Updating the evidence. A systemic review of what works in preventing childhood unintentional injuries: Part 2

A Feasibility Randomized Trial Evaluating Safe Peds: A Virtual Reality Training Program to Teach Children When to Cross Streets Safely

OBJECTIVE

Injury as pedestrians is a leading contributor to childhood deaths. This study evaluated the effectiveness of Safe Peds, a fully immersive virtual reality training program to teach children when to cross street safely, with the focus on a number of foundational skills and practicing these in traffic situations of varying complexity.

METHODS

Children 7-10 years old were randomly assigned to a control (N = 31) or intervention (N = 26) group. Eligibility criteria included English speaking and typically developing. Testing took place on campus. All children completed pre- and post-testing measures, with those in the intervention group receiving training in between. Training comprised 1 session with 3 phases for a total of up to 1.5 hr and was tailored to each child's performance over trials. On each trial, children decided when to cross and fully executed this crossing, with measures automatically taken by the system as they did so.

RESULTS

Negative binomial regression and analysis of covariance tests were applied, predicting post-test scores while controlling for pre-test scores, age, and sex. The intervention was effective in improving children's street crossing skills, including stopping and checking skills (stop at the curb, look left/right/left, check for traffic before crossing the yellow line), and choosing safe inter-vehicle gaps. Children in the control group did not show significant improvements in any crossing skills.

CONCLUSIONS

The Safe Peds program effectively teaches children skills to support their deciding when to safely cross in a variety of traffic situations. Implications for pedestrian injury are discussed.

Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan

BACKGROUND

Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions.

METHODS

This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age.

RESULTS

A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]).

CONCLUSION

An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

Prevention of unintentional injuries in children under five years

We looked at existing recommendations for preventing unintentional injuries in children under five years of age, and we attempted to identify the main sources used as evidence for formulating these recommendations.

We conducted a literature search up to the 18th October 2019 by using key terms and manual search in selected sources. We summarized the recommendations and source of the evidence in tables for each of five areas of unintentional injuries: road traffic injuries, drowning, poisoning, thermal injuries, falls.

In 2008, the World Health Organization (WHO) published a comprehensive report with strategies for child injury prevention for the European region. More recently, the WHO published several guidance documents focused on one area such as drowning, usually with a global focus. The PrevInfad workgroup (Spanish Association of Primary Care Pediatrics) updated their document on road safety in April 2019, providing recommendations and a summary of the existing evidence. Preventive strategies for injuries in childhood are mainly based on surveillance data and the identification of risk factors. The key strategies for preventing unintentional injuries are a combination of environmental and behaviour modification, that can be achieved through engineering, enforcement and education. Consequently, for this kind of strategies, it is important to evaluate the effectiveness of both the intervention itself, and the way the intervention is advised to parents and caretakers so that there is good compliance of the recommendation.

Environmental change interventions to prevent unintentional home injuries among children in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Unintentional home injury is an important cause of death and disability among children, especially those living in low- and middle-income countries (LMICs). This systematic review aimed to synthesize evidence about the effectiveness of environmental interventions to prevent unintentional child injury and/or reduce injury hazards in the home in LMICs.

METHODS

Seven electronic databases were searched for randomized controlled trials (RCTs) and controlled before and after (CBA) studies published up to 1 April 2018. Potentially eligible citations were screened by title and abstract and full texts of studies obtained. Synthesis was reported narratively, and where possible, meta-analysis was conducted.

RESULTS

Four studies met the inclusion criteria: One CBA study reported changes in injury incidence, and three RCTs reported changes in frequency of home hazards. In one study, child resistant containers were found effective in reducing the incidence of paraffin ingestion by 47% during and by 50% postintervention. A meta-analysis of two trials found that home inspection, safety education and safety devices reduced postintervention mean scores for poisoning hazards [mean difference (MD) -0.77; 95% CI [-1.36, -0.19]] and burn-related unsafe practices (MD -0.37; 95% CI [-0.66, -0.09]) but not for falls or electrical and paraffin burn hazards. A single trial found that home inspection and safety education reduced the postintervention mean scores for fall hazards (MD -0.5; 95% CI [-0.66, -0.33]) but not for ingestion hazards.

CONCLUSION

There is limited evidence that environmental change interventions reduce child injuries but evidence that they reduce some home hazards. More evidence is needed to determine if altering the physical home environment by removing potential hazards reduces injuries in LMICs.

A Pilot Randomized Controlled Trial Testing the Effectiveness of a Pedestrian Training Program That Teaches Children Where and How to Cross the Street Safely

Objective

Pedestrian injury is a leading cause of injury-related mortality for children. This pilot randomized controlled trial tested the efficacy of a training program to teach where and how to cross safely.

Methods

Using fully immersive virtual reality technology, 142 children 7-10 years of age were recruited, with 130 completing crossing measures before (pretest) and immediately after (posttest) training. Training comprised 1.5 hr, was tailored to each child's performance over trials, and focused on either where to cross (n = 44 children completed testing) or how to cross safely (n = 43); corresponding control groups comprised 22 and 21 children, respectively. Following training, children in the intervention groups completed additional tasks to test conceptual knowledge and generalization of learning. Children in the control groups spent the same time as those in training groups but played a video game that used the same game controller but provided no training in street crossing.

Results

The primary outcomes were errors in crossing at posttest, controlling for pretest error scores. Children in the intervention group made from 75% to 98% fewer errors at posttest than control children for all pedestrian safety variables related to where and how to cross safely, with effect sizes (incidence rate ratios) varying between 0.02 and 0.25. They also showed a generalization of what they had learned and applied this knowledge to novel posttraining situations.

Conclusion

Training within a virtual pedestrian environment can successfully improve children's conceptual understanding and crossing behaviors for both where and how to cross streets safely.

Risk Factors at Birth Predictive of Subsequent Injury Among Japanese Preschool Children: A Nationwide 5-Year Cohort Study

OBJECTIVE

To identify risk factors at birth that are predictive of subsequent injury among preschool children.

METHODS

Retrospective analysis of population-based birth cohort data from the "Longitudinal Survey of Babies Born in the 21st Century" was performed from 2001 through 2007 in Japan (n = 47,015). The cumulative incidence and the total number of hospitalizations or examinations conducted at medical facilities for injury among children from birth up to the age of 5 years were calculated. To identify risk factors at birth that are predictive of injury, multivariate analysis of data for hospitalization or admission because of injury during a 5-year period (age, 0-5 years) was performed using the total number of hospital examinations as the dependent variable.

RESULTS

The cumulative incidence (95% confidence interval) of hospital examinations for injury over the 5-year period was 34.8% (34.2%-35.4%) for boys and 27.6% (27.0%-28.2%) for girls. The predictive risk factors at birth we identified for injury among preschool children were sex (boys), heavy birth weight, late birth order, no cohabitation with the grandfather or grandmother, father's long working hours, mother's high education level, and strong intensity of parenting anxiety.

CONCLUSION

Based on the results of this study, we identified a number of predictive factors for injury in children. To reduce the risk of injury in the juvenile population as a whole, it is important to pursue a high-risk or population approach by focusing on the predictive factors we have identified.

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996–2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary.

Self-harm, Assault, and Undetermined Intent Injuries Among Pediatric Emergency Department Visits

OBJECTIVES

Although injuries are a known cause of morbidity and mortality among children and adolescents, little is known about the epidemiology of injury-related emergency department (ED) visits in the United States by injury intent. The objective of this analysis was to examine ED outcomes, defined as death in the ED, inpatient admission, and visit cost, among ED visits stratified by injury intent (i.e., self-harm, assault, and injury with undetermined intent, as compared with unintentional injuries).

METHODS

All injury-related ED visits in the United States for children and adolescents, ages 8 to 17 years, were identified using the 2008 Nationwide Emergency Department Sample. Multivariate survey weighted logistic and linear regression analyses were then used to estimate the likelihood of death on ED visit, inpatient admission, and cost across the 4 injury types.

RESULTS

In 2008, with the use of weighted estimates, there were 66,895 self-harm, 176,125 assault, 24,144 undetermined injury, and 4,244,589 unintentional injury ED visits among children 8 to 17 years. Visits due to self-harm, assault and undetermined injuries were more likely to result in death during the ED visit compared with visits due to unintentional injuries. Self-harm and undetermined intent were also associated with greater odds of inpatient admission as well as 90% and 60% higher ED visit costs, respectively.

CONCLUSIONS

Data from this nationwide sample of pediatric ED visits highlight the resource burden of self-harm, undetermined intent, and assault injury visits. Pediatric EDs may provide a window of opportunity for better case identification and intervention with children experiencing violence and injury.

Preventing childhood scalds within the home: Overview of systematic reviews and a systematic review of primary studies

OBJECTIVE

To synthesise and evaluate the evidence of the effectiveness of interventions to prevent scalds in children.

METHODS

An overview of systematic reviews (SR) and a SR of primary studies were performed evaluating interventions to prevent scalds in children. A comprehensive literature search was conducted covering various resources up to October 2012. Experimental and controlled observational studies reporting scald injuries, safety practices and safety equipment use were included.

RESULTS

Fourteen systematic reviews and 39 primary studies were included. There is little evidence that interventions are effective in reducing the incidence of scalds in children. More evidence was found that inventions are effective in promoting safe hot tap water temperature, especially when home safety education, home safety checks and discounted or free safety equipment including thermometers and thermostatic mixing valves were provided. No consistent evidence was found for the effectiveness of interventions on the safe handling of hot food or drinks nor improving kitchen safety practices.

CONCLUSION

Education, home safety checks along with thermometers or thermostatic mixing valves should be promoted to reduce tap water scalds. Further research is needed to evaluate the effectiveness of interventions on scald injuries and to disentangle the effects of multifaceted interventions on scald injuries and safety practices.

Healthcare providers' knowledge, attitudes and counselling on injury prevention for preschool children in Croatia

Injuries are the leading cause of death for children and young adults in Croatia. Research has indicated that health care providers can be effective in reducing the risk for traumatic injury through anticipatory guidance, but successful guidance requires that providers have injury knowledge and informed safety attitudes. This is the first study in Croatia to identify health care provider's knowledge, attitudes, and practices regarding anticipatory guidance on injury prevention for children. A stratified, random sample of licensed Croatian healthcare providers was mailed a survey, with a response of rate of 39.5 %. Participants included pediatricians, family physicians, gynecologists, each with a focus on primary care, and community nurses. Participants filled out a 15-minute paper-and-pencil survey that tested their knowledge of injury risks and prevention strategies, assessed their safety-prone attitudes, and measured the extent to which they counselled their patients on injury prevention. Pediatricians had the highest knowledge of injury risks and intervention approaches, with an average correct score of six out of ten (significantly higher than all other provider types). Knowledge was highest regarding infant fall risk and lowest for safe sleep positions. Pediatricians and community nurses had the highest safety-prone attitudes. Safety prone attitudes were strongest for transportation safety and weakest for safe sleeping position for all providers. Community nurses reported the highest level of patient counselling, followed by pediatricians. Both factual education and support in translating knowledge into everyday practice are necessary for health care providers. Implementing anticipatory guidance for child safety is a promising approach in Croatia.

Home and other nontraffic injuries among children and youth in a high-income Middle Eastern country: a trauma registry study

A trauma registry in the United Arab Emirates was used to ascertain nontraffic injuries of 0- to 19-year-olds. The registry's value for prevention was assessed. A total of 292 children and youth with nontraffic injuries were admitted for >24 hours at surgical wards of the main trauma hospital in Al Ain region during 36 months in 2003-2006. Injuries were analyzed by external cause, location, body part, and severity. Nontraffic represented 60% (n = 292) of child and youth injuries. Incidence/100 000 person-years was 91 for males, 43 for females. Unintentional included falls 65% (n = 191), burns 17% (n = 49), animal-related (mainly camel) 3% (n = 10), and others 10% (n = 29). Intentional accounted for 4% (n = 13). Falls affected all ages, burns mainly 1- to 4-year-olds. Of the injuries, 70% occurred at home. Most frequent and severe injuries measured by the Injury Severity Score and Abbreviated Injury Scale involved extremities. Prevention of home falls for all ages and burns of 1- to 4-year-olds are priorities. Registries should cover pediatric wards and include data on fall locations and hazardous products.

Preventing unintentional childhood injury at home: injury circumstances and interventions

New Zealand's (NZ) preschoolers carry the greatest injury burden among children aged 0-14 years. These injuries commonly occur at home. To identify how NZ addresses child injury the 1990s national injury datasets and associated free text were examined retrospectively, NZ injury circumstances and interventions were compared to internationally recognised hazards and best practice, and whether NZ interventions addressed common circumstances of injury was assessed. Certain injuries, often associated with activities of daily living, were not addressed by interventions, although most interventions advocated internationally are implemented in NZ. Possible reasons for main injuries not being addressed were the specificity and variable effectiveness of interventions, normality of many injury circumstances, difficulties in evaluating complex environments, and the need for active intervention. There is considerable scope for NZ to improve its child safety. It is unlikely that simple solutions will be found for complex circumstances in which injury events occur. Strategies to address multifaceted problems requiring changes to personal, social and societal factors are required, with evaluation methods able to match their complexity.

Trends and future projections of child injury in New South Wales: A tool for advocacy?

AIMS

To describe the trend of unintentional hospitalised injury in children aged 0-14 years in New South Wales (NSW), Australia during 1993-1994 to 2004-2005 and to estimate future projections of common child injury hospitalisations from 2006 to 2021.

METHODS

NSW hospitalisation data were used to describe injury trends of children aged 14 years or less who were residents of NSW (1993-1994 to 2004-2005). Projected injury-related hospitalisations of children for 2006-2021 were estimated assuming that the current observed rate of change in childhood injury hospitalisation rates continued to 2021.

RESULTS

During 1993-1994 to 2004-2005, there were 238 093 injury-related hospitalisations of children aged 14 years or less in NSW. Assuming the rate of change in injury hospitalisation observed between 1993-1994 and 2004-2005 continued into the future, the all hospitalised injury incidence rate for children aged 14 years or less is projected to decrease by 1.0% each year to 2021. Injury mechanisms such as burns and scalds, swimming pool non-fatal drowning and poisoning are all projected to decrease in the future, although not for all age groups. Falls (excluding those from playground equipment) and falls from playground equipment hospitalisations (excluding children less than 1 year) are projected to increase.

CONCLUSION

Although the incidence of hospitalisation for some common child-related injury mechanisms is projected to decrease over the coming years, others are projected to increase. It is possible that advocacy efforts might benefit from using projected injury trends. Co-ordinated cross-government action is needed to successfully implement child injury prevention strategies, particularly in the playground environment.

Pattern of injury mortality by age-group in children aged 0-14 years in Scotland, 2002-2006, and its implications for prevention

BACKGROUND

Knowledge of the epidemiology of injuries in children is essential for the planning, implementation and evaluation of preventive measures but recent epidemiological information on injuries in children both in general and by age-group in Scotland is scarce. This study examines the recent pattern of childhood mortality from injury by age-group in Scotland and considers its implications for prevention.

METHODS

Routine mortality data for the period 2002-2006 were obtained from the General Register Office for Scotland and were analysed in terms of number of deaths, mean annual mortality rates per 100,000 population, leading causes of death, and causes of injury death. Mid-year population estimates were used as the denominator. Chi-square tests were used to determine statistical significance.

RESULTS

186 children aged 0-14 died from an injury in Scotland during 2002-06 (MR 4.3 per 100,000). Injuries were the leading cause of death in 1-14, 5-9 and 10-14 year-olds (causing 25%, 29% and 32% of all deaths respectively). The leading individual causes of injury death (0-14 years) were pedestrian and non-pedestrian road-traffic injuries and assault/homicide but there was variation by age-group. Assault/homicide, fire and suffocation caused most injury deaths in young children; road-traffic injuries in older ones. Collectively, intentional injuries were a bigger threat to the lives of under-15s than any single cause of unintentional injury. The mortality rate from assault/homicide was highest in infants (<1 year) and decreased with increasing age. Children aged 5-9 were significantly less likely to die from an injury than 0-4 or 10-14 year-olds (p < 0.05). Suicide was an important cause of injury mortality in 10-14 year-olds.

CONCLUSION

Injuries continue to be a leading cause of death in childhood in Scotland. Variation in causes of injury death by age-group is important when targeting preventive efforts. In particular, the threats of assault/homicide in infants, fire in 1-4 year-olds, pedestrian injury in 5-14 year-olds, and suicide in 10-14 year-olds need urgent consideration for preventive action.

The impact of a home visitation programme on household hazards associated with unintentional childhood injuries: a randomised controlled trial

BACKGROUND

The continued high mortality and morbidity rates for unintentional childhood injuries remain a public health concern. This article reports on the influence of a home visitation programme (HVP) on household hazards associated with unintentional childhood injuries in a South African low-income setting.

METHODS

A randomised controlled trial (n=211 households) was conducted in a South African informal settlement. Community members were recruited and trained as paraprofessional visitors. Four intervention visits were conducted over 3 months, focusing on child development, and the prevention of burn, poison, and fall injuries. The HVP, a multi-component intervention, included educational inputs, provision of safety devices, and an implicit enforcement strategy. The intervention effect (IE) was measured with a standardised risk assessment index that compared post-intervention scores for intervention and control households.

RESULTS

A significant reduction was observed in the hazards associated with electrical and paraffin appliances, as well as in hazards related to poisoning. Non-significant changes were observed for burn safety household practices and fall injury hazards.

CONCLUSIONS

This study confirmed that a multi-component HVP effectively reduced household hazards associated with electrical and paraffin appliances and poisoning among children in a low-income South African setting.

Assessing psychosocial correlates of parental safety behaviour using Protection Motivation Theory: stair gate presence and use among parents of toddlers

Unintentional injury due to falls is one of the main reasons for hospitalization among children 0-4 years of age. The goal of this study was to assess the psychosocial correlates of parental safety behaviours to prevent falls from a staircase due to the lack of or the lack of adequate use of a stair gate. Data were collected from a cross-sectional survey using self-administered questionnaires mailed to a population sample of 2470 parents with toddlers. Associations between self-reported habits on the presence and use of stair gates and family and psychosocial factors were analysed, using descriptive statistics and multiple regression models, based on Protection Motivation Theory. The presence of stair gates was associated with family situation, perceived vulnerability, response efficacy, social norms and descriptive norms. The use of stair gates was associated with family situation, response efficacy, self-efficacy and perceived advantages of safe behaviour. The full model explained 32 and 24% of the variance in the presence of stair gates and the use of stair gates, respectively, indicating a large and medium effect size. Programmes promoting the presence and adequate use of stair gates should address the family situation, personal cognitive factors as well as social factors.

The role of psychosocial, behavioural and emotional factors on self-reported major injuries in Brazilian adolescents: a case-control study

INTRODUCTION

The objective of this research was to investigate the sociodemographic, psychosocial, behavioural and emotional risk factors associated with self-reported major injuries.

METHODS

A case-control study, nested in a two-stage survey, was carried out in two cities of the Distrito Federal, Brazil. Cases were defined as subjects who reported an event resulting in injury or physical harm to the person, about which a hospital was visited or a doctor consulted (major injury), during the period of 6 months preceding the interview. Controls (n=640) were matched to cases (n=231) based on sex and neighbourhood. Information on determinants of injuries was collected by self-completed questionnaires and included sociodemographic, psychosocial, behavioural and emotional variables. Data analysis used conditional logistic regression models.

RESULTS

Controlling for social support and pro-social behaviour, adolescents reporting "abnormal" behaviour and emotional problems had more than three times the chance of reporting a major injury compared to "normal" status adolescents (OR=3.65, 95%CI=1.83-7.32).

DISCUSSION

The findings of this study suggest that preventive strategies, while addressing the broader community and environmental risk factors for injuries, need to address the behavioural and emotional factors associated with these injuries.

Presence and use of stair gates in homes with toddlers (11-18 months old)

BACKGROUND

The aim of this study was to assess demographic correlates of the presence and use of stair gates in homes with toddlers.

METHODS

In 2004, self-administered questionnaires were mailed to 2470 parents with toddlers living in both urban and rural areas (response rate 70.1%). The questionnaires were sent by the youth healthcare providers that the parents visited regarding their toddler.

RESULTS

In total, 83% of the parents reported to have at least one stair gate installed; however, 50% of these parents reported that they did not always close the stair gate. Households with a non-Dutch ethnic mother, one child, a female child, a young child or a child who cannot crawl, were less likely to have a stair gate. Households with one child, a toddler who cannot walk, and a mother with a higher educational level were less likely to use the gate adequately.

CONCLUSIONS

This study shows that parents of toddlers often report to have a stair gate; however, in homes with a gate the parents do not necessarily use the gate adequately. Different demographic characteristics were shown to be correlated with both having a stair gate and the use of a stair gate.

Twenty-year trends in fatal injuries to very young children: the persistence of racial disparities

OBJECTIVE

Mortality trends across modifiable injury mechanisms may reflect how well effective injury prevention efforts are penetrating high-risk populations. This study examined all-cause, unintentional, and intentional injury-related mortality in children who were aged 0 to 4 years for evidence of and to quantify racial disparities by injury mechanism.

METHODS

Injury analyses used national vital statistics data from January 1, 1981, to December 31, 2003, that were available from the Centers for Disease Control and Prevention. Rate calculations and chi2 test for trends (Mantel extension) used data that were collapsed into 3-year intervals to produce cell sizes with stable estimates. Percentage change for mortality rate ratios used the earliest (1981-1983) and the latest (2001-2003) study period for black, American Indian/Alaskan Native, and Asian/Pacific Islander children, with white children as the comparison group.

RESULTS

All-cause injury rates declined during the study period, but current mortality ratios for all-cause injury remained higher in black and American Indian/Alaskan Native children and lower in Asian/Pacific Islander children compared with white children. Trend analyses within racial groups demonstrate significant improvements in all groups for unintentional but not intentional injury. Black and American Indian/Alaskan Native children had higher injury risk as a result of residential fire, suffocation, poisoning, falls, motor vehicle traffic, and firearms. Disparities narrowed for residential fire, pedestrian, and poisoning and widened for motor vehicle occupant, unspecified motor vehicle, and suffocation for black and American Indian/Alaskan Native children.

CONCLUSIONS

These findings identify injury areas in which disparities narrowed, improvement occurred with maintenance or widening of disparities, and little or no progress was evident. This study further suggests specific mechanisms whereby new strategies and approaches to address areas that are recalcitrant to improvement in absolute rates and/or narrowing of disparities are needed and where increased dissemination of proven efficacious injury prevention efforts to high-risk populations are indicated.

The silent epidemic of falls from buildings: analysis of risk factors

This study wanted to search for potential risk factors associated with falls from windows and balconies in order to eventually improve prevention. All children under the age of 16 years suffering from head injuries/multiple trauma due to falls from windows or balconies treated over the last 7 years at the intensive care unit (ICU) of the University Children's Hospital Zürich were analysed retrospectively (group A). Fifty patients out of all children suffering from head injuries/multiple trauma due to other types of accidents in the same period were selected at random as controls (group B). Out of a total of 241 children with head injury and/or multiple trauma, 31 (13%) fell out of a building. Twenty-seven of these victims (87%) fell from the third floor or lower. Twenty-one of the falls (68%) occurred at home. Fifteen children (49%) climbed on a piece of furniture before falling. In almost 20% of the accidents dangerous balcony or house constructions led to the fall. Parents did not witness the fall, except for three cases (10%) with direct parental involvement (one mother jumped out with her child, two mothers threw their child out of the window). Two children (6%) attempted suicide. Children aged 0-5 years were predominantly represented (84%), and all six children who died were in this age group. There were significantly more patients with foreign nationalities and lower socio-professional categories in group A than in group B. In both groups, the accidents concerned the youngest child of the family in approximately 50% and happened mostly during summer evenings. There were no significant differences in injured systems and in injury severity between the two groups. This study identified young age, an immigrant family setting, low socio-professional category of the parents, dangerous house constructions, inappropriate furniture placement, and summertime evenings as risk factors for serious building falls in children. This information may foster focused prevention.

Trends in childhood injury mortality in Canada, 1979-2002

OBJECTIVE

To examine national trends in mortality rates for injuries among Canadian children younger than 15 years in 1979-2002.

METHODS

Data on injury deaths were obtained from the Canadian Vital Statistics system at Statistics Canada. Injuries were classified using the codes for external cause of injury and poisoning (E-codes) by intent and by mechanism. Mortality rates were age adjusted to the 1990 world standard population. Negative binomial regression was used to estimate the secular trends.

RESULTS

Annual mortality rates for total and unintentional injuries declined substantially (from 23.8 and 21.7 in 1979 to 7.2 and 5.8 in 2002, respectively), whereas suicide deaths among children aged 10-14 showed an increasing trend. All Canadian provinces and territories showed a decreasing trend in mortality rates of total injuries. Motor vehicle related injuries were the most common cause of injury deaths (accounted for an average of 36.4% of total injury deaths), followed by suffocation (14.3%), drowning (13.5%), and burning (11.1%); however, suffocation was the leading cause for infants. The number of potential years of life lost due to injury before age 75 decreased from 89 343 in 1979 to 27 948 in 2002 for children aged 0-14 years.

CONCLUSIONS

During the period 1979-2002, there were dramatic decreases in childhood mortality for total injuries and unintentional injuries as well as various degrees of reduction for all causes of injury except suffocation in children aged 10-14 years and drowning in infants. The reason for the reduction in injury mortality might be multifactoral.

Children's acquisition and retention of safety skills: the Lifeskills program

OBJECTIVES

Assessment of safety skills performance and knowledge, to evaluate the education offered by the Lifeskills "Learning for Living" village, Bristol, UK which emphasizes interactive learning-by-doing.

DESIGN

Two quasi-experimental matched control group studies. Study 1: knowledge and performance three months post-intervention. Study 2: knowledge pre-intervention and post-intervention at three time points, to distinguish between immediate learning and longer term retention.

SETTING

The Lifeskills training village, Bristol, UK; primary schools in four education authorities in the area.

PARTICIPANTS

Study 1: 145 children aged 10-11 years; 109 from the Lifeskills program, 36 control. Study 2: 671 children aged 10-11 years; 511 Lifeskills, 160 control.

OUTCOME MEASURES

Three areas (road, home, and fire safety). Five performance tests: observation of children's safety skills. Five knowledge tests: pictorial quiz.

RESULTS

Study 1: Lifeskills/intervention children did better than control children on performance and knowledge tests. The knowledge-performance correlation was r = 0.51. Study 2: intervention children did better than control children immediately after the intervention and three months later on all five knowledge tests. On three tests the intervention group showed retention of knowledge from immediately post-intervention to three months, but on two tests there was some loss. This loss was primarily among children from scholastically lower achieving schools. In all other respects the intervention was equally successful for boys and girls, and for children from higher and lower achieving schools.

CONCLUSIONS

The Lifeskills package improved both knowledge and performance but had shortcomings. Complexity of material did not affect knowledge acquisition but did affect its retention.

Language barriers and paediatric burns: Does education make a difference?

A focused first aid education campaign was conducted in Sydney in 1996 for parents of children from Non-English speaking backgrounds (NESB) to improve their knowledge of correct burns first aid treatment (BFAT). This study sought to determine the correlation, if any, between the reported beneficial results of this education campaign and the subsequent severity of burns in children. A retrospective review of all patients admitted to the state Burns Unit at The Children's Hospital at Westmead (CHW) over a 7-year period from January 1995 to December 2001 was performed. Number of patients, language spoken at home (English, Chinese, Arabic, Vietnamese or Other) and the rate of burns requiring skin grafting was assessed. A total of 1,283 patients were admitted over 7 years. Skin grafting was required in 544 (42%). NESB children required grafting in up to 88% of cases prior to the first aid education campaign, reducing to a minimum of 37% at 1 year and 65% at 5 years following the campaign. This compared to 40 and 36%, respectively, for English speaking children. While the initial decrease in grafting requirements may reflect an effective education campaign, the subsequent rise suggests the need for reinforcement.

Contributing factors to preschool unintentional injury

Injury is the leading cause of death and disability for preschoolers in the United States. Young children suffer disproportionate morbidity and mortality when injured. Pediatric nurses modify injury risk through injury prevention strategies and child and family education. Effective injury prevention programs cannot be designed, implemented, or evaluated without a fundamental understanding of the factors that contribute to the phenomenon of preschool unintentional injury. This article includes a discussion of the factors that contribute to preschool unintentional injury occurrence and is based on a combination of epidemiology theory and the health belief model. Evidence-based suggestions for modification of nursing practice are provided.

Prevention of unintentional injury to people with intellectual disability: a review of the evidence

BACKGROUND

Recent research evidence shows that people with intellectual disability (ID) have double the unintentional injury risk of the general population and the risk is further increased in the presence of psychopathology and epilepsy. The pattern of injury and the circumstances surrounding an injury event in those with ID have some similarity with that of young children in the general population. Interventions to prevent injuries are an important health priority in this vulnerable population. This paper reviews evidence from injury prevention studies for people with ID and also considers the relevance of general population injury interventions for this population.

METHOD

Information regarding injury prevention in both ID and general populations was identified using online systems and consultation with research and public health organizations.

RESULTS

Few published studies were identified addressing the issue of injury prevention for those with ID. Possible injury prevention strategies appropriate for the major causes of injury in the ID population were identified from the general population literature. While many environmental injury prevention strategies for young children in the general population are applicable to the population with ID, some may require design modification to ensure effectiveness. Other promising approaches include improved information for parents/carers, primary care physician counselling, and home visits by well-informed and motivated professionals. There may be injury prevention benefit from improved management of psychopathology and epilepsy.

CONCLUSIONS

The issue of injury prevention for those with ID has not been addressed to the extent that the magnitude of the problem requires. Injury prevention programmes trialling a variety of evidence-based approaches and strategies are needed to protect the quality of life for the ID population and their families.

Design and implementation of injury prevention curricula for elementary schools: lessons learned

OBJECTIVES

Project objectives were to: (1) design and produce an easy-to-use, replicable comprehensive injury prevention curriculum for elementary schools; (2) pilot the program to determine instructors' ease in teaching the material and its usefulness in enhancing student knowledge and behavior change; (3) present material in subject-integrated, grade-specific lessons that would meet state and national student learning objectives; and (4) submit and obtain adoption of the curriculum by the State Department of Education.

METHODS

A pilot program was developed, implemented, and evaluated in six intervention and six control schools. The curriculum was revised and implemented in five other schools and finalized according to evaluation results and teachers' and parents' suggestions. Community resources such as police, fire, and county health departments participated in program implementation.

RESULTS

The program showed a significant increase from 21% to 36% in seatbelt use during the school year in program schools compared with a 1% decrease in control schools. Bicycle helmet use increased from 0% to 10% in the program schools. Pre-test and post-test results showed significant differences in student knowledge, attitudes, and behaviors within the program schools, and in comparing the program and control schools. On a Likert scale of 1 (poor) to 7 (excellent), teachers rated lesson content, exercises, and the usefulness of materials and resources as 5.8, 5.5, and 5.4, respectively. Evaluations for the revised curricula ranged from 5.7 to 6.2.

CONCLUSIONS

The favorable evaluation results resulted in the adoption of the curriculum as a state textbook, and widespread teaching of the curriculum. The product is appropriate and efficacious in these elementary schools and their communities.

The burden of injury in preschool children in an urban medicaid managed care organization

BACKGROUND

Efforts to control injuries within managed care organization (MCO) populations require information about the incidence and costs associated with the injuries cared for in MCOs.

OBJECTIVE

This study uses administrative data to measure the rates and the costs of burn, choking, poisoning, blunt, and penetrating injuries in an urban Medicaid MCO.

DESIGN/METHODS

A database was assembled from all medical claims submitted to a Medicaid MCO covering children aged < or =6 years in urban Baltimore between the dates of July 1, 1997, and August 7, 1999. The database included claims submitted on behalf of 1732 children observed for 2180 person-years. International Classification of Disease-9 codes were reviewed to identify claims for burn, poisoning, choking, and blunt/penetrating injuries. Trained coders reviewed outpatient records to assign E-codes.

RESULTS

A total of 796 injuries occurred. The overall injury rate was 36.5% per year. The total cost of the medical care for these injuries was $863 552, or $396 per covered person-year, representing 42%-55% of the capitated rate received in Baltimore. Falls, being struck by something, and cutting/piercing injuries accounted for 68% of injuries. Emergency departments were the most common service sites for injured children for all injuries except in the case of burns.

CONCLUSION

The children enrolled in this urban Medicaid population had nearly twice the rate of injury when compared to the national average. The medical costs of injuries account for about half of the capitated reimbursement for this age group.

Interventions for promoting smoke alarm ownership and function

BACKGROUND

Residential fires caused at least 67 deaths and 2,500 non-fatal injuries to children aged 0-16 in the United Kingdom in 1998. Smoke alarm ownership is associated with a reduced risk of residential fire death.

OBJECTIVES

We evaluated interventions to promote residential smoke alarms, to assess their effect on smoke alarm ownership, smoke alarm function, fires and burns and other fire-related injuries.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, Cochrane Injuries Group database, MEDLINE, EMBASE, PsycLIT, CINAHL, ERIC, Dissertation Abstracts, International Bibliography of Social Sciences, ISTP, FIREDOC and LRC. Conference proceedings, published case studies, and bibliographies were systematically searched, and investigators and relevant organisations were contacted, to identify trials.

SELECTION CRITERIA

Randomised, quasi-randomised or nonrandomised controlled trials completed or published after 1969 evaluating an intervention to promote residential smoke alarms.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

We identified 26 trials, of which 13 were randomised. Overall, counselling and educational interventions had only a modest effect on the likelihood of owning an alarm (OR=1.26; 95% CI: 0.87 to 1.82) or having a functional alarm (OR=1.19; 0.85 to 1.66). Counselling as part of primary care child health surveillance had greater effects on ownership (OR=1.96; 1.03 to 3.72) and function (OR=1.72; 0.78 to 3.80). Results were sensitive to trial quality, however, and effects on fire-related injuries were not reported. In two non randomised trials, direct provision of free alarms significantly increased functioning alarms and reduced fire-related injuries. Media and community education showed little benefit in non randomised trials.

REVIEWER'S CONCLUSIONS

Counselling as part of child health surveillance may increase smoke alarm ownership and function, but its effects on injuries are unevaluated. Community smoke alarm give-away programmes apparently reduce fire-related injuries, but these trials were not randomised and results must be interpreted cautiously. Further efforts to promote smoke alarms in primary care or through give-away programmes should be evaluated by adequately designed randomised controlled trials measuring injury outcomes.