WHO VIP Webinar
THE CARDIFF MODEL FOR VIOLENCE
PREVENTION
Jonathan Shepherd
Professor of Oral & Maxillofacial Surgery
Director, Violence Research Group
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
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
LOW POLICE ACSERTAINMENT OF SERIOUS
VIOLENCE IS AN INTERNATIONAL PROBLEM
1403 (100%) victims
869 (62%)
victims
327 (23%)
victims
ODENSE UNIVERSITY
HOSPITAL
207 (15%)
victims
POLICE
(Faergemann 2006)
 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)
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
INJURY-BASED APPROACH:
National / Regional violence measurement
Emergency Department data
Local surveillance/prevention
INDEPENDENT NATIONAL CORRELATES
WITH ED TREATMENT AFTER VIOLENCE
 Unemployment / Deprivation
 Ethnic minority population
 Alcohol expenditure
 Alcohol price
 Season
PROTOTYPE COMMUNITY SAFETY
PARTNERSHIP
PROTOTYPE CRIME REDUCTION
PARTNERSHIP: CARDIFF VIOLENCE
PREVENTION GROUP
Statutory in UK: 373 crime reduction partnerships
 Crime and Disorder Act 1998
 Police Reform Act 2002
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
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
VIOLENCE HOTSPOTS IN 21st
CENTURY CARDIFF
CHOLERA HOTSPOTS IN
VICTORIAN LONDON
VIOLENCE RELATED ATTENDANCES –
CARDIFF A&E
Woundings per 1000 population
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
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
ANNUAL COSTS AND BENEFITS
 Annual cost of Intervention: £5,176
 Annual cost of recorded woundings avoided (benefits):
£789k
 Cost/Benefit Ratio - total costs avoided = 1:152
 Cost/Benefit Ratio - criminal justice costs avoided = 1:31
Analyses carried out by Curtis Florence at the US Centres for Disease
prevention and Control, Atlanta, using 2008 costs
How does the Cardiff Model work?
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
Targeted policing prevents violence
Eg Braga 2007
and has violence prevention diffusion effects
Eg Weisburd et al 2007
EFFECT OF CCTV ON POLICE
VIOLENCE DETECTION
12
CCTV towns
(n=5)
Percentage change
10
8
6
Control towns
(n=5)
4
2
0
-2
-4
2 years before CCTV
2 years after CCTV
Sivarajasingam et al, 2003
EFFECT OF CCTV ON ASSAULT
ED ATTENDANCE
12
Control towns
Percentage change
10
Control towns
8
6
4
2
0
-2
-4
2 years before
2 years after CCTV
CCTV towns
CCTV towns
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
PREVENTION INGREDIENTS
 Emergency physician/surgeon
contributions to local community safety
partnerships: advocacy from health makes
a difference
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
A NEW WEAPON STRATEGY: PREVENTING
GLASS INJURY
Non-toughened
glass
Toughened
glass
NATIONAL EFFECT: USE OF
WEAPONS IN VIOLENCE
British Crime Survey
All violence
(%)
Domestic
(%)
Stranger
(%)
Acquaintance
(%)
1998 2000 1998 2000 1998 2000 1998 2000
Glass /
bottle
weapon
5
2
<1
<1
12
4
6
3
No
weapon
80
82
88
93
72
81
81
78
HIGH PROFILE HOMICIDES CAN
GALVANISE PREVENTION
UK IMPLEMENTATION
Profession guidelines
Government Policy
Wales:
Welsh Government
England: Department of Health
Scotland: Violence Reduction Unit
INTERNATIONAL IMPLEMENTATION
US (CDC), Western Cape, Holland
WHO IMPLEMENTATION
Implementation of the recommendations of
the World Report on Violence and Health