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 associated 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 individuals, families, workplaces, and the community. Yet behaviors that give rise to
injury and violence are amenable to preventive interventions. Experts in the behavioral 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 community 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 prevention and provide further examples of applying behavioral and social-psychological
*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.
397
398 D.A. Sleet and A. Carlson Gielen
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 understanding and modification of injury risk behaviors and harms. Behavioral science applications 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; Thompson, Sleet,
& Sacks, 2002; Geller et al., 1990). A growing body of work is emerging that demonstrates 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 environmental 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 prevention 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-
Behavioral Interventions for Injury and Violence Prevention 399
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 environments 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 maintenance 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 behavior to be changed (Rimer & Glanz, 2005).
22.4.1.
Ecological Models
What has emerged recently in public health is the importance of taking an ecological 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 interaction changes over the life course (Committee on Health and Behavior, 2001;
Schneiderman, Speers, Silva, Tomes, & Gentry, 2001). This definition conveys the
400 D.A. Sleet and A. Carlson Gielen
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 behaviors. 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 mobilization, 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 dramatically 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 organizations, 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
Behavioral Interventions for Injury and Violence Prevention 401
(Committee on Health and Behavior, 2001; Smedley & Syme, 2000). Behavioral change theories, methods, and applications in injury prevention have been
described by Gielen et al. (2006). Here, we describe several examples of wellrespected 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 individuals’ 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 prevention 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 increasing 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 behavioral 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
402 D.A. Sleet and A. Carlson Gielen
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). Identifying 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
Behavioral Interventions for Injury and Violence Prevention 403
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 (Ragnarsson & 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 Subjective 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 reactions, 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:
404 D.A. Sleet and A. Carlson Gielen
• 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 outweigh 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 positive 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 conditions. 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 collaborate 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 communitybased 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 intervention will succeed if the practitioner (1) builds from a base of com-
Behavioral Interventions for Injury and Violence Prevention 405
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 organizational 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 interdisciplinary 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 community model (Coggan & Bennett, 2004; Moller, 1995) In each project, the community, which ranged from large suburban areas to small country towns, was
involved in developing a series of injury prevention strategies. Multidisciplinary layprofessional 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 leaderinitiated 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.
406 D.A. Sleet and A. Carlson Gielen
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 following 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 recognizes 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 increasingly 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 protection 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 contribute to building successful injury prevention programs.
22.6.
CONCLUSIONS
The use of behavioral theories and methods has been critical to progress in improving 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 behavioral change applications to injury control (Gielen et al., 2006; Grossman &
Johnston, 2004; Zaza & Thompson, 2001; Sleet & Hopkins, 2004), and some scholarly journals have dedicated whole issues to this topic (Gielen, 2002; Liller and
Sleet, 2004; Ludwig, Geller, & Mawhinney, 2000; Schwartz, 2003; Sleet & Bryn,
2003).
Behavioral Interventions for Injury and Violence Prevention 407
Because of the wide range of types of injury, preventive behaviors, and various
target groups and community characteristics, there remains a great need for additional 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 associated 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 population 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, SimonsMorton, & 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 prevention. 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.
408 D.A. Sleet and A. Carlson Gielen
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 behavioral 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 Psychological 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.
Behavioral Interventions for Injury and Violence Prevention 409
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 alcoholimpaired 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 Association, 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 occupational 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 community 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.
410 D.A. Sleet and A. Carlson Gielen
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 behavioral & 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 prevention 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: Applications 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 behavioral 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 Conference, 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 Preventive Medicine, 21 (4S), 1–90.