CDC Injury Research Agenda

Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Atlanta, Georgia

June 2002
The CDC Injury Research Agenda is a publication of the National Center for Injury Prevention and Control,

part of the Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention

David W. Fleming, M.D.

Acting Director

National Center for Injury Prevention and Control

Sue Binder, M.D.

Director

Suggested citation: National Center for Injury Prevention and Control. CDC Injury Research Agenda.

Atlanta (GA): Centers for Disease Control and Prevention; 2002.
CDC Injury Research Agenda i

Injuries are the number-one killer of children and young adults in the United States. They are the leading

cause of years of potential life lost before age 65. More than 5 million people in the U.S. report suffering

from chronic, injury-related disabilities, and the lives of millions of others have been dramatically affected

by injuries to themselves or someone they love.

These statistics are staggering. Our goal at the National Center for Injury Prevention and Control—CDC’s

Injury Center—is to reduce injuries and their resulting deaths and disabilities. We have made a lot of

progress, but there is still much to learn and much work to do. Research is needed to provide valuable

knowledge for the injury field and to inform our prevention efforts.

In December 2000, the Injury Center embarked on an 18-month process to develop an agenda to guide our

research. The agenda articulates our highest priorities—those research questions that we must answer to fulfill

our public health responsibilities.

The research agenda focuses on answering questions that will have a relatively rapid impact on how we

prevent injuries and reduce their consequences. Thus, many of the research issues of highest priority for this

agenda relate to evaluating interventions and understanding how to ensure that effective interventions are

widely used.

Many people helped develop the research agenda. Injury Center staff worked extensively—planning, writing,

discussing, revising. Many individuals from a variety of organizations served on work groups, attended

meetings, and reviewed documents. Under the leadership of Dr. Edward Brandt, members of the Research

Agenda Steering Committee shared their own thoughtful perspectives that were extremely important in

shaping the agenda. Hundreds of others took time to provide comments and participate in discussions that

proved vital to the agenda-setting process. The names of individuals who were most involved in the process

are listed in the acknowledgments. CDC extends a grateful thank you to all who generously gave of their

knowledge, wisdom, creativity, and time.

Implementing this agenda will be challenging. The funds allocated for injury research and programs are not

at all commensurate with the size of the injury problem. But investing in the priorities of this research

agenda will make a difference. It will help prevent needless deaths and painful, costly injuries. We look

forward to working with the injury prevention and control community to implement this agenda for a safer,

healthier nation.

Sue Binder, M.D., Director

National Center for Injury Prevention and Control

Foreword

CDC Injury Research Agenda iii

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Cross-cutting Priorities for Injury Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Preventing Injuries at Home and in the Community . . . . . . . . . . . . . . . . . . . . . . . . .17

Preventing Injuries in Sports, Recreation, and Exercise . . . . . . . . . . . . . . . . . . . . . . .27

Preventing Transportation Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Preventing Intimate Partner Violence, Sexual Violence, and Child Maltreatment . . . . . .49

Preventing Suicidal Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Preventing Youth Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

Acute Care, Disability, and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105

Contents

CDC Injury Research Agenda 1

Background

Injuries have a substantial impact on the lives of individual Americans,

their families, and society. The consequences of injuries can be extensive

and wide ranging. They are physical, emotional, and financial; in the case

of disabling injuries, the consequences are enduring.

The mission of the National Center for Injury Prevention and Control

(Injury Center) at the Centers for Disease Control and Prevention (CDC)

is to prevent premature death and disability and to reduce the human

suffering and medical costs caused by injuries. To prevent injuries and

minimize their consequences when they occur, the Injury Center uses the

public health approach—a systematic process to:

• define the injury problem;

• identify risk and protective factors;

• develop and test prevention interventions and strategies;

• ensure widespread adoption of effective interventions and strategies.

The Injury Center is the only organization in the federal government with

the responsibility to address all phases of the injury research

framework—from foundational research through dissemination

research—for all major causes of injury among all age groups. (The injury

research framework is described on page 7.) To reach its goal of

translating science into effective programs and policies, the Injury Center

collaborates with other federal agencies and partners to document the

incidence and impact of injuries, understand the causes, identify effective

interventions, and promote their widespread adoption.

The importance of research in diminishing the problem of injuries has

been described before. For example, the 1985 Institute of Medicine

(IOM) report Injury in America concluded that supporting injury research

is necessary to substantially reduce injury rates; the Injury Center’s

formation was, in part, a result of this IOM finding. Fourteen years later,

another IOM report, Reducing the Burden of Injury, re-emphasized the

importance of a scientific foundation for injury prevention and called on

the Injury Center to work with foundations, states and communities,

businesses, and other federal agencies to stimulate and facilitate

Introduction
investment in injury research activities. Publishing this research agenda is

a step toward that goal.

The Public Health Burden of Injury 

In 1999 in the United States, nearly 150,000 people died from injuries, and

1 in 10 people experienced a nonfatal injury serious enough to require a

visit to the emergency department. Injuries—including unintentional

injuries, homicide, and suicide—are the leading cause of death for people

ages 1 to 44 (table 1). Injury is the leading cause of years of potential life

lost before age 65.

For people ages 1 to 34, unintentional injuries alone claim more lives than

any other cause. In 1999, motor vehicle traffic fatalities accounted for

42% of unintentional fatal injuries, representing more than 40,000 deaths

(table 2). Poisoning, suffocation, drowning, falling, and fire each

accounted for a substantial proportion of unintentional injury deaths.

Adverse effects in medical settings caused an additional 2,540 fatalities.

The impact of injuries resulting from violence is also great. Homicide is

the second leading cause of death for people ages 15 to 24 and the third

or fourth leading cause for every other group between the ages of 1 

and 34. Suicide is not only the eleventh leading cause of death across all

ages but ranks second for people ages 25 to 34 and third for people ages

15 to 24.

Many injuries do not result in death but nevertheless place a considerable

burden on individuals and society. Approximately one third of all

emergency department visits and 8% of all hospital stays are due to

injuries. Data from the National Electronic Injury Surveillance System

indicate that falls account for an estimated 7.43 million emergency

department visits annually, or 25% of all injury visits (table 3). Another

4.95 million visits (17%) are transportation related, and 1.67 million

(5.7%) result from assaults. In addition, many injuries have consequences

well beyond the initial need for medical attention. For instance, it is

estimated that 5.3 million people in the U.S. have long-term disabilities

from traumatic brain injury and 200,000 from spinal cord injury. The

topic-specific chapters that follow present more detailed data, but clearly,

injuries constitute a major burden on the public’s health.

2 CDC Injury Research Agenda

Injuries—including

unintentional injuries,

homicide, and

suicide—are the

leading cause of

death for people

ages 1 to 44.
C

DC

 

Injury Research

 

Agenda

3

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDCData Source: National Center for Health Statistics, Vital Statistics System

Table 1

10 Leading Causes of Death, United States, 1999

All Races, Both Sexes

Age Groups

Rank <1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+ All Ages

1 Congenital Unintentional Unintentional Unintentional Unintentional Unintentional Malignant Malignant Malignant Heart Heart

Anomalies Injury Injury Injury Injury Injury Neoplasms Neoplasms Neoplasms Disease Disease

5,473 1,898 1,459 1,632 13,656 11,890 16,732 46,681 89,067 607,265 725,192

2 Short Congenital Malignant Malignant Homicide Suicide Unintentional Heart Heart Malignant Malignant

Gestation Anomalies Neoplasms Neoplasms 4,998 5,106 Injury Disease Disease Neoplasms Neoplasms 

4,392 549 509 503 15,231 34,994 64,167 390,122 549,838

3 SIDS Malignant Congenital Homicide Suicide Homicide Heart Unintentional Bronchitis Cerebro- Cerebro2,648 Neoplasms Anomalies 246 3,901 4,231 Disease Injury Emphysema vascular vascular

418 207 13,600 11,639 Asthma 148,599 167,366

11,297

4 Maternal Homicide Homicide Suicide Malignant Malignant Suicide Liver Cerebro- Bronchitis Bronchitis

Pregnancy 376 186 242 Neoplasms Neoplasms 6,466 Disease vascular Emphysema Emphysema

Comp. 1,724 4,005 6,368 9,652 Asthma Asthma

1,399 108,112 124,181

5 Respiratory Heart Heart Congenital Heart Heart HIV Cerebro- Diabetes Influenza & Unintentional

Distress Disease Disease Anomalies Disease Disease 6,232 vascular Mellitus Pneumonia Injury

1,110 183 116 221 1,069 3,066 5,563 9,097 57,282 97,860

6 Placenta Influenza & Benign Heart Congenital HIV Liver Suicide Unintentional Diabetes Diabetes

Cord Pneumonia Neoplasms Disease Anomalies 2,729 Disease 5,081 Injury 51,843 Mellitus

Membranes 130 64 161 434 3,302 7,285 68,399

1,025

7 Unintentional Perinatal Bronchitis Bronchitis Bronchitis Diabetes Homicide Diabetes Liver Alzheimer’s Influenza &

Injury Period Emphysema Emphysema Emphysema Mellitus 3,206 Mellitus Disease Disease Pneumonia

845 92 Asthma Asthma Asthma 582 4,735 5,637 44,020 63,730

49 90 209

8 Bacterial Septicemia Septicemia Influenza & HIV Cerebro- Cerebro- HIV Suicide Unintentional Alzheimer’s

Sepsis 87 47 Pneumonia 198 vascular vascular 3,907 2,896 Injury Disease

691 47 580 2,574 32,219 44,536

9 Circulatory Benign Influenza & Cerebro- Cerebro- Congenital Diabetes Bronchitis Nephritis Nephritis Nephritis

System Neoplasms Pneumonia vascular vascular Anomalies Mellitus Emphysema 2,864 29,938 35,525

Disease 63 46 39 182 465 1,942 Asthma

667 3,110

10 Atelectasis Bronchitis HIV Benign Influenza & Liver Influenza & Influenza & Septicemia Septicemia Septicemia

647 Emphysema 38 Neoplasms Pneumonia Disease Pneumonia Pneumonia 2,714 24,626 30,680

Asthma 37 179 407 1,063 1,697

54
4 CDC Injury Research Agenda

Table 2

Unintentional Injury Deaths, United States, 1999

All Ages, All Races, Both Sexes

Cause of Deatha Number of Deaths Percentage of Deaths

Motor vehicle traffic 40,965 41.9

Falls 13,162 13.5

Poisoning 12,186 12.5

Suffocation 5,503 5.6

Drowningsb 3,529 3.6

Fires and burns 3,471 3.6

Natural disasters, animals, and

environmental exposures 1,923 2.0

Pedestrianc 1,502 1.5

Struck by or against a person

or object 894 0.9

Firearms 824 0.8

Machinery 622 0.6

Pedal cyclistc 185 0.2

Cut or pierced by sharp object 74 0.07

Overexertion 21 0.02

Other transport 3,275 3.3

Other and unspecified causes 9,724 9.9

Total Deaths 97,860 100.0

a From Centers for Disease Control and Prevention. Recommended framework for presenting injury mortality data. MMWR

1997;46(RR-14).

b An additional 501 water transportation–related drownings are included in Other transport.

c An additional 4,545 pedestrian fatalities and 615 pedal cyclist fatalities are included in Motor vehicle traffic.

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC

Data Source: National Center for Health Statistics, Vital Statistics System
CDC Injury Research Agenda 5

Mechanisma Number Percent Rateb

Total (overall) 29,549,711 100.0 10,752.6

Unintentional 27,550,181 93.2 10,025.0

Falls 7,434,032 25.2 2,705.1

Struck by or against a person or object 4,970,710 16.8 1,808.7

Transportc 4,954,232 16.8 1,802.7

Overexertion 3,233,993 10.9 1,176.8

Cut or pierced by sharp object 2,364,651 8.0 860.5

Bite or sting other than dog bite 1,036,796 3.5 377.3

Foreign body 735,214 2.5 267.5

Fires and burns 539,423 1.8 196.3

Dog bites 345,563 1.2 125.7

Poisonings 334,652 1.1 121.8

Other 1,600,915 5.4 582.5

Assault 1,672,117 5.7 608.5

Sexual Assault 63,984 0.2 23.3

Struck by or against a person or object 1,294,597 4.4 471.1

Cut or pierced by sharp object 122,080 0.4 44.4

Bites 52,141 0.2 19.0

Firearms 48,570 0.2 17.7

Other 90,745 0.3 33.0

Self-harm 264,108 0.9 96.1

Poisonings 170,243 0.6 61.9

Cut or pierced by sharp object 65,256 0.2 23.7

Other 28,609 0.0 10.4

Legal Interventiond 63,304 0.2 23.0

Table 3

Leading Causes of Nonfatal Injuries Treated in Hospital Emergency Departments,

United States, 2000

All Ages, All Races, Both Sexes

a From Centers for Disease Control and Prevention. National estimates of nonfatal injuries treated in hospital emergency departments—

United States 2000. MMWR 2001;50(17):340–6.

b Annual rates are expressed on a number of injuries per 100,000 of population.

c The number, percentage, and rate of Transport injuries consist of the following subcategories combined: Motor vehicle occupant,

Motorcyclist, Pedal cyclist, Pedestrian, and Other transport.

d Injuries inflicted by law enforcement personnel in the course of official duties.

Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC

Data Source: National Electronic Injury Surveillance System (NEISS), U.S. Consumer Product Safety Commission
Scope of the Research Agenda for CDC’s Injury Center

CDC’s Injury Center works to prevent unintentional and violence-related

injuries and to minimize the consequences of injuries when they do

occur. Its public health approach draws on such sciences as epidemiology

and other biomedical sciences, biomechanics and other engineering

sciences, social sciences, and economics in seven topic areas:

• Preventing Injuries at Home and in the Community

• Preventing Injuries in Sports, Recreation, and Exercise

• Preventing Transportation Injuries

• Preventing Intimate Partner Violence, Sexual Violence,

and Child Maltreatment 

• Preventing Suicidal Behavior

• Preventing Youth Violence

• Acute Care, Disability, and Rehabilitation

Research about occupational injury, an important part of the injury field,

is addressed by CDC’s National Institute for Occupational Safety and

Health (NIOSH). NIOSH and its partners established the National

Occupational Research Agenda (NORA) to address occupational injuries.

NORA can be viewed at http://www.cdc.gov/niosh/nora. However,

research conducted in occupational settings that has important

implications for nonoccupational injury prevention and control is also

within the scope of the Injury Center research agenda.

Far beyond the borders of the U.S., injuries remain an important cause of

death and disability. The Injury Center is committed to working with the

research community to better understand and prevent injuries worldwide.

However, because Injury Center funds for global health are limited, this

research agenda focuses on domestic issues.

The Agenda-Development Process

To ensure consideration of a broad range of research, the Injury Center

invited a wide array of constituents to participate in developing the

research agenda. At the beginning of the agenda-setting process, Injury

Center staff gathered input from key partner organizations and agencies

that represented researchers, practitioners, and policy makers. Staff then

drafted materials and presented them to topic-specific work groups

consisting of 10 to 15 members, including relevant federal partners,

6 CDC Injury Research Agenda
invited experts outside of the federal government, and Injury Center

staff. Each work group met for two days to identify, discuss, and prioritize

potential research needs.

The Injury Center posted a draft of the agenda on the Internet and

announced its posting in the Federal Register, inviting public comment.

Through correspondence with all current grantees, relevant federal

agencies, researchers, practitioners, and professional organizations, the

Injury Center solicited input from the injury prevention community. The

Injury Center also offered to mail copies of the draft research agenda to

groups and individuals without Internet access.

Throughout the process, the Injury Center relied on guidance from

members of its Research Agenda Steering Committee, which consisted of

six leaders in injury control and public health with an encompassing

variety of perspectives. Additionally, members of the Secretary’s Advisory

Committee on Injury Prevention and Control commented on the content

of the draft research agenda and provided advice about its

implementation.

Research Phases 

To organize the body of potential research about injury prevention and

control for this agenda, the Injury Center used a model for the phases of

research that extends from work by Holder and his colleagues (figure 1).

Building on other health research, the approach suggests that research

moves along a continuum: from basic and descriptive research to

intervention development and testing to research about disseminating and

maintaining effective intervention strategies. The research priorities in the

chapters that follow address all of these phases.

CDC Injury Research Agenda 7
8 CDC Injury Research Agenda

Figure 1

Phases of Injury Research: The Injury Research Framework

Foundational

Foundational research covers the basic studies and public health surveillance approaches that

define and quantify the extent of an injury problem. These activities establish the causes of

injuries, create causal models for injury prevention, and provide a foundation for developing

theory-based interventions.

Developmental

Developmental research supports the design and preliminary testing of potential strategies to

prevent and control injuries. Included are risk-factor research and pilot and feasibility studies that

measure how interventions affect key variables in the causal chain.

Efficacy and Effectiveness

Efficacy and effectiveness research assesses whether a given intervention actually reduces injuries.

These studies establish whether an intervention has the desired effect, estimate the effect size

under optimal and real-world conditions, measure the costs of the intervention, and identify

unintended consequences. Ideally, efficacy should first be established under conditions that

optimize both the intensity of implementation and the study population’s acceptance of the

intervention.

Dissemination

Dissemination research examines the robustness of intervention effectiveness given variations in

implementation and/or acceptance of the intervention. Studies focus on methods to encourage

practitioners and policy makers to adopt science-based programs, policies, and laws that reduce

intentional and unintentional injuries and on factors that increase organizational and community

capacity for tailoring, implementing, and sustaining effective interventions.
Developing Research Priorities

This agenda defines a research priority as an important injury problem

that can be meaningfully addressed with a modest number of research

studies (approximately 10 to 20) and that can include several related

research questions. Figure 2 shows an example of a research priority for

the topic Preventing Injuries at Home and in the Community.

CDC Injury Research Agenda 9

RESEARCH QUESTIONS

Preventing Injuries at 

Home and in the 

Community 

Preventing Injuries at 

Home and in the 

Community 

TOPIC

Evaluate strategies for 

widespread 

dissemination and 

implementation of 

effective interventions 

to reduce injuries at 

home and in the 

community

Evaluate strategies for 

widespread 

dissemination and 

implementation of 

effective interventions 

to reduce injuries at 

home and in the 

community

PRIORITY

1) What are the barriers to 

disseminating effective 

home injury prevention 

programs in indigent 

urban populations?

2) How can effective 

community smoke 

alarm installation 

programs be extended 

inexpensively to large 

populations?

1) What are the barriers to 

disseminating effective 

home injury prevention 

programs in indigent 

urban populations?

2) How can effective 

community smoke 

alarm installation 

programs be extended 

inexpensively to large 

populations?

RESEARCH QUESTIONS

Preventing Injuries at 

Home and in the 

Community 

Preventing Injuries at 

Home and in the 

Community 

TOPIC

Evaluate strategies for 

widespread 

dissemination and 

implementation of 

effective interventions 

to reduce injuries at 

home and in the 

community

Evaluate strategies for 

widespread 

dissemination and 

implementation of 

effective interventions 

to reduce injuries at 

home and in the 

community

PRIORITY

1) What are the barriers to 

disseminating effective 

home injury prevention 

programs in indigent 

urban populations?

2) How can effective 

community smoke 

alarm installation 

programs be extended 

inexpensively to large 

populations?

1) What are the barriers to 

disseminating effective 

home injury prevention 

programs in indigent 

urban populations?

2) How can effective 

community smoke 

alarm installation 

programs be extended 

inexpensively to large 

populations?

Figure 2 

Example of Topic, Priority, and Research Questions

To identify research needs for each topic, Injury Center staff reviewed the

current state of knowledge in the field and noted the most critical

research gaps. Then, work group members generated many priorities,

revised them, and identified those the Injury Center should address in the

near term. The work group process fostered debate and created a forum

where ideas and suggestions could be introduced to broaden the Injury

Center’s perspective. This breadth is reflected in the priorities enumerated

in the topic-specific chapters.
10 CDC Injury Research Agenda

Priority Selection Criteria

Three criteria guided the selection of Injury Center research priorities:

institutional mission, public health burden, and research opportunity

(figure 3). Above all, the research priorities had to match the Injury

Center’s mission of reducing the incidence, severity, and adverse

outcomes of injury through the application of public health methods.

Thus, research that applies directly to public health practice received

primary emphasis. Consideration of the public health burden ensured

inclusion of research about the major types and causes of injuries. An

emphasis on research opportunity encouraged further focus on risk

factors and interventions associated with a large, preventable fraction as

well as on interventions that will soon be ready for widespread

dissemination.

Three criteria guided

the selection of

research priorities:

institutional mission,

public health burden,

and research

opportunity.
CDC Injury Research Agenda 11

Figure 3

Criteria for Injury Center Research Priorities 

Mission (Note: Mission supercedes other criteria.)

• congruent with CDC’s priorities and mission (e.g., emphasis on applying research

findings and on public health methods)

• congruent with Injury Center’s mission and objectives

• congruent with programmatic niche to advance specialization and avoid duplication of

effort in the field

• opportunity for leadership and coordination in the field

• interest and demand from practitioners, policy makers, and the public 

Public Health Burden

• absolute number of people affected

– mortality and hospitalization

– economic and social costs

– disability and quality of life

– duration of effect

• equity or social justice (i.e., addresses the needs of vulnerable populations)

Research Opportunity

• portion of the injury problem that will likely be reduced (i.e., preventable fraction)

• likelihood that the research will lead to widespread adoption of an effective intervention 

in a short time

• opportunity for innovation and broad application (i.e., cross-cutting knowledge)

• availability of rigorous methods for effective and ethical research

• accessible populations (e.g., managed care)

• responsiveness to emerging issues
Selection Criteria Summary

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the most

important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks in each topicspecific chapter. Staff also identified research priorities that span topics.

These cross-cutting research priorities are described in the section that

follows.

NOTE: For all priorities in this agenda, special attention should be paid

to vulnerable populations that experience disparate, elevated risks. Such

groups include racial and ethnic minorities, persons with disabilities, the

youngest and oldest Americans, recent immigrants, and rural residents.

12 CDC Injury Research Agenda

Staff identified the

priorities that

warrant the greatest

attention and

intramural and

extramural resources

from the Injury

Center over the next

three to five years.
CDC Injury Research Agenda 13

Cross-cutting Priorities for

Injury Research

This research agenda presents priorities in topic-specific chapters.

However, certain issues are relevant to multiple topics. The breadth of the

Injury Center’s research and its place within the broader public health

field offer tremendous opportunities for investigating these cross-cutting

issues. Including priorities of this nature greatly enhances the applicability

of the research results and increases the opportunities for independent

and joint funding from multiple sponsors.

A. Evaluate the most effective methods for translating

research findings into public health programs and policies. 

Once researchers have demonstrated the effectiveness of an

intervention in a limited setting, they must consider a number of

issues before bringing the intervention to a larger population.

These issues share similar characteristics across a range of

intentional and unintentional injuries and even other public health

problems. For example, research should investigate how to

increase organizational and community capacity for tailoring,

implementing, and sustaining effective interventions. Solutions

might involve knowledge of sociocultural and environmental

influences on behavior, organizational leadership and

infrastructure, community engagement, and coalition building.

Dissemination and communication research to learn how to

encourage practitioners and policy makers to adopt science-based

programs and enforce policies, laws, and regulations that reduce

intentional and unintentional injuries will have a broad impact.

B. Evaluate the effectiveness of interventions to improve

parenting skills and reduce risky use of alcohol.

Among the modifiable risk factors that affect many types of

injury, parenting and risky alcohol use may be two of the most

prominent. Parenting interventions are effective in reducing and

preventing child maltreatment. Increasingly, evidence suggests

that parenting interventions may also affect the risk of other types

of violence, including intimate partner violence, youth violence,

and suicide.
The effectiveness of various modes of parenting in preventing

unintentional injuries is not understood as well as in the case of

child maltreatment. Parenting appears to influence health

behaviors such as risk taking by teen drivers. In addition,

parenting programs designed to prevent child maltreatment have

demonstrated a simultaneous reduction of home hazards.

Excessive alcohol intake and alcohol dependence increase the risk

of a variety of injuries and medical conditions. Primary

prevention strategies to reduce youth access to alcohol are

particularly important because individuals who begin drinking

alcohol as teens and adolescents are at greater risk for alcohol

abuse and dependence in adulthood. Although researchers and

practitioners have identified some effective strategies, more

research is needed to better understand which factors and policies

have the strongest influence on youth alcohol use.

Secondary prevention strategies for alcohol use and abuse often

involve screening medical patients for alcohol problems when

they present for care. Screening and brief counseling

interventions have shown promising results for emergency

department and trauma patients. However, before these clinical

preventive services can be broadly disseminated, further research

is needed to demonstrate effectiveness in multiple settings, refine

procedures, and increase efficiency. Legislative and communitybased behavioral interventions that address alcohol and effectively

reduce transportation injuries may also reduce violence, falls, and

drowning or require minor modifications to do so. The entire field

of public health, including injury prevention, can benefit from a

better understanding of the barriers and solutions to wider

adoption of alcohol interventions that reduce injuries.

C. Identify the costs and consequences of injury.

Information about the costs and consequences of injury is crucial

so that employers, government leaders, and the public can

accurately gauge the impact of injury relative to other issues they

face. Long-term physical, psychological, and economic

consequences of injuries for all affected groups—injured persons,

their families and employers, and society—require better

delineation. Epidemiologic and economic research can augment

14 CDC Injury Research Agenda
the information currently available and can be used to prioritize

prevention and control activities. Standardizing methods to

estimate costs is essential to facilitate useful cost-effectiveness

research and to stimulate investments in injury prevention and

control by both public and private sectors.

D. Build the research infrastructure.

Reducing the burden of injury requires ongoing investment in the

injury research infrastructure. An entire field of injury control

research has evolved over the last two decades. For injury research

to move to the next level of maturity, an integrated network of

researchers, mentors, and students must exist. Individual research

grants alone are insufficient to continue this progress. There is a

need to introduce students to injury research both in the

classroom and through hands-on experience, to improve linkages

between classroom and community learning, and to cultivate

opportunities for new and experienced researchers as well as

community practitioners to exchange ideas and develop a greater

appreciation of the depth and breadth of the field of injury

research. Many activities can serve these goals: training programs;

programs linking researchers with practitioners; conferences;

effective use of information technology, including data

clearinghouses; injury research centers; and interdisciplinary

collaborations. The injury research field can also benefit from

integration with the public health research community that

addresses issues other than injury. Such integration can include

training, participating in longitudinal studies or other large-scale

research projects, and developing research methods that extend

beyond injury.

CDC Injury Research Agenda 15

Information about

the costs and

consequences of

injury is crucial so

that employers,

government leaders,

and the public can

accurately gauge the

impact of injury

relative to other

issues they face.

CDC Injury Research Agenda 17

Preventing Injuries at Home and

in the Community

Public Health Burden

In 1998 in the United States, more than 10 million people were injured at

home severely enough to warrant an emergency department (ED) visit.

This constituted 29% of all injury-related ED visits and 11% of all ED

visits overall. Many factors and events contribute to injuries in the home

and community. For the purposes of the Injury Center’s research agenda,

home and community safety research includes fires, falls, dog bites,

poisonings, consumer product–related injuries, choking (including

strangulation and suffocation), and scalds and other nonfire burns. Other

injuries such as playground, pedestrian, and bicycling injuries are included

in the agenda’s chapters about sports, recreation, and exercise and

transportation.

Two major sources of injuries at home and in the community are fires and

falls. In 1999, fires were the third leading cause of injury-related deaths

among children 1 to 9 years old and the fifth leading cause among people

65 and older. Falls were the third leading cause of injury-related deaths

among Americans of all ages and were the leading cause of injury-related

deaths among people ages 65 and older. Of older adults who fall, 20% to

30% suffer moderate to severe injuries that reduce mobility and

independence and increase the risk of premature death. The total direct

cost of fall injuries for people 65 and older in 1994 was $20.2 billion. Falls

are the leading cause of ED visits among children, accounting for an

estimated 3 million visits annually. Infants and children who fall from low

heights are at substantial risk for head injuries, while those falling from

heights of 10 feet or more may also sustain other, multiple, serious

injuries.

The Injury Center’s Niche in Home and Community

Injury Prevention

Injuries occurring in the home and in the community represent a

significant public health burden in health care costs, injuries, and deaths.

CDC’s Injury Center can lessen this burden by developing, evaluating, and

promoting effective interventions in the home and in the community.

Public perception that injuries are “accidents” that cannot be prevented

hinders prevention efforts. Using the public health approach to injuries,

Two major sources of

injuries at home and

in the community are

fires and falls.
18 CDC Injury Research Agenda

CDC’s Injury Center conducts surveillance and research and translates

science into effective public health practice.

Residential and community injuries derive from many sources and involve

many products, environments, and risk groups. Addressing this

complexity requires varied approaches and multiple partners. One of the

Injury Center’s key partners is the U.S. Consumer Product Safety

Commission (CPSC), which conducts research to protect the public from

unreasonable risks of injury or death caused by consumer products.

CPSC and the Injury Center jointly conduct nationally representative ED

surveillance of injured persons.

The National Institute for Child Health and Human Development

(NICHD) conducts research about home and community safety,

including pilot work about child supervision. The Injury Center intends

to conduct applied research about supervision using results from NICHD

foundational research. The Maternal and Child Health Bureau (MCHB)

of the Health Resources and Services Administration provides training

and technical assistance in injury prevention. The Injury Center

complements MCHB work in state health departments by funding

prevention programs in states with active MCHB programs.

Several nonprofit organizations conduct programs to promote safety in

the home and community, particularly the National SAFE KIDS

Campaign, the National Fire Protection Association, and the National

Safety Council. The Injury Center has collaborated with these as well as

other federal and nonprofit partners to build more effective interventions

at the community level. Examples include research about smoke alarm

technology; analysis of residential fires, including their causes and risk

factors; prevention of older adult falls; and promotion of effective

childhood injury prevention strategies. The U.S. Fire Administration

(USFA) has authority in fire suppression and responsibility for primary

data collection on causes and consequences of fires. The Injury Center

works with USFA to support improved fire and burn surveillance. Other

federal agencies also address older adult falls, including the Centers for

Medicare and Medicaid Services (quality-of-care and cost/benefit issues),

the National Institute on Aging (biology of aging, older adult fall

prevention trials), and the Administration on Aging (programs). The

Injury Center pursues many opportunities for collaboration with these

agencies to support science and public health practice promoting home

and community safety.

Residential and

community injuries

derive from many

sources and involve

many products,

environments, and

risk groups.

Addressing this

complexity requires

varied approaches

and multiple

partners.
The Injury Center’s Research Priorities in Home and

Community Injury Prevention

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the five most

important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

Priorities

A.* Evaluate strategies for widespread dissemination and

implementation of effective interventions to reduce injuries

at home and in the community.

Research has demonstrated that many interventions at home and

in the community work: smoke alarms and sprinklers, bicycle

helmets, stair gates and window bars, secured storage for poisons,

child-proof cigarette lighters, and others. However, many of these

strategies have not gained wide acceptance in some areas and

among particular racial, ethnic, and socioeconomic groups for

economic and other reasons. Encouraging widespread adoption

of these efficacious interventions calls for dissemination research.

Research should focus on effective home- and community-based

interventions, especially large-scale community injury prevention

programs and policies. Demonstration programs should be

developed and evaluated to determine the effectiveness of various

persuasive communications techniques, audience segmentation,

various dissemination strategies and communication channels,

tailored messaging, and collaboration models to speed diffusion

and widen adoption. Research that builds on the strengths of a

community and encourages the community to participate in the

research process and develop the capacity to sustain the benefits

of interventions will be of additional value.

CDC Injury Research Agenda 19

Research has

demonstrated that

many interventions at

home and in the

community work.

However, many of

these strategies have

not gained wide

acceptance.
B.* Identify modifiable behavioral responses to residential fires

and evaluate interventions to prevent fire-related injuries in

mass trauma events.

Almost three-quarters of all fire and burn deaths occur in the

home. Residential fires killed nearly 2,900 people and injured

16,000 in 1999. Researchers have identified the major causes of

most fires: cooking, heating equipment, and smoking. They have

also identified the groups at highest risk of injuries from fires:

very young children, older adults, people with disabilities, and

people who live in poverty. Additionally, research has shown that

residential smoke alarms, when functional, can prevent 50% to 80%

of deaths by providing early warning of fires, which often occur

at night when people are sleeping.

Research should identify behavioral responses—what people

do—when a residential fire breaks out. Researchers need a better

understanding of the social, environmental, and behavioral

circumstances that affect an individual’s ability to escape safely

once a fire starts. These circumstances include the development,

practice, use, and effectiveness of fire escape plans and other

aspects of evacuation; the presence and use of appropriate fire

extinguishers; the existence of functioning smoke alarms in

appropriate areas of the home; and fear of and maladaptive

responses to uncontrolled fire and smoke. Further, research is

needed to identify strategies that improve the abilities of high-risk

persons to detect and escape from a fire, including older adults,

who may not hear commercially available smoke alarms; young

children, who may not know how to respond effectively; and

people with physical and mental disabilities. Rural residents are 1.5

to 3.5 times more likely to die in a fire than urban dwellers.

Interventions to reduce this disparity are needed.

Research is also needed to address evacuation strategies in mass

trauma events, such as large office and school building fires. Such

findings can also be applied to events related to bioterrorism,

terrorist attacks, bombings, and building collapses. Although the

2001 World Trade Center fire was the most dramatic, recent

example of fire-related mass trauma, fires killed more than 100

people in commercial buildings in 1999. Strategies such as fire

20 CDC Injury Research Agenda
safety policies, disaster planning, education programs, and other

methods of preventing and escaping fires in emergencies should

be evaluated. Examples of this type of research include evaluating

the effectiveness of environmental modifications that facilitate

egress, such as architectural design, exit signs, construction

specifications, and building codes; improving residential and

building safety inspections; and adding or modifying home and

commercial sprinklers and other fire extinguishing systems, floor

and stair designs, electrical systems, and hard-wired smoke alarms.

To integrate human factor issues into performance-based fire

safety designs and regulations, researchers will need a better

understanding of human reaction to fire and of fire risk

perception. Such research will necessitate a broad,

interdisciplinary approach involving many professionals in fire

prevention, safety science, engineering, psychology, design, and

environmental and policy science.

C.* Develop and evaluate community-based interventions to

prevent falls among older, community-dwelling adults and

study the dissemination of those programs.

Approximately 30% of older adults and 40% of those over age 80

report having fallen in the past year. Falls account for 29% of

injury deaths among adults ages 65 and older and result in 300,000

hip fractures annually at a cost of more than $10 billion.

Individual factors known to increase the risk of a fall include low

muscle tone and balance problems, vision problems, polydrug and

psychotropic medication use, and sedentary lifestyles. Less

conclusively, research suggests that some home hazards and

lifestyle behaviors may also contribute to the risk of falling.

Research about fall prevention is needed for three phases:

dissemination, efficacy and effectiveness, and developmental. For

proven interventions such as strength and balance training and

medication review and adjustment (especially for psychotropic

drugs), research is needed to identify barriers to widespread

adoption by public health and health care professionals.

Researchers have already identified some barriers. For example,

some health professionals do not have adequate information

about effective interventions; others may have the information

CDC Injury Research Agenda 21

Research about fall

prevention is needed

for three phases:

dissemination,

efficacy and

effectiveness, and

developmental. 
but do not use it in their work with patients and the public. Once

researchers have identified the barriers to widespread adoption,

they should develop and test strategies for overcoming them.

Research is needed to develop and evaluate approaches to

implementing and disseminating effective fall prevention

programs in the community, especially programs involving

multiple strategies. This includes research to identify the best

formats and channels for delivering interventions to ensure that

older adults adopt them. Health services and operations research

is necessary to develop model infrastructures for service delivery

that include partnerships between public health agencies and

networks that serve the aging community. Research is also needed

to identify people most in need of falls prevention programs and

to discern whether different programs work for different

subgroups (e.g., frail older adults, people who have fallen

previously, and people with a fear of falling).

Finally, for some interventions, researchers and practitioners have

little information about the intervention’s effectiveness when it is

broadly applied in the community. Examples include vision

enhancement (e.g., vision screening and correction, home lighting

improvements) and hip pads. Research should evaluate these

interventions and determine how best to implement them in

community settings with older adults. Further, researchers should

use the results of biomechanic and other research to design and

test new interventions.

D.* Among young children, determine the immediate causes

of the most severe and disabling types of falls and develop

and evaluate interventions to prevent them.

Of the nearly 3 million ED visits each year for falls among

children and adolescents, more than 40% occur among infants,

toddlers, and preschoolers. Annual direct medical costs for falls

among young children are estimated at $958 million. Two key

determinants of fall-related injuries are characteristics of children

at greatest risk and the causal sequence of events leading to the

fall. Falls that result in a traumatic brain injury are of particular

concern. In the home, such an injury may occur after a fall from

22 CDC Injury Research Agenda
a great height (e.g., down a staircase) or from a lesser height (e.g.,

off a changing table). Research should develop and evaluate

interventions in home and community settings to reduce the

major risks and most serious consequences of falls among

children.

E.* Develop methods to better define and measure aspects of

supervision for children and impaired older adults.

Supervision is generally considered one of the strongest yet least

understood protective factors against many types of home and

community injuries, including playground injuries, drowning

deaths, dog bites, and child pedestrian injuries. The developmental

ability, temperament, and cognitive and physical abilities of

children affect their requirements for supervision and the

effectiveness of supervision. These factors also influence the

degree of supervision needed for impaired older adults, such as

those with Alzheimer’s disease, Parkinson’s disease, or stroke, and

for children with special needs.

Research should develop and validate a classification scheme for

supervision to capture the variety of supervisory patterns

currently used across a spectrum of ages and cultures.

Researchers should develop measurement tools to describe and

compare various styles of supervision and their relative

effectiveness in preventing injuries.

F. Determine the impact of legislation, litigation, 

and regulation in preventing specific home and

community injuries. 

Legislation, litigation, and regulation have been used to prevent

injuries, but their relative effectiveness has not been established.

Legislation addresses motor vehicle traffic and the design,

manufacture, sale, possession, or use of a product. Litigation is

used to uphold the law. Regulation addresses specific issues, such

as building codes or ordinances banning specific dog breeds.

Researchers should evaluate each of these approaches to injury

prevention.

CDC Injury Research Agenda 23

Supervision is

generally considered

one of the strongest

yet least understood

protective factors

against many types

of home and

community injuries.
G. Develop and evaluate interventions to prevent dog 

bite injuries.

Dog bites accounted for an estimated 4.7 million injuries in 1994;

of the nearly 800,000 people who sought medical care for dog

bites, approximately half were children. Modifiable risk factors

for dog bites include victim behaviors, characteristics of the dog,

and behaviors of the dog owner. Modifiable community factors

include dog leash laws, neutering norms, and the prevalence of

dog ownership training and school-based and educational

programs delivered by veterinarians and medical care personnel.

Researchers should develop and evaluate programs to modify risk

factors to prevent dog bites and related injuries.

H. Develop and evaluate programs to prevent scalds and

nonfire burns. 

Scalds, contact burns, and electrical and chemical burns are

frequent causes of nonfatal, nonfire injuries. Scalds from hot

liquids are the most frequent cause of these injuries; 95% of

scalds occur among children younger than 5 years old. Research is

needed to identify or develop, then evaluate, practical and

effective solutions to reduce scalds and nonfire burns. Important

factors to investigate include the role of supervision and water tap

temperature regulators.

I. Study the relationship between the urban environment 

and the occurrence of unintentional and 

violence-related injuries. 

Community changes in land use, housing development, and

personal transportation may increase or decrease residents’

exposure to harm. For example, changes in exposure can occur by

shifting transportation from car to bicycle or foot; by increasing

the amount of recreational time spent outdoors near traffic; by

isolating homes and schools from traffic; or by other structural

changes. These aspects of the community environment and their

construction, maintenance, and alteration may have consequences

for unintentional injury or interpersonal violence.

24 CDC Injury Research Agenda
Structural changes are rarely studied in a comprehensive manner.

Researchers should investigate the relationship between

characteristics of the built environment and the occurrence of

unintentional and violence-related injuries and assess how

changing these characteristics affects these types of injury.

CDC Injury Research Agenda 25

Public Health Burden

Participation in sports, recreation, and exercise (SRE) is increasingly

popular and widespread in American culture. SRE activities include

organized sports (school or club) and unorganized sports (backyard or

pick-up), such as basketball, football, and hockey; recreational activities,

such as boating, biking, skiing, swimming, and playground activities; and

exercise and training activities, such as weight-lifting, aerobics, and

jogging.

Participation in SRE activities contributes to health-related fitness;

however, the risk of injury is inherent in any physical activity. Drowning

is the second leading cause of injury death among children ages 1 to 14

and kills more than 4,000 Americans annually. More than 10,000 people

receive treatment in the nation’s emergency departments (ED) each day

for injuries sustained in SRE activities. At least one of every five ED visits

for an injury results from participation in sports or recreation. In 1999,

Americans made an estimated 1.5 million ED visits for injuries sustained

while playing basketball, baseball, softball, football, or soccer.

Approximately 715,000 sports and recreation injuries occur each year in

school settings alone. Injuries are also a leading reason people stop

participating in potentially beneficial physical activity.

Risk of injury varies by many factors, including specific activity and

participant age. Children younger than 15 account for 25% of all

drownings and about 40% of all SRE-related ED visits. They may be at

risk because of immature or undeveloped coordination, skills, and

perception. Adolescents and young adults under age 25 have high

participation rates in SRE activities and experience almost one third of all

SRE-related injuries. The population of older adults is increasing, and

little is known about their injury risk during participation in SRE. In 1996,

EDs treated more than 53,000 SRE-related injuries among people 65 and

older, a 54% increase from 1990.

Few data exist about injury incidence and prevalence, costs, relative risks

of injury from different activities, risk and protective factors, and effective

programs to prevent SRE injuries. While some ED surveillance data are

available, they lack exposure information and exclude the large

CDC Injury Research Agenda 27

Preventing Injuries in Sports,

Recreation, and Exercise

At least one of every

five ED visits for an

injury results from

participation in

sports or recreation.
proportion of SRE injuries that are treated in primary care settings, sports

medicine clinics, orthopedic clinics, and chiropractic clinics.

The Injury Center’s Niche in Sports, Recreation, and

Exercise Safety 

CDC’s mission includes both promoting physical activity and preventing

injuries. While another center at CDC has an active research program in

physical activity, the Injury Center includes a focus on sports, recreation,

and exercise injury prevention. Although the scope and depth of this

research has been limited, the Injury Center is uniquely positioned to

provide epidemiologic and prevention research about SRE-related

injuries. Few other federal agencies or national organizations consistently

fund broad-based research into SRE injuries. Examples of federal

agencies with interest in SRE include the National Institutes of Health

(NIH), the U.S. Coast Guard, and the U.S. Consumer Product Safety

Commission (CPSC). NIH supports some foundational research in SRErelated trauma and injury prevention and the Coast Guard supports

boating safety programs and some surveillance. CPSC provides excellent

ED surveillance; however, its information does not include data about

participation rates (exposure data) that could facilitate comparisons.

CPSC traditionally focused on product-based research to protect

consumers from hazardous products; with Injury Center funding, CPSC

recently expanded its ED surveillance to include all injuries treated in the

ED, regardless of cause.

Working with other agencies, nonprofit organizations, and professional

organizations, the Injury Center can provide complementary research to

facilitate safe sporting environments and identify risk and protective

behaviors. The Injury Center has convened two working groups related to

surveillance and research methodologies in SRE, and it continues to play

a coordinating role in the field. Through its connections with

organizations such as the National Collegiate Athletic Association,

National Athletic Trainers’ Association, and the American Academy of

Orthopaedic Surgeons, the Injury Center can foster collaborations to

leverage maximum benefit from scarce funding for SRE injury prevention

research. Other important and appropriate activities include developing

new surveillance methods to capture exposure data; providing linkages to

medical care, emergency department, and other public health–oriented

data bases; and developing and effectively disseminating science-based

interventions.

28 CDC Injury Research Agenda

The Injury Center is

uniquely positioned

to provide

epidemiologic and

prevention research

about sports-,

recreation-, and

exercise-related

injuries.
The Injury Center’s Research Priorities in Sports,

Recreation, and Exercise Safety

Every research priority in this agenda is important. After considering input

from experts in the field, Injury Center staff identified the four most

important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

Priorities

A.* Evaluate strategies to increase dissemination and use of

effective interventions to prevent SRE injuries.

Effective interventions exist to prevent SRE injuries, but they

frequently are not used. Examples include bike helmets and other

protective equipment, break-away bases, impact-reducing

playground surfacing, and isolation pool fencing. Research should

assess factors that hinder and encourage individuals’ and

organizations’ adoption of these effective interventions, including

sociocultural and environmental influences, organizational

leadership and infrastructure, community engagement, and

coalition building. Studies should also assess different methods to

increase awareness of effective interventions, tailor programs to

local circumstances, and maintain fidelity to intervention

guidelines. CDC’s strength in program implementation, evaluation,

and health communication makes research in this area a natural

opportunity, and advances will be broadly applicable to other

health promotion areas. Research would benefit current

interventions and programs in drowning prevention, playground

safety, bicycle safety, and any SRE activity with efficacious

interventions.

B.* Evaluate environmental, behavioral, and legislative or

regulatory interventions to prevent SRE injuries.

Many promising interventions exist but have not been evaluated.

These include modifications of physical play environments, use of

current and newly designed safety gear, and gender- and agespecific equipment requirements. The importance of the presence

CDC Injury Research Agenda 29

Effective interventions

exist to prevent SRE

injuries, but they

frequently are not

used.
and training of coaches and certified athletic trainers should be

examined, as should be the roles of parents and physicians in

preventing injury in organized sports. Finally, research is needed

to assess the effects of policies and practices about the use of

safety gear, practice guidelines and rules of play, and informed

officiating. Tools to evaluate interventions in these areas may

include impact biomechanics and epidemiologic research.

C.* Evaluate existing and develop new methods to obtain

exposure and injury incidence data for SRE.

Recent reports estimate that approximately 3.7 million ED visits

occur each year for injuries related to participation in sports and

recreation. However, without reliable methods for estimating

frequency and duration of participation in these physical activities

(i.e., exposure data to calculate denominators), researchers cannot

determine injury rates and compare them across activities.

Population-based SRE injury information may be obtainable from

a variety of sources. Several population-based participation

surveys exist and, if validated, may serve as sources of

denominator data for such studies. Accurate estimates of

numbers of injuries combined with injury rates will enable

researchers to examine risk and protective factors and explore

prevention strategies. These findings will facilitate more effective,

programmatic decision making.

D.* Determine the short-term economic costs of injuries

related to SRE.

SRE injuries are not a major source of mortality, but they do place

a large burden on the health care system for both initial care and

rehabilitation. They also result in costs related to lost productivity

and other factors. Despite the large number of ED visits for these

injuries, most medically treated SRE-related injuries are treated by

health care providers outside of the emergency setting, indicating

that the magnitude of the problem is much greater than ED

statistics suggest.

30 CDC Injury Research Agenda
For example, in the U.S., anterior cruciate ligament (ACL) knee

injuries are usually sports related, and the vast majority occur in

active, healthy 15- to 24-year-olds. ACL rupture can be debilitating

in the short term, preventing continued physical activity. The cost

of ACL reconstruction alone, not including initial evaluation or

rehabilitation, is just under $1 billion per year in the U.S. Data

from other countries also suggest that the cost of other SRErelated injuries is quite high. Quantifying health care and other

economic costs to society of SRE-related injuries and delineating

the sources of those costs will provide an important foundation

for documenting the public health burden of these injuries.

E. Identify risk and protective factors and evaluate

interventions for injuries related to open-water recreation.

Submersion injuries and drownings in lakes, canals, rivers, and

oceans are a growing problem, accounting for one quarter to one

third of all drownings (or 1,200 drownings in 1998). While openwater drowning fatalities represent only about 12% of drownings

among children ages 14 and younger, they account for more than

30% of drownings among adolescents over age 14 and among

adults. Ninety-one percent of open-water drowning victims are

men. Much of the problem can be attributed to unsafe boating. In

fact, in 1999, 734 people died and another 4,300 required medical

care as a result of boating activities.

To design effective interventions, it is necessary to identify

modifiable risk factors. Research is needed to assess the role of

cultural factors responsible for ethnic and gender disparities in

drowning rates; the role of alcohol in drownings and in boatingrelated injuries and deaths; the importance of swimming ability,

supervision, and lifeguarding services; and the contribution of

drowning prevention skills in preventing open-water submersions

in various environments.

Although many safe boating programs, policies, and

recommendations are in effect, few have been rigorously

evaluated. Research about the components of safe boating should

investigate the efficacy and effectiveness of boating safety

education courses, personal flotation devices (PFD), and various

CDC Injury Research Agenda 31

The cost of anterior

cruciate ligament

reconstruction alone,

not including initial

evaluation or

rehabilitation, is just

under $1 billion per

year in the U.S. 
laws and policies aimed at improving boating safety. To further

reduce the number of boating-related injuries, the effectiveness of

these and other interventions as they relate to size and type of

boat, water environment type, and operator characteristics must

be improved. CDC can supplement the Coast Guard’s injury

surveillance and educational efforts by evaluating promising

interventions and programs.

F. Evaluate residential pool safety measures for children.

About 4,000 Americans drown each year; approximately 1,000 are

children under age 15. A majority of child drownings occur in

residential, backyard pools. While some drowning prevention

interventions have been evaluated, further delineation and

evaluation of their risks and benefits is necessary. Interventions to

be evaluated may include those that address either

physical/environmental factors such as pool alarms, pool covers,

and door alarms or behavioral factors such as PFD use, CPR

training, supervision, and swimming lessons.

G. Identify ways to minimize injury risk among people

initiating or increasing physical activity.

Many factors influence recommendations for starting and

increasing physical activity, including age, gender, fitness level,

nutritional status, anthropometry, and injury history. Research

should identify strategies to improve physical fitness of

participants at all fitness levels while minimizing the risk of injury.

Knowledge about differences in human tolerance by age, fitness

level, and gender is an important prerequisite for prevention, as is

knowledge about the biomechanics and injury tolerances of

tissue, bone, and other human structures. Ideally, researchers

should develop science-based guidelines for choosing an activity

and recommend the frequency, intensity, and duration of

participation given a prospective participant’s current fitness level

and past injuries. Research should also evaluate personal

protective devices and training programs. Special populations,

including children, older adults, women, and people who are

obese or undernourished, should receive particular attention.

32 CDC Injury Research Agenda

Research should

identify strategies to

improve physical

fitness of participants

at all fitness levels

while minimizing the

risk of injury. 
H. Identify risk and protective factors for and evaluate

interventions to prevent injuries from outdoor recreation.

Little is known about the risk factors for, and prevention of,

injuries in common outdoor recreational activities, such as riding

personal watercraft, snowmobiles, and all-terrain vehicles; hiking

and climbing; skiing; and participating in equestrian activities.

Approximately 73,000 ED visits annually are related to

participation in equestrian activities alone, and many thousands of

people are injured each year while using personal recreational

vehicles. Other injuries from outdoor recreation result from

recreational fires, avalanches, and insect, snake, and other animal

bites. Studies should address education, protective equipment,

vehicle design, the role of alcohol, and posted warnings as well as

promising public policy and legislative interventions.

I. Evaluate the effectiveness of interventions to improve

bicycling safety.

Approximately 81 million people ride bicycles, and each year,

more than 600,000 visit the ED for bicycle-related injuries. Many

of these injuries occur in traffic. Research should examine the

traffic interaction of bicycles and motor vehicles to identify ways

to improve road sharing and increase safety for bicyclists. It

should evaluate safety training, bike skills classes, and bike

maintenance as components of bicycle safety programs.

Additionally, biomechanics research can contribute to improved

bike and helmet design.

J. Evaluate how injuries are affected by changing the

physical environment to increase physical activity while

promoting and preserving safety.

A 1994 survey reported that 20% of adults (38 million) rode

bicycles outdoors and 73% (138 million) walked for exercise in the

30 days before the survey. During this time period, 1% to 1.5%

reported that they had been injured while doing these activities.

As efforts increase to promote walking and bicycling for

improved health and for transportation, the potential for injury

CDC Injury Research Agenda 33
may also increase. Research is needed to assess the health and

safety effects of environmental changes designed to increase

physical activity in a community, such as community exercise

facilities, sidewalks and bike trails, bike lanes, pedestrian malls,

sports parks, and skate parks. It is important to study the effects

of these dedicated spaces on injury rates, use rates, and exercising

behavior to help identify and promote safe environments for

physical activity.

K. Quantify the injury risks of physical activity among 

older Americans.

In 1996, people ages 65 and older made 53,000 sports-related ED

visits. This represented an increase of 54% since 1990, while the

population grew by only 8% in the same time period. As

Americans live longer, they will likely remain active longer,

increasing the need for effective injury prevention strategies for

active older adults. Additionally, research suggests that exercise is

important for older Americans to maintain physical and mental

health and independence. Research in this area should focus on

understanding the risks of various SRE activities in this

population and, where possible, examine risk in the context of

research about the benefits of these activities.

L. Determine the effect of playground design on 

injury patterns.

Approximately 200,000 children each year visit EDs for

playground-related injuries. Injury prevention efforts should

focus on identifying environmental and supervisory

modifications. Research should begin by studying the components

of the problem: developmental and other characteristics of

children, physical aspects of indoor and outdoor equipment and

play spaces, and the balance between safety and the level of

challenge the equipment poses. Effective prevention strategies

will address each component, as well as the relationships among

them. Research may also help define the role of supervision in

various settings.

34 CDC Injury Research Agenda
About 60% to 80% of playground-related injuries involve falls.

Research should include testing of indoor and outdoor

playground surfaces to determine which ones protect children

from injury and which ones increase the likelihood of injury.

Researchers should study children’s behavior, human tolerances or

impact biomechanics, and ideal surface characteristics.

Research should also address how best to combine injury

prevention and requirements of the Americans with Disabilities

Act (ADA). ADA requirements are intended to ensure that

children with disabilities have equal access to appropriate play

spaces. However, common playground surfaces that lessen injuryproducing forces may hamper the mobility of children with

disabilities, and pathways that allow easy access are frequently

tripping hazards. Research should identify materials and

mechanisms that will accomplish both safety and accessibility

needs.

CDC Injury Research Agenda 35

Public Health Burden

Transportation-related injuries occur from travel on the ground, in the air,

and on water. The overwhelming majority of these deaths and injuries

result from motor vehicle ground transportation. In 1999, motor vehicle

traffic crashes resulted in 40,965 deaths and were the leading cause of

death in the United States among people ages 1 to 34. Each year, an

additional 3.5 million people suffer nonfatal motor vehicle-related

injuries, causing about 4 million emergency department visits and 500,000

hospitalizations. The economic impact is substantial. In 1994, motor

vehicle crashes cost more than $150 billion in property damage, lost

productivity, and medical expenses. These estimates do not include the

unquantifiable costs of pain and suffering or the value of lives lost.

Despite achievements such as increased safety belt use and declining

numbers of crashes involving alcohol, injuries and fatalities caused by

motor vehicle crashes remain a serious public health problem. Data reveal

the need to direct prevention efforts to specific groups, such as older

adults, teens, and children. Pedestrian fatalities are a growing problem,

and alcohol persists as a factor in many crashes and injuries. Collaboration

among many partners is essential to prevent a wide array of

transportation-related injuries.

The Injury Center’s Niche in Transportation Safety

CDC’s Injury Center conducts and sponsors population-based

epidemiologic, public health, behavioral, biomechanic, and trauma

research to develop practical, community-based prevention strategies for

motor vehicle–related injuries. CDC has been instrumental in framing

motor vehicle injury as a public health problem and in helping to raise

public awareness that these injuries are predictable and preventable.

The Injury Center’s research programs focus on determining the

magnitude, severity, and cost of motor vehicle injuries; the size and

vulnerability of populations at risk; the influence of co-existing medical

conditions on crashes and injuries; and causes, risk factors, and effective

CDC Injury Research Agenda 37

Preventing

Transportation Injuries

CDC has been

instrumental in

framing motor

vehicle injury as a

public health

problem and in

helping to raise

public awareness

that these injuries are

predictable and

preventable.
interventions applicable to public health settings. It is unique in its use of

hospitals and emergency departments to collect motor vehicle injury data

and to conduct brief interventions. The Injury Center’s peer-review

process to select and fund research also distinguishes its work and

advances the field; grantees publish their findings in peer-reviewed

literature, accelerating the accessibility of knowledge for scientists and

public health practitioners. Seven of the 11 CDC-funded university

Injury Control Research Centers conduct research about transportationrelated injury issues.

The Injury Center’s research priorities in transportation safety build on

CDC’s expertise. The focus on alcohol as a risk factor draws on longstanding efforts to document the effects of alcohol on health and safety.

Ongoing research includes behavioral risk factor surveillance of alcohol

and driving and the identification of risk and protective factors. An

emphasis on older drivers reflects CDC’s focus on “healthy aging.”

Similarly, the Injury Center’s focus on teen drivers takes advantage of

CDC’s expertise in quantifying and understanding adolescent health risks.

For example, CDC’s Youth Risk Behavior Survey tracks motor vehicle

injury risk behaviors among teenagers. The Injury Center takes a

developmental-risk perspective on teen drivers, which is characterized by

its cooperative research with the National Institutes of Health (NIH) to

study the effects of persuasive communication and parental behavior on

teen driving behavior. The Injury Center also focuses attention on highrisk, hard-to-reach populations with projects such as Niños Atrás (Kids in

the Back), which encourages adults to place children in the back seats of

motor vehicles, the safest place for children to ride. And it emphasizes

evaluation of community-based interventions. Its research in this area

provided the science base for The Guide to Community Preventive Services

(produced by the Task Force for Community Preventive Services), which

recommends strategies to reduce alcohol-impaired driving and to

increase use of safety belts and child safety seats.

The Injury Center works closely with other federal agencies, nonprofit

organizations, and researchers. For example, it has a strong partnership

with the National Highway Traffic Safety Administration (NHTSA), the

lead regulatory agency for motor vehicle safety. The Injury Center’s

efforts complement those of NHTSA, which sponsors and conducts

research and produces technical reports aimed at supporting traffic safety

38 CDC Injury Research Agenda
regulations, motor vehicle safety standards, and legislative initiatives. With

NHTSA, the Injury Center hosted the first international conference

about preventing childhood pedestrian injuries and widely disseminated

national strategies for child pedestrian safety to transportation and public

health researchers and policy makers. In partnership with the World

Health Organization, the Injury Center developed surveillance guidelines

and recommended strategies for motor vehicle injury prevention in

developing countries. Injury Center staff also participate on

Transportation Research Board committees on transportation for an

aging society, alcohol-impaired driving, pedestrian safety, and school bus

safety. Other key partners in transportation safety include NIH’s National

Institute for Child Health and Human Development, the National

Transportation Safety Board, the Insurance Institute for Highway Safety,

the AAA Foundation for Traffic Safety, the National SAFE KIDS

Campaign, and the National Safety Council.

State and local health departments are a natural constituency for the

Injury Center’s research, and they provide important entries to develop

and implement effective interventions in communities. CDC’s long

history and close relationships with all 50 state health departments, local

health jurisdictions, and schools of public health provide a foundation

from which the Injury Center can support effective collaborations to

prevent transportation-related injuries.

The Injury Center’s Research Priorities in

Transportation Safety 

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the six most

important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

CDC Injury Research Agenda 39
Priorities

A.* Evaluate strategies to implement and disseminate known,

effective interventions to reduce alcohol-impaired driving

and test the effectiveness of new, innovative strategies.

Driving after drinking alcohol is a major risk factor for motor

vehicle crashes and is associated with approximately 15,000 deaths

and 300,000 injuries annually. In 2000, alcohol-related fatality

rates increased for the first time in several years, accounting for

almost 40% of motor vehicle deaths. For motorcyclists, the rate

of alcohol involvement in fatal crashes is even higher. Children

are frequent victims of alcohol-impaired drivers. Annually, about

600 children under age 15 die in motor vehicle crashes while

riding with drivers who are impaired by alcohol. In addition to the

human costs, crashes involving alcohol are expensive. In 1997,

these crashes cost Americans $29 billion in direct costs and lost

earnings. Law enforcement sources report about 1.4 million

arrests for drinking under the influence (DUI) every year, but

there are more than 126 million self-reported episodes of DUI.

Since 1970, states and communities have implemented an array of

strategies to reduce alcohol-impaired driving. Laws and

enforcement strategies to deter alcohol-impaired driving and to

control the sale or public consumption of alcohol are among the

most widely used strategies. Community-based interventions

including sobriety checkpoints, lower legal limits for bloodalcohol content, zero tolerance laws, enhanced enforcement of

alcohol control policies, and training programs for servers of

alcoholic beverages have been demonstrated effective. However, a

better understanding of the factors that most influence successful

implementation of these prevention strategies and policies is

needed. Research should include strategies drawn from health

communication, policy development, advocacy, and other

approaches relevant to improving dissemination and adoption of

effective interventions.

40 CDC Injury Research Agenda

In 2000, alcoholrelated fatality rates

increased for the first

time in several years,

accounting for

almost 40% of motor

vehicle deaths. 
Research should assess existing interventions directed to high-risk

groups and implemented in special settings; screening and early

intervention for alcohol-impaired driving in public settings;

licensing requirements; and the benefits, costs, and social

acceptability of successively lower blood-alcohol concentration

standards. Simultaneously, the search for new and innovative

strategies for reducing alcohol-impaired driving should continue.

B.* Develop methodologies for and evaluate the effectiveness

of various means to translate transportation safety

research findings into public policy. 

Laws have been applied at both state and federal levels to prevent

motor vehicle injuries. However, few tools exist to measure how

research translates into laws and regulations to encourage people

to adopt safety behaviors. Research about the evolution of

prevention strategies—from scientific evidence to legislation to

product design and manufacturing changes—has the potential to

reduce injury rates on a large scale. For example, research might

evaluate the role of tort litigation in providing incentives for

industry to make safer products, whether through design

modifications or changes in product use. Successful examples

include restraint systems, such as safety belts, child safety seats,

and vehicle air bags. Research might also evaluate the types of

information used to support successful policies and regulatory

decisions. For instance, to determine the components of

successful campaigns, evaluations could consider the

persuasiveness of data about injury’s incidence, prevalence, and

outcomes (e.g., disabilities and functional impairments) or the

persuasiveness of cost and cost-effectiveness data.

Research should focus on the use of scientific information in

formulating public policy that promotes sustainable social

changes, on the costs and benefits of changes, and on

improvements in public safety. The research should identify best

practices for providing useful information to policy makers.

Improved social marketing techniques are essential to educate

opinion leaders and the public about the causes of motor

vehicle–related injuries and about effective personal safety

practices.

CDC Injury Research Agenda 41

Research should

focus on the use of

scientific information

in formulating public

policy that promotes

sustainable social

changes, on the

costs and benefits of

changes, and on

improvements in

public safety.
C.* Evaluate the effectiveness of behavioral and environmental

strategies to prevent pedestrian injury. 

Pedestrians account for about 14% of motor vehicle–related

deaths in the U.S. Most pedestrians injured or killed are young

children, older adults, or alcohol-impaired individuals. Annually,

more than 5,000 pedestrians are killed and another 77,000 are

injured in motor vehicle incidents. Pedestrian injuries that occur in

rural areas are more likely to be fatal than those occurring in

urban areas.

Because the problem is so complex—involving pedestrian and

driver behaviors, road characteristics, travel patterns, vehicle

speed, and environmental variables—no single intervention is

likely to sufficiently reduce the number of pedestrian injuries. For

example, infants are usually injured in strollers, toddlers are often

injured in driveway backovers, and preschoolers and young

elementary school-age children are often injured when they dart

out between cars parked on residential streets, particularly during

play. Adult pedestrian injuries often involve alcohol.

Multidisciplinary approaches involving theory-based education

and training programs, engineering solutions, and strong law

enforcement may be necessary to effectively reduce pedestrian

injuries. Research should include interventions that focus not only

on pedestrians, but also on drivers and the driving environment,

such as strengthening enforcement strategies for speed limits,

yield-to-pedestrian laws, and school zones. Changes in pedestrian

and driver behaviors and modifications in roadway environments,

including traffic-calming measures, may provide the strongest mix

of prevention strategies. Research should develop and evaluate

strategies that reduce the risk of collisions, such as increased

pedestrian and vehicle visibility. Research should also address the

different risk factors of various groups in urban and rural settings.

42 CDC Injury Research Agenda
D.* Identify the underlying behavioral and situational 

factors associated with crashes involving teens; develop 

and evaluate appropriate interventions to address 

those factors. 

In 1999, 5,700 teenagers died of injuries caused by motor vehicle

crashes. Research shows that teenagers are more likely than other

drivers to speed, run red lights, make illegal turns, ride with an

intoxicated driver, and drive after using alcohol or drugs. They are

more likely than other drivers to underestimate the dangers in

hazardous situations, and they have less experience coping with

those situations. Young people who drive after consuming alcohol

pose an inordinate risk to themselves, their passengers, and other

road users.

To prevent motor vehicle crashes among teens, research should

evaluate strategies that limit their access to alcohol and that

promote safety belt use. Research should also identify the

behavioral and developmental characteristics that predispose

some teens to take higher risks than their peers. Research to

identify constellations of behavioral and developmental risk

factors that could be used to develop and target interventions

should focus on behavioral rather than epidemiologic studies. It

should examine both protective factors and risk factors, such as

the roles of supervision, family, peers, risk perception, decisionmaking skills, and community characteristics.

E.* Develop and evaluate interventions that address the

proper and consistent use of measures to protect child

occupants in motor vehicles.

In 1999 (the latest year for which fatality data are available), more

than 1,100 children ages 15 and younger were killed while riding

in motor vehicles. In 2000, nearly 330,000 were injured. Proper

installation of age-appropriate child restraint systems, such as

child safety seats or booster seats, and correct placement of

children in restraints increase safety. Data show that Hispanic

Americans have lower rates of child safety seat use than nonHispanic Caucasian Americans. Research also shows that children

CDC Injury Research Agenda 43

Research shows that

children seated in

the back seat are

safer than children

seated in the front

seat. Nevertheless,

47% of children

killed in crashes are

not seated in the

back.
seated in the back seat are safer than children seated in the front

seat. Nevertheless, 47% of children killed in crashes are not

seated in the back.

Further research about the efficacy and effectiveness of booster

seats is needed to make reliable recommendations for children

who have outgrown their child safety seats. Children usually do

not fit into adult seat belts until they are 4’ 9” tall. Epidemiologic

and biomechanic research are needed to document the efficacy of

booster seats and to establish guidelines for their proper use based

on variables such as age, height, weight, and other relevant

anatomic dimensions.

Research might also assess the impact of child safety seat and

booster seat laws as well as enforcement strategies and

training/checking programs intended to increase proper use.

Continued research is needed about the effectiveness of universal

fasteners and alternative restraint designs, including devices that

improve comfort and convenience. Research should evaluate

strategies to improve proper use and decrease misuse of safety

devices and to improve communication efforts to promote child

occupant safety.

In addition to restraint use, research should investigate factors

that influence drivers to place children in the back seat. The

results of such research should guide intervention development,

evaluation, and dissemination. A focus on special populations

such as inner-city or non-English-speaking groups not reached by

common communication channels is crucial.

F.* Among older adults, identify and measure factors that

affect safe motor vehicle use.

Each year more than 7,000 persons ages 65 and older die in motor

vehicle crashes, and 250,000 are injured. These numbers are likely

to rise with the expected growth in this population segment. Many

older adults change their transportation habits to allow for

declining performance with age. For example, many stop driving

at night because of vision problems. Yet little is known about how

functional capacity, medical conditions, medications, and other

44 CDC Injury Research Agenda

Little is known about

how functional

capacity, medical

conditions,

medications, and

other factors affect

safe motor vehicle

use. 
factors affect safe motor vehicle use. Several approaches are

available to document these relationships, including cognitive

testing, simulator studies, and applied biomechanics research.

Studying the effects of vehicle design on these human

interactions is another potential direction for related research.

Findings from these lines of research can be used to identify older

adults at greatest risk and to design public health programs to

reduce the risks of crashes and injuries among that group.

G. Develop and evaluate interventions to increase the use of

occupant protection devices, such as seat belts, in high-risk

and hard-to-reach populations. 

Certain groups of people—such as inner-city, non-Englishspeaking, immigrant, and rural populations and those who do not

perceive the risk of driving unprotected—are at higher risk for

motor vehicle–related injuries and may also be difficult to reach

with traditional prevention messages or interventions. Further

reductions in motor vehicle–related injury rates will require

tailoring interventions, such as those to increase seat belt use, to

these groups.

Research should evaluate the effectiveness of changes in vehicle

and restraint design and strategies to increase adoption and

maintenance of seat belt use. Developing and conducting

intervention research with hard-to-reach populations presents

special challenges for any public health issue, including motor

vehicle safety. Knowledge gained in this field, such as innovative

recruitment techniques to engage study participants and elicit

valid survey responses, may be useful to other areas of public

health research. Investigations should include risk factor research

to support prevention programs and interventions that are

targeted, tailored, and evaluated.

CDC Injury Research Agenda 45
H. Develop and evaluate interventions to reduce motorcycle

crashes and injuries. 

Motorcycle safety initiatives have placed their major emphasis on

wearing helmets and on helmet laws to prevent crash-related head

injuries and deaths. Research should continue to evaluate the

effectiveness and sustainability of these interventions. It should

also identify methods for promoting the most effective

interventions and for identifying the barriers to implementing and

sustaining effective interventions. Research should extend beyond

the focus on helmets to determine the effectiveness of other

strategies to prevent not only injuries and deaths but also

crashes—strategies that involve motorcycle safety training,

reduction of alcohol–impaired motorcycle driving, and licensing

interventions. In addition to behavioral approaches,

epidemiologic and biomechanic assessments of the effectiveness

of different motorcycle helmet designs may improve rider safety.

(See Sports, Recreation, and Exercise section for bicycle safety

research.)

I. Develop and evaluate interventions to modify hazardous

behaviors such as aggressive, inattentive, and 

drowsy driving.

Many motor vehicle crashes reportedly result from hazardous

behaviors, such as aggressive, inattentive, and drowsy driving.

Research should address both individual behavior-change

strategies as well as community-based strategies that could reduce

the impact of these types of risky behaviors on motor vehicle

safety. Attention must be given to developing methods for

measuring risky behavior, assessing its impact on crash risks and

outcomes, and understanding the role of risk perception.

46 CDC Injury Research Agenda
J. Develop and evaluate interventions to prevent crashes and

injuries caused by modes of transportation other than

motor vehicles.

While motor vehicle crashes are the most common cause of

transportation-related fatalities and injuries, other modes of

transportation also pose threats to public safety. Research is

needed to identify strategies that prevent collisions, crashes,

injuries, and deaths from other modes of transportation, such as

railroad trains (including pedestrian-train and motor vehicle–train

events), aviation, public transportation, and others.

K. Evaluate the effects of emerging vehicle technologies on

the risks of crashes, the risk of injuries during crashes, and

crash avoidance.

Various emerging technologies may improve traffic safety.

However, these same technologies may have unintended negative

consequences. For example, air bags provide additional crash

protection in some situations but are known to place some smaller

and younger occupants at greater risk. Also, windshield

information displays may allow drivers to obtain more

information while driving, but these same displays may exceed

information processing thresholds or may confuse older drivers

who have declining cognitive processing skills. Cellular telephones

make calling for emergency assistance quick and easy, but they

may also distract drivers. Research should evaluate how

innovations such as side air bags, new seat designs, cellular

phones, laser detection devices, and telematic and other devices

affect driving performance, crashes, and injuries. Cognitive,

biomechanic, and other hazards of new technologies should be

investigated. Researchers should give attention to the impact of

vehicle and auxiliary equipment design on changes in risk and in

drivers’ perception of risk.

CDC Injury Research Agenda 47

Research should

evaluate how

innovations such as

side air bags, new

seat designs, cellular

phones, laser

detection devices,

and telematic devices

affect driving

performance,

crashes, and injuries.
L. Identify the modifiable risk factors for and mechanisms 

of nonfatal neck, back, and soft tissue 

(“whiplash-like”) injuries. 

Research should focus on the epidemiology, biomechanics, and

medical outcomes of nonfatal neck, back, and soft tissue

(“whiplash-like”) injury and should emphasize the research’s

utility in prevention. Better knowledge of the types, severity, and

mechanisms of such injuries is needed to assess accurately the

public health impact and associated costs of the problem and to

guide prevention strategies.

48 CDC Injury Research Agenda
Public Health Burden

Intimate partner violence, sexual violence, and child maltreatment have a

significant effect on public health. Victims of violence can experience

physical injury; adverse mental health consequences such as depression,

anxiety, and low self-esteem; and harmful physical health consequences

such as suicide attempts, cardiovascular disease, and substance abuse. Any

of these consequences can lead to hospitalization, disability, or death.

Intimate partner violence is actual or threatened physical, sexual,

psychological, or emotional abuse by a current or former spouse

(including common-law spouse), dating partner, or boyfriend or

girlfriend. Intimate partners can be of the same or opposite sex. Nearly

25% of women have been raped and/or physically assaulted by an

intimate partner, and more than 40% of the women who experience 

partner rapes and physical assault sustain a physical injury. Women 

experience more chronic and injurious assaults from intimate partner 

violence than men.

Sexual violence is committed by an intimate or non-intimate perpetrator

such as a spouse, family member, person in position of power or trust,

friend, acquaintance, or stranger. Although there is some overlap between

intimate partner violence and sexual violence, sexual violence is

committed by a wider range of perpetrators. Sexual violence includes

completed or attempted sex acts against the victim’s will or involving a

victim who is unable to consent; abusive sexual contact; and non-contact

sexual abuse, including sexual harassment. Women are the primary

victims of sexual violence. Approximately 15% to 25% of women

experience an attempted or completed rape at some time in their lives.

More than half of the women reporting rape are sexually assaulted before

age 18.

Child maltreatment is any recent act or failure to act resulting in imminent

risk of death, serious physical or emotional harm, sexual abuse, or

exploitation of a child by a parent or caretaker who is responsible for the

child’s welfare. Much of the child maltreatment field divides child

maltreatment into four categories: physical abuse, child neglect, sexual

abuse, and emotional abuse (e.g., psychological or verbal abuse; mental

CDC Injury Research Agenda 49

Preventing Intimate Partner

Violence, Sexual Violence, 

and Child Maltreatment

Victims of violence

can experience

physical injury,

adverse mental

health consequences,

and harmful physical

health consequences.
injury). In the United States, child protective services identify

more than 825,000 children annually as victims of maltreatment.

Childhood exposure to maltreatment, parental violence, and other

adverse experiences is associated with risky behaviors, such as smoking,

overeating, suicidal behavior, and perpetrating youth and intimate partner

violence, and with negative health outcomes such as heart disease and

cancer.

These three types of violence are interrelated. They share common risk

and protective factors and often co-occur within the same households.

Elder abuse is an emerging problem that may usefully be studied

alongside intimate partner violence, sexual violence, and child

maltreatment. Although data are poor, the best national estimate is that

nearly 450,000 people ages 60 and older experienced abuse and/or

neglect in domestic settings in 1996. Of these cases of abuse, only 16%

(nearly 71,000) were reported to and substantiated by Adult Protective

Service (APS) agencies; the remaining 379,000 were either not reported

to APS or not substantiated.

The Injury Center’s Niche in Preventing Intimate Partner

Violence, Sexual Violence, and Child Maltreatment

Many agencies and organizations have developed programs to prevent

violence against women and children. As noted in the Institute of

Medicine report Reducing the Burden of Injury, however, very few of these

programs have been evaluated rigorously to assess their effectiveness and

to determine which among them merit widespread adoption. CDC’s

Injury Center provides leadership in developing and assessing the

effectiveness of violence prevention programs and policies.

Numerous federal agencies conduct research about many aspects of

intimate partner violence, sexual violence, and child maltreatment. In its

work, the Injury Center emphasizes research with direct implications for

prevention. This research perspective complements the work of other

federal agencies. For example, the Injury Center’s focus on identifying

ways to prevent the development of perpetration of intimate partner

violence, sexual violence, and child maltreatment complements the U.S.

Department of Justice’s focus on persons already charged with violent

offenses associated with these behaviors. The Injury Center’s focus on

applied dimensions of prevention in these areas complements the

National Institutes of Health’s focus on basic scientific questions.

50 CDC Injury Research Agenda

CDC’s Injury Center

provides leadership

in developing and

assessing the

effectiveness of

violence prevention

programs and

policies. 
Currently, efforts to prevent or intervene in intimate partner violence,

sexual violence, and child maltreatment focus on reducing victims’ risks

for future violence and on mitigating the consequences of exposures to

such violence. The field is dominated, therefore, by an emphasis on

secondary and tertiary prevention strategies tailored to victims. Many

leaders in the field are calling for greater attention to primary prevention

of intimate partner violence, sexual violence, and child maltreatment. To

prevent these types of violence from occurring in the first place,

researchers and practitioners must place greater emphasis on approaches

directed at perpetrators and potential perpetrators. Many questions,

especially about young perpetrators, remain unanswered, seriously

hindering the development and identification of effective violence

prevention strategies. Thus, even though research on perpetration is still

in the foundational stage, it is essential that the Injury Center focus on

perpetration research to support future development of effective

prevention programs. Parallel efforts must continue to prevent revictimization.

The Injury Center’s Research Priorities in Preventing

Intimate Partner Violence, Sexual Violence, and

Child Maltreatment

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the seven

most important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

Priorities

A.* Evaluate strategies to disseminate and implement sciencebased parenting interventions to prevent 

child maltreatment.

Research has shown that parenting interventions can reduce and

prevent child maltreatment. For these interventions to reach the

broadest audience possible, more applied research about their

dissemination and implementation is necessary. For example, a

program’s effectiveness may vary depending on the setting in

which it is delivered; research should examine the impact of

CDC Injury Research Agenda 51
delivering parenting programs in a variety of specific settings,

such as the work place and primary care settings, and through the

media. Research to guide the adaptation of interventions to

specific communities, subcultures, and populations will further

enhance their effectiveness.

Victims of child maltreatment are at risk for other types of

violence later in life, including youth violence, suicide, and

intimate partner violence. Therefore, it is plausible that parenting

interventions may also reduce the likelihood of experiencing

these other types of violence.

B.* Evaluate the efficacy and effectiveness of interventions and

policies to prevent perpetration of intimate partner

violence, sexual violence, and child maltreatment.

The key to preventing intimate partner violence, sexual violence,

and child maltreatment is to intervene with individuals, families,

and communities in ways that stop the perpetration of violent

behaviors. Programs and policies that provide counseling for

batterers, improve parenting skills, or prevent dating violence, for

example, intervene with perpetrators and potential perpetrators

before the violence occurs or recurs. Research should focus on

evaluating these programs and policies with a particular emphasis

on those that attempt to address two or more types of

perpetration simultaneously. Identifying programs and policies

that can effectively address multiple types of perpetration will

facilitate a more efficient allocation of prevention resources.

Further, large public demand exists for effective programs and

policies in this area.

C.* Identify social norms that support intimate partner

violence, sexual violence, and child maltreatment and

evaluate strategies to change them.

Research has demonstrated the importance of changing social

norms to reduce major public health problems such as smoking

and HIV. In some social contexts, intimate partner violence,

52 CDC Injury Research Agenda

Research has shown

that parenting

interventions can

reduce and prevent

child maltreatment.

More applied

research about their

dissemination and

implementation is

necessary. 
sexual violence, and child maltreatment are considered normative

behavior. To design effective interventions, researchers must first

identify the particular social norms and beliefs that support these

types of violence and then find ways to alter or replace them with

ones that prevent violence. Even when such violent behaviors are

not considered “acceptable,” cultural attitudes and beliefs may

exacerbate these problems by blaming victims or by supporting

attitudes and behaviors that create social atmospheres conducive

to, or tolerant of, such violence. Given CDC’s role in addressing

the contribution of social norms to other public health problems,

the Injury Center—as part of CDC—is well-positioned to

address this research opportunity. Research about social norms

related to intimate partner violence, sexual violence, and child

maltreatment will also apply to other forms of violence.

D.* Evaluate training programs about intimate partner

violence, sexual violence, child maltreatment, and elder

abuse for health professionals.

According to the Institute of Medicine, programs to train health

professionals about intimate partner violence, sexual violence,

child maltreatment, and elder abuse have received insufficient

attention and evaluation. Few studies investigate whether

curricula have the desired impact on delivery of health care to

victims. Evaluation research is needed to determine the impact of

training programs on the practices of health professionals as well

as their effects on victims. Factors that affect the development,

implementation, and maintenance of such programs include the

nature of accreditation, licensure, and certification; characteristics

of health professional organizations; views of the stakeholder

groups; attitudes of health professionals; and the existence of

mandatory laws and education requirements. It is also important

to consider whether a health professional’s own experience with

violence may influence his or her response to victims and to

identify training strategies that account for that influence.

CDC Injury Research Agenda 53

Research has

demonstrated the

importance of

changing social

norms to reduce

major public health

problems.
E.* Evaluate the health consequences of intimate partner

violence, sexual violence, and child maltreatment

victimization across the life span.

Research has linked intimate partner violence, sexual violence, and

child maltreatment to a wide range of negative health outcomes

and risk behaviors. However, little information exists about the

mechanisms that may be responsible for these negative outcomes

or the factors that may diminish them. Further understanding of

the relationship between victimization and various health

outcomes is important to guide interventions. Research in this

area will guide development of interventions tailored to victims’

needs.

F.* Examine the development of intimate partner violence,

sexual violence, and child maltreatment perpetration to

identify at-risk populations, modifiable risk and protective

factors, and optimal times and settings for intervention.

Ultimately, the cause of and responsibility for intimate partner

violence, sexual violence, and child maltreatment lie with the

perpetrators. Programs and policies that address the needs of

victims (including same-sex victims), while critically important,

fail to address the root causes for the behaviors that lead to the

violence. However, important knowledge about these root causes

is lacking. To understand how the propensity to behave violently

toward partners and children develops, researchers must follow

study populations for extended periods. A better understanding of

the developmental pathways and social circumstances that

contribute to perpetration will greatly enhance the development

of effective primary prevention programs and guide refinement

of existing prevention programs. Research about the

development of perpetration may also apply more broadly to

areas of youth violence and suicide prevention because of their

association with intimate partner violence, sexual violence, and

child maltreatment.

54 CDC Injury Research Agenda

To understand how

the propensity to

behave violently

toward partners and

children develops,

researchers must

follow study

populations for

extended periods. 
G.* Develop and evaluate surveillance methods for intimate

partner violence, sexual violence, and child maltreatment.

Few data are available to monitor intimate partner violence, sexual

violence, and child maltreatment, and those that exist are of

questionable validity and reliability; better tracking and

monitoring methods are necessary to support prevention efforts.

To develop better surveillance systems, research should determine

the sensitivity and specificity of alternative definitions, the utility

of alternative surveillance methodologies, and the validity and

reliability of the specific measures. Biomechanics research may be

useful in diagnosing intimate partner violence and child

maltreatment, identifying specific injuries that are highly

predictive of these types of violence and establishing appropriate

case definitions. Data sources for information about intimate

partner violence, sexual violence, and child maltreatment differ to

some extent, so evaluation of the methods for each must

frequently be done independently. Improved surveillance

methods will render better information to guide program

development and evaluation. Because states and localities often

lack adequate monitoring systems, research findings will be

particularly valuable to them as they expand their efforts to

address violence as a public health issue.

H. Evaluate strategies to disseminate information about

preventing intimate partner violence, sexual violence, and

child maltreatment.

Dissemination of research findings is especially important to

guide prevention and intervention activities, but little research to

assess alternative dissemination strategies has been done in the

violence prevention field. Moreover, information dissemination

activities present many opportunities for collaboration with

agencies and organizations working to prevent intimate partner

violence, sexual violence, and child maltreatment. It is important

to identify and evaluate methods to facilitate collaboration across

advocacy, consumer, research, and practice settings in conducting

dissemination. Encouraging collaboration among these groups is

necessary to maintain the public’s interest and meet policy makers’

need for information to guide development of appropriate

policies, legislation, and litigation procedures.

CDC Injury Research Agenda 55
The prominence of the Rape Prevention and Education Grant

Program (RPE), administered by the Injury Center, presents a

unique opportunity to test models of dissemination through the

sexual violence service infrastructure. The RPE distributes funds

to states to support sexual violence prevention services and

programs. It is crucial that state programs have access to and

distribute the most up-to-date information. Research should

identify the most effective strategies for translating and

disseminating knowledge about sexual violence victimization and

perpetration.

I. Evaluate the efficacy and effectiveness of interventions and

policies for preventing intimate partner violence, sexual

violence, and child maltreatment victimization and

its consequences.

Federal, state, and local government agencies and private

organizations currently invest many resources in services for

battered and sexually assaulted women and maltreated children. It

is critically important to determine the effectiveness of these

programs and policies in preventing victimization and its

consequences. This type of research can help agencies and

organizations that provide victim services determine whether

their investments actually reduce violence and maltreatment.

Intimate partner violence, sexual violence, and child maltreatment

often overlap in families, so evaluating the effectiveness of

programs and policies that address two or more of these

behaviors simultaneously is of high priority. Identifying programs

that can effectively address multiple types of victimization

(including same-sex violence) at once will facilitate a more

efficient allocation of prevention resources. One area requiring

particular attention is the evaluation of screening instruments for

intimate partner violence, sexual violence, and child maltreatment

used in health care and social service settings to identify victims

needing additional services.

56 CDC Injury Research Agenda
J. Evaluate models for integrated community responses 

to intimate partner violence, sexual violence, and 

child maltreatment.

Collaboration among various members of a community and

various groups working in intimate partner violence, sexual

violence, and child maltreatment prevention is essential to

preventing such violence. Expanding prevention research to

include the development of integrated community responses to

these public health problems will significantly advance prevention

and intervention research. Further development of integrated

community responses depends largely on advances in

effectiveness research about specific prevention policies and

interventions.

K. Examine the development of intimate partner violence,

sexual violence, and child maltreatment victimization to

identify at-risk populations, modifiable risk and protective

factors, and optimal times and settings for intervention.

The Injury Center’s mission of violence prevention emphasizes

primary prevention of intimate partner violence, sexual violence,

and child maltreatment. Currently, many research efforts focus on

secondary or tertiary prevention, that is, preventing

revictimization. Research is needed to identify the different risk

and protective factors related to victimization in order to prevent

first-time victimization. In addition, research should explore the

commonalities and differences among risk factors for

victimizations involving these kinds of violence.

To understand the characteristics that place people at risk of

victimization, researchers must follow study populations for

extended periods. Longitudinal research helps researchers specify

optimal times and methods for intervention and prevention. For

example, research indicates that early exposure to violence in the

home can lead to future risk of victimization. Identifying

potential moderators will aid in designing prevention programs.

Longitudinal research can also identify patterns of coping and

resilience across the life span for victims of intimate partner

CDC Injury Research Agenda 57

Research is needed

to identify risk and

protective factors

related to

victimization in order

to prevent first-time

victimization.
violence, sexual violence, and child maltreatment; this

information can enhance prevention and intervention activities.

As with preventing perpetration, a better understanding of the

risk factors associated with victimization would greatly enhance

the development of effective primary prevention programs.

L. Identify risk and protective factors and effective prevention

strategies for elder abuse.

Elder abuse is an emerging area of public health concern. As the

population ages, this form of abuse may become a much greater

problem. Little research about risk and protective factors for elder

abuse victimization and perpetration currently exists. Risk factors

appear to differ according to the type of elder abuse; physical and

psychological abuse, for example, share risk factors that are

distinct from those for neglect and financial abuse. Absent

important foundational research, program development is

difficult. Similarly, little information is available about the

effectiveness of existing interventions to prevent elder abuse and

mitigate its consequences. Given the limited body of scientific

knowledge about elder abuse, this is an important priority for the

future.

M. Study the role(s) of substance use and abuse as precursors

to and consequences of intimate partner violence, 

sexual violence, and child maltreatment victimization 

and perpetration.

Researchers do not clearly understand the roles of substance use

and abuse as precursors to and consequences of victimization and

perpetration across intimate partner violence, sexual violence, and

child maltreatment. Studies investigating substance use and its cooccurrence with perpetration of and victimization by these types

of violence should identify key components for prevention and

intervention programs. Other federal agencies such as the

National Institute of Drug Abuse and the Substance Abuse and

Mental Health Services Administration support research and

programs in this area. Injury Center research activities should

complement the efforts of these agencies whenever possible.

58 CDC Injury Research Agenda
N. Evaluate the impact of extreme community and

environmental stressors on intimate partner violence,

sexual violence, and child maltreatment.

Natural and man-made disasters such as floods and terrorism may

exacerbate intimate partner violence, sexual violence, and child

maltreatment in affected communities. Research should assess the

impact of community and environmental stressors on these three

types of violence. Findings from this research can aid service

agencies as they develop appropriate responses during periods of

extreme stress. Injury Center research on this issue would

complement other CDC work related to disaster response and

terrorism.

O. Describe service delivery use, impact, and costs of

interventions for intimate partner violence, sexual violence,

and child maltreatment. 

Better information about service delivery use, impact, and costs

of interventions for intimate partner violence, sexual violence,

and child maltreatment is needed to support research about the

cost effectiveness of interventions and policies designed to

prevent these problems and their consequences. This research will

become more important as more information about the efficacy

and effectiveness of prevention programs and policies becomes

available.

CDC Injury Research Agenda 59

Public Health Burden

Injury from suicidal behavior is a major public health problem in the

United States. In 1999, suicide was the eleventh leading cause of death

overall in the U.S.; it was the third leading cause of death among people

ages 15 to 24 and second among people ages 25 to 34. Although suicide

is a problem among youths and young adults, rates of death due to suicide

continue to be highest among people ages 65 and older.

The number of completed suicides reflects only a small portion of the

impact of suicidal behavior. Many more people are hospitalized as a result

of nonfatal suicide attempts than are fatally injured, and a still greater

number are treated in ambulatory settings or are not treated at all for

injuries resulting from suicidal acts. Data from the 1999 Youth Risk

Behavior Survey indicate that 8.3% of all high school students reported

attempting suicide in the 12 months before the survey, which translates

into approximately 1.3 million students across the U.S. Prior studies have

also shown a high prevalence of nonfatal suicidal behavior among adults.

According to data from the National Hospital Ambulatory Medical Care

Survey, an estimated 671,000 visits were made to U.S. hospital emergency

departments for self-directed violence in 1998. Other research indicates

that more than 70% of people who attempt suicide never seek health

services afterwards. As a result, prevalence figures based on health

records substantially underestimate the societal burden of suicidal

behavior.

The Injury Center’s Niche in Preventing 

Suicidal Behavior

Injuries and deaths resulting from self-directed violent behaviors

represent a substantial drain on the economic, social, and health resources

of the nation. The Injury Center seeks to lessen these burdens by

developing and promoting the widespread adoption of policies and

practices that effectively prevent suicide and suicidal behaviors. A center

within CDC, the Injury Center is uniquely positioned to address the need

for effective, population-based prevention and intervention strategies.

CDC Injury Research Agenda 61

Preventing Suicidal Behavior

The Injury Center

seeks to develop

and promote the

widespread adoption

of policies and

practices that

effectively prevent

suicide and suicidal

behaviors. 
Currently, however, public perceptions that suicide is solely a mental

health issue and a lack of scientific knowledge about effective populationbased strategies hinder efforts to intervene and prevent suicide.

To address these challenges, the Injury Center draws on historical

strengths and continues to expand into areas where suicide experts have

identified substantial needs that the Injury Center should address. These

activities fall into four categories:

• Disseminating information about suicidal behavior and its prevention

by supporting the implementation of proven programs and policies.

• Applying scientific methods to evaluate the effectiveness of current

intervention and prevention programs.

• Enhancing the knowledge base about risk and protective factors and

the consequences of suicidal behavior in order to develop more

effective prevention strategies.

• Continuing to improve methods for data collection in order to

describe and track suicidal behaviors.

The Injury Center works with a variety of partners at the local, state, and

national levels to disseminate scientific information about suicide

prevention. These efforts are directed to the public, policy makers, health

departments, community-based organizations, and other entities. By

promoting research that addresses the information needs of constituents,

the Injury Center contributes substantially to encouraging widespread

adoption of effective suicide prevention strategies.

Many communities have implemented a wide range of programs that

attempt to reduce injuries and deaths resulting from self-directed

violence. Little is known, however, about the effectiveness of these

programs. Finding successful strategies, especially those that focus on

developing positive skills and social relationships, may also have a broad

impact on an array of violent behaviors. Given the Injury Center’s

ongoing activities in child maltreatment, youth violence, and intimate

partner violence prevention, it is in a unique position to support the

development and evaluation of programs that address suicide and

interpersonal violence prevention within an integrated framework. In

addition, while research has identified many important risk and protective

factors for suicidal behavior, studies have rarely investigated the

62 CDC Injury Research Agenda
interaction between these factors. Developing a better understanding of

the dynamics of suicidal behavior is essential for building effective

interventions.

Several other federal agencies and national organizations focus significant

research efforts on understanding the causes of suicidal behavior and its

prevention. The Injury Center collaborates regularly with these groups as

evidenced by the recent release of the Surgeon General’s National Strategy

to Prevent Suicide. The Injury Center’s contributions to suicide prevention

highlight public health interventions and broad-based strategies that

complement important mental health research and treatment efforts

conducted by key federal partners at the National Institute of Mental

Health and the Substance Abuse and Mental Health Services

Administration.

The Injury Center’s Research Priorities in Preventing

Suicidal Behavior

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the seven

most important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

Priorities

A.* Develop, evaluate, and institutionalize processes for

creating and implementing suicide prevention activities.

Many state and local health departments and other agencies

across the U.S. are developing community, regional, or statewide

suicide prevention plans and implementing them across their

jurisdictions. However, researchers currently know very little

about the ways that broader political and social processes affect

the creation and implementation of large-scale suicide prevention

plans and activities. To foster the widespread adoption of

effective programs and policies, researchers must examine how

states and communities develop suicide prevention plans; study

how agencies establish cooperation and coordination across

CDC Injury Research Agenda 63

Researchers currently

know very little about

the ways that

broader political and

social processes

affect the creation

and implementation

of large-scale suicide

prevention plans and

activities. 
agencies; identify key infrastructure requirements for plan

adoption; recognize barriers to universal implementation; and

develop strategies to overcome these barriers to enhance the

power of implementation. By supporting research addressing

these key issues, the Injury Center can contribute to the larger

effort to plan for and establish effective suicide prevention

activities at the local, state, and national levels.

B.* Evaluate the impact of restricting access to lethal means

used in suicidal behavior.

Research indicates that the means used in suicidal behavior (e.g.,

jumping from a bridge or using a firearm versus taking pills) has

a substantial impact on whether the act results in significant injury

or death. When people have easy access to highly lethal means, the

likelihood of serious injury and death increases. Early evidence

suggests that restricting access to specific means used in suicidal

behavior (e.g., installing bridge barriers) can reduce overall rates of

suicide-related death and injury. Debates about this strategy

continue because the majority of means-restriction policies and

interventions have not been tested.

Additionally, there is a substantial gap in scientific knowledge

about how suicidal individuals choose among means. Previous

research has shown that without ready access to lethal means,

some individuals will choose not to engage in a suicidal act or will

be more likely to survive their injuries; however, some subset of

suicidal individuals will substitute other means. This substitution

may shift the death from one cause category to another rather

than preventing it. Researchers can better understand the

potential impact of means-restriction interventions by learning

more about how individuals make choices about the means they

use. Furthermore, if researchers demonstrate that meansrestriction policies effectively reduce suicide mortality and serious

injury, additional investigation will be necessary to learn how to

increase the acceptability of these policies so they can be

implemented nationwide.

64 CDC Injury Research Agenda
C.* Evaluate whether interventions proven to reduce other

forms of violence can also prevent suicidal behavior.

Researchers have documented the success of several different

types of intervention strategies designed to reduce behaviors that

are either risk factors for suicidal behavior (e.g., child abuse and

neglect, alcohol and drug abuse) or outcomes with similar risk

factor profiles (e.g., youth interpersonal violence). Especially

promising among them are comprehensive parenting programs

that provide usable knowledge to parents of young children and

adolescents and improve child-rearing skills, and positive health

promotion strategies that seek to enhance social competency,

conflict management, and coping skills.

Given the overlap between suicide and other behavioral problems,

such strategies show strong potential for preventing suicidal

behaviors. But few, if any, evaluations of these programs have

examined the direct impact on suicidal behaviors. At present, the

lack of well-designed suicide prevention and intervention

research that can demonstrate an effective reduction in suicidal

behaviors is a major deficiency in the field. Including suicide

prevention in interventions for behavioral health threats that

overlap with suicide has the potential to bring a wide range of

physical and emotional health benefits to the population. In

addition, by examining proven prevention programs that target

common risk or protective factors for suicidal behavior,

researchers can build on existing programs to make more efficient

use of limited resources and eliminate potential redundancies.

D.* Evaluate the efficacy and effectiveness of interventions to

prevent suicidal behavior.

Arguably, the greatest challenge in the field of suicide prevention

is identifying strategies and programs that actually reduce the

occurrence of suicide-related death and injury. In their attempts

to respond to community concerns about self-directed violence,

many public and private organizations have rushed to implement

suicide prevention activities. These activities include interventions

to increase primary care providers’ awareness of suicide as a

CDC Injury Research Agenda 65
problem and to promote patient screening for suicidal thoughts

and suicide attempts. Other efforts focus on strategies

implemented after a crisis or traumatic event has occurred.

Although several types of interventions have been developed for

use in schools and other specific settings after a suicide, research

does not appear to support the claim that such efforts prevent

additional suicidal behavior. Furthermore, while adult males ages

25 to 50 make up the majority of suicide deaths, few interventions

focus specifically on this group.

In sum, little is known about whether current approaches

effectively reduce injuries and deaths resulting from self-directed

violence. Because many programs are already in place, they

represent a significant opportunity to study prevailing practices

and demonstrate their impact on suicidal behavior. As researchers

evaluate these activities, they can also improve methods for

identifying promising strategies and programs.

E.* Clarify the influence of contextual forces on rates of

suicidal behavior.

Previous research indicates that a variety of non-mental health

factors can significantly affect rates of suicidal behavior and

completed suicides. These are societal- and community-level

factors such as the structure of social relationships (e.g., the

percentage of people in the community who are involved in

religious activities); changes in the economy; community norms,

values, and attitudes; and the availability of resources for people

who are struggling with day-to-day difficulties. The evidence also

suggests that these influences can vary in their presence and

impact across demographic groups. Researchers do not clearly

understand the mechanisms through which these broad,

community-level factors affect rates of suicidal behavior, which

hinders their ability to design effective prevention strategies.

Researchers, practitioners, and public health agencies need this

information to design and test more population-based approaches

that will effectively reduce suicide-related injuries and deaths in

particular communities.

66 CDC Injury Research Agenda

The many programs

already in place

represent a

significant

opportunity to study

prevailing practices

and demonstrate

their impact on

suicidal behavior.
F.* Clarify the impact of individual-level risk and protective

factors on suicidal behavior.

While individual mental health problems can contribute

substantially to suicidal behavior, mental disorder alone does not

cause it. Numerous additional factors may increase the risk of

suicidal behavior in some individuals. These include stressful life

events such as the death of a relative or losing a job; ongoing

difficulties such as child maltreatment, bullying, intimate partner

violence, physical illness or disability; and social isolation

characterized by living alone and having few or no social supports.

But researchers still lack insight into how these problems affect

suicide risk. Under some conditions, difficult life events appear to

motivate individuals to develop more effective coping skills,

thereby enhancing protection against suicidal behaviors. Current

research perspectives, however, generally fail to acknowledge

these challenges as possible opportunities for suicide prevention.

As a result, very little is known about how to recognize and

bolster potentially protective effects.

In addition to life stresses and social isolation, other individuallevel problems such as substance use or abuse and a tendency

toward impulsive behavior significantly increase the risk of

suicidal behavior. As with life events and interpersonal difficulties,

though, it is not clear how and under what conditions substance

use or abuse and impulsiveness may increase the likelihood of

suicidal behavior. More research is needed to understand the

individual-level dynamics of suicidal behavior, in particular, how

ongoing stresses, difficult events, interpersonal and familial

relationships (including parenting practices), as well as

impulsiveness and substance use or abuse, affect the likelihood of

suicide across the life span. The Injury Center would contribute

substantially to the development of effective interventions by

bringing a more dynamic and socially informed understanding of

suicidal behavior into risk and protection research.

CDC Injury Research Agenda 67
G.* Develop better methods for collecting data about fatal

suicides, nonfatal suicidal acts, and related behaviors.

Having accurate, timely, and accessible information about suicidal

behaviors is crucial, both for tracking the problem of suicide and

for evaluating the effectiveness of interventions. Information

should include data about suicidal behaviors that result in death,

hospitalization, or outpatient medical treatment, as well as those

where no medical care is sought. Currently, national data about

self-directed violence are limited almost exclusively to fatalities;

however, estimates indicate that for each suicide fatality,

approximately 20 people may be seen in hospital emergency

departments for attempted suicide. The Injury Center is working

to enhance the quality of suicide injury data collected from

hospital emergency departments, but very little is known about

injuries due to suicidal behaviors that are treated in other settings

or not treated at all.

Additionally, there is general consensus that official fatality data

underestimate the number of suicide deaths and that there may be

differential undercounting among groups, such as women, with

relatively low suicide rates. To create and implement enhanced

surveillance strategies, researchers must refine and validate

current definitions of suicide, attempted suicide, and related

behaviors; develop better methods for implementing high-quality,

timely data collection systems (including data systems outside of

the health and medical community); and evaluate the utility,

quality, and efficiency of the data and collection procedures.

H. Develop and evaluate methods to disseminate information

about effective suicide prevention strategies 

and interventions.

As effective suicide prevention strategies and interventions are

recognized, it will become increasingly important to identify

successful methods and mechanisms for disseminating and

encouraging the adoption of those evidence-based interventions.

Research is needed to identify key audiences for programs,

uncover the best formats and channels for providing information

to ensure that it is useful, and assess the level and kinds of training

and technical assistance required for successful implementation.

68 CDC Injury Research Agenda

Having accurate,

timely, and

accessible

information about

suicidal behaviors is

crucial, both for

tracking the problem

of suicide and for

evaluating the

effectiveness of

interventions.
At present, little is known about the role and impact of specific

models for distributing information about and support for

interventions to prevent suicidal behavior and intentional, selfinflicted injuries. By supporting this line of research, the Injury

Center will fulfill its role in promoting the widespread adoption of

successful suicide prevention programs.

I. Examine how effective interventions can be modified for

diverse and culturally distinct populations.

Accumulated research evidence indicates that rates of suicidal

behaviors and suicide risk profiles can vary widely among distinct

social and cultural groups. For example, among American Indians,

some subgroups have severely elevated levels of suicide mortality;

African American females have especially low rates of suicide

mortality, but they may have high rates of nonfatal suicidal

behavior. It is not clear whether gay, lesbian, bisexual, and

transgendered youths have elevated levels of nonfatal suicidal

behavior because findings from different studies have been

contradictory. These rate disparities suggest that there is wide

variation in suicide risk across social and cultural groups. In

addition, risk and protective factors may affect suicidal behavior

differently in specific populations.

Intervention strategies must be robust enough to account for

social and cultural differences because such variations may affect

the impact of prevention activities. Strategies that are effective

with one group either may not be effective with others or may

need to be tailored in particular ways to maintain their

effectiveness and ensure that they are culturally acceptable.

Presently, however, a substantial gap exists in the knowledge

about how to translate interventions across groups or contexts

while ensuring that modifications do not compromise the

intervention’s essential components. Studies must examine how

social and cultural factors such as stigma, beliefs about suicide and

suicide acceptability, and social and cultural history might alter

how a community views an intervention. Understanding how to

modify strategies proven effective in other settings will improve

substantially the likelihood that interventions will be acceptable to

diverse communities.

CDC Injury Research Agenda 69

Studies must examine

how social and

cultural factors might

alter how a

community views an

intervention.
J. Create and evaluate new communication campaigns for

suicide prevention.

Experts believe that greater public understanding of suicide

would enhance prevention efforts. It is important to raise

awareness about key risk factors for suicide, emphasize the fact

that suicidal behavior is preventable, and reduce the stigma

associated with seeking help for suicidal feelings. To accomplish

these tasks, researchers and practitioners need to know more

about how to construct general and targeted public education

campaigns to maximize their beneficial effects; that is, identify the

messages that work as well as the audiences for which those

messages are effective. Campaigns should also be evaluated to

determine whether they have a substantial impact on audiences’

understanding of and beliefs about suicidal behavior. Evaluation

findings will be useful in refining communication messages to

enhance their impact.

K. Evaluate the influence of news and entertainment media

on suicidal behavior.

Research supports the potential for “contagion” effects of factual

news stories about suicidal behavior, particularly among youths

and young adults, but the effect of fictional portrayals on

vulnerable individuals is unclear. Specifically, research is needed to

understand how both fictional and nonfictional media accounts

influence individuals to engage in suicidal behavior, as well as how

to construct messages and portrayals that discourage suicidal

behavior.

L. Clarify the relationship between suicidal thoughts and

feelings and suicidal behavior.

Thoughts of suicide, whether or not expressed to others, often

precede suicidal acts. Researchers typically conceptualize the

range of suicidality as a continuum extending from ideas and

thoughts about suicide that are not acted upon to nonfatal suicidal

acts to completed suicide. The process through which individuals

move from thought to action, however, remains unclear. Few who

experience suicidal ideas and thoughts engage in self-injurious

70 CDC Injury Research Agenda

Thoughts of suicide

often precede

suicidal acts. The

process through

which individuals

move from thought to

action, however,

remains unclear. 
behavior, and even fewer die from these behaviors. Evidence

suggests that some subgroups of individuals grapple repeatedly

with suicidal ideation and may make numerous nonfatal attempts.

While identifying individuals struggling with suicidal ideation

presents an important opportunity for intervention, better

knowledge about how ideation moves into action—both for the

first time and over the course of repeated acts—will help

researchers develop intervention strategies that can counter the

process more effectively.

M. Quantify the social and economic costs of 

suicidal behavior.

Fatal and nonfatal suicidal behaviors result in significant medical,

economic, and social costs, including lost wages and trauma for

family members and friends. Little research, however, has focused

on quantifying the total costs of suicidal behavior in the U.S., in

either monetary or nonmonetary terms. The definition of

nonmonetary costs such as pain, suffering, and reduced quality of

life needs further exploration and refinement. Such information

would be useful for educating the public about the need for

prevention as well as for assessing the cost-effectiveness of

prevention programs.

N. Examine how characteristics of specific institutional settings

affect risk for suicidal behavior and evaluate the

effectiveness of interventions designed to reduce risk in

these settings.

Relatively little is known about how the physical and social

characteristics of specific institutional settings such as schools and

jails can heighten or lessen the risk of suicidal behavior. More

research is needed to understand how suicidal individuals may or

may not be recognized within specific social and institutional

settings. Researchers also need to examine the organizational or

institutional factors that facilitate effective interventions when

suicidal individuals are identified. Such factors include physical

features of the environment that allow staff to monitor students

or clients effectively and students’ or clients’ abilities to access

means for engaging in suicidal behavior.

CDC Injury Research Agenda 71
O. Determine the long-term consequences of nonfatal

suicidal behavior.

There is substantial evidence that individuals who die from

suicide often have a history of previous suicide attempts. Yet little

research exists about the long-term outcomes of nonfatal suicidal

behavior. Studies are needed to follow suicidal individuals to

determine whether suicidal thoughts and behaviors are likely to

abate over time, and if so, to identify the factors that increase the

likelihood of diminution.

72 CDC Injury Research Agenda

Little research exists

about the long-term

outcomes of nonfatal

suicidal behavior.
Public Health Burden

Youth violence, perpetrated both by and against young people, results in

enormous physical, emotional, social, and economic consequences.

Although youth violence has declined significantly in recent years, much

work remains to reduce this public health burden. Homicide is the second

leading cause of death among 15- to 24-year-olds overall. In this age

group, homicide is the number one cause of death among African

Americans, the second leading cause of death among Hispanic

Americans, and the third leading cause of death among American Indians.

In 1999, 4,998 youths ages 15 to 24 were murdered—an average of 14 per

day. This represents approximately one third of all homicide victims that

year. Among the homicide offenders in 2000 whose age was known by

authorities, approximately 48% were age 24 or younger, and 9% were

younger than 18. Guns are a factor in most youth homicides. In 1999,

81% of homicide victims ages 15 to 24 were killed with firearms.

Violence is also an important cause of nonfatal injuries among young

people. Between 1992 and 1998, young people ages 12 to 24 were 14

times more likely than adults 50 and older to be injured as a result of a

violent crime. Although nonfatal acts of violence are relatively common

on school property, most acts of serious and fatal violent crime occur

outside of school. For instance, less than 1% of all violent deaths among

school-age children occur in schools. These data highlight the need for

prevention programs that address risk for violent behaviors both on and

off school property, including school-, family-, and community-based

programs.

The Injury Center’s Niche in Preventing Youth Violence

For many years, the predominant approach to youth violence was reactive;

disproportionate attention and resources were given to the medical

treatment of injured victims and the apprehension and incarceration of

violent offenders. A public health approach brings emphasis and

commitment to identifying policies and programs to prevent youth

violence. It derives from a tradition of collaboration among a broad

spectrum of scientific disciplines, organizations, and communities to

solve the problem of violence. In particular, the health sector, including

CDC Injury Research Agenda 73

Preventing Youth Violence

Homicide is the

second leading

cause of death

among 15- to 24-

year-olds overall.
emergency departments and community health agencies, plays a

prominent role as a source of data and a potential site for interventions

to prevent future violence. The public health approach also highlights the

potential utility of applying a variety of scientific tools (e.g., the tools of

epidemiology, behavioral and social sciences, and engineering) explicitly

toward identifying effective prevention strategies. In these key ways, the

perspective and methods of public health complement those of criminal

justice and other sectors in understanding and responding to violence.

CDC’s Injury Center is dedicated to studying interpersonal and selfdirected violence, including youth violence, intimate partner violence,

child maltreatment, and suicidal behavior. Research has documented

strong links among youth violence, family violence, and suicidal ideation.

The Injury Center’s inclusive focus on a range of violence-related injuries

provides a unique opportunity to better understand and address the

linkages between youth violence and other forms of violence.

The Injury Center’s violence prevention research is intended to have

practical implications and immediate relevance for prevention. For

example, studies about risk and protective factors are conducted to guide

prevention programs and policies. The Injury Center’s evaluation studies

focus on determining not only how well programs work but also on

identifying the processes through which they have an impact. This

information is crucial to dissemination efforts so that schools and

communities can implement programs effectively.

Several other federal agencies, including the Departments of Education

and Justice, the National Institute for Occupational Safety and Health,

and the National Institutes of Health study the causes and consequences

of youth violence and work to prevent it. The Injury Center routinely

collaborates with these and other agencies to study youth violence and to

ensure that research findings are applied to practice. For example, recent

partnerships with the Departments of Education and Justice have

facilitated studies about school-associated violent deaths and nonfatal

injuries from violent crimes such as assault, robbery, and rape. The Injury

Center’s research on violence-related injuries across contexts (e.g., school,

family, community), roles (i.e., victim or perpetrator), and proximal causes

(e.g., intoxication, bullying, robbery), combined with its emphasis on

prevention strategies, complements and extends the violence-prevention

activities of other federal agencies and community-based organizations.

74 CDC Injury Research Agenda

The Injury Center’s

violence prevention

research is intended

to have practical

implications and

immediate relevance

for prevention. 
The Injury Center’s Research Priorities in Preventing

Youth Violence 

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the seven

most important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

Priorities

A.* Evaluate dissemination strategies for the most effective

youth violence prevention programs. 

Research has identified several individual-, family-, and schoolbased approaches that effectively reduce youth violence and

aggression, some of which have also demonstrated effectiveness

in different settings and with different populations. Youth

violence prevention research should move beyond conducting

efficacy and effectiveness studies to conducting research that

identifies ways to disseminate the most effective strategies while

maintaining the benefits of original programs. Studies should

investigate factors that influence a program’s acceptability,

adoption, safety, and costs. These issues are critical for

implementing programs with “fidelity,” that is, in the manner in

which they are thought to be most effective. As described in the

Surgeon General’s report on youth violence, “more research is

needed on how to implement youth violence prevention

programs with fidelity . . . how to monitor program fidelity . . .

and how to increase community and agency capacity for

implementing these programs.”

Although dissemination research in youth violence prevention is

underdeveloped, researchers and community organizations that

have collaborated to develop and evaluate programs are

increasingly seeking opportunities to facilitate wider

dissemination of effective programs. Researchers should study

methods to improve adoption of proven youth violence

prevention programs. Necessary steps are to identify programs

and strategies that rigorous evaluation has demonstrated to be

CDC Injury Research Agenda 75

Researchers should

study methods to

improve adoption of

proven youth

violence prevention

programs.
effective and then to assess current practice to discover where

research and practice diverge. Research about bridging this gap in

dissemination practice is critical to improving the ability to

disseminate the most effective violence prevention strategies.

B.* Evaluate the effectiveness of community-wide parenting

programs for youth violence prevention.

Several recent documents, including CDC’s Best Practices of Youth

Violence Prevention and Youth Violence: A Report of the Surgeon General,

highlight the benefits of parenting programs. The substantial

evidence for the link between parenting practices and youth risk

for violence, as well as the increasing evidence that parenting

practices are modifiable, supports the need for research

investigating prevention strategies that affect families on a broad

level.

Research in this area would further knowledge about family-level

interventions that reduce youth violence and would provide

strategies for influencing families and parenting. This line of

research would build on the knowledge gained from evaluating

existing parenting interventions to support the development and

evaluation of public health-oriented parenting programs. These

programs should be comprehensive and population based, and

they should include multiple levels of intervention. For early

childhood interventions, research should include long-term

evaluations of their impact on youth violence.

C.* Evaluate the effectiveness of youth violence 

prevention strategies.

Many communities and schools are implementing violence

prevention strategies with little empirical evidence of their

effectiveness. Research is needed to examine the effectiveness of

these programs in “real-world” circumstances. It is also important

to evaluate emerging community-based programs to prevent

youth violence as well as programs that effectively prevent other

problem behaviors such as drug abuse, which may influence youth

risk for violent victimization or perpetration. The potential to

76 CDC Injury Research Agenda
identify effective programs for preventing multiple problems, for

example drug abuse and violence, provides an opportunity for

cross-agency collaboration. It may also be cost effective—schools

and community-based organizations can address more than one

problem with the same time and resources. Research should

provide information about the cost effectiveness of prevention

programs and generate tools for schools and communities to use

to evaluate the effectiveness of their programs.

Research should evaluate the preventive impact of the most

promising programs for which efficacy data are available, as well

as programs that lack efficacy data but are being implemented

widely. Ongoing monitoring of the practices, interventions, and

policies that communities and schools adopt is essential.

D.* Identify and evaluate strategies to decrease inappropriate

access to and use of firearms among youths. 

Firearms are used in the majority of youth homicides. In addition,

many youths carry and use firearms to intimidate their peers and

may or may not intend to harm others. While much is known

about the prevalence and correlates of inappropriate gun carrying

among youth and the consequences of youth gun use, less is

known about the factors associated with youth access to firearms

and use of firearms to threaten or injure others. Research about

gun carrying is needed to improve existing strategies, to develop

novel strategies, and to evaluate whether strategies actually

prevent inappropriate gun carrying and use and reduce firearmrelated injuries.

E.* Identify modifiable sociocultural and community factors

that influence youth violence.

Most of the research about risk and protective factors for youth

violence has been limited to characteristics such as behavior and

attitudes of the youths themselves or of their families. A

significant gap in knowledge exists about the role of the larger

social environment in youth violence and its prevention. For

CDC Injury Research Agenda 77

Ongoing monitoring

of the practices,

interventions, and

policies that

communities and

schools adopt is

essential. 
example, while the strong negative association between

socioeconomic indicators and youth violence is well documented,

little is known about the mechanisms linking low socioeconomic

status to youth violence. Understanding these mechanisms will be

extremely important in improving existing community programs

and developing new programs for low-income communities.

Other sociocultural and community factors that require greater

research attention include the role of illicit drug markets, the

nature and quality of public housing, the role of formal and

informal social networks, the role of social norms, and the

relationship between social capital and community rates of youth

violence. Research should also examine the interaction between

physical and social environments and assess how modifications in

the physical environment influence behavior and risk for

violence.

Certain communities are disproportionately affected by youth

violence. By addressing factors in the larger social and physical

environments, interventions will be better able to reduce the

racial, ethnic, and social disparities for youth safety that exist in

many communities. This work has important implications for

policies designed to reduce injury and adverse health outcomes

other than youth violence. It also is an area of research that is not

currently being addressed by other funding agencies but that is

directly relevant to CDC’s focus on community and populationbased health.

F.* Identify modifiable factors that protect youths from

becoming victims or perpetrators of violence.

Research about factors that buffer or moderate the effects of risk

factors for youth violence is very important to the development

of effective prevention strategies. To date, research about the

causes of youth violence has been focused almost exclusively on

understanding factors that place children and youths at greater

risk for violence. While researchers have made substantial

progress in identifying risk factors, a significant gap remains in

understanding the factors that mitigate risks.

78 CDC Injury Research Agenda

Improved

understanding of

protective factors has

immediate

implications for youth

violence prevention

efforts in schools and

communities.
Improved understanding of protective factors has immediate

implications for ongoing youth violence prevention efforts in

schools and communities. For example, as information becomes

available about how parents in low-income communities can

protect their children from violence, it can be immediately

communicated through existing parenting programs and public

service announcements. Research about modifiable protective

factors has important implications for prevention and is not being

addressed elsewhere.

G.* Clarify the relationships between youth violence and other

forms of violence and determine implications

for prevention.

Research has consistently shown that different forms of

violence—that is, child maltreatment, intimate partner violence,

youth interpersonal violence, and suicide—are interrelated. For

example, victims of early child maltreatment may become

perpetrators of violence later in life. Another example emerging

from recent acts of violence in school settings suggests that being

a victim of bullying and violence may be a risk factor for suicidal

behavior and violence perpetration. Most prevention strategies

focus on specific forms of violence or other health-risk

outcomes. Because many school-based violence prevention

specialists are seeking programs with fewer individual curriculum

modules and more integrated approaches to youth risk behavior,

prevention strategies that are effective in multiple areas could be

very valuable.

The Injury Center’s experience studying suicide, family violence,

and youth violence provides a unique environment for

understanding the shared and independent factors that contribute

to the different forms of violence. Research about the

relationships among various forms of violence can guide the

development and evaluation of prevention programs that reduce

multiple forms of violence. Efforts to include multiple forms of

violence in studies of risk and protective factors or evaluation

studies are urgently needed to improve researchers’ understanding

CDC Injury Research Agenda 79

Research about the

relationships among

various forms of

violence can guide

the development and

evaluation of

prevention programs

that reduce multiple

forms of violence. 
of the specificity of youth violence prevention strategies and the

ability to generalize their results. Given the limited funding

available to prevent youth violence, strategies should address

multiple forms of violence whenever feasible.

H. Examine strategies for and benefits of adapting

prevention programs for specific cultural or genderdefined groups.

Prevention programs may require modification to be effective

with groups other than the original target groups for whom the

programs were designed. Research should test ways to adapt

programs to strengthen their impact within various groups. Such

research can provide useful operational definitions of cultural

issues and identify limits for generalizing youth violence

prevention programs across subgroups of the population.

Research should identify strategies for overcoming limitations and

for maximizing the impact of scarce prevention resources. The

knowledge gained from this research will likely be relevant to

other violence- and injury-related prevention efforts.

I. Assess the cost-effectiveness of youth violence prevention

programs and their components.

Prevention science should be accountable and responsive to

public health issues, and so it is necessary to evaluate not only the

effectiveness of programs, but also the cost to the public to

implement those programs on a broad scale. In programs with

more than one component (e.g., classroom curricula, media

campaigns), information about the costs, required resources, and

relative contribution of individual components could be used to

improve program efficiency. Researchers should build on ongoing

effectiveness research and test new methods for determining the

cost-effectiveness of prevention programs.

80 CDC Injury Research Agenda
J. Develop and evaluate media-based public health

strategies to prevent youth violence.

Prevention strategies that incorporate a broad array of media and

are based on a public health approach to violence prevention may

influence the behaviors of large audiences of youths and/or

families. Research should investigate how to develop effective

messages and how to identify the most appropriate audiences and

venues for campaigns. Prevention campaigns serve two goals—to

convey prevention messages directly to their audiences and to

provide information about available programs. Both outcomes

should be evaluated. The results of these evaluations will likely be

relevant to similar strategies for preventing other forms of

violence and other injuries.

K. Evaluate the impact of public policy on youth violence.

Researchers should study the effects of broad policy shifts, such

as welfare reform, as well as policies directed specifically at

youths, such as curfews. The specific policies evaluated will

depend on the types of policies that emerge from federal, state,

and local agencies. This policy research can be applied to a range

of violence-related outcomes and will likely have relevance

beyond youth violence prevention.

L. Evaluate how violence portrayed in the media affects 

youth violence.

Little consensus exists on the influence of various forms of

media—including television, film, radio, music, print, and the

Internet—on the risk for violent victimization or perpetration,

especially severe forms of violence. Because of the pervasive

presence of the media, developing methodologically sound

approaches to evaluate its influence and building consensus on

these approaches are important activities. The results of such

research should inform policies and programs to decrease youth

susceptibility to violence portrayed in the media.

CDC Injury Research Agenda 81

Research should

investigate how to

develop effective

messages and how

to identify the most

appropriate

audiences and

venues for

campaigns.
M. Evaluate the impact of directly witnessing violence on

violent behavior.

A relatively large subgroup of youths has witnessed violence. A

better understanding of the consequences of exposure to

violence will help guide programs designed to support these

youths. Research should examine how exposure to violence

affects the risk of perpetrating violence, including the potential

for contagion effects (e.g., learned response, imitation), with the

goal of identifying factors that may reduce the impact of

witnessing violence. It should also investigate the effect that

witnessing violence has on young people’s perceptions of

vulnerability, attitudes and norms about violence, and emotional

and social health.

N. Identify situational factors that contribute to incidents 

of violence.

Researchers know relatively little about how the factors

immediately associated with an incident of violence, such as the

behavior of bystanders, the lack of adult supervision, the

presence of alcohol or weapons, and other physical factors,

interact with individual-level factors to influence risk for violent

behavior. Research should build upon information about the

circumstances under which interpersonal conflicts are most likely

to result in injury or death. The results of this research should be

incorporated into existing prevention efforts and help generate

novel strategies to address situational factors.

O. Increase the understanding of violent behavior and

victimization among young women. 

Research should identify the causes of violence and victimization

among young females; examine patterns of perpetration over the

female life course; and develop and evaluate interventions

intended for young females. Interventions should be sensitive to

cultural variations in the risk factors for violence among this

population.

82 CDC Injury Research Agenda
When it is appropriate in ongoing research, the Injury Center will

test for gender differences in the risk and protective factors

studied and gender-specific effects of the prevention strategies

tested. Although females are included in these other etiologic and

efficacy studies, it is important to consider the unique needs of

females who are at risk for being victimized or victimizing others.

As the results from other research indicate that specific gaps

remain in the knowledge about gender differences, this line of

research may be given a higher priority.

CDC Injury Research Agenda 83

Public Health Burden

Each year, Americans make 30 to 40 million emergency department (ED)

visits for injuries. While the majority of injured patients are treated and

released, many are admitted to inpatient trauma units and later receive

rehabilitative services. The most favorable patient outcomes result when

acute care and subsequent rehabilitation begin as early as possible and

when they focus on returning patients to their baseline or an optimal level

of functioning. Trauma systems are designed to match trauma patients

with the acute care and rehabilitative facilities they need, but in many parts

of the United States, trauma systems are not fully operational or do not

exist at all. Where these systems are lacking, as many as 30% to 40% of

deaths among trauma patients are due to preventable problems in clinical

care, including missed diagnoses and treatment delays. Follow-up studies

have shown as much as a 50% reduction in preventable trauma deaths

after trauma systems are introduced.

Injuries are a major cause of disability in the U.S. Central nervous system

injuries—those to the brain and spinal cord—are most likely to result in

serious, long-term disability. Each year, an estimated 80,000 Americans

sustain traumatic brain injuries (TBI) that result in disabilities; an

estimated 5.3 million Americans live with TBI-related disability. Although

physical impairments from the injury may contribute to TBI disability,

cognitive deficits are the hallmark, frequently resulting in secondary

conditions such as depression and other adverse outcomes such as the

inability to work. An estimated 200,000 people in the U.S. live with spinal

cord injuries (SCI), and this number increases annually by as many as

20,000 individuals. Secondary conditions such as pressure ulcers are a

common cause of lost productivity among people with SCI.

Other important disabling injuries include limb injuries, back injuries, eye

injuries, and burns. Injuries to the lower extremities constitute the leading

cause of trauma admissions among adolescents and young adults,

accounting for 235,000 hospitalizations each year. In addition to their

high incidence, lower extremity injuries often result in significant

impairment and loss of function.

CDC Injury Research Agenda 85

Acute Care, Disability, 

and Rehabilitation

The most favorable

patient outcomes

result when acute

care and subsequent

rehabilitation begin

as early as possible

and when they focus

on returning patients

to their baseline or

an optimal level of

functioning. 
86 CDC Injury Research Agenda

Injured patients may suffer a variety of psychosocial effects, including

post-traumatic stress disorder, depression, misuse of alcohol and other

drugs, and difficulties returning to the routines of pre-injury work and

social lives. Screening and intervention programs may reduce the

frequency and severity of these consequences and may also decrease the

number of ED and trauma center visits for future injury. In one study, for

example, screening and intervention for alcohol problems among patients

hospitalized for trauma reduced hospital admissions for injuries by 48%

for the following three years. To prevent adverse outcomes, pre-existing

injury risk factors, such as excessive alcohol use, must be addressed in a

comprehensive way, including during acute care and rehabilitation.

The Injury Center’s Niche in Acute Care, Disability, 

and Rehabilitation

CDC’s Injury Center maintains close ties with practitioners and

researchers working in acute care and rehabilitation, as well as with public

health professionals working in injury prevention and control. These

relationships help foster cooperation and strategically advance a broadbased, multidisciplinary approach to injury. The Injury Center’s

multidisciplinary orientation also provides unique opportunities to

catalyze and coordinate innovations in clinical preventive services in acute

care and rehabilitation facilities. It recently developed a research program

on clinical preventive services for alcohol problems in EDs and brought

together federal partners and experts in alcohol research, emergency

medicine, and trauma care to set a research agenda for this emerging field.

The Injury Center’s partnerships with state health agencies, academic

injury research programs, and health care practitioners provide a vital

foundation for establishing and maintaining population-based

surveillance systems and conducting outcomes research. More

comprehensive and timely information about injury incidence, causes, and

outcomes in defined populations can help guide injury prevention

programs as well as efforts to improve treatment and rehabilitation for

those injuries that do occur. With its focus on population-based

surveillance and research, the Injury Center is positioned to lead the

development and dissemination of appropriate case definitions, data

elements, and data collection methods. Activities involving evaluation of

community- and clinic-based interventions, community services, and

systems of care also distinguish the Injury Center’s work from that of

many other agencies.

CDC’s Injury Center

maintains close ties

with practitioners

and researchers

working in acute

care and

rehabilitation. These

relationships help

foster cooperation

and strategically

advance a broadbased,

multidisciplinary

approach to injury. 
Although lead federal responsibility for trauma care systems resides with

the Health Resources and Services Administration (HRSA), the Institute

of Medicine (IOM) report Reducing the Burden of Injury: Advancing Prevention

and Treatment specifically recommends that the Injury Center collaborate

on new trauma outcomes research. The Injury Center staff has extensive

experience working with public and private sector organizations

responsible for trauma care system planning and development at the local,

state, and national levels. This experience positions the Injury Center to

help set research priorities, provide technical assistance for research

programs, and facilitate translation of new findings into practical

methods for evaluating trauma care systems.

The Injury Center’s research and programs in the area of disability and

rehabilitation are designed to inform efforts to reduce the impact or

prevent the development of secondary conditions and other adverse

outcomes of TBI and SCI. Findings from Injury Center-funded TBI

surveillance provide crucial information to guide primary prevention

efforts, not only for TBI but for many other injuries as well.

Many of CDC’s injury research activities can support the work of other

federal, state, and local agencies. The Injury Center collaborates with

agencies involved in trauma care and disability prevention, including

HRSA, the National Institute for Disability and Rehabilitation Research

(NIDRR), the National Center for Medical Rehabilitation Research at the

National Institutes of Health, and the Social Security Administration. All

research activities should include interaction among related organizations

and agencies to develop case definitions and enhance the ability to

generalize across agencies’ studies.

The Injury Center’s Research Priorities in Acute Care,

Disability, and Rehabilitation

Every research priority in this agenda is important. After considering

input from experts in the field, Injury Center staff identified the eight

most important priorities, those that warrant the greatest attention and

intramural and extramural resources from the Injury Center over the next

three to five years. They are designated with asterisks.

CDC Injury Research Agenda 87
Priorities

A.* Develop and evaluate protocols that provide onsite

interventions in acute care settings or linkages to off-site

services for patients at risk of injury or psychosocial

problems following injury.

Clinical preventive services for patients treated in emergency

departments, hospital trauma units, and other acute care settings

can help reduce the risk of injury and mitigate the effects of

injuries that do occur. Such services might include instruction in

the proper use of safety restraints and screening and interventions

for alcohol problems, intimate partner violence, or child

maltreatment. For injured patients, ED visits and inpatient

hospital admissions for trauma care may provide crucial

opportunities for early identification of and intervention for posttraumatic stress disorder and other psychosocial problems that

can follow or be exacerbated by injury.

Decision makers are often reluctant to fund preventive clinical

services because they believe the investment needed to implement

a single service in one clinical setting is too high. Research should

demonstrate the effectiveness and value of such services and

examine ways to implement multiple services simultaneously to

amortize operational costs.

B.* Measure the benefits and costs of trauma care systems.

Despite evidence that trauma care systems save lives, many areas

of the U.S. lack trauma system coverage. New methods of

measuring morbidity, quality of life, functional status, and cost

will help define the benefits and costs of trauma care systems,

including determining which patients benefit most from trauma

care systems and at what costs. In all aspects of trauma care, these

new approaches to studying outcomes and costs will likely yield

insights that influence policies and practices at the national, state,

and local levels. They can be applied in ongoing efforts to

monitor and improve system performance and may be useful in

research conducted about specific clinical interventions.

88 CDC Injury Research Agenda

Clinical preventive

services for patients

treated in acute care

settings can help

reduce the risk of

injury and mitigate

the effects of injuries

that do occur. 
C.* Identify risk factors and develop and evaluate interventions

for secondary conditions following TBI or SCI, particularly

among patients who have not received treatment or

rehabilitation at state-of-the-art facilities.

Secondary conditions of TBI and SCI result in reduced capacity

to perform daily activities, lost work productivity, and decreased

quality of life. Secondary conditions range from medical

conditions resulting from the injury, such as pressure ulcers

among people with SCI, to behavioral changes, such as alcohol

and substance abuse. Much of the research about the incidence

and risk factors for secondary conditions of TBI and SCI has

been conducted by researchers from NIDRR’s Model Systems

project, which focuses on a relatively small subgroup of patients

treated by specialized Model Systems facilities. Research should

increase understanding about the risk factors for secondary

conditions among all persons with TBI and SCI, especially those

who do not have access to state-of-the-art information and care.

The relationship between treatment for secondary conditions and

longer-term outcomes of TBI and SCI is not well understood.

Additional research is needed to develop more effective

rehabilitation methods that include treatment or management of

secondary conditions and to evaluate the costs and benefits of

these approaches.

D.* Identify methods and strategies to ensure that people with

TBI and SCI receive needed services.

People disabled by an injury often do not receive the help they

need. A CDC-funded follow-up study of TBI in Colorado found

that one year after injury, about one third of people with a

disability said they had not received any services since their

discharge from the hospital. According to a 1998 General

Accounting Office report, people who have cognitive or behavior

problems, but not physical problems, resulting from TBI are

among those most likely to have unmet service needs. Without

treatment, people with behavior problems are the most likely to

become homeless, be committed to mental institutions, or be

CDC Injury Research Agenda 89

Research should

increase

understanding of the

gaps between

needed and

available services for

people with TBI and

SCI and should

identify strategies to

close those gaps.
sentenced to prison. A recent study showed that people with TBI

who received the services they needed reported a better quality of

life. Research should increase understanding of the gaps between

needed and available services for people with TBI and SCI and

should identify strategies to close those gaps.

People with “mild” TBI may not even be diagnosed with a TBI,

making it even more difficult for them to get assistance. Research

should explore the possibility of adapting case identification

methods to help link people with TBI and SCI to services. To that

end, the Injury Center has already funded two small, pilot projects

to investigate the feasibility of using state-based TBI surveillance

to identify people hospitalized with TBI who may need help

finding out about services. Studies should investigate specific

methods for linking people to information and services, such as

evaluating the usefulness of toll-free telephone numbers that

serve as single points of entry to the service delivery system.

Studies should also describe the spectrum of rehabilitation

services and trends in service provision, and they should evaluate

access to medical, rehabilitation, and social services to prevent

disabling outcomes and secondary conditions.

E.* Develop and evaluate methods of using point-of-care

clinical information systems to report injuries and other

acute health problems to public health agencies. 

As electronic clinical information systems enter the mainstream

of acute care practice, new opportunities arise to use clinical data

for public health surveillance of injuries and other acute health

problems. However, methods of using point-of-care clinical

information systems in this manner are not well developed and

require evaluation. Research should identify the point-of-care data

to be recorded and reported, resolve questions about terminology

and classification systems, guide decisions about linking disparate

systems, and evaluate the benefits and costs of new approaches to

public health surveillance of injuries and other acute conditions.

Findings from this research can help establish and maintain

90 CDC Injury Research Agenda
relevant data standards. For example, in emergency and trauma

care, standards would include data elements, clinical vocabularies,

and coding systems that convey information about the nature,

severity, treatment, and outcomes of injuries.

Point-of-care clinical information systems can facilitate

surveillance of access to acute care. Diversions of patients

transported by ambulance have increased in recent years in many

metropolitan areas in the U.S. When a hospital places its

emergency department on diversion, patients transported by

ambulance must be taken to another hospital for emergency care.

Prolonged patient transports and resulting treatment delays cause

dissatisfaction among patients, practitioners, and health care

managers. They also may lead to worsening clinical outcomes.

More systematic and population-based research is needed to

evaluate the impact of diversions on patient care in defined

geographic areas. Research about emergency department

diversions can be aided by Web-based reporting systems that

enable hospitals to communicate their diversion status to other

hospitals and to health agencies. Linking data from these systems

to patient outcome data can provide an important measure of the

magnitude and consequences of ambulance diversions.

F.* Develop and apply methods for calculating populationbased estimates of the incidence, costs, and long-term

consequences of SCI and nonhospitalized TBI.

Developing methods to identify and characterize people with TBI

and SCI is an essential first step to conducting surveillance and

outcome studies. Such methods are lacking for some subgroups

of people with TBI, particularly those with “mild” TBI. Research

should focus on increasing uniformity of case identification

methods to improve the comparability of national-level data for

people with TBI. Increased collaboration among federal agencies

is crucial to such research. Considering available resources and the

language in the TBI Act Reauthorization for 2000, case

identification of people with “mild” TBI, including those who do

not receive medical care, should receive highest priority.

CDC Injury Research Agenda 91

Case identification of

people with “mild”

TBI, including those

who do not receive

medical care, should

receive highest

priority.
The Injury Center conducts population-based surveillance to

develop nationally representative estimates of the incidence,

prevalence, nature, and causes of injuries that result in long-term

disability. This activity includes conducting population-based

follow-up studies to identify and track the long-term outcomes of

disabling injuries. Research should investigate the unique

outcomes and special needs of specific subgroups of TBI and

SCI populations, such as those injured as a result of violence.

Better information about outcomes could improve estimates of

the true burden of disability for individuals with “mild” TBI by

helping to document long-term problems resulting from these

injuries. Research should also identify the service needs of people

with TBI and SCI, providing useful information for injured

persons, service providers, and policy makers.

The direct medical costs and indirect costs associated with

disabling injuries are not well documented; however, this

information is important to guide decisions about resource

allocation and other policies. For TBI, the study most often cited

was published 10 years ago. Research should provide

comprehensive, up-to-date information about the direct and

indirect costs of TBI and SCI. In addition, research should

estimate the costs associated with secondary conditions such as

pressure sores, depression, and alcohol abuse.

G.* Determine the impact of TBI on special populations.

The majority of population-based studies of TBI outcomes have

focused on adults generally. Documenting the true impact of

disability from TBI requires additional research on populations

that have not been well studied to date, including children and

youths, working adults, institutionalized individuals, victims of

intimate partner violence, and people within school systems and

the criminal and juvenile justice systems. Some subgroups within

the adult TBI population, for example people in prisons, are

difficult to locate and are often lost to follow-up. Considering

available resources and language in the TBI Act Reauthorization

of 2000, determining the prevalence of TBI and related disability

among children, youths, and people in institutions should receive

highest priority.

92 CDC Injury Research Agenda
H.* Determine the incidence, causes, nature, biomechanics,

and outcomes of limb injuries.

The few studies to date about limb injuries have shown that these

injuries result in substantial disability and affect one’s ability to

return to work. In fact, only about 50% of people who were

working before being injured return to work within six months.

The extent of physical impairment is one key factor that

influences disability, but other factors exist about which data are

limited. Research using population-based studies is needed to

describe accurately the public health burden of limb injuries and

to suggest appropriate interventions to prevent these injuries and

resulting disability. In addition to epidemiologic studies, research

about the biomechanics of injuries to the extremities, such as

fractures and dislocations, is necessary to devise prevention

strategies.

I. Develop and evaluate interventions to improve patient

safety in health care settings using strategies that have

helped prevent and control injuries.

The IOM report To Err is Human: Building a Safer Health System has

spurred new efforts to monitor and improve patient safety. The

report highlights injuries in health care settings that are amenable

to systematic surveillance, epidemiologic study, and targeted

interventions to prevent them or control their effects. Although

the Injury Center is not a lead federal agency for efforts to

improve patient safety, its expertise and experience in developing,

disseminating, and evaluating countermeasures for a wide range

of injury problems provides a powerful injury-prevention

paradigm appropriate to the problem. For example, much has

been learned about preventing falls and suicides in community

settings that can be extended to health care facilities. The Injury

Center’s partnerships with professional associations, community

groups, national coalitions, prevention specialists, injury

researchers, and state and federal health agencies will be

advantageous in building support for and disseminating

interventions to improve patient safety.

CDC Injury Research Agenda 93

An IOM report

highlights injuries in

health care settings

that are amenable to

systematic

surveillance,

epidemiologic study,

and targeted

interventions.
94 CDC Injury Research Agenda

J. Develop and evaluate interventions for reducing disability

due to “mild” TBI.

People with “mild” TBI, especially those who are not

hospitalized, frequently receive little information about the

potential impact of their injuries and may not even be diagnosed

by health professionals. Some clinical psychologists report that

early counseling and intervention can reduce the likelihood of

long-term problems. For example, early training in adaptive

strategies to cope with memory problems may minimize an

injury’s impact. Identifying appropriate interventions and

documenting their effects will support the development of a

service infrastructure for people with “mild” TBI.

K. Develop and evaluate injury and disability interventions

using biomechanical and computer models.

Knowledge of injury tolerance and injury mechanisms for the

most prevalent and disabling injuries among children and adults

of different sizes should be applied to the design of injury and

disability prevention strategies. These strategies should be

evaluated using biomechanical models, “crash dummies,” and

computer simulation and models.

L. Determine how the environment affects disability from TBI

and SCI.

Physical and social factors in the environment may contribute to

the risk of disability among people with TBI and SCI. According

to the 1991 IOM report Disability in America, physical risk factors

are primarily the product of the built or human-made

environment, for example, the lack of stair ramps or inadequate

transportation. Social factors are a function of the opportunities

and expectations that may interfere with a person’s ability to get a

job; the presence of discriminatory attitudes about the capabilities

of people with disabilities is one example. The relationship

between these factors and disability among people with TBI and

SCI has not been well studied.
CDC Injury Research Agenda 95

M. Investigate the long-term effects of TBI and SCI on 

the health and longevity of people with disability

from these injuries.

Early research suggests that people with disabilities may have

shorter life spans and poorer health overall as they age than do

people without disabilities. Specific research about the

relationship between injury-related disability and long-term health

effects is needed to guide interventions to reduce the likelihood of

these adverse outcomes as persons with disabilities age. Research

should include longitudinal studies of people with TBI- and SCIrelated disabilities, as well as studies of older adults who sustain

these injuries.

CDC Injury Research Agenda 97

The Injury Center would like to thank the many injury control experts who contributed to the

conceptualization and content of the research agenda by participating on work groups, writing chapters,

reviewing documents, and providing valuable comments.

Acknowledgments

Ileana Arias, Ph.D.

(Coauthor, Chapter on Preventing Intimate Partner

Violence, Sexual Violence, and Child Maltreatment)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services 

Atlanta, Georgia 

Bernard Auchter, M.S.W.

Violence and Victimization Division

Office of Research and Evaluation

National Institute of Justice

Washington, District of Columbia 

Donna Barnes, Ph.D.

Department of Sociology

College of Liberal Arts

Southwest Texas State University

San Marcos, Texas 

Lisa C. Barrios, Dr.P.H.

National Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Allan I. Bergman

Brain Injury Association of America

Alexandria, Virginia 

Sandra I. Berrios-Torres, M.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Sue Binder, M.D.

(Coauthor, Introduction)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services 

Atlanta, Georgia

Alfred Blumstein, Ph.D.

The H. John Heinz III School of Public Policy 

and Management

Carnegie Mellon University

Pittsburgh, Pennsylvania

Julie Bolen, Ph.D., M.P.H.

National Center for Chronic Disease Prevention and 

Health Promotion

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Christine M. Branche, Ph.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Edward N. Brandt, Jr., M.D., Ph.D.

The University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma 

Ruth Brannon, M.A., M.S.P.H.

National Institute on Disability and Rehabilitation Research

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, District of Columbia
98 CDC Injury Research Agenda

David Buchner, M.D., M.P.H.

National Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia 

Eric D. Caine, M.D.

Department of Psychiatry

School of Medicine

University of Rochester Medical Center

Rochester, New York 

Dawn N. Castillo, M.P.H.

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Morgantown, West Virginia

Betty M. Chemers

Office of Juvenile Justice and Delinquency Prevention

Office of Justice Programs

U.S. Department of Justice

Washington, District of Columbia 

Katherine Kaufer Christoffel, M.D., M.P.H.

Department of Pediatrics

Northwestern University Medical School

Children’s Memorial Institute for Education and Research

Chicago, Illinois 

Demetra Collia, M.S.

Safety Data Initiative Project 

Bureau of Transportation Statistics

U.S. Department of Transportation

Washington, District of Columbia

John D. Corrigan, Ph.D.

Department of Physical Medicine and Rehabilitation

College of Medicine and Public Health

Ohio State University

Columbus, Ohio 

Alexander E. Crosby, M.D., M.P.H.

(Coauthor, Chapter on Preventing Suicidal Behavior)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

LeMyra DeBruyn, Ph.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Ann M. Dellinger, Ph.D., M.P.H.

(Coauthor, Chapter on Preventing 

Transportation Injuries)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Sujata Desai, Ph.D.

(Coauthor, Chapter on Preventing Intimate Partner

Violence, Sexual Violence, and Child Maltreatment)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Herman Diesenhaus, Ph.D.

Center for Substance Abuse and Treatment

Substance Abuse and Mental Health 

Services Administration

U.S. Department of Health and Human Services

Rockville, Maryland 

Carolyn DiGuiseppi, M.D., M.P.H.

Department of Preventive Medicine and Biometrics

School of Medicine

University of Colorado Health Sciences Center

Denver, Colorado 

Sureyya Dikmen, Ph.D.

Department of Rehabilitation Medicine

School of Medicine

University of Washington

Seattle, Washington

Lynda S. Doll, Ph.D.

(Coauthor, Introduction)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services 

Atlanta, Georgia
CDC Injury Research Agenda 99

Mary Dufour, M.D., M.P.H.

National Institute on Alcohol Abuse and Alcoholism

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Chhanda Dutta, Ph.D.

National Institute on Aging

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Mary Ann Dutton, Ph.D.

Department of Psychiatry

School of Medicine

Georgetown University

Washington, District of Columbia 

A. Brent Eastman, M.D.

Trauma Services

Scripps Memorial Hospital - La Jolla

La Jolla, California

Richard L. Ehrenberg, M.D.

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Jacqueline Elder, B.S.

Office of Hazard Identification and Reduction

U.S. Consumer Product Safety Commission

Bethesda, Maryland

David Fleming, M.D.

Office of the Director

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Jennifer Friday, Ph.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Andrea Gielen, Sc.D.

Department of Health Policy and Management

Bloomberg School of Public Health

The Johns Hopkins University 

Baltimore, Maryland 

Julie Gilchrist, M.D.

(Coauthor, Chapter on Preventing Injuries in Sports,

Recreation, and Exercise)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Denise Gottfredson, Ph.D.

Department of Criminology and Criminal Justice

College of Behavioral and Social Sciences

University of Maryland

College Park, Maryland 

David Grossman, M.D., M.P.H.

Harborview Injury Prevention and Research Center

Harborview Medical Center

University of Washington

Seattle, Washington 

Robert Hahn, Ph.D., M.P.H.

Epidemiology Program Office

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia 

John Hall, Ph.D.

National Fire Protection Association

Quincy, Massachusetts

W. Rodney Hammond, Ph.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services 

Atlanta, Georgia

Steve Hargarten, M.D., M.P.H.

Injury Research Center

Medical College of Wisconsin 

Milwaukee, Wisconsin 
100 CDC Injury Research Agenda

LT Betty Hastings, M.S.W.

Maternal and Child Health Bureau

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, Maryland 

Lynne M. Haverkos, M.D., M.P.H.

National Institute of Child Health and 

Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Darnell Hawkins, Ph.D., J.D.

Department of African American Studies

College of Liberal Arts and Sciences

University of Illinois at Chicago

Chicago, Illinois 

Doug Heir, Esq.

National Spinal Cord Injury Association

Cherry Hill, New Jersey 

J. Howard Hill, B.S.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Daniel W. Hungerford, Dr.P.H.

(Coauthor, Chapter on Acute Care, Disability,

and Rehabilitation)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Bruce Jones, M.D., M.P.H.

(Coauthor, Chapter on Preventing 

Transportation Injuries)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Dean Kilpatrick, Ph.D.

National Violence Against Women Prevention

Research Center

Department of Psychiatry and Behavioral Science

Medical University of South Carolina

Charleston, South Carolina

C. Dexter (Bo) Kimsey, Jr., Ph.D., M.S.E.H.

National Center for Chronic Disease Prevention and 

Health Promotion

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia 

David J. Kolko, Ph.D.

Department of Psychiatry

School of Medicine

University of Pittsburgh

Pittsburgh, Pennsylvania 

Candy Kragthorpe, M.S.W., L.G.S.W.

Family Health Division Director’s Office

Minnesota State Department of Health

St. Paul, Minnesota

Dan Lammertse, M.D.

Craig Hospital

Englewood, Colorado 

Jean Langlois, Sc.D., M.P.H.

(Coauthor, Chapter on Acute Care, Disability,

and Rehabilitation)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

David Litts, O.D.

Office of the Surgeon General

Office of the Secretary

U.S. Department of Health and Human Services

Washington, District of Columbia

Lawrence P. Lonero, M.S.

Northport Associates

Baltimore, Ontario, Canada 
CDC Injury Research Agenda 101

John Lowe, Dr.P.H., M.P.H.

Department of Community and Behavioral Health

College of Public Health

University of Iowa

Iowa City, Iowa 

Keri M. Lubell, Ph.D.

(Coauthor, Chapter on Preventing Suicidal Behavior)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Ellen MacKenzie, Ph.D.

Center for Injury Research and Policy

Bloomberg School of Public Health

The Johns Hopkins University 

Baltimore, Maryland

Ronald F. Maio, D.S., M.S.

Department of Emergency Medicine

University of Michigan Medical School

University of Michigan

Ann Arbor, Michigan 

Sue Mallonee, R.N., M.P.H.

Injury Prevention Service

Oklahoma State Department of Health

Oklahoma City, Oklahoma

Susan McHenry, M.S.

Emergency Medical Services Division

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, District of Columbia

A. James McKnight, Ph.D.

Transportation Research Associates

Annapolis, Maryland

James A. Mercy, Ph.D.

(Coauthor, Chapters on Preventing Intimate Partner

Violence, Sexual Violence, and Child Maltreatment;

and Preventing Youth Violence)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Denise Middlebrook, Ph.D.

Center for Mental Health Services

Substance Abuse and Mental Health 

Services Administration

U.S. Department of Health and Human Services

Rockville, Maryland 

Barbara Morrongiello, Ph.D.

Department of Psychology

College of Social and Applied Human Sciences

University of Guelph

Guelph, Ontario, Canada

Fred Mueller, Ph.D.

Department of Exercise and Sport Science

College of Arts and Sciences

University of North Carolina

Chapel Hill, North Carolina

Rich Mullins, M.D., F.A.C.S.

Department of Surgery

School of Medicine

Oregon Health Sciences University

Portland, Oregon

Barry S. Myers, M.D., Ph.D.

Orthopaedic Surgery Division

Department of Biomedical Engineering

Duke University

Durham, North Carolina 

James L. Nichols, Ph.D.

Office of Research and Traffic Records 

Traffic Safety Programs

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, District of Columbia

Lynda Nutt

National Water Safety Program

United States Army Corps of Engineers

The United States Army

Walla Walla, Washington 

K. Daniel O’Leary, Ph.D.

Psychology Department

College of Arts and Sciences

State University of New York

Stony Brook, New York 
102 CDC Injury Research Agenda

Sarah J. Olson, M.S., C.H.E.S.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Richard Pain, Ph.D.

Transportation Research Board

Washington, District of Columbia 

James Panagis, M.D., M.P.H.

National Institute of Arthritis and Musculoskeletal

and Skin Diseases

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Jane Pearson, Ph.D.

National Institute of Mental Health

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Ray Peck, M.A.

RC Peck and Associates

Sacramento, California 

Chester L. Pogostin, D.V.M., M.P.A.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Daniel A. Pollock, M.D.

(Coauthor, Chapter on Acute Care, Disability,

and Rehabilitation)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Lloyd Potter, Ph.D., M.P.H.

Center for Violence and Injury Prevention

Health and Human Development Programs

Education Development Center, Inc.

Newton, Massachusetts 

Ron Prinz, Ph.D.

Department of Psychology

College of Liberal Arts

University of South Carolina

Columbia, South Carolina 

Linda Quan, M.D.

Department of Pediatrics

School of Medicine

University of Washington

Seattle, Washington 

Ralph K. Requa, M.S.P.H.

Center for Sports Medicine

Saint Francis Memorial Hospital

San Francisco, California 

William Riley

Office of Community Services

Administration for Children and Families

U.S. Department of Health and Human Services

Washington, District of Columbia 

Lisa Riolo, Ph.D., P.T.

Department of Rehabilitation Science 

Department of Geriatric Medicine

University of Oklahoma Health Science Center

Oklahoma City, Oklahoma

Linda Saltzman, Ph.D.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Richard A. Schieber, M.D., M.P.H.

(Coauthor, Chapter on Preventing Injuries at Home 

and in the Community)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Ulonda Shamwell, M.S.W.

Office of the Administrator

Substance Abuse and Mental Health 

Services Administration

U.S. Department of Health and Human Services

Rockville, Maryland
CDC Injury Research Agenda 103

Ruth Shults, Ph.D., M.P.H.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Morton Silverman, M.D.

Department of Psychiatry

Pritzker School of Medicine

University of Chicago

Chicago, Illinois 

Thomas R. Simon, Ph.D.

(Coauthor, Chapter on Preventing Youth Violence)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Bruce G. Simons-Morton, Ed.D., M.P.H.

National Institute of Child Health and 

Human Development

National Institutes of Health 

U.S. Department of Health and Human Services

Bethesda, Maryland 

David A. Sleet, Ph.D.

(Coauthor, Chapters on Preventing Injuries at Home 

and in the Community; Preventing Injuries in Sports,

Recreation, and Exercise; and Preventing

Transportation Injuries)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Emilie P. Smith, Ph.D.

(Coauthor, Chapter on Preventing Youth Violence)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Daniel Sosin, M.D., M.P.H.

Epidemiology Program Office

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Jana L. Telfer, M.A.

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Diane Thompson, M.S.

Harborview Injury Prevention and Research Center

Harborview Medical Center

University of Washington

Seattle, Washington

Nancy Thompson, Ph.D., M.P.H.

Department of Behavioral Sciences and Health Education

Rollins School of Public Health

Emory University

Atlanta, Georgia 

David Thurman, M.D.

National Center for Chronic Disease Prevention 

and Health Promotion

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Farris Tuma, Sc.D.

National Institute of Mental Health

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Lisa R. Tylor

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Donald Vernon, M.D.

Department of Pediatrics

School of Medicine

University of Utah

Salt Lake City, Utah

Elinor Walker

Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services

Rockville, Maryland
104 CDC Injury Research Agenda

Richard J. Waxweiler, Ph.D.

(Coauthor, Introduction)

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Atlanta, Georgia

Michael Weinrich, Ph.D.

National Institute of Child Health and 

Human Development 

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, Maryland 

Margaret West, Ph.D., M.S.W.

Seattle Field Office

Health Resources and Services Administration 

U.S. Department of Health and Human Services

Seattle, Washington 

Flaura Winston, M.D., Ph.D.

TraumaLink at the Children’s Hospital of Philadelphia

Division of General Pediatrics

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania

The Injury Center would also like to acknowledge Sandra E. Bonzo, M.L.I.S., for technical consultation;

Carole A. Craft for editing; and Andrea J. Davis, Patricia A. Skousen, and Brenda Strong for administrative

support.

Lela N. Baughman, M.S.W., Senior Manager

Bonnie S. Bates, M.A., Senior Research Associate

Judith M. Berkowitz, Ph.D., Project Manager

Antoinette Buchanan, Publications Manager

Thomas Chapel, M.A., M.B.A., Vice President and

Senior Manager

David Cotton, Ph.D., M.P.H., Vice President

Mary Margaret Driskell, Project Associate

Sarah A. Gill, Editor

Shuntay L. Gordon, Desktop Publisher

Amy B. Harris, M.P.A., Senior Research Associate

Nicole Lezin, M.P.P.M., Technical Advisor,

Cole Communications, Inc.

Dayanara Lizcano, Document Specialist

Jennifer L. McLaren, Program Assistant

Regina Portee, Meeting Coordinator

Lawrence E. Scholl, M.P.H., Project Associate

Rosalyn A. Shepherd, Administration Manager

Robin Taylor, Web Group Manager

Elise M. Vallone, Web Developer

Dari B. Wayne, Program Assistant

Staff at ORC Macro provided strategic counsel, prepared background papers, facilitated meetings and

expert panels, and provided logistical support for the development of the research agenda.
CDC Injury Research Agenda 105

AAA Foundation for Traffic Safety, 39

Acute care, 6, 85-88, 90

Administration on Aging, 18

Adolescents, 14, 22, 27, 31, 37-38, 43, 65, 85

Adult Protective Service, 50

Air bags, 41, 47

Alcohol (and other Drugs), 13-14, 31, 33, 37-43, 46, 65, 82, 86, 88-89, 92 

Ambulance, 91

American Academy of Orthopaedic Surgeons, 28

Americans with Disabilities Act, 35

Bicycles, 33

Biomechanical models, 94

Biomechanics, 6, 22, 30, 32-33, 35, 37, 44-48, 55, 93-94

Bioterrorism, 20

Boating, 27-28, 31-32

Burns, 17, 24, 85

Centers for Medicare and Medicaid Services, 18

Child maltreatment, 6, 13-14, 49-59, 62, 67, 74, 79, 88

Child occupant safety, 38, 41, 43-44, 47

Child protective services, 50

Child sexual abuse (see Child maltreatment)

Children, 14, 17, 20, 22-24, 27, 31-32, 34-35, 37-38, 40, 42-44, 50, 54, 56, 65, 73, 78-79, 92, 94

Coast Guard (see U.S. Coast Guard)

Communication, 13, 19, 29, 38, 40, 44, 70

Community, 1, 6-9, 13-15, 17-19, 21-24, 29, 34, 37, 38-40, 43, 46, 52, 57, 59, 62-63, 65-66, 68-69, 73-79, 86, 93

Consumer Product Safety Commission (see U.S. Consumer Product Safety Commission)

Cost of injury, economic, 15, 17, 21-22, 30-31, 37, 40, 71, 92

Cultural, 13, 29, 31, 53, 69, 77-78, 80, 82

Index

B

C

A
106 CDC Injury Research Agenda

Disability, 1-2, 6, 11-12, 20, 35, 41, 49, 67, 85-87, 89, 92-95

Dog bites, 5, 17, 23-24

Domestic violence (see Intimate partner violence)

Drowning, 2, 4, 14, 23, 27, 29, 31-32

Elder abuse, 50, 53, 58

Elderly persons (see Older adults)

Emergency Department, 2, 5, 14, 17-18, 22, 27-28, 30, 33-34, 37-38, 61, 68, 74, 85-86, 88, 91

Enforcement, 13, 40, 42, 44

Environment, 4, 13, 18, 20-21, 24-25, 28-29, 31-34, 42, 59, 71, 77-79, 94

Ethnicity, 12, 19, 31, 78

Exercise, 17, 27-29, 33-34, 46

Falls, 2, 4-5, 14, 17

Fire(s), 2, 4-5, 17-18, 20-21, 24, 33

Firearms, 4-5, 64, 73, 77

Fractures, 21, 93

Framework, injury research, 1, 7, 8, 62

Health Care Financing Administration (see Centers for Medicare and Medicaid Services)

Health communication, 29, 40

Health Resources and Services Administration, 18, 87

Helmets (see protective equipment)

Hospitalization, 11, 37, 49, 61, 68, 85-86, 90-91, 94

D

E

F

H
CDC Injury Research Agenda 107

Infants, 17, 22, 42

Infrastructure, 13, 15, 22, 29, 56, 64, 94

Injury tolerance, 32, 94

Institute of Medicine, 1, 50, 53, 87, 93-94

Insurance Institute for Highway Safety, 29

Intimate partner violence, 6, 13, 49-59, 62, 67, 74, 79, 88, 92

Knee injuries, 31

Laws (see Legislation)

Legislation, 8, 13, 23-24, 32, 40-42, 44, 46, 53, 55

Lethal means, suicide, 64

Limb injuries, 85, 93

Mass trauma events, 20

Maternal and Child Health Bureau, 18

Media, 52, 70, 80-81

Medications, 21, 44

Motor vehicles, 2, 5, 23, 33, 37-47

Motorcycles, 46

K

L

M

I
108 CDC Injury Research Agenda

National Athletic Trainers’ Association, 28

National Center for Health Statistics, 4

National Collegiate Athletic Association, 28

National Electronic Injury Surveillance System, 2, 5

National Fire Protection Association, 18

National Highway Traffic Safety Administration, 38-39

National Hospital Ambulatory Medical Care Survey, 61

National Institute for Occupational Safety and Health, 6, 74

National Institute of Child Health and Human Development, 18, 39

National Institute of Mental Health, 63

National Institute on Aging, 18

National Institute on Drug Abuse, 58

National Institutes of Health, 28, 38-39, 50, 74, 87

National Occupational Research Agenda, 6

National SAFE KIDS Campaign, 18, 39

National Safety Council, 18, 39

National Transportation Safety Board, 39

Occupant protection (see also Child occupant safety), 43-45

Older adults, 17-18, 20-23, 27, 32, 34, 37, 42, 44-45, 95

Outdoor recreation, 24, 33-35

Parental (see Parents)

Parents, 13-14, 30, 38, 49-52, 65, 67, 76, 79

Patient safety, 93 

Pedestrians, 4, 5, 17, 23, 34, 37, 39, 42, 47

Perpetration, 49-52, 54, 56, 58, 73-74, 76, 78-79, 81-82

Perpetrator(s) (see Perpetration)

Personal floatation device(s) (see Protective equipment)

Pharmaceuticals (see Medications)

Playgrounds, 17, 23, 27, 29, 34-35

Poison(s), 2, 4-5, 17, 19

Poisoning (see Poison)

Pools, 29, 32

Protective equipment, 19, 29-30, 31-34, 46

Public health approach, 1, 6, 17, 73-74, 81

N

O

P
CDC Injury Research Agenda 109

Racial, 12, 19, 78

Rape (see Sexual violence)

Recreation, 6, 14, 17, 24, 27-29, 31, 33, 46

Rehabilitation, 6, 30-31, 85-87, 89-90

Residential fires (see Fires)

SAFE KIDS (see National SAFE KIDS Campaign)

Safety gear (see Protective equipment)

Scalds, 17, 24

Schools, 20, 24, 27, 39, 42, 66, 71, 73-79, 93

Screening and brief interventions, 14, 41, 56, 66, 86, 88

Seat belts (see Occupant protection)

Sexual violence, 49, 56, 74

Social marketing, 41

Social norms, 52-53, 66, 78, 82

Spinal cord injury, 2, 85, 87, 89-92, 94

Sports, 6, 14, 17, 27-28, 30, 34

Substance Abuse and Mental Health Services Administration, 58, 63

Suicidal behavior, 6, 50, 61-72, 79

Suicide, 2-3, 13, 49, 52, 54, 61-70, 72, 79, 93

Supervision, 14, 18, 23-24, 31-32, 34, 43, 82

Surgeon General, 63, 75-76

Surveillance, 2, 5, 8, 18, 27-28, 32, 38-39, 55, 68, 86-87, 90-93

Teenagers (see Adolescents)

Terrorism, 20, 59

Transportation, 2, 4-6, 14, 17, 24, 33, 37-39, 41, 44, 47, 91, 94

Trauma system, 85, 88

Traumatic brain injury, 2, 22, 85, 87, 89-92, 94-95

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U.S. Coast Guard, 28, 32

U.S. Department of Education, 74

U.S. Department of Justice, 50, 74

U.S. Fire Administration, 18

U.S. Consumer Product Safety Commission, 5, 18, 28

Victimization, 49-54, 56-58, 76, 78-79, 81, 83, 92

Violence, 2, 6, 13-14, 24-25, 49-59, 61-62, 65-66, 73-82, 88, 92

Whiplash, 48

World Health Organization, 39

Youth Risk Behavior Survey, 38, 61

Youth violence, 6, 13, 52, 54, 62, 73-81

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