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Edited by Gielen AC, Sleet DA, DiClemente RJ. San Francisco: Published by Jossey‐Bass, 2006, pp 534. ISBN 978-0-7879-7764-1
At last we have a scholarly tome that confirms the shift from a purely passive, environmental change model of injury prevention to an active, complex, and integrated model which acknowledges the contribution of the many ways and means required to reach the common goal. Injury and violence prevention: behavioral science theories, methods, and applications is intended to analyze theories, methods, and applications in behavioral science in relation to injury prevention. The book is presented in four parts: Behavior change theories and models; Research and assessment methods for behavior change interventions; Behavior change interventions to reduce injury risk; and Cross‐cutting issues. Each part has an introduction followed by specific topic chapters (20 chapters in all).
Most of us can recall seminal moments in our careers. One such moment in my injury prevention career came when I reviewed a study1 that struck me particularly strongly, so strongly that it has remained a key lesson for a decade. Using the Delphi technique, researchers from the North Carolina Injury Prevention Research Center elicited from 23 of the best and brightest US injury control experts their priority topics for inclusion in counseling provided to parents of young children. Without exception they selected environmental strategies such as car restraints, smoke alarms, lowered hot water temperatures, and other passive measures. It was only in the second round, after the researchers had included 12 behavioral interventions in the list for their review, that several nominated these as a ‘high priority'.
The strength and consistency of the unprompted response made me wonder why it was so. Perhaps it reflected the power of the prevailing paradigm, or peer pressure, but, more importantly, it demonstrated what an effort lay ahead for those who were shaking the tree to gain the acceptance from the B&B of the legitimacy of the techniques that are the driving force of behavior change and which this book now presents to us.
As recently as this year, an eminent colleague stated in a professional forum that there was no strong case for education to drive behavior change and that most of the gains in injury prevention had been achieved through engineering modification, legislation, and enforcement. How little they understood about the precursors to successful environmental and legislative change: that education is fundamental to gaining a critical mass of support for any intervention designed to achieve sustained shifts in behavior.
Perhaps the resistance also relates to the greater focus of injury prevention on preventing an outcome, albeit a predictable one, than on the process of getting there. We sometimes overlook the annoying fact that behavior involves choice: the option to choose between two or more courses of action, perhaps knowing that one is safer than the other, but choosing the riskier action anyway. Why is it, for instance, that consumers remove safety guards from dangerous equipment? In his excellent chapter on preventing occupational injury, Geller notes that risky behavior is rewarded by such positive consequences as comfort, convenience, and efficiency. In these terms it is perhaps understandable that risky behavior can become accepted practice across whole industries, such as the practice of removing guards from farm machinery and equipment to increase efficiency. This issue needs to be understood, and tackled head‐on, by engineers, designers, and injury professionals alike.
One chapter of particular interest, because it represents what we all aspire to, is ‘Behavior change interventions in road safety'. Without the illuminating presence of road safety, many of us may not have found our route into injury prevention as smooth or the preventive models as clear. The gains that have been achieved thus far cannot possibly continue without the active engagement and participation of drivers, pedestrians, cyclists, and other road users in changing their behavior and shifting the culture as a whole.
For too long the legitimacy of the behavioral approach has been denied and yet herein lies the greatest potential to progress our understanding of preventive methodologies. Now that environmental interventions have largely been exhausted without further pushing the technological envelope, it is time to depart the comfort zone and embrace the less well understood (and less expensive) behavioral techniques and strategies. The editors note a welcome recent development whereby behavioral science research is being integrated into the requirements for injury prevention funding, indicating that this avenue of enquiry has finally made its mark.
What is most striking is that each part of the book considers, as the title promises, applications. I particularly commend the chapter on planning models, of which the excellent PRECEDE‐PROCEED model of health promotion is an exemplar. Planning itself, together with sound behavioral theory, underpins the success of many an intervention, yet there are few stand‐out models available.
Although the book is somewhat US‐centric in its authors and references (“Every three minutes, someone in the United States dies from an injury…”), the 39 authors have treated us to a galaxy of ways of thinking about the universal questions of what drives behavior change and how. Although I am surprised that the editors and authors of this magnificent work were not deterred by their mammoth task—maybe they were and that is why it has taken them a decade to bring it to us—I am grateful for the enlightenment.
For some, this will be the book you would like to have written yourselves. Skeptics might gain an insight into what many of us have been thinking, saying, and doing for decades, all the while feeling just a little defensive. Congratulations are due to Gielen, Sleet, DiClemente, and their colleagues for opening a door that can never be closed again.