Childhood Injuries and Violence: Improving Care and Global Efforts
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Injuries and violence are a significant cause of child death and physical and psychological disability. It would be tragic to achieve significant gains in child survival only to lose those gains to injuries. Every year injuries and violence kill approximately 950,000 children (aged less than 18 years) and injure or disable tens of millions more as discussed in the recent World report on child injury prevention (1). Several recent surveys have highlighted the significant risk of disability experienced by injured children. While the distinction is inadequately captured in most databases, disability results from the interaction between the injured child and their environment, and encompasses impairments in body functions and structures as well as limitations in activities and participation. The major impact on the lives of injured children is typically compounded by the adverse psychological and financial consequences for their families. Injury control must be better addressed in health policy and integrated into other major agendas. There are many proven interventions that need to be put into action. To do so, injury prevention must be integrated into child health and survival initiatives and also into the broader development agenda. There is a need to increase the knowledge base on the extent and outcome of injury, as well as risk factors that should be targeted with prevention efforts. At this stage, what is needed more than anything else in injury control are model country programs. One of the most compelling arguments to bring the attention of policy-makers is the documentation of successful programs in similar countries.
The purpose of this document is to increase attention in the field of injury control, the violence prevention and to stimulate research on what works to prevent and treat injuries, especially in low- and middle-income countries, as well as increased advocacy / partnership to confront child injury. Women's Health and Education Center (WHEC) hopes its efforts encourage countries and governments to implement injury control policies and programs that will actually lower the currently unacceptable toll of child injury. While much remains to be learned about the effectiveness of rehabilitation approaches, they signal the potential to actualize the full and meaningful participation of young people who experience disability following an injury.
The burden of injury is especially pronounced in low- and middle-income countries, where 95% of all childhood injury deaths occur. It is important to point out that child sexual abuse is a global problem. A 2007 study carried out by the United Nations Children's Fund (UNICEF) in association with the Centers for Disease Control and Prevention (CDC) in the United States of America describes approximately 1 in 3 females experienced some form of sexual violence as a child, nearly 1 in 4 experienced physical violence, while 3 in 10 experienced emotional abuse, in low- and middle-income countries. Even in high-income countries, it is estimated that more than 1 in 5 females experience some form of sexual abuse as a child, and 1 in 5 children experience severe parental physical abuse (1). Unintended injuries are a leading cause of death among children and young adults. Over 875,000 children <18 years of age die annually in the world as a result of injuries, mostly in low- and middle-income countries, where injuries account for 13% of the total burden of morbidity among children <15 years of age. According to report from the UNICEF, childhood injuries declined by 50% in high-income countries between 1970 and 1995. Unfortunately, several reports from low-income countries have shown the opposite trend (2). The burden and pattern of child injuries are just now being studied in low- and middle-income countries, where the age distribution of the population compounds the problem by child injuries. In 2005, 23% of the world's population of children <5 years of age (i.e. 141 million children) lived in Africa, while only 10% lived in high-income countries. Child maltreatment prevention is poised to become a global health priority due to four main factors. First, retrospective and prospective studies have established that child maltreatment has strong, long-lasting effects on brain architecture, psychological functioning, mental health, health risk behaviors, social functioning, life expectancy and health-care costs. Second, full implications of these effects on human capital formation, the workforce, and ultimately, social and economic development in low-, middle- and high-income countries are now better understood. Third, epidemiological studies have clearly established that child maltreatment is not peculiar to the West but a truly global phenomenon that occurs in some low- and middle-income countries at higher rates than in wealthier countries. Fourth, evidence strongly suggests that treating and later trying to remedy the effects of child maltreatment are both less effective and more costly than preventing it in the first place.
A United Nations treaty prohibiting the use of children in hostilities has been ratified by 126 countries, but at least 250,000 child soldiers are currently involved in armed conflicts worldwide. They are recruited to act as fighters, porters, cooks, messengers, spies and sex slaves. They are often forced to bear arms and participate in killing. But the physical and psychological harm done to so-called 'child soldiers' is not limited to the combat zone. The collapse of civil society resulting from protracted conflicts and the unchecked abuses of marauding militias expose children to a range of health risks from cholera to malnutrition; from deliberate mutilation to perhaps a lesser known consequence of their deployment in conflict -- sexual abuse. These children have often lost their families and so have no network of support, and no way to make a living.
The Importance of Child Injury:
Injury is a significant cause of death and morbidity among children from the age of one, and increases to become the leading cause of death among children aged 10 to 19 years. Each year approximately 950,000 children aged less than 18 years die as a result of an injury or violence. Nearly 90% of these -- about 830,000 -- are due to unintentional injuries -- about the same number that die from measles, diphtheria, polio, whooping cough and tetanus combined. Most of these unintentional injuries are the result of road traffic crashes, drowning, burns, falls and poisoning, with the highest rates occurring in low-income and middle-income countries. In addition to these deaths, tens of millions more children sustain injuries that do not kill them but are serious enough to require hospital treatment and sometimes result in disability. The importance of child injury can be obscured by a focus on the major causes of mortality of children aged less than 5, which in most of the world's countries do not include injury. Even in regions where injury deaths are known to be underreported and child survival is determined mainly by perinatal causes, lower respiratory infections, diarrhea, malaria and measles, child injury has an impact on mortality rates of children aged less than 5 and comprises a substantial proportion of child deaths after the age of 5 years. In countries that have made substantial progress in eliminating or reducing childhood deaths from other causes, however, child injury clearly emerges as a major problem. For example in high-income countries, unintentional injuries account for nearly 40% of all child deaths, even though these countries generally have substantially lower child injury fatality rates than low- and middle-income countries (1),(3).
Facts about child injuries:
Data shows that child injuries take an unacceptable high toll on children's health and development and on society. Furthermore, if current global trends continue, the global burden of injuries is expected to rise in the next 20 years. If the groundwork to prevent child injuries is not laid now, the processes that currently drive change in our world are likely to exacerbate the problem. Some processes such as globalization and urbanization may bring benefits that can bolster prevention efforts -- for example: increased resources, improvements in access to and quality of health services, knowledge transfer of effective injury prevention measures, and fostering a culture of safety. Without a concerted effort to harness these benefits in the implementation of child injury prevention measures, however, the negative effects of the processes will prevail. The evidence base for child injury prevention is not fully developed, especially regarding evidence of effective practice in low- and middle-income countries, but enough is known about what works to begin taking action. Countries that have achieved the greatest gains in child injury prevention have implemented a combination of multisectoral strategies to reduce the risk of new injuries occurring, to reduce the severity of injuries that do occur, and to reduce the frequency and severity of injury-related disability.
Challenges in Child-Injury Prevention:
Child safety as a public health concern has gained momentum and a strong research foundation over the past decades, as demonstrated by the material reviewed for the World report on child injury prevention. To achieve large gains in child safety, however, child injury prevention knowledge and practice must be integrated into main-stream child and adolescent health initiatives. From a child safety perspective, such integration is needed to overcome obstacles to child injury prevention. Injury prevention must be included in child and adolescent health policy development and practice. Several steps may be taken to begin this integration. Most common challenges in child-injury prevention are (4):
Many of these challenges are not unique to the injury field. Child and adolescent practitioners have been struggling with similar challenges to address pneumonia, malaria, malnutrition, HIV / AIDS and the provision of quality pregnancy, childbirth and neonatal care. There are learned lessons about implementing successful multisectoral interventions, generating political will, addressing human-resource constraints, adapting effective interventions and improving data. These lessons must be shared and compared with similar lessons learned in the context of child injury prevent. Countries with a high burden of child injuries need to give special attention to addressing the issue and linking prevention efforts with other child / adolescent health initiatives. In countries with a high burden of violence against children and young people, violence prevention measures should be included as part of larger child injury prevention initiatives. Health-promoting initiatives in schools can incorporate injury prevention and safety promotion in policies designed to create a healthy school environment and also in the curricula of school health programs aimed at students. Similarly, child-injury prevention can be taken up by "healthy cities" programs in areas where the burden is large but not currently on the agenda.
Child Maltreatment Prevention:
Despite the epidemiological data on the policies and programs against child maltreatment, conspicuously lacking in most low- and middle-income countries, and in high-income countries, such as the United States of America (USA), are resources invested in child protection systems and it continues to outweigh prevention budgets (5). The following types of interventions are commonly used and are most widely implemented:
Early Childhood Home Visitation: Trained personnel visit parents and children in their homes and provide support, education and information to prevent child maltreatment. They also seek to improve child health and parental care giving abilities. Overall reviews suggest that early home visitation programs are effective in reducing risk factors for child maltreatment but whether they reduce direct measures is less clear-cut. Nurse Family Partnership in the USA has shown the home visiting program whose effectiveness has been unambiguously demonstrated. A randomized controlled trial showed a 48% reduction in actual child abuse at 15-year follow up (6). Supportive home visiting programs with visits carried out by trained, professional visitors (e.g. nurses) can provide family support, lead to improvements in the home environment and be used for parent education and training.
Parent Education Programs: This type of intervention, usually center-based and delivered in groups, aims to prevent child maltreatment by improving parents' child-rearing skills, increasing parental knowledge of child development, and encouraging positive child management strategies. Two of the meta-analysis reported small and medium effect sizes for parent education programs on the basis of both risk factors and direct measures of child maltreatment (7). Other reviews concluded, however, that while the evidence shows improvements in risk factors for child maltreatment, evidence of an effect on actual child maltreatment remains insufficient.
Child Sexual Abuse (CSA) Prevention Programs: Most of these programs are universal programs delivered in schools and teach children about body ownership, the difference between good and bad touch, and how to recognize abusive situations, say no, and disclose abuse to a trusted adult. On the one hand, school-based interventions to prevent child sexual abuse are effective at strengthening protective factors against this type of abuse (e.g. knowledge of sexual abuse and protective behaviors), and on the other, that evidence about whether such programs reduce actual abuse is lacking. Most studies that measured future sexual abuse as an outcome reported mixed results.
Abusive Head Trauma: Shaken baby syndrome and inflicted traumatic brain injuries are included in many studies in this category. Maternal anxiety and depression and severe punishment are modifiable risk factors; therefore, intervention efforts to support parents emotionally may help them adopt more adequate child-rearing practices. The most important study to date in this field is from the evaluation of a comprehensive hospital-based parent education program in New York State (8). The program founded has reduced the incidence of abusive trauma by 47%, but it remains unclear whether interventions to reduce abusive head trauma are effective.
Multi-Component Interventions: This typically includes services such as family support, pre-school education, parenting skills and child care. Reviews judged the evidence for their effectiveness in reducing risk factors for child maltreatment is mixed or insufficient or borderline promising. A meta-analysis found the effectiveness of multi-component interventions to be 0.58 (9).
Media-Based Interventions: Media campaigns to raise public awareness are often regarded as a critical part of any child treatment strategy. The review focused on the effectiveness of such campaigns found the evidence was either mixed or insufficient (9).
Social Support and Mutual Aid Groups: Reviews focused on social support and mutual aid groups aimed to strengthen parents' social network. The conclusions of this type of intervention are either mixed or insufficient.
There is evidence that four of the seven types of universal and selective interventions discussed above are promising for preventing actual child maltreatment: home visiting, parent education, abusive head trauma prevention and multi-component programs. The evidence on the three remaining types -- child sexual abuse prevention, media-based interventions and social support and mutual aid groups -- is either insufficient or mixed. It is important to emphasize that when a particular type of intervention is judged to be promising, it may mean that only a single program has been unambiguously shown to be effective, as is the case from home-visiting programs. In low- and middle-income countries, child maltreatment represents a greater health burden and slows economic and social development to a greater extent than in high-income countries. Yet research on the effectiveness of universal and selective interventions appears to be almost exclusively the affair of English-speaking, high-income countries.
The major impact on the lives of injured children is typically compounded by the adverse psychological and financial consequences for their families. The "injury poverty trap" is an inevitable outcome for many low-income households (10). Rehabilitation is a process designed to assist the injured child, who is experiencing or likely to experience disability, to achieve and maintain optimal functioning in interaction with their environment. By addressing evolving needs and building on the strengths and resources of child and their family, early initiation of rehabilitation can reduce acute health care costs and prevent disability. In addition to the goals of trauma rehabilitation programs in general (e.g. facilitating recovery of pre-injury health), child-oriented programs must also actively consider: the physical and psychosocial developmental needs of children, increasing levels of autonomy with regard to care and decision-making as they transition through adolescence; as well as their relationships with families, peer, schools and vocational settings. For many injure children living with disabilities, assistive devices (e.g. crutches, wheelchairs, prostheses and computer aids) can play a vital role enabling mobility, education and social engagement. Adequate provision of assistive devices usually requires trained professionals such as prosthetic and orthopedic technicians, occupational therapists and physical therapists. It is estimated, however, that only 3% of individuals who need rehabilitation, globally, receive any kind of support. The reasons for this include inadequate primary care, a lack of trained personnel, prohibitive costs, limited availability of transport and difficulties in accessing health-related rehabilitation (13).
Healing Child Soldiers:
In 2003 the Agoro Community Development Association started working with RESPECT International, a Canadian NGO that links refugee communities with online volunteers from the United Nations Volunteers program. One of the fruits of this association is a computer resource center that today gives IT training to students with a view to creating work opportunities later on. Encouraging life skills and economic autonomy is also a key aspect of UNICEF's rehabilitation and integration efforts. It provides support to get these children back to school or into vocational training or work. These activities take place in local communities and include other vulnerable children, not just former child soldiers, to promote a sense of community and reduce stigmatization. Children who successfully complete a vocational training receive a start-up kit, for example in dress-making, carpentry or hairdressing, to help them along the long road to recovery, reintegration and independence. These efforts are very helpful to put a shattered life back together and point them in the right direction. When children enter a UNICEF transitory care center, they soon receive a general medical check up followed by treatment where indicated. In Democratic Republic of the Congo (DRC), where sporadic fighting is still going on since 1998, the centers are designed for a three-month stay, and are often the children's first contact with normality after their horrific experiences. Because the number of children needing help -- in Goma transitory care center in eastern DRC there are currently around 205 -- it is not possible to work exclusively one-on-one, so the children have been grouped into 'families' of 30 or so, each group with a separate dormitory and assigned staff counselors. The children, who came from different ethnic backgrounds and armed groups, are deliberately mixed. The families are there to listen and to support one another; they deal with a range of issues from grief to outbursts of violence. While reintegration into the community and establishing their own autonomy are important parts of children's rehabilitation, individual counseling is also provided, particularly to those with specific disorders or behavioral issues. There is no data on just how effective this approach is; the initial results are encouraging. Effective rehabilitation is extremely expensive and takes a long time.
Global Efforts of Improve Care:
There is often a misconception that improvements in trauma care would be expensive and impractical in low- and middle-income countries. However, the Disease Control Priorities Project has shown that several interventions that need to be promoted to improve trauma care are among the most cost-effective in the health-care armamentarium. Among these, the following interventions were identified as having cost-effectiveness ratios of below 100 (US $ 100 per disability-adjusted life year averted): strengthening of pre-hospital care through training of community-based paramedics and village lay-first responders; community ambulances; and basic surgical care (including care of injuries) at district hospitals. Thus, these interventions are considered extremely cost-effective when assessed on a scale ranging from 1 (most cost-effective) to 100,000 (least cost-effective) (10). In this review, the focus is on how to better implement the array of cost-effective and sustainable trauma care improvements globally, especially regarding care of the injured child. To expand the individual efforts, there are two foundations on which to build the global efforts. Both of these foundations emphasize improving health care through improved organization and planning. The first is the essential services approach on international public health. Essential services are those that are high-yield, but low-cost, and which realistically could be assured to almost everyone in a given population. Programs have included defining the core services to promote, identifying barriers to such services, and providing technical input and assistance to countries and high-need areas to improve capacity to deliver these services. Until recently, this approach had not been applied to trauma care. The second foundation to build on is the trauma system development from high-income countries. This has entailed improving the spectrum of care for the injured in both pre-hospital and hospital-based settings, as well as streamlining referrals between hospitals. Such improvements in organization and planning for system-wide trauma care have resulted in 15-20% reductions in mortality of treated trauma patients and 50% reductions in medically preventable deaths. Thus far, similar system-wide approaches have been only minimally applied in low- and middle-income countries.
The Essential Trauma Care Project has sought to combine these two different perspectives. It has sought to promote improved trauma system planning in low- and middle-income countries by applying a public health approach. This project has been a collaborative effort of World Health Organization (WHO) and the International Society of Surgery. Representatives of these two organizations, working with other groups and with trauma care clinicians and administrators from many countries globally, have created the Guidelines for essential trauma care (11). This defines 11 core essential trauma care services that every injured person in the world should realistically be able to receive. These are the most cost-effective and high-yield trauma care services. Injury has become a leading cause of death and disability globally. The two groups most affected are older children (aged 5-14 years) and adolescents and younger adults (aged 15-44 years). For every person injured, many more are left with temporary or lifelong disabilities.
Essential trauma care services:
There are many dedicated people working hard to strengthen care of the injured in general and care of injured children particularly, in circumstances of low- and middle-income countries. They have reported several practical, innovative solutions to overcome resource restrictions for a range of clinical issues. Their efforts have recently been aided by increased international attention to this problem. Although there are no major, well-funded global programs to improve trauma care yet, recent the broad net work of collaborators who have worked on them have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased national attention, including conduct of needs assessments and implementation of recommendations in national policy. Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and given the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. There are several practical steps that can be taken to achieve this goal. These are summarized below and primarily include low cost and affordable steps to improve the organization and planning for trauma care services for children.
Summary table of recommendations on ways in which to strengthen care of the injured child globally (12):
By taking these practical steps, countries worldwide can lower the unacceptably high and tragic care of childhood death and disability from injury. Trauma care needs assessments being conducted in a growing number of countries need to focus more on capabilities for care of injured children. Trauma care policy development needs to better encompass childhood trauma care. More broadly, the growing network of individuals and groups collaborating to strengthen trauma care globally needs to engage a broader range of stakeholders who will focus on the champion for the improvement in the care of injured children.
Legislation and Enforcement:
Urgent attention is required to tackle the problem of child and adolescent injury across the world. Policies and programs to reduce child injuries should incorporate several effective approaches including the following. Legislation requiring the use of protective equipment such as helmets, child passenger restraints, seat-belts, smoke alarms, child-resistant containers and fencing around swimming pools can lead to increased usage of such equipment and thereby reduce the risk of injuries and their severity. Mandatory standards for various goods and services (e.g. playground equipment, safety equipment, toys, furniture and packaging) also show commitment to child safety and can reduce risk. To be effective, of course, legislation and regulations must be enforced. In many such cases the degree of enforcement determines the effectiveness of these prevention measures.
Rehabilitation services for children may be funded through a variety of sources including government budgets, health and social insurance, external funding, private sources, including non-governmental arrangements, and out-of-pocket payments. Of the 114 countries providing data to the global survey on government action in 2005, only 73 countries (64%) allocated budget for rehabilitation services. In 66 (58%) of countries surveyed, no government funding was allocated to make the physical environment accessible to persons with disabilities, and 43 countries (38%) provided no support for children with disabilities with regard to assistive devices and support services (13). Third payer and insurance schemes in high-income countries can also influence the type, amount and extent of rehabilitation services for injured children. However, a wheelchair cannot facilitate access to an inaccessible school. Changes are also required in the child's environment if they are to use technologies effectively (e.g. availability of ramps and accessible toilets). The 2008 Convention on the Rights of Persons with Disabilities is the first legally binding treaty that reaffirms that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms. The Convention underscores the need for interdisciplinary collaborative efforts at local, national and global levels to enhance the quality of life of children with disabilities, promote their rights and protect their dignity. In many low- and middle-income countries human resources for rehabilitation are less-developed than for acute care, with specialized services such as speech pathology virtually absent while physiotherapy services were more likely to be available. Donated or mass-produced assistive devices can pose particular difficulties as they are often not child-sized, customized or provided with appropriate support services.
Proven interventions in child injury prevention (1):
Improvement in access and quality of pre-hospital and essential trauma care and rehabilitation are important measures for reducing the severity of injuries and their sequelae, for reducing the frequency and severity of injury-related disability and for improving outcomes for children living with injury-related disability. Promotion of safety devices (e.g. helmets, smoke alarms, seat-belts) can take place through a variety of methods, including media campaigns, professional counseling and enforcement of legislation. Environmental modification is an especially important strategy for preventing road traffic injuries. Under this type of strategy, area-wide engineering measures, such as traffic-calming schemes or separating motorized and non-motorized traffic, are used to reduce the risk of crash. Modification of products such as cooking stoves, lamps, playground surfaces, furniture and furnishings (e.g. cribs, stairway railing) and modification of product packaging can be effective prevention strategies by reducing the risk of injury, reducing access to a hazard and/or by reducing injury severity.
To be able to influence policy, there must be stronger advocacy in injury control. To undertake sustainable injury control work, there must be sufficient individual and institutional capacity. At this stage, what is needed more than anything else in injury control are model country programs. One of the most compelling arguments to bring to the attention of policy-makers is the documentation of successful programs in similar countries. Children have the right to health, a safe environment and protection from injury. Countries that have signed the Convention on the Rights of the Child are obligated to take legislative, administrative, social and educational measures to ensure to the maximum extent the survival and development of the child; this obligation includes protecting children from injury. Unless the multisectoral initiatives described above are disseminated and implemented in a timely manner worldwide, the burden of injuries on children's health and survival will increase, and some of the investment in and gains won through child survival initiatives will be eroded as children lose their lives and health to injury later in childhood. The obstacles that currently hinder progress in child injury prevention can be partially overcome by integrating child and adolescent health agenda, both in policy and in practice. Conversely, progress in child and adolescent health will be limited if child injuries are not addressed systematically.
Although many disciplines and many branches of government have important roles to play in preventing childhood injuries, we must hold on to the view that, in the end, injuries are a health problem. The main points are: first, the need for everyone to accept the view that, ultimately, injuries are a health problem and health departments must view them as such. Second, although increased and improved research is undoubtedly important, it is futile and frustrating if the results of existing research are not acted upon. Third, governments must pay a central role by creating a national focus for the coordination and implementation of programs whose value has been established. These points require widespread support if we hope to make genuine progress towards the goals reflected in this document. Work to create a national center. Consider doing so by mobilizing or consolidating parent groups. Be prepared to operate at the political level.
This work was funded by the WHEC Initiative for the Global Health.