LAUNCH OF WHO REPORT ON VIOLENCE AND HEALTH

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WHO VIP Webinar THE CARDIFF MODEL FOR VIOLENCE
PREVENTION
Jonathan Shepherd Professor of Oral
Maxillofacial SurgeryDirector, Violence Research
Group
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TOP EIGHT GLOBAL CAUSES OF DEATH 2008 SOURCE WHO
Rank 5-14 years 15-29 years 30-44 years
1 Childhood cluster 200 139 HIV / AIDS 855 406 HIV / AIDS 855 406
2 Road traffic injuries 118 212 Road traffic injuries 354 692 Tuberculosis 368 501
3 Drowning 113 614 Tuberculosis 238 021 Road traffic injuries 354 692
4 Respiratory infections 112 739 Self-inflicted injuries 216 661 Ischaemic heart disease 224 986
5 Diarrhoeal diseases 88 430 Interpersonal violence 188 451 Self-inflicted injuries 215 263
6 Malaria 76 257 War injuries 95 015 Interpersonal violence 146 751
7 HIV / AIDS 46 022 Drowning 78 639 Cerebrovascular disease 145 965
8 War injuries 43 671 Respiratory infections 65 153 Cirrhosis of the liver 135 072
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RECORDING OF VIOLENCE BY THE POLICE AND IN EDs

• Police recording varies by victim age and gender
  and violence location
• Only 23 of people injured in violence who attend
  EDs are known to the police
• Crime surveys in UK, Sweden and US demonstrate
  similar police recording rates

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LOW POLICE ACSERTAINMENT OF SERIOUS VIOLENCE IS
AN INTERNATIONAL PROBLEM
1403 (100) victims
869 (62) victims
327 (23) victims
207 (15) victims
ODENSE UNIVERSITY HOSPITAL
POLICE
(Faergemann 2006)
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• Police recording is not closely related to injury
  severity
• 13 of firearm violence recorded in Atlanta EDs
  was not recorded by police (Kellerman el al 2003)

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REASONS WHY VIOLENCE IS NOT KNOWN TO THE POLICE

• Non reporting reflects fear of reprisals,
  inability of injured people to identify
  assailant(s), unwillingness to have own conduct
  scrutinised and need for emergency treatment
• Non recording of reported incidents

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INJURY-BASED APPROACH
National / Regional violence measurement Emergen
cy Department data Local surveillance/prevention
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INDEPENDENT NATIONAL CORRELATES WITH ED TREATMENT
AFTER VIOLENCE

• Unemployment / Deprivation
• Ethnic minority population
• Alcohol expenditure
• Alcohol price
• Season

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PROTOTYPE COMMUNITY SAFETY PARTNERSHIP
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PROTOTYPE CRIME REDUCTION PARTNERSHIP CARDIFF
VIOLENCE PREVENTION GROUP

• Statutory in UK 373 crime reduction
  partnerships
• Crime and Disorder Act 1998
• Police Reform Act 2002

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SUSTAINABLE ED DATA COLLECTION AND USE
Step One 24 hour electronic data collection
(precise violence location, time and weapon)
by ED clerical staff when patients first
attend Step Two Monthly anonymisation and data
sharing by hospital IT staff with
crime analyst Step Three Monthly combination of
police and ED data by analyst Step Four
Summary of violence times, locations and weapons
for police deployment and
license regulation Step Five Continuous
implementation and updating of
prevention action plan
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VIOLENCE PREVENTION

• Licensed premises traffic light scheme. Effective
  policing, situational and environmental
  interventions

• Targeted street patrols, CCTV, redeployment of
  police from suburbs into city centre at night
• Plastic glassware, fast food outlet relocation
• Pedestrianisation of entertainment streets
• Identification of people injured in domestic
  violence

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VIOLENCE HOTSPOTS IN 21stCENTURY CARDIFF
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CHOLERA HOTSPOTS IN VICTORIAN LONDON
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Woundings per 1000 population
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Case Studies

• ED information identified a source of blunt
  weapons a construction site next to a night
  club with skips containing bricks, concrete
  blocks and pieces of wood. Skips were secured and
  violence fell
• ED information identified series of attacks on
  cyclists in a neighbourhood. Police targeted this
  area and violence fell
• ED information identified several violence
  hotspot pubs/night clubs. Alcohol licence
  conditions imposed and some licences revoked.
  Violence fell
• 
  Source Dines 2011

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CHANGES IN VIOLENCE RELATED HOSPITAL ADMISSIONS
AND WOUNDINGS RECORDED BY THE POLICE

• Hospital Admissions
• down 24/year/100,000 population in Cardiff
• up 36/year/100,000 in comparison cities
• Woundings recorded by police
• up 336/year/100,000 population in Cardiff
• up 720/year/100,000 in comparison cities
• Florence et al
  BMJ 2011

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ANNUAL COSTS AND BENEFITS

• Annual cost of Intervention 5,176
• Annual cost of recorded woundings avoided
  (benefits) 789k
• Cost/Benefit Ratio - total costs avoided 1152
• Cost/Benefit Ratio - criminal justice costs
  avoided 131
• Analyses carried out by Curtis Florence at the US
  Centres for Disease prevention and
  Control, Atlanta, using 2008 costs

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How does the Cardiff Model work?
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• The Cardiff Model works by facilitating earlier
  and more frequent police intervention through the
  use of information from EDs and keeps people
  out of hospital and out of prison

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• Targeted policing prevents violence
• Eg Braga 2007
• and has violence prevention diffusion effects
• Eg Weisburd et al 2007

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EFFECT OF CCTV ON POLICE VIOLENCE DETECTION
12
CCTV towns (n5)
10
8
6
Control towns (n5)
Percentage change
4
2
0
-2
-4
2 years after CCTV
2 years before CCTV
Sivarajasingam et al, 2003
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EFFECT OF CCTV ON ASSAULTED ATTENDANCE
Control towns
Control towns
CCTV towns
CCTV towns
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OTHER MECHANISMS OF EFFECTIVENESS

• Identification and support of people injured in
  domestic violence prevents repeat victimisation
• Identification of weapon trends informs
  weapon-orientated prevention strategies
• Identifies violence hotspots, park locations and
  walkways for example, which can be targeted by
  city government officials

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PREVENTION INGREDIENTS

• Emergency physician/surgeon contributions to
  local community safety partnerships advocacy
  from health makes a difference

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PITFALLS

• Lack of leadership and management
• Low data quality
• Poor analysis
• Information not used
• Purpose of information not explained
• Too much strategy, not enough tactics
• Complicating a simple process

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A NEW WEAPON STRATEGY PREVENTING GLASS INJURY
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Non-toughened glass
Toughened glass
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NATIONAL EFFECT USE OF WEAPONS IN VIOLENCE
British Crime Survey
All violence Domestic Stranger Acquaintance ()
() () ()
1998 2000 1998 2000 1998 2000 1998 2000 Glass
/ 5 2 lt1 lt1 12 4 6 3bottle weapon No 80 82 88 9
3 72 81 81 78weapon
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HIGH PROFILE HOMICIDES CAN GALVANISE
PREVENTION
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• UK IMPLEMENTATION
• Profession guidelines
• Government Policy
• Wales Welsh Government
• England Department of Health
• Scotland Violence Reduction UnitINTERNATIONAL
  IMPLEMENTATION
• US (CDC), Western Cape, Holland

WHO IMPLEMENTATION Implementation of the
recommendations of the World Report on Violence
and Health