Research core

Our research core focuses on three primary objectives: (1) to describe injury epidemiology in Connecticut; (2) to design, implement and evaluate innovative interventions for reducing injury and (3) to effectively translate research-supported prevention and intervention frameworks into practical community-based programmes and policies.

Surveillance is an essential element of injury prevention, allowing for an understanding of the frequency, distribution and geographical patterns of injuries. To evaluate and monitor injury epidemiology in Connecticut, we developed the Connecticut Injury Surveillance System. We began this system with local paediatric emergency department (PED) and discharge data, and then expanded to include statewide hospital data. However, we found that we could not fully answer our injury prevention questions with hospital data alone, so other datasets were sought out. In so doing, we developed collaborative relationships with key partners, including the Connecticut Department of Transportation, the medical examiner's office and the Department of Public Health. The current system now incorporates several large computerised Connecticut databases: (1) death certificates, (2) inpatient hospital discharges, (3) emergency department visits and (4) motor vehicle crashes (MVCs). These data include all ages and all sites throughout the state.

The CIPC was also an early adopter of geographical information systems (GIS), which allow us to spatially analyse and map fatal and non-fatal injuries at the county, town, census tract, census block or street address-level. Our GIS framework also enables us to integrate and correlate injury data with other geographical, census and economic data. The ability to geocode by incident location is one limitation that varies by dataset. And while most demographic health data incorporates residential information, we have identified data sources that have enabled us to geocode for incident location, including our study of drowning deaths,2 pedestrian injuries3 and house fires.4

In addition to academic papers, our injury surveillance information is disseminated broadly using newsletters, fact sheets, social media and internet web pages. Connecticut injury epidemiology determines our core research and programming areas. We have used our surveillance system to describe childhood injury patterns both in the city of Hartford and across Connecticut.5–8 Additionally, our surveillance system has driven studies of motorcycle injury,9 ,10 bicycle injury,11 firearm injury,12 ,13 child victims of homicide,14 work-related injury in adolescents,15 burn injury,16 injury reporting in newspapers,17 domestic violence screening in healthcare settings,18 safe transport for children with special needs,19 bullying among special needs students,20 violent death and safety device coding on police accident report forms,21 ,22 injury epidemiology among admitted trauma patients,23 ,24 all-terrain vehicle injuries25 ,26 and knee injury prevention among high school coaches.27

Intervention studies that evolved from our surveillance work include the impact of a pedestrian safety intervention at school bus stops,28 the impact of a safety programme to reduce lacerations among supermarket workers,29 the effect of concrete barriers to reduce urban crime,30 the impact of a violence prevention programme in elementary schools31 and the impact of a home safety outreach programme.32

In collaboration with the Injury Prevention Center at Rhode Island Hospital, we were one of seven paediatric trauma centres to collaborate on screening and brief intervention for alcohol use among paediatric trauma patients, while simultaneously monitoring for change in institutional policy, implementation and sustainability. As a result of this successful approach, our trauma programme manager monitors implementation of the validated alcohol screening instrument, CRAFFT, for all admitted adolescents at our Level One Trauma Center. She also follows up on any positive screens with a referral to our social work department for further assessment, brief intervention and referral to treatment. Monthly reports are reviewed by the Trauma Center Director to ensure compliance with this American College of Surgeons’ mandated alcohol screening activity for Level One Trauma Centers.

The CIPC has developed a collaborative relationship with the PED at Connecticut Children's Medical Center to facilitate research and programmes focused on identified injury trends. The PED has experienced a dramatic increase in mental health patients over the past 10 years. In 2014, CIPC examined suicidal behaviour among mental health patients in the PED and assessed the use of lethal means restriction (LMR) counselling by hospital staff. LMR counselling is an evidence-based suicide prevention strategy that informs families to restrict access to potentially fatal items and has demonstrated efficacy in preventing suicide. About 34% of the patients studied had suicidal ideation, 22% had a suicide plan, 32% had documented suicidal behaviour and 25% reported having access to lethal means.33 However, only 4% of the total patient population received any LMR counselling, and only 15% of those with access to lethal means had received LMR counselling. The PED is a key point of entry into services for suicidal youth and presents an opportunity to implement effective secondary prevention strategies. The low rate of LMR counselling found in this study suggested a need for improved LMR counselling for all at-risk youth. As a result, in a current project, we are working to identify the most effective way to provide LMR counselling in the busy PED setting.

In response to our study (and many others) demonstrating inadequate screening and identification of intimate partner violence (IPV) from among our patient population at Hartford Hospital,18 ,23 we are currently conducting a research study among admitted adult trauma patients. This project is designed to improve identification and screening of IPV by employing a dual-method screening and decision-making system. Data from this study will be used to create a probabilistic algorithm that uses existing patient record information to flag patients at high risk for IPV. This study uses tablet-based technology to provide patients with brief educational modules to increase knowledge of health costs and community resources related to IPV. It is our hope that this project will provide the healthcare field with new technology capable of improving identification of IPV within the patient population.

Education and training core

Another venue for describing, discussing and disseminating our surveillance system involves engagement of students via our Education and Training Core. Since 1992, we have worked with the University of Connecticut and other local colleges, universities and high schools to offer injury prevention education and research experiences to students. The CIPC provides structured injury prevention training for University of Connecticut paediatric, emergency medicine and surgery residents and fellows through a community longitudinal elective that spans the entire length of their training programme. In addition, regular injury prevention surveillance data and topics are highlighted in a weekly paediatric resident case management conference. Our 1996 study highlighted injury prevention deficiencies and opportunities for physicians in training.34

Since 1991, a full course, ‘Injury and Violence Prevention’ has been offered in the University of Connecticut Master of Public Health (MPH) curriculum. MPH thesis, research and mentored community practicum projects are provided by CIPC faculty. Student research projects have resulted in peer-reviewed publications focused on topics including firearm injury,35 ,36 all-terrain vehicle crash-related injuries,25 ,26 novice teen drivers37–40 and child safety seats.41 ,42

Community outreach programmes

CIPC community programmes and outreach are guided by our injury surveillance system. These activities are community-based, data-driven and led by community coalitions consisting of membership from trauma centres, community and state agencies and local government. In 1993, we established Safe Kids Connecticut, which has over 300 member organisations and 500 individuals from across the state and is organised into six local chapters and one county coalition. In 2001, we became an Injury Free Coalition for Kids site. Many of our surveillance and outreach activities have been supported by state agency grants (including the Departments of Public Health, Transportation, Children and Families) and foundation grants (including the Robert Wood Johnson Foundation, Allstate Foundation, Kohl's Cares and Safe Kids).

The CIPC has developed an array of outreach activities centred on child passenger and teen driver safety. We provide child passenger safety technician training, recertification activities and child passenger safety check events. We also distribute free child safety seats to low-income families through hospital and community referrals. There are now 25 certified child passenger safety instructors and 387 certified child passenger safety technicians in the state. We have developed educational modules to promote teen driver safety and have distributed these materials to paediatricians and family physicians.43 ,44 We have also organised conferences to promote teen passenger safety and developed an evaluation of the mandatory teen driver curriculum for all newly licensed drivers and their parents.

Much of our community outreach activities include engaging key stakeholders in training events. In 2014, the CIPC collaborated with the Connecticut Coalition against Domestic Violence to develop and host a conference highlighting the most recent evidence and challenges for law enforcement officers in responding to family violence calls involving children, with a focus on reducing psychological trauma for children at the scene. The conference was led by individuals with expertise in law enforcement, domestic violence, criminal justice, medicine, public health, psychology, social work and anthropology. The target audience included local police officers and child protective services workers and provided training on the consequences of exposure to violence, specific strategies for how to respond to and protect children at the scene and information about regional resources. The law enforcement representatives appreciated concrete information on consequences of exposure to violence as well as the specific examples provided through vignettes on how to handle particular situations of child-impacted family violence. The CIPC conducted follow-up interviews and focus groups and ultimately made recommendations to Connecticut's Model Policy Governing Council for Law Enforcement's Response to Family Violence.

Public policy

The CIPC addresses major causes of injury through data-driven advocacy and outreach in our efforts to change and improve injury-related public policy. We have successfully improved our state's policies on bicycle helmets, child passenger safety, graduated driver's licensing and safety belt legislation.1 ,38 In the early 1990s, we described the frequency, severity and costs of bicycle injury in the state. In 1993, our advocacy resulted in the passage of a safety law mandating helmet usage for children less than 12 years.11 In 1997, the law was upgraded, mandating helmet use for children less than 16 years of age. In 1994, our extensive advocacy efforts resulted in the passage of improved child passenger safety laws, with further refinements in 1996, and another upgrade in the booster seat law in 2005.

MVCs are the leading cause of death for teens. In the 1990s, the CIPC began a concerted effort to study this problem and support legislation to improve the graduated driver licensing (GDL) system in the state. GDL system phases in driving privileges for novice teen drivers over a 12–18 month period and control high-risk driving situations such as night driving and driving with teen passengers. In 1996, three CIPC staff members were recognised for their work leading to the passage of the learners permit law for teen drivers and were named as Traffic Safety Leaders by the National Advocates for Highway Safety. In 1997, our advocacy resulted in the passage of the Connecticut Learner's Permit Law and the addition of passenger and night restrictions in 2004 and 2005.

In 2010, we studied the impact of the Connecticut GDL system on MVC rates over the 10-year period from 1999 to 2008.37 Using our surveillance system, we examined police reported MVC data, with and without injury, excluding MVCs on local roads where no injuries occurred (ie, property damage only). We determined the average number of registered drivers within the age groups of 16, 17, 18, 19, 20–24, 25–29 and 30–59 and calculated the percentage change in MVC rates according to age, gender and year over the 10-year study period (table 1). The specificity of our surveillance system allowed us to also calculate the percentage change in MVC rates during the GDL-restricted night hours (23:00–05:00), as well as the percentage change in MVC rates with at least one passenger. Our analyses of these data provided evidence of the effectiveness of the GDL system in reducing MVC rates among young, novice drivers in Connecticut. MVC rates fell 40% among 16-year-olds and 30% among 17-year-olds. MVC rates for young drivers with passengers fell even more, where we saw a 65% decrease among 16-year-olds and a 53% decrease among 17-year-olds. In comparison, MVC rates among older drivers fell 29% for 18-year-olds, 23% for 19-year-olds, 8% for those aged 20–24 years, 21% for those aged 25–29 years and 17% for those aged 30–59 years. While these statistics reflect the national trend of declining crash rates, the substantial decrease among those aged 16–17 years provides robust support for GDL policies.

In 2008, we continued our advocacy efforts to support the GDL system by providing evidence of positive public opinion of GDL policies.45 This led to the passage of significant improvements in the GDL system in 2009, including stronger passenger and night restrictions, increased requirements for parent-supervised driving, a 2-h mandatory parent class and increased sanctions for GDL violations. More recently, CIPC staff analysed MVC data, helped organise a broad-based traffic safety coalition and testified at public hearings to promote adoption of a full GDL system for Connecticut's teen drivers. The reports provided by the CIPC were integral in GDL policy development and passage, which has led to a clear reduction in MVCs among our youngest drivers.

The CIPC also continues to engage in advocacy activities focused on children who are impacted by IPV. In July of 2015, the Connecticut legislature established a task force to study the statewide response to family violence and its impact on children. The director of the CIPC, Garry Lapidus, was appointed as co-chair of the task force, which will examine existing policies and procedures used by the Department of Children and Families, the Department of Mental Health and Addiction Services, healthcare professionals, law enforcement, guardian's ad litem, attorneys for minor children and the Judicial Branch. The goals of this task force are to better understand the impact of family violence on children, to articulate the current system response to this problem and to develop recommendations to address family violence throughout the state. The task force will submit a report on its findings and recommendations in January 2016 to the joint standing committees relating to human services and children.

The CIPC has demonstrated success in additional injury prevention topics such as home safety,32 ,46 firearm injury, playground safety (building safe playgrounds and sports fields) and concussion prevention. In the early 1990s, we described severe firearm injury in our state and in 1993 our advocacy resulted in passage of an assault weapon law that prohibited the sale of selected firearms with large capacity ammunition magazines that are designed for short quick-firing without the need for skilled marksmanship.12 We also organised and evaluated several local gun buy-back events in the city of Hartford. And while our research supports prior work demonstrating that gun buy-backs alone are unlikely to cause changes in homicide and suicide rates, this highlights the importance of our advocacy efforts to impact legislative changes.35 ,47

Establishing collaborative relationships across institutions has been essential to build our surveillance system and use this system to affect policy. We have worked closely with the Department of Transportation, the Department of Children and Families, state and local police as well as other stakeholders, enabling access to the databases we use to continuously build and strengthen our surveillance system. These relationships have facilitated our ability to emerge as a leader in injury prevention advocacy. We continue to reinforce these relationships by serving on important state committees guiding policy, frequently disseminating injury prevention surveillance data and prevention messages through internet, radio and television spots, hosting press conferences, providing media interviews and offering technical advice for injury prevention-related legislation.

Looking ahead

Throughout the 25-year history of the CIPC, collaboration and data sharing in conjunction with surveillance has led to important policy and legislative changes and helped to make Connecticut safer. As we move into the next quarter century, we will continue our efforts to bring together important stakeholders and their datasets, and will use new technologies to analyse and disseminate this information. The CIPC is collaborating with the Connecticut Coalition against Domestic Violence and the Connecticut Department of Children and Families to reduce trauma and costs for families impacted by IPV. This collaboration will bring the opportunity to collect and consolidate data around families impacted by IPV, services accessed within the shelter system and how the needs of those families are being addressed. Items to be included in this data representation and visualisation project, which will supplement the Connecticut Injury Surveillance System, include intake and assessment data from all 18 local domestic violence centres throughout the state and all data collected from the Connecticut police officers’ lethality assessment project (available in over half of the police departments in Connecticut, used to screen and refer victims of IPV). Data visualisation presents a new and important opportunity for understanding and connecting data. Working with the Department of Education at Trinity College, the CIPC provided an internship to a Trinity College senior who created a data visualisation presentation of information collected from the Connecticut Children’s Medical Center paediatric trauma database (see http://commons.trincoll.edu/dataviz/2014/04/19/ipc-pediatric-injury-trends-2007-2012/). In the future, projects will draw from our new collaborative databases and include interactive maps that will represent and visualise multiple aspects of the impact of IPV on victims and their families including injuries by type, risk, frequency and other meaningful categories.

In summary, the foundation of our 25 years of work has been a robust statewide fatal and non-fatal injury surveillance system that has guided our research, education and training, community programmes, outreach and policy advocacy core activities. This work has been effective in reducing injuries and deaths in Connecticut. We believe that the application of our surveillance system can serve as a model for others who wish to engage in collaborative, community-based, data-driven injury prevention programmes in their own communities.