High Rates Of Interpersonal Violence Research Articles

Interpersonal violence and suicide risk: Examining buffering effects of school and community connectedness

BackgroundExposure to interpersonal violence is associated with elevated suicide risk. Preventing suicide among high-risk adolescents is most often discussed from a clinical treatment perspective, resulting in a gap in research examining whether school and community connectedness can buffer the relationships between forms of interpersonal violence and suicide risk in clinical samples of adolescents. MethodsBaseline data from 294 adolescents who received substance use treatment were analyzed to help fill this gap in research. Adolescents in this sample were at greater risk for suicidal thoughts and behaviors given their histories of substance use disorders and high rates of interpersonal violence, with 57% reporting experiencing at least one form of abuse/violence. Independent variables included lifetime exposure to physical abuse, sexual abuse, and weapon violence; moderators included various measures of school and community connectedness. Multinomial logistic regression models were estimated to examine the main and interaction effects predicting a three-category measure of suicide risk: non-suicidal, suicidal ideation only, and prior suicide attempts. ResultsSexual abuse survivors had the highest predicted probability of a prior suicide attempt when reporting lower levels of teacher support, school-based positive peer interactions, or neighborhood social connection, but at higher levels of these protective factors, their predicted probability was similar to those not exposed to sexual abuse. The same protective pattern was observed for physical abuse survivors with high neighborhood social connection. ConclusionThe buffering effects observed in this study identified dimensions of school and community social connectedness as protective factors for youth exposed to abuse. Although promoting social connectedness is often cited as a universal suicide prevention approach, tailored efforts to enhance connectedness within this population may also be a promising secondary prevention strategy. Thus, in addition to clinical treatment, more emphasis should be placed on systems-level approaches to reducing risk among youth most vulnerable to suicide.

Geospatial Analysis of Social Vulnerability, Race, and Firearm Violence in Chicago

IntroductionUrban firearm violence (UFV) is associated with inequities rooted in structural racism and socioeconomic disparities. Social vulnerability index (SVI) is a composite measure that encompasses both. We sought to understand the relationship between SVI and the incidence of UFV in Chicago using geospatial analysis for the first time. Materials and methodsFirearm assaults in Chicago 2001-2019 were obtained from the Trace. Locations of incidents were geocoded using ArcGIS and overlaid with census tract vector files. These data were linked to 2018 SVI measures obtained from the Center for Disease Control and Prevention. Shooting rates were calculated by tabulating the total number of shootings per capita in each census tract. We used Poisson regression with robust error variance to estimate the incident rate of UFV in different levels of social vulnerability and Local Moran's I to evaluate spatial autocorrelation. ResultsIn total, 642 census tracts were analyzed. The median shooting rate was 2.6 per 1000 people (interquartile 0.77, 7.0). When compared to those census tracts with very low SVI, census tracts with low SVI had a 1.7-time increased incident rate of shootings (incidence rate ratio [IRR] 1.74, 95% CI 1.08, 2.81), tracts with moderate SVI had a 3.1-time increased incident rate (IRR 3.07, 95% CI 2.31, 4.10), and tracts with high SVI had a 7-time increased incident rate (IRR 7.03, 95% CI 5.45, 9.07). ConclusionsIn Chicago, social vulnerability has a significant association with rates of firearm violence, providing a focus point for policy intervention to address high rates of interpersonal violence in similar cities.

Childhood and Adult Sexual Violence Exposures as Predictors of PTSD, Dissociation, and Substance Use in Women in Jail

ABSTRACT Women involved in the criminal legal system report high rates of interpersonal violence, particularly sexual violence, and mental health problems. Although existing research has linked experiences of interpersonal violence to multiple negative mental health outcomes, few researchers have examined concurrent psychopathology as an outcome of child and adult sexual violence in system-involved women. The purpose of this study was to examine child sexual abuse (CSA) and adult sexual violence, while controlling for other forms of interpersonal violence, as predictors of current symptoms of posttraumatic stress disorder (PSTD), substance use disorder (SUD), and dissociation in women in jail in the Mountain West. Randomly selected participants (N = 146) completed clinician-administered measures of trauma histories and mental health symptoms. The majority of the women (73%) reported experiences of CSA and about half reported experiences of adult sexual violence. Over half of the women reported symptoms consistent with current probable PTSD, about 20% reported dissociation symptoms in a clinical range, and over 70% met criteria for a SUD in the past year. The proposed model was tested with path analysis. CSA significantly predicted current symptoms of PTSD while adult sexual violence exposure predicted symptoms of SUD and dissociation. These results illustrate the high rates of sexual violence exposure as well as the complexity of mental health needs associated with these exposures in system-involved women. Findings highlight the need to comprehensively assess incarcerated women’s trauma exposure and psychological distress to better meet the needs of this population.

Clinical Care of Victims of Interpersonal Violence and Rape in Tanzania: A Qualitative Investigation

IntroductionAfrica has high rates of interpersonal violence and rape, although little is known about how these cases are handled in the clinical setting.MethodsWe enrolled 121 health care professionals and students in Tanzania from the fields of midwifery, nursing and medicine, and conducted 18 focus group discussions stratified by both professional and clinical experience. Two clinical scenarios were presented across all groups and participants were asked to give their opinions on how the hospital they worked in would manage the cases. Case 1 focused on how to address a case of an injured woman beaten by her husband (and whether the perpetrator would be reported to the police). Case 2 focused on how to handle a rape victim who is brought to the hospital by the police.ResultsParticipants considered both cases as emergencies. There was a similarity in the clinical care procedures across both scenarios. This included building rapport with the patient, prioritization of the medical care, history taking, and referring to other specialties for follow-up. Participants differed in how they would handle the legal aspects of both cases, including whether and how to best follow mandated reporting policies. Providers wondered if they should report the husband in case study 1, the criteria for reporting, and where to report. Providers displayed a lack of knowledge about resources needed for sexual violence victim and the availability of resources.ConclusionThese findings indicate that cases of intimate partner violence and rape are likely to be under-reported within hospitals and clinics in Tanzania. Health care providers lack training in their required obligations and procedures that need to be followed to ensure victim’s safety. The findings confirm that there is a need for health care students in Tanzania (and possibly Africa) to receive comprehensive training in how to handle such cases.

Reproductive health risks and clinician practices with gender diverse adolescents and young adults.

Reproductive health counseling is essential for adolescents and young adults (AYAs). Transgender and gender diverse (TGD) AYAs would benefit from tailored counseling given concerns about iatrogenic infertility and sexual dysfunction, and high rates of interpersonal violence, unplanned pregnancies and sexually transmitted infections, yet there are multiple obstacles to providing this care at the patient/family and clinician levels. This narrative review summarizes the literature on reproductive health considerations for TGD AYAs, current practices, and clinician barriers and facilitators to providing culturally sensitive reproductive care for TGD AYAs. Specific areas of focus include reproductive health goals, risks, and access barriers; clinician knowledge practices and challenges; and strategies for improving counseling practices. PubMed, Google Scholar, Medline, Web of Science, and PsycInfo databases were searched using the following terms: transgender, non-binary, gender expansive, gender non-conforming, reproductive health, sexual health, fertility, family planning/building, contraception, sexual dysfunction; gender-affirming hormones/surgery, clinician, physician or provider knowledge and attitudes; counseling. Many TGD AYAs desire biological children and improved sexual experiences. TGD AYAs may experience infertility and sexual dysfunction associated with transition; have disproportionate HIV/STI risk; experience high rates of interpersonal/sexual violence and trauma; and encounter barriers to accessing competent medical care. Clinicians lack knowledge about reproductive health needs of TGD AYAs; inconsistently discuss family building options; perceive counseling challenges; and desire more training in this area. Enriched communication training for medical/mental health clinicians is necessary to provide a skilled workforce for TGD AYAs. Web-based reproductive health training with other populations (eg oncology) demonstrates efficacy for improving communication skills and confidence in counseling, CONCLUSION: This review highlights barriers to adequate reproductive care encountered by TGD AYAs, exacerbated in underserved minority youth. Dedicated training for providers, and programs increasing access are important goals for improving care. The need for additional research is also emphasized.

Posttraumatic stress and depression among women in Kenya’s informal settlements: risk and protective factors

ABSTRACT Background: Approximately 56% of Kenya´s population resides in informal settlements (UN-Habitat, 2016). Female residents experience a range of psychosocial stressors including chronic poverty and high rates of interpersonal violence. Despite evidence that this population has some of the worst physical health outcomes in the country (APHRC, 2014), few studies have evaluated their mental health status and its correlates. Objective: The purpose of this study was to identify risk and protective factors associated with mental health problems (posttraumatic stress & depression) among women living in informal settlements in Kenya. Hypothesized risk factors included economic stress, a history of experiencing childhood abuse and sexual violence, as well as partner-perpetrated psychological and physical abuse. Hypothesized protective factors were supportive relationships with family members and friends and having a sense community connection. Method: Local community health workers were trained to collect data via individual interviews using validated measures. Participants were recruited using systematic random sampling in two informal settlements in Nakuru County. We used path analysis to test the hypothesized model among a sample of 301 women. Results: The model had an excellent fit (χ2 = 13.391, df = 8, p =.099; GFI =.99; CFI =.99; RMSEA =.05) and explained 25% of the variance in PTSS and 28% of the variance in depression. All predictor variables except support from friends were statistically significant in the expected direction. Specifically, economic stress, childhood abuse, sexual violence, as well as physical and psychological abuse from one´s partner had significant positive associations with PTSS and depression. Having supportive family members and a sense of being part of the community had significant negative associations with symptoms. Conclusions: Results highlight the importance of addressing intimate partner and other forms of interpersonal violence in these settings and hold implications for tailoring interventions for this marginalized population.

Violence Typologies Among Youth: A Latent Class Analysis of Middle and High School Youth.

Research documents high rates of interpersonal violence (e.g., bullying, dating violence, sexual assault) among middle and high school youth, during which time dating and sexual relationships are emerging. Most research to date focuses on one type of violence at a time or examines the co-occurrence of violence within an age group. This study examined interpersonal violence victimization and perpetration (IVVP) within the context of middle and high school with data from 738 middle school students and 1,311 high school students. Results show distinct classes, or groups, of IVVP among middle and high school students. Three classes emerged for the middle school sample and included a normative class (66.8%; n = 493), a victim of bullying class (28.1%; n = 207), and a mixed/poly-victim class (5.2%; n = 38). Five classes emerged for the high school sample and included a normative class (66.7%; n = 975), a victim of bullying class (18.1%; n = 237), a homophobic bully-victim class (11.0%; n = 144), a poly-victim class (3.1%; n = 40), and a sexual assault perpetrator class (1.1%; n = 15). Demographic and adjustment indicators differentiated many of the classes in each age group. The findings illustrate that there are distinct differences between middle and high school student's exposure to and perpetration of violence. Middle school students may be best served by programs that address victimization experiences while high school may be a developmental moment to introduce sexual assault prevention programs.

Punitive Welfare on the Margins of the State: Narratives of Punishment and (In)Justice in Masiphumelele

While there is an established literature on the relationship between political economy and state punishment, there is less work on how punishment is constituted from below in contexts of inequality. This article analyses the discourse around incidents of lethal collective violence that occurred in 2015 in a former black township in South Africa. I use this as a lens for examining how punitive forms of popular justice interact with state punishment. Whether via the slow violence of structural inequality or the viscerally corporeal high rates of interpersonal violence, my interviewees were intimately acquainted with violence. Although they supported long-term imprisonment, none of them came across as stereotypical right-wing populists. Instead, they adopted complex positions, calling for a type of punitive welfarism, which combined harsh solutions to crime with explicit recognition of the importance of dealing with ‘root causes’. I argue that when the state is perceived to be failing to both impose punishment and provide welfare, violence becomes a technology of exchange, which simultaneously seeks both more punishment and more welfare. The result is an assemblage of exclusionary penal forms.

Divorce Ambivalence and Reasons for Divorce in Iran.

This study examined divorce attitudes and reasons for divorce in Iran, a nation experiencing a rapid increase in divorce. Using instruments translated into Farsi with a sample of 230 Iranian spouses filing for divorce, we found a preponderance of common relational reasons for divorce (such as growing apart and not getting enough attention), along with high rates of interpersonal violence reported by wives. Study participants showed considerable rates of divorce ambivalence, along with openness to reconciliation services. The findings were compared with similar studies of the United States spouses in the divorce process. Clinical implications include a careful approach to considering how discernment counseling might be adapted to the cultural situation of Iran, and particularly the special concerns of Iranian women.

"I really want people to use our work to be safe"…Using participatory research to develop a safety intervention for adults with intellectual disability.

People with intellectual disability experience disproportionately high rates of interpersonal violence (IPV) due, in part, to disability-related risks that often can be minimized through targeted intervention. In this article, we describe using an academic and community participatory research approach to develop and test the feasibility of an accessible IPV prevention program for people with intellectual disability. The Safety Class, which is an interactive, structured, eight-session, weekly face-to-face group program, was found feasible for implementation in an efficacy study. Working in partnership with the intellectual disability community through all phases of the project helps ensure the relevance, inclusion, and accessibility of The Safety Class.

1.0 Trauma-Focused Cognitive-Behavioral Therapy for Interpersonal Violence: Practical Strategies for Child Psychiatrists

Interpersonal violence is associated with increased risk for developing PTSD and associated problems (e.g., depression, substance abuse). Lesbian, gay, bisexual, and transgender (LGBT) youth, youth in child welfare, and those in the juvenile justice system experience high rates of interpersonal violence, but PTSD is under recognized in these populations. This extended workshop provides additional time and opportunity for child and adolescent psychiatrists to learn core trauma-focused (TF)-CBT techniques that can improve their ability to care for youth who experience interpersonal violence

Posttraumatic disorders in patients with schizophrenia spectrum disorders

The findings of international studies suggest high rates of interpersonal violence and posttraumatic stress disorder (PTSD) among patients with schizophrenia spectrum disorders. Only few studies, however, have so far been conducted in the German-speaking countries. The aim of our study was to determine the prevalence of lifetime experiences of interpersonal violence and comorbid PTSD among inpatients in a German university hospital. In N = 145 consecutively admitted patients with schizophrenia spectrum disorders (67 % male) the structured trauma interview (STI) was used to assess experiences of interpersonal violence and the structured clinical interview for DSM-IV (SCID) to assess comorbid PTSD. Sexual violence under the age of 16 years was reported by 17 % of the patients (women 27 %, men 12 %). Approximately one third (32 %) reported physical violence by parental figures (women 38 %, men 29 %). At least one form of early violence (sexual or physical) was reported by half of the women (48 %) and one third of the men (34 %). Negative sexual experiences later in life were reported by 17 %, physical violence by 38 % and at least one of these forms by 48 % of the patients. In total two thirds of all patients (66 %) reported experiences of violence during their lifetime. The prevalence of acute PTSD was 12 %. Another 9 % of patients had a subsyndromal PTSD. The present study confirmed the high rates of experiences of interpersonal violence and comorbid PTSD in a German sample of patients with schizophrenia spectrum disorders. Violence and it's consequences should therefore be routinely assessed and the full spectrum of trauma-specific therapies should be integrated into the treatment of this group of patients.

Are Interpersonal Violence Rates Higher Among Young Women in College Compared With Those Never Attending College?

Estimates of sexual violence and partner violence rates among young women are generated primarily from college samples. Few studies have data to compare rates among similar-aged women attending college with those who never attended college. This study aims to estimate rates of partner violence by type (sexual, physical, and psychological) and severity (mild, moderate, severe), sexual harassment, and knowing or suspecting that someone put a drug in a drink (drugged drink) among a national sample of 959 young women aged 18 to 24 in an intimate relationship in the past 12 months who were either currently in college (college;n= 272) or never attended college (non-college;n= 687). After adjusting for demographic differences between these two groups, no significant differences were found in rates of sexual partner violence (28.4% non-college, 23.5% college), physical partner violence (27.9% non-college, 26.3% college), psychological partner violence (Mscore: 6.10 non-college, 5.59 college), sexual harassment (15.5% non-college, 14.1% college), or drugged drink (8.5% non-college, 7.8% college). Finding high rates of interpersonal violence among young women who are and are not currently attending college indicates the need to target all young adults with violence prevention interventions in educational, workplace, and other community-based settings.

Mediators of interpersonal violence and drug addiction severity among methamphetamine users in Cape Town, South Africa

South Africa has high rates of interpersonal violence and a rapidly growing methamphetamine epidemic. Previous research has linked experiences of interpersonal violence to higher rates of substance use, and identified mental health constructs as potential mediators of this association. The aim of this study was to examine the relationship between interpersonal violence and addiction severity among active methamphetamine users in Cape Town, South Africa, and to explore symptoms of posttraumatic stress disorder (PTSD) and substance use coping as mediators of this relationship. A community sample of 360 methamphetamine users was recruited through respondent driven sampling and surveyed on their experiences of violence, mental health, coping, and drug use and severity. A series of one-way ANOVAs were conducted to examine the relationship of self-reported interpersonal violence with drug addiction severity, and multiple mediation analyses were used to determine if PTSD symptoms and substance use coping mediated this relationship. The majority (87%) of the sample reported experiencing at least one instance of interpersonal violence in their lifetime, and the number of violent experiences was associated with increased drug addiction severity. PTSD and substance use coping were significant mediators of this association. Only the indirect effect of substance use coping remained significant for the female sample when the mediation model was conducted separately for men and women. The findings point to the need for integrated treatments that address drug use and PTSD for methamphetamine users in South Africa and highlight the importance of coping interventions for women.

The spectrum and outcome of pregnant trauma patients in a metropolitan trauma service in South Africa

IntroductionPregnant patients involved in trauma pose unique diagnostic and treatment challenges as the physiological and anatomical changes associated with pregnancy, and the need to preserve foetal well-being, result in a number of nuances in the standard resuscitation algorithms. This clinical audit within a busy developing world trauma service describes the spectrum and outcome of pregnant trauma patients. MethodsAll pregnant patients presenting to the Pietermaritzburg Metropolitan Hospital Complex following trauma were included in the study. Data were retrieved from the trauma registry and analyzed using descriptive statistics on a spreadsheet. The study ran from the 1st of July 2011 to the 31st of December 2013. ResultsDuring the study period, 1075 female trauma patients were admitted, with a 4% incidence of pregnant patients (42/1075). The mean age of the patients in the study was 24.9 years with an average age of gestation of 21.4 weeks. Blunt trauma accounted for the majority of injuries (57%). Trauma was by way of intentional assault in 52% of the cases. Of the cases of assault, 81% of the time, the assailant was known to the victim and in the majority of cases (55%) the assailant was the patient's intimate partner. Polytrauma predominated as the most common pattern of injury. Foetal death occurred in more than a third of cases (15/42). In 90% of the patients with an Injury Severity Score greater than fifteen, there was foetal death. Eighty-six percent (6/7) of the patients who required surgery had an unfavourable foetal outcome. In 73% of the cases of foetal death, the pregnancies were less than 28 weeks gestation. ConclusionIn an environment with high rates of interpersonal violence, trauma in pregnancy is not an uncommon occurrence. It is most commonly due to assault and the assailant is known to the victim in the majority of cases. Blunt trauma still predominates in this setting but there is a high incidence of penetrating trauma. Foetal mortality in this group is high and reflects the severity of the trauma experienced.

Sexualized and Dangerous Relationships: Listening to the Voices of Low-Income African American Girls Placed at Risk for Sexual Exploitation

Introduction: Youth from low-income, urban backgrounds face significant challenges to maintaining a positive developmental trajectory. Dangerous neighborhoods and stressed relationships are common in these settings and threaten adaptation by weakening the natural assets that undergird resilience. African American girls in these contexts face specific, multiple risks, including gender stereotyping, violence, and sexual exploitation. The commercial sexual exploitation of children (CSEC) is a multibillion-dollar industry victimizing over 1 million children around the globe. The typical victim in 1 city in the southeastern United States is an African American girl 12–14 years old. There has been little research investigating the characteristics of girls placed at risk for CSEC and even less research on the personal perspectives of these girls.Methods: Over 3 school terms we provided preventive intervention groups for 36 African American middle school girls who were placed at risk because they lived in neighborhoods with high rates of interpersonal violence and CSEC. Two group leaders and a process recorder took detailed notes on each group session. Our focus on group conversations over a period of weeks increased the probability of recording spontaneous, open comments by the children and is a promising method with this population. The data were analyzed qualitatively and resulted in an account of the girls' own views of the environmental challenges and personal experiences that may influence their development.Results: The girls' language during the group sessions contained 4 themes: difficulty forming trusting relationships, frequent peer aggression, familiarity with adult prostitution, and sexuality as a commodity.Conclusion: Our research shows how girls placed at risk for CSEC view their own lives. These children described violence and sexual exploitation and cited limited supports to protect them from these risks. Understanding the perspectives of these girls should generate future research and intervention strategies to support their coping and resilience.

Abstract 210: Facilitators to Learning Cardiopulmonary Resuscitation in High-Risk Neighborhoods

Background: Previous research in Columbus, Ohio has identified three high-risk neighborhoods, comprised primarily of African-American residents and with a median household income of <$30,000, where the incidence of OHCA is high and bystander cardiopulmonary (CPR) is low. Objectives: To identify 1) facilitators to learning CPR and 2) perceived attributes of people most likely to learn CPR in high-risk neighborhoods. Methods: Five focus groups, lasting 90-120 minutes, were conducted in January-February 2011 in the three identified neighborhoods in Columbus. We utilized purposeful and snowball sampling to recruit 42 residents to participate. A qualitative study design using grounded theory was used to develop codes, categories and themes in an iterative process. The focus groups were audiotaped and transcribed verbatim. Three reviewers independently read through each transcript and discussed major themes to develop a conceptual framework. Results: Three main thematic areas were identified as facilitators for residents to learn CPR: family/self-preservation, emotional factors and economic incentives (Table 1). The importance of showing how learning CPR might save the lives of family members was the most consistent theme. Participants felt that tying CPR instruction to basic first aid, especially in the setting of traumatic arrest was very important due to the high rates of interpersonal violence in the community. Obtaining academic credit and job skills through CPR training were also important. The participants perceived certain attributes of people likely to learn CPR: self-motivated, concerned and people with prior medical training. Conclusion: Linking CPR instruction to saving the lives of family members and saving the life of a violent crime victim were consistent themes. Future work will be conducted with residents from these neighborhoods to implement and measure the success of a community-based approach to CPR training based on this research.

Interpersonal Violence and Mental Health Outcomes among Asian American and Native Hawaiian/Other Pacific Islander College Students.

In a cross-sectional survey of college students (N = 614) we studied interpersonal violence victimization, perpetration, and mental health outcomes in an ethnoracially diverse rural-based sample of Asian Americans (27%), and Native Hawaiian/Other Pacific Islanders (25%), two groups vastly underrepresented in trauma research. High rates of interpersonal violence (34%), violence perpetration (13%), and probable psychiatric diagnoses (77%), including posttraumatic stress disorder, were found. Exposure to physical violence, sexual violence, and life stress all were predictive of psychopathology. Female participants were associated with higher likelihood of sexual violence victimization compared to male participants, and Asian American status (especially among males) was associated with lower likelihood of physical and sexual violence compared with European Americans. These data enhance our understanding of interpersonal violence and mental health outcomes among previously understudied minority groups.

Psychotherapies for Trauma and Substance Abuse in Women

Women are subject to high rates of interpersonal violence. One frequent co-occurring issue is substance abuse, which may arise posttrauma as a way to cope. In this article, psychosocial therapies for co-occurring trauma and substance abuse are reviewed. Description of empirically studied models is provided, as well as results of the empirical studies. Overall, this area of work suggests positive growth in the availability of new models but very limited empirical work thus far for all but one model. Directions for the future include the need for greater study of treatments in this area, as well as the need to address issues beyond specific models (e.g., workforce issues, access to care, and changing the culture of treatment systems). Policy implications are also offered.

An evaluation of the Australian Football League Central Australian Responsible Alcohol Strategy 2005–07

In 2004, the Australian Football League Central Australia (AFLCA) implemented the Responsible Alcohol Strategy (RAS), which aimed to decrease alcohol consumption at matches, and to promote healthy lifestyle messages to the youth of Central Australia participating in Australian Rules football. The evaluation adopted a pre- and post-implementation design to monitor a number of performance indicators. The evaluation analysed routinely collected data from AFLCA, its Security Company, Alice Springs Police Department and Alice Springs Hospital; we surveyed AFLCA staff, club officials and umpires; and undertook direct observation at AFLCA events. The volume of alcohol sold at matches decreased. Survey data indicate decreased alcohol related violence, improved spectator behaviour and decreased spectator attendances. Police data suggest declining alcohol-related and violent behaviours, but trends were not statistically significant. Alice Springs Hospital injury admission data indicate a non-significant interaction between year and season effect. In a community context of high alcohol consumption and high rates of interpersonal violence, the strategies implemented were successful in decreasing alcohol consumption and related undesirable behaviours at football games. However, these measures have resulted in unintended consequences: decreased numbers of spectators attending games, decreased canteen sales and falling sponsorship. The decreased revenue has raised serious issues about sustainability of the alcohol intervention, and stimulated discussions with government and others about strategies to maintain this important alcohol reduction policy.