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Chapter 12

INJURY CONTROL

PAUL J. AMOROSO, MD, MPH*; NICOLE S. BELL, ScD, MPH†; SUSAN P. BAKER, ScD, MPH‡; and

LAURA SENIER, PhD, MPH, MA§

INTRODUCTION

Definition of Injury

Classification of Injury

Intentional Versus Unintentional Injuries

Determining Injury Severity

INJURIES IN A MILITARY ENVIRONMENT

Recent Conflicts and Wars

War Injuries and Special Environmental Circumstances

Injury Risk After Redeployment

INJURY CONTROL IN THE MILITARY

Understanding the Dynamics of Injury: The Epidemiological Triangle

Intervention Strategies: Different Approaches

Unintended Consequences and Risk Compensation

PLANNING INJURY PREVENTION PROGRAMS

The Haddon Matrix: Identifying Injury Intervention Opportunities

Haddon’s 10 Strategies for Control of Hazards of All Types

Passive Intervention Strategies

Active Intervention Strategies

MANAGEMENT OF INJURIES IN THE FIELD AND ACCESS TO CARE

Short-Range Management of Injury 

Medium-Range Management of Injury 

Long-Range Management of Injury 

SUMMARY

*Colonel (Ret), Medical Corps, US Army; Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, Washington 98431-1100; currently retired

†Vice President, Social Sectors Development Strategies, Inc, 2330 South Third Street, Tacoma, Washington 98433-1038 

‡Professor, Department of Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, 624 North Broadway, 

Baltimore, Maryland 21205-1999

§ Assistant Professor, Department of Community & Environmental Sociology and Department of Family Medicine, University of Wisconsin–Madison, 

1450 Linden Drive, Madison, Wisconsin 53706
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

INTRODUCTION

and nearly 80% of active-duty deaths.6 The injury 

incidence pyramid in Figure 12-1 depicts the relative 

importance of various measures of injury morbidity 

and mortality in the US Army. 

The effect of injuries is seen in many ways, including 

lost productivity, decreased mission effectiveness, human suffering, and the significant economic expenses 

associated with the care and rehabilitation of injured 

personnel. Because of the number of surgical procedures and the relatively long hospital stays required for 

the management of acute and chronic injuries, hospital 

expenses associated with the musculoskeletal system 

rank at the top of the scale (Table 12-1).7 In addition, the 

US government pays more than $1 billion per month 

to individuals who have been disabled because of 

their service in the armed forces (Figure 12-2). Almost 

half of this amount is related to injury. Many of the 

costs associated with injury, however, are difficult to 

estimate, especially those associated with human suffering, lost opportunities, diminished capacity to lead 

a fully functional lifestyle, and indirect costs imposed 

on family members who must adjust their lifestyle or 

work to care for those who are injured or disabled.

Definition of Injury

Injuries will be defined in this chapter as the end 

result of a transfer of energy, usually sudden, above or 

below certain absorption limits of human tissue, causing physical damage to tissue or death.8,9 Table 12-2 

lists some of the methods of energy transfer that may 

cause damage to human tissue and gives examples 

of some specific injuries that can result, as well as the 

events that may cause them. 

Mechanical or kinetic energy, the energy of motion, 

is responsible for most common injuries.10 For example, 

Injuries remain the most underrecognized health 

problem of the US military. Whether we examine time 

lost from duty because of hospitalization,1 permanent 

disability,2 or premature death,3 injuries and their sequelae top the list in every category. Individuals under 

age 40 are at greatest risk for fatal and nonfatal injuries. 

Injury disproportionately affects young people because 

they tend to take greater risks and have more exposure 

to health hazards. In addition, young people have more 

potential years of life to lose. Therefore, an untimely 

death for a young person results in greater loss of productive life. If diseases of the elderly (eg, heart disease, 

stroke, and cancer) are eliminated from consideration, 

injury is the leading cause of morbidity and mortality 

in the United States. The armed forces consist of young 

adults engaged in many hazardous occupations. This 

chapter provides an overview of the effect of injuries 

in the US military and offers a framework that can be 

used to develop prevention and control strategies for 

militarily relevant hazards. 

The military presents a unique occupational environment, particularly during times of war. The discipline of injury control, which has its roots in public 

health, has not been explicitly applied to the control 

of war-related injuries; thus, data on the burden of 

injuries in a deployed environment are sparse. Conflict 

situations yield injuries that are uncommon among any 

other occupational cohort, and they require triage and 

treatment under difficult conditions. Even peacetime 

military operations are hazardous in the extreme when 

compared with civilian occupational environments, 

because maintaining an effective fighting force requires 

active-duty soldiers to be in peak physical condition 

and to train continually. Soldiers, sailors, airmen, and 

marines must maintain a high state of preparedness, 

and their ongoing training often necessitates the use 

of potentially hazardous equipment or materials. Injury epidemiologic research has, however, produced a 

wealth of knowledge about causes, consequences, and 

effective intervention to prevent injury in nonbattle 

settings, and some of this knowledge may be applied 

with equal effectiveness in reducing war injuries. For 

that reason, in this chapter, we draw heavily on examples from the civilian medical literature; but, where 

possible, we provide examples of how these injury 

control strategies may be adapted for applicability in 

a deployed environment. 

Among US military personnel, acute injury and 

musculoskeletal conditions account for more than 20% 

of outpatient clinic visits (830,000 visits in 1998),4 approximately 26% of hospitalizations (6,200 hospitalizations in 1998),4

 almost 60% of permanent disabilities,5 Fig. 12-1. Injury incidence in the Army.

Deaths

350

Disabilities

4,500

Hospitalizations

20,000

Injury SickCall Visits

400,000

Numbers Ratios

1

15

60

1,100
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Injury Control

TABLE 12-1

WORLDWIDE HOSPITALIZATION, US ARMY, 1995*

1995 Total Cost Average Cost 

Principal Discharge Diagnosis by Major ICD-9-CM Group Code (Millions) Per Hospitalization

Diseases of the Musculoskeletal System and Connective Tissue (710–739) $110.6 $9,211

Injury and Poisoning (800–999) $68.6 $9,378

Diseases of the Digestive System (520–579) $65.9 $7,171

Mental Disorders (290–319) $45.9 $7,565

Diseases of the Respiratory System (460–519) $40.2 $6,823

Complications of Pregnancy, Childbirth, and the Puerperium (630–676) $35.7 $4,840

Diseases of the Genitourinary System (580–629) $28.7 $7,493

Infectious and Parasitic Diseases (001–139) $24.0 $7,527

Symptoms, Signs, and Ill-defined Conditions (780–799) $22.1 $7,389

Diseases of the Circulatory System (390–459) $21.8 $10,422

Supplementary Classification (V01–V82) $20.0 $6,623

Neoplasms (140–239) $19.6 $10,507

Diseases of the Nervous System and Sense Organs (320–389) $17.3 $8,652

Diseases of the Skin and Subcutaneous Tissue (680–709) $10.8 $6,784

Congenital Anomalies (740–759) $5.0 $10,947

Endocrine, Nutritional, Metabolic Diseases, and Immunity Disorders (240–279) $4.2 $9,039

Diseases of the Blood and Blood-forming Organs (280–289) $2.5 $11,301

Total $542.9 $7,819

ICD-9-CM: International Classification of Diseases, 9th Revision, Clinical Modification

*Calendar year 1995, estimated based on national HCFA DRG codes. 

Data source: Amoroso P, Swartz W, Hoin F, Yore M. Total Army Injury and Health Outcomes Database [TAIHOD]. Natick, Mass: USARIEM; 

February 21, 1997. Technical Note 97-2. The TAIHOD has been described in Amoroso PJ, Yore MM, Weyandt MB, Jones BH. Chapter 8: Total 

Army Injury and Health Outcomes Database: a model comprehensive research database. Mil Med. 1999;164(suppl 8):1–36.

moving objects and projectiles are common causes of 

injury, as are vehicle crashes, falls, and physical assault. 

Thermal energy, chemical energy, electrical energy, and 

ionizing radiation may also cause injuries. Recall that, 

from the definition given previously, injury may occur 

from the transfer of energy above or below human tolerance. Thus, application of thermal energy can cause 

burns, and the withdrawal of thermal energy can also 

cause injury (eg, frostbite or hypothermia). Chemical 

energy can lead to injuries such as poisonings (eg, 

mustard gas) (Figure 12-3). An absence of necessary 

chemical substrates, or interference of normal energy 

processes—such as oxygen exchange—may also lead 

to an injury (eg, drowning and suffocation). Electrical 

energy can result in electrocution or electrical burns. 

Ionizing radiation can result in various forms of injury. 

For instance, looking at the sun during a solar eclipse 

(nonionizing radiation) could cause retinal injury, and 

exposure to atomic weapons explosions (ionizing radiation) can result in radiation burns or instant death. 

Sometimes energy transfers result in conditions that 

are more commonly thought of as illnesses rather than 

injuries. The etiological agents for injury and illness 

may therefore be identical.11 Energy transfers that 

culminate in injury are generally rapid or acute. As 

with most rules, however, there are exceptions. Chronic 

exposure to low levels of mechanical energy may result 

in repetitive motion injuries, such as carpal tunnel 

syndrome, back pain, or other overuse injuries.12 In 

contrast, long exposure to low levels of ionizing radiation may result in leukemia—an illness (Figure 12-4). 

Thus, there is some ambiguity, even in differentiating 

between illness and injury. 

Despite the enormous impact of injuries in the military, much remains to be done in terms of prevention 

and control. Perhaps one of the reasons injury prevention has not received adequate attention is the tendency 

to focus only on injuries resulting in death. Although 

the need to reduce injury fatality is indeed pressing, 

focusing on only the top of the pyramid diverts attention from the hundreds of thousands of other service 

members who suffer nonfatal, permanent, or partially 

disabling injuries each year.

Another reason that injuries may receive too little 

attention at the command level, and too little priority as a health problem, is the misleading association 

of injuries with the concept of accidents. For many 

people, the term accident suggests an event that is 
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

random and unpredictable, and therefore unpreventable. In fact, however, the events surrounding most 

injuries are scientifically understood and largely 

predictable. Although it is not possible to predict 

precisely which individual will be injured at a specific moment or in a specific situation, it is possible to 

identify high-risk groups of people. Once a specific 

population has been defined, it becomes possible 

to identify and rectify situations that have a high 

likelihood of causing injury, to tailor appropriate 

interventions, and to reduce ultimately the incidence 

of injuries in that population.

The concept of an accident, moreover, is understood 

to have behavioral connotations that place emphasis 

on individual behaviors that may contribute to an incident. As a result, preventive interventions may focus 

on the difficult and often unsuccessful task of trying 

to change behavior. The result is that these strategies 

may underplay or ignore the role of environmental or 

equipment-related interventions that could reduce the 

likelihood of injury regardless of individual actions or 

inactions. Injuries are not simply the result of random 

events but, like diseases, follow patterns that can be 

described and predicted.10 Perhaps most significantly, 

these patterns can be altered by various behavioral or 

environmental intervention strategies. For example, 

ankle injuries among parachutists have been reduced by 

using ankle braces13,14 and by decreasing the porosity of 

parachutes (thereby increasing air resistance and reducing the speed and impact forces on landing).15 These are 

both approaches that might have been ignored if the 

preventive intervention had focused only on improper 

landing technique. For this reason, many injury control 

practitioners prefer a definition of injury that entirely 

avoids the word “accident.”

Classification of Injury

In addition to the challenges in defining injuries, 

there may also be uncertainty in the categorization 

and description of specific types of injuries. There are 

a number of schemes for classifying injuries. Several 

approaches to injury classification are in widespread 

use, including the following16: 

	 •	 body part affected (eg, head or spinal cord);

	 •	 pathological mechanism (eg, fractures, burns,

amputations);

	 •	 etiological mechanism (eg, blunt trauma,

penetration by sharp object);

Fig. 12-2. (a) World War II amputee receiving therapy. (b) 

CPT Luckett wears a modern prosthetic that exhibits the 

technology that is allowing seriously injured soldiers to 

return to combat duty.

Photographs: Reproduced from the Archival Research Catalog, the National Archives and Records Administration, ARC 

identifier 195903. 

a

b
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Injury Control

•	 intent (eg, homicide, suicide, unintentional

injury);

•	 severity (eg, Trauma Severity Score, Abbreviated Injury Scale, fatal); 

	 •	 event (eg, car crash, earthquake);

	 •	 location (eg, workplace, ship, home, battlefield); and 

	 •	 activity (eg, working, fighting, sports).

Individual researchers may use more than one 

scheme for classifying and evaluating injuries in a 

population. 

Injury information, especially regarding hospital 

inpatients, is typically collected and coded based 

on the nature and cause of injury. Civilian hospital 

records are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification

(ICD-9-CM).17 The nature of injury codes (previously 

referred to as N-codes) define the type of injury 

sustained (eg, fracture) and the body part affected 

(eg, femur). The range of codes from the ICD-9-CM 

Fig. 12-3. Men and horses fitted with gas masks, circa 1917–1918.

Photograph: Reproduced from the Archival Research Catalog, the National Archives and Records Administration, ARC 

identifier 516483.

TABLE 12-2 

VARIOUS METHODS OF ENERGY TRANSFER 

AND THE INJURIES THAT MAY RESULT FROM 

THEM 

Energy Injury Event

Mechanical Bullet wound Enemy fire

Skull fracture Jeep rollover

Pneumothorax Landmine explosion

Ankle fracture Basketball

Thermal Burn Air crash on flight deck

Hypothermia Man overboard

Chemical Asphyxiation Scud missile attack

Burns Mustard gas release

Electrical Tissue destruction Electric shock

Ionizing Cerebral edema Nuclear power plant

radiation Gastroenteritis breach
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

that are commonly considered injury-related fall between 800 and 900.18 External cause-of-injury codes 

(or E-codes) describe the cause of the injury and 

are also derived from the ICD-9-CM coding system 

(Exhibit 12-1).

US military medical databases do not use E-codes, 

but they do include ICD-9-CM N-codes (for type of 

injury and body part affected). Instead of E-codes, 

military hospitals in most nations that have signed 

the North Atlantic Treaty Organization Standardization Agreement (STANAG) 2050 use a set of codes 

that were developed to provide additional precision 

for military causes of injury. As an example, a 23-year 

summary (a period covered by the Total Army Injury 

and Health Outcomes Database) of these codes for 

all worldwide Army hospitalizations (1980–2002) is 

provided in Table 12-3. 

Intentional Versus Unintentional Injuries

Determination of intent, although an integral 

component of injury cause-coding schemes, is rarely 

a simple matter. From a research and surveillance 

perspective, it is not the mechanism of injury that 

sets intentional injury apart from unintentional injury. 

Rather, it is the circumstances under which these injuries occur that are different. Thus, it is necessary to 

distinguish between unintentional injury (eg, homicide 

and assault) and intentional injury (eg, self-inflicted 

Fig. 12-4. Military personnel exposed to open air testing. 

Photograph: Reproduced from the Archival Research Catalog, the National Archives and Records Administration, ARC 

identifier 558591.

EXHIBIT 12-1

INJURY RESEARCH USING HOSPITALIZATION FILES: 

CODING FOR HIGH-QUALITY RESEARCH

Researchers and practitioners should exercise caution when interpreting published accounts of injury hospitalization 

rates. Many such studies commonly include all ICD-9-CM–coded cases between 800 and 999 that also have an injury 

E-code. This approach may include some conditions that may not be of interest to injury epidemiologists and may miss 

some potentially important injury outcomes. Although the range of ICD-9-CM codes between 800 and 999 includes 

most injuries, it also includes codes for some conditions that are not necessarily of interest to injury researchers (eg, 

adverse reactions to medications or other iatrogenic “injuries”). It also omits codes for some chronic conditions that 

may have originally been injury-related (eg, internal derangement of the knee may be coded with other musculoskeletal 

conditions, even if it was the result of an older, acute injury to the anterior cruciate ligament). 

The US military does not use E-codes, but instead uses cause of injury codes utilizing the STANAG system. Regardless of whatever coding system is used, however, codes must be applied accurately and consistently to ensure effective surveillance of causes of injuries and identification of risk factors. In the civilian world, there have been recent 

efforts to coordinate the coding and recording of external causes of injuries. Improved data collection efforts can be 

expected to improve injury surveillance, to enable the design and delivery of targeted interventions, and to facilitate 

international comparisons. 

ICD-9-CM: International Classification of Diseases, 9th Revision, Clinical Modification

STANAG: Standardization Agreement
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Injury Control

wounds and suicide), whenever possible, to develop 

better preventive approaches. 

The STANAG injury coding system, unlike the 

ICD-9-CM, uses two components, or axes, to code intent and mechanism of injury. It begins with a trauma 

code—a single-digit code with 10 possible values that 

distinguish among general classes of injury (Table 

12-4). The trauma code conveys information on both 

TABLE 12-3

DESCRIPTION OF STANAG CODES AND FREQUENCY (CAUSE OF HOSPITALIZED INJURY) FOR 

US ARMY: 23-YEAR SUMMARY (1980–2002)*

Frequency Total

STANAG Code Group Men Women Overall Frequency Overall %

Falls (900–999) 74,028 7,669 81,697 26.97

Medical Complications (250–299) 44,708 9,941 54,649 18.03

Land Transport Accidents (100–149) 41,333 3,569 44,902 14.81

Athletics (200–249) 35,294 1,931 37,225 12.28

Machinery and Tools (600–699) 29,096 2,375 31,471 10.38

Poisons, Fire, Hot/Corrosive Substances (700–790) 20,639 5,715 26,354 8.69

Air Transport Accidents (000–059) 9,551 334 9,885 3.26

Environmental Injuries (800–899) 7,793 1,119 8,912 2.94

Guns, Explosives (500–599) 6,396 150 6,546 2.16

Enemy Instruments of War (300–479) 1,111 24 1,135 0.37

Water Transport Accidents (150–199) 216 11 227 0.07

Own Instruments of War (480–499) 94 3 97 0.03

Total 270,259 32,841 303,100 100

STANAG: Standardization Agreement

*Major groupings based on the North Atlantic Treaty Organization STANAG 2050 coding system. 

Data source: Total Army Injury and Health Outcomes Database (TAIHOD). The TAIHOD has been described in Amoroso PJ, Yore MM, 

Weyandt MB, Jones BH. Chapter 8: Total Army Injury and Health Outcomes Database: a model comprehensive research database. Mil Med.

1999;164(suppl 8):1–36.

TABLE 12-4

NATO STANAG TRAUMA CODES

General Trauma Class Code Definition

Battle wound or injury 0 Direct result of action by or against an organized enemy

1 Other battle casualties

Intentionally inflicted nonbattle injuries 2 Result of intervention of legal authority

3 Assault, or intentionally inflicted by another person

4 Intentionally self-inflicted

Accidental injury 5 Occurring while off-duty (includes leave, pass, AWOL, and other off duty)

6 Schemes and exercises

7 All other scheduled training (includes basic training, assault courses, etc)

8 Occurring while on duty

9 Unknown whether on or off duty

AWOL: absent without leave

NATO: North Atlantic Treaty Organization

STANAG: Standardization Agreement 

Data source: North Atlantic Treaty Organization. NATO STANAG 2050 Statistical Classification of Diseases, Injuries and Causes of Death. Brussels, Belgium; 1989.
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

intent and work activity. This code distinguishes between battle-related, non–battle-related intentional, 

and non–battle-related unintentional injuries. It also 

provides information about whether the injury occurred while the person was on duty or off duty, and 

whether the on-duty activity was specific to certain 

training activities or exercises. The 10 possible codes 

are, however, not mutually exclusive, but rather are 

listed in order of priority, such that war-related injuries are given highest priority, followed by intentional 

injuries, and then unintentional injuries. An assault 

occurring on duty (eg, a military police officer assaulted by a prisoner) can therefore be coded only as 

a 3 (“assault”) and not as an 8 (“on duty”), because 

information regarding intent takes precedence over 

duty status. Similarly, an injury that occurs to an individual attempting to evade police arrest while on 

vacation would be coded as a 2 (“legal intervention”) 

and not as a 5 (“off duty”) (Table 12-4). Although the 

STANAG system performs well in coding militarily 

relevant injuries, the lack of mutually exclusive and 

exhaustive codes creates some difficulties, especially 

in coding injuries that commonly occur off duty or 

for intentional injuries. 

TABLE 12-5

SEVERITY SCALES USED TO CLASSIFY GENERAL TRAUMA 

System Common Uses

AIS Physiologically based classification system that describes individual injuries and rates them based on 

severity. Impractical for comparing patients with multiple injuries in different regions of the body.(1)

APACHE III Physiologically based classification system for measuring severity of illness in critically ill patients (not 

necessarily injured). Comprises an APACHE III score (provides initial risk stratification for severely ill 

patients within patient group) and an APACHE III predictive equation (provides risk estimate of hospital mortality for individual intensive care unit patients). Scores range from 0 to 299, with ratings in 78 

major medical and surgical categories.(2)

CRAMS scale Used to prioritize which patients require the services of a level I trauma center and which ones can be 

treated at local facilities. Simple, 10-point scale; scores less than or equal to 8 signify major trauma, 

requiring transport to level I trauma facility.(3,4)

GCS Assesses three measures of neurological function in victims of head trauma: eye-opening, motor response, and verbal response. Scores range from 3 to 15, depending on extent of trauma.(5)

ISS Combines ratings of several injuries into a single score of severity; composite score based on the most 

severe AIS scores for the three most severely injured regions of the body.(6)

IPCAR Assesses trauma victims on the basis of five criteria: injury and pain, pulse, consciousness, appearance 

and bleeding, and respiration and airway. Each indicator is measured on a 4-point scale; total scores 

range from 15 for a healthy person to a low of 0.(7)

RTS Combines GCS scores with measures of cardiovascular and respiratory sufficiency.(8)

TRISS Predicts mortality based on severity of injury, patient’s age, and RTS (see above).(9)

ICISS Simplifies the ISS; is a better predictor of survival in trauma centers.(10)

AIS: Abbreviated Injury Scale; APACHE III: Acute Physiology and Chronic Health Evaluation III; CRAMS: Circulation-RespirationAbdomen-Motor-Speech (scale); GCS: Glasgow Coma Scale; ICD: International Classification of Diseases; ICISS: ICD-9–based Injury Severity 

Score; IPCAR: Injury, Pulse, Consciousness, Appearance, Respiration (score); ISS: Injury Severity Score; RTS: Revised Trauma Score; TRISS: 

Trauma and Injury Severity Score.

Data sources: (1) Brenneman FD, Boulanger BR, McLellan BA, Redelmeier DA. Measuring injury severity: time for a change? J Trauma.

1998;44:580–582. (2) Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality of 

critically ill hospitalized adults. Chest. 1991;100:1619–1636. (3) Clemmer TP, Orme JF Jr, Thomas F, Brooks KA. Prospective evaluation of the 

CRAMS scale for triaging major trauma. J Trauma. 1985;25:188–191. (4) Gormican SP. CRAMS scale: field triage of trauma victims. Ann Emerg 

Med. 1982;11:132–135. (5) Becker DP. Injury to the head and spine. In: Wyndgarden JB, Smith LH, eds. Cecil Textbook of Medicine. Philadelphia, 

Pa: WB Saunders; 1988: 2239–2247. (6) National Committee for Injury Prevention and Control (US). Injury Prevention: Meeting the Challenge. 

New York, NY: Oxford University Press; 1989. (7) Buckingham RE Jr. The IPCAR score: a method for evaluation of the emergency patient. 

J Indiana State Med Assoc. 1974;67:21–25. (8) Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the 

trauma score. J Trauma. 1989;29:623–629. (9) Bonnie RJ, Fulco CE, Liverman CT, eds. Reducing the Burden of Injury: Advancing Prevention and 

Treatment. Washington, DC: National Academy Press; 1999. (10) Meredith JW, Evans G, Kilgo PD, et al. A comparison of the abilities of nine 

scoring algorithms in predicting mortality. J Trauma. 2002;53:621–628.
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Determining Injury Severity

Severity scales are often used to describe injuries 

and to evaluate their relative severity or economic 

impact. There are a number of classification schemes 

used in the United States, many of which are diseasespecific or patient-specific. Table 12-5 lists some of 

the more common systems in use to describe general 

trauma. Other indicators of severity include length 

of hospital stay, days lost from duty, or diagnosticrelated groups. These diagnostic-related group 

codes are a means of classifying patients into similar groups based on their utilization of healthcare 

resources and length of stay. These codes capture 

information on a patient’s diagnosis, procedures, 

complications, preexisting conditions, and discharge status. They are used by many institutions 

to evaluate quality of care and to plan for utilization 

of services.

There are several injury severity scales:

	 •	 Abbreviated Injury Scale (AIS),

	 •	 Maximum Abbreviated Injury Scale (MAIS),

	 •	 Injury Severity Score (ISS), and the

	 •	 ICD-9–based ISS.

The most commonly used anatomically based 

injury severity scale is the AIS, developed by the 

Association for the Advancement of Automotive 

Medicine.19 The AIS system rates each injury based 

on the body region and consensually derived assessment of damage to that region, ranging from 

1 (minor) to 6 (not treatable with current medical 

technology). A related scale, the MAIS, is sometimes 

used instead of the AIS. The MAIS uses the single 

highest AIS scored injury for each individual. Another derivative of the AIS is the ISS. This score is 

the sum of the squares of the highest AIS scores for 

three different body regions.20 The ISS is a better 

predictor of overall morbidity or survivability and 

length of hospital stay for individuals experiencing 

multiple traumas.21,22 A simplification of the ISS, the 

new ICD-9-CM–based ISS,23 is an even better predictor of survival in trauma centers.24 Even though the 

AIS does not provide an assessment of disability or 

impairment, it has proven useful in estimating injury 

costs.25–28 A computer program is available that links 

ICD-9-CM codes to an AIS score and makes the AIS 

system relatively easy to use, therefore avoiding the 

tedious task of reviewing each individual medical 

record.29 

INJURIES IN A MILITARY ENVIRONMENT

As noted previously, the military is a unique occupational environment that presents hazards not found 

in civilian occupational settings, both in garrison and 

on deployment. This section describes some of the 

common types and causes of injuries among military 

personnel during war and peacetime, and highlights 

some of the unique aspects of military life that contribute to the injury hazard (Exhibit 12-2). 

Recent Conflicts and Wars

It has been estimated that since 1700 ad, more than 

100 million people have died because of wars. Of 

these, more than 90 million people have been killed 

in the 20th century.30 Although the prevention of intentional injuries and combat casualties remains the 

major focus of command during conflict situations, 

unintentional injuries—at least in recent history—also 

exact a substantial toll on the health of deployed 

forces. During Operation Desert Storm (1990–1991), 

unintentional injury deaths exceeded combat casualties (147 [or 39.5%] deaths were a result of combat 

during the war, whereas 194 [or 52.2%] resulted from 

injuries not incurred in battle).31 In addition to these 

fatalities, injuries were the leading cause of hospitalization among deployed forces, with more than 

5,000 soldiers being hospitalized in theater during the 

conflict (25% of all hospitalizations).1 The majority of 

injuries whose cause was known were unintentional, 

and most of the nonbattle fatalities were caused by 

transportation (motor vehicle accidents were most 

prevalent, followed by aircraft). Hospital admissions 

were also commonly related to motor vehicle crashes 

or falls, followed by athletic activities.5 More than 400 

soldiers were hospitalized for athletic injuries during 

the war, suggesting that commanders of deployed 

units should expand their focus to include prevention 

of sports injuries to preserve military readiness and 

maintain critical capabilities. 

War Injuries and Special Environmental 

Circumstances 

Military environments are inherently hazardous 

because they combine service members and lethal 

weapons in terrains that are often hostile. Whether 

these environments are training areas, staging areas, 

or actual battlefields, a number of circumstances can 

contribute to injuries. This section will discuss the 

most prevalent of these circumstances: (a) weapons, 

(b) transportation systems, (c) environmental hazards, 

(d) stress, and (e) sports and athletic injuries. 
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

Weapons

Firearms, mines, grenades, missiles, biological and 

chemical agents, and related equipment are used during conflicts to support the war effort (ie, to fight). All 

of these hazards create the potential for intentional 

or unintentional injury. This chapter is not intended 

to serve as a tactical guide for strategies on how to 

avoid enemy fire, but rather to serve as an overview 

of the types of injuries that could occur, a review of 

the prevention options in general, and factors that 

may influence survivability and long-term sequelae. 

Weapons may cause injury when discharged unintentionally, while being transported, or when a friendly 

soldier is mistaken for the enemy. Intentional, nonbattle 

injury may also occur through self-inflicted wounds (approximately 4% of nonbattle deaths during Operation 

Desert Storm).5 Measures designed to prevent weaponrelated injuries may also lead to unintentional injury. 

For example, pharmacological treatments taken for prophylaxis or as antidotes to chemical weapons attack 

may cause undesirable side effects or adverse reactions 

among service members. Full chemical protective gear 

can limit mobility, obscure vision, and interfere with safe 

performance of tasks. Transportation and use of hazardous substances, such as chemical and biological weapons, 

may result in unintentional exposure among friendly 

forces. Grenades, missiles, and mines are also potential 

EXHIBIT 12-2

PEACETIME INJURIES AND UNIT READINESS

In recent history, peacetime injuries have been more of a threat to unit readiness than wartime injuries. In training 

exercises and maneuvers and in fitness activities and physical conditioning, soldiers are exposed to myriad other hazards in the performance of their everyday duties in garrison. Soldiers who are injured hinder mission accomplishment 

and create a substantial drain on resources through additional medical care utilization and lost time from work. For 

these reasons, it is important to be aware of peacetime injury threats and to comply with regulations and programs 

designed to minimize risk of injuries at all times. 

Training Exercises and Maneuvers 

Training, although important to maintaining unit effectiveness, also has the potential to cause many injuries and could 

even lead to short- or long-term disability. Physical readiness training, whether addressing specific military skills or 

multiday unit maneuvers or field exercises, exposes soldiers to some or all of the hazards of the military environment 

described previously: weapons accidents; materiel handling; transportation and aviation accidents; sleep deprivation; 

and exposure to adverse weather conditions, such as extreme heat and cold. 

Fitness Training 

Even though the specific types of exercises and procedures for assessing physical fitness vary from service to service, 

all require individuals to maintain a certain level of fitness. This is usually achieved through a variety of calisthenics 

(eg, sit-ups, push-ups) and marching or running. Some training combines rudimentary military skills with elements 

from athletic or recreational sports training, such as some of the SEAL boat and log drills. 

Environmental Hazards in an Occupational Environment 

Other environmental hazards are as varied as the jobs that exist in each branch of the service. Aviators face risks ranging from air transport crash to hypoxia and altitude illness. Sailors face a host of risks ranging from falling overboard 

to injury from handling heavy equipment.(1) Workers may also be exposed to poisonous substances in the course of 

performing their duties. 

Other Hazardous Exposures

Unintentional injuries related to motor vehicle use and to athletic activities are among the most common reasons for 

hospitalization, both in peacetime and in times of war. Thirty-five percent of the 12 most common injuries among 

hospitalized Air Force personnel during 1992 were either from athletic and sports activities or motor vehicle crashes.(2)

Intentional injuries, whether self-inflicted or an assault, are also a risk, as belligerent behavior resulting in physical 

injury was the 10th most common cause for hospitalization among Air Force and Army personnel in 1992.(2)

SEAL: Sea, Air, and Land (US Navy)

Data sources: (1) Krentz MJ, Li G, Baker SP. At work and play in a hazardous environment: Injuries aboard a deployed US Navy 

aircraft carrier. Aviat Space Environ Med. 1997;68:51–55. (2) US Army Center for Health Promotion and Preventive Medicine (USACHPPM). Injuries in the Military: A Hidden Epidemic. Report for the Armed Forces Epidemiologic Board. Aberdeen Proving Ground, Md: 

USACHPPM; November 1996. Report 29 HA 4844 97.
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Injury Control

sources of unintentional injury among friendly forces. 

Long after conflicts have ended, landmines continue to 

pose a serious injury problem in a number of countries.32,33

Transportation

Transportation of troops is an essential element of 

any war or peacekeeping mission. During World War 

II, US military personnel experienced more than 20,000 

nonbattle aviation deaths,34presumably because of troop 

movement, supply transportation, and pilot training. 

Unfortunately, motor-vehicle crashes related to the 

movement of troops remain one of the leading causes 

of mortality in recent military deployments. Hazardous 

travel conditions, unfamiliar terrain, sleep deprivation, 

stress, and illness may all contribute to the injury morbidity and mortality associated with the use of motor 

vehicles, aircraft, and ships. Sometimes an assault or 

maneuver requires parachuting troops or landing small 

boats on enemy shores. The potential for enemy fire is 

ever present; but, during recent low-intensity conflicts, 

the greatest risk of injury has been posed by the maneuver itself. Often, troops must parachute onto unforgiving 

surfaces, such as a concrete airfield, or rapidly transfer 

from one moving transport vehicle to another (Figure 

12-5). The resulting impact injuries are debilitating not 

only for the individual service member who is injured, 

but also for the one or two other members of the unit who 

may end up dividing their energy between the planned 

mission and the rescue of their injured companions.

Environmental Hazards

Environmental conditions and related factors also 

present hazards. Unfamiliar and dangerous flora and 

fauna may lead to injuries. Poisonous plants, animal 

bites, and insect bites and stings may cause acute injury and may serve as vectors for the transmission of 

diseases. Pesticides and insecticides, meant to provide 

protection, may also cause injury or illness. Exposure 

to cold or heat can also directly lead to injuries such 

as frostbite, heatstroke, or heat illness (see Chapter 8). 

Such exposure may also indirectly contribute to injuries by compromising a soldier’s vigilance—the ability 

to respond to risks or make decisions. In the Persian 

Gulf War, oil-well fires caused poor visibility in some 

areas and may have contributed to poorer health and 

increased susceptibility to injury.35

Stress

The stress soldiers experience in war environments 

may also contribute to their injury risk. War environments require extraordinary adaptation on the part 

of the individuals involved. Often, a soldier leaves a 

spouse and children behind, crosses through several 

time zones, enters new climatic conditions, and faces 

the ever-present risk of being killed or seriously injured. Although the human body adapts well, coping 

mechanisms are better suited for short-term stress 

than to the chronic stress of a drawn-out conflict or 

even a long peacekeeping mission. During stressful 

situations, a number of physical and mental responses 

occur, including “arousal, alertness, vigilance, cognition...focused attention...aggression...[and] inhibition of pathways that subserve vegetative functions, 

such as feeding, [growth], and reproduction,” and 

changes in the body’s immune and inflammatory 

responses.36 Heart rate and respiration increase, blood 

pressure increases, and the body starts to produce 

glucose more rapidly to prepare itself for rapid response to the stressor. These mental and physiological 

responses to stressors associated with deployment 

and war conditions may influence a service member’s 

ability to respond to a hazard or injury situation. 

“Chronic stress may result in melancholic depression, 

poor appetite and weight loss, hypogonadism, peptic 

ulcers, immunosuppression, memory loss, inability 

to concentrate and think clearly, anxiety, as well as 

severe chronic disease, panic disorder, obsessivecompulsive disorder, chronic active alcoholism, 

alcohol and narcotic withdrawal, chronic excessive 

exercise, hyperthyroidism [or] hypothyroidism, 

premenstrual tension syndrome, vulnerability to 

addiction, Cushing’s syndrome, seasonal depression 

[and other] atypical depression, anorexia nervosa [or] 

obesity, PTSD [posttraumatic stress disorder], nicotine 

withdrawal, vulnerability to inflammatory disease.”36 

Stress may also increase risk for psychiatric conditions, such as depression and PTSD. High rates of 

clinical depression, PTSD, and other psychiatric conditions have also been documented among soldiers 

returning from deployment. Such conditions have been 

documented among US, British, and Danish veterans 

of Operation Desert Storm.37–49 A more recent survey 

of soldiers deployed to Iraq and Afghanistan in the 

winter and spring of 2003 found that major depression, 

generalized anxiety, and PTSD symptoms were more 

common in those deployed to Iraq (15%–17%) than in 

those deployed to Afghanistan (11%). Moreover, less 

than one half of soldiers who reported mental health 

symptoms reported having sought care, citing concerns about stigmatization and other barriers.50

Civilian studies have shown that depression and 

PTSD are associated with subsequent risk for selfinflicted injury.51–60 In the civilian world, suicide is an 

important cause of mortality among teenagers and 

young adults, and suicide rates appear to be increasing 
350

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

Fig. 12-5. Two examples of high-risk military training. (a) 

COMPUTEX ’98 (or Composite Training Unit Exercise, 1998). 

US Navy SEALS conduct a fast-rope exercise from the cargo 

door of an SH-60H-Seahawk assigned to the Helicopter 

Anti-Submarine Squadron Seven (HS-7 “Dusty Dogs”) onto 

the hull of the fast-attack submarine USS Hampton (SSN 

767). This photograph provides another example of the 

many hazardous activities military personnel are exposed 

to in the conduct of their duties. Photograph: Taken by PH2 

Michael W. Pendergrass, US Navy. (b) During Kernel Blitz 

’99, a biannual amphibious training exercise designed to test 

and develop US Navy and Marine Corps forces to operate 

in littoral areas and project combat power ashore. CH-46 

helicopters fast-roped and retrieved Marine Corps reconnaissance members during the exercise. One consideration to 

reduce the hazard is to carefully consider the weather conditions under which such training will be allowed to proceed. 

Photograph: Taken by PH3 Eric S. Logsdon, US Navy.

a

b
351

Injury Control

among adolescents, particularly young men.61,62 Although rates of suicide are generally lower among 

active-duty military personnel than among their civilian counterparts, significant variation in suicide rates 

exists across the services by gender and occupation. 

Certain subgroups seem to be at especially high risk, 

such as military security and law enforcement personnel.63 Studies among military populations have shown 

that suicide risk and PTSD were greatest among Vietnam veterans who had been wounded during battle 

and/or had experienced psychological trauma while 

in Vietnam.64–66 These psychiatric conditions may also 

be indirectly associated with increased risk for unintentional injuries. Depression, for example, may slow 

response time and is associated with alcohol use. 

In addition to affecting risk of injury, psychiatric 

conditions that are related to deployment have other 

consequences for military readiness and for the delivery of healthcare services both in military and civilian 

settings. Studies of mental health in the military population generally have found that personnel hospitalized with a mental health disorder as the primary diagnosis are more likely to separate from service within 6 

months than those hospitalized for other reasons (45% 

and 11%, respectively). Early separation from service 

was also associated with misconduct, legal problems, 

unauthorized work absences, and failure to comply 

with alcohol treatment programs.67 Combat-related 

stress may also contribute to increased use of healthcare services.68

Sports and Athletic Injuries 

Recreation may provide a means to help relieve 

wartime tensions and boredom. It is a normal aspect of 

human activity, and should be expected and planned 

for as part of deployment operations. This is especially 

true as an operation transitions from the maneuver 

phase to sustained operations in theater, and soldiers 

have more free time on their hands. Sports and athletics programs can be useful in staving off boredom and 

distraction, especially in contexts where soldiers are 

prohibited from leaving the area and mingling with 

local civilian populations. Recreation and more coordinated physical fitness training can also be important 

in enhancing and promoting physical fitness so that 

soldiers can maintain compliance with Army physical fitness standards, especially during an extended 

deployment. 

There is, however, a tradeoff between recreation that 

is necessary for health, and well-being, and prevention 

of injuries. It is easy to take for granted the safety precautions and protective equipment available for sports 

and recreation activities in garrison. Battalion surgeons 

should be involved in the planning and coordination 

of recreation activities. Among other things, playing 

fields should be screened for uneven playing surfaces 

or other hazards. Courses set for physical fitness runs 

should be designed with safety in mind. Basketball 

backboards and other stationary sports equipment 

should be securely mounted on sturdy structures that 

are free from sharp edges. Protective gear should be 

requisitioned and inspected for adequacy. Finally, battalion surgeons and other medical personnel should 

be prepared to treat a variety of sprains, strains, and 

other injuries that are likely to accompany sports and 

leisure activities.

During the Vietnam War, injuries related to recreation resulted in evacuation of many soldiers from 

theater. We do not always retain the lessons we learn 

from history, however, as evidenced by the relatively 

high number of soldiers evacuated during Operation 

Desert Storm for injuries incurred playing “combat 

football.” Even for military personnel treated without 

evacuation, sports injuries can significantly impair a 

soldier’s readiness for battle. Given the Army’s recent 

transition to smaller and more streamlined operational 

units, even a small number of injuries to key personnel 

may have significant and negative impact on the unit’s 

overall readiness. Commanders and medical personnel 

should be vigilant about the potential for recreational 

injuries, and should attempt to make sports and fitness 

activities that take place in theater safer—if not as safe 

as possible, then at least safe enough so that they do 

not compromise a mission’s effectiveness. 

Injury Risk After Redeployment

Over the past several decades, and especially since 

Operation Desert Storm, researchers have devoted 

considerable time and resources to studying the effect of deployment on long-term health.69–74 An often 

overlooked fact, however, is that the only significant 

difference in postdeployment mortality is with respect 

to injury: returning soldiers are at significantly greater 

risk of injury mortality than their nondeployed counterparts. This was true for both US and Australian 

soldiers deployed during the Vietnam War and for US 

soldiers deployed during Operation Desert Storm. US 

veterans of the Vietnam conflict experienced greater 

risk for injuries resulting from motor-vehicle crashes, 

poisonings, fires and burns, homicide, and suicide after 

returning home.64,65,75–80 An Australian study found 

that injury accounted for 74% of the postwar mortality 

among their soldiers who served in Vietnam.81 Nonbattle injury remains the only documented cause of 

increased postwar mortality among the soldiers who 

fought in Operation Desert Storm.35,82,83
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

Several explanations for how deployment to a hostile environment may directly or indirectly increase 

risk of injury after redeployment have been proposed 

(Figure 12-6). First, higher rates of injury mortality may 

be a consequence of increases in clinical depression, 

PTSD, or other psychiatric conditions subsequent to 

deployment. As reviewed previously, such conditions 

may be associated directly with self-inflicted injuries 

and suicide or indirectly with unintentional injuries. 

Second, the physical and psychological traumas 

experienced during war may result in the postwar 

adoption of potentially unhealthy “coping behaviors.” Several studies have documented an association 

between exposures to emotional or physical trauma 

and increased use of alcohol or other substances.84–88

Changes in behavior may occur independent of any 

diagnosed mental illness or condition, yet still be an indirect consequence of an experience occurring during 

deployment. For example, perceived near-death experiences have been shown to result in profound changes 

in values, beliefs, and behaviors as they relate to living and dying.89–91 Such changes might result in more 

reckless behavior and less regard for personal safety. 

Third, increased risk of injury may be the indirect 

consequence of the ill-defined diseases and symptoms 

reported by many veterans, including fibromyalgia, 

chronic fatigue syndrome, and symptoms such as dizziness, shakes or tremors, unrefreshing sleep, fatigue, 

muscle and joint pain, and confusion.92–101 Whether 

or not these conditions are a direct consequence of 

deployment-related service, they are frequently reported by soldiers returning from deployment. (They 

were especially common among soldiers who served in 

the 1990–1991 Persian Gulf conflict.) These conditions 

may result in reduced response time or an inability 

to safely negotiate out of a hazardous situation (eg, 

motor-vehicle collision avoidance). Alternatively or 

concurrently, soldiers suffering from these conditions 

might be more likely to make decisions that may 

increase exposures to hazardous circumstances. For 

example, they may be more inclined to enter a quarrel, 

which could escalate to interpersonal violence. Thus 

far, the documented association between deployment 

and increased injury mortality has not been evaluated 

to determine if certain subgroups (eg, those suffering 

from multisymptom illnesses) are responsible for the 

observed differences in injury risk. 

Fourth, the observed increase in postwar injury 

mortality may be masking broader patterns of increased susceptibility to both injury mortality and 

morbidity. Without an understanding of the prevalence 

of nonfatal injury among deployed and nondeployed 

soldiers, it is impossible to ascertain whether or not 

deployers are at increased risk for injury events, or 

whether they are at increased risk for death (or poorer 

outcomes in general) once they experience a given 

type of injury (eg, motor-vehicle crash–related injury). 

Psychological distress, coping behavioral responses, 

and illness symptoms may act as modifiers of an injury 

event. A deployed soldier who incurs a postwar injury 

may be more likely to experience adverse sequelae than 

an injured veteran who was not deployed, because of 

the presence of war-related comorbidities. 

Finally, findings of excess injury morbidity among 

deployed soldiers may reflect a bias in selecting individuals for deployment who are inherently at greater 

injury risk (self-selection). This increased injury risk 

may stem from a number of baseline personality or 

occupational characteristics, such as belonging to an 

occupational group with documented hazards (eg, 

vehicle drivers) or risk-taking (eg, speeding, smoking, 

alcohol consumption). These factors could elevate the 

risk of experiencing an injury event and/or result in a 

poorer outcome after the event.

There is little baseline information available 

that would allow exploration of pre- and postwar 

risk-taking habits and injury predisposition among 

Fig. 12-6. Potential explanations for the association between 

deployment and increased risk of injury. PTSD: posttraumatic stress disorder. 

Illustration: Reproduced with permission from Bell NS, Amoroso PJ, Wegman DH, Senier L. Why are people who return 

from war at increased risk of injury? Injury Prev. 2001;7:4–9.

Baseline

characteristics

(eg, risk-taking

behaviors,

occupational

exposures)

Deployment

Psychological

distress (eg,

PTSD depression) Behavioral/coping

(eg, alcohol or drug

use, reckless

behavior)

Disease

symptoms (eg,

dizziness,

headaches,

unrefreshing sleep)

Excess

risk for injury

events

and/or

poorer

outcomes after

injury event
353

Injury Control

deployed and nondeployed soldiers. It is plausible, 

however, that the same factors that make a soldier a 

likely candidate for deployment may also be associated with a greater risk of injury independent of war. 

Soldiers who are sensation seekers or risk takers may 

be more inclined to self-select into or be assigned to 

occupational specialties with a higher likelihood of 

deployment (eg, Infantry, Airborne, Rangers, and Special Forces). A recent study demonstrated that soldiers 

who received hazardous duty pay for activities such 

as parachuting or exposure to enemy fire in the period 

well before the start of Operation Desert Storm were 

the same ones most likely to be deployed to the Gulf 

during the 1990–1991 conflict, even after controlling 

for occupation.102

Increased injury frequency or severity may stem 

from any one of these five proposed explanations, 

some combination of them, or some other yet undiscovered pathway. In any case, the relationship between 

deployment experiences and postdeployment injuries 

needs further study. This requires more support and 

attention from policymakers and researchers alike.

INJURY CONTROL IN THE MILITARY

The history of the armed forces provides numerous 

examples of injury control successes. Safety programs 

and injury prevention initiatives have resulted in the 

remarkable reduction of aircraft crashes, the near 

elimination of fires after crashes of helicopters, and 

the dramatic reductions of parachuting injuries over 

the past several decades. No single factor can be cited 

as the reason for these successes. Only through multidisciplinary approaches can injury reduction of this 

magnitude be accomplished. Cooperation and collaboration of medical, safety, command, legal, engineering, 

and behavioral scientists are necessary to obtain true 

success in injury control. Yet, fatalistic attitudes still 

prevail, embodied in the notion that there will always 

be some injuries we are powerless to prevent. A class 

A accident is one in which the total cost of property 

damage is $1 million or more; an aircraft or missile is 

destroyed, missing, or abandoned; or an injury and/or 

occupational illness results in a fatality or permanent 

total disability.103 Although there will likely always be 

injury, class A aviation crashes did not appear any more 

preventable decades ago—when rates were greater 

than 100 per 100,000 flying hours—than now, when 

there are only 1.5 per 100,000 flying hours; and the rate 

is still dropping.104 Figure 12-7 illustrates Navy aviation fatality rates, demonstrating the effect that injury 

prevention interventions have had on the trend line. 

Understanding the Dynamics of Injury: 

The Epidemiological Triangle

Recall the definition of injury: the end result of a 

transfer of energy, usually sudden, above or below 

certain absorption limits of human tissue, causing 

physical damage to tissue or death.8,9 The key to injury 

control lies in modifying the injury-causing agent (energy), individual behavior, the environment, or the interaction of any of these factors. The goal is to interrupt 

Fig. 12-7. Navy rates of aviation fatalities, 1949–1995. This graph demonstrates that class A aviation accidents have dropped 

precipitously over the past 50 years. The steepest declines have happened concurrently with the implementation of accidentprevention initiatives, beginning with the angling of carrier decks in the mid-1950s. NATOPS: Naval Air Training and Operating Procedures Standardization; RAG: Replacement Air Group (now Fleet Replacement squadron). 

Illustration: Courtesy of the Naval Safety Center, Norfolk, Virginia. Rate per 100,000 Flight Hours 60

50

40

30

20

10

0

Angled carrier decks installed

Aviation Safety Center

Naval Aviation Maintenance Program

RAG Concept Initiated

NATOPS Program

Squadron Safety Program

Safety Instruction Module

Year

49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 92 93 94 95
354

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

the normal injury-causing sequence of events. It is 

not always necessary to prevent the energy transfer 

entirely; sometimes, a change in the interaction of the 

person and the energy can bring the energy transfer 

within the limits of human tolerance. A traditional 

epidemiological host–environment–agent model is 

sometimes used to describe this process (Figure 12-8).

This model is often used when studying infectious 

diseases and identifying intervention opportunities. In 

the infectious disease model, these elements include 

the following:

	 •	 the agent (or disease pathogen),

	 •	 the host (the human suffering from or at risk

from the infectious agent), 

	 •	 the environment (taken broadly to include

both the physical and sociocultural milieus 

that may contribute to the infection), and 

	 •	 the vehicle or vector that carries the agent to

the host. 

If the infectious disease is malaria, for example, 

the agent is the parasite Plasmodium falciparum, and 

the host is the human. Malaria is transmitted by mosquitoes, which, because they are living creatures, are 

classified as the vectors. To prevent malarial infections, 

we should examine each element in this triangle and 

consider the intervention options we could apply to 

each. We may choose to address the agent itself. For example, a chemical could be developed and distributed 

(eg, aerial spraying) that would alter the Plasmodium

in such a way as to disrupt its reproductive capabilities. Alternatively, or in addition, we could focus on 

the host and try to build up host resistance through 

inoculation (eg, in the past, people were given quinine 

as a prophylactic agent against malaria). We could also 

try to prevent host contamination by eliminating the 

vectors. For example, we could introduce bats and 

mosquito fish (Gambusia sp.) to reduce the mosquito 

population. We could also make changes in the physical environment by eliminating stagnant water where 

mosquitoes tend to breed. Environmental changes 

should be viewed broadly to also include normative 

behavior changes, such as teaching people to not wash 

clothes or bathe in sluggish water where mosquitoes breed. Environmental changes can also include 

encouraging the use of mosquito netting, including 

pesticide-impregnated mosquito netting or repellents 

alone, or fostering an environment where it is socially 

acceptable, even macho, to practice self-protection.

The epidemiological triangle can also be used to 

identify strategies to prevent or reduce harm from 

injury. In injury control, it is the magnitude of the energy that is transferred to the potential victim that is 

the agent of concern, rather than a disease pathogen. 

Most commonly, kinetic energy is the culprit. The host 

is, again, the human. The environment, as with infectious disease interventions, includes both the physical 

and broader socioeconomic and cultural environments, 

including command-level influences. As with disease, 

in injury control we need to think about vehicles and 

vectors that transmit the unwanted energy to the host. 

Usually, in injury control, these are inanimate vehicles, 

such as electric power lines or motorcycles. However, 

in some cases, the energy carrier is a living creature—as 

in assaults by humans—and, in these cases, the energy 

carrier is correctly called a vector. Each of these elements is discussed herein in more detail.

Host Factors

Host factors are characteristics that predispose an 

individual either to experience an unintended transfer of energy or that cause the individual to be more 

susceptible to tissue damage given the occurrence of 

such an event. These intrinsic factors might include 

an individual’s age; gender; race; anthropometric 

characteristics, such as height, weight, and muscle 

mass; and behavioral factors, such as the propensity 

to use or abuse alcohol or drugs, or engage in other 

high-risk activities. Some acquired individual factors 

that may place active-duty personnel at risk include 

sleep, diet, general nutrition, immunization status, 

and stress responses. Deploying to new environments 

often involves traversing several time zones, losing 

contact with friends and family, and coping with the 

uncertainty of survival in a war zone. All of these factors combine to create substantial stress that, in turn, 

may contribute to poorer cognitive functioning (and 

thus increased risk for exposure to injury) or poorer 

response and recovery from an injury. Certain host 

Fig. 12-8. The epidemiological triangle: a traditional epidemiological host–environment–agent model.

Agent

Vector or

Vehicle

Host Environment
355

Injury Control

behaviors (eg, risk-taking behaviors, alcohol use, 

smoking status) have been associated with an increased risk for experiencing an injury event,9,61,105–131 

increased severity of injury, or ability to survive and recover from the injury event once it has occurred.20,132–141 

Environmental Factors

In thinking about environmental factors that contribute to injury risk, we should consider not only 

aspects of the physical or structural environment, but 

also how the sociocultural or socioeconomic milieu 

may contribute to injury. Certain environmental physical factors and structural conditions may encourage, 

or at least not inhibit, the unwanted transfer of energy. 

These may include driving on unfamiliar, hazardous 

terrain, or parachuting onto a hard surface.142–145 Sociocultural factors include attitudes about risk-taking 

and health, such as beliefs about wearing a safety 

belt and awareness of, or beliefs about, the risks of 

consuming alcohol before or while operating a motor 

vehicle. Sociocultural factors also include community 

and command-level attitudes and support of safetyrelated issues. The example set by senior noncommissioned officers, officers, and others in command sets 

a precedent for the behavior of subordinates. Law 

enforcement presence, cultural views of violence, and 

the presence of safety-related laws are also examples of 

environmental factors. For example, most bases require 

gun owners who live in the barracks, usually younger 

enlisted personnel, to register and lock up their weapons in a secure, centralized location, usually the unit 

arms room. Because this makes it difficult to obtain the 

weapon, the result could be a significant reduction in 

intentional and unintentional firearm injuries resulting 

from impulsive actions. The inconvenience of obtaining the weapon when it is needed, however, may give 

soldiers the incentive to find other places to store their 

weapons, such as in the glove compartment of their car 

or at a friend’s house. These unintended consequences 

are discussed further in the section titled Intervention 

Strategies: Different Approaches. 

Vehicles, Vectors, and Equipment

Design characteristics of vehicles and equipment 

have a great potential to either mitigate or cause injuries. Some of the greatest advances in injury prevention 

have been achieved through modification of vehicles 

or equipment. Indeed, of all of the advancements in 

motor-vehicle safety, the most substantial reductions in 

morbidity and mortality have been obtained through 

the reengineering of vehicles and roadways. For example, helicopters are now equipped with breakaway 

or collapsible control sticks, thereby reducing the risk 

of impaling the pilot during a crash. Many helicopters 

now have airbags as well. As noted previously, Navy 

Safety Center data shows a 90% decrease in the rate 

of class A aviation accidents (see Figure 12-7), but we 

should note that the greatest gain in this reduction 

came in the mid-1950s, when aircraft carrier decks were 

angled (eg, the runways were laid out at an angle), 

thereby reducing the likelihood of a crash when a plane 

touched down (Exhibit 12-3). 

Agents

Energy transfer, most commonly the transfer of 

kinetic energy, causes injuries. The development of 

intervention strategies should incorporate approaches 

to modify the energy transfer in such a way as to prevent the release of the energy or reduce the amount 

of energy that may be released. Safety mechanisms 

on firearms, for example, reduce the chance that the 

firearms will be unintentionally fired. Bulletproof vests 

and Kevlar helmets reduce the character of the energy 

transfer, and thus the morbidity and mortality that an 

individual may experience when hit by a bullet or fragments. Injuries among parachutists are influenced by 

drop zone terrain, obstacles, and environmental conditions, but are also a function of the vertical sink rate of 

the parachute and jumper. Low-porosity parachutes 

that reduce the kinetic energy at the moment of impact 

have been shown to significantly reduce the injury 

rate to parachutists, both in terms of overall injuries 

and for each of the three types of injuries examined: 

(1) fractures, (2) strains/sprains, and (3) contusions.15

Intervention Strategies: Different Approaches 

There are two basic approaches to preventing or 

reducing injuries in the military: (1) active strategies 

are interventions that require an individual to make 

a conscious decision to behave in a certain way (eg, 

choosing to put on a seatbelt); whereas (2) passive strategies do not require a specific change in an individual’s 

behavior to be effective (eg, an air bag). Although each 

approach has merit, each also has disadvantages. Most 

members of the injury control community agree on 

the virtues of both passive and active approaches to 

injury prevention, but there is often considerable debate over the specific implementation of various active 

and passive countermeasures. The basics of these two 

strategies will be described briefly; further discussion 

will follow later in the chapter. 

Active strategies require an individual to make decisions regarding his or her health. Such approaches 

are usually less intrusive on personal liberties and are 
356

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

often, if successful, less expensive than engineering 

approaches, although the cost per success may be high. 

On the downside, some people will never change their 

behavior, and everyone is subject to momentary lapses 

in attention or judgment. Those who are at greatest risk 

of injury because of risk-taking habits are often among 

those least likely to alter their behavior.10 In addition, 

some fall victim to the behavioral transgressions of 

others—often the result of actions entirely beyond individual control. Behavior change requires maintenance 

and tends to erode over time as education campaigns 

end or lose their novelty. Moreover, active strategies 

require that a person possess a specific skill or level of 

cognitive functioning to be effective. Thus, individuals 

with a temporary cognitive deficit (eg, someone who 

is sleep deprived, is in an extremely fearful state, is 

injured, or who has used alcohol or medication) may 

be unable to perform the safety procedure effectively. 

Most importantly, active strategies ignore the potential for human error. No matter how many times a 

person rehearses a specific skill, there will always be 

the potential for a small mistake. The question, then, 

is should the penalty be death for a momentary lapse 

in judgment or a small slip-up? 

Passive strategies have several distinct advantages 

over active strategies when it comes to accounting 

for human error potential. Passive strategies provide 

automatic protection and cover all members of a 

population, even those who take great risks or who 

are temporarily or permanently impaired. They do 

not erode over time and do not require any specific 

set of skills for an individual to be protected. Nor do 

passive strategies require an action each time someone 

is to be protected. Furthermore, they are generally the 

most effective. On the downside, some passive strategies may be viewed as intrusive on personal liberties 

and some are expensive. Distribution of the costs for 

these interventions may be a contentious issue as well. 

EXHIBIT 12-3

PIONEERS IN INJURY EPIDEMIOLOGY

Epidemiology is the branch of medical science that examines the spread of disease in human populations. The application of these techniques to injury prevention and control is a fairly recent phenomenon, dating back to mid-20th 

century. One of the first pioneers was Hugh De Haven, a former World War I pilot who drew on his own experience 

as a crash survivor to argue that injury could be minimized by altering the structural environment.(1) His work applied biomechanical principles to injury prevention questions, measuring the body’s ability to withstand changes in 

mechanical injury, and how measures such as seat belts, airbags, and other safety devices could protect a vehicle’s 

occupant. Further developments in the field were made by John Gordon, who argued that injury could be studied 

with the tools and methods applied to infectious disease epidemiology, and that by examining epidemic episodes, 

seasonal variation, long-term trends, and demographic characteristics of injured parties, we could design appropriate 

and effectively targeted interventions.(1) 

But the greatest conceptual and theoretical developments in the field, by far, were advanced by William Haddon, Jr, an 

occupational physician with the New York State Health Department. Haddon pioneered two conceptual frameworks 

that are still widely used in injury epidemiology today: (1) the Haddon matrix and (2) 10 principles to reduce hazards 

of all kinds.(1–3) 

The contributions of De Haven, Gordon, and Haddon, and others who have followed them, have served to mitigate the 

attitude that accidents are random, unpredictable, or the result of unwise behavior on the part of careless individuals. 

By applying the tools and methods of epidemiologic inquiry, they demonstrated that it is possible to predict where and 

how injuries may occur, and, more importantly, by leveraging the expertise of biomechanical engineers, they showed 

it is possible to alter the structural environment in ways to reduce the burden of injury. Their early foundational contributions have spawned decades of scholarly work expanding our understanding of the causes and consequences 

injury has for our society. These insights have shifted the focus of injury prevention programs away from educational 

interventions aimed at changing individual behaviors; have led to the design of safer products and the institution of 

environmental modifications to reduce injuries in many different settings; and have become the basis of policy recommendations, programs, and legal mechanisms to make our society a safer place. 

Data sources: (1) National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. The National 

Committee for Injury Prevention and Control. Am J Prev Med. 1989;5(suppl 3):1–303. (2) Haddon JW. The basic strategies for reducing damage from hazards of all kinds. Hazard Prev. 1980;Sept/Oct:8–12. (3) Haddon matrix: eliminating the mumbo jumbo. 

IIHS Status Report. 1986;21:8. 
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There are strengths and limits to both active and 

passive approaches. A comprehensive injury control 

program capitalizes on the most effective measures 

(usually passive) while also incorporating strategies 

to change the behavior of individuals (ie, consumers, 

manufacturers, and legislators whose decisions ultimately affect the risk of injuries to others). Injury control 

in the military might be enhanced by procurement decisions and product assessments that include an evaluation of the potential utility of passive safety features. 

Unintended Consequences and Risk Compensation 

Injury interventionists must be concerned not only 

with the prevention of injury through appropriate intervention, but also with the potential for unintended 

consequences. Knowledge that a safety device is in 

place has the potential to change the behavior of an 

individual or an organization (economists refer to this 

idea as risk compensation). However, the idea of risk 

compensation is by no means universally accepted in 

injury control circles. In essence, risk compensation 

is said to occur when an individual takes additional 

risks that he or she may have been unwilling to take 

in the absence of the safety device or intervention. A 

good example from a civilian context may be found 

in differences among drivers of vehicles with and 

without airbags (ie, a person driving a car with an 

airbag may be less likely to fasten the seat belt). As a 

final example, boxing gloves allow boxers to exchange 

blows for longer periods of time and target the bonier 

face and head. Although each punch may seem to be 

less injurious (because of the padding afforded by the 

gloves), the cumulative effect of sustaining repeated 

blows to the head may still result in long-term neurological consequences or even death. 

Risk compensation may also be used to the advantage of safety by increasing the perceived riskiness of 

an activity. For example, speed bumps in roadways 

actually increase risk of damage to the vehicle by mimicking the hazards of driving over a bad road. Driving 

quickly over a speed bump may cause damage to the 

vehicle or could cause the driver to lose control of the 

car, leading to an injury-producing accident. It is also 

uncomfortable for vehicle occupants to drive quickly 

over a speed bump. The combination of these factors 

ensures that most drivers will slow down when approaching a speed bump. In parks, residential areas, 

and near schools, the net effect of this is to make the 

roads safer for all. Although this particular example 

may not relate to conditions common during deployment, the concept of risk compensation may be useful 

in thinking about how hazards present in theater may 

increase risk of injury and how risk compensation 

mechanisms may be useful as adjuncts to other types 

of injury prevention strategies. 

In some cases, the trade-offs in terms of risks and 

benefits associated with an intervention are not easy 

to evaluate. The relative benefits of interventions to 

address specific and different types of problems can be 

even less clear. For example, a recent analysis of Army 

Safety Center data suggests that adding protective armor to “Humvees”(actually “HMMWV” [high-mobility multipurpose wheeled vehicle]) makes the vehicle 

more top heavy and thus more prone to rollover.146

Approximately 70% of the soldiers killed in Humvee 

accidents in Iraq between March 2003 and November 

2005 were killed when the vehicle rolled over. Decades 

of research in the civilian world have demonstrated 

that light trucks and sport utility vehicles are more 

prone to rollover than automobiles because of their 

height and high center of gravity.147 Although other factors (eg, driver behavior and environment) have also 

been shown to increase rollover risk, such factors are 

difficult to predict and control, thus making modifying 

the vehicle to reduce rollover risk an appealing option. 

As this example shows, however, all proposed vehicle 

modifications should be made in joint consideration 

of the overall impact on risk of both intentional and 

unintentional injuries. Injury interventions should be 

evaluated not only for their efficacy in preventing the 

target injury, but also for unintended consequences. 

Proper evaluation research of newly proposed injury 

prevention programs is necessary to identify unintended consequences that may appear and to make 

plans to mitigate or eliminate them. 

PLANNING INJURY PREVENTION PROGRAMS 

Injury prevention has been considered an important component of the medical arts since the time 

of Hippocrates, but was not systematized until the 

mid-20th century through the efforts of several injury 

control pioneers. William Haddon, Jr, is credited with 

the most substantial methodological and theoretical 

advances in the field, having created two widely accepted tools related to the prevention and control of 

injuries. The first of these tools is known as the Haddon matrix and provides a conceptual framework for 

considering approaches that target the host, agent, 

and environment at different temporal points during 

the injury-producing event. The second tool is a set of 

prevention strategies known in the injury control field 

simply as the “10 strategies.” The 10 strategies provide 

a scientific approach to injury control; when coupled 
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with the Haddon matrix, they provide an extremely 

useful methodology for the control of injury hazards 

of all kinds.11,148

The Haddon Matrix: Identifying Injury Intervention 

Opportunities

All elements of the injury epidemiological triangle 

are incorporated in a deceptively simple tool known 

as the Haddon matrix (Figure 12-9).149 The matrix plots 

the elements of the epidemiological triangle against 

another dimension that is important in the development of injury prevention strategies—time. 

The Haddon matrix is essentially a heuristic technique. It facilitates the careful evaluation of all options 

available to prevent or reduce harm resulting from a 

specific injury event. Haddon noted that there are three 

different stages to the injury process: 

1. a preevent phase, in which the energy transfer 

has not yet occurred; 

2. an event phase, or the actual point at which 

energy is transferred to the host; and

3. a postevent phase, after the incident has 

occurred. 

There are different intervention strategies that can 

be applied in each of these phases. Each of these intervention strategies corresponds to each element of 

the injury epidemiological triangle. Haddon proposed 

that it is often necessary to implement several different 

interventions to control injuries effectively. As with 

attempts to control infectious agents, the goal should 

be to identify the weakest link and apply appropriate 

intervention strategies.8

The Haddon matrix, as it was initially developed, 

was intended for use as a tool to identify ways to 

Fig. 12-9. The Haddon matrix illustrated with examples of the Army Safety Center and other Army proponent responsibilities. Haddon’s breathrough concept was to parse accident events into modifiable elements involving timing (preevent, during, and postevent) and contributor (people or hosts, vehicle or vector, and environment). BEAR: Battlefield Extraction and 

Retrieval Robot (Vecna Technologies, Inc, Greenbelt, Md); HMMWV: high-mobility multipurpose wheeled vehicle; MRAP: 

mine-resistant ambush-protected (vehicles). 
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Injury Control

reduce injuries and their sequelae. Some researchers 

who have used the Haddon matrix have incorrectly 

related the individual rows directly to primary, secondary, and tertiary prevention approaches.150 Dr Haddon, 

however, did not agree with this interpretation. In 

fact, he proposed the three-phase model because the 

primary/secondary/tertiary model did not fit injury 

well, inasmuch as primary prevention strategies could 

be applied in the event phase, the preevent phase and, 

to a limited degree, even in the postevent phase (W 

Haddon, oral communication with S Baker, 1970s).

The Haddon matrix can be used to identify options 

for preventing or reducing harm in each phase of the 

injury event and for each element of the injury epidemiological triangle. In each cell of the matrix, one 

could list the ideas for injury prevention strategies 

that apply to that stage. For example, the first row 

of the matrix could include strategies that attempt to 

prevent the injury event from occurring. Examples of 

interventions that might fit in this row could include 

combat survival training, pilot training and requalification, flight checklists, and military aircraft/vehicle 

maintenance programs. 

In the second row of the matrix, one could list strategies that attempt to modify the individual, environmental, or protective equipment to reduce or eliminate 

energy transfer to prevent injury altogether, or to 

minimize the damage caused by the energy transfer. 

Examples of interventions in this row might include 

required use of safety belts, helmets, life jackets, flak 

vests, and parachute ankle braces. This type of intervention strategy would also mandate the installation 

of crashworthy fuel systems and breakaway sticks 

in helicopters. Note that none of these interventions 

would prevent the energy transfer event from occurring (ie, the plane or car would still crash), but they 

might prevent the individual from being hurt during 

that event. 

Most injury control efforts tend to focus on the first 

and second rows because it is optimal to prevent or 

reduce the severity of the injury altogether, if possible. 

Irving Zola captured the essence and importance of 

prevention as follows, 

[Y]ou know, sometimes it feels like this. There I am 

standing by the shore of a swiftly flowing river and

I hear the cry of a drowning man. So I jump into the 

river, put my arm around him, pull him to shore and 

apply artificial respiration. Just when he begins to

breathe, there is another cry for help. So I jump into 

the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, 

another cry for help. So back into the river again, 

reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the 

sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that

I have no time to see who . . . is upstream pushing 

them all in.151

One approach to solving the problem of injury 

morbidity and mortality is to stand on the riverbank 

and try to pull people out as they float by. A better 

approach may be to go upstream and see what can be 

done to stop them from jumping in or being thrown in 

the water in the first place. Because some people will 

inevitably end up in the river, however, it is worthwhile 

to consider interventions that could be placed in the 

third row of the Haddon matrix (those that influence 

the long-term sequelae of injuries once they have 

occurred and prevent reinjury or injuries that occur 

subsequent to the initial injury event). Strategies that fit 

in this row include field hospital readiness and access, 

secured runways for medical evacuation (MEDEVAC), 

and training all soldiers in basic first aid and cardiopulmonary resuscitation. 

Columns of the Haddon matrix correspond to the elements of the injury epidemiological triangle. The first 

column includes all intervention strategies that relate 

directly to host behavior or susceptibility to injury and 

attempts to modify these factors. Such interventions 

might include improving physical fitness, training, 

and providing good reconnaissance information about 

terrain. The second column focuses on changes in 

the vehicle (which carries energy to the person) and 

protective equipment (eg, airbags, seatbelts, helmets, 

ankle braces, and so forth). The third column focuses 

on modifications to the physical and broader social environmental factors (eg, system support of MEDEVACs 

and disaster preparedness, norms and laws against 

driving while impaired, and enforcing safe behaviors). 

The easiest way to understand and begin using 

the Haddon matrix is by example. Consider injuries 

occurring among airborne soldiers during tactical 

parachuting exercises and jump operations. To control these types of injuries, we will attempt to identify 

strategies within each cell of the matrix (Table 12-6). 

The first cell should inspire thoughts of interventions 

that may be implemented prior to jumping to improve 

human performance. Examples include prior training, 

proper nutrition, and physical conditioning. The event 

phase for human interventions would include using 

protective gear (eg, ankle braces) and being well-rested 

and in good condition. Postevent measures might also 

include training, because soldiers should know what 

to do if they are injured in a jump operation, including 

basic first-aid training. 

Preevent interventions in the second column (vehicles and equipment) include the choice of low-porosity 
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parachutes if the situation warrants. Event-phase 

equipment strategies might include the presence of a 

reserve chute if the primary chute fails. Postevent interventions might include the availability and proximity 

of well-maintained first-aid equipment and phone or 

radio communication systems, if appropriate. 

Preevent strategies in the third column should target 

social and physical environmental factors. Airborne 

soldiers need to be prepared to jump in a variety of 

drop-zone conditions, in varied weather conditions, 

and with prior consideration of enemy position and 

disposition. Modifications to these plans could be 

made to enhance the accuracy and support of a reconnaissance team. Event-phase strategies might include 

weather conditions, which could make drop-zone terrain or obstacles more hazardous or could make it more 

difficult for a jumper to maneuver out of a hazardous 

situation. Postevent strategies might include factors 

such as accessibility for a MEDEVAC crew, lighting for 

the crew, command support of a MEDEVAC program, 

knowledge of the distance to a field hospital, and training of the field hospital staff (Figure 12-5b). 

Many of the interventions that appear in the first 

column (human factors) derive from models for changing individual behaviors, whereas most strategies 

listed in the second column, and some in the third 

column, involve engineering or structural changes 

that do not require specific actions by the host. Many 

interventions may also be appropriate in more than one 

cell. For example, training may both prepare a soldier 

in proper jump techniques, but should also address 

first-aid and other emergency procedures if an injury 

should occur. Likewise, interventions aimed at increasing physical fitness generally or specific behavioral 

interventions around reducing tobacco and alcohol use 

may be relevant in many cells. Although alcohol use is 

prohibited in forward-deployed zones, habitual use of 

alcohol may impact physical conditioning and would 

be relevant in the preevent phase of injury prevention. Some research suggests that alcohol and tobacco 

impede tissue-repair processes and thus may prolong 

rehabilitation or contribute to adverse sequelae.106

The Haddon matrix has been a useful tool in the 

design and implementation of injury interventions for 

more than 50 years, but some researchers have recently 

proposed adding a “third dimension” or a third axis to 

it.152 The third axis comprises factors that may impact the 

acceptability of the various proposed interventions (eg, 

cost, feasibility, and potential for stigmatization). Once 

all possible ideas for interventions have been collected 

and placed in the appropriate cells, it is useful to establish the guidelines by which the pros and cons of each 

suggestion can be assessed, and from those, make decisions about which interventions to develop and implement. The conceptual model of the matrix then becomes 

more cubelike, with the addition of these factors aligned 

along the edge of one of the sides of the cube. Each of 

the ideas recommended in each of the cells of the matrix 

is then weighed by these standards in deciding which 

intervention ideas get developed and implemented. For 

TABLE 12-6

HADDON MATRIX OF INTERVENTIONS TO REDUCE WARTIME MOTOR-VEHICLE CRASHES 

Factors

Phase Human (Host) Equipment (Vector or Vehicle) Environment

Preevent Degree of fatigue, familiarity with Antilock brakes, vehicle in good Terrain, weather, visibility, enemy

terrain and vehicle, driving condition (eg, lights, brakes), position and disposition

experience, personality, speed, weight distribution to avoid reconnaissance accuracy, 

smoking, use of alcohol/drugs rollover, good tire traction, speed command enforcement of

capability training protocol and alcohol/

drug prevention, speed limit

Event Use of safety belt, speed Air bags, helmets, collapsible Obstacle-free road, vehicle

steering column, structural following distance

integrity (roll bars, side bars)

Postevent Knowledge of first-aid, general Fire-retardant interior and gas tank, Open terrain for rapid evacuation, 

health, age, smoking, alcohol first-aid gear on board, fire command support of MEDEVAC,

or drug use, prior injury history extinguisher planning for triage, distance to

field hospital, training of field 

hospital staff

MEDEVAC: medical evacuation
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Injury Control

example, in designing an intervention to reduce ankle 

fractures among airborne parachutists, commanders 

might weigh such factors as cost, efficacy, feasibility, 

soldier preferences, or effect on readiness. This expansion of the matrix formalizes the process of weighing 

the costs and benefits of the various ideas that have 

been suggested and conceptualizes the decision-making 

process within the tool to an even greater degree.

Haddon’s 10 Strategies for Control of Hazards of 

All Types

The 10 strategies allow each aspect or component of 

an energy transfer to be analyzed separately152:

1. prevent the creation of the hazard in the first 

place; 

2. reduce the amount of the hazard brought into 

being; 

3. prevent the inappropriate release of a hazard 

that already exists; 

4. modify the rate or spatial distribution of the 

release of a hazard from its source; 

5. separate, in time or space, the hazard and that 

which is to be protected; 

6. separate the hazard and that which is to be 

protected by the interposition of a material 

barrier; 

7. modify relevant basic qualities of the hazard; 

8. make that which is to be protected more 

resistant to damage from the hazard; 

9. begin to counter damage already done by the 

environmental hazard; and 

10. stabilize, repair, and rehabilitate the object of 

the damage. 

In essence, the 10 strategies are a multidimensional 

approach to discover the best or most practical intervention point or points. In some cases, a given strategy 

may suggest an intervention that is not practical, economical, or feasible. Nevertheless, by considering each 

strategy carefully, the probability of finding a viable 

intervention is greatly increased. 

Strategy 1: Prevent the Creation of the Hazard in the 

First Place 

Without the buildup of thermal, kinetic, or electrical 

energy, few high-energy hazards would exist. If we 

could avoid war, no one would be killed in battle. If 

nuclear weapons were never created, no detonation 

of nuclear weapons could take place. In some cases, 

international law bans certain weapons. Examples of 

this strategy include the following: 

	 •	 banning chemical weapons; and

	 •	 banning rifle or pistol ammunition without

full-metal jackets (eg, soft-point or hollowpoint bullets that expand or fragment on 

entering the body).

In a more basic sense, the decision not to put a 2,359 

kg HMMWV in motion also illustrates this first strategy. On one hand, as the first and perhaps most basic 

of the 10 strategies, it can also be the least practical 

from a sociopolitical standpoint. On the other hand, 

the military is an environment in which commanders have broad powers to dictate policy pertaining to 

individual and unit activities (Figure 12-10), as well 

as the choice of equipment and vehicles. With proper 

Fig. 12-10. Weather watchers give parachute training the all 

clear. Two soldiers at the Fryar Drop Zone (Fort Benning, 

Ga) take measurements at a weather station. If weather 

conditions are hazardous, training jumps may be canceled. 

This illustrates Haddon’s first strategy of hazard control: to 

prevent the creation of a hazardous situation in the first place.
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

command support, safety measures that may not be 

possible to implement in a civilian environment may 

be initiated with little debate in the military. Examples 

of this strategy include: 

	 •	 banning personnel weapons and all munitions

from barracks;

	 •	 banning alcohol consumption during deployment in Muslim countries; and

	 •	 declaring businesses such as massage and

tattoo parlors off-limits to military personnel 

to control disease and physical assaults.

Strategy 2: Reduce the Amount of the Hazard 

Brought Into Being 

The second strategy is similar to the first, except 

that it requires only a significant reduction of a 

hazard, not its complete elimination (Figure 12-11). 

This strategy is more viable because it represents 

a degree of compromise. Most people are used to 

having limits placed on their activities and will accept reasonable constraints. Many successes have 

come from the employment of this second strategy, 

such as the reduction in motor-vehicle fatalities by 

lowering the speed limit. Examples of this strategy 

include the following: 

	 •	 substituting nonalcoholic orlow-alcohol beer

for alcoholic beverages, 

	 •	 instituting a speed limit based on terrain,

	 •	 reducing the speed capability of vehicles, and

	 •	 shortening the length of a training run during

hot weather to avoid heatstroke. 

Strategy 3: Prevent the Inappropriate Release of a 

Hazard That Already Exists 

Sometimes it may not be feasible to eliminate or 

even reduce the amount of a hazard that is present. 

The next logical step, then, is to try to prevent a hazard 

from being released in an inappropriate or unintenFig. 12-11. Destruction of antipersonnel mines. These Marines are stacking antitank and antipersonnel land mines for destruction at Guantanamo Bay, Cuba. During the Cold War, more than 50,000 land mines were buried in the buffer zone separating 

the Marine installation from mainland Cuba. They have been replaced with motion detectors and sound sensors. This is an 

example of Haddon’s second strategy of hazard control: to reduce the amount of the hazard that exists, especially when it 

already exists or where it cannot be eliminated completely. The work these Marines do will protect future generations of 

Marines patrolling the periphery at Guantanamo Bay. They may be placing their own safety in jeopardy, however; although 

they are wearing some EOD (Explosive Ordnance Destruction) protective gear, they are working without helmets. 

Photograph: Reproduced from the Department of Defense. Taken by PO1 Ronald L. Heppner, US Navy. 
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tional manner. Although this can be accomplished by 

destroying a hazard that already exists (Figure 12-12), 

it can also be accomplished by stopping or controlling 

its release, or some combination of both. Examples of 

this strategy include the following: 

	 •	 following deicing procedures on ship decks,

aircraft carriers, and aircraft wings; 

	 •	 eliminating delivery vehicles of biological

weapons (eg, destroy Scud missiles);

	 •	 designing grenades with safety pins;

	 •	 installing and engaging safety mechanisms

that prevent accidental discharge of weapons; 

and

	 •	 installing self-sealing fuel bladders and auto

shut-off fuel valves on aircraft. 

Strategy 4: Modify the Rate or Spatial Distribution 

of the Release of a Hazard From Its Source 

Modifications that influence the rate at which the 

hazard is released are particularly useful in cases of mechanical (kinetic) energy transfers in which reducing the 

speed of the transfer is key in determining the degree of 

damage caused. Human tissue can often sustain transfers 

of large amounts of energy if the energy transfer occurs 

slowly enough. For example, low-porosity parachutes 

decrease the velocity of descent and thus reduce the 

energy of ground impact. Likewise, increasing the spatial distribution of release of energy also reduces injury 

risk. For example, the parachute landing fall allows 

the jumper to distribute the energy of landing across 

a wider area (Figure 12-13). Doing so dissipates the 

Fig. 12-12. Crashworthy fuel systems. (a) This OH-58C helicopter crashed, but both soldiers on board survived the crash, in 

part because these aircraft are designed with a crashworthy fuel system. (b) The fuel bladder, which seals on impact, prevents 

fuel from spilling after the crash. Crashworthy fuel systems for helicopters have reduced postcrash fires from one of the most 

important causes of aviation-related deaths and injuries, and such fire-related deaths are now relatively rare events. This 

demonstrates Haddon’s third strategy of hazard control: to prevent inappropriate release of a hazard that already exists. 

a b

Fig. 12-13. Parachute landing fall allows the jumper to distribute the energy across five separate body regions rather 

than one. Doing so dissipates the force of the impact over a 

larger area, thus lessening (and usually eliminating) trauma 

to the ankles and feet. The pack will hit the ground first, 

further minimizing the forces of ground impact. 
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force of the impact over a larger area, thereby lessening, 

and usually eliminating, trauma to the ankles and feet. 

Other examples of this strategy include the following: 

	 •	 installing fire-, smoke-, or heat-activated

sprinkler systems;

	 •	 providing diver-decompression tables;

	 •	 installing emergency shut-off valves;

	 •	 using low-porosity parachutes; and

	 •	 installing UH-60 Black Hawk helicopter Gforce reducing seats.

Strategy 5: Separate, in Time or Space, the Hazard 

and That Which Is to Be Protected 

This strategy seeks to keep the hazard and personnel 

from being present at the same place or time. This can 

be accomplished through a variety of methods, including physical and temporal phasing of transportation 

or work schedules. Examples of this strategy include 

the following: 

	 •	 maintaining altitude spacing of aircraft (instrument flight rules),

	 •	 setting shipping lanes,

	 •	 evacuating civilians before political upheaval

in foreign nations, 

	 •	 applying insecticides before troops arrive,

	 •	 storing weapons and munitions in a secure

facility on military installations, and

	 •	 installing aircraft ejection seats to remove pilot

from aircraft before the crash.

Strategy 6: Separate the Hazard and That Which Is to 

Be Protected by the Interposition of a Material Barrier 

This strategy, using protective gear (Figure 12-

14), is perhaps the most straightforward of all of the 

strategies. It has been used successfully for centuries. 

Examples in a military context include the following:

	 •	 wearing Kevlar helmets;

	 •	 using safety glasses, earplugs, and sunglasses

with ultraviolet protection;

	 •	 using torpedo nets;

	 •	 wearing Mission-Oriented Protective Posture

(MOPP) gear;

	 •	 wearing surgical gloves;

	 •	 issuing Nomex flight suits to flight crews; and

	 •	 wearing flak vests.

Strategy 7: Modify Relevant Basic Qualities 

of the Hazard 

Common sense applied to the manufacture and 

design of equipment, vehicles, and materials can go 

a long way toward injury prevention (Figure 12-15). 

Two simple attributes of objects, known since the 

Fig. 12-14. This Air Force technician is outfitted in full protective gear as he checks the fins of a sidewinder missile. Haddon’s 

sixth strategy for injury prevention recommends the separation of a person from hazardous substances by a material barrier. 

Although such protective equipment is important in shielding military personnel from chemical and biological hazards, it 

may carry with it unintended consequences. It may encumber the individual, limit dexterity to accomplish certain tasks, 

and cause a risk of heat exhaustion. 

Photograph: Reproduced from the Best of the US Air Force CD-ROM, Defense Visual Information Center, image 88-08702.
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Injury Control

time of Hippocrates,153 are that softness and a large 

radius of curvature make objects less likely to cause 

injury during collisions. The application of these basic 

engineering principles to the design of tools, vehicles, 

and equipment can improve safety with little or no 

additional cost. This seventh strategy thereby focuses 

on the hazard itself. A few examples of this strategy 

include the following: 

	 •	 applying nonskid surfaces;

	 •	 using less lethal rubber bullets and fire hoses

instead of night sticks and firearms for riot 

control;

	 •	 eliminating sharp or hard surfaces in aircraft

cockpits;

	 •	 installing shock-absorbent surfaces on

obstacle courses;

	 •	 designing collapsible control sticks in

helicopters;

	 •	 placing sand- or water-filled barrels at roadblocks, control points, and cliff edges;

	 •	 using low-voltage lighting or electrical systems where possible; and

	 •	 constructing ships with double hulls.

Strategy 8: Make That Which Is to Be Protected 

More Resistant to Damage From the Hazard 

In contrast to the seventh strategy, this strategy attempts to redesign or modify the victim of injury rather 

than modify the hazard (Figure 12-16). This strategy 

attempts to increase the strength, stamina, conditioning, or other inherent qualities of a person or his/her 

environment that will, in turn, make that person better 

able to withstand an injury-producing event. Some 

examples of this strategy include the following: 

	 •	 applying sunscreen before sun exposure;

	 •	 maintaining psychological and physical conditioning of soldiers or athletes;

	 •	 ensuring that soldiers get adequate nutrition

and rest;

	 •	 administering appropriate vaccines to counter

the effect of biological agents;

	 •	 inducing pharmacological sleep on transcontinental flights; and

	 •	 ensuring gradual, staged ascent to altitude

to ensure acclimatization or preconditioning 

in a hypobaric chamber before conducting 

training or operations at altitude.

Fig. 12-15. “Designed to crash,” the UH-60 Black Hawk helicopter was developed to the military’s specifications with consideration of the decades of crash data and to maximize survivability on impact. Its safety features include a self-sealing, crashresistant fuel system; energy-absorbing landing gear and crew seats; and a collapsible control stick. Despite affectionately 

saying that the Black Hawk is “built to crash,” many a thankful aviator has walked away from a devastating crash with a 

greater appreciation for the meaning of the word “crashworthy.” Efforts to modify the hazardous elements of the vehicle and 

protect its occupants in the event of a crash render the Black Hawk a fine example of Haddon’s seventh strategy: to modify 

relevant basic qualities of the hazard. 

Photograph: Reproduced from the Defense Image Digest CD-ROM, Defense Visual Information Center, image 329.
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

Fig. 12-16. Physical training exercises. Military personnel routinely undergo physical conditioning to maintain their strength 

and stamina. Doing so may make them better able to withstand an injury-producing event. 

Photograph: Reproduced from the Best of the US Air Force CD-ROM, Defense Visual Information Center, image 92-06073.

Fig. 12-17. After tragedy, relief in Oklahoma City. These Air Force members are distributing bottled water to search and 

rescue workers in the aftermath of the explosion of the Alfred P Murrah Federal Building. Secondary prevention measures 

such as this are an important example of Haddon’s ninth strategy: to begin to counter damage already done by a hazard. 

Photograph: Reproduced from the Best of the US Air Force CD-ROM, Defense Visual Information Center, image 96-00585.
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Strategy 9: Begin to Counter Damage Already Done 

by the Environmental Hazard 

Most of the methods suggested by this strategy 

are secondary rather than primary prevention efforts (Figure 12-17). The first step in this strategy is 

to detect damage that has already occurred or that is 

still occurring and to take steps to stop the damage 

from continuing. This stage also initiates the recovery 

process. Although it is generally preferable to prevent 

injury in the first place, rapid detection and prompt 

treatment of injuries can eliminate or greatly reduce 

their consequences. The ninth strategy may involve 

primary prevention in some cases, because it may 

prevent reinjury or development of a fatal condition 

among those already injured. A few examples of this 

strategy include the following: 

	 •	 reconstructing orrestoring bridges, hospitals,

and key infrastructure sites; 

	 •	 activating an emergency radio beacon on a

downed aircraft;

	 •	 equipping water survival gear with a radio

and water-soluble dye indicator to increase 

the likelihood of rescue;

	 •	 restoring damaged desalination plants;

	 •	 establishing telemetry with higher echelons

of care/telemedicine links;

	 •	 airdropping food, water, and medicine to warravaged territory; and

	 •	 providing rapid first aid and evacuation for

victims of injury.

Strategy 10: Stabilize, Repair, and Rehabilitate the 

Object of the Damage 

Once damage has occurred, it is important to stabilize the victim to prevent further damage. The next 

step is to begin the process of treating the injury and 

facilitating rehabilitation to prevent reinjury or susceptibility to new injuries. The Air Force MEDEVAC 

program provides a good example of this strategy 

(Figure 12-18). Other examples include the following: 

	 •	 detecting and responding to injuries on the

battlefield—combat lifesaver training for all 

deployed soldiers,

	 •	 placing Forward Surgical Teams in the war

zone,

	 •	 establishing trauma centers,

	 •	 establishing burn centers (eg, Brooke Army

Medical Center was instrumental in treating 

military burn patients from the Vietnam War 

to the present), 

Fig. 12-18. US Army UH-60 Medical Evacuation (MEDEVAC) helicopter lands on the USS New Orleans during a joint-service, 

mass-casualty exercise held in Somalia during Operation Restore Hope. Rescue is the first step in rehabilitation and convalescence, Haddon’s tenth strategy (to stabilize, repair, and rehabilitate the object of damage). 

Photograph: Reproduced from the US Forces in Somalia CD-ROM, Department of Defense Joint Combat Camera Center, 

image 364.
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

	 •	 creating the MilitaryAdvanced Training Center for Soldier Amputees at Walter Reed Army 

Medical Center, and

	 •	 providing rehabilitation services.

Passive Intervention Strategies

Over the past few decades, there has been increased 

emphasis on environmental and engineering-based 

injury prevention interventions and a reduced emphasis on interventions directed at changing individual 

behavior. Focusing on external solutions rather than 

on personal actions in injury prevention has had a 

twofold advantage. First, physicians and other healthcare personnel who may have been discouraged in 

their attempts to influence the behavior of individuals 

have found other ways to address injury prevention 

in their practices. Second, researchers have discovered 

other opportunities for preventing injury, even when 

the injury-producing activity itself cannot be averted.

Passive strategies generally use engineering and 

biophysical modifications to vehicles, equipment, or 

the environment. They may also apply to clothing 

and other equipment, if the garments are treated to 

provide sun protection or to protect the wearer from 

hot surfaces, burns, and insects. The principal advantage to passive strategies is that they often prevent 

injury, regardless of human behavior, and they can be 

very cost effective. Because passive interventions are 

engineered into the environment, they usually provide 

their benefits without having to rely on the memory, 

training, skill, sobriety, or mental state of the individuals being protected. The problem of blaming the victim 

can also be avoided. 

Active Intervention Strategies

Although all active strategies require an individual 

to consciously make a behavior choice, the approaches 

available to achieve this are varied and largely determined by the particular philosophical and methodological inclinations of the injury prevention specialist 

designing the intervention. Much research has been devoted to understanding and predicting health behavior 

choices. If one examines the behavior of individuals 

within large populations, one will observe substantial 

differences in the types of health behaviors in which 

those individuals engage. There are many reasons why 

these differences exist and, as a result, many different 

ways one might attempt studying these variations 

and, ultimately, modifying relevant behaviors. Some 

of these approaches to understanding differences in 

health behaviors focus on factors extrinsic to the individual, and some approaches focus on factors intrinsic 

to the individual.154

Extrinsic factors that affect health behaviors include 

environmental regulations and legal restrictions. In a 

military setting, examples may be found on individual 

military installations, where rewards are conferred on 

units with the highest fitness scores, completion of a 

year without an injury fatality, or in the provision of 

easy access to healthcare. Legal restrictions are laws 

and regulations that ban dangerous substances or punish individuals for engaging in undesirable behavior 

(eg, not using safety belts, not wearing helmets). Thus, 

power to leverage behavior change is generally in the 

form of social or economic sanctions and incentives. 

For example, although it may happen rarely, service 

members who allow themselves to get sunburned may 

be punished under Article 15 of the Uniform Code of 

Military Justice. Sailors ordered not to consume alcohol 

the night before deployment could be subjected to a 

Breathalyzer test and face punishment if found to be 

noncompliant. 

As previously mentioned, there are certain features 

of the military environment that make passive intervention strategies easier to implement than they might 

be in civilian settings. The military command structure 

and nature of the military’s top-down decision-making 

processes make it easier to adopt changes quickly and 

uniformly. Communication systems make it easy to 

disseminate information fairly rapidly to all units and 

personnel. Although it may seem that having these 

features in place may make it easier to implement an 

injury prevention program, it is important to remember 

that nothing can happen without command support 

and explicit agreements by individuals at all levels 

of the command structure to enforce standards and 

regulations once they are implemented. In light of this, 

proposed intervention strategies should be appropriate to the nature of military occupational setting and 

requirements, and must be acceptable to the military’s 

unique social and cultural environment. Finally, it is 

important to remember that, in designing and promoting injury prevention programs, all parties at all levels 

of command need to be briefed on the need for and the 

rationale for the intervention. Getting all parties to buy 

into the intervention is important to make sure that it 

is fully and appropriately implemented. 

Interventions that modify extrinsic factors arise 

primarily from deterrence theory. Deterrence theory 

suggests that these extrinsic factors may effectively 

deter one from engaging in unsafe behaviors (or as a 

corollary, encourage one to engage in safe behaviors) if 

the following holds true: (a) the individual believes that 

he/she has a high probability of getting caught if he/

she fails to engage in the desired behavior; (b) the person will, once caught, have a high probability of being 
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convicted; (c) the time between being caught and being 

convicted is short; and (d) the punishment following 

conviction is severe. These elements are sometimes 

abbreviated as “swift, severe, and certain.”155

Deterrence strategies essentially coerce behavior 

change through the leverage of power.156 The strategies 

may be either proscriptive or prescriptive. Proscriptive 

approaches include rules, laws, regulations, and incentives designed to discourage the adoption of unsafe 

behaviors (eg, fines for speeding, docking of pay for 

unsafe behavior). For example, the military’s policy of 

performing routine urine screening for certain illicit 

drugs is widely credited for the decrease in drug abuse 

among service members since the early 1980s. Prescriptive strategies also leverage power; but, instead 

of discouraging unsafe behavior, these approaches 

encourage the adoption of safe behaviors. These strategies include safety belt regulations, helmet rules, and 

pilot safety checklists to be completed before takeoff. 

There are some problems that may arise when using deterrence approaches to control injuries. First, 

deterrence strategies assume that individuals engage 

in a process of rationally weighing the costs and 

benefits of an action before proceeding. In reality, 

behavior choices are influenced by other factors as 

well, such as the psychological and social status of 

the individual. The use of alcohol or drugs may also 

affect decision-making ability. To be completely effective, this approach also requires that an individual be 

capable of performing the desired behavior 100% of 

the time. Overdeterrence may also be a problem. It is 

possible to create a great enough deterrence effect that 

the person overcompensates.157 For example, it is wise 

for a soldier in a battle situation, or a pilot in flight, to 

proceed with great caution to avoid serious trouble. 

However, if these individuals are too cautious in using 

life-preserving efforts, vital missions may never be accomplished. Some element of risk-taking is necessary. 

Deterrence approaches are somewhat retrospective, in 

that for deterrence to work, an individual must first 

engage in the behavior; individuals are punished after 

the behavior has already hurt them. Finally, the ability to enforce policies consistently in a manner that 

is “swift, severe, and certain” is often hampered by 

limited resources and by the discretionary behavior of 

those called to the task of enforcement.158,159 Also, the 

development of laws and regulations occurs through a 

level of command that may be influenced as much by 

concerns over broad military objectives as by reductions in key risky behaviors.160 The need to achieve 

military objectives may necessarily trump concerns 

about individual risk-taking and safety that might 

impact or impede pursuit of those objectives. 

Intrinsic factors affecting behavior choices include 

demographic characteristics (eg, gender, age, and race), 

personality traits, social support, social networks, and 

cognition. Behavioral theories have arisen out of each 

of these intrinsic factors. However, because most of 

these elements are intractable (ie, one cannot change 

a person’s gender or age), it seems most prudent to 

focus on cognition as a predictor and motivator of 

health behavior choices. In addition, cognition is important in predicting how an individual will react to 

extrinsic factors.

Cognition is the thought processes that occur between experiencing a stimulus and making a behavior 

choice in various situations.154 It is how individuals 

make sense of the world in a specific situation and 

with the information they possess (including beliefs, 

attitudes, and knowledge the individual maintains 

about a particular health behavior). 

Several models, all broadly described as socialcognitive, have been developed to assist in understanding and predicting health behavior choices. 

Each model holds certain assumptions about human 

nature. Intervention strategies are derived from the 

particular model believed to be valid or useful in 

predicting a particular health behavior decision. Like 

deterrence theory, social-cognitive models assume a 

person will engage in a process in which he/she rationally weighs costs and benefits of a behavior and then 

makes a choice. Instead of focusing on the nature of 

those costs and benefits, however (as with deterrence 

models), social-cognitive models focus on how people 

interpret costs and benefits, how they perceive their 

environment, and then use that information to make 

health-related behavior choices. Interventions are then 

derived from these models. Once a behavior is understood, efforts can be made to alter the perceived cost 

or benefit of an action to change behavior.

Although there are many social-cognitive models, 

a few of the more common models are particularly 

salient to this discussion and worth a quick review. 

These include the health belief model, health locus of 

control, social learning theory, the theory of reasoned 

action, stage models, and the social contagion model. 

The Health Belief Model 

This is one of the oldest of the social-cognitive models, and it has been moderately useful in predicting 

actual health behaviors. This model focuses on how 

perceptions of a threat to one’s well-being influence 

beliefs and behaviors that are associated with that 

threat. This model suggests that, to motivate an individual to change risky behavior, the person must first 

believe that engaging in a certain behavior makes it 

likely that he/she will experience an injury and that the 
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injury must be viewed as serious. Behavior alternatives 

are selected on the basis of the person’s awareness of 

behavior options, beliefs about the efficacy of those 

alternative behaviors, and perceptions about the costs 

(or barriers) of engaging in the new behavior.161 Cues 

to action, such as education efforts that suggest new 

behavior choices, are also often included in this model.

Examples of injury prevention efforts that are 

derived from this model include programs designed 

to modify risk perceptions (eg, education about the 

importance of helmets while parachuting and posters 

that remind sailors of the risks involved in drinking 

before or during scuba diving). Such programs may 

also attempt to change perceptions about the benefits 

of adopting a new health behavior, reduce barriers to 

changing behaviors, and provide cues to action (eg, a 

pilot’s preflight checklist). Thus, most efforts designed 

to provide military personnel with additional information (educational campaigns) come from the health 

belief model. 

When healthcare practitioners endeavor to prevent 

or reduce injuries, it often seems that the first intervention plan they develop involves educating those at 

risk. Even though there are some situations in which 

education is useful in preventing injuries, there are 

some significant limitations to this approach. First, 

some key cognitive variables that have been found to 

be very useful in predicting health behavior decisionmaking are missing. Social and peer pressures are not 

taken into account (except as a modifier of perceived 

risk of injury). Peer groups may have an enormous 

influence on risk-taking, particularly in certain settings. Self-efficacy, or beliefs about how much control 

one has over a behavior, is not included in the health 

belief model or in general education campaigns. In 

injury prevention terms, this might mean that a person believes injuries are the result of random events 

and not something to be controlled or avoided. He or 

she may believe that seat belts are uncomfortable or 

that they even increase risk; thus, the person may be 

unwilling to buckle up. When the risky behavior in 

question includes use of alcohol or drugs, there may 

be a physical inability to control the behavior without 

some form of medical intervention. 

Health Locus of Control

Related to self-efficacy is the concept of locus of 

control. Health locus of control is an important axiom 

in the entire health promotion field. In essence, it 

describes an individual’s sense about how much the 

person controls or influences his/her own health 

and well-being. There are three possible beliefs that 

individuals can have about control over their own 

health: (1) internal control, (2) external control with 

a belief in powerful others, and (3) external control 

with a belief in fate. Internal control means that individuals believe they are in control of their health and 

can affect their health status through their behavior 

choices. Those who subscribe to external control with 

a belief in powerful others believe they have little 

control over their health status, but believe that others 

(eg, their spouse, doctors, or nurses) can affect their 

health. External control with a belief in fate means 

that these individuals believe they have little control 

over their health status and that injuries and illnesses 

are a result of fate or acts of a deity.162 The association between individuals’ sense of control over their 

health is strengthened when the relative value they 

place on their health is also included.106 Interventions 

deriving from the health locus of control arena strive 

to increase perceptions individuals hold about their 

control over their health and well-being. For example, 

fitness programs may be enhanced when individuals 

are also counseled about the effectiveness of this effort in achieving overall good health. A program that 

documents improvement in health (eg, reduced blood 

pressure, lower weight, better lung capacity, less foot 

pain or low back pain) also may facilitate a sense of 

control over health and well-being. An individual with 

a belief in external powers may be encouraged to adopt 

safer behaviors if a respected person (eg, physician, 

commander) suggests it.

Social Learning Theory

Many commonly used social-cognitive models 

are based or draw on key components from Albert 

Bandura’s social learning theory.163 Social learning 

theory suggests that a person’s perception of control 

(self-efficacy) and environmental controls and incentives interact to affect the adoption of health behaviors. 

A person is most likely to engage in safe behaviors if 

that person thinks choosing the safe behavior (over an 

unsafe action) will result in positive reinforcement (eg, 

better health, positive feedback from important others, 

such as friends and family) and if that reinforcement 

has value to the individual. The theory of reasoned 

action, which is discussed in the next section, is closely 

related to this model. 

The Theory of Reasoned Action

This model focuses on an individual’s attitudes 

about a particular safe (or unsafe) behavior, as well as 

the social context in which the individual engages in 

the behavior. Like the social learning theory, this model 

recognizes that peer and social groups are important 
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Injury Control

elements in making behavior choices. This model also 

focuses on intentions to behave in a given manner (ie, 

is the person motivated to adopt the safe behavior or 

does the person have a conscious plan in place to determine behavior?). Attitudes about safe behavior are 

also important (eg, does the individual enjoy exercising and maintaining physical fitness?) and affect the 

likelihood of actually performing the behavior, because 

these attitudes directly affect intention to behave. Attitudes are developed not just from thinking about the 

relative enjoyment (or costs) of a behavior, but also 

from subjective norms (eg, what will people think of 

me if I wear safety goggles and protective gear?) and 

how much one values the opinions of others. 

Interventions that incorporate tenets from social 

learning theory and the theory of reasoned action 

focus on peer groups and norms. Examples in the 

civilian world include the “Friends Don’t Let Friends 

Drive Drunk” media campaign. The military environment is perhaps particularly well suited for development of these types of interventions because much 

emphasis is placed on teamwork, camaraderie, and 

caring for one another. Examples include having a 

buddy check camouflage before a maneuver, restricting privileges for an entire group if one member 

does not comply with a safety rule, or giving the 

entire unit a 4-day pass if there are no motor-vehicle–

related injuries in a set period of time. Although no 

one in a unit would admit to valuing a 4-day pass 

more than life, awareness of motor vehicle safety is 

heightened as the end of the time period nears, and 

thus the likelihood of obtaining the award becomes 

a powerful motivator. 

Stage Models

Stage models suggest that different cognitive stages 

or thought processes are important at different stages 

in the development of a health behavior. One of the 

best-known stage models, the transtheoretical model of 

change, was developed by Prochaska and DiClemente 

to understand and predict addictive behaviors.164–167

The model has now been widely applied to other 

health behaviors, including some injury-associated 

risk-taking behaviors (eg, alcohol use, smoking, and 

exercise). In this model, individuals are seen progressing through a series of stages on their way to adopting 

a new, desirable health-related behavior. 

There are six stages of change in this model: (1) 

precontemplative stage, (2) contemplative stage, (3) 

preparation stage, (4) action stage, (5) maintenance 

stage, and (6) relapse stage. In the precontemplative stage, the individual is unaware that an existing 

behavior is risky. In the contemplative stage, the individual becomes aware of the risks related to his or 

her behavior. At the preparation stage, the individual 

begins preparing to change the risky behavior. The 

action stage is when the person begins putting intentions to change into action. In the maintenance stage, 

he/she establishes and supports the continuance of 

this new behavior. A relapse stage often occurs when a 

person reverts back to the old unsafe behavior and then 

must cycle through some or all of the stages again to 

reacquire the new safe behavior. Decisional balance is 

a key component of stage models. Intervention efforts, 

developed around an individual’s stage of readiness to 

change behavior, are designed to help tip the balance 

toward moving on to the next stage.

It is important to ascertain an individual’s or a community’s level of readiness to design an appropriate 

intervention. Individuals or communities in precontemplative stages require interventions that focus 

on making them aware of the risks of their current 

behaviors and supporting thoughts about the desirability and feasibility of a new, alternative healthy behavior. Individuals and communities that are moving 

toward the preparation and action phases do not need 

educational campaigns telling them of the dangers of 

their current behavior. Instead, they need assistance in 

developing a plan for changing their behavior. Those 

who have already adopted a new, safe behavior (in 

the action/maintenance phases) require intervention 

efforts that support their efforts and provide feedback 

on how well they are doing in achieving their expected 

goals (Exhibit 12-4). 

The Social Contagion Model

This model is derived from the study of infectious 

diseases. It suggests that behaviors (eg, diseases) may 

be thought of as contagious if an individual is more 

likely to engage in that behavior when a significant 

other has already done so. In many ways, this model 

is similar to social learning theory. However, the model 

also postulates that contagion will cause an increase 

in the prevalence of a behavior as the size of the 

population that engages in that behavior increases. The 

model has been shown to have some use in predicting 

behaviors in teenagers and young adults, such as promiscuity, drug abuse, binge eating, suicide, and driver 

speeding. For example, a driver’s decision to speed is 

only partly predicted by his demographic background, 

attitudes toward speeding (theory of reasoned action), 

beliefs about the consequences of speeding (social 

learning theory and health belief model), and law 

enforcement efforts to enforce speed restrictions (deterrence theory). The remaining variation in speeding 

behavior may be dependent, at least in part, on the 
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

behaviors of drivers around the individual at a given 

point in time (eg, “Yes, officer, but I was just driving 

fast enough to keep up with the rest of the traffic.”).168

Models of health behavior have some utility in 

predicting the choices that individuals make about 

their own safety. However, they are all limited, in that 

they require an individual to be capable of engaging in a particular behavior (ie, they require rational 

thought and the physical and mental abilities to make 

behavior changes). They do not take into account that 

some injuries are caused by other individuals, nor do 

these models acknowledge that humans are simply 

not capable of operating at 100% effectiveness 100% 

of the time (people sometimes make mistakes or are 

in situations that limit behavior choices). Moreover, 

because of tactical conditions, enemy action, and unit 

discipline and practices, soldiers may have limited 

choices to pursue safer behaviors. Human behavior 

is motivated by a multitude of factors, some of which 

are not amenable to change through intervention, or 

at least they are not easily changed (ie, behavior is 

influenced by culture, peers, income, education, etc). 

EXHIBIT 12-4

LESSONS OF HISTORY

It is important to note that health promotion interventions must be periodically evaluated for them to remain effective. This applies to both passive and active interventions, because even passive interventions require active behavior 

change, especially insofar as they require the formulation, implementation, and periodic enforcement of regulations. 

A review and evaluation of a health behavior program may often need to cover the same cognitive ground that was 

traversed when the program was initially designed and put in place, whether the program involves active or passive 

intervention strategies. Failure to periodically review the rationale for injury prevention programs and to reaffirm 

their necessity and importance may lead to noncompliance with safety standards and practices, and could bring 

about resurgence in injury rates. As an example, consider use of the outside-the-boot ankle brace used to reduce ankle 

injuries among Airborne soldiers (described previously). Another example is the recurrence of cold injuries in military 

populations, especially trenchfoot and frostbite, despite a repeated history of outbreaks and subsequent medical and 

command interventions from World War I to Bosnia and Afghanistan. 

The command at Fort Bragg was initially briefed about the high rate of ankle injuries associated with the Army Airborne 

operations. Reviewing this information made commanders aware of the scope of the injury problem associated with 

this particular type of injury. After reviewing the data, the commanders granted permission to a team of researchers to 

pilot-test an ankle brace designed to prevent ankle injuries. Data the researchers gathered demonstrated a significant 

reduction in ankle injuries when the ankle brace was used. This intervention has both an active component (command 

support; parachutists must put braces on) and a passive component (once donned, the braces offer protection independent of any action by the jumper). Ankle braces became routine equipment for students in the Army Airborne School 

at Fort Benning and were made available to all Airborne soldiers in the Army. Several years after the program was 

implemented, however, the Army Airborne community began to question the necessity of the continued costs of the 

program, and also to question the efficacy of the brace, as they began to receive anecdotal reports of proximal injuries 

that may have been related to use of the brace. A new evaluation study was commissioned to reevaluate efficacy of 

the ankle brace as a means of preventing ankle injuries during airborne training and operations. These data resulted 

in renewed support and reimplementation of this intervention.(1)

The effects of health promotion interventions may atrophy over time; this may be especially true in the Army, because 

there is a fairly steady rate of turnover among commanders and key decision-making personnel (eg, medical officers, 

senior noncommissioned officers). Although this may seem dispiriting, because it may feel like relearning the lessons 

of history the hard way, it is important to recognize and be open to new opportunities to identify injury hazards and 

to look for creative ways (some new, others less so) to mitigate them.

Source: (1) Schmidt MD, Sulsky SI, Amoroso PJ. Effectiveness of an outside-boot ankle brace in reducing parachuting related ankle 

injuries. Inj Prev. 2005;11:163-168.

MANAGEMENT OF INJURIES IN THE FIELD AND ACCESS TO CARE 

In this section, we provide a new approach to the 

organization of wartime, battle-related injury prevention. The proposed model incorporates some of the 

unique characteristics of war environments in the 

development of injury control approaches. 

Comprehensive injury prevention programs 

attempt not only to prevent or reduce the severity of 

injuries, but also to provide a plan for management of 
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injuries when they do occur (Figure 12-19). Access to 

care may pose a major barrier to the effective management of injuries in the field. Although the purpose of 

this chapter is not to provide great detail on combat 

casualty care, injury control covers the full spectrum 

of care from prevention to rehabilitation. 

The principal goals of injury management in the 

field should be to stabilize the individual, take steps 

to minimize long-term consequences of the injury, and 

facilitate the rapid return of the individual to as normal 

a level of functioning as possible. Three distinct phases 

in the management of field injuries may be identified: 

(1) short-range or immediate needs, (2) medium-range 

care, and (3) long-range care and rehabilitation. Access 

to care is important at all levels or phases of injury 

management.

Short-Range Management of Injury

Short-range management refers to what happens in 

the time interval immediately after the injury has occurred. During this time, the victim must be stabilized 

and transported to treatment, if necessary. The following 

three components of access to care must be considered 

in planning for short-range field management of injury: 

(1) availability, (2) accessibility, and (3) accommodation. 

Availability

Does the service exist (eg, are MEDEVACs or 

trained medical technicians in the area?)? Does it 

exist in quantities sufficient to meet the demand (eg, 

are there enough UH-60 Black Hawk helicopters to 

pick up all those who are seriously injured in a particular area?)? Injury mortality and injury morbidity 

are related to the types of injuries incurred on the 

battlefield, and the proximity and sophistication of 

available medical care. Experience in past conflicts, 

for example, has shown that putting surgeons and 

surgical facilities at or near the front lines helps reduce injury deaths.169 The widespread deployment 

of Forward Surgical Teams during Operation Iraqi 

Freedom is evidence of this. 

Accessibility 

Can the injured person be readily picked up or can 

the injured person easily reach the treatment center? 

What sort of assistance will he or she require to get 

to the facility? Factors that affect accessibility include 

the terrain or vegetation where the injured person is 

located, the number of noninjured soldiers available 

to assist in evacuation, the presence of enemy fire and 

backup friendly fire, distance to the MEDEVAC crew, 

and distance to the hospital or treatment center. 

Accommodation

Are the resources available for the injured person 

sufficient to meet his or her needs? Factors that influence accommodation include the severity of the injury 

and the presence of co-morbidities or other factors 

that might reduce the ability to stabilize the victim for 

transport. Training factors include training the MEDEVAC crews in how to stabilize the injury, and training 

other soldiers in the unit to assist with treatment of the 

individual. Finally, medical resources must be available to stabilize and treat the injured person (eg, the 

MEDEVAC helicopter must be adequately equipped). 

Fig. 12-19. South Vietnam—medical evacuation patients on 

the deck of the amphibious assault ship USS Tripoli (LPH-10) 

await transfer to the 22nd Casualty Station in Danang from 

which they will be sent to the States. Wounded Marines who 

cannot be returned to duty, or who will require more than 

6 days of hospitalization, are removed from the USS Tripoli

and returned to the States. 

Photograph: Reproduced from the Archival Research Catalog, the National Archives and Records Administration, ARC 

identifier 58511.
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

Medium-Range Management of Injury 

Medium-range management of injuries involves 

medical treatment and short-term rehabilitative efforts to save the injured person’s life, reduce adverse 

sequelae, and improve functioning. The following 

components of access must be considered: availability, 

accessibility, and accommodation.

Availability 

Is there an adequate treatment facility available for 

the injured person, and is it near enough to the site 

of the injury event? Administrators must accurately 

estimate the number of field hospitals needed in a 

particular area and must have alternate plans in place 

to accommodate overflow at other installations. The 

field hospital must have enough beds, surgical rooms, 

and emergency supplies and services. 

Accessibility

Can injured personnel reach the care facility 

quickly? Of prime importance are the proximity of the 

field or shipboard hospital to the battle area, as well as 

the availability of MEDEVAC resources, presence of 

helicopter landing pads or ambulance-accessible roadways, and availability and ability of staff to transport 

and triage patients. The care facility must be located so 

that it is safe from enemy fire and strategically located 

away from flood plains and other potential hazards. 

Injured personnel must ultimately be evacuated from 

the theater. 

Accommodation

Are services sufficient to meet the patients’ needs? 

It is essential for the medical treatment staff to be adequately trained and experienced to handle the specific 

level (ie, severity) of injuries they will encounter, and 

there must be enough staff at the site. The staff must 

have the ability to link up with other facilities and experts. The severity of injuries encountered by soldiers 

in the field influences accommodation, as well as the 

general state of individuals on arrival. Their state on 

arrival depends not only on the severity and type of 

injury they have sustained, but also on their physical 

fitness and health habits (smoking, alcohol use, illness 

history, sleep, and nutritional status) and how well 

they were stabilized and managed in the field and 

during transport.

Long-Range Management of Injury

Long-range management of injury is related to the 

ability to manage and support the longer rehabilitation necessary for treating some types of injuries, and 

to facilitate recovery of function and independence. 

Several elements affect this ability, including adequate 

facilities (staffing and resources) to provide for the 

physical and mental recovery and rehabilitation of 

military personnel. A comprehensive program will also 

include counseling and training for the development of 

new life skills or occupational skills to facilitate return 

to work in some capacity. 

As the nature of modern warfare changes, soldiers 

are finding themselves deployed to a variety of setEXHIBIT 12-5

LONG-TERM CARE NEEDS

Planning and management of long-term care of war-related injuries will depend, in large part, on whether the 

injured soldier is returned to active duty or separated from service. For soldiers who remain in the military, 

changes may need to be made to their duty assignment so that they can continue to succeed in their military career. Soldiers who are separating from service may need different kinds of support, depending on whether they 

suffer a temporary or permanent disability as a result of their injury. Medical advocates need to assist injured 

military personnel in understanding benefits and options available to them, including navigating the administrative complexities of the military and the Department of Veterans Affairs healthcare systems. Follow-up is needed 

to continue monitoring the recovery process and document the progress of reintegration. Latent development of 

physical or mental problems related to injury must also be monitored. Some soldiers may require the assistance 

of a social worker or other counseling services to facilitate their reintegration into a job in the civilian sector. 

Finally, long-range planning should include incentive programs for disabled members of the armed forces to 

adopt a healthy lifestyle, such as programs to promote smoking cessation and to prevent and treat substance 

abuse. Efforts should be made to encourage the maintenance of physical fitness, as well as appropriate nutrition, 

rest, and mental health.
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tings and in a variety of contexts, from extended 

combat situations to short-term humanitarian or 

peacekeeping assignments. An expanded research 

agenda is urgently needed to examine the effects of 

deployment in these different contexts on soldier 

health, to plan for services that can deliver appropriate care to manage the short- and long-term health 

needs of those injured in action, and to design and 

develop appropriate interventions to minimize the 

burden of injury. The achievements and sacrifices 

of individual injured military personnel must never 

be overlooked, and we must continue searching for 

ways to restore their health and protect the health of 

all future deployed forces (Exhibit 12-5). 

SUMMARY 

Injuries are a preventable military health problem. 

Prevention strategies are best developed when the 

full spectrum of injury events (preevent, event, and 

postevent) is considered and when each element of 

the epidemiological triangle is considered (agent, 

host, environment, and vehicle). Using the Haddon 

matrix and Haddon’s 10 strategies will help ensure 

that a comprehensive list of intervention alternatives is developed. Although medical officers are in 

a unique position to prevent injury on an individual, 

case-by-case basis through the provision of care and 

education of patients, and through the training of clinic 

personnel, they may have even greater influence on 

injury prevention through their influence on those 

in command. Medical officers can accomplish this by 

acquiring knowledge of injury patterns, problems, and 

costs, and by applying common sense and the injury 

prevention principles outlined herein. Success depends 

on presentation of viable options at the appropriate 

command level. 

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