Policy and Position Statements


Preventing Injuries and Violence Position Statement

I. ASTHO Supports Comprehensive Policies and Programs to Prevent Injuries and Violence

The Association of State and Territorial Health Officials (ASTHO) affirms that injury and violence prevention activities are an integral component of public health practice to improve health outcomes. Efforts should use a multidisciplinary approach, address prevention of injury and violence across the lifespan, and focus on a broad range of injury prevention issues.

II. Background

Injuries and violence are major contributors to morbidity and mortality across every age and demographic group and in every state and territory. Unintentional injuries, for example, such as those sustained in motor vehicle-related crashes or as a result of poisoning or falls, represent the leading cause of death for people ages 1-44 in the United States.Each year, more than 3 million people are hospitalized, 27 million people are treated in emergency departments and released, and more than 192,000 people die as a result of unintentional and violence-related injuries. The total medical and work-loss costs of deaths from unintentional injuries was nearly $130 billion in 2013, a portion of the $671 billion in total costs of injuries and violence.2

The most common mechanisms for injury death and disability are not static. For example, in 2008, poisoning surpassed motor vehicle crashes as the leading cause of injury death in the United States.3 In the past three decades, the percentage of poisoning deaths caused by drugs increased from about 60 percent to about 90 percent. While the majority of these deaths were unintentional, opioid analgesics were involved more frequently than other specified drugs, including heroin and cocaine.4 Older adult falls also contribute to injury disability; one out of three older people falls each year, and one out of five falls causes a serious injury.Sexual violence prevention is another vital component; roughly one in five women and one in 71 men has experienced rape at some point in his or her life.6 As new drugs continue to emerge, as the older adult population continues to grow, and as sexual violence persists, the mechanisms for injury death and disability will continue to shift.

III. Principles for Addressing Injury and Violence Prevention

Use a Multidisciplinary Approach

ASTHO supports state and territorial health departments’ efforts to prevent injuries and violence using a multidisciplinary approach. This approach draws on the expertise of public health practitioners, healthcare providers, and community partners. Similarly, ASTHO supports the work of state, territorial, and tribal governments to promote health equity, including the application of strategies that directly address social determinants of health and the legal, cultural, social, and economic factors that are barriers to positive health outcomes and contribute to violence and injury.

Over the last few years, injury and violence prevention has become an increasingly integral part of the national public health dialogue. Several national cross-sector injury and violence prevention initiatives indicate this area to be a growing area for improving population health. One example is the National Prevention Strategy, which serves as a blueprint for federal agencies to work across sectors to address health and safety.

State and territorial health departments provide essential leadership in preventing unintentional and intentional injuries and violence, as well as in coordinating injury responses. They serve as integrating bodies that extend best practice, share data and leverage the range of assets and expertise possessed by key partners, such as local public health departments and healthcare, education, criminal justice, public safety, housing, labor, businesses, faith-based organizations, community leaders, decisionmakers and policymakers, and nonprofit organizations, to prevent injuries and violence before they occur. Alignment across and within these sectors is essential for developing cohesive approaches to promote the health, safety, and well-being of children, youth, and families. As the causes of injury and death continue to change, ASTHO affirms it is essential that state and territorial health departments be equipped to address a broad range of injury prevention activities, in accordance with the National Public Health Performance Standards Program’s Essential Public Health Services that describe the state’s role in enforcing laws and regulations that protect health and ensure safety.7

Address Violence and Injury Prevention Across the Lifespan

ASTHO supports state and territorial health departments addressing injury and violence prevention across the lifespan. Effective strategies should address all age groups to encourage the systematic and long-term prevention of injuries and violence. Prevention strategies that intersect families, schools, neighborhoods, and worksites reinforce core principles that safeguard against injury and discourage violence. Violence discourages economic growth and diminishes the quality of life for people who must contend with a reduced sense of personal safety and the safety of their property. Positive social environments and networks within families, schools, neighborhoods, and communities are platforms for role modeling and appropriate conflict resolution.

State and territorial health departments that integrate injury and violence prevention into other public health initiatives, such as maternal and child health and chronic disease prevention programs, may also maximize resources to improve multiple health outcomes. Like all areas of public health, injury prevention requires solid partnerships. State health departments should look to many national organizations for information and as key partners, such as the Safe States Alliance, the Council of State and Territorial Epidemiologists, the Association of Maternal and Child Health Programs, the National Association of Chronic Disease Directors, and Injury and Violence Prevention Network member organizations. Additionally, state health departments are also encouraged to collaborate with national health organizations, such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Preventive Medicine, in representing healthcare providers to support the integration of public health and the health system and include a focus on injury and violence prevention.

Focus on a Broad Range of Injury Prevention Issues

  • ASTHO supports focusing on a broad range of injury prevention issues using the following policy and environmental change strategies and lens of health equity to address them, including the following:
  • Adverse Childhood Experiences (ACEs): Utilize a public health framework for building social-emotional protective factors to foster resilience to trauma. Various forms of child maltreatment and trauma are associated with enduring changes that produce long-term, negative effects on biological aging and health, including suicide, tobacco use, obesity, depression, and anxiety.8
  • Alcohol-Related Injuries: Legislative policies and community-based behavioral interventions and ecological approaches that address risky alcohol usage and alcohol-impaired driving that contribute to violence, falls, drowning, or other injuries.
  • Bullying Prevention: Improve school environments and create cohesive communities by increasing communication and encouraging cooperative relationships between parents, school staff, and local partners; teaching and promoting youth evidence-based problem-solving and conflict management techniques; and developing, implementing, and enforcing anti-bullying policies.9
  • Child Abuse and Neglect: Develop multifaceted approaches that address behavior change at the individual level, and support the creation of healthy relationships between families and neighbors by supporting community involvement and promoting policies and societal norms to create safe, stable, and nurturing environments.
  • Elder Abuse: Support interventions that can reduce, counteract, or moderate risks for elder maltreatment, including strategies for widespread dissemination and implementation of effective practices to reduce injuries at home and in the community.
  • Firearm Misuse, Injury and Death: Use a multidisciplinary approach to prevent firearm misuse, injury and death that encompass all age groups to encourage the systematic and long-term prevention of firearm injury and death, including prevention strategies in multiple sectors: family, school, neighborhood, worksite, and healthcare.
  • Home and Recreational Safety: Implement community-based, comprehensive interventions to prevent unintentional injuries and promote safe and healthy homes including, but not limited to, playground safety, smoke alarms, bicycle helmets, swimming pool fencing, stair gates and window bars, secured storage for poisons and medicines, and child-resistant cigarette lighters.
  • Intimate Partner Violence: Develop uniform definitions and survey methods to measure sexual and intimate partner violence, victimization, and child maltreatment; develop improved precautions against violence; and respond to immediate crises and long-term behavioral and physical vulnerabilities of victimized youth and others.
  • Motor Vehicle Crashes and Road Safety: Enact behavioral and environmental strategies to prevent injuries related to motor vehicle crashes, including passenger, child occupant, and pedestrian injuries, through multidisciplinary approaches involving education and training programs, engineering solutions to modify roadway environments, and law enforcement.
  • Older Adult Falls and Injuries: Implement a range of community-based fall prevention strategies that address the modifiable risk factors for falls as well as enhancing the uses of electronic health and other data and surveillance to inform strategy selection.
  • Poisoning Surveillance and Data: Develop surveillance for poison-related injuries and deaths through improved use of medical examiner data, police reports, and toxicology databases; assessment of risk factors for drug overdoses, strategies for preventing poisoning-related injuries, and improved prescribing and dispensing procedures.
  • Prescription Drug Overdose: Support legislative, state, and community-based interventions that address prescription drug misuse, abuse, and diversion through a framework that includes prevention, surveillance, enforcement, and treatment and recovery to reduce and prevent opioid overdose deaths across all populations. Prescribing practices that may be addressed through guidelines include: determining when to initiate or continue opioids for chronic pain outside of end-of-life care; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing the risk and addressing the harms of opioid use.
  • Sexual Violence Prevention: Improve the understanding of how different forms of violence are linked to one another and legislation that increases campus accountability for addressing sexual violence; enact comprehensive, evidence-based sexual violence prevention plans that address risk and protective factors at the community or organization level that have the greatest potential for population-level impact.
  • Suicide Prevention: Improve modes of implementation, measurement, and monitoring of fatal and nonfatal suicidal behavior, including the social and economic burdens of suicidal behavior, as well as evaluation of programs and policies to prevent suicide.
  • Traumatic Brain Injuries (TBI): Fully implement surveillance and prevention system for TBI that would yield comparable state- and territory-level TBI statistics. Appropriate mechanisms for diagnosis, management, referral, and education are necessary to help individuals who have suffered TBI, ranging from young athletes to military veterans, recover or reduce significant cognitive or emotional impairments.
  • Youth Sports Concussions: Support legislative efforts related to youth sports concussions, including bills that support funding for states to collect data on the incidence and prevalence of youth sports concussions, adopt and implement Return to Play guidelines, and implement preseason baseline and post-injury testing of youth athletes. Adopt policy approaches to help improve early TBI detection, prevention, and treatment, and to help increase the adoption of Return-To-Play protocols.
  • Youth Violence: Identify modifiable factors that protect youth from becoming victims or perpetrators of violence, and strengthen social- and community-level factors at multiple levels of the social-ecological model,10 such as neighborhood cohesion programs that protect against risks for youth violence.

IV.   ASTHO Recommendations for Addressing Injury and Violence Prevention:

  • Strengthen state and community level infrastructure, partnerships, and competencies for injury and violence prevention to improve the capabilities of state health departments, local coalitions, and formal alliances to support policies and other evidence-based strategies that prevent injuries and violence.
  • Adopt policy and programmatic strategies intended to prevent death and disability through specific goals, benchmarks, and quality metrics to generate significant cost savings and better parity in the resources available for underserved populations.
  • Evaluate the legal authorities, program regulations, and other policy guidance to ensure they have the authority, clarity, and capacity to guide and direct state-wide responses to injury and violence prevention.
  • Embrace laws, policies, and funding opportunities to build comprehensive infrastructure for injury and violence prevention programs that is integrated into public health practice to improve health outcomes.
  • Allocate sufficient funding for injury and violence prevention programs, as well as for the planning and maintenance of recommended datasets (e.g., National Violent Death Reporting System) to drive effective prevention strategies through improved surveillance and data linkages; enhance surveillance systems to improve reporting of firearm injury and death; and extend surveillance to all states and territories.
  • Include injury and violence prevention in healthcare initiatives. Because injuries and trauma are major drivers of healthcare utilization, injury prevention should be an important part of efforts to reduce healthcare costs.
  • Evaluate and translate evidence- and practice-based research to strengthen the capacity of state and territorial health departments to apply policy, organizational, and individual behavior change strategies to the field of injury and violence prevention.
  • Use health information technology systems to collect and organize data for surveillance, measuring performance, supporting clinical decisions, designing prevention strategies and evaluating quality improvement processes.
  • Identify funding sources and mechanisms to support integrated studies and cross-disciplinary research agendas, including work with Injury Control Research Centers, academia, and other networks and institutions.
  • Strengthen state and regional trauma systems to ensure rapid, well-coordinated care and treatment.
  • Continue trauma system research to identify the optimal components of trauma systems to reduce short-term disability and improve long-term outcomes, commensurate with the level of resources available.
  • Consider pursuing accreditation of health departments as a systematic tool to improve the quality of injury prevention and public health practice.

Approval History:

ASTHO position statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Board of Directors. Position statements are not voted on by the full ASTHO membership.

Prevention Policy Committee Review and Approval: May 2016
Board of Directors Review and Approval: September 2016
Policy Expires: September 2019

Related Policy Statements:
Achieving Optimal Health for All
Access to Health Services

Related Position Statements:
Firearm Misuse, Injury and Death
Health in All Policies
Healthy Aging
State Home Visiting Programs
Workforce Development

For further information about this position statement, please contact ASTHO Injury & Violence Prevention staff at lchaiken@astho.org.


  1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Injuries cost the US $671 billion in 2013. Available at: http://www.cdc.gov/media/dpk/2015/dpk-injury-costs.html. Accessed 7-21-2016.
  2. Ibid.
  3. Warner M, Chen LH, Makuc DM, et al. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief, No. 81. Hyattsville, MD: National Center for Health Statistics. 2011.
  4. Ibid.
  5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Important Facts About Falls. Available at: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed 7-21-2016.
  6. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
  7. National Public Health Performance Standards Program. Ten Essential Public Health Services. Available at http://www.cdc.gov/nphpsp/essentialServices.html. Accessed 7-20-2016.
  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 study. Am J Prev Med. 1998; 14(4):245-258.
  9. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Bullying Prevention. Available at: http://www.cdc.gov/violenceprevention/youthviolence/bullyingresearch/. Accessed 7-21-2016.
  10. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. The Social-Ecological Model: A Framework for Prevention. Available at: http://www.cdc.gov/ViolencePrevention/overview/social-ecologicalmodel.html. Accessed 7-21-2016.