Works? A Literature Review. Preventing Childhood Unintentional Injuries - What
Works? A Literature Review. Preventing Childhood Unintentional Injuries - What
Works? A Literature Review. Preventing Childhood Unintentional Injuries - What
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REVIEW ARTICLE
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,
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
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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evaluation.73-81
144
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
drowning
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."'
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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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