Have we become so accustomed to being passive that we've forgotten how to be active?

In the theory of injury prevention, whether you subscribe to the school that espouses active strategies or the one that prefers the passive approach, it often seems to be a choice between irreconcilable differences. Legislative and environmental changes are the key principles of the passive approach, while education and behaviour change are the cornerstones of the active approach. When did the school of thought that asserts the supremacy ofpassive approaches come into being? Waller speaks of a 'conceptual shift' from attributing injuries to defective behaviour (requiring education to change that behaviour) to a reliance on environmental modifications. ' In fact, the passive approach was well entrenched by 1980, when Baker wrote that 'measures that have proved most likely to work are those that never require any action by a child or his family', and that this protection is 'totally independent or the wisdom, caution, skill, and psychological makeup of the individuals who are protected'. 2 Further, Baker notes that 'despite all the evidence that posters, pamphlets, media campaigns, and other educational programmes do not produce changes in daily behaviour that would effectively reduce injuries, this kind of approach is often relied upon'. These views are reiterated by Wilson and colleagues who counsel that educating decision makers, although challenging, is less formidable than educating parents and children.3 This advice neglects the fact that many decision makers are subject to lobbying by powerful external forces that often influence whether safety makes it onto the agenda or not. What do we mean by education, and does it work in health and safety promotion? Education can be directed to both individuals and populations. A 1981 UK case-control study concluded that health education did not reduce injuries,4 confirming the results of two earlier United States studies. The UK program used 'conventional health education techniques', that is leaflets, posters, and lectures, in one area of a small city. Data were collected for five weeks before the campaign and for nine weeks after. Not only was the sample very small and the time period short, the materials used were probably less sophisticated than those we may use today. Robertson warns that some educational programs may actually do more harm than good. However, his principal, and certainly valid, criticism is that too many programs have been implemented without prior rigorous evaluation.5 Blanket disapproval of similar educational strategies may have been based on similarly scant evidence. No-one seems to have asked why they didn't work. Were they based on false premises or were there design problems in the studies? Nevertheless, under the weight of a great deal of learned opinion that education doesn't work, you might be forgiven for wondering how you ever graduated from university and gained employment! Perhaps the point has been made so forcefully and so often that it has become a self fulfilling prophecy. What troubles those of us who believe that education has been undervalued and underutilised, is the sneaking suspicion that when the opportunitites for passive intervention run out, that leaves us with-yes, education and behaviour modification! Other opinions acknowledge the role of education in 'creating a climate of opinion in which safety features in the product or the environment, or a particular safety action',6 and 'the need for flexibility in combining strategies to arrive at the most effective mix'. 7 A comprehensive review of the role of education in injury prevention found many educational materials wanting, but that definitions of education were also too narrow. To be effective, educational approaches should be based on appropriate learning theory, applied to the right target audience, over a sufficient length of time, evaluated and then strongly promoted.8 There are several injury topics, for example food related choking, for which few passive interventions exist. Should these be ignored in favour of interventions where a product or an environmental modification might solve a problem? It is interesting to note that journal literature on such topics is sparse. I suggest that to ignore these topics borders on neglect. Parents are entitled to as much information as possible to protect their children and we should not be afraid to give it to them. During the last few years, two highly successful health promotion campaigns have shown that education, appropriately targeted, could be effective on its own. These provide compelling evidence that community-wide education does work. The campaigns were the skin cancer campaign to reduce the incidence of melanomas in Australia,9 and the assault on sudden infant death (SIDS), which has spread world wide. '0 Now that we have some models to follow, why hasn't injury prevention and control taken Royal Children's Hospital Safety Centre, Flemington Road, Parkville, Victoria 3052, Australia