CDC Injury Research Agenda

2009-2018

CDC Injury Research Agenda

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Atlanta, Georgia

January 2009

2009-2018
2

The CDC Injury Research Agenda, 2009–2018, is a publication of the 

National Center for Injury Prevention and Control, 

Centers for Disease Control and Prevention, 

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Richard E. Besser, MD

Director (Acting)

Tanja Popovic, MD, PhD

Chief Science Officer

James W. Stephens, PhD

Associate Director for Science

Coordinating Center for Environmental Health and Injury Prevention

Henry Falk, MD, MPH

Director

National Center for Injury Prevention and Control

Ileana Arias, PhD

Director

Robin M. Ikeda, MD, MPH

Associate Director for Science

Division of Injury Response

Richard C. Hunt, MD, FACEP

Director

Vikas Kapil, DO, MPH

Associate Director for Science

Division of Unintentional Injury Prevention

Grant T. Baldwin, PhD, MPH

Director

David A. Sleet, PhD

Associate Director for Science

Michael F. Ballesteros, PhD, MS

Deputy Associate Director for Science 

Division of Violence Prevention

W. Rodney Hammond, PhD

Director

Linda L. Dahlberg, PhD

Associate Director for Science

Thomas R. Simon, PhD

Deputy Associate Director for Science

Tamara M. Haegerich, PhD

Special Assistant to the Associate Director for Science
Contents

Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Cross-Cutting and Emerging Priorities for Injury Research . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Injury Response

Acute Injury Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Unintentional Injury Prevention

Home and Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Sports, Recreation, and Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Violence Prevention

Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Sexual Violence and Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Suicidal Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Youth Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Suggested Citation:

National Center for Injury Prevention and Control. CDC Injury Research Agenda, 2009–2018. 

Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and 

Prevention; 2009. Available at: http://www.cdc.gov/ncipc.
4

Abbreviations and Acronyms

ACIPC Advisory Committee on Injury Prevention and Control

ACL anterior cruciate ligament

BAC blood-alcohol concentration

BRFSS Behavioral Risk Factor Surveillance System

CPS Child Protective Services

CPSC Consumer Product Safety Commission

DALYs disability-adjusted life years

DUI driving under the influence

DVP Division of Violence Prevention

(within CDC’s National Center for Injury Prevention and Control)

ED emergency department

EMS emergency medical services

GDL graduated driver licensing

HIV human immunodeficiency virus

HRSA Health Resources and Services Administration

IOM Institute of Medicine

MCHB Maternal and Child Health Bureau

MV motor vehicle

NHTSA National Highway Traffic Safety Administration

NICHD National Institute for Child Health and Human Development

NIH National Institutes of Health

NIOSH National Institute for Occupational Safety and Health (CDC)

NORA National Occupational Research Agenda

PTSD posttraumatic stress disorder

SCI spinal cord injury

SIDS sudden infant death syndrome

SRE sports, recreation, and exercise

SSNRs safe, stable, and nurturing relationships

TBI traumatic brain injury

USFA U.S. Fire Administration

WISQARS Web-based Injury Statistics Query and Reporting System
5

Foreword

We want people to live to their full potential . Every day at CDC’s National Center 

for Injury Prevention and Control, we face the statistics that reflect how a life full 

of promise can be shortchanged by injury . Unintentional injury is the number one

killer of children and young adults . Approximately 5 million people in the United

States suffer from chronic, injury-related disabilities, and the lives of millions of 

others have been dramatically affected by injuries to themselves or someone they 

love . Although we have made significant progress during recent years to lessen the

public health burden of injury, we see the possibility of doing much more .

At CDC’s Injury Center, we translate science into effective programs and policies 

that prevent unintentional and violence-related injuries and that minimize the 

consequences of injuries when they occur . Research is fundamental to our success

because thorough, accurate data are essential in making sound, smart investments . 

Research provides the knowledge that we need to understand what is possible, 

what is not, and the best way to proceed in our intervention efforts .

This CDC Injury Research Agenda describes our research needs and priorities 

for 2009–2018 . Our initial research agenda was published in 2002 to guide 

research through 2007, and it has been invaluable in directing our research 

efforts . Throughout the past 2 years, we updated and revised the agenda, 

reviewing research accomplishments to date and progress toward achieving the 

goals outlined in the original agenda . In developing this update, we considered 

information and recommendations from the CDC report, Advancing the Nation’s 

Health: A Guide to Public Health Research Needs, 2006–2015, as well as the 

objectives and strategies outlined in action plans associated with CDC’s Health 

Protection Goals (http://www .cdc .gov/osi/goals/goals .html) and Healthy People 

2010 (http://www .healthypeople .gov) .

Investing in the priorities outlined in this research agenda will help prevent 

needless deaths and painful, costly injuries . We know that we can make a 

difference . We look forward to working with the injury prevention and control 

community to implement this agenda for a safer, healthier nation — one in which 

all people can live to their full potential .

Ileana Arias, PhD

Director

National Center for Injury Prevention and Control
6

Introduction

Background

Injuries have a substantial impact on the lives of U .S . residents, their families and 

communities, and society . During 2005, a total of 173,753 injury-related deaths 

occurred, and during 2006, an estimated 29,821,159 persons with nonfatal injuries were 

treated in U .S . hospital emergency departments .1

 The consequences of these injuries 

can be extensive and wide-ranging . They are physical, emotional, and financial, and in 

the case of disabling injuries, the consequences are enduring .

The mission of CDC’s National Center for Injury Prevention and Control (Injury 

Center) is to prevent injuries and violence and reduce their consequences so that people 

can live to their fullest potential . To prevent injuries and minimize their consequences 

when they occur, the Injury Center uses the public health approach (Figure 1), which is 

a systematic process that

■ describes the problem;

■ identifies risk and protective factors;

■ develops and tests prevention interventions and strategies; and

■ ensures widespread adoption of effective interventions and strategies .

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

for addressing all phases of the injury research framework, from foundational research 

through dissemination research, for all major causes of injury among all age groups . 

To reach its goal of translating science into effective programs and policies, the Injury 

Center collaborates with other federal agencies and partners to document the incidence 

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

promote their widespread adoption .

The importance of research in diminishing the problem of injuries has been described 

before . For example, the 1985 Institute of Medicine (IOM) report Injury in America 

concluded that supporting injury research is necessary to substantially reduce injury 

rates .2

 The Injury Center’s formation was, in part, a result of this IOM finding . Fourteen 

years later, another IOM report, Reducing the Burden of Injury, reemphasized the 

importance of a scientific foundation for injury prevention and tasked the Injury 

Center to work with foundations, state and local organizations, businesses, and other 

federal agencies to stimulate and facilitate investment in injury research activities .3

 The 

first Injury Center research agenda published in 20024

 was intended to be applicable 

throughout 2002–2007 . This revised edition outlines Injury Center priorities applicable 

for 2009–2018 .
7

Figure 1. Public health approach to prevention

Step 1. Describing the problem includes not only systematically 

counting cases but also delineating the demographic characteristics of 

the persons involved, the temporal and geographic characteristics of 

the problem, the victim-perpetrator relationship, and the severity and 

cost of the injury. Closely integrated is the timely dissemination of data 

to decision makers and monitoring and tracking trends.

Step 2. The second step considers why injuries occur. It involves 

conducting research to determine the causes and correlates of injury, 

the factors that increase or decrease the risk for injury, and identifying 

the factors that might be modifiable through interventions.

Step 3. Potential strategies for preventing and controlling injuries 

are based on the information collected in Steps 1 and 2, and 

those strategies are tested through intervention research by using 

randomized controlled trials, experimental and control group 

designs, time-series analyses, or observational studies. Efficacy and 

effectiveness research further assesses whether an intervention 

reduces injuries. When programs are developed and modified on the 

basis of such research, the likelihood of having effective prevention 

programs is increased.

Step 4. The final stage of the public health model involves 

dissemination of information that supports prevention and the 

broader implementation and adoption of evidence-based strategies. 

This area also requires research and is an important niche for CDC. 

Studies focus on methods, structures, and processes to encourage 

communities and policymakers to adopt evidence-based programs, 

policies and laws that reduce unintentional injuries and violence, and 

on factors that increase organizational and community capacity for 

tailoring, implementing, and sustaining interventions.

* Figure adapted from Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public 

health policy for preventing violence. Health Aff 1993;12:7–29.
8

Overall Public Health Burden of Injury

In 2005 in the United States, 173,753 persons died from injuries, and approximately 

1 in 10 persons experienced a nonfatal injury serious enough to require a visit to 

a hospital emergency department (ED) . Injuries, including unintentional injuries, 

homicide, and suicide, are the leading cause of death for persons aged 1–44 years 

(Table 1) . Injury is the leading cause of years of potential life lost before age 65 .

Among persons aged 1–34 years, unintentional injuries alone claim more lives 

than any other cause . In 2005, motor vehicle traffic fatalities accounted for 37 .1% 

of unintentional fatal injuries, representing 43,667 deaths (Table 2) . Poisoning, 

suffocation, drowning, falls, and fire each accounted for a substantial proportion 

of unintentional injury deaths . Adverse effects of medical and surgical care and of 

therapeutic use of drugs caused an additional 2,653 fatalities .

The impact of injuries resulting from violence is also substantial . Homicide is the 

second leading cause of death for persons aged 15–24 years and the third and fourth 

leading cause for every other group aged 1–34 years . Suicide is not only the 11th leading 

cause of death across all ages, but it ranks second for persons aged 25–34 years and 

third for those aged 15–24 .

Injuries often do not result in death but nevertheless place a considerable burden on 

the injured person, his or her family, other caregivers, the community, and society . 

Approximately one third of all ED visits and 8% of all hospital stays are the result 

of injuries . Data from the National Electronic Injury Surveillance System All Injury 

Program indicate that in 2006, a total of 7,934,840 unintentional falls occurred, or 

26 .6% of all injury-related ED visits (Table 3) . Another 4,262,553 visits (14 .3%) were 

transportation-related, and 1,670,002 (5 .6%) resulted from assaults .5

The economic consequences of injury are also substantial . The book Incidence and 

Economic Burden of Injuries in the United States describes the lifetime costs associated 

with injuries occurring in a single year .6 In 2000 alone, >50 million injuries required 

medical attention, with an estimated total cost of $406 billion . This total cost includes 

$80 .2 billion in medical care costs and $326 billion in productivity losses, including 

lost wages and benefits and the inability to perform normal household functions .6

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

injuries constitute a major burden on the public’s health .
Table 1. Ten leading causes of death, including unintentional and intentional injury, by age group, all race/ethnicities, both sexes — United States, 2005

AGE GROUP (yrs)

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

Congenital Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Malignant Malignant Heart Heart

anomalies injury injury injury injury injury injury neoplasms neoplasms disease disease

5,552 1,664 1,072 1,343 15,753 13,997 16,919 50,405 99,240 530,926 652,091

1

Short Congenital Malignant Malignant Homicide Suicide Malignant Heart Heart Malignant Malignant

gestation anomalies neoplasms neoplasms 5,466 4,990 neoplasms disease disease neoplasms neoplasms

4,714 522 485 515 14,566 38,103 65,208 388,322 559,312

2

SIDS Malignant Congenital Suicide Suicide Homicide Heart Unintentional Chronic lower Cerebro- Cerebro2,230 neoplasms anomalies 270 4,212 4,752 disease injury respiratory vascular vascular

377 196 12,688 18,339 disease 123,881 143,579

3 12,747

Maternal Homicide Homicide Homicide Malignant Malignant Suicide Liver Diabetes Chronic lower Chronic lower 

pregnancy 375 121 220 neoplasms neoplasms 6,550 disease mellitus respiratory respiratory 

complication 1,717 3,601 7,517 11,301 disease disease

4 1,776 112,716 130,933

Placenta Heart Heart Congenital Heart Heart HIV Suicide Unintentional Alzheimer Unintentional

cord disease disease anomalies disease disease 4,363 6,991 injury disease injury

membranes 151 106 200 1,119 3,249 10,853 70,858 117,809

5 1,110

Unintentional Influenza and Cerebro- Heart Congenital HIV Homicide Cerebro- Cerebro- Influenza and Diabetes

injury pneumonia vascular disease anomalies 1,318 3,109 vascular vascular pneumonia mellitus

1,083 110 52 146 504 6,381 10,028 55,453 75,119

6

Respiratory Septicemia Influenza and Chronic lower Diabetes Diabetes Liver Diabetes Liver Diabetes Alzheimer

distress 85 pneumonia respiratory mellitus mellitus disease mellitus disease mellitus disease

860 51 disease 202 617 2,688 5,691 7,126 55,222 71,599

7 55

Bacterial Cerebro- Chronic lower Influenza and Cerebro- Cerebro- Cerebro- HIV Suicide Unintentional Influenza and

sepsis vascular respiratory pneumonia vascular vascular vascular 4,516 4,210 injury pneumonia

834 62 disease 55 196 546 2,260 36,729 63,001

8 49

Neonatal Perinatal Benign Septicemia Complicated Congenital Diabetes Chronic lower Nephritis Nephritis Nephritis

hemorrhage period neoplasms 45 pregnancy anomalies mellitus respiratory 4,141 36,416 43,901

665 58 40 183 436 2,045 disease

9 3,977

Necrotizing Chronic lower Septicemia Cerebro- Influenza and Influenza and Influenza and Viral Septicemia Septicemia Septicemia

enterocolitis respiratory 36 vascular pneumonia pneumonia pneumonia hepatitis 3,912 26,243 34,136

546 disease 43 172 354 934 2,314 10 56

HIV: human immunodeficiency virus; SIDS: sudden infant death syndrome. Produced by the Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC. Data Sources: National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed July 30, 2008; and National Center for Health Statistics, National Vital Statistics System.
10

Table 2. Unintentional injury deaths, all ages, all race/ethnicities, both sexes — 

United States, 2005

Cause of death No. %

Motor vehicle traffic 43,667 37.07

Poisoning 23,618 20.05

Falls 19,656 16.68

Suffocation 5,900 5.01

Fires and burns 3,299 2.80

Drownings 3,582 3.04

Natural disasters, animals, and environmental 2,462 2.09

exposures

Pedestrian 1,157 0.98

Struck by or against a person or object 880 0.75

Machinery 755 0.64

Firearms 789 0.67

Pedal cyclist 227 0.19

Cut or pierced by sharp object 90 0.08

Overexertion 11 0.01

Other transportation* 2,666 2.26

Other and unspecified causes† 9,050 7.68

Total deaths 117,809 100.0

* The number and percentage of other transportation deaths includes the following subcategories combined:

other land transport and other transport.

†

 The number and percentage of other and unspecified causes of death includes the following 

subcategories combined: unspecified; other specified, classifiable; and other specified, not elsewhere 

classifiable. Produced by the Office of Statistics and Programming, National Center for Injury Prevention 

and Control, CDC. 

Data Source: National Center for Health Statistics, Vital Statistics System.
11

Table 3. Leading causes of nonfatal injuries treated in hospital emergency departments, 

all ages, all race/ethnicities, both sexes — United States, 2006

Mechanism No. % Rate*

Total 29,821,159 100.0 10,003.39

Unintentional injuries 27,671,499 92.8 9,282.58

Falls 7,934,840 26.6 2,647.23

Struck by or against a person or object 4,663,517 15.6 1,579.87

Overexertion 3,474,597 11.7 1,167.85

Transportation† 4,262,553 14.3 1,426.90

Cut or pierced by a sharp object 2,215,211 7.4 742.33

Bite or sting other than a dog bite 1,095,521 3.7 369.41

Poisoning 703,702 2.4 233.83

Foreign body 621,433 2.1 209.50

Fires and burns 417,540 1.4 140.03

Dog bites 306,273 1.0 103.84

Machinery 278,676 0.9 92.01

Assault 1,670,002 5.6 559.82

Sexual assault 71,296 0.2 24.23

Struck by or against a person or object 1,310,697 4.4 439.49

Cut or pierced by a sharp object 113,970 0.4 38.10

Bite or sting other than a dog bite 50,586 0.2 16.85

Firearms 52,748 0.2 17.40

Self-harm 395,276 1.3 132.63

Poisonings 216,358 0.7 72.65

Cut or pierced by a sharp object 77,058 0.3 25.82

Legal intervention§ 84,383 0.3 28.36

* Per 100,000 population

†

 The number, percentage, and rate of transportation-related injuries includes the following subcategories

 combined: motor vechicle occupant, motorcyclist, pedal cyclist, pedestrian, and other transportation.

§

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

 Produced by the office of Statistics and Programming, National Center for Injury Prevention and Control, CDC. 

Data Source: National Electronic Injury Surveillance System (NEISS), U.S. Consumer Product Safety Commission. 

 Available at http://www.cpsc.gov/cpscpub/pubs/3002.html. Accessed July 30, 2008.
12

The Injury Center Research Agenda’s Scope

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

to minimize the consequences of injuries when they occur . Its public health approach 

draws on such sciences as epidemiology and other biomedical sciences, biomechanics 

and other engineering sciences, social and behavioral sciences, and economics in the 

following broad topic areas:

■ acute injury care;

■ child maltreatment;

■ home- and community-related injuries;

■ sexual and intimate partner violence;

■ sports-, recreation-, and exercise-related injuries;

■ suicidal behavior;

■ traumatic brain injury;

■ transportation-related injuries; and

■ youth violence .

Research regarding occupational injury, an important part of the injury field, is 

addressed by CDC’s National Institute for Occupational Safety and Health (NIOSH) . 

NIOSH and its partners established the National Occupational Research Agenda 

(NORA) to address work-related injury and death .7

 However, research conducted in 

occupational settings that has implications for nonoccupational injury prevention and 

control is also within the scope of the Injury Center research agenda .

Agenda Development Process

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

external constituents to participate in developing the original 2002 research agenda .4

For this revision, Injury Center staff first reviewed research accomplishments to date 

and progress toward achieving the goals outlined in the original agenda . Findings 

and recommendations from recent Injury Center research portfolio reviews were also 

examined . These portfolio reviews were conducted by external panels and focused 

on four specific topic areas — youth violence (conducted during 2005), falls among 

older persons (2006), traumatic brain injury (2007), and biomechanics (2007) . Also 

considered were the CDC health protection goals (available at http://www .cdc .gov/

about/goals .htm), the CDC Research Guide,

8

 and Healthy People 2010 objectives .9 On the 

basis of these activities, a relatively modest revision of the original agenda was proposed 

as the most appropriate approach . This decision was supported by senior Injury Center 

leaders and the Advisory Committee for Injury Prevention and Control (ACIPC) .

Injury Center subject matter experts drafted initial materials and shared them with 

ACIPC members for their review and comment . Additional external input was 

solicited from selected federal partners and nonfederal injury prevention researchers, 

practitioners, and organizations .
13

Research Phases

To organize the body of potential research regarding injury prevention and control 

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

that extends from work by Mercy et al . (Figure 1) .10 This approach demonstrates the 

research continuum, from basic and descriptive research to intervention development 

and testing, to dissemination and implementation research . The research priorities in 

the chapters that follow address all of these phases .

The social-ecological model was also used to frame discussion and organization of the 

research ideas . Multiple chapters in this agenda use this model to facilitate understanding 

of the multifaceted nature of injury and violence . First introduced in the late 1970s for the 

study of child abuse11,12 and subsequently used in other fields of research,13–18 including 

unintentional injuries,19–22 the social-ecological model is still being developed and 

refined as a conceptual tool . Its strength is that it helps to distinguish between the myriad 

influences on injury and violence while providing a framework for understanding how 

they interact (Figure 2) .
14

Figure 2. Social-ecological model

The model assists in examining factors that increase or decrease the risk 

for violence or injury or recovery from trauma by dividing them into the 

following four levels:

■ Individual. The first level identifies biologic and personal history factors that 

influence how persons behave and their likelihood of becoming a victim of injury, 

or in the case of violence, becoming either a victim or a perpetrator of violence. 

Examples of factors that can be measured include demographic characteristics (e.g., 

age, education, and income), attitudes and beliefs, alcohol impairment or other 

substance abuse, and a history of behaving aggressively or experiencing abuse.

■ Relationship. The second level examines such close relationships as those with 

family, friends, intimate partners, and peers, and explores how these relationships 

increase the risk for injury or for being a victim or perpetrator of violence. For 

example, being exposed to friends who engage in violence can increase a young 

person’s risk for being a victim or perpetrator of violence. Similarly, inadequate 

supervision (e.g., by parent, caregiver, or other significant adult) can increase the 

risk for injuries and violence during both childhood and adolescence (e.g., children 

riding in a car with someone who has been drinking).

■ Community. The third level explores the community context in which social 

relationships occur (e.g., schools, workplaces, other institutions, or neighborhoods) 

and seeks to identify the characteristics of settings that increase the risk for violence 

or injury. Risk at this level might be influenced by such factors as population density, 

crowded housing, levels of employment, the existence of a local drug trade, or 

inadequate designs of environmental spaces for work, travel, or leisure.

■ Societal. The fourth level examines the broad societal factors that help create a 

climate in which injury and violence is encouraged or inhibited. These include 

absent, weak, or insufficiently enforced laws and regulations; social and cultural 

norms; and the health, economic, education, and social policies that help to 

maintain economic or social inequality between groups in society.

SOCIETAL COMMUNITY RELATIONSHIP INDIVIDUAL
15

The overlapping rings in the model illustrate how factors at each level are strengthened 

or modified by factors at another . Besides helping to clarify the causes of injury and 

violence and their complex interactions, the social-ecological model also illustrates that 

to prevent injury and violence, acting across multiple levels simultaneously is mandatory . 

This multilevel action includes

■ addressing individual risk factors and taking steps to modify them;

■ influencing close personal relationships and working to create healthy and safe 

family environments as well as providing professional help and support for 

disadvantaged families;

■ monitoring such community factors and places as schools, workplaces, other 

institutions, and neighborhoods, and taking steps to mitigate problems that can 

lead to injuries or violence; and

■ addressing the larger legal, cultural, social, and economic factors that contribute to 

violence and injury and taking steps to change them, including measures to close 

the gap between rich and poor and to ensure equitable access to goods, services, 

and opportunities .

Developing and Categorizing the Research Priorities

This agenda defines a research priority as a critical injury problem that can be 

meaningfully addressed with a modest number of research studies (approximately 10 

to 20) and that can include related research questions . Box 1 provides an example of 

a research priority related to preventing injuries in the home and community .

Box 1. Example of topic, priority, and research questions

Topic

Preventing injuries at home and in the community.

Priority

Evaluate strategies for widespread dissemination and implementation of 

effective interventions to reduce injuries at home and in the community.

Research Questions

1. What are the barriers to disseminating effective home injury prevention 

programs among indigent urban populations?

2. How can effective community smoke alarm installation programs be 

extended inexpensively to broader populations?
16

Three specific criteria guided the selection of Injury Center research priorities — 

institutional mission, public health burden, and research opportunity (Box 2) . 

Ultimately, the research priorities must match the Injury Center’s mission of reducing the 

incidence, severity, and adverse outcomes of injury through application of public health 

methods . Thus, research that applies directly to public health practice receives primary 

emphasis . Consideration of the public health burden ensures inclusion of research 

related to the major types and causes of injuries . An emphasis on research opportunity 

encourages further focus on risk and protective factors and interventions associated with 

a substantial, preventable fraction as well as on interventions that might be ready for 

widespread dissemination .

Box 2. Criteria for Injury Center research priorities

Mission (Supersedes all other criteria)

■ Congruent with CDC’s priorities and mission (e.g., an emphasis on 

applying research findings and wide-ranging methods).

■ Congruent with Injury Center’s mission and objectives.

■ Congruent with programmatic scope to advance specialization and 

avoid duplication of effort in practice settings.

■ Opportunity for leadership and coordination in practice settings.

■ Interest and demand from practitioners, policymakers, and the public.

Public Health Burden

■ Absolute number of persons affected by mortality and hospitalization, 

economic and social costs, disability and quality of life, and effect duration.

■ Equity or social justice (i.e., addresses the needs of vulnerable populations).

Research Opportunity

■ Portion of the injury problem that will likely be reduced (i.e., 

preventable fraction).

■ Likelihood that the research will lead to widespread adoption 

of an effective intervention within a limited period.

■ Opportunity for innovation and broad application 

(i.e., cross-cutting knowledge).

■ Availability of rigorous methods for effective and ethical research.

■ Accessible populations (e.g., managed care).

■ Responsiveness to emerging concerns.
17

The research priorities in this agenda were identified as the most critical priorities 

(i .e ., those that warrant the greatest attention and intramural and extramural 

resources from the Injury Center during the next 10 years) . Given the finite resources 

for conducting research, the research priorities listed in each chapter have been 

categorized into two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin . Rather, the tiers 

reflect the logical progression of research along the continuum from basic research 

to implementation of those interventions and prevention strategies that have been 

demonstrated to be effective . Moreover, for all priorities, special attention should be 

paid to vulnerable populations who experience disparate, elevated risks (e .g ., racial/

ethnic minorities, persons with disabilities, the youngest and oldest groups, recent 

immigrants and refugees, and rural residents) .

Injury Center staff also identified research priorities that span topics, as well as 

emerging areas for consideration . These cross-cutting and emerging research 

priorities are described in the Cross-Cutting Priorities chapter .
18

References

 1. National Center for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System. US Department of Health and Human Services, CDC; 

2008. Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed July 30, 2008.

 2. Institute of Medicine. Injury in America: A Continuing Public Health Problem. 

Washington, DC: National Academies Press; 1985.

3. Institute of Medicine. Reducing the Burden of Injury: Advancing Prevention and 

Treatment. Washington, DC: National Academies Press; 1999.

 4. National Center for Injury Prevention and Control. CDC Injury Research Agenda, 

2002. Atlanta, GA: US Department of Health and Human Services, CDC; 2002. 

Available at: http://www.cdc.gov/ncipc/pub-res/research_agenda/agenda.htm.

Accessed July 30, 2008.

 5. US Consumer Product Safety Commission (CPSC). National Electronic Injury 

Surveillance System. Bethesda, MD: CPSC; 2007. CPSC document no. 3002. Available 

at: http://www.cpsc.gov/cpscpub/pubs/3002.html. Accessed July 30, 2008.

 6. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in 

the United States. New York: Oxford University Press; 2006.

 7. National Institute for Occupational Safety and Health. National Occupational 

Research Agenda. Atlanta, GA: US Department of Health and Human Service, CDC; 

2007. Available at: http://www.cdc.gov/niosh/nora. Accessed July 30, 2008.

 8. CDC. Advancing the Nation’s Health: A Guide to Public Health Research Needs, 

2006–2015. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. 

Available at: http://www.cdc.gov/od/science/PHResearch/cdcra

AdvancingTheNationsHealth.pdf. Accessed July 30, 2008.

 9. US Department of Health and Human Services. Healthy People 2010 

(conference ed. In 2 vols). Washington, DC: US Department of Health and Human 

Services; 2000. Available at: http://www.healthypeople.gov/Publications/. 

Accessed July 30, 2008.

10. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for 

preventing violence. Health Aff 1993;12:7–29.

11. Garbarino J, Crouter A. Defining the community context for parent-child relations: 

the correlates of child maltreatment. Child Dev 1978;49:604–16.

12. Bronfenbrenner U. Ecology of Human Development: Experiments by Nature and 

Design. Cambridge, MA, Harvard University Press; 1979.

13. Garbarino J. Adolescent Development: An Ecological Perspective. Columbus, OH: 

Merrill Publishing Co.; 1985.
19

14. Tolan P, Guerra N. What Works in Reducing Adolescent Violence: An Empirical 

Review of the Field. Boulder, CO: University of Colorado, Center for the Study and 

Prevention of Violence; 1994. Center paper no. 001. Available at: 

http://www.colorado.edu/cspv/publications/papers/pdf/CSPV-001.pdf. Accessed 

July 30, 2008.

15. Heise LL. Violence against women: an integrated ecological framework. Violence 

Against Women 1998;4:262–90.

16. Schiamberg LB, Gans D. Ecological framework for contextual risk factors in elder 

abuse by adult children. J Elder Abuse Negl 1999;11:79–103.

17. Carp FM. Elder Abuse in the Family: An Interdisciplinary Model for Research. New 

York: Springer; 1999.

18. Dahlberg LL, Krug EG. Violence—a global public health problem. In: Krug EG, 

Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. 

Geneva: World Health Organization; 2002: 1–21. Available at: 

http://www.who.int/violence_injury_prevention/violence/world_report/en/. 

Accessed July 30, 2008.

19. Runyan CW, Casteel C, eds. State of Home Safety in AmericaTM: Facts About 

Unintentional Injuries in the Home. 2nd ed. Chapel Hill, NC: Home Safety Council; 

2004. Available at: http://www.homesafetycouncil.org/

state_of_home_safety/sohs_2004_p017.pdf. Accessed July 30, 2008.

20. CDC. Nonfatal sports- and recreation-related injuries treated in emergency 

departments—United States, July 2000–June 2001. MMWR Morb Mortal Wkly Rep 

2002;51:736–40.

21. Dellinger AM, Sleet DA, Shults RA, Rinehart CF. Interventions to prevent motor 

vehicle injuries. In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury 

and Violence Prevention. New York: Springer; 2007: 55–79.

22. Peden M, Scurfield R, Sleet D, et al., eds. World Report on Road Traffic Injury 

Prevention. Geneva, Switzerland: World Health Organization; 2004. Available at: 

http://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/en/.

Accessed July 30, 2008.
20

Cross-Cutting and 

Emerging Priorities

for Injury Research

Background

This research agenda presents priorities in topic-specific chapters . However, certain 

injury-related concerns are relevant to multiple topics . The breadth of the Injury 

Center’s research and its place within the broader public health field offer tremendous 

opportunities for investigating these cross-cutting challenges . Including these priorities 

enhances the applicability of the research results and increases the opportunities for 

independent and joint funding from multiple sponsors .

Cross-Cutting Priorities

A. Prevent injury and violence globally. Injuries and violence are a threat to all 

persons worldwide . Approximately 5 million persons throughout the world 

die each year from injuries and violence, with the rates of death highest among 

low- to middle-income countries .

1

 Such countries often do not have the 

infrastructure or capacity to effectively address injury prevention . Global injury 

and violence prevention priorities include identifying the causes, consequences, 

and costs of unintentional injuries and violence, as well as assessing the efficacy, 

effectiveness, and economic efficiency of interventions to prevent injuries and 

mitigate consequences .

2

 Other critical research concerns include determining 

the association among diverse aspects of globalization (e .g ., economic, 

environmental, and cultural factors) and violence and injury; identifying risk 

and protective factors common to different population groups, cultures, and 

settings; developing primary and secondary prevention approaches that affect all 

populations in different settings; focusing on developing countries; and evaluating 

diverse international public health programs created to prevent injuries, improve 

injury care, and reduce adverse health outcomes .

2

B. Evaluate the effectiveness of interventions to reduce excessive alcohol use and 

alcohol dependency. Excessive alcohol use and alcohol dependency increase the 

risk for both violence-related and unintentional injuries . Thousands of deaths 

occur each year as a result of alcohol-related injuries, and alcohol is involved 

in a substantial proportion of hospital admissions and emergency department 

visits . The problem of alcohol-related injuries is particularly high in certain 

geographic areas and among specific groups (e .g ., American Indians/Alaska 

Natives) where alcohol consumption and injury rates are higher than among the 

general population . However, the role of alcohol in injuries is not understood 

well enough to facilitate development and implementation of adequate injury 

prevention policies and programs . Uniform collection of blood alcohol levels 

among trauma patients, for example, is still lacking in certain states and 

jurisdictions . Primary prevention strategies to reduce exposure to and use of 

excessive alcohol are particularly important because persons who begin drinking 

alcohol as preadolescents and adolescents are at greater risk for alcohol abuse 

and dependence during adulthood . Binge drinking is a commonly unrecognized 
21

public health problem, particularly among youth, and can lead to serious injuries .3

Although effective strategies have been identified to reduce alcohol harms,4

 more 

research is needed to better understand which factors and policies have the 

strongest influence on reducing alcohol-related injuries . 

 Secondary prevention strategies for identifying persons at high risk for alcohol 

use and abuse include medical screening in patient care settings . Screening 

and brief counseling interventions have demonstrated promising results in 

emergency departments and with trauma patients .5 However, before these clinical 

preventive services can be broadly disseminated, further research is needed to 

demonstrate effectiveness in multiple settings, refine procedures and systems for 

implementation, and develop strategies to increase adoption and efficiencies of 

scale . Legislative- and community-based behavioral interventions and ecological 

approaches that address risky alcohol use in the community and that effectively 

reduce alcohol-impaired driving can also help reduce alcohol-related violence, 

falls, drowning, and other injuries . The entire field of public health can benefit 

from a stronger evidence base on alcohol-related harms and the barriers and 

solutions to wider adoption of effective and promising alcohol interventions that 

reduce injuries .6

C. Understand and reduce health disparities. Eliminating health disparities has 

been identified as a national goal .7

 Examples of populations disproportionately 

affected by injury and violence include, but are not limited to, populations with 

low incomes, racial/ethnic minorities, and persons with mental and physical 

disabilities . For any given injury topic, disparities exist across all age groups, sexes, 

regions, income levels, and race/ethnicities . Efforts to better understand and reduce 

these injury-related disparities will enhance and facilitate prevention efforts overall . 

Priorities include identifying and evaluating efficient and effective programs to 

prevent different types of injury and violence among those disproportionately 

affected, as well as accelerating widespread use of effective programs for 

populations at highest risk .

Emerging Priorities

D. Apply the public health approach to preventing maltreatment of older 

persons. Maltreatment of older persons (also referred to as elder mistreatment) 

is any destructive behavior that is directed toward an older adult, occurs within 

the context of a relationship connoting trust, and is of sufficient intensity or 

frequency to produce harmful physical, psychological, social, or financial effects of 

unnecessary suffering, injury, pain, loss, or violation of human rights and poorer 

quality of life for an older adult .8

 Elder maltreatment is an emerging area of public 

health concern that might become a more substantial problem as the general 

population ages . Although approximately 37 million U .S . residents were aged 

≥60 years in 2006,9

 by 2030, this population is expected to increase to 70 million 

persons . These population changes are anticipated to be accompanied by increases 

in incidents of elder maltreatment .

 Efforts to address elder maltreatment have been hampered by a lack of data 

regarding the magnitude of the problem, factors affecting the likelihood of its 

occurrence, and effectiveness of existing interventions to prevent or mitigate 

its consequences . Although capturing the incidence and prevalence of elder 

maltreatment is difficult, these data are needed to measure, monitor, and document 

Approximately 

37 million U.S. 

residents were 

aged ≥60 years 

in 2006.
22

trends associated with this problem . Further development of knowledge regarding 

risk, promotive and protective factors, and processes is also necessary to create 

interventions that can reduce, counteract, or moderate risks for elder maltreatment . 

Finally, rigorous evaluations of existing programs and strategies are required for 

determining their relevance, effectiveness, and impact; developing evidence-based 

guidance regarding ways to address elder maltreatment; and defining the most 

appropriate approaches for implementation .

E. Prevent consumer product-related injuries. Deaths, injuries, and property damage 

from consumer product-related incidents cost the nation >$700 billion annually .10

Promotion of safe use of products that might pose fire, electrical, chemical, or 

mechanical hazards is critical to public health and safety . Focus has often been on 

products used by or disproportionately injuring children . CDC researchers work 

closely with the U .S . Consumer Product Safety Commission (CPSC) in identifying 

hazardous toys and other products and in increasing awareness of the public health 

dangers they pose .

 In 2005, an estimated 202,300 toy-related injuries were treated in U .S . hospital 

emergency departments .10 Forty-six percent of the total injuries (94,000) occurred to 

the head and face area .

 Public health efforts contribute to examining and describing the epidemiology of 

product-related injury events through surveillance and research . Although CPSC 

can influence product design modification through standards and regulation, 

evidence indicates that product-related injuries often are preventable through 

correct product use and adult supervision . CDC’s research priorities related to 

supervision are discussed in the Home and Community section of this agenda and 

have direct applicability to preventing product-related injuries .

F. Prevent poisoning-related injuries and deaths. Poisoning is no longer simply a 

childhood injury problem . Adults are increasingly exposed to poisoning-related 

incidents, including those related to prescription drugs .11 During 1999–2005, 

the annual number of unintentional drug poisoning deaths in the United States 

increased from 11,155 to 22,448 . Drug overdose became the second leading 

cause of unintentional injury death in the United States in 2002, with only motor 

vehicle injuries causing more deaths . The 35–44 age group experienced the most 

substantial increase .12

 Enhancement of active surveillance for poisoning-related injuries and deaths 

through improved use of medical examiner data, police reports, and toxicology 

databases is needed . Additionally, strategies to reduce deaths from unintentional 

poisonings can be strengthened through examining risk factors for drug overdoses 

and analyzing the results of all injury deaths . New interventions for preventing 

poisoning-related injuries appear promising but require further evaluation . 

Additional changes in prescribing and dispensing practices also are critical to 

reducing unintentional poisoning deaths .
23

In conclusion, the ongoing investment in the injury research infrastructure is of equal 

importance with Priorities A–F in reducing the burden of injury . Since 1985, an entire 

field of injury control research has evolved . For injury research to move to the level of 

dissemination and implementation, an integrated network of researchers, mentors, and 

students is needed . Individual research grants alone are insufficient to continue this 

progress . Students should be introduced to injury research both in the classroom and 

through hands-on experience . Fully developing or improving existing links between 

classroom and community learning can cultivate opportunities for new and experienced 

researchers as well as community practitioners . Moreover, such links can facilitate 

exchange of ideas and development of a greater appreciation of the depth and breadth of 

the field of injury research . Carefully selected activities can serve these goals, including 

training programs, programs linking researchers with practitioners, professional 

conferences and consensus groups, effective use of information technology (including 

data clearinghouses and enhanced Internet technology), injury research centers, capacity 

building, and interdisciplinary collaborations . The injury research field can also benefit 

from integration with the public health research community, addressing topics other than 

injury (e .g ., training, participating in longitudinal studies or other large-scale research 

projects, and developing research methods that extend beyond injury) .
24

References

 1. World Health Organization. WHO Mortality Databases: Tables. Geneva: World 

Health Organization; 2007. Available at: http://www.who.int/healthinfo/

morttables/en/. Accessed July 30, 2008.

 2. CDC. Work together to build a healthy world [Section VII]. In: Advancing the 

Nation’s Health: A Guide to Public Health Research Needs, 2006–2015. US 

Department of Health and Human Services, CDC; 2006: 70–81. Available at: 

http://www.cdc.gov/od/science/PHResearch/cdcra/. Accessed July 30, 2008.

 3. Brewer RD, Swahn MH. Binge drinking and violence. JAMA 2005;294:616–8.

 4. Howat P, Sleet D, Elder R, Maycock B. Preventing alcohol-related traffic injury: a 

health promotion approach. Traffic Inj Prev 2004;5:208–19.

 5. Hungerford DW. Recommendations for trauma centers to improve screening, 

brief intervention, and referral to treatment for substance use disorders. J Trauma 

2005;59(3 Suppl):S37–42.

 6. Hingson R, Swahn M, Sleet DA. Interventions to prevent alcohol-related injuries. 

In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence 

Prevention. New York: Springer; 2007: 295–310.

 7. US Department of Health and Human Services. Healthy People 2010. 2nd ed. With 

Understanding and Improving Health and Objectives for Improving Health. 2 vols. 

Washington, DC: US Government Printing Office; 2000. Available at: 

http://www.healthypeople.gov/Publications/. Accessed July 30, 2008.

 8. Hudson MF. Elder mistreatment: a taxonomy with definitions by Delphi. J Elder 

Abuse Negl 1991;3(2):1–20.

 9. US Census Bureau. American Community Survey (ACS). Washington, DC: US 

Census Bureau; 2007. Available at: http://www.census.gov/acs/www/. 

Accessed July 30, 2008.

10. US Consumer Product Safety Commission. (CPSC) National Electronic Injury 

Surveillance System. Bethesda, MD: CPSC; 2007. CPSC document no. 3002. 

Available at: http://www.cpsc.gov/cpscpub/pubs/3002.html. 

Accessed July 30, 2008.

11. CDC. Unintentional poisoning deaths—United States, 1999–2004. MMWR Morb 

Mortal Wkly Rep 2007;56:93–6.

12. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the 

United States. Pharmacoepidemiol Drug Saf 2006;15:618–27.
Injury Response

Acute Injury Care

Public Health Burden

Injury remains a major global public health problem . Approximately 5 million deaths 

occur worldwide annually that are attributed to injury,1

 representing approximately 

one-tenth of all deaths globally .2,3 In addition to those who die from their injuries, 

millions more suffer temporary or permanent impairment,2 exacting a substantial 

toll on families, communities, and societies .4

 When measured in disability-adjusted 

life years (DALYs), the burden of injury is greater than that of cardiovascular disease, 

cancer, or vaccine-preventable childhood diseases .5

In the United States, injury is the leading cause of death for persons aged 1–44 years .6

In 2005, injuries accounted for 173,753 deaths in the United States, with an additional 

29 million injuries serious enough to involve a visit to a hospital emergency 

department (ED) in 2006 .6

 In addition to the impact injuries have on the lives of 

affected persons and their families, injuries have a substantial economic impact, with 

lifetime medical costs for acutely injured persons in the United States estimated at 

$80 billion per year .7

Injuries, similar to other disease processes, involve interactions among host, agent, 

and environment, with physical (i .e ., tissues, organs, and systems) and psychological 

impact . Injuries are often both predictable and preventable . Moreover, they have 

short- and long-term effects, not only on the lives of those injured but also on 

their families, healthcare workers, and society . Because of the diverse health effects 

associated with injuries, positive outcomes are often dependent on the availability of a 

continuum of multidisciplinary care .

27
28

The Injury Center’s Approach to Acute Injury Care

CDC’s Injury Center is the U .S . Federal Government organization having primary 

responsibility for addressing all phases of the injury research framework — from 

foundational research through dissemination research, as described in the 2002 

CDC Injury Research Agenda — for all major causes of injury among all age groups .

8

As part of this responsibility, the Injury Center focuses on the entire continuum 

of acute injury care (e .g ., emergency medical services, emergency medicine, and 

trauma surgery) as it relates to public health . CDC’s Injury Center staff have extensive 

experience working with organizations responsible for the care of the acutely injured 

at local, state, and national levels . This experience best positions the Injury Center 

to set research priorities, provide technical assistance for research programs, and 

facilitate translation of new findings into practical methods for evaluating outcomes 

of the acutely injured . The Injury Center’s partnerships with state health agencies, 

academic injury research programs, nongovernmental organizations, and healthcare 

practitioners provide a vital foundation for establishing and fostering a broad-based, 

multidisciplinary approach to acute injury care . These partners provide unique 

avenues and opportunities to facilitate, coordinate, and disseminate innovations 

in care for acutely injured persons . These relationships are also critical for system 

planning and preparedness activities for managing mass casualty incidents associated 

with acts of terrorism or natural disasters worldwide .

The Injury Center’s research activities and programs in the area of acute injury care 

are designed to provide information on which to base efforts to reduce the impact 

of acute injuries and to prevent injury-associated adverse outcomes or secondary 

conditions . This focus differs from and complements the activities of other federal 

agencies involved in acute injury care . For example, federal responsibility for 

supporting trauma care systems to administer quality, cost-effective care at the local 

level resides with the Health Resources and Services Administration (HRSA), whereas 

CDC’s Injury Center supports evaluation of the effectiveness of trauma systems and 

the outcomes among acutely injured persons . The Injury Center’s focus on applied 

acute injury care research in the civilian sector complements the National Institutes of 

Health’s focus on basic scientific research and the U .S . Department of Defense’s focus 

on prehospital acute injury care to improve outcomes on the battlefield .

One of the Injury Center’s key collaborative efforts is with the National Highway 

Traffic Safety Administration (NHTSA) in the area of training and research related 

to prehospital care . NHTSA has developed national standard curricula for training 

prehospital emergency care personnel and is completing work on a national 

emergency medical system research agenda, which addresses acute injury care in the 

prehospital setting .

The Injury Center staff reviewed its 2002 CDC Injury Research Agenda

8

 chapter on 

acute care, disability, and rehabilitation and determined that, of the 13 priority areas 

for research in that chapter, only three specifically address acute injury care and 

none were related to acute injury care in the context of terrorism preparedness and 

response . In close collaboration with its partners, the Injury Center has identified 

critical gaps in the care of acutely injured persons and the systems that manage that 

care . Recognizing these gaps, the Injury Center, together with support from federal 

partners and national organizations representing the full spectrum of acute injury 

care, has worked to supplement the previous agenda with a revision of the acute 

injury care chapter .
29

This revision represents the culmination of a process that was guided by a steering 

committee that included 13 leaders in emergency medical services (EMS), emergency 

medicine, trauma surgery, epidemiology, and public health, as well as other federal 

agency partners . Additionally, members of the Advisory Committee on Injury 

Prevention and Control (ACIPC) commented on the content of the draft research 

agenda chapter and provided recommendations regarding its implementation . Input 

was also solicited from representatives of key partner organizations and agencies 

representing researchers, practitioners, policymakers, and the public .

Building Research Capacity. CDC’s Injury Center, together with the Steering 

Committee and ACIPC, recognizes that the successful implementation of the acute 

injury care research priorities relies heavily on the simultaneous development of 

a research infrastructure that can support investigations in the proposed research 

priorities . To this end, the Injury Center recommends infrastructure development in 

the following four primary areas:

1. Research efforts in injury prevention and control across the spectrum of acute 

injury care, including development of an acute injury care research network, 

or use of existing networks that encourage and facilitate coordination of 

research activities .

2. Examination of existing data sources to determine how they might best 

be used to assess, evaluate, and improve systems of acute injury care, 

including efforts to strengthen the information infrastructure and maximize 

use of data sources .

3. Expansion or restructuring of existing injury care and prevention training and 

education programs targeting healthcare professionals . This education and 

training remains crucial to successful injury prevention and control efforts, is 

necessary for infrastructure development, and is necessary for creating a cadre 

of acute injury care research professionals to ensure long-term success .

4. Assessment, evaluation, and dissolution of barriers and obstacles to conducting 

acute injury care research, including those presented by institutional, 

jurisdictional, clinical, legislative, and administrative challenges .
30

The Injury Center’s Research Priorities 

in Acute Injury Care

Given the finite resources available for conducting research, the following priorities are 

listed in two tiers . The first tier contains those priorities that reflect the most immediate 

research needs and those that should be supported first as resources become available . 

Categorizing the priorities into two tiers does not imply, however, that the first tier of 

priorities is more important than the second tier or that research related to the second 

tier of priorities should wait until 2014 to begin .

Tier 1

A. Evaluate strategies to implement and adopt science-based 

recommendations and guidelines for the care of acutely injured persons 

and effectively translate and disseminate this information. New treatments 

involving acute injury care are often not adopted uniformly . Developing 

and implementing acute injury treatment strategies that result in evidencebased management protocols for persons who sustain life-threatening or 

disabling injuries can substantially improve the care of injured persons . As 

the initial step in identifying and ensuring best practices, knowledge gained 

from clinical studies has the potential to decrease mortality and to improve 

the outcome of serious injuries . These studies might focus on treating or 

reducing the effects of specific injuries (e .g ., on outcomes from such organspecific injuries as traumatic brain injury and long-bone fractures in the 

patient with multiple injuries) or on specific mechanisms and circumstances 

associated with injury . Other examples include optimal airway support in 

prehospital settings, outcomes from blast injuries after explosions, optimal 

fluid management across the spectrum of acute injury care, and optimal 

management of severely injured older patients . In the conduct of these types 

of research activities, multicenter investigations might be required to provide 

sufficient statistical power to support evidence-based recommendations .

 Another related concern deals with dissemination of these recommendations 

throughout the acute care community . Critical research is often conducted 

and the results published, yet the resulting guidelines or recommendations 

are not always widely used because the mechanisms to ensure their 

translation, dissemination, implementation, and adoption are nonexistent . 

To achieve these goals, acute injury care researchers should first examine 

successful models and methods used in other arenas for dissemination, 

implementation, and evaluation of evidence, protocols, and guidelines 

to identify key principles that are applicable in acute injury care . On 

the basis of these analyses, strategies should be developed for effective 

dissemination, including not only use of existing and future technology and 

specialty journals, but also identification of new and novel approaches to 

dissemination . The Injury Center has worked in collaboration with multiple 

internal and external partners to develop toolkits and training materials for 

healthcare providers, public health professionals, and others who play a role 

in the acute care of injured persons and their recovery . Examples include 

a curriculum for terrorism-related blast injuries, educational toolkits for 

preventing sports-related traumatic brain injury, and the cross-cutting fall 

prevention materials for older adults . Determining the efficacy, effectiveness, 

and impact of each strategy is critical . Research is needed to identify and 

overcome the barriers, both administrative and legal, to effective translation 
31

and subsequent use . Finally, methods to validate protocols, guidelines, and other 

materials — before and after dissemination — should be developed .

B. Determine and evaluate the components of trauma systems that contribute to 

improved outcomes for acutely injured persons. Investigators have demonstrated 

that trauma systems save lives, but which components of a trauma system improve 

health outcomes other than mortality remain unknown .9,10 Therefore, research is 

needed to identify and evaluate the specific components of trauma systems across 

the continuum of care — from prehospital through hospital and rehabilitation — 

that contribute to improvements in outcomes for injured persons and to determine 

how specific components can be tailored to improve system performance . 

Evaluating clinical care provided in different aspects of the system, including 

prehospital care, hospitals (i .e ., EDs, trauma centers, operating theaters, intensive 

care units, and burn units), and rehabilitation facilities, is crucial . Research is 

needed to

■ evaluate data collection and use throughout each aspect of the system;

■ evaluate the field triage decision-making process and impact 

on outcomes;

■ determine the potential for using the existing trauma care infrastructure 

during any disaster event, including chemical, biologic, nuclear, and 

conventional incidents;

■ compare care within urban versus rural environments;

■ evaluate application of recent advances in military medical care to injury care 

in the civilian sector;

■ determine the health outcome effects of dispatch, response, scene time, and 

other prehospital system components and evaluate the impact of prehospital 

care; and

■ define the benefits and costs of trauma care systems and their components 

on overall trauma care and outcomes, including morbidity, quality of life, 

functional outcomes, and cost .

 Particular emphasis should be placed on the application and role of emerging 

technologies in improving care and providing information for systemic 

approaches to acute injury care . Such activities as vehicle and personal 

telematics, geographic information systems for trauma system mapping and 

assessment (e .g ., the American Trauma Society’s Trauma Information Exchange 

Program), prehospital data systems (e .g ., NHTSA’s National EMS Information 

System), and enhancement of existing electronic registries (e .g ., the American 

College of Surgeons’ National Trauma Data Bank) offer prime opportunities for 

systemic improvements in acute care delivery .

C. Determine and evaluate the impact of mass casualty events and disasters on 

acute injury care. Mass casualty situations and disasters related to conventional 

weapon terrorism (e .g ., explosions), declared or undeclared military conflicts, 

natural phenomena (e .g ., cyclonic storms, floods, tornadoes, earthquakes, 

tsunamis, or volcanic eruptions), or other events (e .g ., structural collapses or 

airplane or railway crashes) remain a real and ongoing concern for acute injury 

care providers both in the United States and abroad . The injuries, deaths, disability, 

and psychosocial effects resulting from such events can create both real and 

perceived challenges in accessing medical care and other vital services . The impact 

Research is 

needed to 

identify and 

evaluate trauma 

systems across 

the continuum 

of care.
32

of these events on an already overburdened system of trauma care — with regard 

to operations, surge capacity, staffing, and logistical concerns — remains unknown . 

Further examination and evaluation of these systemic effects of mass casualties is 

warranted, including learning from other nations that have experienced terrorist 

acts or natural disasters .

 Optimal data systems for use during mass casualty and disaster events remain 

a challenge . Identifying and evaluating strategies for data collection and use, 

maximizing use of existing data systems, and achieving the real-time use of data 

during an event, all remain important research needs . Effective communication is 

difficult during a mass casualty or disaster event; therefore, strategies to maximize 

communication through improving systems’ interoperability and eliminating 

redundancy should be developed and evaluated . Often, trauma care systems 

are not well-integrated with disaster planning efforts, which focus primarily 

on law enforcement, fire prevention, power supply, and other infrastructure 

challenges than on the care of the acutely injured . Strategies to integrate trauma 

systems with disaster planning need to be developed and evaluated . Models of 

field triage, which might relegate certain persons to receive no further care at 

the scene, should be reexamined and evaluated in the context of community 

resource availability, specialty services, and legal constraints . Despite the multiple 

educational programs available, the exact type and extent of education and 

training ideal for different types of care providers (prehospital and hospital) is 

unknown . Research should identify and evaluate the core competencies for those 

responding to or involved in mass casualty or disaster events to 

ensure an appropriate level of knowledge and expertise . Serious secondary 

injuries often occur after disasters; improvements in acute injury care 

management in these difficult environments and situations should be developed 

and evaluated .

D. Develop and evaluate protocols that provide on-site interventions in acute care 

settings or links to off-site services for patients at risk for injury or psychosocial 

problems after injury. Clinical preventive services for patients treated in EDs, 

hospital trauma units, and other acute care settings can help reduce the risk for 

injury and mitigate the effects of injuries that do occur . Examples of such services 

include screening and interventions for alcohol-associated problems, instruction 

for healthcare providers in use of safety restraints, and recognition of intimate 

partner violence or child maltreatment . For injured patients, ED visits and inpatient 

hospital admissions for trauma care can provide crucial opportunities for early 

identification of and intervention for posttraumatic stress disorder (PTSD) and 

other psychosocial problems that can follow or be exacerbated by injury . Assessing 

the baseline mental health status of trauma patients and determining intervention 

needs (e .g ., for alcohol abuse, PTSD, or illicit drug use) is needed . Decision makers 

are often reluctant to fund clinical preventive services because they believe the 

investment needed to implement a single service in a clinical setting is too high . 

Research should demonstrate the effectiveness and value of such services and 

examine ways to implement services in the most efficient manner .

E. Develop and evaluate interventions for the personal, sociocultural, and 

community consequences of acute injury. The financial, psychosocial, and longterm physical effects of an acute injury can be more debilitating than the actual 

physical injury itself . The severity and duration of these effects is an essential 

determinant of long-term impairment and disability . An acute injury not only 

has an immediate effect on the injured person but can also result in long-term 
33

consequences on the lives of others in the person’s family and community . 

Healthcare providers themselves might also be subject to psychosocial 

consequences resulting from caring for the acutely injured persons and their 

families on a daily basis . In the event of a mass casualty or disaster event, these 

causal sequences can affect a community’s societal and functional infrastructure 

extensively . Identifying and evaluating strategies to mitigate consequences to 

persons, families, and society after injury and assessing the cost-effectiveness 

and cost benefit of these strategies is crucial . For example, the impact of 

appropriate and timely referral to mental health and rehabilitation professionals 

should be thoroughly evaluated and incorporated into the clinical care of 

injured patients .

F. Identify and evaluate new or existing health measures to better assess shortand long-term outcomes for persons treated in prehospital and hospital acute 

injury care settings. Determining improvements in outcomes for acutely injured 

persons can be difficult if trauma centers, emergency care facilities, and hospitals 

focus on reducing mortality alone without focusing on morbidity and other 

longer term health outcomes . Therefore, a need exists for developing additional 

health measures in the acute care setting (e .g ., healthcare costs and lost work or 

school days) and quality indicators related to pain management, palliative care, 

and stress experienced by injured persons and their families . Also, different 

treatments received in the prehospital and hospital acute care setting can lead 

to different long-term outcomes for the acutely injured . Thus, evaluation and 

validation are needed for both new and existing methods of reporting acute injury 

care and trauma system outcomes that extend beyond mortality to include longterm functional outcome, familial and social outcomes, and economic impact and 

outcome . New methods of measuring morbidity, quality of life, functional status, 

and cost will help define the benefits and costs of trauma care systems .

Tier 2

G. Develop estimates of the associated risk factors, incidence, and prevalence of 

spinal cord injury and associated costs and long-term consequences, including 

secondary conditions. Identifying and characterizing spinal cord injuries 

(SCIs) is an essential first step in conducting surveillance and outcome studies . 

Increased collaboration among federal agencies is crucial to such research . The 

Injury Center conducts population-based surveillance to develop nationally 

representative estimates of the incidence, prevalence, nature, and causes of 

injuries that result in long-term disability . This activity can lead the conduct of 

population-based follow-up studies to identify and track the long-term outcomes 

of disabling injuries . Research should investigate the unique outcomes and special 

needs of patients with SCI and associated secondary conditions . The spectrum of 

rehabilitation services and trends in service provision should be described, and 

access to medical, rehabilitation, and social services to prevent disabling outcomes 

and secondary conditions should be assessed . Better information regarding 

outcomes can improve estimates of the true burden of disability for persons with 

SCI by helping to document long-term problems resulting from these injuries .
34

 Direct medical costs and indirect costs associated with SCIs are not well-documented; 
35

References

 1. Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, eds. 

Injury Surveillance Guidelines. Geneva: World Health Organization and Atlanta, 

GA: US Department of Health and Human Services, CDC; 2001. Available at: 

http://whqlibdoc.who.int/hq/2001/WHO_NMH_VIP_01.02.pdf. 

Accessed July 30, 2008.

 2. Butchart A, Harvey AP, Krug E, Meddings D, Peden M, Sminkey L. Preventing Injuries 

and Violence: A Guide for Ministries of Health. Geneva: World Health Organization; 

2007. Available at: http://www.who.int/violence_injury_prevention/publications/

injury_policy_planning/prevention_moh/en/. Accessed July 30, 2008.

 3. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing the growing burden 

of trauma and injury in low- and middle-income countries. Am J Pub Health 

2005;95:13–7.

 4. Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital Trauma Care Systems. 

Geneva: World Health Organization; 2005. Available at: http://www.who.int/

violence_injury_prevention/publications/services/39162_oms_new.pdf. Accessed 

July 30, 2008.

 5. Ahmed N, Andersson R. Differences in cause-specific patterns of unintentional 

injury mortality among 15–44 year-olds in income-based country groups. Accid 

Anal Prev 2002;34:541–51.

 6. National Center for Injury Prevention and Control. Web-based Injury Statistics Query 

and Reporting System. US Department of Health and Human Services, CDC; 2008. 

Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed July 30, 2008.

 7. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in the 

United States. New York: Oxford University Press; 2006.

 8. National Center for Injury Prevention and Control. CDC Injury Research Agenda. 

Atlanta, GA: US Department of Health and Human Services, CDC; 2002. Available 

at: http://www.cdc.gov/ncipc/pub-res/research_agenda/Research%20Agenda.pdf.

Accessed July 30, 2008.

 9. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. National evaluation of the effect of 

trauma-center care on mortality. N Engl J Med 2006;354:366–78.

10. Nathens AB, Jurkovich GJ, Rivara FP, Maier RV. Effectiveness of state trauma systems 

in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25–30; 

discussion 30–1.

11. Sheikh K. Return to work following limb injuries. J Soc Occup Med 1985;35:114–7.
36

Traumatic Brain Injury

Public Health Burden

Traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating 

injury that disrupts the function of the brain . TBI is an important public health 

problem globally with ≥10 million TBIs serious enough to result in death or 

hospitalization occurring each year .1

 In the United States, an estimated 1 .6 million 

TBIs occurred among persons treated in civilian medical facilities in 2003, including 

1 .2 million emergency department (ED) visits, 290,000 hospitalizations, and 51,000 

deaths .2 However, U .S . national data2 underestimate the true occurrence of TBIs for at 

least three key reasons . First, the data do not include persons treated for TBI in other 

settings (e .g ., hospital outpatient settings or doctors’ offices) . Second, the number 

of persons who receive medical care during which the TBI is undiagnosed or who 

experience a TBI but do not receive care, is unknown . Finally, TBIs treated in military 

facilities both in the United States and abroad are not included .

TBI is an increasing concern among certain groups . On the basis of studies of 

convenience samples, research indicates that 25%–87% of persons incarcerated in 

prisons and jails report a history of head injury, including TBI .3,4 Military personnel 

in both combat and noncombat situations are at high risk for sustaining TBIs .5,6 In 

2003, Ivins et al . reported that 23% of noncombat active-duty soldiers at Fort Bragg 

had sustained a TBI during their military service .7 Military personnel serving in Iraq 

and Afghanistan5,8 are at particularly high risk for concussions and more severe TBIs, 

especially as a result of blasts .9,10 Recent reports indicate that as many as one in five 

service members returning from Iraq and Afghanistan have screened positive for 

possible mild TBI .11,12 Rescue workers and victims of terrorism-related attacks13–15 

are also at risk for sustaining TBIs . Sports and recreation-related TBIs, including 

concussions, are of increasing concern . According to a CDC estimate,1 .6–3 .8 million 

sports-related TBIs occur each year, including those for which no medical care is 

sought .16 This estimate might also be low because concussions are often unrecognized 

and thus cannot be counted .

TBI can result in long-term or lifelong physical, cognitive, behavioral, and emotional 

consequences .17 Even mild TBI, including concussion, can cause long-term cognitive 

problems that affect a person’s functional abilities and limit his or her potential to 

return to work or school .18–21 As a result of these consequences, TBI is one of the most 

disabling injuries . Although similar to that for other types of injuries, the percentage 

of injury-related productivity loss attributed to TBI (15 .7%) is 14 times that associated 

with spinal cord injury,22 another important disabling condition . Annually, an estimated 

125,000 U .S . civilians are hospitalized with TBIs that are expected to result in longterm or lifelong disability .23 Because the prevalence of disability associated with TBIs 

treated in other healthcare settings and those that are not treated is unknown, the true 

incidence of TBI-related disability might be much higher . The lifetime costs of TBI in 

the United States, including medical costs and lost productivity, total approximately $60 

billion annually .22 Of note, this estimate does not address the indirect effects on families 

or other caregivers, friends, and communities . Additional research is needed to guide 

medical, public health, and other TBI prevention professionals and to ensure a healthier 

future for persons who have sustained TBIs .
37

The Injury Center’s Approach to Traumatic Brain Injury Response

The Injury Center’s research activities and programs are focused primarily on reducing 

the impact or preventing development of secondary conditions and other adverse 

outcomes of TBI through translation of science into practice . Among CDC’s unique 

roles is the collection, analysis, and reporting of population-based data regarding 

the incidence of TBI and prevalence of TBI-related disability . Findings from CDC’s 

national TBI surveillance and CDC-funded state-based surveillance provide crucial 

information for guiding prevention efforts as well as policy decisions and research 

planning at both the state and national levels . CDC also plays an important role 

in supporting research aimed at improving systems for the acute care of injuries, 

including TBI .22 During recent years, CDC has increased its efforts to ensure that its 

TBI research and programs have a positive impact not only on policy and planning, 

but on the lives of persons with TBIs, their families, and caregivers .

CDC’s injury research activities support the work of other federal, state, and 

local agencies in regard to TBIs . At the federal level, these include the Defense 

Center of Excellence for Psychological Health and Traumatic Brain Injury, the 

Health Resources and Services Administration, the National Center for Medical 

Rehabilitation Research, and the National Institute on Neurological Disorders and 

Stroke of the National Institutes of Health, the National Institute for Disability and 

Rehabilitation Research, and the Social Security Administration . At the national 

level, CDC also collaborates with other TBI organizations, including the Brain 

Trauma Foundation, the National Brain Injury Research, Treatment and 

Training Foundation, the National Association of State Head Injury Administrators 

and the Brain Injury Association of America . At all levels, CDC collaborates with 

diverse acute injury care partners .24 All of CDC’s TBI research activities are aimed at 

including interaction among related organizations and agencies to avoid duplication 

and to leverage resources and enhance the usefulness of the research findings .
38

The Injury Center’s Research Priorities 

in Traumatic Brain Injury Response

Given the finite resources available for conducting research, the following priorities are 

listed in two tiers . The first tier contains those priorities that reflect the most immediate 

research needs and those that should be supported first as resources become available . 

Categorizing the priorities into two tiers does not imply, however, that the first tier of 

priorities is more important than the second tier or that research related to the second 

tier of priorities should wait until 2014 to begin .

Tier 1

A. Improve identification, assessment, and management of TBI. Accurate 

identification, assessment, and management of concussions or mild TBIs are 

critical for ensuring correct diagnoses and for reducing the risks for reinjury 

and long-term consequences . Although advances in identification and 

management have been made, substantial limitations remain .25 Thus, research 

is needed to develop and validate improved clinical diagnostic measures 

(e .g ., biomarkers), symptom-based methods (e .g ., the Acute Concussion 

Evaluation26), and neurocognitive performance-based assessment methods 

(e .g ., ImPACT27) . These include studies to determine the ecological validity 

of existing neurocognitive measures to determine whether inadequate 

performance is associated with difficulties in performing real-world tasks . In 

addition to symptom-based and neurocognitive assessments, development of 

rapid, accurate, and practical measures of motor dysfunction after mild TBI 

(e .g ., gait, balance, and simple reaction time) can lead to improved diagnoses . 

Studies are needed to demonstrate the potential for implementing effective 

systems that result in improved identification and assessment in different 

primary care settings, especially in EDs where the majority of mild TBI cases 

are treated, as well as in schools and sports and recreation settings . Research 

is also needed that demonstrates how systems can better identify and assess 

mild TBIs among populations suspected to be at high risk for concussion that 

might remain undiagnosed . These populations include older adults, children 

(especially young children and those of any age for whom child maltreatment 

is suspected), persons injured as a result of terrorism-related attacks,28 and 

military personnel returning from war zones . Although evidence exists that 

early educational information provided during the acute phase of mild TBI 

recovery can reduce long-term complaints,29 further studies are needed to 

validate existing management protocols and to evaluate improved methods for 

reducing the potential for long-term disability resulting from mild TBI .

B. Develop and apply methods for calculating population-based estimates of 

the incidence, costs, and long-term consequences of TBI. Population-based 

surveillance and research to develop nationally representative estimates of the 

incidence and prevalence of disability associated with TBI, including temporal 

trends, are one of CDC’s primary responsibilities, as described in the Children’s 

Health Act of 2000 .30 This includes calculating the incidence and prevalence of TBI 

among institutionalized populations and supporting population-based follow-up 

studies to identify and track the outcomes of TBI . Better estimates of the incidence 

of mild TBI treated in outpatient settings and those that are untreated (e .g ., sports-
39

related concussions) are needed to improve the accuracy and completeness of TBI 

surveillance efforts to determine the impact of TBI on the nation’s population and 

healthcare systems . CDC has supported studies of TBI among prison inmates and 

nursing home residents, but estimates are needed for military personnel injured 

both in the United States and abroad as well as those in other institutional settings, 

including juvenile detention facilities, psychiatric institutions, developmental 

disability facilities, and child care centers . Of particular concern is the need for 

better data regarding the long-term outcomes among persons with mild TBI, for 

which estimates of the prevalence of disability are lacking,31 including among both 

active-duty military personnel and veterans who have been exposed to blasts . 

Differences between the sexes throughout recovery from TBI, especially mild TBI, 

also need further study . Future research should also investigate critical outcomes 

of TBI that have not yet been well-described on a population level (e .g ., prevalence 

of neurobehavioral problems, including aggressive behavior and intimate partner 

violence), which anecdotal evidence demonstrates might be increasing with 

improvements in survival of persons with severe TBI . Additional research is also 

needed to determine the incidence and prevalence of disability and other longterm outcomes among military personnel returning from combat and other 

veterans . Although updated information on the direct medical costs and indirect 

costs associated with disabling injuries was reported in 2006,22 routine updates 

are needed to provide timely information for guiding resource allocation and 

other policies . In addition, research should estimate the costs associated with such 

secondary conditions as depression and substance abuse .

C. Identify methods and strategies to ensure that persons with TBI receive needed 

services. Meeting the need for services among persons with TBIs is critical for 

ensuring optimal recovery and quality of life . Among persons hospitalized with 

TBI, 35%–40% have at least one unmet need for services at 1 year after TBI .32,33

Experience has demonstrated that changes to the system to ensure better linkage 

of persons with TBI to different types of available services are needed .34 However, 

anecdotal reports and limited research indicate that the disability that persons with 

cognitive but not obvious physical problems experience poses unique challenges 

for persons with TBI in accessing health services and maintaining a healthy 

lifestyle .35,36 Additional research is needed to identify service needs and barriers 

to accessing those services and to develop model programs for addressing these 

needs and ensuring that persons with TBIs are successfully reintegrated into the 

community . Of particular concern are military personnel returning from combat 

and other veterans, as well as prisoners with TBI, both while they are incarcerated 

and after they are released .

D. Develop and evaluate interventions for reducing TBI-related disability. TBI 

is among the most disabling conditions, but unlike such conditions as heart 

disease and stroke, TBI has only recently become a focus of research aimed at 

improving clinical care and rehabilitation .37 Consequently, research to evaluate 

the effectiveness of interventions to reduce disability from TBI are lacking and 

additional research is needed . Among needed areas of investigation are the 

effectiveness of cognitive rehabilitation, especially as it relates to daily functioning, 

interventions to improve community integration and psychological health, and 

strategies to help caregivers .37

Among persons 

hospitalized wit

d

h

TBI, 35%–40% 

have at least 

one unmet nee

for services at 

1 year after TBI.
40

 An insufficient number of interventions for mild TBI have been evaluated, and 
41

important area . Multiple concerns have been raised in this regard, including the 

effects of transportation decisions, referral and hospital admission policies, overall 

quality of care, and how guidelines are used in the provision of care . Trauma 

systems and referral and hospital admission policies greatly influence not only the 

characteristics of patient populations, but also the outcomes of care .49 Although 

the benefits of concentration of care for more severe TBI in high volume centers 

have been reported,50,51 prospective studies are needed to evaluate the effect of case 

load on functional outcomes . Systematic reviews of existing evidence regarding 

the effect of Level I trauma center volumes, quality of care, and guidelines-directed 

care52 as well as lessons learned from advances in military trauma care on TBI 

outcomes can be useful in guiding how TBI care should be delivered and funded in 

the United States .

G. Develop effective and innovative methods to inform audiences 

regarding TBI. Results of a 2006 CDC-supported environmental scan of the 

literature and availability of TBI-related materials and resources provided evidence 

that the need continues for informing diverse audiences regarding the importance 

of TB as a public health problem and how to prevent and reduce the impact of 

TBI-related disability and other adverse outcomes (unpublished data, NCIPC, 

Traumatic Brain Injury: What Is Needed? What Is Available? An Environmental 

Scan Review of Academic Literature and Websites, 2006). This research 

demonstrated that audiences need information and resources, including educators 

(e .g ., teachers, playground staff, and school nurses), healthcare providers, 

caregivers (e .g ., family members and significant others of persons with TBIs), 

persons with TBIs, and the general public . Because identification, assessment, 

and management of sports-related concussion remain critical concerns, further 

education and training for coaches, parents, and athletes is also needed . Using 

evidence-based approaches in providing this information and understanding the 

level of knowledge and behaviors of these audiences will be critical in ensuring 

success in future educational efforts . Specifically, research is needed that evaluates 

different educational strategies for primary prevention as well as prevention of 

disability and other adverse effects of TBI . Although a recent review identified 

materials and campaigns aimed at raising awareness among the general public, 

educational interventions have rarely demonstrated substantial reductions in TBI 

incidence (unpublished data, NCIPC, Traumatic Brain Injury: What Is Needed? 

What Is Available? An Environmental Scan Review of Academic Literature and 

Websites, 2006).

 Studies are also needed of the effectiveness and cost-effectiveness of providing 

information to specific target audiences (e .g ., teachers, healthcare professionals, 

parents or other caregivers, persons with TBIs, the media, and the general public) 

on preventing TBI and its adverse effects . Comparing the impact of delivering such 

information within diverse settings (e .g ., physicians’ offices, hospitals, or public 

health clinics) and identifying mediators of any changes that are detected is also 

important . Research to identify new and effective strategies and technologies for 

information dissemination is also needed .
42

 Finally, although recent national media coverage and educational initiatives, 
43

References

1. World Health Statistics. Global Health Statistics, 2007. 3rd ed. Geneva: World 

Health Organization; 2007. Available at: http://www.who.int/whosis/en/. 

Accessed July 30, 2008.

2. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of traumatic brain injury 

in the United States, 2003. J Head Trauma Rehabil 2006;21:544–8.

3. Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: 

prevalence, neuropsychological functioning and psychiatric disorders. Brain Inj 

2003;17:731–41.

4. Morrell RF, Merbitz C, Jain S, Jain S. Traumatic brain injury in prisoners. Journal of 

Offender Rehabilitation 1998;27(3-4):1–8.

5. Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352:2043–7.

6. Ommaya AK, Dannenberg AL, Salazar AM. Causation, incidence, and costs of 

traumatic brain injury in the U.S. military medical system. J Trauma 1996;40:211–7.

7. Ivins BJ, Schwab KA, Warden D, et al. Traumatic brain injury in U.S. army 

paratroopers: prevalence and character. J Trauma 2003;55:617–21.

8. Scott SG, Vanderploeg RD, Belager HG, Scholten JD. Blast injuries: evaluating and 

treating the postacute sequelae. Federal Practitioner 2005;22(1):67–75.

9. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil 

2006;21:398–402.

10. Cavallaro G. A sort of homecoming. War and PCS orders: Carson helps brigade 

cope. Army Times [Serial online]; September 5, 2005: Approximately 3 pages. 

Available at: http://www.armytimes.com/legacy/new/0-ARMYPAPER-1020102.php. 

Accessed July 30, 2008.

11. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive 

Injuries, Their Consequences, and Services To Assist Recovery. Santa Monica, CA: 

Rand Corp.; 2008.

12. Hoge CW, McGuirk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain 

injury in U.S. soldiers returning from Iraq. N Engl J Med 2008;358:453–63.

13. Mallonee S, Shariat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries 

and fatalities resulting from the Oklahoma City bombing. JAMA 1996;276:382–7.

14. CDC. Injuries and illnesses among New York City Fire Department rescue workers 

after responding to the World Trade Center attacks. MMWR Morb Mortal Wkly Rep 

2002;51(Special Issue):1–5.

15. CDC. Rapid assessment of injuries among survivors of the terrorist attack on the 

World Trade Center—New York City, September 2001. MMWR Morb Mortal Wkly Rep 

2002;51:1–5.
44

16. Langlois JA, Rutland-Brown W, Wald MM. Epidemiology and impact of traumatic 

brain injury: a brief overview. J Head Trauma Rehabil 2006;21:375–8.

17. National Institutes of Health, Consensus Development Program. Rehabilitation 

of Persons with Traumatic Brain Injury: National Institutes of Health Consensus 

Development Conference Statement—October 26–28 1998. Bethesda, MD: 

National Institutes of Health; 1998;16(1):1–41. Available at: 

http://consensus.nih.gov/1998/1998TraumaticBrainInjury109html.htm. 

Accessed July 30, 2008.

18. McAllister TW, Sparling MB, Flashman LA, Guerin SJ, Mamourian AC, Saykin 

AJ. Differential working memory load effects after mild traumatic brain injury. 

Neuroimaging 2001;14:1004–12.

19. Alves W, Macciocchi SN, Barth JT. Postconcussive symptoms after uncomplicated 

mild head injury. J Head Trauma Rehabil 1993;8:48–59.

20. Englander J, Hall K, Stimpson T, Chaffin S. Mild traumatic brain injury in an 

insured population: subjective complaints and return to employment. Brain Inj 

1992;6:161–6.

21. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Minich N. Prospective study of 

short- and long-term outcomes after traumatic brain injury in children: behavior 

and achievement. Neuropsychology 2002;16:15–27.

22. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in 

the United States. New York: Oxford University Press; 2006.

23. Selassie AW, Zaloshnja E, Langlois JA, Miller T, Jones P, Steiner C. Incidence of longterm disability following traumatic brain injury hospitalization in the United States, 

2003. J Head Trauma Rehabil 2008;23:123–31.

24. National Center for Injury Prevention and Control. CDC Acute Injury Care Research 

Agenda: Guiding Research for the Future. Atlanta, GA: US Department of Health 

and Human Services, CDC; 2005.

25. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain 

injury in the United States, 1998–2000. Brain Inj 2005;19:85–91.

26. Gioia G, Collins M. Acute concussion evaluation (ACE). In: Heads Up: Brain Injury 

in Your Practice; A Tool Kit for Physicians. Atlanta, GA: US Department of Health 

and Human Services, CDC; 2006. Available at: http://www.cdc.gov/

ncipc/tbi/physicians_tool_kit.htm. Accessed July 30, 2008.

27. Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport 

concussion. Clin Neuropsychol 2003;17:460–7.

28. Rutland-Brown W, Langlois JA, Nicaj L, Thomas RG Jr, Wilt SA, Bazarian JJ. Traumatic 

brain injuries after mass-casualty incidents: lessons from the 11 September 2001 

World Trade Center attacks. Prehosp Disaster Med 2007;22:157–64.
45

29. Borg J, Holm L, Peloso PM, et al. Non-surgical intervention and cost for mild 

traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild 

Traumatic Brain Injury. J Rehabil Med 2004:76–83.

30. Children’s Health Act of 2000 (Public Law 106-310), 42 USC 201 § XIII ¶1301–2; 2000.

31. Carroll LJ, Cassidy JD, Peloso PM, et al. Prognosis for mild traumatic brain injury: 

results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J 

Rehabil Med 2004:84–105.

32. Corrigan JD, Whiteneck G, Mellick D. Perceived needs following traumatic brain 

injury. J Head Trauma Rehabil 2004;19:205–16.

33. Pickelsimer EE, Selassie AW, Sample PL, Heinemann AW, Gu JK, Veldheer LC. Unmet 

service needs of persons with traumatic brain injury. J Head Trauma Rehabil 

2007;22:1–13.

34. Sample PL, Johns N, Gabella B, Langlois J. Can traumatic brain injury surveillance 

systems be used to link individuals with TBI to services? Brain Inj 2004;18:1177–89.

35. Nosek MA. Health concerns of women with brain injury. Brain Injury Professional 

2006;3:28–32.

36. Sample PL, Darragh AR. Perceptions of care access: the experience of rural and 

urban women following brain injury. Brain Inj 1998;12:855–74.

37. Gordon WA, Zavonte R, Cicerone K, et al. Traumatic brain injury rehabilitation: state 

of the science. Am J Phys Med and Rehabil 2006;85:343–82.

38. Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome 

following mild head injury in adults. J Neurol Neurosurg Psychiatry 2002;73:330–2.

39. Ponsford J, Willmott C, Rothwell A, et al. Factors influencing outcome following mild 

traumatic brain injury in adults. J Int Neuropsychol Soc 2000;6:568–79.

40. Horner MD, Ferguson PL, Selassie AW, Labbate LA, Kniele K, Corrigan JD. Patterns of 

alcohol use 1 year after traumatic brain injury: a population-based, epidemiological 

study. J Int Neuropsychol Soc 2005;11:322–30.

41. Selassie AW, McCarthy ML, Ferguson PL, Tian J, Langlois JA. Risk of 

posthospitalization mortality among persons with traumatic brain injury, South 

Carolina 1999–2001. J Head Trauma Rehabil 2005;20:257–69.

42. Silver JM, Kramer R, Greenwald S, Weissman M. Association between head injuries 

and psychiatric disorders: findings from the New Haven NIMH Epidemiologic 

Catchment Area study. Brain Inj 2001;15:935–45.

43. Holsinger T, Steffens DC, Phillips C, et al. Head injury in early adulthood and the 

lifetime risk of depression. Arch Gen Psychiatry 2002;59:17–22.
46

44. Plassman BL, Havlik RJ, Steffens DC. Documented head injury in early adulthood 

and risk of Alzheimer’s disease and other dementias. Neurology 2000;55:1158–66.

45. Sherman KB, Goldberg M, Bell KR, Traumatic brain injury and pain. 

Phys Med Rehabil Clin N Am 2006;17:473–90, viii.

46. National Center on Birth Defects and Developmental Disabilities. Disability and 

Health State Chartbook, 2006: Profiles of Health for Adults with Disabilities. 

Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available 

at: 

http://www.cdc.gov/ncbddd/dh/chartbook. Accessed July 30, 2008.

47. He W, Sengupta M, Velkoff VA, DeBarros KA. 65+ in the United States: 2005. 

Current Population Reports, Special Studies. Washington, DC: US Department of 

Health and Human Services, National Institutes of Health, and US Department of 

Commerce, US Census Bureau; 2005. Publication no. P23-205. Available at: 

http://www.census.gov/prod/2006pubs/p23-209.pdf. Accessed July 30, 2008.

48. Coronado VG, Thomas KE, Sattin RW, Johnson RL. CDC traumatic brain injury 

surveillance system: characteristics of persons aged 65 years and older 

hospitalized with a TBI. J Head Trauma Rehabil 2005;20:215–28.

49. Patel HC, Bouamra O, Woodford M, et al. Trends in head injury outcome from 

1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 

2005;366:1538–44.

50. Smith RF, Frateschi L, Sloan EP, et al. Impact of volume on outcome in seriously 

injured trauma patients: two years’ experience of the Chicago Trauma System. 

J Trauma 1990;30:1066–75.

51. Maas AI, Murray G, Henney H 3rd, et al. Efficacy and safety of dexanabinol in severe 

traumatic brain injury: results of a phase III randomized, placebo-controlled, 

clinical trial. Lancet Neurol 2006;5:38–45.

52. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly 

addressing the early coagulopathy of trauma. J Trauma 2007;62:307–10.

53. Kushel MB, Hahn JA, Evans JL, Bangsberg DR, Moss AR. Revolving doors: 

imprisonment among the homeless and marginally housed population. 

Am J Public Health 2005;95:1747–52.

54. Burdon WM, Messina NP, Prendergast ML. California treatment expansion initiative: 

aftercare participation, recidivism, and predictors of outcomes. Prison Journal 

2004;84:61–80.

55. Coid J. Correctional populations: criminal careers and recidivism. In: Oldham JM, 

Skodol AE, Bender DS, eds. Textbook of Personality Disorders. Washington, DC: 

American Psychiatric Publishing; 2005: 579–606.
Unintentional Injury Prevention

47

49

Home and Community

Public Health Burden

During 1997–2001 in the United States, approximately 12 million persons were 

injured each year at home severely enough to warrant an emergency department 

(ED) visit .1 Injuries at home constituted 33% of all injury-related ED visits .2

Multiple factors and events contribute to injuries in the home and community . For 

the purposes of the Injury Center’s research agenda, home and community safety 

research includes fires, falls, dog bites, poisonings, consumer product-related injuries, 

choking (including unintentional strangulation and suffocation), scalds and other 

nonfire-related burns and injuries . Transportation-related injuries and sports-, 

recreation-, and exercise-related injuries are included as separate topics after this 

section on home and community .

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

2005, fires were the third leading cause of injury-related deaths among children aged 

1–9 years and the fifth leading cause among adults aged ≥65 years . Falls were the 

third leading cause of injury-related deaths among U .S . residents of all ages and were 

the leading cause of injury-related deaths among adults aged ≥65 years . Of older 

adults who fall, 20%–30% suffer moderate-to-severe injuries that reduce mobility and 

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

injuries among adults aged ≥65 years in 2000 was $19 billion .3 Falls are the leading 

cause of ED visits among children aged <15 years, accounting for an estimated 

2 .2 million visits in 2006 .4 Infants and children who fall from low heights are at 

substantial risk for head injuries, and those falling from heights of ≥10 feet can also 

sustain other, multiple, serious injuries .

The Injury Center’s Approach to Preventing Injuries 

at Home and in the Community

Injuries occurring in the home and in the community represent a substantial public 

health burden in healthcare costs, injuries, and deaths . CDC’s Injury Center can 

lessen this burden by developing, evaluating, and promoting effective interventions in 

the home and in the community . Public perception that injuries are “accidents” that 

cannot be prevented hinders prevention efforts . By using the public health approach 

to injuries, CDC’s Injury Center conducts surveillance, injury risk and protective 

factor research, and intervention and adoption research . The Injury Center also 

translates that research into effective public health practice .

Residential and community injuries derive from multiple sources and involve 

different products, environments, and risk groups . Addressing this complexity 

requires varied approaches and multiple partners . One of the Injury Center’s key 

partners is the U .S . Consumer Product Safety Commission (CPSC), which conducts 

research to protect the public from unreasonable risks for injury or death caused 

by consumer products . CPSC and the Injury Center jointly conduct nationally 

representative ED surveillance for injuries .
50

The National Institute for Child Health and Human Development (NICHD) conducts 

research on home and community safety, including pilot work regarding child 

supervision . The Injury Center has funded developmental and applied research on 

parental supervision . The Federal Emergency Management Agency works with the 

Injury Center to support research on strategies to improve community fire safety . 

The Injury Center works with the U .S . Fire Administration (USFA) to improve fire 

and burn surveillance . CDC works closely with the Administration on Aging to 

evaluate the costs of implementing evidence-based programs and the long-term 

impact of fall prevention programs, and with the Center for Medicare and Medicaid 

Services to evaluate risk factors and long-term outcomes for falls among the Medicare 

population . The Maternal and Child Health Bureau (MCHB) of the Health Resources 

and Services Administration provides training and technical assistance in injury 

prevention . The Injury Center complements MCHB work through state health 

departments by funding prevention programs in states with active MCHB programs . 

The U .S . Department of Housing and Urban Development works with CDC to 

improve healthy and safe housing . The Bureau of Indian Affairs (U .S . Department of 

the Interior) and the Indian Health Service (U .S . Department of Health and Human 

Services) work with the Injury Center to improve the health and safety of American 

Indians and Alaska Natives .

Nonprofit organizations conduct programs to promote safety in the home and 

community, including among others, the Home Safety Council, SAFE KIDS 

Worldwide,® the National Council on Aging, the National Fire Protection Association, 

the Home Safety Council, Meals on Wheels Association of America, and the National 

Safety Council . The Injury Center often pursues opportunities for collaboration with 

these agencies to support science and public health practices that promote home and 

community safety . Examples include research on smoke alarm technology; analysis of 

residential fires, including their causes and risk factors; prevention of falls among older 

adults; poisoning and overdose prevention; and promotion of effective childhood injury 

prevention strategies .

The Injury Center’s Research Priorities 

for Preventing Injuries at Home and 

in the Community

Given the finite resources available for conducting research, the following priorities are 

listed in two tiers . The first tier contains those priorities that reflect the most immediate 

research needs and those that should be supported first as resources become available . 

Categorizing the priorities into two tiers does not imply, however, that the first tier of 

priorities is more important than the second tier or that research related to the second 

tier of priorities should wait until 2014 to begin .
51

Tier 1

A. Develop and evaluate strategies for widespread dissemination and 

implementation of effective interventions to reduce injuries at home and in 

the community. Research has demonstrated that interventions at home and 

in the community are often effective in preventing home injuries, including 

for example, smoke alarms, bicycle helmets, swimming pool fencing, stair 

gates and window bars, secured storage for poisons, and child-resistant 

cigarette lighters . However, these strategies have not gained wide acceptance 

in certain areas and among particular racial/ethnic and socioeconomic groups 

because of purchase or installation costs or for other reasons . Encouraging 

widespread adoption of these efficacious interventions requires disseminationand implementation-related research, especially when related to largescale community injury prevention programs and policies . Demonstration 

programs should be developed and evaluated to determine the effectiveness of 

communication techniques, audience segmentation, dissemination strategies 

and communication channels, tailored messaging, and collaboration models to 

speed dissemination and to widen adoption .5

B. Develop and evaluate strategies and intervention programs to prevent 

injuries from residential fires and study the dissemination of communitybased programs. Approximately 80% of all fire deaths occur in the home . In 

2006, residential fires killed 2,580 persons and injured 12,925 .6 Researchers have 

identified the major causes of residential fires — cooking, heating and electrical 

equipment, and candles . The groups at highest risk for injury from fires are 

young children, older adults, persons with disabilities, and persons who live in 

poverty . Additionally, research has demonstrated that functioning residential 

smoke alarms in all homes can prevent one third of fire deaths by providing early 

warning of fires, which often occur at night when residents are sleeping .7

 Researchers should develop prevention strategies based on behavioral responses 

to a fire, examine fire risk perceptions, and test interventions among selected 

populations at high risk (e .g ., older adults and young children) . Because 

vulnerable populations (e .g ., rural residents, homebound and older adults, 

persons with disabilities, and children) are at higher risk for residential fires or 

fire-related injury death, interventions and programs to reduce these disparities 

are needed .8

 Rural residents are >2 times more likely to die in a fire than urban 

dwellers .9

 Interventions and programs to reduce this disparity are needed . In 

addition, rigorous evaluation of community-based programs, legislation and 

policy strategies, and engineering advances should be conducted to identify the 

most effective approaches .10 Research on the effectiveness of automatic firesuppression systems (e .g ., residential sprinklers) is also needed .
52

C. Develop and evaluate strategies and interventions to prevent falls among 

older adults and study dissemination of community-based programs.

Approximately 30% of older adults and 40% of those aged >80 years report 

having fallen during the previous year . Falls account for 43% of injury deaths 

among adults aged ≥65 years4 and result in 300,000 hip fractures annually . 

Individual factors known to increase the risk for a fall include decreased muscle 

tone and balance problems, vision problems, polydrug and psychotropic 

medication use, and sedentary lifestyles . Less conclusively, research indicates 

that certain home hazards and lifestyle behaviors might also contribute to the 

risk for falling .11

 Research regarding fall prevention interventions is needed for three phases — 

development, efficacy and effectiveness, and dissemination . For such proven 

interventions as strength and balance training and medication review and 

adjustment (especially for psychotropic drugs), research is needed to identify 

barriers to widespread adoption by public health and healthcare professionals . 

Researchers have already identified certain barriers . For example, health 

professionals lack adequate information regarding interventions demonstrated to 

be effective; others might have the information but do not use it in their work with 

patients and the public . After researchers have identified the barriers to widespread 

adoption, they should develop and test strategies for overcoming those barriers .

 Research is needed to translate effective fall prevention interventions into 

community-based programs . This includes research to identify the best formats 

and channels for delivering interventions to ensure that older adults adopt 

them . Health services and operations research is necessary for developing model 

infrastructures for service delivery that include partnerships between public health 

agencies and networks that serve the aging community . Research is also needed to 

identify persons most in need of fall prevention programs and to discern whether 

different programs work for different subgroups (e .g ., frail older adults, persons 

who have fallen previously, and persons with a fear of falling) .

 Finally, researchers and practitioners only have limited information regarding fallrelated interventions’ effectiveness when broadly applied in the community . Two 

examples are vision enhancement (e .g ., vision screening and correction and home 

lighting improvements) and the effectiveness and use of hip pads . Research should 

evaluate these types of interventions and determine how best to implement them 

in community settings with older adults . Further, researchers should use the results 

of biomechanics research to design and test new interventions .

D. Determine the burden and nature of nonpediatric poisoning and develop and 

evaluate intervention and dissemination strategies. Unintentional poisoning 

is an example of an emergent public health problem and is second only to motor 

vehicle traffic crashes as a leading cause of unintentional injury death in the United 

States . Ninety-five percent of poisoning deaths are attributed to drugs, including 

a substantial number resulting from prescription drugs . Unintentional poisoning 

mortality rates tripled in the United States during 1990–2004 . In 2005, a total 

of 23,618 unintentional drug poisoning deaths occurred in the United States, 

exceeding the number of homicides that year (18,124) .4,12,13

 Active surveillance for deaths by using medical examiner data, police reports, and 

toxicology databases is needed to further characterize unintentional poisonings . 

Research examining the risk for overdose by drugs, prescription history of those 

Falls account 

for 43% of injury

deaths among 

adults aged 

≥65 years.
53

persons who die from drug overdoses, and results of all injury deaths is necessary 

to target strategies to reduce deaths from unintentional poisonings . Evaluations 

of new interventions (e .g ., naloxone [a drug used to counter the effects of opioid 

overdoses], distribution programs, and Medicaid lock-in programs [restriction 

of selected Medicaid recipients from receiving prescriptions for abusable drugs]) 

and changes in prescribing and dispensing practices are critical to reducing 

unintentional poisoning deaths .

Tier 2

E. Determine the immediate causes of the most severe and disabling types of 

injuries among young children and develop and evaluate interventions to 

prevent them. Annually, injuries are the cause of half of the deaths that occur 

among children aged 1–4 years, and >6 .4 million children aged <15 years are 

examined in U .S . EDs for injury .

4

 Of approximately 9 million ED visits each 

year for unintentional injuries among children and adolescents, >25% occur 

among infants, toddlers, and preschoolers .

4

 In 2000, total lifetime medical costs 

of injuries for children aged <5 years totaled $3 .7 billion .14 The most common 

causes of injury deaths for young children are suffocations, fire and burns, and 

drownings .15 In addition, >1 million young children are examined in EDs each 

year for fall-related injuries .

4

 Research should better characterize childhood 

injuries and then develop and evaluate interventions in home and community 

settings to reduce the major risks and most serious consequences of injuries for 

this age group . Research is needed to test the effectiveness of population-based 

parenting and caregiver programs that can be implemented in a cost-effective 

manner to produce changes in childhood injury risks and injury outcomes .

F. Define and measure aspects of supervision for children and impaired older 

adults that improve injury prevention. Supervision is considered one of the 

strongest yet least understood protective factors against home and community 

injuries; potentially, enhanced supervision can reduce playground injuries, 

drowning deaths, dog bites, injuries to infirm older adults, and child pedestrian 

injuries . Prior CDC research has demonstrated that the developmental ability, 

temperament, and cognitive and physical abilities of children affect their 

requirements for supervision and the effectiveness of supervision .16 These 

factors also influence the degree of supervision needed for impaired older adults 

(e .g ., persons with Alzheimer disease, Parkinson disease, or stroke) and for 

children with special needs . Research should continue to focus on developing 

and validating classification schemes for supervision to capture patterns used 

throughout all ages and cultures . Researchers should develop measurement tools 

to describe and compare styles of supervision and test different supervisory 

interventions to measure their relative effectiveness in preventing injuries .

G. Develop and evaluate community-based, comprehensive interventions to 

prevent unintentional injuries and to promote safe and healthy homes. An 

average 18,048 deaths from unintentional home injuries occur annually, and 

another 12 million unintentional home injuries require some form of medical 

attention .

1

 In 1998, the cost of these injuries was estimated at $217 billion .17 The 

five leading causes of unintentional home injury death are falls, poisonings, fires 

or burns, choking or suffocation, and drownings; together these causes account 

for 90% of all unintentional home injury deaths . 

1
54

 For proven interventions (e .g ., smoke alarm installation and education or 

home modification for fall prevention), implementation and dissemination 

research is needed . Research that targets changes in the built environment18 and 

interventions to modify the social environment (e .g . social norms) to reduce 

injuries at home19 are also needed . This includes research to identify the best 

formats and channels for delivering interventions to ensure that households and 

communities adopt them . Health services research is necessary to develop model 

infrastructures for service delivery that include partnerships between public 

health agencies and networks that serve the community .

As part of dissemination research, investigators should identify barriers 

to widespread adoption by public health and healthcare professionals and 

organizations, as well as by individual home residents . Methods for overcoming 

those barriers should also be tested .5

Testing also is needed to determine the effectiveness of removing or reducing 

physical hazards in the home .20 Poisoning, choking or suffocation, and drowning 

prevention need particular attention . Healthy home assessments should be made 

and strategies tested to improve home safety among hard-to-reach populations and 

those at high risk . Studies are also needed to detect the influence of home type or 

age on injuries, and the influence of single and multihazard prevention programs .

H. Determine the impact of legislation, litigation, and regulation in preventing 

specific home and community injuries. Legislation, litigation, and regulation 

have been used to prevent injuries, but their relative effectiveness and costeffectiveness have not been firmly established . Legislation addresses the design, 

manufacture, sale, possession, or use of products, changes in human behavior, or 

changes in physical, social, or environmental risks . Litigation is used to uphold 

laws, and regulations address specific problems (e .g ., building codes or ordinances 

banning specific dog breeds) .21 Research should evaluate the effectiveness and 

cost-effectiveness of each of these approaches, their impact on individual and 

community risk, and their association with injury severity and costs .
55

References

1. Runyan CW, Casteel C, eds. State of Home Safety in AmericaTM: Facts About Unintentional 

Injuries in the Home. Chapel Hill, NC: Home Safety Council; 2004. Available at: 

http://www.homesafetycouncil.org/state_of_home_safety/sohs_2004_p017.pdf.

Accessed July 30, 2008.

2. Runyan CW, Perkis D, Marshall SW, et al. Unintentional injuries in the home in the United 

States. Part II: morbidity. Am J Prev Med 2005;28:80–7.

3. Stevens JA, Corso PS, Finkelstein EA, Miller TR. Costs of fatal and non-fatal falls among 

older adults. Inj Prev 2006;12:290–5.

4. National Center for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health and 

Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars. 

Accessed July 30, 2008.

5. Sogolow ES, Sleet DA, Saul J. Dissemination, implementation and widespread use of 

injury prevention interventions. In: Doll L, Bonzo S, Mercy J, Sleet D, eds. Handbook of 

Injury and Violence Prevention. New York: Springer; 2007: 493–510.

6. Karter MJ. Fire Loss in the United States During 2006. Quincy, MA: National Fire 

Protection Association, Fire Analysis and Research Division; 2007. Available at: 

http://www.nfpa.org/assets/files/PDF/OS.fireloss.pdf. Accessed July 30, 2008.

7. Ahrens M. Home Structure Fires. Quincy, MA: National Fire Protection 

Association, Fire Analysis and Research division; 2007. Available at: 

http://www.nfpa.org/assets/files/PDF/OS.Homes.pdf. Accessed July 30, 2008.

8. Warda LJ, Ballesteros MF. Interventions to prevent residential fire injury. In: Doll LS, 

Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence Prevention. New 

York: Springer; 2007: 97–115.

9. Warda L, Tenenbein M, Moffatt ME. House fire injury prevention update. Part I. 

A review of risk factors for fatal and non-fatal house fire injury. Inj Prev 1999;5:145–50

10. McDonald EM, Gielen AC. House fires and other unintentional home injuries. In: 

Gielen A, Sleet DA, DiClemente R, eds. Injury and Violence Prevention: Behavioral Change 

Theories, Methods, and Applications. San Francisco, CA: Jossey-Bass; 2006: 274–96.

11. Rubenstein LZ, Stevens JA, Scott V. Interventions to prevent falls among older adults. 

In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence 

Prevention. New York: Springer; 2007: 37–53.

12. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United 

States. Pharmacoepidemiol Drug Saf 2006;15:618–27.
56

13. CDC. Unintentional poisoning deaths—United States, 1999–2004. MMWR Morb 

Mortal Wkly Rep 2007;56:93–6.

14. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in the 

United States. New York: Oxford University Press; 2006.

15. Borse NN, Gilchrist J, Dellinger AM, Rudd RA, Ballesteros MF, Sleet DA. CDC 

Childhood Injury Report: Patterns of Unintentional Injuries Among 0–19 Year 

Olds in the United States, 2000–2006. Atlanta, GA: US Department of 

Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Injury Prevention and Control; 2008. Available at: 

http://www.cdc.gov/SafeChild/images/CDC-ChildhoodInjury.pdf. 

Accessed December 23, 2008.

16. Morrongiello B, Lasenby J. Supervision as a behavioral approach to reducing childinjury risk. In: Gielen A, Sleet DA, DiClemente R, eds. Injury and Violence Prevention: 

Behavioral Change Theories, Methods, and Applications. San Francisco, CA: JosseyBass; 2006: 395–418.

17. Zaloshnja E, Miller TR, Lawrence BA, Romano E. Costs of unintentional home injuries. 

Am J Prev Med 2005;28:88–94.

18. Staunton C, Frumkin H, Dannenberg AL. Changing the built environment to prevent 

injury. In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and 

Violence Prevention. New York: Springer; 2007: 257–75.

19. Mercy JA, Mack KA, Steenkamp M. Changing the social environment to prevent 

injuries. In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and 

Violence Prevention. New York: Springer; 2007: 277–94.

20. Lyons RA, Towner EE, Kendrick D, et al. UK Burden of Injury Study—a protocol. 

BMC Public Health 2007;7;317.

21. Shaw F, Ogolla CP. Law, behavior, and injury prevention. In: Gielen A, Sleet DA, 

DiClemente R, eds. Injury and Violence Prevention: Behavioral Change Theories, 

Methods, and Applications. San Francisco, CA: Jossey-Bass; 2006: 442–66.
57

Sports, Recreation, 

and Exercise

Public Health Burden

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

and widespread in U .S . culture . SRE activities include organized sports (e .g ., 

school- or club-sponsored); unorganized sports (e .g ., backyard or pick-up 

basketball, football, and hockey); recreational activities at home and in national 

parks, forests, and waterways (e .g ., boating, camping, rafting, hiking, biking, 

skiing, swimming, and playground activities); and exercise and training activities 

(e .g ., weight-lifting, aerobics, and jogging) .

Participation in SRE activities contributes to health-related fitness; however, the 

risk for injury is inherent in any physical activity and in high-risk environments . 

In 2005, unintentional drowning was the second leading cause of injury 

death among children aged 1–14 years, killing 3,582 U .S . residents that year .1 

Approximately 11,000 persons receive treatment in U .S . emergency departments 

(EDs) each day for injuries sustained during SRE activities .2 One of every six 

ED visits for an injury results from participation in sports or recreation . During 

July 2000–June 2001, an estimated 1 .4 million U .S . residents were examined in 

EDs for injuries sustained while playing basketball, baseball, softball, football, or 

soccer . Injuries are also a leading reason people stop participating in potentially 

beneficial physical activity .

Risk for injury varies by factor, including specific activity and participant age . 

Children aged <15 years account for 23% of all drownings1 and approximately 

45% of all SRE-related ED visits .2

 They might be at risk because of immature 

or underdeveloped coordination, skills, and perception . Adolescents and 

young adults aged <25 years have high participation rates in SRE activities and 

experience approximately 29% of all SRE-related injuries .2 The population of 

older adults is increasing, but knowledge is limited regarding their injury risk 

during participation in SRE .

Data are limited regarding injury incidence and prevalence, costs, relative risks 

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

programs to prevent SRE injuries . Although ED surveillance data are available, 

they lack exposure information and exclude the substantial proportion of 

SRE injuries that are treated in primary care settings, sports medicine clinics, 

orthopedic clinics, and chiropractic clinics .
58

The Injury Center’s Approach to Sports, Recreation, 

and Exercise Safety

CDC’s mission includes both promoting physical activity and preventing injuries . 

Although CDC’s National Center for Chronic Disease Prevention and Health Promotion 

has an active research program in physical activity, the Injury Center includes a focus on 

SRE injury prevention . The scope and depth of this research has been limited, and the 

Injury Center is uniquely positioned to provide epidemiologic and prevention research 

regarding SRE-related injuries . Although other federal agencies or national organizations 

sometimes fund SRE injury research, that research has not been as broad-based as 

activities in the Injury Center . Examples of federal agencies with particular interest in 

SRE include the National Institutes of Health (NIH), the National Park Service, the 

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

supports foundational research in SRE-related trauma and injury prevention; the Coast 

Guard supports boating safety programs and surveillance; and the National Park Service 

has a visitor’s safety program . CPSC provides selected ED surveillance; however, its 

information does not include data related to participation rates (i .e ., exposure data) that 

might facilitate comparisons . CPSC traditionally focuses on product-based research 

to protect consumers from hazardous products . With Injury Center funding, CPSC 

expanded its surveillance to include all injuries treated in EDs, regardless of cause .1

The Injury Center’s Research Priorities 

in Sports, Recreation, and Exercise Safety

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Examine strategies to increase dissemination and adoption of effective 

interventions to prevent sports-, recreation-, and exercise-related injuries.

Effective interventions exist to prevent SRE-related injuries, but they 

frequently are not used . Examples include bike helmets and other protective 

equipment, break-away baseball bases, impact-reducing playground surfacing, 

and swimming pool fencing . Research should assess factors that hinder or 

encourage adoption of these effective interventions, including sociocultural 

and environmental influences, organizational leadership and infrastructure, 

community engagement, and coalition building . Studies should also assess 

different methods to increase awareness of effective interventions, test different 

strategies to disseminate effective interventions, tailor programs to local 

circumstances, and maintain fidelity to intervention guidelines .3 Research should 

strengthen the successful implementation of interventions and programs related 

to drowning prevention, playground safety, bicycle safety, and other SRE injury 

prevention activities .
59

B. Develop and evaluate environmental, behavioral, and legislative or 

regulatory interventions to prevent sports-, recreation-, and exercise-related 

injuries. Existing interventions are often promising but have not yet been 

evaluated . The lack of evidence regarding the effectiveness of interventions 

in SRE is apparent, including the effects of modifying aspects of the physical 

environment (e .g ., changing playground designs), equipment (e .g . hockey 

sticks or baseballs), use of existing and newly designed safety gear, and sex- and 

age-specific equipment use requirements and rules of play .4

 The importance of 

the presence and training of coaches and certified athletic trainers, supervision 

of young children participating in SRE, and the roles of caregivers, schools, 

and physicians in preventing injury during organized sports activities should 

be examined . Finally, research is needed to assess the effects of policies and 

practices regarding safety gear usage (e .g ., bike helmets), school and club 

practice guidelines, modification in the rules of play for organized sports, and 

the use of highly skilled officiating .

C. Evaluate existing and develop new methods to obtain exposure and injury 

incidence data for sports-, recreation-, and exercise-related injuries. Recent 

reports estimate that approximately 4 .2 million ED visits occur each year for 

injuries related to participation in sports and recreation .2

 However, without 

reliable methods for estimating frequency and duration of participation 

during these physical activities (i .e ., exposure data to calculate denominators), 

researchers cannot determine injury rates and compare them across activities . 

Population-based SRE-related injury information can be obtained from multiple 

sources . Population-based participation surveys exist and, if validated, can serve 

as sources of denominator data for such studies . Accurate estimates of numbers 

of injuries combined with participation rates will enable researchers to examine 

risk and protective factors and to develop prevention strategies . These findings 

will facilitate more effective, programmatic decision making .

Tier 2

D. Determine the short-term economic costs of injuries related to sports, 

recreation, and exercise. SRE-related injuries are not a major source of 

mortality; however, they place a substantial burden on the healthcare system 

for both initial care and rehabilitation . They also result in costs related to lost 

productivity and other economic factors . Despite the considerable number 

of ED visits for these injuries, the majority of medical treatments for SRErelated injuries are administered by healthcare providers outside of emergency 

settings, indicating that the magnitude of the problem is much greater than ED 

statistics indicate . For example, in the United States, anterior cruciate ligament 

(ACL) knee injuries are usually sports-related and can be debilitating enough to 

prevent continued physical activity . The cost per ACL injury is approximately 

$17,000, and surgical and rehabilitative costs total approximately $646 million 

annually in the United States .5

 Data from other countries also demonstrate that 

the cost of other SRE-related injuries is considerable . Quantifying healthcare 

and other economic costs to society of SRE-related injuries and delineating the 

sources of those costs will provide a critical foundation for documenting the 

public health burden of these injuries .
60

E. Identify ways to minimize injury risk among persons initiating or increasing 

physical activity. Certain factors influence recommendations for starting and 

increasing physical activity, including age, sex, fitness level, nutritional status, 

anthropometry, and injury history . In 1996, persons aged ≥65 years made 53,000 

sports-related ED visits . This represented an increase of 54% since 1990 .6

 As the U .S . 

population continues to live longer, they will likely remain active longer, increasing 

the risk for injury with aging . Research should identify strategies to reduce injuries 

while attempting to improve physical fitness of participants at all fitness levels . 

Knowledge regarding differences in human tolerance by age, fitness level, and sex is 

an important prerequisite for prevention . Researchers should develop science-based 

guidelines for choosing an activity, and they should recommend the frequency, 

intensity, and duration of participation, given a prospective participant’s fitness level, 

propensity toward injury, and injury history . Research should also evaluate use of 

personal protective devices and training programs . Special populations, including 

children, older adults, women, and persons who are obese or undernourished, 

should receive particular attention . Additionally, research indicates that exercise is 

critically needed among older persons to maintain physical and mental health and 

independence . Research in this area should focus on understanding the risks related 

to different SRE activities among this population and, where possible, examine those 

at risk in relation to the benefits of these activities .

F. Identify risk and protective factors for and evaluate interventions to 

prevent injuries in outdoor recreation environments. Extreme and protected 

environments (e .g ., national parks, forests, and waterways) offer wide-ranging 

recreational opportunities (e .g ., wilderness camping, mountaineering, trail 

hiking, rafting, swimming, boating, and biking) and attract tens of millions of 

visitors each year . During January 2004–December 2005, approximately 425,400 

persons were treated in EDs in the United States for outdoor recreational injuries . 

However, data are limited regarding injury circumstances and risk and protective 

factors related to injury in these environments .7 Because of the diverse types of 

activities in which visitors to these locations engage, the origin and experience 

level of these visitors, and the inherent risks within these protected settings, 

visitor risk management in the extreme outdoor environments continues to be 

an injury problem of increasingly complexity .8,9 Furthermore, because federal 

recreational lands are often preserved and protected, common engineering 

solutions are not always feasible . Risk management evaluation and health 

communication research can enhance federal land managers’ efforts in identifying 

effective injury prevention strategies that also protect the natural environment 

and preserve opportunities for tourism . Studies should address education, 

protective equipment use, road and vehicle design, the influence of alcohol and 

posted warnings, and public policy and legislative interventions applicable to 

outdoor recreation environments .

Approximately

d

on 

4.2 million ED

visits occur 

each year for

injuries relate

to participati

in sports and 

recreation.
61

References

1. National Centers for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health and 

Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars. 

Accessed July 30, 2008.

2. CDC. Nonfatal sports- and recreation-related injuries treated in emergency 

departments— United States, July 2000–June 2001. MMWR Morb Mortal Wkly Rep 

2002;51:736–40.

3. Sogolow ES, Sleet DA, Saul J. Dissemination, implementation and widespread 

use of injury prevention interventions. In: Doll L, Bonzo S, Mercy J, Sleet D, eds. 

Handbook of Injury and Violence Prevention. New York: Springer; 2007: 493–510.

4. MacKay M, Liller K. Behavioral considerations for sports and recreational injuries in 

children and youth. In: Gielen AC, Sleet DA, DiClemente RJ, eds. Injury and Violence 

Prevention: Behavioral Science Theories, Methods, and Applications. San Francisco, 

CA: Jossey-Bass; 2006: 257–73.

5. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular 

training on the incidence of knee injury in female athletes: a prospective study. 

Am J Sports Med 1999;27:699–706.

6. Rutherford GW Jr., Schroeder TJ. Sports-Related Injuries to Persons 65 Years of Age 

and Older. Washington, DC: US Consumer Product Safety Commission; 1998. 

Available at: http://www.cpsc.gov/CPSCPUB/PUBS/GRAND/aging/injury65.PDF. 

Accessed July 30, 2008.

7. Flores AH, Haileyesus T, Greenspan AI. National estimates of outdoor recreational 

injuries treated in emergency departments, United States, 2004–2005. Wilderness 

Environ Med 2008;19:91–8.

8. National Outdoor Leadership School. Wilderness Risk Management Conference 

Proceedings. Snowbird, Utah, October 28–30, 2005.

9. Roehl WS, Fesenmaier DR. Risk perceptions and pleasure travel: an exploratory 

analysis. Journal of Travel Research 1992;30(4):17–26.
62

Transportation

Public Health Burden

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

open water . The overwhelming majority of these deaths and injuries result from motor 

vehicle (MV) ground transportation . Transportation injuries for the purposes of this 

research agenda include drivers, occupants, and pedestrians affected by motorized 

vehicles . In 2005, MV crashes resulted in 45,343 deaths and were the leading cause of 

death in the United States among persons aged 1–34 years .1 Annually, approximately 

8,000 children ages 0–19 years die from transportation-related injuries, with the highest 

rates among those aged 15–19 years .2 In 2006, an estimated 4,262,553 persons suffered 

nonfatal transportation–related injuries that required an emergency department (ED) 

visit, and of those, 346,813 required hospitalization or were transferred for specialized 

care .1 The economic impact is substantial . In 2000, MV crashes cost >$230 billion in 

property damage, lost productivity, and medical expenses . These estimates do not 

include the unquantifiable costs of pain and suffering or the value of lives lost .3

Despite such achievements as increased safety belt use and declining numbers of alcoholrelated crashes, injuries and fatalities caused by MV crashes remain a serious public 

health problem . Data reveal the need to direct prevention efforts toward specific groups 

(e .g ., child safety and adolescent and older adult drivers) . Pedestrian fatalities are a 

growing problem, and alcohol and drug use persist as key factors in crashes and injuries . 

Collaboration among partners is essential in preventing transportation-related injuries .

The Injury Center’s Approach to Transportation Safety

CDC’s Injury Center conducts and sponsors population-based epidemiologic, public 

health, behavioral, biomechanics, and trauma research to develop practical, evidencebased prevention strategies for MV–related injuries . CDC has been instrumental in 

framing MV injury as a public health problem and in helping to raise public awareness 

that these injuries are predictable and preventable .4,5

The Injury Center’s research programs focus on determining the magnitude, severity, 

and cost of MV injuries; the size and vulnerability of populations at risk; the influence 

of coexisting medical conditions on crashes and injuries; and causes, risk factors, and 

effective interventions applicable to public health settings . Its use of hospitals and 

EDs for collecting MV injury data and for conducting brief interventions add critical 

contributions to the field . The Injury Center’s peer-review process for selecting and 

funding research also distinguishes its work and advances this area of study; grantees 

publish their findings in peer-reviewed literature, accelerating the accessibility of 

knowledge for scientists and public health practitioners . Finally, multiple CDCfunded academic Injury Control Research Centers conduct studies regarding 

transportation-related injury .
63

The Injury Center’s research priorities in MV safety build on CDC’s focus on 

the public health implications of traffic injuries, one of the major causes of death 

and disability in the United States and globally . Ongoing research includes 

behavioral risk factor surveillance for alcohol and driving and identification of 

risk and protective factors related to child safety seats . An emphasis on older 

drivers reflects CDC’s focus on healthy aging . Similarly, the Injury Center’s focus 

on adolescent drivers takes advantage of CDC’s expertise in quantifying and 

understanding adolescent health risks and implementing effective interventions 

(e .g ., graduated driver licensing [GDL] laws) . For example, CDC’s Youth Risk 

Behavior Surveillance Survey tracks self-reported MV injury risk behaviors 

among adolescent drivers .

6

 The Injury Center takes a developmental-risk 

perspective regarding adolescent drivers, which is characterized by its cooperative 

research with the National Institutes of Health (NIH) in studying the effects of 

persuasive communication, parental monitoring of youth driving behavior, and 

GDL systems for adolescents . The Injury Center also focuses on populations 

traditionally underserved and at high risk through such projects as the Tribal 

Motor Vehicle Injury Prevention program, which works to decrease deaths and 

injuries on the road among Americans Indians/Alaska Natives . It also emphasizes 

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

the science base for the MV injury prevention chapter in The Guide to Community 

Preventive Services (available at http://www .thecommunityguide .org), in which 

recommendations are made regarding use of evidence-based strategies to reduce 

alcohol-impaired driving and to increase use of safety belts and child safety seats .

7

The Injury Center works closely with other federal agencies, nonprofit organizations, 

and researchers . For example, it has a strong partnership with the National Highway 

Traffic Safety Administration (NHTSA), the lead regulatory agency for MV 

safety . The Injury Center’s efforts complement those of NHTSA, which sponsors 

and conducts research and produces technical reports on supporting traffic 

safety regulations, MV safety standards, and legislative initiatives . In partnership 

with the World Health Organization, the Injury Center developed surveillance 

guidelines and recommended strategies for MV injury prevention for developing 

countries, coauthoring the World Report on Road Traffic Injury Prevention .

8

 Injury 

Center staff also participate on Transportation Research Board committees on 

transportation for an aging society, alcohol-impaired driving, pedestrian safety, and 

school transportation safety . Other key partners in transportation safety include 

NIH’s National Institute for Child Health and Human Development, the National 

Transportation Safety Board, the Transportation Research Board of the National 

Academy of Sciences, the Insurance Institute for Highway Safety, the American 

Automobile Association’s Foundation for Traffic Safety, SAFE KIDS Worldwide,® 

and the National Safety Council .

State and local health departments are a natural constituency for the Injury Center’s 

research, and they provide key entries for developing and implementing effective 

interventions in communities . CDC’s long history and close associations with 

all 50 state health departments, local health jurisdictions, and schools of public 

health provide a foundation from which the Injury Center can support effective 

collaborations to prevent transportation-related injuries .
64

The Injury Center’s Research Priorities 

in Transportation Safety

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Evaluate strategies to implement and disseminate known, effective 

interventions for reducing alcohol-impaired driving and test the 

effectiveness of new, innovative strategies. Driving after drinking alcohol is 

a major risk factor for MV crashes and is associated with >16,000 deaths and 

250,000 injuries annually .9

 In 2000, alcohol-related fatality rates increased for 

the first time in years, accounting for approximately 40% of MV deaths .10 For 

motorcyclists, the rate of alcohol involvement in fatal crashes is even higher . 

Children are frequent victims of alcohol-impaired drivers . Annually, hundreds 

of children aged <15 years die in MV crashes while riding with drivers who 

are impaired by alcohol .9,11 In addition to the human costs, crashes involving 

alcohol are expensive . In 2000, these crashes cost U .S . residents $51 billion in 

direct costs and lost earnings .12 Law enforcement sources report 1 .4 million 

arrests for driving under the influence (DUI) every year; however, according 

to the annual Behavioral Risk Factor Surveillance System, >150 million selfreported episodes of DUI also occur .13

 Since 1970, states and communities have implemented an array of strategies 

for reducing alcohol-impaired driving, with varying success . Laws and 

enforcement strategies for deterring alcohol-impaired driving and controlling 

the sale or public consumption of alcohol are among the most widely used 

strategies . Community-based interventions including sobriety checkpoints, 

lower legal limits for blood-alcohol concentration (BAC), zero-tolerance laws, 

enhanced enforcement of alcohol control policies, and training programs 

for servers of alcoholic beverages have been demonstrated to be effective .14–16 

However, a better understanding of the factors that most influence successful 

implementation of these prevention strategies and policies is needed . 

Research should include strategies drawn from health communication, policy 

development, enforcement, advocacy, and other approaches relevant to 

improving dissemination and adoption of effective interventions .

 Research should assess existing interventions directed toward groups at high 

risk and those implemented in special settings; screening and early intervention 

for alcohol-impaired driving in public settings; licensing requirements; and the 

benefits, costs, and social acceptability of successively lower BAC standards . 

Simultaneously, searches for new and innovative strategies for reducing alcoholimpaired driving should continue .
65

B. Develop methodologies for and evaluate the effectiveness of translating 

transportation safety research findings into public policy. Laws have been 

applied at both state and federal levels to prevent MV injuries . However, tools 

are rare by which to measure how research translates into laws and regulations 

that encourage drivers to adopt safer behaviors . Research regarding the 

evolution of prevention strategies — from scientific evidence to legislation 

to product design and manufacturing changes — has the potential to reduce 

injury rates on a substantial scale . For example, research on the effectiveness 

of 0 .08% BAC was critical to the success of the passage of new 0 .08% BAC 

legislation .15 Research on the role of tort litigation is needed to measure its 

effectiveness in changing industry practices or personal safety behaviors behind 

the wheel . Research should also evaluate the types of information used to 

support successful policies and regulatory decisions (e .g ., GDL laws) . Although 

the most comprehensive GDL systems are associated with the greatest benefits, 

states vary widely in their implementation, and the reasons for this lack of 

uniformity are largely unkown .17

To determine the components of a successful MV injury prevention program, 

campaign, or policy action, research should evaluate the persuasiveness of 

data regarding injury’s incidence, prevalence, severity, costs, and related 

outcomes of MV–related injuries (e .g ., disabilities and functional impairments) . 

Likewise, evaluation data are needed regarding the cost and cost-effectiveness 

of interventions and the power that a personal or family member car crash 

can have on opinions and legislative action . Research is also needed that 

examines the effects of broad policy shifts (e .g ., reforms in traffic enforcement, 

vehicle safety improvements, or speed cameras), the effects of policies directed 

specifically at younger or older drivers (e .g ., driving curfews, restrictive 

licensing, or retesting before driver license renewals), and the effects of policies 

aimed at scaling up effective interventions to achieve population impact .

C. Identify the underlying behavioral and situational factors associated with 

crashes involving adolescent drivers and develop and evaluate appropriate 

interventions to address those factors. In 2006, approximately 7,500 young 

drivers died of injuries caused by MV crashes .18 Research indicates that 

young drivers are more likely than others to speed, fail to stop at red lights, 

make illegal turns, ride with an intoxicated driver, and drive after using 

alcohol or drugs . They are more likely than other drivers to underestimate 

the dangers of hazardous situations, and they have less experience coping 

with those situations . Youth who drive after consuming alcohol pose an 

inordinate risk to themselves, their passengers, and other road users .

To prevent MV crashes among young drivers, research should evaluate 

strategies that limit access to driving and increase new drivers’ time behind 

the wheel under safe driving conditions (e .g ., those implemented in GDL 

programs) . Research is needed to determine the most efficient combination 

of elements in GDL laws to protect young drivers, limit adolescents’ access to 

Driving after 

drinking is 

associated with 

≥16,000 deaths 

and 250,000 

injuries annually.
66

alcohol, and increase use of safety belts . Research should also identify behavioral 

and developmental characteristics that predispose certain adolescents to take greater 

risks than their peers . Research to identify constellations of risk factors that can be 

used to develop and target interventions should focus on behavioral rather than 

epidemiologic studies, and it should examine both protective factors and risk factors 

(e .g ., the roles of supervision, family, peers, risk perception, decision-making skills, 

and community characteristics) .

D. Develop and evaluate interventions that address correct and consistent use of 

measures for protecting child occupants in motor vehicles. In 2005, a total of 1,617 

children aged ≤15 yeas were killed while riding in MVs,1,19 and an estimated 225,096 

sustained nonfatal injuries requiring an ED visit in 2006 .1 Correct installation of 

age-appropriate child restraint systems (e .g ., child safety seats or booster seats) and 

correct placement of children in those restraints increase safety . Data demonstrate 

that in the United States, Hispanics have lower rates of child safety seat use than 

non-Hispanic whites . Research also indicates that children seated in the back seat 

are safer than children seated in the front seat .

 Further research regarding the efficacy, effectiveness, and safety of using air bags 

with child passengers and using booster seats for children who have outgrown 

their child safety seats is needed . More research is needed to document the 

efficacy and effectiveness of booster seats in preventing injury and to establish 

more rigorous guidelines for their correct use on the basis of such variables as age, 

height, weight, and other relevant anthropometric variables . This research can 

provide information for performance standards development and highway safety 

regulation implementation .

 Research should also assess the impact of child safety seat and booster seat laws as 

well as enforcement strategies and training or seat-checking programs intended to 

increase correct use . Continued research is needed regarding the effectiveness of 

universal fasteners and alternative restraint designs, including devices that improve 

comfort and convenience . Research should evaluate strategies to improve correct 

use and decrease misuse of safety devices and to improve communication efforts to 

promote child occupant safety .

 In addition to restraint use, research should investigate factors that persuade 

drivers to place children in the back seat or to refrain from drinking alcohol before 

transporting children . The results of such research should guide intervention 

development, evaluation, and dissemination . A focus on special populations (e .g ., 

innercity or non-English–speaking groups) not reached by common communication 

channels is crucial, and a focus on researching the effectiveness of health literacy 

efforts with these populations is needed .

E. Evaluate the effectiveness of behavioral and environmental strategies to prevent 

pedestrian injury. Pedestrians account for approximately 13% of MV–related deaths 

in the United States . Annually, >5,000 pedestrians are killed and another 170,000 are 

injured in MV incidents .1

 The majority of pedestrians injured or killed are young 

children, older adults, or alcohol-impaired persons .20 Pedestrian injuries that occur 

in rural areas are more likely to be fatal than those occurring in urban areas .21
67

 Because the problem is complex and ecological — involving pedestrian and 
68

 Research should evaluate the effectiveness of changes in vehicle and restraint 
69

References

1. National Center for Injury Prevention and Control. Web-based Injury 

Statistics Query and Reporting System (WISQARS). Atlanta, GA: US 

Department of Health and Human Services, CDC; 2008. Available at: 

http://www.cdc.gov/ncipc/wisqars. Accessed July 30, 2008.

2. Borse NN, Gilchrist J, Dellinger AM, Rudd RA, Ballesteros MF, Sleet DA. CDC 

Childhood Injury Report: Patterns of Unintentional Injuries Among 0–19 Year 

Olds in the United States, 2000–2006. Atlanta, GA: US Department of 

Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Injury Prevention and Control; 2008. Available at: 

http://www.cdc.gov/SafeChild/images/CDC-ChildhoodInjury.pdf. 

Accessed December 23, 2008.

3. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in 

the United States. New York: Oxford University Press; 2006.

4. Dellinger A, Sleet DA, Jones BH. Drivers, wheels, and roads: motor vehicle safety 

in the Twentieth Century. In: Ward JW, Warren C, eds. Silent Victories: The History 

and Practice of Public Health in Twentieth-Century America. New York: Oxford 

University Press; 2007: 343–62.

5. Sleet DA, Dinh-Zarr TB, Dellinger AM. Traffic safety in the context of public health 

and medicine. In: Improving Traffic Safety Culture in the United States: The Journey 

Forward. Washington, DC: AAA Foundation for Traffic Safety; 2007: 41–58.

6. National Center for Chronic Disease Prevention and Health Promotion. 

YRBSS: Youth Risk Behavior Surveillance System. Atlanta, GA: 

US Department of Health and Human Services, CDC; 2008. Available at: 

http://www.cdc.gov/HealthyYouth/yrbs/index.htm. Accessed July 30, 2008.

7. Task Force on Community Preventive Services. Motor Vehicle Occupant Injury. 

Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available 

at: http://www.thecommunityguide.org/. Accessed on July 30, 2008.

8. Peden M, Scurfield R, Sleet D, et al., eds. World Report on Road Traffic Injury 

Prevention. Geneva: World Health Organization; 2004. Available at: 

http://www.who.int/violence_injury_prevention/publications/

road_traffic/world_report/en/index.html. Accessed July 30, 2008.

9. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 2006 

data: alcohol-impaired driving. Washington, DC: US Department of Transportation, 

NHTSA; 2008. Publication no. DOT HS 810 801. Available at: http://www-nrd.nhtsa.

dot.gov/Pubs/810801.PDF. Accessed July 30, 2008.

10. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2000: alcohol. Washington, DC: US Department of Transportation, NHTSA; 2001. 

Publication no. DOT HS 809 323. Available at: http://www-nrd.nhtsa.dot.gov/

Pubs/2000ALCFACTS.PDF. Accessed July 30, 2008.
70

11. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2006 data: children. Washington, DC: US Department of Transportation, 

NHTSA; 2007. Publication no. DOT HS 810 803. Available at: 

http://www-nrd.nhtsa.dot.gov/Pubs/810803.PDF. Accessed July 30, 2008.

12. Blincoe L, Seay A, Zaloshnja E, et al. Economic Impact of Motor Vehicle Crashes, 

2000. Washington, DC: US Department of Transportation, National Highway Traffic 

Safety Administration; 2002. Available at: http://www.nhtsa.dot.gov/

staticfiles/DOT/NHTSA/Communication%20&%20Consumer%20Information/

Articles/Associated%20Files/EconomicImpact2000.pdf. Accessed July 30, 2008.

13. National Center for Chronic Disease Prevention and Health Promotion. Behavioral 

Risk Factor Surveillance System. Atlanta, GA: US Department of Health and Human 

Services, CDC; 2008. Available at: http://www.cdc.gov/brfss/. Accessed July 30, 2008.

14. Elder RW, Nichols JL, Shults RA, Sleet DA, Barrios LC, Compton R; Task Force on 

Community Preventive Services. Effectiveness of school-based programs for 

reducing drinking and driving and riding with drinking drivers: a systematic review. 

Am J Prev Med 2005;28(5 Suppl):288–304.

15. Shults RA, Elder RW, Sleet DA, et al.; Task Force on Community Preventive Services. 

Reviews of evidence regarding interventions to reduce alcohol-impaired driving. Am 

J Prev Med 2001;21(4 Suppl):66–88.

16. Hingson RW, Swahn MH, Sleet DA. Interventions to prevent alcohol-related injuries. 

In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence 

Prevention. New York: Springer; 2007: 295–310.

17. Baker SP, Chen L-H, Li G. Nationwide Review of Graduated Driver Licensing. 

Washington, DC: AAA Foundation for Traffic Safety; 2007.

18. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2006 data: young drivers. Washington, DC: US Department of 

Transportation, NHTSA; 2007. Publication no. DOT HS 810 817. Available at: 

http://www-nrd.nhtsa.dot.gov/Pubs/810817.PDF. Accessed July 30, 2008.

19. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2005 data: occupant protection. Washington, DC: US Department of 

Transportation, NHTSA; 2006. Publication no. DOT HS 810 621. Available at: 

http://www-nrd.nhtsa.dot.gov/Pubs/810621.PDF. Accessed July 30, 2008.

20. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2006 data: pedestrians. Washington, DC: US Department of Transportation, 

NHTSA; 2007. Publication no. DOT HS 810 810. Available at: 

http://www-nrd.nhtsa.dot.gov/Pubs/810810.PDF. Accessed July 30, 2008.

21. Mueller BA, Rivara FP, Bergman AB. Urban-rural location and the risk of dying in a 

pedestrian-vehicle collision. J Trauma 1988;28:91–4.
71

22. Hakamies-Blomquist L. Safety of older persons in traffic. In: Transportation in an 

Aging Society: A Decade of Experience. Conference Proceedings 27, Bethesda, MD, 

November 7–9, 1999.

23. National Highway Traffic Safety Administration (NHTSA). Traffic safety facts, 

2006 data: motorcycles. Washington, DC: US Department of Transportation, 

NHTSA; 2008. Publication no. DOT HS 810 806. Available at: 

http://www-nrd.nhtsa.dot.gov/Pubs/810806.PDF. Accessed July 30, 2008.

24. Glassbrenner D, Ye J. Motorcycle helmet use in 2006—overall results. Washington, 

DC: US Department of Transportation, National Highway Traffic Safety 

Administration; 2006. Publication no. DOT HS 810 678. Available at: 

http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/RNotes/2006/810678/810678.

html. Accessed July 30, 2008.

25. CDC. Trends in motorcycle fatalities associated with alcohol-impaired driving—

United States, 1983–2003. MMWR Morb Mortal Wkly Rep 2004;53:1103–6.

26. Dellinger AM, Sleet DA, Shults RA, Rinehart CF. Interventions to prevent motor 

vehicle injuries. In: Doll LS, Bonzo SA, Mercy JA, Sleet DA, eds. Handbook of Injury 

and Violence Prevention. New York: Springer; 2007: 55–79.

Violence Prevention

75

Child Maltreatment

Public Health Burden

Child maltreatment is any act or series of acts of commission or omission by a parent 

or caregiver that results in harm, potential for harm, or threat of harm to a child . Child

l, 

l, 

, 

h

ge

e 

maltreatment can be divided into two broad types . Acts of commission (i .e ., abuse) 

involve words or overt actions that cause harm, potential harm, or threat of harm to 

a child . Acts of omission (i .e ., neglect) include indirect forms of maltreatment (e .g ., 

failure to provide for a child’s basic physical, emotional, or educational needs, or to 

protect a child from dangerous or possibly dangerous situations) . Much of the child 

maltreatment field divides acts of commission into three broad categories — physica

sexual, or emotional abuse (e .g ., psychological or verbal abuse and mental injury) . 

Acts of omission are often referred to as child neglect and divided into two categories

— failure to provide for a child’s basic needs (e .g ., physical, emotional, medical/denta

or educational neglect) and failure to protect a child (e .g ., inadequate supervision or 

exposure to violent or unsafe environments) .1

The magnitude of child maltreatment in the United States is not easily determined, 

but is clearly substantial . In 2006, Child Protective Services (CPS) confirmed 

approximately 905,000 cases of child maltreatment in the United States, and an 

estimated 1,530 children died as a result of abuse or neglect .2 However, confirmed 

cases of maltreatment represent only a fraction of the true magnitude of the 

problem because cases often are not reported to social service agencies . Survey 

data provide a more troublesome picture of the problem of child maltreatment . 

Estimates based on a national survey of children aged 2–17 years conducted during 

2002–2003 indicate that approximately one in eight children reported having 

experienced maltreatment .3 Surveys of adults also reveal high rates of childhood 

maltreatment, with 20%–32% of women and 14%–40% of men reporting some 

form of abuse or neglect during childhood .4,5

Child maltreatment often has immediate sequelae (e .g ., traumatic brain injury, death

and childhood emotional and behavioral problems), but research in neurobiologic, 

behavioral, and social sciences indicates that early childhood experiences also affect t

long-term development of the brain and subsequent vulnerability to multiple mental

and physical health problems during adolescence and adulthood . Such problems ran

from anxiety disorders and depression to cardiovascular disease and diabetes .6–9

The Injury Center’s Approach 

to Child Maltreatment Prevention

The mission of CDC’s child maltreatment prevention program is to prevent 

maltreatment and its consequences through surveillance, research and development, 

capacity building, communication, and leadership . In pursuit of this mission, CDC’s 

public health approach complements such other approaches as those of the criminal 

justice and mental health systems . In particular, CDC’s approach emphasizes primary 

prevention of perpetration of child maltreatment or efforts that focus on preventing 

maltreatment before it occurs . CDC places emphasis on rigorous science in its efforts 

to monitor and track trends, research risk and protective factors, rigorously evaluate 

interventions, and learn how best to implement them . This multipronged effort adds 

to the knowledge base regarding violence and how to prevent it . The long-term goal of 
76

CDC’s work in child maltreatment prevention is to achieve lasting change in the factors 

and conditions that place children at risk through making changes at the individual, 

family, community, and societal levels of the social ecology that reduces rates of child 

maltreatment among populations .

The Division of Violence Prevention (DVP) has identified safe, stable, and nurturing 

relationships (SSNRs) between caregivers and children as the foundation of a unified 

strategic approach and message to empower parents and caregivers and to reduce child 

maltreatment . Further, SSNRs have been identified as a means to strengthen parenting 

practices that prevent child maltreatment by focusing on positive caregiving behaviors . 

The relationships between children and the key adults in their lives are fundamental 

to the healthy development of the brain and consequently, physical, emotional, social, 

behavioral, and intellectual capacities .8,10 Accordingly, promotion of SSNRs can have 

synergistic effects on health problems as well as contribute to development of skills that 

enhance acquisition of healthy habits and lifestyles .

To promote SSNRs and reduce maltreatment, additional research is needed across 

the different social contexts in which children develop and interact, including the 

individual, family, peer, community, and society . These nested social ecologies provide 

a framework and context for examining the relationships children have both within 

and outside the immediate family . Research is needed to investigate the prevalence of 

SSNR behaviors and activities by caregivers to develop a foundation from which to 

study positive caregiver behaviors and child outcomes . A complete etiologic picture of 

child maltreatment is still emerging, and the myriad risk and protective factors related 

to child maltreatment at all levels of the social ecology and their relation to SSNRs 

remains unexplored . Evidence is available that different types of maltreatment have 

different etiologies and lead to different child outcomes .11 Further, strong evidence 

exists that different types of maltreatment events often co-occur .12 Thus, prevention 

efforts for differing and multiple co-occurring forms of maltreatment might require 

distinct prevention strategies . For example, the most common sexual abuse prevention 

strategies have focused on educating children by using school-based programs . In 

contrast, the most commonly investigated and implemented prevention efforts for 

child physical abuse and neglect have targeted adults, or more specifically caregivers, 

by providing education and skills training programs . Additional research is needed 

to examine the most efficacious prevention strategies for each type of maltreatment . 

Training of caregivers in child-rearing and management strategies is a basic approach 

to facilitating SSNRs, and establishment of SSNRs in environments children encounter 

outside the home and the central family unit are essential . Further, critical questions 

regarding the effectiveness of prevention programs still remain . As noted in the 

Institute of Medicine report, Reducing the Burden of Injury,13 rigorous research is 

needed to assess the effectiveness of prevention programs and to determine which 

among them merit widespread use . To ensure the feasibility of widespread use of child 

maltreatment prevention programs, research is also needed to assess program costeffectiveness and the cost of initiating or expanding effective programs .

In looking toward the future, preventing such adverse exposures as maltreatment 

by ensuring that all children are protected and raised in a safe, stable, and nurturing 

environment is strategic for achieving measurable and lasting impacts on health 

throughout life . This research agenda is designed to provide a foundation from which to 

accomplish this goal during the next 10 years .
77

The Injury Center’s Research Priorities 

in Child Maltreatment Prevention

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Examine the context and development of child maltreatment perpetration 

and SSNRs to identify populations at risk, modifiable risk and protective 

factors, and optimal times and settings for prevention. Caregiving 

behaviors occur in a broad context and develop with time . Understanding the 

development of caregiving behaviors and how the context influences child 

development is key to understanding which prevention strategies, programs, 

and policies will promote SSNRs and reduce child maltreatment . To gain a 

full understanding of the ideal times and settings for prevention, research 

is needed that examines how SSNRs and negative caregiving behaviors, 

including child maltreatment, develop . Previous work has focused primarily 

on individual- and family-level influences, with relatively limited attention 

paid to community- and broad societal-level factors (e .g ., policies, broad social 

norms, and collective efficacy) . Community and societal-level factors might 

influence development of SSNRs or maltreatment directly, and they might 

interact with individual- and family-level factors . Additionally, prevention 

strategies, programs, and policies that operate at a community or societallevel might reach broader segments of a population and be influential in 

widespread promotion of SSNRs and reductions in child maltreatment . Finally, 

understanding the development of different forms of child maltreatment 

perpetration (e .g ., physical abuse, neglect, and sexual abuse) is critical because 

the different forms of child maltreatment might have different etiologies and 

thus require different strategies and timing .

B. Identify and quantify the social and economic burden of child maltreatment 

victimization and factors that mitigate child maltreatment outcomes. Victims 

of child maltreatment are at risk for multiple detrimental health outcomes, 

including biologic, psychological, and social deficits .14–16 Child maltreatment not 

only negatively affects the victims but society as a whole . For example, maltreated 

children are at increased risk for becoming perpetrators of violence and for 

engaging in criminal behavior that exacts considerable societal cost . Additionally, 

substantial economic costs are incurred for victims of maltreatment in terms 

of medical and nonmedical resources consumed, losses in productivity, and 

human capital development . Further research quantifying the social (including 

health- and nonhealth-related outcomes) and economic burden (i .e ., direct and 

indirect costs) of child maltreatment is warranted . Research is also needed to 

examine factors that can mitigate the burden of maltreatment, with an emphasis 

on potential mechanisms that might influence positive outcomes for maltreated 

persons . A greater understanding of the association between child maltreatment 

and its social and economic burden can help guide future policy development 

regarding prevention and intervention .
78

C. Evaluate the effectiveness of parenting-focused strategies for preventing 

child maltreatment and promoting SSNRs . Healthy parent-child relationships 

are fundamental in protecting children from child maltreatment and for 

development of the brain, and consequently, development of children’s physical, 

emotional, social, behavioral, and intellectual capacities . Parent training 

programs have been used to promote positive caregiving behaviors and to 

address child behavior problems among populations at risk, including caregivers 

involved with child protective service agencies . Parent training programs can be 

used to teach parents or caregivers to care for children properly and to manage 

their children’s behavior by using positive parenting strategies and noncoercive 

discipline strategies . Because much of physical child maltreatment stems from 

attempts at discipline, parent training programs can be used to preempt the 

negative behaviors that can lead to maltreatment . However, research is still 

needed to examine the extent to which parenting programs can be used for the 

primary prevention of child maltreatment and for the promotion of SSNRs on 

a broad scale . For example, can parenting programs be broadly implemented 

in communities to reduce the overall incidence of child maltreatment and to 

promote SSNRs at a population level? Evaluating the costs and cost-effectiveness 

of parenting-focused prevention strategies is needed so that widespread use of 

strategies can focus on those that are most cost-effective .

D. Evaluate the effectiveness of public and organizational policies for preventing 

child maltreatment and promoting SSNRs. Public and organization policies 

potentially play a key role in contributing to child maltreatment and in 

preventing it . Public or organizational policy can be defined as a course of 

action or inaction chosen by public or organizational authorities to address a 

problem . Public policy is expressed in the body of laws, regulations, decisions, 

and governmental action . An organizational policy is reflected in the rules and 

regulations governing its operation . These policies can be critical in shaping 

the environment in which child maltreatment occurs . For example, laws that 

impose criminal penalties for child maltreatment might increase the safety 

of children by deterring such acts, or legislation that permits parents to take 

time off during family crises might help relieve stress, promote nurturing 

relationships, and reduce child maltreatment . Moreover, organizational policies 

in child-serving agencies that establish procedures for hiring and appropriate 

interactions between staff and children can also serve to prevent child 

maltreatment and ensure safe environments . These and other types of policies 

should be evaluated to determine if they are effective in promoting SSNRs and 

preventing maltreatment . The cost-effectiveness of evidence-based policies 

should also be determined where feasible .

E. Evaluate the dissemination and implementation of evidence-based strategies 

for preventing child maltreatment and promoting SSNRs. Identifying and 

evaluating efficient and effective methods for dissemination and implementation 

is critical in optimizing the access and reach of evidence-based programs to 

prevent child maltreatment and to promote SSNRs . For example, research has 

documented the efficacy of prevention programs (e .g ., skill-based parenting 

programs and home visitation programs) in positively changing parental 

behavior and decreasing the manifestation of abusive and neglectful acts 

within families at risk .17–23 Despite the success of these and other programs 

in preventing child maltreatment risk, research that examines how to best 

disseminate and implement existing empirically supported prevention strategies 

is substantially limited . To address this gap, at least five steps are needed . First, 

researchers should evaluate strategies for translating empirically supported 
79

programs into such products as training manuals that can guide implementation 

in the field .23 Second, methods for providing the training and consultation 

needed to support implementation in the field should be examined . Third, 

the degree to which programs should be implemented as developed (i .e ., with 

fidelity) or can be adapted for local settings and groups without compromising 

the program’s effectiveness warrants investigation . Fourth, how characteristics 

and capacities of persons, practice settings, organizations, and communities 

influence implementation and dissemination of evidence-based strategies for 

preventing child maltreatment and promoting SSNRs should be examined as 

should the methods used to increase these necessary capacities . Finally, economic 

evaluation related to product development, training, and capacity-building 

should be conducted to determine the most efficient methods for bringing 

prevention programs to scale . Such work will facilitate the dissemination of 

successful prevention programs from research to real-world settings .

Tier 2

F. Develop and evaluate surveillance methods for child maltreatment and 

behaviors or activities that promote SSNRs. Data are limited regarding how to 

monitor the incidence and prevalence of child maltreatment, and the data that 

exist are of questionable validity and reliability; therefore, better tracking and 

monitoring methods are necessary to support prevention efforts . To develop 

better surveillance systems, research has been undertaken to examine (1) the 

sensitivity and specificity of alternative definitions of child maltreatment and (2) 

the incidence and prevalence of child maltreatment mortality using secondary 

data sources traditional to public health . Further research is needed to assess 

the utility of alternative surveillance methodologies (e .g ., survey surveillance 

to examine child maltreatment) . Additionally, SSNRs have been identified as a 

unifying concept for promotion of positive parenting and prevention of child 

maltreatment . Surveillance efforts are needed to develop a foundation from 

which to monitor positive caregiving behaviors and child outcomes .

 Child maltreatment morbidity and mortality and SSNRs are likely to require 

different approaches to surveillance . Rigorous evaluation of child maltreatment 

surveillance methods should be incorporated into research projects to provide 

feedback regarding the most suitable approach to surveillance for different 

aspects of maltreatment . Improved surveillance methods will render better 

information for guiding program development and evaluation . Because states 

and localities often lack adequate monitoring systems, improved surveillance 

will be particularly valuable to them as they expand their efforts to address child 

maltreatment as a public health concern .

G. Evaluate the impact of extreme community and environmental stressors on 

child maltreatment. Chronic community stressors (e .g ., severe poverty or the 

demise of a critical local industry) as well as catastrophic events (e .g ., natural or 

intentionally created disasters or terrorism) might exacerbate both the incidence 

and sequelae of child maltreatment in affected communities, but research in this 

area is still emerging . Research is needed to assess the impact of community and 

environmental stressors, both chronic and discrete, on the relationships between 

caregivers and children . In addition to assessing the impact of such events, 

development of evidence-based tools and materials that can be implemented to 

buffer the impact of these stressors are needed . Research after hurricane-related 

disasters demonstrates a need to screen volunteers as well as a need for public 

information messages about family cohesion and parental monitoring and 

Parent training 

programs can 

be used to 

teach parents 

or caregivers to 

care for children 

properly and 

to manage 

their children's 

behavior by 

using positive 

parenting 

strategies.
80

supervision of children; however, materials, tool kits, and appropriate messages are 

sparse, and information is lacking regarding their efficacy and effectiveness . Injury 

Center-related research on these topics will complement CDC’s other work related 

to disaster preparedness and terrorism response . Research is also needed to facilitate 

development of approaches for addressing chronic community stressors and 

outcomes throughout the lifespan related to these chronic stressors . Findings from 

this research can aid service agencies as they develop and implement appropriate 

responses and public advisories during periods of extreme stress and provide a 

roadmap for developing strategies to address chronic stressors .

H. Evaluate development and delivery of training strategies for professionals that 

build capacity and skills for supporting parents in providing SSNRs for their 

children and for promoting policies and practices that create supportive social 

environments for children. Programs are common for training professionals in 

child maltreatment recognition, intervention, diagnosis, treatment, and to a lesser 

degree, prevention . However, evaluation of these training programs is needed to 

determine their impact on the practices of professionals, particularly with regard 

to primary prevention and promotion of healthy caregiving and organizational 

practices . Strong evidence points to SSNRs as the buffer against maltreatment 

and other adverse exposures occurring during childhood that compromise health 

throughout the lifespan . Professionals who interact with and provide services for 

caregivers and children have important roles to play in supporting caregivers and 

promoting SSNRs . Professional training programs rarely have been developed 

specifically to build the capacity of professionals to integrate policies and practices 

that promote protective factors into their service setting . Training programs that 

(1) incorporate anticipatory guidance in healthcare settings, (2) build practices 

in child care settings that support caregivers and promote protective factors, (3) 

develop professionals’ knowledge of support services in the community and skills 

for early recognition of need and referral to these services, and (4) identify and 

promote organizational policies that help create safe and nurturing environments 

and relationships for children, are all needed . Additionally, research is needed 

regarding whether professionals who receive such training might be better 

equipped to support parents in ensuring SSNRs for their children .
81

References

1. Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child Maltreatment Surveillance: 

Uniform Definitions for Public Health and Recommended Data Elements, Version 

1.0. Atlanta, GA: US Department of Health and Human Services, CDC, National 

Center for Injury Prevention and Control; 2007.

2. US Department of Health and Human Services, Administration for Children and 

Families. Child Maltreatment 2006. Washington, DC: US Government Printing Office; 

2008. Available at: http://www.acf.hhs.gov/programs/cb/pubs/cm06/index.htm. 

Accessed July 30, 2008.

3. Finkelhor D, Ormrod R, Turner H, Hamby SL. The victimization of children and youth: 

a comprehensive, national survey. Child Maltreat 2005;10:5–25.

4. Briere J, Elliott DM. Prevalence and psychological sequelae of self-reported 

childhood physical and sexual abuse in a general population sample of men and 

women. Child Abuse Negl 2003;27:1205–22.

5. Scher CD, Forde DR, McQuaid JR, Stein MB. Prevalence and demographic correlates 

of childhood maltreatment in an adult community sample. Child Abuse Negl 

2004;28:167–80.

6. Cerezo MA, Frias D. Emotional and cognitive adjustment in abused children. 

Child Abuse Negl 1994;18:923–32.

7. National Academy of Sciences. From Neurons to Neighborhoods: The Science 

of Early Childhood Development. Shonkoff JP, Phillips DA, eds. Committee on 

Integrating the Science of Early Childhood Development, Board on Children, Youth, 

and Families, Washington, DC: National Academies Press; 2000.

8. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and 

household dysfunction to many of the leading causes of death in adults. The 

Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245–58.

9. Kendall-Tackett KA. Treating the Lifetime Health Effects of Childhood Victimization. 

Kingston, NJ: Civic Research Institute, Inc.; 2003.

10. National Scientific Council on the Developing Child. Young Children Develop 

in an Environment of Relationships. Working Paper No. 1. Cambridge, MA: 

National Scientific Council on the Developing Child; 2004. Available at: 

http://www.developingchild.net/pubs/wp/Young_Children_Environment_

Relationships.pdf. Accessed July 30, 2008.

11. Portwood SG. What we know—and don’t know—about preventing child 

maltreatment. J Agg Maltreat Trauma 2006;12(3/4):55–80.

12. Higgins DJ, McCabe MP. Multi-type maltreatment and the long-term adjustment 

of adults. Child Abuse Rev 2000:9:6–18.
82

13. Institute of Medicine, Committee on Injury Prevention and Control. Reducing 

the Burden of Injury: Advancing Prevention and Treatment. Bonnie RJ, Fulco CE, 

Liverman CT, eds. Washington, DC: National Academies Press; 1999.

14. Crittenden PM. Dangerous behavior and dangerous contexts: a 35-year perspective 

on research on the developmental effects of child physical abuse. In: Trickett PK, 

Schellenbach CJ, eds. Violence Against Children in the Family and the Community. 

Washington, DC: American Psychological Association; 1998: 11–38.

15. Edwards VJ, Holden GW, Felitti VJ, Anda RF. Experiencing multiple forms of 

childhood maltreatment and adult mental health: results from the Adverse 

Childhood Experiences study. Am J Psychiatry 2003;160:1453–60.

16. Kendall-Tackett KA., Williams LM, Finkelhor D. Impact of sexual abuse on children: a 

review and synthesis of recent empirical studies. In: Bull R, ed. Children and the Law: 

The Essential Readings. Essential Readings in Developmental Psychology Series. 

Malden, MA: Blackwell; 2001: 31–76.

17. Dumas JE. Treating antisocial behavior in children: child family approaches. Clin 

Psychol Rev 1989;9:197–222.

18. Eisenstadt TH, Eyberg S, McNeil CB, Newcomb K, Funderburk B. Parent-Child 

Interaction Therapy with behavior problem children: relative effectiveness of two 

stages and overall treatment outcome. J Clin Child Psychol 1993;22:42–51.

19. Feldman J, Kazdin AE. Parent management training for oppositional and conduct 

problem children. J Consult Clin Psychol 1995;48:3–5.

20. Borrego J, Urquiza AJ, Rasmussen RA, Zebell N. Parent-Child Interaction Therapy 

with a family at high risk for physical abuse. Child Maltreat 1999;4:331–42.

21. Lutzker JR, Rice JM. Using recidivism data to evaluate Project 12-Ways: an 

ecobehavioral approach to the treatment and prevention of child abuse and 

neglect. J Fam Violence 1987;2:283–90.

22. Geeraert L, Van den Noortgate W, Grietens H, Onghena P. The effects of early 

prevention programs for families with young children at risk for physical child abuse 

and neglect: a meta-analysis. Child Maltreat 2004;9:277–91.

23. Whitaker DJ, Lutzker JR, Shelley GA. Child maltreatment prevention priorities at the 

Centers for Disease Control and Prevention. Child Maltreat 2005;10:245–59.
83

Sexual Violence and 

Intimate Partner Violence

Public Health Burden

Sexual violence and intimate partner violence have a substantial effect on public 

health . Victims of violence can experience the immediate consequences of physical 

injury and long-term physical and mental health consequences, including depression, 

anxiety, posttraumatic stress, suicide attempts, substance abuse, chronic pain, 

gastrointestinal problems, cardiovascular disease, and a range of reproductive health 

concerns .1–3 The economic cost of intimate partner violence against women has 

been conservatively estimated at $5 .8 billion/year, a figure that includes only the 

medical and mental health expenditures, lost productivity, and lost lifetime earnings

4

; 

however, no national estimate of the total cost of intimate partner and sexual violence 

has yet been calculated .

Sexual violence includes completed or attempted sex acts against the victim’s will or 

involving a victim who is unable to consent, abusive sexual contact, and noncontact 

sexual abuse, including sexual harassment . Child sexual abuse is also included in the 

range of behaviors considered sexual violence . Sexual violence can be committed by 

a current or former intimate partner, a nonintimate partner family member, a person 

in position of power or trust, a friend, an acquaintance, another nonstranger, or a 

stranger .

5

 Both women and men are victims of sexual violence, although women are 

>3 .5 times more likely to report experiencing rape or attempted rape during their 

lifetime then men, according to data from 23 states and two territories that employed 

the sexual violence module of the Behavioral Risk Factor Surveillance System 

(BRFSS) (18 .5% and 5 .8%, respectively) (unpublished data, Black MC, Basile KC, 

Breiding MJ, and Ryan GW, Prevalence of sexual violence in 24 states and two U .S . 

territories, BRFSS, 2005) . For women, 22% of all first attempted or completed rapes 

occurred before they were age 12 years, and 32% of first attempted or completed rapes 

occurred during ages 12–17 years . For men, 48% of first attempted or completed 

rapes occurred before they were age 12 years, and 23% occurred during ages 12–17 

years .

6

 Lifetime prevalence estimates of child sexual abuse range from 7% to 36% for 

women and from 3% to 29% for men .7,8

Intimate partner violence is defined as actual or threatened physical, sexual, 

psychological, or emotional abuse by a current or former spouse (including commonlaw spouse), dating partner, or boyfriend or girlfriend . Intimate partners can be of 

the same or opposite sex . Data from the 2005 BRFSS (16 states and two territories) 

indicate that approximately one in four women (26 .4%) and one in seven men 

(15 .9%) reported some form of physical intimate partner violence victimization 

(threatened, attempted, or completed physical violence) or nonconsensual sex by an 

intimate partner during their lifetime .

9

 Twelve-month prevalence of nonconsensual 

sex or completed physical violence was 1 .4% and 0 .9% for women and men, 

respectively, translating to >25 million women and 7 million men annually . Findings 

from other national studies have yielded varying estimates; prevalence measures are 

influenced substantially by the behaviors included and the context (e .g ., health, crime, 

or family conflict) in which the questions are asked .6,10,11 Although considerable 

partner violence occurs to both women and men, women experience greater injuries 

and harms from intimate partner violence than men .6,12
84

The Injury Center’s Approach to Preventing Sexual 

Violence and Intimate Partner Violence

Multiple agencies and organizations have developed programs and prevention 

strategies to respond to sexual violence and intimate partner violence . However, 

as noted in the Institute of Medicine report, Reducing the Burden of Injury, only 

a limited number of these programs have been evaluated thoroughly enough to 

assess their effectiveness and to determine which among them merit widespread 

adoption .13 The Injury Center emphasizes rigorous research with direct implications 

for achieving health impact . This research perspective complements the work of 

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

to prevent development of perpetration of sexual and intimate partner violence 

complements the U .S . Department of Justice’s focus on persons already charged with 

violent offenses also being associated with these behaviors . The Injury Center’s focus 

on applied prevention in these areas complements the National Institutes of Health’s 

focus on basic scientific questions .

The majority of efforts that address sexual and intimate partner violence focus 

on reducing victims’ risks for future violence, mitigating the consequences of 

exposures to such violence (i .e ., secondary and tertiary prevention), and holding 

perpetrators accountable through the criminal justice system . Greater attention 

is needed to prevent sexual and intimate partner violence from occurring in the 

first place (primary prevention) . This might require researchers and practitioners 

to take new approaches in addressing sexual and intimate partner violence . 

Certain questions, particularly questions regarding early risk and protective factors 

related to perpetration, remain unanswered, seriously hindering development and 

identification of effective violence prevention strategies . Thus, the Injury Center 

must focus on perpetration research to support future development of effective 

prevention programs . Such research will complement efforts focused on preventing 

initial victimization and revictimization . Documenting program costs and costeffectiveness, when appropriate, will help practitioners and policymakers understand 

what resources are needed to implement effective programs . As effective strategies 

are identified, research examining how to best disseminate, implement, and adapt 

evidence-based prevention strategies will become increasingly important .

That research related to understanding and preventing sexual and intimate 

partner violence examine a full range of potential social-ecological influences is 

critical . According to social-ecological models,14 such behaviors as sexual and 

intimate partner violence perpetration are influenced by different variables, 

including individual-level influences, small-group influences (e .g ., dyads, peers, 

and families), and community and societal influences . Although research has 

been done regarding the individual and small-group levels of the social ecology, 

more empirical work is needed on how the upper levels of the social ecology (i .e ., 

community and societal levels) influence sexual and intimate partner violence and 

how those influences interact with lower levels to influence behavior .
85

Finally, although this chapter includes discussion of both sexual and intimate 

partner violence, understanding the similarities and differences between the two 

is important . Sexual violence can be perpetrated by an intimate partner and is one 

type of intimate partner violence, but other persons also perpetrate sexual violence . 

Studies have reported the most common type of perpetrators of sexual violence are 

acquaintances or friends (unpublished data, Black MC, Basile KC, Breiding MJ, and 

Ryan GW, Prevalence of sexual violence in 24 states and two U .S . territories, BRFSS, 

2005) .15 Sexual and intimate partner violence share common risk factors, but they 

also have unique risk and protective factors . Understanding the common risk factors 

can lead to prevention strategies that address both of these public health problems . 

Understanding the unique risk factors to both sexual and intimate partner violence, 

as well as risk factors unique to subtypes of each, can ensure that appropriate 

prevention strategies are developed . Finally, sexual violence prevention research 

is less well-developed than intimate partner violence prevention research . Less is 

known regarding how sexual violence perpetration develops and how to prevent 

that development . Thus, the research needs for sexual violence are greater than for 

intimate partner violence .

The Injury Center’s Research Priorities 

in Preventing Sexual Violence and 

Intimate Partner Violence

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Develop and evaluate surveillance methods for sexual violence and intimate 

partner violence victimization and perpetration . Improved surveillance 

methods are needed to better understand the prevalence of and trends in 

sexual and intimate partner violence at the state and national levels, to provide 

information on which to base development and evaluation of prevention 

and intervention programs, and to monitor and measure the effectiveness 

of prevention efforts . A substantial need exists to use uniform definitions 

and survey methods in measuring sexual and intimate partner violence 

victimization and perpetration temporal trends . Particularly with regard to 

perpetration, innovative methods are needed to improve the reporting when 

using survey methodology . In addition, new methods for conducting and 

improving surveillance should be explored, as well as the cost-efficiency of 

different ways of conducting such surveillance through cost-efficient means . 

Ultimately, establishing cost-efficient and timely surveillance systems for 

all states, by using consistent definitions and uniform survey methods, will 

assist states by providing their policymakers much-needed information for 

enhancing prevention efforts at the state level .
86

B. Examine the etiology of sexual violence and intimate partner violence 

perpetration to identify modifiable risk and protective factors and optimal 

times and strategies for prevention. Effective primary prevention of sexual and 

intimate partner violence should focus on preventing first-time perpetration . 

Although addressing the needs of victims is critical, such approaches fail to 

address the root causes of violence . Multiple individual, relationship, community, 

and societal factors and their cumulative and interactive effects are believed 

to contribute to the likelihood of perpetrating violence .16 Research examining 

such factors and their interactions at all levels of the social ecology is key to 

understanding how perpetration of violence develops and to determining 

optimal times, settings, and strategies for preventing sexual and intimate partner 

violence . Priorities for etiologic research in sexual and intimate partner violence 

should focus on ■ identifying modifiable risk factors at the outer levels of the social ecology 

(i .e ., relationship, community, and societal levels) — In particular, increased 

understanding of community (e .g ., chronic and acute environmental 

stressors) and societal-level factors (e .g ., cultural norms conducive to violence 

and sexualization of women and children in advertising and other media) 

that contribute to violence can inform policymakers regarding prevention 

strategies that have the broadest impact .

■ examining developmental trajectories for the perpetration of sexual and 

intimate partner violence — Such research will be essential in identifying 

optimal times and strategies for prevention efforts .

■ identifying protective or buffering factors that can alter adverse 

developmental trajectories or moderate the impact of risk factors to prevent 

violence from occurring .

■ identifying promotive factors for development of nonviolent and respectful 

environments and relationships (e .g ., for intimate partner relationships, 

factors that promote shared decision-making, trust, belief in nonviolent 

conflict resolution, and effective communication skills) — This research has 

the potential to provide information needed for the development of health 

promotion approaches to ending sexual and intimate partner violence .

C. Clarify the contexts within which violence occurs and the associations 

among types and subtypes of sexual violence and intimate partner violence, 

other types of violence, other risk behaviors, and other health outcomes 

to determine implications for prevention of perpetration. Research has 

demonstrated that different types of violence are interrelated and frequently 

co-occur .17,18 Certain factors associated with multiple types of violence and 

health risk behaviors have been identified (e .g ., being socioeconomically 

disadvantaged) . However, additional understanding of the shared modifiable risk 

and protective factors will be important in developing and implementing broad 

violence prevention strategies, and such understanding will have the potential 

to affect multiple violence and health promotion outcomes . Such general 

approaches have the potential to be a more efficient use of resources . In contrast, 

research on different types, subtypes, and contexts of sexual and intimate partner 

violence (e .g ., research on batterer typologies, sexual violence perpetrated within 
87

and outside of relationships, different types of sexual and intimate partner 

violence, or intrafamilial and extrafamilial child sexual abuse) indicates 

certain different and unique etiologic or contextual contributors that might 

require more tailored prevention approaches to be effective .19,20 Disentangling 

these common and unique etiologic factors will be essential in identifying 

the most efficient and effective approaches for preventing violence and other 

adverse health outcomes .

D. Examine the role of disparities in the occurrence and development of 

sexual violence and intimate partner violence and determine implications 

for prevention of perpetration. Research provides evidence that different 

subgroups of the population are at greater risk for perpetrating or 

experiencing sexual or intimate partner violence .21,22 One risk factor that 

has been consistently identified for both types of violence is socioeconomic 

disadvantage, which differentially affects certain minority groups . These 

disparities and inequities might be rooted in cultural as well as institutional 

practices and policies, yet the role of different cultural factors, norms, and 

policies, either as risk or protective factors for sexual and intimate partner 

violence, is inadequately understood . In addition, the majority of perpetrators 

of sexual violence tend to be male,23 whereas women and children of both 

sexes are at greater risk for victimization . Similarly, women tend to be at 

greater risk for harm from intimate partner violence,12 indicating the need for 

greater attention to sex- or gender-associated disparities . Such research can 

provide information for development or tailoring of prevention approaches to 

make them more relevant and effective . In addition, after effective approaches 

have been identified, research on disparities can assist dissemination and 

implementation efforts .

E. Evaluate the efficacy and effectiveness of programs, strategies, and policies 

across all levels of the social ecology to prevent and interrupt development 

of perpetration of sexual violence and intimate partner violence. Intervening 

in ways that prevent perpetration of violence, that alter developmental 

trajectories leading to initial perpetration of violence, and that promote an 

environment of nonviolence and respect is key to eliminating sexual and 

intimate partner violence . The number of efficacious or effective primary 

prevention strategies that have been identified for sexual or intimate partner 

violence is limited .24 Because multiple individual, relationship, community, 

and societal factors and their interactions might influence the perpetration 

of violence, a critical need exists for research to evaluate prevention strategies 

at and across all levels of the social ecology . For example, research should 

examine the effects of changing organizational and public policies and societal 

norms, given the success of these approaches in addressing other health 

behaviors (e .g ., smoking and human immunodeficiency virus risk behavior) . 

Although a limited number of effective primary prevention strategies have 

been identified at any level of the social ecology, prevention strategies 

implemented at the community and societal levels might have a broader reach 

and result in greater reductions in sexual and intimate partner violence .
88

F. Evaluate the efficacy and effectiveness of programs, strategies, and policies 

to prevent both sexual violence and intimate partner violence, multiple 

types of sexual violence and intimate partner violence, and other forms 

of violence. Studies have indicated that sexual and intimate partner violence 

perpetration overlap and that they overlap with other forms of violence 

perpetration . That is, perpetrators of one type of violence often perpetrate 

other types of violence .17,18 A single prevention strategy might be able to 

prevent more than one form of violence, resulting in a more efficient use 

of resources . For example, within the field of intimate partner violence, 

researchers have distinguished between physical violence that occurs with 

aspects of psychological abuse and control versus violence that occurs without 

those aspects .20 These researchers have recommended that different prevention 

strategies are needed for the two forms of intimate partner violence . Physical 

intimate partner violence might require different types of strategies than 

sexual violence among partners . Similarly, different types of sexual violence 

perpetration (e .g ., sexual harassment, date rape, or child sexual abuse) might 

require multiple prevention approaches . Although evidence indicates that 

sexual and intimate partner violence share certain common risk and protective 

factors, research is needed to determine if an approach targeting these shared 

factors will adequately reduce both types of violence as well as other types of 

violence and risk behaviors . Among all types of violence, for example, certain 

prevention strategies (e .g ., interventions promoting overall social or emotional 

health) can address a range of violent behaviors that emerge during adolescence 

(e .g ., dating violence, youth violence, or suicide) .

Tier 2

G. Assess the cost and health burden of sexual violence and intimate partner 

violence throughout the life span. No national cost estimates for sexual 

violence victimization are available; therefore, a national study that estimates 

the full range of costs of sexual violence is needed . Further, estimates of the 

cost and health burden of intimate partner violence

4

 have been limited by 

the quality of the methodology and approaches used to measure cost and 

health burden, and they have not included the full range of costs caused by 

intimate partner violence . For example, the 2003 Injury Center report, Costs 

of Intimate Partner Violence Against Women in the United States, included 

medical costs and costs resulting from lost productivity and earnings, but 

excluded other costs (e .g ., social service costs to victims and perpetrators, 

costs from pain and suffering, and the healthcare costs of female victims 

who eventually died from intimate partner violence) . Also, the 2003 report 

was limited to costs associated with victimization of women only, not men . 

Improved estimates of cost and burden are needed for intimate partner 

violence for both sexes .

 Preliminary research might be needed to facilitate the accurate estimation of 

sexual and intimate partner violence costs . For instance, although research 

has demonstrated substantial short- and long-term physical and mental 

health consequences for female victims,1–3 the methodology and approaches 

used to assess health burden have not controlled for confounding factors, 

which include among others, experiencing multiple forms of violence 

(e .g ., intimate partner violence, youth violence, or suicide) nor sufficiently 

included male victims of intimate partner violence and sexual violence . Also, 

methods and tools might be needed that allow a fuller examination of the 
89

various costs associated with victimization and perpetration, including 

costs to those close to the victim or perpetrator . As surveillance methods 

and research findings improve, better estimates of cost and health burden 

can be generated . A better understanding of the cost and health burden 

of sexual and intimate partner violence is essential for examining and 

comparing the cost-benefit and efficiency of prevention strategies .

H. Evaluate the economic efficiency of programs, strategies, and policies to 

prevent perpetration of sexual violence and intimate partner violence. 

A limited number of evidenced-based programs for preventing sexual 

and intimate partner violence have been identified . As research identifies 

additional programs that work, measuring the cost of those programs to 

understand their cost-effectiveness relative to one another is critical . Given 

that the resources for sexual and intimate partner violence prevention are 

limited, economic efficiency is crucial to ensuring that available resources are 

used wisely . Research also might be needed to understand the best ways to 

conduct cost and cost-effectiveness analyses of sexual and intimate partner 

violence programs, strategies, and policies . This might include, for example, 

understanding which violence outcomes can be adequately addressed by 

using the same approach and which might need separate programs or 

strategies . A single, more intensive program that affects multiple outcomes 

might be more economically efficient than a shorter one that affects only one 

outcome . Researchers should build on ongoing effectiveness research and 

test new methods for determining the economic efficiency of prevention 

measures as well .

I. Evaluate interventions for persons exposed to sexual violence and 

intimate partner violence to reduce risk for associated negative health 

consequences. Children, adolescents, or adults with previous exposure 

to sexual or intimate partner violence are at increased risk for multiple 

adverse health outcomes,1

 including later perpetration of violence and 

revictimization .18 Interventions are needed for populations with previous 

exposure to sexual or intimate partner violence (e .g ., children who have 

witnessed or experienced such violence) and populations with previous 

histories of perpetration . Interventions are needed that disrupt developmental 

pathways that might lead witnesses or victims to become perpetrators and 

that might lead to revictimization or reperpetration . One example of such an 

intervention that has received considerable attention is screening for partner 

violence in healthcare and social service settings . Such interventions should 

be evaluated to determine if they can prevent revictimization and the longterm health consequences of sexual and intimate partner violence . However, 

other types of interventions for persons already exposed to such violence are 

also needed (e .g ., screening and intervening with adolescents at high risk) .

Children, 

adolescents, 

or adults 

with previous 

exposure 

to sexual or 

intimate partner 

violence are at 

increased risk for 

multiple adverse 

health outcomes.
90

J. Conduct dissemination and implementation research regarding programs, 

strategies, and policies used in the primary prevention of sexual violence 

and intimate partner violence. Research that identifies the best audiences 

and methods for disseminating and implementing evidenced-based programs, 

strategies, and policies used in the primary prevention of sexual and intimate 

partner violence is substantially limited . Multiple types of dissemination 

and implementation research are needed to support adoption of evidencebased prevention approaches .25 First, researchers should evaluate methods for 

synthesizing, translating, and packaging programs, strategies, and policies into 

products as training manuals or technology that can guide implementation . 

Second, what and how characteristics and capacities of persons, organizations, 

and communities influence implementation and dissemination of science-based 

programs, strategies, and policies for preventing sexual and intimate partner 

violence should be examined . Third, methods (i .e ., technical assistance, coaching, 

monitoring, and funding) for building personal, organizational, and community 

capacities, readiness, and partnerships to support implementation of sciencebased programs, strategies, and policies in the field should be examined . Finally, 

economic evaluation related to product development, training, and capacitybuilding should be conducted to determine the most efficient methods for 

ensuring widespread adoption of science-based programs, strategies, and policies .

K. Examine when and how to adapt effective programs, strategies, and policies 

to prevent sexual violence and intimate partner violence for new settings 

and among diverse populations. Effective prevention programs, strategies, 

and policies are often modified when they are delivered in new settings . To 

what extent these modifications affect the effectiveness of prevention programs, 

strategies, and policies is largely unknown . Information is also needed regarding 

organizational and community barriers and facilitators to implementing 

programs, strategies, and policies with fidelity . Research is needed in multiple 

areas to address these gaps . First, the effects of implementing a program, 

strategy, or policy, as originally developed (i .e ., fidelity to the approach) should 

be compared with the effects of changing the content or delivery format (i .e ., 

adaptation) . Research should also work to identify the core components of a 

program, strategy, or policy that are critical to leading to successful outcomes . 

This body of inquiry can illuminate key topics, exercises, or other facets of a 

program, strategy, policy, or practice that should not be changed or eliminated . 

Identifying core components can also enable practitioners to maintain 

effectiveness while setting the stage for efforts to adapt prevention strategies 

to meet the needs of diverse populations or settings . Also, research is needed 

to examine whether effective programs, strategies, and policies can be used 

effectively among different populations (e .g ., racial/ethnic groups or younger 

versus older populations) . This research should use data to define approaches 

for dealing with practical and logistic differences between original and evolving 

settings, because such differences might facilitate or impede implementation 

efforts . Finally, adaptation research needs to identify organizational and 

community barriers and facilitators to implementing programs, strategies, and 

policies with fidelity . This research might indicate that modification of a program, 

strategy, or policy is unnecessary, compared with building organizational and 

community capacities and readiness to implement them with fidelity .
91

References

1. Campbell JC. Health consequences of intimate partner violence. Lancet 

2002;359:1331–6.

2. Coker AL. Does physical intimate partner violence affect sexual health? 

A systematic review. Trauma Violence Abuse 2007;8:149–77.

3. Plichta SB. Intimate partner violence and physical health consequences: policy and 

practice implications. J Interpers Violence 2004;19:1296–323.

4. National Center for Injury Prevention and Control. Costs of Intimate Partner Violence 

Against Women in the United States. Atlanta, GA: US Department of Health 

and Human Resources, CDC; 2003. Available at: http://www.cdc.gov/ncipc/pub-res/

ipv_cost/IPVBook-Final-Feb18.pdf. Accessed July 30, 2008.

5. Basile KC, Saltzman LE. Sexual Violence Surveillance: Uniform Definitions and 

Recommended Data Elements. Version 1.0. Atlanta, GA: US Department of Health 

and Human Services, CDC, National Center for Injury Prevention and Control; 2002. 

Available at: http://www.cdc.gov/ncipc/pub-res/sv_surveillance/SexViolSurv.pdf. 

Accessed July 30, 2008.

6. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences 

of Violence Against Women: Findings from the National Violence Against Women 

Survey. Washington, DC: US Department of Justice; 2000. Publication no. NCJ 

183781. Available at: http://www.ncjrs.gov/pdffiles1/nij/183781.pdf. 

Accessed July 30, 2008.

7. Finkelhor D. International epidemiology of child sexual abuse. Child Abuse Negl 

1994;18:409–17.

8. Finkelhor D, Ormrod R, Turner H, Hamby SL. Victimization of children and youth: 

a comprehensive, national survey. Child Maltreat 2005;10:5–25.

9. Breiding MJ, Black MC, Ryan GW. Prevalence and risk factors of intimate partner 

violence in eighteen U.S. states/territories, 2005. Am J Prev Med 2008;34:112–8.

10. Fisher BJ. Measuring rape against women: the significance of survey questions 

[Section I-4-1]. In: Fisher BS, ed. Violence Against Women and Family Violence: 

Developments in Research, Practice, and Policy. Washington, DC: 

US Department of Justice; 2004. Publication no. 199701. Available at: 

http://www.ncjrs.gov/pdffiles1/nij/199701_sectionI.pdf. Accessed July 30, 2008.

11. Straus MA. Controversy over domestic violence by women: a methological, 

theoretical and sociology of science analysis. In: Arriaga XB, Oskamp S, eds. Violence 

in Intimate Relationships. Thousand Oaks, CA: Sage Publications, Inc.; 1999: 17–44.

12. Archer J. Sex differences in aggression between heterosexual partners: 

a meta-analytic review. Psychol Bull 2000;126:651–80.

13. Institute of Medicine. Reducing the Burden of Injury: Advancing Prevention 

and Treatment. Bonnie FJ, Fulco CE, Liverman CT, eds. Washington, DC: National 

Academies Press; 1999.
92

14. Bronfenbrenner U. Ecology of Human Development: Experiments by Nature 

and Design. Cambridge, MA: Harvard University Press; 1979.

15. National Victim Center, Crime Victims Research and Treatment Center. Rape 

in America: A Report to the Nation. Arlington, VA: National Victim Center and 

Charleston, SC: Medical University of South Carolina; 1992. Available at: 

http://academicdepartments.musc.edu/ncvc/resources_prof/rape_in_america.pdf.

Accessed July 30, 2008.

16. Stith SM, Smith DB, Penn CE, Ward DB, Tritt D. Intimate partner physical abuse 

perpetration and victimization risk factors: a meta-analytic review. Aggression and 

Violent Behavior 2004;10:65–98.

17. Appel AE, Holden GW. Co-occurrence of spouse and physical child abuse: a review 

and appraisal. J Fam Psychol 1998;12:578–99.

18. Fang X, Corso PS. Child maltreatment, youth violence, and intimate partner 

violence developmental relationships. Am J Prev Med 2007;33:281–90.

19. Holtzworth-Munroe A, Stuart GL. Typologies of male batterers: three subtypes and 

the differences among them. Psychol Bull 1994;116:476–97.

20. Johnson MP, Leone JM. Differential effects of intimate terrorism and situational 

couple violence: findings from the National Violence Against Women Survey. 

J Fam Issues 2005;26:322–49.

21. Catalano S. Intimate Partner Violence in the United States. Washington, DC: US 

Department of Justice, Bureau of Justice Statistics; 2007. Available at: 

http://www.ojp.usdoj.gov/bjs/intimate/ipv.htm. Accessed July 30, 2008.

22. Tjaden P, Thoennes N. Prevalence, incidence, and consequences of violence 

against women: findings from the National Violence Against Women Survey. 

Washington, DC: US Department of Justice, Office of Justice Programs; 1998. 

Available at: http://www.ncjrs.gov/pdffiles/172837.pdf. Accessed July 30, 2008.

23. Bureau of Justice Statistics. Criminal Victimization in the United States, 2005—

Statistical Tables. Washington, DC: US Department of Justice, Bureau of Justice 

Statistics; 2007. Available at: http://www.ojp.usdoj.gov/bjs/abstract/cvusst.htm. 

Accessed July 30, 2008.

24. Whitaker DJ, Baker CK, Arias I. Interventions to prevent intimate partner violence. 

In: Doll LS, Bonzo SE, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence 

Prevention. New York: Springer; 2007: 203–21.

25. Fixsen DL, Naoom SF, Blasé KA, Friedman RM, Wallace F. Implementation 

Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, 

Louis de la Parte Florida Mental Health Institute; 2005. Available at: 

http://nirn.fmhi.usf.edu/resources/publications/Monograph/. 

Accessed July 30, 2008.
93

Suicidal Behavior

Public Health Burden

Self-directed violence encompasses a range of behaviors, including acts of fatal and 

nonfatal suicidal behavior, suicidal ideation (i .e ., thinking about, considering, or 

planning for suicide), and nonsuicidal intentional self-harm (i .e ., behaviors with 

the intention not to kill oneself, as in self-mutilation) . Although injury from selfdirected violence is a major public health problem throughout the United States and 

the rest of the world, fatal and nonfatal suicidal behaviors have the most pronounced 

morbidity and mortality and thus will be the focus of this chapter .1–3

In 2005 in the United States, suicide was the 11th leading cause of death overall, 

resulting in 32,637 deaths4; it was the third leading cause of death among persons 

aged 15–24 years, fourth among persons aged 25–44 years, and eighth among those 

aged 45–64 years .5 Although suicide continues to be problematic throughout the 

lifespan, overall rates of death resulting from suicide are highest among groups aged 

≥80 years, followed by those aged 45–49 years .4 The number of completed suicides 

reflects only a limited portion of the impact of suicidal behavior . Substantially more 

persons are hospitalized as a result of nonfatal suicidal behavior than are fatally 

injured, and an even greater number are treated in ambulatory settings or are not 

treated at all for injuries resulting from suicidal acts than those who are hospitalized .5

Comparative descriptions of suicidal ideation and behavior demonstrate certain key 

differences among population groups . For example, rates of suicide are higher among

males than among females, but studies of suicidal thoughts and nonfatal suicidal 

behavior routinely indicate females have higher rates than males .6

 Suicide rates are 

exceptionally high among certain population groups, including white males aged 

>75 years, American Indians/Alaska Natives, and certain professions (e .g ., health 

professions and police) .1 National data also demonstrate a high prevalence of nonfatal 

suicidal behavior among adults . For example, in 2006, a total of 395,276 persons with 

nonfatal self-harm injuries were treated in U .S . hospital emergency departments .4

Other research indicates that >70% of persons who engage in suicidal behavior 

never seek health services .7

 Consequently, prevalence figures based on health records 

substantially underestimate the societal burden of suicidal behavior .

Total lifetime costs associated with nonfatal injuries and deaths caused by suicidal 

behavior in 2000 were approximately $33 billion, including $1 billion for medical 

treatment and $32 billion for lost productivity .8

 Compounding these costs is the 

incalculable impact of loss of life and the emotional trauma experienced by surviving 

family, friends, and communities that are affected by each person’s fatal or nonfatal 

suicidal behavior .9
94

The Injury Center’s Approach 

to Preventing Suicidal Behavior

Injuries and deaths resulting from suicidal behaviors represent a substantial 

drain on the economic, social, and health resources of the nation . CDC’s Injury 

Center seeks to lessen these burdens by developing and promoting the widespread 

adoption of policies and practices that effectively prevent fatal and nonfatal suicidal 

behaviors . In pursuit of that goal, the Injury Center’s public health approach 

complements such approaches as those of the criminal justice and mental health 

systems . Thus, the Injury Center is uniquely positioned to address the need for 

effective, population-based prevention and intervention strategies . However, public 

perceptions that suicide is solely the purview of mental health practice and a lack of 

scientific knowledge regarding effective population-based strategies hinder efforts 

to prevent suicide .1,10

To address these challenges, the Injury Center draws on historical strengths and 

continues to expand into areas where identified needs are substantial . One area 

of promise includes promotion of social connectedness as a global strategy for 

preventing suicidal behavior . Social connectedness can be defined as quality social 

ties and supportive relationships between individual persons and their peers, 

families, and communities; the connections between persons and their families to 

community organizations; and the connections among community organizations 

and social institutions . Typically, suicide is less likely to occur within communities, 

schools, and families with strong social cohesion or among persons who have strong 

interpersonal connections . Increasing social connectedness is likely to have universal 

as well as targeted impact on suicidal behavior . By supporting healthy interpersonal 

relationships (e .g ., family, peer, and intimate partner relationships) and by 

encouraging communities to care about and care for their members, the population 

at large is likely to experience more positive health and well-being, resulting in lower 

risk for suicidal behavior .

The Injury Center works with multiple partners at the local, state, and national levels 

to disseminate scientific information about suicide prevention . These efforts are 

directed toward the public, policymakers, health departments, faith- and communitybased organizations, and other entities . By promoting research that addresses the 

information needs of constituents, the Injury Center contributes substantially to 

encouraging widespread adoption of effective suicide prevention strategies .

Communities have often implemented programs that attempt to reduce injuries and 

deaths resulting from suicidal behavior; however, knowledge is limited regarding 

the effectiveness of these programs . Finding successful strategies, especially those 

that focus on developing positive skills and social relationships, might also have a 

broad impact on violent behaviors . Given the Injury Center’s ongoing activities in 

child maltreatment, youth violence, and intimate partner violence prevention, it is 

in a unique position to support development and evaluation of programs, within an 

integrated framework, that address suicide and interpersonal violence prevention 

throughout the lifespan . In addition, although domestic and international research 

has identified critical risk and protective factors related to suicidal behavior, key gaps 

remain in our understanding of community- and societal-level factors that influence 

rates of suicidal behavior and the mechanisms through which these factors exert an 

influence .11 Developing a better understanding of the dynamics of suicidal behavior is 

essential for building effective prevention strategies, programs, and policies .

Suicide is 

less likely to 

occur within 

communities, 

schools, and 

families with 

strong social 

cohesion.
95

Other federal agencies and national organizations focus considerable research efforts 

on understanding the causes of suicidal behavior and its prevention . The Injury 

Center collaborates regularly with these groups as evidenced by the release of the 

U .S . Surgeon General’s National Strategy To Prevent Suicide.6

 The Injury Center’s 

contributions to suicide prevention highlight public health and broad-based strategies 

that complement important mental health research and treatment efforts conducted 

by such key federal partners in the U .S . Department of Health and Human Services 

as the Office of the Surgeon General, the Public Health Service, the National Institute 

of Mental Health (within the National Institutes of Health), the Substance Abuse 

and Mental Health Services Administration, the Indian Health Service, and the 

Administration on Aging .

The Injury Center’s Research Priorities 

in Preventing Suicidal Behavior

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Develop better methods for operationalization, measurement, and 

monitoring of fatal and nonfatal suicidal behavior, including the social and 

economic burdens of suicidal behavior. Having accurate, timely, and accessible 

information regarding self-directed violence (e .g ., suicides, nonfatal suicidal 

behavior, and nonsuicidal intentional self-injury) is crucial, both for monitoring 

the problem and for evaluating the impact of prevention efforts .1 However, the 

Division of Violence Prevention’s primary focus is on suicidal behavior . Because 

the number of suicides reflects only a limited portion of suicidal behavior 

(i .e ., substantially more persons are hospitalized as a result of nonfatal suicidal 

behavior than are fatally injured),5

 collected information should include data 

related to suicidal behaviors that result in death, hospitalization, or outpatient 

medical treatment, as well as those where no medical care is sought . Although 

national data exist that describe fatal and nonfatal suicidal behavior, this 

information is either limited in its collection of potentially modifiable variables 

or does not contain state or locally representative data . Research is needed to 

enhance the quality of nonfatal suicidal behavior data collected from hospital 

emergency departments and from population-based surveys . To create and 

implement enhanced surveillance strategies, researchers should (1) refine and 

validate definitions of suicidal and related behaviors; (2) collect more specific 

data regarding methods and circumstances surrounding suicide; (3) develop 

better methods for implementing high-quality, timely data collection systems, 

including data systems outside of health and medical communities; and (4) 

evaluate the utility, quality, and efficiency of the data and collection procedures .
96

 In addition to routine monitoring and surveillance, quantifying the social and 
97

D. Examine the influence of community- and societal-level factors on rates of 

suicidal behavior. Previous research indicates that multiple social factors can 

substantially affect rates of fatal and nonfatal suicidal behavior .2 These include 

such societal- and community-level factors as social connectedness; the structure 

of social relationships (e .g ., the percentage of persons in the community who 

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

values, and attitudes; the availability of resources for persons who are struggling 

with day-to-day difficulties; and severe community and environmental stressors 

(e .g ., natural and human disasters) .16 The evidence also demonstrates that these 

influences can vary in their presence and impact across population groups .17,18

Researchers do not fully understand the mechanisms through which these 

broad, community-level factors affect rates of suicidal behavior, which hinders 

their ability to design effective prevention strategies .19 Researchers, practitioners, 

and public health agencies need multidisciplinary information that addresses 

the interaction of factors to design and test more community- and society-level 

approaches that can effectively reduce suicide-related injuries and deaths among 

particular communities .

E. Clarify the contribution of individual-level risk and protective factors other 

than those related to mental health on suicidal behavior, emphasizing the 

identification and role of protective factors. Although mental health problems 

can contribute substantially to a person’s suicidal behavior, mental disorder alone 

does not cause suicide .20 Additional factors can increase the risk for suicidal 

behavior, including stressful life events (e .g ., the death of a relative or losing a 

job), ongoing difficulties (e .g ., child maltreatment, bullying, intimate partner 

violence, or physical illness or disability), or social isolation characterized by 

living alone and having limited or no social supports .21,22 However, researchers 

still lack insight into the relative contribution of these problems on suicide risk . 

Studies have indicated that persons exposed to multiple suicide-related risk 

factors are able to avoid engaging in suicidal behavior because of the presence of 

protective factors .23 Research perspectives, however, often miss opportunities to 

assess these protective factors for future use in suicide prevention .24 As a result, 

knowledge is limited regarding how to recognize and bolster such potentially 

protective effects as social connectedness . Research in this area can contribute 

substantially to development of effective prevention strategies by providing a 

more dynamic and socially informed understanding of suicidal behavior .

F. Evaluate whether evidence-based programs for other forms of violence can 

also prevent suicidal behavior. Surveillance and epidemiologic data provide 

evidence that substantial overlap exists in suicidal behavior and interpersonal 

violence . Victims of interpersonal violence (e .g ., child maltreatment or intimate 

partner violence) have a higher risk for suicide than nonvictims .25,26 In addition, 

both previous and continuing perpetrators of interpersonal violence are at 

increased risk for suicidal ideation and behaviors .27,28 From these and other 

studies, evidence also continues to accumulate that suicidal behavior and 

interpersonal violence share certain complex risk and protective factors .
98

 Given the overlap between suicide and interpersonal violence, strategies to 
99

 In addition, research is needed to prepare for adopting and adapting prevention 
100

 Research is also needed to improve understanding of the progression and 
101

L. Examine effective approaches to synthesizing, translating, and packaging 

evidence-based strategies for preventing suicide. Research has identified 

individual-, family-, and school-level strategies to reduce risk factors for suicidal 

behaviors; however, these empirically supported prevention strategies are not 

widely used in practice settings . Consequently, a gap exists between research and 

practice in preventing suicidal behavior in real-world settings .44 To address this 

gap and to increase dissemination and uptake of evidence-based strategies in 

practice settings, research should examine optimal ways to synthesize, translate, 

and package effective suicide prevention and social connectedness strategies for 

use by practitioners . For example, survivor groups are strong advocates for suicide 

prevention, yet evidence in support of science-based strategies is rarely translated 

into practical language or communicated in ways survivor groups can embrace . 

Research is needed to understand which formats (e .g ., paper, electronic, or direct 

contact) most effectively communicate scientific knowledge for integration into 

suicide prevention programs . Greater understanding of the variation and content 

of different formats as well as which elements are most critical in changing practice 

behavior will benefit this area of practice substantially . By addressing the researchto-practice gap, the Injury Center can increase the likelihood of dissemination of 

effective practices and programs .

M. Examine how effective programs and policies can be developed or modified 

for use among diverse and culturally distinct populations. Accumulated 

evidence indicates that rates of suicidal behaviors and suicide risk profiles 

can vary substantially among distinct social and cultural groups . The factors 

commonly used to define disproportionately affected populations (e .g ., race/

ethnicity, sex, age, sexual orientation, and geographic region) typically are not 

modifiable factors that programs and policies can address easily . Therefore, 

prevention strategies should focus not only on intervening with a specific 

population but on the conditions and behaviors that help explain why 

documented disparities exist among different groups . For example, research can 

determine if a particular disparity can be explained by such modifiable factors 

as social connectedness, impulsivity, or access to lethal means . Programs and 

policies can then be developed or adapted to address the underlying explanatory 

factors for a specific population .
102

References

1. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, eds. Reducing Suicide: 

A National Imperative. Washington, DC: National Academy Press; 2002.

2. World Health Organization. Prevention of suicide: guidelines for the formulation and 

implementation of national strategies. Geneva: World Health Organization; 1996.

3. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence 

and Health. Geneva: World Health Organization; 2002. Available at: 

http://www.who.int/violence_injury_prevention/violence/world_report/en/. 

Accessed July 30, 2008.

4. National Center for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health 

and Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars/. 

Accessed July 30, 2008.

5. Rosenberg ML, Gelles RJ, Holinger PC. Violence: homicide, assault and suicide. In: 

Amler RW, Dull HB, eds. Closing the Gap: The Burden of Unnecessary Illness. New 

York: Oxford University Press; 1987.

6. US Department of Health and Human Services, Public Health Service. National 

strategy for suicide prevention: goals and objectives for action. Washington, DC: US 

Department of Health and Human Services, Public Health Service; 2001. Available 

at: http://download.ncadi.samhsa.gov/ken/pdf/SMA01-3517/SMA01-3517.pdf. 

Accessed July 30, 2008.

7. Diekstra RFW. Epidemiology of attempted suicide in the EEC. In: Wilmott J, 

Mendlewicz J, eds. Bibliotheca Psychiatrica. New trends in suicide prevention. 

New York: Karger; 1982.

8. Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR. Medical costs and 

productivity losses due to interpersonal and self-directed violence in the United 

States. Am J Prev Med 2007;32:474–82.

9. Crosby AE, Sacks JJ. Exposure to suicide: incidence and association with suicidal 

ideation and behavior: United States. Suicide Life Threat Behavior 2002;32:321–8.

10. Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive 

interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 

2003;42:386–405.

11. Herrera A, Dahlblom K, Dahlgren L, Kullgren G. Pathways to suicidal behaviour 

among adolescent girls in Nicaragua. Soc Sci Med 2006;62:805–14.

12. Ringwalt C, Ennet S, Vincus A, Thorne J, Rohrbach LA, Simons-Rudolph A. Prevalence 

of effective substance use prevention curricula in U.S. middle schools. Prev Sci 

2002;3:257–65.

13. Livet M, Wandersman A. Organizational functioning: facilitating effective 

interventions and increasing the odds of programming success. In: Fetterman DM, 

Wandersman A, eds. Empowerment Evaluation Principles in Practice. New York: 

Guilford Press; 2005: 123–54.
103

14. Turvey CL, Conwell Y, Jones MP, et al. Risk factors for late-life suicide: a prospective, 

community-based study. Am J Geriatr Psychiatry 2002;10:398–406.

15. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: 

findings from the National Longitudinal Study on Adolescent Health. 

JAMA 1997;278:823–32.

16. Weiss MG, Saraceno B, Saxema S, van Ommeren M. Mental health in the aftermath 

of disasters: consensus and controversy. J Nerv Ment Dis 2003;191:611–5.

17. De Leo D. Why are we not getting any closer to preventing suicide? Br J Psychiatry 

2002;181:372–4.

18. Range LM, Leach MM, McIntyre D, et al. Multicultural perspectives on suicide. 

Aggression and Violent Behavior 1999;4:413–30.

19. Knox KL, Conwell Y, Caine ED. If suicide is a public health problem, what are we 

doing to prevent it? Am J Public Health 2004;94:37–45.

20. Inskip HM, Harris EC, Barraclough B. Lifetime risk of suicide for affective disorder, 

alcoholism and schizophrenia. Br J Psychiatry 1998;172:35–7.

21. Brent DA. Risk factors for adolescent suicide and suicidal behavior: mental and 

substance abuse disorders, family environmental factors, and life stress. Suicide 

Life Threat Behav 1995;25(Suppl):52–63.

22. Moscicki EK. Identification of suicide risk factors using epidemiologic studies. 

Psychiatr Clin North Am 1997;20:499–517.

23. Borowsky IW, Ireland M, Resnick MD. Adolescent suicide attempts: risks and 

protectors. Pediatrics 2001;107:485–93.

24. Pollard JA, Hawkins JD, Arthur MW. Risk and protection: are both necessary 

to understand diverse behavioural outcomes in adolescence? Soc Work Res 

1999;23:145–58.

25. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: 

specificity of effects on adolescent and young adult depression and suicidality. J 

Am Acad Child Adolesc Psychiatry 1999;38:1490–6.

26. Simon TR, Anderson M, Thompson MP, Crosby A, Sacks JJ. Assault victimization and 

suicidal ideation or behavior within a national sample of U.S. adults. Suicide Life 

Threat Behav 2002;32:42–50.

27. Connor KR, Cerulli C, Caine ED. Threatened and attempted suicide by partnerviolent male respondents petitioned to family violence court. Violence Vic 

2002;17:115–25.

28. Kaltiala-Heino R, Rimpelä M, Marttunen M, Rimpelä A, Rantanen P. Bullying, 

depression, and suicidal ideation in Finnish adolescents: school survey. BMJ 

1999;319:348–51.

29. Lubell KM, Vetter JB. Suicide and youth violence prevention: the promise of an 

integrated approach. Aggression and Violent Behavior 2006;11:167–75.
104

30. Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries—

United States, 2001. MMWR Surveill Summ 2004;53(No. SS-07):1–57.

31. Lester D. Suicide from bridges in Washington, DC. Percept Mot Skills 1993;77:534.

32. Clarke RV, Lester D. Toxicity of car exhausts and opportunity for suicide: comparison 

between Britain and the United States. J Epidemiol Community Health 

1987;41:114–20.

33. Roberts DM, Karunarathna A, Buckley NA, Manuweera G, Sheriff MH, Eddleston M. 

Influence of pesticide regulation on acute poisoning deaths in Sri Lanka. Bull World 

Health Organ 2003;81:789–98.

34. Hawton K. United Kingdom legislation on pack sizes of analgesics: background, 

rationale, and effects on suicide and deliberate self-harm. Suicide Life Threat Behav 

2002;32:223–9.

35. Wandersman A, Duffy J, Flaspohler P, et al. Bridging the gap between prevention 

research and practice: the interactive systems framework for dissemination and 

implementation. Am J Community Psychol 2008;41:171–81.

36. Bonner RL. Correctional suicide prevention in the year 2000 and beyond. Suicide 

Life Threat Behav 2000;30:370–6.

37. Boxer PA, Burnett C, Swanson N. Suicide and occupation: a review of the literature. 

J Occup Environ Med 1995;37:442–52.

38. Firestone RW, Firestone L. Voices in suicide: the relationship between selfdestructive thought processes, maladaptive behaviour, and self-destructive 

manifestations. Death Stud 1998;22:411–43.

39. Steinhausen HC, Metzke CW. The impact of suicidal ideation in preadolescence, 

adolescence, and young adulthood on psychosocial functioning and 

psychopathology in young adulthood. Acta Psychiatr Scand 2004;110:438–45.

40. Gould M, Jamieson P, Romer D. Media contagion and suicide among the young. Am 

Behav Sci 2003;46:1269–84.

41. Chambers DA, Pearson JL, Lubell K, Brandon S, O’Brien K, Zinn J. The science of 

public messages for suicide prevention: a workshop summary. Suicide Life Threat 

Behav 2005;35:134–45.

42. CDC. Suicide contagion and the reporting of suicide: recommendations from a 

national workshop. MMWR Recomm Rep 1994;43(No. RR-6):9–18.

43. Sly DF, Hopkins RS, Trapido E, Ray S. Influence of a counteradvertising media 

campaign on initiation of smoking: the Florida “truth” campaign. Am J Public Health 

2001;91:233–8.

44. Clancy CM, Cronin K. Evidence-based decision making: global evidence, local 

decisions. Health Aff (Millwood) 2005;24:151–62.
105

Youth Violence

Public Health Burden

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

considerable physical, emotional, social, and economic consequences . Although 

rates of youth homicide have declined substantially during recent years, much work 

remains in reducing this public health burden . Homicide is the second leading cause 

of death among youth aged 10–24 years .1

 Among this age group in 2005, homicide 

was the leading cause of death for non-Hispanic blacks; the second leading cause 

of death for Hispanics and non-Hispanic Asian/Pacific Islanders; the third leading 

cause of death for non-Hispanic American Indians/Alaskan Natives; and the 

fourth leading cause of death for non-Hispanic whites .1 Moreover, this represents 

approximately one-third of all homicide victims that year . Guns are a factor in the 

majority of youth homicides — In 2005, a total of 81 .6% of homicide victims aged 

10–24 years were killed with a firearm .1

Violence is also a critical cause of nonfatal injuries among youth . In 2006, a total of 

720,371 youths aged 10–24 years were treated in emergency departments for nonfatal 

injuries sustained from assaults .1 Although nonfatal acts of violence are relatively 

common on school property, the majority of acts of serious and fatal violence occur 

outside of school . For example, <1% of all violent deaths among school-age children 

occur in school, on the way to or from school, or at school-sponsored events .2

Apart from deaths and injuries, youth who are victims of violence or who witness 

violence in their communities suffer other serious consequences, including 

posttraumatic stress disorder, depression, anxiety, and substance abuse .3 They might 

also experience longer term health problems associated with the effects of such 

exposure .4

 Communities with high rates of youth violence suffer as well through its 

negative effects on safe mobility, the nature and quality of social relations, business 

activity, and housing prices .4,5 Overall, the direct and indirect costs of youth violence 

(e .g ., medical, lost productivity, and quality of life) exceed $158 billion a year .6

 

These data highlight the need for prevention programs and policies that address risk 

and protective factors for youth violence, including policies and programs aimed at 

promoting prosocial behavior, strengthening families, and creating communities in 

which youth are safe from violence .
106

The Injury Center’s Approach to Youth Violence Prevention

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

attention and resources were given to the medical treatment of injured victims and 

the apprehension and incarceration of violent offenders . A public health approach 

to solving the problem of violence includes an emphasis on and a commitment to 

identifying policies and programs for preventing youth violence . Such an approach 

derives from a tradition of collaboration among multiple scientific disciplines, 

organizations, and communities . Multiple factors, including the availability of 

effective prevention strategies, social determinants, disparities, parenting practices, 

and school and neighborhood safety all affect trends in violence . Because public 

health encompasses different disciplines and perspectives, its approach is well-suited 

for examining and addressing such multifaceted problems as violence . The public 

health approach also highlights the potential utility of applying different scientific 

tools (e .g ., epidemiology, behavioral and social sciences, and engineering) explicitly 

toward identifying effective prevention strategies . When these key tools are applied, 

the perspective and methods of public health complement those of criminal justice 

and other sectors in understanding and responding to youth violence .

In pursuit of its mission to prevent violence-related injuries and deaths, CDC’s Injury 

Center places a special emphasis on primary prevention — that is, preventing youth 

violence before it occurs . The Injury Center also is dedicated to understanding the 

links between youth violence and other types of violence (e .g ., intimate partner 

violence, sexual violence, child maltreatment, and suicidal behavior), as well as links 

between youth violence and other health problems .

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

implications and immediate relevance for prevention . For example, studies regarding 

risk and protective factors are conducted to guide prevention programs and policies . 

The Injury Center’s evaluation studies focus on determining not only how well 

programs work but also on identifying the processes through which they have an 

impact . This information is critical in helping schools and communities identify and 

use the best existing evidence to prevent violence .

Other federal agencies, including the U .S . Departments of Education and Justice and 

the U .S . Department of Health and Human Services’ National Institutes of Health 

study the causes and consequences of youth violence and work to prevent it . The 

Injury Center routinely collaborates with these agencies and with nongovernmental 

organizations to study youth violence and to ensure that research findings are 

applied to practice . For example, recent partnerships with the Departments of 

Education and Justice have facilitated studies regarding school-associated violent 

deaths and nonfatal injuries from such violent crimes as assault, robbery, and rape . 

The Injury Center’s research regarding violence across contexts (e .g ., school, family, 

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

intoxication, bullying, or robbery), combined with CDC’s emphasis on primary 

prevention strategies, complements and extends the violence-prevention activities of 

other federal agencies and community-based organizations .
107

The Injury Center’s Research Priorities

for Youth Violence Prevention

Given the finite resources available for conducting research, the following priorities 

are listed in two tiers . The first tier contains those priorities that reflect the most 

immediate research needs and those that should be supported first as resources 

become available . Categorizing the priorities into two tiers does not imply, however, 

that the first tier of priorities is more important than the second tier or that research 

related to the second tier of priorities should wait until 2014 to begin .

Tier 1

A. Evaluate dissemination and implementation strategies for effective youth 

violence prevention programs and policies. Research has identified multiple 

individual-, family-, and school-based approaches that effectively reduce youth 

violence and aggression, some of which have also demonstrated effectiveness 

with diverse populations in different settings . However, these empirically 

supported prevention approaches are not widely used in practice settings; thus, 

a gap exists between research and action to prevent youth violence in real-world 

settings .7–9 To bridge this gap, at least three research areas require attention . 

First, to increase the adoption of evidence-based strategies in practice settings, 

research should examine optimal ways to synthesize, translate, and package 

effective prevention approaches .10,11 Second, efforts to build individual,12

organizational,13 and community capacities14,15 to use effective approaches 

should be examined further . For example, the type and quality of technical 

assistance (e .g ., training, coaching, or monitoring) necessary to support 

effective implementation is inadequately understood .16 Third, understanding 

how individual, organizational, and community characteristics influence the 

adoption and effective use of empirically supported youth violence prevention 

approaches is critical .17–19

B. Evaluate strategies for adapting effective prevention programs, policies, 

and practices. Effective prevention programs, policies, and practices are 

often modified when they are delivered in new settings . However, certain 

areas require further attention . First, after an effective prevention approach 

is adopted, the effects of implementing the program, policy, or practice as 

originally developed (i .e ., fidelity to the approach) should be compared with 

the effects of changing the content or delivery format (i .e ., adapting) . Second, 

limited empirical evidence exists to guide decisions regarding what can be 

modified without reducing effectiveness and what must be delivered exactly 

as originally developed to be effective . To this end, research should examine 

the core components that are critical to a prevention strategy’s effectiveness . 

This body of inquiry can illuminate the key topics, exercises, or other facets 

of a prevention strategy that should not be changed or eliminated . Identifying 

core components can also enable practitioners to maintain effectiveness while 

setting the stage for efforts to adapt prevention strategies to meet the needs of 

diverse populations or settings .
108

 A related need is research that establishes the effectiveness of original programs and 
109

D. Examine the economic efficiency of strategies, programs, and policies 

designed to prevent youth violence. Prevention science should be accountable 

and responsive to public health problems; therefore, evaluating not only the 

effectiveness of strategies, programs, and policies, but also the cost to the public 

to implement these prevention measures on a broad scale is needed . Given 

that resources for youth violence prevention are limited, economic efficiency 

is crucial for ensuring that available resources are used wisely . For example, 

information regarding the costs, required resources, and relative contribution of 

individual components can be used to improve program efficiency, particularly 

with prevention efforts that include more than one strategy (e .g ., a school-based 

curriculum combined with a parenting program) . Researchers should build 

on ongoing effectiveness research and test new methods for determining the 

economic efficiency of prevention measures as well .

E. Identify modifiable factors that protect youth from becoming victims or 

perpetrators of violence . The attention given to identifying modifiable factors 

that protect against risk factors for youth violence has risen substantially in the 

past decade .24 In response to calls to define such protective factors, influences that 

might exhibit protective effects relative to risks, contexts, and ecological levels 

have been proposed and examined by using varying procedures . Although these 

efforts have identified selected variables with demonstrable protective effects, 

critical questions remain . For example, etiologic research should continue to 

focus on identifying protective factors while extending this work to

■ test factors that buffer against risk factors (e .g ., moderators) from those that 

have a direct inverse association with behavior (e .g ., promotive effects) and 

from those that have both buffering and promotive effects25;

■ investigate the specificity and potency of protective effects in relation to 

varying risk factors and particular violence-related outcomes;

■ determine whether protective and promotive effects are replicable across 

studies involving diverse populations and study designs;

■ clarify the mechanisms and processes through which protective and 

promotive effects are exerted; and

■ examine the duration of protective and promotive effects across different 

developmental periods .

 Research should also be expanded to investigate the existence of societal- and 

community-level protective factors and modifiable factors that protect against 

risks at multiple ecological levels .26

 Improved understanding of protective factors has immediate implications 

for ongoing youth violence prevention efforts among families, schools, and 

communities . For example, as information becomes available regarding how 

parents in low-income communities can protect their children from violence, 

that information can be communicated immediately through existing parenting 

programs and public service announcements . Research about modifiable 

protective factors has important, immediate implications for prevention .
110

F. Identify the processes by which modifiable sociocultural and community factors 

influence youth violence. Although research has established that youth violence is 

influenced by sociocultural and community factors, the processes, pathways, and 

mechanisms through which this influence is exerted have not been well-defined or 

clearly described empirically . For example, the strong negative association between 

socioeconomic indicators and youth violence is well-documented; however, 

knowledge is limited regarding the mechanisms linking low socioeconomic status 

to youth violence .27–29 Greater attention should be given to demonstrating how 

such social and economic forces might cause or increase the likelihood of youth 

violence . Understanding these underlying mechanisms will be critical in improving 

existing community programs and developing new programs for low-income 

communities . Additionally, studying processes and pathways of influence can 

yield information regarding intervention points that can be effectively targeted to 

disrupt those processes or pathways that promote youth violence . Similarly, such 

information can assist efforts to produce social and economic differences in the 

youth violence public health burden .

 Although socioeconomic indicators are the most commonly studied sociocultural 

and community factors, other factors should also be examined . In particular, research 

should delineate the pathways through and conditions under which youth violence is 

shaped by illicit drug markets, the nature and quality of public housing, formal and 

informal social networks, social norms defining communities and other social spaces, 

and community status regarding social capital . Such research can reveal how these 

factors act and interact with other key variables to elicit violent behaviors among 

youth . Lastly, youth violence occurs within and is shaped by physical as well as social 

contexts . Although this fact is commonly accepted, work to specify ways that physical 

and social structures combine to create or deny opportunities is still developing . 

Future research should thus continue to examine interactions between physical 

and social environments and assess how modifications in the physical environment 

influence behavior and risk for violence .

G. Clarify the associations among youth violence, other forms of violence, and 

other risk behaviors, and determine implications for prevention. Research 

has consistently demonstrated that different forms of violence — that is, child 

maltreatment, intimate partner violence, sexual violence, youth interpersonal 

violence, and suicide — are interrelated . For example, youth who engage in violence 

with same-sex peers are at increased risk for engaging in dating violence, and both 

forms of violence are associated with suicidal behavior .30 In addition, youth who are 

most at risk for engaging in violence are also at higher risk for involvement in other 

health risk behaviors, including substance abuse, dangerous driving, and high-risk 

sexual behavior .31 The majority of prevention strategies focus on specific forms of 

violence or other health risk outcomes . Because school-based violence prevention 

specialists often seek programs with fewer topic-specific curriculum modules and 

more integrated approaches to improving health outcomes, prevention strategies that 

are effective in multiple areas will be of substantial value .

 Research regarding the associations among different forms of violence and other 

health risk behaviors can guide development and evaluation of prevention programs 

that reduce multiple forms of negative health outcomes . Efforts to include multiple 

forms of violence in studies of risk and protective factors for negative health 

outcomes or evaluation studies are needed to improve researchers’ understanding 

of the specificity of youth violence prevention strategies and the ability to generalize 

their results . Given the limited funding available to prevent youth violence, strategies 

should address multiple forms of violence whenever feasible .
111

Tier 2

H. Evaluate the effectiveness of strategies, programs, and policies designed 

to enhance protective and promotive factors that reduce youth violence.

As research continues to identify factors that protect youth from becoming 

victims or perpetrators of violence (see Priority E), the question becomes 

how best to modify these factors so that youths can experience the benefits . 

Research should assist in developing and evaluating the strategies, programs, 

and policies that enhance factors that buffer against risks (e .g ., moderators) 

as well as those that have a direct inverse association with violent behavior 

(e .g ., promotive effects) . Protective factors can exist at the individual, family, 

school, and community levels, and prevention strategies, programs, and 

policies might target factors from any level .24 Research in this area might 

include universal efforts to enhance protective and promotive factors within 

entire populations or efforts directed at the groups who are most at risk for 

violence . Research should examine the extent to which prevention strategies, 

programs, and policies contribute to greater levels of the protective and 

promotive factors of interest, the sustainability of these factors, and the 

impact the prevention strategies, programs, and policies have on youth 

violence victimization and perpetration .

I. Identify and evaluate strategies to decrease inappropriate access to and 

use of firearms among youth. Firearms are used in the majority of youth 

homicides .1 In addition, approximately 1 in 10 male high school students 

reported having carried a gun at least once during the previous 30 days .32 

Although the prevalence and correlates of inappropriate gun carrying among 

youths and the consequences of gun use are well-known, less is known 

regarding the factors associated with youths’ access to and use of firearms to 

threaten or injure others . Research related to youths’ access to firearms and 

gun carrying is needed to improve existing strategies, develop novel strategies, 

and evaluate whether strategies actually prevent inappropriate gun carrying 

and use and reduce firearm-related injuries .

J. Assess the economic and social burden of youth violence. Evaluations of 

the economic and social burdens of violence typically focus on violence as a 

broad class of behaviors affecting persons of all ages . Although isolated studies 

have described the effects of specific forms of violence (e .g ., child and elder 

abuse) on relevant age groups, the magnitude of the social and economic 

burden of youth violence has not been documented systematically . Data 

regarding the social and economic burden of youth violence are needed to 

achieve a comprehensive understanding of the full nature of this public health 

problem .33 Acquiring these data is essential to advancing comprehensive 

attempts to address youth violence because the data can enable assessment 

and appreciation of the full impact of youth violence on the well-being 

of individual persons and their communities . These data can also aid in 

determining activities with the greatest potential to moderate the adverse 

effects of youth violence .
112

 Burden measures are typically used to describe the costs of violence . Consequently, 
113

References

 1. National Center for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health 

and Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars/. 

Accessed July 30, 2008.

 2. Anderson M, Kaufman J, Simon TR, et al. School-associated violent deaths in the 

United Status, 1994–1999. JAMA 2001;286:2695–702.

 3. Lynch M. Consequences of children’s exposure to community violence. Clin Child 

Fam Psychol Rev 2003;6:265–74.

 4. Greenbaum RT, Tita GE. Impact of violence surges on neighborhood business 

activity. Urban Stud 2004;41:2495–514.

 5. Tita GE, Petra TL, Greenbaum RT. Crime and residential choice: a neighborhood 

level analysis of the impact of crime on housing prices. Journal of Quantitative 

Criminology 2006;22:299–317.

 6. Children’s Safety Network Economics and Data Analysis Resource Center. Cost of 

youth violence in the United States [Fact sheet]. Newton, MA: Education Development Center, Inc.; 2000. Available at: http://www.childrenssafetynetwork.org/. Accessed July 30, 2008.

 7. Glasgow R, Lichtenstein E, Marcus AC. Why don’t we see more translation of health 

promotion research to practice? Rethinking the efficacy-to-effectiveness transition. 

Am J Public Health 2003;93:1261–7.

 8. Sogolow E, Sleet DA, Saul J. Dissemination, implementation, and widespread use 

of injury prevention interventions. In: Doll LS, Bonzo SE, Mercy JA, Sleet DA, eds. 

Handbook of Injury and Violence Prevention. New York, NY: Springer; 2007: 493–510.

 9. Wandersman A, Duffy J, Flaspohler P, et al. Bridging the gap between prevention 

research and practice: the interactive systems framework for dissemination and 

implementation. Am J Community Psychol 2008;41:171–81.

10. Backer TE. Failure of success: challenges of disseminating effective substance abuse 

prevention programs. Am J Community Psychol 2000;28:363–73.

11. Schoenwald SK, Hoagwood K. Effectiveness, transportability, and dissemination of 

interventions: what matters when? Psychiatr Serv 2001;52:1190–7.

12. Joyce B, Showers B. Student Achievement Through Staff Development. Alexandria, 

VA: Association for Supervision and Curriculum Development; 2002.

13. Livet M, Wandersman A. Organizational functioning: facilitating effective 

interventions and increasing the odds of programming success. In: Fetterman DM, 

Wandersman A, eds. Empowerment Evaluation Principles in Practice. New York, NY: 

Guilford Press; 2005: 123–54.

14. Goodman RM, Speers MA, McLeroy K, et al. Identifying and defining the dimensions 

of community capacity to provide a basis for measurement. Health Educ Behav 

1998;25:258–78.
114

15. Miller RL, Shinn M. Learning from communities: overcoming difficulties in 

dissemination of prevention and promotion efforts. Am J Community Psychol 

2005;35:169–83.

16. Fixsen DL, Naoom SF, Blase KA Friedman RM, Wallace F. Implementation 

Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, 

The National Implementation Research Network; 2005. Available at: 

http://nirn.fmhi.usf.edu/resources/publications/Monograph/. 

Accessed July 30, 2008.

17. Cooke M. Dissemination of a smoking cessation program: predictors of program 

awareness, adoption and maintenance. Health Promot Int 2000;15:113–24.

18. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations 

in service organizations: systematic review and recommendations. Milbank Q 

2004;82:581–629.

19. Klein KJ, Sorra JS. Challenge of innovation implementation. Acad Manage Rev 

1996;21:1055–71.

20. Elliott DS, Wilson WJ, Huizinga D, Sampson RJ, Elliott A, Ranklin B. Effects of 

neighborhood disadvantage on adolescent development. Journal of Research in 

Crime and Delinquency 1996;33:389–426.

21. Sampson RJ, Lauritson JL. Violent victimization and offending: individual-, 

situational-, and community-level risk factors. In: Reiss AJ, Roth JA, eds. 

Understanding and Preventing Violence. Vol. 3: Social Influences. Washington, DC: 

National Academy Press; 1994: 1–114.

22. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel 

study of collective efficacy. Science 1997;277:919–24.

23. Valdez A, Kaplan CD, Curtis RL Jr. Aggressive crime, alcohol and drug use, 

and concentrated poverty in 24 U.S. urban areas. Am J Drug Alcohol Abuse 

2007;33:595–603.

24. Lösel F, Bender D. Protective factors and resilience. In: Farrington DP, Coid JW, eds. 

Early Prevention of Adult Antisocial Behavior. Cambridge Studies in Criminology. 

Cambridge, MA: Cambridge University Press; 2003: 130–204.

25. Stouthamer-Loeber M, Loeber R, Wei E, Farrington DP, Wikströrm PO. Risk and 

promotive effects in the explanation of persistent serious delinquency in boys.

 J Consult Clin Psychol 2002;70:111–23.

26. Bronfenbrenner U. Ecology of Human Development: Experiments by Nature and 

Design. Cambridge, MA: Harvard University Press; 1979.

27. Kramer R. Poverty, inequality, and youth violence. Ann Am Acad Pol Soc Sci 

2000;567:123–39.

28. US Department of Health and Human Services (DHHS). Youth Violence: 

A Report of the Surgeon General. Rockville, MD: DHHS; 2001. Available at:

 http://www.surgeongeneral.gov/library/youthviolence/toc.html. 

Accessed July 30, 2008.
115

29. Williams K, Rivera L, Neighbours R, Reznik V. Youth violence prevention comes of 

age: research, training and future directions. Annu Rev Public Health 2007;28:195–

211.

30. Swahn MH, Simon TR, Hertz M, et al. Linking dating violence, peer violence, and 

suicidal behaviors among high-risk youth. Am J Prev Med 2008;34:30–8.

31. Sosin DM, Koepsell TD, Rivara, FP, Mercy JA. Fighting as a marker for multiple 

problem behaviors in adolescents. J Adolesc Health 1995;16:209–15.

32. CDC. Youth risk behavior surveillance—United States, 2007. MMWR Surveill 

Summ 2008;57(No. SS-4).

33. Sattin R, Corso P. Epidemiology and costs of unintentional and violent injuries. 

In: Doll LS, Bonzo SE, Mercy JA, Sleet DA, eds. Handbook of Injury and Violence 

Prevention. New York, NY: Springer; 2007: 3–22.

34. Anderson CA, Berkowitz L, Donnerstein E. Influence of media violence on youth. 

Psychological Science in the Public Interest 2004;5:1–30.
116

Contributors

The CDC Injury Research Agenda, 2009–2018, was prepared by the following staff from CDC’s 

National Center for Injury Prevention and Control and their public health partners:

Introduction and Transportation

Cross-Cutting Priorities Michael F. Ballesteros, PhD, MS, and

Robin M. Ikeda, MD, MPH David A. Sleet, PhD

 Chapter Team Lead Chapter Team Leads, 2008

Linda L. Dahlberg, PhD Daphne B. Moffett, PhD

Jeffrey E. Hall, PhD, MSPH Chapter Team Lead, 2006–2007

Daphne B. Moffett, PhD Ann M. Dellinger, PhD, MPH

Chester L. Pogostin, DVM, MPA Violence Prevention David A. Sleet, PhD Child Maltreatment

Rebecca T. Leeb, PhD Injury Response Chapter Team Lead Acute Injury Care Sandra P. Alexander, MEd Vikas Kapil, DO, MPH James A. Mercy, PhD Chapter Team Lead, 2008 Shannon R. Self-Brown, PhD Charles Magruder, MD Daniel J. Whitaker, PhD Chapter Team Lead, 2006–2007 Child Maltreatment Prevention Working Group Richard C. Hunt, MD, FACEP

Scott M. Sasser, MD Sexual Violence and 

Richard W. Sattin, MD Intimate Partner Violence

Daniel J. Whitaker, PhD Traumatic Brain Injury Chapter Team Lead Vikas Kapil, DO, MPH Michele C. Black, PhD Chapter Team Lead, 2008 Pamela C. Cox, PhD Charles Magruder, MD Linda A. Valle, PhD Chapter Team Lead, 2006–2007 Violence Against Women Working Group Jean A. Langlois, MPH, MS, ScD

Marlena M. Wald, MPH, MLS Suicidal Behavior

Richard W. Puddy, PhD, MPH

Unintentional Injury Prevention Chapter Team Lead

Home and Community Alexander E. Crosby, MD, MPH

Michael F. Ballesteros, PhD, MS, and Jennifer Wyatt Kaminski, PhD

Suicide Prevention Working Group David A. Sleet, PhD

 Chapter Team Leads, 2008 Youth Violence

Daphne B. Moffett, PhD Jeffrey E. Hall, PhD, MSPH Chapter Team Lead, 2006–2007 Chapter Team Lead Karin A. Mack, PhD Linda L. Dahlberg, PhD Leonard J. Paulozzi, MD, MPH Joanne Klevens, MD, PhD Judy A. Stevens, PhD Rita Noonan, PhD

Sports, Recreation, and Exercise Thomas R. Simon, PhD

Michael F. Ballesteros, PhD, MS, and Youth Violence Prevention Working Group

David A. Sleet, PhD

 Chapter Team Leads, 2008

Daphne B. Moffett, PhD

 Chapter Team Lead, 2006–2007

Julie Gilchrist, MD

Edited by

C. Kay Smith-Akin, MEd, Health Communication Specialist, Office of Workforce and Career Development, CDC

The contributors thank Lee Annest, PhD; Kevin Webb; Lily Xi, MS; and Dionne Williams, MPH, NCIPC’s Office of Statistics 

and Programming, for their assistance in providing data for this research agenda.

Graphic Design and Desktop Publishing

Leslie L. Dorigo, MA, and Jane P. Mitchko, MEd, 

National Center for Health Marketing, Health Communication Science Office • Emily Eisenberg, MSJ, Quantell, Inc.

Helping People Live to Their Full Potential

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

www.cdc.gov/injury

1-800-CDC-INFO

cdcinfo@cdc.gov

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