7
State and Community Response

Further progress in reducing the burden of injuries not only depends on concerted research and treatment efforts but also requires a strengthened focus on prevention implementation. Great strides have been made in developing injury prevention strategies that have been shown to be successful in promoting safety and reducing injury morbidity and mortality (Chapter 4). In most cases, injury prevention is best achieved through a multifaceted approach that utilizes the range of available prevention strategies (Box 7.1). However, widespread implementation of proven injury prevention strategies is often impeded by political, social, and economic barriers.

In large measure, prevention is a local effort. Because the implementation of prevention measures frequently involves interacting with individuals and families (e.g., providing education, distributing safety measures such as bike helmets), it is at the state and community levels that most prevention programs are implemented. As problems and needs are identified, public support is garnered at the local level, and a number of organizations (including hospitals, schools, civic groups, athletic leagues, businesses, and fire and police departments) frequently work together to address injury hazards and concerns. Therefore, local capacity to develop, implement, and evaluate prevention interventions must be supported.

This chapter first provides a brief overview of the broad landscape of state, local, and nonprofit efforts that are involved in addressing different facets of the injury problem. The remainder of the chapter discusses several steps that need to be taken to move toward more systematic and widespread implementation of injury prevention programs.



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Reducing the Burden of Injury: Advancing Prevention and Treatment 7 State and Community Response Further progress in reducing the burden of injuries not only depends on concerted research and treatment efforts but also requires a strengthened focus on prevention implementation. Great strides have been made in developing injury prevention strategies that have been shown to be successful in promoting safety and reducing injury morbidity and mortality (Chapter 4). In most cases, injury prevention is best achieved through a multifaceted approach that utilizes the range of available prevention strategies (Box 7.1). However, widespread implementation of proven injury prevention strategies is often impeded by political, social, and economic barriers. In large measure, prevention is a local effort. Because the implementation of prevention measures frequently involves interacting with individuals and families (e.g., providing education, distributing safety measures such as bike helmets), it is at the state and community levels that most prevention programs are implemented. As problems and needs are identified, public support is garnered at the local level, and a number of organizations (including hospitals, schools, civic groups, athletic leagues, businesses, and fire and police departments) frequently work together to address injury hazards and concerns. Therefore, local capacity to develop, implement, and evaluate prevention interventions must be supported. This chapter first provides a brief overview of the broad landscape of state, local, and nonprofit efforts that are involved in addressing different facets of the injury problem. The remainder of the chapter discusses several steps that need to be taken to move toward more systematic and widespread implementation of injury prevention programs.

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Reducing the Burden of Injury: Advancing Prevention and Treatment BOX 7.1 Child Passenger Safety Seats: An Example of the Lessons Learned and the Challenges Faced in Implementing an Efficacious Injury Prevention Strategy Child passenger safety seats were developed to protect children and are known to be efficacious in reducing the risk of death and injury in car crashes. From 1988 to 1995, the motor vehicle occupant death rate declined 18 percent for children less than 1 year of age. (SAFE KIDS, 1998b). The efforts contributing to the increase in the use of safety seats are indicative of the multiple approaches needed to implement injury prevention measures and include: legislatively mandated child seat use in all states and the District of Columbia; education of police regarding enforcement of child passenger safety laws; development of a national certification program to train child passenger safety specialists; development and dissemination of educational and technical material for health care practitioners, safety professionals, car dealers, and the general public; advances in crash testing technology and biomechanics that led to specific safety requirements; establishment of low-cost safety-seat loaner programs; increases in hospital policies requiring discharge of newborns in child safety seats; investment by corporate entities (e.g., Johnson & Johnson, General Motors, Allstate, State Farm) in national campaigns such as SAFE KIDS; provision of technical assistance, seed funds, and mini grants to local agencies by state governor highway safety offices and state health departments; and policy statements on the use of child occupant restraints by professional organizations such as the American Academy of Pediatrics, the American Public Health Association, and the American School Health Association. Given the success of this intervention, there are still problems in implementation. It is estimated that 35 percent of children 4 years old and under are riding unrestrained and that nearly 80 percent of children riding in child safety seats are improperly restrained (SAFE KIDS, 1998b). In short, even proven injury prevention interventions require a multifaceted approach. A reduction in injuries is achieved only after a long period of intervention and sustained attention to the issue.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Because of their number and diversity, it is difficult to quantify the total extent of government, community, and private-sector endeavors in the injury field. At the state and local levels of government, many agencies are charged with protecting the public's well-being, including health and safety (Table 7.1). Although all of these agencies may not consider themselves part of the injury field per se, each is an integral component of broader safety efforts to prevent or reduce injuries. Private-sector organizations, ranging from corporations to foundations and other nonprofit organizations, provide substantive support for injury prevention through injury-related advocacy, sponsorship of research, and implementation of prevention programs. A number of individuals and groups have started grass-roots organizations on injury prevention, often turning personal tragedies into dedicated injury prevention efforts. All of these endeavors have an impact on increasing public awareness about injury, providing funding for injury prevention programs, and galvanizing support for the implementation of injury prevention goals. Nonprofit organizations garner financial support (and often volunteer support) from concerned citizens, small businesses and corporate sponsorship, philanthropic foundations, and through state and federal government agencies. For-profit corporations and businesses also contribute to safety efforts by implementing employee safety programs (often providing information about both on-the-job and off-the-job safety issues), focusing on product safety, and providing consumer education. The examples provided in Box 7.2 reflect only a snapshot of the numerous nonprofit, foundation, and grassroots efforts dedicated to injury prevention. The examples were chosen to reflect the diversity of ongoing injury efforts. Additionally, a number of professional organizations focus their attention on injury issues (Box 7.3). These organizations often develop educational materials, sponsor continuing education classes and workshops, hold conferences to discuss ongoing research, and support injury prevention programs. Although the current response is impressive, it is also fragmented. Many of the organizations and agencies focus on a specific cause of injury (e.g., sports, vehicles, fires), type of injury (e.g., spinal cord injury, burns), or target population (children, teenagers, elderly). As depicted throughout this report, one of the prime opportunities for the injury field is to leverage the resources and expertise of the numerous agencies, organizations, and individuals interested in reducing injuries. Additionally, it is important for the injury field to focus educational efforts on legislators, administrators, manufacturers, and the media, to continue to inform them about the effectiveness and cost-effectiveness of injury prevention and to keep them updated on new developments.

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Reducing the Burden of Injury: Advancing Prevention and Treatment BOX 7.2 Examples of Nonprofit Organizations Brain Injury Association (BIA): Founded in 1980, the BIA works to increase awareness and promote prevention of brain injury. Additionally, it works through state associations and in conjunction with health care facilities to develop a network of community services and support groups for individuals with brain injury and their families. Administered by the BIA, the American Academy for the Certification of Brain Injury Specialists has developed a three-level certification program for individuals working in brain injury rehabilitation (BIA, 1998). The California Wellness Foundation: Targeting youth violence prevention as one of its five key strategic initiatives, the foundation funds grants on policy change, funds research grants, encourages grassroots leadership through community leadership awards, strengthens postgraduate programs through academic fellowship grants, and supports community action by providing resources and technical assistance for pilot programs. Insurance Institute for Highway Safety (IIHS): Sponsored by more than 80 automobile insurance companies, IIHS is a nonprofit research organization that focuses on the primary factors involved in automobile collisions: human factors, vehicle crashworthiness and safety features, the physical environment, and legal measures. The Highway Loss Data Institute, one of the two major components of IIHS, gathers, analyzes, and publishes data on vehicles and their insurance losses. In 1992, IIHS opened the Vehicle Research Center, which utilizes full-scale crash testing and investigation of on-the-road crashes to collect and analyze information on vehicle crashworthiness and the implications of safety measures on occupant protection. Mothers Against Drunk Driving (MADD): MADD has worked for the past 17 years to raise awareness about the often fatal consequences of drunk driving, to look for effective solutions to drunk driving and underage drinking problems, and to provide support to victims of drunk driving crashes. Started by a small group of California women after the death of a teenager, the nonprofit association now has over 600 local chapters throughout the United States and receives both individual and corporate support (MADD, 1998).

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Reducing the Burden of Injury: Advancing Prevention and Treatment National Fire Protection Association (NFPA): NFPA has worked since 1896, to educate the public and develop codes and standards for fire safety. The membership of the nonprofit organization has over 68,000 individuals and 100 organizations (NFPA, 1998). Through technical committees, the NFPA has developed more than 300 codes and standards, known collectively as the National Fire Code. Additionally, the NFPA is active in developing and disseminating educational materials and its safety programs include the Fire Prevention Week activities and the Learn Not to Burn curriculum. National SAFE KIDS Campaign: Founded in 1987, SAFE KIDS promotes childhood safety through the implementation of community-based strategies and is an example of a nationwide collaborative effort between the private and public sectors. SAFE KIDS is sponsored by the Children's National Medical Center, Johnson & Johnson, General Motors Corporation, Bell, First Alert, Toy Manufacturers of America, Gas Appliance Manufacturers Association, National Fire Protection Association, the Health Resources and Services Administration (HRSA), the National Highway Traffic Safety Administration (NHTSA), the Maternal and Child Health Bureau (MCHB), and the U.S. Fire Administration (SAFE KIDS, 1998a). SAFE KIDS supports over 240 state and local injury prevention coalitions, each of which draws on a diversity of local resources, including school systems, fire departments, local hospitals, civic organizations, and parks and recreation departments. National Safety Council: Although federally chartered in 1913, the Council is a not-for-profit, nongovernmental organization with over 18,500 members representing business, labor, industry, and government. The Council works both through topic-oriented divisions (e.g., agriculture, construction, labor, motor transportation, utilities, youth activities) and state and local chapters. The Council provides training, education programs, consulting, and advocacy leadership with the goal of improving safety and environmental health. Snell Memorial Foundation: Founded in 1957, the Foundation is dedicated to improving sport helmet safety and develops standards for helmets including those used in bicycling, equestrian events, motorcycle riding, skiing, and auto racing. Additionally, prior to Snell certification, the Foundation conducts extensive testing to evaluate the extent of the helmet's protection.

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Reducing the Burden of Injury: Advancing Prevention and Treatment BOX 7.3 Examples of Professional Organizations American Academy of Pediatrics, Section on Injury and Poison Prevention American Association for the Surgery of Trauma American College of Emergency Physicians, Trauma Care and Injury Control Committee American College of Surgeons, Committee on Trauma American Pediatric Surgical Association, Committee on Trauma American Public Health Association, Injury Control and Emergency Health Services Section American School Health Association, National Task Force for Injury Prevention American Society of Safety Engineers American Trauma Society Association for the Advancement of Automobile Medicine Emergency Nurses Association Human Factors Society Institute of Transportation Engineers Intelligent Transportation Society of America International Association of Chiefs of Police International Association of Fire Chiefs International Association of Fire Fighters International Council on Alcohol, Drugs, and Traffic Safety International Society for Child and Adolescent Injury Prevention International Trauma Anesthesia and Critical Care Society National Association of Governors' Highway Safety Representatives National Association of State Fire Marshalls Society of Automotive Engineers Society of Trauma Nurses State and Territorial Injury Prevention Directors' Association As illustrated above, many agencies, organizations, and individuals work on some facet of injury prevention. However, the state and community response is often hampered by federal and state funding constraints and a lack of awareness of injury prevention measures. The committee has identified five areas that, if successfully addressed, could optimize proven strategies for prevention: (1) strengthening the public health infrastructure; (2) building and encouraging collaboration and coalitions of state and local safety agencies and organizations; (3) improving training and technical assistance; (4) improving the translation of research findings into practice; and (5) increasing public awareness and advocacy.

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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 7.1 State and Local Government Agencies and Organizations Agency or Organization Infrastructure Injury Focus Examples of Funding Sources for Injury Activities Child Death Review Teams (CDRTs) All states have state and/or local CDRTs; some state teams are legislatively mandated • Gather and analyze data on the circumstances surrounding child deaths • Make recommendations on measures to prevent future childhood deaths • Funding sources vary widely Child Protective Services State agencies • Screen and investigate cases of child abuse and neglect; assist families in finding solutions • State appropriations Emergency Medical Services (EMS) Agencies Transport services in every state; more than 600,000 regional or local EMS providers • Care of the injured person at the scene and transportation to hospitals • Preventative Health and Human Services block grants • State appropriations • EMS for Children grants Fire Service Agencies More than 31,500 county, city, local, or district fire departments • Fire fighting and rescue operations • Fire prevention programs, and broader fire and life safety education programs • State and local taxes Labor and Occupational Offices 25 states operate their own occupational safety and health agencies; the Occupational Safety and Health Administration (OSHA) runs the programs in other states • Investigate injuries in the workplace • Develop and implement prevention programs • Provide input on regulations • Multiple sources: OSHA, state appropriations

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Reducing the Burden of Injury: Advancing Prevention and Treatment Agency or Organization Infrastructure Injury Focus Examples of Funding Sources for Injury Activities Law Enforcement Agencies State, county, municipal, and other local jurisdictional police or law enforcement agencies • Enforce laws (e.g., driving under the influence, safety belt and child safety seat laws) • Provide prevention measures (e.g., sobriety checkpoints, bicycle and motorcycle safety programs) • State and local taxes Poison Control Centers 85 centers nationwide • Provide information about poisonings and appropriate treatment protocols • Involved in poisoning prevention • State appropriations • Municipal funding • Hospital or university funding Public Health Departments • Each state has a state health department • Over 3,000 local health departments • Use surveillance data to identify injury problems • Implement and evaluate injury prevention programs • Federal block grants: Maternal and Child Health (MCH) and PHHS • State appropriations   SOURCES: NRC (1993); Garrison et al. (1997); NACCHO (1998); NFPA (1998).

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Reducing the Burden of Injury: Advancing Prevention and Treatment STRENGTHENING THE PUBLIC HEALTH INFRASTRUCTURE The strengthening of a well-developed injury prevention program in the state health department is the foundation for state and local injury prevention efforts. In many states, however, this key element is only a fledgling effort. There is wide disparity between states in the extent to which injury prevention is a priority program at the health department level. A 1988 survey of state and territorial health departments found that 10 states had a separate injury program or unit devoted solely to injury prevention (Harrington et al., 1988). Forty percent of the states or territories allocated one full-time equivalent (FTE) or less to injury prevention, and the major sources of funding for state injury prevention efforts were MCH block grants, and PHHS block grants (Harrington et al., 1988). This picture seems to have changed little in the intervening 10 years. The committee and staff interviewed state personnel from 30 state departments of health and found that there is still wide disparity in the size and funding of injury prevention programs independent of state size and population: 3 of the 30 states have extensive injury programs with 14–23 FTEs and more than $1.5 million in funding, whereas 8 of the 30 states have 1.5 FTEs or less devoted to injury prevention. The primary sources of funding continue to be MCH and PHHS block grants, and the majority of states have only limited direct state funding. Little funding for state capacity building is available from the National Center for Injury Prevention and Control (NCIPC) and the funding that is made available is often earmarked for specific programs of NCIPC interest. Consequently, locally prioritized prevention programs often lack needed resources. Injury prevention programs are administratively placed in a variety of different divisions of the state health department (e.g., epidemiology, health promotion, maternal and child health, chronic disease prevention, EMS, environmental health). Program placement is important in that it may influence not only the division's priorities for the injury prevention program but also the specific injuries that the program may target (e.g., maternal and child health may target only childhood injuries). The State and Territorial Injury Prevention Directors' Association (STIPDA)1 Safe States initiative outlines five core elements necessary for a well-developed injury prevention program: (1) statewide and local data collection and analysis; (2) program design, implementation, and evaluation; (3) coordination and collaboration; (4) technical support and training; and (5) policy development (STIPDA, 1997). In some cases, components (e.g., surveillance) may be administratively located in separate divisions of the health department, and close collaboration between divisions is crucial. 1 STIPDA is a national organization made up of designated members from every state health department. STIPDA's mission is to sustain, enhance, and promote the ability of state, territorial, and local health departments to reduce death and disability from injury.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Data and Surveillance To set priorities for injury prevention programs, state and local practitioners need morbidity and mortality injury data (see Chapter 3). However, data collected at the local and community levels have not always been available. In the past 10 years a number of specialized, topic-specific state and local surveillance systems (e.g., traumatic brain injury surveillance, firearm injury surveillance) have been funded as demonstration projects by federal agencies. Unfortunately, funding for such programs has generally been intermittent or time limited, preventing long-term implementation, analysis, evaluation, or dissemination (see Chapter 3). Local hospital discharge data that are accompanied by an external cause-of-injury code (E-codes) are also useful for developing injury prevention interventions (see Chapter 3). These data provide a perspective on the more serious injuries that require hospitalization, allow comparisons to be made with other medical conditions and diseases, and pinpoint localities with higher than normal injury incidence, which then may be targeted for specific programs and resources. Almost half of the states now require E-coding, which allows this information to be routinely analyzed and available on a statewide basis (Chapter 3). However, practitioners cannot access community data directly from the local hospital because such data are available only from a central collecting agency. Other untapped sources of injury data include records of emergency departments, EMS and police investigations. However, those records often are not computerized or not linked to hospital data or other data sets, and unresolved issues of confidentiality make it difficult—if not impossible—to trace the injuries in a useful way for targeted prevention interventions. Technical assistance by state personnel trained in injury surveillance methods can help communities and local professionals access, analyze, and transform locally collected data into useful information. Strategic Planning As states embrace injury prevention efforts and work toward strengthening their injury prevention programs, it is important to incorporate injury prevention into many diverse strategic planning processes and documents. For example, the State of Utah Annual Plan for Maternal and Child Health devotes sections to injury control and youth suicide prevention (Utah Department of Health, 1997); New York's Highway Safety Strategic Plan contains a section on injury (Klein et al., 1997); and the Emergency Preparedness and Injury Control Program of the California Department of Health Services has produced a five-year strategic plan dedicated to injury prevention. The California Department of Health Services' strategic plan for 1993–1997 contains specific objectives for reducing injury morbidity and mortality and suggests mechanisms for incorporating injury pre-

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Reducing the Burden of Injury: Advancing Prevention and Treatment vention efforts into other health department and state agency programs (California Department of Health Services, 1992). California's plan is noteworthy because it was developed with the input of local practitioners and researchers and used annual injury conferences to facilitate this consensus-building process (Kelter, 1997). Annual state health plans should establish injury prevention goals, specific performance indicators, and outcome measures for monitoring unintentional injury, suicide, and violence. The plans should include specific actions for the integration of injury prevention within existing service delivery mechanisms in relevant state agencies. Similar efforts should be made for planning documents related to transportation, social services, criminal justice, and other state functions. An important component of all state programs should be the inclusion of careful evaluation of all implemented injury programs. Technical Assistance Strengthening, and in some cases, building the public health infrastructure could be greatly facilitated by direct technical assistance to state and local injury programs. As discussed in Chapter 8, the committee supports an increased role for NCIPC in providing technical assistance. This could be accomplished in a number of ways. One approach would be to team states having extensive and long-standing injury programs with states that have new, inexperienced, or fledgling programs. Sharing expertise and lessons learned would hasten the maturation of new injury programs and could be linked to incentives for both members of the state teams. Another model would be to use regional offices to provide technical assistance directly to states within the region. A third approach would utilize technical assistance teams composed of multidisciplinary staff (e.g., state health commissioner, injury program manager, epidemiologist, health educator) with field experience in injury prevention at the state and local levels. Such a team could conduct site visits and assist state health injury prevention staff in developing specific action plans, identifying means to overcome state and local barriers, and providing follow-up technical assistance at regularly scheduled intervals. A potential resource for assembling such teams is STIPDA, which through its membership from every state can access the needed expertise of personnel who have developed similar injury prevention programs in other states and localities. The site visit team approach was utilized by NHTSA to assist state EMS agencies in the development and implementation of state level EMS plans. Funding Funding for injury prevention programs by the public and private sectors has been inadequate when compared to the magnitude of the injury problem (see

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Reducing the Burden of Injury: Advancing Prevention and Treatment and state and federal agencies) with the common goal of reducing injury morbidity and mortality and promoting highway safety. Local, state, and federal leadership and collaboration is also needed to support poison control centers. Poison control centers coordinate care for poison victims from the point of exposure to information sources and therapies, as well as serving as a locus for prevention, training, and research on poisoning. The number of poison control centers in the United States has declined steadily over the past two decades and is currently precariously low (Litovitz et al., 1994). Currently, many poison control centers face serious funding constraints while others face closure, and no one federal agency is responsible for sponsorship (Poison Control Center Advisory Work Group, 1996). Yet, it has been estimated that poison control centers prevent an estimated 50,000 hospitalizations and 400,000 doctors' visits annually (Poison Control Center Advisory Work Group, 1996). The committee urges federal leadership in supporting and sustaining poison control centers in the United States. Coalition Building At the community level, injury prevention becomes the responsibility of numerous organizations and agencies. Day-care facilities, nursing homes, schools, police and fire departments, civic organizations, athletic leagues, families, and numerous other groups all implement measures to prevent or minimize injuries. As a result of this diverse group of stakeholders, coalitions have been found to be particularly useful as a means of pooling resources, targeting specific injury problems, and educating the interested parties on effective injury prevention interventions (National Committee, 1989). Injury prevention coalitions range in the degree of formality and the breadth of their mission and activities. Grassroots coalitions have been started by concerned parents, health professionals, and other individuals. For example, the San Francisco Bay Area Coalition on Drowning Prevention advocated for a change in county ordinances to require safety measures for backyard pools (National Committee, 1989). Other coalitions are nationwide efforts and include the National SAFE KIDS Campaign which works through more than 240 state and local coalitions to promote children's safety efforts (SAFE KIDS, 1998a). Safe Communities, a program initiated by NHTSA, strives to reduce traffic safety injuries by working at the community level through broad coalitions of public safety officials, medical services providers, civic and industry leaders, and citizens (NHTSA, 1998; see Chapter 8). Since injury prevention is often most successful at the local level, where specific injury problems can be addressed, coalition building is crucial to strengthening the nation's response to the injury problem. Financial and technical assistance is needed from federal and state government agencies and from the private for-profit and nonprofit sectors.

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Reducing the Burden of Injury: Advancing Prevention and Treatment TRAINING AND TECHNICAL ASSISTANCE In 1985, Injury in America identified the shortage of trained injury prevention professionals and scientists as a major impediment to the development of the field (NRC, 1985); this continues to be a significant barrier. Additionally, further education on injury prevention has to be incorporated into the education of health care professionals so that nurses, physicians, physician assistants, and nurse practitioners can integrate injury prevention into their clinical practice. Training Injury Prevention Practitioners The need to train practitioners is confirmed by surveys of the staffs of state health departments, traffic safety agencies, and schools of public health (Harrington et al., 1988; Dana et al., 1990; Miara et al., 1990). A 1990 survey found that only 25 percent of health department personnel and 20 percent of traffic safety professionals had graduate-level coursework in injury epidemiology or prevention. Additionally, 92 percent of health department personnel and 47 percent of traffic safety staff requested additional training (Miara et al., 1990). Most states do not currently have the resources to conduct training and continuing education for local agencies, nor do they have the capacity to keep current on the latest research and its application. Moreover, career paths are not well defined for injury prevention practitioners, and training opportunities are not readily available or accessible (in fact, state and local practitioners often have difficulty in obtaining travel approval to attend out-of-state conferences or training programs). Training and continuing education most often occur through state and national conferences and via sessions on injury prevention at the annual meetings of national professional organizations (e.g., the American Public Health Association). A one-week training course has been restarted recently by the Johns Hopkins Center for Injury Research and Policy. Although these developments are positive signs, they are of no value to those who cannot attend because of funding constraints. Federal agencies provide training that is most often focused on specific injury topics. MCHB provides technical assistance to state maternal and child health agency staff through the Children's Safety Network (CSN) National Injury and Violence Prevention Resource Center. This information is targeted to maternal and child health practitioners and is focused on child and adolescent injury prevention. NHTSA offers regional workshops on traffic safety topics. The National Institute for Occupational Safety and Health (NIOSH) funds 15 Education and Research Centers (ERCs), primarily at universities, that offer continuing education courses in occupational health and safety. The Indian Health Service (IHS) offers an Injury Prevention Specialist Fellowship program that allows 10 to 20 IHS field staff to receive training in the use of data collection systems and the development of intervention strategies. These efforts are

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Reducing the Burden of Injury: Advancing Prevention and Treatment critical to the continued education of injury professionals; however, additional opportunities are needed. An interesting interdisciplinary model currently under development is a national satellite training program on violence prevention for education, public health, justice, and community-based professionals. Each of the six parts of the curriculum will involve a three-hour national broadcast supplemented by two hours of facilitated training on site and a website for follow-up. The primary sponsors are the Office of Safe and Drug Free Schools in the U.S. Department of Education, MCHB, the Office of Juvenile Justice and Delinquency Prevention, NCIPC, and IHS. This unique collaboration recognizes that practitioners with a different perspective need a common language and approach. A teleconference offered in June 1997 through the University of North Carolina Injury Prevention Research Center shows promise as a method for providing education. Federal leadership is needed to prepare a cadre of trained injury prevention practitioners and to continue to keep them informed of best practices. The 1993 agenda-setting report Injury Control in the 1990s: A National Plan for Action identified the training of injury professionals as one of its 22 recommendations (NCIPC, 1993). Specific elements of the proposed approach included the following: the development of a national injury control training plan; collaboration among federal agencies that fund training of professionals (e.g., engineers and police) to incorporate an injury prevention component; funding for Injury Control Research Centers (ICRCs) to enable them to provide training to state and local safety professionals, as well as to faculties of health professional schools; designation and funding of a resource center to collect and disseminate curricula and learning materials; and support for the inclusion of injury in the core curricula of medical schools. These recommendations have not been fully implemented and appear stalled because several federal agencies bear the responsibility for coordination, funding, and implementation. The committee believes that the 1993 NCIPC training recommendations should be implemented and that training should be a key mission of NCIPC (see Chapter 8), in collaboration with other federal agencies. In addition to focusing on specific injury topics, training should emphasize program development, implementation, and evaluation processes. Further, practitioners should be integrally involved in research on the practice of prevention. While this may be considered the primary function of researchers, practitioners are ideally positioned to provide feedback about the effectiveness and utility of prevention interventions through the evaluation process. This role may require expanded training and would necessitate greater two-way communication be-

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Reducing the Burden of Injury: Advancing Prevention and Treatment tween practitioners and researchers. The committee believes that this more integrative process will result in more effective prevention interventions. Core curricula for injury practitioners have to be developed through a consensus and peer review process. One model is the EMS curriculum development process conducted by NHTSA. Training curricula should include information on working with culturally diverse populations. Professionals working in the field, whether focused on childhood injury, teen violence, driver safety, domestic violence, or injury problems of the elderly, must be able to address these concerns in the context of varied socioeconomic levels and cultures. The ICRCs and ERCs, located throughout the United States, are excellent resources and potential sites for training programs. However, current funding for such centers is limited and would have to be increased in order to expand their mandate. Consideration should be given by multiple federal agencies to the expansion of training opportunities for state and local injury prevention professionals. The committee recommends the expansion of training opportunities for injury prevention practitioners by the relevant state and federal agencies (e.g., NCIPC, NHTSA, MCHB, and NIOSH) in partnership with key stakeholders such as STIPDA. Training should emphasize program development, implementation, and evaluation as well as participation in program research. Training Health Care Professionals in Injury Prevention Comprehensive curricula materials should be developed to allow the subject of injury prevention and treatment to be integrated into the curricula of medical and nursing schools and schools of public health. The Educating Professionals in Injury Control series funded by the Pew Charitable Trust may serve as a model; however, it requires updating and expansion for the multiple causes of injury (EDC, 1990). With its modular format, the series has a flexible design that allows different disciplines to adapt the materials (including lectures, slides, and case studies) for their own use. Despite a positive evaluation by faculty users on the modules relating to firearms, fire and burns, falls in the elderly, and general injury prevention principles, modules for other causes of injury have not yet been developed. Materials have been developed to assist pediatricians and others in injury prevention counseling. The American Academy of Pediatrics (AAP) provides a set of standard, developmentally appropriate protocols in its Injury Prevention Program (TIPP) for pediatricians who are counseling patients up to age 12 on injury and violence prevention. The AAP has also developed the Steps to Prevent Firearm Injury (STOP) program which provides a training tape for pedia-

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Reducing the Burden of Injury: Advancing Prevention and Treatment tricians on how to counsel about firearms issues.3 Similar protocols are needed for other types of injuries, settings, ages, and providers. Technical Assistance Training must be accompanied by technical assistance to support states and communities in developing and implementing practical injury prevention plans, building and sustaining an injury prevention infrastructure, evaluating prevention programs, and making the transition from research to practice. Technical assistance must be conducted by experienced professionals who know how to overcome state and local barriers to program implementation and are knowledgeable about conducting evaluation studies. For example, the CSN's National Injury and Violence Prevention Resource Center provides technical assistance by developing publications and resources that synthesize best practice from different disciplines; conduct needs assessments and site visits; assisting states in overcoming institutional barriers in implementing prevention programs; developing or facilitating the development of continuing education programs for state and local practitioners; operating a national resource library and website; and representing the interests of practitioners in national forums and committees. Additional examples include the National Children's Center for Rural and Agricultural Health and Safety recently funded by NIOSH and the National Program for Playground Safety funded by the Centers for Disease Control and Prevention. Many of the federal agencies discussed in Chapter 8 are involved in technical assistance to states and communities, and the committee supports continuation of these efforts. Further, the committee supports an increased technical assistance role for NCIPC, particularly in providing assistance (including the site-visit teams discussed earlier in this chapter) to state health departments. In addition to implementing technical assistance mechanisms, there should be a periodic assessment to determine the status of injury prevention programming and capacity, the specific barriers that must be overcome to enhance implementation, and the needs for technical assistance and training. A survey, such as the 1988 survey of state health departments (Harrington et al., 1988), should be updated and the results used to develop a technical assistance plan for states. INTEGRATING RESEARCH AND PRACTICE As described in Chapter 4, emphasis is needed on evaluating prevention interventions in real-world settings so that effective interventions can move from research and demonstration projects to wide-scale dissemination. A recent NCIPC 3 STOP 2, an educational program developed for all health care providers, by the Center to Prevent Handgun Violence with funding from the Metropolitan Life Foundation, is now available.

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Reducing the Burden of Injury: Advancing Prevention and Treatment publication, Demonstrating Your Program's Worth, provides a guide to assist injury practitioners and researchers in evaluating injury prevention programs (Thompson and McClintock, 1998). Local injury prevention practitioners need applied information on best practices based on current research. Likewise, practitioners can provide valuable input to researchers on areas requiring future research. Best practices should be informed by an overall assessment of evidence-based research and current practices in the field. Resource libraries, such as the Trauma Foundation's Injury and Violence Prevention Library, facilitate the flow of information from research to practice (Craig et al., 1998). This function is crucial to the success of state and local injury prevention efforts and consideration should be given to expanding the library and information networking efforts at NCIPC. The 1989 report Injury Prevention: Meeting the Challenge provided information on then-current prevention interventions from a multidisciplinary perspective (National Committee, 1989). The report was designed to serve as a tool to adapt and combine research findings in light of local data and available resources. It reviewed interventions in terms of those proven effective (e.g., bicycle helmets), those that were promising (e.g., raising alcohol taxes to reduce availability), those ineffective or counterproductive (e.g., painted crosswalks), and creative ideas whose efficacy was unknown and should be studied (e.g., designated driver and safe ride programs). There is a need for additional and updated resources that provide information on effective prevention interventions. Such an effort could be linked to reviews of evidence-based research on injury interventions, such as those conducted through the Cochrane Collaboration,4 and should be disseminated widely through technical assistance efforts. Cochrane Collaboration reviews relevant to the injury field have been completed on childhood injury prevention (Rivara. et al., 1998) and falls in the elderly (Gillespie et al., 1998), and are in progress on a number of other injury topics. One of the difficulties in facilitating the translation of research into policy and practice is the limited communication between practitioners and researchers. Vehicles that may be utilized for synthesizing and disseminating research findings include publication of newsletters (e.g., NHTSA's Traffic Tech Transfer Series), publication of bulletins on topics of recent research (e.g., NIOSH's Alert series), and an annual conference to foster hi-directional communication between practitioners and researchers. PUBLIC AWARENESS AND ADVOCACY A crucial challenge faced by injury prevention professionals is the lack of public and legislative awareness of the scope of injury morbidity and mortality 4 Cochrane Collaboration reviews are systematic reviews of controlled trials of health care interventions conducted by international panels of experts (Cochrane Collaboration, 1998).

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Reducing the Burden of Injury: Advancing Prevention and Treatment and the utility of potential interventions. Many members of the general public as well as many policy makers still believe that injuries are "accidents" that just happen. This perception often precludes policy makers from identifying injury prevention as a discrete public health issue and limits the earmarking of federal and state dollars for injury research and for the development of prevention programs. Raising Public Awareness The breadth of the injury field has resulted in a number of advocacy and nonprofit organizations that generally focus on one type or cause of injury (e.g., BIA, MADD) or one population of concern (e.g., National SAFE KIDS Campaign). These organizations have a significant contribution to make to their issues of concern and to the broader field of injury prevention; together they can raise the visibility of injury prevention, build a broad base of support, and provide a recognizable constituency for the field of injury prevention and treatment. Policy makers' attitudes and interest in this field will not change easily without a change in society's attitudes and perception of the field. The field has to engage existing social marketing techniques to determine the messages that should be employed to raise the profile of injury prevention research and focus the public's and policy makers' attention on the preventability of injuries. Advocacy Public education, advocacy, and constituency building are key elements of modern public health practice at the state and community levels. Proactive "marketing" of public health is needed to arouse public awareness and concern, to counteract complacency or sluggishness, and to prod policy makers into action. The need for injury officials and program directors to embrace advocacy as a core professional role is a recurrent theme in the field (Rivara, 1997). According to the Institute of Medicine (IOM) report The Future of Public Health , educating legislators and political leaders "on public health issues and on the rationale for strategies advocated and pursued by the health department" is a key element of public health leadership (IOM, 1988). Eight years later, another IOM (1996, p. 39) committee noted: Even when promising solutions exist, public health agencies too often have difficulty generating support for intervention among elected officials and the general public. A key struggle for [public health leaders] is making the benefits of community-based, population-wide public health activities and initiatives more recognizable, and finding allies who will speak on behalf of those initiatives and the unique role for government public health agencies in carrying [them] out. . . .

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Reducing the Burden of Injury: Advancing Prevention and Treatment These important activities—public education, constituency building, and advocacy—must be carried on with due regard for long-standing legal constraints on ''lobbying," which are designed to limit contact with legislators, directly or through grassroots efforts concerning specific legislative proposals. Federal grantees may not use federal funds for lobbying, and nonprofit organizations lose their tax-exempt status if they devote too much of their activities to lobbying. However, these restrictions on lobbying still leave the organizations free to engage in a wide range of educational activities. Unfortunately, many organizations in the injury field appear to be unsure about the boundaries between advocacy and lobbying and thus are uncertain about the legitimate scope of educational and constituency-building efforts. Nonprofit organizations in the injury field should understand the federal and state rules that govern lobbying. By better understanding these rules, nonprofit organizations can maximize their effectiveness as advocates for the public's health, while minimizing the likelihood that they will jeopardize their nonprofit legal status. The federal government itself has recognized that changes in state and local policy are often necessary to help effectuate national public health policy goals. Many Healthy People 2000 goals focus on state legislative action (U.S. DHHS, 1990). Congress often makes state eligibility for federal program support conditional upon state legislative action (e.g., the 21-year-old minimum drinking age). In many situations, however, Congress is not so directive, relying instead on public education and local constituency building to arouse public support and eventually achieve state and local legislative action. It is well understood that nonprofit organizations interested in public health issues devote substantial resources to public education and issue advocacy, even though their lobbying for a specific piece of legislation is restricted. Thus, advocacy for national public health objectives by federal grantees and nonprofit organizations is often encouraged by federal policy. Against this background, the committee believes that recent proposals to curtail advocacy by federal grantees and nonprofit organizations are troubling. For example, proposals have been made to preclude federal grants to organizations that spend more than a specified amount on "political advocacy," thereby broadening the constraints and compelling the use of nonfederal funds by these organizations (Moody, 1996). In the committee's view, the achievement of national public health priorities, including injury prevention objectives, would be significantly impeded if Congress were to broaden traditional constraints on lobbying by federal grantees and nonprofit organizations beyond their long-accepted meanings and boundaries to include advocacy. Traditional restrictions adequately carry out the federal government's legitimate interest in avoiding taxpayer-subsidized political activity and the distortion of the political process to which subsidized political activity might lead. More sweeping restrictions on the advocacy of ideas or positions not only would have a chilling effect on constitutionally protected activities by federal grantees and tax-exempt organizations, but would also undermine the U.S. government's strong interest in promoting public

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Reducing the Burden of Injury: Advancing Prevention and Treatment understanding of and support for national public health objectives. The committee urges Congress to preserve its customary support for public health advocacy. SUMMARY Although it is difficult to quantify the total extent of government, community, and private-sector endeavors in the injury field, there is a wide range of ongoing efforts, many of which have begun or expanded within the past 20 years. Although the current response is impressive, it is also fragmented. A core injury prevention program is needed in each state that can implement (and assist other agencies and organizations in implementing) injury prevention interventions. State injury prevention programs require a sustained federal commitment to funding and to providing technical assistance to the states. Further, training opportunities for state and local injury prevention practitioners should be expanded. Beyond the public health arena, numerous safety organizations and agencies have an important role to play in injury prevention efforts. Collaboration between state agencies and coalition building, particularly at the local level, are crucial for addressing injury prevention. As new prevention interventions are developed and evaluated, ongoing information exchange between researchers and practitioners is needed that will facilitate the implementation of new interventions and the refinement of these interventions to meet real-world demands. A final component of strengthening the state and local response is raising public awareness and increasing advocacy efforts. Both the general public and policy makers need information on the effectiveness of injury prevention measures in order to make informed decisions and choices. REFERENCES BIA (Brain Injury Association). 1998. 1996–1997 Annual Report. Washington, DC: BIA. California Department of Health Services. State Injury Control Advisory Task Force. 1992. Strategic Plan for Injury Prevention and Control in California, 1993–1997. Sacramento, CA: California Department of Health Services. Cochrane Collaboration. 1998. The Cochrane Collaboration. [World Wide Web document]. URL http://hiru.hirunet.mcmaster.ca/cochrane/ (accessed June 1998). Craig A, Tremblay-McGaw R, McLoughlin E. 1998. Injury prevention in the information age: The Injury and Violence Prevention Library. Injury Prevention 4(2):150–154. Dana AJ, Gallagher SS, Vince CJ. 1990. Survey of Injury Prevention Curricula in Schools of Public Health. Paper presented at the annual meeting of the American Public Health Association, October 2, 1990, New York City. Newton, MA: Education Development Center.

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Reducing the Burden of Injury: Advancing Prevention and Treatment EDC (Education Development Center, Inc.), Johns Hopkins Injury Prevention Center. 1990. Educating Professionals in Injury Control (EPIC). Newton MA : EDC. EDC (Education Development Center, Inc.). 1994. Motor Vehicle Injury Prevention: An Assessment of Highway Safety and Public Health Activities in Selected States. Washington, DC: National Highway Traffic Safety Administration. Garrison HG, Foltin GL, Becker LR, Chew JL, Johnson M, Madsen GM, Miller DR, Ozmar BH. 1997. The role of emergency medical services in injury prevention. Annals of Emergency Medicine 30(1):84–91. Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH. 1998. Interventions to Reduce the Incidence of Falling in the Elderly [World Wide Web document]. URL http://som.flinders.edu.au/fusa/cochrane/cochrane/revabstr/ab000340.htm (accessed April 1998). Harrington C, Gallagher SS, Burgess LL, Guyer B. 1988. Injury Prevention Programs in State Health Departments: A National Survey. Boston, MA: Harvard School of Public Health, Massachusetts Department of Maternal and Child Health. Hersey JC, Abed J, Butler MO, Diver AR, Mitchell K. 1995. Reducing the Burden of Injury: An Evaluation of CDC Injury Grant Programs. Final Report. Arlington, VA: Battelle. Report to the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control and the Office of Program Planning and Evaluation. HRSA (Health Resources and Services Administration). 1997. Title V Block Grant Program Guidelines. Rockville, MD: HRSA, Maternal and Child Health Bureau. HRSA (Health Resources and Services Administration). 1998. Emergency Medical Services for Children. FY 1997 Report. Rockville, MD: HRSA. IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press. IOM (Institute of Medicine). 1996. Healthy Communities: New Partnerships for the Future of Public Health. Washington, DC: National Academy Press. Kelter A. 1997. Reinventing injury prevention in California: A model for reinventing local public health programs. Journal of Public Health Management and Practice 3(6):30–4. Klein SH, O'Connor P, Fuhrman JM. 1997. Injury prevention capacity building in New York State: Federal support played a significant role. Journal of Public Health Management and Practice 3(6):17–24. Litovitz T, Kearney TE, Holm K, Soloway RA, Weisman R, Oderda G. 1994. Poison control centers: Is there an antidote for budget cuts? American Journal of Emergency Medicine 12(5):585–599. MADD (Mothers Against Drunk Driving). 1998. About MADD. [World Wide Web document]. URL http://www.madd.org/ (accessed May 1998). Miara C, Gallagher SS, Malloy P. 1990. National Survey of the Training Needs of Health Department & Traffic Safety Injury Control Professionals . Paper presented at the annual meeting of the American Public Health Association, October 2, 1990, New York. Newton, MA: EDC and Harvard Injury Control Center. Moody AE. 1996. Conditional federal grants: Can the government undercut lobbying by non-profits through conditions placed on federal grants? Boston College Environmental Affairs Law Review 24:113–158. NACCHO (National Association of County and City Health Officials). 1998. NACCHO Overview. [World Wide Web document]. URL http://www.naccho.org/overview/index.html (accessed May 1998).

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Reducing the Burden of Injury: Advancing Prevention and Treatment National Committee (National Committee for Injury Prevention and Control). 1989. Injury Prevention: Meeting the Challenge. New York: Oxford University Press. Published as a supplement to the American Journal of Preventive Medicine 5(3). NCIPC (National Center for Injury Prevention and Control). 1993. Injury Control in the 1990s: A National Plan for Action. A Report to the Second World Conference on Injury Control. Atlanta, GA: Centers for Disease Control and Prevention. NFPA (National Fire Protection Association). 1998. National Fire Protection Association: A Century of Service . [World Wide Web document]. URL http://www.nfpa.org (accessed July 1998). NHTSA (National Highway Traffic Safety Administration). 1998. Safe Communities. [World Wide Web document]. URL http://www.nhtsa.dot.gov/safecommunities/ (accessed June 1998). NRC (National Research Council). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press. NRC (National Research Council). 1993. Understanding Child Abuse and Neglect. Washington, DC: National Academy Press. Poison Control Center Advisory Work Group. 1996. Final Report of the Poison Control Center Advisory Work Group. Report to the National Center for Injury Prevention and Control and the Maternal and Child Health Bureau. Rivara FP. 1997. Should we be advocates for injury prevention? Injury Prevention 3(3):158–159. Rivara FP, Beahler C, Patterson MQ, Thompson DC, Zavitkovsky A. 1998. Systematic Reviews of Childhood Injury Prevention Interventions. [World Wide Web document]. URL http://weber.u.washington.edu/~hiprc/childinjury/ (accessed April 1998). SAFE KIDS (National SAFE KIDS Campaign). 1998a. National SAFE KIDS Campaign. [World Wide Web document]. URL http://www.safekids.org (accessed July 1998). SAFE KIDS (National SAFE KIDS Campaign). 1998b. Safe Kids at Home, at Play, and on the Way: A Report to the Nation on Unintentional Childhood Injury. Washington, DC: National SAFE KIDS Campaign. STIPDA (State and Territorial Injury Prevention Directors' Association). 1997. Safe States: Five Components of a Model State Injury Prevention Program and Three Phases of Program Development. Oklahoma City, OK: STIPDA. Thompson NJ, McClintock HO. 1998. Demonstrating Your Program's Worth: A Primer on Evaluation for Program to Prevent Unintentional Injury . Atlanta, GA: National Center for Injury Prevention and Control. U.S. DHHS (Department of Health and Human Services). 1990. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: U.S. DHHS. Utah Department of Health. 1997. State of Utah Annual Plan for Maternal and Child Health. Salt Lake City: Utah Department of Health.