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- evaluation research
- intentional injury
- violence prevention
- Montreal Declaration
- WHO world report
Keys to success, WHO’s world report on violence and health, Montreal Declaration, motor vehicle injuries
KEYS TO SUCCESS: SOLID DATA AND STORY TELLING
For success in injury prevention measured not just as doing good research and having it published in good journals (such as this), but in getting action to follow, at least two elements are needed. One is essential; the other, compelling but unproven.
Solid data are essential. You must have convincing evidence in support of the preventive measures you want adopted by whomever—your government, local community, professional group, etc. We should not take a position on a safety issue if we cannot back up that position with reasonably solid data or some other kind of credible evidence. That said, I am not suggesting that we should not press for action until the evidence is “perfect”. It never will be and we cannot hold off forever.
Papers published in journals such as this are one form of such evidence. Rarely, however, is a study beyond criticism and it is even more rare for it to be conclusive. Nor does every study have a preventive message. In fact, the implications for prevention with which we urge authors to conclude their papers are often a bit of a stretch. But most research reports are solid starting points that can lead at least to informed speculation about preventive measures. Although most of what we publish is based on data from quantitative studies, we also encourage qualitative studies because they offer useful insights. Occasionally we include case reports that initiate the research continuum.
Armed with reasonably solid evidence, the second element is stories that illustrate the message. If we want action to follow we often need to engage the media or policymakers. To do so we must learn how to tell good stories. One graphic account may be worth 1000 statistics. In fact, too many data may confuse or turn off reporters or their audience. The kinds of stories that are so often persuasive are anecdotes related by victims or their families. Such accounts have been used successfully by organizations like MADD when seeking public support. They tell what happened, how it happened, and what the consequences were. And they do so in simple, often horrifying terms.
Buried in the data and the stories lie messages. Over the years there has been a shift in the advice we offer to the public regarding injury prevention. Initially most safety professionals sang from a health education songbook. The tunes conveyed the idea that we needed to be more alert to the hundreds of dangers that lurked around us. We were urged to take often impossible steps to prevent these from causing injury.
As it became increasingly clear that this sort of message was ineffective, we moved to messages that were more balanced, credible, and realistic. These spoke of the need to act sensibly and take reasonable precautions, but also spoke of the need for society to provide appropriate protection. Many are rightly troubled by messages that may be interpreted as a basis for blaming the victim. Equally undesirable are the overly simple messages so often used by public health authorities or other branches of government to exempt themselves from taking the tough measures needed to protect the public. For example, public health agencies often use leaflets in lieu of action to assuage their consciences. Knowing which messages work and which are ineffective (or possibly harmful) can only be answered by evaluation research.
For example, a colleague in Europe asked what I thought of a popular Canadian program, Heroes. This multimedia presentation is aimed at encouraging high school students to take risks “smartly”. It features loud music and bright lights and a “hero”—a disabled teenager who has survived a major injury. This message is puzzling and confusing. Although this programme undoubtedly tells a good story, it lacks supporting data. It is reasonable to assume that students exposed to a Heroes presentation are shaken, but what we need to know is whether they are also stirred to action. Does it change their behaviour and in what direction? Perhaps Heroes sends the right message; perhaps not. Given the uncertainty, such a popular program cries out for evaluation. The same applies to a more recent Canadian creation: “I Promise” aimed at reducing teenage drivers’ injuries (http://www.ipromiseprogram.com/). This may also be an excellent idea, but before sponsors (especially government) climb on the bandwagon they should demand evidence of effectiveness.
These programs are but two examples of the many that tell good stories or portray good ideas but which still must demonstrate their value. The challenge is a reasonable one and there are many examples of organizations that have done so. They include Think First, Safe Kids Canada, and the Safe Kids Campaign in the US. As the reviewers of the paper by Tamburro et al (see p 242) on Think First noted, the evaluation design is far from perfect but it is a major step in the right direction. It should encourage others to follow.
WHO’S WORLD REPORT ON VIOLENCE AND HEALTH: A LANDMARK CONTRIBUTION
Unlike Caesar’s Gaul, the world of injury prevention is customarily only divided into two parts: unintentional and intentional injuries. For many years the former has dominated in the health related scientific literature. The latter, violence in its many forms, is harder to come to grips with because it encompasses such a wide variety of manifestations. Each reflects a different cluster of disciplines, most of which are outside the health sector. Thus the report by WHO is a landmark contribution because it so successfully breaches the interdisciplinary gulf.
This long awaited monograph (see www.who.org) will be reviewed in depth in a later issue. A team of experts, many of whose names are familiar to our readers, have coedited under the leadership of Etienne Krug. This report is noteworthy because it moves WHO to center stage in this area of injury prevention. The six substantive areas covered—violence among youth, child abuse, intimate partner, elderly, sexual, and self directed violence—are each dealt with in a remarkably comprehensive and interdisciplinary manner. The foreword by Nelson Mandela is eloquent and captures the essence of the great challenge before us.
This outstanding document includes many valuable data for scholars. However, my attention was on the concluding sections addressing prevention. Here, one phrase recurs: “remarkably few initiatives have been rigorously evaluated”. Although the report includes many suggestions and recommendations for prevention practitioners, the absence of formal evaluations means that many efforts will be futile and many resources squandered.
An equally unsettling element in the document leaves uncertain what further role WHO might have. The introduction refers to a resolution (World Health Assembly 49.25) adopted in 1996 that asserts that WHO “has the responsibility to provide leadership and guidance to Member States in development of public health programs”. Most chapters end with a call for more data, more research and more evaluation, but few say explicitly how WHO should go about providing “leadership and guidance”.
Make no mistake: the very act of putting this excellent document together involved leadership of a pivotal kind. However, it is not evident what actions WHO must take to fulfil the 1996 resolution. Obviously, WHO is limited by political considerations and there are many circumstances where the problems are far more national than international. But with respect to conflict and assault, in my view there are leadership options that should be spelled out and agreed upon. One obvious example is landmines—a modest success story for WHO; another opportunity is small arms control, along the lines noted by Christoffel (see p 177).
These concerns aside, this is a superb, timely document. It is presented in a scholarly manner, well referenced, and clearly written. For the most part, it pulls few punches. Readers of this journal must not ignore this report—a copy belongs on every shelf.
THE MONTREAL DECLARATION: PEOPLE’S RIGHT TO SAFETY
Those who missed the World Conference in Montreal missed a marvelous scientific exchange, great food, and terrible weather. They also missed a chance to endorse the Declaration published in its entirety on our web site: http://www.injuryprevention.com. Be sure to visit the site and reflect on this document. It contains much food for thought and concludes with a heavy duty challenge in Article 11 that spells out “State responsibilities”: “2. All States shall respect and protect the right to safety. Accordingly all States shall formulate injury prevention and safety promotion policies”. What a wonderful world it would be even if only this Article were fully accepted and implemented. Kudos to Dinesh Mohan for moving this along.
MOTOR VEHICLE INJURIES: TWO SUPPLEMENTS FOCUS ON DRIVERS
For epidemiologists, it is not surprising that so many injury papers centers on drivers. One way or another, drivers are justly viewed as the “cause” of many road related injuries and deaths. Several groups of drivers are known to be at higher risk than others, both to themselves and to other road users. These include the old, the young, and those who are intoxicated or distracted. Two of these groups are addressed in supplements that accompany this issue.
Bruce Simons-Morton, a behavioural scientist at the National Institute of Child Health and Human Development in the US assembled and edited one on young drivers. It includes five papers on topics ranging from graduated licensing to parental management. Each is followed by a discussion (critique). The conference at which these papers were presented and discussed was held in May. The night before we had our last but one major snowstorm and I wimpishly cancelled my flight.
The second, by Solomon and Chamberlain, is an argument in support of Canada making driving with a blood alcohol concentration above 0.05 a criminal offence. There can be no doubt that drunk drivers are among the highest of the high risk drivers in any country. Whether such a measure would be effective in reducing the risk is for readers to decide. Although some of the peculiarities of law enforcement in Canada are pivotal to the points being made, the general problem and proposed solution apply equally to most other countries.
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