ELDER ABUSE IS A PUBLIC HEALTH PROBLEM
EA refers to “any intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult” (Hall, Karch, & Crosby, 2016). The acts and behaviors globally captured by the term EA have been categorized into several subtypes. These most commonly include physical abuse, sexual abuse, psychological abuse, financial abuse, and neglect. In this conception, the term older adult refers to any person whose chronological age is 60 years or older. EA has been framed or portrayed as a public health problem for several decades. The adoption of this framing reflects not only the innate characteristics of this problem, but also the motivations of those advocating its prevention and elimination.
The Innate Characteristics of EA
In terms of characteristics, EA has been justifiably considered a public health problem because it has the potential to affect the health of a large proportion of the U.S. population. The most recent national level, population based study to establish the prevalence of EA indicated that approximately 11.4% of older adults may experience EA (Acierno et al., 2010). When this prevalence estimate is applied to the most recent estimates of the U.S. resident population by age to more concretely illustrate the possible magnitude of this problem, the number of older adults who may have suffered EA in 2014 is approximately 7,388, 265 (U.S. Census Bureau, 2015).1 This estimate is approximately 14 times greater than the upper enumeration estimate for the size of the U.S. public health workforce (516,193) most recently reported by the University of Michigan Center of Excellence in Public Health Workforce Studies (2013).2 Stated plainly, for every one person in the U.S. public health workforce, there may be approximately 14 persons who may have experienced EA. Within this context, EA is not simply a health problem experienced by just a few persons, but rather a widespread problem that affects the lives of many older adults residing in a variety of places and settings around the nation. In addition, the problem is not confined to the older adults who experience it; the older adults are at the center of a problem that touches the lives of affected others—families and friends, organizations, and society as a whole are all touched by the abuse in tangible and intangible ways.
EA causes segments of the older adult population to suffer harm, injury, loss, and, in the most unfortunate cases, death. The impacts of exposure to EA are extensive and diverse, given that its perpetrators frequently inflict more than one type of EA upon their victims (Ramsey-Klawsnik & Heisler, 2014). Moreover, the impacts of different types of abuse accumulate over time additively and multiplicatively, increasing the likelihood that and extent to which various domains of health will be compromised (e.g., cognition, physical functioning, socialization). The severity of the effects of EA is too often conceived in a disconnected fashion where its respective physiological, psychosocial, and economic consequences are described abstractly and as if they occur separately (Ramsey-Klawsnik & Heisler, 2014). EA’s status as a public health problem, however, is further accentuated when it is borne in mind that older adults commonly experience polyvictimization, which occurs “when a person aged 60 or older is harmed through multiple co-occurring or sequential types of elder abuse by one or more perpetrators, or when an older adult experiences one type of abuse perpetrated by multiple others with whom the older adult has a personal, professional, or care recipient relationship in which there is a societal expectation of trust.” (Ramsey-Klawsnik & Heisler, 2014)
Older adults subjected to EA and those who are concerned about their well-being may have to simultaneously contend with any or all of the following types of abuse, among others:
Cuts, bruises, and fractures after having been degraded, humiliated, and isolated from their friends by adult children
Coercive, controlling behaviors by guardians who have stolen heirlooms that have been passed down through generations of family members and who threaten them with institutionalization if they dare tell others about what they are experiencing
Overmedication and sedation at the hands of caregivers who misuse prescription drugs to lower or remove capacities to resist or reject unwanted sexual contact and who may dismiss complaints as attributable to delirium or cognitive impairment
Frailty associated with deprivation caused by a grandchild’s constant failure to provide adequate meals and access to fresh drinking water, indifference to insulin injection abscesses, and restriction of movement to a single small, cluttered room
Such experiences represent just a small sample of the universe of incidents and enduring population-wide patterns of EA that may simultaneously or sequentially produce impairments of cognitive, emotional, physical, physiological, interpersonal, and social functioning and affect the ability of older adults to satisfy their needs for safety, security, social connection, and respect. Insults, violations, and harms occur across these dimensions of health, so the actual and possible undesirable consequences of EA are far greater than most typically acknowledge or contemplate. A phenomenon with so many diverse forms, facets, and health implications cannot be effectively addressed by small groups of individuals on a case-by-case basis, regardless of whether they use intervention efforts or prevention efforts. Therefore, EA has been rightfully promoted for treatment as a priority for societal action that demands comprehensive initiatives, strategies, and resources (addressed systemically in Aravanis, 2002; Bonnie & Wallace, 2003; Connolly, Brandl, & Breckman, 2014; Dong & Simon, 2011; Institute of Medicine & National Research Council, 2014).
The economic toll of EA has also been an element of the frame construing it as a public health problem. This element has been quantified mainly in two ways: healthcare/direct medical care costs and losses associated with financial exploitation. The most current sources place the annual estimated costs of EA at approximately $8.2 billion, with more than $5.3 billion of this cost attributed to direct medical costs and the remaining $2.9 billion representing assets lost because of financial exploitation (MetLife Mature Market Institute, 2011). Other nonmedical costs of EA can include, but are not necessarily limited to, (a) expenses for legal, counseling, mental/behavioral, therapeutic, and rehabilitative services; (b) productivity losses; and (c) costs of funding court proceedings, incarceration, victim compensation processes, and the provision of adult protective services and crisis/emergency response services. Elders who have been abused have a 300% higher risk of death when compared to those who have not been mistreated (Dong et al., 2009). Although EA-related costs are likely under-reported, elder financial abuse costs older Americans $2.9 billion per year. Yet, financial exploitation is self-reported at rates higher than emotional, physical, and sexual abuse or neglect (Acierno et al., 2010). Estimating the items in the nonmedical category of costs is extremely challenging and has not been successfully accomplished to date. Nevertheless, the high direct costs of EA referenced here are acknowledged as underestimating the true societal costs of this problem. Both medical and nonmedical costs are considered diverted costs, as funds and resources used to address EA could be used to address other needs or desires among individuals or invested in community or societal development efforts. It is important to recognize that these costs are likely to escalate sharply as the proportion of older adults in the U.S. population continues to grow. According to the U.S. Census Bureau, in 2050, the population aged 65 years and older is projected to be 83.7 million, almost double the estimated population of 43.1 million in 2012 (Ortman & Velkoff, 2014).
These characteristics of EA have been presented in reference to three criteria commonly used to define occurrences as public health problems. In summary, EA is a common, prevalent phenomenon; detrimentally affects both individual older adults and large segments of the older adult population of the United States in a variety of ways and at all levels of the social ecology; and exacts a considerable financial and economic toll. The framing of EA as a public health problem using a narrative that includes the aforementioned elements has become common practice throughout the field developed to address EA. This frame now coexists and is frequently used in combination with other frames, such as those depicting EA as a social problem, a crime, or an elder justice issue. Its development and use have helped to alter general misconceptions that EA occurs infrequently, primarily takes place in nursing homes and other long-term care facilities, is a problem relegated to families, and can be addressed only through deterrence-oriented strategies.
Advocacy Motivations
Most stakeholders—groups that can affect or that will be affected by EA or EA-related initiatives—use the frame of EA as a public health problem with three primary goals in mind: (a) encourage others to view the problem as serious and noteworthy, (b) attract attention to and achieve legitimation of the problem, and (c) obtain adequate resources to support actions to address it. With respect to the first goal, many in the U.S. general population are still largely unaware that EA is a problem that our society is currently facing. Although EA was first identified in developed countries, where most of the existing research has been conducted, anecdotal evidence and other reports from some developing countries have shown that it is a universal phenomenon (World Health Organization, n.d.). There is an abiding need to “awaken” groups who are not aware of EA’s health impacts and enlist their aid in confronting this problem. Many stakeholders frame EA as a public health problem to inspire thought about the acute need for action, why movement is necessary, and the dire consequences of inaction for our loved ones, communities, and nation, both now and for future generations.
Turning to the second goal, the framing of EA as a public health problem has also been carefully crafted to attract the attention and arouse the interest of both the general public and specific actors. Details regarding the need to obtain acceptance of this issue by the public are provided in the next section of this chapter. Specific actors from whom attention is overtly sought can be collectively labeled “decision makers.” These decision makers are public or private persons, entities, or bodies with the authority or capital to (a) place EA on legislative, administrative, fiscal, practice, or scientific agendas to ensure that it achieves and remains an action item; (b) identify relevant goals for efforts to address EA; (c) recommend and/or select specific actions to be taken; and (d) decide which organizations or units will implement selected initiatives, policies, programs, or practices. Decision makers also include agencies, boards, or committees that determine whether authorized actions will receive resources, the levels of resources to be made available, and, in some cases, how the appropriate resources can be deployed. Some stakeholders have framed EA as a public health problem to secure its acceptance and treatment as a priority by a wide array of decision makers. This has involved legitimation processes that not only seek acknowledgment of the need to address EA, but also compel formal, normative commitments to action. The achievement of such commitments has been signified by organizational changes such as developing EA-centered policy positions and policy statements; enacting relevant laws, resolutions, or standard operating procedures; creating units officially dedicated to and charged with addressing the problem; and fashioning specialty tracks, concentration areas, or curricula to instill/ensure applicable competencies.
The third and final goal of framing EA as a public health problem has been to provide necessary information so that appropriate decisions can be made about the appropriate level of resources needed to address EA. The use of this frame alongside frames of EA as an aging issue, as a crime, and as a human rights violation has increased substantially since the late 1990s. Increasingly, more stakeholders have adopted all-encompassing frames or alternated between different frames to help inform different constituencies and decision makers so that they may respond appropriately to address EA. These strategies have been used to help inform decisions that will support EA initiatives to levels and mixtures that are commensurate with the scale, complexity, and dynamics of this problem. The incorporation of the public health frame into the mix of strategies previously employed helped shift the discourse away from the perception of EA as a problem to be handled principally by one or two sectors and toward a perspective that addressing EA requires resources from multiple sectors because it involves and impacts multiple dimensions of health and social life, as argued earlier in this chapter.
ELDER ABUSE IS THE PUBLIC’S HEALTH PROBLEM
EA is more than just a public health problem: It is also the public’s health problem. This specific framing of EA is essential, as it is a problem that the American public thinks about only in very abstract terms and experiences only episodically in a largely detached way (Volmert & Lindland, 2016). EA only occasionally becomes concrete, real, and fully present in the eyes of the public. When the confluence of specific events and incidents is brought to the forefront of society by news outlets and other media venues. Even on the rare occasions when this problem breaches the public’s consciousness (e.g., Mickey Rooney, Brooke Astor), its impacts are fleeting and superficial because its significance to and implications for the life of the average person are perceived as low or unrelatable. The salience of EA is even more attenuated because the public may not regard it as an ominous problem or may consider it a problem that is less threatening than other problems that society must confront (i.e., it is a problem that impacts distant others). Consequently, even though segments of the American public are aware of EA and its consequences for public health, heretofore there has been little incentive for the public as a whole to make it a priority for societal action.
A report released by the FrameWorks Institute and focused on the gaps between expert and public understandings of EA in America indicates that the public does not see EA as its own issue and devotes little attention to it (Volmert & Lindland, 2016). The public’s ambivalence and indifference regarding EA may be problematic because public motivation can lead to systemic actions to repel public health threats. In its absence, decision makers in critical sectors are less likely to understand EA as an urgent, important matter deserving of immediate attention and action and warranting the allocation of resources commensurate to eradicate the problem.
The framing of EA as the public’s health problem is neither congruent with nor resonates with the personal, everyday experiences of individual members of the public body. Many individuals do not (think they) personally know someone who has experienced EA. Others may have observed problematic behaviors formally considered EA but have failed to recognize the behaviors as problematic generally or as abusive, neglectful, or exploitative specifically. Still others may consider the behaviors problematic and even abusive but chose to ignore, dismiss, or rationalize the behavior as isolated incidents. In each of the aforementioned situations, EA is interpreted as an unfortunate occurrence that is uncommon, extreme, or atypical. Sometimes, it is difficult to recognize or take signs of EA seriously. EA could appear to be symptoms of dementia or signs of an older adult’s frailty—or caregivers may explain them as such. In fact, many of the signs and symptoms of EA do overlap with symptoms of mental deterioration (Robinson & Saisan, 2016). As a result, EA may not be afforded the appropriate recognition or response as a problem that the public is facing and must face collectively.
In reality, EA is a relatively common occurrence, involves problematic behaviors and experiences of variable severity, and can include single as well as repeated acts or failures to act. It is time that the public interest embraces ownership of this problem, given that EA is experienced by at least one out of every 10 older adults. Moreover, it is a problem with which each American must ostensibly contend, as most aging individuals eventually become older adults. Thus, among each group of 10 constructed from our older relatives, friends, neighbors, and acquaintances, at least one person may experience some form of abuse, neglect, or exploitation. Furthermore, as we ourselves become and live our lives as older adults, one out of every 10 of us may well face this problem. From this perspective, EA is not a distant or abstract threat, but rather a real and insidious threat to our personal well-being and to that of the older adults who matter to us the most. Also, the real and insidious threat of EA occurs precisely at a time in our lives when, individually, we may be the most powerless to ward off the problem.
The framing of EA presented here explicitly seeks to eliminate perceptions of this problem as a matter facing only older adults as a group that is often seen and discussed as somehow “different and separate” from other segments of America’s population. Recognition of EA as a problem for the entire population of the United States—older adults as well as those who love and care for them—is critical to ensure that neither EA nor the plight of all those affected by it will be ignored.
Each member of the American public is morally compelled to work with and on behalf of older adults to create arrangements and environments that promote welfare, prevent harm, and eliminate and alleviate suffering when it occurs. Each time an elder is subjected to any of the adverse exposures and experiences associated with EA, individually and collectively, we should be disturbed, outraged, and compelled to take action. These reactions should create sustained institutional and societal changes to improve the present and future life conditions experienced in older adulthood.
Embracing EA as the public’s health problem communicates and conveys the message that the lives, fates, and health states of older adults, younger adults, youth, and children are all inseparably intertwined and interdependent. Consequently, investments and actions to address EA will accomplish more than instituting changes that will benefit the older adult population alone. When combined with actions to reduce and prevent the forms of violence impacting other age groups, they will contribute to the creation of a nation where people of all ages and communities of all kinds are safer, healthier, and well positioned to enjoy prosperity and contribute to the public good.
ELDER ABUSE IS PUBLIC HEALTH’S PROBLEM
EA is also public health’s problem. The introduction of this additional frame is necessary because public health has not, as a sector, assumed full ownership of EA as a problem with which it should and must deal. This present reality exists despite the fact that EA has clear implications for the public’s health and for the operations of public health systems and agencies. Public health’s reluctance to address EA may arise in part because many public health professionals do not themselves see or think of EA as a public health problem. Most undergraduate, graduate, and postgraduate public health trainings do not incorporate content, exposures, or experiences that provide specific insights into EA as a health topic or into EA prevention as a concentration for public health practice. In addition, work to address EA is not required of most state and local health departments to carry out essential public health services. In the absence of professional socialization that calls attention to and presents models for understanding and approaching this problem, many public health professionals may not be fully aware of EA’s public health impacts or know how to use their training and skills to address it. Few public health agencies or organizations have the authority or the infrastructural capacity to implement EA-focused programs. Together, these conditions serve to reinforce the perception that addressing EA is not public health’s responsibility.
Although the constraints created by the aforementioned conditions should not be minimized, it is important to consider why the problem of EA is and should be considered public health’s problem or, more appropriately, public health’s concern. The precedent for public health work in this domain is well established in several areas of public health practice. The most obvious of these precedents entails the specific focus of some members within the public health sphere on promotion of healthy aging. This particular objective and its supporting tasks were wisely embraced by public health decades ago, in light of and in response to observed and expected sociodemographic transitions, trends in the prevalence and impacts of chronic disease, and achievements in the extension of life expectancy.
Achievements in life expectancy were attained as public health and clinical medicine grew steadily more adept in dealing with and limiting the effects of infectious diseases and sources of unintentional injury. These health threats had historically set limits on the average life span of adults in the United States. Gains in preventive medicine and public health practice removed these constraints, allowing life expectancy to be extended by decades. These achievements paved the way for sociodemographic transitions that signaled the beginninng of a new era of older adulthood, where life could be lived to its fullest and society could continue to benefit from the presence and contributions of its oldest members.
Unfortunately, as the threats posed by acute conditions declined, their niche was filled by conditions and diseases whose course and impacts were of a more enduring nature. These emergent chronic threats to public health make a concentrated and increased focus on older adulthood essential. Although many of the factors associated with the onset of chronic diseases occur early in life, the diseases themselves and their sequelae tend to become more prevalent and/or severe with age.
As health leaders in society reflected on the health and demographic transitions occurring across the nation, it quickly became evident that the steady growth of the older adult population and the growing problem of chronic disease within this population could easily strain and outstrip the resources of public health, healthcare financing, and healthcare delivery systems (Goulding, Rogers, & Smith, 2003; Mrsnik, Beers, Morozov, & Standard and Poor’s, 2010; Prince et al., 2015; World Health Organization & National Institute on Aging, 2011). It also became clear that the presence of chronic disease could create circumstances in which extensions in longevity would not necessarily be accompanied by increased or preserved quality of life during older adulthood. This eventuality could transform older adulthood into a period of life characterized by an increased disease burden, in which individuals would live longer but demonstrate far worse health states than previous generations. Public health evolved to face this challenge by developing units that would work directly to promote healthy aging. To this day, the sector retains components that actively identify, create, and enact policies and programs designed to promote, protect, and preserve the health and well-being of older adults and to ensure that health is maximized as the public ages.
From an operational standpoint, EA is public health’s problem because it impedes progress toward ensuring optimal health in older adulthood. EA is itself a source of injuries, disabilities, and dysfunctions that compromise health, create functional impairments, and reduce quality of life. The individual and overlapping effects of different types of EA produce harms that endanger health in ways that are not typically addressed or accounted for by prevailing approaches to promoting healthy aging. Such approaches often focus primarily on early detection and prevention of diseases, rather than on the prevention of abuse, neglect, and exploitation. To achieve the conditions necessary for older adults to enjoy good health and well-being, it is essential that EA prevention be considered for inclusion in public health’s agenda for promoting healthy aging, given its status as a fundamental cause of injury and poor health.
EA can also exacerbate the existing health conditions of those who experience it. This can occur most directly via physical damage or injuries to the body and its structures and systems. However, exacerbation can also occur indirectly by intensifying the anxiety and stress experienced by victims (which can, in turn, affect immune system functioning, cognitive status, and emotional stability) or by depleting or removing access to protective coping and social support resources (Begle et al., 2011; Luo & Waite, 2011; Wong & Waite, 2017). Through either of the pathways, EA interacts with and amplifies the health-related stressors already afflicting those exposed to it. Moreover, the complications and setbacks associated with EA may confound the provision of public health services by attenuating the effectiveness of health promotion actions taken by public health professionals.
Finally, EA can disrupt or prevent self-care, health promotion, and disease management activities. The coercive, controlling, and exploitive behaviors associated with some forms of EA can prevent individuals from completing activities necessary to maintain and improve their health (e.g., diet, exercise, foot care, and blood glucose testing among persons with diabetes). These behaviors may also prevent older adults from accessing beneficial interactions specifically designed to decrease health risks or to promote management of existing health conditions (e.g., appointments with healthcare providers such as physicians, optometrists, and counselors; preventive screening programs; immunizations; tai chi for falls prevention). It is through these additional impacts that EA further erodes the lives of older adults. Likewise, it is through such dynamics that EA can complicate and frustrate the work of the health promotion and disease/injury prevention specialists who serve older adults.
The work of public health professionals does not end with the provision of services to address the direct features and facets of the conditions of primary concern. The work of public health professionals also extends to ensuring the safety of those served, given the presence of factors or circumstances that may increase risks for victimization and other negative outcomes. Many conditions that become more common with age are accompanied by health-related vulnerabilities that may place older adults at increased risk for EA victimization. For example, some sources of cognitive impairment, such as dementia, stroke, and fall-related traumatic brain injuries, may increase victimization risks by reducing decision-making or disclosure abilities. In addition, visual impairments associated with cataracts, diabetes, hypertension, or hypercholesterolemia may impair self-protection capacities or abilities to effectively critique legal documents, such as contracts. To fully advance and safeguard client well-being, it is important for public health professionals working with older adults with such impairments to understand and work to address the EA-related risks these impairments introduce.
In the preceding paragraphs, EA was described as public health’s problem, because its existence creates difficulties for those persons working in public health. The premise of this framing is that EA must be addressed because of its effects on public health’s primary interests and its impacts on the sector’s ability to perform its official duties. EA is more than just an obstacle, annoyance, or inconvenience—and public health can do more than simply “attend to” EA because it complicates other activities. Specifically, this sector can help evolve thinking about its causes and how it can be more proactively addressed.
Public health is part of an interdependent community of sectors that shares the task of promoting and protecting the public’s welfare and well-being. Other sectors may be officially or more directly responsible for addressing EA. Distinct from other sectors, the public health sector can assist these sectors in fulfilling their responsibilities. Enhancements to EA prevention efforts resulting from public health’s collaborative involvement confer collective benefits for all involved sectors. Most importantly, the populations targeted by these sectors may be better positioned to live safely and enjoy good health.
There are numerous ways in which public health can join other sectors in addressing EA. A hallmark of public health is that its toolkit includes a variety of specific alternatives for collaborative leadership and involvement, which are presented in depth in other chapters of this book. Two main opportunities for action are described here as this chapter’s concluding act: (a) completing and strengthening the interpretive frames used to pursue EA-related action and (b) developing and enhancing capacities for the primary prevention of EA.
Completing and Strengthening Interpretive Frames for EA
At this point, it should be evident that interpretive frames have the potential to shape actions and efforts to address EA. They determine thoughts about the innate characteristics of the problem such as its characteristics and impacts. They may also influence ideas about its causes, solutions, and ownership.
Most existing EA frames are purely descriptive in nature. They describe the problem’s character, scope, and consequences and may include statements about who in the society has a responsibility for addressing it (e.g., all Americans, everyone, and persons working in criminal justice). Few frames explicitly and strategically present information about what causes, contributes to, or affects the likelihood of EA. Even fewer propose specific effective or promising strategies for its prevention.
This tendency may be one reason why the prevailing frames often successfully generate general support for efforts to address EA, yet fail to elicit the precise types or levels of action desired by EA prevention stakeholders. In the absence of specifics regarding causes and possible solutions, public audiences and decision makers draw on default understandings and conceptions of EA that depict it as analogous to child abuse or domestic violence and that portray it largely as a criminal justice or Adult Protective Services issue. Using these frames as a reference point creates situations where EA may be accepted as a public health problem but continue to be primarily responded to as a crime. Such situations are undesirable because no new actions, or the wrong actions, may be taken to address the problem.
A second characteristic of existing frames for EA may also limit the field’s success where the achievement of policy and practice actions is concerned—namely, the field has not reached broad consensus on what constitutes credible indicators. As is noted at several points throughout this book, there is no single, universally accepted estimate of either the prevalence or the incidence of EA. This lack of agreement arises because different data sources, methods, and approaches yield highly variable findings owing to differences in the purpose and scope of each data collection effort. Furthermore, although population-based prevalence studies have been conducted and provided informative snapshots of EA prevalence for specific periods, data of this type are not collected on an ongoing basis at local, state, or national levels. Given the variability in estimates of the magnitude of EA and the lack of data describing changes in its incidence and prevalence over time, decision makers may not have adequate information to make decisions about how to address this important issue.
The characteristics highlighted here, while problematic, also present public health with a unique opportunity to demonstrate its usefulness where the framing of EA is concerned. As a sector and a field of practice unto itself, public health is defined by specific analytic and methodological skill sets and concentrations of expertise that can be drawn on to help complete and strengthen existing interpretive frames used to seek action to address EA. First, public health’s innate emphasis on risk and protective factors as an element of prevention can be modeled to simply and clearly describe those classes of factors that can be modified to decrease risks for EA perpetration and victimization. This could assist with presenting specific stakeholders with concrete, actionable “targets” for attention within strategies intended to address EA and its consequences. Second, specific effective or promising prevention or intervention strategies could be showcased within technical packages. Such packages, which have proved useful in promoting action to address other public health problems, offer specific directions for actions to achieve stakeholder goals, suggest approaches (e.g., programs, policies, or practices) that can be used to pursue these goals, and present the best available research evidence supporting the use of each described approach. Finally, public health’s vast expertise in engaging stakeholders to achieve measurement standardization could be leveraged to promote data harmonization and reconciliation. This expertise could help achieve the desperately needed uniformity of “voice” needed to enhance the actual and perceived credibility of estimates of EA’s magnitude and severity.
Developing and Enhancing Capacities for the Primary Prevention of EA
Most of the sectors traditionally viewed as responsible for addressing EA were designed to respond to this problem after perpetration has already occurred. In the aftermath of abusive experiences, these sectors treat harms inflicted upon individuals, act to limit the impacts of these adverse experiences, and take steps to stop further perpetration and/or reduce the likelihood of revictimization. Many of these sectors acknowledge the need to complement such reactive responses with more proactive strategies directed toward the primary prevention of EA (in which actions are taken to prevent the onset of EA). However, only a few of these sectors have acted to address EA as a health problem experienced by whole populations, and even fewer have adopted population-based, primary prevention–oriented approaches.
The broad acceptance of EA as a “public health problem” provides the public health sector with an opportunity to cultivate and extend a focus on the primary prevention of EA within the field. Public health can make the most of this opportunity by collaborating with professionals in other sectors to demonstrate and make the case that actions must be taken to prevent EA from ever occurring. This could be done by building upon existing research about the factors influencing the likelihood of EA to develop and by systematically testing and assessing the effectiveness of EA prevention policies, programs, and practices. This might also involve efforts to highlight and spread the word about existing primary prevention–oriented programs whose effectiveness and pathways of effect have been established or whose effectiveness requires further examination to fully characterize their utility. Finally, public health could work with other sectors to systematically document the best practices and procedures for implementing strategies and approaches for the primary prevention of EA. Special attention could be given to establishing the relationships, resources, and infrastructures required to achieve population-level impacts using the examined strategies.
