Childhood injury prevention: Where we've been and where we need to be

“If a disease were killing our children at the rate unintentional injuries are, the public would be outraged and demand that this killer be stopped.”

C. Everett Koop, MD, ScD

Pediatric Surgeon &

Former US Surgeon General

The critical importance of injury prevention is highlighted by the simple fact that more than half of pediatric trauma-related deaths occur within minutes of injury, and there are no clinical interventions that can improve survival for these Figure 1 patients.1 Over the last century there have been many injury prevention success stories which have led to lower injury rates in the United States (US), but even with these advances, injury remains the leading cause of death and disability for American children (Table 1).2,3 This review will provide a concise history of injury prevention in the US and highlights three areas where pediatric surgeons could create impactful change in their communities: lessening the risk of firearm injury, addressing the social determinants of injury, and through the development of hospital based violence intervention programs.

The application of the scientific method to injury prevention work started about 50 years ago. In 1966 the National Research Council published Accidental Death and Disability: The Neglected Disease of Modern Society which focused on trauma care and research emphasizing the lack of recognition of injury as a major public health problem.4 Concurrently with this, William Haddon, Jr. argued for a more scientifically driven approach to injury control in the public health framework where health problems are conceptualized to result from interactions between the host, the agent, and the environment.5

The decreasing incidence of injury deaths observed over the last century resulted from three distinct factors. First, there was a general reduction in exposure to dangerous jobs (e.g., mining, manufacturing, and farming), and to safety improvements related to transportation and housing. The second factor was related to improvements in the medical care provided to injured patients. Many of these clinical advancements occurred during wartime and subsequently translated to better care for civilians. The third reason for the reduction in injury mortality was the development of a wide array of evidence-based injury control strategies –such as seat belts, smoke detectors, and helmet use.

As the concept of trauma center verification and regional trauma systems began to develop, thought leaders began to recognize the importance and potential value of injury prevention research. This led to development of comprehensive programs directed at lessening the burden of preventable injury and pediatric surgeons have been at the forefront of these efforts (Table 2). The American College of Surgeons (ACS) recognizes injury prevention as a foundational component of trauma center resources and has refined and improved the trauma center requirements for injury prevention work over the last 25 years.6,7 In the current iteration of Resources for the Optimal Care of the Injured Patient, all ACS verified trauma centers are required to have a designated injury prevention professional, to prioritize injury prevention work based on local injury trends, and to implement at least two clearly defined injury prevention activities in collaboration with community partners during each verification cycle.7

We have known that exposure to firearms is associated with increased risk of injury and death for more than 50 years, and well-designed epidemiologic studies have repeatedly demonstrated a strong association between the presence of household firearms and an increased risk of firearm-related homicide, suicide, and unintentional shooting.8,9 In 2020, firearm-related injuries overtook motor vehicle crashes as the leading cause of death for children in the US.10

Survey studies of American households have shown that more than one-third have at least one firearm, which means approximately 22 million American children live in a home where at least one firearm is present. Of those households with guns, 43% keep at least one firearm unlocked, and nearly one-in-ten (9%) have firearms that are stored unlocked and loaded.11 Parents fail to appreciate the limitations of their children's developmental stages, and erroneously believe younger children can distinguish between real and toy guns, and loaded and unloaded firearms when they are unable to do so.12,13,14 In December 2012 a shooting at Sandy Hook Elementary school in Connecticut where 20 children and 6 educators were killed provided the impetus for changing the way clinicians, public health scientists, and injury prevention professionals approached firearm injury. In the aftermath of this tragic event many American medical organizations representing physicians who care for children released strong statements with recommendations in order to lower the risk of firearm injury in the US.15, 16, 17

The ACS produced a bold new statement on firearm injury prevention with specific recommendations supporting legislation banning civilian access to assault weapons and large capacity ammunition clips, enhancing mandatory background checks for all firearm purchases, assuring that health care professionals can provides guidance on safe firearm ownership, developing programs directed at improving safe gun storage, teaching non-violent conflict resolution, and promoting evidence based research on firearm injury. They also went on to survey their entire membership to better understand the perspectives of surgeons, many of whom care for the victims of firearm violence. Survey questions asked about experience with firearms, attitudes towards firearm ownership, and degree of support for clinician directed firearm injury prevention programs and for a broad range of firearm injury prevention policies. The ACS survey also asked questions about firearm ownership, type of firearm(s) owned, personal reasons for firearm ownership, and storage practices. The bottom line from all of these studies was that there was broad support from American surgeons, including those who own guns, to pursue evidence-based firearm injury prevention programs, and to advocate for mandatory background checks, making federal funding available for firearm injury research, and preserving the rights of healthcare providers to counsel their patients on safe firearm ownership.18,19

There is broad support from major American medical organizations to allow physicians to provide counseling on safe firearm ownership and to incorporate primary prevention of firearm related injury into clinical practice, but developing effective ways to incorporate this into clinical practice has proven challenging. 20,21,22 A recent survey showed that most gun owners (81%) did not think that physicians would be good or excellent messengers to teach them about safe firearm storage.23 These data illustrate the potential value of engaging firearm owners in this work. It is important for physicians to recognize that the public health message about the importance of safely storing firearms is very similar to the safe storage message promoted by gun rights and shooting sports groups.

Many firearm injury prevention programs are developed by well-meaning groups focused on this issue and are designed around behavioral interventions. Unfortunately, most these programs, e.g., Scared Straight, Eddie Eagle, Straight Talk About Risks, are rarely based on theoretical models or preliminary effectiveness data. Based on these shortcomings, the National Research Council Committee to Improve Research Information and Data on Firearms recommends that firearm prevention programs be based on general prevention theory and research, and that they incorporate rigorous evaluation into the implementation and design of these programs.24

There have been two recent studies which have shown that the counseling of the parents of young children about safe storage can work, especially when they are provided with free or low cost safety devices.25,26 Recently, nine trauma centers piloted a tablet-based firearm safety module in the outpatient setting, and showed that this approach is feasible, and that the majority of parents of pediatric patients are receptive to receiving anticipatory guidance on firearm safety.27,28 Other promising modalities for implementing firearm safety into clinical practice used an educational module for clinicians with a visual aid developed by the American Academy of Pediatrics. This approach received positive feedback from the clinicians who used it, and this approach increased the delivery of this type of anticipatory guidance on firearm safety.29 Finally, one major teaching hospitalproduced a two-part training curriculum for first-year residents in all specialties, which included a didactic presentation outlining a framework to understand types of firearm-related injuries. It also reviewed strategies for approaching discussions about firearms with patients using interactive case scenarios that were adjusted for clinical disciplines with standardized patients.30

While each of the aforementioned studies hold promise, further studies are needed to evaluate whether these approaches will translate into lower firearm injury risk and lower rates of firearm-related injury and death. Broad, multidimensional measures using a public health approach will be required to lower the incidence of firearm injury in the US, and devising scientifically sound public health interventions that can be broadly applied to clinical practice will be required.

On the forefront of injury prevention is gaining a better understanding of how social and economic factors play a role in intentional and unintentional injury. For years, the medical community has accepted social determinants of health (SDH) and socioeconomic disparities as factors that are important in the development of medical diseases and for chronic disease prevention. Though injury is the leading cause of morbidity and mortality, the burden of injury is not shared equally among the population in the US. In fact, minority populations have historically and continue to bear a disproportionate burden of violent injury and death in the US. In addition to this, minority populations are also more likely to have worse outcomes and higher rates of mortality following traumatic injury.31, 32, 33 Therefore, understanding and leveraging primordial prevention strategies can be instrumental in ongoing and future injury prevention efforts.

Many tools exist for studying SDH which in turn can be used to study SDI. The ones used most often include the Hazards & Vulnerability Research Institute's Social Vulnerability Index (SoVI), Economic Innovation Group's Distressed Community Index (DCI), Index of Concentration at the Extremes (ICE), Area Deprivation Index (ADI), and the Social Vulnerability Index (SVI). The SVI is a composite measure developed by the CDC that is geocoded at the census tract level. This tool is comprised of fifteen societal factors that have been grouped into four themes: socioeconomic status; household composition; minority status and language; and English proficiency, housing, and transportation. The SVI was initially developed to help with disaster preparedness; however, it has also been utilized in identifying at-risk populations for traumatic injury.34,35

Indices, such as the SVI, are important because they move away from the simplistic determination of risk of injury, and therefore efforts to prevent it, based on individual patient demographic data, and focus on a vast array of other social domains that have an inherent geospatial component. This acknowledges that injury prevention efforts are not a “one size fits all” endeavor. Rather, providing data about societal determinants and distribution of injury at the community-level is more relevant and can be used for policy and program implementation that is tailored towards the individual needs of the community.

In the last several years there has been a growing interest and effort amongst trauma providers to look beyond addressing the physical injury and identify ways to address the risk factors associated with violent injury. One focus of the discussions during the Medical Summit on Firearm Injury Prevention in 2019 involved addressing violence by going upstream to understand and mitigate the root causes of violence (Figure 2).36 Significant attention gravitated towards the SDH as the focal point when addressing upstream factors associated with violence, i.e., primordial prevention strategies. To address this, the ACS Committee on Trauma (COT) leadership established the Improving the Social Determinants to Attenuate Violence (ISAVE) work group under the leadership of Dr. Rochelle Dicker.37 ISAVE is composed of a multi-disciplinary group that includes physicians, community-based organization representatives, hospital-based violence intervention programs, and law enforcement, with a common focus on shifting the paradigm of care for survivors of violence to create a more holistic approach. Four main ISAVE initiatives have been developed:

1)

Development of a Trauma Informed Care Curriculum

2)

Investment in at-risk communities

3)

Integrating social care into trauma care, and

4)

Advocacy.

Through this work, there is a potential to better understand the relationship that exists between injury and SDI. It is possible that this relationship is determined by a threshold or gradient effect, or likely a combination of the two, that will be informed by future research in this arena.

Hospital-based Violence Intervention Programs (HVIPs) have been around in some measure for more than three decades. There is now a national organization, The Health Alliance for Violence Intervention (HAVI) that was formerly known as the The National Network of Hospital-based Violence Intervention Programs, seeking to build the evidence-base around what works and what does not work among hospital models. The HAVI is also building a rigorous training program that provides a base-level Violence Prevention Professional (VPP) certification. The purpose of HVIPs is to prevent violent re-injury and retaliation, and to support care and recovery with a trauma informed approach.38 That being said, there is a wide variety in HVIP implementations from types of staffing to services provided. At its core all HVIPs do the following: a) connect a specialist to injured patients and their families in the hospital at the bedside, b) provide crisis intervention, c) refer to community resources based on assessed needs, d) follow-up post discharge, and, e) provide long-term case management.38 Another key to HVIPs has to be the centrality to all HVIP Models of the need for a trauma informed approach that is based in recognizing cultural difference, bias, racism, and valuing of lived experience.39

While gaps in the literature exist, evidence supports the efficacy of HVIP programs in reducing re-victimization and retaliation for victims with gunshot wounds.40, 41, 42 Some studies have shown a reduction in overall rates of firearm violence in specific geographic areas.43 Additional research has examined the cost-benefit of HVIP services, revealing that these services can prove to be cost effective when looking at the financial burden of repeated injuries.44,45 Some HVIP and/or street intervention models are exploring the additional impact of poverty alleviation strategies as a means for addressing financially driven social determinants of health that serve to drive violence exposure.46

Much work remains to determine the particular aspects of HVIPs that are driving change for patients and their families. This will be key as organizations like The HAVI seek to develop models that have replicable components. Some evidence points to the importance of addressing mental health and employment as predictors of success.47 And, because these programs target the violently injured of all ages, the field still has a lot to learn about the differences in supporting adult versus minor patients. Some reports indicate that engagement of HVIPs with youth can be challenging with at least one study reporting a particular issue with low rates of youth engagement.48

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