Chapter 17
Injuries as a Community Health Problem
CHAPTER SYNOPSIS
In this chapter we define and examine the scope of both unintentional and intentional injuries as community health problems. Injuries are among the leading causes of premature death and disability. We also discuss approaches to reducing the number and seriousness of unintentional and intentional injuries in the community.
CHAPTER OUTLINE
I. Introduction
A. Definitions
1. Injury is physical harm or damage resulting from an acute exchange of energy that exceeds the body's tolerance.
2. Unintentional injuries are those judged to have occurred without anyone intending harm to be done.
3. Intentional injuries are injuries that have been purposefully inflicted whether by oneself or another.
B.Cost of injuries to society
1. Each year nearly 150,000 people die from fatal injuries.
2. This includes approximately 93,320 unintentional injury deaths and 31,284 suicides, and 22,895 homicides.
3. There are 59 million episodes of injuries each year and 40 million injury related emergency department visits each year in the United States.
4. In 1995, there were 2.5 million injury related hospital discharges.
5. Injuries cost this country billions of dollars each year because of foregone productivity, and costs of hospitalization and rehabilitation.
6. Injuries are the fifth leading cause of death in the U. S. and the third leading cause of years of potential life lost before the age of 75 (YPLL - 75).
7. Federal funding for injury prevention and control is modest in comparison to that spent for heart disease and cancer research.
8. Injuries put a special burden on emergency departments.
II. Unintentional Injuries
A. General
1. Unintentional injuries, by themselves, are the fifth leading cause of death in the United States.
2. In 1995, fatal and nonfatal unintentional injuries cost Americans approximately $225 billion in lost wages and productivity, $75 billion in medical expenses, $76 billion in insurance administration costs, and $39 billion in motor vehicle damage.
B. Types of unintentional injuries
1. Motor vehicle crashes
a. The leading cause of unintentional injury deaths is motor vehicle crashes.
b. In 1997, there were 6.7 million police-reported motor vehicle crashes, involving 12 million drivers and causing 3.4 million injuries, including 42,000 fatalities.
2.Other types of unintentional injuries
a. In 1996, non-motor vehicle, unintentional injury deaths numbered about 50,000.
b. Examples of other causes of unintentional injuries, in order of numbers of incidences, are falls, poisonings, fires and burns, drownings, suffocation, and the discharge of firearms.
c. Three common sources of injuries are stairs, bicycles, and toys.
B. The epidemiology of unintentional injuries can be examined by person, place, and time.
1.Person
a. Age - Unintentional injuries are the leading cause of death in children 1-4 and 5-14 years of age and in young adults 15-24 years of age. In the 25 to 44-year old group they are second, after HIV/AIDS.
b. Gender - Males are twice as likely to suffer a fatal unintentional injury as females.
c. Minority Status - People with minority status bear a heavier burden of unintentional injury deaths than whites. Non-Hispanic, Native Americans have the highest unintentional injury fatality rate, followed by Asian and Hispanics and then blacks.
2. Place
a. Home - More unintentional injuries (39%) occur in the home than in any other place.
b. Highways - Highways rank second in the number of unintentional injuries with 14% of the total, but rank first in number of fatal injuries.
c. Workplace - Workplace ranks third as a place for unintentional injuries.
3.Time - Unintentional injury rates vary with season.
a. 60% of drownings occur in May - August.
b. 65% of deaths from fires occur in November - April.
c. More motor vehicle deaths occur at night; mileage death rates are more than three times higher at night. More fatal crashes occur on Saturdays.
d. Holidays, in general, are not more dangerous than other days.
4.Alcohol and other drugs as risk factors
a. Alcohol is the single most important factor associated with both intentional and unintentional injuries.
i. There has been a decline in the percentage of motor vehicle fatalities that are alcohol related. About 41% of fatal motor vehicle crashes in 1996 involved alcohol, down from the 57% reported in 1982.
ii. There has been a decline in the percentage of fatal crashes involving a legally intoxicated driver.
a. Alcohol is involved in nearly half of adult drownings.
b. In one study, more than half of adult cyclists with brain injuries were legally intoxicated at the time of their injury.
C. Prevention through epidemiology
1.Early contributors to injury prevention and control
a. Hugh De Haven designed vehicle interiors for greater safety.
b. John E. Gordon proposed using the methods of epidemiology to study the causes of injuries.
c. William Haddon, Jr. insisted that research on accident prevention be developed into public policy.
1. A model for unintentional injuries incorporates energy as the agent in the standard public health model of agent, host and environment.
2. Prevention and control tactics based upon the public health model stress interrupting transmission of damaging energy to the host.
a. Prevent accumulation of energy
b. Prevent the inappropriate release of energy
c. Place a barrier between humans and energy
d. Completely exclude humans from proximity to energy source
4.Other tactics
a. Strengthen educational programs
b. Strengthen EMS response capabilities
c. Strengthen ordinances against dangerous behaviors
D. Community based approaches to the prevention of unintentional injuries.
1. Education is the process of changing people's health directed behavior to reduce unintentional injuries.
2. Regulation is the enactment and enforcement of laws to control conduct to reduce unintentional injuries.
3. Automatic protection is the technique of designing a product or the environment to reduce unintentional injuries.
4. Litigation is the process of seeking justice for injury through the courts.
III. Intentional Injuries are the Outcome of Self-Directed or Interpersonal Violence
A. Scope of the problem
1. More than 50,000 people die each year from intentional injuries.
2. About 1.4 million receive nonfatal injuries as a result of interpersonal violence, in 1994.
B. Types of intentional injuries include, assault, abuse, rape, robbery, homicide, and suicide.
1. There were 10.9 million violent crimes committed in 1994 of which 2.7 million resulted in an injury to the victim.
2. In 1996, homicide and legal intervention ranked as the 14th leading cause of death in the United States accounting for 20,738 deaths.
3. In 1996, suicide was the 9th leading cause of death, accounting for 30,863 deaths.
4. Suicides accounted for one-fifth of all injury deaths.
B. Epidemiology of intentional injuries
1. Interpersonal violence disproportionately affects those who are frustrated and homeless, jobless, live in poverty, and have low self-esteem.
2. More violent acts are committed by males.
3. Firearms are increasingly involved.
4. Perpetrators of violent acts are more likely to have been abused or neglected as children.
5. Rates of homicide, assault, and rape are highest among minorities.
a. The homicide rate for black American male, aged 15-34, in 1992 was eight times higher than for white males.
b. Persons with low incomes and minorities are more likely to be victims of violent crimes.
c. Only 42% of violent crimes are reported to police.
6.Suicide and attempted suicide
a. More than 30,000 suicides are reported each year, accounting for 20% of all injury related mortality.
b. Men are three to six times more likely to commit suicide than women.
c. Suicide rates among the young have tripled since 1950.
7. Firearm injuries and injury death statistics include both intentional and unintentional injuries.
a. Firearm injuries are the second leading cause of injury deaths after motor vehicle crashes, but in some states they rank first.
b. Sixty percent of suicides and 68% of homicides involved a firearm.
c. Teenage boys and young males 15-24 years of age are at highest risk for death by firearms.
D. Violence in our society
1.Individuals and violence
a. Many individuals lack the communication and problem solving skills to settle disagreements nonviolently.
b. Firearms are easy to obtain and deadly.
c. Murder is the number one cause of death for blacks aged 15-34.
d. Some conflict resolution programs have been developed to teach communication skills.
2.Family violence and abuse
a. One in six homicides is the result of family violence.
b. Children who survive family violence (abuse or neglect) are at greater risk for becoming violent as adults.
c. Child abuse is the intentional inflicting of physical, emotional, verbal, or sexual injury upon a child. In 1994, more than 1 million children under the age of 19 years were victims of abuse and at least 1,111 children died.
d. Child neglect is the failure to provide necessary subsistence for a child - physical, emotional, or educational.
e. Spouse abuse can be physical, emotional, or sexual.
i. Two to four million spouses are abused each year.
ii. More than 1 million women seek medical attention for injuries received from domestic violence each year, but this may be only 23% of those who suffer abuse.
iii. Only about half the women who are abused are married.
f. The cycle of violence depicts the progression of steps leading up to an episode of domestic violence.
g. Alcohol and other drugs are among the stress factors that increase the risk that violence will occur.
1. Prevention of domestic abuse
2. Violence in schools
a. In general, schools are safe, but there have been rare but highly publicized acts of violence.
b. There has been little funding for school violence initiatives.
1. Gangs and violence
a. Youth gangs have been around a long time.
b. Violence has increased recently because of the availability of drugs, the money to be made selling drugs, and easy access to firearms.
c. Gang related homicides increased from 271 in 1979 to 771 in 1991.
d. There are 1,000 nonfatal injuries for each fatality.
e. Gangs and gang related violence place enormous demand on law enforcement agencies.
f. Gangs deface property, which is costly to repair.
g. Community response should be multifaceted and include: law enforcement, education, diversion activities, and social services support.
E. Approaches to prevention of intentional injuries
1.Education
a. Parenting skills for adults
b. Nonviolent problem solving skills for youth
c. Self-esteem raising programs for youths and adults
2.Opportunities for employment and recreation
a. Jobs programs
b. Recreation programs
3.Regulation and enforcement
a. The " Brady Bill" regulates hand gun purchases
b. Electronic detection of weapons
c. Other types of regulation
4. Counseling and treatment represent secondary and tertiary prevention
F. A comprehensive approach includes improved surveillance and training, community empowerment and evaluation of existing programs.
1. Reduction in injuries resulting from firearm violence
a. Education and behavioral changes
b. Technological and environmental efforts
c. Enhanced enforcement of existing laws
d. New legislation and regulation
1. Reduction in use of alcohol and other drugs
a. Decrease chronic use by high risk individuals - treatment
b. Prevent first use by high risk individuals
c. Review current drug laws
1. Improvement of childhood experiences
a. Home visitation programs
b. Educational intervention
c. Crisis intervention programs
4.Prevention and management of mental disorders.
a. Better treatment
b. Expand training for professionals who are gatekeepers for treatment services
c. Increase funding for out patient treatment of patients with mental disorders