Health Promotion International, Vol. 17, No. 4, 293-295,
December 2002
© Oxford University Press 2002
EDITORIAL |
Violence and health: the ultimate public health challenge
Regional Editor, Western Europe Over the 15 years or so I have been involved in the editorial process of Health Promotion International, I cannot recall reading an article, published either as original research or as a perspective, on the vexing issue of violence and its effect on health. This is very surprising given the overwhelming evidence that violence, in one form or other, is a major contributor to premature death, injury and disability across the globe. Personal, mainly one-to-one violence such as homicide, attempted homicide and other non-fatal assaults, places a truly global burden on health. If we also consider the added effects of war or other types of organized or institutional violence, the burden in terms of lives lost and disability would be far greater.
Recent research has attempted to determine the global health burden of premature mortality and disability from all diseases and injury through a comprehensive methodological assessment (Murray and Lopez, 1996). This assessment covered all known causes of premature death and disability, including violence. The total burden to health caused by violence was measured by combining premature mortality, as indicated by numbers, rates and years of life lost due to homicide, with Disability Adjusted Life Years (DALYs). The DALY is a way of measuring disease burden by quantifying years of life lost through death and years of life expected to be lived with disability. Both homicide mortality data and DALY data may be flawed to some extent. For example, accidental or unintentional firearm deaths are not differentiated from intentional homicides, and DALYs are not capable, as yet, of measuring the psychological impact of violent assault (Mercy and Hammond, 1999
). Nevertheless, the Murray and Lopez assessment tool provides a useful crude indicator of the health burden of personal violence.
The figures are quite staggering. In 1990 there were an estimated 563 000 homicides across the globe, representing 1.1% of all deaths in that year. Homicide rates vary according to age and gender, peaking in males in the 15- to 29-year-old age group and in the 0- to 4-year-old age group for females. Male homicide rates were nearly four times that of females. Homicide rates also varied according to region in the world. Sub-Saharan Africa had the highest rates by far (40.2 per 100 000), with the lowest rates in Western Europe (3.8 per 100 000). Although homicide had never been one of the 10 leading causes of death in males or females in the developing or developed world, it was the third most common cause of premature death in males aged 15–44 years in the world as a whole, and the 10th most common cause for females in the same age group. Assuming that current trends continue, it has been calculated that there will be >1 million homicides globally by the year 2020, and that it will be the 10th leading cause of death among all males.
Globally, it is estimated that males and females lost approximately 13.7 million and 3.8 million DALYs, respectively, in 1990. By 2020 this combined total is expected to rise to nearly 30 million DALYs, or 2.4% of the total burden of disability. The global health burden of personal-level violence is already set to be the 12th leading cause of DALYs in the next 15 years (Murray and Lopez, 1996).
Violence is, then, undoubtedly a public health issue, and yet public health and health promotion have proved shy of addressing ways to reduce this health burden. This might be because there is a perception that violence in any society is inevitable and largely non-preventable; however, this might not be the case. As a subcategory of violent deaths and injury, suicide—or at least attempted suicide—was once considered a punishable crime in most western societies. Yet, encouragingly, some successful suicide prevention programmes have now been documented (Healthworks, 1996).
One way forward could be to develop predictive models of violence by identifying causes of violent behaviour and then plot violent episode characteristics against them. We might then be able then to come up with a public health approach that helps prevent the number and severity of violent crimes. A lot of research has already identified key triggers of violence. These include, amongst other things, endemic exposure to violence, cultural acceptance, poor social skills, poverty, and drug and/or alcohol misuse (Public Health Alliance, 1997). Building on this, other researchers, particularly in the United States, have already suggested models based upon ‘time’ ‘place’ and ‘person’ (Powell et al., 1999).
With respect to ‘time’, data can be collected that groups violent episodes according to hour of the day, day of the week, month of the year or indeed other time periods. We know, for example, that suicide rates increase during festival periods or during winter months. Secondly, it is possible to develop ‘spot’ maps that identify violent episodes by ‘place’. Data can be disaggregated according to country, region, province, state or county. Furthermore, the episode could be coded by type of location, e.g. urban or rural, and it may be possible to identify the location in more detail, such as home, work, public place, etc. However, code standardization could be a problem here, at least for international comparisons. Thirdly, victims of violent crime may be categorized by ‘person’. Here it is possible to identify age, gender, ethnicity, marital status, religion and occupation. Other characteristics, such as socio-economic status, maybe more problematic since they are subject to varying international interpretations. By combining ‘time’, ‘place’ and ‘person’, a detailed picture can emerge between and within countries that helps to profile the violent episodes in terms of trends and magnitude. It is a useful beginning for a public health assessment of the problem.
Once this has been achieved, and most developed countries have access to these data, an epidemiological triangle can be proposed that links the perpetrator of the violence to both the method (usually a weapon) and the environment. This can be thought of in the same way as linking host, agent and environment in traditional epidemiological studies. A detailed picture of the characteristics of the perpetrators of violence can be constructed through psychological profiling and assessment, and by utilizing similar categories, described above, for the victims of violent crime. Method is an important variable, and information on type, ownership or access to a weapon, and how the weapon came to be used, may help in future prevention strategies. It is not surprising that farmers in the UK, for example, more often commit suicide by using a gun than by any other means, simply because they own and have access to firearms. The third aspect of the epidemiological triangle, environment, refers to characteristics described above, such as cultural acceptance, pockets of poverty and/or a history of violence.
We have then an epidemiological triangle that relates to and builds upon the characteristics of the violent episode in terms of ‘time’, ‘place’ and ‘person’, which allows for a better planned and executed public health prevention programme.
A public health or health promotion programme that aims to prevent violent crime can combine primary, secondary and tertiary methods, with a population-wide approach and/or one that identifies high risk (of offending) individuals.
At the primary prevention level, approaches could involve:
- violence risk education for all school students (population wide);
- parenting education for all new parents (population wide);
- targeting communities where violence is more endemic with appropriate risk reduction strategies such as street lighting, surveillance cameras and community policing (population wide);
- reduction in mass media portrayal of violence (population wide); and
- poverty reduction strategies (population wide).
At the secondary prevention level, approaches could involve:
- support counselling or post-traumatic counselling for victims of violent crime (high risk);
- peer mediation techniques to resolve disputes in schools or the workplace (high risk);
- home visits to families identified as having a high risk of domestic violence or child abuse (high risk); and
- violence prevention coalitions targeted to high-risk neighbourhoods (population wide/high risk).
At the tertiary prevention level, approaches could involve:
- appropriate treatment/rehabilitation for violent offenders (high risk);
- improving parent management strategies and child bonding techniques in families with violent children (high risk);
- adequate shelter provision for victims of domestic violence (population wide/high risk);
- training and strategies for health and social care professionals in identifying and referring victims of family violence (high risk); and
- increasing the penalties for perpetrators of violent crime (high risk).
These illustrative examples of approach levels, targeting high-risk individuals or whole populations, demonstrate a health promotion strategy that is not only aimed at prevention but is, in parts, more pro-active and seeks to educate and, in a sense, transform cultural norms and attitudes towards violence.
However actual violent crime is only a part, albeit a very important part, of the relationship between violence and health. The fear of crime, particularly violent crime, can also have serious effects on health. Although it may be difficult to quantify the fear of violent crime, it might be that the work already done on the way individuals and groups assess certain behaviours and health risks can inform the work on public perception of risk of becoming a victim of crime. More research is needed on quantifying the fear of violent crime and its impact on psychological and emotional health. This much-needed research could then help to develop another aspect of health promotion strategies designed to prevent or reduce violence in families and communities.
The effects of homicide and violent crime on public health is well documented and reported on, but the causal link between potential perpetrators, time, place and environment, makes prevention and health promotion strategies more problematic.
The three-level typology described above may provide the outline for a public health approach, but the detail requires a greater understanding of the cause–effect chain. Why do some people, usually men, become violent; why are some families more at risk of violence and child abuse; why are some communities more violent than others? These essentially psychological, structural and environmental aspects require much more research to enable an effective health promotion strategy to be initiated. The paper of Baum and Palmers in this issue touches on some of the environmental issues that could be addressed, within an urban context, in order to provide a more acceptable ambience. Only then can public health address this largely forgotten, but challenging issue.
REFERENCES
Healthworks (1996) Suicide, Young Men and the Media. Healthworks, Dorset, UK.
McCabe, A. and Raine, J. (1997) Framing the Debate: Crime and Public Health. Public Health Alliance, UK.
Mercy, J. A. and Hammond, R. (1999) Combining action and analysis to prevent homicide. In Smith, M. and Zahn, M. (eds) Homicide: a Sourcebook of Social Research. Sage, New York.
Powell, K. E., Mercy, J. A., Crosby, A. E., Dahlberg, L. L. and Simon, T. R. (1999) Public Health Models of Violence and Violence Prevention. Encyclopaedia of Violence, Peace and Conflict. Vol 3. Academic Press, Washington, DC.
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