Childhood Injury Prevention：儿童伤害预防

InjuryPreventionDavidLawrenceCenterforInjuryPreventionPolicyandPracticeApril22,2003CHE560ThePublicHealthApproachToday’spresentation…MagnitudeoftheproblemInjurydefinitionInjurypreventionmodelsEnvironmentalandtechnologicalapproachesPolicyandRegulatoryApproachesSuccessfulinjurypreventionstrategiesChallengesResourcesforfurtherinformationTMDeathRatesfrom

InjuriesandOtherCauses,UnitedStates,1910-2000Injury Leadingcauseofdeathofchildren,adolescents,andyoungadultsintheU.S.Foreveryinjurydeath,thereare45hospitalizationsand1,300ERvisits.Mostseriousinjuriescanbeprevented.InjuryPyramid145,655Deaths2,701,000Hospitalizations33,950,000EmergencyDepartmentVisits65,555,000VisitstoOffice-basedPhysicians59,550,000InjuriesRequiringMedicalAttentionorTimeOffWorkSource:NationalCenterforHealthStatistics(1999)GlobalperspectiveEachyear>5millionpeopledieofinjuries.2/3aremales.Majorityyoungadults15-44.MVcrashesarethelargestcauseofinjurydeath.Source:GlobalBurdenofDisease,WHO,WorldBank,HarvardUniversity,1996-2001.ChildhoodInjuryinCaliforniaEveryyearinCalifornia:About2,200childrensufferfatalinjuries.About38,000childrensufferinjuriesthatrequirehospitalization.Around7,100oftheseareduetoassault/self-infliction.Averagemedicalchargesoffatalinjuriesto<15yearoldswas$8million.Medicalchargesofnonfatalinjuriesto<15yearoldswas$436million.

Source:EPICBranchInjuryDefinitionAnyunintentionalorintentionaldamagetothebodyresultingfromacuteexposuretothermal,mechanical,electrical,orchemicalenergyorfromtheabsenceofessentialssuchasheatoroxygen.Weusuallydefineinjuriesasoccurringduringashortperiodoftime,asopposedtotheeffectsofrepeatedexposurestochemicalagentsorcumulativedamagefromrepetitivemotions.“Accident”VaguetermBetter:Fall,Carcrash,PoisoningSuggestslackofunderstandingofcausesSuggestsrandomchance,luck,orfateSuggestsunpredictabilityInjuryasaPublicHealthProblemFormostofthe20thCentury,injurypreventionfocusedonassumedshortcomingsofthevictims.Trafficsafetymovementof1920sEducation,pamphlets,postersHomesafetymovementof1950sEducation,pamphlets,postersInjuryasaPublicHealthProblem“Onceasenseofpersonalresponsibilityforaccidentcausationcanbecreatedinthemindsofpeople,greatprogresswillhavebeenmade.Thenthesequeltoanaccidentwillnolongerbeanorgyofself-pityforhavingbeenthevictimofanuncontrollableevent.Insteadtherecanbeacharacter-buildingperiodofself-evaluationduringwhichactsofpersonalstupidity,carelessness,andindifferencemaybeidentified.”

-ChapmanAL.In:AccidentPrevention.HalseyMN,ed.NewYork:McGraw-HillforAmericanPublicHealthAssociation;1961.ModernviewofinjuryPersonalresponsibilitynoteliminatedbut:GreaterweightisnowassignedtootherissuessuchasenvironmentalfactorsHughDeHavenfallstudies:Nottheforce,perse,thatproducedtheinjurybutthestructuralenvironmentthatcontrolledthedecelerationoftheforceandthedistributionoftheforceoverthebody.DeHavenFallStudiesIfthefallcouldnotbeprevented,then“Structuralprevisionstoreduceimpactanddistributepressurescanenhancesurvivalandmodifyinjury...inaircraftandautomobilecrashes.”-DeHavenH.Mechanicalanalysisofsurvivalinfallsfromheightsoffiftytoonehundredfiftyfeet.WarMed1942:586-596.EnvironmentalModel“Manrespondstothefluxofenergieswhichsurroundhim–gravitational,mechanical,radiant,thermal,andchemical...Injuriescanonlybeproducedbyanenergyexchangebetweenmanandhisenvironment.”JamesJ.Gibson,1961.InjuryPreventionThefundamentaltaskis:Preventtheagent(energy)fromreachingpeopleinamountsorratesthatexceedthecapacityoftheirbodytotolerateitEpidemiologicalModelEnvironmentHostAgentEpidemiologicalModelEnvironmentHumanEnergyVehicleInjuryTriadPhysicalSocialEpidemiologicalModelEnvironmentHumanEnergySpeedVehicleDesignStateofRepairInjuryTriad–MotorVehicleCrashesPhysicalRoadConditionsWeatherSocialAcceptanceof

speedlimitsRejectionofDUI

ExperienceAgeWilliamHaddon,Jr.ExpandedonGibsontoaddresspreventiveapproaches.Demonstratedthatthehost,agent,andenvironmentalfactorsinteractovertimetocauseinjury.HaddonPhase-FactorMatrixPhaseHost

(Human)Vector

(Vehicle)PhysicalEnvironmentCulturalEnvironmentPre-

EventEventPost-

EventUsefulforplanning,strategyidentification,resourceallocationHaddonPhase-FactorMatrixPhaseHost

(Human)Vector

(Vehicle)PhysicalEnvironmentCulturalEnvironmentPre-

EventAlcoholExperienceJudgmentBrakestatusTiresNight,RainAcceptanceofdrinkinganddrivingEventNoseatbeltNoairbagHardnessofsurfacesTreetooclosetoroad,noguardrailSpeedlimitsEnforcementofseatbeltlawsPost-

EventPhysicalconditionFuelsystemintegrityCellphoneDistanceofemergencyresponseSupportfortraumasystemsTraininglevelofEMSpersonnelUsefulforplanning,strategyidentification,resourceallocationMotorvehiclecrash

Haddon’s10CountermeasuresPreventcreationofthehazardStopproducinghazardoussubstanceslikehighlytoxicpesticidesorfireworksReducetheamountofthehazardPackagetoxicdrugsinsmaller,safeamountsReducespeedlimitsPreventinappropriatereleaseofanyexistinghazardMakebathtubslessslipperyHaddon’s10CountermeasuresModifytherateorspatialdistributionofthehazardRequireautomobileseatbeltsandairbagsRequiresoftplaygroundsurfaces Morethan170,000childrensustainplaygroundequipmentrelatedinjurieseachyear;90%oftheseriousinjuriesarefromfallstothegroundsurfacebeneaththeequipment.Source:AmericanAcademyofPediatricsPlaygroundinjuriesModifytherateorspatialdistributionofthehazardHaddon’s10CountermeasuresSeparatereleaseofthehazardintime

orspaceInstallpedestriansidewalks

Haddon’s10CountermeasuresReroutehighspeedtrafficaroundresidentialneighborhoodsorslowitwithspeedbumpsandroundaboutsSpraypesticidesatatimeofdaywhenpeoplearen’taroundSeparatereleaseofthehazardintimeorspaceHaddon’s10CountermeasuresInstallRedLightCamerasSeparatereleaseofthehazardintimeorspaceHaddon’s10CountermeasuresInstallRedLightCamerasSeparatereleaseofthehazardintimeorspace

Haddon’s10CountermeasuresPutabarrierbetweenthehazardandpeopleatriskInstallfencesaroundpoolsInstallcoverguardsondangerousmachineryInstallproperguardrailsalongroadsUsechild-proofpackagingStorehandgunsinalockedmetalbox

UseextensioncordswithgoodinsulationProtectiveclosuresPoolisolationfencesSafetyguardsontools

andmachinesPutaBarrierBetweenthe

HazardandthePotential

Victim:PlaceABarrierBetweentheHazardandthe

PotentialVictim:Child-ResistantCapsonBabyAspirinRate*ofAspirinDeath,Children>5,UnitedStates,1955-1990*Permillionchildren

Sources:Clark&Walton,Pediatrics,1979;RogersGB,ArchPedAdolMed,2002;NCHSVitalRecordsPublicityAnnouncementMajorMfgFederalLawPlaceABarrierBetweentheHazardandthe

PotentialVictim:WindowGuards

WindowFallDeathsinChildren,

NewYorkCity,1972-1975Code

Established

Haddon’s10CountermeasuresChangethebasicnatureofthehazardMakecribslatspacingtoonarrowtostrangleachildModifyequipmentbyroundingsharpcorners

Haddon’s10CountermeasuresIncreaseresistanceofpeopletothehazardImprovephysicalconditionthroughpropernutritionandregularexerciseBegintocounterdamagealreadydonebythehazardProvideemergencymedicalcareStabilize,providedefinitivecare,rehabilitateAvailabilityofappropriateacutecareandrehabilitationfacilitiesGeneralModelforInjuryControlMonitorIncidenceIdentifyRiskFactorsInterveneEvaluateIdentifyMorbidityMortalityCostsSocialGeneticEnvironmentalInjuryPrevention:

TheRoleofPolicyandLawIndealingwithanypublichealthproblem,governmentscanfundprogramsorenactlaws.Legislationcanprovideagencieswiththepowertoestablishadministrativerules.ProvenInjuryPreventionInterventionsCarsafetyseatsandbeltsAirbagsMotorcyclehelmetsBicyclehelmetsChildresistantpackagingSwimmingpoolfencingSmokedetectorsSelfextinguishingcigarettesSUCCESS

-

MotorVehicleInjuriesSince1920’sSixfoldincreaseinnumberofdrivers11timesthenumberofmotorvehicles10timesthenumberofmilestraveled90%decreaseintheannualdeathrate

per100millionvehiclemilestraveledSource:NHTSASUCCESS-PoisonPreventionPackagingAct45%decreaseinpoisoningdeathsWhy?Child-proofcontainersPackaginginnon-lethaldosesSUCCESS-

MotorVehicleInjuries27%decreaseinMVoccupantdeathsamong16-20yearoldsWhy?IncreaseinthelegaldrinkingageGraduatedlicensingSuccess:ResidentialFireInjuriesSmokeAlarmDistributionProgramsSaveLivesOklahomaCityLifesaversProjectOutcomeEvaluationPer100,000Population

OklahomaCity,May1990-April1994*InjuryRateper100,000

Population80%Decrease 8%Increase*NEJM335:27-31,1996OccupantFatalityRates,Infants,UnitedStates1960-2000“Correctlyinstalledandusedchildsafetyseatsreducetheriskofdeathby71%,hospitalizationsby67%,andminorinjuriesby50%.”Source:AmericanAcademyofPediatricsReducetheAmountofEnergyTransferredChangestovehiclesChangestoroaddesignChangestosigns,lightposts,andbarriersReducetheAmountofEnergyTransferred“Bicyclehelmetsreducetheriskofheadinjuryby85%andriskofbraininjurybyalmost90%,yetonly5%ofchildbicyclistsintheU.S.A.wearhelmets.”Source:AmericanAcademyofPediatricsBicycleHelmetsChallengesNeedtomaintainwhatworksPoisonControlCentersTraumaSystemsNeedtoimplementwhatworksBicyclehelmetsSmokedetectorsInjuryPreventionPolicyTheidealpolicyis:aprudentcourseofactionselectedfromamongthealternativestoguidepresentandfuturedecisionsandbehavior.Itisanideaorplanofwhattodoinaparticularsituationthathasbeenagreedtobyagroupofpeople,abusiness,oragovernment.Thus,althoughlawsarepolicies,notallpoliciesarelaws.

Surveillance + Hypothesistestingstudies + Clinicalexperience BasisforpolicyPublicHealth:IlluminatethepatternsPutincontextwithotherhealthissuesIdentifygroupsatriskinthepopulationPublicHealthPolicyFormationInjuryPreventionPolicy

CellularTelephonesinMotorVehiclesBusinessesshallestablishrulesthatprohibittheuseofcellulartelephoneswhiledrivingavehicle.Communitiesshallenactlocalordinancesthatrestricttheuseofcellulartelephoneswhiledrivingavehicle.Professional,civic,social,andfaithorganizationsshallrecommendtomembersthattheyrefrainfromusingcellulartelephoneswhiledrivingavehicle.InjuryPreventionPolicy

ChildDeathReviewTeamsEverystateandcountyshallhaveamultidisciplinaryteamthatreviewsthecausesandcircumstancesofeachchild'sdeathtofindhazardsthatmayplaceotherchildrenatriskfromneglect,abuse,violence,andunintentionalinjuries.Thisinformationshouldbeusedtoprioritizeandfocuscommunitypreventionactivitiesandnotexclusivelytoestablishblame.InjuryPreventionPolicy

ChildrenLeftAloneInMotorVehicles

Statesandcommunitiesshallenactandenforcelawsorordinancestoprohibitchildrenfrombeingleftunattendedinmotorvehicles.InjuryPreventionPolicy

EnforcementofPassengerrestraintLaws

Localpoliceshallenforcelawsthatrequiremotorvehicleoccupantstobeappropriatelyrestrainedwithseatbeltsorsafetyseats.InjuryPreventionPolicy

IsolationFencesAroundResidentialSwimmingPoolsStatesandcommunitiesshallenactandenforcebuildingcodesthatrequirefour-sidedisolationfencingaroundresidentialswimmingpools.Thefencingshallbeofappropriateheightandwithself-closing,self-latchinggates.NatureofInjuryPreventionLawsFederalAuthorityStateandLocalAuthorityStatutorylawscaneitherREQUIREorPROHIBITTheycanbedirectedat:IndividualbehaviorProductsEnvironmentalconditionsorplacesExamplesofStateandLocalLawsRegulatethecolorandspeedcapacityofschoolbusesMandatebuildingstobeconstructedtomeetcodesandstandards.RequirechildabusereportingRestrictsaleorgivingofalcoholtochildrenExamplesofStateandLocalLawsProhibitRequireHumanFactors(people)DragracingSeatbeltuseVehicle/Agent(things)Speedometersregisteringover

80m.p.h.SpecifiedmaximumwindowtintEnvironment(places)RigidbarrierswithinspecifieddistanceofroadwayBreak-awaysignposts,softbridgerailendpointsRegulationversusIndividualFreedomYouandIcan’ttellifabridgeorbuildingisatriskforfallingdown,but…EngineersandarchitectscanforeseesuchthingsStandardscanbeestablishedandrequiredinconstructionInspectorscanprovideassurancethatstandardsaremetRegulationversusIndividualFreedomWhatofindividualfre