Chapter 36. Prevention of childhood injuries
Jo Sibert, Donna Mead and Jim Richardson
LEARNING OUTCOMES
• Explore strategies for reducing the incidence and severity of childhood accidents.
• Describe and evaluate effective health education and promotion measures in relation to accident prevention.
• Examine specific accidents, their associated aetiology and their incidence.
Introduction
The prevention of injuries is an important issue for all those working with children because of the scale of the morbidity and mortality they cause. Injuries are unlikely to be prevented by campaigns covering all types of injury: the aetiology and preventative solutions are far too complex for that. However, a well-researched multidisciplinary action on individual types of accidents can be successful.
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wwwYou can find information and tables about the scale of the problem of accidents in childhood at:
In preventing a particular injury, a methodological approach is needed: looking first at the size and nature of the problem, then deciding what preventive solutions are possible, implementing them on a small scale and then introducing them more widely when they have proved to be effective. There are three main strategies for injury control:
• Education of children and parents
• Changing the environment
• Enforcing changes in the environment by law.
This approach of education, environment and enforcement has become known as the 3 E’s strategy. The introduction of child-resistant containers for medicines and household products is an example of a change in the environment that has reduced the incidence of accidental poisoning. Likewise, the reduction of the speed limit through enforcing local speed management strategies (particularly around schools, town centres and residential areas) has reduced both the incidence and severity of road traffic accidents. Teaching children to swim is an example of an education intervention that can reduce death from drowning. However, whereas all three strategies have had some success in reducing the incidence of childhood accidents, most successes have followed environmental changes. Educational campaigns by themselves are of only limited value. However, they do have a role and this is explored in detail further in the chapter.
What can a practitioner do?
Possible roles of the practitioner in injury prevention are:
Activity
• as an advocate for children
• through working with local authorities and non-governmental organisations on safe community activities
• through encouraging a safe environment for children during the child surveillance programme
• through opportunistic education
• through responding to local issues.
ActivityChildren’s nurses working in the trauma area of an inner city hospital have noted that, in the summer months, many more children are admitted with serious trauma following road traffic accidents with the child as pedestrian:
• Using the 3 E’s approach outlined above, make a list of proposals for action that might reduce the number and seriousness of the accidents.
As an advocate for children
Before environmental measures are introduced by legislation, campaigns are needed to encourage the voluntary uptake so that ergonomic and effectiveness evaluation can be undertaken. Education can result in a change in public opinion, and the nurse can act as advocate and empower parents to lobby for environmental change. For instance, parents can be educated that safe playground equipment is needed for their children. They can then pressure the local authority to act.
In 1977, the Child Accident Prevention Trust (CAPT) was formed in England. The Trust brings many disciplines together to foster research and action on accidents involving children. There are similar, but less well funded, groups in Wales (Child Safe Wales; Diogelu Plant Cymru), Scotland (Child Safe Scotland) and in other parts of the world. Similar groups exist throughout the word, e.g. Kidsafe in Australia – which claims to have halved childhood accidents since its inception in 1979.
www
wwwFor details on Kidsafe, go to:
For details on CAPT, which includes Child Safe Wales:
Encouraging a safe environment for children during the child surveillance programme
A number of studies (Schlesinger et al 1966, Sibert & Williams 1983) have shown that, by themselves, mass education campaigns to prevent accidents to children are ineffective. However, there is evidence to suggest that health visitors visiting the home and giving specific one-to-one attention to accident prevention can make a difference in the way that families behave, in particular with regard to the installation of safety equipment (Roberts et al 1996).
Activity
ActivityA health visitor is undertaking a safety review for a family comprising a single, unsupported mother with three children aged 6 months, 18 months and 2.5 years:
• Consider each child’s characteristics and stage of development together with the physical layout of the home and social determinants.
• Make notes on the areas that the health visitor and mother will look into and proposals for improving safety in each of those areas.
One of the problems is that it is extremely difficulty to establish firm cause and effect between safety interventions and reduction in incidence of severity of accidents. For example, a paper by Kendrick & Marsh (1997) reports on a randomised controlled trial of an intervention package of safety education in primary care assessed by the frequency of minor injuries. The intervention package was not effective in reducing the frequency of minor unintentional injuries in children at home. This is perhaps not surprising with such a difficult outcome measure where attendance in A & E is dependent on so many factors apart from the severity of the injury and when severe injuries (the ones we want to prevent) are not common enough to assess in this way.
The Child Surveillance Programme is an excellent example of an initiative that stresses injury prevention through the various editions of ‘Health for all children’. This has become the basis for work with children in primary care. It stresses injury prevention.
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wwwMore information on the Child Surveillance Programme can be found at:
Working with local authorities and non-governmental organisations on safe community activities
The least effective way, in the long-term, of tackling the problem of childhood accidents is for locally derived actions to develop haphazardly. Strategies need to be within a national strategy, which encompasses epidemiology, legislation and evaluation, and with appropriate resource allocation. Once the overall strategy is in place, coordinated local activities can set the direction. In 1996, a public health team from the Karolinska Institute in Stockholm developed the concept of local action through safe communities. The first World Injury Control Conference (1989) approved a manifesto for safe communities: ‘Safety – a universal concern for all’. The second World Conference in Atlanta, Georgia, confirmed this.
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wwwFor details of road safety strategies in Wales and Scotland, visit:
Experience with Safe Child Penarth (Sibert & Stone 1998) showed that safe community projects on an individual child basis are possible but difficult to assess. Problems in demonstrating causal relationships between preventative intervention and outcomes such as reduction in overall injury presentation are problematic. It is very difficult to establish with any certainty whether the change that is observed was brought about by an intervention or by some other factor in the child’s life and experience. Similarly, an increase in presentation at A & E departments does not necessarily mean a failed intervention. However, a paper by Sibert et al (1999), looking at preventing injuries in public playgrounds, showed that there has been some success with limited projects involving one type of injury such as playground injury. Throughout the UK there are small groups undertaking community projects.
Much is done on a low budget or voluntary level. One should not expect too much from community projects and it is not reasonable to expect them not only to show that an injury prevention method works but also that the method of applying the method works. One of the problems of small-scale community projects is sustainability, in that interest often lapses over time. It is essential that sustainability is incorporated into the design of initiatives.
Overall, practitioners should take the opportunity for opportunistic safety education. A randomised trial by Clamp & Kendrick in 1998 showed that GP advice coupled with access to low-cost equipment for low-income families resulted in increased use of safety equipment and other safe practices. These findings are encouraging for provision of injury prevention in primary care.
Scenario
Activity
ScenarioChildren and families in some communities have a tradition of cooking with an open fire. The following factors are important:
• flammable clothing
• young women and female children undertaking cooking wearing loose clothing
• the high incidence of accidents resulting in burn injuries.
ActivityPropose a set of information which could be used to give to these families that would help them to reduce the risk of burn injuries in this situation.
Risk factors for injury
Social gradients
Among children aged 0–14 in England and Wales, fires are the second leading cause of accidental death. There is a steep social class gradient in the risk of fire-related death, due in part to social class differences in the prevalence of risk factors for residential fires, such as lone parenthood, financial difficulties and living in rental accommodation or poor quality housing.
Difference in smoke alarm ownership might also help to explain this social class gradient. Households least likely to have alarms include lone parent and low-income households and rental accommodation.
Activity
ActivityConsider the advantages and disadvantages of fire alarm giveaway schemes, targeted at high-risk households in a densely populated, multicultural, materially deprived community.
Social factors are important in childhood injuries. Road traffic injuries to children are five times more common and deaths in house fires 16 times more common in materially disadvantaged families. Similar social class gradients are seen in other injuries to children, with the disadvantaged children having more injuries. The reasons are complex. Poorer families usually live in more dangerous environments, for example, it is much easier for a child to have a road accident if the house opens straight onto a main road in the inner city than if it is a detached house with a garden. Psychosocial stress factors are also involved in the aetiology of many childhood injuries, particularly road traffic injuries and accidental childhood poisoning.
Personality
The question of personality in childhood accidents and whether children can be injury prone is difficult. It is much more likely that injury proneness is related to the environment, both physical and social, rather than to personality factors. It is probably more correct to speak of an injury-prone community than an injury-prone child. Nevertheless, the characteristics of the child as a person will have a role to play. For example, adolescence is a particularly vulnerable time because children of this age are striving to become independent, are inclined to ignore rules and are prone to thrill-seeking and risk-taking behaviour.
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wwwFor details of the European Parliament’s Injury Prevention Programme, go to:
Details of British activity in this field can be found at:
Specific accident types
Road traffic accidents
Pedestrian road traffic injuries
Pedestrian road traffic injuries are particularly common in the inner city and in children from socially deprived families. Fatality rates are correlated with the prosperity of the area. Psychosocial stress is an important factor in road traffic injuries and the interaction of a poor environment with stress is probably involved in many injuries.
Children, particularly boys under 10 years, are particularly at risk from pedestrian road traffic injuries. Parents may overestimate the ability of their children to handle traffic and let them go out on the road unsupervised. Sharples et al (1990), looking at deaths from head injuries in the northern region, found that 72% of these deaths occurred between 3 pm and 9 pm and mostly to boys playing after school.
Environmental change and child pedestrian road traffic injuries
The most effective means of preventing pedestrian road traffic accidents is by modifying the environment. Residential areas can be redesigned to give priority to pedestrians and to separate them from traffic. The speed of traffic can be reduced by speed humps and safe crossings can be provided. There is now good evidence that area-wide engineering schemes and traffic-calming schemes reduce injuries (Towner et al 2001). The provision of play areas will reduce the number of children on dangerous streets. The Safe Community approach is a way of introducing traffic calming.
Education and child pedestrian road traffic injuries
It is possible to teach some children pedestrian skills. One approach is designating safer routes to school. Two randomised trials (Thomson et al., 1992 and Thomson and Whelan, 1997) have showed improvements in children’s finding safe places to cross the road. However, there is little evidence that these programmes have actually gone on to prevent injuries. Roberts (1994) concluded that safety and traffic education are unlikely by themselves to prevent road traffic injuries. School-based traffic clubs have not been shown to be effective.
Passenger accidents
The protection of children in cars from serious injury and death must be an important part of any child safety programme. A major part of such protection is the development of child-restraint systems and seat belts. The campaign group Belt Up School Kids (BUSK) has been campaigning since 1993 for the introduction of seatbelts on minibuses and other vehicles used by school children.
Much of the research on seat belts has been on adult passengers. There is good evidence that seat belts are effective in preventing death and serious injury. The Transport and Road Research Laboratory found that no child died in a 2-year period when in a restraint whereas 264 non-restrained children were killed in that period. Child-restraint systems have the unexpected bonus of improving children’s behaviour and this probably improves driving standards. The problem is getting children to use them.
In young children and babies the barrier to the use of child restraints has in many cases been cost, and child-restraint loan schemes have been developed to help poorer families. They appear to be an effective strategy to increase the number of children safely transported in cars (Towner et al 2001). However, a randomised controlled trial demonstrating restraint use did not appear to increase correct use (Christopherson et al 1985).
Educational campaigns used to persuade children to wear seat belts have had mixed results. Miller & Pless (1977) found no significant differences in seat belt use, although Macknin et al (1987) found a campaign effective in the short term. Most countries have believed that legislation is needed to ensure seat belt usage. Serious injuries fell by 20% following the 1983 legislation in the UK compelling the wearing of seat belts in front seats. A systematic review (Towner et al 2001) of nine studies in the US evaluating seat belt legislation concluded that it was associated with reductions of injuries and death and increases the numbers of children using restraints. Many children remain unrestrained, however.
Cycle helmets
The story of cycle helmets illustrates the international evolution of an environmental solution to a problem. Analysis by Clarke & Sibert (1986)
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