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Three common beliefs that are impediments to injury prevention
  1. David Hemenway
  1. Correspondence to Professor David Hemenway, Harvard Injury Control Research Center, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA; hemenway{at}hsph.harvard.edu

Abstract

Three common beliefs that are impediments to injury prevention are: (1) the optimistic belief that nothing bad is going to happen, especially to me (‘it will never happen to me’); (2) the fatalistic belief that, if something bad does happen, nothing could have been done to prevent it (‘accidents happen’); and (3) the moralistic belief that if the injury happens to someone else (eg, you), you probably deserved it—so do not blame me or expect that I should have done anything to help prevent it (‘blaming the victim’). On-line blogs and comments are used to illustrate these beliefs. Counter-arguments are discussed.

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In my book on success stories in injury prevention,1 I discuss some three-dozen injury ‘heroes’ whose efforts have helped make the world a safer place. Every one of these heroes faced many obstacles, including people who tried to impede their activities. I have often joked that I should write a follow-up book on the injury prevention ‘anti-heroes’.

This essay does not discuss individuals, but instead describes three common beliefs that are impediments to injury prevention:(1) the optimistic belief that nothing bad is going to happen, especially to me (‘it will never happen to me’); (2) the fatalistic belief that, if something bad does happen, nothing could have been done to prevent it (‘accidents happen’); and (3) the moralistic belief that if the injury happens to someone else (eg, you), you probably deserved it (‘blaming the victim’)—so when something bad happens to you, do not blame me or expect that I should have done anything to help prevent it. These beliefs are illustrated with comments from web on-line comments and blogs. For each belief, I discuss some counter-arguments with respect to both individual behaviour and policy prescriptions.

1. Optimism: ‘It will never happen to me’

An impediment to reducing injury at the individual level is the common tendency for people to think: ‘It will never happen to me’. And indeed, each individual is usually correct about any specific injury—particularly if ‘never’ is replaced by ‘rarely’. Serious injuries are rare—there is a low probability that a randomly chosen individual will be seriously injured this year. The large majority of unsafe behaviour is not immediately punished by an injury either to the person behaving unsafely or to anyone else—on the contrary, the risk-taker is typically immediately rewarded with convenience, comfort, time saved, or even thrills.

A gun in the home typically increases rather than reduces the danger of serious injury, but only a very small fraction of individuals in gun owning households will be hurt by their household gun this year. The experience of the vast majority of gun owning households is that the gun does not cause harm. Similarly, talking on the phone while driving increases the risk of collision and injury, but more than 99% of the time when a motorist decides to make a phone call, nothing terrible happens. One of the reasons that the large majority of motorists think they are better-than-average drivers is that even the worst drivers virtually always arrive safely at their destinations.

Should bike riders wear helmets? This question is often debated on-line. One of the arguments against helmet use is the notion that it will never happen to me. “Yes, a helmet will probably reduce your overall likelihood of injury—but the likelihood of any kind of major injury (speaking with regard to my own personal case specifically) is so small in the first place, it doesn't make that much difference”.2 “Think about the statistics involved here: most people in America have ridden bikes extensively in their lives, especially as children. Yet, even after millions and millions of miles ridden by all of us, most (or all) of which were ridden sans helmet, we are all still here in one piece. It has to be one of the safest activities in the world, statistically”.3 “Helmets were unheard of growing up in the 1950s–1960s. Somehow we all survived”.3

Response

We are, in general, terrible at understanding low probability risks.4 For events recently in the news, we tend to overestimate the actual probability of future occurrence, but for most rare events, we too often act as if the probability were effectively zero.5 ,6 Thus it is often difficult to get us to act to reduce the likelihood of injury.

Since a serious injury to any particular person is unlikely in any particular year, workplace safety experts stress the importance of intermittent praise and rewards for safe behaviour, and for creating a culture of safety in the company, creating a sense of belonging to a community where workers look out for each other.7

I commute to work on my bike. I am an injury control advocate, but one very hot day a few years ago I remember thinking, “why am I wearing this helmet? I have ridden for over 30 years and I have not had a serious crash, do I really need this helmet?” Five minutes later a parked motorist decided to open his door just as I was riding by. I crashed into the door, flipped over and landed on my back and head. As I was lying in the street I thought, “OK, I understand, this is why I wear my helmet”.

While any particular adverse event may be rare, there are so many low probability dangerous events that if we do not act to make ourselves safer, there is a high probability that something bad is going to happen—a serious injury—maybe not today or tomorrow, but sometime in our lifetime.

2. Fatalism: ‘accidents happen’

When an injury occurs, an all-too-common belief is that the injury was inevitable—‘accidents happen’ and there is not much to be done. A related idea is that when people deliberately place themselves in risky situations (eg, they drive, they play sports) they must accept the chance that injury may result.

Days before the opening of the 2010 Winter Olympics in Canada, on a training run, a luge athlete crashed and died after he slammed into unpadded steel beams while travelling nearly 90 mph. Many of the hundreds of on-line comments to the news emphasised that the Olympian understood the danger and took the risk. “Obviously this is a tragic accident…but everyone has to remember it was an ACCIDENT. He was 21….a grown boy who knew exactly the risks in competing in this sport and he was obviously doing what he loved if he made it all the way to the Olympics”. “It is unfortunate to have an occurrence of injury or death during a sport, but that is the risk we all take when we compete”. “But please, this person knew he was playing with his life trying to break a speed record with a little helmet”. “It is an unfortunate accident. What do you expect to happen in a sport where you lie on a sled and go 100 mph on a sheet of ice?

If you cannot handle the danger, risk and inherent accidents…stay at home”.8

In other comments, people made the argument that the problem was human error—that the victim was at fault (see next section). One commenter summed up the argument. “Hundreds of world-class athletes trained on that luge course prior to the Georgian luger's unfortunate accident…if hundreds of others stay on course and one does not, that seems to indicate that the individual had a bigger momentary problem…How about that one rare airplane that crashes at the end of a runway when thousands of planes successfully take off and land every day? More often than not, it is pilot error…The vast majority of the racers did not crash and only one died…the odds indicate that the individual was at fault”.9

The International Luge Federation and Vancouver Olympic officials quickly investigated the incident and concluded that the crash was the result of human error and that ‘there was no indication that the accident was caused by deficiencies in the track’. Fortunately, they nonetheless made some fairly significant adjustments to the track, moving the start of the men's competition farther down the track and erecting a 12-foot high wooden wall to cover the exposed steel beams.10

Response

Most injuries are both predictable (on average, not to a particular individual) and preventable. The injury field decided to limit its use of the word ‘accident’ because this word seemed to imply that nothing could have been done to prevent the ‘accident’ or the seriousness of the injury. A fatalistic view of the world can lead to resignation and the feeling of powerlessness; by contrast, the injury field promotes an optimist and pragmatic belief that it is possible to find ways to increase safety.

Instead of focusing solely on the individual as the potential cause of the problem, injury control specialists analyse all factors that affect injury. Injuries are rare events, and while it is true that most lugers (or airline pilots) do not crash and die, it is also likely that the risk of death varies considerably across luge tracks (or airports). Instead of trying solely to prevent human incompetence or misbehaviour, the goal of injury prevention is to help create environments in which it is difficult for individuals to make mistakes or behave inappropriately, but when there is a mistake or bad behaviour, no one gets seriously injured. Indeed, this is what the Vancouver officials attempted to do—after the injury.

3. Moralism: ‘blaming the victim’ (so do not blame me)

When an injury occurs, it is common for people to look for someone to blame and a tendency to put the blame on the victim. In 2011 on the Fair Warning website, an article appeared about the 2000+ American children under age 6 in the past decade who have been severely burned on the glass front of gas fireplaces. The fireplace industry's voluntary standard allows the glass to reach 500° Fahrenheit, a limit designed not to prevent people from getting burned but to keep the glass from cracking. A former Consumer Product Safety Commission psychologist calls heated glass an ‘insidious and unappreciated hazard’.11 Homeowners typically do not even see a warning, which may be in a manual that often goes to the building contractor rather than the home's original owner.

The on-line discussion about the article included parents’ comments such as: “We learned the hard way. We were visiting someone's home and I had no idea there was a fire on. Within 5 min our 10 month old daughter severely burned her hand…We have talked with so many people who have no idea the glass gets so hot. Why can't all manufacturers add the mesh screens?” It also included comments from some manufacturers: “Good story. Our company has been making safety screens for gas fireplaces for the last 5 years and we completely agree that these fireplaces are hazardous”.11

But the more typical comments involved blaming the victim: “C'mon folks, there has to be some personal responsibility here…” “Common sense people. It is about personal responsibility and using your brain”. “Just out of curiosity, has anyone ever heard of personal responsibility?” and “Two words: Nanny State”. There was also the argument that the market works: “If consumers want fireplaces with added safety features, then the marketplace will dictate what is made and sold”.11

Response

When something bad happens, it is common for people to look for fault and to try to assess blame.12 Typically they blame anyone with the ‘last clear chance’ of avoiding the injury—which is often the victim. However, many things had to happen for any particular injury to occur. It is not good policy to focus only on the last one.

In general, assigning blame is often counter-productive for prevention. It is well known that the most cost-effective methods of prevention may not even directly involve the person or entity deemed to be most responsible. For example, airbags significantly reduced fatalities from drinking-and-driving without affecting either behaviour.

De-coupling fault and prevention is critical for effective injury control. Indeed, not assigning fault is often key to the best prevention efforts. For example, blame-free reporting has been credited with helping to improve airline safety and suggested as a model for reducing medical error.13

There is a common psychological tendency to believe that I deserve whatever good happens to me, but am the victim of misfortune when something bad happens; conversely, when good things happen to someone else, they were probably lucky, and when bad things happen to them they probably deserved it.14 This psychological tendency reduces empathy, leads to blaming the victim, and reduces the chance for successful prevention.

Discussion

People oppose safety improvements for many reasons. For example, change is typically hard psychologically, while maintaining the status quo is typically easy; thus tradition-bound resistance is common. Some people are against anything they perceive as an increase in government authority over individual behaviour. And many powerful interests have financial incentives to prevent beneficial change.

Three typical arguments used against virtually every injury prevention policy are: futility, perversity and jeopardy.15 The futility argument is that the proposed reform will have no beneficial effect; the perversity argument is that the reform will actually lead to the opposite of its intended effect; and the jeopardy argument is that the reform will downgrade fundamental values, such as freedom. Libertarians, for example, use the jeopardy argument to` attack the ‘nanny statists’ of public health whom they see as undermining individual rights.

Virtually every suggested injury prevention policy faces these three claims. For example, common arguments against seat belt laws are that seat belts are not effective—indeed they may increase the danger (eg, via ‘risk compensation’ as motorists take more risks)—and motorists should have the freedom to decide for themselves. Those against the laws can find anomalous situations where the seat belt may have reduced safety—what if the car catches fire and I cannot get out because I am stuck in my seatbelt. A libertarian blog on seat belt laws elicited such responses as: “A friend was broadsided by a drunk…The only thing that saved his life (when the door replaced him as the driver seat occupant) was NOT WEARING his seat belt…”16 (Unfortunately, people who died because they did not wear their seatbelts are not alive to tell their personal stories to friends or on blogs).

In my injury class, I highlight impediments that injury prevention advocates face in the real world. This essay discusses three common beliefs that are impediments to injury prevention: (1) the overly optimistic belief that ‘it will never happen to me’; (2) the fatalistic belief that ‘accidents happen’ and there is nothing that can be done to prevent them; and (3) the moralistic desire to find fault which often leads to ‘blaming the victim’—concluding that other people who are injured ‘got what they deserved’. In psychology, these tendencies might be explained by various distinct but overlapping biases,17 including Self-Serving Bias,18 Optimism Bias,19 Just World Hypothesis,20 Defensive Attribution Bias21 and Fundamental Attribution Error.22 These psychological biases tend to enhance individual self-esteem and defend individuals from concern that they may be at risk for, or the cause of, problems such as injury.

Assume that a mishap occurs to another person. The Self-Serving Bias attributes my own personal success to personal factors. Thus the fact that I was not injured reflects well on me, and shows my good sense and behaviour. The Optimism Bias is a self-serving bias that leads to the (incorrect) belief that I am at lower risk of injury than others (‘it will never happen to me’), making it less likely that I will take adequate safety precautions.

The Just-World hypothesis assumes that outcomes are guided by some universal force for justice, so the victim of the mishap must have done something wrong and got what was coming to her (‘blame the victim’). Similarly, the Defensive Attribution Bias tends to attribute responsibility to the victim, particularly if the victim was different than myself or was in a situation I am unlikely to be in.

Finally, the Fundamental Attribution Error (or actor-observer bias) is a tendency to overvalue personality explanations for the problems of others, while undervaluing situational explanations. Therefore the injury to this other person was probably due to her bad or clumsy behaviour rather than to the environmental circumstances (‘blame the victim’), This also means that there was not much that anyone else, or society, could have done to make her safer (fatalism). Embedded in a number of these biases is the notion that even if the mishap was not her fault, accidents happen, there is little that could have been done, so do not blame me (or the society in which I am a part).

Injury control practitioners should expect to encounter these beliefs and biases, which lead to unsafe behaviour, and must be prepared effectively to counter them. It needs continually to be emphasised that our goal is injury prevention, not fault-finding, and we are trying to determine and implement the most cost-effective measures to make the world a safer place.

Geoffrey Rose (1992)23 popularised a central concept of prevention—that many public health problems (eg, bike injury) arise from small but widespread risks. Moderate, achievable changes in the population as a whole (eg, helmet use) can substantially reduce the overall risk. Rather than focusing prevention efforts solely on the highest risk individuals, a population-based strategy, such as changing normative behaviour and the environment for everyone, is often the best way to reduce the total injury burden.

Key points

  • There are many reasons people oppose safety improvements.

  • Three common beliefs are impediments to injury prevention.

  • Such beliefs need to be recognised and addressed.

Sexual assualts in the US military

The US Pentagon estimates that 26 000 people in the armed forces were sexually assaulted last year. That is an increase from 19 000 in 2010. Ironically, the survey results came out two days after the officer in charge of the Air Force's sexual assault prevention programmes was arrested and charged with sexual battery. In a separate finding, the military said it received 3374 sexual assault reports last year, suggesting that many victims fail to report these crimes for fear of retribution (The New York Times).

Highway deaths due to speeding

Following a recent holiday weekend in Canada, there was the usual increase in highways deaths. This is partly because more cars are on the road, but also because of speeding. For example, over the three days, in one region, of 5039 tickets issued, 3843 were for speeding. This included 67 tickets to drivers going at least 50 km over the speed limit. A 15-year-old unlicensed driver was travelling at 187 km an hour, and a motorcycle was travelling at 181 km an hour.

Acknowledgments

Deb Azrael and Matt Miller provided helpful comments.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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