The Public Health Approach to Injury Prevention

T o solve public health problems—

including injuries—CDC uses
a systematic process called the public
important questions. Once we have
that information, we can develop and
implement programs to eliminate or
health approach. This approach has reduce risk factors for injuries and to
four steps: define the problem, identify capitalize on or increase factors that
risk and protective factors, develop and protect people from being injured.
test prevention strategies, and assure
widespread adoption of effective injury Develop and test
prevention principles and strategies. prevention strategies
In this step, we put knowledge into
Define the problem action. Using information gathered in
Before we can address an injury our research, CDC develops strategies
problem, we need to know how big to prevent particular injury problems.
the problem is, where it is, and whom We implement these strategies in
it affects. CDC accomplishes this communities that are experiencing the
by gathering and analyzing data— problem. And we study the effects of
processes often called “surveillance.” these strategies to determine whether
These data can show us how an injury and how well they’re working. We
problem changes over time, alert us use this information to identify
to troubling trends in a particular any elements we need to change
type of injury, and let us know what to eliminate difficulties or increase
impact prevention programs are having. effectiveness.
Decision makers use these critical data
in allocating programs and resources to Assure widespread adoption
the areas most in need. What we learn in the developing and
testing step has little benefit if we
Identify risk and protective factors keep the information to ourselves.
It is not enough to know that a certain In this final step of the public health
type of injury is affecting a certain approach, CDC shares its knowledge
group of people in a certain area. We and may provide funding or expert
also need to know why. What factors consultation so that communities can
put people at risk for that injury? replicate these successful strategies.
And conversely, what factors protect
people from it? CDC conducts and
supports research to answer these

The Public Health Approach

Identify Risk Develop

Define Assure
and and Test
the Widespread
Protective Prevention
Problem Adoption
Factors Strategies

4 Introduction
The Public Health Approach at Work
Defining the Problem Weekly Report found
that injuries and
For some injury issues, CDC has
violence account for
already moved through the first three
75% of all deaths
steps of the public health approach and
among Native
is encouraging widespread adoption
Americans in this
of programs that work. For other
age group—a rate
issues, CDC is working to fully define
that is about twice
the problem. Always, CDC addresses
that of all children
injury issues that affect diverse
and youth in the
populations, in every stage of life.
United States. Motor
vehicle crashes were
The examples in this book demonstrate
the leading cause of
how the public health approach is at
injury-related death,
work in CDC’s Injury Center.
followed by suicide,
homicide, drowning,
Violent death in America
and fires. Between
In the United States in 2002, 17,638
1989 and 1998, Report to Congress on mild TBI
people died as a result of homicide and
more than 3,300 Native American Evidence indicates that mild traumatic
31,655 died from suicide. Although
children and youth living on or near brain injury (MTBI) is a public
public health officials may know
reservations died from injuries or health problem, the magnitude and
how many people die from violence
violence (Wallace et al. 2003). impact of which are underestimated
each year, information about the
circumstances surrounding those by current surveillance systems. Much
Intimate partner and research is needed to determine the
deaths is often lacking. Federal, state,
sexual violence full magnitude of MTBI, to identify
and local agencies all have detailed
An estimated 2.3 million Americans— preventable and modifiable risk
data that could answer important,
1.5 million of them women—are raped factors, to develop and test strategies
fundamental questions about
or physically assaulted by an intimate to reduce MTBI, and to improve
violence patterns and trends, but the
partner each year. But inconsistencies outcomes for those who sustain these
information is fragmented and difficult
in data collection and different ways injuries. Such research will inform the
to access. The system that pulls
of describing the problem have development of more effective primary
together this vital information to be
fostered a lack of consensus about its prevention strategies and policies to
shared among states and communities
magnitude. In 2002, CDC’s Injury address the service and rehabilitation
is the National Violent Death
Center revised its publication of needs of persons with MTBI. The
Reporting System (NVDRS). NVDRS
definitions designed to improve data recommendations in the CDC report
gathers data from states that can be
collected about intimate partner to Congress, Mild Traumatic Brain
used to increase our understanding of
violence. This publication standardized Injury in the United States: Steps to
violent deaths in America. NVDRS
the terminology used by all parties Prevent a Serious Public Health Problem,
data can assist policy makers and
involved in the problem: the criminal can help shape that research.
community leaders in making
justice system, hospitals, and others.
informed decisions about strategies
Similar standards for sexual violence Nonfatal drownings at
and programs to prevent violence.
were also published in 2002. Uniform recreational water sites
Currently, 17 states have been funded
definitions and recommended data In 2004, CDC scientists published
to implement the system.
elements for both intimate partner in the Morbidity and Mortality Weekly
violence and sexual violence are Report the first national estimate for
Injury mortality among Native
important to ensure consistency in the nonfatal drowning injuries treated
American children and youth
use of terminology and to standardize in emergency departments (Gilchrist
Native Americans ages 19 years
data collection. Consistent data allow et al. 2004). Findings for the United
and younger are at greater risk of
researchers to better gauge the scope of States in 2001 and 2002 showed more
preventable injury-related deaths than
the problem, identify high-risk groups, than 4,100 people sought care in an
are other children and youth in the
and monitor the effects of prevention emergency department each year for
United States. A 2003 study published
programs. nonfatal drowning injuries, with more
in CDC’s Morbidity and Mortality

Introduction 5
than half requiring hospital admission will interview survivors of residential Parenting strategies to
or transfer for higher levels of care. fires to gather information about the prevent child maltreatment
Children ages 4 and under and males sequence of events and learn more CDC has launched several initiatives
of all ages were at the greatest risk. The about their behaviors before, during, aimed at preventing child maltreatment
most common locations of nonfatal and after the fire. Researchers will through evidence-based parenting
injuries for very young children were gather and analyze data about the root programs. These programs and policies
residential pools. As children grew cause of the fire, the events that led to encourage and promote positive
older, more injuries occurred in an injury, the state of awareness and parent-child interactions. Improving
natural water settings. The study also impairment level of those involved, parenting skills will help parents and
confirmed that injuries happen most and the actions taken in response to caregivers better manage behavior
often on weekends and during summer the fire. Results from this study will before violence can occur. CDC is
months—times when people typically inform public health interventions funding the University of South
enjoy water-related activities. to reduce the number of injuries and Carolina to examine the effectiveness
deaths in residential fires. CDC is of the Triple P–Positive Parenting
Identifying Risk and developing this study with the Battelle Program in reducing the risk of
Protective Factors Centers for Public Health Research child maltreatment by enhancing the
and Evaluation, in collaboration with knowledge, skills, and confidence
Suicide
the Department of Fire Protection of parents. Even the most effective
More than 31,000 people took
Engineering at the University of parenting programs will have a limited
their own lives in 2002. Public
Maryland at College Park. impact on child maltreatment if
health officials want to expand the
parents either do not attend or do not
understanding of what puts people
at risk for committing or attempting
Developing and Testing learn to apply alternative parenting
Prevention Strategies skills. CDC is working with Purdue
suicide and what prevents them
University and the University of
from doing so. Injury Center staff Targeting injury problems
Oklahoma Health Sciences Center
and CDC-funded researchers have in states
to test ways to reduce attrition and
begun studying factors that may Solving the problems of injury and improve engagement and compliance
increase or decrease a person’s risk for violence in America requires a strong in parenting programs.
suicide. One study in Texas, which public health response. Both research
interviewed people who experienced and effective injury prevention Community-based cognitive
nearly lethal suicide attempts, found programs in states are needed to therapy for suicide attempters
that many factors—in addition to help those at risk and to avoid costly CDC is working with the University
mental health factors—may influence injuries and needless deaths. In 2002, of Pennsylvania to test the effectiveness
suicidal behavior including alcohol CDC began funding the Targeted of a cognitive therapy intervention for
use, geographic mobility, exposure Injury Intervention Program in four suicide attempters. Trained therapists
to suicidal behavior, hopelessness, states to individually plan, develop, at community mental health centers
help-seeking behavior, impulsiveness, and implement prevention programs are conducting the intervention.
and physical illness. Researchers at that target an important injury The target group—people who have
Emory University examined suicide problem identified in each state. Maine attempted suicide—consists largely of
risk factors among African Americans and Virginia have each developed ethnic minorities and economically
ages 18 to 44 and found a strong suicide prevention programs, while disadvantaged individuals exhibiting
connection between intimate partner Washington and Michigan have high rates of mental health and
violence and suicidal behavior among focused on fall prevention. In 2002– substance-use disorders. A previous
African-American women. 2003, state injury experts planned and study found that a brief cognitive
developed their prevention programs, intervention designed specifically
Human behavior in and in 2004 the programs were for this high-risk population and
residential fires implemented. The targeted programs delivered in a university setting
CDC is directing development of continued through 2005, as the reduced subsequent suicide attempts.
the Human Behavior in Fire Study states tested prevention strategies in The current study will implement
to identify behavioral factors in preparation to share the results. the program in the community and
residential fires that are associated
evaluate its effectiveness for preventing
with injuries and fatalities. Researchers
subsequent suicide attempts.

6 Introduction
 Remembering When: a fire and
fall prevention program
In October 2000, CDC began funding
state health departments in Arkansas,
Maryland, Minnesota, North Carolina,
and Virginia to implement and evaluate
Remembering When: A Fire and Fall
Prevention Program for Older Adults.
This curriculum, which was developed
by the National Fire Protection
Association, the U.S. Consumer
Product Safety Commission, CDC,
and other partners, is the first program
of its kind to educate older adults
about prevention of both fall- and fire-
related injuries. To date, more than
510 group presentations (with 12,427
attendees) and 3,566 individual/
home presentations have been
conducted. More than 4,300 smoke
alarms and 525 grab bars have been
Violence prevention for car seat checkpoints. Evaluation data installed in the homes of older adults.
middle school students from Colorado showed a significant Research is underway to measure the
CDC is testing one of the largest increase in booster seat use in target program’s effectiveness.
efforts to date to assess the effectiveness communities when compared with
of school-based violence prevention control communities. Results from Assuring Widespread
among middle school students. It these intervention evaluations will help Adoption
teaches students conflict resolution guide future efforts to increase booster
and problem-solving skills, trains Effective interventions against
seat use.
teachers about violence prevention, alcohol-impaired driving
and engages family members in Fall prevention strategies and
In systematic reviews of published
program activities. The project is being effectiveness: Dane County
research studies, CDC researchers
conducted in 37 middle schools in SAFE Study
found strong evidence for the
four states. Affiliations include Virginia In October 2002, CDC’s Injury Center effectiveness of 0.08% blood
Commonwealth University, University funded the Wisconsin Department alcohol concentration (BAC) laws,
of Illinois–Chicago, University of of Health, in collaboration with minimum legal drinking age laws,
Georgia, and Duke University. the University of Wisconsin, to sobriety checkpoints, and mass
conduct a randomized controlled media campaigns that meet certain
A boost for children ages 4 to 8 trial to assess the effectiveness of a conditions (i.e., careful audience
CDC’s Injury Center funded state comprehensive approach to preventing research, adequate audience exposure,
health departments in Colorado, falls among higher-risk adults age and presence of other alcohol-impaired
Kentucky, and New York to develop, 65 and older. This project will use driving prevention activities). They
implement, and evaluate community- two complementary strategies: a also found sufficient evidence of the
based programs to increase booster comprehensive at-home assessment effectiveness for lower BAC laws
seat use among children ages 4 (followed by individualized risk specific to young or inexperienced
to 8. Between 2000 and 2003, reductions) and a broad-based program drivers (“zero tolerance” laws) and
grantees implemented and evaluated to educate primary care physicians and intervention training programs for
community awareness campaigns other health practitioners. To learn alcohol servers. Finally, they found
and school-based programs, aired more about preventing falls among sufficient evidence that school-based
public service announcements, older adults, visit www.cdc.gov/ncipc/ education programs decrease riding
posted billboards, and conducted pub-res/toolkit/toolkit.htm. with alcohol-impaired drivers (though
booster seat distribution events and there was insufficient evidence

Introduction 7
regarding the programs’ effects on TBI tool kit for health care References
alcohol-impaired driving itself ). professionals Finkelstein EA, Fiebelkorn IC, Corso
These school-based interventions In 2002, CDC produced Heads Up: PS, Binder SC. Medical expenditures
were effective in reducing fatal and Brain Injury in Your Practice specifically attributable to injuries—United States,
nonfatal alcohol-related motor vehicle for primary care physicians—CDC’s 2000 [published erratum appears in
first educational tool kit related Morbidity and Mortality Weekly Report
crashes. The reviews were published
2004;53(03):66]. Morbidity and Mortality
in The Guide to Community Preventive to traumatic brain injury (TBI). Weekly Report 2004;53(01):1–4.
Services (2005) and are online at www. The tool kit contains practical,
Gilchrist J, Gotsch K, Ryan GW. Nonfatal
thecommunityguide.org. easy-to-use clinical information,
and fatal submersion injuries in recreational
patient information in English and water settings—United States, 2001 and
Smoke alarm installation and Spanish, scientific literature, and 2002. Morbidity and Mortality Weekly
fire-safety education CD-ROM with printable versions of Report 2004;53(21):447–452.
CDC has funded states to install the materials in the kit. More than Wallace LJD, Patel R, Dellinger A. Injury
smoke alarms and to provide fire-safety 150,000 copies have been distributed mortality among American Indian and
education in high-risk communities, to health care providers nationwide Alaska Native children and youth—United
targeting households with children ages and internationally. Although the States, 1989–1998. Morbidity and Mortality
5 years and younger and adults ages 65 Weekly Report 2003;52(30):697–701.
tool kit was originally developed for
years and older. An informal sample of physicians, many other health care
program homes found that since 1998, providers, such as nurse practitioners
an estimated 1,071 lives may have been and physical therapists, have requested
saved. In addition, program staff have the materials. CDC has received
canvassed more than 382,000 homes positive feedback from more than
and installed more than 275,000 long- 2,000 recipients of the tool kit.
lasting smoke alarms.

8 Introduction
 CDC
Injury Fact Book

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Atlanta, Georgia
November 2006
The CDC Injury Fact Book is a publication of the National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention

Julie Louise Gerberding, MD, MPH
Director

Coordinating Center for Environmental Health and Injury Prevention

Henry Falk, MD, MPH
Director

National Center for Injury Prevention and Control

Ileana Arias, PhD
Director

Acknowledgments

Thank you to the staff of the National Center for Injury Prevention and Control (NCIPC),
CDC’s Injury Center, for help in compiling the CDC Injury Fact Book. Special thanks go to
Carole Craft and Sue Swensen for editing material found in this book and to Kendra Godbold
for editorial assistance; Krista Hopkins Cole, Sandee L. Coulberson, Michele Huitric, Alida Knuth,
Marie Legg, Jennifer Middlebrooks, Jane Mitchko, Sarah Olson, Kelly Sarmiento, and Robin Sloan
for their prompt, cheerful responses to the seemingly endless requests for data and program
descriptions; Tracey Foster-Butler for identifying and obtaining photographs; Sara Cote for
desktop publishing and creative solutions; Julie Hentz, Robert Noble, and Sevena Quattlebaum
for graphics support; and Sandra Bonzo for her counsel, broad knowledge of injury topics, and
diligence beyond the norm. To those who are dedicated to the Injury Center, this book celebrates
your achievements and contributions.

Suggested citation: National Center for Injury Prevention and Control. CDC Injury Fact Book.
Atlanta (GA): Centers for Disease Control and Prevention; 2006.