Application of Behavior-Change Theories and Methods to Injury Prevention

Abstract

Reducing the burden of injury is an international health goal, one that requires an interdisciplinary perspective. Injuries, whether self-inflicted, inflicted by others, or unintentional, have one thing in common: They are largely preventable. Behaviors that give rise to violence and injury are amenable to preventive intervention, just as are many of the behaviors that give rise to diseases. Thus, behavioral science is an integral part of a comprehensive injury prevention strategy. Applications of behavioral science to injury prevention lagged behind other approaches during the last half of the 20th century. Despite recognition by injury control professionals of the importance of behavioral research in injury prevention, behavioral solutions to preventing injury were deemphasized until recently (1, 2). Historically, little scholarly attention has been paid to understanding determinants of injury-related behaviors or how to initiate and sustain behavioral changes. Interventions often seemed to have been based on simplistic assumptions that changing people’s awareness about the injury problem would change their behavior. Many authors have noted the need to improve behavioral interventions by using better empirical data about determinants of behavior as well as theories and frameworks pertaining to change in health behavior (3–6). A growing body of work is emerging that demonstrates the positive impact of using behavioral science approaches in order to both understand and reduce injury risk behaviors (6–10). In this paper, we describe the role of behavior change in injury prevention and illustrate how the application of selected behavior-change theories to injury problems, within the context of a health promotion framework, can contribute to the enhancement of injury prevention programs. In planning for injury prevention and control, there has been a historical tension between the use of “active” (behavioral) strategies and “passive” (structural) strategies (1). The notion of passive protection arose from the great success of public health measures such as immunization and water fluoridation, which has been unparalleled. Passive approaches rely on changing products or environments to make them safer for all, irrespective of the behavior of individuals. Active approaches encourage or require people to take an active role in protecting themselves, despite hazards in their environments. Adding to the controversy has been the opinion of some that a focus on individual behavior could be interpreted as “blaming the victim” (11–14). However, in response to the victim-blaming assertion, it is also apparent that empowering individuals can lead to the political or social action necessary to achieve structural changes (6, 15). It is rarely feasible to achieve injury reduction without some element of behavior change. In fact, while the structural intervention paradigm might seem straightforward, there is rarely an environmental change that does not require human adaptation. For every technologic advance, there are behavioral components that must be addressed. Children need to wear helmets while bicycling; parents need to correctly install child safety seats and booster seats; homeowners 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 prevention through the use of child-resistant closures—one of the great successes in injury control—requires active individual effort in replacing lids correctly (16, 17). In road safety, for example, it is clear that behavioral countermeasures lagged behind the development of safer, more crashworthy vehicles, road engineering measures, and road safety education. However, it has been asserted that the failure of many early educational programs may have led to unwarranted conclusions that the use of behavior-change interventions for injury control is futile (17, 18). Lonero et al. point out that although weak and ineffective attempts to influence road safety behavior have led to widespread discouragement about the use of active safety measures, “effective and lasting modification of behavior is essential to effective road safety management” (19, p. 1). A recent example is the passive protection provided by passenger-side air bags. Once considered a panacea for injury prevention in crashes, the unexpected deaths of children and small adults from air bag deployment have resulted in a growing recognition of the need for education and behavioral change. Public health professionals are now educating parents to place children in the back seat, away from the passenger-side air bag, and educating drivers about air bag on-off switches so they remember to reactivate them when an adult is seated in the passenger compartment. We call this the active approach to pass