Chapter 7.

Implementing Injury Prevention Strategies at the Community Level

By Janice Yuwiler, MPH

• Overview
• Assign Responsibility for Injury Control
• Case Study by Bob Parker
• Apply a Systems Approach to Prevention
• Step One: Gather and Analyze Data
• Step Two: Select Priority Injuries and Populations
• Step Three: Determine Intervention Strategies
• Step Four: Develop an Implementation Plan
• Step Five: Identify, Select and Commit Community Agencies to Implement and Support the Plan
• Step Six: Develop Protocols and Materials
• Step Seven: Orient and Train Agencies/Individuals Implementing the Intervention Plan
• Step Eight: Monitor and Support Implementation of the Plan
• Step Nine: Evaluate and Revise
• Step Ten: Disseminate Lessons Learned

Overview

An implementation plan is essential for focusing and guiding prevention activities. This section will describe the key elements of an implementation plan and address how to mobilize the community for injury control and violence prevention activities.

I'd like to start with section by giving you a definition of "injury prevention program" as I will be using the term throughout the following discussion. An injury prevention program is a comprehensive approach, where you look at what the data says, what resources are out there, and bring together the collaboration that will be necessary for implementing an intervention effort.

Assign Responsibility for Injury Control

There are a couple of things we have found that really make a difference. First of all, you need to assign somebody the responsibility for your effort, or the program is not going to happen. There must be someone who can pull together the resources and the data, who can really look at the problem and who can support the injury prevention effort. Responsibility really is a key issue.

Second, you really need to be able to link with others. You don't have enough time, you don't have enough energy, and you don't have the resources to do everything on your own, so you're going to have to work with other people out in your community. Actually, that's the fun of injury control. I never thought that I would know so much about the legislative process, building codes, or doing city planning.

And there are a lot of folks out there that you can link with in your community: public safety officers who are doing enforcement and education programs, coalitions that are addressing specific age groups or a particular injury type, public service organizations that are already working to install existing technology, professional organizations that are providing service and education on a particular issue, youth programs, and pediatricians doing injury prevention counseling.

At the state level, there is your state health department, Office of Traffic Safety and Governor's Highway Safety Representative, State Fire Marshal, Emergency Medical Services Agency, Department of Education, and Attorney General's Office, among others.

At the National level there are organizations including the U.S. Consumer Products Safety Commission, which has responsibility for seeing that we have safe consumer products; the National Highway Traffic Safety Administration, making sure that we have safer cars; the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention working to prevent and control all types of injuries; the Injury Prevention Research Centers located throughout the nation and funded by CDC, the State and Territorial Injury Prevention Directors Association with a representative from every state health department and the Children's Safety Network funded by the Maternal and Child Health Bureau of the Health Research and Services Administration to provide technical assistance to state health departments and other working to prevent injuries. So there are a lot of resources out there that you can utilize to help you build an injury prevention program.

Last, leadership is key. When you get right down to it, it's people who make things happen. You need someone who can take on the leadership role, who can be a catalyst -- someone who can bring things together and make things happen. We have seen over and over again that one individual can really make a difference. So think about what you can do, in terms of injury prevention, within your organization and as an individual.

What I'd like to do now is take a look at a case study. Back in the late 1980's, Bob Parker was the public health director for the New Hanover County Health Dept. in Wilmington, NC. He came to a training and went back and said, "We're going to do something about injury prevention." I thought it would be good to see what he did, because they've done as many as 14 different interventions locally, based on that one training

Case Study by Bob Parker, MS


You can see why Bob Parker's approach makes a real difference. When you listen, you realize he is talking about responsibility and leadership -- he is talking about the fun of injury prevention. And the fact that they were able to do this without any additional resources by pulling together what they had, is particularly impressive.

Apply a Systems Approach to Prevention

Let's get back to the systems approach to injury prevention. In looking at this approach, we need to realize that in real life things don't always go clockwise, or counter-clockwise like the arrows in the figure. The reality is that you may start off with one particular issue, then move down, and then maybe bounce back up. For example, you might be trying to identify a strategy and then you'll realize you need more data. Or you'll bring all of your partners together and say, "Hey that's a brilliant idea. Let's go back and redo one of our strategies because we can do this better now that we know more." So it's an iterative approach.

Each step will not necessarily happen in the order described below, earlier steps may modify the work done in previous steps and you will need to remain flexible throughout in order to be most effective.

You also need to make an effort throughout your program to enlist organizations and to design your interventions so that your prevention efforts can be institutionalized if they are proven to be effective.

Step One: Gather and Analyze Data

Where should you begin? I always start with the data, because you want to gather and analyze information to understand what your injury problems are. You don't have the time, energy and resources to address something that is not a problem. For instance, there is no point in addressing snowmobile injuries in San Diego. Ask yourself, "What types of injuries are there and where are they clustering in terms of space, time, age, gender, or ethnicity? How could I address those kinds of injuries?"

You also want to know, right from the beginning, what your community thinks. Find out what the community thinks are the problems. Why do they think that particular injury occurs? What do they think would prevent the injury from happening?

The last thing you want to know is what is already being done to solve the problem, because you don't want to reinvent the wheel and you want to build on what is already out there. You will be more successful by building on what is out there than by starting from scratch.


Step Two: Select Priority Injuries and Populations

Once you have the data, you need to select your injury priorities. Selecting priorities helps you to define your prevention strategies, identify resources and potential partners, and clarify objections for evaluation. For example, let's say I have a motor vehicle occupant problem -- children are being killed in motor vehicle crashes while they are riding in the car. I need to ask myself, "At what age group am I focusing my intervention?" If the children are under 4, for example, I really want to focus on getting them into child safety seats and making sure those seats are used correctly.

So I want to target the adults putting the children into the child safety seats, and I might want to work with the manufacturers who design the seats, to get them to make seats you can put in without getting your daily aerobic exercise. But if I were addressing adolescent motor vehicle occupant injuries -- adolescents who were killed during motor vehicle crashes while occupants in the car, then I would focus on seatbelts, driving speed, and alcohol use. So in designing my strategy, I need to select my injury priorities and know where I am focusing my efforts.

Selecting your injury priorities also helps you identify resources and potential partners. For instance, if I am addressing drowning I'm going to look to someone different than if I am talking about poisoning, domestic violence or suicide. Similarly, I will look to different people and agencies if I am going to address drowning in a residential swimming pool, versus drowning in a lake, stream or ocean.

Also, once you have selected your injury priorities, you can clarify your objectives for evaluation. For example, what if I was doing a program to prevent scald injuries among children? When I go back to see if I've had any success -- to see if I've made a difference -- I might go back and examine burn injuries. If I do that, though, I am looking at house fires as well as scald injuries. I may have gotten rid of all the scald injury problems, but because I am looking at all burn injuries I may not be able to see the difference I made in scald injuries. So setting your injury priority helps you design your evaluation.

Looking at your data and selecting injury priorities also allows you to address something specific. Since you can not do everything, you have to start somewhere. By looking at the data, and focusing on an injury prevention problem, your efforts will be more successful. In fact, we have found that the more specific you get -- the more narrowly you can focus your efforts -- the more successful you will be. For example, instead of addressing poisoning among young children in general, where I might be addressing household cleaning products, medication, and plants, I might focus on a problem with iron poisoning among young children due to prenatal vitamin consumption. This gives me an idea of where to begin. For instance, I can try to get pharmaceutical companies to stop making prenatal iron supplements that look like M-n-M candy.

So how do you select your injury priorities? Ask yourself, "What are my injury problems? Is there an effective intervention strategy? Is my community interested?" Remember that whether your community is interested can make a tremendous difference. For example if the mayor's son was just injured out on the playground, the mayor may be determined that no other child will be injured on a playground again. He may be willing to put money, resources and political power behind seeing that children do not get injured on playgrounds in his city. You should jump on that. Playground injuries may be at the bottom of your priority list, but you have a chance of success, a chance for visibility, and a chance to build credibility that will help you later to address other injury problems.

This was really key in San Diego years ago. We had a huge problem with residential swimming pool drownings. The only intervention we knew would be effective was to put a fence between the house and the pool because the kids who were drowning were the kids who lived inside that house. But there was not much we could do to encourage this. Homeowners did not think it was a problem, builders did not think it was a problem, and policy makers did not think it was a problem. So we addressed something else for which we had a chance for success and began to educate our public about the swimming pool problem. Now, ten years later, we have an ordinance that requires that a fence be constructed between the house and a residential swimming pool.

Step Three: Determine Intervention Strategies

Now that you have researched your data and narrowed your focus, you want to look at prevention strategies. What you need to know and understand is the typical scenario of your injury problem -- how your injury occurs. If you understand this, you have a chance to intervene. Sometimes that intervention can be as simple as chopping down a tree so you can see a stop sign. In the earlier case study, Jackie Moore found a buildup problem, so they went to clean the chimneys.

Another classic example is Queens Boulevard, New York City. In New York, they found there was a huge clustering of injuries on Queens Boulevard, so they went out to find out what was going on. There was a huge high-rise complex for senior citizens on one side of the street, which was a large main thoroughfare with lots of busy traffic. On the other side of the street there was shopping. So senior citizens were crossing the street to go shopping. The timing on the light, however, was such that there was not time for an elderly person to walk across the street. They changed the timing on the lights so elderly individuals could get across the street safely and the pedestrian problem greatly decreased. If you can figure out how your injury problem occurs, you will have a much better idea of how to intervene.

There has been a lot of discussion about playground injuries as a part of this program. When you go to look at the typical scenario for playground injuries, 90% of the serious injuries are from falls to the ground surface beneath the playground equipment. When I hear that, two interventions pop into my mind immediately. First, if I lower the height of the equipment, the falls are going to be less serious. And second, I can make the ground surface more absorbent, so if the children do fall, the injuries are not so severe. Again, looking at the typical scenario can give you a good sense about how you might intervene.

When identifying potential strategies you also want to make sure you use a multifaceted approach. Look at the possible levels for intervention, and look at the Haddon Matrix. Ask yourself, what can you do in terms of preventing things from happening, pre-event, post-event, and during the event. What can you do in terms of education, technology, legislation, or enforcement? Look at all your options and weave together your intervention strategy. You will be much more effective if you use a multifaceted approach.

The other piece is talking about the Spectrum of Prevention and looking at different levels in our society. So look at what can be done in terms of the individual but also at what can be done in terms of community, what can be done within an organization, and what can be done on a societal level. This will give you different points where you can intervene. For example, to prevent motor vehicle occupant injuries, you can set a policy that within your agency everyone is required to buckle up when they are on company business and you will only buy cars with airbags. So you've made a decision to incorporate an injury intervention within your own existing structure.

You also want to pick a proven strategy for your first effort. You want to be successful with the first thing you do because that success will help you gather resources and build your credibility so you can go on and do something more difficult. We saw that with Jackie Moore's case study - first they cleaned the chimneys and installed escape ladders. Both addressed major problems and both were fairly easy fixes. Then they went back and changed the building materials that were used in the stairwells and installed a second exit from the homes. As a result of the success of their first effort they were able to gather the resources and support to go back and accomplish the more difficult changes needed. And they've been able to expand to address different injury types because their earlier successes have built their credibility. People want to be involved with something successful -- it's fun and with a success under their belt, it's easier to go and tackle things that are more difficult.

The final thing is to make sure you don't reinvent the wheel. There is a lot of stuff that is already out there and you want to make sure that you take full advantage of it. You don't have the time, energy or resources to begin everything from scratch. A real classic example of this is educational materials.

There are a million and one brochures out there. If you find materials that are not precisely what you want, you may have to adapt them for your population, but it's a start.

Look at what's out there -- this is an example a photo from the Silent March on Washington where 40,000 shoes were brought to symbolize the 40,000 folks that were killed due to gun violence in a year. About 3,500 of those shoes came from Orange County California, so taking that local effort and linking it with the national effort, made both stronger. Remember, you want to build on whatever is already out there.

Next: Chapter 7. Implementing Injury Prevention Strategies at the Community Level (continued)

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