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Equity as the fourth ‘E’ in the ‘3 E’s’ approach to injury prevention
  1. Audrey Giles1,
  2. Michelle E E Bauer2,
  3. Janet Jull3
  1. 1 School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
  2. 2 School of Population Health, University of Ottawa, Ottawa, Ontario, Canada
  3. 3 School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
  1. Correspondence to Dr Audrey Giles, School of Human Kinetics, University of Ottawa, Ottawa, ON K1N 6N, Canada; agiles{at}


The education, engineering and enforcement (3 E’s) approach to injury prevention is grounded in assumptions that it is effective for everyone; however, evidence demonstrates that it fails to consider opportunities for all populations to experience safe and injury-free lives. In this way, the 3 E’s approach does not support health equity in the injury prevention field. In this brief report, we argue that a fourth E, equity, must also be used with the 3 E’s approach to injury prevention.

  • Injury prevention
  • Equity
  • Health disparities
  • Education
  • Engineering
  • Enforcement

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In March 2019, the world’s attention was drawn to a piece of personal protective equipment—a spacesuit. At issue was the lack of appropriately sized spacesuits at the International Space Station, leading to the cancellation of the planned, first-ever all-female spacewalk. As a result, a male astronaut, who had access to a properly sized spacesuit, took the place of one of the women. The incident is useful for demonstrating the ways that inequities in injury prevention are present—even in the high-profile world of space travel in which every detail is checked and rechecked by teams of engineers and technicians. It also demonstrates the impacts of equity issues for those affected directly, and more broadly, for society. Further, it encourages us to revisit injury prevention frameworks for their capacity to consider factors that underpin the occurrence of inequities in injury prevention.

The 3 E’s injury prevention framework

One well-known injury prevention framework is referred to as the education, engineering and enforcement (‘3 E’s’) approach to injury prevention. The 3 E acronym refers to education (ie, knowledge and skill translation), engineering (ie, built and non-built environments and materials) and enforcement (ie, adherence to safety protocols through policies and governing laws).1 The 3 E’s approach is believed to have been coined in 1923 by the director of the Kansas City Safety Council, Julien H Harvey, in his discussion on road traffic safety.1 Critiques of the 3 E’s approach have included calls to expand the acronym to include additional ‘E’s’ such as exposure, examination, emergency response and evaluation,1 as well as advocating for a more nuanced framework that considers human behaviour.2 While these critiques identify to the need to consider human behaviours in the expansion and revision of the 3 E’s injury prevention framework, they do not consider factors that relate to equity. The 3 E’s approach to injury prevention is grounded in the assumption that it is an effective framework for everyone; however, despite the framework’s general success,1 injury continues to be disproportionately experienced by some people.3 Without equity as an integral feature of the 3 E’s approach, people will be at risk of experiencing avoidable and unfair risks for serious injuries.3 In this brief report, we call for the addition of a foundational and underpinning fourth ‘E’, equity, to the 3 E’s approach.

Using equity to reduce disproportionate injury experiences

Equity advocates within the field of population health are concerned with understanding and addressing unfair differences in health for populations of people. Differences in health within or between populations are labelled health ‘inequities’ when they are considered unfair4; that is, when they are potentially avoidable.5 Despite years of using the 3 E’s approach, inequities in injury persist between many populations and are considered ‘one of the causes of mortality with the steepest social gradient’.6 According to Parachute Canada (n.d.), social determinants of injury such as income, employment and work conditions, social environments and social exclusion, education and literacy, housing, rural and urban environments, and gender, all influence the likelihood and severity of injury experience. For example, people who are situated in a society in which general populations have access to adequate protective equipment yet themselves face a lack of accessibility to personal protective equipment because of income, are more prone to experience injuries and are considered to be affected by inequity.6 In general, populations who have low socioeconomic status are more likely to experience fatal and serious injuries.6 To promote health equity in injury prevention, it is necessary to consider the social determinants of health.

One organising framework for the social determinants of health is ‘PROGRESS-Plus’, which enables the examination of the relationships within and between the multiple, interacting and socially structured characteristics that may influence the opportunities for health of individuals and populations: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status and social capital.7 The degree to which PROGRESS-Plus characteristics are associated with health inequity depends on time, place and interaction between the different dimensions.8 These characteristics are important to understand how to influence opportunities for injury prevention and health equity.

To promote the consideration of health equity in injury prevention research, the PROGRESS-Plus characteristics should be used in the 3 E’s approach. The consideration of social determinants of health would help injury prevention advocates and researchers to determine if the creation, delivery or results of using the 3 E’s approach differ across populations. The result of failing to account for the social determinants of health in injury prevention means that people will continue to be at risk for injury in their daily lives—risk that is potentially avoidable with equity as an integral feature of the framework.

Revising the 3 E’s approach

As we have argued above, the 3 E’s approach does not include considerations of factors that influence equity. We suggest that the failure to include the consideration of equity limits the ability of the 3 E’s approach to be used by researchers and to meet the needs of populations who may be at risk of experiencing injury. Equity ought to be added as the fourth E in a revised ‘3 E’s’ approach to injury prevention framework (figure 1).

Figure 1

Equity as the fourth ‘E’ to strengthen the ‘3 E’s).’ approach to injury prevention (adapted from Stone and Pearson)9

Injury prevention researchers and practitioners have a responsibility to ensure that injury prevention frameworks meet the needs of the entirety of the population. They also have an obligation to address the inequitable burdens of injury within and between populations, and should contribute to achieving health equity in their work. For this reason, and as strong advocates for achieving health equity, we propose that ‘equity’ be added as the fourth E in the 3 E’s injury prevention framework.

What is already known on this subject

  • Injury continues to be one of the leading causes of hospitalisations and death. The burden of injury is disproportionately experienced by the members of some populations.

What this study adds

  • Including equity in the education, engineering and enforcement (3 E’s) approach would better enable consideration of those disproportionately affected by injury.

  • Adopting an equity lens can strengthen the 3 E’s approach.



  • Contributors All three authors made substantial contributions to the conceptualisation of the work, drafted the work and approved the final version for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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