Evaluation of a child safety program based on the WHO safe community model.

OBJECTIVES: To evaluate the outcome of the World Health Organization (WHO) Safe Community model with respect to child injuries. STUDY DESIGN: A population based quasiexperimental design was used. Cross sectional pre-implementation and post-implementation data were collected in intervention (Motala municipality) and control (Mjölby municipality) areas, both in Ostergötland county, Sweden. RESULTS: The total relative risk of child injury in the intervention community decreased more (odds ratio 0.74; 95% confidence interval (CI) 0.68 to 0.81) than in a control community exposed only to national level injury prevention programs (0.93; 95% CI 0.82 to 1.05). The relative risk of moderately (abbreviated injury scale (AIS) 2) severe injury in the study area was reduced to almost a half (odds ratio 0.49; 95% Cl 0.41 to 0.57), whereas the risk of minor (AIS 1) injuries decreased only slightly (odds ratio 0.89; 95% CI 0.80 to 0.99). The risk of severe or fatal (AIS 3-6) injuries remained constant. CONCLUSIONS: After introduction of an injury prevention program based on the WHO Safe Community model, the relative risk for child injury in the intervention community decreased significantly more than in a control community exposed only to national injury prevention programs.

Long-term effects of legislation and local promotion of child restraint use in motor vehicles in Sweden.

The main objective is to study long-term effects of legislation and promotion of child-restraint use in motor vehicles. Subgoals are to describe the level of restraint use in cars and changes in mortality and morbidity patterns in regard to differences among age groups and geographical areas (morbidity). The study areas were; 'The First Four', 'The Six Counties', 'The Rest of Sweden', and 'Sweden as a whole', and the population were two age groups--0-6 and 7-14 years. The incidence of restraint use comes from observations of car-seat-belt usage. Outcome evaluation was based on hospital-discharge data 1978-1996 and mortality statistics 1970-1996. The level of restraint use for children in the front seat was 97% in 1988 and was equal to 1995. Mortality data shows a decrease of 2.8% on an average per year, 76% over the study period. A significant change over time in the two intervention areas was shown (annual changes of -2.8 and -1.8%), but not in the rest of Sweden. The local authorities that started early with preventive programs, such as safety seat loan schemes and those having an organised safety-promotion program showed a much better improvement than the rest of Sweden. There is a need for appropriate information for local action on childhood injury prevention to accompany national legislation.

Evaluation of an inter-organizational prevention program against injuries among the elderly in a WHO Safe Community.

The aim of the study was to evaluate the outcome of a participatory community-based prevention program against injuries among the elderly. A population-based quasi-experimental design was used with pre- and post-implementation measurements in an intervention and a control area. The program was based on cross-sectoral participation in detecting and taking action against injuries among the elderly. Change in the relative risk of injury was estimated by the odds ratio. Morbidity in moderately (AIS 2) severe injury in the study area was reduced from 46 per 1000 population years to 25 per 1000 population years (odds ratio 0.55; 95% confidence interval 0.46-0.65), while the minor (AIS 1) injuries increased (odds ratio 1.55; 95% confidence interval 1.21-1.91). The risk of severe or fatal (AIS 3-6) injuries remained constant. In the study area, only a slight decrease in the total morbidity rate was observed (odds ratio 0.87; 95% confidence interval 0.77-0.99). In the control area, there was no evident change in the total morbidity rates. Falls decreased or showed a tendency to decrease in the age groups 65 to 79-y-old in the study area, while they increased in the older age group. The results indicate that no sharp boundaries should be drawn between safety education, physical conditioning, environmental adjustments and secondary prevention measures when planning safety promotion among the elderly. Future studies should address these issues along with the methodological complexity associated with assessment of participatory community-based safety promotion programs.

Evaluation of inter-organizational traffic injury prevention in a WHO safe community.

The objective of the study was to examine the effect of a community-based injury prevention program on traffic injuries. A population-based quasi-experimental design was used with pre- and post-implementation measurements in an intervention and a control area. The program was based on inter-organizational participation in detecting and taking action against traffic injuries. The total relative risk for traffic injury in the study area showed only a tendency to decrease following program exposure (odds ratio 0.91; 95% confidence interval 0.81-1.02). No change in relative risk was observed in the control area. The analyses of program impact on injury severity showed that the relative risk for moderate injuries in the study area was reduced by almost half (odds ratio 0.59; 95% confidence interval 0.49-0.69), the risk for severe or fatal injuries remained constant (odds ratio 1.27; 95% confidence interval 0.80-2.02), and the risk for minor injuries increased (odds ratio 1.34; 95% confidence interval 1.13-1.59). The relative risk for moderate injuries was reduced by at least half for mopedists, cyclists, pedestrians, and those leaving or entering a motor vehicle. Community-based injury prevention can be a complement to national traffic safety programs.

Bicycle-related injuries among the elderly--a new epidemic?

Bicycling in Sweden has almost doubled between 1980 and 1992/3 among persons aged 25-64 y. The upward trend is continuing. For the elderly (65 or older) the bicycle is a common means of transport, in both Sweden and a number of other countries. Almost one-third of the Swedish population aged 65 or older bike at some time during the year. The objectives of this study are to describe the pattern of, and trend in, bicycle-related injuries among the elderly in Sweden and to discuss possible means of injury prevention. Mortality data come from official death certificates (1967-96). Hospital-discharge data (1985-96) are also employed, divided into three age groups (-14, 15-64 and 65-), by external cause according to the ICD-9, and also into 'all diagnoses' and 'head injuries'. Number of cases and days of hospital care for persons aged 65 or more, on aggregate and by gender, are reported for 1996. The whole of Sweden and its northern and southern parts separately were investigated. 2830 bicyclists were killed over the period 1967-96, of which 47% were 65 or older. The risk of dying due to bicycling was about 3.7 times greater among the elderly than among children aged 14 or under. There were significant changes in injury trends for all age groups between 1985 and 1996 with regard to hospital care. Annual average decreases for children, of 2.2% for all diagnoses and of 3.4% for head injuries, were observed. For the other two age groups there were increases in all injuries of 3.4% (15-64) and of 2.9% (65-), and increases in head injuries of 4.6% (15-64) and 2.7% (65-). For the elderly living in the southern part of Sweden, there was an increase on average of 2.2% per year over the period, compared with 4.2% for those in the northern part. Males showed a higher incidence of injuries and received longer periods of care than females. Do we have an epidemic of bicycle injuries among the elderly? They face a greater risk of being injured or killed than his/her younger counterpart. For all ages the risk is 7.4 times higher for a bicyclist than for a car driver. The risk for the elderly is about 3 times greater than for the average bicyclist, and as much as 6 times higher for the age group 75-84 y. With some few exceptions, there is no doubt that society has neglected the problem. Decision-makers have a tendency to focus on the relatively young. But people are living longer today and the elderly are healthier, which indicates the need for greater interest and more intervention. We have signs of an epidemic, but one that can be ameliorated or prevented. Just waiting for injury to occur leads only to premature death or lifelong disability.

The community safety approach in Falun, Sweden--is it possible to characterise the most effective prevention endeavours and how long-lasting are the results?

The safe community concept was put into practice in order to reduce the number of unintentional injuries occurring in the Falun municipality. A community-based injury prevention programme was initiated in 1989 and has been gradually built up since that time. The prevention endeavours were based primarily on active intervention strategies through the provision of information, supervision, education and training. After 5 years of an active intervention programme, a significant effect was found as regards the injury rates for both outpatients as well as patients discharged from hospitals. The objectives of this study were: to examine whether the character of the prevention endeavours was a determining factor on the outcome (recorded as in-patient injury cases); to evaluate the effects of this programme, which is still in practice, compared to long-term historical trends; and to draw comparisons with other community-based programmes. A category of 'most targeted risks' was identified as being different with respect to how the injury mechanisms involved were targeted through the programme activities. The development within the injury rates for this group, comprised predominantly of injuries caused by falls at the same level, was significantly different than those for the groups categorized as 'less targeted' and 'non-targeted'. The general effect of the programme appeared to be a neutralization of an otherwise upward trend in the injury rates. A particular effect was demonstrated in the number of fall injuries, including femoral fractures. It was also noted that there was still a reduction in injuries after 7 years. However, it was possible to surmise a waning effect during the last 2 years of the programme while still in progress. This observation suggests that a community-based injury prevention programme must be continuously renewed and reinforced.

Community-based injury prevention: effects on health care utilization.

BACKGROUND: Worldwide, an estimated 78 million people are disabled each year because of unintentional injuries and about 3 million die. The WHO Safe Community model is a framework for community-based injury prevention programmes. The aim of this study is to evaluate the outcome on health care utilization of a Safe Community programme. METHODS: The incidence of injuries treated at health care facilities in an intervention municipality (pop. 41,000) was compared to the injury incidence in a control municipality (pop. 26,000). The incidence was recorded immediately before and one year after programme implementation from registrations made during all first-contact health care visits and from examination of hospital discharge registers. RESULTS: The incidence of health care treated injuries in the intervention area had decreased by 13% (95% CI: 9-16%) from 119 (95% CI: 115-122) per 1000 population-years to 104 (95% CI: 101-107). In the control area, the corresponding injury incidences were 104 (95% CI: 100-108) and 106 (95% CI: 102-109). The hospital-treated injuries in the intervention area decreased by 15% (95% CI: 7-24%) from 19 (95% CI: 17-20) per 1000 population-years to 16 (95% CI: 15-17), while in the control area, the incidences remained at 13 (95% CI: 11-14) per 1000 population-years. Utilization of acute care in the intervention area for reasons other than injuries increased by 8% (95% CI: 6-10%), while in the control area, the number of visits did not show significant change. CONCLUSION: This first controlled evaluation showed that an injury prevention programme based on local action groups can significantly reduce injuries requiring health care in a community. Local prevention can provide a complement to national level campaigns.

Bicycle injuries in Western Sweden: a comparison between counties.

The objectives of the study were to investigate whether there are differences in the incidence of bicycle-related injuries by geographic district (county), age, and gender in Sweden's Western Road Administration Region, and to utilize any detected differences to suggest priorities for intervention and prevention. Injury data come from the Swedish national hospital-discharge registry and a specialized national register of occupational injuries. Both bodily injuries in general and head injuries in particular show intra-regional differences. The rural part of Skaraborg County was shown to have a significantly higher injury incidence than other parts of the Western Region. Females generally show a lower incidence than males, but older women are more likely to be seriously injured than younger (age-related differences being greater than for males). Some striking findings were found with regard to occupational differences. Females sustain more work-related bicycle injuries than males. Head injuries account for more than half of the bicycle injuries in the Western Region that require hospitalization. All this indicates that targeted measures are required. Some studies have shown that the use of bicycle helmets reduces the incidence of head injuries, the degree of their severity, and the number of bicycle-related fatalities. There is a need for mandatory helmet-wearing legislation, which must go hand-in-hand with special efforts to reach groups with a low rate of helmet wearing, in particular those in the middle age range. Although the grown-up/older cycling population has been the subject of targeted action in some countries, the focus of preventive activity has generally been on children. The results of the study suggest the need for further injury-related research into adult cycling.

The WHO safe community program for injury prevention: evaluation of the impact on injury severity.

Despite the fact that injuries consume a considerable amount of health care resources world-wide, 3.5 million people die from unintentional injuries each year. To handle this central public health problem, WHO has introduced the Safe Community accreditation for injury prevention programs. This study was to investigate the impact from a Safe Community program with regard to injury severity. Data were collected in Motala municipality (population = 41,000), Ostergötland county, Sweden, during one year before and one year after program intervention, from two sources: registration of trivial (AIS 1) and non-trivial (AIS 2-6) unintentional injuries from all acute care episodes in the area and recollection of hospital bed days from discharge registers. The incidence of non-trivial injuries treated in health care was found to have decreased by 41% (95% confidence interval, 37-45%), while the trivial injuries increased by 16% (9-22%). The larger decrease of non-trivial injuries was observed in all ages and injury event environments. The total number of bed days at emergency hospitals due to injuries decreased by 39% (37-41%) from 1983-84 to 1989, while the hospital bed utilization for other reasons decreased by 9% (8-9%). The study showed the implementation of a WHO Safe Community program led to the harm from unintentional injuries within the community being considerably more reduced than that of the injury incidence. In future assessments of injury prevention programs, classification of injury severity should be included to increase the validity of inter-program comparisons.

Can a combination of local, regional and national information substantially increase bicycle-helmet wearing and reduce injuries? Experiences from Sweden.

Is it possible to substantially reduce the incidence of injuries related to cycling through the provision of information on helmet wearing? This issue has been investigated in Skaraborg County, Sweden, where 90 percent of all pre-school children now use bicycle helmets. For children under 15, there was an average annual decrease in all bicycle-related injuries of 3.1 percent, equivalent to a decrease of 48 percent over the study period, 1978-93 (for head injuries, 59%). Sweden as a whole showed a reduction of 32 percent in bicycle-related injuries (head injuries, 43%). In Skaraborg, children have been the target of helmet-wearing programs at local and regional levels since 1982, and at national level since 1987. The elderly have not been targeted in helmet-wearing programs; currently, they scarcely wear helmets at all, and showed a significant increase in their injury rate over the period (4.7% annually). The number of concussions sustained by helmet-wearers is estimated to be one-third fewer than that of non-wearers. Comparisons with Australia and some parts of the U.S.A. indicate that, despite the significant decrease in Skaraborg, greater effects might be achievable if information is supplemented by compulsory-helmet-wearing legislation.

An epidemiological study of bicycle-related injuries.

The objectives of this study were to describe bicycle-related injuries in relation to injury patterns, age, gender and medical treatment in a defined Swedish population and to identify factors contributing to injury. The study group comprised all patients living in the county of Västmanland, Sweden, visiting a physician or dentist because of bicycle-related injury during one year (November 1989-October 1990). Cyclists were mostly injured on pavements, pedestrian malls and cycle tracks. Twenty percent of the events occurred on public roads in urban areas; most frequently, the injured were in the age range 0-24. The most common bicycle injury event involved no other party. The events were often caused by environmental factors, in combination with behaviour such as excessive speed, lack of attention, breach of traffic regulations or a co-ordination problem. Head injuries, including oral injuries, were the most common, in particular among children and adolescents. One in four children in the age range 0-9 sustained an oral injury.

Ten years of experiences from a participatory community-based injury prevention program in Motala, Sweden.

Exploratory studies in the Scandinavian countries have suggested that the national cost of unintentional injuries is equal to 4% of the Gross National Product (GNP). One way for Swedish society to handle this situation has been through community-based injury prevention programs. This study used action research methods to supplement the understanding of the community development for injury prevention. The aim of this paper is to present the participative model used in one of the first of these programs, the Motala Injury Prevention Program, and lessons learned from the first 10 years of its operation. The program 'succeeded' in 1993, when Motala Municipality formed a regular Safety Board chaired by the Municipal Commissioner. These are five main messages from the initial phases of the program: a community-based injury prevention program has to be regarded as a long-term project; preferably over more than a 10 year period, economic calculations are important in the community analysis phase of the program, inter-linkage between community organizations is essential in the design phase, the hand-over from the initial program developers to practitioners is critical in the implementation phase, it is important to maintain a high-quality data collection routine even after the conclusion of the community analysis phase of the program. These observations have a potential to be valid at least for Northern Europe, which, by comparison with other parts of the world is a relatively homogenous area with regard to external causes of injuries. Regarding other communities, there are known differences in injury rates and community organization.

The Lidköping Accident Prevention Programme--a community approach to preventing childhood injuries in Sweden.

OBJECTIVES: In Sweden about 100 children 0-14 years die from accidental injuries every year, roughly 40 girls and 60 boys. To reduce this burden the Safe Community concept was developed in Falköping, Sweden in 1975. Several years later a second programme was initiated in Lidköping. The objectives of this paper are to describe the programme in Lidköping and to relate it to changes in injury occurrence. SETTING: The Lidköping Accident Prevention Programme (LAPP) was compared with four bordering municipalities and to the whole of Skaraborg County. METHODS: The programme included five elements: surveillance, provision of information, training, supervision, and environmental improvements. Process evaluation was based mainly on notes and reports made by the health planners, combined with newspaper clippings and interviews with key people. Outcome evaluation was based on information from the hospital discharge registry. RESULTS: In Lidköping there was an on average annual decrease in injuries leading to hospital admissions from 1983 to 1991 of 2.4% for boys and 2.1% for girls compared with a smaller decline in one comparison area and an increase in the other. CONCLUSION: Because the yearly injury numbers are small there is a great variation from year to year. However, comparisons over the nine year study period with the four border municipalities and the whole of Skaraborg County strengthen the impression that the programme has had a positive effect. The findings support the proposition that the decrease in the incidence of childhood injuries after 1984 could be attributed to the intervention of the LAPP. Nevertheless, several difficulties in drawing firm conclusions from community based studies are acknowledged and discussed.

The occurrence of farm--environmental injuries in a Swedish municipality.

The objectives of the present baseline study were to investigate work- and nonwork-related injuries in farm environments. 364 or 10% of all injuries in the study area occurred within farm environments. 174 (84%) of these were classified as work-related and 190 (52%) as home injuries. Most of the cases of farming injuries occurred during repair and maintenance work, animal care, and machine and vehicle use. The dominant types of injuries were falls, crushes, and eye injuries. Home injuries on farms accounted for 22% of all home injuries in the study area. Fourteen percent of these involved people who were not living on farms. Child injuries occurred in the home as well as in the work environment.

School accidents during a three school-years period in a Swedish municipality.

The aim of this study was to analyse the scope and nature of accidents that occurred at school as a basis for countermeasures. There were a total of 204 school accidents during the three school-years period, causing 222 injuries. Accidents during breaks and physical education were most common (85%). Fractures (24%), wounds (21%), sprains/strains (15%) and dental injuries (14.5%) were the dominating types of injuries. The site of injury was most commonly the upper extremity (22%), head and neck (18.5%), and lower extremity. Accidents during breaks dominated in age-group 7-12 years, while sports accidents were most common in age-group 13-19 years. Surveillance of school accidents on the municipal level is needed as a base-line for countermeasures as well as the evaluation of their effects.

Safety rounds in public environments: experience of a new tool for prevention of accidental injuries.

Accident prevention concerns everyone in society. A large number of organisations have the responsibility and the means to fight the increasing injury rate. Many preventive measures require changes and improvements to the physical environment. In Sollentuna, Sweden, the work concentrated on making inventories of the pedestrian physical environment and pressuring those responsible to take measures to correct deficiencies discovered through the municipal "safety round." The inventory of injury risk factors was documented in a report along with information about the type of risk-object, its geographical location, and those responsible for remedial measures. The environmental deficiencies were marked on a map and most of them were photographed. With the help of expert know-how and local knowledge, 88 risk factors were identified in the area of investigation, which covered slightly over 1 square kilometer. With the report as a basis, those responsible for countermeasures were contacted by letter and asked to take measures to eliminate the risk factors. The responsibility for eliminating these risk factors was divided among various authorities, organizations, and private persons. Despite a lack of legal support for the demand for countermeasures most of those responsible proved to have a positive attitude towards eliminating the accident risk factors that had been identified during the safety rounds. The method worked satisfactorily and the risk factors were eliminated after one or two contacts in almost all cases.

Road traffic accidents in a Swedish municipality.

A continuous all embracing registration of acute, in-patient and out-patient visits at hospitals and primary health care centres, was conducted in Skaraborg County in western Sweden. A special focus was directed at accident cases which account for 20% of the total number of acute visits. The accidents were divided up by environment: home, work, traffic and other. Cases of road traffic accidents have been mapped out in more detail with the help of standardised and structured surveys via telephone interviews, information from hospital records, and death certificates. This study aimed at achieving an increased understanding and knowledge about the accident pattern in the traffic environment in a municipality. Road traffic accidents accounted for 6.5% of all accidents. Cyclists, car drivers, car passengers and pedestrians were the most common victims. Children showed a high frequency of bicycle accidents. There was an increased risk of injury for young car-drivers. Thirty-six per cent were single-accidents. Cars and bicycles dominated among injury-inducing vehicles. Head, arm and knee injuries were most common. Twenty-six per cent of the victims were hospitalized. Safety devices were not used in 10% of cases where they should have been used according to legislation. A comparison of our registration system for road traffic accidents with the official statistics of Sweden reveals a substantial under-reporting of road traffic accidents in the latter. Consequently, a need exists for the surveillance of injuries by the public health services as a basis of injury control.

The role of organizations in community participation--prevention of accidental injuries in a rural Swedish municipality.

Accidental injuries are a major public health problem in most of the industrialized world. It is no longer justifiable to accept accidents as unfortunate but unavoidable occurrences. Their prevention is important and appears increasingly possible. The health care sector is uniquely knowledgeable about health hazards and must be more involved in social planning. An intervention programme towards the prevention of accidental injuries based on local epidemiological data has since 1980 been conducted in a geographically defined population in Skaraborg County in western Sweden. This article describes a community intervention approach. The programme has been implemented in a local community with the application of a community oriented and organization oriented perspective. This has above all constituted a starting point for initiating the programme. The programme includes as well active as passive strategies and consists of information, education, supervision and changes in the physical environment. Intersectorial cooperation and community involvement are emphasized.

One-year incidence of occupational injuries among teenagers in a Swedish rural municipality.

The aim of this study was to investigate occupational injuries among teenagers in a defined population and geographical area with regard to incidence and severity and to compare our registration system with that of the Swedish Occupational Injury Information System. All occupational accidents in the age group 15-19 years were registered at public health centres. We found a higher incidence compared to school accidents in the same age group as well as in relation to occupational accidents in the older population. Part-time work, lack of experience, temporary employment, unskilled work, and age-specific behavioural patterns are factors that might explain the higher incidence rate. The highest rates were found in service, military and unspecified occupations. Only 25% of the work-related accidents in our study were registered by the Swedish Occupational Injury System (ISA). It seems possible to reduce the number of accidents through the instigation of fairly simple measures. The coverage of the registration by the ISA seems to be incomplete.