Elsevier

The Lancet

Volume 384, Issue 9937, 5–11 July 2014, Pages 64-74
The Lancet

Series
Prevention of injury and violence in the USA

https://doi.org/10.1016/S0140-6736(14)60074-XGet rights and content

Summary

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Introduction

Nearly 180 000 people in the USA die every year from injuries and violence related to preventable events such as car crashes, drug overdoses, falls, assaults, drowning, and self-harm, according to numbers from the US Centers for Disease Control and Prevention (CDC).1 This number is equivalent to one injury death every 3 mins. Millions more people survive these events every year and are left with substantial physical, emotional, and financial problems as a result of acts of violence or unintentional injury. No individual is immune from these tragedies—people of all ages, races, and levels of education and income are affected.

Injuries and violence are not accidents and are not inevitable. They can be prevented. Yet, although figures in public health maintain a common understanding for the definition, causes, and solutions to injuries and violence, this recognition might not be widely accepted by other audiences, including policy makers, clinical health professionals, and the public. Injuries and violence can be seen as inevitable and unpredictable.2, 3 Representatives in public health have struggled to change this perception in some key stakeholders such as policy makers and even health professionals. When the need for injury prevention is recognised by individuals in health systems, training, time, and skill are often insufficient to enable a suitable response.

In clinical settings, injury prevention is not integrated fully in practice and patients are not as familiar with ways to prevent injuries as they are with those for other major killers such as heart disease, stroke, and cancer.4 Physicians and other health-care workers have not yet included screening for injury risk into routine standards of care. National estimates are that one in five adults visiting health-care providers receive counselling about injury prevention.5 This absence might be partly due to the increase in demands on practitioners—if primary care physicians were to satisfy fully the clinical recommendations of the US Preventive Services Task Force, then they would need to devote longer than 7 h per day to preventive services alone.6 Managed-care organisations and other health-care institutions have not fully codified injury prevention counselling into clinical workflow and electronic medical records to improve the delivery of injury prevention services.7

Although the USA has achieved some important milestones in injury and violence prevention in the past century, greater improvements are attainable.8 Even in individuals who have awareness of the preventability of injuries and violence, perception of risk is incongruent with actual risk.9 The tendency for optimistic bias, an attitude of self-exception, or an inaccurate perception of the consequences of actions can all disrupt prevention efforts. And similar to other major public health challenges (especially those attached to broad public policy solutions), tension exists between the protections of personal freedom and the sought after benefits for public health. Stated simply, how does the USA achieve the greatest good for the greatest number of people, while also respecting civil liberties?

Key messages

  • In the first three decades of life, more people in the USA die from injuries and violence than from any other cause

  • Injuries and violence take an enormous economic toll on the USA, including the cost of medical care and lost productivity; they are preventable and have been linked to a wide range of physical, mental health, and reproductive health problems, and chronic diseases

  • For all ages, the five largest causes of injury deaths are motor-vehicle crashes, poisoning, falls, firearm suicides, and firearm homicides

  • Injury and violence-prevention strategies include education, behavioural changes, policy, engineering, and environmental supports; they have a positive return on investment and can be supported through use of communication framing theory, sharing of success stories, and provision of data to decision makers

  • Systems must be in place to allow the widespread adoption of effective strategies for injury and violence prevention and to bridge the gap between research and practice

  • Professionals in public health must work in partnership with those in clinical medicine to ensure that health delivery systems are well integrated and perform effectively, efficiently, and equitably to prevent injuries and violence and to improve outcomes

  • Continuing investments for research and innovation are needed to achieve further reductions in injury and violence

In a Comment in a 2012 issue of The Lancet, Shakur and colleagues10 stated that “…to reduce the human and economic effect of injury, we need better prevention, effective and affordable treatments, and the tenacity to ensure their universal access”. The viability of attention to public health issues is linked to features of the problem, the way in which stakeholders portray the issue, the policy environment, and the strength of organisations concerned with the issue.11 Using these perspectives, we posit that to advance injury and violence prevention, the communication frame should be enhanced (so that messages increase awareness and change perceptions), success stories be shared, science be translated, data be provided to decision makers, effective interventions be disseminated, and public health be integrated with clinical medicine.

Section snippets

Morbidity, mortality, and the effect of injuries and violence

From age 1 year to age 30 years, more individuals in the USA die from injuries and violence than from any other cause (figure 1).1 In 2010, the ten leading causes of death in this age group were, in order, unintentional injury, suicide, homicide, cancer, heart disease, congenital anomalies, cerebrovascular disease, influenza and pneumonia, diabetes, and chronic low respiratory disease. An alarming 79% (n=41 121) of deaths were due to injuries, whereas 20% were due to chronic diseases and 1%

Choice of focus

Some types of injury, such as homicide, suicide, prescription drug overdose, falls in older adults, traumatic brain injury, and child injury, have received increased recognition because of changing trends, striking disparities, and rising public concern. These topics underscore new pressing demands in the USA and offer compelling reasons to respond swiftly. Other types that we have not expanded on in this article, such as road traffic injuries, have reduced substantially and are considered

Social determinants

Many social and economic factors contribute to disparities in injury risk and outcomes in the USA, including income, education, employment, and community environment. For example, men who are unmarried, have a low-income, are unemployed, or are poorly educated are at increased risk for death by motor-vehicle injury.38 Young people growing up in communities with concentrated disadvantage are more likely to witness violence, attend underperforming schools, and have poor employment opportunities;

Effective interventions

The scientific evidence to support prevention of injury and violence is strong.8, 42, 43 Public health strategies for prevention such as education, behaviour change, policy, engineering, and environmental support are guided by the social-ecological model that informs how strategies should be implemented across individual, relationship, community, and society levels. Interventions that address the social and economic determinants of health and change the context to make individuals' default

Conclusion

Greater success in the USA is possible through public health and medical practice working together to frame injuries and violence as preventable, identify cost-effective and evidence-based interventions, provide evidence to decision makers, and strengthen the capacity of the health-care system.83 Clinical medicine and public health partnerships can help to ensure that life is not stopped by a preventable injury and that thousands are spared the debilitating effects of a car crash, non-fatal

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