Preventing unintentional injuries in childhood in primary care
Unintentional injuries in childhood are a major cause of mortality and morbidity. Numerous risk factors for unintentional injury have been identified over recent years, and there have been several suggestions that injury prevention programmes should be targeted at children identified as high risk, based on these risk factors. There has also been increasing interest in, and emphasis on, the role of members of the primary health care team in preventing unintentional injuries to children, including within recent government policy. There is some evidence, so far, that primary care interventions can be effective in reducing hazards, increasing knowledge and changing behaviour. There is however, less evidence that they can be effective in reducing injury frequency or severity, with very few studies of high quality addressing this issue. The objectives of the research presented in this thesis are: 1.) to examine the relationship between accident and emergency department attendance and future hospital admission following unintentional injury, and to consider the transmission of injury data between secondary and primary care and the uses of such data within primary care; 2.) to examine the associations between risk factors for childhood injury and a variety of injury outcomes and to calculate the sensitivity, specificity and positive predictive value for risk factors in identifying children who will subsequently suffer an unintentional injury, and to consider high risk group and whole population strategies for injury prevention in the light of the findings; 3.) to assess knowledge, attitudes and current practices in childhood injury prevention amongst members of the primary health care team and to consider the implications of the findings for injury prevention in primary care. The first objective has been achieved by a matched case-control study. The main findings were that children who had been admitted to hospital following an unintentional injury were twice as likely to have previously attended the accident and emergency (A&E) department than community controls. However, only one third of hospital admissions had a history of previous A&E department attendance, hence most of the children admitted to hospital would not have been identified using A&E attendance. Current practice in many A&E departments is that a paediatric liaison health visitor notifies the community health visitor of children attending A&E following injury. Most authors in the field discuss post injury follow up visits as an appropriate response to receipt of such notifications, but there is little evidence for their effectiveness, and several studies show such visits are perceived to be difficult for both parents and health visitors. There is little evidence that, at present, injury data transmitted from secondary care is collated in a systematic way, to be used in primary care for needs assessment or injury surveillance. It is therefore recommended that the role of the paediatric liaison health visitor in the collection and transmission of injury data is in need of further consideration, and that post injury follow up visits require further study to demonstrate their effectiveness. The second objective has been achieved by a cross sectional survey followed by a cohort study. The main findings from this study are that only previous injury and male sex were associated with A&E department attendance and only previous injury with primary health care team attendance, despite sufficient power to demonstrate associations for several other risk factors. Consequently the sensitivity and positive predictive value of the risk factors in identifying children who will suffer previous injury was found to be low. The specificity was high for most risk factors, suggesting they will miss most children who will have injuries but will correctly identify most children who will not suffer future injury. The number of children needing to be targeted with an intervention to prevent one injury was similar for most risk factors, and similar to that if the whole population received an intervention. The results could not be adequately explained by bias, confounding or insufficient power Further work examining associations between risk fectors and unintentional injury in childhood is needed with larger sample sizes and in a population with a wide cross section of socioeconomic status to confirm these findings. At present, it is recommended that injury prevention programmes in primary care use a population approach. The third objective was achieved by a cross sectional survey of general practitioners, practice nurses and health visitors in Nottinghamshire. The main findings from this survey were that health visitors had a significantly higher score for knowledge of childhood unintentional injury epidemiology than general practitioners or practice nurses. They held significantly more positive attitudes to, and were undertaking significantly more injury prevention than, both general practitioners and practice nurses. Despite this both general practitioners and practice nurses held positive attitudes to at least some injury prevention activities. The activities most commonly undertaken were those using a preventive model of health education, for all professional groups. Activities involving empowerment or radical or political models of health education were used less often. There was little evidence of a systematic approach to injury prevention, with prevention occurring most often opportunistically. For all activities, and across all professional groups, a greater proportion of respondents agreed that an activity should be undertaken than actually undertook that activity, suggesting there may be barriers to undertaking injury prevention in primary care. The difference between the proportion agreeing an activity should be undertaken and doing so, was greatest for lobbying or campaigning and for collecting injury data. The conclusions from this study are that current injury prevention practice, which often uses a preventive model of health education, often as an isolated approach, and most often opportunistically, may not be the most effective strategy for reducing unintentional injuries in primary care. Further studies are needed to assess the effectiveness of primary health care team interventions offered systematically, using a combination of health education models and approaches. Such studies must address the barriers to injury prevention in primary care. The findings from this study suggest there is already some knowledge, and positive attitudes towards injury prevention, amongst at least some primary health care team members, on which to build interest in such future research. NB. This ethesis has been created by scanning the typescript original and contains some inaccuracies. In case of difficulty, please refer to the original text.