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Injuries as a Public Health Problem

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1 Injuries as a Public Health Problem
Intermediate Injury Prevention Course Billings, Montana August 2011 Turn to Section ____ of your notebooks. We’ll now look at the issue of Injuries as a Public Health Problem, to help us understand why we consider injury deaths and disabilities, and especially the prevention of those deaths and disabilities, to be such a priority health issue throughout Indian Country.


3 Session Objectives Severity of injuries facing AI/AN communities
Costs of injury / cost benefits of prevention Community benefits of injury prevention Public Health Approach to preventing injuries Value of data in preventing injury The objectives of this session are : (Read the list)

4 Why Injury Prevention? AI/AN injury rate higher than US all races
AI/AN’s ages 1-44 are greatly affected Injuries are very costly to treat Why Injury Prevention? FIRST, in injury prevention we seek to address injury death rates throughout Indian Country that are much higher than those of the overall U.S. population in some cases 2 to 3 times. There are many issues involved in this, including such factors as personal behavior, community law enforcement, and access to medical care, as well as geographic factors and lifestyles that contribute to injuries in many areas. You’ll be seeing more about these and other factors throughout this course. SECOND, AI/ANs ages 1-44 are hugely affected by injury deaths and disabilities. Within this age range, injuries are the largest cause of death and disability. It’s only after reaching age 45 that deaths from other conditions like cancer and heart disease exceed injuries. However, it’s very important to remember that, when AI/ANs reach age 45, the injury problem doesn’t just go away. It remains a strong cause of death and disability among older populations, and in some communities it’s still the largest cause. We need to carefully identify the causes, locations and other factors of these injuries, in order to accurately identify prevention measures that effectively address these injury causes affecting different age groups. Please don’t misunderstand the third point. We ARE NOT placing more importance on money over people. Quite the opposite – our priority is to have enough resources to treat ALL eligible patients for ALL medical conditions. But the treatment of injuries, especially severe injuries, is often very expensive, and is often needed by many injury victims for the rest of their lives. All the hospital stays, surgeries, medications, therapies and other treatments needed for severe injuries can become a major drain on health care budgets. And because IHS, like all other agencies, has a limited annual budget, all the funds used to treat severe injuries reduces the funds available for non-injury treatments. In many Tribal communities, there are often several “non-emergent” medical conditions that cannot be treated because of a lack of funds, since so much health care money is spent to treat local severe injuries.

5 Injury Types Unintentional Injury Intentional Injury
falls, motor vehicle crashes, drowning, fire/burn, bicycle, off-road vehicles, Intentional Injury Suicide or attempt homicide & assault child/elder abuse Injuries are considered to be either unintentional or else intentional in nature. Unintentional injuries (like the falls, car crashes, drowning and burns) occur without the intent of anyone involved; and Intentional injuries (including the varied types of violence) occur because of a person’s deliberate intent to harm another person Our ability to prevent these types of injuries is based on our ability to effectively use the public health approach.

6 What Injuries Are Not Injuries are not accidents!
They do not happen by chance. They are not random acts. Accidents are events that are without apparent cause, or are unexpected. Ask the audience: Was the rollerblader’s injury an accident? Could we have predicted it would occur?



9 Swift River Rescue Injury Prevention Specialist
“You know sometimes it feels like this. There I am standing by the shore of a swiftly flowing river and I hear they cry of a drowning man, so I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, another cry for help. So back in the river again, reaching, pulling, and CPR – and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, and applying artificial respiration that I have not time to go upstream to see who is pushing them in.”

10 “An ounce of prevention is worth a pound of cure.”

11 1981 - 2006, United States All Injury Deaths and Rates per 100,000 Am Indian/AK Native and All U.S.
Ask the class……. What does this slide show you? (Decreased Injury Fatality Rate among AI/AN Population, Still much higher than all US Races Rate, Leveled Off) Ask the class…….. Why do you think we’ve seen this decrease? (MVC-Lower 48 & Drowning-Alaska) Ask the class…….. What are some things we could do to jumpstart this? (This should be a quick discussion) (Mandatory seat belt laws, stricter enforcement of traffic safety law, increase law enforcement staff, increase resources to behavior health and alcohol treatment programs, improve access to medical care, etc) Instructor should add additional items. CDC WISQARS,

12 Injury Severity Fatal Injury Severe Injury Ambulatory Injury
Injury that results in death of the victim Severe Injury Injury that results in a hospital stay Ambulatory Injury Less severe injuries that do not require a hospital visit In terms of a local injury problem, it’s first important to define the severity of the injuries that are occurring. As you see, we prioritize injuries in three major categories: (1) fatalities, (2) severe injuries or disabilities, and (3) minor injuries.

13 Fatal Injury Rates Per IHS Area
US All Races Rate: 52.2 Portland 119.5 Billings 168.4 Aberdeen 174.0 Bemidji 164.1 WA MT ND MN OR ID SD WI ME WY MI NE IA NY NV IN PA UT CO California 70.9 Nashville 81.5 CA KS Oklahoma City 87.8 AZ NM OK NC TN The data for this slide came from the most recent IHS Injury publication entitled Indian Health Focus - Injuries Note to Instructors: This slide shows data for only one year, which represents an unstable rate. Therefore, if possible, updating this slide with data for multiple years may be worthwhile to show a more accurate pictured of rates by Area over time. Ask the class…….. What does this slide show you? (An Area-by-Area comparison of injury death rates. US all-races rate is included in the top right corner. ) Ask the class……. What area has the highest Injury Death Rate? (Alaska) Ask the class…….. What area has the lowest Injury Death Rate? (California) Ask the class……..You might have noticed that the rates vary widely, why do think this is? (Some areas have poor local access to advanced medical care needed in order to survive trauma events; historically, some areas have had problems in the accurate classification of tribal members in deaths certificates and mortality statistics - injury death rates in those areas are underreported, i.e., California) SC Phoenix 156.1 MS AL Tucson 166.1 TX LA Navajo 170.2 FL AK Albuquerque 120.6 Source: Indian Health Focus - Injuries US DHHS Data includes all injury types Rates are per 100,000 service population Alaska 185.1

14 Leading Causes of Injury Death
All ages AI/AN – (2007) Billings Area Cause Rate US Rate Suicide 23.9 11.4 Poisoning 27.6 9.9 MVC 69.0 13.7 Homicide 13.8 6.0 Firearms 2.5 4.9 Fall 7.0 Fire/Burn 0.0 1.0 Note to instructor: This slide should be changed to reflect data from your Area. See Area-specific file. For the Billings Area, the leading causes injury death is motor vehicle. Rates are per 100,000 service population CDC WISQAR’S

15 What are the costs of injury?
Physical Losses Financial Emotional Treatment Ask the class… “What the costs of Injury” in terms of the following variables. Try to get participants to provide possible answers (provided in parentheses below) instead of giving them to them. Physical (Loss of mobility, Loss of independence) Financial (Personal – loss of salary, cost of funeral, single parent, Community – loss of community member (tribal councilperson), contract health costs) Emotional/Impact on Family (Loss of a parent, Loss of a child, Loss of a friend) Treatment (ER costs, Hospitalization, Rehab)

16 Financial burden of injury
Let’s spend a little time talking in a little detail about the financial burden of injury. There have been several research and evaluation reports that have documented cost of injuries. In the next several slides, we will discuss some of these reports. Keep in mind that financial costs do not include the needless suffering and deaths.

17 Buzz Group: What injuries affect YOUR community?
Do these data agree with the injury problem in your community/region? What are leading causes of severe injury in your community? Why might these lists look different? Note to Instructor: Each student should be referred to the section of the binder that includes Area-specific injury data. After participants have had a chance to examine their Area’s data, and to start large group discussion, the instructor should ask the following two questions: 1. What are the leading causes of severe injury in your community? 2. How have severe injuries affected you or your family? In addition, the instructor could ask the students additional questions, such as: 3. Does the data agrees with their perception of the injury problems within their Area/community? 4. If the injury death chart for your area necessarily reflect those injury deaths that occur in YOUR community? It may, or it may not. The most accurate picture of a local injury problem is obtained through analysis of local data.

18 National Injury Costs $224 Billion Annually
Cost involved Medical care, rehabilitation, lost wages / productivity Who pays Private share 72% (or about $161 Billion) Public share 28% (or about $63 Billion) Federal share $12.6 Billion in medical costs $18.4 Billion in disability/death costs Source: CDC, National Center for Injury Prevention and Control While it’s very true that we can help prevent needless suffering and deaths through injury prevention, we should also remember that there can be genuine monetary benefits to preventing injuries. First, though, we need to consider the economic burden of treating severe injuries. In the Level I course, we briefly discussed the costs of injuries. In this course, we intend to expand our discussion of it. It’s uniformly true that the costs of providing health care treatments only go in one direction, and that’s up, not down. ALSO, the hospital rates that you see do not include emergency treatment costs (including ambulance transport and Emergency Room treatments), nor do they include the costs of post-hospital treatments and therapies often needed for many severe injuries. Injury costs throughout the US are now about $224 BILLION each year, including direct medical care and rehabilitation costs, as well as lost wages of the individuals, and productivity losses to the nation. But WHO actually PAYS for these treatment costs? - PRIVATE source (e.g., insurance) pay about 72% (or about $161 Billion) of the cost of injuries. - PUBLIC sources (federal, state and local) pay about 28% (or about $63 Billion) of the cost of injuries. The Federal government (which is part of the public share) pays out about $12.6 Billion annually in medical costs and $18.4 Billion in disability and death benefits.

19 Average Cost of Hospitalizations California, 1996-1997
We have been discussing the fact that injury hospitalizations are expensive. In fact, typically they are the most expensive type of hospitalization. This data from the state of California shows the average comparative hospitalization costs per discharge type for a two year period. Injury is the most costly. Its important to note that some injuries can lead to catastrophic costs. Serious head and spinal cord injuries can lead to millions of dollars in costs over a lifetime. Source: California Department of Health Services

20 AI/AN Injury Costs IHS Injury Treatment Costs
Inpatient $1507/day (Medicaid reimbursement rate for 1 day at an IHS facility) Contract Health $11,305/inpatient case $570/outpatient case One Alaska Corporation (TCC) spent $4.15 million for injury hospitalizations from ’94-’98 Sources - (1) Indian Health Focus-Injuries (2) Chandler B, Berger L: Financial Burden of Injury-Related Hospitalizations to an Alaska Native Health System The cost of treating injuries among AI/AN populations continues to grow. For fiscal year 2002, the Medicaid reimbursement rate for 1 day at an IHS facility was $ Between FY 94-97, IHS spent over $128 million just on injury hospitalizations at contract care facilities. This came to about 18% of the entire IHS Contract Health Services budget for that period. At $11,305 per contract hospitalization as you see here, that works out to over 11,400 inpatient cases treated at contract facilities. During the same period, the cost of contract care for outpatient injuries totaled an additional $41 million, for the treatment of nearly 73,000 outpatient cases, again just at contract facilities. Now how many other beneficial treatments do you suppose IHS might have been able to provide to AI/AN if this huge amount of funds had not been spent on injury hospitalizations? A fellowship project in 1999 sought to determine the total injury costs to the Tanana Chiefs Conference (TCC) for years 94 through 99. TCC is comprised of 14,000 Alaska natives scattered among 42 villages and the city of Fairbanks. TCC does not have a hospital instead they pay for medical expenses not covered by 3rd party health insurance. Approximately 60% of the TCC service population have medical insurance. The study found that even with the utilization of 3rd party sources, TCC still spent $4.15 million dollars for injury hospitalizations over a 5 year period. This is a considerable portion of the TCC healthcare budget..

21 Cost of Injury Hospitalizations TCC 1994-1998
As a part of the TCC injury cost study, the average cost per case was calculated. Firearm related injuries were the most costly at $17,250 with off road injuries very close behind at $16,933 per case. (Off road injuries were those that involved snowmobiles and ATVs.) MVC injury related cases was third costing $11,538 per cases. Source - Chandler B, Berger L: Financial Burden of Injury-Related Hospitalizations to an Alaska Native Health System

22 Conceptual Shifts in Injury Prevention
Single-cause, Behavioral approach “Blaming the victim” Multiple-causes, Environmental approach Focus on “engineering out” injuries Discuss the role of education in this model. Multiple-causes, Multiple approaches Balanced approach

23 Public Health Approach
Implement & Evaluate Programs Prevention Find what Prevents the Problem What Works? Identify Risk Factors Who, What? Define the Problem Surveillance Who can remember the Public Health Approach? What’s the first step? (defining the specific injury problem) Then where do we go? (identifying the specific factors involved in the problem) Next? (identifying solutions to the problem) And Finally? (implementing AND evaluating the preventive measures that reduce the problem;) It’s very important to include the evaluation of the prevention measures, in order to verify the success or failure of the preventive measures in reducing the injury problem.) And, if you remember from Level 1... Traditional health care often focuses on the TREATMENT of the individual. The public health focuses on the PREVENTION of disease and disability in the overall population. Injury prevention serves both the community and the individual. Source: National Center for Injury Prevention and Control, CDC

24 A Public Health Approach:
Starts with defining the problem and moves toward identifying risk and protective factors. It also includes developing, implementing, and evaluating injury prevention interventions Public Health often takes a two pronged approach to health care; concern with the health of the public in general, as well as the health of individuals within the public. In injury prevention we tend to focus on both. Let’s all read this together (READ GRAPHIC). As you can see, the public health approach calls for us to do four things: ·        identify the specific problem ·        identify the various factors that contribute to the problem ·        identify, develop, and evaluate potential preventive measures to reduce the problem (sometimes this involves a pilot project before full implementation in a community

25 Financial benefits of injury prevention
Now that we’ve discussed the burden of injury, let’s discuss some of the benefits of injury prevention. In preventing injuries, we can prevent needless suffering and deaths, and we should also remember that there can be genuine monetary benefits to preventing injuries, not just to the individual but to the community as well. There have been a few research and evaluation reports that have documented the cost savings of injury prevention in terms of dollars. Let’s look at a few……

26 Interventions that $ave Money
Primary seat belt laws/Child Car Seats Streetlights and guardrails Bike helmets We know that there are many effective measures that help reduce both the number and severity of injuries. These are just a few of the many interventions that we can use to reduce injury deaths and disabilities. Ask the class…… Are you aware of any of the listed interventions going on in their communities?. Ask the class…… Are you aware of any additional injury prevention examples? (Other examples could include: -reduced speeds -improved signage -new striping -road edge grooving on roads -sidewalks/bike paths separate from roads -police radar/video -carbon monoxide detectors -gun closets)

27 Interventions that $ave Money
DUI Laws Personal Floatation Devices Smoke detectors Gun locks We know that there are many effective measures that help reduce both the number and severity of injuries. These are just a few of the many interventions that we can use to reduce injury deaths and disabilities. Ask the class…… Are you aware of any of the listed interventions going on in their communities?. Ask the class…… Are you aware of any additional injury prevention examples? (Other examples could include: -reduced speeds -improved signage -new striping -road edge grooving on roads -sidewalks/bike paths separate from roads -police radar/video -carbon monoxide detectors -gun closets)

28 Safety equipment saves more than lives . . .
Every bike helmet (for kids 4 – 15) saves $395 in treatment costs Every child seat saves $1,360 Every smoke detector saves $900 While injury prevention measures often don’t totally eliminate injuries, they are often effective in reducing the SEVERITY of the injury or injuries suffered. This in turn helps make for lower overall treatment costs. For example, every bike helmet utilized saves $395 dollars in treatment costs if an injury occurs. Every child seat properly utilized save $1360 and every smoke detector save $900. References: National Public Services Research Institute / National SAFE KIDS Campaign

29 Injury Prevention: Potential for Cost Savings
Victim Treatment costs resulting from each Motor Vehicle Crash: NOT wearing a seat belt $2,395 Wearing a seat belt $470 Source - Phipps L: Cost Comparison of Medical Treatment for Restrained vs. Unrestrained Motor vehicle crash victims at a northeast Oklahoma IHS hospital (IHS Injury Prevention Fellowship) A fellowship conducted by Lovetta Phipps looked at the treatment costs for Native Americans injured in motor vehicle crashes at a hospital in northeastern Oklahoma for a nine month period. Ms. Phipps compared costs for those wearing seat belts to those who were not. Her findings indicated that treatment costs were reduced by 80% when wearing seat belts in a crash as compared to not wearing them. ($2,395 as compared to $470.) These estimates are very conservative as they were only for emergency room care and hospitalization for injured motor vehicle occupants at an IHS hospital. It did not include subsequent ambulatory and inpatient charges or charges for the 4 unrestrained patients who were treated in contract health care facilities. Note to Instructors: Refer to/point out location of article by Lovetta Phipps in Student Manual or CD ROM (IHS Primary Care Provider – March 1997 edition.)

30 Injury Prevention Cost Savings Projects in Indian Country
Navajo Nation – occupant restraint usage Whiteriver, AZ – pedestrian crash reduction White Mountain Apache – livestock control Y-K Delta, AK – drowning prevention A cost outcome (cost benefit and cost effectiveness) analyses of 4 transportation injury prevention efforts was undertaken by the Pacific Institute for Research and Evaluation. The article is included in your binder. Pre and post intervention data were analyzed to estimate the projects’ impact on injury reduction. The four transportation injury prevention efforts were the (1) the passage and implementation of a primary safety belt law; (2) the street light project designed to reduce pedestrian crashes in Whiteriver, Arizona; (3) a motor vehicle-livestock crash reduction project on the Fort Apache Reservation (Whiteriver, Arizona),; and (4) a drowning prevention project in the Y-K Delta in Alaska. This paper was the first to analyze the economic consequences of safety intervention in AI/AN jurisdictions. The analyses performed was a pretty technical process as it calculated both costs (project and operating) and savings ( in terms of estimated reduction in medical and public program expenses, estimated decrease in lost productivity, and estimated quality adjusted life years saved.) All four projects yielded positive benefit cost ratios. In short, they saved money while saving lives and they suggest that many other injuries can be prevented cost effectively by similar interventions. Note to Instructors: Provide the following background information to participants about each of the projects. Navajo Nation Occupant Restraint - In 1988, the Navajo Nation passed a primary seat belt law. The law permitted officers to stop vehicles for seat belt use violations alone. The transition period between passage of the law and full enforcement saw an intensive public information campaign promoting the new law and the benefits of seat belt use. Whiteriver Pedestrian Crash Reduction - A cluster of pedestrian fatalities was identified within a 1.1 mile stretch of roadway in downtown Whiteriver. 28 streetlights were installed. IHS funded a demonstration lighting project, AZ DOT widened the road. Recently, BIA funded reinstallation and upgrade of the lights. White River Livestock -Data showed that 1/3 of all collisions were animal related in Whiteriver and the surrounding area. A law regarding the impoundment of livestock already existed, but allowed exemptions for tribal members. The Tribal Council amended the law and hired a livestock coordinator who picked up and impounded the livestock. Y-K Delta Drowning – The Yukon Kushokwim Health Corporation launched a drowning prevention project aimed at reducing drowning deaths in Y-K rivers. A float coat program was implemented which initially was unsuccessful. After changing the marketing strategy (message and incorporating consumer preferences such as color and style), the purchase of float coats increased dramatically. Ask participants where they could see Cost Savings from each of these projects? (possible answers: fatalities, damage to vehicles, vehicle insurance, less severe injuries) Note to Instructors: remind participants to read the article to obtain additional information that may be useful to their injury prevention efforts back at home.

31 Community Cultures/Values
Extended families Knowledge of community infrastructure Local, non-appointed influential people Traditional values and teachings Tribal communities can have added benefits in addressing local injury problems. The extended family connections in many tribal communities often make for far better understanding and awareness of local injury factors. As opposed to a big city that has a large bureaucratic structure, members of tribal communities can more readily identify those persons and agencies that can be enlisted to participate in local injury prevention measures. In addition to elected or appointed community leaders, many tribal communities contain traditionalists or/or spiritual leaders who can also influence community action in support of injury prevention initiatives. And it is the traditional values and teachings of most tribes that directly support the preservation of life and culture, which commonly supports many potential injury prevention measures. When you as a public health professional, or community member understand the values and culture of the community you work/live in, this helps you partner with the community to design and implement injury prevention projects.

32 Community benefits from injury prevention cost savings
Elective medical services more non-emergent treatments (surgeries, therapies, preventive services, other programs) Resources for additional community services housing authorities transportation programs Many IHS / Tribal medical facilities have “waiting lists” of patients needing treatment for conditions that aren’t life-threatening, but which can strongly impact their quality of life. Unfortunately, the funds for such treatments are all too often used up in treating severe injury cases. In addition, Tribal services are also strained by injuries, as housing authorities often must “rehab” homes to accommodate wheelchairs, and Tribal transportation services are often strained to accommodate local residents needing frequent trips for ongoing treatments and/or therapy for severe injuries. It makes sense that, if we can reduce severe injuries in a community, then treatment funds are more available to serve the rest of the community for the non-emergent “quality of life” treatments that benefit the entire community. And Tribes can also make better use of their program funds to provide a greater range of services to benefit the ENTIRE community. Remember, this can be a strong potential selling point for promoting injury prevention in your communities.

33 Using Data to Define Injury Problems
Data identifies patterns and trends Observation data documents behaviors Interview and Focus Group data can be used to identify knowledge, perceptions, and attitudes Collection of data are vital to both DEFINE THE PROBLEM and help IDENTIFY THE SOLUTIONS. First and foremost, we collect injury data to better identify those persons being injured. We identify the causes of severe injuries, and also details like WHERE, WHEN and HOW they’re being injured. Ask participants… What are some examples of data sources . . . ER log, hospital charts, police data, EMS run sheets, fire department logs, etc. These helps us to identify local trends and patterns that we can address with preventive measures. Observational surveys document individuals behavior – both risky and protective behaviors. Observational surveys helps us to identify what preventive measures are needed. (ex. If we conduct a seat belt survey and people aren’t wearing their seat belts, then maybe we near to work on increasing seat belt usage through education and enforcement.) Plus observational surveys provide a more accurate measure of people’s behavior than personal interviews. Ask participants ….. What are some examples of observational surveys. (like seat belt/car seat use, helmet use, personal floatation device use, vehicle speed on hazardous roadways, etc. Interviews and Focus Groups help us to better understand the public’s awareness of local injury issues, and their attitudes about these issues. This information can help us to more effectively design educational materials, market, advocate, and implement specific preventive measures in local communities. Ask participants…. Have any of you been involved in conducting interviews or focus groups?

34 Collecting and Analyzing Data to Determine Injury Risk Factors
Population at risk age, gender, specific group Location(s) of events inside home, road location, at work Environmental factors lighting, road conditions, weather Other factors alcohol use, use of safety devices As shown in the last slide, we need to collect and analyze injury data to better understand the many factors contributing to local severe injuries. Before going through the list of risk factors, ask the class…. Can anyone think of some risk factors associated with a MVC? (brainstorm with the class) -age of the driver -condition of the roadway (paved, gravel, dirt) -gender of the driver -weather conditions (snowy, dry, wet) -alcohol involvement -use of seat belt By collecting and analyzing data, we can determine such risk factors as: (read the slide) By determining injury risk factors, we are able to : -improve local awareness of actual injury priorities vs. individual perceptions Focus our prevention strategies to address particular aspects of an injury problem (e.g., seat belt use) or to aim resources at a specific location (e.g., “Dead Man’s Curve”) “sell” community members, local leaders, and other agencies on supporting these identified prevention initiatives (Instructor should be prepared to discuss how risk factors help us to accomplish the above mentioned 3 items)

35 3 E's Using Data to Select Preventive Measures Modify the Environment
Educate the public Enact and Enforce safety legislation We can take some varied measures to address local injury problems. We can: ·        modify the environment (like providing car seats or boater’s float coats, installing smoke detectors in homes, getting highways repaired or having street lights and signs installed) ·        educate the public on effective ways to protect themselves from injuries (like using seat belts/car seats, driving sober, changing smoke detector batteries, and removing tripping hazards in their homes) ·        enact and ENFORCE safety legislation to require public compliance in activities like using seat belts/car seats, obeying posted speed limits, driving sober, and restraining domestic dogs It’s not often that a single injury prevention measure eliminates an injury problem. Injury prevention activites are usually most effective when we apply a mix of these measures to address the various aspects of the problem. 3 E's

36 Using Data to Evaluate Programs
Help develop intervention materials Analyze effectiveness of methods used Use evaluation to improve prevention measures Once we identify the measures to be used in reducing an injury problem, we must evaluate their potential effectiveness in reducing the problem (“will it work here?”). Hopefully, one is using a proven intervention. Once you determine you intervention, don’t forget to plan for evaluation. Next, implement the measures with a blend of both marketing (attractively selling the measure to the public) and advocacy (effectively gaining community leaders’ and members’ support). Following this, we evaluate our prevention measures to (a) identify their effectiveness and (b) make improvements and/or additions to the prevention measures. Evaluation can also be used to develop intervention materials such as brochures, pamphlets and other materials.

37 Summary Severity of injuries facing AI/AN communities
Costs of injury / cost benefits of prevention Community benefits of injury prevention Public Health Approach to preventing injuries Value of data in preventing injury The objectives of this session are : (Read the list)

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