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Traditionally, violence has been regarded as a ‘law and order’ issue. The health sector’s principal role has been to deal with the consequences of violent behaviour by providing treatment to victims. More recently, the success of public health approaches to other environmental and behaviourrelated health problems such as heart disease, smoking and HIV/AIDS has encouraged a shift in perception. There is growing recognition that violence is preventable and that strategies to reduce and prevent violence and abuse can be developed using a ‘public health’ model.

Violence in Scotland

The level of violence in Scotland has remained largely unchanged for the last 30 years or more. This results in unacceptable levels of physical injury, emotional distress and psychological harm. The true cost of this to our judicial system, health service, social services, communities, families and individuals is practically incalculable. Violence is a diffuse and complex phenomenon. Notions of what is acceptable and unacceptable behaviour and what constitutes harm are culturally influenced and constantly under review as values and social norms evolve.

To assist in the development of strategic policy, the World Health Organization (WHO) has developed a definition of violence that several countries, including Scotland have adopted:

“The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” (1)

The WHO report highlighted Scotland as having a homicide rate of 5.3 per 100,000 population in males aged between 10-29, with an overall rate of 3.1. This is similar to Argentina, Costa Rica and Lithuania. The rate in England and Wales for the same age group is 1.0 per 100,000. More local data shows that in 2006-07 there were 119 homicide victims in Scotland, a 26% increase on the 2005-06 (2). Data from previous years also indicate levels of serious violence and abuse in addition to the homicide rates, one typical year showing 859 attempted murders, 1,327 cases of cruelty to children and 80,000 assaults (3).

As well as homicide and assault there are significant rates of suicide and self-harm, sexual assault and abuse, abuse of vulnerable adults and neglect and abuse of children. Other associated issues include high levels of alcohol and drug use, possession and use of weapons. Violence and abuse can be spontaneous and unpredictable; it can also be systematic and recurring. Interpersonal violence, such as a significant proportion of youth violence, is often opportunistic and alcohol and /or drug fuelled, occurring in public places at fairly predicable times. Other forms of violence such as intimate partner violence, child abuse and abuse of vulnerable adults takes place most often within the home or residential accommodation and may be perpetrated in a calculated, sustained and systematic manner over months or years.

Violent incidents and the perceived threat of violence can increase fear of crime and concerns regarding personal safety within communities. This can lead to vulnerable groups such as older people becoming isolated and fearful. High crime levels, characterised by high incidence of violence can affect local businesses and inhibit local investment. Dealing with the effects of violence and abuse creates pressure through the demand on the finite resources of the health service, the police, social services and the judicial system.

The cost of dealing with violence, though complex to calculate, is significant. Each murder costs the criminal justice services around £1.3 million and every attempted murder costs as much as £750,000. Serious assault will cost services around £23,000 and every minor assault £2,000 (3). This amounts to something in the region of £650 million for Scotland each year. Treating violence also accounts for around 3-6% of health service budgets, amounting to as much as £585 million a year (4).

The impact of violence and abuse, as well as having potentially devastating effects on individuals, can also undermine the well-being of families, friends, witnesses and local communities. The effects on victims and those close to them can include mental health and emotional problems such as depression, anxiety, loss of selfconfidence and self-esteem.

Reporting and Recording

A true understanding of the impact of violence is difficult to ascertain as a significant level of violence and abuse goes unrecorded. Victims’ fears of reprisal; low levels of self-esteem and confidence leading to low expectation; lack of confidence in effective resolution, victims involvement in violence and other criminal behaviour and cultural influences all inhibit reporting.

Under-reporting occurs in all aspects of the issue. In the area of domestic violence alone it has been indicated that just 21% of female victims of intimate partner violence report incidents to police, with reporting being even lower amongst male victims at 7%. Information published by the Home Office reveals that on average there will have been 35 assaults before a victim calls the police (5).

Older people, particularly those who are frail and in care, or other vulnerable adults such as those with profound learning difficulties, may find it difficult to report incidents of abuse.

Using data from the UK Home Office survey on Crime and Victimisation, the Violence Reduction Unit, a national unit based in Glasgow, estimate that police record only 24% of violent incidents and that only 3% of offenders are convicted (3). This situation presents challenges in finding opportunities to work directly with perpetrators of violence. It might also serve to undermine public faith in the effectiveness of the judicial system, particularly for those who have been victims of violence.

Violence prevention

A wide range of influences combine to contribute to and shape behaviour. Studies suggest it is the confluence of certain ‘risk’ factors that contribute to violent behaviour, and the existence of certain ‘protective’ factors, that create resiliency against this behaviour. The design of effective prevention and intervention strategies needs to take into account both types of factors.

The WAVE Trust report (6) on tackling the roots of violence proposes that violence occurs when there is an interaction of two components: an individual’s propensity (individual factors) and external triggers (social factors). The WHO Report on Violence and Health (1) argues for the use of the ‘ecological model’ in promoting an understanding of the risks of violence (Figure 1). This classifies risk factors for violence by four levels: individual, relationship, community, and societal. Although some risk factors may be unique to a particular type of violence, the various types of violence commonly share several risk factors.

There is broad agreement that, whatever model you apply, no single risk factor or combination of factors is a guarantee that an individual will be a perpetrator or victim of violence and abuse. The greater the number of risk factors obviously creates a higher potential risk and various types of violence share common risk factors.

Sustainable responses – aplying a prevention based aproach

Taking a concerted, sustained and co-ordinated approach to preventing and reducing violence is still a relatively recent notion but the model underpinning this is already well established (see Box 1). It relies on developing strategies, policies and actions to prevent violence and abuse from occurring; modifying or entirely eliminating the event, conditions, situations or exposure to influences (risk factors) that result in violence; identifying and enhancing protective factors that reduce the likelihood of violence in at-risk populations and in the community at large.

Many existing strategies, policies and services address key risk factors and factors that promote protection and resilience with regard to violence. Examples of these are shown in the box. As indicated earlier, attitudes, values and social norms are not fixed and unchanging. They develop and evolve. Through the efforts of other public health campaigns we have seen that the acceptability of some behaviours can be changed. Public tolerance of violence and the idea that at some level violence is normal can be altered.

By providing expertise, leadership and resources the health service can make a significant contribution to this in both the immediate and longer term. Scotland, through the commitment of the Government and the work of the Violence Reduction Unit, is at the forefront of the world-wide efforts to address this issue.

The Violence Reduction Unit’s Strategic Plan (7) aims to work with Community Safety Partnerships throughout the country, in which the NHS is a key partner, to enable them to develop action plans for Violence Reduction. The plan also indicates that dedicated resources will be made available to meet the objectives of these plans.

Throughout Lothian, action is already being developed across a range of related issues involving a variety of key stakeholders. The establishment of a Violence Reduction Steering Group in Edinburgh with specific key targets will help inform the development of longer-term strategic action. Multi-agency work looking at preventing and reducing suicide and self-harm in West Lothian will work closely with the local community. Violence Against Women Partnerships and the Violence Against Women Training Consortium are well established and support a wide range of support services and strategic action. The Health Promotion Service Capacity Building programme will include training for those working with boys and young men looking at how to address issues relating to self-esteem and emotional development.

There are many more services and initiatives being provided by agencies and organisations in the statutory and voluntary sectors. These help address risk factors and build resilience in individuals and communities. The development of a cohesive, strategic plan to address violence would help increase the effectiveness and coordination of this work as well as to identify and address gaps in service.

Key points

  • As the police and judicial system continue to contain and manage incidence of violence and ensure that justice is served, policies must be developed and implemented in a wider context to change societal and individual attitudes towards violence.
  • Using the public health model as its basis, Scotland’s Violence Reduction Unit published its 10-year strategic plan in December 2007 (7).
  • The report outlines how a permanent and sustainable reduction in violence is achievable but requires significant commitment from a range of agencies and communities.
  • The health service is a key partner and has a vital role to play in preventing and reducing violence as well as continuing to provide treatment to victims.
Box 1: Levels of Violence Prevention

Level: Primary prevention – Seeks to prevent the onset of violence. The goal is to alter some factor in the environment, to bring about a change in the status of the host, or to change behaviour so that violence is prevented from developing. An example of this is parenting programmes.

Potential actions - Interventions seek to promote positive parent child relationships, stable and nurturing home environments, promoting empathy skills in families, positive self-esteem, self-confidence and emotional literacy.

Level: Secondary prevention – Aims to halt the progression of violence once it is established. This is achieved by early detection or early diagnosis followed by prompt, effective treatment. An example of secondary prevention is conflict resolution within schools.

Potential actions - Anti-bullying policies, teaching gender awareness, the introduction of school campus police officers, initiatives with youth gangs, substance misuse programmes, policing and regulating the night time economy, youth diversionary activities, improving young people’s communication and negotiation skills, enabling front line staff to identify address clients who might be at risk of violence, initiatives to reduce suicide and self harm.

Level: Tertiary prevention – Concerned with rehabilitation of people with an established violent behaviour – this would encompass behavioural change programmes within a prison setting.

Potential actions - Violence prevention and parenting programmes in custodial settings, perpetrator rehabilitation programmes, adequate treatment and support for victims of violence and abuse, initiatives to increase reporting of violence (from the general public as well as better information collection and sharing between agencies), support for families of victims of violence.