Feature

Psychologists are underrepresented in efforts to prevent a leading cause of death in the United States--not heart disease or cancer, as one might suspect, but injuries, say Rodney Hammond, PhD, and David Sleet, PhD, two psychologists at the Centers for Disease Control and Prevention (CDC).

Injuries, both violent and unintentional, are the No. 1 cause of death for Americans ages 1 to 44. And many injury-related deaths are related to behaviors that psychologists know much about--violence in the home and in schools, drug and alcohol use, risk-taking and sensation-seeking, parenting and supervision practices and noncompliance with safety rules. A disproportionate number of these injuries and fatalities occur among young people. In fact, injuries account for nearly 80 percent of all deaths among young people ages 15 to 24, Hammond and Sleet point out.

"From a public health perspective, someone looking at this and doing the math would think, 'Gee, why aren't we doing more about this problem?'" says Sleet, associate director for science in the Division of Unintentional Injury at CDC's National Center for Injury Prevention and Control.

Despite the fact that behavioral and other preventive interventions can save lives and reduce health-care costs, Sleet adds, the money spent on injury prevention research is regrettably small--about 11 percent of that spent for research on cancer and 18 percent of that spent on cardiovascular disease.

Meanwhile, "psychologists have just the sorts of skills needed to address these problems," says Hammond, director of the CDC's Division of Violence Prevention. As experts in so many areas related to injury--among them risk perception, motivation, developmental psychology, stages of change, social learning theory, protection motivation, counseling and education and trauma--psychologists can play a central role in addressing these problems, Hammond and Sleet say.

Increasingly, psychologists are beginning to explore the injury-prevention field and institutions like the CDC are recognizing psychologists' expertise and finding a place for them in public health. Recently, APA and the CDC jointly sponsored a conference on behavioral and social sciences in public health, and the CDC has formed an international working group on behavioral science and injury prevention.

With this article, the Monitor offers a taste of what's shaping up in this budding area.

Safety devices

One CDC grant is enabling Emory University psychologist Nancy Thompson, PhD, to disseminate state-of-the-art behavioral information on people's use of bicycle helmets, smoke alarms and child safety seats.

"All of these devices are very effective, but the problem is getting people to use them and use them effectively," says Thompson, associate professor in the department of behavioral sciences and health education at Emory's Rollins School of Public Health.

In the three-year project, now in its final year, Thompson and her graduate students have been synthesizing the best research studies in each area and compiling a list of all of the behavioral constructs associated with them. For example, constructs relating to peer pressure, social norms and supervision are all relevant to children's use of bike helmets, she says.

In addition, Thompson is convening a panel of experts to develop integrative models that combine their expertise and the research findings. Sometimes she's been surprised by what's emerged: The panel on smoke alarms, for instance, focused more on what people should do once an alarm goes off than on making sure people test whether detectors are still functional. One reason for this, she discovered, is that new smoke-detector technology is making dysfunctional alarms a thing of the past because new alarms are hard-wired rather than using batteries that can wear out.

The last phase of the project will determine how to disseminate the panel's findings. It's possible it will come in two forms: One for scientists and another for those who run safety programs, such as fire departments that direct smoke-detector campaigns and day-care centers that train parents on installing child safety seats.

"Until now, people have been running programs for all of these devices without much guidance from behavioral scientists," Thompson says. "Our hope is that by giving people some guidance through CDC, they'll understand the best steps to take to enhance correct usage."

Intimate-partner violence and suicide

Another series of CDC-funded studies is looking at ways domestic violence and other social and mental-health factors can influence suicide risk among low-income African-American women. The studies, led by Nadine Kaslow, PhD, of Emory University, have recently been testing a culturally based group-empowerment intervention to help these women cope.

In the first study of its kind, Kaslow found that domestic violence was indeed related to suicidal behavior among low-income African-American women. She and her team interviewed 285 women in all, half of whom entered the hospital following a suicide attempt, and the other half, who entered for other medical issues.

In two other studies, Kaslow and colleagues explored which low-income African-American women who were in abusive relationships were more likely to attempt suicide. They found that those in physically and sexually abusive relationships were 2.3 times more likely to attempt suicide than those who had not been abused, while those in emotionally abusive relationships were 2.8 times as likely.

Abused women who were more likely to attempt suicide also reported higher levels of psychological distress, hopelessness and drug use, the team found. On the other hand, social support, a sense of self-efficacy, good social skills and the ability to obtain material resources were linked to lower rates of suicide attempts.

Drawing from those findings, Kaslow and colleagues are now in the first year of a three-year study to see how an intervention might affect these women's outcomes. The team is comparing a group of abused, suicidal African-American women who are taking part in an experimental 10-session empowerment group with a group of matched controls who receive treatment in the traditional mental health referral system. Kaslow designed the experimental treatment and created a manual for it.

"The intervention is designed to capitalize on these women's reported strengths, and to decrease their reported problems, including negative psychological symptoms, substance abuse and feelings of hopelessness," Kaslow says.

Results from the study are not yet available, but the team is hopeful the intervention will make a difference, Kaslow says. Anecdotally, she adds, the women report they're excited about the chance to increase their skills and strengths and to be more connected to women like themselves.

Fire and burn victims

Virginia Polytechnic Institute and State University psychologists Russell T. Jones, PhD, and Tom Ollendick, PhD, are studying the impact of residential fires on the mental health of children ages 7 to 16 with a $1.3 million grant from the National Institute of Mental Health.

The study is one of the first to examine the impact of home-based fires on children of different age groups over time, says Jones.

So far, the team has found that about 10 percent of youngsters from a sample of about 100 families show elevated levels of depression and post-traumatic stress disorder after this trauma, and that their level of distress is related to their degree of exposure to and loss from a fire.

The results show a high degree of unwarranted guilt among the children. About 30 percent of the children felt they should have been able to do something to prevent the fire from occurring, and 18 percent believed the fire was their fault, the team found. Sixteen percent felt they could have done more to stop the fire, while 85 percent said they'd never experienced anything as bad as the fire. Twenty percent reported never having been trained in fire safety, suggesting the need for more preventive coaching and an easy avenue through which to help youngsters avoid injuries from happening in the first place, Jones says.

The team also is examining how variables, including demographic characteristics, negative life events, parental reactions, types of coping and amount of social support, moderate or mediate youngsters' response.

Preliminary data on about 52 families interviewed at three and six months after a fire show that children use both avoidant methods of coping, such as denial and wishful thinking, as well as active methods such as direct problem-solving and positive cognitive restructuring. While the team found no significant differences between these two coping methods at six months, they hypothesize that the mental health symptoms of children who continue to engage in avoidant coping over time will worsen. Active coping strategies, however, they believe, may stabilize and eventually reduce levels of stress. The team will continue to look at these factors as they play out over time.

The team is also developing treatment strategies to help youngsters and families cope with a fire's aftermath. Using a cognitive-behavioral program called Rehearsal-Plus (R+), the team will help youngsters process and move on from the fire, says Jones. One particularly promising part of the intervention will help youngsters rehearse the steps of how to escape a fire should it happen again, Jones says.

Violence prevention in the schools

Excellent models for youth-violence prevention programs abound, and many middle and high schools have tried to implement them. But there's still a wide gap between the quality of these models and how they're applied, says psychologist Patrick H. Tolan, PhD, director of the Institute for Juvenile Research at the University of Illinois at Chicago.

Tolan and about 25 other behavioral scientists are tackling that problem in a major four-year study funded by the CDC. The study, to take place at 52 middle and high schools in Chicago, Athens, Ga., Durham, N.C., and Richmond, Va., will compare three strategies that schools often use to determine which is most effective: an ecological approach that includes the whole school; one that exclusively targets young people who show aggression and their families; and a third that combines these two approaches.

The study is unique in two ways, says Tolan, principal investigator at the Chicago site. It's the first to compare programs using such a careful research design--each school will be randomly assigned to receive one of the interventions or serve as a nonintervention control. It's also the first to compare synthesized versions of the two current approaches in the field, the ecological approach and the targeted approach. These approaches have heretofore been conceptualized and run only as very controlled and small-scale research projects that don't resemble how schools actually choose and implement programs, he says.

The psychologists involved "jumped onto the project because it is where this scientific work needs to go," Tolan says. "With the large funds put into youth violence prevention programs, most of which aren't using approaches that have been found to work and most others that aren't being done in a way that works, there's a lot of money being wasted, and kids and communities aren't being helped."

Other site investigators--all of whom are long-time experts in violence prevention--include Tolan's colleagues Deborah Gorman-Smith, PhD, and David Henry, PhD, both psychologists at the University of Illinois at Chicago; principal investigator at the Durham, N.C., site, Duke University psychologist David Rabiner, PhD, and Duke colleagues and psychologists Sherry Miller-Johnson, PhD, and Ken Dodge, PhD; Richmond, Va., principal investigator and psychologist Al Ferrell, PhD, and psychologist Aleta Meyer, PhD, of Virginia Common- wealth University; and Athens, Ga., principal investigator and psychologist Andy Horne, PhD, of the University of Georgia, among others.

The team spent a year designing the project and launched a pilot at 20 schools across the sites in January. In 2002 and 2003, they'll conduct the intervention proper. The scientists also hope to extend funding for another year to permit follow-up and to analyze results, Tolan says.

"We know prevention can work--we know it's promising," Tolan comments. "Now we need to do these studies to get people to use the interventions and administrative protocols in the most effective ways."

Tori DeAngelis is a writer in Syracuse, N.Y.

APA participates in national injury prevention alliance

APA and more than 25 other national organizations have teamed up with the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control to form SafeUSA--an alliance with a goal of making American homes, schools, work sites, transportation and communities safer.

SafeUSA was formed to combine scientific research, programmatic efforts, public policy initiatives and community involvement to enhance public awareness and support injury prevention efforts. Its partners include public and private organizations working in diverse areas, including public safety, public health, transportation, law enforcement, education, medicine and research. By pulling these member organizations together, SafeUSA aims to draw from the strengths of each and minimize duplicated efforts.

"An appealing aspect of the group is that its concept of safety encompasses injury resulting from violence as well as unintentional injury," says Jacquelyn Gentry, PhD, the APA representative on the SafeUSA Partnership Council and chair of its handbook committee. "Behavioral sciences have a lot to contribute in both areas."

This year, the alliance will have its official kickoff at the SafeUSA National Conference, Dec. 3­5, in Atlanta. Participants will have the opportunity to exchange information on science-based injury prevention programs; develop partnerships with national, state and local organizations; identify resources that support injury prevention and control research; and advance a research agenda.

However, several SafeUSA efforts are already under way. The alliance is developing a Corporate Partners program as well as community guidelines and a handbook that will provide prevention strategies, explain the attributes of effective prevention efforts and offer additional resources.

The alliance has also established an information clearinghouse through its Web site (www.cdc.gov/safeusa) and through an information hotline at (888) 252-7751 or TTY: (800) 243-7012. Both resources provide information on safety issues in a variety of settings and provide resources for additional information.

--D. SMITH

Further Reading

For more information on research, training and job possibilities available at or through the CDC, contact www.safeyouth.org. Visit the CDC's Web site at www.cdc.gov.