Injury Prevention

Discussion Summary

Date of Discussion: December 2002
Discussion Moderator: Lori Byron, MD

As all of us in Indian country are aware, injuries are a leading cause of morbidity and mortality for our patients and are 2-3 times higher than national average.

A big issue for us in doing direct patient care is whether our anticipatory guidance helps. The best response on this question involved the motivation interviewing, "A directive client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence." Motivation interviewing has been applied in problem drinking and other addictions and has been proposed as a technique for counseling families on obesity and now possibly on injury for prevention.

Ben Hoffman in New Mexico, while agreeing that counseling is a "low-yield enterprise," said that it is something we all have to do and even one taker may help prevent an unintentional death. "It is imprudent to plan an entire campaign around counseling session anticipatory guidance, but it is an important component."

Bill Green also comments that the PCC Plus customizable encounter form that automatically includes some of the anticipatory guidance topics are age specific has helped him in his injury prevention counseling.

Possibly most importantly, Bill Green also contributed that we should not abandon counseling but make it more effective by trying to make it part of a collaborative effort. More on serious collaborative efforts will be discussed below.

The greatest response and storytelling came in the area of passenger safety, which is certainly the highest yield on morbidity and mortality in our kids.

Jim Gaudino of Oregon mentioned Ms. Sharon John, a public health nurse at the Northwest Portland area Indian Health Board, who worked with seat belt issues on the Yakima nation. I am familiar with her work and this was published recently in the IHS Observer, I believe. She developed a model for working on seat belt issues and put out a video on her reservation. They went through the Yakima nation to pass seat belt laws. Sharon has done a great job and we can all learn from her.

Bill Green mentioned Ben Hoffman's program in Gallup and Ben himself discussed this issue. Gallup, apparently, combined a community education project using a visible logo, education materials distributed through the clinics, WIC offices, Head Start, and retailers. They got funding for billboards on the roads. They developed a program with their local Wal-Mart to provide seats at cost to their families. They also developed a community-based coalition and trained 25 NHTSA certified car seat technicians and held monthly car seat clinics throughout the community. They worked with healthcare, fire/EMS, law enforcement, schools, retailers, local medical and healthcare providers to saturate the community. It was a community-wide effort and not a strictly Native American effort.

Ben's issue certainly shows us that just talking to a patient one-on-one in a well child visit is not all that is needed. He and others obviously put a huge amount of work into their program.

A similar program was begun at Crow where we began a county to reservation child safety coalition. We also worked to train NHTSA car seat technicians. We have become a safe kid, safe community site and have some funding through that program. We used some of our injury prevention money for some grant writing, but so far have not achieved the finances through grants that we are still hoping for. Our effort has also been a multidisciplinary community effort.
George Brenneman of Maryland describes a car seat program run by IHSOEH and a 4-H chapter. This program involved low-cost car seats sold by the 4-H chapter at car seat roadblocks done at his previous service unit by the Navajo police department. Grant was used to pay the police officers overtime to do the roadblocks. The 4-H brought kids to local radio stations to do public service announcements about passenger safety and announcing the upcoming roadblock. Anyone who was "caught" without proper child restraint was given a ticket and an opportunity to buy a low-cost car seat from the 4-H office. They also had child passenger safety clinics each year.

Mark Miller, OEH injury prevention specialist from Shiprock from 1994-2000, said he was involved with a chid restraint program that involved enforcement, low-cost car seats, car seat clinics and strong involvement from the pediatric clinic. He wisely comments that it takes a comprehensive and sustained effort to make a difference.

In summary regarding passenger safety, a broad-based community coalition with some hardworking members appears to be the most effective way to deal with this issue. Success rates are not terrific and certainly do no happen overnight. Car seat funding was briefly discussed by a couple of people. Some thought that Medicaid was helping pay for them, although that certainly does not happen in my state. Some of our hospitals are funding for the car seat for infants. Some people have apparently gotten funding through grants with community coalitions for their car seats. Some people are giving away car seats and others are charging small fees for them.

Actual passenger restraint laws on the reservation was another issue discussed. After many years of effort by our injury prevention specialists at Crow, we finally got laws passed in the Crow nation, but the BIA has refused to enforce them for the past five years claiming "unconstitutionality." We are still fighting that effort.

The Yakima nation apparently did pass seat belt laws thanks in part to the work by Ms. Sharon John and her coalition.

Another major point in injury prevention involved our injury prevention specialist in Indian health country. As I have learned from our fledgling child safety coalition, injury prevention specialists believe in effecting change by improving the condition. This may involve straightening out roads, adding turning lanes, placing traffic lights in critical locations, etc. Dave Grossman comments on the fact that our public health injury program in Indian health service is excellent but rarely have the involvement of physicians. He has noted in many CONACH visits that there is rarely a connection between the injury people and the medical staff. He feels the program could be more visible if IHS doctors were involved in it. Most reservations seem to run the injury prevention program out of the environmental health department, but it could certainly use the support and advice of the medical staff.

Bill Green also commented on the engineering or automatic prevention solutions to injury that are generally more effective than counseling. He points to better lighting on the road between Gallup and the turn to Window Rock, which decreased pedestrian death. He points to automobile manufacturers installing side air bags and built-in passenger restraint systems. As many of us know, vehicles will soon have built-in clips in which newer model car seats will snap automatically, since 90% of Americans install their car seats incorrectly. Some of these things can be addressed locally by our environmental engineers, some on a national level thanks to advocacy groups including the Academy of Pediatrics working to legislate these improvements in safety.

Several people commented on other issues besides passenger restraint issues, some still involve pedestrian issues such as bikes, equestrian and four-wheeler helmets and safety programs.

It was generally agreed that helmets and safety on bicycles and four-wheelers is an issue, but Nelson Barenko of California is the only one who discussed the program he did. He had a bicycle safety program occurring when he was at Shiprock. They did a bike safety rodeo, and they had a bike repair and safety day held at the boys and girls club. He wrote a few grants during that time and was able to purchase bike helmets, which were given away in the pediatric clinic and the boys and girls club. He found that it was pretty easy to get grant dollars for bike helmets despite the fact that there are few documented bike injuries in their database. His program gave the helmets away. His goal was to blanket the community with helmets and thus create an expectation that kids should have and wear one.

At Crow, we also did a bike safety rodeo for about ten years at our health fair. All the kids that went through the bike safety course received a free helmet. We had several hundred kids go through each year. We also photographed each kid in their new helmet and put out signs advertising "It's cool to wear a helmet." Regrettably, my literary bent with Reach Out and Read has prevented me from doing the bike safety rodeo at our health fair for the past three years.

Another question I asked was whether or not funding sources were found. No specific sources were mentioned by any of the contributors. Nelson Barenko did comment that grants were fairly easily obtained. I, too, have found that grants going to Indian country are fairly accessible, but it still takes time and energy to write these grants.

In summary, all of us can and should continue to do anticipatory guidance. Hopefully, motivational interviewing seminars will become more available, and we will all be trained in this so that we can counsel more effectively. I agree with others who say that we are a visible presence in the community, and we do have long-term relationships with our families. Our opinions on subjects still do matter.

However, for injury prevention to truly work, we need coalitions in our communities with some dedicated people to help us. We certainly should be aligning ourselves with our injury prevention specialists on our reservation. They generally have a wealth of information on injuries, have some funding and have some incentive through their job description to reduce injuries. There are other people in all of our communities, even if our particular reservation does not have safety laws or our police department is not particularly effective.

I personally hope to hear further discussion on this in the future. I hope that motivational interviewing can be offered at a future IHS pediatric meeting. I look forward to hearing Benjamin Hoffman's success stories. In the future, I continue to enjoy hearing any additional comments from any of you on injury prevention topics.