Trends in community violence in England and Wales 1995-1998: an accident and emergency department perspective

Males as victims of intimate partner violence - results from a clinical-forensic medical examination centre

Only few studies have reported on males as victims of intimate partner violence (IPV) so far. The aim of the present study is to analyse frequency and case characteristics of physical violence against male IPV victims examined in a clinical-forensic medical examination centre for victims of violence in Germany over an 11-year period, contributing to a better understanding of IPV in men. Male victims represented 6.2% of IPV cases (n = 167) with a median age of 40 years. Cases were reported to the police in 78.4% before medicolegal examination. In 60.5% of the cases, the perpetrator was the current partner, and 82% occurred in a domestic environment with a predominance of female offenders. In more than half of the cases (57.5%), the victims consulted the examination centre without prior healthcare utilisation. About one-third of the victims reported previous IPV (31.7%). The findings point to the relevance of men as victims of IPV, case group–specific risk factors, injury-dependent behaviour related to healthcare utilisation, the need to establish or strengthen specialised support services for affected men and underscore the importance of clinical-forensic services in documenting and assessing violence-related injuries.

Violence and delayed social independence among young adult British men

OBJECTIVE

To explain why a subgroup of young men aged 20-24 years do not follow the general trend within the adult general population, of declining violence with age.

METHOD

A cross-sectional survey of 8,397 adults in households in Great Britain in 2000. Computer-assisted interviews to measure self-reported violence and psychiatric morbidity.

RESULTS

Young men age 20-24 years had the same high prevalence of self-reported violence as those 16-19 years (52 vs 50%; P = 0.737), contrasting with women whose violence demonstrated a progressive decline (24.1 vs 14.5%; P = 0.002). This age-related gender difference was explained primarily by young men who continued to live at home with their parents (OR = 2.53; 95%CI 1.23-5.20), with smaller effects from childhood conduct disorder (OR = 1.56; 95%CI 0.75-3.21), and hazardous drinking (OR = 2.23; 95%CI 0.76-6.56). Young men living at home were only 4.3% of all male respondents but yielded an attributable risk fraction of 21.4% reporting victim injury.

CONCLUSION

The persisting high prevalence of violence among young adult men is explained by delay in moving to social independence. Public health interventions to reduce effects of known risk factors for violence must consider progressive economic and social changes in young men's lifestyles in westernised countries.

When violence strikes the head, neck, and face

INTRODUCTION

The aim of this study was to find characteristics in head-neck-facial (HNF) injuries among victims of violence and to test the hypothesis that the type of injury, location, and mechanism behind it vary between the genders.

METHODS

A 1-year prospective study including all victims of violence attending the Accident & Emergency (A&E) Department or the Institute of Forensic Medicine in Aarhus was conducted. Every violence-related injury was recorded along with the mechanism behind it, the type of injury, and the specific anatomic location.

RESULTS

A total of 1,106 victims were examined of whom 83% had HNF injuries. Thirty-seven percent had more than one HNF injury. Injuries around the nose and mouth were significantly associated with male victims, whereas injuries to the neck were significantly more common among female victims. Most injuries were the results of assault with a blunt object, where the men much more frequently had open wounds, whereas injuries such as ecchymoses were significantly more frequent among female victims. Use of weapons, such as blunt objects and blows with glass/bottles, was associated much more with male victims, whereas strangulation attempts were significantly more frequent among women. Ten percent of the women had been exposed to strangulation attempts.

DISCUSSION

The findings support former studies that HNF injuries might be considered as markers of violence. Thus, the staff at A&E Departments must consider anyone with these types of injuries as potential victims of violence. The A&E Department may be the primary entrance for the victims and the main way in which to offer help. The high incidence of women who had been assaulted with strangulation, which is a potentially very dangerous trauma mechanism, intensifies the importance of conducting a careful medical examination, in part, because of the possible legal implications.

CONCLUSION

HNF injuries are characteristic among victims of violence, although significant differences exist in the type of injuries, the location, and the trauma mechanism between men and women.

The seasonal relationship between assault and homicide in England and Wales

Investigating the seasonal asymmetry of violent behaviour has a long history. Despite this, there still remains considerable debate about the nature and aetiology of this phenomenon. Reports on homicide, for example, are mixed: some have found homicide seasonality but most have not. In contrast, all published studies on assault report that this behaviour is seasonal. Moreover, only two studies, both using US data, have examined the seasonal variation of assault and homicide in the same population over the same period of time. One group found assault was seasonal but homicide was not, whilst the other found, overall, that both homicide and assault were seasonal. This first of these findings seems paradoxical, in that there is no seasonal variation in injury related deaths (i.e. homicides), despite the antecedent behaviour (i.e. assaults) having a seasonal pattern of occurrence. We examined the seasonal variation in homicide and assault in UK and found a similar result. Furthermore, our findings are not easily understandable using conventional social models of seasonal behaviour and we suggest biologically mediated seasonal variation in the capacity of equally injured individuals to survive trauma may also play a role, which should be investigated further.

Tackling alcohol related violence in city centres: effect of emergency medicine and police intervention

OBJECTIVES

To identify correlates of alcohol related assault injury in the city centre of a European capital city, with particular reference to emergency department (ED) and police interventions, and number and capacity of licensed premises.

METHODS

Assaults resulting in ED treatment were studied using a longitudinal controlled intervention, a three stage design during a three year period of rapid expansion in the night-time economy, when ED initiated targeted police interventions were delivered. A controlled ED intervention targeted at high risk night-clubs was carried out. Main outcome measure was ED treatment after assault in licensed premises and the street.

RESULTS

Targeted police intervention was associated with substantial reductions in assaults in licensed premises but unexpected increases in street assault were also observed (34% overall: 105% in the principal entertainment thoroughfare). Combined police/ED intervention was associated with a significantly greater reduction compared with police intervention alone (OR = 0.61, 95% CI 0.40 to 0.91). Street assault correlated significantly with numbers and capacity of premises. Risk of assault was 50% greater in and around licensed premises in the city centre compared with those in the suburbs, although dispersion of violence to more licensed premises was not observed.

CONCLUSIONS

Marked decreases in licensed premises assaults resulting from targeted policing were enhanced by the intervention of ED and maxillofacial consultants. Capacity of licensed premises was a major predictor of assaults in the city centre street in which they are clustered. City centre assault injury prevention can be achieved through police/ED interventions targeted at high risk licensed premises, which should also target the streets around which these premises are clustered.

Prevalence of victims of violence admitted to an emergency department

OBJECTIVE

To collect data on the consultation frequency and demographic profile of victims of violence attending an emergency department (ED) in Switzerland.

METHODS

We undertook screening of all admitted adult patients (>16 years) in the ED of the CHUV, Lausanne, Switzerland, over a 1 month period, using a modified version of the Partner Violence Screen questionnaire. Exclusionary criteria were: life threatening injury (National Advisory Committee on Aeronautics score > or =4), or inability to understand or speak French, to give oral informed consent, or to be questioned without a family member or accompanying person being present. Data were collected on history of physical and/or psychological violence during the previous 12 months, the type of violence experienced by the patient, and if violence was the reason for the current consultation. Sociodemographic data were obtained from the registration documents.

RESULTS

The final sample consisted of 1602 patients (participation rate of 77.2%), with a refusal rate of 1.1%. Violence during the past 12 months was reported by 11.4% of patients. Of the total sample, 25% stated that violence was the reason for the current consultation; of these, 95% of patients were confirmed as victims of violence by the ED physicians. Patients reporting violence were more likely to be young and separated from their partner. Men were more likely to be victims of public violence and women more commonly victims of domestic violence.

CONCLUSIONS

Based on this monthly prevalence rate, we estimate that over 3000 adults affected by violence consult our ED per annum. This underlines the importance of the problem and the need to address it. Health services organisations should establish measures to improve quality of care for victims. Guidelines and educational programmes for nurses and physicians should be developed in order to enhance providers' skills and basic knowledge of all types of violence, how to recognise and interact appropriately with victims, and where to refer these patients for follow up care in their local networks.

Linkage of ambulance service and accident and emergency department data: a study of assault patients in the west midlands region of the UK

OBJECTIVE

The objectives of this study are to determine whether it is possible to link ambulance service and Emergency Department (ED) data for assault patients, to look at the potential advantages of this linkage and to investigate the quality of coding in the two data sets.

DATA AND METHODS

Data from West Midlands Ambulance Service and seven EDs in the urban West Midlands were linked using probabilistic linkage. The linked data were analysed to investigate demography, priority category, diagnosis, conscious level, disposal and assault coding.

PRINCIPAL FINDINGS

84.2% of the ambulance records were linked to an ED record. Only 40.7% of the linked records were coded as assault in the ED data and only 46.7% of ED assault cases brought by ambulance could be linked. 77.6% of all assault injuries were to the head, face and neck. Only 1.0% of patients presented with coma. 12.0% of all assault patients and 53.5% of the highest priority cases were admitted.

CONCLUSIONS

Data linkage is possible and can increase the amount of information available. Data quality problems were identified in both datasets, which has implications for the monitoring and prevention of assaults. The use of a common identifier would aid the following of patient pathways.

Development, utilisation, and importance of accident and emergency department derived assault data in violence management

OBJECTIVES

To develop formal processes for the collection, disclosure, and effective use of accident and emergency (A&E) department derived assault injury data for city violence reduction.

METHODS

Over a four year period, managed by a multi-agency steering group, A&E data collection, collation, and disclosure processes were developed, instituted, and refined. Consultations and negotiations between agencies identified the most effective and ethical methods, appropriate recipients, and the nature of the information of most use.

RESULTS

Disclosure of A&E data to city authorities, the police, and local media drew substantial attention and crime prevention resources to the locations of violence. As a result, a police task force responsible for targeting city street crime was funded, which analysed both A&E and police information. Monthly, electronic transfer of raw, anonymous data to the task force crime analyst informed and prompted violence prevention initiatives by several agencies. Police mounted overt and covert interventions targeted at violence hotspot licensed premises and used the data to oppose, on injury grounds, drinks/entertainment licence applications. Transport authorities established new half hourly night time city centre bus services. The local authority mounted an assault awareness campaign in schools and public libraries, and licensing magistrates used the data to measure, for example, the impact of continuous 36 hour drinks licensing on public safety.

CONCLUSIONS

The principal finding of this evaluation was that judicious sharing of unique information about locations and times of violence derived from A&E patients was a powerful and effective means of targeting police and other local resource to bring about violence reduction.

The epidemiology of assault across the West Midlands

OBJECTIVES

The purpose of this study is to look at accident and emergency (A&E) attendances and admissions after assault in the West Midlands NHS region across a wide range of acute units.

METHODS

This study used data from two sources, the A&E Minimum Data Set and the Hospital Episode Statistics database. Analyses were based on data from 12 of the 21 acute trusts in the West Midlands NHS region for the period 1 April 1999 to 31 March 2000.

RESULTS

Analyses were performed on 15 969 A&E attendances and 1596 admissions. Some 67.4% of attenders and 84.2% of those admitted were male. The mean age of the patients was between 27 and 29 years. Attendance peaked between 2100 and 0259, especially on Friday and Saturday night. The most common injury was to the head. Some 75.3% of A&E attenders were discharged home. The average stay in hospital was two days and six deaths were recorded. Those living in the most deprived areas were nearly four times more likely to be admitted than those in the least deprived areas (175.9 per 1000 compared with 45.1 per 1000).

CONCLUSIONS

This study shows assault is predominately a male phenomenon, worst in the evenings and at weekends, and is positively related to deprivation. It is probable that the levels recorded will be an underestimate, however with some additions to the information collected hospital records could create the basis for a comprehensive surveillance system.

Use of, and outputs from, an assault patient questionnaire within accident and emergency departments on Merseyside

OBJECTIVES

To describe the implementation, use of, and outputs from an assault patient questionnaire (APQ) introduced in accident and emergency (A&E) departments to determine Crime & Disorder and Community Safety priorities on Merseyside, a metropolitan county in north west England, UK.

METHODS

Why and how the APQ was implemented, data collected, and information obtained. The subsequent incorporation of the APQ into the Torex Patient Administration System (PAS) at the Royal Liverpool University Hospital A&E department and its routine completion by trained reception staff.

RESULTS

Analysis is based upon anonymised data-for example, patient ID and date of birth information is suppressed. A summary of "baseline" information obtained from the data collected is provided.

CONCLUSIONS

It is possible for the APQ to be implemented at no extra cost in a large A&E department in an acute general teaching hospital. Valuable intelligence can be obtained for Crime & Disorder Act and Community Safety processes. The APQ forms part of a medium to long term strategy to prevent and reduce violent assaults in the community that subsequently require treatment in an A&E department. Such incidents include assaults both inside and outside licensed premises, attacks by strangers on the street, and domestic violence. Emphasis is also placed upon the feedback of results to staff in A&E departments.

Identification and characteristics of victims of violence identified by emergency physicians, triage nurses, and the police

OBJECTIVES

The objectives of the study were threefold-to evaluate the identification and characteristics of victims of assault who attend an accident and emergency (A&E) department; to compare the total number of assaults recorded in the A&E department with the number recorded by the police; and to assess a system for collecting the location and method of assault.

SETTING

The A&E department of Chorley and South Ribble Hospital Trust, Lancashire, England.

METHODS

A three month prospective study was performed. Victims of violence recorded on computer by doctors at discharge were compared with those identified at initial nurse triage. A comparison of police data with the A&E data relating to Chorley residents was performed. Additional information on the method and location of assault was also collected.

RESULTS

During the period 305 (2.6%) of the patients attending A&E were identified as having been assaulted. Of the 305 individuals, 236 (77%) were identified by a doctor while 173 (57%) such patients were identified by a triage nurse. A&E identified twice the number of assaults involving Chorley residents as the police. Both men and women were most likely to have been injured on the street (44% and 37% respectively), although a greater proportion of women were injured at home (24%) than men (10%). The majority of injuries were sustained by blows from fists, feet, and heads (73%).

CONCLUSIONS

A&E doctors identify significantly more patients as the victims of violence than do nurses at triage. Using A&E data identifies assaulted individuals not identified by the police. Computer systems can be used in A&E to provide a more complete picture of the occurrence of violence in the community.

Temporal and demographic variations in attendance at accident and emergency departments

OBJECTIVES

Little has been reported of the demographic and temporal variations in accident and emergency (A&E) attendances despite the importance of this information in planning services. The purpose of this paper to is to explore the variations in attendance patterns across the West Midlands region of the NHS.

METHODS

The data were obtained from the A&E minimum dataset from a sample of 13 hospitals. Arrival dates and times, age, and sex of all patients attending A&E in the year from 1 April 1999 to 31 March 2000 were analysed to look at the pattern of attendance by hour, day and month, age, and sex.

RESULTS

No differences were found in attendance patterns in respect to sex. Attendances by children under 15 years peaked in the evening between 18:00 and 19:59. In contrast, peak attendance in those over 15 years was between 09:00 and 11:59. The percentage of "out of hours" attendances in this dataset was highest in the under 1 age group (58.5%), the 15-24 age group (57.1%), and the 25-44 age group (54.6%). The highest proportion of patients attended A&E on a Monday, while the percentage of weekend attendances decreased with age. In children aged 1-14 years there were more attendances in summer than winter. In those aged under 1 and over 65 there was a winter peak with December having the most attendances.

CONCLUSIONS

No sex differences were found in the temporal attendance patterns at A&E. However, many differences were found in the attendance of different age groups. These differences are of great importance in the planning of services, and further research is required to explain the reasons behind these variations.

Criminal deterrence as a public health strategy

Deterrence is an established theme in criminal justice, but its role in prevention of assault has been treated with ambivalence and even hostility in medicine. The extent to which offenders can be persuaded, through knowledge of criminal and health risks, not to injure others is emerging from studies of the health effects of firearm and other crime legislation, and from macro-level studies and controlled experiments of police interventions. There is convincing evidence that motorists can be deterred from alcohol-impaired driving, and recognition that specific, targeted, and visible police work and increasing certainty of punishment are effective interventions. By contrast, duration of imprisonment and generic police initiatives such as blanket increases in police numbers seem to have little effect on deterrence, at least in the context of the decline in US homicide rates since 1991, to which demographic and economic factors seem to have contributed little. Together with established and cost-effective preschool education and early family support, targeted policing and increasing rates of conviction should be integrated into strategies for injury prevention.