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Editors Choice

Special online issue of Injury Prevention

25 Mar, 15 | by Barry Pless

In a recent email, the editor of Injury Prevention, Brian Johnston, announced that in recognition of the Journal’s 20th Anniversary a special online issue was available. This features “some of the best papers in global injury prevention” that ordinarily would have been presented at the Safety 2014: the World Conference on Injury Prevention and Safety Promotion. Unfortunately, the Conference, scheduled to convene in Atlanta last year, was cancelled for various reasons known only to a few. As Brian notes, despite what some have written about the value of such conferences, these biennial meetings provide an excellent “opportunity for members of our disparate community to meet one another and share ideas, often informally. Apart from Brian’s editorial, the issue includes an assessment by WHO’s injury leader, Etienne Krug of the state of the discipline from a world-wide perspective. Please note that the content of the special issue will only be free to read online through the end of April.


To make life simpler for our readers, here is a list of the contents:



 Safety 2014: global highlights in injury prevention B D Johnston

 Next steps to advance injury and violence prevention EGKrug

Original articles

Costs of traffic injuries M Kruse

Rates of intentionally caused and road crash deaths of US citizens abroad M K Sherry, M Mossallam, M Mulligan, A A Hyder, D Bishai

Bus stops and pedestrian–motor vehicle collisions in Lima, Peru: a matched case–control study
D A Quistberg, T D Koepsell, B D Johnston, L N Boyle, J J Miranda, B E Ebel

The association of graduated driver licensing with miles driven and fatal crash rates per miles driven among adolescents M Zhu, P Cummings, S Zhao, JHCoben,GSSmith

Official blame for drivers with very low blood alcohol content: there is no safe combination of drinking and driving D P Phillips, A L R Sousa, R T Moshfegh

Extending the value of police crash reports for traffic safety research: collecting supplemental data via surveys of drivers D R Durbin, R K Myers, A E Curry, M R Zonfrillo, K B Arbogast

Unintentional drowning mortality, by age and body of water: an analysis of 60 countries C-Y Lin, Y-F Wang, T-H Lu, I Kawach

Children reporting rescuing other children drowning in rural Bangladesh: a descriptive study T S Mecrow, A Rahman, M Linnan, J Scarr, S R Mashreky, A Talab, AKMFRahman

Socioeconomic and disability consequences of injuries in the Sudan: a community-based survey in Khartoum State S E Tayeb, S Abdalla, I Heuch, G V den Bergh

Supervision and risk of unintentional injury in young children P G Schnitzer, M D Dowd, R L Kruse,
B A Morrongiello

Incidence, characteristics and risk factors for household and neighbourhood injury among young children in semiurban Ghana: a population-based household survey A Gyedu, E K Nakua, E Otupiri, C Mock, P Donkor, B Ebel

Risk of fatal unintentional injuries in children by migration status: a nationwide cohort study with 46 years’ follow-up N Karimi, O Beiki, R Mohammadi

Occupational noise exposure and noise-induced hearing loss are associated with work-related injuries leading to admission to hospital S-A Girard, T Leroux, M Courteau, M Picard, F Turcotte, O Richer

Deaths due to injury, including violence among married Nepali women of childbearing age: a qualitative analysis of verbal autopsy narratives K T Houston, P J Surkan, J Katz, K P West Jr, S C LeClerq, P Christian, L Wu, SMDali,SKKhatry

Sexual violence experienced by male and female Chinese college students in Guangzhou C Wang,
X Dong, J Yang, M Ramirez, G Chi, C Peek-Asa, S Wang

Brief reports

The implications of the relative risk for road mortality on road safety programmes in Qatar R J Consunji,
R R Peralta, H Al-Thani, R Latifi

Seatbelt and child-restraint use in Kazakhstan: attitudes and behaviours of medical university students
Z S Nugmanova, G Ussatayeva, L-A McNutt

Are national injury prevention and research efforts matching the distribution of injuries across sectors? H Jaldell, L Ryen, B Sund, R Andersson

Firearms and suicide in US cities M Miller, M Warren, D Hemenway, D Azrael


How well do principal diagnosis classifications predict disability 12 months postinjury? B J Gabbe,
P M Simpson, R A Lyons, S Polinder, F P Rivara, S Ameratunga, S Derrett, J Haagsma, J E Harrison

Counting injury deaths: a comparison of two definitions and two countries T-H Lu, A Hsiao, P-C Chang,
Y-C Chao, C-C Hsu, H-C Peng, L-H Chen, I Kawachi

Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma:
a feasibility study R P Berger, S Parks, J Fromkin, P Rubin, P J Pecora

Systematic reviews

An international review of the frequency of single-bicycle crashes (SBCs) and their relation to bicycle modal share P Schepers, N Agerholm, E Amoros, R Benington, T Bjørnskau, S Dhondt, B de Geus, C Hagemeister, BPYLoo,ANiska

Inequalities in unintentional injuries between indigenous and non-indigenous children: a systematic review
H Möller, K Falster, R Ivers, L Jorm


The Mysterious Green Hand

24 Feb, 15 | by Barry Pless

FullSizeRenderI voted for the design of the Journal’s new cover even though I was not sure why I liked it better than the alternatives. I’m pleased that whatever attracted me to it pleased others as well. But, from the start, the small green hand has puzzled me. It seemed a bit mysterious and not just because it cleverly merged into the background. I’m still not sure what it is intended to represent. The red is obvious: it is what most injury prevention messages say, “Stop; don’t go here.” Or, “Don’t do this; it’s dangerous and could cause a serious injury.” So, the red hand is no mystery. But the green hand is another matter. It could mean many things.

 One thing I hope it is not intended to convey is that the Journal encourages risk-taking. I know some regard my opposition to this as foolish, but even if I’m wrong, at least I’m consistent because I’ve held this view for many years. Recently, however, some distinguished colleagues insisted that I was wrong because they were convinced risk-taking is essential for healthy child development. They even argued that risk avoidance was itself ‘harmful’. When I asked for evidence in support of these assertions they insisted that not all evidence needs to be ‘scientific’.

 Respectfully, I disagree. I am not an evidence-based evangelist but I do believe that there is a clear hierarchy in the many paths to knowledge. Most scientists agree that clinical wisdom, years of experience, or the convergence of opinions from diverse disciplines is not equivalent to what we learn from disciplined, well-designed research. They (and I) believe the best evidence comes from true experiments but we accept that these are often impossible in a field such as ours. So we often resort to quasi-experimental designs. But I hope there are not many among us who would accept that ‘proof’ of a position can comfortably rest only on anecdotal accounts or personal experience.

 Back to the green hand: I repeat that I trust it is not intended as a symbolic nod to those who are convinced that risk taking is essential to healthy development or even a good way to prevent injuries. Instead, I hope it is intended to say something like, ‘Follow me along this path. Evidence suggests it may be risky but it is safer than the alternatives.’ In other words, the green hand is intended to remind us that there is a middle ground. For example, some communities in the US and Canada have recently banned tobogganing on hills that were found to be extremely dangerous. I think this makes good sense. However, many of these and other communities pointed users to hills that are far less dangerous because icy patches and obstacles have been removed. 

I hope the green hand is there to wave us towards safer alternatives but NOT to urge abandoning reasonable caution.

 PS. I urge, beg, implore all who disagree to submit comments to this blog. Let’s liven things up and debate our views vigorously.

Mental Models in Injury Prevention

18 Apr, 12 | by Brian Johnston

This month’s editor’s choice is Injury Prevention and Risk Communication: a mental models approach by Laurel Austin and Baruch Fischhoff.

We’ve published this special feature (which is free online) to highlight an empirically-grounded, systematic approach to thinking about health behavior, behavior change and intervention design. I suspect many of us use a ‘mental models’ framework as we think about prevention interventions, but fewer explicitly design and test their work in this fashion. And that’s a shame.

The authors make a strong case for the utility of a mental models approach and point to examples where the technique has been used to improve risk communication and preventive intervention. They outline 5 steps in systematically applying a ‘mental models’ framework to problem analysis and intervention:

  1. Elicit domain expert beliefs and integrate them in a formal model of the risk situation.
  2. Elicit lay beliefs about the same domain.
  3. Compare expert and lay beliefs to identify consequential gaps and misperceptions.
  4. Use structured surveys to estimate the population prevalence of beliefs.
  5. Develop and empirically evaluate contextually relevant communications.

Have a look at the paper here and let us know what you think.

We’d love to see submissions to the journal that make explicit use of this approach in understanding health behavior and designing preventive interventions.

Disseminating and implementing injury prevention across cultures

30 Oct, 10 | by Brian Johnston

The field of injury prevention enjoys a growing evidence base supporting the efficacy and effectiveness of interventions to prevent or mitigate many common injuries. Unfortunately, access to these interventions, policy and products is often limited in low and middle income countries. Dissemination of these effective interventions is an important but neglected strategy to address the disproportionate injury burden faced by individuals in less-resourced settings.

But can an intervention that works in the UK, Australia or North America be simply ported over to another country? Language barriers aside, are there not likely to be factors that might impact the acceptability and effectiveness of an intervention introduced into a new socio-cultural environment?

Danielle Erkoboni and colleagues have tackled just this issue in a paper that is the editor’s choice for October 2010: Cultural translation: acceptability and efficacy of a US-based injury prevention intervention in China.

In the study, the authors did NOT simply assume that an intervention shown to promote booster seat use in North America would work equally well when employed in China. Instead they tested that hypothesis.

It is notable that they did not start from scratch either. They repackaged the intervention in Chinese language but used essentially the same messaging and approach that had been successful with US parents. They recognized that for this approach to be successful there would need to be a fundamental cross-cultural comparability of the underlying theoretical constructs and models of health behavior.

That the intervention was accepted and successful offers a potential toll for promoting child passenger safety in this rapidly motorizing economy. But the study also provides a nice model for testing dissemination and implementation of our interventions in diverse settings. This is worth doing and it is worth doing well. Erkoboni and colleagues have shown us how.

As always, the editor’s choice is freely available at the journal’s website online.

Studying Firearm Regulation and Suicide in Quebec: Joinpoint Regression

26 Aug, 10 | by Brian Johnston

The August 2010 issue of Injury Prevention is available now. The editor’s choice for this month is “Firearms regulation and declining rates of male suicide in Quebec,” by Mathieu Gange and colleagues from the Institut national de santé publique du Québec. As always, the editor’s choice is freely available online.

In their analysis, the authors use joinpoint regression techniques to analyse age-specific suicide rates over time. They were looking for evidence of an effect of Bill C-17, which increased firearms regulation, including requirements around safe storage of weapons and ammunition. Although the bill was passed in 1991, the requirements were phased in over several years and pubic awareness, uptake and compliance might also be expected to lag. Thus, it is not clear when one would expect to see a change in suicide rates potentially attributable to this regulation

The interesting aspect of the joinpoint method, to me, is that one doesn’t need to know when an effect is expected – the program fits a line or series of line segments, with inflections, or changes in slope, positioned at points which maximize the statistical fit of the line to the data.  A joinpoint is only added to the model if the change in trend at that point is statistically significant. In effect, the program finds the point at which an effect can be demonstrated.

In this case, there was a demonstrable drop in firearm suicide rates in 1995, several years after enactment of the law. As with any ecological study, it is not possible to link the law directly to the observed reductions in firearm suicide among young men. The late 1990’s saw a drop in suicide among young men in a number of Western countries. Even in Quebec, there was a joinpoint noted around the same time, associated with a fall in the rate of suicide by hanging. Broader suicide prevention initiatives, changes in the economy and increased availability of medications to treat depression may all have contributed.

Nevertheless, the paper is consistent with others in the literature which suggest that interventions to reduce availability of lethal means – in this case, easily accessible firearms – can result in reductions in suicide. This is especially true among younger men whose suicide attempts tend to more impulsive and more lethal.

The joinpoint methodology is worth a look if you work with injury time series. It is available online from the US National Cancer Institute here:

Media Reporting of Road Traffic Injury

23 Jun, 10 | by Brian Johnston

The editor’s choice paper for the June 2010 issue is “Reporting on Road Traffic Injury: Content Analysis of Injuries and Prevention Opportunities in Ghanaian Newspapers.” The brief report, prepared by Isaac Kofi Yankson and colleagues, is a simple bibliographic analysis of newspaper coverage of road traffic injuries in Ghana. As the authors point out, similar assessments have been undertaken in looking at the US press, but this is the first to use this method to study the subject in a low or middle-income country.

The results, however, are distressingly familiar: most reports omitted mention of recognized risk factors or possible safety interventions. Only editorials or submitted commentaries routinely discussed possible interventions.

It isn’t surprising, of course. The journalistic impulse is to focus on the particular, the human and individual facts of a tragedy – this is what makes a story compelling. Is it fair, really, to expect a reporter to place the crash into a broader pattern? To, in essence, strip the individuality from the event?

I am not sure. Tom Vanderbilt wrote a nice piece on this topic in the Columbia Journalism Review last year (hat tip to Deborah Girasek, Director of Social and Behavioral Sciences at the Uniformed Services University of the Health Sciences, as well as a diligent reviewer and friend of the journal). He points out the real reluctance of journalists to promote safety messages in the face of a personal or public tragedy. That Princess Diana was not wearing a seatbelt at the time of her fatal crash was not widely noted until more than 10 years after her death, when the road safety minister in the UK finally broke silence to point out that safety restraints might have saved Diana’s life.

It does seem to me that law enforcement and first responders – who have a much more clearly vested interest in injury control –  could be prepped with “talking points” or simple facts to share with the media in an attempt to put crashes into context. And if public health is to engage with the media to develop “reporting standards for road traffic crashes,” I suggest we work to focus on the relentless predictability of this epidemic. Not the individual tragedy, but the horrifying, senseless and demeaning anonymity of falling victim to a plague most of us manage to deny and ignore. If any other condition were killing so many otherwise healthy individuals day in and day out, the public would be outraged and demanding a response. Can we move road traffic safety to that level of public engagement?

Applying best practices in behavioural interventions to injury prevention

9 Apr, 10 | by Brian Johnston

The Editor’s Choice in the April 2010 issue of IP is “A practical approach for applying best practices in behavioural interventions to injury prevention,” a special feature authored by Flaura Winston and Lela Jacobsohn, from the Center for Injury Research and Prevention in Philadelphia, USA.

In this paper, the authors outline a practical approach for using behavioural theories to develop and implement prevention programs. Their approach borrows from existing theories in health promotion and disease and injury prevention and involves 2 sets of 3 steps.  The first 3 steps articulate a theoretically-grounded, actionable plan. The second 3 steps utilize the plan to guide intervention development, testing and refinement. The key emphasis of this approach is starting with a clearly defined, broad and measurable vision for the outcome rather than some preconceived idea about what the necessary interventions will be (based on assumptions, familiarity or resources available).

I think this deliberate approach has the potential to stop us from making some of the more common mistakes we see in ineffective prevention campaigns. These include rushing too quickly to a specific intervention that does not target key constructs required to promote or facilitate behavior change (no more brochures, please!), and failing to evaluate the programs we implement to see how well they do (or do not) work in diverse real-world settings.

While many talented people have brought behavioral theories to bear on injury problems in the past, this paper offers a welcome tutorial and structured approach for those in the trenches who know we could all be doing a better job of applying those behavioral principles in our daily practice.

The importance of doing this the right way was underscored by Dr. Winston in a recent conversation:

In this environment of limited resources, we need to make sure that prevention dollars are spent wisely.  We need to systematically apply evidence and theory to ensure the highest likelihood for success and then test and refine, particularly before large scale dissemination. Then, we will then have the greatest chance that interventions will be shown to effect positive change when implemented. I believe that the 6-step approach can provide a framework for guiding efficient prevention planning and execution.

Remember that the Editor’s Choice in each issue is freely accessible from the time of publication.

Traffic calming assessed by GIS

7 Mar, 10 | by Brian Johnston

In the February 2010 issue of IP, the Editor’s Choice is “Using geographical information systems to assess the equitable distribution of traffic-calming measures: translational research.”

This paper by Sarah Rodgers and colleagues complements the Advocacy in Action study currently underway by the same group.

In the study, the authors used traffic calming data on almost 100,000 km of road in various areas in the UK. They were able to link these data using GIS analysis to population data, including measures of local deprivation.

Two findings stand out. First, only a small proportion of roadways are traffic calmed (3.7%). Of course, it is not clear what fraction of all roadways are eligible for such. And the data sets used registered only speed humps, whilst traffic islands, chicanes, “road diets,” etc. are all addition forms of traffic calming for speed reduction.

Second, deprived areas had a relatively higher proportion of roads calmed than did more affluent neighborhoods. It is interesting to see (finally) a health intervention that is disproportionately applied to poorer communities. What is not clear is why this happens: is there reduced demand in affluent areas? Do wealthier neighborhoods resist these modifications? Are they less valued in well-off communities where walking is less likely to be a common mode of transport? Or is traffic calming in richer areas already achieved through zoning or street treatments not apparent in the database used?

Editor’s Choice

Using geographical information systems to assess the equitable distribution of traffic-calming measures: translational research

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