Transcript Have car seat - University of Michigan Transportation Research

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
Lifetime Cost of Injury in the US:
$406 Billion
Productivity
losses due to
disability For
Children
Productivity
losses due to
death
(0-14)
35%
45%
$50.5 Billion 20%
Total
45
$11.9 Billion Medical
Medical and
related costs
20%
CDC, 2006
Deaths are only the tip of the injury
iceberg . . .
7,273 Deaths
1
136,635 Hospitalizations
19
11.2 Million Medical Visits
1,544
U.S. Children Ages 0-14
Finkelstein EA, Corso PS, Miller TR. The Incidence and Economic Burden of
Injuries in the United States, New York, NY: Oxford University Press, 2006
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.
1987 – 2004 Unintentional Injury Deaths,
Ages 0 to 14, United States
Type of Incident
Percent
Change
Motor vehicle crash
Drowning
Pedestrian injury
Fire and/or burn injury
Falls
Poisoning
Firearm
Suffocation
32%
44%
55%
58%
28%
14%
74%
28%
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
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
Postevent
1984, 1991
1991
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:
Caregiver:
Pediatric
Counseling
Knowledge
Beliefs
Skills
Safety
Behaviors:
Smoke alarms
Cabinet locks
[Syrup of Ipecac]
Children’s
Safety Center
Social
support
Home Visit
Access to
resources
Safety gates
Safe hot water
Pediatric Counseling
Training
Program
5 hours, faculty led, handson, role plays, homework
Solicit
Advise
Focus
Encourage
Counseling
Framework
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
Children’s Safety Center
Free
personalized
education
Reduced cost
safety
supplies
Home Visits
HOME VISITS
• Community health workers Community health workers:
– Identify hazards in client’s home
• Identify hazards in client’s home
– Personalize education/coach on installation
– Refer to the Children’s Safety
Center education/coach on
• Personalize
installation
• Refer to the Children’s Safety
Center
SAFE Home Study Design
COHORT 1
Baby’s Age
Control
Intervention1
0-6
O
O
EAG
12-18mos.
O
O
COHORT 2
Baby’s Age
Intervention2
Intervention3
0-6
12-18mos.
O EAG + CSC
O
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
Funders
FEMA
BP
Annie E Casey
Foundation
Weinberg
Foundation
CareFirst
BlueCross
BlueShield
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
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, computertailored 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
Stage
Profile 4: Have car
seat inspected /
installed by expert
Profile 3:Use correct
car seat consistently
Profile 2: Have
correct car seat for
age / weight
Profile 1:
Have car seat
Stage 6 – Acting ------------------
Message Concepts
Increase self-efficacy
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
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 Seats
Best way to keep child safe
State law requires
Percent used incorrectly
Smoke Alarms
Number needed
House fires leading cause
How to use properly
Poison Storage
Best way to store
Adult prescription meds
Hair 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 for
eligibility
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
Intervention
N=448
2-week follow-up
N=385
Control
N=453
2-week follow-up
N=375
Sample
Child Characteristics
Age
<1 year
25%
1-2 years
42%
3-4 years
27%
5 years
6%
% Male
% Injury visit
50%
28%
Respondent Characteristics
Relationship to child
Mother
90%
Father
6%
% Married/
Coupled
30%
Education
< High School
High School
> High School
10%
74%
15%
Per Capita Income
< $5,000/year
64%
Anxiety
Mean score
34.95
KNOWLEDGE CONCEPTS
TESTED
INTERVENTION
CONTROL
GROUP, N=384 GROUP, N=375
t-test, p-value
Child Safety Seats
Best way to keep child safe
State law requires
Percent used incorrectly
Mean Percent Correct (SD)
51.2 (22.0)
49.7 (22.8)
t = 0.937, p = 0.35
Smoke Alarms
Number 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 Storage
Best way to store
Adult prescription meds
Hair 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 Outcomes
Odds 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 and
no 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)
Figure 2. Percent Distributions of Child Safety Seat,
Smoke Alarm, and Poison Storage Outcomes
by Study Group and Exposure to the Intervention
100
90
80
70
%
60
Control, N=375
50
Low Exposure, N=233
High Exposure N=151
40
30
20
10
0
Child Safety Seat
Smoke Alarm
Poison Storage
Child Safety Seat: Always using correct car seat, inspected or installed by expert
Smoke 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)
Figure 3. Percent Distribution of Child Safety Seat Outcome by Study
Group and Per Capita Income*
60
50
40
%
Lower Income
30
Higher Income
20
10
0
Control Group
Low Exposure
Group
High Exposure
Group
*p=0.02
Child 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
Passion
“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
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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.