Ashley van Niekerk

Violence and injuries in South Africa: prioritising an agenda for prevention

Violence and injuries are the second leading cause of death and lost disability-adjusted life years in South Africa. The overall injury death rate of 157.8 per 100,000 population is nearly twice the global average, and the rate of homicide of women by intimate partners is six times the global average. With a focus on homicide, and violence against women and children, we review the magnitude, contexts of occurrence, and patterns of violence, and refer to traffic-related and other unintentional injuries. The social dynamics that support violence are widespread poverty, unemployment, and income inequality; patriarchal notions of masculinity that valourise toughness, risk-taking, and defence of honour; exposure to abuse in childhood and weak parenting; access to firearms; widespread alcohol misuse; and weaknesses in the mechanisms of law enforcement. Although there have been advances in development of services for victims of violence, innovation from non-governmental organisations, and evidence from research, there has been a conspicuous absence of government stewardship and leadership. Successful prevention of violence and injury is contingent on identification by the government of violence as a strategic priority and development of an intersectoral plan based on empirically driven programmes and policies.

Health in South Africa: changes and challenges since 2009

Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the worlds largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.All the authorsKarim QA, Karim SS, Barron P, Bradshaw D, Chopra M, Churchyard GJ, Coovadia HM, Jewkes R, Lalloo UG, Lawn JE, Lawn SD, Mayosi BM, Pattinson R, Seedat M, Sitas F, Suffla S, Tollman SM, Van Niekerk A.

Community, intervention and provider support influences on implementation: reflections from a South African illustration of safety, peace and health promotion

BackgroundThe development, implementation and evaluation of community interventions are important for reducing child violence and injuries in low- to middle-income contexts, with successful implementation critical to effective intervention outcomes. The assessment of implementation processes is required to identify the factors that influence effective implementation. This article draws on a child safety, peace and health initiative to examine key factors that enabled or hindered its implementation, in a context characterised by limited resources.MethodsA case study approach was employed. The research team was made up of six researchers and intervention coordinators, who led the development and implementation of the Ukuphepha Child Study in South Africa, and who are also the authors of this article. The study used author observations, reflections and discussions of the factors perceived to influence the implementation of the intervention. The authors engaged in an in-depth and iterative dialogic process aimed at abstracting the experiences of the intervention, with a recursive cycle of reflection and dialogue. Data were analysed utilising inductive content analysis, and categorised using classification frameworks for understanding implementation.ResultsThe study highlights key factors that enabled or hindered implementation. These included the community context and concomitant community engagement processes; intervention compatibility and adaptability issues; community service provider perceptions of intervention relevance and expectations; and the intervention support system, characterised by training and mentorship support.ConclusionsThis evaluation illustrated the complexity of intervention implementation. The study approach sought to support intervention fidelity by fostering and maintaining community endorsement and support, a prerequisite for the unfolding implementation of the intervention.

Fatal injuries among urban children in South Africa: risk distribution and potential for reduction

OBJECTIVE To determine the leading causes of fatal injury for urban South African children aged 0-14 years, the distribution of those causes and the current potential for safety improvements. METHODS We obtained injury surveillance data from the National Injury Mortality Surveillance System 2001-2003 for six major South African cities varying in size, development and sociodemographic composition. We calculated age-adjusted rates, by sex, population group and city, for death from the five leading causes of fatal injury as well as population attributable risks (PARs). FINDINGS The leading causes of fatal injury in childhood included road traffic injuries - among vehicle passengers and especially among pedestrians - drowning, burns and, in some cities, firearm injuries. Large differences in PARs were observed, particularly for population groups and cities. Disparities between cities and between population groups were largest for deaths from pedestrian injuries, while differences between boys and girls were greatest for drowning deaths. CONCLUSION In the face of the high variability observed between cities and population groups in the rates of the most common types of fatal injuries, a safety agenda should combine safety-for-all countermeasures - i.e. lowering injury rates for all - and targeted countermeasures that help reduce the burden for those at greatest risk.

Female homicidal strangulation in urban South Africa

BackgroundFemale strangulation in South Africa occurs in a context of pervasive and often extreme violence perpetrated against women, and therefore represents a major public health, social and human rights concern. South African studies that provide accurate descriptions of the occurrence of strangulation incidents among female homicide victims are limited. The current study describes the extent, distribution and patterns of homicidal strangulation of women in the four largest South African metropolitan centres, Tshwane/Pretoria, Johannesburg, Cape Town and Ethekwini/Durban.MethodsThe study is a register-based cross sectional investigation of female homicidal strangulation, as reported in the National Injury Mortality Surveillance System for the four cities, for the period 2001 to 2005. Crude, unadjusted female strangulation rates for age and population group, and proportions of strangulation across specific circumstances of occurrence were compiled for each year and aggregated in some cases.ResultsThis study reports that female homicidal strangulation in urban South Africa ranges from 1.71/100 000 to 0.70/100 000. Rates have generally declined in all the cities, except Cape Town. The highest rates were reported in the over 60 and the 20 to 39 year old populations, and amongst women of mixed descent. Most strangulations occurred from the early morning hours and across typical working hours in Johannesburg and Durban, and to a lesser extent in Cape Town. Occurrences across Johannesburg, Durban and Pretoria were distributed across the days of the week; an exception was Cape Town, which reported the highest rates over the weekend. Cape Town also reported distinctly high blood alcohol content levels of strangulation victims. The seasonal variation in strangulation deaths suggested a pattern of occurrence generally spanning the period from end-winter to summer. Across cities, the predominant crime scene was linked to the domestic context, suggesting that perpetration was by an intimate partner or acquaintance.ConclusionThe study contributes to an emerging gendered homicide risk profile for a country with one of the highest homicide rates in the world. The results support the call for the development of evidence-based and gender-specific initiatives to especially address the forms of violence that instigate fatalities.

Unintentional drowning in urban South Africa: a retrospective investigation, 2001–2005

Drowning is a major public health concern in low- and middle-income countries. In South Africa there is sound information and an emerging knowledge base for drowning prevention. However, there remains a scarcity of analyses of drowning in the country. The purpose of this analysis was to quantify the magnitude and describe occurrence of unintentional drowning deaths in five major South African cities, recorded between 2001 and 2005 by the National Injury Mortality Surveillance System. Drowning in South African cities occurred at rates of between 1.4 and 2.7/100,000 population. The majority of drowning occurred among males, while the highest rates were observed among 0–4 year olds. Most drowning deaths occurred during recreational periods, over weekends and in the afternoon. Of adult drowning victims, 41.5% were alcohol-positive at the time of death. This study is based on one of only two known systematic sources of drowning mortality in Africa. It provides an indication of drowning rates in South African cities with young children and males at considerably more risk. The most likely locations for drowning varied from city to city. Among adult victims, especially men, alcohol is an important risk factor.

Epidemiology of fatal burns in rural South Africa: A mortuary register-based study from Mpumalanga Province

AIM The study investigates the epidemiology of fatal burns in the predominantly rural province of Mpumalanga, South Africa. METHOD The study is cross-sectional and investigates region specific data extracted from a National Injury Mortality Surveillance System (NIMSS) and originally gathered at mortuaries. Fatal burns sustained during the 2 year period 2007 and 2008 are analysed (n=304 cases). Mortality rates by age group, sex and district were compiled and attention was paid to manner of death, location, and temporal characteristics (time of day, weekday, season). RESULTS The overall fatal burn rate was 3.8 per 100,000 inhabitants (95% CI 3.4-4.3). The highest rates were among the oldest age group (8.2/100,000; 95% CI 6.1-10.7), males (5.3/100,000; 95% CI 4.6-6.2) and in one of the three districts, Nkangala (4.8/100,000; 95% CI 3.9-5.6). Most burns were accidental (68.4%) and intentional ones (13.5%) occurred in particular among older people and in the home. Burns were sustained frequently at home (55.6%), between midnight and 5a.m. and towards the end of the week. Seasonal variations were more pronounced in Nkangala. CONCLUSIONS Fatal burns could be less common in rural than urban South Africa. As in urban South Africa, however, older people, young children, and males are more at risk. Not surprisingly, the occurrence of fatal burns is strongly related to living conditions and lifestyle, which vary even within rural areas of South Africa.

Barriers and Enablers to the Use of Measures to Prevent Pediatric Scalding in Cape Town, South Africa

OBJECTIVE Little attention has been paid to the prevention of pediatric scalding injuries in low-income settings, especially from the standpoint of local stakeholders. This study investigates stakeholder understandings of potential measures to prevent childhood scalding and the related hinders and enablers to such measures. DESIGN AND SAMPLE The study utilized an exploratory qualitative design. Content analysis was applied to the transcriptions of interviews with 13 caregivers and 8 burn prevention research, policy, and practitioner professionals. MEASURES The study used semistructured interviews using illustrations to generate data. The 21 individual interviews were audio-recorded, transcribed verbatim, and analyzed using content analytic steps. Interviews focused on 2 illustrations that depict circumstances that surround the occurrence of pediatric scalding typical for Cape Town. RESULTS 3 categories of prevention measures were identified: enhancements to the safety of the home environment, changes to practice, and improvements to individual competence. The barriers identified were spatial constraints in homes, hazardous home facilities, and multiple family demands. CONCLUSIONS Caregivers and professionals report a similar range of measures to prevent pediatric scalding. Many of these might not be readily implementable in low-income settings with key barriers that would need to be addressed by policymakers and prevention practitioners.

Towards the Development of a Responsive, Social Science-informed, Critical Public Health Framework on Male Interpersonal Violence

Emerging out of a larger study whose main focus was to identify the risk and protective factors in male interpersonal violence, and based on analysis of local and global empirical and theoretical literature, the main aim of this article is to develop a conceptual foundation for understanding and preventing male interpersonal violence in South Africa within the context of responsive local manifestation and dynamics of male violence. The conceptual foundation developed has been informed by both public health and social science perspectives. The impetus for the development of a conceptual foundation is not only the scale of the problem of violence in the country but, more importantly, the urgent need for a theoretically sound, locally-grounded and better-integrated understanding of male interpersonal violence and violence generally. The article describes violence in a global context before turning to violence in South Africa. Then it briefly looks at different theoretical approaches on violence before focusing on the public health approach to violence generally, and male interpersonal violence more specifically. Next it describes the ecological framework, given that this perspective tends to accompany the public health studies in violence. A critical appraisal of this approach is then offered. Finally, the article attempts to bring together these disparate perspectives in the process of developing a locally responsive, social science-informed critical public health conceptual framework on male interpersonal violence, drawing on and including a focus on the political, economic and social history of South Africa.

Psychological research and South Africa’s violence prevention responses

South Africa’s unprecedented levels of violence, which trigger significant health, economic, and social consequences, are marked by pronounced gendered, age-related, and socio-economic features. Extensive poverty, prolonged unemployment and income inequality, gender inequality, patriarchal notions of masculinity, exposure to abuse in childhood and compromised parenting, access to firearms, pervasive alcohol misuse, and fragilities in law enforcement are among the many factors inherent to the social dynamics of violence. We briefly describe some of psychology’s recent contributions to violence prevention research and interventions. The review, by no means a comprehensive one, is intended to encourage reflections and conversations about how psychology may increase its influence as a critical and intervention-oriented discipline alongside other disciplines, such as public health, social work, criminology, anthropology, development studies, social medicine, and urban studies. We suggest that as much as it is important for psychology to provide a relevant research response, it is equally important for psychology to undertake critical work on the responses to violence, including the intellectual traditions that underlie such responses.