Resources Lesson 1: Development and Implementation of Intervention Strategies
Prevention of injuries is the ultimate goal of Public Health in this field. Here we start to discuss the issues with links to useful resources.
Setting the scene
In Injuries: the neglected burden in developing countries the authors state:
“More than 90% of injury deaths occur in low- and middle-income countries, where preventive efforts are often nonexistent, and health-care systems are least prepared to meet the challenge. As such, injuries clearly contribute to the vicious cycle of poverty and the economic and social costs have an impact on individuals, communities and societies. The socioeconomic impact of injury-related disability is magnified in low-income countries, where there are often poorly developed trauma care and rehabilitation systems and little or no social welfare infrastructure. Of all categories of injury, road traffic crashes have appropriately received the greatest attention.
Despite the weight of evidence, the importance of preventing and treating injuries in low- and middle-income countries has yet to be embraced by the global public health community. Research is grossly underfunded and insufficient resources have been allocated for strengthening the delivery of medical services. Better treatment of injuries will help achieve three of the UN’s Millennium Development Goals, namely the reduction of child mortality, improving maternal health and promoting gender equality with respect to access to health-care services.
The World Bank’s Disease Control Priorities Project estimates that building speed bumps could cost US$ 2–5 per disability-adjusted life year (DALY) averted, which compares favourably to the costs per DALY averted from supplementation with, for example, vitamin A and zinc, with or without measles vaccination (US$ 25 and US$ 19, respectively). Other safety interventions, such as seatbelt and helmet use, sidewalks and roundabouts, have been used successfully in selected low-income countries. In addition, data on evidence-based interventions for road traffic injuries, particularly for non-fatal outcomes, are mostly from developed countries and not always transferable to developing countries’ environments, where vulnerable populations are different (driver/passenger versus pedestrian/cyclist). “
Please keep an eye on the third issue of the Disease Control Priorities (DCP3) mentioned above, where: Injury Prevention and Environmental Health: Key Messages from the Volume will be able to be explored for much valuable information:
“As part of the Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Injury Prevention and Environmental Health that identifies essential prevention strategies and related policies that address substantial needs, are cost effective, and are feasible to implement. This review summarises and critically assesses the volume’s four key findings. First, there is a large burden of death and disability from these conditions. Worldwide, injuries result in more than 5.1 million deaths per year out of a global total of 56 million deaths. There are also large numbers of deaths attributable to risk factors related to non-injury occupational exposures (560,000); inadequate access to clean water, sanitation, and hygiene (1.4 million deaths); and air pollution (5.5 million). The vast majority of these deaths are in low- and middle-income countries. Second, risk factors for these diseases vary with stages of development in ways that can be understood and used in designing prevention strategies. Third, there are a range of interventions that can effectively address these problems, many of which are among the most cost-effective and cost-beneficial of all interventions used to prevent disease. Fourth, this review synthesizes the volume’s prevention strategies to identify an effective essential package of interventions and policies, most of which have been inadequately applied globally. Better implementation of these interventions and policies would help to bring down the high rates of death and disability from these conditions in low- and middle-income countries towards the lower rates in high-income countries. Doing so could avert over 7,500,000 deaths annually from environmental and occupational exposures, and injuries.”
Three chapters will include: Road Traffic Injuries; Non-Transport Unintentional Injury; and Interpersonal Violence: Global Impact and Paths to Prevention.
The policy settings
Example from Sri Lanka
As identified in the National policy and strategic framework on injury prevention & management by the Sri Lanka Non Communicable Diseases (NCD) Unit, Ministry of Health, Sri Lanka, injury prevention can be:
1. Primary prevention - Reductions in the exposure to risk and prevention of injuries from occurring, through the adoption of safer behaviours and safer environments
2. Secondary prevention - In the event of an injury, reductions in the severity of injury and its impact e.g. early diagnosis and appropriate management of an injury by applying basic first aid at the scene of an incident and early transport to hospital in an ambulance with facilities to stop an injury from having more serious consequences
3. Tertiary prevention - Reductions in the consequences of injury through post-event care (e.g. emergency care, essential trauma care, physical and psychological rehabilitation)- involves preventing further complications in the form of more severe injury, disability or death.
Their policy framework includes 8 Strategic objectives
1. Establish a National Authority to strengthen coordination for injury prevention and management within the health sector and with other agencies
2. Strengthen advocacy and multi-sectoral involvement
3. Develop evidence for population wide injury prevention interventions
4. Review, update or introduce legislative and regulatory mechanisms and strengthen their enforcement
5. Empower community and healthcare providers for prevention of injuries and disabilities, and harnessing health literacy
6. Strengthen the organization capacity to improve pre-hospital and institutional care for emergency care and rehabilitation
7. Strengthen the injury information system
8. Monitor and evaluate on-going activities
The Sri Lankan approach might be a model for others to follow.
Ministries of health
The World Health Organisation, in Preventing injuries and violence A GUIDE FOR MINISTRIES OF HEALTH, offers the suggestion that ministries of health should play a key role (you can download the full report from the above site).
“With the public health approach to violence and injury prevention becoming more accepted around the world, those in the field are seeking guidance for their work. A wide array of governmental and nongovernmental organizations is involved in violence and injury prevention. This document, though, will focus on the main governmental body
responsible for carrying forward the public health response: the ministry of health. The document was developed to help ministries of health understand their precise role in violence and injury prevention at the national and local levels, and set up durable and effective programmes.” Ministries should start by setting up a violence and injury prevention unit.
Universal or targeted interventions?
As stated in Precision prevention: time to move beyond universal interventions
“Based on strong evidence from evaluations of tiered risk strategies for mental and physical health promotion, there is reason for substantial hope that the successes that have been achieved in injury prevention can be extended to those at highest risk. Just as precision medicine aims to tailor medical therapy to the needs of the individual, precision injury prevention should provide comprehensive strategies that aim to meet the needs of all individuals within a population in achieving low-risk outcomes over time. This commentary highlighted the application of a tiered-risk approach to addressing the needs of individual higher risk young drivers and their families. However, the urgent need for interventions to meet the prevention needs of individuals in populations across all injury mechanisms should serve as a ‘road map’ guiding future research needs to fill gaps.”
What makes community based injury prevention work? In search of evidence of effectiveness
“Community based injury prevention work has become a widely accepted strategy among safety promotion specialists….. Thirty years after the implementation of the first community based injury prevention programs, local involvement has become an important component of such programming. While the rationale for community based injury prevention programs is logically sound, there is, unfortunately, still a lack of literature describing the effectiveness of this approach to reduce community injury rates.”
This paper leads nicely to the next section:
The evidence base
Road Traffic Injury Prevention Initiatives: A Systematic Review and Metasummary of Effectiveness in Low and Middle Income Countries is an excellent review. It concludes: "Legislation was the most common intervention evaluated with the best outcomes when combined with strong enforcement initiatives or as part of a multifaceted approach. Because speed control is crucial to crash and injury prevention, road improvement interventions in LMIC settings should carefully consider how the impact of improvements will affect speed and traffic flow. Further road traffic injury prevention interventions should be performed in LMICs with patient-centered outcomes in order to guide injury prevention in these complex settings."
Why isn't more injury prevention evidence-based? is a plea for a more evidence based approach to injury prevention (abstract reproduced here, the link above requires purchase of the full report)
“The focus on evidence-based practice is critical to addressing the issue of injuries, yet advances in the science of injury prevention have not always led to advances in practice. Effective approaches are not always adopted, or when adopted and transferred from one setting to another, they do not always achieve expected results. These challenges were the basis of two breakout sessions at the second European Injury Control and Safety Promotion Conference in Paris, France (October 2008). In summarising the key issues raised during those sessions, this article describes what is meant by evidence-based practice, discusses why evidence-based practice tends not to occur and considers approaches that may facilitate the adoption and implementation of evidence-based strategies. To address the challenge, specific action is required, both on the part of the research community and those responsible for developing and implementing injury prevention policies and programmes.”
You might want to explore The University of Michigan Injury Center interactive database with 'convenient access to evidence-based injury prevention programs, databases of evaluated prevention programs, and best-practice educational materials'. Levels of evidence are nicely described.
You might also want to refer back to Topic 2 for the Haddon’s matrix expansion by Runyan – the third dimension – which outlines other criteria for selection of interventions from among several options, like cost-effectiveness, feasibility, acceptability etc.
Some examples of child injury prevention – they may have relevance beyond childhood
The National Action Plan for Child Injury Prevention from the CDC (You can download the whole report or one-page summaries of the causes from the web site) summarises: “The Centers for Disease Control and Prevention (CDC) is committed to preventing child injury by supporting solutions that will save lives and help children live to their fullest potential. The National Action Plan for Child Injury Prevention was developed by CDC and more than 60 stakeholders to spark action across the nation. The National Action Plan’s overall goals are to:
Raise awareness about the problem of child injury and the effects on our nation.
Highlight prevention solutions by uniting stakeholders around a common set of goals and strategies.
Mobilize action on a national, coordinated effort to reduce child injury.”
The paper: Injury prevention and the attainment of child and adolescent health
identifies Proven interventions in child injury prevention as follows:
Introduce (and enforce) minimum drinking-age laws
Set (and enforce) lower blood alcohol concentration limits for novice drivers
Wear motorcycle and bicycle helmets
Set (and enforce) seat-belt, child-restraint and helmet laws
Reduce speed around schools, residential areas, play areas
Separate different types of road user
Introduce (and enforce) daytime running lights for motorcycles
Introduce graduated driver licensing systems
Remove (or cover) water hazards
Require four-sided fencing around swimming pools
Wear a personal flotation device
Ensure immediate resuscitation
Set (and enforce) laws on smoke alarms
Develop and implement a standard for child-resistant lighters
Set (and enforce) laws on hot tap water temperature, and educating the public
Treat patients at a dedicated burns centre
Redesign nursery furniture and other products
Establish playground standards for the depth of appropriate surface material, height of equipment and maintenance
Legislate for window guards
Implement multifaceted community programmes such as ‘Children can’t fly’
Remove the toxic agent
Legislate for child-resistant packaging of medicines and poisons
Package drugs in non-lethal quantities
Establish poison control centres
We finish this section with a comment about:
A practical approach for applying best practices in behavioural interventions to injury prevention
Behavioural science when combined with engineering, epidemiology and other disciplines creates a full picture of the often fragmented injury puzzle and informs comprehensive solutions. To assist efforts to include behavioural science in injury prevention strategies, this paper presents a methodological tutorial that aims to introduce best practices in behavioural intervention development and testing to injury professionals new to behavioural science. This tutorial attempts to bridge research to practice through the presentation of a practical, systematic, six-step approach that borrows from established frameworks in health promotion and disease prevention. Central to the approach is the creation of a programme theory that links a theoretically grounded, empirically tested behaviour change model to intervention components and their evaluation.
The six steps are:
Set a key health outcome (a clear, measurable, long-term vision related to injury reduction).
Identify behavioural objectives linked to the key health outcome.
Identify target constructs and their influence on the behavioural objectives.
Design and develop intervention content to address constructs.
Evaluate effectiveness of interventions.
Refine interventions and behaviour change model, when needed.