Health professionals traditionally try to change behaviors that affect health by counseling patients and their families. Understanding of successful physician communication and counseling techniques continues to grow. Certainly, anticipatory guidance for injury prevention must go beyond the simple delivery of information. Increased knowledge about an injury problem and prevention strategies does not lead reliably to action. Counseling for behavior change requires soliciting information (finding out what the parent or patient knows, is doing, and intends to do); providing sensitive and sensible advice; focusing on parental or patient perceptions of risks, benefits, and barriers to change; and encouraging change through time.

An increasing number of injury issues are being added to the list of possible subjects for anticipatory guidance. They compete for the limited time available during a health supervision visit. The health provider must have a strategy for setting
priorities among injury-prevention topics. An implicit and an increasingly more explicitly stated approach is to base choices on the child’s developmental age, features of the preventable injury (severity, frequency), and features of the recommended prevention strategy (e.g., demonstrated effectiveness, availability, and cost).

Gains have been made with a health promotion approach that delivers the message from many respected sources and provides rewards for demonstrating the desirable behavior. Schools, community groups, agencies, and the popular media all can have roles in modifying beliefs and behaviors that affect injury and injury prevention. Informed health care providers can stimulate and advise on these efforts by providing leadership or consultation.

Educating persons in power, whose decisions determine the risk of injury for many, may produce the best results. These people include leaders in schools and child-care centers, health care providers, leaders of public agencies, legislators and regulators, law enforcement professionals, leaders of voluntary organizations, designers, architects, builders, engineers, leaders of business and industry, and those controlling the mass media.

Legislative and regulatory efforts to bring about injury control can occur at the local, state, or federal level. Little uniformity exists among local jurisdictions or states with regard to measures affecting injury. Illustrating this is motor vehicle occupant safety. Although an increasing number of states require seat belt use by front-seat car occupants and all require car safety seat use for particular categories of young passengers, the specific legislation varies widely. Some states allow primary enforcement, which means that noncompliance is sufficient reason to stop the driver. Others allow only secondary enforcement, meaning that the citation can be made only if another offense has prompted action. Passenger ages and positions, vehicle types, and penalties under the law also vary, leaving many persons unprotected even by full compliance with the law. The level of enforcement is not uniform and often is so spotty that it negates the intention of the measure. Nevertheless, the impact of such legislation on injury can be documented. States with long-standing car safety seat laws have experienced decreased infant motor vehicle occupant death rates. Specifically designed legislation has been shown to be an effective strategy for injury control. Health professionals should be advocates for children in the legislative arena.

Legislative authority or specific legislation must precede agency action in many cases. Agencies that control personal practices and the environment (e.g., boards of parks and recreation, health departments, schools, athletic associations, traffic authorities, regulators of consumer products) can promulgate within their authority regulations that decrease the likelihood of childhood and adolescent injury. Smoke alarm and sprinkler system requirements can be set for building construction, specific pool fencing requirements can be mandated, children transported in private cars on school trips can be required to wear seat belts, and fireworks can be prohibited within city limits. The success of well-designed regulations depends on enforcement or the perception of enforcement. Unenforced regulations, like knowledge without behavior change, cannot prevent injury.

Legislation enacted for other reasons may also have injury-reduction potential. The Emergency Highway Energy Conservation Act (1974) reduced the speed limit to 55 miles per hour to conserve gasoline. The highway death rate fell. When many states revoked this conservative limit, deaths increased with speeds. A bill requiring a deposit on glass bottles, promulgated for environmental reasons, resulted in fewer pediatric emergency department treatments of lacerations. The activity of the Consumer Product Safety Commission (CPSC), created by the Consumer Product Safety Act of 1972, is the centerpiece of federal efforts to eliminate unreasonable hazards associated with consumer products. In this role and as administrator of several earlier acts (the Flammable Fabrics Act, 1953; the Refrigerator Safety Act, 1956; the Federal Hazardous Substances Act, 1960; and the Poison Prevention Packaging Act, 1970), the CPSC has had a special role in injury control for children. It reacts to petitions, complaints, or clues from its surveillance
systems, including the National Electronic Injury Surveillance System, which collects injury data from approximately 100 hospital emergency departments nationally. The CPSC can negotiate voluntary product changes, and it can regulate sales and force product recalls. There has been significant public concern over the safety of children’s products and furniture, which often are not subject to stringent testing standards, and the effectiveness of the product recall system. Health professionals can advocate for voluntary product testing by manufacturers and encourage parents and child care providers to be aware of product recalls announced by the CPSC. Health professionals should bring product-related injuries to the attention of the CPSC and CPSC findings to the attention of their patients and communities.

Where educational, legislative, and regulatory options have failed to bring about injury control, litigation may succeed. Pertinent to the protection of adolescent drivers, for instance, is the facilitating role that litigation against automobile makers has played in expediting the provision of airbags in automobiles. More recently, various municipalities have pursued lawsuits against gun manufacturers, modeled on successful litigation against the tobacco industry, in hopes of encouraging manufacturers to take steps to limit children’s access to firearms.

Throughout the lifespan, male subjects have higher injury death rates than female subjects. This increased risk is apparent even before the age of 1 year; the total injury death rate for infant boys is approximately 1.3 times the rate for girls. In adolescence, the differential is even more striking, with a male-to-female ratio of approximately 2.8:1.0. The differences appear to reflect differences in likelihood of involvement in hazardous activities. Whether these differences in male behavior are entirely because of socialization (i.e., role expectations) or reflect innate behavioral characteristics specific to boys and men is not clear. Gender differences are greatest for fatal and other severe injuries.

If the full spectrum of injury is considered, rates are highest for both genders during adolescence. The adolescent injury death rate is exceeded only by that for the most elderly segments of the population.

Injury death rates vary with ethnicity and economic status. Native Americans have the highest injury rates of population groups in the United States. Blacks are a second group at particularly high risk. Asian Americans have the lowest rates. Some of the differences by race can be explained by differences in socioeconomic status. Considerable evidence suggests that unintentional injury rates are highest in the lowest-income areas. Unintentional injury death rates fall markedly as the per capita income increases. Whites and blacks of the same income level have approximately the same death rates from unintentional injury.

There are unique injury concerns in children with special health care needs. For example, children with behavior disorders such as attention deficit hyperactivity disorder (ADHD) have been found to have 1.5 times the odds of sustaining injuries than children without behavior disorders. Targeted injury prevention measures can address the increased risk of children with special needs. For instance, children with seizure disorders are at greater risk for drowning and should be supervised closely while taking a bath or swimming; showers should be used instead of baths if privacy concerns prevent direct supervision.

Although homicide rates are highest where the population is most dense, unintentional injury rates are highest in the most remote rural areas. Unlike differences in injury rates by race, disparities by population density do not narrow when adjustments are made for differences in per capita income.

Demographic associations, although they provide interesting clues to the complexity of injury causation and are helpful in program development, do not significantly narrow the task for health care providers. Persons who belong to the higher-risk demographic categories may require extended counseling time and effort, but patients who do not fall into the demographic categories of highest risk cannot be excluded from counseling, because no group is free from all injury risk. Although the concept of the accident-prone person has been popular, evidence has provided no easy rubric for limiting injury control counseling to a small subset of patients. Injury appears to be far too evenly spread across the population to allow any narrow definition of the subpopulation at risk.