Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 37
3
Prevention of Injury
GENERAL APPROACHES TO INJURY PREVENTION
A number of approaches for identifying injury-control
options have been developed. One of the more useful (the
three-phase approach discussed in Chapter 1) was first
presented by Haddon7. and elaborated on by numerous
authors for various types of injury. .. ~s S3 72 73 7S
~ 6 0 ~ 6 ~ ~ 6 3 ~ 6 ~ Three general strategies are available
to prevent in jur ies: ~ 6 ~
· Persuade persons; at rzak of injury to alter their
behavior for increased Elf-protection--for example, to
use seatbelts or install smoke detectors.
· Require individual behavior change by law or
administrative rule--for example, by laws reguir ing
seatbelt use or requiring the installation of smoke
detectors in 811 new buildings.
· Provide automatic protection by product and
environmental design~for example, by the installation of
seatbelts that automatically encompass occupants of motor
vehicles or built-in sprinkler systems that automatically
extinguiab f ires .
Each of these general strategies has a role in any
comprehensive injury-control program; however, a basic
finding from researched is that the second atrategy--
requiring behavior change--will generally be more effec-
tive than the f irst, and that the third providing
automatic protection--will be the most effective. A
fundamental reason for this is that members of high-ri';k
groups tend to be the hardest to influence with approaches
37
OCR for page 38
38
that involve either voluntary or mandated changes in
individual behavior. Teenagers, for example, are much
less likely than adults to wear seatbelts, whether or not
a law requires them to do so. 2 2 ~ Program intended to
change alcohol-related behavior voluntar fly have not pro-
duced sustained reductions in death rates. ~ ~ 9 Elderly
pedestrians admonished by police for jaywalking were no
less likely to do it again. 2 ~ 6 Scofflaw drivers whose
licenses had been revoked were more likely than the aver-
age licensed driver to be involved in fatal crashes. 6 7
Arid not only are young children hard to influence, but
intensive efforts at a well-baby clinic, for example, had
no effect on dangerous maternal behavior, such as leaving
knives and matches within the reach of small children. \2
Education
The tendency to attribute injuries to human error"
has nour ished the hope that they can best be prevented
through voluntary behavior change. Yet neither safety-
education campaigns nor driver-education programs have
been shown by scientific evaluation to justify the faith
and large budgets accorded them.~° ~ 6 2 Educational
and informational programs should be held to the same
standards of efficacy as other prophylactic interventions;
furthermore, it should not be assumed that such programs
cannot do harm.
Many injuries (including highway injuries) result less
from lack of knowledge than from failure to apply what is
known. Failure to use available information is found not
only in the persons who may be injured ~ teenagers who
know that seatbelts will reduce the likelihood of death
or injury, but fail to use them, or parents who know that
children can be burned by stoves, but fail to keep their
children away from stoves--but in decision makers who can
influence the probability of injury to others, including
manufacturers who must consider that their products will
be used by less-than-perfect people. One problem with
relying on educational approaches is the counterinfluence
of the mass media in implicitly encouraging violent or
hazardous behavior; children burned while imitating tele-
vised activities are a tragic example. Many television
shows aimed specifically at young children show frequent
high-speed car chases and crashes from which occupants
emerge uninjured--a gross distortion of reality. 12
OCR for page 39
39
I f automatic protection has not been developed or
implemented and behavior is not amenable to legal counter-
measures, persuasion might be the only strategy available.
For example, pedestrian injuries to children have been
reduced by an in-school education program. s 7 However,
behavioral research is too often confined to behavioral
responses of college students, and the relevance of most
such research to injury control has not been established.
Furthermore, funds, manpower, and motivation for research
on education programs are often lacking. Educational
efforts, advertising campaigns, and incentive programs--
many on a large and costly scale--are therefore typically
introduced with no knowledge of their effectiveness.
Another problem with education-based approaches is
that, despite the large body of research on human
behavior, individual traits that are easily modifiable
for injury control have thus far not been identified.
Identification of age, sex, and racial groupings with
widely differing risks can be useful for targeting
control efforts , including education programs, but those
factors are not modifiable.
Laws
Education by itself has rarely proved to be an adequate
preventive approach. Individual behavior change to pre-
vent injuries has been more successful when the behavior
was easily observable and required by law. For example,
in the absence of laws requiring the use of protective
helmets, only about SO percent of motorcyclists volun-
tarily wear them, but helmet-use laws result in almost
100 percent use.2~2 Laws mandating individual behavior
are clearly more effective than education and protect more
members of society. Many laws , however , have limitations ;
for example, even with intensive enforcement, many motor-
ists violate speed limits and ignore laws on seatbelt use
and child-restraint use. 7 ~ ~ ~ ~ 2 2 0
As with voluntary behavior change, laws and regulations
aimed at changing individual behavior tend to be least
effective among the very groups that are at highest risk
of injury. For example, in 'several countries with
seatbelt-use laws, seatbelt use was observed to be subs
stantially less among teenagers and among persons with
h igh blood alcohol concentrations~two groups with a h igh
risk of involvement in serious motor-vehicle crasbes.2 ~.
As a result, seatbelt-use laws typically do not reduce
OCR for page 40
40
fatalities as much as would be expected on the basis of
the known effectiveness of belts when used.1 6 S
Factors that have increased or decreased the effective-
ness of laws include the extent to which prohibited or
required behavior can be directly observed by law-
enforcement officers, the probability of arrest for
violation of a law, the extent to which enforcement is
augmented by members of the community other than the
police (e.g., parents, bartenders, and gun dealers), and
the severity of punishment of those convicted of viola-
tions. The relative ef feats of these factors are only
par fly under stood . ~ 6 ~
Despite the overwhelming evidence of the injury-
reducing benefits of many mandated injury-control
measures--such as federal motor-veh~cle safety standards,
seatbelt-use laws, and motorcycle helmet laws--the value
of such measures has been challenged.~`S The chal-
lengers hypothesize that the effectiveness of mandatory
approaches is partially or wholly offset by changes in
behavior by persons who take greater risks to compensate
for their increased safety. A number of variations.on
this notion of human behavior have been developed, and
they have been variously referred to as the "risk-
compensation~ and ~risk-homeostasis. hypothesis. 2 ~ 7
This view of human behavior has been the subject of much
theoretical debate, as well as prolonged dispute on the
extent to which the benefits of federal mstor-vehicle
safety standards might beve been reduced because of such
compensation. i . 2 ~ S ~ ~ 5 9 The debate continues, but
the evidence is overwhelming that the federal motor-
vehicle safety standards have substantially reduced
car~occupant fatalities. s ~ Furthermore, in careful
assessments of risk compensation based on direct
observations of behavior--as opposed to the mainly
theoretical arguments of the proponents of these
hypotheses no evidence of increased risk-taking has been
found. ~
Product and Environmental Den ign
The most successful injury-prevention approaches have
involved improved product designs and changes In the
man-made environment that will protect e~rervone. Such
built-in or automatic protection, now taken f or granted
in insuIated electric hand tools and household fuses, is
gradually gaining acceptance in other realms, because of
its great potential for preventing deaths and injuries.
OCR for page 41
41
A basic finding from health-behavior research is that,
as the frequency and amount of required individual
effort increase, the proportion of the population that
w ill respond by adopting the recommended behavior
decreases. 16 ~ Consider, for example, ~ e protection of
children from toxic substances. Limiting the amount of
substance in each container sold to a subtonic dose does
not require any effort by the parent or child and is the
method most likely to prevent fatal poisoning; childproof
closures on containers of toxic materials have greatly
reduced fatal poisonings, but occasionally the closures
are left off and children gain access to the contents;
admonitions to lock cabinets after each use of a toxic
substance are the least effective.~° Furthermore, even
in homes where poisoning has already occurred, measures
to prevent a recurrence remain rare.209
Some product and environmental changes achieve
impor ten t changes in behavior . For example, exper imental
equipping of fleets of vehicles with high-mounted brake
lights substantially reduced the incidence of rear-end
crashes. Hiss Such experiments are outstanding
examples of the research needed to test the effectiveness
of new and developing technology, including ergonomic
designs for human-vehicle and human-environruent
interaction. ~ s s
The perception of, and reaction to, motion (one 's own
and that of other moving objects) and the effect of
environmental factors on such perception and reaction
have not been sufficiently researched. Results of
experiments with the placement of brake lights,i5.
daytime use of headlights,~95 and reflective lines 3 ~
on roads suggest that environmental changes to improve
perception of hazards can effectively reduce the
incidence and severity of injuries.
PREVENTION OF SPECIFIC TYPES OF INJURY
Transportation Injuries
Although.safety standards have reduced the motor-
vehicle death rate per mile of travel,i'° the total
number of deaths remains high, because of growth in the
number of vehicles and particularly growth in the use of
less regulated and less protective vehicles, such as
motorcycles. Motorcycle deaths were estimated to bave
increased by 158 percent between 1968 and 1979.~.
OCR for page 42
42
Although much researab ha';. been conducted on passenger
vehicles, little analogous re';earch has been done on
motorcycles; and large trucks or on ways to reduce the
damage they inflict on pedestr tans, bicyclists, and other
road users. Large trucks are substantially over involved
in crasher, and when they collide with other vehicles,
they are especially hazardous to the occupants of those
vehicles. 'I
There is convincing evidence that h igh speed is a
factor in many serious highway crashes. ~ 98 An obvious
way to reduce the kinetic energy of vehicles is to reduce
their maximal speed. Those who oppose such an approach
claim that the engine power is needed in some situations.
However, it has not been determined whether that is true
for specific types of vehicles or whether designs could
be developed to allow power for legitimate needs, but not
for substantially exceeding legal speed limits.
I f r isk is measured in terms of deaths per person-mile
of travel, light aircraft rival motorcycles. About half
the planes used in general {noncommercial) aviation can
be expected to be involved in a potentially in jury-
producing mishap at some time, but most occupant protec-
tion standards have not been upgraded for more than 30
years.~83 As a result, hundreds of people die each
year in plane crashes who could survive If seats, fuel
systems, etc. were designed to protect occupants in a
crash.
Workplace Injuries
The kinds of equipment especially likely to cause
severe injury to workers can be identified--such as trac-
tors and forklifts that are likely to overturn, cranes
and other machinery with booms that can contact electric
wires, and farm equipment with exposed moving parts that
can entangle or amputate limbs. But little research has
},een done on designs for safer machinery and operating
procedures.
Some research should also focus on the prevention of
injuries during operations, such as repairs and cleaning,
that are associated witch a high incidence of injuries.
Research on work-related injuries has generally
emphasized industrial settings, with little attention to
many high-risk occupations, such as fire fighting and
truck driving. Unlike approaches to work-related
diseases, many approaches to work-related injuries have
OCR for page 43
43
tended to emphasize unproven educational programs to make
workers more careful, rather than reducing exposure to
job hazards.
Recreation Injuries
The prevention of injuries related to most types of
recreation remains nearly unresearched. For example, the
effectiveness and use of protective sports equipment and
of environmental modifications--such as energy-absorbing
playground surfaces and gymnasium walls--are largely
unknown. Research showed the risk of spinal cord injury
associated with trampolines to be so great that many
schools stopped trampoline activities; as a result,
spinal cord injury rates decreased. 7 0 In boxing ,
football, and other contact sports, rules permitting or
restricting particular maneuvers are a major determinant
of rates of severe injury to the brain and neck; research
is needed in many sports to identify the most hazardous
aspects and to evaluate corrective measures.
Programs to reduce drowning and other forms of
asphyxiation have seldom been studied before implementa-
tion. Boating-related deaths per 1,000 boats decreased
after standards for flotation of the boats and readily
available personal flotation gear were introduced, but we
do not know whether those standards made the difference.
We do not know whether more visible swimwear, underwater
lighting in pools, or belts that inflate at the push of a
button would affect drowning rates. The value of child-
proof fences in reducing pool drownings has been
demonstrated, but further research is needed on the
relative effectiveness of various barriers and of
measures to increase their use.
Falls
More than 14,000 people die of injuries from falls
each year, but the cause'; and possible countermeasures
are rarely researched. Little is known about the
effectiveness of energy-absorbing materials, either worn
by persons at high risk or incorporated in the surfaces
onto which they fall. Research on such materials would
have application in homes and institutions that house
children and the elderly, as well as in environments,
such as playgrounds and high-risk workplaces, where
OCR for page 44
hi:
~ 44
epidemiologic studies have indicated that severe injuries
f rom falls occur most frequently. Architectural designs
that should reduce injuries from falls are known, but
research on how to increase their use is lacking.
· ~
Fires ana Burns
Nearly 7, 000 people die each year from f ires and
burns, most of which occur in the home. Little is known
about the effects of gases from burning mater ials and
about the flammability of many materials used in houses,
furniture, and bedding. Adequate escape routes from
buildings and aircraft are essential for reduction of
asphyxiation and burns in fires, but they are often
lacking. More widespread use of smoke detectors and
automatic fire-extinguishing systems would help to reduce
the toll taken by housefires. Designs of such ignition
sources as cigarettes, matches, and lighters to prevent
inadvertent ignition are available and can be further
improved and used.
Assaultive Injuries
Nonfatal assaultive injuries and homicides have been
subjected to little prevention-oriented research.
Typically, they have been regarded as a Crime problem,.
rather than as a health problem, and blame and punishment
of the perpetrators have been emphasized, rather than
measures to reduce the frequency and severity of such
injuries. Firearms could probably be designed with
safety catches and trigger tension to keep small children
from firing guns when they find them and play with them.
The f irearms laws in various jur isdictions and the changes
in laws when they are enacted or amended have not been
thoroughly researched to measure their effects on the
frequency and severity of injuries caused by firearms.
In addition to research on laws, research on the effec-
tiveness of other measures to reduce firearm homicide is
needed. Asssultive injuries involving other weapons or
personal force are virtually unresearched.
Self-Inflicted Injuries
Much research on suicide and on nonfatal self-inflicted
injury has emphasized personal characteristics and methods
OCR for page 45
45
of treating depressed or suicidal people. Changes in the
physical and social environment and their effect on sui-
cide rates have been the subject of little research and
need to be evil Hated. The validity of the widespread
assumption that nonfatal suicide attempts represent a
lack of desire to kill oneself, and therefore involve the
choice of less lethal means, should be subjected to
scientific scrutiny; there is evidence that reducing
the availability of popular means of committing suicide
can cause a major reduction in the suicide rate.~°
Research on reducing the lethality of colon means of
committing suicide should be encouraged; for example,
changes in the formulation, number of pills per bottle,
and prescribing practices related to antidepressants
should be implemented on a trial basis and evaluated.
Relationship of Alcoholic Beverages to Injury
Alcoholic beverages are involved in a large proportion
of all types of in jur ies, including workplace and inten-
tional injuries. Most of the alcohol-related injury
researab, however, has focused on the ef fectiveness of
various programs to reduce drunken dr ~ ving . In addition
to continued evaluation of such efforts ~ other questions
should be addressed. Will the marketing of low-alcohol
beverages result in less alcohol-related impairment
leading to injury, or will most people, and heavy drinkers
in particular, consume more to obtain the same dose of
alcohol? Is it possible to reduce absorption across the
stomach and intestinal walls or otherwise reduce impair-
ment among persons who abuse alcoholic beverages? Are
there environmental designs, signals, or conditic-~s that
reduce the risk of crashes by intoxicated drivers?
STATUS OF INJURY-PREVENTION PRO&RAMS AND RESEARCH
The prevailing injury rates represent the failure of
society to address today's major public health problem.
Despite the injuries associated with light aircraft,
boats, farm and industrial machinery, firearms, and
cigarette-related fires, federal agencies with relevant
responsibilities have conducted very little injury-
related research.
Research to evaluate programs, laws, and regulations
should be insulated from the agencies responsible for the
OCR for page 46
46
injury control efforts. It is the rare organization that
can objectively evaluate its own activities Such self-
evaluation all too often ends in justificaLv:~on of the
status quo, rather than a critique of what is being done
relative to what could be done. At pres,-~t, very little
evaluation of injury control efforts is Undertaken by the
responsible agencies, and even less by organizations
independent of the agencies charged with injury control.
Schools of public health and medical schools are a
potential source for independent evaluations, but they
generally do not have courses aimed at training in injury
epidemiology, prevention-program development, or evalua-
tion of injury-control measurers The few knowledgeable
teachers and researchers in th,..se settings are expected
to raise all or most of their salaries and research funds
from sources outside the universities.
The shortage of health professionals and other scien-
tists with relevant train) fig is a major impediment to
injury control. Partly as a result of the lack of
trained research person; and partly as a result of the
lack of a coordinated i`~jury-control policy at the
federal level, most state and local health departments
have little invol~rement in efforts to control injury. As
in the case of wate.~orne disease, which was a major
health problem until recent decades, many injuries result
from local conditions and can be prevented only by local
programs designed to deal with those conditions. Without
knowledgeable and interested persons trained in the
sciences relevant to research and programmatic efforts,
the injury ~_1 from local, regional, and national
conditions ~-.~11 continue.
A wide variety of researchable questions related to
the prevention of injuries must be addressed, if we are
to make Progress in reducing injuries and the disabili-
ties, d-~atbs, and societal losses *at result. Funding
is critically needed, not only for research, but for
training researchers in injury control and keeping them
act He in this field. Some general recommendations for
research on the prevention of injuries follow.
RECOMMENDATIONS
1. Education, training, and information programs
intended to control injuries should be evaluated
experimentally.
2 . Laws and regulations aimed at controlling in jut ies
OCR for page 47
47
should be scientif ically evaluated . The separate
influences of degree of enforcement, severity of
punishment, and speed of administration of punishment
should also be researched.
3. Continuing research is needed on efficacy of
product designs and environmental modifications in
protecting people effectively and automatically.
4. Research is needed to understand the barriers to
implementing existing effective injury control measures
that are not widely applied.
5. Research is needed in the prevention of injuries
in the recreational, occupational, and home environments.
6. Training health professionals and other scientists
in injury research and the basic concepts of injury con-
trol is crucial, if we are to develop and apply new
k nowledge about the prevention of in jury .
Representative terms from entire chapter:
individual behavior
