Education is generally the first approach taken to encourage the public to accept an active countermeasure of proven efficacy. Implicit in its approach is the belief that once people are taught what to do, they will change their behavior and reduce their risk of injury. Driver's education programs, child pedestrian training, and bicycle helmet campaigns are examples of this strategy.

Although these campaigns are popular and attract large numbers of volunteers, they rarely result in sustained behavior change. One study evaluated the impact of a $78 million federal "alcohol safety action program." Although it was launched in dozens of communities around the United States, subsequent evaluation revealed that the program did not reduce the rate of alcohol-related fatalities in the target population. 5

Robertson and colleagues evaluated a saturation advertising campaign promoting safety belts in one city served by two cable systems. One system aired over 1000 high-quality promotional spots; the other aired none. Subsequent observation revealed no difference in rates of safety belt use among subscribers of either system. 6

Not all public education efforts have yielded such discouraging results. A large-scale community action campaign promoting bicycle helmet use in Seattle, Washington produced sharp increases in helmet sales. Observed rates of helmet use among school-aged children increased from 5.5 percent in 1986 to 40.2 percent in 1992. More importantly, head injuries that came to medical attention decreased by approximately two-thirds in this age group.7

The impact of many public education campaigns is blunted by attenuation of effect. No matter how powerful, pervasive, and repetitive a safety message may be, there are always some who never encounter it. Among those who see or hear the message, some actively reject it. Some are not sufficiently motivated to change their behavior. Among those changing their behavior, some relapse into old habits over time. Others fail to follow the message on a consistent basis. Finally, not everyone who adopts a protective strategy escapes injury.

Educational interventions may be enhanced by incorporating theoretical models that include important determinants of individual behavior. 8 These include a number of personal, community, and political factors. The PRECEDE health promotion model has been used with some success in planning injury prevention programs. 9 PRECEDE is an acronym for predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation. Predisposing factors are characteristics of a patient, consumer, or community that motivate behavior. Reinforcing factors are rewards or punishments that are anticipated or follow as a consequence of these behaviors. Enabling factors are environmental characteristics that facilitate or hinder injury-prevention behaviors. This framework has been successfully used to assess educational needs and select appropriate strategies to encourage car seat-belt use and prevent motor vehicle injuries. 10

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