CLOSING THE GAP: PROGRESSING FROM INJURY PREVENTION RESEARCH TO SAFETY PROMOTION PRACTICE

Closing the Gap Progressing from Injury Prevention Research to

Safety Promotion Practice

Dale Hanson Caroline Finch

John Allegrante David Sleet

Safety 2012 Wellington NZ: 1st of October 2012

Acknowledgement

Closing the Gap Between Injury Prevention Research and Safety Promotion Practice

Revisiting the Public Health Model

Public Health Reports Volume 127

Issue 2 http://www.publichealthreports.org/

Dale W Hanson Caroline F Finch John P Allegrante David A Sleet

Back to the beginning!

The Broad Street Pump Dr. William Farr

(bureaucrat) Rev. Henry Whitehead

(community activist)

Dr John Snow (researcher)

Sir Edwin Chadwick (politician)

Cholera Strikes England

Flying off the handle

“Soho always gave me the shit’s!”

Comedian Billy Conarty is again in hot water. His quip “What’s new, Soho always gave me the shits!” has been widely condemned in the context of the recent epidemic in Soho. Next Friday’s performance at the Royal Theatre has been cancelled after the Arts Council withdrew sponsorship incensed by Conarty’s comments

Soho turned into ghost town More than three quarters of Soho residents packed up and left town last week in response to the recent cholera epidemic. Fears that air pollution has risen to lethal levels drove residents to the country in search of clean air. Broad St has been borne the brunt of the epidemic with more than half of households affected.

Sunday 5th September, 1854

God will not be mocked say Puritans.

Puritan preacher Rev. Brimstone has called on the people of Soho to repent. The infamous red light district

has inci ted Gods Judgment according to Brimstone. The stench of their sin has so polluted the atmosphere that the epidemic was inevitable.

Getting a handle on the problem

Cholera Deaths London July to November 1854

A doubling of the deaths occurred during the Soho outbreak, centered around the Broad St Pump, in which over 600 people die

Brewery 70 workers, no cases

drank beer!

Work House 535 residents

5 deaths amongst recent admissions

Islington 1 death - she preferred

water from Broad St Well it had more flavour!

Hampstead 1 death - visited her aunt in Islington & drank her

water

Local Residents

Deaths = 77

Population = 412

Death / Pop = 19%

Workhouse

Deaths = 5

Population = 535

Death / Pop = 1%

Frerichs RR., SoC Bulletin Vol 34 No 2 2001


31st August Broad St outbreak begins 126 people die 8th September Broad St pump handle removed Mid October St James’s parish bows to popular pressure to reinstall the pump handle

Cholera Deaths London July to November 1854

A doubling of the deaths occurred during the Soho outbreak, centered around the Broad St Pump, in which over 600 people die


John Snow

The Lancet, Saturday 14th, 1854

John Snow presents his theory on the transmission of cholera to the Medical Society of London on October 14th, 1854


But the medical community is not convinced!

“Dr Snow claims to have discovered that the law of propagation of cholera is drinking of sewerage water. His theory, of course, displaces all other theories. Other theories attribute great efficacy in the spread of cholera to bad drainage and atmospheric impurities … The fact is that the well whence Dr Snow draws all sanitary truth is the main sewer. His specus, or den, is the drain. In ridding his hobby very hard, he has fallen down the gully-hole and has never since been able to get out again.”

The Lancet, March 1855

Rev. Henry Whithead

“Dr Snow’s views on cholera,” said a medical friend to me in 1855, “are generally regarded in the profession as very unsound.”

“If that be the case,” I replied, “then heresy may be as good a thing in your profession as some of you are apt to suppose it is in mine”

Whitehead undertook his own review, setting out to disprove Snow’s theory. Instead he discovered the index case and became convinced Snow was right.


Index Case: 2nd Sept 1854, Dr William Rogers certified that Frances Lewis (aged 5 months), died of “exhaustion, after an attack of diarrhea four days previous to death”


August 1855 (1 year later), based on evidence presented by Rev Henry Whithead, St James Vestry orders inspection of the sewer at No 40 Broad St. finding it directly abuts the Broad St Well and that the walls are in poor condition


Dr. William Farr

1854 Cholera Epidemic Believed the miasmic theory. Published a study showing cholera incidence related to height subject lived above the Thames. He didn’t believe Snow, but assisted him with data collection

1866 Cholera Epidemic Demonstrated that mortality was very high for people who drew their water from the Old Ford Reservoir. By now the Germ Theory was accepted and Farr’s evidence was consider conclusive

Chief Statistician of the General Register Office.


Who made the difference?

Dr. William Farr (bureaucrat)

Rev. Henry Whitehead (community activist)

Dr John Snow

(researcher)


The Public Health Model

Define the problem Data collection & surveillance

Identify causes Risk factor identification

Develop & test interventions Efficacy & Effectiveness research

Adoption & widespread use Community development & dissemination program

All talk and no action!

Define the problem Data collection & surveillance

Identify causes Risk factor identification

Develop & test interventions Efficacy & Effectiveness research

Adoption & widespread use Community development & dissemination program

16%

5%

63%

1210 Health Promotion articles in 12 major Public Health Journals in 1994

Oldengurg BF, Sallis JF, French ML, et al., Health Education Research, 14;1: 1210139

16%

The Efficacy to Effectiveness Gap

The Research to Practice Gap

The Disease Prevention to Health Promotion Gap

Scientific Problem Efficacy to Effectiveness Gap

Is this sufficient to describe what a car does?

The Efficacy / Effectiveness Gap

Efficacy to Safety Effectiveness Gap

Efficacy

•  Scientific content •  Internal validity •  Best evidence •  Impact is determined by

–  Reach –  Efficacy

•  Context excluded

Effectiveness

•  Community context •  External validity •  Best practice •  Impact is determined by

•  Adoption •  Implementation •  Maintenance (sustainability)

•  Context the subject of investigation

Glasgow RE, Vogt TM, Boles SM, Am J of Public Health, 1999;89:132207

Can’t see the forest for the trees

Implementation Problem Research to Practice Gap

The Research to Practice G

ap

Research

•  Start with the scientific definition of need

•  Adverse to type 1 error –  Researchers want proof that an

intervention works

•  Forgiving of type 2 error –  Evaluation failure: i.e. failing to prove

that an effective intervention works

•  Success is determined by –  “Scientifically proven”

interventions designed by experts

Practice

•  Start with community perception of need

•  Attempts to engage experts, solutions & resources to solve the problem

•  Empower the community to solve its own problem

•  Success is determined by •  The ability to build consensus •  Communities capacity to work

together


Practice

Context driven

Research

Context excluded

Define the problem

Data collection & surveillance

Identify causes Risk factor

identification

Develop & test interventions

Efficacy & Effectiveness research

Adoption & widespread use

Community development & dissemination program


The Research to Practice G

ap

Science Push Approach

Political Problem Injury Prevention to Safety

Promotion Gap


The Injury Prevention to Safety Promotion G

ap

Disease Prevention

•  Prefer “hard” sciences –  Biochemistry –  Biomedicine

•  Suspicious of “soft” sciences –  Sociology –  Psychology

•  “Health” is hard to define and therefore hard to investigate

•  Success dependent on scientifically proven interventions

Health Promotion

•  Behaviour is influenced by •  Personal beliefs, attitudes and

perceptions •  Social Context

•  People won’t change their behaviour if the social, cultural and physical environment resist this change

•  Success dependent on building enough consensus to intervene


The Injury Prevention to Safety Promotion G

ap

Disease Prevention

•  Prefer “hard” sciences –  Biochemistry –  Biomedicine

•  Suspicious of “soft” sciences –  Sociology –  Psychology

•  “Safety” is hard to define and therefore hard to investigate

•  Success dependent on scientifically proven interventions

Health Promotion

•  Behaviour is influenced by •  Personal beliefs, attitudes and

perceptions •  Social Context

•  People won’t change their behaviour if the social, cultural and physical environment resist this change

•  Success dependent on building enough consensus to intervene

The real world is complex!

1.   The Efficacy to Effectiveness Gap Scientific complexity of generating knowledge in the real world

2.   The Research to Practice Gap Complexity of applying knowledge in the real world

3.   The Injury Prevention to Safety Promotion Gap Social complexity of building sufficient consensus to intervene

Who made the difference?

Dr. William Farr (bureaucrat)

Rev. Henry Whitehead (community activist)

Dr John Snow

(researcher)


Three different types of experts are required

More Information?

Closing the Gap Between Injury Prevention Research and Safety Promotion Practice

Revisiting the Public Health Model

Public Health Reports, 2012 Volume 127

Issue 2 http://www.publichealthreports.org/


More Information?

Research alone is not sufficient to prevent sports injury

British Journal of Sports Medicine, 2012

Volume 45 Issue 16 p1253


CLOSING THE GAP: PROGRESSING FROM INJURY PREVENTION RESEARCH TO SAFETY PROMOTION PRACTICE

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