18 March 2002
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Preventing falls in older people: outcome evaluation of a randomized controlled trial.
- Stevens M, Holman C D, Bennett N, de Klerk N. J Am Geriatr Soc 2001; 49(11):1448-1455.
Correspondence: M Stevens, Department of Public Health, The University of Western Australia, Nedlands, Australia.
OBJECTIVES: To evaluate the outcome of an intervention to reduce hazards in the home on the rate of falls in seniors.
METHODS: The researchers conducted a randomized controlled trial, with follow-up of subjects for 1 year. at a community-based study in Perth, Western Australia. Participants were people age 70 and older. One thousand eight hundred seventy-nine subjects were recruited and randomly allocated by household to the intervention and control groups in the ratio 1:2. Because of early withdrawals, 1,737 subjects commenced the study. All members of both groups received a single home visit from a research nurse. Intervention subjects (n = 570) were offered a home hazard assessment, information on hazard reduction, and the installation of safety devices, whereas control subjects (n = 1,167) received no safety devices or information on home hazard reduction. Both groups recorded falls on a daily calendar. Reported falls were confirmed by a semistructured telephone interview and were assigned to one of three overlapping categories: all falls, falls inside the home, and falls involving environmental hazards in the home. Analysis was by multivariate modelling of rate ratios and odds ratios for falls, corrected for household clustering, using Poisson regression and logistic regression with robust variance estimation.
RESULTS: Overall, 86% of study subjects completed the 1 year of follow-up. The intervention was not associated with any significant reduction in falls or fall-related injuries. There was no significant reduction in the intervention group in the incidence rate of falls involving environmental hazards inside the home (adjusted rate ratio, 1.11; 95% CI = 0.82-1.50), or the proportion of the intervention group who fell because of hazards inside the home (adjusted odds ratio, 0.97; 95% CI = 0.74-1.28). No reduction was seen in the rate of all falls (adjusted rate ratio, 1.02; 95% CI = 0.83-1.27) or the rate of falls inside the home (adjusted rate ratio, 1.17; 95% CI = 0.85-1.60). There was no significant reduction in the rate of injurious falls in intervention subjects (adjusted rate ratio, 0.92; 95% CI = 0.73-1.14).
CONCLUSIONS: The intervention failed to achieve a reduction in the occurrence of falls. This was most likely because the intervention strategies had a limited effect on the number of hazards in the homes of intervention subjects. The study provides evidence that a one-time intervention program of education, hazard assessment, and home modification to reduce fall hazards in the homes of healthy older people is not an effective strategy for the prevention of falls in seniors.
Preventing falls in older people: impact of an intervention to reduce environmental hazards in the home.
- Stevens M, Holman C D, Bennett N. J Am Geriatr Soc 2001; 49(11):1442-1447.
Correspondence: M Stevens, Department of Public Health, The University of Western Australia, Nedlands, Australia.
OBJECTIVES: To evaluate the impact of an intervention to reduce fall hazards in the homes of older people.
METHODS: The intervention was administered to the 570 subjects in the experimental arm of a randomized controlled trial, with follow-up of subjects for 1 year. SETTING: Community-based seniors living in Perth, Australia. Participants were people age 70 and older. Registered nurses delivered the intervention. It consisted of a home hazard assessment, an educational strategy on general fall hazard reduction and ways to reduce identified home hazards, and the free installation of safety devices: grab rails, nonslip stripping on steps, and double-sided tape for floor rugs and mats. All intervention subjects received the home hazard assessment, and 96% received the educational strategy. Grab rails were installed in 77% of homes, rugs were stabilized in 8%, and nonslip step stripping was installed in 36%. Hazard prevalence was assessed at baseline in all homes and 11 months later in a random sample of 51 homes. Action taken in response to the intervention was assessed by a self-completed postal questionnaire completed 11 months after the intervention.
RESULTS: All homes had at least one fall hazard. The most prevalent were floor rugs and mats (mean of 14 per home), stepovers (Stepovers are structural changes to the height of the floor that were designed to be stepped over rather than stepped upon, for example, the lip of a shower or a bath side.) (mean of seven per home), steps (mean of four per home), and trailing cords (mean of two per home). The intervention was associated with a small but significant reduction in four of the five most prevalent hazards. The mean number of unsafe rugs and mats was reduced by 1.57 per house (95% confidence interval (CI) = 0.91-2.24); the mean number of unsafe steps was reduced by 0.61 per house (95% CI = 0.28-0.94); the mean number of rooms with trailing cords was reduced by 0.43 per house (95% CI = 0.10-0.76); and the mean number of unsafe chairs was reduced by 0.10 per house (95% CI = 0.02-0.18). Safety devices were installed in 81.9% of homes. Advice on modifying specific hazards identified on the home hazard assessment resulted in over 50% of subjects removing hazards of floor rugs and mats, trailing cords, and obstacles. The general education message prompted less activity to reduce these hazards than did the advice on identified hazards.
CONCLUSIONS: Fall hazards are ubiquitous in the homes of older people. The intervention resulted in a small reduction in the mean number of hazards per house, with many study subjects taking action but removing only a few hazards. The impact of the intervention in achieving self-reported action to reduce hazards was high.
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Trends and patterns of playground injuries in United States children and adolescents.
- Phelan KJ, Khoury J, Kalkwarf HJ, Lanphear BP. Ambul Pediatr 2001; 1(4):227-233.
OBJECTIVE: To determine the prevalence, trends, and severity of injuries attributable to playground falls relative to other common unintentional mechanisms that resulted in an emergency department (ED) visit in the United States.METHODS: Data were from the emergency subset of the National Hospital Ambulatory Medical Care Survey collected from 1992 to 1997 for children <20 years. Injury rates and 95% confidence intervals (CIs) were estimated and injury severity scores were computed.
RESULTS: There were 920551 (95% CI: 540803 to 1300299) ED visits over the 6-year study period by children and adolescents that were attributable to falls from playground equipment. The annual incidence of visits for playground injuries did not significantly decrease over the course of the study (187000 to 98000, P =.053). Injury visits for playground falls were twice as prevalent as pedestrian mechanisms, but they were less prevalent than visits for motor vehicle-- and bicycle-related injuries. A larger proportion of playground falls resulted in "moderate-to-severe" injury than did bicycle or motor vehicle injuries. Children aged 5 to 9 years had the highest number of playground falls (P =.0014). Playground falls were most likely to occur at school compared to home, public, and other locations (P =.0016).
CONCLUSIONS: Playground injury emergency visits have not significantly declined and remain a common unintentional mechanism of injury. Injury visits for playground falls were proportionally more severe than injury visits attributable to other common unintentional mechanisms. Interventions targeting schools and 5- to 9-year-old children may have the greatest impact in reducing emergency visits for playground injuries.
All-terrain vehicle and bicycle crashes in children: Epidemiology and comparison of injury severity.
- Brown RL, Koepplinger ME, Mehlman CT, Gittelman M, Garcia VF. J Pediatr Surg 2002; 37(3): 375-830.
Correspondence: Rebeccah L. Brown, MD, Assistant Professor of Clinical Surgery and Pediatrics, Assistant Director of Trauma Services, Department of Pediatric Surgery, Children's Hospital Medical Center, OSB-3, 3333 Burnet Ave, Cincinnati, OH 45229-3039.
BACKGROUND: Despite statements by the American Academy of Pediatrics (AAP) and the US Consumer Product Safety Commission (CPSC) against the use of all-terrain vehicles (ATVs) by children under the age of 16 years, nearly half of ATV-related injuries and over 35% of all ATV-related deaths continue to occur in this age group. Because ATV and bicycle crashes have been associated with serious injury in children, the authors compared the demographics, mechanism of injury, injury severity, and outcome of children with ATV- and bicycle-related injuries. Further, the authors sought to identify whether ATV-related injuries elicited changes in risk-taking behavior.
METHODS: A retrospective, comparative analysis of 109 children admitted for ATV-related injuries and 994 children admitted for bicycle-related injuries to a level 1 pediatric trauma center between January 1991 and June 2000 was performed. A phone survey was conducted to determine self-reported changes in safety behaviors or use patterns after ATV injury.
RESULTS: Mean age was 11.1 plus minus 3.5 years (range, 2 to 18 years) for ATV crashes versus 9.4 plus minus 3.3 years (range, 1 to 17 years) for bicycle crashes (P <.05). Ninety-three percent of ATV crashes occurred in children less than 16 years of age; 31% in children less-than-or-equal10 years of age; and 7% in children less-than-or-equal5 years of age. Male-to-female ratio was about 3:1 for both groups. White race accounted for 97% of ATV injuries compared with 79% of bicycle injuries (P <.05). Falls from ATVs or bicycles were the most common mechanism of injury (41% v 59%, respectively). Collisions with motor vehicles were more common for bicyclists (32% v 10%), whereas collisions with stationary objects were more common among ATV riders (27% v 9%). Sixteen percent of ATV crashes were caused by a roll-over mechanism. Mean injury severity score (ISS) were significantly higher for victims of ATV crashes (8.3 ATV v 6.7 bicycle; P <.05). ATV-related trauma was associated with multiple injuries, more operative interventions, and longer hospital stays. Location and distribution of injuries were similar for both groups. Helmet use was low in both groups but higher for ATV riders (23% v 8%; P <.5). Mortality rate was similar for both groups (0.9% for ATV riders v 0.7% for bicyclists). There was a 39% response for the phone survey post-ATV injury. Twenty-three of 43 (53%) respondents owned the ATV, and 70% of these received safety information at the time of purchase. However, only 14% of injured riders received any formal training before riding ATVs. Postinjury, 60% of children continued to ride, although 42% reported decreased riding time. Fifty-four percent of children reportedly wore helmets preinjury, and there were no changes in helmet usage postinjury. There were no differences in pre- and postinjury parental supervision (61% v 65%).
CONCLUSIONS: Both ATV and bicycle-related injuries occur predominantly in boys, but ATV victims are older and almost all are white. Almost all ATV injuries occurred in children under the age of 16 years. Although both ATV and bicycle crashes cause severe injuries in children, injury severity is higher for ATV crashes in terms of multiple injuries, need for operative intervention, and longer length of stay. Despite severe injuries, the majority of children injured by ATVs continue to ride, albeit fewer hours per day, and safety behaviors are unaltered. These data reinforce the current AAP stance that legislation prohibiting the use of ATVs in children under the age of 16 years without a valid driver's license should be pursued and enforced aggressively.
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Comparing hospital discharge records with death certificates: Can the differences be explained?
- Johansson LA, Westerling R. J Epidemiol Community Health 2002; 56(4):301-308.
Correspondence: L A Johansson, Johan Enbergs v 48 A, 6 tr, SE-171 61 Solna, Sweden (email:
lars.age.johansson@sos.se).
Study objective: The quality of mortality statistics is important for epidemiological research. Considerable discrepancies have been reported between death certificates and corresponding hospital discharge records. This study examines whether differences between the death certificate's underlying cause of death and the main condition from the final hospital discharge record can be explained by differences in ICD selection procedures. The authors also discuss the implications of unexplained differences for mortality data quality. Design: Using ACME, a standard software for the selection of underlying cause of death, the compatibility between the underlying cause of death and the final main condition was examined. The study also investigates whether data available in the hospital discharge record, but not reported on the death certificate, influence the selection of the underlying cause of death. Setting: Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 people who had been hospitalised during their final year of life. Main results: The underlying cause of death and the main condition differed at Basic Tabulation List level in 54% of the deaths. One third of the differences could not be explained by ICD selection procedures. Adding hospital discharge data changed the underlying cause in 11% of deaths. For some causes of death, including medical misadventures and accidental falls, the effect was substantial. Conclusion: Most differences between underlying cause of death and final main condition can be explained by differences in ICD selection procedures. Further research is needed to investigate whether unexplained differences indicate lower data quality.
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Trends in head injury mortality among 0-14 year olds in Scotland (1986-95).
- Williamson LM, Morrison A, Stone DH. J Epidemiol Community Health 2002; 56(4):285-288.
Correspondence: D H Stone, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, University of Glasgow, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, UK (email:
dhs1d@clinmed.gla.ac.uk).
OBJECTIVE: To examine the trends in childhood head injury mortality in Scotland between 1986 and 1995.
METHODS: Design: Analysis of routine mortality data from the registrar general for Scotland. Setting: Scotland, UK. Subjects: Children aged 0-14 years.
RESULTS: A total of 290 children in Scotland died as a result of a head injury between 1986 and 1995. While there was a significant decline in the head injury mortality rate, head injury as a proportion of all injury fatalities remained relatively stable. Boys, and children residing in relatively less affluent areas had the highest head injury mortality rates. Although both these groups experienced a significant decline over the study period, the mortality differences between children in deprivation categories 1-2 and 6-7 persisted among 0-9 year olds, and increased in the 10-14 years age group. Pedestrian accidents were the leading cause of mortality.
CONCLUSIONS: Children residing in less affluent areas seem to be at relatively greater risk of sustaining a fatal head injury than their more affluent counterparts. While the differences between the most and least affluent have decreased overall, they have widened among 10-14 year olds. The decline in head injury mortality as a result of pedestrian accidents may be partly attributable to injury prevention measures.
Violence in the community: a health service view from a UK Accident and Emergency Department.
- Howe A, Crilly M. Public Health 2002 Jan;116(1):15-21.
Correspondence: Andy Howe, Public Health Medicine, East Lancashire Health Authority, Lancashire, UK (email: andyhowe@clara.co.uk
).
A retrospective analysis of information recorded on victims of assault, who attended the Accident and Emergency department of Chorley and South Ribble Hospital over a 1 y period, was performed in order to describe the epidemiology of violent assault. During the year 735 (1.7%) of the patients attending A & E were identified as being victims of assault (71% were male). Victims were predominantly in their late teens and early 20s (median age 23 y, inter-quartile range 17 to 32 y). They attended at weekends (44% on Saturday or Sunday) and predominantly between the hours of 8 pm and 4 am (54%). Minor injuries were the most frequent (43%) while 21% of victims sustained lacerations and 11% had a fracture. The commonest site of injury was to the neck, face and throat (55%). The crude rate of attendance following violent assault for Chorley District was 4.67 per 1000 population per year. Information routinely collected by A & E departments can be used to describe the epidemiology of violence in the community. Further work is required to ascertain the optimal method of collection and dissemination of this information.
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Suicide risk following child sexual abuse.
- Plunkett A, O'Toole B, Swanston H, Oates RK, Shrimpton S, Parkinson P.
Ambul Pediatr 2001; 1(5):262-266.
Correspondence: Angela Plunkett, Department of Paediatrics and Child Health, University Teaching Unit, Children's Hospital, Camperdown, Australia.
OBJECTIVE: To determine the suicide rate and prevalence of suicide attempts and suicidal ideation in 183 young people who had experienced child sexual abuse and to examine variables related to the abuse, which may correlate with suicide attempts or suicidal ideation.
METHODS: Adolescents and young adults who had experienced child sexual abuse and individuals from a nonabused comparison group were asked about suicide attempts and suicidal ideation 5 and 9 years after intake to the study. Nine years after the abuse, a national death search was carried out to ascertain the number and causes of death in the 2 groups. Logistic regression was used to assess information on demographic and family functioning variables, the sexual abuse, notifications for other child abuse, criminal convictions, and out-of-home placements that were related to the outcome variables.
RESULTS: Young people who had experienced child sexual abuse had a suicide rate that was 10.7 to 13.0 times the national Australian rates. There were no suicides in the control group. Thirty-two percent of the abused children had attempted suicide, and 43% had thought about suicide since they were sexually abused.
CONCLUSIONS: Little information seems to be available to clinicians at the time of investigations for child sexual abuse in children that may identify those who are at increased risk of suicide. Abuse by an acquaintance, parental denial, or being angry with the child and not the abuser may predispose to suicide attempts but not necessarily to a completed suicide.
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Informal parental traffic education and children's bicycling behaviour.
- Johansson B, Drott P. Ups J Med Sci 2001; 106(2): 133-144.
Correspondence: B Johansson, Institute of teacher Training, University of Uppsala, Sweden.
The aim of this study was to analyze the relation between traffic intensity and traffic hazards in the local traffic environment, the parents' view of their child's traffic situation and the actions taken by the parents to cope with these hazards. 58 parents were interviewed. The traffic intesity in the vincinity of the home was estimated. 19% of the parents lived in inner city areas, 62% in suburbs and 19% in the countryside. Suburbian children had a safe traffic environment. Inner city- and countryside children predominately lived in high-intensity traffic environment. Inner city- and suburb children frequently used the bike, in inner city as a tool for play and in the suburbs mainly as a means of transport. Countryside children seldom used their bicycle. In inner city areas carefulness in traffic and in the other two independence was emphazised. Only 16% reported cooperation between home and school on traffic matters. Traffic accidents were concentrated to children living in suburbs (p<0.01). 81% of accidents were reported by parents having independence as a goal for traffic training (p<0.01). The reasults underline that traffic accident risk is strongly contingent on the local traffic environment and informal parenteral education in traffic safety.
Pediatric Residents Buckle Up: A Child Safety Seat Training Program for Pediatric Residents.
- Tender JAF, Taft CH, Frey C, Mickalide A, Gitterman BA. Ambul Pediatr 2001; 1(6):333-337.
Correspondence: Benjamin A. Gitterman, Children's National Medical Center, Washington, DC, USA (email: bgitterm@cnmc.org).
Objectives: To assess the effectiveness of supervised installation of child safety seats (CSSs) as a teaching tool for pediatric residents and to evaluate acceptance of this hands-on learning experience.
Methods: Pediatric residents were divided into an intervention group and a control group. All residents completed an initial questionnaire regarding knowledge about CSS use. The intervention group listened to a CSS lecture, viewed a video, and installed CSSs under the supervision of certified CSS technicians. The control group received no intervention. A second questionnaire was administered to all residents. We compared the knowledge gained since the initial questionnaire. The intervention group answered questions regarding their acceptance of this learning experience.
Results: Sixty-one residents participated in the study. Most residents had never installed a CSS and felt uncomfortable with their CSS knowledge. The percentage of the intervention group that received a passing score for knowledge increased from 3% initially to 97% on the posttest (P < .001). There was no change in the passing rate of the control group. The intervention group rated the CSS installation session as extremely helpful.
Conclusion: A hands-on educational program can be an effective, well-accepted method for increasing pediatric residents' knowledge about CSS use.
Changes in crash risk following re-timing of traffic signal change intervals.
- Retting RA, Chapline JF, Williams AF. Accid Anal Prev 2002; 34(2):215-220.
Correspondence: Richard Retting, Insurance Institute for Highway Safety, Arlington, VA 22201-4751, USA (email: rretting@iihs.org).
More than I million motor vehicle crashes occur annually at signalized intersections in the USA. The principal method used to prevent crashes associated with routine changes in signal indications is employment of a traffic signal change interval--a brief yellow and all-red period that follows the green indication. No universal practice exists for selecting the duration of change intervals, and little is known about the influence of the duration of the change interval on crash risk. The purpose of this study was to estimate potential crash effects of modifying the duration of traffic signal change intervals to conform with values associated with a proposed recommended practice published by the Institute of Transportation Engineers. A sample of 122 intersections was identified and randomly assigned to experimental and control groups. Of 51 eligible experimental sites, 40 (78%) needed signal timing changes. For the 3-year period following implementation of signal timing changes, there was an 8% reduction in reportable crashes at experimental sites relative to those occurring at control sites (P = 0.08). For injury crashes, a 12% reduction at experimental sites relative to those occurring at control sites was found (P = 0.03). Pedestrian and bicycle crashes at experimental sites decreased 37% (P = 0.03) relative to controls. Given these results and the relatively low cost of re-timing traffic signals, modifying the duration of traffic signal change intervals to conform with values associated with the Institute of Transportation Engineers' proposed recommended practice should be strongly considered by transportation agencies to reduce the frequency of urban motor vehicle crashes.
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Public health and peace.
- Laaser U, Donev D, Bjegovic V, Sarolli Y. Croat Med J 2002; 43(2): 107-113.
Correspondence: Section of International Public Health, Faculty of Health Sciences, University of Bielefeld, PO Box 10 01 31, D-33501 Bielefeld, Germany (email: ulrich.laaser@uni-bielefeld.de).
The modern concept of public health, the New Public Health, carries a great potential for healthy and therefore less aggressive societies. Its core disciplines are health promotion, environmental health, and health care management based on advanced epidemiological methodologies. The main principles of living together in healthy societies can be summarized as four ethical concepts of the New Public Health essential to violence reduction equity, participation, subsidiarity, and sustainability. The following issues are discussed as violence determinants: the process of urbanization; type of neighborhood and accommodation, and consequent stigmatization; level of education; employment status; socialization of the family; women's status; alcohol and drug consumption; availability of the firearms; religious, ethnic, and racial prejudices; and poverty. Development of the health systems has to contribute to peace, since aggression, violence, and warfare are among the greatest risks for health and the economic welfare. This contribution can be described as follows: 1) full and indiscriminate access to all necessary services, 2) monitoring of their quality, 3) providing special support to vulnerable groups, and 4) constant scientific and public accountability of the evaluation of the epidemiological outcome. Violence can also destroy solidarity and social cohesion of groups, such as family, team, neighborhood, or any other social organization. Durkheim coined the term anomie for a state in which social disruption of the community results in health risks for individuals. Health professionals can make a threefold contribution to peace by 1) analyzing the causal interrelationships of violence phenomena, 2) curbing the determinants of violence according to the professional standards, and 3) training professionals for this increasingly important task. Because tolerance is an essential part of an amended definition of health, monitoring of the early signs of public intolerance is important. The vital interplay between the informed public and efficient administration, however, can only exist in an open society. The link between democracy and health of the people, and between public health and economic welfare is real. The Public Health Collaboration in South Eastern Europe (PH-SEE) evolved just in time to reconnect and strengthen disrupted professional networks in the region as a prerequisite of effective public health action.
Domestic violence.
- Kennett MR. JONA Health Law Ethics Regul 2000; 2(3):93-101.
Correspondence: M.R. Kennett, Padberg Law Firm, St. Louis, MO, USA (email: mba1@aol.com.)
Domestic violence, a serious health problem, affects millions of people every year. Healthcare providers are in a unique position to identify and provide intervention in such cases. Unfortunately, providers under diagnose victims of domestic violence. Thus, some states have mandated reporting of domestic violence. This article presents the advantages and disadvantages of mandatory reporting and suggests alternatives that improve the response to domestic violence in the healthcare setting.
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