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Injury prevention: An evidence-based public health approach
Unintentional injury is the leading cause of death and disability among those aged 1 to 44 years in the United States. Suicide is the second leading cause of death in those aged 10 to 34, and homicide is the third leading cause of death in those aged 1 to 4, 15 to 24, and 25 to 34, thus making trauma (whether intentional or unintentional) the cause of death in an astounding proportion of the American population. Globally, in 2017, all-cause injury accounted for 4 to 5 million deaths per year, 57 million years living with disability, and almost 200 million years of life lost, according to reports from the World Health Organization and the Global Burden of Disease Study Group. Clearly, prevention efforts are required to make an impact on these dismal figures. Trauma surgeons are uniquely qualified to lead this charge, along with multidisciplinary groups of health care workers, epidemiologists, public health experts, emergency medical services personnel, and lawmakers, given our expertise in the management of severely injured patients. In fact, early calls for injury prevention efforts are found in the late Dr. Donald Trunkey’s seminal work where he defined the trimodal distribution of trauma deaths. Furthermore, injury prevention is now a required component of a trauma program for verification by the American College of Surgeons Committee on Trauma, underscoring the importance of trauma surgeon participation in these efforts. It is critical that these injury prevention efforts are operationalized using an evidence-based public health approach that allows us to define the problem, identify risk and protective factors, develop and test prevention strategies, and, perhaps most importantly, assure widespread adoption. In this chapter, we will discuss the public health approach to injury prevention, highlighting different categories of prevention and general approaches to study injury from a public health perspective and providing examples of targets for injury prevention programs and potential interventions.
Public health approach to injury prevention
In a 1979 report titled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention , U.S. Surgeon General Julius B. Richmond, M.D., first identified injury as one of the 15 health priorities for the United States. However, it was not until Surgeon General C. Everett Koop, M.D., F.A.C.S., convened a workshop in 1985 that violence was recognized as a public health issue. It is thanks to these initial steps and the contributions of several subsequent leaders in trauma surgery, epidemiology, and public health that efforts to treat injury as a disease with public health implications have endured.
Indeed, the monumental role that injury and violence play on health is increasingly recognized. Born out of the Affordable Care Act in 2010, the National Prevention Strategy, created by the National Prevention, Health Promotion, and Public Health Council, sought to “realize the benefits of prevention for all Americans’ health,” with the predominant goal to increase the number of Americans who are healthy at every stage of life ( Fig. 1 ). To achieve this, a list of seven priorities contributing to the leading causes of preventable death and major illness were identified. These priorities include tobacco free living; preventing drug abuse and excessive alcohol use; healthy eating; active living; injury and violence free living; reproductive and sexual health; and mental and emotional well-being. Notably, three of the seven National Prevention Strategy priorities are directly related to injury.
Trauma as a disease
The role of the trauma surgeon as a leader in injury prevention cannot be understated. It is imperative that we become fluent in the language of public health to actively participate in prevention efforts in an effective way. Fundamentally, our view of trauma as a random or sporadic event needs to change. For far too long, trauma has been considered an unpreventable occurrence, resulting from a combination of being “accident prone” or being “at the wrong place at the wrong time.” Like heart disease, cancer, and infectious diseases, trauma is a disease—not an “accident”—with identifiable risk factors, mediators, moderators, and the need for disease prevention. Injury prevention experts have slowly begun to help shift the paradigm from considering trauma as an accident to recognizing it as a disease process with significant public health implications. One simple but effective method involves how to refer to the causal nature of traumatic injury. For example, changing the term “motor vehicle accident” to “motor vehicle crash” or “motor vehicle collision” (MVC) removes the accidental connotation of the event. While these changes may seem trivial, they actually help provide a different framework for how we approach injury prevention.
Prevention science and the role of theoretical frameworks in injury prevention
Prevention science is one of the basic pillars of public health practice. Its focus is on identifying risk and protective factors that affect health and health behavior, developing models to study those health behaviors, and implementing and disseminating prevention programs to improve outcomes and promote healthy living. Prevention science is heavily informed by epidemiological data, which focus on studying the distribution of disease, determinants of health, risk factors, and outcomes. The interplay between prevention science and epidemiology allows for the implementation of evidence-based prevention programs. For example, epidemiological data suggest that certain risk factors for violence exist (e.g., socioeconomic status, education, substance abuse) and that these risk factors play particularly important roles during certain developmental milestones (e.g., young adulthood). The identification of these risk factors helps inform prevention efforts targeting those specific populations to maximize the potential for successful interventions. The importance of using prevention science principles when developing injury prevention programs cannot be overstated. These evidence-based approaches allow for implementation of injury prevention programs that have been shown to be effective at mitigating risky behavior.
The use of theoretical frameworks is vital to assist in our understanding of health-risk behaviors among populations, and they help inform pathways through which prevention programs can be helpful. These theoretical frameworks serve as road maps to help understand a public health problem. They can be broadly categorized as individual-level and ecological-level theories. Individual-level theories include the health-belief model, the transtheoretical or stages of change model, theory of reasoned action, and social cognitive theory. Ecological-level theories include the social-ecological model and eco-developmental theory. While a comprehensive description of each of these theoretical frameworks is outside the scope of this textbook, it should be noted that each of these has been used to guide injury prevention programs for interpersonal and domestic violence, falls, motor vehicle crashes, helmet use, and other traumatic injuries.
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