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Helping the helpers
  1. B Pless, Editor

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    In previous editorials I have written about risk factors for injuries that seem “ubiquitous”. By this I mean that they are found in most countries and affect most, if not all, types of injury. A good example is alcohol. In this column I comment on a related phenomenon, not as a risk for injury but as a risk for failing to implement preventive measures adequately.

    It has been repeatedly stated that the quintessential problem in injury prevention is that so much of what we know to be effective is not applied, or not applied fully. Rivara and others have estimated that if we were able to fully implement all we know, there would be about 30% fewer injury deaths among children. I have no doubt the figure for adults would be the same, and possibly even higher, and there is no reason to think that the same shortfall is not seen with respect to non-fatal injuries.

    Thus, injury prevention presents a sharp contrast to other health problems. Although in all instances investigators seek to find causes or remedies, in the case of “ordinary diseases” once either of these meets with success, it is rarely a problem to take the next steps to fully harvest the fruits of the research. For example, it is difficult to imagine the results of a successful study of a drug to prevent or treat a disease being ignored. Its manufacturers, clinicians, and occasionally patients will press for the drug's general adoption.

    Unfortunately, there are no parallels in injury prevention. There is no equivalent of a manufacturer with an economic motive to move forward. True, for some products such as smoke detectors, tap water valves, or protective sports equipment, there are profits to be made and manufacturers have a financial stake in having their product widely adopted. But this journal and others like it have nothing like the pages upon pages of attractive (and lucrative) ads that are sprinkled throughout mainstream medical journals promoting a new drug or a variant of an old one. Part of the reason we have no advertisements is that it is not clear who the consumer is, even if it could be assumed that they read the journal in question. The sad fact is that few safety groups, with some notable exceptions like MADD, are like those who vigorously demand better therapies or preventive measures.

    Whatever the reasons, the problem is all too evident. We have been slow to realise that the implementation issue requires the same painstaking, tedious, step-by-step elements of research as have been devoted to discovering what works. Three papers in this issue and another in a previous issue illustrate the sort of studies likely to be needed before further progress can be made towards implementation. I trust the authors would agree that none of these are as rigorous as we might like, but these reports are critical first steps on which others should quickly build.

    The paper in our September issue by Coyne-Beasley and her colleagues (200) found that even in the hands of law enforcement officers, trigger locks are used far less often than we might expect. Although it is doubtful that police are a good sample of the general population of gun users, the reasons they give for not using gun locks are illuminating and may well have broader applicability.

    In this issue, Begg's paper describes how effective a graduated driver licensing (GDL) system can be and identifies one of the most useful components (292). All well and good. But, as Steenburgen notes, if parents, police, or the judiciary fail to do what is needed to fully implement a GDL system, there is no reason to expect it will accomplish the desired goals. We need to better understand the difficulties these key partners have and how to eliminate or minimize the difficulties before we will be successful.

    A variation on this need to know more about the links in the chain from what works to making it work, is provided by Jaye et al (302). Tap water scalds is an issue that Safe Kids Canada has begun to tackle. In doing so, they like Jaye and her colleagues, uncovered a myriad of barriers. In the New Zealand example the focus is on the attitudes of plumbers. For Safe Kids Canada other actors appeared on the stage.

    It is one thing to say that the solution is simple—see to it that the water coming from taps are at “safe” temperatures by lowering the setting on heating tanks. It is another to persuade others to work towards this goal. Not everyone has access to hot water heaters, or the courage to fiddle with the settings. They need help. And there continues to be strong opposition from those who are convinced that lowering temperatures will increase the chances of legionella infection. Although I have no doubt the microbe grows better in cooler than it does in hotter water, I know of no evidence that this translates into more disease. Nevertheless, those who hold this belief are part of the chain; they must be persuaded that lower temperatures are safe before they can be expected to cooperate.

    Each of the examples point in the same direction: that the safety community alone cannot succeed without enlisting the help of others. Some are potential allies whose support we need to enlist; others represent obstacles whose opposition needs to be overcome. An early report in this journal noted that clerks selling bike helmets who do not understand the safety issues may either fail to promote their use or give bad advice. Similarly, as Chamberlain and Solomon note (272), police officers who are not convinced speeding or drunk driving are as serious as robbery may resent ticketing offenders and divert their attention elsewhere. Similar examples can be found wherever we look.

    The question some potential allies may ask is, “Apart from doing good for others, why should I sacrifice time, effort or income, to help achieve injury prevention goals?” In an ideal world no such sacrifice would be required. In fact, even in the imperfect realms in which most of us live, it is conceivable that an enlightened government would make it a policy to provide subsidies, or, if necessary, penalties or both, to facilitate such cooperation. One way or another we need to recognize how essential the help of others is to achieve success in preventing injuries. To do so we must find ways to help the helpers.

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