Health Education Research, Vol. 17, No. 2, 221-237,
April 2002
© 2002 Oxford University Press
Social deprivation and the prevention of unintentional injury in childhood: a systematic review
Community Child Health, University of Newcastle upon Tyne, 13 Walker Terrace, Gateshead NE8 1EB, UK
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Abstract |
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There is a known association between social deprivation and risk of death from unintentional injury in childhood. In the UK context, these inequalities do not appear to be decreasing. This paper reports on the findings of a systematic review of the world literature between 1975 and 2000 on the prevention of childhood injuries, with particular reference to social deprivation. Literature was identified via electronic databases, key journals and informants. All papers were read independently by at least two reviewers and information was extracted using a standardized form. Results indicate that of 155 studies identified in the systematic review, 32 addressed the issue of social deprivation. The way social deprivation was defined in different studies varied considerably. The literature was not evenly spread across different injury types and did not reflect the burden of injury. There is a paucity of evidence relating to the prevention of child pedestrian injury. Very few studies examined the impact of interventions in different social groups. Without such evidence, it remains difficult for those involved in health promotion to know how to design and target interventions to address inequalities in child injury rates.
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Introduction |
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The inverse relationship between affluence and the risk of morbidity and death from unintentional injury has been recognized for many years (Office of Population Censuses and Surveys, 1998
). Evidence of this relationship has emerged in a number of different countries, and with respect to injuries overall and for specific injury types, in particular injury from fires and child pedestrian injury (Dougherty et al., 1990; Roberts et al., 1992; Woodroffe et al., 1993; Spencer, 1995). This relationship seems to emerge no matter how deprivation has been measured, and there is increasing although still limited evidence that it emerges in relation to both severe injuries and death, and to less severe medically attended injuries (Jarvis et al., 1995; Jackson, 1997; Jackson and Towner, 1997; Laing and Logan, 1999). Further, these inequalities do not appear to be decreasing over time. In the period between 1981 and 1991 in the UK, while the overall number of injury deaths declined, the reduction in deaths for children from the most disadvantaged homes was much less marked than for those from more affluent backgrounds (Roberts and Power, 1996).
Epidemiological and observational studies have suggested a number of factors to explain the links between injury risk and deprivation. The risk of death for child pedestrian injuries is highly class related and a number of papers have linked the areas in which children live with the risk of injury (White et al., 2000). One US study (Mueller et al., 1990) suggested that children living in disadvantaged areas were more likely to be exposed to higher traffic volumes and vehicle speeds (White et al., 2000). Other studies have suggested mechanisms whereby disadvantage may increases risk by less direct means. Towner examined children's exposure to risk, and reported that children from more deprived backgrounds were more likely to walk to school (rather than travel by car) and were less likely to be accompanied by adults than children from more affluent homes (Towner et al., 1994). Increased exposure of children from deprived homes to the traffic environment may arise from broader issues, such as housing design and the lack of safe areas to play (Sharples et al., 1990). Houses which open directly onto the street are an important factor in child pedestrian accidents (Sharples et al., 1990; Christie, 1995). In a UK study, Pless identified that material deprivation was associated with increased levels of family stress and this (through a variety of mechanisms which are not understood) may have contributed to greater injury risk (Pless et al., 1989).
In the home setting, parental knowledge and behaviour have been suggested as factors influencing risk (Santer and Stocking, 1991). However, it is not clear how knowledge and behaviour relate to social deprivation or what the mechanisms are whereby risk is increased. It is also possible children from disadvantaged homes are not `reached' by some health promotion campaigns, e.g. the Streetwise Kids Club in London (Downing, 1988).
The factors which have been invoked to explain the relationship between child injury risk and social deprivation are complex, may interact and are generally not well understood. However, they may have important implications for targeting health promotion seeking to address inequalities in health. The possible causal mechanisms leading to inequalities also have an important bearing on the types of interventions that may be appropriate. If parents in disadvantaged social groups simply have informational deficits then, potentially, these can be addressed by an educational approach. If families face economic barriers to engaging in safer practices then addressing such barriers (e.g. by providing free safety devices) may be a means of addressing inequalities. However, if children face increased risk because they live in areas where they are exposed to high volumes of traffic then area-wide environmental and policy measures may be required. If increased risk arises from more complex causes then more complex approaches or a combination of approaches may be needed. The range of possible strategies to reduce inequalities in health have been set out by Whitehead (Whitehead, 1995). Here, four approaches were outlined: strengthening individuals, strengthening communities, improving access to services, and broad economic and cultural change.
The known inequalities in health with respect to child injury raise a number of questions about health education and broader health promotion activities carried out in this area. In this paper we examine the literature on child injury prevention and address some of these questions. First, have interventions been targeted at socially disadvantaged groups? If so, how many have done so, where were they carried out and when? How was social deprivation defined and how were target groups identified? What approaches were utilized? Using Whitehead's four approaches above, were approaches aimed at strengthening individuals or communities, or did they seek to increase access to services or bring about wider change? Were interventions designed to address some aspect of inequality or unequal access? For example, were families provided with free or low-cost equipment to overcome economic barriers to behavioural change? What was the role of health education within these interventions? Were interventions effective in reducing child injury risk? If children from different social backgrounds were included, were interventions equally effective irrespective of background? Finally, what policy implications arise from the literature in this area?
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Methods |
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This paper uses as its source a systematic review of the literature which attempted to answer the question `How effective are health promotion interventions in preventing unintentional injuries in childhood and young adolescence?' (Towner et al., 2001
). It includes studies published between 1975 and 2000 and builds on two earlier reviews published in 1993 and 1996. In the systematic review of 2001, 155 studies were identified, of which 32 studies targeted socially deprived groups. In the systematic review, relevant literature was identified by a variety of means. Computerized databases including MEDLINE, BIDS (and more recently the Web of Science), Excerpta Medica and more specialized sources such as the Transport and Road Laboratory (TRL) databases were searched (a full list of databases searched and search terms used is available on request). This electronic search was supplemented by hand searching of a number of key journals such as Accident Analysis and Prevention and Injury Prevention along with the reference lists of relevant published articles and books. In addition, key informants (researchers and specialists in the area of child injury prevention) were consulted. The criteria for inclusion of studies were:
- They were written in English, and published between 1975 and 2000 (the last search was carried out in June 2000).
- They related to the prevention of unintentional injuries (solely or in part).
- The target population included children under 15 and results were reported for this group.
- They described either a primary intervention measure to prevent accidents occurring or a secondary measure to prevent or reduce the severity of injuries.
- They had been evaluated using some measure of outcome or impact. These included changes in injury mortality or morbidity, changes in observed or reported behaviour, environmental change or hazard removal, or changes in knowledge or attitudes.
Violence prevention studies were excluded, except in those cases where they were combined with unintentional injury studies.
All studies were read and reviewed independently by two reviewers. Where statistical advice or other specialized knowledge was required a third reviewer was consulted. A standardized data extraction form was devised and used to record details from each study included (available on request). Details recorded included the date and place of the study, the injury target group, and the aim, content and setting of the intervention. Where interventions had been targeted at socially or economically disadvantaged groups this was noted. In addition, details about the evaluation were recorded. This included a brief description of the methods used (the study design, sample size, data collection methods, outcome and impact measures), and a note was made of strengths and weaknesses of the evaluation. The process of assessing the quality of the evidence of the various studies was informed by the British National Health Service's Centre for Reviews and Dissemination guidelines on carrying out systematic literature reviews (Arblaster et al., 1995). The reviewers reached a consensus decision on the quality of the evidence. Each study was graded on a five-point scale ranging from weak to good (i.e. weak, reasonable/weak, reasonable, reasonable/good, good).
Key results were recorded and a consensus decision made about the effectiveness of the intervention. Where results were reported for subgroups within the sample (e.g. for children attending schools in higher or lower income areas) these were recorded.
Details from the data extraction forms were used to devise summary tables for each study included. At this stage, those studies where the evidence was rated as weak were excluded.
In the results section, after a brief summary of the main findings of the review, we will move on to concentrate on those studies dealing with social deprivation. The target groups for interventions, features of the intervention and results (particularly where results are reported for different social groups) will be described. In the concluding section we will discuss the implications of these studies, and the potential impact of health education and broader health promotion activities in reducing health inequalities in the area of childhood injury.
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Results |
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A full set of tables for all studies included in the review and details of those studies excluded are reported elsewhere (Towner et al., 2001
). Overall, 199 papers were identified and reviewed. Of these, 44 were excluded on the grounds that eligibility criteria had not been met, the study design was weak or too little information had been provided to make a decision on study quality. Table I provides a breakdown of the number of papers included in the review relating to different injury types and health promotion approaches, and the number of studies in each section addressing issues of social deprivation.
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In this paper we focus specifically on those 32 studies targeting socially deprived groups. In Tables II–IV
the key features and findings of these studies are summarized. Table II sets out details of those studies relating to the prevention of injuries in the road environment. Table III focuses on injuries in the home environment and Table IV summarizes features of community-based interventions. There were no studies relating to the prevention of injuries in the leisure environment or to mass-media interventions which specifically targeted socially deprived groups.
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The 32 studies were published throughout the period covered by the review. Four studies were published between 1975 and 1984, 13 between 1985 and 1994, and 15 since then. The studies were mainly carried out in the US, UK and Canada with 19, seven and five in each country, respectively.
Table I
illustrates that the literature is not evenly spread over the injury target areas. While child pedestrian injury is the main cause of child injury death in a number of countries (including the UK), and there is a known association between this type of injury and social deprivation, there was only one study specifically targeted at socially deprived groups. Six studies focused on the promotion of cycle helmets and eight promoted the use of car passenger restraints. Fifteen studies focused on injuries in the home environment and two community-based studies addressed the issue of social deprivation.
Definitions of social deprivation and identification of target groups.
There is no consensus on what social deprivation means and this was illustrated in the papers reviewed. While all the interventions were aimed at disadvantaged individuals or groups, the way deprivation was defined and the way target groups were identified varied.
In an early study in the UK by Colver and colleagues, the definition of social deprivation was based on the characteristics of the inner city wards in which families lived (Colver et al., 1982). The study sample was recruited via mother and toddler groups and nurseries, and the authors provided a range of socio-demographic information about the families. For example, 89% of families lived in social housing and 52% were in receipt of means-tested state benefits.
In some studies, attendance at certain schools, child care centres or medical settings which served more deprived communities was used as a means of identifying target families. In other studies identification occurred at the level of individual children, parents or families. For example, in a UK study families identified by health visitors as being on a `low income' were referred to a safety equipment loan scheme (Thompson et al., 1998). In one US study, unmarried, teenaged, low-income pregnant women were targeted (Olds et al., 1994). In the US study described by Gallagher, identification of deprivation related to the type of housing families occupied (Gallagher et al., 1985). Here, areas of multi-occupancy, substandard housing were targeted in a study seeking to reduce home hazards.
Only in a relatively small number of studies were different social groups targeted and compared (Goodson et al., 1985; Parkin et al., 1995; Farley et al., 1996).
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The interventions |
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Interventions in the road environment (Table II
)Preventing injuries to child pedestrians
Child pedestrians living in deprived areas are particularly vulnerable road users. Seven studies were included in the main review which evaluated the effectiveness of area-wide engineering schemes or transport policy initiatives, but none of these studies explicitly targeted disadvantaged areas or examined the differential impact of schemes in affluent and more deprived residential areas. Similarly, there is little evidence regarding the effectiveness of pedestrian skills training or other educational approaches. Table V
sets out a range of possible interventions to reduce injuries in child pedestrians. Interventions can strengthen individual children or families, can strengthen neighbourhoods, or involve wider change. However, Table V illustrates that very few possible interventions have been evaluated with socially deprived groups. One Scottish study, the Drumchapel Road Safety Initiative, was carried out in a low-income area. The intervention included practical roadside training for child pedestrians by parent volunteers. This project, carried out in a deprived part of Glasgow, achieved positive results. Following training, children were less likely to select unsafe places to cross the road (Thomson and Whelan, 1997).
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Injuries to child bicyclists
One study examined the effects of a bicycle skills training session and six focused on the promotion of cycle helmets.
A study in Canada (MacArthur et al., 1998) evaluated a school-based bicycle training session in low-, medium- and high-income areas. The same intervention was delivered in each intervention school but there were no features of the programme designed to take account of the different environments in which these children lived and cycled. In this study it was not clear that the bicycle skills training session was effective in either low- or high-income areas. Here, children in both the control and intervention groups improved their knowledge scores and cycling skills between baseline measurements and follow-up.
In most of the studies promoting cycle helmets, the interventions were designed to take account of the economic circumstances of the target population by overcoming economic barriers to helmet ownership. In five studies bicycle helmets were either provided free or were available to children at discounted prices. The results of these studies were mixed. Puczynski and Marshall reported that following school-based activities and a mass-media campaign, 73% of children in the intervention group reported wearing helmets compared to 23% of the control group (Puczynski and Marshall, 1992). Increases in observed helmet use in favour of the intervention group were reported in a study targeting very young cyclists (Britt et al., 1998).
The restraint of child car passengers
Only two studies involving the loan of infant restraint seats were targeted specifically at low-income families. These studies suggest that such schemes can increase the numbers of babies restrained in cars (Berger et al., 1984; Robitaille et al., 1990). Neither of these studies examined the effect of the programme on higher income groups.
None of the five studies promoting the use of restraints or seat belts addressed the issue of economic barriers to infant seat purchase. Two of these studies compared high- and low-income populations. Goodson reported that overall reported use of safety seats was high following a hospital campaign to promote restraint use (Goodson et al., 1985). A second study promoting seat belt use (and more general road safety) also included a comparison of different social groups. In this study results were mixed and difficult to interpret (Hazinski et al., 1995).
One study (Hanfling et al., 2000) evaluated a mass-media campaign and police enforcement of seat belt laws. Here, safety education was carried out in schools in low-income areas.
Injuries in the home environment (Table III)
A relatively large proportion of interventions seeking to prevent general home accidents were targeted at disadvantaged families. Eight studies from a total of 11 identified in the main review were carried out in low-income areas or targeted low-income families. All interventions involved parent counselling on home safety. In some cases advice was tailored to individual home circumstances following home assessments [e.g. (Colver et al., 1982; Gallagher et al., 1985)]. In several studies families were provided with free, low-cost safety devices, including cupboard locks, electric socket covers and window guards. The results of these studies were mixed. In those studies where free safety equipment was provided, families tended to use it. We will return to this issue of free equipment in the discussion.
Colver et al. reported that 60% of intervention families compared to 9% of controls made at least one change in their homes to promote child safety following the intervention. This finding led the authors to conclude `even severely disadvantaged families will respond to health education if the education is appropriate' [(Colver et al., 1982), p. 1179]. Kendrick reported no differences between intervention and control families in terms of reported behaviour and knowledge following a multi-faceted programme to increase home safety (Kendrick et al., 1999). None of these studies compared low- and high-income groups although in one study (Clamp and Kendrick, 1998) those families receiving state benefits (and likely to have the lowest incomes) were more likely to report safer practices and the use of safety equipment than others in the intervention group.
None of the studies that included the collection of injury outcome data was able to demonstrate any change in injury rates following the interventions.
Children from deprived backgrounds are particularly vulnerable to injury and death in house fires. Table VI sets out a range of interventions to prevent such injuries. As with pedestrian injuries, very few potentially valuable interventions have been evaluated with children from deprived backgrounds.
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In studies which targeted the prevention of burns and scalds, four were carried out in low-income areas and all but one addressed economic barriers to behavioural change. As part of an intervention to prevent scalds, temperature regulating devices were fitted onto bathroom hot water taps (Fallat and Rengers, 1993
). Two studies involved the distribution of free smoke alarms in deprived neighbourhoods (Mallonee et al., 1996; DiGuiseppi et al., 1999). The studies examining interventions to prevent burns mainly produced positive results in that large numbers of devices were distributed. Mallonee reported that at 4-year follow-up 45% of the smoke alarms distributed were still functioning (Mallonee et al., 1996). In this study reductions in injury rates were reported following the giveaway campaign.
The free distribution of anti-scald devices did not seem an effective way of reducing scald injuries. Seventeen of 20 devices fitted had been removed at follow-up as the devices became blocked with sediment and water flow was restricted (Fallat and Rengers, 1993).
Community-based interventions (Table IV)
A number of major programmes in different countries have focused on the prevention of injury at a community-wide level. Two programmes have specifically focused on disadvantaged communities. Both programmes were carried out in the USA. The `Safe Block Project' (Schwarz et al., 1993) aimed to reduce falls, burns, scalds and poisonings in all age groups. The intervention was delivered by community workers and housing block representatives, and involved home inspections and targeted advice. This intervention produced some positive results, and led to increases in knowledge and use of some safety devices (e.g. smoke alarms) in those homes where residents were exposed to the programme. In addition, the programme generated considerable community involvement and leadership amongst housing block tenants using `cascade training'. In a second initiative, The `Safe Kids/Healthy Neighbourhoods Program', the intervention included playground renovation, organized play activities and child education (Davidson et al., 1994; Kuhn et al., 1994). This project resulted in 10 000 children participating in activities and a decline in targeted injuries was reported for the intervention area.
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Conclusions and discussion |
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Study intervention
The design of the systematic review and the search strategies utilized will inevitably have consequences in terms of the literature identified. The databases selected tended to be biased towards medical, rather than psychological or technical/engineering sources. This means that literature on, for example, road engineering or car design will have been under-represented. Although we attempted to include some of the grey literature, again it is likely that some relevant literature was not identified for inclusion.
Discussion
The papers reviewed used a range of different definitions of social deprivation and means of identifying deprived groups. This broad conceptualization of what social deprivation is, means that generalizing results from one context to another is difficult. Nevertheless, a number of interventions aiming to reduce injuries in children from socially deprived backgrounds have produced positive results. However, there remain areas where there is very little evidence. For injuries in the road environment there is a striking paucity of evidence. Where evaluations have occurred, strategies have invariably targeted individual children and parents and have mainly sought changes in knowledge and behaviour, rather than environmental change that would offer children passive protection. Table V shows that very few potentially valuable interventions have been evaluated. For example, whilst evidence regarding traffic calming schemes is generally positive, it is not clear whether injury reductions have been achieved in the most disadvantaged areas.
The provision of free cycle helmets as part of cycle helmet promotion campaigns has resulted in increased helmet ownership. However, there is only limited evidence concerning the effect of cycle helmet programmes on different population subgroups. It is also unclear whether children living in different neighbourhoods use their bicycles on different types of journeys in different types of traffic environments. It is not clear whether the protective effect of an helmet is the same where a child is exposed to high traffic volumes travelling at speed. There have been no evaluated interventions where environmental changes (such as the provision of cycle paths) have been used to reduce the exposure of socially deprived children to injury risk.
Studies of interventions to promote in-car safety suggest that campaigns to increase restraint use are partially effective. There remain large numbers of children unprotected in cars despite these campaigns. Again, campaigns have invariably sought behavioural change in individual parents or children, and there was little information about the differential effect of campaigns with families facing different economic and social circumstances. It is also unclear whether exposure is similar for children from different social groups, i.e. whether children in certain groups are more likely to travel in different traffic environments with different exposure to crashes. There is good evidence that wearing seat belts or riding in safety seats reduces the risk of injury and death, so approaches to increase their use, in all social groups, is likely to have beneficial effects. Car safety seats are an expensive item and the provision of free seats may be a means of increasing their use.
For injuries in the home environment, evaluated interventions have tended to focus on strengthening individuals rather than seeking broader change. The provision of safety devices to prevent injuries in the home environment remains controversial. In the studies described above, families provided with devices designed to offer passive protection from injury tended to use them. However, there is very little evidence that the presence of devices such as electric socket covers or cupboard locks have any effect on injury risk. The provision of such devices may increase more general awareness of home hazards, but they may also produce a harmful effect. Parents may assume that children are protected and reduce levels of supervision. It is important that families are aware of the limitations of some home safety devices.
A number of smoke alarm giveaway campaigns have aimed to strengthen neighbourhoods. There is increasing evidence that smoke alarms do offer protection against smoke and burn injuries. As children from deprived backgrounds are at particularly high risk of injury in house fires, the promotion of smoke alarms in deprived areas may be an effective means of addressing inequalities in health (Warda et al., 1999; Bunn et al., 2000).
Overall, there is very little evidence relating to the effectiveness of interventions to increase access to services or to achieve broader economic change. There is also very little information on the reach/penetration of different programmes. Without such process information, it is not known whether injury risk is partly attributable to exposure/lack of exposure to health promotion activities. It is possible that socially deprived groups are less likely to be reached by some interventions. For example, in the study by Kendrick et al., most of the intervention group were exposed to only very limited aspects of the intervention (Kendrick et al., 1999). Information on programme reach is helpful to interpret results of studies. Information on the reach in different social groups could lead to strategies to increase exposure to programmes in those groups most at risk.
The review indicates the paucity of evidence with respect to children's exposure to injury risk and to the differential effect of types of interventions on different social groups. Without such evidence, it remains difficult for those involved in health promotion to know how best to target their efforts and to design interventions to reduce inequalities in child injury rates. Much more evidence is needed regarding the impact of community wide campaigns, broader policy change and strategies to increase the reach of health promotion campaigns on deprived groups.
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Acknowledgments |
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This project has been funded by England's NHS Executive National R & D Programme in Mother and Child Health (CH 10-21). This support is gratefully acknowledged.
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References |
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Received on February 15, 2001; accepted on May 24, 2001
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