Ronald V. Maier and Charles Mock
Trauma has been termed the “neglected disease of modern society.” It is also now the costliest medical problem, with trauma costs nearly doubling since the mid-1990s.1 Until recently, injuries were considered to be due to “accidents,” or randomly occurring, unpredictable events. Injuries were thus regarded in a fundamentally different manner from other diseases, which are viewed as having defined and preventable causes. This viewpoint, on the part of the public, professionals, and policy makers, induced a nihilistic attitude and severely limited the development of injury prevention efforts.
Trauma, as with any other disease, should be approached from a scientific vantage point, with delineation of causative factors and with development of preventive strategies targeting such factors. This scientific approach has been successful in decreasing the toll of mortality and morbidity from most diseases. However, this same organized scientific approach has only recently been applied to the prevention of injury.2–7
The importance of injury prevention efforts is pointed out by trauma mortality patterns. One-third to one-half of trauma deaths still occur in the field,8,9 before any possibility of treatment even by the most advanced trauma treatment system. Such deaths can only be decreased by prevention efforts. In terms of severely injured persons who survive long enough to be treated by prehospital personnel, very few “preventable deaths” occur in a modern trauma system with a well-run emergency medical system and designated trauma centers. Even among those who survive to reach the hospital, a significant portion of in-hospital deaths are directly related to head injuries and occur despite optimal use of currently available therapy. Hence, injury prevention is critical to further significantly reduce the toll of death caused by trauma. Moreover, prevention efforts can also decrease the severity of injuries and thus the likelihood of disability that arises after trauma.
In the following chapter, the historical development of the scientific approach to prevention is discussed and practical considerations for implementation of prevention efforts and for assessment of their effectiveness are reviewed. The chapter will discuss how these basic principles have been successfully applied to the prevention of both unintentional and intentional injuries. Finally, the chapter will conclude with a discussion of surgeons’ roles in injury prevention programs.
SCIENTIFIC APPROACH TO PREVENTION OF INJURIES
Historical Development of the Science of Injury Prevention
Early attempts at injury prevention were largely based on the premise that injured individuals had been careless or were “accident prone.” Although this may be true in some circumstances, the resulting injury prevention strategies, limited to generic admonitions to be careful, were greatly limited in their scope and success.7,10 The current foundation for the scientific approach to understanding the causation of injuries and to developing rational prevention programs was laid by several pioneers.
One of the earliest developments of the science of injury prevention was the work of Hugh DeHaven in the 1930s–1940s. DeHaven demonstrated that during an injury-producing event such as a crash or a fall, the body could withstand varying amounts of kinetic energy depending on how that energy was dissipated. He pointed out the possibility of disconnecting the linkage of “accident” and the resultant “injury.”11,12 He provided a biomechanical foundation for subsequent injury prevention work and introduced the concept of injury thresholds. His groundwork is credited with eventually leading to the introduction of automotive seatbelts.11,12
In the 1940s, John E. Gordon introduced the use of epidemiology to the evaluation of injury. He pointed out how, similar to any other disease, injuries occurred with recognizable patterns across time and populations. He also pointed out how, as with other diseases, injuries were the result of the interaction of the host, the agent of injury production, and the environment within which they interacted.13
The most notable of the early pioneers of injury prevention was William Haddon, the first director of the National Highway Traffic Safety Administration (NHTSA). Haddon advanced these early works and developed a systematic approach to the evaluation and prevention of injuries. He based his approach upon the recognition that virtually all injuries resulted from rapid and uncontrolled transfer of energy to the human body. Furthermore, such energy transfers were understandable and predictable, and hence preventable. Haddon expanded Gordon’s ideas on the interaction of the three factors of host, agent, and environment into what ultimately became known as Haddon’s Matrix (Table 3-1). In this model, each of the three factors influences the likelihood of injury during each of the three phases: pre-event, event, and post-event. In the pre-event phase, each of the three factors influences the likelihood of an injury-producing event, such as a crash, to occur. During the event phase, they influence the probability that such an event will result in an injury and determine the severity of that injury. During the post-event phase, these same components determine what ultimate consequences the injury will have. Table 3-1 gives examples of such interactions.14
TABLE 3-1 Examples of the Interactions of Phases and Factors Within Haddon’s Matrix of Injury Etiology
Haddon provided a firm basis for the modern approach to injury control. The principles summarized in his matrix have also served as guidelines for the development of prevention efforts. He went on to develop 10 strategies to dissociate potentially injury-producing “energy” from the host. Most current strategies for prevention and control of injuries are conceptually derived from these 10 strategies. They are listed below with examples.
A. Pre-Event Phase
1. Prevent the creation of the hazard; prevent the development of the energy that would lead to a harmful transfer. For example, prevent manufacture of certain poisons, fireworks, or handguns.
2. Reduce the amount of the hazard. For example, reduce speeds of vehicles.
3. Prevent the release of the hazard that already exists. For example, placing a trigger lock on a handgun.
B. Event Phase
4. Modify the rate or spatial distribution of the release of the hazard from its source. For example, seatbelts, airbags.
5. Separate in time or space the hazard being released from the people to be protected. For example, separation of vehicular traffic and pedestrian walkways.
6. Separate the hazard from the people to be protected by a mechanical barrier. For example, protective helmets.
7. Modify the basic structure or quality of the hazard to reduce the energy load per unit area. For example, breakaway roadside poles, rounding sharp edges of a household table.
8. Make what is to be protected (both living and nonliving) more resistant to damage from the hazard. For example, fire and earthquake resistant buildings, prevention of osteoporosis.
C. Post-Event Phase
9. Detect and counter the damage already done by the environmental hazard. For example, emergency medical care.
10. Stabilize, repair, and rehabilitate the damaged object. For example, acute care, reconstructive surgery, physical therapy.7,10,14
Practical Considerations in Injury Prevention Work
Almost all prevention efforts can be conceptually derived from Haddon’s 10 strategies. However, implementing such strategies in the real world involves a variety of practical considerations. In general, interventions can be thought of as either being active or passive on the part of the person being protected. Active interventions involve a behavior change and require people to perform an act such as putting on a helmet, fastening a seatbelt, or using a trigger lock for a handgun. Passive interventions require no action on the part of those being protected and are built into the design of the agent or the environment, such as airbags or separation of vehicle routes and pedestrian walkways. In general, passive interventions are considered more reliable than active ones.14,15 However, even passive interventions require an action on the part of some segment of society, such as passage of legislation to require certain safety features in automobiles.
The accomplishment of injury prevention strategies in society can be undertaken through three primary modalities: (i) legislation and enforcement, (ii) education and behavior change, and (iii) engineering and technology. These are often referred to as the three “E’s.”
Enforcement and legislation can work at different governmental levels. For example, national or federal level legislation regulates safety features built into the design of motor vehicles. States define what constitutes drunk driving and establish the strictness with which such laws are enforced. Local governments establish safety-related building codes.
Education and behavior change were once the mainstay of injury prevention work. However, if used uncritically and without evaluation, they usually have limited effect.16 Educational efforts need to be delivered in a well-thought-out manner, utilizing the techniques of social marketing, to succeed in actually effecting behavior change. Moreover, educational work is often most effective when coupled with other methods of injury prevention, such as informing the public of the risk of being apprehended and prosecuted under new and more stringent anti-drunk driving laws. Also, to be most effective, a committed and ongoing program is required.
Engineering and technology address a variety of issues, such as development of safer roadways, more effective safety features for automobiles, and automatic protection for manufacturing equipment.
These three main modalities are frequently complementary. For example, seatbelts are a technological development. Convincing people to adopt the behavior of using them requires education and is reinforced through legislation. Convincing legislators to pass seatbelt laws requires lobbying and education.7 In the later sections of this chapter, specific examples of use of these modalities are discussed.
Certain common principles run through many successful injury prevention programs. These include a multidisciplinary approach, community involvement, and should involve ongoing evaluation of both the process and outcome of the program. Depending on the targeted injury type, a program might involve contributions from health care professionals, public health practitioners, epidemiologists, psychologists, manufacturers, traffic safety and law enforcement officials, experts in biomechanics, educators, and individuals associated with the media, advertising, and public relations. Health care professionals might include those in primary care, such as pediatricians, and those involved in acute trauma care. Finally, individual members of the public might be involved.15,17
There is frequently the need to organize several groups with diverse interests into a coalition focusing on one particular injury prevention goal. Such groups might include governmental agencies, such as the health department, schools, and transportation department. They might also include academic institutions, the media, community groups, private foundations, corporations, and medical associations.14–16Coordination of these diverse groups and interests is an important component of the overall prevention program and is often best performed by having one organization act as a “lead agency.”7
Programs are more likely to be successful when they have specific objectives and focus on a few or even just one key intervention. In general, interventions that can be integrated into existing programs will be more sustainable than will be short-term, temporary programs. When a prevention program achieves ongoing support and commitment from the agency, organization, or community in which it is based, it can be considered to be “institutionalized”.7 Such sustainability is especially necessary for interventions based on education and behavior change.
Funding for injury prevention is frequently a limiting factor, as these programs are almost always nonprofit endeavors. However, much can be accomplished by utilizing available community resources. These can include volunteer labor, publicity from the media in the form of free advertising space or special interest stories, and gifts in kind, such as donations of safety devices from manufacturers. The greater the level of involvement of the community, the greater the availability of such resources. Hence, a key component of many injury prevention programs is to elicit and sustain the interest of the community.
A critical element of injury prevention programs, which is frequently given inadequate attention, is evaluation of effectiveness. This requires two main activities: evaluation of both the process and the outcome. Process evaluation can be regarded, in part, as quality assurance of the program. For example, are the various items in a public information campaign progressing at the scheduled rate? The main purpose of such evaluation is to provide feedback for modification of the intervention.
Most importantly, outcome assessment evaluates possible changes or impact in the incidence of injury. Ideally, outcomes would monitor the most severe consequences of injury, namely, fatalities and injuries producing disability. This may not always be possible, given the limitations of size of the target population and the influence of other factors influencing injury rates. In these circumstances, measurement of “proxy outcomes” can be suitable, if carefully chosen. These are outcomes that are more frequent and hence more easily measurable, but that are less important and represent less tangible benefit than the more important outcomes. However, they should reflect or initiate a change ultimately in the more serious outcomes. For example, a program to promote bicycle helmet use would reasonably start by measuring changes in the percentage of bicycle riders wearing a helmet rather than changes in head injuries or deaths. Such a program would be more likely to demonstrate changes in the proxy measure, helmet use, in a shorter period or in a smaller population, whereas serious head injuries and deaths are more likely to change only over longer periods. Using such measurable outcomes are critical to “document” the success of a program and hence to increase or sustain community “buy-in” and support.
Injury outcomes can be thought of as a hierarchy, with the highest level being fatalities. These are the most desirable to prevent, but the hardest in which to reliably evaluate changes, due to their relatively infrequent occurrence. The lower levels of the outcome hierarchy are the easiest in which to assess change, especially in small-scale projects. However, the lower levels have the disadvantage of being less directly and less definitely associated with ultimate decreases in the more serious outcomes. The list below indicates this hierarchy from most desirable, but more difficult to assess, to less important, but more easily measured:
1. Injury fatalities
2. Injury admissions
3. Injury cases treated as outpatients
4. All injury cases
5. Direct observation of behavior or the physical environment
6. Measures of self-reported behavior
7. Measures of knowledge, attitudes, beliefs, or intentions
Factors that influence the choice of outcome to measure include size of project, size of population to be studied, specific intervention planned, and funding available. Larger programs should focus on more important and tangible outcomes such as injury fatalities and injury admissions. However, these are not usually possible for smaller programs. Moreover, if smaller programs are implementing an intervention that has had proven success in other areas or in similar circumstances, then changes in behavior or attitudes regarding this intervention may suffice to prove success.
Whichever outcome is chosen, it is important to build outcome assessment into the design of the prevention program. In this way baseline measurements can be obtained, which will subsequently enable comparisons before and after an intervention and comparisons of groups with and without an intervention.
Such outcome assessment is useful for identifying strategies that have been successful and hence are worth promulgating on a wider scale. Outcome assessment is also useful for identifying those strategies that are not working and hence should be changed or discontinued.
In circumstances where educational efforts seek to increase voluntary compliance with safety measures, ethical issues in injury prevention are minimal. Ethical issues usually arise with laws mandating compliance with safety practices. These issues typically involve the balancing of an individual’s personal rights with the overall good of society. In circumstances where an individual’s actions adversely affect others, the ethical questions are usually straightforward. For example, an individual’s “right” to drink and then drive is easily deprived in favor of protecting other members of society from the potential harm of such an action. Similarly, laws mandating use of restraint seats for children in automobiles may be viewed as an infringement on the rights of their parents to choose how they wish to treat their children. However, the vulnerable state of children and the precedent of protecting them from potentially harmful acts of their parents is well established and such laws, once passed, have easily stood.
The difficult issues in injury prevention arise with laws to protect against injuries in which the potential victims are primarily harming themselves. One of the best examples of this is mandatory motorcycle helmet laws. Such laws have been opposed by motorcycle groups, who feel that they are only risking their own safety by riding without a helmet. Proponents of helmet laws have generally pointed to the societal costs of treatment of severely head-injured motorcyclists as the rationale as to why the issue affects society as a whole.18 Courts have consistently backed the latter view, as best summed up in the case of Simon v Sargent in Massachusetts:
“From the moment of the injury, society picks the person up off the highway; delivers him to a municipal hospital and municipal doctors; provides him with unemployment compensation, if after recovery, he cannot replace his lost job and, if the injury causes permanent disability, may assume the responsibility for his and his family’s continued subsistence. We do not understand the state of mind that permits the plaintiff to think that only he himself is concerned.”19
Ethical issues related to injury prevention will continue to evolve. Most activities in life require some degree of risk taking. Societal norms and legal standards as to what represents acceptable risk taking are continually shifting. As these values change and as injury prevention strategies evolve, which might call upon legislation for mandatory compliance, new ethical issues will continue to arise.
Even when scientifically proven and cost-effective, the acceptance by society and government of safety measures to prevent important causes of injury are often blocked by a variety of political issues.3,20 In some cases, there is resistance to behavior change on the part of a specific segment of society. For example, motorcycle helmet laws are frequently challenged by motorcycle groups. Besides ethical issues, the actual alternating legislative enactment and repeal of state motorcycle helmet laws have been due to political pressures from motorcycle groups on one hand and safety advocates on the other.3
In other cases, however, safety measures have been specifically blocked by the active efforts of special interests that would stand to loose financially. For example, one of the major advances in automotive safety in recent decades has been the enactment of the Federal Motor Vehicle Safety Standards (FMVSS). These have been estimated to have saved 10,000–20,000 lives per year since their initial enactment in the 1960s.3,21–23 Despite their effectiveness, efforts to promote such safety advances are often hindered by lobbying from the automobile industry or opposition from anti-regulatory–minded members of the government.3,24
Another example of political opposition involves efforts to legislate mandatory setting of hot water heater temperatures at 120–125°F. As will be described later, this is a tremendously effective strategy to prevent scald burns in young children. Initial work on such regulation was carried out at the state level. Despite the obvious low-cost and significant benefits of such laws, they were frequently opposed. As one particular example, the legislative fight to pass a 120°F water heater temperature bill in Wisconsin has been well documented.20 This bill was opposed by legislators who considered it to be anti-business. Although a state level bill, it was lobbied against by national interests, such as the Gas Appliance Manufacturers Association, as representing too much government interference in their business. Such opposition was eventually overcome by lobbying from several groups, including the State Medical Association and the state chapter of the American Academy of Pediatrics (AAP), and by a public letter writing campaign.
Unfortunately, many other examples are also common.
Among these is the opposition to efforts to promote responsible alcohol advertising on the part of alcohol manufacturers and retailers.20 One of the more extreme examples is the vehement opposition to efforts to any limit on availability of firearms by the National Rifle Association and its allies in the gun manufacturing industry. Such groups have opposed even efforts such as closing the gun-show loophole, which has allowed convicted criminals to continue to purchase guns.
In addition to specific injury prevention issues, addressing deeper issues in our society is pertinent in protecting the health of the public from injury-related death and disability. Virtually every form of injury is more common in the lower socioeconomic strata of society. The inequities that produce this situation need to be confronted as well. This has been well stated by Christoffel and Gallagher in their book, Injury Prevention and Public Health: “Truly effective injury prevention interventions challenge the structural underpinnings of the status quo. Effective injury prevention means things like worker participation in production decisions, community involvement in land use policy, equitable distribution of risk… These are dangerous ideas; they challenge unbridled free-market competition. Yet they are necessary for long-term, meaningful advances in injury prevention.”3
These deep-seated political challenges indicate the need for those who wish to promote injury prevention to develop skills in advocacy and lobbying. This includes becoming proficient at efforts such as testifying before legislatures, pushing behind the scenes as individuals or through organizations such as professional societies, publicly countering unproven or non–evidence-based arguments used by safety opponents (such as motor cycle helmets increase the risk of crashes), and by working to mobilize public support for safety-related measures. Simultaneously, this challenge places the burden on the injury prevention community to develop scientific, evidence-based proposals that can withstand the appropriate public scrutiny before imposing legislative constraints on selected components of society.
STRATEGIES TO PREVENT UNINTENTIONAL INJURIES
The remaining portions of this chapter will demonstrate how Haddon’s principles of injury causation and his strategies for prevention, as well as three main modalities for implementation (legislation, education, and technology), can be utilized in programs directed at specific types of both unintentional and intentional injury.
Motor Vehicle and Transportation
Several well-established groups have been working in motor vehicle–related safety, including NHTSA, the Centers for Disease Control and Prevention (CDC), state and local highway departments, as well as various injury prevention coalitions. Progress in road safety has been made along multiple avenues, as indicated by the examples given in Table 3-1. Some of those warranting special discussion are detailed below.
Safety-related Vehicle Design and Occupant Protection
Much has been accomplished to make motor vehicles safer. This includes engineering features that make it less likely for a vehicle to crash. This is referred to as crash avoidance and takes into account such features as brakes, headlights, triple brakelights, and signals. Automotive safety also includes engineering features that make occupant injury less likely in the event of a crash. This is referred to as crashworthiness and takes into account such features as collapsible steering columns, shatter proof glass, and improved side impact protection. These improvements have resulted from both improved car design on the part of the automobile manufacturers and regulations from NHTSA, in the form of FMVSS.
One of the greatest advances in automotive safety was the realization that a significant component of the injuries sustained in crashes were due to ejections and to secondary collision of the occupant with the vehicle interior after the vehicle had collided with another object. This understanding led to the development of seatbelts to allow occupants to “ride down” the crash, dissipating their kinetic energy more slowly and in a controlled fashion.
However, this accomplishment of engineering is an active intervention, requiring the occupant to decide to put on the belt each time they begin a new journey. Hence, convincing people to use seatbelts remains a major injury prevention challenge. Even though the addition of airbags has enhanced safety and is a completely passive intervention, concomitant use of seatbelts is required to optimize their benefit and avoid airbag-related injuries. Efforts to increase belt usage include both education and legislation. Legislation includes mandatory seatbelt laws. Although some form of such a law has been passed in most states, only 27 states have laws allowing primary enforcement. Belt usage in the United States remains incomplete, at 84% overall, including 88% in those states with primary enforcement and 77% in states with secondary enforcement of seatbelt laws.25
A particular subset of restraint use that warrants special attention is that of infant and child car seats and booster seats. These are necessitated by the fact that infants and children do not fit into adult-size seatbelts and hence such seatbelts do not provide adequate protection for these age groups. The need for infant car seats was recognized many years ago. These are required by legislation in all states. These laws require infant/child harness seats that are appropriate for children ages 0–4 years. These have played a major part in decreasing occupant deaths for children ages 0–4 years from 682 deaths nationwide in 1994 to 261 deaths in 2006.26,27
The need for booster seats for children ages 4–9 years (under 4 ft 9 in.) has been more recently recognized. The need for these arises from the fact that adult seatbelts rarely fit children of this age group. The shoulder belt portion typically lies over the face, leading children to place it behind their backs. Likewise, the lap belt portion rides high, over the abdomen. These factors have been associated with intra-abdominal and spinal injuries, known as seatbelt syndrome.28 Such factors have contributed to the minimal declines in occupant death rates for children of this age group.
Booster seats raise the child into a position where the shoulder belt fits more properly over the chest and shoulder and where the lap belt is properly positioned low, across the pelvis. Booster seats reduce severe injuries to child occupants.29 The recognition of the importance of booster seats has led an increasing number of states to pass booster seat laws.
Occupant protection is obviously difficult to engineer for motorcycles and bicycles due to the exposed position of the riders. However, head injuries are the primary cause of death and prolonged disability for crashes involving both types of vehicles.5,6 Helmets have been shown to decrease the probability of a head injury during crashes, to decrease the severity of head injuries when they occur, and to decrease the probability of death in both bicycle and motorcycle crashes.30–34 As with seatbelts, helmets are an active intervention and the challenge has been to get riders to wear them. Programs to accomplish this have involved both education and legislation. The two case studies at the end of this section of the chapter detail examples of each approach.
In the precrash, environmental segment of Haddon’s Matrix, two factors that stand out are roadway design and traffic regulations, including speed limits. Safety aspects of roadway design have been greatly advanced by such features as greater use of limited access highways, which have eliminated the risk of head-on collisions and decreased intersection-related conflicts. One of the most important safety-related traffic regulations has been the speed limit. The nationwide 55 MPH speed limit contributed significantly to lowering the motor vehicle crash fatality rate. The move toward higher speed limits can be considered a societal sacrifice to directly appease personal freedom demands. As a consequence, the nation sustained a rise in motor vehicle–related deaths in the early and mid-1990s.25
Another of the major risk factors for motor vehicle crashes is alcohol-impaired driving. Risk of a crash increases dramatically with increasing blood alcohol concentration (BAC). The risk of a crash increases 5-fold at a BAC of 80 mg/dL; 7-fold at a BAC of 100 mg/dL; and 25-fold at 150 mg/dL.7,35 On weekend nights, when a large percentage of severe crashes occur, 2% of all drivers are legally intoxicated. Drunk driving is associated currently with 32% of all fatal crashes in the United States.36,37
In light of these dramatic facts, anti-drunk driving efforts have been a cornerstone of road safety efforts in the United States and most other developed nations. These have employed both educational and legislative approaches.38 A great many anti-drunk driving educational campaigns have been undertaken by diverse groups such as NHTSA, state agencies, and citizen groups such as Mothers Against Drunk Driving. Many of these have targeted younger drivers, who are at especially high risk for drunk driving.7
In terms of legislation, all states have adopted per se laws, in which any driver with an alcohol level above a specified level is considered impaired, regardless of any witnessed driving infractions. This legal limit has now been decreased to 80 mg/dL in all states. Likewise, many states have moved toward zero tolerance laws for underage drivers.25
However, legislation must be linked to enforcement because any law is only as good as its enforcement. Drunk-driving laws are enforced to extremely varying degrees in different jurisdictions. Random sobriety checkpoints and administrative license suspension are just two methods to increase enforcement effectiveness and should strongly be considered.7
Another avenue to pursue in the fight against drunk driving is identification of injured, alcohol-impaired drivers following hospital admission. There is a documented high rate of recidivism among intoxicated trauma patients in general, and not only among drunk drivers. Hence, identification and appropriate treatment of injured persons with alcohol abuse problems is a means toward decreasing the level of alcohol-related injury from all causes.5,6,39,40
Blood alcohol screening on admission, accompanied by brief questioning, such as the Short Michigan Alcohol Screening Test, Michigan Alcohol Screening Test, or CAGE, can detect patients at a high risk for alcohol-related injury recidivism. The CAGE questionnaire consists of four basic questions: Have you every tried to Cut down on your drinking? Are you Annoyed when people complain about your drinking? Do you ever feel Guilty about your drinking? Do you ever drink Eye-Openers?5,6,39,40
Referring these patients for counseling or even engaging in very brief interventions by trained professionals in the hospital is a potentially effective way of getting these patients to decrease their alcohol intake. In a prospective, randomized, controlled trial of screening and brief intervention (SBI) among admitted trauma patients, it was found that patients who had undergone this brief counseling demonstrated a long-term (>1 year) decrease in their alcohol intake. This group reduced their alcohol intake by more than 20 drinks per week compared to only 7 per week in patients not undergoing such brief counseling. In addition, there was a 43% reduction in new injuries in treated individual compared to controls.41 Brief interventions generally entail one or more counseling sessions, adding up to less than 1 hour. These have been shown to be effective in the context of acute injury hospitalization for all except the most severely impaired patients. The reader is directed to the cited references for more details on brief intervention counseling methods.39–41
The effectiveness and importance of alcohol SBI has recently led the American College of Surgeons Committee on Trauma (ACSCOT) to add a requirement that SBI programs must be present to its list of requirements for trauma center verification for Level I and II trauma centers. CMS has recognized the merit of intervention programs and created a specific billing code to enable reimbursement.
Graduated Drivers Licensing Systems
A particularly high-risk group for crashes is new adolescent (16–17-year-old) drivers. Rates of crashes and crash-related death are higher than for older drivers due to having less experience and skill coupled with more risk-taking behavior. Drivers ages 16–20 have an annual rate of involvement in fatal crashes of 44/100,000 licensed drivers, compared with 24/100,000 for the general public.25
One particularly effective method to decrease the crash rate in this age group has been graduated driver licensing (GDL). Details vary from state to state and between countries; however, several common features include (1) new adolescent drivers first obtain a learner’s permit that allows them to drive only while supervised by a licensed adult; (2) a provisional license is next obtained that allows new adolescent drivers to drive unsupervised only under restricted conditions, such as only during certain times of day (usually not late at night), and with restrictions on the numbers and ages of passengers (e.g., with only limited numbers of other adolescents). Progression from one stage to the next and to a full license can only occur after specified minimum time periods and is contingent upon the absence of traffic violations or at-fault crashes.42
GDL programs have been shown to be effective in decreasing rates of crashes and crash-related death among new adolescent drivers. For example, after institution of a GDL system for 16-year-old drivers in North Carolina, rates of fatal crashes involving 16-year-old drivers declined by 57%, from 5 to 2/10,000 population per year.43
As of 2010, all states and several other countries have adopted GDL. However, only 35 such states have achieved a rating of “good” according to the scale developed by the Insurance Institute for Highway Safety, which takes into account the toughness of the restrictions and the length of the period after the 16th birthday for which these restrictions apply. Factors in this rating include the hour at which nighttime restrictions apply, the number of adolescent passengers that are allowed, and the age at which a full license may be obtained, among other criteria. The other states have been rated as fair, marginal, or poor, indicating that much work still needs to be done.42
The rapidly growing use of cellphones has brought the subject of distracted driving to the forefront of road safety. Distracted driving is one of several forms of driver inattention and can be defined as occurring when “a driver’s attention is diverted away from driving by a secondary task that requires focusing on an object, event, or person not related to the driving task.”44 Various forms of distraction include conversations with passengers, eating, smoking, reaching for objects inside the vehicle, manipulating controls, and cellphone use.44
Such distracted driving, in general, is a significant contributor to crash causation. NHTSA estimates that 10.5% of crash-involved drivers were distracted at the time of their crash involvement44 and that, in 2008, there were 5,870 deaths in crashes in which at least one form of driver distraction was reported on the police crash report.45 Given the difficulties in knowing whether distraction was occurring or contributing to a crash, these figures are likely underestimates.
Use of cellphones while driving has been shown in driving simulator studies to result in driving performance degradation, slowed response times (including braking), and reduced awareness of other traffic.44,46 Studies have consistently shown an increase of approximately 4-fold (i.e., 400% increase) in risk of a crash compared to baseline.44,46,47 This increased risk becomes especially problematic, given the widespread and growing use of cellphones, both in the USA and globally. Observational studies show 1–6% of drivers using cellphones at any given time while driving.46
Furthermore, use of hands-free units does not appear to eliminate the risk. Some studies indicating no change in risk and others decreased risk, but not to baseline. This is likely because drivers are still at risk due to the diversion of attention away from driving caused by the conversation itself.44,46,47
In an attempt to confront this problem, several states have adopted laws prohibiting use of cellphones while driving. As of 2010, 7 states had bans on handheld cellphones, 21 states had bans on text messaging while driving, and 24 had bans on teen drivers use of cellphones.48 In general, these laws lead to 50% reductions in cellphone use after they become effective. However, long-term effectiveness appears weaker.46 For example, a law in New York state in 2001 (the first such law in the USA) resulted in a decrease in the percentage of drivers using handheld mobile phones from 2.3% before the law to 1.1% one month after the law became effective, at which time there had been considerable publicity and enforcement. However, after 1 year the percentage of drivers using handheld mobile phones had risen back to 2.1%.46,49 Thus, as with many other road safety and injury prevention laws, there is a need for ongoing social marketing and law enforcement for the safety effect of the law to be realized. Furthermore, there are no data at this time confirming that such laws have an effect in lowering rates of crashes or injuries.46
There is considerable need for research on this topic. Priorities include better definition of the extent of the problem, especially the contribution of cellphone use and other types of distracted driving to the number of crashes and crash deaths. There is especially a need to understand the effect of interventions, such as laws and methods for their enforcement, as well as new, potential, technological solutions such as methods to block mobile use while driving similar to the use of interlocks to prevent alcohol-impaired driving or speed governors to automatically limit vehicle speed. There is also a need to approach the use of cellphones within the broader context of other sources of driver distraction.46
Residential Safety: Burns
Improved residential safety encompasses poisoning, suffocation, drowning, falls, and burns. In the United States, burns are the fourth leading cause of injury-related mortality. There are three major causes of death and injury due to burns. House fires account for 75% of burn deaths, but only 4% of burn admissions, due to their high case fatality rate. Many of these deaths from fires are actually due to smoke inhalation.5,6,50 Scalds from hot liquids and burns from clothing ignition each account for only about 3% of burn deaths, but these mechanisms account for a large percentage of burn admissions (scalds—29%; clothing—10%).51 Hence, burn prevention efforts have been oriented toward these three most common causes.
Most house fire deaths occur because of entrapment in burning buildings. In many cases, people do not know their building is on fire until it is too late to escape or to call the fire department. Many injuries and deaths could be prevented if people knew earlier that a fire had started and had time to escape. Therefore, a key component to injury prevention for house fires is the early warning system provided by smoke detectors.
Smoke detectors are an extremely effective injury prevention tool. They have been found to lower the potential for death in 86% of fires.7 This is an example of the use of engineering in injury prevention. However, the tool is of no value if people do not use it. Use of smoke detectors has been promulgated by both education and legislation. Educational campaigns have been run on a regular basis by local fire departments and nonprofit groups, such as the Northwest Burn Foundation in Seattle. These activities educate people about the importance of having a smoke detector in their home and the need to change the batteries every 6–12 months. In addition, most states have laws that require placement of smoke detectors in all new buildings. These measures have been extremely effective. The percentage of homes having smoke detectors rose from 5% in 1970 to 67% in 1982. Primarily based on increased use of smoke detectors, fire-related deaths in the United States decreased by 20% between the 1970s and the 1980s.7,51
Other efforts to prevent deaths due to house fires have attempted to attack root causes.52 Most house fires arise from (1) faulty heating equipment, especially in lower-income housing, and (2) ignition of mattresses or upholstered furniture from cigarettes. The first has been addressed primarily through legislation regarding housing codes. The second, cigarette-related fires, has been worked on by (a) educating people about the dangers of smoking in bed and (b) laws that require mattresses to be made with less flammable materials.7 Unfortunately, the most effective measure, manufacture of self-extinguishing cigarettes, has been effectively blocked by the industry, even though the technology exists.20
Young children, ages 0–4 years, account for half of scald injuries.51 The leading cause is hot water, especially hot tap water used for bathing. A typical scenario is a child being bathed and the faucet being turned on too hot, either unintentionally by a child playing with the knobs or by an adult not realizing how hot the water is. Thus, a major prevention focus is lowering the temperature in hot water heaters. Hot water heaters can heat water as high as 160°F (71°C), which can produce a first-degree burn in 1 second of exposure, and more severe burns with longer periods of exposure. However, temperatures of 125°F (52°C) require three or more minutes of exposure to produce burns. Hence, essentially all scald burns due to tap water can be prevented by keeping the temperature in hot water heaters to 125°F or less.7,51
Reduction in thermostat settings is the engineering aspect. To achieve this, injury prevention groups have been educating parents of the dangers of high temperatures for hot water heaters and the importance of lowering the thermostat on the heater. Liquid crystal thermometers have been made specifically for the purpose of checking the temperature at the faucet. As regards legislation, many states have introduced laws that require manufacturers to preset their hot water heaters at 120–125°F (49–52°C). These scald prevention efforts have been very effective. Between the 1960s and the 1980s, scald-related deaths have decreased by over half for all age groups and by 75% for children.7,51
The second leading cause of burn-related admissions is ignition of clothing. This may happen from contact with stoves, electrical heating units (space heaters), cigarettes, matches, or other sources. The two major groups in whom these occur are young children, who do not realize the dangers, and the elderly, in whom reaction time is slowed.
One of the most notable examples of burn prevention efforts is in this field. Most of the clothing ignition burns to children occurred from sleepwear, which was formerly made of easily flammable fabrics. In the 1970s, the Children’s Sleepwear Standard law required children’s sleepwear to be made of less flammable materials and required that any new sleepwear products pass a flame test before being allowed in the market. These measures have resulted in a dramatic decrease in childhood clothing related burns to the point where burns related strictly to clothing ignition are very rare. However, a major problem remains in clothing ignition burns among the elderly, which currently account for over 75% of clothing ignition burns. Likewise, clothing industry lobbyists have had some recent success in loosening some of the sleepwear standards for children, thus indicating that vigilance and continued advocacy are required even after safety-related laws are passed.7,51
Two Contrasting Case Studies: Helmet Promotion
These two case studies address a similar issue, the use of protective helmets: in one case for bicycle riders and in the other for motorcycle riders. Both affect the crash phase and human factor of Haddon’s Matrix (i.e., decreasing the likelihood of injury once an injury-producing event has occurred). In addition, both involve the same concepts of Haddon’s 10 principles of prevention, namely, separation of the hazard from the people to be protected by a mechanical barrier. This particular strategy has been shown to decrease the severity of head injuries in victims of both bicycle and motorcycle crashes.30–34 From an implementation viewpoint, use of helmets for bicyclists and motorcyclists is an active intervention, requiring the rider to put on a helmet, voluntarily and repetitively, each time he or she performs the act of riding. The challenge in both circumstances has been to increase compliance with this behavior. However, due to selective social circumstances and pressures in the populations to be protected, very different modalities of implementation have been required.
The Seattle Bicycle Helmet Campaign
The Seattle bicycle helmet campaign has been considered a model program in health promotion and injury prevention. It utilized a multidimensional approach, emphasizing a broad-based community coalition building and focusing on young elementary school-aged children. The initial step consisted of a background survey of schoolchildren and their parents, undertaken to assess the current knowledge, attitudes, and practices regarding bicycle helmets. Over 1,000 elementary school-aged children and their parents were surveyed. Only 12% of children who had bicycles reported that they used helmets when they rode. Among the large majority of children who did not use helmets, three main barriers to helmet use were identified. (1) Parents were largely unaware of the danger of head injuries to bicycle riders and were also unaware of the effectiveness of helmets in preventing such injuries. (2) The price of helmets at the time was $40–60 and was considered too high. (3) Children were reluctant to wear helmets as most other children did not do so and hence wearing a helmet would result in them being viewed as “nerds.”53,54 These barriers subsequently became the main targets of the bicycle helmet campaign.
After this background survey, the Harborview Injury Prevention and Research Center (HIPRC) elicited the support and involvement of a number of organizations in forming a coalition to promote helmet use. This coalition relied on use of volunteer labor and gifts in kind. Members of this coalition included the Cascade Bicycle Club, local and state health departments, the Washington State Medical Association, the Parent Teachers Association (PTA), local television and radio stations, local sports figures, manufacturers of bicycle helmets, and Group Health Cooperative, the state’s largest health maintenance organization. The HIPRC acted as the lead agency in the program and coordinated the activities of the other coalition members.54–56
The program focused on elementary school-aged children as these were felt to be most amenable to changes in behavior. Increasing parental awareness was primarily undertaken via the mass media. Air time was donated as a gift in kind from local radio and television stations for public service announcements about bicycle helmets. The media provided reports by the Level I trauma center at Harborview Medical Center to publicize, as human interest stories, head injuries to unhelmeted children bicyclists. Families of bicycle crash victims were asked if their child’s case could be publicized on behalf of the helmet campaign. Compliance was usually high with these requests. The pediatricians and surgeons caring for these children played a key role in identifying their cases for publicity and also acted as spokespersons for helmets in the subsequent news stories. The trauma registry at Harborview Medical Center provided up to date statistics on bicycle trauma, which were popular with reporters and news broadcasters.
In addition to the direct mass media approach, articles on bicycle helmets appeared in the newsletters of the Washington State PTA and the Boy Scouts. Similar articles, directed at health care providers, also appeared in the newsletters of the Washington State Medical Association and the state chapter of the AAP. Such items stressed the importance of injury prevention counseling in general and, in particular, about bicycle helmets, in primary care practices involving children. Through the state medical association, informational pamphlets were provided to physicians to distribute to their patients.
At the start of the campaign, helmets were primarily sold at specialty bicycle shops catering to adults and retailed for $40–60. Few stores that sold children’s bicycles also sold helmets. A “partnership” was developed between the helmet coalition and Mountain Safety Research, a Seattle-based helmet manufacturer. This company mass produced and marketed helmets for children under a different label for $20–25. In exchange, retailers of bicycles who were involved with the coalition, agreed to attach “hang tags” on children’s bicycles they sold to promote helmets. Large chain stores that sold children’s bicycles were convinced to also provide helmets at reduced costs. The retail outlets likewise received public commendation and hence publicity from the state chapter of the AAP. In addition, helmets were made available through the PTA. Other cost-lowering activities included distribution of discount coupons through physicians’ offices, schools, and youth and community groups. Other helmet manufacturers eventually became involved in the campaign.
To promote helmet use among school-aged children, bicycle safety programs were conducted in Seattle public elementary schools. These included posters, assemblies, and endorsements by local sports figures. Outside of school, bicycle rodeos and rallies were put on in city parks and other public sites, hosted by radio stations, and the Cascade Bicycle Club. At these bicycling events, rewards were given to children wearing helmets, including coupons for free French fries and free tickets to Seattle Mariner baseball games.54–56
This campaign has been held annually since 1986 with most intensive activities from April to September each year.54–56 The direct monetary costs of the program were primarily for printing and mailing. The only full-time personnel was a health educator for years two and three of the campaign. A public relations specialist was employed on a part-time basis for the most intensive periods of the campaign, during the riding season. Otherwise, the bulk of activities of the campaign were provided for by “in-kind” donations of services.55
A key element in the program was assessment, both of the process of the campaign and of its outcome. Process factors that were followed included (i) number of discount coupons distributed and percentage redeemed; and (ii) number of helmets sold. During the first 2 years of the campaign, 109,450 discount coupons were distributed, of which 4.7% were redeemed, a figure that is deemed very high by standards of product promotion. Discount coupons distributed at the bicycle rodeos and fairs were especially productive, with an 8.7% redemption rate. Seattle area bicycle helmet sales also rose dramatically during the early years of the campaign, from 1500 in 1986 to 20,000 in 1988.55
In terms of assessment of outcome, death or major neurological disability related to bicycle crashes would be the most important to decrease. Given the proven efficacy of helmets at preventing severe head injuries and death in bicycle crashes it was felt that a change in helmet use behavior would be a reasonable surrogate measure of the program’s effectiveness.54–56 Observations on randomly chosen bicyclists were carried out throughout the Seattle area, utilizing a formal epidemiological sampling strategy. To fully assess the effectiveness of the helmet campaign, such observations were carried out before the initiation of the public information campaign. Moreover, as a control for general societal trends in helmet use, similar observations were carried out simultaneously in Portland, Oregon, a city without a helmet promotion campaign at the time.54,56 These observations were carried out on 8,860 Seattle area bicycle riders from 1987 to 1993. During the first 2 years of the program, the percentage of helmeted riders rose from 5% in 1987 to 16% in 1988, during which time the helmet use rates in Portland remained below 3%54 Helmet use rates in Seattle continued to rise to 62% in 1993.57
This helmet promotion campaign has continued for the past 15 years, becoming partially “institutionalized” in that pamphlets and other educational materials are available on a regular basis from the state medical association; helmets are now a routine item for sale at stores that sell children’s bicycles; free helmets are available for all children on public assistance through the state welfare office; and many pediatricians and family practitioners routinely work injury prevention and bicycle helmet promotion into their counseling of families. In turn, over the years of the program, the program’s success at decreasing the more serious sequelae of bicycle crashes has materialized. In a study of the population enrolled in the state’s largest health maintenance organization, Group Health Cooperative, it was found that from 1987 to 1992, medically treated (admitted or emergency room) bicycle-related head injuries decreased by 72% among 5- to 9-year-olds and by 78% among 10- to 14-year-olds.56 Likewise, at the state’s only Level I trauma center, at Harborview Medical Center, among patients admitted for bicycle crashes, the proportion of patients with severe head injuries (Abbreviated Injury Scale [AIS] for head of 4 or 5) declined from 29% in 1986 to 11% in 1993. The mortality rate for admitted bicyclists also decreased from 7% in 1986–1990 to 3% in 1991–1993.57
Washington State Motorcycle Helmet Law
In contrast to the bicycle helmet campaign, efforts to improve use of helmets by motorcyclists in Washington State have emphasized legislation. Mandatory motorcycle helmet laws have been the subject of nationwide debate. During the 1960s and 1970s many states enacted such legislation, primarily due to the threat of the withholding of federal highway funds. In 1976, Congress withdrew the U.S. Department of Transportation’s authority to withhold highway funds based on individual states’ helmet laws. Many states, including Washington, repealed their mandatory motorcycle helmet laws, primarily due to lobbying by motorcyclists groups. Increases in motorcycle related deaths and severe head injuries were noted nationwide.7,18
In Washington State, attempts were made to reinstitute a motorcycle helmet law during the 1980s. Such efforts were defeated twice in the legislature. A third and final lobbying effort by proponents of the helmet law utilized not only information on the terrible human consequences of preventable motorcycle-related head trauma but also data on the financial cost of these injuries. These data showed that not only does helmet use decrease the incidence of severe head injury by more than 50% but also that the average cost ($15,592) of an admission for motorcycle-related trauma was increased dramatically by the presence of a severe head injury ($46,936), with even more costs accruing for subsequent rehabilitative and custodial care of those with these severe head injuries.58 Of special interest to the state legislature was the fact that 63% of the costs of treatment for motorcycle-related injuries were borne by general public funds, primarily state Medicaid.59 In part, because of these data showing the stake of taxpayers and the state budget in the motorcycle helmet debate, the Washington State Legislature passed a law the following year requiring helmets for all motorcycle drivers and passengers, effective June 7, 1990. Follow-up of the results of the reinstitution of the motorcycle helmet law has re-established the efficacy of this law. Among victims of motorcycle crashes admitted to the state’s Level I trauma center, the proportion of those sustaining severe (AIS 4 or 5) head injuries declined from 20% before enactment of the helmet law to 9% afterward. The mortality rate declined from 10% to 6%.57
These case studies point out several important principles about injury prevention efforts. First, they show the need for multidisciplinary collaboration and point out the important role that surgeons and other clinicians caring for injured patients can play in both education and advocacy work. Second, they show the importance of considering the political and cultural environment in which the prevention effort is occurring. Parents were more than ready to listen to messages about the safety of their children, when those messages were properly delivered. Although many motorcyclists were utilizing helmets without a mandatory law, those who were not using helmets have been unlikely to appreciably respond to educational efforts, hence the need for legislation.23 Advocacy for passage of this legislation was aided by publicizing information on the public costs of motorcycle trauma at a time when fiscal conservatism was a priority. Third, these efforts each focused on one key injury prevention strategy, rather than a wide array of activities, such as promotion of safe riding habits by riders of both types of vehicles. Although such efforts might be useful and should be promoted, intensive efforts, as in the helmet campaigns, are more likely to succeed when focused on a simple message.55 Fourth, outcome assessment was a key component, especially of the bicycle campaign. Outcomes that were feasible to measure and that would reliably indicate the success of the campaign were chosen (e.g., change in behavior of wearing helmets). Assessment of this outcome was built into the design of the campaign, both in before-and-after comparisons and in comparisons with a control community. Finally, both efforts were accomplished largely with a minimum of funding and in the case of the bicycle campaign with a generous input of volunteer labor.
Nationwide Effectiveness of Prevention Efforts Aimed at Unintentional Injury
Other examples of successful prevention programs aimed at unintentional injuries abound, so do examples of the complementary use of the three primary injury prevention modalities. These have been applied particularly well to traffic-related trauma. On a nationwide scale, this is especially well seen with promotion of restraints. The technological advancements, first of seatbelts and then the development of child safety seats and airbags have been complemented by promotion and education and by advocacy for legislation. Increased awareness of the importance of seatbelts has enabled passage of mandatory safety seats for children under 4 years old in all states and of mandatory seatbelt laws for all occupants in many states.7,25
The field of traffic-related injury prevention has also been advanced by other means, including vehicle design, highway design, lower speed limits, increased minimum legal drinking age, and increased public awareness about and increased enforcement of laws against driving while intoxicated. Similar advancements have been recorded in other types of unintentional injuries such as occupational injuries, residential injuries, and burn prevention.
These advances in prevention, coupled with advances in trauma treatment, have reduced the death rate for unintentional injuries to some of the lowest rates recorded since statistics were first collected in the early part of the past century.51 The accomplishments have been especially notable in the last two decades. During the 1980s and 1990s, the rate of death due to unintentional injury declined by 19%, from 42.8 deaths/100,000/year (1981) to 34.9/100,000/year (2000). Obviously, there is still much to do. In fact, there has been some erosion of gains in the past few years, with rates increasing from the nadir of 34.9 deaths/100,000/year in 2000 to 39.8/100,000/year in 2006.26,60
Priorities for future work in the prevention of unintentional injuries include decreasing public acceptance of driving while intoxicated, especially among younger drivers; increasing use of seatbelts both through educational efforts and through advocacy for passage of mandatory seatbelt laws with provisions for primary enforcement in all states; further promotion of helmets for motorcyclists and bicyclists; and increased occupational safety especially in the highest risk professions of mining, construction, logging, and transportation.
STRATEGIES FOR PREVENTION OF INTENTIONAL INJURIES
Organized injury prevention efforts do not have as long a history for intentional injuries as it does for unintentional injuries. Prevention of intentional injuries has traditionally been the realm of the criminal justice system, with health care professionals and injury prevention personnel being relative newcomers. However, the same basic principles of injury etiology apply. Likewise, prevention work can be based on the development of strategies to identify and decrease risk factors. These strategies can use the same modalities of engineering, education, and enforcement to accomplish change in society.
Some of the prevention efforts that have been utilized against some of the more common forms of intentional injury will be reviewed briefly. Fatal intentional injury is commonly categorized as either homicide or suicide. However, it is important to remember that homicide is a final common pathway for several types of violent behavior, each of which produces many more nonfatal injuries. These include domestic violence, child abuse, elder abuse, and assaultive behavior in general. Prevention strategies for each of these are fairly different and examples will be considered separately.
A minority of interpersonal violence occurs between strangers. The majority occurs between people who know each other and occurs in the course of interpersonal relationships, which have evolved into conflicts. Hence, a focus for violence prevention has been to promote nonviolent “conflict resolution.” The teaching and promotion of conflict resolution skills has been undertaken within two broad categories of programs: school based and community based.7,61–64
These usually involve an educational curricula aimed at changing students’ attitudes toward violence and teaching adaptive interpersonal skills for nonviolent conflict resolution. Several standardized curricula are available, oriented for a variety of grades, from primary through high school. These curricula have been shown to change students’ attitudes toward violence and to decrease interpersonal aggression in the short term. However, their long-term effectiveness at decreasing assaultive behavior is not known.7
An example of one such curriculum is Second Step: A Violence Prevention Curriculum, Grades 1–3. The curriculum consists of 30, half-hour lessons. Each lesson involves the presentation of a social scenario, with an accompanying photograph. This scenario forms the basis for discussion and role playing by the students. Teachers who participate are usually given a 2-day training session. The lessons are arranged in three groups: (1) empathy training, (2) impulse control, and (3) anger management.
In a study to evaluate the effectiveness of this curriculum, 12 elementary schools in King County, Washington State, were randomized to have the curriculum taught or to be a control. Observers rated specific children’s interactions with other children and with teachers using a standardized social science behavior coding system. These observers were blinded as to whether or not a given school or specific children had received the curriculum. There was a decrease in physical aggression and an increase in neutral/prosocial behavior in the group receiving the curriculum compared with the control group. This was true at both 2 weeks and at 6 months after the course was taught. These changes were significant at both time periods, but less pronounced at 6 months. The ultimate effect on violent behavior in adolescence and adulthood remains unknown.63
These programs focus on decreasing youth violence outside of the school environment. This has the advantage of reaching older adolescents and dropouts. Some community-based programs utilize conflict resolution education, similar to school-based programs. Such education is delivered by public education campaigns and via neighborhood health centers. In some cases, high-risk youths, such as those seen in emergency rooms for assaultive injuries, are identified and referred for violence prevention counseling.65
Some community-based programs are parts of more general youth development programs, featuring mentoring, as well as recreational and cultural activities. These include some traditional approaches that have been active for years, such as the Boys Club. Such programs seek to decrease violent behavior as part of decreasing overall delinquency and drug dependency.
An example of a successful community-based program is the Harlem Hospital Injury Prevention Program (HHIPP). This program, founded in 1988, sought to decrease childhood injuries from all causes, including violence. The program used a broad multidimensional approach, including educational programs on health and safety; increased environmental safety in parks and playgrounds; and increased availability of supervised recreational activities for children and adolescents. The program was community based, with the HHIPP acting as the lead agency in building a coalition, which included neighborhood organizations and agencies of the local and state government.61,62
The results of these activities were evaluated using the Northern Manhattan Injury Surveillance System. The incidence of all injuries targeted by the HHIPP decreased by 44% after the institution of the program. Violent injuries decreased by 50%, in comparison to control communities, where such violent injuries increased by 93% during the study period.61,62
Although a large proportion of all violent acts involve persons living in the same household, a specific subset of such violence warrants special attention. This is violence involving spouses or other intimate partners and hence is often know as intimate partner violence. The vast majority of such abuse involves a man injuring his female partner.
This is often regarded as a separate entity because of the interpersonal dynamics involved and the associated prevention implications. Domestic violence usually is a chronic, repetitive phenomenon. It is usually associated with psychological abuse and verbal intimidation. It is usually characterized by a man who seeks to dominate his partner both physically and emotionally and by a woman who is afraid to leave the relationship because of psychological and/or financial dependency. The more extreme forms of domestic violence, including homicide, are usually the endpoints of long abusive relationships.7,66,67 It is the identification of domestic violence at its earlier stages upon which most preventive strategies are built.
For years, the mainstay of domestic violence prevention has been the criminal justice system. This has included both active interventions, such as restraining orders against abusive men, and deterrence by threat of punishment. None of the other newer interventions are likely to work unless such a system is functional. However, as traditionally used, the criminal justice system is underutilized primarily because many women are afraid to step forward and file complaints.
Hence, other modalities have been deemed necessary. These have included the use of hot lines, counseling services, and shelters for battered women. Another component of prevention has included early identification of battered women through the health care system. This has included identification in the setting of both emergency departments and primary care practices. Although many battered women may not volunteer information as to a history of battering, many are willing to divulge the information when asked. Hence, questioning about domestic violence is critical for screening and identification. Both the American Medical Association and the American College of Emergency Physicians strongly recommend routine screening for domestic violence.66–69 Specific programs aimed at domestic violence have included programs to improve training of health care workers (including doctors, nurses, and receptionists) in such screening for domestic violence. This includes techniques for eliciting confidential information from victims, for establishing severity and risk, and for presenting options for safety and counseling. Such programs have been documented to improve screening and case identification of abused women.7,66,67,70
In addition, further work is needed to identify the most effective interventions, once a woman at risk for repeated domestic violence has been identified. The same rigor that has been applied to outcome assessments for unintentional injury needs to be applied for intentional injury. This implies a furthering of scientific inquiry into domestic violence and other forms of intentional injury. As one example of such evaluation, Holt et al. demonstrated that year-long restraining orders were more likely to lead to a decrease in subsequent acts of violence against women than short-term orders.71
High-risk groups for suicide include adolescents and young adults in all races, but especially Native Americans. Unlike other forms of intentional injury however, one of the highest risk groups is older white men.51 A common problem with suicide prevention efforts is the relative lack of evaluation of their effectiveness. In part, this has been due to a difficulty in monitoring suicides due to underreporting. Also, the sporadic nature of actual suicides mandates very large sample sizes in order to assess effectiveness. Thus, a variety of different prevention strategies have been utilized.
Identification and Treatment of Individuals at High Risk of Suicide
Such identification has most often been done within the health care system, especially in emergency departments and primary care practices. Patients who present to an emergency department having just made an unsuccessful suicide attempt are obviously one high-risk group to identify. Identifying patients with depression or other “warning signs” of impending suicide within the context of a primary care practice, however, is much more difficult.72
In addition to a history of prior suicide attempt, studies have shown several risk factors for future attempts, including alcohol or substance abuse and mental illness, especially affective disorders.73 However, none of these factors is sufficiently sensitive or specific to be a good screening test in and of itself. Special efforts to upgrade the training of primary care providers to improve recognition of these risk factors and to increase their familiarity with treatment for these disorders has shown some promise in improving the detection and treatment of high-risk individuals.74–77
Education Programs Aimed at General Public
These have most notably been utilized in school-based settings. The goals of such programs are to educate teachers, students, and parents about warning signs of impending suicide attempts and to provide them with information about available resources for help.7,78
Crisis Intervention Services
Accessible self-referral resources for suicidal persons have included hot lines and personal counseling. In addition to the services they directly provide, these also function as an entry point into the mental health system. Such crisis intervention services have been the most frequently utilized suicide prevention strategies. However, their impact on lowering the suicide incidence rate has not been well demonstrated.7,78
Reducing the Availability of the Means of Suicide
Reducing access to the means of suicide can be considered on both an individual and a societal level. It might seem that someone who wishes to commit suicide would find alternative means. However, most cases of suicide involve complex psychological processes in which both ambivalence and spontaneity play major roles. Elimination of a convenient and acceptable way to commit suicide may not lead to choosing another alternative, but rather to a decision not to complete the act.7,78
One of the best examples of the effects of decreasing the availability of the means of suicide was in England. Prior to the 1960s, half of the persons committing suicide in England used cooking gas to asphyxiate themselves. At the time, cooking gas was coal-based and consisted of 10–20% carbon monoxide. During the 1960s and 1970s, this was replaced by natural gas, both for safety and for economic reasons. The overall suicide rate in Britain decreased by 35% in the years after the gas supply had changed.79,80 This example has obvious implications for the United States, where the majority of suicides are committed with firearms.
The Roles of Alcohol and Firearms
As can be seen, there are a variety of interventions to decrease specific types of intentional injury, based on the human, psychological, and interpersonal factors at play. However, there are several common risk factors for all forms of intentional injury. These are the high frequency of involvement of alcohol and firearms. Between 30–60% of all homicides involve alcohol on the part of at least either the assailant or victim.7 Alcohol involvement in suicides also appears frequent, although the exact percentages are more difficult to identify. Similarly, firearms are used in 60% of suicides and 70% of homicides.5–7,51
Strategies to decrease the availability or impact of alcohol in society are also ways to decrease alcohol’s involvement in intentional injuries. Such strategies include institution of a 21-year-old drinking age, higher alcohol excise taxes, and increased availability of alcohol rehabilitation services. Hospital- and trauma center-based counseling interventions aimed at patients who present with any type of alcohol-related injury are another strategy to consider, as discussed in the section on unintentional injury.39–41
Likewise, strategies to decrease the availability or impact of firearms are ways to decrease intentional injuries in general. However, probably no other aspect of injury prevention engenders a greater debate than this issue. Firearms are more common in American society than in almost any other developed country. The United States has higher rates of firearm-related injury than any other developed country that is not at war. Attempts to decrease the availability of firearms have met with sustained, emotional resistance from Americans who consider unrestricted ownership of firearms a constitutionally guaranteed right.
However, it is important to recognize that communities with differing gun laws causing resultant differences in the prevalence of gun ownership also demonstrate decreases in homicide rates in those communities with more restrictive gun control laws.81 Data on the effects of the institution of more restrictive gun ownership laws in a given area over time are less clear cut. However, the weight of the evidence does indicate a net reduction in firearm-related deaths from such laws.5,6,82,83
The CDC recommends a greater use of restrictive licensing for firearms, especially for handguns. Such gun control laws restrict possession of handguns to those with a clearly demonstrated need. The CDC also recommends greater enforcement of existing firearms laws, such as requiring waiting periods and background checks for those wishing to purchase guns.7 In addition, another matter requiring attention is closing the current gun-show sales loophole.
Other preventive measures directed at firearms include educational programs to teach safe gun handling, as a way primarily to decrease unintentional firearm injuries. However, similar to other generic nonfocused educational programs, the efficacy of such programs is not well demonstrated. Moreover, unintentional injuries account for only a small proportion of all firearm-related injuries.7 Finally, there has been increased emphasis lately on safer storage of firearms. This includes keeping guns stored unloaded with ammunition stored separately. Other alternatives include the use of trigger locks and locked gun boxes. These devices allow a loaded gun to be kept more immediately available for those who feel the need to have such weapons rapidly available for self-protection. All these techniques are felt to be ways to decrease not only unintentional firearms injuries, but also both assaultive and suicidal use of firearms.84–86 In addition to social marketing efforts to promote use of these devices, mandated trigger locks on all guns sales is a currently proposed approach.
RECENT GLOBAL INITIATIVES
This chapter primarily addresses the circumstances of North America and other high-income countries. However, the vast majority of injury-related deaths occur in low- and middle-income countries (LMICs). This is because this is where the majority of people live; injury rates are higher; there have been limited application of organized injury prevention efforts; and trauma care systems are less than optimally developed. Moreover, injury rates are declining in most high-income countries, but rising, sometimes rapidly, in most LMICs.87,88
Many of the general injury prevention principles discussed in the current chapter are applicable under any circumstances. However, some of the specific applications need to vary to fit the circumstances of most of the world. This is due to varying injury mechanisms, resource restrictions, and cultural differences. There is a need to develop local injury prevention expertise and locally applicable strategies.
After years of neglect by international agencies, injury control has been gradually receiving justifiable increases in attention worldwide. One of the groups spearheading these efforts has been the World Health Organization (WHO). Two recent landmark publications by the WHO have addressed two of the biggest injury problems, road traffic injury and violence. The World Report on Road Traffic Injury Preventionhas helped raise awareness about the problem and to promote practical policy solutions for countries at varying economic levels worldwide.89 The World Report on Violence and Health has emphasized the role that the health sector can have in violence prevention, in addition to sectors, such as criminal justice, that have traditionally been the foundation of violence prevention.90 This report points out the complementary role that the health sector brings by its focus on changing the behavioral, social, and environmental factors that give rise to violence. Health also brings its focus on prevention, its scientific outlook, and its potential to coordinate multidisciplinary approaches.
In similar fashion, the Global Burden of Surgical Disease working group has been formed, consisting of surgeons, anesthesiologists, public health specialists, and others from the United States and from many other countries. This group has worked closely with the American College of Surgeons and WHO. It is working to get increased global attention to a spectrum of issues that involve surgical care, including trauma, obstetrics, and emergency surgical conditions. Among other activities, the group is attempting to get better estimates of the toll of surgical conditions especially within the Global Burden of Disease study, and to promote increased attention to planning for surgical care within the world’s ministries of health.91
This increased attention to global injury control has gradually resulted in increasing political commitment. In 2009, the First Global Ministerial Conference on Road Safety was held. This was attended by ministers of health and/or transportation and other senior officials from 150 countries, who committed their countries to greater attention to road safety. This was followed shortly thereafter, in March 2010, by the United Nations General Assembly declaring 2011–2020 as the Decade of Action for Road Safety. Through this Decade of Action, country governments worldwide committed to action in such areas as developing and enforcing legislation on key risk factors, including speed reduction, reducing drunk-driving, and increasing the use of seatbelts, child restraints, and motorcycle helmets. Efforts will also be undertaken to improve trauma care, upgrade road and vehicle safety standards, promote road safety education and enhance road safety management generally.92 Of course, it is still up to injury control advocates to actively lobby their governments to see that these commitments become reality.
There has also been increasing commitment to injury control by funders. For example, the U.S. National Institutes of Health established the Fogarty International Collaborative Trauma and Injury Research Training Program. This funds collaborative training programs linking U.S. universities with partners in developing countries for the purpose of increasing the capacity of developing country institutions to conduct research on injury prevention and trauma care. Similarly, several private foundations have begun funding injury control issues. For example, the Bloomberg Philanthropies has recently funded a consortium of partners, headed by WHO, to improve road safety in 10 developing countries that currently account for half of all road traffic deaths globally.93 Nonetheless, overall funding for injury prevention remains inadequate compared to the extent of the problem and major bilateral donors, such as USAID, have not yet established programs that encompass injury prevention.
Readers interested in learning more about the application of injury prevention programs in LMICs are encouraged to read these and other related2,88,93,94 publications, as well as the WHO website (www.who.int/violence_injury_prevention/en/).
BOX 3-1 COMPONENTS OF A SUCCESSFUL INJURY PREVENTION PROGRAM
1. Identify a significant, eminently preventable, injury problem and a potential, eminently feasible, intervention.
Problem should be a significant health problem, in terms of mortality or morbidity.
Focus on injuries that are severe or common, or both.
An effective intervention should exist, especially one which is being suboptimally utilized in a given environment.
Gather information on the extent of the problem and the effectiveness of possible interventions.
Be able to communicate this information in terms understandable to the public, politicians, and other constituencies.
2. Identify and elicit the support of potential partners.
Create a coalition of those with similar interests and goals.
This coalition could include clinicians, public health practitioners, government, members of the lay public,
insurance companies and other industry representatives, and others.
Having one of these partners function as a “lead agency” is helpful to coordinate and stimulate the actions of the other partners.
3. Identify barriers to the use of the intervention. Such barriers could include:
The knowledge and attitudes of the public.
Available interventions may need to be modified or presented differently to certain high-risk groups.
Lack of political will.
Opposition by special interest groups.
4. Develop and implement a plan to address these barriers.
Such a plan could involve a wide variety of actions and goals, such as, among other items:
A public information campaign to change a dangerous behavior.
A change in a law or the enforcement/application of a law.
Change in the availability or characteristics of a product.
Change in a hazardous environment.
Surgeons and other clinicians can play key roles in all of the above, through actions, such as, among others:
Bearing witness to the human toll of injury, so as to increase public and political will for changes.
Advocacy for changes with local, state, and national government.
Institute changes in injury prevention practice in their own institutions, such as with instituting alcohol interventions in hospitals.
Injury prevention related counseling and advice for patients and their families.
Successful programs usually involve:
Need to mobilize resources:
Publicity/free advertising/human interest stories.
More resources usually available with increased community interest and involvement.
Other aspects of successful programs.
Specific tasks assigned to specific partners.
Set reasonable, meaningful, yet achievable goals.
Regular meetings and updates by coalition members.
5. Evaluate the outcome of this program.
Potential items to assess.
Change in a law or its enforcement.
Change in behavior, such as use of safety devices (e.g., smoke detectors, helmets).
Decreases in rates of death or severe injury.
Be prepared to change plans, if needed, based on feedback from outcome assessment.
6. Prevent the erosion of success.
Most successful injury prevention campaigns are those that eventually become “institutionalized” and thus a regular part of the function of government or other groups.
Guard against successful programs being rolled back by opposing interest groups or apathy by the public.
CONCLUSION: THE SURGEON’S ROLE IN INJURY PREVENTION
Injury prevention efforts do work. Such efforts have had considerable success in lowering the toll of injury-related death and disability. These successes have been most notable in unintentional injury, especially due to road safety. Organized injury prevention work is also being increasingly applied to intentional injury. Obviously, much more remains to be done. This is especially true in light of recent setbacks in highway safety, motorcycle helmet use, and flame retardant clothing for children’s sleepwear. In addition, the raising of speed limits in most states resulted in an increase in the motor vehicle crash death rate in the early 1990s with stagnation in the death rate thereafter, until the most recent few years.25
The accomplishments and successes of injury prevention programs rely on multidisciplinary input. Although many surgeons may not consider themselves as a usual part of injury prevention work, there is much they can contribute. In some injury prevention programs, they have played a pivotal role. Their contributions can be on both individual and societal levels. Surgeons, along with emergency physicians and prehospital providers, have more direct contact with acutely injured patients than do any other health care professionals. Hence, they are in a position to provide individual patient counseling regarding safety at a time when many injured persons are in a receptive state. Examples include emphasizing the importance of bicycle helmets to the parents of a child who has been injured bicycling without one and stressing the necessity of wearing a seatbelt to a motorist injured without one.
Perhaps one of the biggest roles for surgeons is to screen patients for alcohol abuse. Surgeons in hospitals that receive large numbers of injured persons should make sure that their hospitals institute mandatory screening, counseling, and referral programs, as now required by the American College of Surgeons for Level I and II trauma centers.
The voice of authority with which health care professionals speak allows them to be effective advocates for injury prevention educational campaigns and for legislation. Surgeons and other clinicians were instrumental in the public information campaigns that formed a component of the Seattle bicycle helmet campaign. Likewise, surgeons and other clinicians provided testimony in the motorcycle helmet debate, which eventually led to the passage of numerous state motorcycle helmet laws.
Research is another avenue through which surgeons have and can contribute to injury prevention. This includes research that demonstrates the extent of a problem. For example, research on the costs of nonhelmeted motorcyclists in Washington State has provided useful data in the motorcycle helmet debate.31,58,59 Such research also includes evaluation of the effectiveness of injury prevention programs.57 In addition to such analytic research, surgeons have contributed to the development of systems to collect basic information on the extent of the toll from injury. For example, surgeons have been actively involved in the ongoing development of the National Violent Death Reporting System, created by the CDC. This system is seeking to provide information on the toll of violence in our society and to provide answers to questions about violence prevention strategies (http://www.cdc.gov/ViolencePrevention/NVDRS/index.html).
For surgeons and other clinicians wishing to get involved in injury prevention, many of the references cited in this chapter offer useful practical information. We especially recommend Injury Prevention: Meeting the Challenge, published by the CDC,7 Injury Prevention and Public Health by Christoffel and Gallagher,3 and the Handbook of Injury and Violence Prevention by Doll et al.4 Finally, the American Association for the Surgery of Trauma and the American College of Surgeons both have prevention sections on their websites (http://www.aast.org and http://www.facs.org/trauma/injmenu.html). These sites provide useful, practical information on injury prevention and on important injury-related legislation, which is pending. They also have multiple links to other injury prevention resources, including a large number of local programs.
A summary of the components of a successful injury prevention program, with emphasis on a surgeon’s involvement, is included in Box 3-1.
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