relief(PEPFAR), and for many years as a health officer for USAID. She beganher career as a nurse practitioner and a nurse midwife.
Grace Lee Ed.D., directs the Arts for Social Change Research Groupfor the Education Studies Program at Yale University, exploring therole of creative exchange across age groups for violence prevention andpeace promotion. She is also a psychotherapist, former professor, andauthor.
James Gilligan M.D., is a Clinical Professor of Psychiatry and anAdjunct Professor of Law at New York University. Previously, heserved on the faculty of Harvard Medical School, directing the Instituteof Law and Psychiatry, Bridgewater State Hospital for the criminallyinsane, and Mental Health Services for the Massachusetts prisonsystem.
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Editors’ Note
This article is one of ten papers in a Special Sponsored Issue of theJournal of Public Health Policy in 2016, Violence and Health: MergingEvidence and Implementation.
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