Differences in child injury hospitalizations in Sweden: The use of time-trend analysis to compare various community injury-prevention approaches

Home safety education and provision of safety equipment for injury prevention (Review)

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD. There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92). Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96). Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Statistical methods for designing and assessing the effectiveness of community-based interventions with small numbers

Community-based interventions are, by their nature, tailored to the particular needs of the members and stakeholders of the community. In the area of safety promotion, the multifaceted aspects of violence and unintentional injuries necessitate complex intertwining of strategies and approaches. The evaluation of the effectiveness of any 'intervention' programme, either as a whole or of its discrete components, is thus challenging. In addition, standard experimental research designs involving controlled comparisons and the use of randomisation are often not practical. The evaluation is complicated further when the numbers of events in the community that constitute outcomes to be measured, before and after the interventions, are small. This manuscript reviews some of the statistical considerations that impact the evaluation of the effectiveness of such intervention approaches, and proposes a meta-regression methodology to address this complex issue. The application of the proposed methodology to the 'Safe Community' Model is provided as an example.

Controlled evaluation of injury in an international Safe Community: Kashmar, Iran

OBJECTIVES

To determine the degree to which the Safe Community (SC) model is effective in reducing injuries. Although positive results have been reported for some communities in developed countries, there is no consistent relationship between being an international designated SC and subsequent changes in observed rate of injury, and no controlled studies have examined the effectiveness of the SC model in developing countries. The aim of this study was to evaluate and compare the injuries in the SC programme of Kashmar (population 149,358) with injuries in counties in Iran that have not applied the SC model.

STUDY DESIGN

Retrospective study using available data from 20 March 2005 to 19 March 2008.

METHODS

Data were obtained from the Injury Prevention and Safety Promotion Department of the Disaster and Emergency Management Centre of the Ministry of Health and Medical Education of Iran. These data are collected upon presentation of injured patients to the emergency room. Different types of injuries are evaluated, including motor vehicle injuries (including pedestrians, passengers, drivers and motorcyclists), falls, blows by an object or a person, violence, burns, scorpion and snake bites, electrocution, animal attack, toxicity, suicide and other causes. A control group was selected from all counties in Iran with a population between 100,000 and 200,000. The mean injury rate of these counties was calculated, and counties which had an injury rate within one standard deviation (SD) of the mean rate for all 3 years of the study were included in the control group (n=44 counties).

RESULTS

The mean population of the 44 control counties was 142,123 in 2006. The numbers of injuries per 100,000 population in Kashmar were 4654.6 [95% confidence interval (CI) 4584.3-4762.6], 4570.9 (95% CI 4465.5-4678.0) and 4949.2 (95% CI 4839.7-5060.4) in 2005-2006, 2006-2007 and 2007-2008, respectively. At the same time, the mean numbers of injuries per 100,000 population in the 44 control counties were 822.7 (95% CI 815.6-829.8), 1130.0 (95% CI 1121.7-1138.3) and 1245.5 (95% CI 1236.8-1254.2). The injury-related fatality rate in the emergency room was 57.6, 52.9 and 44.2 per 100,000 population in Kashmar and 12.2, 13.0 and 11.9 per 100,000 population in the control counties in the three study years. Although a comparison of the fatality rate between the first and third years of the study shows a decrease of 13.4 per 100,000 population in Kashmar, this was not significant (P=0.1056). In the 44 control counties, the injury-related fatality rate decreased by 0.3 per 100,000 population between the first and third years of the study. The difference between the decrease in injury-related fatality rate in Kashmar (13.4 per 100,000 population) and the 44 control counties (0.3 per 100,000 population) was significant (P<0.0001).

CONCLUSION

The controlled evaluation of injury in the international SC of Kashmar showed an increase in the number and rate of injuries in Kashmar and in the 44 control counties over 3 years, but the injury-related fatality rate decreased over the same time period. A greater decrease was seen in Kashmar than in the control counties. Long-term evaluation is necessary to confirm these results.

The 'WHO Safe Communities' model for the prevention of injury in whole populations

BACKGROUND

The World Health Organization (WHO) 'safe communities' approach to injury prevention has been embraced around the world as a model for co-ordinating community efforts to enhance safety and reduce injury. Approximately 150 communities throughout the world have formal 'Safe Communities' designation. It is of public health interest to determine to what degree the model is successful, and whether it reduces injury rates. This Cochrane Review is an update of a previous published version.

OBJECTIVES

To determine the effectiveness of the WHO Safe Communities model to prevent injury in whole populations.

SEARCH STRATEGY

Our search included CENTRAL, MEDLINE and EMBASE, PsycINFO, ISI Web of Science: Social Sciences Citation Index (SSCI) and ZETOC. We handsearched selected journals and contacted key people from each WHO Safe Community. The last search was December 2008.

SELECTION CRITERIA

Two authors independently screened studies for inclusion. Included studies were those conducted within a WHO Safe Community that reported changes in population injury rates within the community compared to a control community.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Meta-analysis was not appropriate due to the heterogeneity of the included studies.

MAIN RESULTS

We included evaluations for 21 communities from five countries in two geographical regions in the world: Austria, Sweden and Norway, and Australia and New Zealand. Although positive results were reported for some communities, there was no consistent relationship between being a WHO designated Safe Community and subsequent changes in observed injury rates.

AUTHORS' CONCLUSIONS

There is marked inconsistency in the results of the studies included in this systematic review. While the frequency of injury in some study communities did reduce following their designation as a WHO Safe Community, there remains insufficient evidence from which to draw definitive conclusions regarding the effectiveness of the model.The lack of consistency in results may be due to the heterogeneity of the approaches to implementing the model, varying efficacy of activities and strategies, varying intensity of implementation and methodological limitations in evaluations. While all communities included in the review fulfilled the WHO Safe Community criteria, these criteria were too general to prescribe a standardised programme of activity or evaluation methodology.Adequate documentation describing how various Safe Communities implemented the model was limited, making it unclear which factors affected success. Where a reduction in injury rates was not reported, lack of information makes it difficult to distinguish whether this was due to problems with the model or with the way in which it was implemented.

Statistical modelling needed to find the effects from a community-based elderly safety promotion program

BACKGROUND

Multiple control areas and time-series analyses have been recommended for effect evaluations of community-based health promotion. Large fluctuations, maybe due to chance, among the areas and over the years might obscure the intervention effect.

METHODS

A quasi-experimental time-series analysis with several control areas was performed as an effect evaluation of a community-based elderly safety promotion program. The program was implemented during 1995-99 in a community in the Stockholm Metropolitan area (population +65 years: 5500; number of first hip fractures in 1995: 60). Four control areas were selected based on similar hip fracture-related characteristics as the intervention community, complemented with two larger control areas. The time series covered 6 years pre-intervention (1990-95) and 6 years post-intervention (1996-2001). The study population was divided into two age groups and gender, resulting in 28 panels. The first hip fracture incidence was obtained from the Swedish national in-patient register.

RESULTS

The time series revealed no discernible pattern, and conventional analyses showed no conclusive results. A multivariate analysis, examining the time trends by employing the intra-annual and intra-panel variance, revealed the underlying trends in hip fracture rates. Comparisons between predicted numbers of hip fractures in the intervention and control areas was enabled, which resulted in 14 less hip fractures in the intervention community than expected from the control communities. If one extreme value was altered, the result changed considerably.

CONCLUSION

Effect evaluations of community-based health promotion programs using time-series from small communities might give faulty results, if statistical modelling is not employed.

Non-pharmaceutical prevention of hip fractures - a cost-effectiveness analysis of a community-based elderly safety promotion program in Sweden

BACKGROUND

Elderly injuries are a recognized public health concern and are due to two factors; osteoporosis and accidental falls. Several osteoporosis pharmaceuticals are considered cost-effective, but intervention programs aiming at preventing falls should also be subjected to economic evaluations. This study presents a cost-effectiveness analysis of a community-based elderly safety promotion program.

METHODS

A five-year elderly safety promotion program combining environmental structural changes with individually based measures was implemented in a community in the metropolitan area of Stockholm, Sweden. The community had around 5,500 inhabitants aged 65+ years and a first hip fracture incidence of 10.7 per 1,000 in pre-intervention years 1990-1995. The intervention outcome was measured as avoided hip fractures, obtained from a register-based quasi-experimental longitudinal analysis with several control areas. The long-term consequences in societal costs and health effects due to the avoided hip fractures, conservatively assumed to be avoided for one year, were estimated with a Markov model based on Swedish data. The analysis holds the societal perspective and conforms to recommendations for pharmaceutical cost-effectiveness analyses.

RESULTS

Total societal intervention costs amounted to 6.45 million SEK (in Swedish krona 2004; 1 Euro = 9.13 SEK). The number of avoided hip fractures during the six-year post-intervention period was estimated to 14 (0.44 per 1,000 person-years). The Markov model estimated a difference in societal costs between an individual that experiences a first year hip fracture and an individual that avoids a first year hip fracture ranging from 280,000 to 550,000 SEK, and between 1.1 and 3.2 QALYs (quality-adjusted life-years, discounted 3%), for males and females aged 65-79 years and 80+ years. The cost-effectiveness analysis resulted in zero net costs and a gain of 35 QALYs, and the do-nothing alternative was thus dominated.

CONCLUSION

The community-based elderly safety promotion program aiming at preventing accidental falls seems as cost-effective as osteoporosis pharmaceuticals.

Effects of neighbourhood and individual factors on injury risk in the entire Swedish population: a 12-month multilevel follow-up study

In this cumulative incidence study of the entire population of Sweden, we examined the association between neighbourhood income level and injury risks across a comprehensive set of individual variables. The population, stratified by age (0-14, 15-64, and > or =65 years), was followed for incident injury events in 1998. Multilevel logistic regression was used to examine the associations between neighbourhood income level and injury, including deaths from injury. Risks were analyzed, taking individual demographic and socioeconomic variables and alcohol/substance abuse into account. Falls were the most frequent non-fatal injuries in all age groups. People (0-14 years and 15-64 years) in the most deprived neighbourhoods exhibited higher odds of injuries (OR = 1.15; CI = 1.08-1.22 and OR = 1.34; CI = 1.26-1.43, respectively) than those in the same age groups in the most affluent neighbourhoods (OR = 1). In the full model, injury odds ratios decreased but remained significant in people 0-14 years. The large between-neighbourhood variance in all age groups indicated variation between neighbourhoods in injury incidence. Our results suggest that interventions focused on contextual aspects of neighbourhoods, in addition to individual behaviours, may have a positive impact on injury prevention.