Chapter 2.

Why is Injury a Public Health Problem?

By Carol Runyan, MPH, Ph.D.

• Overview
• What do we mean by injury?
• A public health approach to injury prevention
• Moving from problem recognition to action

Overview

The intent of VINCENTweb is to provide a broad introduction to the problem of injury in the United States, and to help you develop an innovative way of thinking about and starting to plan for injury prevention. Although the course will not make you an injury control expert, we hope that you will go away with a basic understanding of the problem and with an understanding of some of the ways you can make a difference in the lives of people locally and nationally. As you'll learn in Chapter Three, injury is a major public health problem in this country that requires the attention of people like you.

As you progress through the course, one of the most important things we would like you to focus on and remember is that injuries are preventable.

Even though injury is a major problem in this country, it is not an insurmountable one. We already have a lot of prevention strategies that work. What we need is help in mobilizing these strategies so that we can make a difference through action at the local, state and national levels. This chapter is intended to provide some general background to orient you to the way the rest of the course will discuss injury prevention. For those from public health fields, much of what follows in this chapter will be very familiar. For those of you who come from fields outside of public health, some of the concepts covered here may be new. Either way, we hope that by the end of the course we will have established some common ground for working together.

What do we mean by injury?

It makes sense to begin a course on injury prevention with a clear perspective on what we mean by injury. Many people are used to thinking that injuries are the result of accidents. But it is important to consider that if injuries really were the result of accidents, it would not make sense for us to make injury prevention such a major priority. This is because accidents are typically considered to be both unpredictable and unpreventable. In contrast, we believe that injuries occur as the result of events that can be predicted and prevented. Therefore, we'll be talking about problems that have defined causes and defined solutions. We'll consider both unintentional injuries -- what you may be used to calling accidents -- and intentional injuries -- also known as violence.

Injuries happen in a variety of ways and places. They happen while people are at home, at school, at work, and while they are moving about in different forms of transportation. In general, injuries can be grouped into two major categories: those that are unintentional, and those that are intentional. However, the strategies that we can use to address these different types can be similar. Here are a few examples of the types of injuries we'll talk about in the course:

Some of the types of unintentional injury that we'll address are: motor vehicle crashes, pedestrian injury, bicycle crashes, occupational injury, drowning, falls, sports injury, choking, and fires and burns. These are examples of some of the major types of injuries, but are certainly not all of the types of injuries that you may encounter in your area. The different types of unintentional injuries are similar in that they tend to happen quickly and as the result of the transfer of energy from an object to a person. For example, the transfer of heat in a fire or a burn, or the transfer of mechanical energy in an automobile crash. Some of the things that you will learn about in this course are strategies for preventing that energy transfer from happening and causing injuries.

Intentional injuries include all different kinds of assaults. Before we go on any further, it is important to recognize that injury categories can overlap and that information is grouped in different ways depending on where you find it and what your purposes are. But when we talk about intentional injuries, we are generally referring to harm that is intentionally inflicted by one person against another.

A public health approach to injury prevention

So now that you know what types of injury problems we'll cover in this course, let's spend a little time addressing the approach we'll use for injury prevention. We're taking a public health approach, which means that we're interested in approaching problems at the community level, focusing on prevention, and approaching the many different kinds of injury causes with many different kinds of solutions.

Approaching problems at the community level means looking for the causes of and solutions to problems in the community as a whole, rather than simply addressing problems one by one as they arise. Here, ìcommunityî might be a neighborhood, a whole city, or even be the entire nation. Instead of simply gathering information about individuals in a community, public health professionals often gather information about the whole community and think of the entire community as the patient. As a result of this approach, we won't be talking much about injury prevention strategies that are directed at specific individuals. Instead, we'll focus on strategies aimed at improving the health of the entire community.

Taking a public health approach also means that we focus on prevention. While the treatment of injured people is certainly important, public health professionals believe that the prevention of injuries should be our primary goal. This means that this course will not focus on emergency medical services, trauma care or rehabilitation. These are important topics that merit entire courses in and of themselves. But this course is about keeping injuries and injury events from happening in the first place.

Finally, taking a public health approach entails uncovering multiple causes and devising multiple solutions to injury problems. In general, one can think of characteristics of the people who get injured that may influence the types and frequencies of injuries that they experience. One can also think of characteristics of the products that people come into contact with, as well as of their physical and social environments, which may influence their risk of being injured. Public health professionals consider all of these factors and then try to leverage them to help us find solutions. Sometimes these solutions involve education, such as training on the proper installation of a car seat or cabinet lock, or about the need for new health promoting public policies. Other times these solutions involve making changes in how products or environments are designed, such as the use of child-proof bottles for the storage of medications, or the use of air bags in automobiles.

Moving from problem recognition to action

The rest of this chapter will provide a more detailed look at host, product and environmental factors, in the interests of demonstrating how a more thorough understanding of the factors that contribute to injury problems can provide the foundations for innovative and successful action plans.

First, let's consider some of the characteristics of people that make them susceptible to injury:

Age, which of course is related to development, is one factor. For example, infants just learning to roll are more likely to roll off of a changing table or bed if there isn't a railing. That stage of their development needs to be taken into account. Similarly, elderly people, particularly those who are on medications that can make them dizzy, may be more likely to stumble and fall. Males and females also tend to have different injury experiences. For example, men are rarely raped and women are much less likely to engage in certain sports, like football, that would result in injury. A person's physical appearance may make him or her more or lass vulnerable to injury. For example, if someone looks unable to resist a robbery at a convenience store, he or she may be a more likely target than someone who appears very strong.

Judgment about what is or isn't dangerous and how to avoid danger can also vary widely. Just think about toddlers who may have no idea that a stove is hot, or teenagers who lack the judgment to determine how fast is too fast or how much beer is too much. Both toddlers and teens need to explore and take risks as part of normal development. But we need to find a way to make that risk taking safe.

Skills, knowledge, and coordination, also all play a role. For example, these factors are involved in knowing how to safely operate factory or farm equipment, being able to ride a bicycle, or, for some of us, just being able to keep from stumbling or doing other clumsy things. Likewise, one's level of stamina can influence their susceptibility to injury, and once injured, how difficult their recovery will be.

Let's look at a couple of specific examples of characteristics that can place individuals at risk for injuries.

The little girl pictured in the slide is very curious and is wanting to know what's in the bottle, and that's normal development for someone her age. But we need to make sure that if she gets into things under the sink, those things are safe for her.

The elderly man moves very slowly and needs some extra time to cross the street. We can make changes to accommodate him, and others, by taking into account how individuals are different.

The types of individual characteristics we have discussed thus far all help to influence which people in our communities get hurt, and why. But many of these individual factors can not be changed, or, at least can not be changed easily. Consequently, it is very important to consider factors at other levels that may be easier to do something about.

Many of the products people use --from cars to cleaning supplies -- also have the potential to create injury. But we can often act to modify these products to make their use safer. We can change the way that things are designed, the way that they are constructed, and the way they are packaged.

For example, here is a poison-proof container that this child is having difficulty opening. This container was designed as part of a very effective strategy for reducing the incidence of poisonings among children.

Similarly, changing the design of this car and putting in air bags has made a difference in saving lives -- although we recently have come to recognize that air bags can represent a hazard for young children.

The physical environments in which people live, play and a work also play a major role in determining what kinds of injuries occur, and how often they occur.

Characteristics of the physical environment include things like the way that highways are built, how workplaces are designed, whether homes are built with fire escapes and fire-proof material, how playgrounds and other recreational areas are constructed, and how schools are designed.

The particular sliding board pictured is very high off of the ground; higher than would now be permitted by OSHA standards for an adult without an harness. It has very steep steps that can be easily slipped through, and it has been built on an extremely hard surface. Though it looks like it might be fun, it has not been built with a safe design.

In contrast, this second sliding board illustrates the fact that we can easily design and construct a safer sliding board that creates a safer physical environment. This sliding board allows children to go just as fast and have just as much fun, but at no point can they fall as far, or onto as hard a surface, as they could with the first slide.

Finally, there are a number of different components of what we refer to as the social environment. These components include informal practices and formal laws that influence how our society functions, and how it encourages or discourages certain behaviors.

Factors from our social environment that can influence injury outcomes include: policies for serving alcohol, norms about whether corporal punishment is an acceptable form of child discipline, policies that set the legal driving age, concealed weapons laws, worker safety policies, and a multitude of mass media social influences, ranging from Barney to Rambo.

Recent efforts to change acceptable norms regarding the use of bicycle helmets and the sale of alcohol to minors seem to have resulted in protective laws regarding helmet use and alcohol sales that may ultimately reduce the incidence of injuries.

In the end, the most important point is that there are many ways that we can intervene to prevent injuries in communities, by addressing the many different kinds of influences that can shape and define injury problems.

Next: Chapter 3. How Big is the Injury Problem?

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