For The Safety of Canadian Children And Youth

Introduction

by Ginette Beaulne, Direction de la santé publique de Montréal-Centre, Québec

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Even fairy tales illustrate stories in which the injured person doesn't magically recover! Thousands of people learned of Humpty Dumpty's tragic end when they were taught the rhyme as children. The stories of the thousands of children and youth who die following an injury, however, remain anonymous more often than not. When consulting For the Safety of Canadian Children and Youth, readers should bear in mind that behind the statistics are names and faces: all of the young Canadians who will never celebrate their twentieth birthday, all of the victims who saw the course of their lives radically changed, the boys and the girls who hoped to be treated as quickly as possible while they waited in the emergency room, and the family members who witnessed their pain.

Injuries among children and youth under the age of 20 must be considered a major health problem. They are the leading cause of death in this age group, and approximately one hospitalization in six for a pathological reason results from an injury. For example, during 1992, 1,452 out of a total of 4,838 deaths among Canadians under the age of 20 resulted from injuries, whereas 310 were due to cancer and 113 were due to infectious diseases (among which 12 were due to AIDS).¹

This work will show that some children and youth are more at risk for injury than others, especially those who come from disadvantaged socioeconomic settings and those belonging to Aboriginal populations. Some professionals working in injury prevention will be tempted to see only behavioural factors. However, various studies show that the environments in which these children and youth live are also characterized by shortfalls in terms of healthy living conditions (2,3).

This book was written mainly for professionals working in injury prevention, especially those working in public health, and other individuals who are interested in this field. It is intended as an additional tool for their work. We feel that the more information such people have at hand, the better prepared they will be to prevent injuries from occurring or to reduce their severity. This book may also be used for education purposes and as a resource for public information by the media or others.

In the following sections, the structure of the book and its limits will be presented. The key concepts of injury control will then be summarized, followed by a discussion of the opportunities for action in injury prevention and the obstacles to consider.

PRESENTATION OF THE BOOK

The writing of this book began in response to a call for proposals from Health Canada's Laboratory Centre for Disease Control (LCDC). It required two and a half years of work. The book focusses on injuries among children and youth under the age of 20, covering childhood, adolescence and young adulthood. The risk factors and protection needs of those under the age of 20 can differ greatly from those of adults. The goals of the book were to present a profile of injuries in children and youth based on data from Statistics Canada and from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), and to suggest opportunities for preventive action.

The originality of this work lies in the fact that it goes beyond analyzing death and hospitalization data and highlights the circumstances surrounding less severe injuries by using CHIRPP data. This book provides interesting information on, for example, a variety of initiatives or legislative measures in the area of injury prevention. It is part of a nationwide series of events and publications that seek to raise awareness of the problem of injuries-especially those that affect children and youth-as a priority health problem, and that support efforts to better control injuries (4-8). These activities have as background the multitude of initiatives undertaken by individuals and organizations in every province and territory.

The texts are the fruit of a remarkable collaboration between numerous Canadian professionals working in injury prevention. Given our appreciation of interdisciplinary and intersectorial alliances, this work could not have been written any other way. The contribution of individuals-whether authors, readers or members of the editorial board-from a wide variety of disciplines and organizations resulted in a quality publication that reflects Canada's vast expertise in injury control.

Sections of Each Chapter

The first two chapters present an overall analysis of injuries based on Statistics Canada death and hospitalization data and CHIRPP data. The other chapters are organized by subject; each is devoted to a single category of injuries. These categories were chosen based on the external causes of injuries (e.g., fall-related injuries) as defined in the 9th edition of the International Classification of Diseases (ICD). This classification is similar to the one used by Baker and collaborators in The Injury Fact Book (9). Farm-related and work-related injuries are each the subject of a chapter, although they are ill-defined by the ICD.

In addition, three general profiles present an overview of injuries related to motor vehicles and other road vehicles (based on death and hospitalization data), those related to sports and recreation activities (based on the same data) and injuries that occur in the residential environment (based on CHIRPP data).

Each thematic chapter contains three major categories of information. First, the chapter establishes a profile of deaths and hospitalizations based on Statistics Canada data. In nearly every chapter this section has been written by the same two authors in order to keep the analysis as uniform as possible. In some chapters, the profile of deaths or hospitalizations may be based on more specific information provided by databases covering a single category of injuries (e.g., work-related injuries).

Second, each chapter gives an overview of the circumstances surrounding the injuries. In this regard, the book intentionally focusses on information particular to the Canadian context. There is no exhaustive review of the literature on the various risk factors. The analysis of the circumstances is essentially based on emergency room consultation data drawn from CHIRPP, since one of the goals of this work is to highlight the information gathered by this program. However, the circumstances surrounding more severe injuries leading to hospitalization or death can differ substantially from those leading to a visit to the emergency room. As such, the authors have included succinct information on the circumstances surrounding more serious injuries when these are linked to a proposed opportunity for action. Occasionally, data sources other than CHIRPP are used to supplement the information on the circumstances surrounding certain categories of injuries that are less well defined by this database. An example of this is injuries resulting from assault or neglect.

Third, the authors have identified some opportunities for action. These include research priorities and preventive measures chosen according to the Canadian context. Each opportunity for action is preceded by a few sentences that support the author's choices. The opportunities for action are not listed in order of priority.

At several points in the book, the authors bring up the need to assess measures put in place in order to determine their effectiveness in preventing injuries or reducing their severity. The evaluation concerns not only educational measures but also legislative ones. It is important to ensure that laws and regulations have the intended effect and have not, once enacted, been poorly enforced or stripped of the elements that are essential to their effectiveness.

Although the texts have been enriched by reader comments, the final choice of opportunities for action was left to the individual authors. At the request of the editorial board, the authors have tried to determine the main organizations or categories of individuals responsible for introducing each of the chosen opportunities for action. These lists are far from exhaustive and do not necessarily include all of the desired collaborators. These selections were made in light of the authors' and editorial board members' knowledge of the different organizations in existence as well as their understanding of responsibilities under provincial, territorial or federal jurisdiction.

Finally, an appendix lets readers know how to contact all of the project's participants. We felt it important to add this information in an effort to contribute to better networking, despite the fact that this information will quickly become outdated.

Limitations

This book is rich in information, but no work of this kind can satisfy every eager mind. The structure and the content of this book therefore have certain limitations that bear mentioning.

The main period of data analysis is 1990-1992 for deaths and hospitalizations, and 1993 for emergency room visits. The death and hospitalization data provided by Statistics Canada are classified according to the ICD, which is not the case for CHIRPP data. To make data analysis as compatible as possible, an effort was made to organize CHIRPP data into categories similar to those of the ICD. There is not always a perfect correspondence; in some chapters, the categories of injuries in the section on the circumstances according to CHIRPP are slightly different from those included in the death and hospitalization data.

At the time of publication, the statistics will already be outdated, though they were the most recent data available at the beginning of the project. This is not unusual for a work of this scope. Despite these limitations, the book should still prove useful and current. Also note that in the case of two provinces and the territories, hospitalization data could not be analyzed. Information on the external causes of hospitalizations due to injuries in Prince Edward Island and New Brunswick was not available for the period studied, and the hospitals in the territories do not provide their hospitalization data to Statistics Canada.

As the number of pages is limited and the field of injuries is vast, not every information need could be met. Certain topics are discussed either briefly or not at all, such as the particular needs of children with handicaps, the reasons behind the historical trends of death and hospitalization data for each category of injuries, or their variation from one province to another. It is also important to emphasize that certain information that is available at the municipal and provincial levels may not be available at the national level. To illustrate their statements, the authors have sometimes used data that are only available from some provinces or territories. In a broad work of this kind it is impossible to present a comprehensive profile of the situation province by province, although this information would be useful because many key preventive measures identified come under provincial or territorial jurisdiction.

Finally, budgetary constraints have led us to favour the use of detailed tables rather than graphs. The latter are simpler but less complete and would have required that a statistical appendix be published. At the end of this text, the members of the editorial committee have provided readers with a list of works that supplement the information in this volume (Appendix 1).

CONCEPTS IN INJURY CONTROL

Injury Prevention and Control

In this book, the expressions "injury prevention" and "injury control" are generally interchangeable. However, some authors distinguish between the two concepts, perceiving injury control as being more inclusive. Injury control includes not only actions aimed at preventing injuries from occurring or reducing their severity, but also all measures involving post-trauma care and victim rehabilitation (10).

The Haddon Conceptual Model

The work of numerous predecessors enabled engineer and physician William Haddon to develop an approach to injury control based on epidemiological principles in the 1960s (11). This approach highlights the fact that injuries are not random, but rather are the result of the complex interaction of human, technological and environmental risk factors.

The Haddon approach led to the creation of a conceptual framework for injury control, called the Haddon Matrix. This matrix, with its many dimensions, makes it possible to determine the different etiological factors and to itemize the various strategies or measures that can be utilized to control injuries related to a given problem (12,13). Table 1 presents an example of this matrix applied to playground equipment-related injuries.

The Haddon Matrix consists of two axes. The first axis comprises three types of risk or protection factors. First are the human factors (e.g., in the case of playground equipment, the child's behaviour on the equipment). Next are the factors related to the physical and technological environment (e.g., the way the equipment is designed). Finally, there are the factors related to the social, economic and legislative environment (e.g., the existence of a safety standard for playground equipment). The second axis is the temporal axis (pre-event, event, post-event) for injury occurrence. In the case of playground equipment-related injuries, the pre-event protective measures could include manufacturers' obligation to comply with the Canadian Standards Association (CSA) standard. In a case where a child or youth falls from a piece of playground equipment, setting the equipment up on a surface that absorbs the impact of a fall would be a protective measure (or a measure aimed at reducing the severity of injury) at the time of the event. Finally, rapid post-event access to a health care facility would be a measure aimed at reducing the severity of injury.

This grid highlights the fact that injuries are caused by many factors. Consequently, whenever possible, it is preferable to opt for mixed strategies-environmental, technological and behavioral modifications-to prevent injury or reduce its severity (14). As such, although injuries are a public health problem, controlling them cannot be the sole responsibility of the health sector.

The concept of safety promotion, which aims to develop overall strategies that favour safety, tends to be linked to that of injury prevention. Safety promotion aims to avoid breaking down the issue of injury into a series of problems to solve (15). In addition, the similarity or interrelation between determinants in different categories of injuries makes safety promotion a fundamental value in a society, just as health promotion is.

Along that line of reasoning, it is interesting to note that the ideology of the Haddon conceptual model is linked to the health promotion strategies advanced in the Ottawa Charter for Health Promotion (16). The strategies of the Ottawa Charter for Health Promotion which aim to build healthy public policies and to create environments that support health are similar to the strategies regarding technology and environment described in the Haddon conceptual framework. Strategies that aim for people to develop personal skills are in keeping with those concerning human behaviour in the Haddon Matrix (14).

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Table 1
Haddon Matrix, Examples of Control Measures for Injuries Related to Playground Equipment in Public Parks

Phases Human Physical and technological environment Social, economic and legislative environment Pre-event1 * Presence of monitors in parks * Child surveillance by parents and teachers * Correct use of the equipment by children * Wearing clothing that cannot catch on equipment (e.g., no clothing with a drawstring neck) * Purchase of playground equipment that complies with the Canadian standard * Playground layout that complies with the Canadian standard * Proper maintenance of playground and equipment * Creation of a safety standard for playgrounds and equipment * Manufacturers' obligation to comply with the Canadian Standards Association standard * Manufacturers' obligation to stop producing clothes with drawstring necks and hoods Event1 * Wearing protective clothing (e.g., pants instead of shorts) * Installation of equipment on surfaces that offer adequate protection * Maintenance of playground and equipment * Equipment (e.g., see-saw seats) made of absorbent material Post-event1 * First aid courses given to parents and caregivers * Installation of emergency telephones in parks * Rapid access to care or trauma centres

1. Before, during or after the injury occurs.

Source: D. Lesage, Direction de la santé publique de Montréal-Centre, Québec, 1996.

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Passive and Active Measures

One of the measures most commonly used with parents is without a doubt the one that tends to impress upon them the need to "watch their children and keep them out of danger." There is no doubt that parental supervision helps prevent many injuries. However, injury prevention cannot be based on that measure alone (17). The ability to monitor every move a child or youth makes and to make sure that he or she is not exposed to any danger requires superhuman abilities. In 1983, Leon Robertson summed up this idea well: "The assumption that human beings are [...] in complete control of their actions is embedded in our mores and laws. [...] Where split-second decisions mean the difference between life and death [...] as is frequently the case in handling highly concentrated energy, reliance on [this] myth [...] is, paradoxically, an irrational act" (18).

The parents or caretakers of a child or youth cannot be the only people held responsible for events that occur in an environment that is often poorly designed for children and youth. Here, the meaning of environment includes its components-physical, technological, social, economic and legislative. Based on their expertise or their role in society, other adults-architects, urban planners, manufacturers, police officers, firefighters, legislators-must share responsibility for making the environment more favourable to the safety of children and youth.

"Active" measures require the participation of individuals any time protection is necessary. These measures affect behavioural determinants, for example, asking parents not to smoke in bed or asking children not to get too close to a pool. Active measures require health education approaches aimed at making individuals adopt or maintain "safe" behaviours. In public health, various health education approaches have been used (19,20).

Conversely, "passive" or automatic measures do not require the individual (be it the adult responsible for a child or youth, or the child or youth) to act to be protected. This is a type of protection that takes place at all times (13,21,22). It affects the environment-related determinants as previously defined. Examples of this include proper fencing-in of a pool or installation of a thermostat valve on a hot water tap to keep the water temperature from exceeding 49°C. Passive measures generally require that public policies be introduced, often in the form of regulations or legislation. Many authors have underlined the importance of public policies where the health of individuals is concerned (2,23-25). Along a continuum between the two poles of active and passive measures are the measures that require, for example, individuals' participation to install a security device that, once in place, will protect the person (e.g., wearing a flotation device while in a boat).

In identifying opportunities for action, this book does not differ from the position of others that favour passive measures that automatically ensure the safety of children and youth through technological or environmental means (9,12,17,18,26,27). Next in order of priority, depending on the case, are the legislative or regulatory measures that aim to ensure adoption of safe behaviours, on the part of the youth or child or the person responsible for him or her (e.g., requiring firearms owners to store their weapons safely). Last in order of priority are the health education strategies introduced to modify behaviours but whose outcomes have been less effective than planned. Various reasons have been cited to explain this apparent failure, such as unrealistic behaviour modification objectives and insufficient length and intensity of programs. In addition, sometimes health education interventions have not been used in combination with other strategies or have not been sufficiently adapted to the specific contexts of the populations in which they were implemented (28-30). More effective behaviour modification strategies must be developed-in part because entirely passive means cannot be used to prevent some categories of injuries easily, and also because numerous constraints are involved in imposing a health-promoting behaviour via legislation or regulation (31) (e.g., ethics, enforcement difficulties, cultural, political or social resistance).

Distinguishing between Accident and Injury

Haddon's work also made it possible to better differentiate between the event, often called the "accident" (e.g., fall, fire), and the resulting injury (e.g., skull fracture, asphyxiation, burn). As is the case with illnesses, injuries can be studied, their occurrence among the population can be predicted and they can be prevented. Certain measures aim at preventing the event from occurring (e.g., the use of childproof containers) whereas others aim to prevent injuries or reduce their severity (e.g., limiting the number of pills in a container to a sublethal level). Many public health professionals prefer to avoid using the word "accident" entirely, since its definition as a "random and unpredictable event, an act of fate" could undermine injury prevention efforts (22). However, in some regions of the world, professionals working in injury prevention use the word "accident" more freely than in North America while adhering to the injury prevention approach.

In this work, the use of the word "injury" was encouraged. However, we have not undertaken a semantic or ideological debate on the use of "accident." As such, it appears a few times, generally in cases where the information comes from a database that uses this word (e.g., a direct quote from a data source such as the ICD).

Definition of Injury

An injury is defined as a lesion to the body resulting from an energy transfer whose intensity or nature cannot be tolerated by the human body. This energy can be mechanical (e.g., the impact of a fall), thermal (e.g., a burn), chemical, electrical or radiation-related. The sudden absence of an essential energy source or element that is vital to humans can also result in an injury (9,13,22). For example, a lack of oxygen in the case of strangling or drowning, and hypothermia in the case of drowning or freezing.

Intent

The intent to injure oneself or another is a concept with a broad meaning as used by practitioners and researchers working in injury prevention. Intentional injuries are considered to be those that result from an act of violence against oneself or others, as defined in the ICD. Although this is the classification used in this work, it is important to clarify some aspects relative to this concept. In a legal context, acts of violence are classified under the penal code depending on the intent and the severity of the acts, and can be considered unintentional (e.g., manslaughter). It is also difficult to determine the intent of certain injuries (e.g., certain cases of suicide attempt, or neglect of children).

THE ABILITY TO ACT IN INJURY PREVENTION: AN OPPORTUNITY TO SEIZE

As will be seen in Chapter 1, Methodological Considerations and Overall Profile of Mortality, Hospitalizations and Emergency Room Visits, mortality rates for Canadians aged under 20 have decreased by more than 50% during the last 40 years. The introduction of various injury control measures has contributed to this positive result. These include an improvement in the design of certain products such as cribs, an increase in the use of products designed to improve safety, such as car restraint devices, smoke alarms or childproof containers for certain drugs, and an improvement in post-trauma care (17).

However, it is estimated that substantial gains can still be made in injury prevention (32). It is felt that the measures identified in this book can contribute to reducing the number and severity of injuries. In the majority of injury categories, the different determinants involved as well as the potentially effective preventive measures or strategies are already known. Thus, the improvement of knowledge should be oriented toward the field of applied research. We must seize the opportunity to act so that we may continue to decrease the toll of injuries in the coming decades.

SOME OBSTACLES TO CONSIDER

Certain obstacles may hinder the implementation of preventive measures, even when they are considered effective. Recognizing these hurdles will ensure better success in implementing preventive measures. Among them is the fact that the implementation of preventive measures can sometimes be thwarted by a misunderstanding of the problem, or by professional concerns and institutional mandates in which health is just one parameter among many. In other cases, the obstacles can be economic; for example, in a low-income family, purchasing a certain safety device may be considered too costly. For an organization, the implementation of a measure can also be deemed too costly, particularly if the organization is not obligated to assume the cost of injuries.

The socio-political context can also constitute a significant barrier. A period of budget cuts and deregulation may not favour the introduction of new legislation. Many injury prevention workers express the need to link opportunistic planning and strategic planning. This means that at some times it is better to intervene in a strategic way when a social opportunity, such as an event that causes many injuries and receives heavy media coverage, or a political opportunity, such as amendments to a law or regulation, occurs (33).

Finally, time constitutes an obstacle that cannot be overlooked, yet it is often skipped over because of unrealistic professional or organizational requirements. A lot of time is usually needed to establish solid intersectorial alliances, for a substantial amendment to be adopted or for a particular behavioral modification to become entrenched within a given population group.

CONCLUSION

What is really needed in injury prevention is well-informed, highly skilled ambassadors who can intercede within the sectors of society that have the power to implement a number of the measures proposed in this book. The job of ambassador is not easy; it requires drive and perseverance, especially when the individuals on behalf of whom we intercede are too young to vote!

This work takes another step toward a better understanding of the problem of injuries among Canadian children and youth. We have endeavored to bridge the gap between statistical data and the priority given to the appropriate measures needed to improve the safety of those under the age of 20. This book highlights the fact that the particular safety needs of children and youth, especially those under the age of 12, must be considered, as these needs depend on a different morphology and cognitive development from those found in adults. It is a common sentiment that our society is designed by and for an adult world. Consider the following examples: the modern design of some new homes, where the spaces are so open that the installation of a simple safety barrier becomes a real headache; playground equipment in public places, which is generally installed on dirt or grass-surfaces that are inexpensive but that cannot offer children adequate protection in the case of a fall; and preventive measures that are designed for adults, such as airbags in cars, which can be detrimental to very young children.

As long as the design of our technology and of our physical and socio-legislative environments does not account for their specific safety needs, children and youth will incur injuries that could otherwise have been avoided. Practitioners and researchers working in injury prevention, especially those in public health, have an important role to play in the adoption of safe public policies. As John Last wrote in the introduction to Maxcy-Rosnau Public Health and Preventive Medicine in 1980, "Public health workers must be prepared to take part in the political dialogue. Often, this requires all sorts of community action, as well as [parliamentary] debates, committees, and enacting of legislation, sometimes based on landmark decisions in courts of law" (28).

BIBLIOGRAPHY

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32. RIVARA, F.P. and D.C. GROSSMAN. 1996. "Prevention of traumatic deaths to children in the United States: How far have we come and where do we need to go?" Pediatrics, 97, 791-797.
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APPENDIX I
GENERAL REFERENCES FOR BUILDING A CHILDREN AND YOUTH INJURY PREVENTION LIBRARY: THE EDITORIAL BOARD'S TOP CHOICES

Books, reports

Periodicals

Articles and others

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1. At the time of publication, similar trends were observed in the most recent data available (1995). As such, 1,405 deaths resulted from injuries, versus 236 from cancer and 82 from infectious diseases (among which 15 were from AIDS), out of a total of 4,615 deaths from all causes (Statistics Canada, Health Statistics Division, unpublished data from 1992 and 1995).