Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom.
Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
PLoS Med. 2020 Nov 9;17(11):e1003383. doi: 10.1371/journal.pmed.1003383. eCollection 2020 Nov.
The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which 'accelerator' provisions can simultaneously reduce multiple types of violence against children.
We pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012) and Mzantsi Wakho (2014-2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: -3.74% points, 95% CI -5.31 to -2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: -5.23% points, 95% CI -7.26 to -3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: -14.72% points, 95% CI -19.11 to -10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: -12.41% points, 95% CI -16.00 to -8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: -7.87% points, 95% CI -11.98 to -3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: -7.30% points, 95% CI -10.50 to -4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: -0.59% points, 95% CI -2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: -2.42% points, 95% CI -4.77 to -0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: -11.74% points, 95% CI -16.91 to -6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: -13.00% points, 95% CI -17.04 to -8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: -5.87% points, 95% CI -10.98 to -0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD -7.46% points, 95% CI -11.57 to -3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies.
In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.
INSPIRE 框架由 10 个全球机构制定，是预防和应对针对儿童暴力的首个全球方案。该框架包括七种相辅相成的战略。在资源有限的情况下，实施所有七种战略具有挑战性。因此，各国政府要求提供更多证据，以确定哪些“加速”条款能够同时减少多种类型的针对儿童的暴力。
我们汇总了两项南非青少年队列研究的数据，包括 Young Carers（2010-2012 年）和 Mzantsi Wakho（2014-2017 年）。合并样本量为 5034 名青少年。每个队列都测量了六种自我报告的暴力结果（性虐待、交易性性剥削、身体虐待、情感虐待、社区暴力受害和青少年违法犯罪）和七种自我报告的与 INSPIRE 一致的保护因素（积极的育儿方式、父母监督和监管、家庭食品安全、家庭基本经济保障、免费上学、免费学校膳食和虐待反应服务）。在性别分层多变量路径模型中，我们联合估计了假设的保护因素与暴力结果之间的关联，控制了基线结果和社会人口统计学因素，并使用 Benjamini-Hochberg 程序对多假设检验进行了校正。我们根据路径模型中与降低至少三种形式暴力的可能性显著相关的保护因素的存在情况，计算了调整后的概率估计值。我们还计算了调整后的风险差异（ARD）和调整后的风险比（ARR）及其 95%置信区间（CI）。样本的平均年龄为 13.54 岁，其中 56.62%为女性。研究存在 4%的失访率。积极的育儿方式、父母监督和监管以及家庭食品安全都与较低的多种暴力结果风险相关（p<0.05）。对于女孩，如果这三个因素都存在，与没有或只有一个因素存在相比，发生暴力结果的调整后概率估计值较低：性虐待，5.38%和 1.64%（ARD：-3.74%点，95%CI-5.31 至-2.16，p<0.001）；交易性性剥削，10.07%和 4.84%（ARD：-5.23%点，95%CI-7.26 至-3.20，p<0.001）；身体虐待，38.58%和 23.85%（ARD：-14.72%点，95%CI-19.11 至-10.33，p<0.001）；情感虐待，25.39%和 12.98%（ARD：-12.41%点，95%CI-16.00 至-8.83，p<0.001）；社区暴力受害，36.25%和 28.37%（ARD：-7.87%点，95%CI-11.98 至-3.76，p<0.001）；青少年违法犯罪，18.90%和 11.61%（ARD：-7.30%点，95%CI-10.50 至-4.09，p<0.001）。对于男孩，如果这三个因素都存在，与没有或只有一个因素存在相比，发生暴力结果的调整后概率估计值也较低：性虐待，2.39%至 1.80%（ARD：-0.59%点，95%CI-2.24 至 1.05，p=0.482）；交易性性剥削，6.97%至 4.55%（ARD：-2.42%点，95%CI-4.77 至-0.08，p=0.043）；身体虐待从 37.19%降至 25.44%（ARD：-11.74%点，95%CI-16.91 至-6.58，p<0.001）；情感虐待从 23.72%降至 10.72%（ARD：-13.00%点，95%CI-17.04 至-8.95，p<0.001）；社区暴力受害从 41.28%降至 35.41%（ARD：-5.87%点，95%CI-10.98 至-0.75，p=0.025）；青少年违法犯罪从 22.44%降至 14.98%（ARD-7.46%点，95%CI-11.57 至-3.35，p<0.001）。主要局限性在于存在残余混杂的风险，并且没有与 INSPIRE 的所有七种策略相关的保护因素信息。
在这项队列研究中，我们发现积极的养育和监督以及家庭食品安全与降低多种针对儿童的暴力风险相关。与存在一种或不存在这些因素相比，同时存在这三种因素可能与更大的风险降低相关。促进积极的养育和监督以及家庭食品安全的政策可能会进一步提高 INSPIRE 的实施效率。
