DTIC ADA515980: A Systematic Process to Prioritize Prevention Activities: Sustaining Progress Toward the Reduction of Military Injuries

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by  Defense Technical Information Center

A Systematic Process to Prioritize
Prevention Activities
Sustaining Progress Toward the Reduction of
Military Injuries
Michelle Canham-Chervak, PhD, MPH, Tomoko I. Hooper, MD, MPH, Fred H. Brennan, Jr, DO,
Stephen C. Craig, DO, MTM&H, Deborah C. Girasek, PhD, MPH,
Richard A. Schaefer, MD, MPH, Galen Barbour, MD, Kenneth S. Yew, MD,
Bruce H. Jones, MD, MPH
Background:To sustain progress toward injury reduction and other health promotion goals,
publichealthorganizationsneedasystematicapproachbasedondataandanevaluationofexisting
scientifıcevidenceonprevention.Thispaperdescribesaprocessandcriteriadevelopedtosystem-
aticallyandobjectivelydefınepreventionprogramandpolicypriorities.
Methods:Militarymedicalsurveillancedatawereobtainedandsummarized,andaworkinggroup
ofepidemiologyandinjuryexpertswasformed.Afterreviewingtheavailabledata,theworkinggroup
usedpredefınedcriteriatoscoreleadingmilitaryunintentionalinjurycausesonfıvemaincriteria
that assessed factors contributing to program and policy success: (1) importance of the problem,
(2)effectivenessofexistingpreventionstrategies,(3)feasibilityofestablishingprogramsandpolicies,
(4)timelinessofimplementationandresults,and(5)potentialforevaluation.Injuryproblemswere
rankedbytotalmedianscore.
Results:Causeswiththehighesttotalmedianscoreswerephysicaltraining(34points),military
parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27
points),andmilitaryvehiclecrashes(27points).
Conclusions:Using a data-driven, criteria-based process, three injury causes (physical training,
militaryparachuting,andprivatelyowned–vehiclecrashes)withthegreatestpotentialforsuccessful
program and policy implementation were identifıed. Such information is useful for public health
practitionersandpolicymakerswhomustprioritizeamonghealthproblemsthatarecompetingfor
limitedresources.Theprocessandcriteriacouldbeadaptedtosystematicallyassessandprioritize
healthissuesaffectingothercommunities.
(AmJPrevMed2010;38(1S):S11–S18)PublishedbyElsevierInc.onbehalfofAmericanJournalofPreventive
Medicine
Introduction
H
istorically, public health policy development
From the Injury Prevention Program (Canham-Chervak, Jones), U.S. has been largely driven by ad hoc, often high-
ArmyCenterforHealthPromotionandPreventiveMedicine,Aberdeen visibilityandemotion-invoking,issuesofpublic
Proving Ground; Departments of Preventive Medicine and Biometrics
concern.1Whilerespondingtotheseissuesisanecessary
(Hooper,Girasek,Barbour),MilitaryandEmergencyMedicine(Craig),
Surgery(Schaefer),andFamilyMedicine(Yew),UniformedServicesUni- component of public health practice and policy, sus-
versityoftheHealthSciences,Bethesda,Maryland;andSeacoastOrthope- tained progress toward the reduction or prevention of
dicsandSportsMedicine(Brennan),Somersworth,NewHampshire
leading health problems requires a more systematic ap-
FredH.Brennan,Jr,DOwasanemployeeofUniformedServicesUni-
versityoftheHealthScienceswhenthisresearchwascompleted proachbasedonareviewofavailableepidemiologicdata
Address correspondence and reprint requests to: Michelle Canham-
and evaluation of the scientifıc evidence on existing or
Chervak,PhD,MPH,U.S.ArmyCenterforHealthPromotionandPreven-
tive Medicine, ATTN: MCHB-TS-DI, Aberdeen Proving Ground MD potential prevention strategies.2,3 As stated in the IOM
21010-5403.E-mail:[email protected].
report,TheFutureofPublicHealth,publichealthpolicy
0749-3797/00/$17.00
doi:10.1016/j.amepre.2009.10.003 developmentwouldbenefıtmostfrom“acarefulassess-
PublishedbyElsevierInc.onbehalfofAmericanJournalofPreventiveMedicine AmJPrevMed2010;38(1S)S11–S18 S11
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1. REPORT DATE 3. DATES COVERED
2010 2. REPORT TYPE 00-00-2010 to 00-00-2010
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
A Systematic Process to Prioritize Prevention Activities: Sustaining
5b. GRANT NUMBER
Progress Toward the Reduction of Military Injuries
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
U.S. Army Center for Health Promotion and Preventive Medicine,ATTN: REPORT NUMBER
MCHB-TS-DI,Aberdeen Proving Ground,MD,21010-5403
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
11. SPONSOR/MONITOR’S REPORT
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12. DISTRIBUTION/AVAILABILITY STATEMENT
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13. SUPPLEMENTARY NOTES
14. ABSTRACT

15. SUBJECT TERMS
16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF
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a. REPORT b. ABSTRACT c. THIS PAGE Same as 8
unclassified unclassified unclassified Report (SAR)
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Prescribed by ANSI Std Z39-18
S12 Canham-Chervaketal/AmJPrevMed2010;38(1S):S11–S18
ment of existing knowledge, establishment of priorities tary Training Task Force of the Defense Safety Oversight
basedondata,andallocationofresourcesaccordingtoan Council.12 The working group consisted of 18 faculty and
objective assessment of the possibilities for greatest graduate student volunteers from the Uniformed Services
impact.”1 UniversityoftheHealthSciences(USUHS).Itsmissionwas
Intheinjurypreventionfıeld,expertopinionhasbeen toreviewandassessexistingnonbattlemedicalsurveillance
thefoundationforprioritysettinginthepast.4–6Atleast andfıeldinvestigationdatatoidentifythelargestandmost
preventableDoDunintentionalinjuryproblemsthat,ifad-
onescoringsystemhasbeendevelopedforuseindefıning
dressed,hadthegreatestpotentialtorapidlyreducemilitary
injury prevention priorities that provides an objective,
injuryrates.
quantitativeassessmentofinjurybasedonthefrequency
Available epidemiologic data were obtained. Aggregate
ofemergencydepartmentvisitsbymechanismofinjury
data on nonfatal, non-deployment-related inpatient and
andtheseverityoftheinjurybasedontheInjurySeverity
outpatientmedicalencounters,asrecordedintheDefense
Score.7 However, in public health policy development,
Medical Surveillance System (DMSS),13 were requested
frequency and severity are only part of what must be
from the Armed Forces Health Surveillance Center (for-
consideredwhendecidingwhatprogramsandpoliciesto
merly, the Army Medical Surveillance Activity). Graphic
implement. Information on the effectiveness of preven- representations and data summaries were prepared by the
tionstrategies,gatheredfromexistingstudiesorsystem- U.S. Army Center for Health Promotion and Preventive
aticreviews,shouldalsobeconsidered.Additionally,po- Medicine, examples of which are presented elsewhere.14
litical,social,andeconomicfactorsinfluencethesuccess Summariesincludeddescriptionsofinjury-relatedmedical
or failure of a public health program or policy. While encounters in relation to other health problems, inpatient
many of these factors have been incorporated into sug- (hospitalization)andoutpatientinjuryratesovertime,and
gestedcriteriatoevaluateinjuryprogramsandpolicies,8,9 leading injury types and causes of hospitalizations among
therearenoprioritizationprocessesthathavecombined active duty military personnel (all Services) between 2003
allofthesefactors,noraretherepublisheddescriptionsof and 2005. Given that activities and causes associated with
outpatientinjurieswerenotroutinelycodedinthemedical
applicationsofprocessesthatcombineallofthesefactors.
data,causeofinjuryinformationfromfıeldinvestigations,
Thispaperdescribestheapplicationofaprioritization
whereinformationoncausesofoutpatientvisitswerecap-
process that includes the review of fatal and nonfatal
tured from medical record reviews, were also summa-
injuryepidemiologicdatawiththeuseofpredetermined
rized.15–17Frequenciesofactivedutyservicememberfatal-
criteria and scoring to obtain an objective, quantitative
ities by type (i.e., accident, illness, hostile action, other
assessment of the degree to which the leading causes of
intentional) were obtained from the Offıce of the Armed
militaryinjuriesarelikelytohavesuccessfulprogramand
ForcesMedicalExaminerforallServicesfor2003and2004.
policy implementation in the U.S. Department of De-
Duringa1-daymeeting,MIEPPWGmemberswerepre-
fense(DoD).Thisworkbuildsontwopriorinjurypriori-
sentedwiththeepidemiologicdatadescribedabove.Work-
tizationefforts:onethatgeneratedinjurypreventionpri-
inggroupmembersthenreviewed,discussed,andreached
orities for the U.S. Army Center for Health Promotion consensus on how they interpreted the previously estab-
and Preventive Medicine’s Injury Prevention Pro- lishedcriteriaforprioritizinginjuryprogramsandpolicies
gram3,10 and another that produced injury prevention (Table 1).2,3,10,18 Following the meeting, working group
priorities for the DoD.11 Rationale and background on memberscompletedtheprioritizationprocess.Worksheets
thedevelopmentofthisprocessareexplainedindetailby werecompletedindependently,thensubmittedtothelead
Jonesetal.2Thepurposesoftheprioritizationinitiative author(MCC)forcompilation.Worksheetswerecompleted
describedinthispaperwereto(1)refınepreviouspriori- foreachofthefollowingleadingcausesofmilitaryinjuries:
tizationeffortsbyutilizinginputfromexpertswithpublic falls/jumps,crashesofprivatelyownedmotorvehicles(in-
healthtrainingandexperienceevaluatingepidemiologic cludes trucks, cars, motorcycles), physical training, sports,
guns/explosives, military parachuting, twists/turns/slips
data and the scientifıc literature; and (2) to apply pre-
withoutfall,militarymotorvehiclecrashes,nontraffıcmo-
defıned criteria to identify top DoD injury causes most
torvehicleincidents,andmachinery/tools.Thesecausecat-
amenable to implementation of prevention programs
egorieswereconsistentwiththeNATOmilitaryinjurycause
andpolicies.
coding system,19 which is employed by the U.S. military
healthsystemtocause-codeinjuryhospitalizations.Nineof
these ten causes were identifıed from medical surveillance
Methods
dataastheleadingcausesofunintentionalinjuryhospital-
ThisinitiativebeganinApril2006withtheformationofthe izationsfortheleadingcausesofDoDinjurytypesamong
Military Injury Epidemiology and Prevention Priorities active duty military personnel in 2004.18 Physical training
WorkingGroup(MIEPPWG),establishedundertheMili- wasincludedbasedonevidencethatapproximatelyhalfof
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Canham-Chervaketal/AmJPrevMed2010;38(1S):S11–S18 S13
Table 1. Criteria for prioritizing injury causes amenable to prevention programs and policies
Criterion Preliminaryrating Finalscore
A.Consistentwiththemissionoftheagency/organization/workinggroup []YES IfYES—Continuewithscoring.
[]NO IfNO—Stophere.
B.Importanceofproblemtohealthandreadiness(10points) (10points;1(cid:1)low,10(cid:1)high)
Considerations:
1.Magnitudeoftheproblem(e.g.,frequency,incidence) 1.[]Low[]Medium[]High
2.Severityofproblem(e.g.,injurydiagnosis,lengthofstayorrecuperation) 2.[]Low[]Medium[]High
3.Costoftheproblem(e.g.,medical,training,property,andpersonnelcosts 3.[]Low[]Medium[]High
suchaslostworktime)
4.Sizeofpopulationatrisk 4.[]Low[]Medium[]High
5.Degreeofconcern(e.g.,leadershipconcern,publicandServicemember 5.[]Low[]Medium[]High
concern,visibilityofproblem)
C.Preventabilityofproblem(10points) (10points;1(cid:1)low,10(cid:1)high)
Considerations:
1.Cause(s)areidentifiable 1.[]Low[]Medium[]High
2.Riskfactorsaremodifiable 2.[]Low[]Medium[]High
3.Provenpreventionstrategiesthatreduceexistinginjuryratesexista 3.[]Low[]Medium[]High
4.Preventionstrategiesthatreduceexistinginjuryratescanbedesigned 4.[]Low[]Medium[]High
5.Effectsize 5.[]Low[]Medium[]High
D.Feasibilityofprogramorpolicy(10points) (10points;1(cid:1)low,10(cid:1)high)
Considerations:
1.Existenceofinfrastructuretosupportimplementationandsustainabilityof 1.[]Low[]Medium[]High
theprogramorpolicy(e.g.,medicalstaffandfacilities,safetystaffand
resources)
2.Perceivedadequacyoffundingtosupportimplementationandsustainability 2.[]Low[]Medium[]High
3.Authoritytoimplementandsustaintheprogramorpolicyisheldor 3.[]Low[]Medium[]High
obtainablebytheimplementingorganization(s)
4.Programorpolicywillnotundermineessentialmissions 4.[]Low[]Medium[]High
5.Politicalandculturalacceptabilityofprogramorpolicy 5.[]Low[]Medium[]High
6.Accountabilityandresponsibilityforimplementationandsustainabilityexists 6.[]Low[]Medium[]High
orcanbeestablished
E.Timeliness(5points) (5points;1(cid:1)low,5(cid:1)high)
Considerations:
1.Implementationtimeb 1.[]Low[]Medium[]High
2.Resultstimeb 2.[]Low[]Medium[]High
F.Evaluationofprogramorpolicy(5points) (5points;1(cid:1)low,5(cid:1)high)
Considerations:
1.Abilitytoevaluateeffectsofprogramorpolicyexists(i.e.,ifametricis 1.[]Low[]Medium[]High
possible)
2.Benefitsofprogramorpolicyoutweighthecostsofimplementationand 2.[]Low[]Medium[]High
sustainability
3.Collateralbenefitsasaresultofimplementation(e.g.,increasedreadiness, 3.[]Low[]Medium[]High
decreasedattrition,anddecreasedotherhealthproblems)
Totalscore
aIfsystematicreviewssubstantiateeffectivenessofapreventionstrategy,scoreas10pointsautomatically.
bAssignhighervaluetoprogramsandpolicieswithshorterimplementationandtimetodesiredresults.
Instructions:Completeascorecardforeachinjuryproblemunderconsideration.First,provideapreliminaryratingforeachoftheConsiderationslistedundereach
criterion.Then,usingthepreliminaryratingsasaguide,assignafinalscoreforeachcriterion.ForcriteriaB,C,andD,assignafinalscorefrom1to10(1(cid:1)lowest
score,10(cid:1)highestscore).ForcriterionEandF,assignafinalscorefrom1to5(1(cid:1)lowestscore,5(cid:1)highestscore).Addingthefinalscoreswillprovideatotal
score,withamaximumof40.
January2010
S14 Canham-Chervaketal/AmJPrevMed2010;38(1S):S11–S18
injuriesoccurringamongactivedutyservicememberswere Results
lowerextremity–overuseinjuries,14themajorityofwhichin
militarypopulationsareattributedtophysicaltraining.24,25 Ninemembersoftheworkinggroup(50%)volunteered
toparticipateinthefullprioritizationprocess.Nonpar-
Medical surveillance data reports indicated that causes of
injury hospitalizations did not vary substantially from ticipants, 44% of whom were graduate students, cited
2000–2004.20–23 “lackoftime”astheprimaryreasonfornotchoosingto
Table1presentsthecompleteworksheetandcriteriaused participate.Memberswhocontributedtotheprioritiza-
torateeachinjurycause.Theprocessfırstrequiredconsid- tionprocesswerealltrainedatthedoctoratelevelinone
erationofwhetheradoptionofprogramsorpoliciesrelated ormoreofthefollowingdisciplines:behavioralscience,
to the injury issue was consistent with the mission of the preventive medicine/epidemiology, occupational medi-
agency applying the scoring criteria (i.e., the working
cine,familymedicine,healthservicesadministration,in-
group’smission).Themedicalsurveillanceandfıeldinves-
ternalmedicine,orthopaedicsurgery,sportsmedicine,or
tigationdataprovidedtoworkinggroupmemberswereused
military medicine. Six of the nine were also formally
toratetheimportanceoftheproblem(CriterionB).Prevent-
trained in public health. Five participants were active
ability, feasibility of prevention, timeliness, and evaluation-
duty military, two were retired military, and two were
potential (Criteria C–F) assessments relied on individual
civilianacademicresearchersemployedbythemilitary.
knowledgeandexperience.Apreliminaryscoreoflow,me-
dium, or high was assigned to 21 factors, or “consider- Thehighestpossibletotalmedianscorewas40.Physi-
ations,”withinthefıvemaincriteria(CriteriaB–F).Work- cal training received the highest score (34), followed by
inggroupmembersconsideredpreliminaryratingsofeach military parachuting (32), privately-owned vehicle
“consideration”indeterminingafınalnumericscoreforthe crashes (31), sports (29), falls (27), and military vehicle
maincriterion.Maincriteriagivenahigher“weight”inthe crashes (27) (Table 2). Physical training and privately
process(importanceoftheproblem,preventability,andfea- owned–vehicle crashes had the highest median score
sibility)werescoredfrom1to10,andmaincriteriagivena
(9points)forimportanceoftheproblem.Militarypara-
lower “weight” (timeliness and evaluation potential) were
chuting had the highest median score (10 points) for
scoredfrom1to5.Theseweightswereadoptedfromprevi-
preventability of the problem and evaluation potential
ouswork.3,10,11
(5points).Physicaltrainingandtools/machineryhadthe
Causeswererankedusingthemediantotalscoreofeach
highestmedianscores(8points)forfeasibility;physical
injury cause. Median values were chosen for ranking in
training,militaryparachuting,andsportshadthehighest
ordertoavoidthepotentialeffectsofscoringvariability,as
mightbeexperiencedwithuseofmeanvalues.Thehigher medianscores(4points)fortimeliness.
thescore,thestrongertheindicationthattheinjurycause Tools/machinery and nontraffıc vehicle incidents,
wasamenabletoprogramandpolicyimplementation. comparedtoallothercauses,hadthelowestmedianscore
Table 2. Prioritization results: median scores for five main criteria, total score, and rank order by cause of injury
Causesofinjury Importancea Preventabilitya Feasibilitya Timelinessb Evaluation Total Rank
median(IR) median(IR) median(IR) median(IR) potentialb scorec
median(IR)
Physicaltraining 9(8,10) 9(7,10) 8(6,9) 4(3,5) 4(4,5) 34 1
Militaryparachuting 6(3,7) 10(6,10) 7(5,9) 4(4,5) 5(4,5) 32 2
Privately-ownedvehiclecrashes 9(8,9) 8(7,10) 7(5,8) 3(2,4) 4(3,4) 31 3
Sports 7(7,9) 7(6,8) 7(5,8) 4(3,4) 4(4,5) 29 4
Falls 7(6,8) 7(5,8) 6(6,7) 3(3,3) 4(3,4) 27 5
Militaryvehiclecrashes 7(7,8) 7(6,9) 6(4,8) 3(3,4) 4(3,4) 27 5
Gunsandexplosives 7(5,8) 7(6,9) 6(5,8) 3(3,4) 3(2,5) 26 7
Toolsandmachinery 5(5,6) 6(5,9) 8(5,8) 2(2,4) 3(3,4) 24 8
Twists/turns(withoutfall) 6(5,7) 5(3,6) 5(4,7) 3(2,4) 3(2,3) 22 9
Nontrafficvehicleincidents 5(5,8) 6(4,8) 4(3,7) 2(2,4) 3(2,4) 20 10
aMaximumscore(cid:1)10
bMaximumscore(cid:1)5
cSumofmedianscoresacrosscriteria,maximumscore(cid:1)40
IR,interquartilerange
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Canham-Chervaketal/AmJPrevMed2010;38(1S):S11–S18 S15
forimportanceoftheproblem(5points)andtimeliness causescoredlowerthanothercausesontheimportance
(2 points). Twist/turns had the lowest median score for oftheproblem.Evaluationshavedemonstratedthatan
bothpreventabilityandfeasibility(5points).Tools/ma- effective prevention measure exists (i.e., an external
chinery and nontraffıc vehicle incidents had the lowest parachute ankle brace), that would be expected to re-
median score for timeliness (2 points), and four injury duce the incidence of the most common injuries
causes (guns/explosives, tools/machinery, twists/turns, among airborne personnel, ankle sprains and frac-
nontraffıcvehicleincidents)receivedthelowestmedian tures,by50%–80%.34–36Thiscombinationoffactorsled
scoreforevaluationpotential(3points). tohighpreventabilityandtimelinessscoresfor“military
parachuting.”Ankleinjuryriskhasbeenshowntobe1.6
to2.9timeshigheramongparatrooperswhodidnotwear
Discussion
ananklebracecomparedtothosewhodidwearabrace.37
Thispaperdescribesaprocessthatproducedaprioritized These evaluations also demonstrate that it is feasible to
list of injury causes that can be used to inform and guide implementandtoevaluatetheeffectsofthisintervention
publichealthpractitionersandpolicymakerswhoneedto inmilitarypopulations,contributingtohighercriterion
prioritize health problems that are competing for limited scoresintheseareas.Thehighpreventability,feasibility,
programresources.Theresultsindicatedthatthetopthree timeliness, and evaluation scores in the prioritization
injury causes most likely to have successful program and processresultedinahighrankingforthisinjuryissue.
policyinterventionsintheDoDwerephysicaltraining,mil- Privately-owned vehicle crashes, which received the
itaryparachuting,andprivately-ownedvehiclecrashes. third-highestrankintheprioritizationprocess,havehis-
Theemergenceofphysicaltrainingasthetoppriorityfor toricallybeenaleadingcauseofmortalityandmorbidity
programandpolicyinterventionisnotsurprising.Investi- among military service members.38,39 Each year, “land
gationsofU.S.Armyactivedutypopulationshaveshown transport” is noted as a leading cause of DoD injury
physicaltraining–relatedinjuriestobetheleadingcauseof hospitalizations, representing 9.1%–18.7% of all injury
injuries, accounting for 25%–50% of all injury vis- hospitalizations (2000–2006) with a valid injury cause
its.15,17,26–29AmongMarineCorpsrecruits,higherfrequen- code.20–23,40–42Safetydatahavealsoindicatedthat59%,
ciesofvigorousphysicaltraininghavebeencorrelatedwith 64%,61%,and55%ofunintentionalinjurydeathsforthe
higher musculoskeletal injury rates.25 Among the other U.S.Army,Navy,MarineCorps,andAirForce,respec-
Services, surveillance of training-related, lower ex- tively, were due specifıcally to privately-owned vehicle
tremityoveruseinjurieshasindicatedthatsuchinjuries, crashes.43 Based on these and other statistics, privately-
which are largely training-related,24,25 account for ap- ownedvehiclecrashesscoredhighonimportanceofthe
proximately50%oftheService-specifıctotalinjurybur- problem.Theavailabilityofrecentsystematicreviewsof
dens.14 These numbers suggest that the frequency and prevention strategies such as graduated licensing, de-
incidence of the problem is large. Given that all Service creasing alcohol-impaired driving, and increasing seat
membersmustalsomaintainspecifıedlevelsofphysical beltuse44–46contributedtoitshighpreventabilityscore.
fıtness,thesizeofthepopulationpotentiallyaffectedby Highscoresonbothofthesemeasures—importanceand
physical training–related injuries is also large. Prevent- preventability—ultimatelycontributedtothehighrank-
abilityofphysicaltraining–relatedinjurieswasratedhigh ingoftheprivately-ownedvehiclecrashesintheprioriti-
because there are proven prevention strategies (e.g., zationprocess.
avoiding overtraining, conducting agility-like training, Ofnote,fallsdidnotrankasoneofthetopthreeinjury
use of mouthguards)30 that could be adopted immedi- programandpolicypriorities,despiteannualdocumenta-
ately to reduce physical training–related injuries. In the tion showing falls to be the leading cause of active duty
UnitedStates(U.S.)Armyastandardizedphysicaltrain- militaryinjuryhospitalizations,accountingfornearlyone
ingprogramthatavoidsovertrainingandutilizesagility- fıfthofallinjuryhospitalizationseachyear.20–23,40–42The
liketraininghasbeenfoundtoreducephysicaltraining– lower ranking of falls as a prevention priority is partially
related injuries while meeting desired physical fıtness explainedbythedearthofdescriptiveandanalyticepidemi-
goals.31,32 Given that the ability to evaluate such pro- ologyidentifyingmodifıablecausesandriskfactorsoffallsin
gramshasbeenpreviouslydemonstrated,31,32theevalu- military and other working-age populations. As a conse-
ation potential for physical training received the maxi- quence, there are also few evaluated interventions in the
mumscore(5). literature for the prevention of falls in military and other
Military parachuting injuries, ranked second in this working-agepopulations.47
process, can be severe and numerous;33 however, they Theprioritizationprocessdescribedhadanumberof
affectarelativelysmallsubsetofthemilitaryandpredom- strengths. First, it attempted to minimize bias through
inantlyoneService(Army)only.Asaresult,thisinjury use of quantifıable, objective measures. Objectivity was
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S16 Canham-Chervaketal/AmJPrevMed2010;38(1S):S11–S18
builtintotheprocessbyrequiringthereviewofavailable such as described by Bullock et al.,30 could assist with
epidemiologicdatatoratetheimportanceoftheproblem strikingthisbalance.
andbytheuseofaworksheet,whichforcedconsideration Alimitationoftheresultsofthisprocessisitsbasison
ofallpredeterminedcriteriaandenhancedthevisibility causesofinjuryhospitalizations.Atthetimethispriori-
ofworkinggroupmembers’preliminaryratingsandfınal tization process was conducted, outpatient injury cause
scores. Second, as has been recommended,48 the data coding was inconsistent and incomplete. The ability to
reviewed were not limited to mortality data. Rather, quantify outpatient causes of injuries would alter the
working group members also reviewed and formulated informationavailableforrankingtheimportanceofthe
theirratingbasedondataonthemorenumerousnonfatal problem(CriteriaB).Improvementsinoutpatientinjury
injuriesandtheircauses.Third,thecriteriaweresimilar causecodingwouldwarrantrepetitionofthisprocess,as
tothosesuggestedorusedelsewhere,8,9,49–51andensured prioritizationresultsmaydifferwiththeadditionofthis
considerationofkeyfactorsfelttoinfluencethesuccessor information. Additionally, repetition of this process is
failureofprogramandpolicyefforts.Finally,thescoring recommended every 5–10 years, to account for other
system and analysis provided a simple and straightfor- changesovertime,suchasadditionstothemedicaland
ward mechanism to weight and score those key factors. publichealthliterature.
Thesecriteriaandweightscouldbeeasilymodifıedtosuit Insummary,thisprocesswasdesignedtoproducealist
thespecifıcneedsandconsiderationsofothercommuni- ofinjurypreventionprioritiesthroughasystematicand
ties.Whileaquantitativeprocessmaynotbeabsolutely objectiveratingofthedegreetowhichtheleadingcauses
necessary,9 it was felt that the commitment to a weight of DoD injuries were amenable to program and policy
andscoreforcedparticipantstoconsidereachfactordur- implementation. Its use is not limited to the military,
ingtheprocess.Inaddition,whileanalternativeanalysis however.Inbothmilitaryandcivilianpublichealthorga-
method52wasconsidered,itwasultimatelynotreported, nizations, establishing data-driven prevention program
giventhedesireforamethodologythatwaseasytoun- and policy priorities can provide a focus for work and
derstand and apply in public health practice, and that continuedprogresstowardinjuryreductiongoalswhen
there was no difference in the results obtained by this not responding to urgent public health concerns. The
alternative,morecomplexmethod. process also should not be limited to use in the injury
These criteria, worksheet, and process could also in- prevention fıeld; the criteria and worksheet could be
formfutureenhancementsofexistingprocessestoprior- adapted and applied to prioritize implementation of
itize prevention research.5,53,54 Criteria to prioritize re- otherpublichealthprogramsandpolicies.Suchsystem-
searchshouldincludesimilarconsiderations,suchasthe atic approaches to prioritizing scarce public health re-
magnitudeandseverityoftheproblemandadequacyof sources are necessary, as Dr. William Haddon, Jr. ex-
resources,butshouldalsoconsidertheexistenceofgaps pressed, in order to avoid “inappropriate choices of
in knowledge (i.e., the absence of “proven” prevention emphasis”that“dissipatefunds,time,andpublicconcern
strategies) and availability of research partners.2 Estab- thatmightbeappliedtomoreeffectivemeasures.”58
lishmentofapublichealthresearchagenda(i.e.,research
priorities)thatconsiderpublichealthprogramandpolicy
Theauthorsgratefullyacknowledgetheparticipationof
needsisneededtoimprovetheeffectivenessofourpublic
CAPT (Dr.) Ken Schor and Dr. Richard Thomas, who
healthsystem.55
contributedtheirtimeandexpertknowledgetothepri-
Opportunities for improvements to the process in-
oritizationprocess,andstatisticalconsultationprovided
clude involving the raters earlier in the process, so that
byMs.RobynLee.
theyhaveinputintothefınalcriteriaandmethodsused.
The views expressed herein are the views of the au-
Inaddition,preventivemedicineandpublichealth,like
thor(s)anddonotreflecttheoffıcialpolicyoftheDepart-
clinical medicine, have become increasingly focused on
mentoftheArmy,theDepartmentoftheNavy,theDoD,
the importance of identifying evidence-based practices
ortheU.S.Government.
prior to implementation.56,57 The rigor of the process
Nofınancialdisclosureswerereportedbytheauthors
couldbefurtherenhancedbyrequiringdenovosystem-
ofthispaper.
atic reviews of the literature on program effectiveness
ratherthanrelyingonexpertopiniontodefıneprevent-
ability, feasibility, timeliness, and evaluation potential.
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