4
Prevention Research

This chapter addresses research on injury prevention, a paramount goal of the injury field. The value of prevention research lies in its contribution to the design and implementation of interventions that successfully reduce injuries or ameliorate their consequences. Over the past quarter century, research has contributed in this way to actual reductions in injury mortality rates (Baker et al., 1992), most clearly in relation to motor vehicle injuries (see Chapter 5). Additionally, injury research has documented the effectiveness of many interventions (i.e., programs and policies) designed to reduce injury. Research also makes an important contribution when it demonstrates that interventions do not achieve the desired results or have unintended consequences. Such research helps to refine and improve interventions and to enhance the conceptual foundation for prevention.

A formal scientific approach to injury prevention calls for interventions to be designed, evaluated, and then implemented based on a research-driven process of surveillance, hazard identification, risk assessment and analysis, intervention design and evaluation, and transfer of successful interventions into widespread practice. However, the actual practice of developing interventions is not always so neatly ordered. Many interventions are undertaken based on intuition, advocacy, or legal considerations rather than on scientific evidence, and many interventions are unevaluated (IOM, 1998). Moreover, many successful injury prevention interventions are serendipitous since they occur as a result of actions undertaken for other reasons. The imposition in 1975 of a federal maximum speed limit of 55 miles per hour, a policy that saved hundreds to thousands of lives per year, was instituted as a fuel conservation measure rather than as a safety measure (TRB, 1984; National Committee, 1989).



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Reducing the Burden of Injury: Advancing Prevention and Treatment 4 Prevention Research This chapter addresses research on injury prevention, a paramount goal of the injury field. The value of prevention research lies in its contribution to the design and implementation of interventions that successfully reduce injuries or ameliorate their consequences. Over the past quarter century, research has contributed in this way to actual reductions in injury mortality rates (Baker et al., 1992), most clearly in relation to motor vehicle injuries (see Chapter 5). Additionally, injury research has documented the effectiveness of many interventions (i.e., programs and policies) designed to reduce injury. Research also makes an important contribution when it demonstrates that interventions do not achieve the desired results or have unintended consequences. Such research helps to refine and improve interventions and to enhance the conceptual foundation for prevention. A formal scientific approach to injury prevention calls for interventions to be designed, evaluated, and then implemented based on a research-driven process of surveillance, hazard identification, risk assessment and analysis, intervention design and evaluation, and transfer of successful interventions into widespread practice. However, the actual practice of developing interventions is not always so neatly ordered. Many interventions are undertaken based on intuition, advocacy, or legal considerations rather than on scientific evidence, and many interventions are unevaluated (IOM, 1998). Moreover, many successful injury prevention interventions are serendipitous since they occur as a result of actions undertaken for other reasons. The imposition in 1975 of a federal maximum speed limit of 55 miles per hour, a policy that saved hundreds to thousands of lives per year, was instituted as a fuel conservation measure rather than as a safety measure (TRB, 1984; National Committee, 1989).

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Reducing the Burden of Injury: Advancing Prevention and Treatment This chapter outlines the challenges ahead for prevention research, which include strengthening the multidisciplinary nature of injury research, developing and evaluating a wide range of prevention interventions, training a highly skilled cadre of injury prevention researchers, and undertaking the research needed to guide the effective prevention of unintentional and intentional injuries. This chapter refers to, but does not concentrate on, treatment research (e.g., acute care and rehabilitation) because treatment research priorities have been addressed by several recent landmark reports, including the NIH Task Force on Trauma Research (NIH, 1994), Disability in America: Toward a National Agenda for Prevention (IOM, 1991), and Enabling America (IOM, 1997). As in other areas of clinical practice, the need to demonstrate the relationship between the quality of acute care and rehabilitation, costs, and outcome has never been more critical (see also Chapter 6). RESEARCH ACCOMPLISHMENTS Prevention research has garnered numerous accomplishments over the past 30 years in terms of understanding risk factors, injury mechanisms, and effective ways to reduce injuries. The greatest research progress has been made with motor vehicle and traffic safety, an area with the longest period of sustained federal support for research and prevention programs (see Chapter 5). The same has not been true for other types of unintentional injuries or for intentional injuries (i.e., suicide and violence). These areas have not received sustained support of sufficient magnitude (Chapter 8). Unintentional Injury Prevention Unintentional injuries, as a group, represent the most common cause of injury death. There were a total of 90,402 unintentional injury deaths in 1995 (Fingerhut and Warner, 1997). A strong research base on motor vehicle and highway safety has contributed to the increased crashworthiness of vehicles, and increased use of safety belts, and to decreases in drinking and driving. Certainly, other factors are involved, such as increased public awareness and consumer demand for safe products; federal, state, and local programs; improved medical care; and legislation and enforcement activities. Separating the contribution of research and these other factors is rarely possible in any area of injury prevention, in part because the factors are so interrelated. Research and surveillance, for instance, are used to galvanize public opinion, to justify legislation, and to evaluate legislative impact. Research forms an essential underpinning to a comprehensive approach to tackling the problem of injury. One of the most impressive research and programmatic accomplishments in the history of injury prevention occurred in the area of childhood poisonings

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Reducing the Burden of Injury: Advancing Prevention and Treatment from consumer products. In 1970, 226 poisoning deaths among children under age 5 occurred in the United States, whereas in 1985, only 55 such deaths occurred (CDC, 1985). Aspirin poisoning—the single leading cause of childhood poisoning death in the 1960s and early 1970s—had virtually disappeared by 1985. This accomplishment was due, in large measure, to a body of research on the epidemiology of childhood poisoning; ongoing surveillance of childhood poisoning through the nation's poison control centers; and innovative work on the development of environmental and legislative approaches to keep hazardous substances, particularly baby aspirin, out of the hands and mouths of young children. The final vehicle for this success was passage of the Poison Prevention Packaging Act of 1970 that required the use of special childproof containers and limited the number of pills of baby aspirin to 30 per bottle. Subsequent research investigated compliance with the legislation (Dole et al., 1986). A recent study by Rodgers (1996) found that child-resistant packaging of prescription drugs was associated with a 45 percent reduction in mortality rates involving children younger than 5 from 1974–1992, resulting in 460 fewer child deaths over this period than otherwise projected. This study controlled for long-term safety trends and changes in consumption of prescription drugs. The overall strategy of combining regulation and community-based intervention through poison control centers has been used as a case study of effective injury prevention (National Committee, 1989). Falls are the most common cause of nonfatal injuries and among the most common causes of injury deaths. They are an especially serious problem for the elderly and for children (Chapter 2). Falls occur annually in about 30 percent of elderly persons living in the community (NCIPC, 1996). Research has provided the scientific foundation for interventions (e.g., hormone replacement therapy, vitamin supplements, exercise, protective hip pads) that can prevent or protect the elderly from hip fractures, the most serious consequence of falls in this group (Paganini-Hill et al., 1991; Grady et al., 1992; Lauritzen et al., 1993; Tinetti et al., 1993, 1994; Meunier et al., 1994; Province et al., 1995). Research has established that many population-based injury prevention strategies are inexpensive and easily integrated into existing systems or practice. For example, counseling by physicians has been found to prevent or alleviate many types of unintentional injuries, including certain traffic-related injuries and injuries related to falls and burns (Christophersen and Sullivan, 1982; Berger et al., 1984; Katcher et al., 1989; Persson and Magnusson, 1989; Bien et al., 1993; Miller and Galbraith, 1995). The installation of smoke alarms in high-risk homes in a community-wide program in Oklahoma City was found to achieve a 74 percent decrease in fatal and nonfatal injuries from residential fires (Mallonee et al., 1996). In a randomized controlled trial of low-income women and children, home visits by nurses during the pregnancy of the women and for two years after the birth were found to significantly reduce childhood injuries (Kitzman et al., 1997). One of the most effective prevention strategies is the use of helmets by bicyclists and motorcyclists (Elliott and Rodriguez, 1996). Helmets prevent trau-

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Reducing the Burden of Injury: Advancing Prevention and Treatment matic brain injury, the foremost cause of death in cycle-related injuries (Rivara et al., 1997a,b). A population-based, case-control study found the use of bicycle helmets to reduce the risk of head injury by 85 percent and the risk of brain injury by 88 percent (Thompson et al., 1989). Bicycle helmets also reduce the risk of injury to the upper and middle face (Thompson et al., 1996b). As a result of sustaining less severe injuries, helmeted cyclists have shorter lengths of stay in hospitals and intensive care units and lower overall hospital costs (Elliott and Rodriguez, 1996). Research has contributed to the enactment of legislation in many states mandating helmet use and the support by many public and private agencies of helmet education programs. These examples illustrate the pivotal value of research in many established interventions that avert unintentional injuries (see Table 4.1, Box 4.1). Yet, although there has been much progress in research, more is needed. The 12 percent decline in unintentional injury deaths from 1985–1995 while encouraging, was driven by the decline in motor vehicle fatalities (Fingerhut and Warner, 1997). The overall decline thus obscures the continued need to reduce unintentional injury fatalities related to falls, poisonings, drownings, suffocations, and fires and burns, particularly in special populations such as children and the elderly. BOX 4.1 Harlem Hospital Injury Prevention Program A program in New York City is a model injury prevention program whose creation epitomizes many of the aspects of prevention research described in this chapter. The Harlem Hospital Injury Prevention Program was created in 1988 as a result of surveillance revealing that the injury rate to Harlem children was twice the national rate. With the aid of community coalitions and public agencies, a broad-based, surveillance-driven prevention program was established to create a safe community for children (Laraque et al., 1995). The program was geared to reduce injuries from violence, motor vehicles, and recreational activities. A surveillance system was established—the Northern Manhattan Injury Surveillance System—to provide population-based injury data by zip code. This system allowed the program to focus and evaluate interventions by neighborhoods. The Harlem Hospital Pediatric Trauma Registry also provided social data on children admitted to the hospital for injury and carefully evaluated the injury event. The community was surveyed and photographed to document dangers in children's play spaces, propelling a risk-factor analysis of unsafe conditions. Interventions, which served more than 10,000 children, included educational projects, renovation of playgrounds, safe activities, and other social changes. For example, intensive educational programs were established for traffic safety and violence prevention. Twenty safe playgrounds were built at community schools, and parks were refurbished. Bicycle helmets were distributed at reasonable cost. Safe activities were developed by the program or supported in the community to keep children engaged in supervised

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Reducing the Burden of Injury: Advancing Prevention and Treatment activities that also provided mentoring and role models. Drug activity at the new play sites was controlled by the district attorney's community outreach project. Following the implementation of these interventions, the Northern Manhattan Injury Surveillance System found a 46 percent decrease in injury due to guns and assaults (Durkin et al., 1996) and about a 50 percent reduction in traffic injury (Davidson et al., 1994; Laraque et al., 1995). The incidence of pediatric neurological trauma, the leading cause of death and disability from injury, was reduced by 44 percent in the intervention cohort (Durkin et al., 1998). Intentional Injury Prevention Suicide Prevention The overall suicide rate has remained relatively stable for the past decade, as it has over much of the past 50 years (Baker et al., 1992; Kachur et al., 1995). This stability masks some disturbing trends among such subgroups as adolescents, young adults, and the elderly. From 1980 to 1992, the suicide rate increased by 121 percent for children ages 10–14, by 27 percent for adolescents ages 15–19, and by more than 10 percent for the elderly ages 70 and older (Kachur et al., 1995). The highest suicide rate is among persons ages 80–84, for whom the rate increased 36 percent over this time frame (Kachur et al., 1995). The increase in suicide among the very old is thought to be related, in part, to longer yet poorer quality of life, for which better palliative care is needed (GAO, 1998). The majority of suicides (60 percent) in 1992 were committed with a firearm, and firearm suicides accounted for most of the increase in age-specific suicide rates during the 1980s (Kachur et al., 1995). Case-control injury studies have shown that the risk of suicide is up to five times higher for persons living in a home where firearms are present (Brent et al., 1991, 1993; Kellermann et al., 1992). Access to firearms raises suicide risk among teens without a psychiatric disorder (Brent et al., 1993), supporting the view that restrictions on firearm access can curtail suicides among teens who, as a group, are often more prone than older adults to suicide as an impulsive act. Mental disorders constitute the most important risk factors for suicide. Many suicide victims have affective, substance abuse, personality, or other mental disorders (U.S. Preventive Services Task Force, 1996). Research also has identified environmental and social risk factors, including access to firearms, problems of social adjustment, serious medical illness, living alone, recent bereavement, family history of completed suicide, and others (Shaffer et al., 1988; U.S. Preventive Services Task Force, 1996).

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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 4.1 Examples of Effective Unintentional Injury Prevention Interventions Injury Problem Interventions Evaluation Studies Bicycle injuries Bicycle helmet use; mandatory helmet laws Maimaris et al. (1994); Thompson et al. (1996a,b); Ni et al. (1997) Choking and suffocation Legislation and product design changes (e.g., refrigerator dis posal, warning labels on thin plastic bags) Kraus (1985) Falls in older adults Weight-bearing exercise; multimodal programs (home visits by nurses, exercise programs, elimination of hazards, etc.); protective hip pads Lauritzen et al. (1993); Tinetti et al. (1993, 1994) Fires and burns Smoke detectors; legislation regulating flammability of children's clothing; legislation requiring safe preset temperatures for water heaters McLoughlin et al. (1977, 1982); Erdmann et al. (1991); Runyan et al. (1992); Mallonee et al. (1996) Motor vehicle crashes Safety belts; airbags; child safety seats; sobriety checkpoints; minimum legal drinking age laws Baker-Dickman (1987); Womble (1988); Henry et al. (1996); NHTSA (1996) Sports injuries Mouthguards; equipment modification (e.g., breakaway bases); protective equipment (e.g., knee and elbow pads, helmets, wrist pads for inline skating) Janda et al. (1988); Schieber et al. (1996)   SOURCE: National Committee (1989); Rivara et al. (1997a,b). Research has helped to fuel awareness that some deaths from suicide are preventable through social and environmental changes. Different lines of evidence converge to suggest that broad-based public health approaches that seek to modify social and environmental risk factors may be enlisted for prevention purposes. Epidemiologic research has highlighted the need for interventions to prevent the presence of youth suicide ''clusters." Clusters are the occurrence of several suicides in the same community or vicinity, apparently triggered by one suicide (Gould et al., 1990). Furthermore, research has found that many adolescent suicide victims do not meet the clinical criteria for depression or other treatable mental disorders (Shaffer et al., 1988). Finally, research has found that reducing access to a means of suicide can lower the suicide rate. Studies from Great Britain in the 1970s found that as the carbon monoxide content of cooking gas was lowered (for reasons unrelated to suicide prevention), the overall suicide

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Reducing the Burden of Injury: Advancing Prevention and Treatment rate declined. Not only was the most common method of suicide (i.e., inhalation of cooking gas) less effective, but individuals did not resort to other means (Kreitman, 1976; Brown, 1979). Much of the subsequent progress in suicide prevention research has been made in identifying risk factors for suicide, as this is one of the first steps toward prevention. Less progress has been made in the design and evaluation of programs to prevent suicides. The major challenge for research is the development and testing of new interventions to prevent suicide. The task ahead is formidable even for the most skillful researchers. Evaluation of prevention efforts has been fraught with methodological problems, including definitions of suicidal behavior, the validity and reliability of assessment instruments, the relative rarity of suicide, and the need for large samples and lengthy follow-up (Meehan et al., 1992; U.S. Preventive Services Task Force, 1996; NIMH, 1998). For example, although teen cluster suicides are seen as preventable, they have proved difficult to study because of definitional and methodological complexities. Research on the prevention of suicide clearly warrants higher priority from the Department of Health and Human Services, which houses virtually all federal suicide prevention programs. The committee applauds the U.S. Surgeon General's recognition of inadequate attention to suicide and his initiation of various measures to prevent suicide, including the first National Suicide Prevention Conference in October 1998. Research must be expanded, as described in Chapter 8. Violence Prevention There can be no doubt that violence exacts a grievous toll on the nation's health (Chapter 2). The toll encompasses death, injuries, long-term disabilities, and strain on the trauma care system (Chapter 6). The homicide rate in 1995 was 8.6 per 100,000 population, a rate that overshadows that of all other industrialized nations (Fingerhut and Warner, 1997; Ventura et al., 1997). The impact is greatest on young people, especially minorities. Homicide is the foremost cause of death for African-American males ages 15–34 and the second most important cause of death for young people of all races ages 15–24 (NCIPC, 1996). The magnitude of nonfatal assaultive injuries—defined as physical harm occurring during the course of an assault, robbery, or rape between strangers, acquaintances, or family members—is much higher than that of homicides but is more difficult to capture because of problems in reporting, especially family violence. According to the National Crime Victimization Survey, assault injuries among those age 12 and older occurred at a rate of 12.7 per 1,000 people in 1994 (CDC, 1996; BJS, 1997). The fields of criminal justice and public health bring different perspectives and strengths to bear on the violence problem. The criminal justice system—the police, courts, and corrections system—works to prevent violence primarily

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Reducing the Burden of Injury: Advancing Prevention and Treatment through arrests and incarceration, which act to deter, incapacitate, and rehabilitate criminals (Moore, 1993). Deterrence is seen as working either on potential offenders in the community or on incarcerated offenders in relation to the commission of future crimes. More recently, there has been an increased emphasis on crime prevention via community policing and other means to prevent crime and violence. A major impetus was the passage of the federal Violent Crime Control and Law Enforcement Act of 1994, which provided funds to state and local governments for new prevention programs. The recognition of the growing health consequences of violence propelled the public health community, beginning in the 1970s, to consider violence as a public health problem (National Committee, 1989). In 1985, the Surgeon General's Workshop on Violence and Public Health signaled the entry of public health into what traditionally had been the domain of the criminal justice system (U.S. DHHS, 1986; Mercy et al., 1993). Viewing violence prevention as a public health goal calls attention to the measurable health consequences of assaultive injuries, highlights the role of the health sector in identifying and reducing the violence embedded in situations and relationships, and highlights the potential utility of epidemiologic tools in identifying risk factors and designing interventions that lie outside the usual sphere of crime prevention and control. In this way the perspective and methods of public health usefully complement the perspective and methods of criminal justice in understanding and responding to violence. Recognizing the validity and benefits of both public health and criminal justice perspectives, Moore and colleagues (1993) argued for a synthesis. In their view, "to deal effectively with what can now be seen as a far more complex problem of violence and its consequences, there is urgent need for an effective collaboration between the two communities." The committee agrees with this assessment and urges continued and expanded collaboration to bring the resources and creative approaches of the criminal justice and public health communities to violence prevention. Although numerous factors enhance the risk of violence, research has determined that some of these factors appear to be salient as proximate causes of potentially lethal violence (i.e., the subset of violent events that present a risk of serious injury or death). These include the use of firearms, the use of alcohol and illicit drugs, the interaction of mental disorders and substance abuse, and the developmental and contextual features of adolescence in urban America that accentuate all other risk factors for violence (NRC, 1993, 1994; IOM, 1996; Zimring and Hawkins, 1997). A number of NRC reports have summarized the accumulating body of knowledge on the causes of violence (NRC, 1993, 1994, 1996, 1998). Progress has been less pronounced in developing and evaluating prevention programs, in large part, because of the time lag between understanding causation and translating this understanding into programs, the complexity of the problem, and the imperfections of current surveillance systems.

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Reducing the Burden of Injury: Advancing Prevention and Treatment The NRC report Violence in Families (NRC, 1998) examined the research literature on evaluations of interventions for child maltreatment, domestic violence, and elder abuse. Although it identified 114 evaluation studies in these areas, it found most to be "not yet mature enough to guide policy and program development." Only one area, home visitation programs for child maltreatment (see Olds et al. [1997]), was recommended as policy for first-time parents living in social settings with high reported rates of child maltreatment. Evaluation research is needed for a number of prevention interventions, including peer mediation, social skills training, comprehensive community initiatives, shelter programs and other services for victims of domestic violence, child fatality review panels, mental health and counseling services for child maltreatment and domestic violence, child witness to violence prevention and treatment programs, and elder abuse services (NRC, 1998). Finally, the committee believes that, from the perspective of violence research, a high priority is to strengthen the health system databases for monitoring nonfatal injuries. Accurate measures of violence can be achieved only by establishing reliable health-based surveillance systems. Strengthening these databases will advance the field of violence research whether it is conducted by criminologists or public health specialists, and whatever the source of funding. Violence prevention research is the purview of multiple federal agencies, including the Office of Justice Programs of the Department of Justice and the following agencies of the Department of Health and Human Services: the National Center for Injury Prevention and Control (NCIPC), the National Institute of Mental Health, the Maternal and Child Health Bureau, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse. Many of these federal programs are discussed at greater length in Chapter 8, where the committee makes several recommendations. In addition, the committee urges that the research recommendations of previous NRC reports be implemented to promote effective violence interventions. Prevention Interventions Injury prevention encompasses a vast array of programs and policies aimed at reducing the frequency or severity of injuries. Although these interventions can be categorized in a variety of ways, the committee elected to group them as follows: (1) interventions for changing individual behavior; (2) interventions for modifying products or agents of injury; (3) interventions for modifying the physical environment; and (4) interventions for modifying the sociocultural and economic environment. These categories are adapted from those originally proposed by William Haddon more than three decades ago (Haddon et al., 1964). Research on injury interventions often begins with estimating their efficacy, effectiveness, and cost-effectiveness. Factors that are considered include feasibility; potential mortality and morbidity reduction; economic impact; ethical,

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Reducing the Burden of Injury: Advancing Prevention and Treatment social, and political considerations; and likely acceptance by the target population. Through this predevelopment analysis, proposed interventions can be categorized and prioritized according to their potential impact. Those interventions with the greatest potential can be targeted for further development and pilot-tested for identification of unexpected consequences and efficacy. What follows is a summary of recent developments, including a few key research areas that appear to be ripe for further advances. Individual Behavior Behavioral research has demonstrated that many injury interventions require changes in human behavior, either to reduce the exposure or vulnerability of potential victims to injury-causing events or to reduce the risk that one person will become the agent or instrument of harm to another. Behavior change can be achieved by incentives and deterrence, education, and persuasion. Research has shown that beneficial behavioral changes rarely occur through education or persuasion alone. Some of the factors that influence the success or failure of education programs are known (including education levels, timing of educational approaches, e.g., child safety information for expectant parents), but focused research on the specification of these factors is needed. As research continues to increase our knowledge of efficacious strategies, promotion of these strategies has to be emphasized. Incentives and deterrence. One of the most significant developments in the injury prevention field over the past two decades has been to include the fruits of behavioral and criminologic research in developing behavioral incentives and disincentives, including threats of legal sanctions (deterrence) (Bonnie, 1986). Incentives are often financial. In the consumer arena, discounts in homeowner and automobile insurance premiums can be used as incentives to promote precautionary behavior, such as installing smoke detectors or purchasing cars with airbags, respectively. In the occupational arena, discounts in workers' compensation premiums are being used as incentives for promoting safe work practices. Deterrence through criminal punishment has been the backbone of the nation's policy for reducing assaultive behavior, and there is a growing body of literature on the preventive effects of criminal sanctions in general and of specific statutory provisions, such as mandatory jail terms for using a weapon in criminal activity (McDowall et al., 1992). Two of the most thorough investigations of deterrence have been in the area of highway safety. Over the past 20 years, a large body of research has been developed on the differential impact of various punishment schemes for drunk driving, including mandatory jail terms and administrative license suspension (Jacobs, 1989; Ross, 1993). More recently, a significant body of knowledge has emerged on the efficacy of laws mandating child restraint and safety belt use, demonstrating that enactment of

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Reducing the Burden of Injury: Advancing Prevention and Treatment these laws has significantly increased the rate of restraint use (Graham, 1993). In both cases, public education efforts have accompanied and spurred enactment of this legislation, transmitted knowledge about the provisions and penalties of laws to promote compliance, and generated public support for law enforcement programs. Self-protection. Another key development has been increased attention to the ways in which potential victims can reduce their own vulnerability or exposure to injury. Research on promoting helmet use by cyclists and safety belt use by motorists and passengers is a natural extension of medical research on the logic of immunization or prophylaxis. When extended to assaultive injuries, self-protection takes the form of bulletproof vests for police officers and other forms of personal security aiming to reduce exposure or vulnerability (NRC, 1993). Avoiding intoxication is another way that potential victims can protect themselves (Room et al., 1995). Increased scientific attention to the opportunities for precautionary behavior reflects an enriched appreciation of the ways in which changing the behavior of potential victims can reduce the risk of injury. It should be acknowledged, however, that one of the potential pitfalls of efforts to promote self-protection is the tendency to blame victims for failing to take precautions if injury does occur. This concern highlights the interaction of attitudes toward prevention and personal responsibility in an overall injury prevention strategy. High-risk groups. Another area requiring systematic research is in understanding and developing strategies for reaching high-risk groups. Although many interventions are appropriately aimed at the general population, research is needed on prevention interventions aimed specifically at groups with above-average risk. However, proper targeting is a first step. For example, most infants and young children traveling in passenger vehicles are in child safety seats. Yet there is an important but relatively neglected subgroup (an estimated 35 percent of children ages 4 and under) that travels without such restraints and has twice the risk of death and injury as those who use safety seats (SAFE KIDS, 1998). Research on protecting children who travel without restraints may be more useful than cataloging all the forms of misuse. Additionally, research has shown the promise of reducing injuries through home visitation for high-risk first-time mothers (Kitzman et al., 1997; Olds et al., 1997). Research demonstrates that at-risk populations do not necessarily have to be addressed directly in order to change their behavior. For example, there has been some success with peer intervention training in high schools as a means of getting students to intervene in the drinking and driving of their associates (McKnight and McPherson, 1986). Others who have some influence over at-risk individuals—for example, sellers and servers of alcohol—can be targeted, and server intervention programs have shown some success in reducing excessive alcohol consumption (McKnight and Streff, 1994).

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Reducing the Burden of Injury: Advancing Prevention and Treatment postdoctoral training (see Chapter 8), there is no comparable training program anywhere in the federal government for injury prevention in a non-occupational setting. Such training has to emphasize the same interdisciplinary orientation that underlies the research described earlier in this chapter. Training should include epidemiology, biostatistics, program evaluation, engineering, ergonomics, economics, biomechanics, law, and behavioral sciences, all of which form the backbone of injury prevention. Recommendations for training in non-occupational prevention research have been made repeatedly by the National Research Council and the Institute of Medicine (NRC, 1985, 1988), but funding has not been forthcoming. The lack of research training is a major barrier to the development of the field of injury prevention. Training attracts young people to a field and equips them for a lifelong commitment to research and education. A cadre of talented young researchers ensures the growth, innovation, and continuity of a field. Training programs are supported in every major field of public health, with the exception of injury prevention. (Treatment of trauma is supported by training programs of the National Institutes of Health; see Chapter 8.) In addition to funds for training, the maintenance of a vital extramural research community will require adequate funding for investigator-initiated, peer-reviewed research grants. It is necessary to ensure viable careers for the country's best young researchers and to sustain experienced investigators. Investigator-initiated research should be encouraged to ensure the emergence of innovative approaches to injury research. To ensure the scientific rigor of this research, proposed projects should be peer-reviewed by scientists outside the sponsoring federal agencies. These points and the need for sustained federal research support are addressed further in Chapter 8. Public health agencies need not be the only sources of research funding. There also are opportunities to recruit employers and health care payers as partners in funding prevention research. These organizations have strong economic incentives to support research that can lead to injury reductions. Injury reductions can yield cost savings, in terms of lower health care costs, workers' compensation costs, and indemnity costs. Moreover, the cost savings to payers can be realized almost immediately after the successful introduction of an intervention program. In contrast, cost savings from disease-oriented prevention programs take longer to realize because of the time lag between intervention and health outcome (e.g., reductions in stroke or heart attack). The immediacy of cost savings should be especially tantalizing for employers, because the total number of fatal and nonfatal job-related injuries is far higher (more than 13 million annually) than that for job-related illnesses (Leigh et al., 1997). The committee recommends the expansion of research training opportunities by the relevant federal agencies (e.g., NCIPC, NIOSH, and the National Highway Traffic Safety Administration [NHTSA]). This includes an increase in the number of individual

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Reducing the Burden of Injury: Advancing Prevention and Treatment and institutional training grants for injury prevention; research grant proposals should have independent peer review. Adequate federal funding must be forthcoming to sustain careers in the injury field. Communicating Results The scientific foundation of injury prevention has grown considerably over the past decade, having been cultivated by many different disciplines. As noted, researchers come from a variety of disparate disciplines. This has been a source of strength for the field and also at times an impediment in terms of scientific communication. The injury field lacks established channels of communication. This is illustrated in a variety of ways. One fundamental problem is that the terminology varies, depending on the discipline represented, for concepts related to risk perception, behavioral change, and prevention measures. Another illustration of the problem is that the scientific literature in injury prevention is indexed in many different government and private-sector databases. No one database contains all of the injury literature. Assembling published research on motor vehicle safety presents a case in point. Articles are separated between the epidemiologic and the engineering research literature. Epidemiologists publish predominantly in the medical literature that is accessible through the National Library of Medicine's (NLM's) MEDLINE database. Automotive safety engineers publish predominantly in Society of Automotive Engineers (SAE) publications that are indexed and accessible only through a subscription to SAE databases. Additionally, NHTSA research publications are often not published in the peer-reviewed literature and can be located only through the National Technical Information Service's database of government reports. Other databases that index scientific literature relevant to the injury field include PsychLIT, Sociological Abstracts, Criminal Justice Periodical Index, National Criminal Justice Reference Service, EMBASE, and Transportation Research Information Services. To date, the field of injury research has generated little interest among those working in medical informatics. There are notable exceptions—for example, the focus on computer applications that support decision making in trauma care (Clarke et al., 1994; Ogunyemi et al., 1995, 1997). Long-term consideration should be given to the opportunities that medical informatics and the Internet can offer. The NLM, in conjunction with relevant federal agencies, could explore the potential of linking injury-related databases by applying online metathesauri (e.g., NLM's Unified Medical Language System Metathesaurus). These approaches integrate diverse vocabularies by linking terms on the basis of conceptual, semantic, and lexical connections (Schuyler and Hole, 1993). Additionally, links could be explored on the Internet to the multiple databases that house the injury field's scientific literature. Although

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Reducing the Burden of Injury: Advancing Prevention and Treatment there are proprietary and search-fee considerations for some of these databases, at a minimum, links to the databases have to be forged. Problems in the communication of research significantly inhibit opportunities for cross-fertilization, collaboration, and growth of the field. The committee encourages the creation of an organization of injury prevention researchers, analogous to scientific organizations that have emerged in other interdisciplinary areas (e.g., College of Problems of Drug Dependence). Such an organization could sponsor annual research conferences, where injury researchers would present the results of new and encouraging research, and could support the development of an injury prevention research journal and electronic networks and work to solve the problems associated with database linkages. A new organization would have far-reaching effects in mobilizing injury prevention researchers. SUMMARY Scientific inquiry has transformed our notions of injury from accidental, unavoidable occurrences to events that are predictable and amenable to prevention. The development of future prevention interventions to address injury and the evaluation of the success of these interventions require a national commitment to expanding the scientific foundation for injury prevention. Support for injury prevention research should be commensurate with the enormous toll of injury on society. In particular, biomechanics, residential and recreational injuries, suicide, and violence are areas of research in need of higher priority. A national, long-term commitment to the expansion of interdisciplinary research and training in injury prevention is essential to public health. Without this commitment, injury research will not achieve the sophistication necessary for effective intervention development; talented new researchers will not be attracted to the field; and existing injury researchers may be forced to leave the field. In short, without a national commitment, the field of injury science will stagnate and the unnecessary toll of injury will persist. REFERENCES Baker SP, O'Neill B, Ginsburg MJ, Li G. 1992. The Injury Fact Book . New York: Oxford University Press. Baker-Dickman F. 1987. Sobriety Checkpoints for DWI Enforcement: A Review of Current Research. Washington, DC: National Highway Traffic Safety Administration. Barke RP, Jenkins-Smith H, Slovic P. 1997. Risk perceptions of men and women scientists. Social Science Quarterly 78(1):167–176. Barlow B, Niemirska M, Gandhi RP, Leblanc W. 1983. Ten years of experience with falls from a height in children. Journal of Pediatric Surgery 18:509–511. Berger LR, Saunders S, Armitage K, Schauer L. 1984. Promoting the use of car safety devices for infants: An intensive health education approach. Pediatrics 74:16–19.

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