Chapter 22
Behavioral Interventions for Injury and Violence Prevention*
David A. Sleet and Andrea Carlson Gielen
22.1. INTRODUCTION
Behavioral science has made a wide range of contributions to developing and sustaining public health. Behavioral, psychosocial and sociocultural factors associ- ated with lifestyle behaviors are major contributors to morbidity and mortality.
Efforts to control behaviors contributing to obesity, heart disease, diabetes, cancer, and HIV have successfully used behavioral and sociocultural strategies to reduce risks and improve the prospects for prevention (Green, 1999; Holtgrave, Doll, Harrison, 1997). Injury control can benefit from this legacy. It has only been recently that researchers and practitioners have recognized the value of using behavioral approaches for injury prevention and control (Gielen & Girasek, 2001;
Gielen & Sleet, 2003).
Whether by violent or unintentional means, injury exacts a large toll on indi- viduals, families, workplaces, and the community. Yet behaviors that give rise to injury and violence are amenable to preventive interventions. Experts in the behav- ioral and social sciences can help by documenting behavioral and social risk factors, developing and evaluating interventions, influencing social norms, assisting in postinjury recovery from psychological harm, and shaping individual and commu- nity preventive behaviors (Sleet, Hammond, Jones, Thomas, & Whitt, 2004).
However, the models, theories, and behavior change strategies so successful in addressing other public health problems have been sorely underrepresented in the injury literature (Trifilitti, Gielen, Sleet, & Hopkins, 2005). This chapter highlights the significance of taking a behavioral approach to the growing problem of injuries in public health and demonstrates how behavioral science strategies can contribute to solutions. As examples, we address the role of behavior change in injury preven- tion and provide further examples of applying behavioral and social-psychological
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*Portions of this chapter were excerpted with permission from Oxford University Press from Gielen, A. C., and Sleet, D. (2003). Application of behavior-change theories and methods to injury prevention, Epidemiologic Review, 25, 65–76.
theory and methods to injury prevention. Other chapters in this book address sociological theories and discuss social science applications (see Chapter 15).
22.2. BEHAVIORAL SCIENCE AND INJURY PREVENTION
It is rarely feasible to achieve injury reduction without some element of behavior change. Behavioral change is integral to any comprehensive approach to injury prevention. We define behavioral interventions as the development and application of behavioral science theory, knowledge, strategies, and techniques to the understand- ing and modification of injury risk behaviors and harms. Behavioral science applica- tions have lagged behind other approaches to injury prevention, despite repeated calls for more behavioral science research in injury prevention (Bonnie, Fulco, &
Liverman, 1999; National Committee on Injury Prevention and Control, 1989).
Historically, little scholarly attention has been paid to understanding determinants of injury-related behaviors or how to initiate and sustain injury behavior changes.
In the past, interventions to change injury behaviors were often based on simplistic assumptions that changing individuals’ awareness about an injury problem would lead to changes in behavior. We know the process is more complex than this and that behavior change strategies cannot rely on information and education alone.
Yet many practitioners in public health still approach behavioral change with this assumption in mind.
Many authors have noted the need to improve behavioral interventions by using better empirical data about behavioral determinants and by employing modern health behavior change theories and frameworks (Runyan, 1993; Thomps on, Sleet,
& Sacks, 2002; Geller et al., 1990). A growing body of work is emerging that dem- onstrates the positive effect of using behavioral science approaches to understand and reduce injury risk behaviors (Gielen, Sleet, & DiClemente, 2006; Sleet &
Hopkins, 2004).
22.3. THE NEED FOR BEHAVIORAL CHANGE
Although the rationale for using structural or environmental interventions to change injury patterns might seem straightforward, there is rarely an environmen- tal change that does not require behavioral adaptation. For every technological advance, there are behavioral components that need to be addressed. Children need to wear helmets while bicycling; parents need to correctly install child safety seats and booster seats; home owners need to check their smoke alarms and change the batteries; parents with four-sided fences around their backyard pool need to ensure that the gate to the pool is always closed; occupants alerted by a smoke alarm still need to find their way to safety. Even the more passive approach to poison pre- vention through the use of child-resistant closures—one of the great successes in injury control—requires active individual effort in replacing lids correctly (DiLillo, Peterson, & Farmer, 2002; Shields, 1997).
Integrating knowledge about behavioral science into the mainstream of injury prevention research and practice will help avoid the false dichotomy between active and passive strategies and reduce the tendency to choose one over the other. In Haddon’s (1980) epidemiological approach to injury, the host’s role in injury reflects only personal risk at the level of the individual. Much of the research on injury behavior change has been on individuals whose behavior puts them at risk, such as the drinking driver (Geller, Elder, Hovell, & Sleet, 1991) or the child pedes-
trian (Cross, Hall, & Howat, 2003). However, because so many of the effective injury countermeasures are policy oriented in nature, practitioners may find behavioral change strategies useful for modifying injury prevention policy at the community level (Gielen, 1992; Gielen & Girasek, 2001; Runyan, 1998). Finding effective ways to activate individuals to become advocates for safer products, policies, and environ- ments represents a new opportunity for behavioral change to contribute to injury prevention (DeFrancesco et al., 2003).
Safer products and environments require behavior change, too, on the part of manufacturers (such as toy makers) and environmental designers (such as city planners) as well as policy makers who regulate exposure to hazards and those who mandate and enforce safety behaviors (such as legislators, judges, and police) (McGinnis, Williams-Russo, & Knickman, 2002; Shaw & Ogolla, 2006). Cataldo et al. (1986, p. 233) emphasised this point when they said “Ultimately, injury control must entail some degree of behavior change, requiring the establishment and main- tenance of appropriate safety behavior—by parents, legislators, judges and juries, police, health educators, physicians, reporters and the like.”
In the following sections, we discuss theories and examples that can help facilitate the change process among individuals at risk as well as among those in a position to influence policy and environmental change.
22.4. THEORIES FROM BEHAVIORAL SCIENCE
In the last few years there has been growing national interest in the contributions of theoretical models from the behavioral sciences to public health (Glanz, Rimer,
& Lewis, 2002; Rutter & Quine, 2002). The limited success of behavioral change efforts in modifying injury related behaviors, however, can be traced, in part, to failure to apply these theories to develop and implement effective injury prevention interventions (Liller & Sleet, 2004). Theories are important not simply because they help us understand causes of problems but because they also allow us to identify mechanisms of change, determine why programs succeed or fail, and perhaps most important guide us to build better prevention programs (DiClemente, Crosby,
& Kegler, 2002). Selecting the most appropriate theory is situation specific and depends on the specific audience, the setting, and the characteristics of the behav- ior to be changed (Rimer & Glanz, 2005).
22.4.1. Ecological Models
What has emerged recently in public health is the importance of taking an ecologi- cal perspective for understanding and intervening on contemporary public health problems such as injury (Allegrante, Marks, & Hanson, 2006). The report Promoting Health (Smedley & Syme, 2000, pp. 9, 2) summarized it this way:
Perhaps the most significant contribution of behavioral and social sciences to health research is the development of strong theoretical models for interventions.
The committee . . . found an emerging consensus that research and intervention efforts should be based on an ecological model.
The ecological model states that health and well-being are affected by a dynamic interaction among biology, behavior, and the environment and this interac- tion changes over the life course (Committee on Health and Behavior, 2001;
Schneiderman, Speers, Silva, Tomes, & Gentry, 2001). This definition conveys the
notion of multiple levels of influence on health and makes clear the importance of both individual level and community level factors in shaping health-related behav- iors. Reductions in motor-vehicle-related deaths and homicide are examples of improving population health through interventions at multiple levels of influence (see Chapters 4, 15, 16, and 17). Legislative policies, educational programs, and changes in the physical and social environment all contribute to changes in injury and injury risks. Thus an ecological model has utility in both describing influencing factors and developing prevention programs (Green, Richard, & Potvin, 1996).
22.4.2. Influencing Change
In translating an ecological model to action programs, Rimer & Glanz (2005) describe three levels of influence for change. (1) Intrapersonal change refers to influencing an individual’s knowledge, attitudes, or beliefs about his or her behavior. Theories of cognition, perception, and motivation are relevant here. (2) Interpersonal change refers to the influence of significant others such as families, friends, and co-workers. Relevant here is the modifying effect of social influence and social norms on individual behavior. (3) Community-level change includes the influence of organizational settings (such as workplaces, schools, and religious institutions such as churches, synagoges, and mosques, and their influence on behavior. On a larger societal level, there are the influences of social and health policies (e.g., those related to welfare reform) and other influences such as poverty and disenfranchisement that affect injury risk behaviors.
Examples of models applied to the community level are community mobiliza- tion, organizational change, and intersectoral action. Theories and models can help explain community and individual change processes in an ecological context.
For example, simple changes in community zoning and urban planning can dra- matically affect injury-related behaviors, ranging from less youth violence and crime to more cycling and walking. Community-level change strategies are described in other chapters this book.
Different intervention strategies and methods are available when working with individuals and with communities (Bartholomew, Parcel, Kok, & Gottlieb, 2001;
Bensley & Brookins-Fisher, 2003). For example, at the individual level, the typical intervention strategies include a variety of behavioral, educational, counseling, skills-development, and training methods. Innovative new technologies such as computer-tailored messaging and behavioral prescriptions, Web-based learning, and motivational interviewing are promising approaches to strengthen the effect of individual level injury prevention interventions (Dunn, DeRoo, & Rivara, 2001;
Kreuter, Jacobsen, McDonald, & Gielen, 2003). When interventions focus on orga- nizations, communities, and policies, the use of social marketing, mass media, and media advocacy are important (Wallack, Dorfman, Jernigan, & Themba, 1993) as are coalition building, social planning, and community development (Bracht, Kingbury, & Rissel, 1999).
22.5. APPLICATION OF HEALTH BEHAVIOR THEORY TO INJURY PREVENTION
A complete enumeration of the theories used in the field of health behavior change is beyond the scope of this chapter, although interested readers are referred to relevant textbooks (DiClemente et al., 2002; Rimer & Glanz, 2005) and reports
(Committee on Health and Behavior, 2001; Smedley & Syme, 2000). Behav- ioral change theories, methods, and applications in injury prevention have been described by Gielen et al. (2006). Here, we describe several examples of well- respected behavior change theories or models that have been applied to injury problems.
22.5.1. Individual Level Theories and Models
The Health Belief Model (HBM), Theory of Reasoned Action (TRA), Stages of Change (SOC), and applied behavioral analysis (ABA) have extensive literature supporting their utility. Each has been used for understanding injury problem.
In this section, we briefly describe the key constructs of each of these models and provide an example of their application to an injury problem.
22.5.1.1. Health Belief Model
The Health Belief Model says that preventive behaviors are a function of individu- als’ beliefs about their susceptibility to the health problem in question, the severity of the health problem, and the benefits versus costs of adopting the preventive behavior, as well as experiencing a cue to action ( Janz & Becker, 1984). In recent years, the concept of self-efficacy was added to the model. Self-efficacy, a concept originally from Bandura’s (1989) work, refers to one’s confidence in his or her ability to perform a specific behavior. An illustration of this model in injury pre- vention comes from Peterson, Farmer, & Kashani’s (1990) study of the beliefs and safety practices of 198 parents of 8- to 17-year-old children. They used the HBM to predict how parents’ attitudes might influence their injury prevention teaching and environmental modifications. Parents were generally not very worried about injuries to their child (i.e., low perceived susceptibility). The HBM constructs most strongly associated with parental safety efforts were beliefs that their actions would be effective (benefits), a realistic appraisal of the costs of action (costs), and feeling knowledgeable and competent to perform the behaviors (efficacy). In this case, the authors suggest that practitioners use interventions influencing parents’
beliefs about their child’s susceptibility to injury through education, while increas- ing parents’ competency to intervene through specific behavior change strategies.
Health education methods and strategies might include direct communications to address susceptibility and skills training and improved access to safety products to address competence.
22.5.1.2. Theory of Reasoned Action
The Theory of Reasoned Action model describes behavior as a function of behav- ioral intention, subjective norms, and attitudes (Fishbein & Ajzen, 1975). The model focuses on the individual’s intention to perform a behavior as predictive of their actual behavior. Intention is a function of attitudes and subjective norms.
Ajzen (1991) later modified the TRA, renaming it the Theory of Planned Behavior, to include the concept of perceived behavioral control, which reflects how easy or difficult the individual perceives the behavior.
In practical use, the TRA was used as the conceptual framework for a survey of parents’ beliefs and practices regarding car safety seat usage (Gielen, Eriksen, Daltroy, & Rost, 1984). Attitude toward car seat use was found to be the single
best variable for distinguishing between car seat users and nonusers. This variable consisted of responses to six items measuring beliefs about the consequences of the behavior (e.g., using a car seat would be a hassle; your child would be better behaved in a car seat). Respondents who believed that their spouse would approve of using a car seat (a measure of subjective norm) were also more likely to report using one. These results can help practitioners develop public and patient education materials using salient messages with credible spokespersons.
For example, media messages might communicate the ease with which car seat use becomes a habit with positive consequences, such as child comfort and spouse approval.
22.5.1.3. Stages of Change
The Stages of Change (SOC) model is also called the Transtheoretical Model because it incorporates constructs from several older models (Prochaska &
DiClemente, 1983). This model conceptualizes behavior change as a dynamic rather than static process, acknowledging that individuals differ in their readiness to change a behavior, and changes occur in discrete steps over time. There are typically five stages in the SOC model: (1) precontemplative, not thinking about changing; (2) contemplative, aware and thinking about changing; (3) preparation, taking steps necessary for changing; (4) action, making the change for a short period of time; and (5) maintenance, having successfully changed the behavior, usually measured as 6 months or longer. This model includes the possibility of relapse to earlier stages, noting that maintained behavior change often occurs after a cyclical process of progressing and relapsing, as in smoking control. The SOC model has been used to describe men’s ability to change their abusive behaviors (Daniels & Murphy, 1997) and to describe abused women’s safety behaviors and their ability to end their abuse (Burke, Gielen, McDonnell, O’Campo, & Maman, 2001). In Burke et al.’s (2001) study of women’s descriptions of how they coped with and ended their abuse, there were clear examples of women moving from precontemplation (e.g., not considering their partner’s behavior toward them as a problem or not labeling their experiences as abuse), to action (e.g., recognizing the abuse as a problem and taking some protective action, such as calling a shelter, contacting legal assistance, moving out), to maintenance (e.g., having experienced no abuse or having been away from the partner for 6 months or more). Identify- ing an individual’s stage of change allows the practitioner to select and apply the most appropriate, stage-matched intervention. For example, increasing knowledge and awareness may help someone progress from the precontemplation to the contemplation stage. To move someone from contemplation to preparation and action may require identifying, providing, and facilitating access to and use of the necessary resources.
22.5.1.4. Applied Behavior Analysis
The term applied behavior analysis (ABA) is a specific subfield within psychology that uses the technology of behavior modification and operant conditioning to facilitate change. Behavior is viewed as learned, and principles of stimulus control, feedback, reinforcement, and punishment shape the acquisition, maintenance, and extinction of behavior (Hovell, Elder, Blanchard, & Sallis, 1986). Applied behavior analysis or behavioral safety addresses the ABCs of behavior by manipulating the
antecedents, behaviors, and consequences associated with behavior. Antecedents occur before the behavior (such as cues in the environment), behaviors include the context in which the behavior occurs, and consequences are those things that follow the behavior.
Understanding the ABCs that control a behavior can help the practitioner intervene by shaping the behavior and the environment to bring about change.
Forbidding roadside billboards that remind drivers of drinking, increasing prompts and cues in the drinking environment that discourage drinking and driving, and selecting a designated driver are all ways that might modify the antecedents of drinking and driving. Slowing the rate of alcohol consumption, learning drinking or binge drinking refusal skills, promoting server interventions in the drinking environment, and providing feedback from blood alcohol consumption meters might be used to modify the drinking behavior. Social and peer support for not drinking and driving, positive feedback, incentives or rewards from bartenders or friends, and punishment for being caught for drinking and driving can be used to modify consequences (Geller et al., 1991; Girasek, Gielen, & Smith, 2002; Sleet &
Lonero, 2002).
In traffic safety, applications of applied behavior analysis have effectively increased the use of safety belts (Streff & Geller, 1986) and child restraints (Cataldo et al., 1986; Sleet, Hollenbach, & Hovell, 1986), reduced vehicle speeding (Ragnars- son & Bjorgvinsson, 1991), and improved bicycle helmet use (Thompson, Sleet, &
Sacks, 2002). In other areas of injury prevention, applied behavior analysis has been used to reduce children’s fall-related behavior on playgrounds (Heck, Collins, &
Peterson, 2001) and to change safety behaviors in a fire in public buildings (Leslie, 2001).
This approach also has a strong history of use and success in promoting occupational health and safety (Margolis & Kroes, 1975) and has been successfully applied to increase the use of personal protection devices such as hard hats and ear protection, to reduce injuries on the job, and to increase worker productivity and morale (Krause, Hidley, & Hodson, 1990).
22.5.1.5. Integrating Individual Level Models
In 1991, the National Institute of Mental Health convened a theorists’ workshop to bring together creators of behavioral theory to develop a unifying framework to facilitate health behavior change (Fishbein et al., 1991). Their discussions led to an enumeration of five theories that, taken together, contain virtually all the variables that have been used in attempts to understand and change human behaviors: The Health Belief Model, Social Cognitive Theory, Theory of Reasoned Action, Theory of Self-Regulation and Self-Control, (Kanfer & Kanfer, 1991), and Theory of Sub- jective Culture and Interpersonal Relations (Triandis, 1980). Considering all five theories and their many variables, eight variables appear to account for most of the variations in health-related behaviors: intentions, environmental barriers, skills, outcome expectancies (or attitudes), social norms, self-standards, emotional reac- tions, and self-efficacy. It is likely that these same eight variables might also regulate and predict change in injury risk behavior (M. Fishbein, personal communication, January 23, 2003).
Translating this guidance to action, Fishbein et al. (2001) concluded that, generally speaking, for a person to perform a given behavior, one or more of the following must be present:
• The person forms a strong positive intention or makes a commitment to perform the behavior.
• There are no environmental barriers that make it impossible to perform the behavior.
• The person possesses the skills necessary to perform the behavior.
• The person believes that the advantages of performing the behavior out- weigh the disadvantages.
• The person perceives more normative pressure to perform than not to perform the behavior.
• The person perceives that performance of the behavior is consistent with his or her self-image or values.
• The person’s emotional reaction to performing the behavior is more posi- tive than negative.
• The person perceives that he or she has the capabilities to perform the behavior under different circumstances.
The first three factors are viewed as necessary and sufficient for producing any behavior, and the remaining five are viewed as modifying variables, influencing the strength and direction of intentions. By way of a hypothetical example, we can apply these notions to the injury control behavior of testing the functionality of a residential smoke alarms. If a homeowner is committed to testing the smoke alarms every month, has access to the alarms in the home, and has the skills necessary to successfully test the alarms, we would predict that there is a high probability he or she will perform the behavior. The probability that the individual will test the smoke alarms monthly would be predicted to increase even more if the homeowner also believes that testing is worth the time and trouble, knows that neighbors all test their alarms, believes that testing is consistent with his or her values as a responsible homeowner, has no negative emotional reaction to testing, and can test the alarms under different conditions in the home. According to this notion, the probability of testing monthly would be predicted to reach nearly 100% under these condi- tions. In practice, this integrated model has not been applied to this or any other injury related behavior but holds promise as an innovative approach to program development, at least until such time as sufficient research is available on specific theories as they related to injury and violence prevention.
22.5.2. Community Level Theories and Models
Community-based injury prevention occurs when people and organizations col- laborate as communities to design and implement strategies to keep citizens safe (Coggan & Bennett, 2004). A community can be defined either geographically or on the basis of common interests. Community organization and mobilization and community-based participatory research focus on the active participation and development of the community to enable members to better evaluate and solve their own health and social problems (Minkler & Wallerstein, 1997).
Gielen and Collins (1993) and McLoughlin, Vince, Lee, & Crawford (1982) described the difference between community-wide interventions and community- based programs, highlighting the importance of treating the community as the source and not simply the site of prevention programs. Green & Kreuter (1991), p.
261 described the necessary components of community interventions this way:
Given reasonable resources, the chances are that a community inter- vention will succeed if the practitioner (1) builds from a base of com-
munity ownership of the problems and the solution, (2) plans carefully, (3) uses sound theory, meaningful data and local experience as a basis for problem decisions, (4) knows what types of interventions work best for specific populations and circumstances, and (5) has an organiza- tional and advocacy plan to orchestrate multiple intervention strategies into a complementary cohesive program.
Among the more successful applications of community level theories and models in injury prevention is the safe community movement, initiated in Sweden in the 1980s (Svanstrom, 1999). The program combining top-down with bottom-up strategies was developed in eight steps: (1) epidemiological mapping, (2) selection of risk groups and hazardous environments, (3) forming coalitions or interdis- ciplinary workgroups, (4) joint action planning with many sectors involved, (5) implementation, (6) evaluation, (7) program modification from feedback, and (8) transfer of program success to others. In the United States, the safe community model has been applied mostly to the traffic safety sector; it was officially adopted by the National Highway Traffic Safety Administration (NHTSA) as a part of its support to the Governor’s Offices of Highway Safety Programs in many parts of the country.
Sweden, Norway, Australia, New Zealand, Canada and many other countries have implemented a number of injury prevention projects based on the safe com- munity model (Coggan & Bennett, 2004; Moller, 1995) In each project, the com- munity, which ranged from large suburban areas to small country towns, was involved in developing a series of injury prevention strategies. Multidisciplinary lay- professional coalitions were formed to develop and implement the strategies.
In the United States, Hingson et al. (1996) describe a community-based program to reduce drinking and driving in which intervention cities reduced fatal crashes by 25% and fatal crashes involving alcohol by 42%, relative to the rest of the state of Massachusetts during the 5 years of the program and in comparison to the previous 5 years without the program. This community level approach is attracting much interest among injury prevention practitioners worldwide and efforts are under way to evaluate its impact (Spinks, Turner, McClure, Acton, &
Nixon, 2005).
22.5.2.1. Community Action
Community action for injury prevention benefits from community organization and mobilization, defined as efforts to involve community members in activities ranging from defining needs for prevention to obtaining community support for a predesigned prevention program. Mobilization emphasizes changing the social and economic structures that influence injury risk. Treno and Holder (1997) note that mobilization can include elements of both grassroots efforts and leader- initiated strategies. In the former, the community members define the problems and decide the solutions, and in the latter outside experts (external or self-appointed community leaders) decide. Because community leaders understand their local culture, politics, and traditions better than outsiders, their participation is essential for tailoring prevention programs to local needs.
In the Community Trials Project to reduce alcohol-involved trauma (Treno &
Holder, 1997), a community-research partnership was formed to focus on changes in the social and structural contexts of alcohol use. They worked to implement prevention policies and activities that were evidence based and asked communities to customize and prioritize their initiatives based on local concerns and interests.
Specific components of the mobilization effort were directed toward responsible beverage service, drinking and driving, underage drinking, and alcohol access.
Coalitions, task forces, and media advocacy were used to raise awareness and support for effective policies with the public and decision makers. An evaluation of the effect of the mobilization efforts demonstrated significant reductions in the fol- lowing indicators: 6% in the reported quantity of alcohol consumed, 51% in driving over the legal alcohol limit, 10% in nighttime injury crashes, 6% in alcohol related crashes, and 43% in alcohol-related assault injuries seen in emergency departments (Holder et al., 2000).
22.5.2.2. Community-Based Participatory Research
Community-based participatory research (CBPR) is a collaborative approach to research that equitably involves all partners in the research process and recog- nizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities (Green & Mercer, 2001; Minkler & Wallerstein, 2003). It contains elements of both community organization and mobilization. While participatory research is increas- ingly being advocated for dealing with a multitude of public health problems, it is perhaps especially important for problems that relate to individual behavior. To implement and evaluate policies and programs that attempt to change personal behavior requires extreme sensitivity to the ethical issues surrounding the protec- tion of individual autonomy. By engaging communities in needs assessment and decision making about program design and evaluation, for example, the strategies that result are more likely to be consistent with the core values of the community and society (see Chapter 27).
For practitioners, these theories at both the individual and the community levels should help clarify assumptions on which interventions are selected; when used in conjunction with thorough needs assessments these theories should con- tribute to building successful injury prevention programs.
22.6. CONCLUSIONS
The use of behavioral theories and methods has been critical to progress in improv- ing public health and injury prevention. Behavioral interventions can complement structural approaches and environmental change efforts and can facilitate the work of law makers and product designers in ways that can ultimately protect whole populations.
This brief review of behavioral approaches should enable practitioners and researchers in injury and violence prevention to more easily identify potentially useful strategies for many injury problems. Researchers and policy makers have highlighted the need for more effective educational approaches and behav- ioral change applications to injury control (Gielen et al., 2006; Grossman &
Johnston, 2004; Zaza & Thompson, 2001; Sleet & Hopkins, 2004), and some scho- larly journals have dedicated whole issues to this topic (Gielen, 2002; Liller and Sleet, 2004; Ludwig, Geller, & Mawhinney, 2000; Schwartz, 2003; Sleet & Bryn, 2003).
Because of the wide range of types of injury, preventive behaviors, and various target groups and community characteristics, there remains a great need for addi- tional research using behavioral theories and models. More attention must also be paid to the issues of training researchers and practitioners in the application of relevant theories. Training more behavioral scientists in the epidemiology of injury and the science of injury control is an urgent first step. Likewise, enhancing the behavioral science training of injury practitioners and researchers is essential.
Theoretical research is needed to clarify the mechanisms by which change occurs across levels of ecological models. Applied research can help us understand and modify risk perceptions, social norms, and other psychosocial factors associ- ated with behavior and improve behavior change programs (Buckley & Sheehan, 2004). Developmental research is needed to reduce child and adolescent injuries.
Community level research is necessary to understand mechanisms for influencing large populations through behavioral and environmental strategies. Evidence from a single study can provide useful information for practitioners about what variables to target and, in some cases, about program efficacy—but only a preponderance of research conducted for each injury preventive behavior and in many popula- tion groups can provide the kind of evidence needed to develop best practices.
Ultimately, what is needed is substantial research on both the determinants of behavior and the efficacy of program approaches so that recommendations can be made to practitioners about the most important strategies (Sleet, Trifilitti, Simons- Morton, & Gielen, 2006). We believe these are important steps for strengthening the application of behavioral science to injury control, which in turn can contribute to changing individual behaviors, environmental conditions, and social structures in ways that prevent injuries.
REFERENCES
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior & Human Decision Processes, 50, 179–211.
Allegrante, J. P., Marks, R., & Hanson, D. (2006). Ecological approaches to unintentional injury preven- tion. In A. Gielen, D. A. Sleet, & R. A. DiClemente (Eds.), Injury and violence prevention: Behavioral science theories, methods and applications. San Francisco: Jossey-Bass.
Bandura, A. (1989). Perceived self-efficacy in the exercise of personal agency. Psychological Bulletin of British Psychological Society, 10, 411–424.
Bartholomew, L. K., Parcel, G. S., Kok, G., & Gottlieb, N. H. (2001). Intervention mapping book. Mountain View, CA: Mayfield.
Bensley, R. J., & Brookins-Fisher, J. (2003). Community health education methods: A practical guide (2nd ed.).
Boston: Jones and Bartlett.
Bonnie, R. J., Fulco, C. E., & Liverman, C. T. (Eds.). (1999). Reducing the burden of injury: Advancing prevention & treatment. Washington, DC: National Academy Press.
Bracht, N., Kingsbury, L., & Rissel, C. (1999). A Five-stage community organization model for health promotion, empowerment and partnership strategies. In N. Bracht, (Ed.), Health promotion at the community level (2nd ed.) (pp. 83–104). Thousand Oaks, CA: Sage Publications.
Buckley, L., & Sheehan, M. (2004). Behavior change programs. In R. McClure, M. Stevenson, &
S. McEvoy (Eds.), The scientific basis of injury prevention and control. (pp. 334–346). Melbourne, Australia: ISA Press.
Burke, J. G., Gielen, A. C., McDonnell, K. A., O’Campo, P., & Maman, S. (2001). The process of ending abuse in intimate relationships: A qualitative exploration of the transtheoretical model. Violence against Women, 7 (10), 1144–1163.
Cataldo, M. F., Dershewitz, R. A., Wilson, M., Christophersen, E. R., Finney, J. W., Fawcett, W. S. B., &
Seekins, T. (1986). Childhood injury control. In N. A. Krasnegor, J. D. Arasteh, & M. F. Cataldo (Eds.), Child health behavior: A behavioral pediatrics perspective. (p. 233). New York: Wiley.
Coggan, C., & Bennett, S. (2004). Community-based injury prevention programs. In R. McClure, M.
Stevenson, & S. McEvoy (Eds.), The scientific basis of injury prevention and control (pp. 347–358).
Melbourne, Australia: ISA Press.
Committee on Health and Behavior. (2001). Health & behavior: The interplay of biological, behavioral and societal influences. Washington, DC: National Academy Press.
Cross, D., Hall, M., & Howat, P. (2003). Using theory to guide practice in children’s pedestrian safety education. American Journal of Health Education (Supplement), 34 (5), S42–S47.
Daniels, J. W., & Murphy, C. M. (1997). Stages of processes of change in batterers’ treatment. Cognitive
& Behavioral Practice, 4, 123–145.
DiClemente, R. J., Crosby, R. A., & Kegler, M. C. (Eds.). (2002). Emerging theories in health promotion practice and research. San Francisco: Jossey-Bass.
DeFrancesco, S., Gielen A. C., Bishai, D., Mahoney, P., Ho, S., & Guyer, B. (2003). Parents as advocates for child pedestrian injury prevention: What do they believe about the efficacy of prevention strategies and about how to create change? American Journal of Health Education (Supplement), 34 (5), S48–S53.
DiLillo, D., Peterson, L., & Farmer, J. (2002). Injury and poisoning. In T. J. Boll, S. B. Johnson, N. W.
Perry, R. H. Rozensky (Eds.), Handbook of clinical health psychology. Vol 1, Medical disorders and behav- ioral applications (pp. 555–582). Washington, DC: American Psychological Association.
Dunn, C., DeRoo, L., & Rivara, F. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction, 96, 1725–1742.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, & behavior: An introduction to theory and research.
Reading, MA: Addison-Wesley.
Fishbein, M., Bandura, A., Triandis, H. C., Kanfer, F. H., Becker, M. H., & Middlestadt, S. E. (1991).
Factors influencing behavior and behavior change. Final Report—theorists workshop. Washington, DC:
National Institute of Mental Health.
Fishbein, M., Triandis, H. C., Kanfer, F. H., Becker, M., Middlestadt, S. E., & Eichler, A. (2001). Factors influencing behavior and behavior change. In A. Baum, T. A. Revenson, & J. E. Singer (Eds.), Handbook of health psychology (pp. 3–17). Mahwah, NJ: Erlbaum.
Geller, E. S., Berry, T., Ludwig, T. D., Evans, R. E., Gilmore, M. R., & Clarke, S. W. (1990). A conceptual framework for developing and evaluating behavior change interventions for injury control. Health Education Research, 5 (2), 125–137.
Geller, E. S., Elder, J. P., Hovell, M. F., & Sleet, D. A. (1991). Behavior change approaches to deterring alcohol-impaired driving. Advances in Health Education & Promotion, 3, 45–68.
Gielen, A. C. (1992). Health education and injury control: Integrating approaches. Health Education Quarterly, 19, 203–218.
Gielen, A. C. (Ed.). (2002). Injury and domestic violence prevention [Special issue]. Patient Education and Counseling, 46 (3), 161–232.
Gielen, A. C., & Collins, B. (1993). Community-based interventions for injury prevention. Family &
Community Health, 15, 1–11.
Gielen, A. C., Eriksen, M. P., Daltroy, L. H., & Rost, K. (1984). Factors associated with the use of child restraint devices. Health Education Quarterly, 11 (2), 195–206.
Gielen, A. C., & Girasek, D. C. (2001). Integrating perspectives on the prevention of unintentional injuries. In N. Schneiderman, M. A. Speers, J. M. Silva, H. Tomes, & J. H. Gentry (Eds.), Integrating behavioral and social sciences with public health (pp. 203–230). Washington, DC: American Psychologi- cal Association.
Gielen, A. C., & Sleet, D. A. (2003). Application of behavior-change theories and methods to injury prevention. Epidemiologic Reviews, 25, 65–76.
Gielen, A. C., Sleet, D. A., & DiClemente, R. (2006). Injury and violence prevention: Behavioral science theories, methods and applications. San Francisco: Jossey-Bass.
Girasek, D. C., Gielen, A. C., & Smith, G. S. (2002). Alcohol’s contribution to fatal injuries: A report on public perceptions. Annals of Emergency Medicine, 39, 622–652.
Glanz, K., Rimer, B., & Lewis, F. (Eds.) (2002). Health behavior and health education: Theory, research and practice (3rd ed.). San Francisco: Jossey-Bass.
Green, L. W. (1999). Health education’s contribution to public health in the twentieth century: A glimpse through health promotion’s rear-view mirror. Annual Review of Public Health, 20, 67–88.
Green, L. W., & Kreuter, M. W. (1991). Health promotion planning: An educational and environmental approach (2nd ed.) (p. 261). Mountain View: CA: Mayfield.
Green, L. W., & Mercer, S. L. (2001). Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Community-based participatory research.
American Journal of Public Health, 91 (12), 1926–1943.
Green, L. W., Richard, L., & Potvin, L. (1996). Ecological foundation of health promotion. American Journal of Health Promotion, 10 (4), 270–281.
Grossman, D., & Johnston, B. (Eds.) (2004). Behavioral approaches to injury control. Participant’s notebook and workshop materials. Seattle: Harborview Injury Prevention and Research Center. Retrieved March 10, 2006, from www.hiprc.gov.
Haddon, W. (1980). Advance in the epidemiology of injuries as a basis for public policy. Public Health Reports, 95, 411–421.
Hingson, R., McGovern, T., Howland, J., Heeren, T., Winter, M., & Zakocs, R. (1996). Reducing alcohol- impaired driving in Massachusetts: The Saving Lives Program. American Journal of Public Health, 86, 791–797.
Heck, A., Collins, J., & Peterson, L. (2001). Decreasing children’s risk taking on the playground. Journal of Applied Behavior Analysis, 34, 349–352.
Holder, H. D., Gruenewald, P. J., Ponicki, W. R., Treno, A. J., Grube, J. W., Saltz, R. F., Voas, R. B., Reynolds, R., Davis, J., Sanchez, L., Gaumont, G., & Roeper, P. (2000). Effect of community-based interventions on high-risk drinking and alcohol related injuries, Journal of American Medical Associa- tion, 284 (18), 2341–2347.
Holtgrave, D. R., Doll, L. S., & Harrison, J. (1997). Influence of behavioral and social science on public health policy making. American Psychologist, 52, 154–166.
Hovell, M. F., Elder, J. P., Blanchard, J., & Sallis, J. F. (1986). Behavior analysis and public health perspectives: Combining paradigms to effect prevention. Education & Treatment of Children, 9 (4), 287–306.
Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education, 11, 1–47.
Kanfer, R., & Kanfer, F. H. (1991). Goals and self-regulation: Applications of theory to work settings.
In M. L. Machr, & P. R. Pintrich (Eds.), Advances in motivation & achievement (pp. 287–326, vol. 7).
Greenwich, CT: JAI Press.
Krause, T. R., Hidley, J. H., & Hodson, S. J. (1990). The behavior-based safety process, New York: Van Nostrand Reinhold.
Kreuter, M. W., Jacobsen, H. A., McDonald, E. M., & Gielen, A. C. (2003). Developing computerised tailored health messages in community health education methods: A practical guide (2nd ed.). Boston: Jones and Bartlett.
Leslie, J. (2001). Behavioral safety: Extending the principles of applied behavioral analysis to safety in fires in public buildings. In Proceedings of the 2nd international symposium on Human Behavior in fire. MIT, Cambridge, MA. Interscience Communications, Ltd., pp. 1–10.
Liller, K. D., & Sleet, D. A. (Eds.). (2004). Injury prevention [Special issue]. American Journal of Health Education, 28 (Supplement 1), S1–S72.
Ludwig, T. D., Geller, E. S., & Mawhinney, T. C. (2000). Intervening to improve the safety of occupa- tional driving: A behavior-change model and review of empirical evidence. Journal of Organizational Behavior Management, 19 (4), 1–124.
Margolis, B. L., & Kroes, W. H. (Eds.). (1975). The human side of accident prevention: Psychological concepts and principles which bear on industrial safety. Springfield, IL: Charles C. Thomas.
McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion, Health Affairs, 21, 78–93.
McLoughlin, E., Vince, C., Lee, A., & Crawford, J. (1982). Project burn prevention: Outcome and implications. American Journal of Public Health, 72, 241–247.
Minkler, M., & Wallerstein, N. (1997). Improving health through community organization and com- munity building. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education:
Theory, research, and practice (pp. 241–269, 2nd ed.). San Francisco: Jossey-Bass.
Minkler, M., & Wallerstein, N. (2003). Community-based participatory research for health. San Francisco:
Jossey-Bass.
Moller, J. (1995). An Introduction to community-based injury prevention. In J. Ozanne-Smith, &
F. Williams (Eds.), Injury research and prevention: a text (pp. 210–220). Victoria, Australia: Monash University Accident Research Center.
National Committee for Injury Prevention and Control. (1989). Injury prevention: Meeting the challenge. Supplement to the American Journal of Preventive Medicine, 5, vol 5 (3). New York: Oxford University Press.
Peterson, L., Farmer, J., & Kashani, J. H. (1990). Parental injury prevention endeavors: A function of health beliefs? Health Psychology, 9 (2), 177–191.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change, Journal of Consulting and Clinical Psychology, 51, 390–395.
Ragnarsson, R. S., & Bjorgvinsson, T. (1991). Effects of public posting on driving speed in Icelandic traffic. Journal of Applied Behavior Analysis, 24, 53–58.
Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide for health promotion practice. Washington, D.C.:
U.S. Department of Health and Human Services. Publication No. 05-3896.
Runyan, C. W. (1993). Progress and potential in injury control. American Journal of Public Health, 83 (5), 637–639.
Runyan, C. W. (1998). Using the Haddon Matrix: Introducing the third dimension, Injury Prevention, 4 (4), 302–307.
Rutter, D., & Quine, L. (2002). Changing health behavior. Philadelphia: Open University Press.
Schneiderman, N., Speers, M. A., Silva, J. M., Tomes, H., & Gentry, J. H. (Eds.) (2001). Integrating behav- ioral & social sciences with public health. Washington, DC: American Psychological Association.
Schwartz, R. (Ed.). (2003). Focal point issue: Injury prevention and control. Health Promotion Practice, 4, 85–196.
Shaw, F. E., & Ogolla, C. P. (2006). Injury prevention behavior and the law. In A. Gielen, D. A. Sleet, &
R. Diclemente (Eds.), Injury & violence prevention: behavioral science theories, methods and applications.
San Francisco: Jossey-Bass.
Shields, J. (1997). Have we become so accustomed to being passive that we’ve forgotten to be active?
Injury Prevention, 3, 243–246.
Sleet, D. A., & Bryn, S. (Eds.). (2003). Injury prevention for children and youth [Special issue]. American Journal of Health Education, 34 (5), (Supplement 1), S1–S64.
Sleet, D. A., Hammond, W. R., Jones, R. T., Thomas, N., & Whitt, B. (2004). Injury and violence preven- tion in the community. In R. H. Rozensky, N. G. Johnson, C. D. Goodheart, & W. R. Hammond (Eds.), Building healthy communities: Psychology’s role in public health (pp. 185–216). Washington, DC:
American Psychological Association.
Sleet, D. A., Hollenbach, K., & Hovell, M. (1986). Applying behavioral principles to motor vehicle occupant protection. Education & Treatment of Children, 9 (4), 320–333.
Sleet, D., & Hopkins, K. (Eds.). (2004). Bibliography on behavioral science research and unintentional injury prevention [CD-ROM]. Atlanta, GA: Centers for Disease Control and Prevention. National Center for Injury Prevention and Control.
Sleet, D. A., & Lonero, L. (2002). Behavioral strategies for reducing traffic crashes. In L. Breslow (Ed.), Encyclopedia of Public Health (pp. 105–107). New York: Macmillan.
Sleet, D. A., Trifiletti, L. B., Simons-Morton, B., & Gielen, A. C. (2006). Individual level models: Applica- tions of behavioral theory. In A. C. Gielen, D. A. Sleet, & R. DiClemente (Eds.), Injury and violence prevention: Behavior change theories, methods and applications. San Francisco: Jossey-Bass.
Smedley, B. D., & Syme, S. L. (Eds.). (2000). Promoting health: Intervention strategies from social and behav- ioral research. Washington, DC: National Academy Press.
Spinks, A., Turner, C., McClure, R., Acton, C., & Nixon, J. (2005). Community-based programmes to promote use of bicycle helmets in children aged 0–14 years: A systematic review. International Journal of Injury Control & Safety Promoton, 12 (3), 131–143.
Streff, F. M., & Geller, E. S. (1986). Strategies for motivating safety belt use: The application of applied behavior analysis. Health Education Research, 1, 47–59.
Svanstrom, L. (1999). Building safe communities—a safety promotion movement entering 2000. In Best Practices; Quality and effectiveness of health promotion. Proceeding of 4th European CIUHPE Confer- ence, Helsinki and Tallinn, 1999, pp. 102–112.
Thompson, N. J., Sleet, D., & Sacks, J. J. (2002). Increasing the use of bicycle helmets: Lessons from behavioral science. Patient Education and Counseling, 46 (3), 191–197.
Treno, A. J., & Holder, H. D. (1997). Community mobilization: Evaluation of an environmental approach to local action, Addiction, 92 (Supplement 2), 173–187.
Triandis, H. C. (1980). Values, attitudes and interpersonal behavior. In H. E. Howe, & M. M. Page (Eds.), Nebraska symposium on motivation 1979 (pp. 197–259). Lincoln: University of Nebraska Press.
Trifiletti L. B., Gielen A. C., Sleet D. A., & Hopkins K. (2005). Behavioral and social sciences theories and models: Are they used in unintentional injury prevention research? Health Education Research, 20 (3), 298–307.
Wallack, L., Dorfman, L., Jernigan, D., & Themba, M. (1993). Media advocacy and public health: Power for prevention. Thousand Oaks, CA: Sage.
Zaza, S., & Thompson R. S. (Eds.). (2001). The guide to community preventive services: Reducing injuries to motor vehicle occupants: Systematic reviews of evidence, recommendations from the Task Force on Community Preventive Services, and expert commentary. American Journal of Preven- tive Medicine, 21 (4S), 1–90.
