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Injury Prevention David Lawrence Center for Injury Prevention Policy and Practice April 22, 2003 CHE 560

Today’s presentation… Magnitude of the problem Injury definition Injury prevention models Environmental and technological approaches Policy and Regulatory Approaches Successful injury prevention strategies Challenges Resources for further information

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Death Rates from Injuries and Other Causes, United States, 1910 - 2000

Injury Leading cause of death of children, adolescents, and young adults in the U.S. For every injury death, there are 45 hospitalizations and 1,300 ER visits. Most serious injuries can be prevented.

Injury Pyramid 145,655 Deaths 2,701,000 Hospitalizations 33,950,000 Emergency Department Visits 65,555,000 Visits to Office-based Physicians 59,550,000 Injuries Requiring Medical Attention or Time Off Work Source:  National Center for Health Statistics (1999)

Global perspective Each year > 5 million people die of injuries. 2/3 are males. Majority young adults 15-44. MV crashes are the largest cause of injury death. Source: Global Burden of Disease, WHO, World Bank, Harvard University, 1996 - 2001.

Childhood Injury in California Every year in California: About 2,200 children suffer fatal injuries. About 38,000 children suffer injuries that require hospitalization. Around 7,100 of these are due to assault/self-infliction. Average medical charges of fatal injuries to <15 year olds was $8 million. Medical charges of non fatal injuries to <15 year olds was $436 million.  Source:  EPIC Branch

Injury Definition Any unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of essentials such as heat or oxygen. We usually define injuries as occurring during a short period of time, as opposed to the effects of repeated exposures to chemical agents or cumulative damage from repetitive motions.

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“Accident” Vague term Better: Fall, Car crash, Poisoning Suggests lack of understanding of causes Suggests random chance, luck, or fate Suggests unpredictability

Injury as a Public Health Problem For most of the 20th Century, injury prevention focused on assumed shortcomings of the victims. Traffic safety movement of 1920s Education, pamphlets, posters Home safety movement of 1950s Education, pamphlets, posters

Injury as a Public Health Problem “Once a sense of personal responsibility for accident causation can be created in the minds of people, great progress will have been made. Then the sequel to an accident will no longer be an orgy of self-pity for having been the victim of an uncontrollable event. Instead there can be a character-building period of self-evaluation during which acts of personal stupidity, carelessness, and indifference may be identified.” - Chapman AL. In: Accident Prevention. Halsey MN, ed. New York: McGraw- Hill for American Public Health Association; 1961.

Modern view of injury Personal responsibility not eliminated but: Greater weight is now assigned to other issues such as environmental factors Hugh De Haven fall studies: Not the force, per se, that produced the injury but the structural environment that controlled the deceleration of the force and the distribution of the force over the body.

De Haven Fall Studies If the fall could not be prevented, then “Structural previsions to reduce impact and distribute pressures can enhance survival and modify injury ... in aircraft and automobile crashes.” - De Haven H. Mechanical analysis of survival in falls from heights of fifty to one hundred fifty feet. War Med 1942: 586-596.

Environmental Model “Man responds to the flux of energies which surround him – gravitational, mechanical, radiant, thermal, and chemical ... Injuries can only be produced by an energy exchange between man and his environment.” James J. Gibson, 1961.

Injury Prevention The fundamental task is: Prevent the agent (energy) from reaching people in amounts or rates that exceed the capacity of their body to tolerate it

Epidemiological Model

Epidemiological Model

Epidemiological Model

William Haddon, Jr. Expanded on Gibson to address preventive approaches. Demonstrated that the host, agent, and environmental factors interact over time to cause injury.

Haddon Phase-Factor Matrix

Haddon Phase-Factor Matrix

Haddon’s 10 Countermeasures Prevent creation of the hazard Stop producing hazardous substances like highly toxic pesticides or fireworks Reduce the amount of the hazard Package toxic drugs in smaller, safe amounts Reduce speed limits Prevent inappropriate release of any existing hazard Make bathtubs less slippery

Haddon’s 10 Countermeasures Modify the rate or spatial distribution of the hazard Require automobile seatbelts and air bags Require soft playground surfaces

"More than 170,000 children..." More than 170,000 children sustain playground equipment related injuries each year; 90% of the serious injuries are from falls to the ground surface beneath the equipment. Source:  American Academy of Pediatrics

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Haddon’s 10 Countermeasures Separate release of the hazard in time or space

Haddon’s 10 Countermeasures Reroute high speed traffic around residential neighborhoods or slow it with speed bumps and roundabouts Spray pesticides at a time of day when people aren’t around

Haddon’s 10 Countermeasures Install Red Light Cameras

Haddon’s 10 Countermeasures Install Red Light Cameras

Haddon’s 10 Countermeasures Put a barrier between the hazard and people at risk Install fences around pools Install cover guards on dangerous machinery Install proper guardrails along roads Use child-proof packaging Store handguns in a locked metal box Use extension cords with good insulation

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Haddon’s 10 Countermeasures Change the basic nature of the hazard Make crib slat spacing too narrow to strangle a child Modify equipment by rounding sharp corners

Haddon’s 10 Countermeasures Increase resistance of people to the hazard Improve physical condition through proper nutrition and regular exercise Begin to counter damage already done by the hazard Provide emergency medical care Stabilize, provide definitive care, rehabilitate Availability of appropriate acute care and rehabilitation facilities

General Model for Injury Control

Injury Prevention: The Role of Policy and Law In dealing with any public health problem, governments can fund programs or enact laws. Legislation can provide agencies with the power to establish administrative rules.

Proven Injury Prevention Interventions Car safety seats and belts Air bags Motorcycle helmets Bicycle helmets Child resistant packaging Swimming pool fencing Smoke detectors Self extinguishing cigarettes

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Success: Residential Fire Injuries

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Occupant Fatality Rates, Infants, United States 1960-2000

"“Correctly installed and used..." “Correctly installed and used child safety seats reduce the risk of death by 71%, hospitalizations by 67%, and minor injuries by 50%.” Source:  American Academy of Pediatrics

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"“Bicycle helmets reduce the..." “Bicycle helmets reduce the risk of head injury by 85% and risk of brain injury by almost 90%, yet only 5% of child bicyclists in the U.S.A. wear helmets.” Source:  American Academy of Pediatrics

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Injury Prevention Policy The ideal policy is:  a prudent course of action selected from among the alternatives to guide present and future decisions and behavior. It is an idea or plan of what to do in a particular situation that has been agreed to by a group of people, a business, or a government. Thus, although laws are policies, not all policies are laws.

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Injury Prevention Policy Cellular Telephones in Motor Vehicles Businesses shall establish rules that prohibit the use of cellular telephones while driving a vehicle. Communities shall enact local ordinances that restrict the use of cellular telephones while driving a vehicle. Professional, civic, social, and faith organizations shall recommend to members that they refrain from using cellular telephones while driving a vehicle.

Injury Prevention Policy Child Death Review Teams Every state and county shall have a multidisciplinary team that reviews the causes and circumstances of each child's death to find hazards that may place other children at risk from neglect, abuse, violence, and unintentional injuries. This information should be used to prioritize and focus community prevention activities and not exclusively to establish blame.

Injury Prevention Policy Children Left Alone In Motor Vehicles States and communities shall enact and enforce laws or ordinances to prohibit children from being left unattended in motor vehicles.

Injury Prevention Policy Enforcement of Passenger restraint Laws Local police shall enforce laws that require motor vehicle occupants to be appropriately restrained with seat belts or safety seats.

Injury Prevention Policy Isolation Fences Around Residential Swimming Pools States and communities shall enact and enforce building codes that require four-sided isolation fencing around residential swimming pools. The fencing shall be of appropriate height and with self-closing, self-latching gates.

Nature of Injury Prevention Laws Federal Authority State and Local Authority Statutory laws can either REQUIRE or PROHIBIT They can be directed at: Individual behavior Products Environmental conditions or places

Examples of State and Local Laws Regulate the color and speed capacity of school buses Mandate buildings to be constructed to meet codes and standards. Require child abuse reporting Restrict sale or giving of alcohol to children

Examples of State and Local Laws

Regulation versus Individual Freedom You and I can’t tell if a bridge or building is at risk for falling down, but… Engineers and architects can foresee such things Standards can be established and required in construction Inspectors can provide assurance that standards are met

Regulation versus Individual Freedom What of individual freedom and free trade? Leave everyone to regulate his own business Let the customer decide Demand and supply are suitable regulators Although some customers will make mistakes, the public will eventually recognize those who offer the best product.

Regulation versus Individual Freedom What of individual freedom and free trade? As the customer is being blown up, crushed, run over, poisoned, or knocked down dead they will discover that they have made a mistake.

Regulation versus Individual Freedom Proverb: A burned child will dread the fire and learn caution. But of what use for safety is dread, after the child has burned to death.

Useful Websites http://www.injurypreventionweb.org Contains injury data for every U.S. state, over 1,100 links to injury prevention sites worldwide, and includes suggestions for injury-related books and journals. http://www.cdc.gov/ncipc/ National Center for Injury Prevention and Control http://www.safetypolicy.org Healthy People 2010 Objectives, Injury Prevention Policy Statements http://www.cippp.org Center for Injury Prevention Policy and Practice

Useful Websites http://www.SafetyLit.org A free weekly update of the research literature selected from over 200 professional journals from the health, engineering, psychology, ergonomics and human factors, economics, law and law enforcement, sociology, social work, anthropology, and other fields.

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