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Original article
‘Do As We Say, Not as We Do:’ a cross-sectional survey of injuries in injury prevention professionals
  1. Allison Ezzat1,
  2. Mariana Brussoni2,
  3. Amy Schneeberg1,
  4. Sarah J Jones3
  1. 1School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
  2. 2Department of Pediatrics School of Population and Public Health Child & Family Research Institute BC Injury Research & Prevention Unit University of British Columbia, Canada
  3. 3Department of Primary Care and Public Health, Cardiff University/Public Health Wales, Temple of Peace and Health, Cardiff, Wales, UK
  1. Correspondence to Dr. Mariana Brussoni, BC Injury Research & Prevention Unit, F511, 4480 Oak Street, Vancouver, BC Canada V6H 3V4; mbrussoni{at}cw.bc.ca

Abstract

Background As the leading cause of death and among the top causes of hospitalisation in Canadians aged 1–44 years, injury is a major public health concern. Little is known about whether knowledge, training and understanding of the underlying causes and mechanisms of injury would help with one's own prevention efforts. Based on the Theory of Planned Behaviour, we hypothesised that injury prevention professionals would experience fewer injuries than the general population.

Methods An online cross-sectional survey was distributed to Canadian injury prevention practitioners, researchers and policy makers to collect information on medically attended injuries. Relative risk of injury in the past 12 months was calculated by comparing the survey data with injury incidence reported by a comparable subgroup of adults from the (Canadian Community Health Survey (CCHS)) from 2009 to 2010.

Results We had 408 injury prevention professionals complete the survey: 344 (84.5%) women and 63 (15.5%) men. In the previous 12 months, 86 individuals reported experiencing at least one medically attended injury (21 235 people per 100 000 people); with sports being the most common mechanism (41, 33.6%). Fully 84.8% individuals from our sample believed that working in the field had made them more careful. After accounting for age distribution, education level and employment status, injury prevention professionals were 1.69 (95% CI 1.41 to 2.03) times more likely to be injured in the past year.

Interpretation Despite their convictions of increasing their own safety behaviour and that of others, injury prevention professionals’ knowledge and training did not help them prevent their own injuries.

https://doi.org/10.1136/injuryprev-2013-040913

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    Introduction

    Injury is a significant health concern and a major burden upon health services in Canada. It is the leading cause of death in Canadians between 1 and 44 years old1 and is also among the top causes of hospitalisation.2 As a substantial cause of premature mortality and disability, injury is the second leading cause of potential years of life lost before age 70.3 The total cost of injuries in Canada in 2004 was $19.8 billion dollars, which includes $10.72 billion of direct healthcare costs and $9.06 billion in indirect costs.4 This represents a substantial economic cost that most experts would argue is unnecessary with the majority of injuries considered both predictable and preventable.5–7 Despite the significant burden, there has been a tradition of neglect of injury as a public health issue.4

    Evidence indicates that risk factors such as living and working conditions are key determinants in population health, including injuries.8 ,9 Less research has investigated the role of protective factors. We hypothesised that the training and knowledge of injury prevention professionals would reduce their incidence of injuries. Our hypothesis is supported by many studies indicating that a deficit in knowledge was a major barrier to injury prevention action.10–12 Furthermore, the Theory of Planned Behaviour (TPB)—a well-supported theory in predicting injury prevention action13 indicates the importance of three different kinds of beliefs in influencing behaviour: behavioural beliefs, normative beliefs and control beliefs (figure 1). TPB states that the underlying volition for a person to engage in a certain action relates directly to their beliefs or attitudes about the importance and outcome of the behaviour, as well as their beliefs about peer attitudes in the social acceptability of this behaviour. Also the individual's perceived behavioural control or ease of performing the behaviour is said to play a key role. Accordingly, a behaviour is most likely to occur if one has a strong intention to perform it, possesses the skills and abilities required to perform it and there are no environmental barriers or other constraints.14 Applying TPB to injury prevention professionals, there is a high likelihood that they should perform injury prevention behaviours. They are well versed in safety and injury prevention actions, would likely value these behaviours in their own attitudes and see them reflected as a social norm among colleagues. Furthermore, their extensive expertise should give them a sense of control over their own injuries. Injury prevention professionals appear to be well positioned to resist injury in the context of the TPB. Therefore, the objective of this study was to test our hypothesis that individuals working in injury prevention would have lower injury rates than a comparable subgroup of Canadian adults.

    Figure 1
    Figure 1

    An integrative Model of Behaviour Change; modified from fishbein and Cappella.

    Methods

    A cross-sectional survey was developed to assess the experience of medically attended injuries in the Canadian injury prevention community. It aimed to collect information about injuries suffered by these professionals during the previous year.

    Sample

    Purposeful convenience sampling was used to identify the study population. Information about the study and a link to the survey was distributed via email lists of national and provincial organisations such as the Canadian Injury Action Forum, British Columbia Injury Research and Prevention Unit and Alberta Centre for Injury Control and Research; to conference attendees at the British Columbia Injury Prevention Conference; in the ‘news and notes’ section of the journal Injury Prevention; and among email contacts in the personal network of one investigator (MB). In addition, recipients were encouraged to forward the study information on to their networks. Individuals who had not sustained medically treated injuries were encouraged to participate to ensure a more complete sense of injury experiences among injury prevention professionals. Excluded from the study were people not on the mailing lists used to circulate details of the survey, those who lacked access to the internet to complete the survey and also those with insufficient English language skills to read and respond to the survey. The survey was available for completion between 1 May and 31 October 2012. Consent was implied by participation in the survey. The Children's and Women's Health Centre of British Columbia Research Ethics Board approved study procedures.

    Survey

    Study data were collected and managed using Research Electronic Data Capture (REDCap) hosted at the Child and Family Research Institute.15 REDCap is a secure, web-based application designed to support data capture for research studies. This internet-based self-report survey asked only for basic demographic information: age band and gender in order to maintain anonymity of participants. Information on numbers of medically treated injuries in the past year was sought with further questions for each injury regarding the anatomical site of the injury (eg, lower leg, shoulder, face), the type of injury suffered (eg, fracture, laceration, sprain) and a brief description of how the injury happened (eg, fell off a rope swing). Additional questions were included pertaining to the use of safety equipment (if applicable) and if the participant believed that this injury was preventable. Lastly, participants were also asked if they believed that working in this field had changed their safety-related behaviour.

    Data analysis

    Descriptive statistics including gender, age category and number of years working in the field were reported as frequencies (percentage) and means ± SD as appropriate. Circumstances of injury were reviewed and categorised into six groups: sport, fall, household, motor vehicle collision, workplace and unclassified. The cumulative incidence of injuries in injury prevention professionals was calculated by: the number of professionals with at least one injury in the past 12 months divided by the entire population at risk, which consisted of all survey respondent that provided a valid answer (yes or no) to “Have you been injured in the past 12 months”.

    The relative risk (RR) of injury in injury prevention professionals in the past 12 months was calculated by comparing the current data with data on injury incidence in three subgroups of Canadian adults from the 2009–2010 cycle of the Canadian Community Health Survey (CCHS).16 The CCHS is a voluntary cross-sectional survey conducted by Statistics Canada that collects information regarding health status, healthcare utilisation and health determinants for Canadians via in person or telephone, computer-assisted interviewing. The target population includes all Canadians 12 years of age or older living in the 10 provinces and three territories. Excluded from the survey are individuals on reserves, full-time members of the Canadian Forces, the institutionalised population and those living in specific remote areas. Complex multistage sampling is employed to identify households that are contacted. Weighting estimates are calculated by Statistics Canada to account for the uneven probability of being selected to take part in the survey, allowing results to be interpreted as a nationally representative sample.

    Three distinct groups were constructed from the CCHS population for the purpose of comparison with respondents to the current survey sample of injury prevention professionals. Recognising the distribution of age, education and employment status in injury prevention professionals is not reflective of the entire CCHS population; the first comparison group (group 1) was restricted to adults aged 20–75 years, with a minimum of undergraduate degree, who indicated they were currently working either full-time or part-time at the time of the survey. For comparison group two, the analysis was further restricted to include only women to address the gender imbalance in the injury prevention professionals survey population. For the final comparison group, only women who were defined as ‘active’ in the CCHS based on daily energy expenditure in leisure activities of at least 3 (kcal/kg/day) were included. This subgroup was created after discussion among authors and colleagues regarding the possibility that those who work in injury prevention may engage in greater levels of physical activity than the population norm, thereby increasing their exposure to the risk of sporting injuries.

    The injury status of individuals in the CCHS was determined using a single question from the survey: “Not counting repetitive strain injuries, in the past 12 months, were you injured?” Respondents could answer ‘yes’, ‘no’, ‘don't know’ or refuse to answer. Respondents who refused to answer or responded, “I don't know” to this question were excluded from analysis. In calculating the risk of injury in the three CCHS comparison groups, frequency weights provided by Statistics Canada were used. All CCHS data in this paper are presented with unadjusted sample sizes and weighted percentages. Analyses were completed using SAS software V.9.3.17

    Results

    Characteristics of injury prevention professionals are shown in table 1. Most participants were women and ages ranged from between 20 to over 70 years old with varying levels of experience working in the injury prevention field. Practitioners were the most common subgroup of injury prevention professionals; however, many individuals remained unclassified.

    View this table:
    Table 1

    Participant characteristics (n=408) and comparison groups

    Between the subgroups, researchers had the highest proportion of injuries with 28.6% of individuals sustaining at least one injury, whereas injuries occurred in 23.2% of unclassified individuals, 19.7% of practitioners and only 1.0% of policy makers. Unclassified participants had the greatest number of people who reported two or more injuries in the past year. Sport participation (33.6%), falls (18.9%) and household-related (4.9%) were the most common circumstances of injury (table 2). Despite the fact that safety equipment was thought not to be applicable in most cases, 75.6% of injuries were believed to have been preventable. Fully 85.5% of participants believed that working in this field had changed the way they behave in terms of safety and 84.8% stated that they were more careful since becoming an injury prevention professional.

    View this table:
    Table 2

    Injury details

    Eighty-six of 405 injury prevention professionals (n=3; non-responders) reported 122 medically attended injuries in the past 12 months, translating to 21 235 people per 100 000 people (table 2). The three distinct subgroups from the CCHS are shown in table 1. Compared with Canadians of similar age, educational background and employment status (Group 1), injury prevention professionals were found to be at 1.69 (95% CI 1.41 to 2.03) times increased risk of injury. Further restricting the comparison group to only women (Group 2), due to the high proportion of women respondents in the injury prevention professional sample, resulted in an increase in the RR (RR=2.00 (95% CI 1.67 to 2.41)). Lastly, further restricting the comparison with active women (Group 3) resulted in a lower, yet still significant, level of increased risk for injury prevention professionals (RR=1.51 (95% CI 1.26 to 1.82)).

    Discussion

    Despite their advanced knowledge in the field, this study showed that injury prevention professionals who responded to the survey were at greater risk of injury compared with analogous subgroups of Canadian adults. Sports and falls were the most common mechanisms. Researchers had the highest proportion of injuries within the profession. Paradoxically, the large majority of participants believed they behaved more carefully since working in this field. These findings are contrary to our hypothesis and do not support predictions based on the TPB. Despite high general knowledge in the area of injury prevention, a sense of self-efficacy in preventing injuries and avowal that working in the field had made them more careful, these beliefs did not appear to translate into action. Perhaps other elements of the TPB have not been adequately captured and are interfering with the ability of injury prevention professionals to avoid injury.

    Potentially, the training that injury prevention professionals receive is too broad to be effective in the manner hypothesised. For example, the evidence on the effectiveness of general educational programmes for injury prevention has been mixed. A Cochrane review examining safety education of pedestrians for injury prevention found that while these programmes succeed in improving the knowledge level of pedestrians, it remains unclear if this results in less injury occurrence.18 Educational campaigns that are broad, fail to target a specific group or contain a large number of messages have been found to be largely ineffective.19 The generalised educational training of the injury prevention professionals may fit this description and might not be enough to influence their injury behaviours in a positive way. Arguably, this training might lead to ‘risk compensation’ with injury prevention professionals placing unwarranted faith in their ability to prevent their own injuries and as a result engaging in more risky behaviours than the general population.20

    Alternatively, injury prevention professionals may be better apt at recalling their injuries for a survey than the general public due to their familiarity with the subject area and this would serve to explain the apparent increase in injury incidence in this group. Conversely, injury prevention professionals may be less likely to disclose their injuries in a survey due to their links to the profession. This parallels a previous work examining physicians’ illness behaviour, which has suggested that they may have trouble accepting their own sickness and that they avoid taking sick leave.21 From this perspective, the true gap in injury rates may actually be larger than we have estimated from this study.

    Using the CCHS, we constructed subgroups of Canadians thought to be most analogous to individuals working in injury prevention. Group 1 was restricted to Canadians of similar age distribution, employment status and educational level, as it is expected that injury prevention professionals have at minimum an undergraduate postsecondary education. This restriction is conservative in that injury prevention professionals are still expected to have a higher-than-average socioeconomic status than the CCHS subgroup, which previous research has shown, should bias them towards less injuries.22 ,23 Women made up over three-quarters of respondents to the injury prevention professionals survey, and although our own experience suggests that there appear to be more women in the field of injury prevention than men, this likely only accounts for part of the gender imbalance. Men are more likely to be injured than women;2 however, previous work has found that women are more likely to seek healthcare utilisation than men for more minor injuries.24 To account for this imbalance, group 2 was restricted to include only women respondents in the CCHS. This resulted in a further increased RR for injury prevention professionals compared with the first analysis. (Injury prevention professionals vs group 1: RR=1.69 (95% CI 1.41 to 2.03); injury prevention professionals versus group 2: RR=2.00 (95%CI 1.67 to 2.41)). Due to the small numbers of men who responded to the injury prevention survey, a stratified analysis by sex was not feasible. The final comparison group from the CCHS included only those classified as ‘active’ based on their participation in leisure activities. It was hypothesised by the authors post hoc that perhaps the increased risk of injury for injury prevention professionals may be due to higher-than-average levels of engagement in sport and exercise. It has been found that the risk of sustaining an activity-related injury increases with greater duration of physical activity per week and higher cardiorespiratory fitness levels.25 Unfortunately, data on physical activity participation were not collected as part of the survey. Therefore, by assuming injury prevention professionals had high activity levels and comparing them with an active subgroup, this conservative approach biased the analysis towards the null. Interestingly, even with this assumption, when comparing injury prevention professionals with active Canadians, they still appear to be at increased risk of injury (RR=1.51 (95% CI 1.26 to 1.82)).

    The CCHS estimated that 4.27 million Canadians 12 years of age and older experienced an injury severe enough to limit their usual activities in 2009–2010.16 Sports, falls and workplace injuries were the leading causes of injury in working age adults, which is comparable with the primary mechanisms found in our survey. Based on descriptions in both the surveys, the majority of injuries sustained by injury prevention professionals and Canadian adults overall, did not require hospitalization; however, these milder injuries are not without consequences.

    Internationally, minor injuries have been shown to be a significant part of the injury-related health burden. In the recent epidemiological study in the Netherlands, such minor injuries accounted for 37.3% of the total burden of injury as measured by disability-adjusted life-year.24–26 In another prospective study from Australia, minor non-life threatening injuries accounted for 80% of morbidity arising over the first 6 months after an injury and 75% of the estimated lifetime morbidity.27 These two studies provide strong rationale for the improved recognition and quantification of minor injuries as an important priority in public health in Canada.

    There were some limitations to this study. First, in order to reach a broad breadth of injury prevention professionals and maintain anonymity, the survey was distributed via list serves. Consequently, we were unable to track the number of recipients, and therefore, to calculate a response rate. Second, the nature of a voluntary survey is subject to selection bias. Participants who experienced a greater number of injuries might be more interested in answering questions about them, which could bias results towards a higher injury rate, if people without injuries failed to partake. Third, the time period for the CCHS was 2009–2010 and the injury prevention professionals reported their injuries for 2011–2012. We believe injury rates are stable enough that this minor difference is likely irrelevant. Finally, the definitions of injury varied slightly between the CCHS and our survey in that CCHS did not specify that the injury had to be medically attended. This would bias our RR for injury prevention professionals towards the null and therefore make the increased risk for this group a conservative estimate. Despite these limitations, this study is unique and valuable as it succeeds in capturing an estimate of the full continuum of injury rates in a specific subgroup of the population.

    In conclusion, when comparing injury risk among those employed in injury prevention to risk found among an analogous subgroup of Canadian adults, this profession appears to be at elevated risk. Their considerable training, knowledge and expertise in this subject area did not have a protective effect. In light of this, one strategy to decrease the injury burden in Canada could be to deliberately reduce the number of injury prevention professionals. Alternatively, we would suggest that the further appreciations of the underlying aetiologies of risk in this group might allow the development of improved interventions for use in the general public. Further investigation of the reasons for their apparent increased susceptibility to injury is warranted, particularly to avoid compromising their credibility with the general public as experts in preventing injuries.

    What is already known on this subject

    • Injury is a major economic and social burden despite the fact that many of them are thought to be predictable and preventable.

    • The Theory of Planned Behaviour provides a model that predicts injury prevention action based on the importance of behavioural, normative and control beliefs.

    What this study adds

    • Injury prevention professionals experience an increased risk of injury compared with a demographically similar population.

    • The extensive knowledge, training and expertise of injury prevention professionals does not reduce their risk of injuries and might put them at increased risk.

    • Investigating subgroups of the population at increased risk of injury may provide valuable insight into the underlying mechanisms behind injuries.

    Acknowledgments

    Career support for Mariana Brussoni is provided by a Michael Smith Foundation for Health Research (MSFHR) scholar award and a British Columbia Child and Family Research Institute salary award. Allison Ezzat is supported by the Canadian Child Health Clinician Scientist Program.

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    Footnotes

    • Contributors All authors contributed to the manuscript. AE took part in the study design, data analysis and interpretation, and drafted and revised the article. MB contributed to the conception and design of the study, acquisition of the data and article revision. AS was involved in the analysis and interpretation of data, and article revision. SJJ contributed to the conception and design of the study, and revising the article. All authors gave final approval for publication.

    • Competing interests None.

    • Ethics approval Children’s and Women’s Health Centre of British Columbia Research Ethics Board.

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

    • Data sharing statement We have additional data on reported lifetime injuries for our sample. Interested researchers should contact the corresponding author for details.