Why are child injuries important?
Unintentional injuries are a major public health challenge facing children in England today. Injuries are a particular problem in young children, with death and hospital admission rates being higher in the under-fives than at other ages in childhood. Unintentional injuries resulted in 311 deaths in the under-fives in England between 2008 and 2012, making injuries the most common cause of death in the 1–4 years age group.1 More than 45,000 children aged < 5 years were admitted to hospital in England in 2012/13,2 and approximately 450,000 under-fives attended an emergency department (ED) in the UK following an unintentional injury in 20023 (the latest year for which detailed national data on unintentional injuries were collected in the UK). Childhood injuries, especially severe injuries, can also have long-term health, educational, social and occupational consequences. These include physical disability,4–6 psychological morbidity,7,8 cognitive or social impairment,9 lower educational achievement9,10 and poorer employment prospects.9 In addition, injuries also impact psychologically on those caring for children.7
Unintentional injuries do not just result in death and injury. They also place burdens on the NHS and other care agencies and on injured children and their families. The Chief Medical Officer (CMO)’s report for England in 2012 highlighted the high cost of injuries to the NHS and the potential for prevention.11 The annual cost of ED attendances was estimated to be £9M, and the cost of hospital admissions was estimated to be £16–87M, depending on injury mechanism.
Unintentional injuries disproportionately affect children living in socioeconomic disadvantage. The socioeconomic gradient in unintentional injury deaths is steeper than for any other cause of death in childhood,12 with children living in the most disadvantaged households having a death rate that is 13 times higher than that for children living in the most advantaged households.13
Child injury prevention policy in England
Child injury prevention has had varying prominence in government policy in England over the past 25 years. The Health of the Nation White Paper14 formed the central health policy in England between 1992 and 1997. It was the first attempt by a government in England to strategically improve the health of the population. Reduction in accidental injury was identified as one of five national targets for health improvement.
This was replaced by Saving Lives: Our Healthier Nation (1999)15 under the Labour administration’s health policy, which included accidental injury as one of its four key public health priorities. It set a target to reduce death rates from accidents by at least one-fifth and to reduce the rate of serious injury from accidents by at least one-tenth by 2010, describing this as a ‘tough but attainable target’. It also recognised that injury was a leading cause of childhood admissions to hospital. The White Paper announced that an interdepartmental and expert task force would be set up to advise on how the targets should be achieved.
The Accidental Injury Task Force published a report for the CMO in 2002 to identify steps that would have the greatest impact on injury prevention.16 One working group focused on child injury. Recommendations included cross-governmental co-ordination of initiatives, data collection and integration, developing the workforce for delivery and leadership, and research and dissemination of evidence. It highlighted the significance of deprivation in childhood injury. The task force recommended that a series of headline interventions should form the core of local implementation plans, giving focus and clarity to the somewhat fragmented approach to injury prevention at the time. It also advised targeting of interventions at areas of health inequality.
The Every Child Matters17 policy arose with the Children Act 2004.18 There were five outcomes that the policy sought to achieve for all children, one of which was ‘stay safe’, which included safety from unintentional injury.
A joint study by the Audit Commission and the Healthcare Commission, Better Safe Than Sorry, in 200719 examined the deployment of resources, arrangements for working in partnership and activities to prevent unintentional injury to children, especially the under-fives. The report contained a series of recommendations for the government, including re-emphasising the recommendations and strategy from the Accidental Injury Task Force and encouraging local organisations to take up and follow the evidence-based guidance contained within the report and commissioning the National Institute for Health and Care Excellence (NICE) to develop guidance on the prevention of unintentional injury for children aged < 15 years.
The Staying Safe: Action Plan was launched in 2008,20 setting out the government’s priorities for the period 2008–11. These included establishing the National Home Safety Equipment Scheme Safe at Home.21 A review examining prevention practice at the time and making recommendations also arose from the action plan and led to the publication of Accident Prevention Amongst Children and Young People: a Priority Review.22 The government also set a Public Service Agreement target (PSA 13) to improve children’s and young people’s safety that included four indicators, including one on a reduction in hospital admissions caused by unintentional and deliberate harm.
In 2010, the coalition government published the Healthy Lives, Healthy People White Paper,23 setting out plans for a comprehensive reform of the public health system. The plans revolved around decentralising public health and giving local authorities more power over public health budgets in their area. The new system took effect from April 2013, when Public Health England was established and public health services formally transferred from the NHS to local authorities. The new system focuses on outcomes rather than targets, which are set out in the Public Health Outcomes Framework,24 including one indicator to reduce hospital admissions from unintentional and deliberate injuries for the 0–4 years age group, with support from other partners in the public health system. Other indicators relate to reducing health inequalities.
In 2013, the CMO for England highlighted the issue of child accident prevention and has made a powerful economic case for preventing childhood injuries.11
Other major national health-related initiatives included the development by NICE of a series of guidance documents on the prevention of unintentional injuries in children aged < 15 years. NICE published public health guidance, Strategies to Prevent Unintentional Injuries among Children and Young People Aged under 15 [public health guidance (PH) 29] in 2010.25 Evidence published since the development of PH29 was reviewed in 2013 but did not result in any changes to the recommendations.26 A further document, Preventing Unintentional Injuries in the Home among Children and Young People Aged under 15 (PH30) was also published in 2010.27 PH29 recommends that local and national plans and strategies for children and young people’s health and well-being include a commitment to preventing unintentional injuries. Emphasis is also given to targeting injury prevention towards the most vulnerable groups to reduce inequalities in health.
Despite the policies described above, Better Safe Than Sorry also highlighted that there was little evidence of a systematic strategic approach to develop, implement and monitor programmes to prevent unintentional injuries in children within the NHS.19 A report in 2012 from the European Child Safety Alliance and EuroSafe, the European Association for Injury Prevention and Safety Promotion, assessed evidence-based national-level child injury prevention policy measures in 31 European Union (EU) member states.28 The report concluded that there was much scope for improvement in implementing child injury prevention measures in England, stating that if England had the unintentional injury death rate in 2010 of the EU country with the lowest rate (the Netherlands), 198 deaths in children and young people would have been avoided. It identified some progress in addressing the issue of child injury, but also that stronger government leadership was needed to produce and implement a national evidence-based child injury prevention strategy including funding for injury prevention measures, co-ordination of child injury prevention activities, infrastructure and capacity building. Recommendations included the integration of evidence-based good practice strategies into national public health programmes, the adoption and implementation of evidence-based injury prevention strategies at national and local levels and capacity building for stakeholders working at all levels.29
The report also highlighted unintentional injuries as the leading cause of inequality in childhood deaths and acknowledged that the English government had supported studies examining inequities and provided time-limited funding for a home safety equipment scheme targeting disadvantaged families. However, it concluded that ‘vacillating government support for the injury issue and related programmes has not resulted in a comprehensive coordinated approach that would ensure equitable coverage of children on safety issues’ (p. 3).29
The Keeping Children Safe (KCS) programme of research was, therefore, undertaken over a period of time in which there was an increasing acceptance of the need for evidence-based injury prevention, development of national guidelines to facilitate this and the use of indicators to reduce admissions for injuries in children and young people. However, during this period of time there was no national strategy or widespread adoption and implementation of co-ordinated evidence-based child injury prevention.
The most important injuries to focus on
The KCS programme of research focused on the prevention of thermal injuries, falls and poisonings. In terms of injury-related deaths in the under-fives in England, deaths from falls are the third most common, deaths from smoke, fire and flames are the fourth most common and deaths from poisoning are the sixth most common.1 Thermal injuries, falls and poisonings are three of the four most common types of injury resulting in hospital admission in the under-fives in England.2 In 2012/13, > 18,300 under-fives were admitted to hospital in England following a fall, > 5100 were admitted with poisoning and > 2210 were admitted following a thermal injury, 1420 of which were scalds. Emergency admissions for falls, poisonings and scalds in the under-fives cost the NHS in England £19.1M in 2012/13.30 There are no recent data available on ED attendances, but data from 2002 show that approximately 280,000 under-fives attended an ED following a thermal injury, fall or poisoning in the UK.3 The cost of these visits to the NHS converted to 2012/13 prices is nearly £32M.31 In total, 80% of all admissions in children aged 0–14 years for thermal injuries occur in the under-fives, as do 73% of all poisonings and 45% of all scalds, highlighting the importance of focusing on this age group. The majority of injuries in the under-fives occur at home,32 hence the KCS programme focused on thermal injuries, falls and poisonings occurring at home in the under-fives.
The need to develop the evidence base for preventing thermal injuries, falls and poisonings
The NHS needs to be able to make evidence-based decisions about which interventions to fund to prevent home injury in childhood, but the lack of evidence on effectiveness and cost-effectiveness of interventions hampers decision-making. Systematic reviews and meta-analyses33–42 show that home safety interventions increase safety behaviours and use of safety equipment, but also highlight the lack of evidence about whether these interventions reduce injury occurrence or are cost-effective. In addition, there is a lack of data on the cost of injuries to children, families and the NHS and on how to implement effective child injury prevention interventions within the NHS. The KCS programme, therefore, aimed to increase evidence-based thermal injury, falls and poisoning prevention by assessing risk and protective factors for these injuries, evaluating the effectiveness and cost-effectiveness of interventions to prevent these injuries, developing injury prevention briefings (IPBs) for effective and cost-effective interventions and evaluating the implementation of one IPB in children’s centres. We have considered thermal injuries in two categories in this research programme – scalds and fire-related burns – because although the tissue injury and pathophysiology are similar, the mechanisms and potential safety measures are very different. Some work streams (e.g. work streams 1, 2 and 6) focus on specific types of thermal injuries (e.g. scalds or fire-related injuries) whereas others focus on all thermal injuries, depending on the existing evidence base. The programme of work to achieve the aims is outlined below.
The Keeping Children Safe programme of research
Research questions
The research questions addressed within six work streams in the KCS programme are outlined in the following sections and shown in .
The Keeping Children Safe programme of research.
Work stream 1
This work stream addressed the question, ‘What are the associations between modifiable risk and protective factors and medically attended injuries resulting from five common injury mechanisms in children under the age of 5 years?’ This question was answered by a series of five case–control studies exploring risk and protective factors for each of the three most common types of medically attended falls (falls from furniture, stair falls and falls on one level), poisonings and scalds. These five studies are collectively referred to as study A. In addition, a study to validate the self-reported exposures was nested within the case–control studies in study A, and this is referred to as study B.
Work stream 2
This work stream addressed the question, ‘What are the NHS and child and family costs of falls, poisonings and scalds?’ This was answered by a cohort study measuring costs and injury outcomes nested within the case–control studies in study A. In addition, as there were no validated tools to measure health-related quality of life (HRQL) in the short term following a range of injuries in the under-fives, this study also validated the toddler version of the Pediatric Quality of Life Inventory (PedsQL™)43 for this purpose. These two studies are referred to as study C, with the costs study referred to as the study C costs substudy and the validation of the PedsQL study referred to as the study C HRQL substudy.
Work stream 3
This work stream addressed the question, ‘What interventions are being undertaken by children’s centres to prevent thermal injuries, falls and poisonings?’. This question was answered by two national surveys of children’s centre managers and staff. These studies are referred to as study D.
Work stream 4
This work stream addressed the question, ‘What are the barriers to, and facilitators of, implementing thermal injuries, falls and poisoning prevention interventions among children’s’ centres, professionals and community members?’. This question was answered by three studies: first, a systematic review of the quantitative and qualitative evidence on barriers to, and facilitators of, injury prevention (study E); second, a qualitative study consisting of interviews with children’s centres managers and staff to explore their views on barriers to, and facilitators of, implementing injury prevention interventions in children’s centres (study F); and, third, a qualitative study of parents of injured and uninjured children to explore views on barriers to, and facilitators of, implementing home injury prevention nested in the case–control studies in study A (study G).
Work stream 5
This work stream addressed the question, ‘How cost-effective are strategies for preventing thermal injuries, falls and poisonings?’. This question was answered by systematic overviews and systematic reviews of the literature on preventing falls, poisonings, fire-related injuries and scalds (study H), a systematic review and pairwise meta-analysis (PMA) of home safety interventions (study I), network meta-analyses (NMAs) of interventions to promote smoke alarm use and promote falls prevention practices, poison prevention practices and scalds prevention practices (study J) and decision analyses of interventions found to be effective in the NMAs (study K).
Work stream 6
This work stream addressed the question, ‘How effective and cost-effective is implementing an IPB for one exemplar injury prevention intervention?’. This question was answered by a randomised controlled trial (RCT), set in children’s centres, which evaluated the effectiveness and cost-effectiveness of an IPB for the prevention of fire-related injury (study M). The trial was preceded by a review of the literature on the implementation and facilitation of health promotion interventions (study L) to inform the design of the intervention. Evidence from the trial was then incorporated into the development of a second IPB. This covered the prevention of fire-related injury, falls, poisonings and scalds, based on findings from studies A and D–M.
Structure of this report
Each work stream is reported in a separate chapter in the report. Each of these chapters includes the following sections: abstract, introduction, methods, results and discussion. This is followed by a chapter reporting the contribution of the lay research adviser who collaborated with the KCS programme from its inception to its completion. The report ends with three chapters drawing together the conclusions, implications and recommendations for research from the programme.
