Injury Prevention Policy Forum

Injury prevention researchers, advocates and practitioners have made extraordinary progress in identifying the risk factors for injury and in proposing interventions to tackle those risks. In several fields, however, we have been less successful at actually formulating, enacting, implementing or enforcing some of those interventions. For example, failure to store firearms in the home so that children are unable to gain access to them has been identified as a risk factor for suicide and unintentional injury.¹,²,³,⁴ But laws requiring safe gun storage have been enacted in only 18 US states, and most of these laws provide only modest sanctions.⁵,⁶ More generally, both the Centers for Disease Control and Prevention (Atlanta, Georgia, US) and the National Institutes of Health (Bethesda, Maryland, US) have increasingly recognized the importance of improving the translation of research findings into practical interventions.⁷,⁸

There are, of course, many different categories of injury interventions, including efforts to modify behavior, products, the physical environment or the social environment to reduce risks.⁹,¹⁰ One important way to achieve any of these intervention goals is through policy change. Policies may be particularly effective because they can be designed to affect large numbers of individuals or institutions at once.

Defining injury prevention policy

What do we mean by “policy”? Different definitions of policy have been proposed depending on the context. One broad definition from the health politics literature is “a series of more or less related activities and their intended and unintended consequences for those concerned”.¹¹ In its influential report The Future of Public Health, the Institute of Medicine identified the three core functions of public health as “assessment, policy development and assurance”. The Institute of Medicine defined policy development as “the process by which society makes decisions about problems, chooses goals and the proper means to achieve them, handles conflicting views about what should be done, and allocates resources”.¹² Dictionary definitions of policy often emphasize efforts “designed to influence and determine decisions and actions”.¹³

Combining features of these and other definitions, an “injury prevention policy” can be defined as “a rule or decision having the capacity to guide or determine the actions of individuals, groups, organizations or governments with the goal of affecting the surveillance, risk, incidence, severity, disability, cost or other aspects of injury.”

This definition strives to cover all phases of injury prevention and control, from primary to tertiary prevention. Examples of policies fitting this definition would include legal instruments such as constitutions, statutes, regulations, executive orders or treaties.¹⁴ Rules or decisions of non‐governmental institutions or groups such as corporations, associations or non‐profit organizations could also qualify. For example, a voluntary industry safety standard for a particular product—such as the standards for playground equipment—would meet this definition.¹⁵ A hospital's decision to implement a new procedure for tracking and responding to medication errors is also an injury control policy.¹⁶

Other types of policies may have an incidental effect on injury outcomes, without themselves qualifying as an injury prevention policy. For example, the Fourth Amendment to the US Constitution prohibits “unreasonable searches and seizures”. This language affects the permissible design of driver sobriety checkpoints in the US,¹⁷ but obviously the Fourth Amendment was not created with injury‐prevention goals in mind. This definition would also exclude rules or decisions proposed by persons or groups without the capacity to influence actions. For example, if a community‐based organization announced that all motor vehicles nationwide must have side‐impact air bags to reduce fatalities in crashes, this would not qualify as a policy. The same group, however, could formulate a proposed policy requiring side‐impact airbags designed to be enacted by the appropriate governmental authority.

Other definitions of injury prevention policy—some more inclusive and others more exclusive—are certainly possible. The goal of defining injury prevention policy here is simply to provide a common framework for considering how policy making can affect injury. The next step is to examine the opportunities for prevention at each stage of the policy‐making process.

Stages of policy making

The policy‐making process can be divided into at least five different stages or phases. These include: (1) problem identification; (2) policy formulation; (3) policy advocacy and enactment; (4) policy implementation and maintenance; and (5) policy evaluation.¹¹,¹⁸ These phases are not wholly distinct, nor is the policy‐making process always linear from start to finish. Nevertheless, each stage in the process has the potential to influence prevention goals. Although the specifics and relative importance of each stage may vary among nations, the stages should be generally applicable in democratic countries.

Problem identification includes defining the scope of the injury problem to be tackled and identifying risk factors. The way a problem is defined can have a major effect on the kinds of interventions that are developed. If drowning of young children in household swimming pools is considered to be primarily a problem of inadequate supervision of children by parents, educational interventions might be at the top of the agenda. If instead, the problem is defined as one of easy access by children to an attractive hazard, a policy involving mandatory four‐sided fencing of home swimming pools might be preferred.¹⁹,²⁰

Policy formulation refers to the process of converting ideas for considering problems and risk factors into tangible policy‐based solutions. This step involves selecting from alternative approaches, including deciding who will develop the policy, the parameters of the policy itself, and the target individual or group who would enact it.²¹ Obviously, this is a critical policy‐making stage for accomplishing injury prevention goals. Several questions must be answered: Will the policy affect several risk factors for a particular injury problem or will it be more narrowly focused? Will the policy be developed at the grassroots level or by a few national leaders? Is the policy designed to be national in scope or will it affect only a region, municipality or single organization? Does the policy conform to other rules such as a local or federal constitution? Is the policy consistent with ethical principles? This is also the stage to determine whether the policy will be a law, regulation, litigation, organizational decision or other formulation.

Policy enactment is the stage in which the policy is adopted by the relevant decision‐making body or individual such as a legislature, administrative agency, board of directors or chief executive. In the period leading up to enactment, there can be opportunities for injury prevention professionals to advocate, educate or lobby for the policy. This may be the policy‐making stage that varies most from country to country, depending on economic, sociopolitical or other factors. Policy advocacy can include use of the media,²² grassroots coalition building²³ or direct contact with decision makers or their staff.²⁴ Researchers do not always take full advantage of these many opportunities.²⁵

Policy implementation and maintenance is an often overlooked or undervalued stage in the policy‐making process. The implementation and maintenance stage describe activities needed to carry out a basic policy decision.²⁶ These activities include training those who will implement the policy, providing adequate financial and other resources for implementation, and monitoring and enforcing the implementation process to assure that it conforms to the intent of the policy. Once a policy is enacted, however, all‐too‐often advocates simply move on to the next challenge without fully appreciating how implementation can determine success or failure for injury prevention. For example, an analysis of a new law in Maryland intended to reduce domestic violence concluded that police officers were uncertain about their authority under the law to remove firearms from batterers. This prevented the law from fully achieving its prevention goals.²⁷

Policy evaluation is probably the policy‐making stage with which researchers are most familiar. Evaluation involves quantitative or qualitative research methods to examine the effects of a policy on desired outcomes.²⁸ Qualitative evaluations are especially useful for understanding how or why a policy produced certain effects.²⁹ Ideally, evaluation results are fed back to policy makers and implementers. Policies that work can then be replicated and those that do not can be modified or eliminated. Of course, many polices remain unevaluated.

Conclusion

Each stage of the policy‐making process is important for injury prevention. Yet, there is currently a natural home within Injury Prevention only for articles at either end of the policy‐making spectrum—at the beginning, with problem and risk factor identification, or at the end, with policy evaluation. Articles on other policy‐making topics are not explicitly excluded, nor are they specifically welcomed. A new section of the journal—Injury Prevention Policy Forum—will provide a home for these topics as well. The new section will encourage scholarship in injury prevention policy and help to advance the translation of science into action.

The Injury Prevention Policy Forum will welcome articles on aspects of policy affecting any country or countries (such as UN or WHO policy). Both full‐length manuscripts (approximately 3000 words) and shorter commentaries (approximately 900 words, generally solicited by the editors) will be considered.

Articles or commentaries might discuss, for example: (1) the formulation of a proposed new injury prevention policy; (2) legal or ethical aspects of new or existing policies; (3) challenges to enactment; (4) strategies for effective advocacy; or (5) issues regarding implementation. Manuscripts identifying risk factors for injury or evaluating the effects of policies should generally be submitted to other sections of the journal, such as Original Articles, Methodological Issues or Brief Reports, as appropriate.

We look forward to your submissions, reactions and comments. Our goal is to provide a scholarly, interesting and, above all, useful forum to reduce the burden of injuries worldwide.