[sustran] Child injury prevention article

[SUSTRAN Resource Centre]

forwarded from the pednet list an interesting article by IAN ROBERTS and
CAROLYN DIGUISEPPI:
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Injury prevention

Archives of Diseases in Childhood
September 1999;81:200-201

Worldwide, some 300 000 children die each year in road traffic crashes, a
further 300 000 children drown, and some 100 000 die in fires.1 Many
millions of children are seriously injured and hundreds of thousands sustain
permanent disabilities. The public health response to this human tragedy is
pitiable and raises important questions for child health professionals. Why,
for example, is the death of a child following abuse taken as clear evidence
of the failure of our collective efforts to protect children, whereas a
child pedestrian death represents only the failure of an individual child to
stop, look, and listen when crossing the road? And why did medical research
"declare war" on cancer and ignore injury, when as many children die from
injury as from all forms of cancer combined?

Most of the road deaths, particularly those in the developing world,
involve children as pedestrians.2 In Britain, the pedestrian injury
epidemic peaked in the 1930s with an average of nine deaths each day.3
Since then death rates have fallen, but not necessarily because our roads
have become safer. On the contrary, the two most likely explanations for
the decline in child pedestrian deaths are the massive reduction in walking
that has accompanied increasing traffic volume,4 and the increased survival
chances of seriously injured children from improvements in hospital care.5
There can be little doubt that in the struggle for the streets, the
pedestrian lost, with tens of thousands of children killed in the process.
But for most of the world the battles are just beginning. Like so many
Western epidemics, the pedestrian injury epidemic is now being exported to
the developing world. European and North American car markets are reaching
saturation point and motor manufacturers are looking east. The road death
epidemic in China is only just beginning, but already an estimated 29 000
children are killed on the roads each year,1 and the epidemic will generate
a mountain of disability. It is estimated that by 2020 road traffic
accidents will be the third leading cause of disability adjusted life years
(DALY) worldwide, and the second leading cause of DALYs in the
demographically developing countries.6

An epidemic of this scale demands an appropriate and timely public health
response. It is a matter of urgency that effective strategies are
identified for the prevention of road traffic accidents, drowning, fire
deaths, and other leading causes of injury, and for the treatment and
rehabilitation of injured victims, particularly in low income countries. A
logical first step would be to find out what we already know about the
effectiveness of injury prevention and injury management by conducting
systematic reviews of controlled intervention studies, and of case-control
and cohort studies where no intervention studies are available. The
Cochrane Injuries Group, an international network that prepares, maintains,
and promotes the accessibility of systematic reviews of the effectiveness
of interventions in the prevention, treatment, and rehabilitation of injury
has been established to facilitate this process.7 To date, findings from
systematic reviews include the demonstration that random breath testing
reduces road deaths,8 that pool fencing reduces the risk of drowning,9 and
that albumin infusion for hypovolaemia following trauma is of no proved
benefit and may even increase the risk of death.10

The effectiveness of some prevention strategies is not in doubt, but for
many mechanisms of injury the value of preventive measures remain
uncertain, and large scale randomised controlled trials are required to
determine their effectiveness. For a problem as common as injury, even
moderate intervention effects would be important. However, to detect
reliably moderate effects, both moderate biases and moderate random errors
must be avoided.11 Injury prevention trials must therefore be large enough
to avoid moderate random errors and should be designed in such a way that
moderate biases are avoided. Some injury prevention interventions cannot be
implemented separately for each individual and individual level randomised
controlled trials will not be possible. Evaluation of these strategies
requires community intervention trials, and recent developments in the
methodology of cluster randomised controlled trials will facilitate
these.12 Probably the main obstacles to the conduct of such studies are
political rather than methodological: first the importance of random
allocation in the unbiased assessment of effectiveness is not widely
appreciated in areas such as transport, housing, and education; second,
injury research is grossly underfunded compared with other health
problems.13

The identification of effective injury prevention interventions is
necessary but not sufficient to prevent childhood injuries. Many injury
prevention strategies require structural change and will encounter strong
opposition from vested interests. The strategy for overcoming structural
barriers to child health is advocacy. Advocacy is structural therapeutics,
which, to date British paediatricians have shown a notable reluctance to
prescribe.14 But there are encouraging signs that things are now changing,
as evidenced by the support by the Royal College of Paediatrics and Child
Health for the Road Traffic Reduction (UK Targets) Bill.15 Striving to make
a better world for children does not require a choice between science and
activism. It requires both.

IAN ROBERTS, CAROLYN DIGUISEPPI
Child Health Monitoring Unit, Department of Epidemiology and Public Health,
Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK, email:
Ian.Roberts at ich.ucl.ac.uk

       References

1.   Murray CJL, Lopez AD. Global health statistics: a compendium of
     incidence, prevalence and mortality estimates for over
     200 conditions. Harvard School of Public Health, Boston: Harvard
     University Press, 1996.
2.   Jacobs GD, Sayer I. Road accidents in developing countries. Accid
     Anal Prev 1983;15:337-353.
3.   Department of the Environment, Transport and the Regions. Road
     accidents Great Britain 1996. London: The Stationery Office, 1997.
4.   Hillman M, Adams J, Whitelegg J. One false move: a study of
     children's independent mobility. London: Policy Studies Institute,
     1991.
5.   Roberts I, Hollis S, Campbell F, Yates D. Declining injury rates for
     children and young adults: the contribution of hospital care. BMJ
     1996;313:1239-1241.
6.   Murray CJL, Lopez AD. Alternative projections of mortality and
     disability by cause 1990-2020: global burden of disease study. Lancet
     1997;349:1498-1504.
7.   Chalmers I, Altman DG, eds. Systematic reviews. London: BMJ
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8.   Peek-Asa C. The effect of random alcohol screening in reducing motor
     vehicle crash injuries. Am J Prev Med 1999;16(1
     suppl):57-67.
9.   Thompson DC, Rivara FP. Pool fencing for preventing drowning in
     children (Cochrane Review). The Cochrane Library, Issue
     1, 1999. Oxford.
10.  The Cochrane Injuries Group Albumin Reviewers. Human albumin solution
     for resuscitation and volume expansion in critically ill patients
     (Cochrane review). The Cochrane Library, Issue 1, 1999. Oxford.
11.  Peto R, Collins R, Gray R. Large-scale randomised evidence: large
     simple trials and overviews of trials. J Clin Epidemiol
     1995;48:23-40.
12.  Donner A. Some aspects of the design and analysis of cluster
     randomised trials. Appl Statist 1998;47:95-113.
13.  Ad Hoc Committee on Health Research Relating to Future Intervention
     Options. Investing in health research and development. Geneva: World
     Health Organisation, 1996.
14.  Viner R. Politics, power and paediatrics. Lancet
     1999;353:232-234.
15.  House of Commons official report (Hansard) Road Traffic Reduction
     (United Kingdom Targets) Bill. 30 Jan 1998: Column 621.

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1999 by Archives of Disease in Childhood
www.archdischild.com