Globalization

Globalization involves a set of socioeconomic, cultural, political and environmental processes that intensify the connections between nations, businesses and people (26– 28). The more rapid dissemination of ideas and knowledge of injury prevention (29), and the growth of a global civil society (26) involving networks of formal and informal groups, can have a positive influence on injury issues. However, there are also negative effects (see Box 1.2). With greater freedom of movement of capital across national boundaries, the production of goods – often a hazardous process – can more easily shift to regions of cheaper labour (28). This, in turn, can lead to increased transport in places where road safety is poorly developed (30). Centres of cheap production often have weaker controls on occupational health and child labour.

BOX 1.2

The effects of globalization on child injuries. Valli was devastated. She had left her small daughter alone for a few minutes, to go out to fetch water from the communal tap. On her return, she found the child had drowned in just 10 cm of water. Valli (more...)

Whether globalization will increase or decrease the amount of child labour has been the subject of debate (31). According to the International Labour Organization, in 2004 there were still 218 million child labourers under the age of 15 years. However, over the past four years, there has been a global fall in the number of children working, particularly of those working in hazardous occupations (32). In some places, though – such as Gujarat state in India – economic growth has led to more children working, which is likely to lead to a greater number of injuries (33, 34).

Urbanization

Urbanization, much of it unplanned and ill-resourced, is accelerating children’s exposure to risk (35). Over the next two decades, a large part of the world’s population growth will be in urban areas. The proportion of the global population in urban areas is predicted to rise from around 50% today to over 60% by 2030 (36). Most of this growth will be in Asia and Africa (37).

Urbanization can promote positive attributes for health (38, 39). Medical care for injuries may be easier to provide in urban than in scattered rural areas and there are economies of scale in providing better housing and services. However, as a result of natural growth and migration, cities may expand beyond the capacity of resources to cope adequately (40, 41). Urban slums and squatter camps pose high risks of injury for children across the world (42, 43).

Motorization

The increase in motorization is related to trends in globalization and urbanization, yet it is worth examining separately because of its significant impact on child injury. Roads have always been dangerous places for children. However, the rapid increase of traffic and the shift of transport systems around the world to roads make the issue especially pressing. Deaths and injuries from road traffic crashes are forecast to rise across the world by 67% between 1990 and 2020 (12).

Improved transport and a good road infrastructure are usually considered crucial for overall development (44, 45). The OECD Development Co-operation Directorate’s Task Team on Infrastructure for Poverty Reduction (46) has pointed to benefits for the poor who need better transport to access markets, job opportunities, education and health facilities. In Morocco, for instance, paved roads have helped increase school attendance substantially (44). A major increase in road infrastructure has been proposed for Africa by the Commission for Africa (47) as part of the efforts to achieve the Millennium Development Goals. It would be ironic, though, if pursuing the Millennium Development Goals – without strictly considering health and safety issues – led to an increase in death and injury among children from road traffic crashes or as a result of increased pollution.

Environmental change

The scale and impact of environmental risks may well be accelerating, induced by the global effects of climate change. The Intergovernmental Panel on Climate Change has predicted an increase of between 1.5°C and 6°C by 2100, depending on future carbon emissions (48). The causal pathways by which climate change could affect children’s health are not clear; they are often indirect and their consequences may be felt at different times (49–53). Children may be exposed to risk of injury through an increase in extreme weather conditions that pose direct hazards – such as flooding, cyclones or mud flows from heavy rains. They may also be exposed through longer-term degradation of environments – such as droughts, desertification or rises in sea level (54, 55). Children in low-income countries face the greatest problems. Squatter and other makeshift urban settlements are often highly vulnerable to flooding, and health systems in these places are generally less able to cope (56). Both extreme and long-term environmental change can lead to migration, with people ending up living in marginal, unsafe conditions.

Injuries and subsequent disability

Head injuries are the single most common – and potentially most severe – type of injury sustained by children. Among minor injuries incurred by children, cuts and bruises are those seen most frequently. However, the most common category of unintentional injuries suffered by children under 15 years and requiring hospital admission are various types of fractures to the arms and legs (see Table 1.4).

TABLE 1.4

Nature of unintentional injuries sustained by children under 15 years, World, 2004.

In addition to mortality, hospital admissions, emergency department attendances and days lost from school can all be used as markers of injury severity. There are also more specific scoring methods, including notably, the Injury Severity Score, the Revised Trauma Score and the Paediatric Trauma Score. A review of the different types of measures currently used indicates that there is no standard method to determine the severity of an injury in a particular child (65). Each type of measure has its drawbacks and may vary according to the cause of injury or access to care. Measures of disability also tend to be non-standard.

Data from the Global Childhood Unintentional Injury Surveillance conducted in four cities showed that nearly 50% of children under the age of 12 years who had suffered an unintentional injury severe enough to warrant presentation to an emergency deparment were left with some form of disability (Statistical Annex, Table C.1). Among children who had suffered a burn, 8% were left with permanent disabilities, while children injured in traffic crashes were significantly more likely to be left with some form of disability (Table 1.5).

TABLE 1.5

Injury severity and estimated long-term effects of unintentional injuries among children presenting to emergency departments in four countries.

Many young people who survive major trauma are left with ongoing disabilities, with a major impact on their own lives as well as on the lives of their families. These disabilities may be physical, mental or psychological. Some of the problems encountered in the years following injury include an inability to attend school, find suitable work or engage in an active social life. There are also other more basic problems such as having to cope with continued pain. Support for these young people most often falls on their close family and friends (66).

What makes children particularly susceptible to injury?

Children are not just small adults. Their physical and cognitive abilities, degrees of dependence, activities and risk behaviours all change substantially as they grow older (50, 71–75). As children develop, their curiosity and wish to experiment are not always matched by their capacity to understand or to respond to danger (76).

At about 3 months of age children will start to wriggle and roll, at about 6 months they will sit up, and they will start crawling at around 9 months. Objects are reached for, grasped and put in their mouth. At 18 months they are mobile and exploring the world. Child development and behaviour is therefore highly associated with particular injuries. Poisoning, for example, is linked to the grasping and drinking behaviour of children aged 1–3 years, while falls are related to the stage of learning to walk.

Analysis of injury using age ranges in years can be too broad to detect the rapid change in development and injury risk among very young children. By using 3-month age brackets, one study showed that falls were the leading cause of injury in children aged under 3 years, but that the particular items that caused their falls – such as furniture, stairs and playground equipment – were important at different ages. The study also showed that poisoning injury started to rise at the age of 9 months, continuing up to 21 to 23 months, and then declined. Burns from hot liquids were substantially higher among those aged 12 to 18 months (73).

The small stature of children increases their risk in a road environment. They are less visible than adults and if hit by a vehicle, they are more likely than an adult to sustain a head or neck injury (77). At the same time, small children have difficulty seeing over vehicles, judging the speed of oncoming vehicles and discerning the distance of a vehicle from the sound of its engine (78).

Other physical characteristics make children vulnerable to injuries. The skin of infants burns more deeply and quickly and at lower temperatures than the thicker skin of adults (77). Smaller airway size increases the danger of aspiration (24). In addition, certain physical characteristics of young children may affect injury outcomes. For example, children’s larger ratio of body surface area to volume means that not only will the size of a burn – for a given volume of hot liquid – be greater than for an adult, but also that there will be more fluid lost from the burnt area, thus complicating the management of the injury (79). Similarly, a given amount of a poisonous substance will more likely be toxic for a child than an adult because of the child’s smaller mass. Children’s smaller size also creates a risk of entrapment of body parts, most dangerously for the head. Many products and settings do not properly take these risks into account.

Studies of children in road traffic have shown that young children may lack the knowledge, skills and levels of concentration needed to manage the road environment, no matter how benign the road conditions (80). Their physical abilities may not be matched by cognitive abilities. For instance young children, in the process of exploring their world, may fall from heights because their climbing ability is not matched by their ability to balance or reason (77).

Children’s worlds

Young children’s behaviour differs from that of adults. A vivid illustration of this is in the home environment. “[They] crawl about the floor, climb onto the window ledge, squeeze through stair balustrades, slide down the stair handrail, swing on the gate, run from room to room and ride bikes inside as well as out, making use of their houses in ways that seem to them reasonable, but have not apparently been foreseen by the designer” (81).

Physical and mental stages are important, but children are especially vulnerable to injury because they live in a world in which they have little power or control. The vulnerability of children is exacerbated by their lack of power and status (6). They find themselves in urban and rural environments constructed by and for adults (82). Their voices are seldom heard and only rarely are places designed in consultation with children (83).

Urban planners and policy-makers know little of children’s concerns and often assume change will benefit all (84). For example, improving water supplies to a neighbourhood may result in young children – often the family water carriers – having to travel an increased distance to a standpipe to fetch water, with possible damage to their head, neck and spine (85). New products are often designed without taking into consideration their possible use by children and the consequent harm.

Definitions of poverty

There are two broad categories of poverty: “absolute poverty” and “relative poverty”. The former relates to the minimum requirements needed for physical survival or subsistence, the latter to the prevailing living standards of a society. It has been suggested that poverty goes beyond mere subsistence, involving also what in a particular society are considered the minimum conditions of well-being (98).

The injury field abounds with different operational definitions of poverty and related socioeconomic factors. These variations have made it difficult to consistently collect comparable data on important demographic factors such as the socioeconomic status of parents, family income and education, as well as on the characteristics of particular areas, schools, medical centres and childcare centres. There is a great need for standardization of definitions and methods to improve the quality and usefulness of information.

Socioeconomic factors and risk for injury

A broad range of socioeconomic factors associated with injury risk has been identified (74). These factors include:

–

economic factors – such as family income;

–

social factors – such as maternal education;

–

factors related to family structure – including single parenting, maternal age, numbers occupying the household, and number of children;

–

factors related to accommodation – such as type of tenancy, type of housing, level of overcrowding and various factors describing the neighbourhood.

Socioeconomic factors affect injury risk in a number of ways (74).

• In poor households, parents may not be able to:

  –

  properly care for and supervise their children, who may need to be left alone or in the care of siblings (see Box 1.3);

  –

  afford safety equipment, such as smoke alarms or safety helmets.

• Children living in poverty may be exposed to hazardous environments, including:

  –

  a high volume of fast-moving traffic;

  –

  lack of space and facilities for safe play;

  –

  cramped living conditions, with no proper kitchen and open cooking fires;

  –

  unprotected windows and house roofs, and stairs without handrails.

BOX 1.3

Child supervision. Supervision is widely recognized as vital to protecting children from harm. Some estimates suggest that 90% of injuries to young children occur in or around their home when they are supposedly being supervised by a caregiver. Despite (more...)

Access, or the lack of it, to good-quality medical services is an important explanatory factor for variations in mortality rates. In a Nigerian study, 27% of 84 children admitted to hospital for a burn injury died as a result of their injury (79), in contrast with a similar study from Kuwait, where 1% of a sample of 388 children died (99). This discrepancy, though, may also be related to differences in the severity of burns seen.

A few studies in developed countries have attempted to look at the association between childhood injuries and socioeconomic status.

• In England and Wales, a study examined injury mortality data by occupational group of the parents for children aged 1–15 years over two time periods – 1979–1983 and 1989–1992 (100). All childhood injury deaths had declined between the two periods of study, but the associations of injury deaths with socioeconomic factors had become stronger. Social gradients were particularly steep for certain types of injury such as homicide, fire burns and pedestrian injuries.
• A recent study in New South Wales confirmed that the association between relative socioeconomic disadvantage and non-fatal injury risk among children in this Australian state was strongest for transport-related injuries, burns and poisoning (101).

There are even fewer studies from developing countries that have examined childhood injuries according to socioeconomic group.

• A study in South Africa explored the incidence and causes of injury across socioeconomic and environmental settings in six neighbourhoods in a poor area of Johannesburg – two informal settlements, two neighbourhoods of council houses and two of council-built apartment buildings (102). The informal settlements reported higher rates of injury than the other types of neighbourhood.
• A survey on the economic impacts of injury in rural Viet Nam showed that poverty was a significant risk factor for injury, and also that children in poor households had higher rates of injury sustained in the home than better-off children (103).

Injuries as a cause of poverty

Poor populations are particularly vulnerable to a range of calamities, which can trigger a further decline in family resources. Crises brought about by ill-health, a road traffic crash or an episode of flooding may push people into poverty (104).

• A study in Bangalore, India and in Bangladesh found that the burden from road crashes had pushed many households into poverty. In Bangalore, 71% of households in urban areas and 53% in rural areas were not poor before the crash; in Bangladesh the comparable figures were 33% in urban areas and 49% in rural areas (105).
• In Viet Nam, the cost of injury to poor households was estimated as equivalent on average to 11 months’ income. The risk of a poor household falling below the poverty line was 21% higher among those that had had an injury than among those that had not (106). Health-care costs and the loss of income were the main factors contributing to this effect.

Children are a particularly vulnerable group, either directly through being injured themselves or indirectly through the loss of their parents.

• In a Bangladesh slum, 40% of malnourished children came from households where the breadwinner had been incapacitated by illness or injury (107).
• In Ghana, a study of the economic consequences of injury within the family found that in rural households, 28% of families reported a decline in food consumption following an injury (108).
• A study in Bangladesh found that injury was the leading cause of children losing a parent, with about 7900 fathers and 4300 mothers dying each year (61).

Certain groups of children have higher than average rates of injury. These rates may be associated with the specific circumstances and environment of the children – for instance, being refugees or being homeless. The groups that stand out most clearly with respect to their higher injury rates are indigenous populations, who also tend to experience greater relative poverty than their compatriots (109).

• Injury is a major cause of death and morbidity among the Maori population in New Zealand (110).
• In the United States and Australia, injury death rates in indigenous people are two to three times the rates for non-indigenous people (111).
• The death rate from road traffic injuries among indigenous Australians under 15 years of age, is two and a half times that for non-indigenous young Australians (16.7 per 100 000, compared to 6.6 per 100 000) (112).

The contribution of Haddon

William Haddon Jr developed a scheme (known as the “Haddon Matrix”) in the 1960s to apply the principles of public health to the problem of road traffic safety (117, 118). It has since been used as a means of developing ideas to prevent injury of all types. The matrix consists of 12 cells. These are arranged in a table of four columns relating to the host, agent/vehicle, physical environment and social environment, and of three rows relating to the periods before, during and after the injury (corresponding to primary, secondary and tertiary prevention).

The resulting matrix provides a means to identify, cell by cell:

–

strategies and priorities for injury prevention, in terms of their costs and effects;

–

existing research and research that needs to be undertaken;

–

the allocation of resources in the past and the future, and the effectiveness of such allocation.

Haddon went on to describe 10 strategies to accompany the matrix, which describe the ways in which the harmful transfer of energy can be prevented or controlled in some way (119) (see Table 1.6, where Haddon’s 10 strategies have been applied to child injuries).

TABLE 1.6

Ten countermeasures and examples of child injury prevention.

The significance of the Haddon Matrix and Haddon’s 10 injury prevention countermeasures is that they highlight the fact that not only can society intervene to reduce injury, but that such interventions can occur at different stages (120).

Public health approaches

As has occurred with several other health issues, the emphasis has shifted over recent years from the individual to the environmental context in which an injury occurs. Along with this shift of emphasis, there has also been a realization that single-cause explanations of injury are incomplete and that models using a range of causes are needed instead. The public health model is therefore useful as it approaches the issue in a systematic and coordinated way, following four logical steps (Figure 1.4) – all of which call for good evidence on which to base activities. It is a model that can reveal important emerging issues in child injury prevention (see Box 1.5).

FIGURE 1.4

The public health approach to injury prevention.

BOX 1.5

Dog bites: injury data reveal significant public health problem. Dog-bite injury has been the subject of very few scientific publications. It was only after the introduction of external cause coding of hospitalized injury cases and the setting up of emergency (more...)

A public health perspective also allows for a holistic approach to the issue of child injury. Such an approach can bring together, as partners, the diverse range of national and local agencies and organizations involved in injury prevention, and coordinate actions under a single umbrella (120).

Legislation and enforcement

Legislation is a powerful tool in the prevention of injury. It can be regarded as a “test of commitment to the cause of child safety” (9). There is evidence that legislation has increased the uptake of preventive measures and reduced childhood injuries in a number of areas. These areas include:

• In the road environment:

  –

  child passenger restraints (139);

  –

  seat-belts (140);

  –

  bicycle helmets (141);

  –

  motorcycle helmets.

• In the home environment:

  –

  smoke alarms (142);

  –

  hot water temperature legislation (143);

  –

  child-resistant containers (144).

• In the leisure environment:

  –

  isolation fencing of swimming pools (145).

There is some evidence of the beneficial effect of legislation on the use of booster seats (restraints in cars for children who have outgrown child seats), though this was mainly from uncontrolled before-and-after studies (146). A systematic review (147) found legislation on bicycle helmets to be effective in increasing helmet use, particularly in the younger age group and in areas with previous low rates of use (148), and in reducing head injuries (141).

As well as the introduction of new laws, how consistently they are applied and how rigorously enforced are important. The UNICEF league table report compared the legislative record for seven areas of injury legislation in 26 OECD countries. Only three countries had legislated in at least six of the seven areas assessed: Australia, Canada and the United States (9).

Many countries have specific standards or regulations – some mandatory – for a wide range of goods and services, including:

–

toys and nursery furniture;

–

playground equipment;

–

items designed for childcare – such as nail clippers and hair brushes;

–

safety equipment such as helmets;

–

furniture and furnishings – such as the provision of baby gates at the top of stairs.

There are also usually regulations and standards related to construction work on buildings, as well as to health and safety generally in the workplace. All these standards and regulations have an important bearing on the extent to which child injury can be prevented.

Since, for many products, standards often do not exist, and the introduction of standards for individual products can be a slow process, a useful approach is to identify the particular hazards for a product and the measures and mechanisms that reduce risk. So-called “vertical standards” based on hazards compile this information so that manufacturers and regulators can identify known hazards in products and reduce them to acceptable levels. This approach is the one adopted, for instance, in ISO/IEC Guide 50: Safety aspects: guidelines for child safety (149). Risk reduction here is meant to cover the way people actually use the products and it should be for the life of the product. In 2007, for example, there was a worldwide recall of toys that had been found to contain hazardous levels of lead paint.

In developed countries, the way in which legislation is enforced varies considerably. Because of a frequent lack of structures and resources, enforcement in developing countries is even more difficult. In Karachi, a study of bus safety showed that legislation was not likely to produce much effect, but that instead increases in bus drivers’ wages and small changes to the vehicles were potentially more effective (150).

Product modifcation

Changing the design and manufacture of products can:

–

reduce the risk of an injury – for instance, by manufacturing staircase railings with the gap between the upright banisters sufficiently narrow to prevent small children putting their heads through;

–

reduce access to a hazard – an example being the use of child-resistant closures for medicines;

–

reduce the severity of an injury – for instance, by modifying the design of the caps on pens to reduce the risk of fatal choking in the case of a cap being inhaled.

Product modification has contributed to preventing childhood injuries. However, often a series of small changes is made in products and it is difficult to attribute a reduction in injuries to any one specific change. There is considerable evidence that the introduction of child-resistant closures has been effective in reducing the number of childhood deaths from poisoning (151). An evaluation of an intervention in South Africa involved the distribution of child-resistant containers for the storage of paraffin. This strategy proved an effective means of reducing paraffin ingestion and provided evidence that families will use such free devices when they are provided (152).

Modification of basic cooking and heating products may also offer considerable possibilities. About half the world’s population still relies on solid fuels – including wood, animal dung, crop residues and coal for every day energy needs – and a high proportion of households burn the fuel in open fires (153). In rural Guatemala, an improved wood-burning stove, the plancha (an enclosed combustion chamber and cooking surface out of reach of young children), has been introduced. The stove has the potential to reduce not only acute lower respiratory tract infections in children, but also burns and scalds. Preliminary results have been promising for young children (153). Reducing the number of open fires would have a beneficial impact in places such as sub-Saharan Africa, where 80% to 90% of rural homes use open fires.

Environmental modification

Modifying the environment to make it more user-friendly has become an important approach in injury prevention, benefiting people of all ages, not just children, in the passive protection that it affords. Area-wide engineering solutions can lower the rate of injuries in pedestrians, cyclists and car occupants. One review examined whether traffic-calming schemes reduced rates of crash-related deaths and injuries, for all age groups (154). It concluded that traffic calming in towns did indeed have the potential to reduce the rate of injuries. As regards modification of the home environment, there is at present insufficient evidence from trials to show that such changes reduce the number of injuries (155).

In high-income countries, there has been considerable progress in making the transport infrastructure safer, including around schools and kindergartens. But in low-income countries, such expensive options may not be possible. In most low-income countries, pedestrians, cyclists, cars, animals and buses share the same road space. The conflicting requirements of non-motorized vehicles need to be addressed using various models of traffic safety, including the separation of different types of road user (156).

Supportive home visits

Home visiting by paediatric nurses to families at high risk of injury has been used for a wide range of purposes. These include: to improve the home environment, to prevent problems of child behaviour or supply and explain safety equipment. A review of the effects of home visits in early childhood has shown substantial positive effects for the prevention of child maltreatment (157). The greatest impacts were for programmes using professional visitors and for programmes of a longer duration. Home-visiting programmes have been shown to be associated with an improvement in the quality of the home environment as a means to reduce unintentional injuries (158).

Safety devices

The promotion of safety devices can lead to a fall in injuries and increased compliance in using the device. A variety of approaches has been used, including professional counselling, to encourage the use of safety devices, supported by a range of media. Some programmes have included rewards or coercion, such as fines, to encourage compliance. The positive effects from such programmes diminish one or two months after the intervention and more intensive programmes produce more positive results (159).

• Wearing a bicycle helmet dramatically reduces the risk of severe and fatal head injuries and facial injuries for bicyclists involved in a crash involving a motor vehicle (148). Community-based projects that provided free helmets along with an educational component led to an increase in the observed wearing of helmets (160). A study in Canada has shown that, despite less wearing of helmets in low-income areas, population-based bicycle helmet campaigns can still have an impact in these areas in cutting the risk of injury (161). The WHO helmet manual (162) provides a number of examples of good practice, such as the Helmets for Kids safety campaign in Viet Nam.
• Motorcyclists are also at high risk in traffic crashes, particularly for head injury. A review of studies concluded that helmets reduce the risk of head injury by around 69% and death by around 42% (163).
• Fires detected with smoke alarms are associated with lower death rates. However, one review found that programmes to promote smoke alarms only, without legislation, function modestly, if at all, and have not yet demonstrated a reduction in fires or fire-related injuries (142).

Education, skills and behaviour change

The value of educational programmes as a form of injury prevention has been subject to debate in the field of child injury. Clearly, education underpins many other strategies – such as legislation, the promotion of safety devices and home visiting. Education on pedestrian safety can result in an improvement in children’s knowledge and can change observed behaviour of crossing roads. Whether, though, this reduces the risk of injury or of a pedestrian suffering a collision with a motor vehicle is unknown (164). The focus of education should extend beyond the immediate caregivers of children, to include health professionals, policy-makers, the media and the business community (120, 165). Novel ways of introducing safety messages into television programmes should be explored. These might include a person testing the water temperature before bathing a child, portrayals of swimming pools surrounded by fencing, and characters in dramas putting on their seat belts in a car (166).

The PRECEDE-PROCEED model (a planning model for health education and health promotion programmes) provides a comprehensive structure to assess people’s health and quality-of-life needs. It also helps in the design, implementation and evaluation of health promotion programmes and other public health programmes to meet those needs (167). These principles have been further elaborated in a guideline on generic behaviour change. This guideline recommends collaboration between individuals, communities and organizations to plan interventions and programmes (168).

Community-based studies

Injury prevention, with its broad range of injury types and possible countermeasures, lends itself to community-based approaches. It is important to have long-term strategies, effective and focused leadership, collaboration between a range of agencies, appropriate targeting and sufficient time to develop local networks and programmes (169). The use of multiple interventions, repeated in different forms and contexts, can lead to a culture of safety being developed within a community.

There is some evidence that the WHO Safe Communities model is effective in reducing injuries in whole populations (170). However, the countries that have evaluated their Safe Communities with a sufficiently rigorous study design are among the wealthier countries and have lower injury rates than most other countries. No evaluations are available yet from other parts of the world.

Closing the childhood injury gap

As stated previously, within all countries, the burden of child injury falls most heavily on those from the most disadvantaged groups. The gap in injury rates between the most affluent and the most disadvantaged provides “some measure of preventability and shows that there is considerable scope for improvement and intervention and a yardstick of what is achievable” (74).

There is a range of interventions known to be effective in preventing and reducing injuries (see Chapter 7). What is less well known, though, is how such approaches can be applied to close the socioeconomic gap with regard to childhood injuries. It is partly in response to this problem, where active strategies have not yet been successful, that passive solutions – that is, design solutions – may be most successful. In the broader field of health promotion, four broad approaches to tackling socioeconomic inequalities in health have been suggested (174):

–

strengthening individuals;

–

strengthening communities;

–

improving access to services;

–

encouraging macroeconomic and cultural change.

Approaches for strengthening individuals can include targeting children and their carers.

• Prevention initiatives for parents on drowning can be integrated into existing child survival and development programmes – particularly for the period, from nine months of age onwards, when children are entering into the ‘window’ of drowning risk (61).
• A study conducted in a deprived community of Scotland, a high-income country, that reviewed a training programme in practical road-safety skills, found improved skills in 5–7-year-old children in crossing the road (175).

Strengthening communities is an approach adopted by many organizations working on safety issues, and is the leading strategy employed in the Safe Communities network.

• The Waitakere Community Injury Prevention Project in New Zealand included a range of programmes targeting different indigenous and ethnic groups (176). For one of these programmes, the coordinator employed was a Maori, with experience of the culture and perspectives of the target group, and injury prevention was incorporated into a holistic view of health.
• The Safe Block project, based in a poor African-American inner-city community in Philadelphia, PA, USA, used a network of community volunteers. The project involved making simple modifications to homes to prevent injuries, inspecting homes and providing information on home hazards, and educating people – with the use of cascade training – on specific injury prevention practices (177).
• A partnership with residents from townships in South Africa worked effectively to lobby the local government to provide a pedestrian bridge over a highway (102).

There are various ways in which improving access to services can help prevent child injuries.

• New roads can contribute to improving access to a range of community services, including to health care, education and leisure facilities.
• Electrification can reduce exposure to more hazardous fuels such as kerosene.
• Removing dangerous debris and improving waste collection can directly reduce injuries to children.
• Providing sanitation can help children avoid having to walk in darkness to toilet facilities.

Encouraging macroeconomic and cultural change includes:

–

broad land-use policies, such as locating schools away from busy roads;

–

transport policies that take into full account the needs of pedestrians;

–

the promotion of walking as a healthy activity;

–

the design of communities, to include safe outdoor play facilities.

Financial problems and poor living conditions have been found to preoccupy adults, with the result that they spend less time supervising children (24, 76). Policies targeting poverty reduction could reduce childhood injuries in the long term, but need to be accompanied by more short-term and medium-term measures.

Most researchers believe that packages of policies and intervention, rather than single policies and interventions, are needed to substantially reduce socioeconomic inequalities in health.

Transfer of knowledge

One study in low-income countries looked at successful interventions to prevent transport and home injuries (25). It also evaluated injury interventions developed in industrialized countries that might be usable in low-income countries. The conclusion was that several interventions could be imported by low-income countries and should be considered, including:

–

vehicle seat-belts, bicycle helmets and motorcycle helmets;

–

speed limits;

–

pedestrian crossing signs;

–

adequate road lighting;

–

the separation of pedestrians from vehicles;

–

measures to enhance conspicuity, such as the use of reflective products;

–

simple safety equipment;

–

packaging of items to prevent poisoning.

The importance of transferring knowledge in a sensitive and context-specific manner has been repeatedly stressed. The Commission for Global Road Safety (44), for instance, has stated: “Public acceptance and support, based on information and knowledge and evidence of effectiveness, will be achieved only if road safety messages are seen to be appropriate and targeted at local needs”.

Interventions that appear most effective are those encompassing a variety of strategies, including legislation, environmental modification and education (178, 179). There is a general need for more interventions to be evaluated and for research experiences to be shared worldwide. Many of the principles of injury prevention can be transferred, but interventions need to be tailored to the social and physical environments of those localities. Interventions should reach across different sectors, build on existing networks and involve communities.

Costs of safety

Not much research has been carried out on the availability, price and affordability of child-safety or family-safety devices, and this is especially the case in low-income and middle-income countries. Data from 18 economically diverse countries have been compared for four effective devices: child safety seats, booster seats, child bicycle helmets and smoke alarms (182). The prices of these devices varied widely and in many countries they were very expensive. A factory worker in a low-income country had to work 11 times as long as a counterpart in a high-income country to buy a bicycle helmet, while for a child safety seat 16 times as many hours’ work were required. Low-income countries manufacturing devices for export did not generally use spare plant capacity to produce devices for local consumption.

Cost-effectiveness of interventions

There are very few analyses in low-income and middle-income countries of the cost-effectiveness of injury prevention measures (183). There is also scarce data on injury epidemiology and the efficacy of interventions in these countries. One study attempted to model the costs and effectiveness of five interventions for which there were data on effectiveness in a low-income or middle-income country (184). Four out of the five interventions related to the road environment: vehicle speed control, treatment of dangerous junctions, bicycle helmet legislation and motorcycle helmet legislation. The fifth was on the home environment, and involved child-resistant containers to reduce poisoning from paraffin.

In the United States, a survey conducted in the late 1990s on the costs of childhood unintentional injuries and the cost-effectiveness of interventions to prevent them showed that approximately 15% of medical spending resulted from an injury (185). The same study found that seven child injury safety measures – child safety seats, bicycle helmets, zero tolerance of alcohol for young drivers, provisional licensing, smoke detectors, childproof cigarette lighters and poison control centres – had similar cost-effectiveness ratios to other well-accepted strategies to prevent childhood illness. The implementation of these strategies, though, is not yet widespread (185). As can be seen from Table 1.7, many cost-effective strategies for unintentional injury can save not only lives but costs to society as well.

TABLE 1.7

Financial savings from selected injury prevention interventions.

Cost and cost-effectiveness analysis of interventions to reduce or mitigate child injuries is urgently called for. Such evidence can have a strong impact on policy-makers and persuade them to invest in the appropriate primary prevention interventions.

“Injuries are due to fate”

If injury is considered to be the result of random, uncontrolled factors and that chance and bad luck or fate are the main factors, then there is little that can be done to prevent injury.

However, injuries are preventable. The public health approach to injury prevention involves data collection, risk factor analysis, intervention, evaluation and the widespread implementation of proven prevention methods. Scientific research and evidence underpin this approach.

The wide range of injury types

The nature of injury presents problems. Injuries fall into a wide range of categories that occur in many different environments. They can therefore be the responsibility of a number of separate agencies or government departments, each of which may favour a different approach.

Injuries need to be viewed collectively as a single “disease”, with broadly similar approaches being used to prevent them. Collaboration between a range of agencies is necessary, with some form of principal agency to coordinate activities.

Limitations of data

Data on the scope and patterns of injury are essential for identifying priority issues, understanding the causes of injury and identifying groups at high risk of injury. With limited data it is difficult to convince policy makers and others that there is an injury problem. It is also impossible to decide how to prioritize and develop effective programmes.

It is estimated that, of the 193 WHO Member States, only 109 currently provide usable vital registration data to WHO in coded form, using the International Classiffication of Disease taxonomy. Unfortunately, the quality of the data tends to be weakest where the problems are greatest. In developing countries, data coverage is particularly poor in relation to child drowning, burns, poisoning, road traffic injuries and bites and stings. Data on the evaluation of interventions and the cost of injuries are also largely absent or – at best – are weak in these places. High-quality data relating to hospital usage are similarly skewed. They are available in some high-income countries, but rare in countries with the highest injury rates.

The general lack of data on health care, in particular on high-cost hospital admissions and trauma care, results in the burden of injury being underestimated in many countries. It also prevents a proper analysis being made of the groups receiving such expensive and scarce health care and of the nature of their injuries. A high proportion of trauma deaths occur outside hospital in developing countries, so that many deaths – and other injuries – are not counted in data collection systems in these countries.

An important goal in injury prevention is thus to establish reliable estimates of the level and pattern of child injury and death, especially in low-income and middle-income countries. To this end, the volume, quality and availability of national and regional data needs to be increased. This should be done through a combination of better data collection systems, improved hospital surveillance, more community-based surveys and other appropriate research.

Lack of political commitment and understanding

The significance of child injury in absolute and relative terms is not always widely appreciated and the possibilities of prevention are often underestimated. This lack of understanding inhibits the allocation of resources to prevention efforts and also the political and organizational will that are necessary for change.

Injury must become an issue for concern and debate at all levels, not just at the global level, but at national and local levels as well. One example of high-level political commitment that led to immediate and observable reductions in injury was in France, where in 2002 the president declared road safety a national priority. This led to the formation of an interministerial committee and a national action plan (131). Between 2002 and 2004, a 34% reduction in road traffic deaths was reported, as a result of the coordinated implementation of a range of preventive measures, including: speed reduction, traffic calming, control of drinking and driving, and increased seat-belt use (187).

Effective and inexpensive interventions must be developed (188). The aim should be to develop measures that give as much return on money invested as immunizing children against measles, polio or tetanus.

Limited capacity

All countries face limitations in their capacity to prevent injury, to provide emergency and continuing care following an injury, and to provide appropriate rehabilitation services. This is particularly the case in countries where the burden of child injury is greatest. The training of more injury prevention practitioners and researchers across the world is urgently needed, and particularly in low-income and middle-income countries. For low-income countries, incentives may be necessary to encourage professionals to remain in their country of origin and not emigrate to high-income countries.

The content of training courses also needs to be carefully planned. Such syllabuses generally include principles and concepts that further knowledge and understanding. Competencies, though, also need to be taught, including skills in group work, community development, collaboration across sectors and lobbying.

Difficulties of implementation

As already stated, the main aim in child injury prevention is the adaptation of proven prevention measures to local circumstances. In areas of the world where substantial progress has already been made, efforts are required to apply effective interventions more widely. A recent analysis conducted in the United States showed that child injury deaths could be reduced by one third if practices that had proved effective in certain states were adopted in other similar states (189).

Lack of funding

Funding levels need to reflect the importance of injury as a major cause of death and ill-health in children. “Those who control the purse strings must be persuaded that most injuries are truly preventable and that the cost of failing to do so greatly outweighs the relatively small costs of prevention” (190).