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

Using emergency department data to reduce late-night alcohol-related presentations in an Australian central business district

INTRODUCTION

The Cardiff Model for Violence Prevention is a data sharing approach aiming to reduce violence-related presentations to emergency departments (EDs). This model has not previously been tested with patients attending EDs in a major Australian urban setting, nor has the use of media reporting of results and letters to venues without a local violence prevention board been tested.

OBJECTIVE

To determine this approach's effect on alcohol-associated presentation rates during high-alcohol hours (HAHs) in a major ED servicing the nightlife district in central Melbourne.

DESIGN

Between July 2017 and June 2020, this prospective study asked people aged≥18 years attending ED about their alcohol consumption and last drink location. From December 2018, quarterly letters were sent to the top five venues identified as the last drink location and press releases were sent to all media outlets.

FINDINGS

A significant gradual decrease in monthly injury attendance rates during HAH was observed (coefficient = -0.001, p= 0.017), however, no step change was found. Venue-level data highlighted a short-term drop in attributed events.

DISCUSSION

Sharing Last Drinks ED data via stand-alone media reporting and letters to venues was associated with a small but significant reduction in alcohol-related injury presentation rates. However, the impact waned as media stopped reporting findings. This study highlights the importance of including a violence prevention board.

CONCLUSION

The model continues to have promise for reducing alcohol-related harm, however, engagement from government agencies free from alcohol industry funding is important for long-term success.

Reducing alcohol harms whilst minimising impact on hospitality businesses: 'Sweetspot' policy options

BACKGROUND

During COVID-19, hospitality businesses (e.g. bars, restaurants) were closed/restricted whilst off-sales of alcohol increased, with health consequences. Post-covid, governments face lobbying to support such businesses, but many health services remain under pressure. We appraised 'sweetspot' policy options: those with potential to benefit public services and health, whilst avoiding or minimising negative impact on the hospitality sector.

METHODS

We conducted rapid non-systematic evidence reviews using index papers, citation searches and team knowledge to summarise the literature relating to four possible 'sweetspot' policy areas: pricing interventions (9 systematic reviews (SR); 14 papers/reports); regulation of online sales (1 SR; 1 paper); place-shaping (2 SRs; 18 papers/reports); and violence reduction initiatives (9 SRs; 24 papers/reports); and led two expert workshops (n = 11).

RESULTS

Interventions that raise the price of cheaper shop-bought alcohol appear promising as 'sweetspot' policies; any impact on hospitality is likely small and potentially positive. Restrictions on online sales such as speed or timing of delivery may reduce harm and diversion of consumption from on-trade to home settings. Place-shaping is not well-supported by evidence and experts were sceptical. Reduced late-night trading hours likely reduce violence; evidence of impact on hospitality is scant. Other violence reduction initiatives may modestly reduce harms whilst supporting hospitality, but require resources to deliver multiple measures simultaneously in partnership.

CONCLUSIONS

Available evidence and expert views point to regulation of pricing and online sales as having greatest potential as 'sweetspot' alcohol policies, reducing alcohol harm whilst minimising negative impact on hospitality businesses.

Reciprocal coproduction as a basis for the diffusion of global health innovations

Global health reciprocal innovations originate in low-income and middle-income countries as well as high-income countries before their developers communicate about them with potential adopters in other countries as a transnational team. While communication technology has enabled a more rapid and broader sharing of information about innovations to prevent disease and improve health, innovations of various types have spread among countries, at all levels of income, for many centuries. In this article, we introduce the idea of reciprocal coproduction as a basis for the international sharing of information about innovations that exhibit potential for improving global health. Reciprocal coproduction occurs through two relational team-based processes: developer-led reinvention of an innovation so that it retains its desirable causal effects and implementer-led adaptation of that innovation so that it is compatible with new contexts into which it is introduced. Drawing on research and our own experiences across a range of health issues, we discuss common barriers to reciprocal coproduction and the diffusion of reciprocal innovations. We conclude with lessons drawn from dissemination and implementation science about the effective translation of reciprocal innovations from country to country so that researchers, policy-makers and social entrepreneurs can best ensure equity, accelerate adoptions and heighten the likelihood that global health reciprocal innovations will make a positive difference in health.

Using the Cardiff model to reduce late-night alcohol-related presentations in regional Australia

INTRODUCTION

The Cardiff model is a data sharing approach that aims to reduce the volume of intoxicated patients in emergency departments (EDs). This approach has not been tested in a rural setting.

OBJECTIVE

This study assessed whether this approach would reduce the number of alcohol-associated presentations during high-alcohol hours (HAH) in a regional ED.

DESIGN

From July 2017, people over the age of 18 attending the ED were asked by the triage nurse (1) whether they had consumed alcohol in the past 12 h, (2) their typical alcohol consumption level, (3) the location where most alcohol was purchased and (4) the location of the last drink. From April 2018, quarterly letters were sent to the top five venues reported within the ED. Deidentified, aggregated data were shared with local police, licensing authorities and local government, identifying the top five venues reported in the ED and providing a summary of alcohol-related attendances to the ED. Interrupted time series analyses were used to estimate the influence of the intervention on monthly injury and alcohol-related ED presentations.

FINDINGS

ITS models found that there was a significant gradual decrease in the monthly rate of injury attendances during HAH (Coefficient = -0.004, p = 0.044). No other significant results were found.

DISCUSSION

Our study found that sharing last drinks data collected in the ED with a local violence prevention committee was associated with a small, but significant reduction in the rate of injury presentations compared with all ED presentations.

CONCLUSION

This intervention continues to have promise for reducing alcohol-related harm.

Public opinion and experiences of crime two and five years following the implementation of a targeted regulation of licensed premises in Newcastle, Australia

INTRODUCTION AND AIMS

In 2008 additional licensing restrictions were imposed on 'high-risk' licensed premises in the entertainment precinct of Newcastle (Australia) including earlier closing, a 'lock-out' and additional responsible service of alcohol restrictions. A study was conducted to assess community perceptions, experiences of crime and support for the restrictions, 2 and 5 years following implementation.

DESIGN AND METHODS

Telephone surveys were conducted with random samples of Newcastle community members (≥18 years) in 2010 and 2013. Change over time in perceptions and experiences of crime, and awareness and support of the conditions was analysed using logistic regression analyses for all participants, and separately for night-time visitors.

RESULTS

Among all participants (2010: n = 376; 2013: n = 314) the perception that alcohol misuse was a problem declined between 2010 and 2013 for all participants (90% to 85%; P = 0.02), and specifically among night-time visitors (87% to 75%; P = 0.06). Awareness of the restrictions was high among all participants and sub-groups, and remained constant over time. Support for the restrictions was also high, with drink restrictions being the most popular. More night-time visitors reported that conditions made the streets safer in 2013 (62%) than 2010 (47%; P = 0.05). Support for applying restrictions to all licensed premises in the Newcastle entertainment precinct (83%) and across New South Wales was high in 2013 (86%).

DISCUSSION AND CONCLUSIONS

At 2 years and 5 years following implementation of additional licensing restrictions, significant improvements in public perceptions of the occurrence of alcohol-related harm and crime were evident, as were high levels of support for the restrictions.

Association of violence with urban points of interest

The association between alcohol outlets and violence has long been recognised, and is commonly used to inform policing and licensing policies (such as staggered closing times and zoning). Less investigated, however, is the association between violent crime and other urban points of interest, which while associated with the city centre alcohol consumption economy, are not explicitly alcohol outlets. Here, machine learning (specifically, LASSO regression) is used to model the distribution of violent crime for the central 9 km² of ten large UK cities. Densities of 620 different Point of Interest types (sourced from Ordnance Survey) are used as predictors, with the 10 most explanatory variables being automatically selected for each city. Cross validation is used to test generalisability of each model. Results show that the inclusion of additional point of interest types produces a more accurate model, with significant increases in performance over a baseline univariate alcohol-outlet only model. Analysis of chosen variables for city-specific models shows potential candidates for new strategies on a per-city basis, with combined-model variables showing the general trend in POI/violence association across the UK. Although alcohol outlets remain the best individual predictor of violence, other points of interest should also be considered when modelling the distribution of violence in city centres. The presented method could be used to develop targeted, city-specific initiatives that go beyond alcohol outlets and also consider other locations.

Alcohol Intoxication-Related Soft Tissue Injuries in Patients With Orbital Wall Fractures

BACKGROUND

To date, involvement of alcohol intoxication (AI) in the occurrence of traumatic bone injuries has been well described in the literature. Still, however, there is a paucity of data regarding its involvement with soft tissue injuries in the oral and maxillofacial region. Considering that it is one of the significant predisposing factors that are involved in facial bone fractures in assault victims, we have speculated that they are also vulnerable to soft tissue injuries. We therefore examined the incidence, type and, pattern of soft tissue injuries in patients with trauma owing to the AI in a single-institution setting.

MATERIALS AND METHODS

A total of 488 patients underwent reconstructive surgery for orbital wall fracture at our medical institution between 2012 and 2017. Of these, 162 eligible patients were enrolled in the present study; they were divided into 2 groups (the AI group and the control group) based on a history of the AI. Then, we compared baseline and clinical characteristics, including the incidence, type, and pattern of soft tissue injury, between the 2 groups.

RESULTS

In our series, assault was the most common cause of traumatic injuries. We found that the patients with AI were at increased risks of preoperatively developing subconjunctival hemorrhage and diplopia and postoperatively developing infraorbital nerve (ION) hypesthesia.

CONCLUSIONS

In conclusion, our results indicate that the AI is closely associated with the preoperative risks of subconjunctival hemorrhage and diplopia and the postoperative risks of ION hypesthesia. But further large-scale, multicenter studies are warranted to establish our results.

Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USA

OBJECTIVES

Violence is a major public health problem in the USA. In 2016, more than 1.6 million assault-related injuries were treated in US emergency departments (EDs). Unfortunately, information about the magnitude and patterns of violent incidents is often incomplete and underreported to law enforcement (LE). In an effort to identify more complete information on violence for the development of prevention programme, a cross-sectoral Cardiff Violence Prevention Programme (Cardiff Model) partnership was established at a large, urban ED with a level I trauma designation and local metropolitan LE agency in the Atlanta, Georgia metropolitan area. The Cardiff Model is a promising violence prevention approach that promotes combining injury data from hospitals and LE. The objective was to describe the Cardiff Model implementation and collaboration between hospital and LE partners.

METHODS

The Cardiff Model was replicated in the USA. A process evaluation was conducted by reviewing project materials, nurse surveys and interviews and ED-LE records.

RESULTS

Cardiff Model replication centred around four activities: (1) collaboration between the hospital and LE to form a community safety partnership locally called the US Injury Prevention Partnership; (2) building hospital capacity for data collection; (3) data aggregation and analysis and (4) developing and implementing violence prevention interventions based on the data.

CONCLUSIONS

The Cardiff Model can be implemented in the USA for sustainable violent injury data surveillance and sharing. Key components include building a strong ED-LE partnership, communicating with each other and hospital staff, engaging in capacity building and sustainability planning.

Changing epidemiology of assault victims in an emergency department participating in information sharing with police: a time series analysis

INTRODUCTION

Violent injury places a large burden on the NHS. We had implemented information sharing in our ED in 2007 and aimed to see which patient groups were most affected by information sharing, as this would provide clues as to how this complex intervention works.

METHODS

Retrospective time series study of all the assault victims presenting for ED care between 2005 and 2014 at a single ED in England.

RESULTS

10 328 patients presented during the study period. There was a 37% decrease in the number of patients presenting after assault, consistent with national trends. The proportions of people arriving by ambulance, and the proportion of men did not change during the study period. There were no important changes in the age of our assault patients in this study. Greater, disproportionate, decreases in rates of violence were seen in patients who presented at the weekend up (incidence rate ratio (IRR)=0.57, 95% CI 0.50 to 0.64) versus weekdays (IRR=0.72; 95% CI 0.62 to 0.83) There were also disproportionately greater decreases over the study period in patients who were discharged with no hospital follow-up (IRR=0.51, 95% CI 0.45 to 0.56) versus those leading to either an inpatient admission (IRR=1.05, 95% CI 0.84 to 1.31) or outpatient follow-up (IRR=1.23, 95% CI 0.93 to 1.64).

CONCLUSIONS

The epidemiology of violent injury at our institution has changed over the last 10 years and is most marked in a reduction of visits at the weekend, and in those who leave without follow up.

Injury resulting from targeted violence: An emergency department perspective

BACKGROUND

Hate crimes - those perpetrated because of perceived difference, including disability, race, religion, sexual orientation or transgender status - have not been studied at the point of the victim's hospital emergency department (ED) use.

AIM

To investigate the frequency, levels of physical harm and circumstances of targeted violence in those seeking treatment at EDs in three UK cities.

METHOD

In a multimethods study, face-to-face semi-structured interviews were conducted with 124 adult ED attenders with violent injuries. Victim and perpetrator socio-demographics were recorded. Patient narratives about perceived motives and circumstances were transcribed, uploaded onto NVivo for thematic analysis.

RESULTS

Nearly a fifth (23, 18.5%) of the injured patients considered themselves to have been attacked by others motivated by hostility or prejudice to their 'difference' (targeted violence). Thematic analyses suggested these prejudices were to appearance (7 cases), racial tension (5 cases), territorial association (3 cases) and race, religious or sexual orientation (8 cases). According to victims, alcohol intoxication was particularly relevant in targeted violence (estimated reported frequency 90% and 56% for targeted and non-targeted violence, respectively).

CONCLUSIONS

Our findings support a broader concept of hate victimisation and suggest that emergency room violence surveys could act as a community tension sensor and early warning system in this regard. Tackling alcohol misuse seems as important in this as in other forms of violence perpetration. Copyright © 2017 John Wiley & Sons, Ltd.

Alcohol abusive use increases facial trauma?

Background

Trauma is among the main death causes and morbidity in the world and is often related to the use of alcohol and its abuse has reached massive proportions, no matter if the country is developed or not, being considered as public health problem. Since there are very few randomized and prospective studies in literature about the association of facial trauma and the use of alcohol, this study aims to investigate the impact of alcohol use in facial trauma.

Material and Methods

This was a prospective and cross sectional study, involving facial trauma patients attended at Oral Maxillofacial Surgery Division of a State Hospital. Variables included patient´s profile, trauma etiology, facial region involved, type of injury and treatment and days of hospitalization. AUDIT test was applied to identify risks and damages of alcohol use and chemical dependence. Absolute distribution, uni and mutilvaried percentages were made for data evaluation. Pearson´s qui-squared and Fisher´s Exact tests were also used.

Results

One hundred patients were evaluated. The patient´s mean age was 33.50 years-old, 48% had between 17 and 29 years old, 28% had 30 to 39, and 24% 40 or more. Most of them were male (86%). The most frequent etiology was traffic accident (57%), the extraoral area was most committed (62%), the most frequent type of injury was fractures (78%) and the most affected bone was the mandible (36%). More than half of the patients (53%) had surgical treatment. 38% had their discharge from hospital right after the first attendance. The AUDIT most frequent answer was “moderate use” (46%) and use at risk (39%). There was significant difference between the use of alcohol (AUDIT) and hematoma (0.003) and number of days of hospitalization (p=0.005).

Conclusions

In this study it was not observed association between alcohol consumption using the AUDIT and trauma etiology, but patient victims of traffic accidents were classified as with risk in the scale. Most of the trauma were caused by traffic accidents using motorcycles and occurred in young aged men.

Key words:Wounds and injuries, traumatology and alcohol-induced disorders.

Process evaluation of an environmental health risk audit and action plan intervention to reduce alcohol related violence in licensed premises

Background

Alcohol-related violence is associated with licensed premise environments and their management. There is a lack of evidence for effective interventions to address these, and there are significant barriers to implementation. This study aims to understand how development and implementation processes can facilitate intervention reach, fidelity and receipt and therefore provides key process data necessary to interpret the results of the randomised controlled trial conducted in parallel.

Methods

A process evaluation, embedded within a randomised controlled trial. Intervention development and implementation were assessed via focus groups (n = 2) and semi-structured interviews (n = 22) with Environmental Health Practitioners (EHPs). Reach and fidelity were assessed via routinely collected intervention data, which was was collected from 276 licenced premises across Wales, UK. Case study semi-structured interviews with licensed premises proprietors (n = 30) explored intervention receipt.

Results

Intervention co-production with senior EHPs facilitated organisational adoption and implementation. Training events for EHPs played an important role in addressing wider organisational concerns regarding partnership working and the contextual integration of the intervention. EHPs delivered the intervention to 98 % of intervention premises; 35 % of premises should have received a follow up enforcement visit, however EHP confidence in dealing with alcohol risk factors meant only 7 % of premises received one. Premises therefore received a similar intervention dose regardless of baseline risk. Intervention receipt appeared to be greatest in premises with an existing commitment to prevention and those in urban environments.

Conclusions

The study suggests that a collaborative approach to the development and diffusion of interventions is associated with high levels of organisational adoption, implementation and reach. However, the lack of enforcement visits represents implementation failure for a key mechanism of action that is likely to influence intervention effectiveness. To be effective, any future intervention may require a longer implementation period to develop EHP confidence in using enforcement approaches in this area and multiagency enforcement support, which includes the police, to deliver an adequate intervention dose.

Systematic review of Australian policing interventions to reduce alcohol-related violence - A maxillofacial perspective

Alcohol-related violence remains to be a health concern, and the oral and maxillofacial surgeons are routinely exposed to its impact on the victims and the healthcare system. At a community level, various policing interventions have been implemented to address this violent crime in and around licensed premises. Current study sought to examine the effectiveness of these interventions in Australia. Ten eligible studies, that evaluated the impact of 15 Australian policing interventions on reducing alcohol-related violence in the night-time economy, were included in this systematic review. Due to the heterogeneity of the study designs and the insufficiency of the reported data, quantitative meta-analysis of the findings was precluded. Instead, a critical narrative approach was used. Police-recorded assault rate was the primary outcome measured to assess the level of alcohol-related violence, which was influenced by the level of police duties implemented during the intervention period. The overall evidence base to support Australian policing interventions was found to be poor and was limited by the low-quality study design observed in the majority of the included studies. However, there is some evidence to suggest interventions involving proactive policing to be more effective than traditional reactive policing. There was also an increased emphasis on developing policing interventions in collaborative partnerships, demonstrating the synergistic benefits in crime prevention through community partnerships, where communities were encouraged to take ownerships of their own problems and develop targeted responses to alcohol-related violence rather than a one-size-fits-all approach. Further research is required to define their effectiveness with the use of more appropriate and robust methodologies.

•

The overall quality of studies on Australian policing interventions in and around licensed premises was poor.

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Police-recorded assault rate was found to be an unreliable source to measure the level of alcohol-related violence.

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There lacks evidence to support the effectiveness of Australian policing interventions in reducing alcohol-related violence.

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There were potential benefits for proactive policing in collaborative partnerships with community stakeholders.

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Studies of higher quality designs are urgently required to appropriately assess current Australian policing strategies.

Alcohol-related crime in city entertainment precincts: Public perception and experience of alcohol-related crime and support for strategies to reduce such crime

Introduction and Aims

Bars, pubs and taverns in cities are often concentrated in entertainment precincts that are associated with higher rates of alcohol‐related crime. This study assessed public perception and experiences of such crime in two city entertainment precincts, and support for alcohol‐related crime reduction strategies.

Design and Methods

A cross‐sectional household telephone survey in two Australian regions assessed: perception and experiences of crime; support for crime reduction strategies; and differences in such perceptions and support.

Results

Six hundred ninety‐four people completed the survey (32%). Most agreed that alcohol was a problem in their entertainment precinct (90%) with violence the most common alcohol‐related problem reported (97%). Almost all crime reduction strategies were supported by more than 50% of participants, including visitors to the entertainment precincts, with the latter being slightly less likely to support earlier closing and restrictions on premises density. Participants in one region were more likely to support earlier closing and lock‐out times. Those at‐risk of acute alcohol harm were less likely to support more restrictive policies.

Discussion and Conclusions

High levels of community concern and support for alcohol harm‐reduction strategies, including restrictive strategies, provide policy makers with a basis for implementing evidence‐based strategies to reduce such harms in city entertainment precincts. [Tindall J, Groombridge D, Wiggers J, Gillham K, Palmer D, Clinton‐McHarg T, Lecathelinais C, Miller P. Alcohol‐related crime in city entertainment precincts: Public perception and experience of alcohol‐related crime and support for strategies to reduce such crime. Drug Alcohol Rev 2016;35:263–272]

Facilitating police recording of the alcohol-related characteristics of assault incidents: A stepped wedge implementation trial

Introduction and Aims

Enforcement of liquor licensing laws is limited by inadequate police information systems. This study aimed to: (i) determine the effectiveness of an intervention in facilitating police recording of the alcohol consumption characteristics of people involved in assaults; and (ii) describe such characteristics by geographic area and setting of alcohol consumption.

Design and Methods

A stepped wedge trial was conducted across New South Wales, Australia. An intervention to facilitate police recording of alcohol consumption information for people involved in incidents was implemented. For people involved in an assault the proportion for which alcohol consumption information was recorded was assessed. The proportion of assaults that were alcohol related, the proportions of people that consumed alcohol prior to the assault, were intoxicated, and had consumed alcohol in various settings, are described.

Results

Post‐intervention, alcohol consumption information was recorded for 85–100% of people involved in an assault incident. The proportion of incidents recorded as alcohol‐related increased significantly (26–44.5%; P < 0.0001). The proportion of assaults classified as alcohol related was significantly greater in regional/rural areas (50–47%) than in metropolitan areas (38%). More people in metropolitan areas (54%) consumed alcohol on licensed premises prior to an assault than in regional/rural areas (39–42%), with approximately 70% of persons intoxicated regardless of setting of alcohol consumption. Twenty per cent of premises accounted for 60% of assaults linked to licensed premises.

Discussion and Conclusions

The intervention was effective in enhancing the recording of alcohol‐related information for assault incidents. Such information could enhance targeted policing of liquor licensing laws. [Wiggers JH, Hacker A, Kingsland M, Lecathelinais C, Tindall J, Bowman JA, Wolfenden L. Facilitating police recording of the alcohol‐related characteristics of assault incidents: A stepped wedge implementation trial. Drug Alcohol Rev 2015;00:000–000]

All-Wales Licensed Premises Intervention (AWLPI): a randomised controlled trial of an intervention to reduce alcohol-related violence

Background

Violence in and around premises licensed for the on-site sale and consumption of alcohol continues to burden the NHS with assault-related injuries.

Trial design

A randomised controlled trial with licensed premises as the unit of allocation, with additional process and cost-effectiveness evaluations.

Methods

Premises were eligible (n = 837) if they were licensed for on-site sale and consumption of alcohol, were within 1 of the 22 local authorities (LAs) in Wales and had previously experienced violence. Data were analysed using Andersen–Gill recurrent event models in an intention-to-treat analysis. An embedded process evaluation examined intervention implementation, reach, fidelity, dose and receipt. An economic evaluation compared costs of the intervention with benefits.

Intervention

Premises were randomised to receive a violence-reduction intervention, Safety Management in Licensed Environments (SMILE), which was delivered by an environmental health practitioner (EHP; the agent). SMILE consisted of an initial risk audit to identify known risks of violence, a follow-up audit scheduled to enforce change for premises in which serious risks had been identified, structured advice from EHPs on how risks could be addressed in premises and online materials that provided educational videos and related material.

Objective

To develop intervention materials that are acceptable and consistent with EHPs’ statutory remit; to determine the effectiveness of the SMILE intervention in reducing violence; to determine reach, fidelity, dose and receipt of the intervention; and to consider intervention cost-effectiveness.

Outcome

Difference in police-recorded violence between intervention and control premises over a 455-day follow-up period.

Randomisation

A minimum sample size of 274 licensed premises per arm was required, rounded up to 300 and randomly selected from the eligible population. Licensed premises were randomly assigned by computer to intervention and control arms in a 1 : 1 ratio. Optimal allocation was used, stratified by LA. Premises opening hours, volume of previous violence and LA EHP capacity were used to balance the randomisation. Premises were dropped from the study if they were closed at the time of audit.

Results

SMILE was delivered with high levels of reach and fidelity but similar levels of dose to all premises, regardless of risk level. Intervention premises (n = 208) showed an increase in police-recorded violence compared with control premises (n = 245), although results are underpowered. An initial risk audit was less effective than normal practice (hazard ratio = 1.34, 95% confidence interval 1.20 to 1.51) and not cost-effective. Almost all eligible intervention premises (98.6%) received the initial risk audit; nearly 40% of intervention practices should have received follow-up visits but fewer than 10% received one. The intervention was acceptable to EHPs and to some premises staff, but less so for smaller independent premises.

Conclusions

SMILE was associated with an increase in police-recorded violence in intervention premises, compared with control premises. A lack of follow-up enforcement visits suggests implementation failure for what was seen as a key mechanism of action. There are also concerns as to the robustness of police data for targeting and assessing outcome effectiveness, while intervention premises may have received greater attention from statutory agencies and, therefore, the identification of more violence than control premises. Although SMILE had high reach and was feasible and acceptable to EHPs, it was found to be ineffective and associated with increased levels of violence, compared with normal practice and it requires additional work to promote the implementation of follow-up enforcement visits. Future work will aim to better understand the role of intervention dose on outcomes and seek more objective measures of violence for use in similar trials.

Trial registration

Current Controlled Trials ISRCTN78924818.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 10. See the NIHR Journals Library website for further project information.

Research utilisation and knowledge mobilisation in the commissioning and joint planning of public health interventions to reduce alcohol-related harms: a qualitative case design using a cocreation approach

Background

Considerable resources are spent on research to establish what works to improve the nation’s health. If the findings from this research are used, better health outcomes can follow, but we know that these findings are not always used. In public health, evidence of what works may not ‘fit’ everywhere, making it difficult to know what to do locally. Research suggests that evidence use is a social and dynamic process, not a simple application of research findings. It is unclear whether it is easier to get evidence used via a legal contracting process or within unified organisational arrangements with shared responsibilities.

Objective

To work in cocreation with research participants to investigate how research is utilised and knowledge mobilised in the commissioning and planning of public health services to reduce alcohol-related harms.

Design, setting and participants

Two in-depth, largely qualitative, cross-comparison case studies were undertaken to compare real-time research utilisation in commissioning across a purchaser–provider split (England) and in joint planning under unified organisational arrangements (Scotland) to reduce alcohol-related harms. Using an overarching realist approach and working in cocreation, case study partners (stakeholders in the process) picked the topic and helped to interpret the findings. In Scotland, the topic picked was licensing; in England, it was reducing maternal alcohol consumption.

Methods

Sixty-nine interviews, two focus groups, 14 observations of decision-making meetings, two local feedback workshops (n = 23 andn = 15) and one national workshop (n = 10) were undertaken. A questionnaire (n = 73) using a Behaviourally Anchored Rating Scale was issued to test the transferability of the 10 main findings. Given the small numbers, care must be taken in interpreting the findings.

Findings

Not all practitioners have the time, skills or interest to work in cocreation, but when there was collaboration, much was learned. Evidence included professional and tacit knowledge, and anecdotes, as well as findings from rigorous research designs. It was difficult to identify evidence in use and decisions were sometimes progressed in informal ways and in places we did not get to see. There are few formal evidence entry points. Evidence (prevalence and trends in public health issues) enters the process and is embedded in strategic documents to set priorities, but local data were collected in both sites to provide actionable messages (sometimes replicating the evidence base).

Conclusions

Two mid-range theories explain the findings. If evidence hassaliency(relates to ‘here and now’ as opposed to ‘there and then’) andimmediacy(short, presented verbally or visually and with emotional appeal) it is more likely to be used in both settings. A second mid-range theory explains how differing tensions pull and compete as feasible and acceptable local solutions are pursued across stakeholders. Answering what works depends on answering for whom and where simultaneously to find workable (if temporary) ‘blends’. Gaining this agreement across stakeholders appeared more difficult across the purchaser–provider split, because opportunities to interact were curtailed; however, more research is needed.

Funding

This study was funded by the Health Services and Delivery Research programme of the National Institute for Health Research.

A GIS-based spatiotemporal analysis of violent trauma hotspots in Vancouver, Canada: identification, contextualisation and intervention

BACKGROUND

In 2002, the WHO declared interpersonal violence to be a leading public health problem. Previous research demonstrates that urban spaces with a high incidence of violent trauma (hotspots) correlate with features of built environment and social determinants. However, there are few studies that analyse injury data across the axes of both space and time to characterise injury-environment relationships. This paper describes a spatiotemporal analysis of violent injuries in Vancouver, Canada, from 2001 to 2008.

METHODS

Using geographic information systems, 575 violent trauma incidents were mapped and analysed using kernel density estimation to identify hotspot locations. Patterns between space, time, victim age and sex and mechanism of injury were investigated with an exploratory approach.

RESULTS

Several patterns in space and time were identified and described, corresponding to distinct neighbourhood characteristics. Violent trauma hotspots were most prevalent in Vancouver's nightclub district on Friday and Saturday nights, with higher rates in the most socioeconomically deprived neighbourhoods. Victim sex, age and mechanism of injury also formed strong patterns. Three neighbourhood profiles are presented using the dual axis of space/time to describe the hotspot environments.

CONCLUSIONS

This work posits the value of exploratory spatial data analysis using geographic information systems in trauma epidemiology studies and further suggests that using both space and time concurrently to understand urban environmental correlates of injury provides a more granular or higher resolution picture of risk. We discuss implications for injury prevention and control, focusing on education, regulation, the built environment and injury surveillance.

The association between sports participation, alcohol use and aggression and violence: a systematic review

OBJECTIVES

To review the current research on alcohol-related violence and sports participation.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to identify relevant studies for inclusion. A search of six databases (EBSCOhost) was conducted.

RESULTS

A total of 6890 studies was were identified in the initial search. Of these, 11 studies met the inclusion criteria. The majority of the studies were from the US (n=10) and focused on collegiate athletes (n=7), adolescents (n=3), professional/former professional athletes (n=1).

CONCLUSION

The reviewed research indicates higher rates of alcohol use and violence in athlete populations when compared against non-athlete populations. Masculinity, violent social identity and antisocial norms connected to certain sports stand out as potential factors that may impact the association between sport and violence in athlete populations.

The gendered trouble with alcohol: young people managing alcohol related violence

BACKGROUND

Alcohol related violence is a troubling backdrop to the social lives and relationships of many young people in post-industrial societies. The development of the night-time economy where young people are encouraged to drink heavily in entertainment precincts has increased the risk of violence.

METHODS

This paper reports on 60 individual structured in-depth interviews about the drinking biographies of young people (aged 20-24) living in Victoria, Australia. Twenty-six males and 34 females participated in the research. The participants discussed their experiences with alcohol over their life course to date. The material on alcohol related violence is analysed in this paper.

RESULTS

Just over half of the participants (33/60) recounted negative experiences with alcohol related violence. The findings demonstrate the continuing gendered nature of experiences of perpetration and victimization. Participants reported that aggression and violence perpetrated by some men was fuelled by alcohol consumption and required ongoing management. Experiences of violence were also spatialized. Men were more likely to report managing and avoiding violence in particular public settings whilst more women than men discussed managing violence in domestic settings.

CONCLUSION

The central argument of this paper is that incidents of alcohol related violence and reactions to it are specific gender performances that occur in specific socio-cultural contexts. In contrast to research which has found some young people enjoy the adventure and excitement of alcohol related violence the mainstream participants in this study saw violence as a negative force to be managed and preferably avoided. Understanding violence as a dynamic gender performance complicates the development of policy measures designed to minimize harm but also offers a more holistic approach to developing effective policy in this domain. There is a need for greater acknowledgement that alcohol related violence in public venues and in families is primarily about particular performances of masculinity and this is where policy should be targeted in addition to venue based interventions.

Evaluation of an educational policing strategy to reduce alcohol-related crime associated with licensed premises

OBJECTIVES

Licensed premises are associated with a considerable level of alcohol-related harm. This study examined the effectiveness of an educational policing strategy, implemented as routine policing practice, to reduce the number of patrons of licensed premises involved in police-recorded incidents of violence, disorder and motor vehicle crashes.

PARTICIPANTS

The educational policing strategy targeted on-licensed premises registered as operating in 2003. The strategy was delivered by police and was overseen by the research team.

SETTING

The intervention was conducted in 21 non-metropolitan New South Wales Police Force commands.

INTERVENTION

On the basis of routinely collected and recorded police data, premises received one of three levels of police response on three separate occasions from December 2002 to July 2003. The police responses were letters, incident reports, covert audits and feedback meetings.

OUTCOMES

The rate of patrons who had last consumed alcohol on licensed premises before being involved in police-recorded incidents decreased from 1.24 per premises in the 4-month baseline period to 1.11 in the 4-month follow-up period (p=0.08). There was a significant reduction, from 7.08 to 5.65 patrons (p=0.03), in such a rate for high-risk premises that received the most intensive police response. High-risk premises also recorded a significant reduction in the rate of intoxicated patrons involved in such incidents, from 5.50 to 4.40 (p=0.05).

CONCLUSION

The findings suggest a potential benefit of an educational policing strategy in reducing alcohol-related harm associated with licensed premises. Further implementation of this strategy concurrent with rigorous evaluation is warranted.

Effectiveness of anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury: experimental study and time series analysis

OBJECTIVE

To evaluate the effectiveness of anonymised information sharing to prevent injury related to violence.

DESIGN

Experimental study and time series analysis of a prototype community partnership between the health service, police, and local government partners designed to prevent violence.

SETTING

Cardiff, Wales, and 14 comparison cities designated "most similar" by the Home Office in England and Wales.

INTERVENTION

After a 33 month development period, anonymised data relevant to violence prevention (precise violence location, time, days, and weapons) from patients attending emergency departments in Cardiff and reporting injury from violence were shared over 51 months with police and local authority partners and used to target resources for violence prevention.

MAIN OUTCOME MEASURES

Health service records of hospital admissions related to violence and police records of woundings and less serious assaults in Cardiff and other cities after adjustment for potential confounders.

RESULTS

Information sharing and use were associated with a substantial and significant reduction in hospital admissions related to violence. In the intervention city (Cardiff) rates fell from seven to five a month per 100,000 population compared with an increase from five to eight in comparison cities (adjusted incidence rate ratio 0.58, 95% confidence interval 0.49 to 0.69). Average rate of woundings recorded by the police changed from 54 to 82 a month per 100,000 population in Cardiff compared with an increase from 54 to 114 in comparison cities (adjusted incidence rate ratio 0.68, 0.61 to 0.75). There was a significant increase in less serious assaults recorded by the police, from 15 to 20 a month per 100,000 population in Cardiff compared with a decrease from 42 to 33 in comparison cities (adjusted incidence rate ratio 1.38, 1.13 to 1.70).

CONCLUSION

An information sharing partnership between health services, police, and local government in Cardiff, Wales, altered policing and other strategies to prevent violence based on information collected from patients treated in emergency departments after injury sustained in violence. This intervention led to a significant reduction in violent injury and was associated with an increase in police recording of minor assaults in Cardiff compared with similar cities in England and Wales where this intervention was not implemented.

Alcohol: no ordinary commodity--a summary of the second edition

This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. This section also documents how international beer and spirits production has been consolidated recently by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is reviewed critically in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy-making process at the local, national and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers and treatment of drinkers with alcohol dependence.

Cross-sectional measures and modelled estimates of blood alcohol levels in UK nightlife and their relationships with drinking behaviours and observed signs of inebriation

BACKGROUND

Management of nightlife in UK cities focuses on creating safe places for individuals to drink. Little is known about intoxication levels as measuring total alcohol consumption on nights out is complicated by early evening interviews missing subsequent consumption and later interviews risking individuals being too drunk to recall consumption or participate at all. Here we assess mixed survey and modelling techniques as a methodological approach to examining these issues.

METHODS

Interviews with a cross sectional sample of nightlife patrons (n = 214) recruited at different locations in three cities established alcohol consumption patterns up to the point of interview, self-assessed drunkenness and intended drinking patterns throughout the remaining night out. Researchers observed individuals' behaviours to independently assess drunkenness. Breath alcohol tests and general linear modelling were used to model blood alcohol levels at participants' expected time of leaving nightlife settings.

RESULTS

At interview 49.53% of individuals regarded themselves as drunk and 79.43% intended to consume more alcohol before returning home, with around one in ten individuals (15.38% males; 4.35% females) intending to consume >40 units (equal to 400 mls of pure alcohol). Self-assessed drunkenness, researcher observed measures of sobriety and blood alcohol levels all correlated well. Modelled estimates for blood alcohol at time of going home suggested that 71.68% of males would be over 0.15%BAC (gms alcohol/100 mls blood). Higher blood alcohol levels were related to drinking later into the night.

CONCLUSIONS

UK nightlife has used substantive health and judicial resources with the aim of creating safer and later drinking environments. Survey and modelling techniques together can help characterise the condition of drinkers when using and leaving these settings. Here such methods identified patrons as routinely getting drunk, with risks of drunkenness increasing over later nights. Without preventing drunkenness and sales to intoxicated individuals, extended drinking hours can simply act as havens for drunks. A public health approach to nightlife is needed to better understand and take into account the chronic effects of drunkenness, the damages arising after drunk individuals leave city centres and the costs of people avoiding drunken city centres at night.

Artikel

Alcohol and Public Policy Group: Alcohol: No ordinary commodity – a summary of the second edition

This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high, middle and low income countries. This section also documents how international beer and spirits production has recently been consolidated by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa, and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is critically reviewed in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy making process at the local, national, and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers, and treatment of drinkers with alcohol dependence.

The roles of doctors and health services in community violence prevention

Violence control and prevention have traditionally been led by criminal justice services. During the last decade, tackling violence has become a multi-agency effort supported by government and regulated according to new legislation, reflecting recognition that health services and local government can contribute uniquely to this.

Patterns of urban violent injury: a spatio-temporal analysis

Objectives

Injury related to violent acts is a problem in every society. Although some authors have examined the geography of violent crime, few have focused on the spatio-temporal patterns of violent injury and none have used an ambulance dataset to explore the spatial characteristics of injury. The purpose of this study was to describe the combined spatial and temporal characteristics of violent injury in a large urban centre.

Methodology/Principal Findings

Using a geomatics framework and geographic information systems software, we studied 4,587 ambulance dispatches and 10,693 emergency room admissions for violent injury occurrences among adults (aged 18–64) in Toronto, Canada, during 2002 and 2004, using population-based datasets. We created kernel density and choropleth maps for 24-hour periods and four-hour daily time periods and compared location of ambulance dispatches and patient residences with local land use and socioeconomic characteristics. We used multivariate regressions to control for confounding factors. We found the locations of violent injury and the residence locations of those injured were both closely related to each other and clearly clustered in certain parts of the city characterised by high numbers of bars, social housing units, and homeless shelters, as well as lower household incomes. The night and early morning showed a distinctive peak in injuries and a shift in the location of injuries to a “nightlife” district. The locational pattern of patient residences remained unchanged during those times.

Conclusions/Significance

Our results demonstrate that there is a distinctive spatio-temporal pattern in violent injury reflected in the ambulance data. People injured in this urban centre more commonly live in areas of social deprivation. During the day, locations of injury and locations of residences are similar. However, later at night, the injury location of highest density shifts to a “nightlife” district, whereas the residence locations of those most at risk of injury do not change.

Trend of alcohol involvement in maxillofacial trauma

BACKGROUND

Ethanol is regularly consumed by individuals in social settings. However, overindulgence can lead to impaired judgment and physical harm. This study examines the trend of alcohol-related facial fractures at a tertiary trauma over 2 consecutive time periods.

STUDY DESIGN

A retrospective database of patients presenting to the Oral and Maxillofacial Surgery service at Christchurch Hospital during an 11-year period was reviewed, and data from the 2 5.5-year periods were compared. Variables examined included demographics, type of fractures, mode of injury, and treatment delivered.

RESULTS

A total of 1,264 patients were identified to have alcohol-related facial fractures, 624 in the first half of the period and 640 in the second half. More than 90% were male, with 66% of these patients in the 15-29-year age group in each period. Assault accounted for 73% in the first period and 82% in the second period, and motor vehicle accidents accounted for 18% and 8% of fractures, respectively, in the two periods. A total of 64% and 58% of these patients required hospital admission and surgery, respectively, in the first period, and 66% were hospitalised and 60% treated surgically in the second period.

CONCLUSION

There was no significant change between the 2 periods in terms of demographics, pattern of fractures, and treatment modality. The incidence of assault-related fractures were on the rise and motor vehicle accident-related fractures were declining. Alcohol-related fractures continued to be the main problem in young male adults involved in fights. There should be public awareness to educate these people on this harmful effect of drinking.

Self-focused attention reduces self-injurious behavior in alcohol-intoxicated men

Both chronic alcohol use and acute intoxication are risk factors for self-aggression (i.e., intentional self-injury) across the spectrum of lethality. Studies designed to identify a cause-and-effect relation between alcohol intoxication and self-aggression, or the factors that facilitate or mitigate this effect, are rare due to the inherent difficulty of studying self-injurious behavior experimentally. In this study, we experimentally demonstrate that alcohol intoxication leads to heightened self-injurious behavior, and that enhanced self-focused attention (self-awareness) attenuates this effect. Specifically, 40 men consumed either alcohol (mean Blood Alcohol Concentration [BAC] = .10) or a veridical control drink, and then completed a laboratory task designed to assess self-injurious behavior. Self-focused attention was experimentally enhanced in half the participants in each drink condition. Results support the notion that prevention and intervention programs designed to reduce intentional self-injurious behaviors should include components that address alcohol misuse and self-awareness.

Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries

AIMS

To critique the methodological adequacy of evaluations of emergency department (ED)-based interventions for alcohol problems and to conduct a meta-analysis to examine the extent to which interventions in this setting are effective in reducing alcohol consumption and related harm.

METHODS

An electronic search of 11 databases and a manual search of reference lists were conducted to identify studies published in peer-review journals between January 1996 and July 2007 (inclusive). Studies evaluating the outcome of an intervention designed to reduce alcohol problems in patients presenting to the ED were eligible for inclusion. Methodological data were extracted using review criteria adapted from the both the Center for Disease Control (CDC) Guide to Community Preventive Services Data Collection Instrument and the Cochrane Effective Practice and Organization of Care Review Group Data Collection Checklist. Continuous outcomes were pooled using a fixed effect inverse variance approach while binary outcomes were pooled in a generic inverse variance meta-analysis.

RESULTS

Thirteen studies were identified for inclusion in the review. Methodological quality was found to be reasonable, with the exception of poor reporting of effect-size information and inconsistent selection of outcome measures. Meta-analyses revealed that interventions did not significantly reduce subsequent alcohol consumption, but were associated with approximately half the odds of experiencing an alcohol-related injury (odds ratio = 0.59, 95% confidence interval 0.42-0.84).

CONCLUSIONS

There are few evaluations of emergency department-based interventions for alcohol problems. Future evaluations should use consistent outcome measures and report effect sizes. The existing evidence suggests that interventions are effective in reducing subsequent alcohol-related injuries.

Examining multi-level relationships between bars, hostility and aggression: social selection and social influence

AIMS

This paper considers statistical relationships often observed between densities of bars and pubs and rates of violence as suggested by two general approaches: (i) social influence and (ii) social selection.

METHODS

A stratified sample of 36 zip code areas in California was identified as having 'high', 'medium' and 'low' densities of bars and pubs. Aggregate US Census 2000 data were used to characterize population demographics of each zip code area. Telephone surveys were conducted assessing respondent demographics, drinking patterns, utilization of different places for drinking, self-report measures of hostility, norms for aggression and norms for alcohol-related aggression. Hierarchical linear models assessed the degree to which densities of bars and pubs were related to self-reports of hostility and norms for aggression, and if the individual measures of hostility and norms for aggression were related to choice of drinking venue.

RESULTS

Respondents living in areas with greater densities of bars and pubs reported lower norms for aggression and greater norms for alcohol-related aggression. Greater peak drinking levels were related directly to greater levels of hostility and norms for both aggression and alcohol-related aggression. Self-reported hostility and norms for alcohol-related aggression were related directly to drinking at bars and pubs, parties and friends' homes. Aggressive norms were related to drinking at parties.

CONCLUSIONS

Whether bars serve to concentrate aggressive people into selected environments, whether these environments serve to increase levels of aggression, or whether both these processes reinforce each other mutually is not known. However, our findings do indicate relationships between certain exogenous measures, including alcohol outlet densities and social-psychological characteristics associated with violence. Many of these measures are also associated with the social contexts in which people drink.

Preventing violence — caring for victims

Part of the great tradition of surgery, exemplified by the Royal College precept, 'From Here Health', is that surgeons are committed to prevention as well as cure. King James IV and his able contemporary in China, where this lecture was delivered, Emperor Hongzhi, would have approved of it. This tradition has, perhaps, been neglected since the emergence of public health as a medical specialty. However, opportunities and reasons for surgeons to contribute to prevention have never been greater. Community violence prevention--increasing public safety in the towns and cities in which surgeons work--is an example. Primary prevention of injury achieved by collecting and sharing unique information about weapons and the locations of assault, secondary prevention achieved by combining wound care with motivational interviewing to reduce alcohol misuse, and tertiary prevention achieved by early referral to mental health professionals for treatment of post-traumatic stress, have been integrated into a new care pathway which combines prevention with surgical care. Individuals and communities would benefit substantially if every surgical specialty incorporated prevention--a professionally highly-rewarding activity--into its training curriculum.

Preventing alcohol-related violence: a public health approach

BACKGROUND

Studies of the relationship between alcohol and violent injury confirm that while there is some evidence of a direct pharmacological association, many other factors are relevant to the frequency and severity of both violent perpetration and being a victim of violence. It is now widely recognized that official police statistics are a poor indicator of the nature and extent of public violence.

AIMS

Accident and emergency departments and trauma surgeons are not only in a position to provide more accurate information on the nature and extent of clinically significant injury, but they can contribute substantially to violence prevention. This can be achieved through individually targeted interventions in conjunction with other clinicians on the one hand, and on the other through public health and community initiatives, in conjunction with other community agencies, including the police and local authorities. This article describes some of those initiatives and the evidence underpinning them.

Price of beer and violence-related injury in England and Wales

OBJECTIVES

Relationships between violence-related injury and potential risk factors in England and Wales were investigated over a five-year period, 1st May 1995 to 30th April 2000.

METHODS

Records from all 10 economic regions of England and Wales relating to price of alcohol, youth real income, wealth, ethnic density, dates of major sporting events and seasonality were studied with reference to violent injury data derived from 58 Emergency Departments (EDs) over the same period. Panel estimation and multi-level modelling was used to evaluate associations between variables.

RESULTS

Overall, 353,443 violence-related A&E attendances were identified over the five-year period. High regional violence-related injury rates correlated with low real price of alcohol as measured by price of beer. Rates of violence were higher during summer months and on days of major sporting events.

CONCLUSIONS

Risk of injury in violence was closely linked to alcohol price. Beer price rises should therefore reduce violent injury. Injury reduction efforts should be intensified during the summer and on days of major sports events.