Center for Injury Research & Policy

Pediatric Injury Prevention Research:

Where have we been?

Where should we be going?

Andrea C. Gielen, ScD, ScM

Professor and Director

Johns Hopkins Center for Injury Research and Policy

December 2, 2009

Outline

• Pediatric injury as a public health problem

• Successes in pediatric injury prevention

• Collaborative research examples

• Future needs and opportunities

INJURY

Global Burden

• 875,000 Children and adolescents die annually

• 95% are from low and middle income countries

• Motor vehicle crashes and drowning are among the top 10 causes of death

• WHO launches the first “world report on child injury prevention”, December 10, 2008

http://whqlibdoc.who.int/publications/2006/9241593385_eng.pdf

20%

45

Productivitylosses due todeath

Productivitylosses due todeath

Productivitylosses due todisability

Productivitylosses due todisability

Medical and Medical and related costsrelated costsMedical and Medical and related costsrelated costs

45%

20%

35%

CDC, 2006

Lifetime Cost of Injury in the US: $406 Billion

For Children (0-14)

$50.5 Billion Total

$11.9 Billion Medical

Deaths are only the tip of the injury iceberg . . .

7,273 Deaths

136,635 Hospitalizations

11.2 Million Medical Visits

1

19

1,544

Finkelstein EA, Corso PS, Miller TR. The Incidence and Economic Burden of Injuries in the United States, New York, NY: Oxford University Press, 2006

U.S. Children Ages 0-14

SUCCESS

1987 – 2004 Unintentional Injury Deaths, Ages 0-14, United States

Source: National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007. Published in Safe Kids Worldwide (SKW). Childhood Injury Trends Fact Sheet. Washington (DC): SKW, 2007.

Type of IncidentPercentChange

Motor vehicle crash 32%Drowning 44%

Pedestrian injury 55%Fire and/or burn injury 58%

Falls 28%Poisoning 14%Firearm 74%

Suffocation 28%

1987 – 2004 Unintentional Injury Deaths, Ages 0 to 14, United States

Source: National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007. Published in Safe Kids Worldwide (SKW). Childhood Injury Trends Fact Sheet. Washington (DC): SKW, 2007.

Science of Injury Control

19911984, 1991

Haddon, W Jr: "On the escape of tigers: an ecologic note." American Journal of Public Health (1970), 60(12):2229-2234.

HADDON MATRIX Host Vehicle Environment

Pre-event

Event

Post-event

Effective Interventions Discovered

In July 1984, Congress and President Ronald Reagan enacted legislation that set the national minimum legal drinking age to 21.

Not Intended for Children under 3 years

COLLABORATION

Safe Home Project

A collaboration with the JH Department of Pediatrics and the Center for Injury Research and Policy Funded by the Maternal and Child Health Bureau, HRSA and private donations

SAFE Home Project

Program Components:

Pediatric Counseling

Children’s Safety Center

Home Visit

Caregiver:

KnowledgeBeliefsSkills

Social support

Access to resources

Safety Behaviors:

Smoke alarmsCabinet locks[Syrup of Ipecac]

Safety gatesSafe hot water

Pediatric Counseling

Solicit

Advise

Focus

Encourage

CounselingFramework

5 hours, faculty led, hands-on, role plays, homework

Training Program

SAFER Counseling Framework• Solicit Information

– Ask about current practices– Use open-ended questions first

• Advise Parent– Recommend parent correct hazard or behavior– Provide information about countermeasures

• Focus on Perceptions of Risk and Barriers– Educate parent about risk– Acknowledge difficulties and barriers

• Encourage Compliance– Acknowledge any progress parent has made toward an injury

prevention goal– Reinforce parents’ intentions to adopt behaviors

• Review Resources and Refer– Describe retail and community options for obtaining safety products– Refer to services / agencies when available

Free personalizededucation

Reduced cost safety supplies

Children’s Safety Center

Home Visits

• Community health workers

– Identify hazards in client’s home

– Personalize education/coach on installation

– Refer to the Children’s Safety Center

HOME VISITSCommunity health workers:

• Identify hazards in client’s home

• Personalize education/coach on

installation

• Refer to the Children’s Safety

Center

SAFE Home Study Design

COHORT 1COHORT 1Baby’s Age 0-6 12-18mos.Control O OIntervention1 O EAG O

COHORT 2COHORT 2Baby’s Age 0-6 12-18mos.Intervention2 O EAG + CSC OIntervention3 O EAG + CSC + HV O

Key: EAG=Enhanced Anticipatory Guidance; CSC=Children’s Safety Center; HV=Home Visit; O= Interviews, Audiotapes, Home Observations

Study funded by MCHB, HRSA and NCIPC, CDC

Safe Home Findings

• Amount and quality of physician counseling improved

• Counseling led to more satisfied patients, but had no effect on safety practices

• Counseling and visiting Children’s Safety Center was associated with more observed safety behaviors

• Home visits had no added benefit

Gielen et al, 2001; 2002; McDonald et al, 2003; Chen et al, 2003

CSC Evaluation (1997-2008)

Hours..................................................M-F 11a-4p

Visitors...............................................15,000 (100% adults)

Average/month

Sales.......................................................$350

Outreach.......................................................7

Average/year

CS Loans/Sales........................................160

CS Installs/Checks……………………......198

Adapted from: Gielen, A.C., McDonald, E.M., Wilson, M.E.H., Hwang, W.T., Serwint, J.R., Andrews, J.S. & Wang, M.C. (2002). Effects of improved access to safety counseling, products, and home visits on Parents’ safety practices. Arch Pediatr Adolesc Med, 156: 33-40.

Impact of the collaboration….

• Sustained program of services through the Children’s Safety Center

• Model for other Children’s Hospitals• New research

– East Baltimore Community

– Harriet Lane Primary Care

– Johns Hopkins Health Care

– Johns Hopkins Pediatric Emergency Department

East Baltimore Community CARES Safety Center

Partners: Baltimore City Fire Department ; Johns Hopkins Center for Injury Research and Policy; Johns Hopkins Children’s Safety Center ; Johns Hopkins Pediatric Trauma Service; East Baltimore Medical Center, Johns Hopkins Health Care; Maryland Science Center; Maryland Institute College of Art (MICA)

Research Grants: Centers for Disease Control, NCIPC; National Institutes of Health, NICHD

Funders

FEMA

BP

Annie E Casey Foundation

Weinberg Foundation

CareFirst BlueCross BlueShield

Where We Go

• Community Events• Health Fairs• Religious Organizations• Schools• Medical Clinics • Conferences• Shopping Centers

What We Do

• Personalized and engaging injury prevention education• Low-cost safety products• Free educational materials• Smoke alarm referrals to BCFD program• Child safety seat installation/checks

CARES Evaluation (1/06-10/09)

APPEARANCES.......400

VISITORS............ 16,403

(67% children)

DISTRIBUTED

....Educ’l Materials = 4407

......BCFD Referrals = 856

......Safety Products = 713

• 81/83 (98%) visitors recommend the safety center

• 80/83 (96%) of visitors reported learning something new

• CARES offers a new approach to disseminating information & products

Adapted from: Gielen AC, McDonald, EM, Frattaroli S, et al. If you build it, will they come? Using a mobile safety center to disseminate safety information and products to low income urban families. Injury Prevention, 2009; 15(2):95-9. and

Bulzacchelli M.T., Gielen, A.C., Shields W.C., McDonald, E.M., Frattaroli S. Parental safety-related knowledge and practices associated with visiting a mobile safety center in a low-income urban . J Comm Family Practice, 2009; 32(3):147-58.

Pediatric Emergency Department Safety in Seconds Study Aims

1. Evaluate effects of theory-based, computer-tailored intervention called Safety in Seconds, delivered in PED on car seat, smoke alarm, and poison storage knowledge and behaviors

2. Examine the role of parental anxiety and children’s reason for visit on intervention effectiveness

Safety in Seconds

• 10-12 minute assessment

• Personalized, tailored feedback

©Johns Hopkins Center for Injury Research and Policy

Safety in Seconds

Precaution Adoption Process Model Applied to Car Safety Seats

Profile 3:Use correct car seat consistently

Stage 5 - Decided to Act -------- Specific plans

Stage 4 - Decided Not to Act –--- Change risk-benefit

Stage 3 – Undecided --------------- Personal susceptibility; precaution effectiveness

Stage 2 - Unengaged by Issue --- Personal experience; significant others

Stage 1 - Unaware of Issue –------- Basic information

Profile 2: Have correct car seat for age / weight

Profile 1: Have car seat

Stage 6 – Acting ------------------ Increase self-efficacy

Stage Message Concepts

Profile 4: Have car seat inspected /

installed by expert

Definitions of Behavioral Profiles and Stages

Goals Behaviors*

Child Safety Seat Use Smoke Alarm Use Poison Storage^

Behavioral Profile 4

Have correct child safety seat, used every time, installed or inspected by expert

Change batteries at correct intervals in all smoke alarms on all levels

N/A

Behavioral Profile 3

Use correct type of child safety seat used every time

Have a smoke alarm on every level with batteries changed in at least one

Return poisons to locked place after each use

Behavioral Profile 2

Have correct type of child safety seat

Change batteries at correct intervals in at least one smoke alarm

Keep poisons in locked place

Behavioral Profile 1

Have a child safety seat Have a smoke alarm Have a locked place

*Within each behavioral profile, there are different stages of readiness to adopt the goal behavior. Individuals may report that they: 1) have not heard about the need for the behavior, 2) have not thought about adopting the behavior, 3) are thinking about adopting the behavior, 4) have decided not to adopt the behavior, 5) are planning to adopt the behavior, or 6) have adopted the behavior. ^Poison storage items asked about adult prescription medications and poisonous household products such as gasoline, products containing lye such as hair relaxing products.

Knowledge Outcomes

Child Safety SeatsBest way to keep child safeState law requires Percent used incorrectlySmoke AlarmsNumber needed House fires leading cause How to use properlyPoison StorageBest way to storeAdult prescription medsHair relaxers with lye Unsafe on high shelf

Evaluation Methods

• Randomized controlled trial

• Personalized tailored injury prevention report vs. Personalized child health report

• 901 caretakers of children ages 4-66 mos

• Telephone follow-up interview at 2-4 weeks

Figure 1. Study Design

Assessed foreligibility

N=1412

Excluded N=509 Not meeting inclusion criteria n=239 Refused to participate n=201 Other reasons (e.g., missed in PED) n=69

Randomized

N=901

Control

N=453 Intervention

N=448

2-week follow-upN=375

2-week follow-upN=385

SampleChild Characteristics

Age<1 year 25%1-2 years 42%3-4 years 27%5 years 6%

% Male 50%

% Injury visit 28%

Respondent CharacteristicsRelationship to childMother 90%Father 6%

% Married/Coupled 30%

Education< High School 10%High School 74%> High School 15%

Per Capita Income< $5,000/year 64%

AnxietyMean score 34.95

KNOWLEDGE CONCEPTS TESTED

INTERVENTION GROUP, N=384

CONTROL GROUP, N=375 t-test, p-value

Child Safety SeatsBest way to keep child safeState law requires Percent used incorrectly Mean Percent Correct (SD) 51.2 (22.0) 49.7 (22.8) t = 0.937, p =

0.35

Smoke AlarmsNumber needed House fires leading cause How to use properly Mean Percent Correct (SD) 82.5 (23.6) 77.6 (23.9) t = 2.82, p = 0.005

Poison StorageBest way to storeAdult prescription medsHair relaxers with lye Unsafe on high shelf Mean Percent Correct (SD) 81.2 (21.6) 70.7 (23.4) t = 6.44, p = 0.000

TOTAL MEAN PERCENT CORRECT (SD) 72.6 (13.9) 66.4 (14.8) t= 5.87, p = 0.000

Behavioral OutcomesOdds Ratio (95% Confidence Interval)

Car Safety Seats^Intervention vs. Control 1.32 (1.03, 1.72)

Smoke Alarm Use*Intervention vs. Control 1.23 (.85, 1.78)

Poison Storage*Intervention vs. Control 1.11 (.81, 1.52)

Anxiety and Reason for Visit had no independent andno moderating effect on any of the outcomes.

^Ordinal Regression Analysis; * Logistic Regression Analysis

Exposure to Intervention

• 98% remembered report• 93% read at least some of report• 57% read entire report• 68% discussed it with family or friends

• Summary Exposure Variable

39% who read the entire report AND discussed

it with others were considered “high exposure”

Exposure Analysis

High exposure compared to control group were significantly more likely to use:

– Car seats 1.70 (1.20-2.41)

– Smoke alarms 2.07 (1.16-3.69)

– Safe poison storage 2.01 (1.27-3.16)

0

10

20

30

40

50

60

70

80

90

100

Child Safety Seat Smoke Alarm Poison Storage

Control, N=375

Low Exposure, N=233

High Exposure N=151

Figure 2. Percent Distributions of Child Safety Seat, Smoke Alarm, and Poison Storage Outcomes by Study Group and Exposure to the Intervention

%

Child Safety Seat: Always using correct car seat, inspected or installed by expertSmoke Alarm: moke alarm on every level and changing batteries at correct intervals Poison Storage: Locking poisons after each use

Adjusting for correlates of exposure

• Marital Status

– Significant effects of exposure remained• Income

– Smoke alarms, adjustment wiped out effects of exposure; neither exposure nor income sig

– Poison storage, high exposure associated with safer behaviors for those with low income (OR = 2.70)

– Car seats, higher income respondents more likely to achieve safer behavior in both exposure groups (OR = 2.09 for low exposure; OR = 3.28 for high exposure)

0

10

20

30

40

50

60

Control Group Low ExposureGroup

High ExposureGroup

Lower Income

Higher Income

%

Figure 3. Percent Distribution of Child Safety Seat Outcome by StudyGroup and Per Capita Income*

*p=0.02Child Safety Seat: percent always using correct car seat, inspected and installed by expert

Conclusions

• The needs of low income families continue to need special attention to reduce financial barriers to safety behavior

• Short term changes in behavior need to be examined over longer period of follow up and with observations

• Computer technology and tailored messages can be effectively used for injury prevention in pediatric emergency departments

FUTURE

Two of the greatest virtues in life are patience and wisdom

PassionPassion

“If a disease were killing our children in the proportions that injuries are, there would be a huge public outcry and we would be told to spare no expense to find the cure -- and to be quick about it. The public would be outraged and demand that this killer be stopped.”

Former Surgeon General C. Everett Koop, M.D.

Conclusions

• Despite great progress, injury remains the number one health threat to children

• Effective interventions exist but challenges remain to wide dissemination, especially for low income families

• Multi-disciplinary expertise and partnerships are needed for future success

Thank you!

References• Gielen AC, Wilson MEH, McDonald EM, Serwint JR, Andrews JS, Hwang WT, Wang MC, A Randomized Trial

of Enhanced Anticipatory Guidance for Injury Prevention, Archives of Pediatric and Adolescent Medicine, 155:42-49, 2001.

• Gielen AC, McDonald EM, Wilson MEH, Hwang WT, Serwint JR, Andrews JS, Wang MC, The Effects of Improved Access to Safety Counseling, Products and Home Visits on Parents’ Safety Practices, Archives of Pediatric and Adolescent Medicine, 156:33-40, 2002.

• Bishai D, McCauley J, Trifiletti LB, McDonald EM, Reeb B, Gielen AC, The Burden of Pediatric Injury in an Urban Medicaid Managed Care Organization, Ambulatory Pediatrics, 2(4):279-283, 2002.

• McDonald EM, Gielen AC, Trifiletti LB, Andrews JS, Serwint JR, Wilson M, Evaluation Activities to Strengthen an Injury Prevention Resource Center for Urban Families, Health Promotion Practice, 4(2):129-137, 2003.

• Chen L, Gielen AC, and McDonald EM, Validity of Self-Reported Home Safety Practices, Injury Prevention, 9:73-75, 2003.

• McDonald EM, Solomon BS, Shields W, Serwint JR, Jacobsen H, Weaver NL, Kreuter M, Gielen AC. Evaluation of kiosk-based tailoring to promote household safety behaviors in an urban pediatric primary care practice. Patient Education and Counseling, 58(2):168-181, 2004.

• McDonald EM, Solomon BS, Shields WC, Serwint JR, Wang M-C, Gielen AC. Do Urban Parents’ Interests in Safety Topics Match Their Children’s Injury Risks? Health Promotion Practice, 7(4):1-8, October, 2006.

• Trifiletti LB, Shields WC, McDonald EM, Walker AR, Gielen AC. Development of Injury Prevention Materials for People with Low Literacy Skills, Patient Education and Counseling, 64(1-3): 119-27, May, 2006.

• Gielen AC, Triflietti LB, McDonald EM, Shields WC, Wang MC, Cheng JU, Weaver N, Walker A, Using a computer kiosk to promote child safety: Results of a randomized controlled trial in an urban pediatric emergency department, Pediatrics, 120(2): 330-339, 2007.