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potential causal factor subsequent to
Accidents and unintentional injuries
Robert G. Frank and Andrea M. Lee
University of Florida
Injury is a leading cause of death and disability for America’s
young adults and children. It is the leading cause of death for
those from ages 1 to 44 (Mokdad et al., 2004) and is the fifth leading
cause of death for all Americans (Centers for Disease Control and
Prevention, 2001). Injuries are associated with higher treatment
costs than the other three leading causes of death. Traffic accidents
are the leading cause of severe brain injury, as well as most paraplegic
and quadraplegic cases (Spielberger & Frank, 1992).
For many years, injuries were viewed as ‘accidents’ that were
inevitable and not responsive to prevention efforts. Injury events
tended to be attributed to human error or misaction; individuals
died or were injured due to driving while intoxicated or a leg was
broken when someone failed to watch their step. This psychological
model of injury was related to the emergence of the concept of
‘accident-proneness’ during the 1930s and 1940s. In this approach,
accidents occurred to individuals as a function of unconscious
wishes or desires (Waller, 1994).
Injury events were also attributed to human error or misaction
because they often involved relatively rare events that were perceived
as unpredictable. Many data systems tended to record only
‘single’ causes of injury, negating the idea that a crash may occur
both because the driver is impaired by alcohol and because the
roadway geometry at the crash location is inadequate (Waller,
1994). Rarely did anyone examine the overall frequency of injuries
to determine if higher risk existed under certain circumstances. For
example, lacking statistics, the crash risk at a particular bend
in a roadway may go unrecognized. Only when examined will the
1 per 250 000 vehicle risk achievable with improved roadway design,
compared with the existing crash risk of 1 per 50 000, be recognized
(Waller, 1994).
Models of injury control
In 1959, James J. Gibson, an experimental psychologist, recognized
that injury was caused by energy interchange which occurred at the
moment of, and subsequent to, the incident. Gibson suggested the
most effective method of classifying sources of energy is the form of
the physical energy involved (Rosenberg & Fenley, 1992). Gibson’s
observation became the lifework of Dr William Haddon, Jr, an
miscarriage in recurrent spontaneous
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Swanson, K. M., Karmali, Z. A., Powell, S. H.
& Pulvemaker, F. (2003). Miscarriage
effects on couples’ interpersonal and
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engineer and public health physician. Haddon narrowed the potential
agents to five forms of physical energy: kinetic, chemical,
thermo, electrical and radiation. Haddon also recognized ‘negative
agents’ for injuries produced by the absence of critical elements
such as oxygen or heat. Haddon labelled these agents as vectors
and the vehicles as energy forms. He divided injuries into three
phases: (i) a preinjury; (ii) a very brief injury phase; and (iii) a postinjury
phase.
During the preinjury phase, the control of the energy source is
lost. The preinjury phase includes everything that determines
whether a crash will occur (e.g. driver ability, vehicle functioning,
seat belt usage). The injury phase typically lasts less than a second
and transfers energy to the individual, thereby causing damage. The
postinjury phase determines whether the injuries and consequences
could be reduced with subsequent prevention of further disability
(e.g. speed, inefficiency of first responders). During the postinjury
phase, attempts are made to retain physiological homeostasis and
repair damage. Haddon also observed that injuries can often be
prevented by attending to the vector (Rosenberg & Fenley, 1992;
Waller, 1994).
Using this model, Haddon developed an innovative plan to intervene
upon injury events by: (i) preventing or limiting energy buildup;
(ii) controlling the circumstances of energy to prevent unlimited
release; (iii) modifying the energy in transfer phase to limit damage;
and (iv) improving emergency, acute and rehabilitative care to affect
recovery (Waller, 1994).
Haddon’s model led to the development of the Haddon Matrix.
Haddon’s ‘phase-factor matrix’ is actually a series of matrices developed
for different purposes. The Haddon Matrix emphasizes the
preventive value of the epidemiological approach to injury control.
In the matrix, the host, agent (vector) and environment are seen as
factors that interact over time to cause injury.
Haddon’s work led to the recognition that, during each of the
three phases, preinjury, injury and postinjury, injury likelihood
can be reduced by changes in the driver (in the case of vehicular
injury), the agent (or vehicle), or the environment. Previous models
of injury prevention have emphasized psychological factors, thereby
allowing only one intervention point. In contrast, the Haddon
Matrix creates nine cells, each of which offers an opportunity for
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