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Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 1
Carolyn J. Cumpsty Fowler, PhD, MPH
Adopting a Systematic Public Health
Problem Solving Approach to:
THINKING ABOUT INTERVENTION
CHOICES
PART 2: Moving Towards Informed Action
Delaware Injury & Violence Prevention Summit 2012
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 2
Intervention planning should not begin
until:
the injury problem is well defined and described
you have identified key causal and contextual factors
you know what you are targeting - and why
Delaware Injury & Violence Prevention Summit 2012
How do I build
an intervention
plan which is
Strategic and
Effective ?
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 3
What are our options?
Understanding the importance of
selecting:
1. Candidate change targets
Which Prevention Phase are You
Targeting? 1. Pre-Event
Reducing the number of events with the potential to cause injury.
2. Event Reducing the number of injuries
that occur.
3. Post-Event Reducing the severity of injury and
optimizing outcome.
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 4
Injury Prevention’s Focus is as Upstream as Possible
Blame the Victim
Train the Victim
We Often Need Help to
Escape the Box
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 5
Continuum of Injury
Prevention Strategies
A
C
T
I
V
E
P
A
S
S
I
V
E
“The Baker Slope”
Prevention Effectiveness
Type of Strategy Active
Passive
Low
High
Requires frequent
actions by person to
be protected
Requires no action
by person to be
protected
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 6
Dr. Bill Haddon gave us:
10 injury prevention strategies known as
“The Haddon Strategies” (I like to think of these as strategic targets)
The 10 Haddon Strategies Range from “upstream” to downstream approaches
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 7
Haddon strategies applied - I
#1 Prevent creation of the hazard
ban 3-wheel ATV’s; restrict types of ammunition
#2 Reduce amount of the hazard
limit pills per container; decrease water temperature
#3 Prevent release of the hazard
provide handrails for the elderly; improve brakes
#4 Alter release of the hazard
blister packaging of pills; child restraints
#5 Separate person and hazard in time and space
bike paths; remove trees near roads; evacuate hurricanes
Haddon strategies applied - II
#6 Place barrier between person and the hazard
bike helmets; childproof closures; pool fences
#7 Modify basic qualities of the hazard
breakaway poles; energy-absorbing surfacing
#8 Strengthen resistance to the hazard
physical conditioning; building codes (earthquake)
#9 Detect quickly
smoke detectors; road side phones; early warning systems
#10Repair the damage
EMS; treatment & rehabilitation; self-care training
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 8
What are our options?
Understanding the importance of
electing:
1. Candidate change targets
2. Candidate change strategies
The 10 Haddon Strategies Range from “upstream” to downstream approaches
Include all categories of intervention strategy
approaches (the E’s)
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 9
The Injury Prevention E’s
Education
Engineering
Enforcement
[Economic incentives]
Injury Prevention Approaches
Education
• Health Promotion
• Health Behavior Change
• Influencing Social Norms and
Social Will
• Advocacy
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 10
Injury Prevention Advocacy
“Injury prevention advocates work to
influence the way the public,
policymakers and other decision
makers think about and act on injury
prevention policies.”
Susan De Francesco, JD, MPH, MAT
Injury Prevention Approaches
Engineering
Technology
Environmental Change
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 11
Injury Prevention Approaches
Enforcement
Law
Regulation
Policy
What do these options mean for us?
LAW
GOOD NEWS! The type of intervention we hope to
achieve is not necessarily the type of work we will have
to do to make it happen.
EDUCATION TECHNOLOGY
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 12
Discussion (A.K.A. “Buzz Group”)
1. For each type of strategy, think about
what factors might be important for
that strategy to have the potential to
succeed.
This is about intervention design and
components rather than funding, etc.
2. Can this type of strategy stand alone?
If yes, why?
If no, what could enhance it?
For education & behavior change
strategies to work, the audience must:
Be exposed to the appropriate information
Understand and believe the information
Have the resources and skills to make the
proposed change
Derive benefit (or perceive a benefit)
from the change
Be reinforced to maintain the change over
time Sleet and Gielen, 1998
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 13
Successful implementation of engineering & technology solutions requires that the technology
Be effective and reliable
Be acceptable to the public and
compatible with the environment
Result in products that dominate the
market place
Be easily understood and properly used
by the public
Sleet and Gielen, 1998
Key factors in making legislation and
law enforcement strategies effective
The legislation is widely known and
understood
The public accepts the legislation and its
enforcement provisions
The probability, or perceived probability,
of being caught if one breaks the law is
high
The punishment is perceived to be swift
and severe Sleet and Gielen, 1998
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 14
So what should we learn
from this?
Even though many wish it were not so,
single “E” strategies seldom work
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 15
Adopt an Ecological (Multilevel)
Intervention Approach
Single strategies are seldom – if ever – successful
in achieving and sustaining change…
Interventions must be sensitive to the ecological context.
They must address several areas.
To achieve lasting change, interventions must be implemented with enough resource intensity (such as time and engagement).
When intrinsic individual risk factors
exist in the person to be protected
the importance of environmental
change and injury prevention policy
increases.
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 16
STAY
ALERT
!!! Interventions to
prevent injury
may have
unintended
consequences
Anticipate All Consequences
We Must Aim for Action to Achieve Positive Ecological Balance
Agent
Host
Environment
Our PH
Problem
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 17
Environmental conditions favor the agent/vehicle and increase the individual’s risk for illness/injury.
“Negative ecological balance”:
Physical Environment
Agent Social Environment
Environmental conditions favor the individual and reduce the risk for disease/injury.
“Positive ecological balance”:
AGENT
Physical Environment
Social Environment
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 18
To Improve Ecological Balance for ANY Vulnerable Group (& Most Issues)
…
Focus on Physical And Social Environmental Change
YOUR GOAL:
MODIFICATION
OF AN UNSAFE
PLAYGROUND
IN THE TARGET
COMMUNITY
An Intended Environmental Change:
3 Candidate Intervention Choices
Do it yourself
Advocate
for policy
which
mandates
change
Build a community coalition to take on
this project #3 #1
#2
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 19
How do I
choose the
right
approach ?
Different Strategies
Have different strengths and
weaknesses ....
…weigh the pro’s and con’s carefully
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 20
When setting priorities, we
consider: Money
People Power
Time
Materials
Space
Who Benefits
From change
From status quo
Politics
Potential risks
+ _
How do I compare interventions?
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 21
The Revised Intervention Decision Matrix ©
Fowler & Dannenberg 1995 (revised 1998, 2003, 2010)
Is a simple tool designed to help people identify
intervention options and choose between them.
It can also help identify long term goals and
intervention options which may support each
other.
Decision criteria used in the
Revised Intervention Decision Matrix ©
Effectiveness
Feasibility
Affordability (Cost-feasibility)
Sustainability
Ethical Acceptability
Social Will
Political Will
Possible Unintended Consequences Benefits
Risks (Avoiding risk = “Potential to do no harm” )
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 22
Intervention Option1 Option 2 Option 3
Effectiveness
Feasibility
Cost Feasibility
Sustainability
Ethical Acceptability
Political Will
Social Will
Potential for Unintended Benefits (maximize benefits)
Potential to “Do No Harm” (avoid unintended risks)
Final Priority Rating
The Revised Intervention Decision Matrix ©
Compare options ranking each cell as “high, medium, or low priority”.
Which option is strongest? Is there a “fatal cell”?
Fowler CJ & Dannenberg AL, 1995. Revised 1998, 2000, 2003 & 2010
Effectiveness Low Medium High
Feasibility High Medium Low
Cost-Feasibility* High (Low) Medium Low (High)
Sustainability Low Low Medium
Ethical Acceptability High High High
Political Will Medium Medium Low
Social Will Medium Medium High
Potential for unintended
benefits (maximize benefits)
Low Low Medium
Potential to “Do No Harm”
(Avoid unintended risks)
Low Medium Medium
FINAL PRIORITY
The Revised Intervention Decision Matrix ©
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 23
Intervention Option1 Option 2 Option 3
Effectiveness
Feasibility
Cost Feasibility
Sustainability
Ethical Acceptability
Political Will
Social Will
Potential for Unintended Benefits (maximize benefits)
Potential to “Do No Harm” (avoid unintended risks)
Final Priority Rating
The Revised Intervention Decision Matrix ©
Compare options ranking each cell as “high, medium, or low priority”. Which option is strongest? Is there a “fatal
cell”?
Fowler CJ & Dannenberg AL, 1995. Revised 1998, 2000, 2003 & 2010
Why do we not use a numeric scoring
system e.g. 1, 2, or 3?
Assembling Our Collective Wisdom
Identify an intervention your group
believes could help prevent the
injury/violence challenge you have
been discussing.
Identify 3 different “candidate”
approaches
Compare them using the RIDM
Carolyn J. Cumpsty Fowler, PhD, MPH
July 24-25, 2012
Delaware Injury & Violence Prevention Summit
Day 1 – Session 2 24
Discussion
