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).
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).
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
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-
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
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
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).
TABLE 4.1 Examples of Effective Unintentional Injury Prevention Interventions
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)
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)
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
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.
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
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.
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. ), 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.
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,
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.
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
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).
The agent of injury is often a product obtained by a consumer in the marketplace (including motor vehicles, firearms, or other consumer products). Many of the great successes of injury prevention have involved research demonstrating that product alterations may reduce the risk of an injury-causing event or ameliorate its effects. Research on pre-event interventions resulted in the development of center high-mounted brake lights on automobiles that assist in preventing rear-end collisions by giving drivers that follow a quicker warning of deceleration (Rausch et al., 1982; Kahane, 1989; McKnight et al., 1989); childproof caps to keep medicine, that can cause poisonings from being opened (discussed earlier); and safety locks on firearms (see Chapter 5).
Prevention of fire-related injuries encompasses a wide range of opportunities for modifying the vector of thermal energy to reduce the risk that the energy will escape from control. For example, research has demonstrated the feasibility of safer designs for cigarettes (to make them self-extinguish more quickly) and lighters (to make them less likely to be ignited by a child). This research has led to product liability litigation against manufacturers of cigarettes and lighters, and has also provided the scientific basis for a 1994 Consumer Product Safety Commission regulation requiring cigarette lighters to be child-resistant. Research has also demonstrated the feasibility of making mattresses and upholstered furniture less flammable and, accordingly, less likely to be ignited by cigarettes, leading to the implementation of industry safety standards.
Research on the safety features of these products is conducted primarily by manufacturers, regulatory agencies, or watchdog consumer organizations. From the perspective of "intervention research," research questions concern the incentives for developing and implementing product safety designs that arise in the market (through which manufacturers respond to consumer preferences for safety); the efficacy of "interventions" designed to modify these incentives through direct regulation by authorized agencies (through standard setting or remedial action); or the indirect regulatory effects of bad publicity and tort liability. Surprisingly few researchers have explored empirically the operation of the market for safety, the effects of tort liability, and the effects of regulatory action. This area of research is in need of greater attention, particularly the safety effects of tort liability; here, public health proponents typically assume that expansive liability rules are safety enhancing, whereas skeptics believe that the existing liability scheme tends to reduce safety by retarding innovation or inducing override behavior (Sugarman, 1990; Rose-Ackerman, 1991; Viscusi, 1992; Viscusi and Magat, 1995; Dewees et al., 1996).
Research has shown that some of the most successfully engineered safety interventions are often unnoticed factors in the environment. Everyday examples are roadway modifications that help drivers stay on the road rather than going off the road at curves or other hazardous locations (TRB, 1990), guard railings on upper-level terraces, and window guards to prevent childhood falls (Spiegel and Lindaman, 1977; Barlow et al., 1983). Through research, safety engineers and injury specialists have been able to modify building codes and change engineering designs to build in these safety features.
In recent years, increasing attention has been paid to preventing assaultive injuries through changes in environmental design. Examples of environmental changes include improved lighting in parking lots, the addition of police call-boxes, installing plexiglass shields for lone employees who need to handle cash transactions especially at night, and locating automatic teller machines in well-lit, high-traffic areas. Creative environmental interventions include efforts to reduce the incentives for committing robbery by using exact fare systems on public transport (Chaiken et al., 1974).
Any planned intervention designed to reduce injuries occurs in the context of broad economic and social forces, such as employment rates, wealth distribution, social norms about health and safety, and population demography, that also fundamentally shape injury rates. Economic conditions, social practices, and cultural understandings constitute the context for of all these other factors and the prospect of altering them. Death rates are high in low-income areas for most types of unintentional injuries and for homicide; however, for suicide, there is little relationship between injury death rate and per capita income (Baker et al., 1992). Racial disparities in childhood unintentional injury rates are associated more with living in impoverished environments that with ethnicity (Singh and Yu, 1996; SAFE KIDS, 1998).
An example of the impact of the socioeconomic environment is seen in the increases in the rate of highway fatalities during economic upturns and the decreases during recessions (Graham, 1993). People tend to drive more during boom times, and the fatality rate per mile also increases (relative to long-term trends) as the economy expands, probably because more miles are driven by more high-risk drivers such as teenagers and people who have been drinking. This example illustrates two points. First, researchers studying the effects of planned injury prevention interventions on injury rates must always be alert to the effects of these background socioeconomic trends and conditions. Second, some types of public policies can be utilized explicitly as levers of injury prevention, even though they are not ordinarily seen from this perspective. A good
example is the excise tax on alcohol, which is largely considered as a means to raise public revenues. In recent years, studies have demonstrated that raising the alcohol excise tax reduces the highway fatality rate and the rate of violent crime (Cook and Moore, 1993). Policies to increase alcohol excise taxes deserve to be viewed in terms of both revenue enhancement and injury prevention.
Studies of recent safety interventions have highlighted the possibility of modifying social norms and expectations about safety. Changes in attitudes toward alcohol-impaired driving have been associated with changes in driver behavior and with consequent reductions in injury rates. Increased parental use of child occupant restraints as well as increased rates of safety belt use among motor vehicle drivers and passengers has also called attention to the "declarative" role played by legal norms in reinforcing, stimulating, accelerating, or symbolizing changes in public attitudes or expectations about socially desirable behavior (Wagenaar and Webster, 1986; CDC, 1991). One of the interesting challenges faced by researchers investigating the effects of legal prohibitions or requirements is to distinguish between behavioral effects attributable to classical deterrence (behavior modified in response to threatened sanctions) and those attributable to the "declarative" effects of the law, which affect behavior indirectly by changing attitudes (Bonnie, 1986). Further attention to this issue will help policy makers design the most promising ways of deploying legal changes together with educational messages to promote safe behavior, such as safe storage of firearms and other dangerous articles.
Broadening the Scope of Prevention Research
Once an injury problem is identified through surveillance or other means, research is brought to bear to identify causes, circumstances, and risk factors, as well as to develop and evaluate interventions. Evaluating interventions encompasses assessments of feasibility, efficacy, effectiveness, and cost-effectiveness. Outcome measures include changes in attitudes, knowledge, behavior, mortality, morbidity and disability reduction, and economic cost.
Prevention research is accomplished through a burgeoning variety of disciplines. Disciplines at the core of injury prevention research—epidemiology, behavioral science, biomedicine, and biomechanics—continue to be critical to the advancement of the field. Other disciplines are playing increasingly important roles, including economics, criminology, sociology, engineering, law, and molecular biology. As the scope of injury prevention is broadened to incorporate concepts and methodologies from many diverse fields, there is the potential for the development and testing of a far-reaching variety of new and better interventions and a fuller, multipronged approach to reducing the incidence and consequences of injury. For example, in the aviation industry, a broad array of inter-
ventions—including pilot training, air traffic control, aircraft design, and the use of safety belts—has been institutionalized to reduce passenger fatalities on U.S. commercial aircraft in 1996 to 1.8 per million passenger enplanements (NTSB, 1998). Such integration of approaches from multiple disciplines is crucial to injury prevention research.
Injury biomechanics has been a fundamental discipline in experimental studies of injury, especially injury causation. Experimental biomechanics reproduces the circumstances of injury under well-controlled laboratory conditions and examines structural and biologic responses. The work of Hugh DeHaven and William Haddon defined the field of injury biomechanics by describing the implications of abrupt dissipation of mechanical energy (see also Chapter 1 and Baker et al. ). Injury biomechanics research uses the principles of mechanics to explore the physical and physiologic responses to impact, including penetrating and nonpenetrating blows to the body (NRC, 1985). Classically, injury biomechanics research has focused on injuries in their acute phase, establishing the causative forces or motions that provoke the injury, allowing countermeasures to be designed and tested. Yet, biomechanics has many applications in injury research, including testing the efficacy of interventions involving product design. Currently, the field of biomechanics includes investigators studying robotics, physical therapy, orthopedics, physical and sports medicine, exercise science, limb prosthetics, orthotics, and tissue engineering. This multidisciplinary science promises to provide the scientific and technical knowledge to develop strategies that will prevent injury or assist impaired neuromuscular systems (IOM, 1997).
Biomechanics research has established injury tolerance levels for many types of body tissue and has elucidated many of the biological processes that affect the injury process. The most complete picture of injury tolerances, pathophysiology, and reparative processes involves adult bone and connective tissue (McElhaney et al., 1976; Nahum and Melvin, 1993). Yet, despite significant strides in the past decade, the biomechanical properties of the brain and the biologic response of the brain to injury are not as well characterized. This variability in the knowledge base of injury biomechanics is also evident in the sophistication of interventions available. Techniques for the prevention and treatment of orthopedic injury are vast, ranging from hormonal supplementation to strengthen bone in order to prevent fracture (Folsom et al., 1995) to successful treatment for the nonunion of fractures by electrical stimulation (Esterhai et al., 1986). The options available to the clinician treating traumatic brain injury are essentially limited to minimizing secondary injuries due to brain swelling or hemorrhage (Chesnut, 1997).
Although the development of head injury tolerances began over 40 years ago and made use of a broad range of innovative experimental techniques, including human volunteer and cadaver tests and animal experiments, conducted by John Stapp and other pioneers in the field (Stapp, 1955), continued progress has been slow. The tests and experiments were extremely useful in developing an understanding of biodynamic responses under well-controlled crash situations. Denny-Brown and Russell (1941) conducted a series of animal experiments to study concussion. As a result of their work, estimates were developed regarding the amount of pressure in head impact that causes concussion. Researchers replicated those pressure levels in head impact tests on human cadavers, and determined average head accelerations required to cause injury across different impact durations (Viano et al., 1989; King et al., 1995). Subsequent analyses showed that mathematical relationships, known as the Severity Index and the Head Injury Criterion (HIM), could be developed from head acceleration data to establish a threshold for life-threatening injury. This elegant evolutionary process in the development of head impact protection stopped, however, when the HIC was adopted as one of the standards for evaluating motor vehicle safety performance. However, research on brain injury mechanisms have shown that HIC may not be appropriate for predicting specific forms of injury, notably diffuse brain injuries (Margulies and Thibault, 1992). Unfortunately, this work has been inadequately funded and restrictions on the use of animal and cadaver surrogates have impeded further progress.
Although there are other areas of biomechanics research (e.g., severe maxillofacial, thoracic, abdominal, and internal organ injuries), neurotrauma to the head resulting in traumatic brain injury continues to be a critical area. In the United States, someone suffers a head injury every 15 seconds. Every 5 minutes, one of those individuals dies and another becomes permanently disabled. There are 75,000 deaths from head injuries every year, and another 70,000 to 90,000 suffer permanent disability. Furthermore, 5,000 of those individuals develop epilepsy and another 2,000 remain in a chronic vegetative state. Traumatic brain injury is primarily a disability of the young, and the economic costs alone approach $25 billion annually (U.S. DHHS, 1992). Thus, research on neurotrauma to the head remains a priority area for biomechanics researchers.
To date, limited funding (Chapter 8) and difficulties in conducting animal and human cadaver research remain significant impediments to biomechanics research. Animal and cadaver use has greatly enhanced our understanding of injuries to specific areas of the body. Unfortunately, societal stigma and institutional policies limit the availability of animals and cadavers for research, particularly on pediatric injury. As a result, most knowledge of injury biomechanics is based on average-sized adults, and child injury (as well as injury to small women) assessment reference values are actually scaled-down estimates based on tests on adults, despite uncertainty regarding the accuracy of the scaling assumptions. There is also limited knowledge of the biomechanics of whiplash-associated disorders, even though neck strains and sprains result in significant
numbers of claims made to insurance companies each year (Insurance Research Council, 1994).
Despite such obstacles, the field of injury biomechanics has made progress; for example, an advanced frontal crash test dummy has been developed that incorporates improved biofidelic features and expanded instrumentation. The new dummy potentially represents an effective tool for whole-body trauma assessment. Additionally, the clarification of design and performance specifications for child crash dummies will be useful for evaluating children's responses and injury potential in automobile crashes (NHTSA, 1998). Other advances are clearly demonstrated by the development of computerized models of injury. The revolution in computer and information technology in the past decade has led to the development of biofidelic models (i.e., realistic computer-based models of human anatomy and physiology). In many instances, anatomically accurate models that only five years ago were considered impractical are now examined routinely by biomechanics researchers. In addition, the decreasing cost of computer technology has allowed more research groups to develop and test computational models for studying injury mechanisms and tolerance.
Nevertheless, the utility of the models is dependent on the use of animals and cadavers for validation. Further, computer models are often developed in parallel with research on animals and cadavers; for example, a computer model of the neck under compressive loading is developed and validated with data from similar experiments on cadavers. Three principal benefits occur when such a parallel approach is used: (1) the computational models are more consistent, since they are validated with experimental data; (2) computational simulations, when exercised over a broad range of mechanical conditions, can highlight important new areas of investigation for the experimental models; and (3) the models are more easily extended to different segments of the human population, thereby increasing their impact. In all, the parallel approach can yield new insights, as well as new research directions, for investigators in injury prevention.
In the future, the role of modeling will continue to grow as an important tool for understanding injury causation and may also represent an effective proactive prevention tool by identifying harmful environments, harmful products, or at-risk populations before injuries occur. However, animal and cadaver research will continue to be an important component because it will be needed to establish the fidelity of computer models and to provide accurate measures of response to injury in children and small adults. Inasmuch as current support for both cadaver and animal experiments is inadequate, research support must be expanded.
The committee recommends the continued development of physical, mathematical, cellular, and biofidelic models of injury, particularly for high-risk populations (such as children and small women), while continuing to use animals and cadavers to validate biomechanical models of injury.
The application of molecular and cellular biology, neurobiology, and pharmacology to the study of injury has shed new light on the pathophysiology and treatment of injury. As an example, study of the role of calcium as a mediator of cell death following brain injury has provided hope that pharmacologic interventions can inhibit this process (Saatman et al., 1996). The exchange of information from other fields has further enhanced the body of knowledge in injury pathophysiology. For example, injury researchers have drawn on cancer biology to study apoptosis, the process of programmed cell death, in relation to injury (Rink et al., 1995; Liu et al., 1997). The application of knowledge regarding apoptosis to the study of populations of cells that die after brain or spinal cord injury has resulted in more sophisticated thinking about a cascade of biochemical events triggered by injury. Knowledge of a greater number of biochemical steps in the process of cell death results in more possibilities for intervention. Promoting the exchange of information and techniques from other areas of research can increase the resources and talent available to solve the complex problems of injury etiology and prevention.
Additionally, there are new and promising developments in the study of the relationship between injury and disease. For example, clinical data have suggested that an episode of trauma to the musculoskeletal system can lead to osteoarthritis many years after the event. Recent biomechanics research has shown that nondebilitating trauma to the knee can cause long-term osteoarthritis in the knee joint (Haut et al., 1995; Newberry et al., 1997). Similarly, clinical data have shown that neuropathological changes in brain-injured patients exhibit striking parallels to brains of Alzheimer's patients (Graham et al., 1995, 1996). The relationship between neurodegenerative diseases and traumatic brain injury is even more convincing in experimental models of brain injury (Roberts et al., 1994) and suggests both a new direction for brain injury prevention and treatment research and the need to extend studies on injury outcomes to include debilitating neurodegenerative disorders.
The committee recommends an investment in research on the pathophysiology and reparative processes necessary to further the understanding of nonfatal injury causes and consequences, in particular, those that result in long-term disability.
The importance of behavioral research to injury prevention was highlighted more than three decades ago by William Haddon in his early publications on preventing motor vehicle injuries (Haddon et al., 1964). The behavioral sciences contribute to injury research by developing knowledge about psychosocial de-
terminants of human behavior, guiding the measurement of these determinants, and shaping the development and measurement of interventions for reducing injuries (National Committee, 1989). It is abundantly clear that injury rates vary according to gender, age, and ethnicity (Chapter 2). Adolescent males, for example, represent one of the groups at greatest risk of injury, especially for motor vehicle and firearm injuries (Fingerhut and Warner, 1997). Behavioral sciences, using a combination of empirical and theoretical approaches, help to explain why gender, developmental age, and ethnicity are important. They examine the influence not only of social and cultural norms, but also of individual and family characteristics that predispose to injury (Irwin et al., 1992; Robertson, 1992). Better understanding of the psychosocial determinants of behavior helps to focus efforts to intervene to change behavior in order to reduce injury risk.
Behavioral research has led to growing awareness of how individuals perceive risk (Kahneman et al., 1982) and how their perception of risk influences their risk-taking behavior (e.g., substance use, recreational vehicle use) that leads to injury (Irwin et al., 1992; Zuckerman, 1993). Risk perception is guided by individuals' understanding of the magnitude of a given risk and also by value judgments about its attributes, such as its familiarity and controllability (Slovic et al., 1982; NRC, 1989). Risk perception and risk decision making are also closely tied to age (Reyna and Ellis, 1992) and gender (Flynn et al., 1994; Barke et al., 1997). This information has helped to explain why facts alone are often insufficient to induce behavioral change for prevention purposes. For example, it is all too clear from the mixed results with HIV (human immunodeficiency virus) prevention efforts that psychosocial determinants, including risk perception and risk-taking behavior, must be taken into account in the design of interventions that strive for enduring behavioral change (IOM, 1994).
Behavioral researchers have also investigated the possibility that people will alter their behavior in response to safety improvements in products or in the environment so as to reduce the safety benefits of these changes. That is, people may increase their level of risk, thereby offsetting some or all of the anticipated safety benefits. It is clear that people behave differently when the risks they perceive change; for example, people walk more carefully when barefoot, drive with greater caution when roads are icy. In similar fashion, consumers are likely to respond in some way to safety-enhanced technology or environmental changes of which they are aware. It may even be that each person has a target level of risk that he or she wishes to maintain, so that, for example, if cars are made safer and the cost of risky driving is lowered, then the driver compensates by taking greater risks. Research seeks to clarify the conditions under which offsetting behavior is likely to occur and to what extent.
Most of the literature on this topic deals with motor vehicle injuries. Evans (1991) outlined some general patterns as to how consumers react to safety-related changes. ''If the safety change affects vehicle performance, it is likely to be used to increase mobility. Thus, improved braking or handling characteristics are likely to lead to increased speeds, closer following, and faster cornering.
Safety may also increase, but by less than if there had been no behavioral response. When safety changes are largely invisible to the user, there is no evidence of any measurable human behavioral feedback. Likewise, when measures affect only the outcome of crashes, rather than their probability, no user responses have been measured." Lund and O'Neill (1986) reached similar conclusions. These conclusions based on studies involving motor vehicles are likely to apply to other injury areas (e.g., falls, firearms) when changes in products or the environment alter perceived risks, but relevant studies are not available. One area that has received attention is child-resistant packaging. Concern was expressed that child-resistant packaging would not decrease poisonings because, for example, parents would be prone to leave the bottles more accessible to children (Viscusi, 1984), but there is definitive evidence that child-resistant packaging does reduce child poisonings (Rodgers, 1996). Behavioral adaptation to safety improvements is an important area for future behavioral research.
The behavioral sciences also contribute to methodological advances in the study of injury causation and intervention effectiveness. They emphasize the importance of developing reliable, valid, and quantitative outcome measures related to attitudes, knowledge, and behaviors. This is extremely important for assessing the effectiveness of educational and regulatory interventions designed to induce behavioral change. They have also contributed to the refinement of study designs widely used in injury research, particularly by epidemiologists (see following section). A more prominent role for behavioral scientists in suicide and violence research is warranted, given the need for increasing methodological rigor in these areas of injury research (see NRC [1993, 1994, 1996, 1998]). Finally, behavioral research has cultivated new research tools, such as qualitative research. By using observation, in-depth interviews, and focus groups, qualitative research strives to make sense of, or interpret, a particular behavioral or clinical issue (Greenhalgh and Taylor, 1997). However, because it lacks quantitative rigor, qualitative research is best used to describe new phenomena and generate research questions and hypotheses (Poses and Isen, 1998).
The committee recommends intensified research on differences in risk perception, risk taking, and behavioral responses to safety improvements among different segments of the population, particularly among those groups at highest risk of injury.
The tools of epidemiology may be used to design studies to elucidate the nature or cause of injury and to determine the effectiveness of interventions. Over the past decade, epidemiologic studies have advanced the injury field by quantifying the relationship between risk factors and injury. Risk-factor identification ranges from identification of risky behavior and at-risk populations to
proximate physical causes of energy exchange (e.g., contact points in vehicle interiors). As the injury field matures, research has to move away from a reliance on descriptive case studies and toward more rigorous analytical methodologies.
Randomized controlled trials (RCTs) are considered the gold standard in evaluating the effectiveness of interventions. Randomization maximizes the comparability of intervention and nonintervention groups with respect to factors that may influence the outcome of the trial. Through randomization to intervention and control groups, RCTs are designed to adjust for a variety of potential confounding factors. In addition, the investigator can control the conditions under which the trial is conducted to ensure that standardized procedures are followed. Although RCTs are expensive, time-consuming, and not always feasible, they are the standard in other fields of research and should be in injury research as well.
Cohort studies are used to compare the rate of injury of individuals exposed to a suspected risk factor with the rate of injury among individuals unexposed to the risk factor (Lilienfeld and Stolley, 1994). One major difficulty is that large numbers of individuals may have to be followed in order to capture a sufficient number of injuries for meaningful analysis of risk. The other major difficulty is the need to follow individuals over time. Together, these often make cohort studies expensive and logistically problematic. Increased attention should be devoted to the development of multi-institutional cooperation to maximize generalizability and spread the burden of subject follow-up. Better ways to ascertain exposure are needed for use in cohort studies of injury. Cost-efficient data collection methods that maintain data quality also are required.
Case-control studies compare injured individuals (cases) with those who are not injured (controls) in order to determine what characteristics are associated with the injury (e.g., lack of safety belt use in severe motor vehicle crashes). Case-control studies are especially useful in the identification of risk factors for rare events. To conduct studies over reasonable periods of time, it is often necessary for investigators at multiple sites to collaborate in order to accrue sufficient numbers of injuries for study. The limitations of case-control studies include vulnerability to recall bias, the possibility of confounding by unidentified factors, and the inability to definitively establish causality.
Recent variants of the case-control design have been used in injury research, including studies that compare persons with specified types of injuries to persons with other types of injuries and studies in which the site of death or injury is compared with a site where an injurious event did not occur (Wright and Robertson, 1976). Studies of the efficacy of helmets have compared bicyclists with head injuries to those with injuries to other regions of the body (McDermott et al., 1993; Thompson et al., 1996a). Another variant is a case-crossover study, which uses study participants as their own controls. This type of study compares behavior during the event (e.g., a crash or injury) with that preceding the event to determine whether participants were exposed to the factor of interest. For example, a case-crossover study was used to determine the risk associated with the
use of cellular telephones in automobile crashes (Redelmeier and Tibshirani, 1997). Case-crossover studies control for variability in individual characteristics and are uniquely capable of identifying transient risk factors.
Researchers also employ ecologic study designs in which the investigator does not assign the exposure and in which the unit of analysis is a group rather than the individual subject. Injury epidemiologists frequently utilize ecologic designs to evaluate laws and regulations. These natural experiments allow comparisons of jurisdictions with a law to those without it, for example, comparing firearm fatality rates in two cities with different firearm laws (e.g., Sloan et al. ); other times, a single jurisdiction after a law has taken effect is compared to the same jurisdiction before the law (time-series design). Time-series designs may use simple before-and-after comparisons, such as comparing fatal motor vehicle crash rates among young people before and after the passage of a law lowering the legal blood alcohol level for young drivers (e.g., Hingson et al. ), but can also incorporate approaches that account for background secular trends. Interpretation of ecologic studies is difficult because, in addition to controlling all the normal sources of bias, researchers must also deal with ecologic bias and the failure of ecologic analyses to account for the distribution of confounders at the individual level.
Finally, case studies are a traditional research design that have yielded important advances in understanding causes of injury but frequently are misused. Case studies are vital when attempting to elucidate the physical mechanisms for excessive energy transmission. For example, the mechanisms by which occupants are injured during motor vehicle crashes were determined by thorough case investigations. However, case studies can be used only to ascertain directly observable proximate causes of injury. One common misuse of case studies is for study of risk factors for injury that are not directly observable, particularly indirect human factors such as fatigue or alcohol. Studies with comparison groups are the only scientifically valid method of quantifying the extent to which indirect risk factors contribute to injury causation.
The committee strongly recommends the utilization of rigorous analytical methods in injury research. Collaborations between research centers are critical for assembling populations and cohort groups necessary for conducting large-scale randomized controlled trials, cohort studies, and case-control studies.
Training and Research Funding
There is a dearth of funding for research training in injury prevention, except for occupational injuries. Although the latter is supported by the National Institute for Occupational Safety and Health (NIOSH), a unit of the Centers for Disease Control and Prevention with a long-standing commitment to pre- and
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
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.
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
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.
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.
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