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Abstract
Objectives To describe the prevalence status of violence and its prevention in China, and to provide reference for the development of strategies regarding violence prevention.
Methods Violence mortality data between 2006 and 2015 were obtained from the national disease/death surveillance data set in 2006–2015. Data on violence-related medical cases were collected from the 2015 National Injury Surveillance System. The laws and policies about violence prevention and violence prevention programmes in China were described.
Results Violence mortality declined by 57.02% during 2006–2015 from 1.21/100 000 to 0.52/100 000. Violent death rate in males peaked in the age group 25–29 years (1.05/100 000) and it was low in the age group <15 years. Female violence mortality rate peaked during infancy (0.54/100 000), aged 25–29 (0.53/100 000) and age above 85 (0.98/100 000). The laws and policies about violence prevention were more perfect, while most prevention programmes were limited in scale and duration.
Conclusions The mortality of violence declined in China during 2006–2015. It is necessary to conduct gender-specific prevention strategies and improve the data collection and prevention service.
- violence
- mortality
- legislation
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Introduction
Violence has lifelong consequences and occurs in all places. Worldwide, 475 000 people were homicide victims in 2012.1 In China, the mortality of violence in 2013 was 0.65/100 000.2 The incidence of violence across the whole population was unclear, although a few studies have focused on specific populations or particular types of violence. Of Chinese women 24.7% are victims of domestic abuse at some point in their lives.3 The overall prevalence of elder abuse was 6.71%.4 The prevalence of intimate partner violence during pregnancy was 7.7%.5 Of young men 18–34 years from Chengdu, 22.0% report experiences of violence.6
The global status report on violence prevention in 2014 states that violence is predictable and preventable.7 It calls on states to develop and assess policies relating to violence prevention, to improve the capacity of data collection concerning violence, to conduct research on violence prevention and control, to strengthen the capacity to respond to victims of violence, and to reduce violence and its risk factors.7 8 Violence is a priority issue of public health and an important social problem. The implementation of relevant laws and multisector services is an important strategy for resolving the problem associated with violence. There are significant differences in the laws and services of violence prevention and control in different countries.7 Little is currently known about how interventions for violence are reflected in the laws, regulations and services of the People’s Republic of China. In order to provide evidence which could further advance the prevention of violence, this study focused on two existing sources of information about violence in China by (1) analysing the prevalence and characteristics of violence recorded in the national annual reports and the National Injury Surveillance System (NISS); and (2) describing the laws/regulations against violence which were already issued by the Chinese government and describing the services related to violence prevention and control in China.
Methods
Data sources
Violence mortality data were collected from the National Disease Surveillance System9–15 and the National Mortality Surveillance System16–18 published by the Chinese Center for Disease Control and Prevention (China CDC) covering the years 2006–2012 and 2013–2015, respectively. The earlier National Disease Surveillance System covered more than 70 million people at 161 surveillance points in 31 provinces (autonomous regions and municipalities directly under the Central Government). The system was expanded in 2013 to form the National Mortality Surveillance System, increasing the number of surveillance points to 605 and the monitored population to over 300 million people. Established on the same general principles applied in developing the earlier, and apparently successful, National Disease Surveillance System, it collected data from medical death certificates of all surveillance points, covering fatal incidences at medical institution of all levels, as well as homes and other locations. The classification of diseases followed the International Classification of Diseases coding, and the violence code was X85-Y09, Y87.1.
Data on violence-related medical cases were collected from the 2015 NISS,19 which includes data from clinics and emergency departments of 126 hospitals in 43 counties (cities and districts), where doctors routinely filled out national injury surveillance report cards and submitted them to the National Center for Chronic and Non-communicable Disease Control and Prevention, China CDC. Four categories were used in the data set used by the NISS: (1) unintentional, (2) self-harm/suicide, (3) intentional and (4) unclear. We analysed the data from the NISS with the parameter of ‘intentional’ (violence/attack) injury.
The description of violence prevention and control in China was based on the WHO Global Violence Prevention Report 2014 compiled from violence prevention questionnaires submitted by member countries in 2013 and 2014. The global status report on violence prevention questionnaire covers the status of legal, policy and programmatic measures taken to prevent the main types of interpersonal violence, and the status of services for victims of violence. China’s National Health and Family Planning Commission, Ministry of Education, Ministry of Civil Affairs, All China Women’s Federation, National Working Committee on Children and Women under the State Council, Ministry of Justice, and some college experts jointly completed the Violence Prevention Questionnaire-China. This study made use of the data from the questionnaire, and supplemented by laws and policies released or renewed after 2014 to picture China’s violence prevention laws and policies, as well as the status of its violence intervention and victim services.
Statistical analysis
The violence data were input into SPSS V.17.0 by gender, age, death count (rural and urban) and mortality rate for descriptive statistical analysis. Data on violent death trend and changes were from 2006–2012 National Disease Surveillance System database and 2013–2015 National Mortality Database. The violent death age distribution and sex characteristics come from the 2015 National Mortality Database. The 2015 national injury surveillance data were input via the National Injury Management Software and were analysed by gender, type of violence and so on with SPSS V.17.0.
Results
Prevalence of violence
Mortality trend
From 2006 to 2015, the crude violent death rate and standardised death rate (based on standard population in 2000) decreased. The crude violent death rate dropped from 1.21/100 000 in 2006 to 0.52/100 000 in 2015 (−57.02%), from 1.64/100 000 to 0.67/100 000 (−59.15%) among males, and from 0.76/100 000 to 0.36/100 000 (−52.63%) among females. The crude violent death rate decreased in the urban population from 1.39/100 000 to 0.39/100 000 (−71.94%) and in the rural population from 1.12/100 000 to 0.58/100 000 (−48.21%). Figure 1 shows the standardised violent death rate by gender and location (rural or urban) from 2006 to 2015, which is basically in line with the crude death rate trend. The common downtrends in standardised violent death rates for both males and females in urban and rural populations were particularly evident in the male and urban population. From 2006 to 2015, the standardised violent death rate for males was always higher than that for females. The standardised violent death rate of urban populations was higher than that of the rural populations before 2007, but has since decreased and is now lower than that of the rural populations.
Standardised violent death rate by gender and location (rural or urban) from 2006 to 2015. From 2006 to 2015, the standardised death rate (based on standard population in 2000) decreased.
Characteristics of violence mortality in 2015
The violent death rate in 2015 was shown as follows in accordance with data in the National Disease Surveillance System: 0.39/100 000 for those aged <1, low level for those aged 1–14, and high for those aged 15 or more. The violent death rate changed with age for both sexes. It was low in males under the age of 15 and peaked in males aged 25–29 (1.05/100 000). The female violence mortality rate peaked during infancy (0.54/100 000), aged 25–29 (0.53/100 000) and age above 85 (0.98/100 000), but remained low in other age groups. There were slight differences between urban and rural populations, with a higher violent death rate in urban populations aged 1–4, 40–44 and 50–54. In urban populations the violent death rate for females was highest for those above 85 years old, while in rural female it peaked for those aged <1 as well as those above 80 (table 1, figures 2 and 3).
Mortality of violence by age, gender and location (rural or urban) in 2015 (1/100 000)
Mortality of violence by age and gender of urban population in 2015. In urban populations the violent death rate for females was highest for those above 85 years old.
Mortality of violence by age and gender of rural population in 2015. In rural populations, female violence mortality peaked for those aged <1 as well as those above 80.
Hospital cases due to violence
In 2015, the NISS recorded data on 45 080 violence-related medical cases. Table 2 shows the occurrence of violence by sex and location (urban or rural). Blunt injury (61.79%) was the most common type of violence, followed by sharp injury (13.03%) and poisoning (6.52%), which were the same for males. Among females, the most prevalent forms of violence were blunt injury (55.75%), poisoning (12.63%) and sharp injury (10.01%). Of violence cases 0.51% are due to sexual harassment (female: 0.85%; male: 0.36%; urban: 0.73%; rural: 0.07%).
Number of cases and proportion of violence methods by sex and location in 2015
Current situation of violence prevention and control
A significant number of Chinese laws and policies covering were found to contain contents relating to violence prevention. Most suggestions made by WHO (table 3) were embodied in Chinese laws and policies, with the exception of marital rape. China was providing services at varying degrees and scopes to each class of violence victims, but most violence prevention and control services were based on projects carried out in pilot areas or with restricted duration (table 3). There were still few projects and services designed to intervene maltreatment of the elderly.
The laws/regulations and services related to violence prevention and control in China
Discussion
Our study showed that China’s violence mortality was in the downtrend from 1.21/100 000 in 2006 to 0.52/100 000 in 2015, one-thirteenth of the global average of 6.7/100 000.7 The analysis of China’s violence prevention and control situation showed that this drop in violence mortality corresponded with the nation’s implementation of relevant laws and policies in line with those recommended by the WHO, suggesting that these developments in regulation are contributing to positive results in an increasingly civilised, advanced and stable Chinese society. Legislation designed to prevent violence included Criminal Law,20 Anti-Domestic Violence Law,21 Security Administration Punishment Act,22 Law on the Protection of Minors,23 Prevent Juvenile Delinquency Law24 and so on. In addition, some laws and policies were established to prevent and control violence risk factors. For example, the Opinions of the State Council for Building and Improving Poor Student Subsidy Policy System at Colleges, Universities, Higher Vocational Schools and Secondary Vocational Schools, and the Tentative Method for Managing Student Subsidies at Colleges, Universities and High Vocational Schools could help to ensure that teenagers facing higher violence risks complete their schooling.25 26 The State Affordable Housing policy aims at lowering population density in poor urban areas in order to reduce the occurrence of violence, and the National Program of Action for Child Development in China 2011–202027 aids in the prevention of child abuse and teenager violence. The National Program of Action for Women Development in China 2011–202028 involved the prevention of violence between intimate partners, while the 13th Five-Year Plan for Development of Aging-Related Services and Pension System Construction in China helps prevent maltreatment of the aged.29 China’s national policy on gender equality urges gender bias elimination. The Official Guidance on Mental Health Education in Middle and Primary Schools includes materials on violence prevention and control,30 and the Standard for Morality and Society Course and Moral Education Course at Compulsory Education Stage has content calculated to reduce bullying on campuses.31 Opinions on Further Improving the Development and Management of Off-Campus Activity Places for the Minors involve supervision of minors after class so as to reduce teenager violence.32 The Policy of Providing Financial Subsidy to Petty Secured Loans to Women helps enhance the economic status of women.33 Yet there are multiple risk factors of violence, such as mental illness, poverty, lack of or inadequate housing, being isolated in the community and lack of a support network.34 35 So the low level and constant decrease in violent death rate may result from the development of China in laws and in other parts, such as improvement in the economic conditions, increase of entertainment facilities in life, more convenient interpersonal communication and improvement of medical service. The reasons for the decline in violence need further indepth research with multiple factors.
Although China registered a low violent death rate, when placed in the context of its population of 1.37 billion this still equates to more than 7000 victims of violence each year. In addition, it was likely that the violent death rate was underestimated due to factors such as the frequent invisibility of violence, human error in identification and reporting of evidence for violence by medical professionals,36 and failure to report or inaccurate reporting in the death registration system, so the surveillance, prevention and control of violence require ongoing stringent attention and efforts towards improvement. Interventions recommended by the international community include programmes for victims or vulnerable people, education for public and professional staff, screening and services, and so on. Many violence prevention and control services in China were based on projects which are typically carried out in restricted locations with limited duration.
This study raised serious concerns regarding the maltreatment of the aged, especially elderly women. A survey conducted in Hunan Province showed the prevalence of rural elder abuse at 2.6%, while another survey conducted in Hubei Province showed the incidence at 36.2%.37 The limited reports on elder abuse in China cannot reach consistent conclusion yet. The causes and risk factors of violence against the elderly are unclear, and there are only few projects and services dealing with it. Further reduction of elderly abuse could be achieved by strengthening data collection to identify evidence-based intervention strategies. In our study, it was known that China already issued a lot of laws/regulations against violence except for marital rape. With regard to marital rape, it is a phenomenon which had existed over a long period of time. The crime on rape is stipulated in the Criminal Law of China. But from the literal interpretation, there is no clear explanation of the specific meaning of women (marriage or extramarital) or men (husband or not). Therefore, due to the ambiguity of the legislation, marital rape is conferred a vague statement in the actual judicial practice, and the phenomenon of related cases with different judgements existed.38 39 Thereby, it calls for stipulating the law on marital rape to reduce sex violence by intimate partners. There is a need for ongoing assessment of violence intervention projects and policies, streamlining and improvement of violence intervention strategies, and effective structuring of routine government provisions and services for violence intervention. The violent death rates varied both with gender and with age group, especially in rural areas, where it was higher among the young and the middle-aged males, as well as among females in infancy and above 85 years old. In violence resulting to high mortality in young and middle-aged males, probable causes could be divided into individual level and social/community level. For the individual level, risk factors include high level of androgen in males in their prime of life (an indicator of aggressive attack), more likely to use direct physical attacks to express anger and more alcohol consumption.40–42 For the social/community level, risk factors include the following: The traditional concept of gender role contributes a lot to male violence. Media and video games provide ‘models’ to male aggressive behaviour. Social responsibility of males such as keeping family income and achieving success resulted to higher pressure.43 44 On the other hand, the methods of exerting violence are closely related to the consequences. With respect to striking and kicking, sharp injuries are more likely to be serious and result in death. The national injury surveillance data showed that 14.42% of male victims suffer sharp injuries, as opposed to 10.01% of females, which partially explained the higher violent death rate for males. The higher violent death rate for females during infancy could be because of the lack of acceptance of their gender (in rural area, people think that male is better than female), so female babies suffer more domestic violence or neglect. With progress in the society, the Chinese government highlights the issue of violence against children, especially violence against girls. The Outline of the Program for Development of Chinese Children requires elimination of discrimination and injuries against girls. Data from the NISS showed the proportion of intentional injuries among children has declined from 2006 to 2014.45 However, more studies are required to evaluate the level and trance of violence against female infants, especially in rural areas. Older women who live with other family members because of physical infirmity may be vulnerable to domestic violence.46 47 The national disease/death surveillance data showed that mortality due to suicide among the elderly is very high. In 2015, the mortality of male suicide among those aged 80–84 was 55.96/100 000 and 71.17/100 000 over 85 years old. The suicide death rates of females aged 80–84 and over 85 years old were 34.73/100 000 and 49.32/100 000, respectively.18 Because violence is a risk factor for suicide, elderly people who have been subjected to violence may commit suicide. In addition, elderly people who were subjected to violence may have died of other diseases due to exacerbation of a primary disease. So we cannot speculate that there is gender difference in violence situation just judging from the elderly violence mortality. Nevertheless, the whole population of elderly people needs to be protected from violence no matter what gender, male or female. In time, China will become a nation with more elderly people. Loss of work and wealth, discrimination, disability and disease are risk factors for violence. Old people are vulnerable groups exposed to these risk factors. Campaigns of ending elder discrimination and programmes of strengthening support to caregivers are needed.48 Different intervention strategies should be adopted to meet the different risk patterns of males and females. For example, in addition to the regulation of potentially offensive weapons and chemicals, nurturing of social skills which enhance non-violent negotiation and problem solving, which can be done from childhood, might reduce male violence. Violence towards females in high-risk categories could be positively impacted by widespread promotion of gender equality and women’s rights issues and imposing severe penalties on perpetrators of domestic violence. More policies should focus on the improvement in the economic level of vulnerable groups (the elderly and women), to increase the income of women and the subsidy of the elderly.
Limitations
There were several limitations to this study. First, the violence data in our study may be underestimated. The mortality data were from the database which was published without under-reporting adjustment. Under the influence of culture, domestic violence issues have long been concealed. Together with the poor capacity of medical professionals to recognise such issues, hospital-based violence data may also be under-reported. Second, the trend in violence mortality data was from a national system which was expanded in 2013. The increase in sample size may affect the continuity of data. Third, the hospital-based data were from the NISS, which still lacks representative evaluation. So the distribution of violence methods and the place of our study may be different from the actual situation in China. Last, our study does not give evidence on the casual association between laws and violence. The reasons for the decline in violence require further indepth study.
What is already known on the subject
The incidence of violence in specific populations or particular types of violence in China.
The distribution of violence mortality in different populations of China in 2013.
What this study adds
Violence mortality has declined between 2006 and 2015 in China.
There were gender and age differences in fatal violence and non-fatal violence (hospital cases) in China.
China already proclaimed numerous laws/regulations against violence; still, the enforcement of these laws needs to be further strengthened and the service responses to violence are still limited.
Acknowledgments
A lot of thanks to those who are engaged in death case surveillance and injury surveillance for their hard work in the data collection, input, sorting and data set compilation. Sincere thanks to experts engaged in violence prevention and control research at the Ministry of Education, Ministry of Civil Affairs, All China Women's Federation, National Working Committee on Children and Women under the State Council, Ministry of Justice, and Xi'an Jiaotong University, who provide valuable information on China's violence prevention and control status.
Footnotes
Contributors LD designed the study and organised the information collection. XG wrote the manuscript. YJ and PY analysed the data. YE and LW gave advice on the study designation and manuscript improvement.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.