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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

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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admonished by police for jaywalking were no less likely to do it again. 2 ~ 6 Scofflaw drivers whose licenses had been revoked were more likely than the aver- age licensed driver to be involved in fatal crashes. 6 7 Arid not only are young children hard to influence, but intensive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

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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

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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.

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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.~.

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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

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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

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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

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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

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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

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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 .