Works? A Literature Review. Preventing Childhood Unintentional Injuries - What

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Preventing childhood unintentional injuries--what


works? A literature review.
T. Dowswell, E. M. Towner, G. Simpson and S. N. Jarvis
Inj. Prev. 1996;2;140-149
doi:10.1136/ip.2.2.140

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Injury Prevention 1996; 2: 140-149

140

REVIEW ARTICLE

Preventing childhood unintentional injuries


what works? A literature review
T Dowswell, EML Towner, G Simpson, SN Jarvis

Abstract
Aim-The aim of this paper is to report
on a systematic review of the world
literature to provide information about
the most effective forms of health promotion interventions to reduce childhood
(0-14 years) unintentional injuries. The
findings are of relevance to policy makers
at a local or national level, to practitioners and researchers.
Methods-The relevant literature has
been identified through the use of electronic databases, hand searching of journals, scanning reference lists, and consultation with key informants.
Results-Examples of interventions that
have been effective in reducing injury
include: bicycle helmet legislation, area
wide traffic calming measures, child
safety restraint legislation, child resistant
containers to prevent poisoning, and window bars to prevent falls. Interventions
effective in changing behaviour include
bicycle helmet education and legislation,
child restraint legislation, child restraint
loan schemes, child restraint educational
campaigns, pedestrian education aimed
at the child/parent, provision of smoke
detectors, and parent education on home
hazard reduction. For the community
based campaigns, the key to success has
been the sustained use of surveillance
systems, the commitment of interagency
cooperation and the time needed to
develop networks and implement a range
of interventions. Education, environmental modification and legislation all have a
part to play and their effect in combination is important.
Department of
Psychology,
University of Leeds
T Dowswell
Department of Child
Health, University of
Newcastle upon Tyne
EML Towner
G Simpson
SN Jarvis
Correspondence to:
Dr EML Towner,

Community Child Health,


Department of Child Health,
Donald Court House,
13 Walker Terrace,
Gateshead NE8 1EB, UK.

Conclusion-The design of evaluations in


injury prevention needs to be improved so
that more reliable evidence can be
obtained. Better information is needed on
process, so that successful strategies can
be replicated elsewhere. There is also a
need for literature reviews on effectiveness to be updated regularly and for their
findings to be widely disseminated to
policy makers, researchers, and practitioners.
(Injury Prevention 1996; 2: 140-149)
Keywords: effectiveness, systematic review, evaluation,
health promotion.

Throughout the developed world, child


unintentional injury is a leading cause of death,
serious morbidity, and permanent disability.
In a number of countries, policy makers have
set targets for reducing injury rates.1`' However, it is important to recognise that unintentional injury encompasses a range of injury
types occurring in a number of settings, for
example on the roads, at home, and in play/
leisure environments. In different injury settings and for different injury types there may be
a number of potential countermeasures that
may achieve reductions in the frequency of
events or in the severity of those injuries which
occur. Hence, there is no single measure that
would solve the injury 'problem', or any single
target group on which to focus interventions.
For this reason, those involved in health promotion need to know which interventions have
been demonstrated to be effective.

Methods
In an earlier paper in Injury Prevention we
examined the role of health education in injury
prevention and contended that criticisms of
health education were based on a narrow view
of what it has contributed.4 The present review
draws on a systematic review of the world
literature.5 It is broader in remit, in that the
earlier review drew on specific examples of
educational interventions to illustrate the argument, whereas this review has included a larger
number of studies and assesses the relative
contribution of education, environmental
modification, and legislation in changing
behaviour and reducing injury. Relevant
studies for inclusion in the present review were
identified by systematic bibliographic searches,
through existing reviews,6"13 and from the
reference lists of important books and articles.
In addition, key 'informants' with particular
expertise in aspects of child injury prevention
identified further sources. Bibliographic searches were carried out through BIDS, MEDLINE, EXCERPTA MEDICA, the DHSS
database, and the Social Science Research
Index. Searches were also carried out at the
Department of Transport and the Transport
and Road Research Laboratory. Most of the
studies were published in English in peer
reviewed journals and were studies in which a
preventive intervention had -been evaluated.
However, in some areas of the literature, and
for some types of interventions (for example
home and product design and environmental

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Preventing childhood unintentional injuries

141

changes) few evaluated studies have been pub- increased journey times to and from school and
lished and what evidence there is regarding a corresponding increase in child casualties.'8
effectiveness is relatively weak. There is also Such studies show the potential impact of land
some evidence from epidemiological studies use and transport policies on child injury rates
that suggests strategies for prevention. These and there is a need for further research to
background studies are discussed within this measure the impact of similar policy changes.
paper because they suggest potential strategies In the meantime, child road safety needs to be
high on the agenda of policy makers and
for future evaluative work.
Given the heterogeneity of injury types, planners.
study designs, outcome measures, and statistical methods in the studies reviewed we have
not attempted a meta-analysis. We have pres- (B) Local changes in the road environment
ented findings from the review in tabular form There is good evidence from a number of
countries that changes in the road layout and, in
elsewhere.56
particular, the separation of children from
traffic by area wide engineering has the potential to reduce injury rates for child pedestrians,
Results
cyclists, and other vulnerable road users.
THE ROAD ENVIRONMENT (TABLE 1)
In a number of developed countries, injuries on Evaluations of area wide engineering schemes
the roads are the leading cause of injury death have been carried out in Britain, Denmark,
in childhood. There is a steep social class Germany, and the Netherlands.'9-26 The
gradient for road injuries. For example, in interventions in different urban safety schemes
England and Wales children in the lowest social have varied, ranging from simple measures to
class (V) are more than four times as likely to close off residential streets to traffic to complex
die as pedestrians than children in social class schemes to reduce traffic speed and volume or
I."4 Most child pedestrian injuries occur in built to restructure the road environment to give
up areas and rather that being concentrated in priority to pedestrians (the Woonerf model).
'blackspots' they are scattered across the road Janssen compared three levels of intervention
and described casualty reductions ofup to 25 %
network.
from a scheme that restricted traffic volumes
and speeds.26 In the UK one demonstration
project that achieved positive results was the
CHILD PEDESTRIAN AND CYCLIST INJURIES
Urban Safety Project.2122 This involved
(A) Broad land use and transport policies
The evidence from evaluated studies demons- changes in the traffic environment in five
trating links between road policy interventions towns. Areas with similar casualty rates were
and injury rates has been limited. Nevertheless, selected for interventions and these were matland use and transport policies have a poten- ched with control sites. The engineering
tially important part to play in reducing child- measures adopted were designed to take
ren's accidents on the roads. Children use roads account of the needs of vulnerable road users
and streets not only to move from place to place and included the provision of central refuges on
but also as an outdoor play area. Policies that wide roads and sheltered parking bays to aid
change the road environment or affect the pedestrians. The measures in one town resulted
volume or speed of traffic have potential to in reductions in casualties among child cyclists
affect child casualty rates. For example, and pedestrians.23 The reduction in casualties
removal of subsidies on public transport in also led to reduced accident costs and the
London led to increased traffic volumes and evidence suggests that such schemes may be
increased road casualties.'5 The design of street cost effective.
environments also has an impact on child
casualty rates. Areas with narrow streets, with
no garden play areas and on-street parking, (C) Education aimed at drivers
have higher casualty rates than those where There is relatively little evidence that driver
children and traffic are separated.'617 There is education has achieved reductions in child
also evidence that broader policies concerning casualty rates. At the same time there is
land use can influence injury rates. Preston evidence that drivers do not always take
demonstrated that an increase in school size in account of the needs of children as legitimate
England during the 1970s was associated with road users. A study by Thomson et al of driver
behaviour showed that drivers do not adjust
their speeds or alter their road position in the
presence of child pedestrians.27 Radar
Table 1 Injuries in the road environment
measurements of vehicle speeds outside school
* There is a need for more studies of the effects of land use entrances by the same research team revealed
policy changes on children's road injury rates
that more than a third of drivers were exceeding
* Environmental modifications of the road environment
have resulted in casualty reductions. More work is
speed limits, and for these drivers if a
posted
needed in this area
child did enter the carriageway there would be
* Road safety education for parents and children may improve knowledge and behaviour, there is less evidence
'nothing' they could do to avoid killing or
that such training achieves injury reductions
seriously injuring the child.28 There are strong
* Cycle helmets are associated with injury reduction and a
number of interventions have achieved increased helmet
links between vehicle speeds and the severity of
wearing
injuries sustained by pedestrians after col* Adequate restraint of children in cars reduces injury risk.
Legislation and education should ensure that all car
lisions.29 Campaigns aimed at reducing speed
occupants are restrained
have considerable potential to save lives and

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Dowswell, Towner, Simpson, Jarvis

142

reduce the severity of injuries sustained by


pedestrians. Meanwhile, more research is
needed on the effectiveness of driver education
campaigns.
A novel educational campaign aimed at both
drivers and pedestrians in Canada has shown
some positive results.30 A multifaceted approach that included road engineering
measures and school based education,
encouraged drivers to yield to pedestrians signalling their intention to cross the road. The
campaign encouraged 'courtesy' by both
drivers and pedestrians. The interventions
resulted in large increases in the number of
drivers yielding right of way to pedestrians.
This is one of the few campaigns that acknowledges the role of both drivers and pedestrians
in road safety. An assumption underpinning
many campaigns is that the main responsibility
for an accident lies with the child.

(D) Road safety education aimed at children and


their parents
Whether it is possible to train children to avoid
injury on the roads is open to question. Some
researchers maintain that children do not have
the perceptual and motor skills necessary to
negotiate difficult road crossing situations.3'
Others take a more pragmatic view and maintain that, given that children are exposed to the
road environment it is necessary to equip them
with at least some knowledge and skills to
improve their chances ofusing roads safely.32 A
number of studies have demonstrated that
children can increase their knowledge about the
road environment. Nevertheless, few studies
have achieved behaviour changes in child
pedestrians and fewer still have been able to
link child education campaigns with changes in
casualty rates.
A campaign in the USA described by Yeaton
and Bailey involving road crossing training for
5 to 9 year olds resulted in improved road
crossing skills in the study group and these
improvements were maintained at one year
follow Up.33 However, this was a small scale
study and there was no control group. Other
road
simulated
using
programmes
environments have also shown improved crossing skills in groups receiving instruction.34-38
Programmes involving observations of children crossing in real road environments have
also resulted in improved crossing behaviour.39
While it is clear that crossing roads demands a
large number of skills, many of these programmes focused on single or groups of target skills,
such as identifying safe places to cross or safe
gaps in the traffic. It is not easy to decide
whether improvement in specific skills will
protect a child from injury on the roads.
Longer term campaigns aiming to improve
children's road safety knowledge and
behaviour at a more general level have achieved
mixed results. An early evaluation of 'The
Tufty Club' - a campaign aimed at preschool
children and their parents - resulted in
knowledge gains in one evaluation' but not in
another.4' Other evaluations of children's
'traffic clubs' have also produced mixed,

although somewhat encouraging results.


Schioldborg reported lower casualty rates for
traffic club members in Norway.42 However,
the lower casualty rate in the intervention
group could be explained by selective club
membership. Since the 1970s similar clubs
have been introduced in a number of European
countries. A disturbing finding from an evaluation of a traffic club in Sweden was that club
members reported more accidents than controls.43 This finding may be explained by a
reporting bias in the intervention group.
Evaluations of the UK traffic club also revealed
mixed findings. West et al report improvements in some aspects of child/parent
knowledge and behaviour, but for many target
skills there were small or no differences
between controls and intervention groups." A
recent evaluation of a UK traffic club claimed
casualty reductions among club members.
Differences of 20% were found between
intervention and control groups for accidents
involving children emerging from behind
parked cars. Eighty one thousand children
were enrolled in the club (half of the target
population of 3 year olds) and all social groups
were represented.4546
Findings from other large scale campaigns
have also produced some encouraging results,
with a number of evaluations claiming casualty
reductions among children exposed to road
safety mass media campaigns.4749 Programmes
involving school based training for pedestrians
have achieved some positive results including
and
in
knowledge
improvements
behaviour.'052 School based cycle training
schemes have also been shown to improve
children's skills,53 54 although there is no
evidence that cycle training programmes have
been associated with casualty reductions. The
lack of coordination in road safety education
programmes has made it difficult to evaluate
the impact of school based training, mass media
campaigns, and other activities on child pedestrian and cyclist injury rates. While educational
campaigns aimed at children have shown
positive results, it is important that effort
should not be solely concentrated on this one
aspect of road safety. Measures that offer
passive protection to children in the road
environment must run alongside campaigns
aimed at making children 'street-wise'.

(E) Cycle helmets and cycle helmet campaigns


Over the past decade a large number of studies
have provided evidence about the effectiveness
of cycle helmets and the effectiveness of campaigns promoting their use. Useful reviews are
provided by Royles55 and Graitcer et al.56 Like
child road safety training, a tacit assumption
underpinning the promotion of cycle helmets is
that responsibility for avoiding injury lies with
the cyclist rather than the driver.57 However,
there is good evidence that the majority of
cyclists killed on the roads sustain head
injuries58 and that cycle helmets offer some
protection from head injury, although helmets
would be unlikely to protect a cyclist from
death in a high velocity impact.59 The evidence

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143

Preventing childhood unintentional injuries

of the relative protective effect of helmets has


been the subject of debate.Y63 Some of the
protection associated with helmet wearing may
be afforded by the safer riding habits of
wearers, and a large number of campaigns
promoting helmet wearing have taken
place.'7- In addition, in some areas in the
USA and Australia, cycle helmet legislation has
been introduced and this has also been subject
to

evaluation.73-81

One of the earliest campaigns promoting


cycle helmet wearing took place in Seattle in the
1980s.60 It involved a range of agencies and
educational methods and provided subsidies
towards the cost of helmets. Observed helmet
wearing rates increased after the campaign
from 5% to 14%. While similarly positive
results have been achieved in campaigns
throughout Europe, North America, Australia
and New Zealand, there is some evidence that
increased wearing rates are achieved most
easily in higher income areas7' and in younger
children rather than teenagers.79 A description
of the components and outcomes of cycle
helmet campaigns is provided elsewhere.4
Until recently there was little evidence that
observed increases in helmet wearing were
associated with casualty reductions. New
evidence from Victoria, Australia, however,
suggests that high helmet wearing rates have
achieved reductions in deaths and injuries by as
much as 70% after the introduction of legislation.75"8' Although it is still too early to evaluate
the total effect of legislation on injury rates,
these results suggest that mandatory helmet
wearing along with educational efforts to promote helmet use do reduce unintentional injury
in young cyclists.
IN CAR RESTRAINT

There is no doubt that children appropriately


restrained in cars are at reduced risk of serious
injury and death in the event of a road traffic
accident.8283 A large number of evaluations
have focused on the effect of legislation on the
use of child restraints and most have reported
injury reductions as a result of changes in the
law. Invariably, legislation preceded by educational campaigns is effective in increasing
observed child restraint use. Nevertheless,
there are still gaps in the legislation in that it
frequently relates to younger children rather
than all ages, and there remain large numbers of
children travelling irn cars either unrestrained
of incorrectly restrained.' " In the UK, an
evaluation of front seat belt legislation revealed
that children aged 11-14 travelling in the front
suffered fewer fatal and serious injuries.'M The
effect on casualty rates of the introduction of
legislation for rear seat belt use has not yet
emerged and there remain gaps in the law.
For infants and young children educational
campaigns and loan schemes have some success
in promoting correct restraint. Nevertheless,
findings in one UK study revealed that many
young babies continue to travel on their
mother's laps in the rear seat of cars, and many
infants were secured in non-approved devices
such as carry cots.86 Campaigns encouraging

older children to 'buckle-up' have met with


mixed results.87-9'
A number of educational campaigns have
achieved changes in behaviour - that is, increased numbers of children observed travelling correctly restrained in cars. Reductions in
death and injury, however, have followed the
introduction of legislation and there is a strong
case for extending legislation to cover all car
occupants. Nevertheless legislation will not
achieve its full potential while children remain
inadequately restrained. Children and parents
need access to approved devices at reasonable
cost and restraints must be properly fitted and
easy to use on every car journey. Hence supportive educational and loan schemes should also
be extended.
INJURIES IN THE HOME ENVIRONMENT
(TABLE 2)

For young children (between 1 and 5) most

unintentional injuries occur in the environ-

ment where this group spend most of their time


at home. Children under 5 are at particular
risk of deaths from fire, falls, suffocation, and
strangulation, and while deaths from poisoning
are rare, a large number of children suffer
non-fatal injury as a result of poisoning. Like
road traffic accidents there is a social class
gradient for unintentional injuries in the home
(particularly for burns), with children from
more deprived homes being at greatest risk.92

(A) Safe home design


There is little direct evidence that
modifications in home design have achieved
injury reductions. Nevertheless, some aspects
of domestic architecture are clearly hazardous
and have been covered by building regulations:
these include the provision of handrails on
stairs and restrictions on the use of interior
glazing in new built homes. To evaluate the
effect of features of home design on injury there
is a need for constant monitoring of home
accident reports.
(B) Product design
A number of products have been associated
with specific injury types and,- therefore, withdrawal of certain products from the market
have resulted in decreases in injuries. Sorensen
describes injuries associated with particular
types of domestic products - coffee makers,
vacuum cleaners, and front loading washing
machines - and the specific injuries resulting
from their poor design.93 Lobbying manufac-

Table 2 Injuries in the home environment


* The provision, installation, and maintenance of home
safety devices (such as smoke detectors) offer potential
for injury reduction. Legislation increases the number of
homes protected by safety devices
* A number of home safety education campaigns aimed at
children and parents have resulted in improved
knowledge and some behaviour changes. There is little
evidence that this approach alone has achieved injury
reductions

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144

Dowswell, Towner, Simpson, Jarvis


turers and policy makers, and the subsequent
withdrawal of these products led to injury
reductions. Avery and Jackson summarise children's products regulated in the UK and
emphasise the need for monitoring new products so that hazardous ones can be withdrawn.94

(C) Safety devices


Despite the fact that many safety devices are
promoted as part of home safety campaigns,
there is little evidence that most of these are
effective in reducing injuries. While some
devices such as fire guards, stairgates, and
cupboard locks are associated with lower risks,
there is a need for further research on the
efficacy of safety devices, such as cooker guards
which may introduce new hazards.98 Smoke
detectors have been evaluated in a number of
studies discussed below.
(D) Parent and child home safety education
A large number of studies have evaluated the
impact of home safety education. Some focus
on a range of target injuries,96-'08 whereas
others have targeted single injury types such as
burns and scalds, poisoning, or falls from
windows.'09-'4' The results of such educational
campaigns have been mixed. An early study by
Colver in the UK involving home visits and
targeted advice from health visitors alongside a
mass media campaign led to the majority of
intervention families making a change to
remove or reduce the effects of a hazard in their
homes.99 Similarly, a study by Dershewitz
evaluating the effect of counselling and the
provision of free devices resulted in some
changes being made but the absolute number of
hazards in the homes of both intervention and
control families remained high.98 These studies
illustrate the difficulties of measuring 'hazard
reduction'. The way that particular hazards
relate to injury risk is unclear, and interpreting
the results of such campaigns is, therefore, not
simple. An early campaign focusing on a single
falls from windows
injury
achieved
positive results. It is one of the few home injury
campaigns achieving injury reductions among
its outcomes. "" As part of that campaign free
window guards were provided to 4200 families
and a 35% decrease in mortality from falls was
reported for the study area. Other single focus
campaigns achieving successful outcomes include the promotion of smoke detectors. Campaigns which involved providing, installing,
and maintaining these devices were more likely
to achieve positive outcomes than those where
individuals had to buy, install, and maintain
them themselves.
Smoke detector legislation has been
associated with injury reductions'20 and such
legislation, along with appropriate support and
education, is likely to achieve the best results. A
large number of studies have also focused on
campaigns aimed at reducing scald injuries
from domestic hot water. Again, the conclusion
seems to be that campaigns that provided,
installed, and maintained devices were more
likely to achieve outcomes such as observed

reductions in tap water temperatures. Nevertheless, there is evidence that some devices
promoted as part of safety campaigns are not
practicable in everyday use. Waller et al'37 and
Fallat and Rengers'38 report on campaigns
where devices were ineffective or not compatible
with heating systems in many households.
Mass media campaigns aimed at burn prevention have been shown to achieve some gains in
knowledge but have not been associated with
reductions in injury."5 Claims that burn injury
reduction was achieved as a result of a large
scale campaign in Denmark are unconvincing.'20 While the authors did show a reduction
in burn admissions, the lack of control group
meant that it was not possible to conclude that
the reductions were attributable to the programme.
For poison prevention the extension of
regulations concerning the safe packaging of
medicines and hazardous substances have been
successful in reducing deaths and hospital
admissions among young children. However,
regulations are patchy and many poisons
remain unregulated. Sibert et al have also
revealed that voluntary codes of practice for
safe product packaging are of limited value.'32
Many substances continue to be dispensed in
unsafe packaging. A campaign in South Africa
encouraging the safe storage of paraffin
achieved a reduction in paraffin ingestions. 16
This study showed that providing families with
a free, fairly effective safety device, achieved
positive results. Nevertheless, 'safe' packaging
is not a panacea. Many poisoning incidents
involve regulated products. Walton has noted
that 'child resistant' is not childproof, and safer
packaging does not reduce the need for safe
storage of poisons and adequate supervision of
young children at risk from poisoning. '" There
is no evidence that poison labelling deters
young children and a study evaluating 'Mr
Yuk' stickers found that children were
attracted to labelled containers rather than
repelled by them.'4'
THE LEISURE ENVIRONMENT (TABLE 3)

There have been few evaluations of programmes aiming to reduce unintentional injury in
the leisure environment despite the fact that
large numbers of children are injured each year
playing and participating in sport. Drowning is
a major cause of unintentional injury death in
England and Wales and among children over 5
(and particularly boys) these submersion
injuries are likely to occur in leisure
environments, especially in open waterways.'42
Teaching children to swim seems to offer some
protection. "4 Whether this protective effect

Table 3 Injuries in the leisure environment


* There have been few evaluated studies of interventions in
the sport and play environment
* Teaching older children to swim reduces the risk of

drowning

* Protective devices are available for many sports. Many


have not been formally evaluated although they show
potential to reduce injury

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Preventing childhood unintentional injuries

extends to younger children is more controversial as it has been suggested that teaching these
children to swim may lead to greater exposure
and poorer supervision by parents. There have
been no large scale trials comparing injury in
children exposed to swimming training programmes. The provision of guards on beaches
and popular swimming areas have been
associated with reductions in drowning
deaths.'44"45 Although there has been no trial
comparing guarded and unguarded pools, the
very small number of drowning deaths in
public pools in England and Wales suggests
that trained lifeguards do offer some protection
against drowning. Of course, this may be
because supervised children take fewer risks
and the potential for drowning incidents is
reduced. However, Kemp and Sibert suggests
that the relatively high ratio between drowning
and near drowning events suggests that prompt
resuscitation by pool guards also saves lives.'42
Barriers for domestic ponds and pools have
been shown to reduce injury deaths in Australia
and the USA.'4"-'55 Above, rather than inground pool design, also reduces the risk of
young children wandering into pools. Legislation in favour of pool barriers has been
estimated to reduce domestic pool deaths by
half.'55 Despite the fact that pool barriers are of
known efficacy, a study by Wintemute and
Wright revealed that the majority of domestic
pool owners were not in favour of legislation
but favoured first aid training instead.'49 Such
findings underline the need for any legislative
changes to be backed by educational campaigns
to raise awareness of the relative efficacy of
different approaches and to create a climate of
opinion in favour of legislation.
A large number of children are injured each
year playing. There are a number of possible
countermeasures for play and sports injuries
including policy changes, environmental improvement, the provision of safety devices, and
child and parent education.
The section on road injury emphasised that
the street environment doubles as a play area
for children, and policy changes that reduce the
volume and speed of traffic in residential streets
have the potential to reduce child injuries.
There have been few evaluated studies examining the impact on child casualty rates of
interventions such as closing off streets to
provide 'play streets'.
Similarly, there has been no reported evaluation of the impact of environmental changes in
playgrounds, and although playground equipment and surfaces have been associated with
injury, there are no before and after trials with
different types of equipment. While public
opinion seems to favour shock absorbing surfaces in playgrounds, there is no study of the
relative effect of different surfacing materials
on injury rates. King and Ball suggest that the
concentration on surfaces rather than equipment or simple overcrowding is based on a
misconception about the scale and severity of
head injuries after playground falls.'56 An
evaluated intervention in the USA however,
did achieve reductions in hazardous equipment
in playgrounds."'

145

There is little evidence that child and adult


education result in reductions in play and
leisure injuries, although there is evidence that
lack of supervision and poor motor control in
children are associated with injury.'58
There is a need for greater investigation of
the value of a number of protective devices used
in sporting activities. While helmets are of
known value for horse riders'59 there is a need
for further surveillance in other sports.
COMMUNITY BASED CAMPAIGNS

A number of studies have targeted all injury


types and all age groups as part of community
based injury prevention campaigns.'61''72
These are discussed in more detail by Popay
and Young9 and Towner et al.5 Many programmes are still underway and longer term follow
up is needed. Nevertheless, some studies have
produced changes in knowledge and behaviour
in the target populations. Several studies have
also claimed injury reductions, although the
lack of adequate controls make these claims
difficult to interpret.'7' 172 A factor underpinning successful community based programmes
has been good local injury surveillance data to
stimulate local interest and to evaluate the
impact of campaigns. Interagency collaboration is essential to develop different elements of
a local campaign and time is needed to develop
the networks and range of local programmes.

Conclusions
What works in child injury prevention? While
legislation, environmental changes, and education each have a part to play to reduce injury in
children and young adolescents the most successful interventions seem to be those where
the three approaches are combined. For
example, legislation or education promoting
the use of infant car restraints achieve increases
in the use of correct restraints. However, the
evidence suggests that education alone achieves
more modest gains and that legislation without
education means that the law is not observed or
that car restraints are used inappropriately.
In the road environment changes in land use
and transport policy show potential to reduce
child injuries. However, the evidence from
evaluated interventions remains scarce.
Environmental changes at the local level have
been associated with injury reductions. Education aimed at the child and parent have been
shown to increase knowledge and to improve
some aspects of behaviour. It is less clear
whether these changes translate into injury
reductions. There is little evidence that training young cyclists protects them from injury,
although encouraging them to wear cycle
helmets seems worthwhile as helmet wearing
has been linked with injury reductions. Car
restraints protect children inside cars and there
is a need for legislation to be extended to cover
all car occupants. At the same time, parent and
child education is necessary to ensure that
children are adequately restrained on all

journeys.

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Dowswell, Towner, Simpson, Jarvis

146

In the home environment, those campaigns


focusing on a single injury type seem to produce the most successful outcomes. Where a
simple, effective device is available and provided free to families the potential for injury
reduction is great (for example smoke detectors, safe containers for hazardous products, or
window bars). More general campaigns have
more limited success, with modest increases in
knowledge, some behaviour changes, but little
evidence of injury reduction.
In the leisure environment there is a need for
more evidence regarding the value of lifeguards
on beaches, although what evidence there is
seems positive. Teaching older children to
swim is also associated with reduced risk of
drowning. For playground and sports injuries
there is a need for more systematic research into
the value of protective devices and to establish
the degree of hazard associated with particular
sports and pieces of equipment.
The early findings from community based
trials suggest positive findings. The key to
success is the sustained use of surveillance
systems, the commitment to interagency
cooperation, and time to develop networks and
implement measures.
A more general conclusion regarding evaluations of programmes aimed at child injury
reduction is that the quality of the research
evidence is mixed and unevenly spread over
different injury types. There have been
relatively few randomised trials in this field
(less than 20% of the studies we reviewed) and
many studies have no adequate control groups.
More robust experimental design tends to be
limited to single measure interventions (for
example cycle helmets), and to 'closed'
environments such as schools and hospitals.
Few studies provided sufficient detail to allow
succesful interventions to be replicated. Lack
of such process information also makes it
difficult to understand why an intervention
works in some localities but not others. Further, many studies are too small to draw any
firm conclusions. Death and serious injury are
relatively rare events and in most smaller scale
studies 'outcome' measures other than injury
(such as increases in knowledge and changes in
behaviour) are used. Unless there is a clear
relationship between these proxy measures and
an injury outcome, it is difficult to judge
whether the gains reported in campaigns are
worth having.
A final conclusion is that many programmes
do not address the issue of social deprivation. It
is known that there is a steep social class
gradient in mortality for unintentional injury.
Some studies did attempt to target more deprived neighbourhoods but in most cases it is
not clear whether findings would be generalisable across different social class groups.
The field of child and adolescent injury
prevention is maturing rapidly and this is
reflected in the rate of increase in publications.
There is a continued need for literature reviews
on effectiveness in injury prevention to be
updated regularly and for their findings to be
widely disseminated to policy makers, researchers, and practitioners.

1 Department of Health. The health of the nation. A strategy


for health in England. London: HMSO, 1992.
2 Department of Community Services and Health. The
national better health strategic plan 1989- 90 to 1990- 92.
Canberra, ACT: Department of Community Services
and Health, 1989.
3 Centers for Disease Control. Injury control in the 1990s: a
national plan for action. Atlanta: Centers for Disease
Control and Prevention, 1993.
4 Towner EML. The role of health education in childhood
injury prevention. Injury Prevention 1995; 1: 53-8.
5 Towner E, Dowswell T, Jarvis S, Simpson G. Preventing
unintentional injuries in childhood and young adolescence.
The effectiveness of health promotion interventions. York:
NHS Centre for Reviews and Dissemination, University
of York (in press).
6 Towner E, Dowswell T, Jarvis S. Reducing childhood
accidents. The effectiveness of health promotion interventions: a literature review. London: Health Education
Authority, 1993.
7 Bass JL, Christoffel KK, Widome M, et al. Childhood
injury prevention counseling in primary care settings: a
critical review of the literature. Pediatrics 1993; 92:
544-50.
8 Pless I. The scientific basis of childhood injury prevention. A
review of the medical literature. London: Child Accident
Prevention Trust, 1993.
9 Popay J, Young A. Reducing accidental death and injury in
children. Manchester: North Western Regional Health
Authority, 1993.
10 Stone D. Accident prevention research - an overview. A
selective review of the health literature, with special
reference to Scotland. Edinburgh: Scottish Office Home
and Health Department, 1993.
11 Kendrick D, Marsh P. The effectiveness of intervention
programmes in reducing accidental injuries to children and
young people: a literature review. Sheffield: Trent
Regional Health Authority, 1994.
12 Klassen T. The effectiveness of injury control interventions.
Hamilton, Ontario: McMaster University, 1995. (MSc
thesis.)
13 Mulligan J, Law C, Speller V. Interventions to control injury
in children and young people: a literature review. Winchester: Wessex Institute of Public Health Medicine,
1995.
14 Office of Population Censuses and Surveys. Occupational
mortality: childhood supplement. London: HMSO, 1988.
OPCS series DS.
15 Allsopp RE, Turner ED. Road casualties and public
transport fares in London. Accid Anal Prev 1986; 18:
147-56.
16 King D, Lawson S, Proctor S, Johal K, Hoyland M. Child
pedestrian accidents in inner areas: patterns and treatment. Proceedings of the PTRC summer annual meeting.
Bath: University of Bath, 1987.
17 Ward H, Cave J, Morrison A, Allsop R, Evans A. Pedestrian activity and accident risk. Basingstoke: AA Foundation for Road Safety Research, 1994.
18 Preston B. Statistical analysis of child pedestrian accidents
in Manchester and Salford. Accid Anal Prev 1972; 4:
323-32.
19 Engel U. 'Short term' and area wide evaluation of safety
measures implemented in a residential area named Osterbro. A case study. Seminar on short-term and area-wide
evaluation of safety measures. Amsterdam, 1982.
20 Jorgensen E. Bicycle tracks in urban areas in Denmark.
Evaluation of the effect on safety. In: Biecheler M,
Lacombe C, Muhlrad N, eds. Evaluation 85. Proceedings
of the International Meeting on the Evaluation of Local
Traffic Safety Measures, Paris, 1985: 755-61.
21 Lynam D, Mackie A, Davies C. Urban safety project. 1.
Design and implementation of schemes. Crowthorne,
Berks: Department of Transport, Transport and Road
Research Laboratory, 1990.
22 Mackie A, Ward H, Walker R. Urban safety project. 3.
Overall evaluation of area wide schemes. Crowthorne,
Berks: Department of Transport, Transport and Road
Research Laboratory, 1990.
23 Ward H, Norrie J, Sang A, Allsop R. Urban safety project:
the Sheffield scheme. Crowthorne, Berks: Department of
Transport, Transport and Road Research Laboratory,
1989.
24 Doldissen A, Draeger W. Environmental traffic management strategies in Buxtehude, West Germany. In: Tolley
R, ed. The greening of urban transport. London: Bellhaven, 1990: 266-84.
25 Nielsen 0. Safe routes to school in Odense, Denmark. In:
Tolley R, ed. The greening of urban transport. London:
Bellhaven, 1990: 255-65.
26 Janssen STMC. Road safety in urban districts: final results
of accident studies in the Dutch demonstration projects
of the 1970s. Traffic Engineering and Control 1991; June:
292-6.
27 Thomson J, Fraser E, Howarth C. Driver behaviour in the
presence of child and adult pedestrians. Ergonomics 1985;
28: 1469-74.
28 Howarth C, Lightburn A. How drivers respond to pedestrians and vice versa. In: Oborne D, Levis J, eds. Human
factors in transport research. Vol 2: User factors. London:
Academic Press, 1980: 363-70.
29 Kimber R. Appropriate speeds for different road conditions. In: Parliamentary Advisory Council for Transport
Safety, ed. Speed accidents and injury: reducing the risks.
London: PACTS, 1990.

Downloaded from injuryprevention.bmj.com on 2 April 2009

147

Preventing childhood unintentional injuries


30 Malenfant L, Van Houten R. Increasing the percentage of
drivers yielding to pedestrians in three Canadian cities
with a multifaceted safety program. Health Education
Research 1989; 5: 275-9.
31 Sandels S. Children in traffic. Revised ed. Surrey: Elek
Books Ltd, 1975.
32 Thomson J, Ampofo-Boateng K, PitcairnT, Grieve R, Lee
D, Demetre J. Behavioural group training of children to
find safe routes to cross the road. BrJ Educ Psychol 1992;
62: 173-83.
33 Yeaton W, Bailey J. Teaching pedestrian safety skills to
young children: an analysis and one-year follow up. J
Appl Behav Anal 1978; 11: 315-29.
34 Young D, Lee D. Training children in road crossing skills
using a roadside simulation. Accid Anal Prev 1987; 19:
327-41.
35 van Schagen I. Training children to make safe crossing
decisions. In: Rothengatter J, de Bruin R, eds. Road user
behaviour: theory and research. Maastricht: van Gorcum,
1988; 482-9.
36 Nishioka N, Ieda S, Takahashi H, et al. An experimental
study on the safety behaviour of children in adashing-out
situation - effects of verbal instructions and traffic
conditions on safety behaviour. IATSS Research 1991;
15: 39-45.
37 Ampofo-Boateng K, Thomson JA, Grieve R, Pitcairn T,
Lee DN, Demetre JD. A developmental and training
study of children's ability to find safe routes to cross the
road. BrJ Dev Psychol 1993; 11: 31-45.
38 Demetre J, Lee D, Grieve R, Pitcaim T, Ampofo-Boateng
K, Thomson J. Young children's learing on roadcrossing simulations. Br J Educ Psychol 1993; 63:
349-59.
39 Rivara FP, Booth CL, Bergman AB, Rogers LW, Weiss J.
Prevention of pedestrian injuries to children:
effectiveness of a school training program. Pediatrics
1991; 88: 770-5.
40 Firth D. The road safety aspects of the Tufty Club. Crowthorne, Berks: Transport and Road Research Laboratory
Department of Transport, 1973.
41 Antaki C, Morris PE, Flude BM. The effectiveness of 'The
Tufty Club' in road safety education. Br J Educ Psychol
1986; 56: 363-5.
42 Schioldborg P. Children, traffic and traffic training:
analysis of the children's traffic club. The voice of the
pedestrian. 1976: 6.
43 Gregersen NP, Nolen S. Children's road safety and the
strategy of voluntary trafffic safety clubs. Accid Anal
Prev 1994; 26: 463-70.
44 West R, Sammons P, West A. Effects of a traffic club on
road safety knowledge and self-reported behaviour of
young children and their parents. Accid Anal Prev 1993;
25: 609-18.
45 Bryan-Brown K. The effectiveness of the General Accident
eastern region children's traffic club. Crowthorne, Berks:
Transport Research Laboratory, 1994. (TRL project
report 99.)
46 Bryan-Brown K. The effects of a children's traffic club.
Britain,
Department of Transport: road accidents Great
1994. London: Department of Transport, 1995: 55-61.
47 Sargent K, Sheppard D. The development of the green cross
code. Department of the Environment: Transport and
Road Research Laboratory, 1974.
48 Preusser D, Blomberg R. Reducing child pedestrian
accidents through public education. J Safety Res 1984;
15: 47-55.
49 Preusser D, Lund A. And keep on looking: a film to reduce
pedestrian crashes among 9 to 12 year olds. J Safety Res
1988; 19: 177-85.
the
50 Harland G, Tucker S. 'Let's decide walk wise'
training resource.
development and testing of a pedestrian
Research
Berks:
Laboratory,
Transport
Crowthome,
1995.
51 Tziotis M. Evaluation of the 'Safe routes to schools' and'walk
with care' programs. Kew, Australia: Road Safety Department, VicRoads, 1994.
52 Penna C. 'Streets ahead' evaluation. Victoria, Australia:
VicRoads, 1994. (VicRoad report GR 94-13.)
53 Transport and Road Research Laboratory. Traffic education. Cycle training: a TRRL investigation. Vol 4.
London: TRRL, 1980.
54 van Schagen I, Brookhuis K. Training young cyclists to
cope with dynamic traffic situations. Accid Anal Prev
1994; 26: 223-30.
55 Royles M. International literature review of cycle helmets.
project report. CrowTransport Research Laboratory
thorne, Berks: TRRL, 1994.
56 Graitcer PL, Kellerman AL, Christoffel T. A review of
educational and legislative strategies to promote bicycle
heimets. Injury Prevention 1995; 1: 122-9.
57 Hillman M. Cycle helmets: the case for and against. London:
Policy Studies Institute, 1993.
58 Mills P. Pedal cycle accidents - hospital based study.
Laboratory Research
Transport and Road Research
Berks: TRRL, 1989.
Report 220. Crowthorne, Somers
R. Do bicycle safety
59 Dorsch M, Woodward A,
helmets reduce the severity of head injuries in real
crashes? Accid Anal Prev 1987: 19: 183-90.
60 Thompson R, Rivara F, Thompson D. A case-control
study of the effectiveness of bicycle safety heimets. N
Engl I Med 1989; 320: 1361 -7.
61 Spaite D, Murphy M, Criss E, Valenzuela T, Meislin H. A
severity among heimeted
prospective analysis of injuryinvolved
in collisions with
and nonheimeted bicyclists
motor vehicles. I Trauma 1991; 31: 1510-6.
-

62 Thomas S, Acton C, Nixon J, Battistutta D, Pitt W, Clark


R. Effectiveness of bicycle helmets in preventing head
injury in children: case-control study. BMJ 1994; 308:
173-6.
63 Maimaris C, Summers C, Browning C, Palmer C. Injury
and emergency
patterns in cyclists attending an accident
of helmet wearers and nondepartment: a comparison1537-40.
wearers. BMJ 1994; 308:
64 Wood T, Milne P. Head injuries to pedal cyclists and the
of helmet use in Victoria, Australia. Accid
promotion 1988;
20: 177-85.
Anal Prev
65 Di Guiseppi C, Rivara F, Koepsell T, Polissar L. Bicycle
of a community-wide
helmet use by children. Evaluation262:
2256-61.
helmet campaign. JAMA 1989;
66 Bergman A, Rivara F, Richards D, Rogers L. The Seattle
children's bicycle helmet campaign. Amj Dis Child 1990;
144: 727-31.
67 Cushman R, Down J, MacMillan N, Waclawik H. Helmet
in the emergency room following a bicycle
promotion
1991; 88: 43-7.
injury: a randomized trial. Pediatrics
68 Cushman R, James W, Waclawik H. Physicians promoting
trial. Am J
a
randomized
for
children:
helmets
bicycle
Public Health 1991; 81: 1044-6.
69 Morris B, Trimble N. Promotion of bicycle helmet use
among schoolchildren: a randomized clinical trial. Can J
Public Health 1991; 82: 92-4.
70 Pendergast R, Ashworth C, DuRant R, Litaker M. Correlates of children's bicycle helmet use and short-term
failure of school-level interventions. Pediatrics 1992; 19:
354-8.
71 Parkin PC, Spence LJ, Hu X, Kranz KE, Shortt LG,
Wesson DE. Evaluation of a promotional strategy to
increase bicycle helmet use by children. Pediatrics 1993;
91: 772-7.
72 Schneider ML, Ituarte P, Stokols D. Evaluation of a
campaign: what
community bicycle helmet promotionHealth
Promotion
works and why. American Journal of
1993; 7: 281-7.
73 Dannenburg AL, Gielen AC, Beilenson PL, Wilson MH,
campaigns:
Joffe A. Bicycle helmet laws and educational
an evaluation of strategies to increase children's helmet
use. Am J Public Health 1993; 83: 667-74.
74 Cote T, Sacks J, Lambert-Huber D, et al. Bicycle helmet
use among Maryland children: effect of legislation and
education. Pediatrics 1992; 89: 1216-20.
75 Leicester P, Nassau F, Wise A. The introduction of compulsory bicycle helmet wearing in Victoria. Melbourne, Australia: Vic Roads report GR 91-4. 1991.
76 Cameron M, Heiman L, Neiger D. Evaluation of the bicycle
helmet wearing law in Victoria during its first 12 months.
Victoria, Australia: Accident Research Centre, Monash
University, 1992.
77 Cameron MH, Vulcan AP, Finch CF, Newstead SV.
Mandatory bicycle helmet use following a decade of
helmet promotion in Victoria, Australia an evaluation.
Accid Anal Prev 1994; 26: 325-37.
78 Finch CF, Heiman L, Neiger D. Bicycle use and helmet
the influence of the
wearing rates in Melbourne 1987-1992:
helmet wearing law. Victoria, Australia: Accident
Research Centre, Monash University, 1992.
79 Finch CF, Newstead SV, Cameron MH, Vulcan AP. Head
injury reduction in Victoria 2 years after introduction of
mandatory bicycle helmet use. Report 51. Victoria, Australia: Accident Research Centre, Monash University,
1993.
80 Vulcan A, Cameron M, Watson W. Mandatory bicycle
helmet use: experience in Victoria, Australia. World J
Surg 1992; 16: 389-97.
81 McDermott FT. Bicyclist head injury prevention by
in Victoria,
helmets and mandatory wearing legislation
Australia. Ann R Coll Surg Engl 1995; 77: 38-44.
82 Agran PF, Dunkle DE, Winn DG. Effects of legislation on
motor vehicle injuries to children. Am J Dis Child 1987;
141: 959-64.
83 Christian M, Bullimore D. Reduction in accident severity
in rear seat passengers using restraints. Injury 1989; 20:
262-4.
84 Lowne R, Roberts A, Roy P, Hill K, Jones H. The effect of
the UK seat belt legislation on restraint usage by children.
Society of Automotive Engineers (SEA), 1984.
85 Transport Research Laboratory. Restraint use by car
occupants 1990- 92. (TRL leaflet, LF2056.) Crowthome,
Berks: TRL, 1992.
86 Downing C, Franklin J. An evaluation of two local infant
restraint loan schemes. Crowthome, Berks: Transport
and Road Research Laboratory, 1989. (Conference on
Accident and Injury Prevention: secondary conference
on Child Accident Prevention, Stockholm: 1989.)
87 Neuwelt E, Coe M, Wilkinson A, Avolio A. Oregon head
and spinal cord injury prevention program and evaluation. Neurosurgery 1989; 24: 453-7.
88 Macknin M, Gustafson C, Gassman J, Barich D. Office
education by pediatricians to increase seat belt use. Am J
Dis Child 1987; 141: 1305-7.
89 Roberts M, Fanurik D. Rewarding elementary school
children for their use of safety belts. Health Psychol 1986;
5: 185-96.
90 Stuy M, Green M, Doll N. Child care centres: a community
resource for injury prevention. J Dev Behav Pediatr
1993; 14: 224-9.
91 Bowman J, Sanson-Fisher R, Webb G. Interventions in
the use of safety restraints by
preschools to increase
preschool children. Pediatrics 1987; 79: 103-9.
92 Alwash R, McCarthy M. Accidents in the home among
children under 5: ethnic differences or social disadvan-

Downloaded from injuryprevention.bmj.com on 2 April 2009

148

Dowswell, Towner, Simpson, Jarvis


tages? BMJ 1988; 296: 1450-3.
93 Sorensen B. Prevention of burns and scalds in a developed
country. J Trauma 1976; 16: 249-58.
94 Avery J, Jackson R. Children and their accidents. London:
Edward Arnold, 1993.
95 Department of Trade and Industry. Child safety equipment
for use in the home. London: DTI, Home and Leisure
Accident Research, 1991.
96 Dershewitz R, Williamson J. Prevention of childhood
household injuries: a controlled clinical trial. AmJ Public
Health 1977; 67: 1148-53.
97 Schlesinger E, Dickson D, Westaby J, Lowen L, Logrillo
V, Maiwald A. A controlled study of health education in
accident prevention. The Rockland County child injury
project. Am J Dis Child 1966; 3: 490-6.
98 Dershewitz R. Will mothers use free household safety
devices? Am J Dis Child 1979; 133: 61-4.
99 Colver A, Hutchinson P, Judson E. Promoting children's
home safety. BMJ 1982; 285: 1177-80.
100 Minchom P, Sibert J, Newcombe R, Bowley M. Does
health education prevent childhood accidents? Postgrad
Med J 1984; 60: 260-2.
101 Gallagher S, Hunter P, Guyer B. A home injury prevention
program for children. Pediatr Clin North Am 1985; 32:
95-112.
102 Barone VJ, Green BF, Lutzker JR. Home safety with
families being treated for child abuse and neglect. Behav
Modif 1986; 10: 93-114.
103 Kelly B, Sein C, McCarthy P. Safety education in a
pediatric primary care setting. Pediatrics 1987; 79:
818-24.
104 Baudier F, Marchias M, Ferry B, Bourderont D, Pinochet
C, Blum D. Programme cooperatif de prevention des
accidents domestiques de l'enfant dans le departement du
Doubs. Arch Fr Pediatr 1988; 45: 499-503.
105 Department of Trade and Industry. Hazard dome evaluation. Cleverdon Steer Ltd for the DTI. London: DTI,
1989.
106 Department of Trade and Industry. Home and leisure
accident research. 1989 data. London: Consumer Unit,
DTI, 1992 (HASS report).
107 Abdelilah M, Mabe B. Prevention aupres des populations
immigrees. In: Felix M, Tursz A, eds. Les accidents
domestiques de l'enfant: un probleme majeur de sante
publique. Paris: Synos/Alternatives, 1991: 217-26.
108 Paul CL, Sanson-Fisher RW, Redman S, Carter S. Preventing accidental injury to young children in the home
using volunteers. Health Promotion International 1994; 9:
241-9.
109 Kravitz H, Grove M. Prevention of accidental falls in
infancy by counselling mothers. Illinois Medical Journal
1973; 144: 570-3.
110 Spiegel C, Lindaman F. Children can't fly: a program to
prevent childhood morbidity and mortality from window
falls. Am J Public Health 1977; 67: 1143-7.
111 Kraus J. Effectiveness of measures to prevent unintentional
deaths of infants and children from suffocation and
strangulation. Public Health Rep 1985; 100: 231-40.
112 Linares AZ, Linares HA. Burn prevention programmes for
children: are they effective? Burns 1979; 6: 73-9.
113 McLoughlin E, Healer C, Crawford J. Burn education
intervention: a controlled study. Burns 1979; 6: 26-9.
114 McLoughlin E, Vince CJ, Lee AM, Crawford JD. Project
Burn Prevention: outcome and implications. AmJPublic
Health 1982; 72: 241-7.
115 Mackay AM, Rothman KJ. The incidence and severity of
burn injuries following Project Burn Prevention. Am J
Public Health 1982; 72: 248-52.
116 Miller R, Reisinger K, Blatter M, Wucher F. Pediatric
counseling and subsequent use of smoke detectors. AmJ
Public Health 1982; 72: 392-3.
117 Thomas K, Hassanein R, Christophersen E. Evaluation of
group well-child care for improving burn prevention
practices in the home. Pediatrics 1984; 74: 879-82.
118 Eckelt K, Fannon M, Blades B, Munster A. A successful
burn prevention program in elementary schools. J Burn
Care Rehabil 1985; 6: 509-10.
119 McLoughlin E, Marchone M, Hanger SL, German PS,
Baker SP. Smoke detector legislation: its effect on
owner-occupied homes. Am J Public Health 1985; 75:
858-62.
120 Elberg JJ, Schroder HA, Glent-Madsen L, Hall KV.
Burns: epidemiology and the effect of a prevention
programme. Burns 1987; 13: 391-3.
121 Varas R, Carbone R, Hammond JS. A one-hour bum
prevention program for grade school children: its approach and success. J Burn Care Rehabil 1988; 9: 69-71.
122 Katcher M, Landry G, Shapiro M. Liquid-crystal thermometer use in pediatric'office counselling about tap
water burn prevention. Pediatrics 1989; 83: 766-71.
123 Webne S, Kaplan B, Shaw M. Pediatric burn prevention:
an evaluation of the efficacy of a strategy to reduce tap
water temperature in a population at risk for scalds.J Dev
Behav Pediatr 1989; 10: 187-91.
124 Erdmann T, Feldman K, Rivara F, Heimbach M, Wall H.
Tap water burn prevention: the effect of legislation.
Pediatrics 1991; 88: 572-7.
125 Hammond J, Varas R. Co-ordinated strategies in burn
prevention programs: a case study. I Burn Care Rehabil
1990; 11: 376-8.
126 Laing R, Bryant V. Prevention of burninjuries to children
involving nightwear. N Z MedJ 1991; 104: 363-5.
127 Grant E, Turney E, Bartlett M, Winbon C, Peterson HD.
Evaluation of burnprevention program in apublic school
system. J Burn Care Rehabil 1992; 13: 703-7.

128 Thompson R, Summers S, Rampey-Dobbs R, Mani MM,


Hiebert JH, Schneider S. The effect of instruction on
burn prevention in eighth-grade students in preparation
for babysitting. J Burn Care Rehabil 1993; 13: 482-6.
129 Maisel G, Langdoc BA, Jenkins MQ, Aycock EK. Analysis
of two surveys evaluating a project to reduce accidental
poisoning among children. Public Health Rep 1967; 82:
555-60.
130 Dershewitz RA, Posner MK, Paichel W. The effectiveness
of health education on home use of ipecac. Clin Pediatr
(Phila) 1983; 22: 268-70.
131 Dershewitz RA, Paichel W. Effectiveness of a health
education program in a lower socioeconomic population.
Replication of an Ipecac guidance study. Clin Pediatr
(Phila) 1984; 23: 686-8.
132 Sibert JR, Clarke AJ, Mitchell MP. Improvements in child
resistant containers. Arch Dis Child 1985; 60: 1155-7.
133 Woolf A, Lewander W, Filippone G, Lovejoy F. Prevention of childhood poisoning: efficacy of an educational
program carried out in an emergency clinic. Pediatrics
1987; 80: 359-63.
134 Woolf AD, Saperstein A, Forjuoh S. Poisoning prevention
knowledge and practices of parents after a childhood
poisoning incident. Pediatrics 1992; 90: 867-70.
135 Schnell LR, Tanz RR. The effect of providing ipecac to
families seeking poison-related services. Pediatr Emerg
Care 1993; 9: 36-9.
136 Krug A, Ellis JB, Hay IT, Mokgabudi NF, Robertson J.
The impact of child-resistant containers on the incidence
of paraffin (kerosene) ingestion in children. S Afr Med J
1994; 84: 730-4.
137 Waller AE, Clarke JA, Langley JD. An evaluation of a
program to reduce home hot tap water temperatures.
AustIPublic Health 1993; 17: 116-23.
138 Fallat ME, Rengers SJ. The effect of education and safety
devices on scald burn prevention. J Trauma 1993; 34:
560-4.
139 Ferguson J, Sellar C, Goldacre M. Some epidemiological
observations on medicinal and non-medicinal poisoning
in preschool children. J Epidemiol Community Health
1992; 46: 207-10.
140 Walton W. An evaluation of the poison prevention packaging act. Pediatrs 1982; 69: 363-70.
141 Venberg K, Culver-Dickinson P, Da S. The deterrent
effect of poison-warning stickers. Am J Dis Child 1984;
138: 1018-20.
142 Kemp A, Sibert J. Drowning and near drowning in
children in the United Kingdom: lessons for prevention.
BMJ 1992; 304: 1143-6.
143 Yamamoto L, Yee AB, Matthews WJ Jr, Wiebe RA. A
one-year series of pediatric ED water-related injuries: the
Hawaii EMS-C project. Pediatr Emerg Care 1992; 8:
129-33.
144 Patrick M, Bint M, Pearn J. Saltwater drowning and near
drowning accidents involving children. Medj Aust 1979;
i: 61-4.
145 Spyker D, Submersion injury. Epidemiology, prevention
and management. Pediatr Clin North Am 1985; 32:
113-25.
146 Ferguson D, Horwood L. Risks of drowning in fenced and
unfenced domestic swimming pools. NZMedJ 1984; 97:
777-9.
147 Gardiner S, Smeeton WMI, Koelmeyer TD, Cairns FJ.
Accidental drownings in Auckland children. N Z MedJ7
1985; 98: 579-82.
148 Cass D, Ross F, Grattan-Smith T. Child drownings: a
changing pattern. MedY Aust 1991; 154: 163-5.
149 Wintemute G, Wright M. Swimming pool owners'
opinions of strategies for prevention ofdrowning. Pediatrics 1990; 85: 63-9.
150 Wintemute G, Drake C, Wright M. Immersion events in
residential swimming pools: evidence for an experience
effect. Am3tDis Child 1991; 145: 1200-3.
151 Pearn J, Nixon J. Prevention of childhood drowning
accidents. MedJ Aust 1977; i: 616-8.
152 Pitt W. Increasing incidence of childhood immersion
injury in Brisbane. Medy Aust 1986; 144: 683-5.
153 Barry W, Little TM, Sibert JR. Childhood drownings in
private swimming pools: an avoidable cause of death.
BMJ 1982; 285: 542-3.
154 Quan L, Gore EJ, Wentz K, Allen J, Novack AH. Ten-year
study of pediatric drownings and near-drownings in
King County, Washington: lessons in injury prevention.
Pediatrics 1989; 83: 1035-40.
155 Milliner N, Pearn J, Guard R. Will fenced pools save lives?
a 10-year study from Mulgrave Shire, Queensland. Med
J Aust 1980; ii: 510-1.
156 King K, Ball D. A holistic approach to accident and injury
prevention in children's playgrounds. London: LSS, 1989.
157 Fisher L, Goddard Harris V, Van Buren J, Quinn J,
DeMaio A. Assessment of a pilot child playground injury
prevention project in New York State. Am I Public
Health 1980; 70: 1000-2.
158 Sahlin Y, Lereim I. Accidents among children below
school age. Changes of incidence after intervention. Acta
Paediatr Scand 1990; 79: 691-7.
159 Condie C, Rivara FP, Bergman AB. Strategies of a
successful campaign to promote the use of equestrian
helmets. Public Health Rep 1993; 108: 121-6.
160 Garraway W, Macleod D, Sharp J. Rugby injuries: the
need for case registers. BM31991; 303: 1082-3.
161 Tellnes G. An evaluation of an injury prevention campaign
in general practice in Norway. FamPract 1985; 2: 91-3.
162 Robertson LS. Community injury control programs of the
Indian Health Service: an early assessment. Public Health

Downloaded from injuryprevention.bmj.com on 2 April 2009

Preventing childhood unintentional injuries

149

Rep 1986; 101: 632-7.


163 Schelp L. Community intervention and changes in accident
pattern in a rural Swedish municipality. Health Promotion 1987; 2: 109-25.
164 Guyer B, Gallagher S, Chang B, Azzara C, Cupples L,
Colton T. Prevention of childhood injuries: evaluation of
the statewide childhood injury prevention program
(SCIPP). Am I Public Health 1989; 79: 1521-7.
165 Bjaras G, Danielsson K, Schelp L, Sjoberg D, Skjonberg
G. Safety rounds in public environments: experience of a
new tool for prevention ofaccidental injuries. Accid Anal
Prev 1990; 22: 223-8.
166 Bass JL, Mehta KA, Ostrovsky MA. Childhood injury
prevention in a suburban Massachusetts population.
Public Health Rep 1991; 106: 437-42.
167 Bass JL. Educating parents about injury prevention.
Pediatr Clin North Am 1985; 32: 233-42.
168 Jeffs D, Booth D, Calvert D. Local injury information,

169

170

171

172

community participation and injury reduction. Aust J


Public Health 1993; 17: 365-72.
Schwarz DF, Grisso JA, Miles C, Holmes JH, Sutton RL.
An injury prevention program in an urban AfricanAmerican community. Am J Public Health 1993; 83:
675-80.
Ytterstad B, Wasmuth HH. The Harstad injury prevention
study: evaluation of hospital-based injury recording and
community-based intervention for traffic injury prevention. Accid Anal Prev 1995; 27: 111-23.
Ytterstad B. The Harstad injury prevention study:
hospital-based injury recording used for outcome evaluation of community-based prevention of bicyclist and
pedestrian injury. Scand J Prim Health Care 1995; 13:
141-9.
Ytterstad B, Sogaard AJ. The Harstad injury prevention
study: prevention of burns in small children by a
community-based intervention. Burns 1995; 21: 259-66.

Editorial Board Member: brief biography


LIZ TOWNER

Liz Towner graduated with a


BSc in geography from the
University of Durham, UK in
1972 and obtained an MA in
_J
geography from York University, Canada in 1974. After
teaching in a range of secondary schools she started working in dental. health education
research in the Department of
Dental Health, University of
Birmingham in 1980. This involved developing and evaluating dental health education
programmes in school and workplace settings, which
formed the basis for a PhD in 1986.
Since 1990 she has worked in childhood injury prevention research in the Department of Child Health, University of Newcastle upon Tyne. She was appointed as Senior
Lecturer in Health Promotion and Executive Director of
the Childhood Injury Prevention and Promotion of Safety
(CHIPPS) Programme. The programme is funded by the
Department of Health and Northern and Yorkshire
Regional Health Authority. The focus of the research
programme is on children, unintentional injury at a local
and regional level, and the effects of social deprivation.
Liz Towner's research interests are measuring the
prevalence of exposure to injury risk and the application of
risk data in local injury prevention, effectiveness reviews in
injury prevention, and evaluation of injury prevention
programmes.

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