Association between childhood community safety interventions and hospital injury records: a multilevel study

Neighborhood risk factors for sports and recreational injuries: a systematic review of studies applying multilevel modeling techniques

Background

Sports and recreational activities are the most commonly reported cause of injury-related emergency department (ED) visits among children and young adults in developed countries, yet studies about the effect of neighborhood environment on sports and recreational injuries (SRI) are very limited. The aim of this study was to systematically review studies that apply multilevel modeling approach in examining the relationships between SRI and neighborhood-level risk factors.

Data sources

A systematic search of peer reviewed English language articles was conducted in four electronic databases including PubMed (1992–2020), CINAHL (2000–2020), Sports Medicine and Education Index (1996–2020), and Web of Science (1991–2020).

Study selection

Selected studies were observational or experimental studies of people of all ages across the world that assessed neighborhood risk factors for SRI (or all injuries including SRI) using multilevel regression analysis.

Data synthesis

Nine studies—five cross-sectional, two prospective cohort, and two incidence studies—were selected out of a potential 1510. Six studies used secondary data and three used primary data. Only three studies examined SRI as the main or one of the main outcomes. These studies showed that neighborhood-level factors, such as higher socioeconomic context, lower street connectivity, and living or attending schools in urban communities, were associated with increased risk of SRI. Most studies did not provide a justification for the use of multilevel regression and the multilevel analytical procedure employed and quantities reported varied. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Institutes of Health) was used to assess the quality or risk of bias of each study. Four quality assessment criteria out of 15 were met by all nine studies. The quality assessment ratings of the reviewed studies were not correlated with the quality of information reported for the multilevel models.

Conclusion

Findings from this review provide evidence that neighborhood-level factors, in addition to individual-level factors, should be taken into consideration when developing public health policies for injury prevention. Considering the limited numbers of studies that were identified by this systematic review, more multilevel studies are needed to strengthen this evidence in order to better inform SRI prevention policy decisions.

Evaluation of community coalition training effects on youth hospital-admitted injury incidence in Victoria, Australia: 2001-2017

BACKGROUND

Injuries are one of the three leading causes of morbidity and mortality for young people internationally. Although community risk factors are modifiable causes of youth injury, there has been limited evaluation of community interventions. Communities That Care (CTC) offers a coalition training process to increase evidence-based practices that reduce youth injury risk factors.

METHOD

Using a non-experimental design, this study made use of population-based hospital admissions data to evaluate the impact on injuries for 15 communities that implemented CTC between 2001 and 2017 in Victoria, Australia. Negative binomial regression models evaluated trends in injury admissions (all, unintentional and transport), comparing CTC and non-CTC communities across different age groups.

RESULTS

Statistically significant relative reductions in all hospital injury admissions in 0-4 year olds were associated with communities completing the CTC process and in 0-19 year olds when communities began their second cycle of CTC. When analysed by subgroup, a similar pattern was observed with unintentional injuries but not with transport injuries.

CONCLUSION

The findings support CTC coalition training as an intervention strategy for preventing youth hospital injury admissions. However, future studies should consider stronger research designs, confirm findings in different community contexts, use other data sources and evaluate intervention mechanisms.

Contextual Determinants of Childhood Injury: A Systematic Review of Studies With Multilevel Analytic Methods

BACKGROUND

The definition of injury that underpins the contemporary approach to injury prevention is an etiological definition relating to bodily damage arising from transfer of energy to tissues of the body beyond the limits compatible with physiological function. Causal factors proximal to the energy transfer are nested within a more complex set of contextual determinants. For effective injury control, understanding of these determinants is critical.

OBJECTIVES

The primary aims of this study were to describe the area-level determinants that have been included in multilevel analyses of childhood injury and to quantify the relationships between these area-level exposures and injury outcomes.

SEARCH METHODS

We conducted a systematic review of peer-reviewed, English-language literature published in scientific journals between January 1997 and July 2014, reporting studies that employed multilevel analyses to quantify the eco-epidemiological causation of physical unintentional injuries to children aged 16 years and younger. We conducted and reported the review in accordance with the PRISMA guidelines.

SELECTION CRITERIA

We included etiological studies of causal risk factors for unintentional traumatic injuries to children aged 0 to 16 years. Methodological inclusion criteria were as follows: Epidemiological studies quantifying the relationship between risk factors (at various levels) and injury occurrence in the individual; Studies that recognized individual exposure and at least 1 higher level of exposure with units at lower levels or microunits (e.g., individuals) nested within units at higher levels or macrounits (e.g., areas or neighborhoods); Injury outcomes (dependent variable) examined at the individual level; and Central analytic techniques belonging to the following categories: multilevel models, hierarchical models, random effects models, random coefficient models, covariance components models, variance components models, and mixed models. We combined criteria from the checklist described by the Cochrane Effective Practice and Organization of Care Review Group with factors in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, and we used several quality assessment items from other injury-related systematic reviews to create a quality assessment checklist for this review.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and selected analysis features for the included studies by using preformatted tables. They extracted information as reported in the articles. We determined statistical significance of estimates and effects by using the conventional threshold, P < .05. Any differences in the information extracted were resolved by discussion between authors and by specifically rereading and rechecking the facts as reported in the relevant articles. We tabulated results from the final multilevel model(s) in each of the included articles with key aspects summarized in text. Interpretations of the results and identification of key issues raised by the collated material are reported in the Discussion section of this article.

MAIN RESULTS

We identified 11,967 articles from the electronic search with only 14 being included in the review after a detailed screening and selection process. Nine of the 14 studies identified significant fixed effects at both the area and individual levels. The area-level variables most consistently associated with child injury rates related to poverty, education, employment, and access to services. There was some evidence that injury rates were lower in areas scoring well on area-level summary measures of neighborhood safety. There was marked variation in the methods used and in the mapping of measured variables onto the conceptual model of ecological causation. AUTHOR CONCLUSIONS: These results help establish the scope for the public policy approach to injury prevention. More consistent reporting of multilevel study results would aid future interpretation and translation of such findings.

Individual factors explain neighbourhood variations in accidents to children under 5 years of age

Previous studies have identified possible neighbourhood-level influences on the risk of injuries to preschool children, but none have had sufficient data at both household and area level to explain these neighbourhood effects. We used data from the Avon Longitudinal Study of Parents and Children, which recruited over 14,062 children at birth in the former county of Avon, UK, and collected information about accidents, as well as extensive social, health and developmental data throughout the first 5 years of life. This information was combined with census and geographical data in order to identify neighbourhood influences on accident risks and then attempt to explain these using multilevel regression modelling. A small but statistically significant amount of between-neighbourhood variance in accident risk was found, with neighbourhood intraclass correlation coefficients of 0.82% for any accident, and 0.84% for accidents resulting in injury requiring medical attention. This was entirely accounted for by a variety of child, parental and household level variables. Independent risk factors for both outcomes were children who were developmentally more advanced or displayed greater conduct and behavioural problems, mothers who were of younger age, who were without work, who were smokers, whose partners were unemployed or drank alcohol excessively, and households in which there had recently been adverse life events, or which were under financial stress. The mother's perceptions of neighbourhood quality also explained some of the risks for any accident, but not for medically attended accidents, and this was a variable that operated at the level of individual households rather than at the level of neighbourhoods. The implications of this study are that differences in accident risk between neighbourhoods are explained by geographical clustering of similar types of children, families and households. Interventions should focus more on parental factors and household social circumstances than on the physical environment or community based risks. However, many of these factors are those most resistant to modification without broader societal change.

The significance of policy documents in municipal child health promotion

AIMS

To investigate municipal utilization of policy documents in child health-promoting activities with reference to document types, substance in the documents and timing in the policy process.

METHODS

Fifty semi-structured interviews were performed using the snowball method, and content analyses of written documentation were made. Data were categorized by means of a policy process matrix, and nine case studies were written. Triangulation was used as a validating method, and the coding reliability was assessed. Statements related to various policy documents were categorized according to document types, substance in the documents, and timing in the policy process.

RESULTS

Various policy documents were spontaneously mentioned by 33 of 50 interviewees, in eight of nine case studies, and in all stages of the policy process. Well-defined statements concerning which content in the policy documents that actually impacted on the policy process development were uncommon.

CONCLUSIONS

This study shows that policy documents are present in policy processes related to child health-promoting activities in Swedish municipalities. As Swedish municipalities are autonomous and not forced to pursue governmental recommendations, this probably demonstrates that policy documents are significant in the development of such processes.

Quantifying the effect of a community-based injury prevention program in Queensland using a generalized estimating equation approach

OBJECTIVE

To develop a generalized estimating equation (GEE) model of childhood injury rates to quantify the effectiveness of a community-based injury prevention program implemented in 2 communities in Australia, in order to contribute to the discussion of community-based injury prevention program evaluation.

DESIGN

An ecological study was conducted comparing injury rates in two intervention communities in rural and remote Queensland, Australia, with those of 16 control regions. A model of childhood injury was built using hospitalization injury rate data from 1 July 1991 to 30 June 2005 and 16 social variables. The model was built using GEE analysis and was used to estimate parameters and to test the effectiveness of the intervention.

RESULTS

When social variables were controlled for, the intervention was associated with a decrease of 0.09 injuries/10,000 children aged 0-4 years (95% CI -0.29 to 0.11) in logarithmically transformed injury rates; however, this decrease was not significant (p = 0.36).

CONCLUSIONS

The evaluation methods proposed in this study provide a way of determining the effectiveness of a community-based injury prevention program while considering the effect of baseline differences and secular changes in social variables.

Association between childhood fatal injuries and socioeconomic position at individual and area levels: a multilevel study

OBJECTIVES

To simultaneously examine the effects of area-level and individual-level socioeconomic position on fatal injuries in children <5 years of age.

METHODS

A retrospective cohort study based on the national birth and death registers of Korea. 2 667 060 children born during 1995-8 were followed up from birth to the 5th birthday. Cumulative incidences of fatal injuries were calculated, and through multilevel Poisson regression models, relative risks (RRs) of incidence rate were estimated according to children's sex, father's occupation and mother's education at individual level, and deprivation and degree of urbanity at area level.

RESULTS

Girls had lower risk for fatal injuries than boys (RR 0.81; 95% confidence interval (CI) 0.75 to 0.87). Compared with children with fathers in non-manual occupations, those with fathers in manual (RR 1.45; 95% CI 1.34 to 1.58) or other occupations (RR 1.35; 95% CI 1.13 to 1.62) had higher risk. Children with mothers who were high school graduates (RR 1.23; 95% CI 1.12 to 1.36) or junior school graduates (RR 1.91; 95% CI 1.66 to 2.19) had higher risk than those whose mothers were college graduates. After controlling for individual-level variables, residence in more deprived districts (RR 1.13; 95% CI 1.05 to 1.21) or non-metropolitan regions (urban RR 1.34; 95% CI 1.22 to 1.47 and rural RR 1.61; 95% CI 1.40 to 1.86) was significantly associated with increased risk.

CONCLUSIONS

Both individual-level and area-level socioeconomic position influenced the risk for childhood fatal injuries. To reduce the socioeconomic inequalities and the absolute burden in Korea, universal strategies should receive priority, and special efforts in implementation should be directed towards both disadvantaged households and areas.

Hospitalized Swedish children with hand and forearm injuries: a retrospective review

AIM

To analyse incidences and find risk groups in children hospitalized with hand injuries in a national retrospective study.

METHODS

All children with a primary hand or forearm injury admitted to Swedish hospitals during 1987-2001 were retrieved from the Swedish Hospital Discharge Register and analysed as to incidence and characteristics.

RESULTS

Among 9855 children included, the median age was 7.0 y and two-thirds were boys. The incidence increased in both younger (0-6 y) and older (7-14 y) children. Wounds and fractures almost doubled, while muscle/tendon injuries decreased. In younger children, wounds and burns were the most frequent diagnoses. In older children, fractures and muscle/tendon injuries were common. Sharp objects caused most of the injuries. University hospitals treated almost half of the children.

CONCLUSION

The number of children with hand injuries admitted to hospitals in Sweden increased annually. Analyses of causes behind the increase are important to counter this trend.

What makes things happen? An analysis of the development of nine health-promoting measures aimed at children and adolescents in three Swedish municipalities

The Swedish municipalities offer important environments for health promotion. However, national actors need increased knowledge on how to support the development of public health measures in the municipalities. The aims of this study were to describe the development of municipal health-promoting measures directed at children and adolescents and to identify factors that might explain the development of such measures. Fifty semi-structured interviews and written documentation gathered from three municipalities in Stockholm County resulted in nine case studies. A policy process matrix, based on the actor-structural approach, was constructed to categorise the data. Five aspects contributing to the trajectory of municipal health-promoting measures aimed at children and adolescents were often mentioned in the data set. These are financial problems, perceived local needs, access to external funding, statements in national and international policy documents and the presence of a local public health sector. Politicians, public officials, and non-governmental organisations were the most mentioned actors, with heavy commitment, professional skills, and powerful position referred to as prevalent characteristics. Public health core concepts such as epidemiological statistics and evidence-based measures were rarely mentioned. The health care sector did not seem to have had any direct influence on municipal health-promoting measures. The dissemination of knowledge about public health related international and national policy documents and support for the institutionalisation of a local public health sector might be useful ways to support municipal public health measures.