Violence Prevention A Strategy for Reducing Health Inequalities

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1 Violence Prevention A Strategy for Reducing Health Inequalities Professor Mark A Bellis Centre for Public Health Liverpool John Moores University WHO Collaborating Centre for Violence Prevention

2 Overview Violence is a Public Health issue Violence and inequalities Routes of Violence in Deprivation Cycles of Violence Breaking the Cycle Intelligence informed action

3 Global Mortality 6000 Number of global deaths, s Interpersonal violence Suicide War 557, , ,000 Road traffic accidents Drownings Poisonings Fires 2000 Falls 1000 Other injuries Violence 0 TB HIV/AIDS Malaria Injuries WHO Global Burden of Disease

4 Health Service Costs Estimated annual burden on health services, billions STIs Obesity Class A Drugs Smoking Alcohol Violence Domestic Violence: 23 billion per year Criminal justice Health care Housing Civil legal Economic output Human and emotional costs Walby, 2004

5 Costs of Violence Stabbed in neck on way home from a party at age 16 Perpetrators 2 offenders strangers age 19 & 20 Police investigation Court case Prison, 10 year / 4 year sentences Half sentence served then freed Victim Paralysed from the neck down Requires 24 hour a day care 32 tablets each day Suffered nightmares and panic attacks Family, employment, education, social costs and community effects

6 Violence as Social Issue Reduced Use of Parks Fear of crime Vandalism Imprisoned at home - Obesity Child Abuse and Domestic Violence Lowered Social Cohesion Distrust of neighbours Adult Behaviour E.g. half women feel unsafe using public transport at night Alcohol Coping Dept for Transport 2005; Margo et al, 2006; WHO 2006

7 National Burden 773 homicides in 2007/08 Police recorded violence, around 1 million annually BCS - >2 million incidents against adults in 2008/9 7% of year olds report serious physical childhood abuse by parents 39% of year olds have been bullied at school Povey et al, 2009; Walker et al, 2009; Cawson 2002; Ofsted 2008 Hospital Episodes - Males Rank Age Unintentional injuries Assault Malignant neoplasm Intentional self harm Diseases of appendix Age Unintentional injuries Malignant neoplasm Assault Intentional self harm Benign neoplasm

8 Hospital Admissions Emergency hospital admissions for assault, England Rate per 100,000 residents, All Ages 2002/3 2003/4 2004/5 2005/6 Deprivation Quintile Poorest Richest 1 Bellis et al., 2008

9 Regional Trends Assault Admission Rate per 100,000 by year North West North East London Yorks & Humber West Midlands East Midlands South West South East East of England / / / /06 Bellis et al., 2008

10 Health Inequalities Prevalence of health measures in North West ratio between the Most Deprived and Least Deprived quintiles Prostate Cancer Breast Cancer Road Traffic Accidents Stroke Coronary Heart Disease Lung Cancer Self Harm Alcohol Conditions Violence Births to Lone Mothers NWPHO, Wood et al,

11 Hospital Admissions Youths Emergency hospital admissions for assault, England Rate per 100,000 residents 0-14 Years /3 2003/4 2004/5 2005/6 Deprivation Quintile 5 (Poorest) (Richest) Bellis et al., 2008

12 ACE Study Adverse Childhood Experiences (USA) 17,000 adult participants Experiences before age 18 Abuse: Physical, sexual, emotional Neglect: Physical, emotional Household Dysfunction: Mother treated violently Household substance abuse Household mental illness Parental separation / divorce Incarcerated household member Number of ACEs linked to behaviour and health in adulthood Felitti et al, 1998; Anda et al, 2006

13 Childhood Violence and Adult Health Increased risk (adjusted odds ratio) of having health behaviours and conditions in adulthood for individuals experiencing four or more ACEs in childhood. Felitti et al, 1998; Anda et al, 2006 Anxiety x 2.4 Severe obesity x sexual partners x 3.6 Alcoholism x 7.2 Illicit drug use x 4.5 Sexually transmitted infections x 2.5 Current smoker x 1.8 Perpetrating partner violence x 8.8 Any cancer x 1.9

14 Drinking behaviour and involvement in violence when drunk year olds, North West % reporting violence when drunk Frequency of drinking Frequency of binge drinking Units drank per week Never Less than once a month 1-3 times a month Once a week Twice a week 3+ times a week Units <5 >5-10 >10-20 >20-30 >30 Increased measures of alcohol consumption related to involvement in violence Even after correcting for alcohol intake drinking is more likely to result in violence in poorer areas (Bellis et al, in press)

15 Violence in Town and City Centres Assault Presentation to Accident & Emergency by by Deprivation Assault Location of Residence Violence occurs in town and city centres yet perpetrators and victims live elsewhere Safer places to get drunk and returning home

16 Recession On trade Retaliation

17 Atkinson et al, in press, Krug et al, 2002; McVeigh et al, 2005 Simple Cycle of Violence Perpetrator of Child Abuse Impaired Bonding Neglect Victim of Child Abuse Unintended Pregnancy Substance Use Academic Problems Antisocial Behaviour Perpetrator of Intimate Partner, Sexual Violence Unemployment Poor Housing Living in High Crime Area Victim and Perpetrator of Youth Violence

18 WHO/CPH Briefings Academic & grey literature Database searches e.g. Pub Med Systematic reviews Internet searches Balance between high quality evidence and geographical coverage Peer review process

19 WHO/CPH Briefings Developing safe, stable and nurturing relationships between children and their parents and caregivers Developing life skills in children and adolescents Reducing the availability and harmful use of alcohol Reducing access to guns, knives and pesticides Promoting gender equality to prevent violence against women Changing cultural and social norms that support violence Victim identification, care and support programmes

20 1 Developing safe, stable & nurturing relationships between children & their parents & caregivers Early, primary prevention to avoid the development of violence such as child abuse and childhood aggression Parenting programmes Information & support for parents Parent & child programmes Preschool education, family support, child/health services etc. Social support groups e.g. peer support for parents Media interventions e.g. raise awareness & knowledge of child maltreatment Nurse Family Partnership, US Some strong evidence Low-income first time mothers that parenting Parenting skills programmes Emotional bonding and parent Health behaviours and child programmes Personal development can Early reduce in pregnancy child to age 2 maltreatment Lower child maltreatment and Fewer arrests/convictions problem/aggressive Fewer injuries behaviours Fewer sexual in partners youth Lower alcohol use

21 3 Reducing availability and harmful use of alcohol Addressing strong links between alcohol & violence Regulating alcohol availability Sales times, outlet density Raising alcohol prices E.g taxation, minimum price Reducing alcohol use in problem drinkers E.g. brief interventions, treatment for alcohol dependence; Improving drinking environments Community partnerships, responsible retailing, strict enforcement, physical design Reduced Evidence alcohol promising, hours Diadema, suggesting Brazil that Sales banned after 11pm alcohol-focused Municipal law interventions can Information campaign reduce violence. Strict enforcement However, Three year impacts barriers to intervening Reduced homicides and few available Around 9 per studies month`

22 preventviolence.info

23 Youth Violence

24 Local Authority Data Local Authority Data

25 Summary Violence is a Public Health issue but receives relatively little attention Routes of inequalities are strongly linked with violence Violence restricts the ability to progress on a range of other public health related issues Established evidence based interventions are already available to break the Cycle of violence Public Health is well placed to coordinate what must be a multi-agency, intelligence led approach to violence prevention

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