Peter Henderson

Many people advocate for a public health approach to preventing violence. What does this actually mean? I’ve encountered several definitions and, despite them all being slightly different, I think they share some core ideas.

I think the public health approach focuses on:

• populations over individuals
• harm reduction over blame
• prevention over punishment
• collaboration over silos
• evidence over assumption

Populations over individuals

The criminal justice system is largely designed to deal with individual violent events. The police investigate violent acts and try to establish who was involved. The courts consider this evidence and try to understand the specific individual motivations behind violence. The focus is on the motivations and actions of the individuals involved.

The public health approach doesn’t focus on individuals. Instead, it aims to understand violence across a group of people (a ‘population’) and asks why it exists and what can be done about it. The key question is not ‘why has this person been violent?’ It’s ‘why do we see so much violence in Central London on a Friday night?’ and ‘how can we intervene to prevent this violence occurring?’

Harm reduction over blame

The focus on populations rather than individuals underpins other important ideas in the public health approach. The first is a focus on harm reduction rather than blame.

It’s tempting to blame violence on individual moral failings. Maybe some people are just evil? But this view is neither useful nor scientifically valid, especially when trying to understand why violence happens within a population. Instead the public health approach takes a deep breath and approaches violence like a public health doctor might approach an epidemic, by looking for the broader social, biological, cultural and economic causes of violence.

Some (though not all) public health approaches will take this further and explicitly describe violence itself as a ‘disease’. This idea is eloquently argued by Gary Slutkin. Gary gives three reasons why it could be useful to think of violence as a disease.

1. The biggest predictor of a case of violence is a preceding case. This is similar to diseases like the flu – you need to come into contact with the disease in order to become ill.
2. Violence appears in geographical clusters. A few geographical areas experience most of the violence. This is common in diseases too.
3. Violence appears in waves over time. It ebbs and flows, just like epidemics.

Gary describes how diseases used to be blamed on ‘bad’ people, like violence often is now. Now we understand the biology of disease, we no longer blame people. He asks: can we do the same with violence? If we understand violence properly, will we treat it like a health problem?

Prevention over punishment

The focus on harm reduction over blame naturally leads to a focus on prevention over punishment. The best way of reducing harm is to prevent it in the first place. Prevention is a core feature of all public health models. They will often break prevention down into three types:

1. Primary prevention is delivered to everyone regardless of their risk
2. Secondary prevention is targeted at people who are at greater risk of harm
3. Tertiary prevention works with people who are experiencing harm and tries to prevent further harm.

Many public health approaches will argue that prevention should focus on early intervention and stopping problems before they arise. This can lead to a focus on the ‘causes of causes’. For example, interventions might focus on early childhood, where children might start to experience the harms that put them at risk of involvement in violence, rather than adolescence, where children actually start to get involved in violence.

Collaboration over silos

Typically people might think that responsibility for dealing with violence sits with the police. Of course the police do play an important role. But in the public health approach they are just one part of a broader team. Focusing on harm reduction and prevention leads public health approaches to work closely with professionals across health, social care, education, youth services and beyond. These are the agencies that can address the upstream causes of violence.

This interest in collaboration often extends beyond professional agencies to include members of the public, especially those with lived experience of violence. The public aren’t just passive recipients of interventions, they are active partners who can contribute valuable information and expertise.

Violence is a complex phenomenon and no single government agency or group of people have all the information needed to address it. So public health approaches emphasise the importance of collaboration between different agencies. This means sharing information to build a clearer picture of why violence is happening and working together to provide a response that addresses these causes.

Evidence over assumption

Public health approaches are led by evidence rather than assumption. Evidence and research are used in several ways:

• Understanding the problem. What are the causes of violence in the population you are working with?
• Identifying solutions. What is the evidence for the impact of interventions that address the causes you’ve identified? What are the ‘best bets’?
• Evaluating success. Did your approach work? If not, why not?

There is no one type of evidence that is all-important – the best type of evidence depends on the question you are asking. It could include consultation with the public, rigorous evaluation methods like randomised control trials, or rich qualitative work to understand the lives and experiences of people caught up in violence.