Mariana J. Brussoni

Risky Play and Children’s Safety: Balancing Priorities for Optimal Child Development

Injury prevention plays a key role in keeping children safe, but emerging research suggests that imposing too many restrictions on children’s outdoor risky play hinders their development. We explore the relationship between child development, play, and conceptions of risk taking with the aim of informing child injury prevention. Generational trends indicate children’s diminishing engagement in outdoor play is influenced by parental and societal concerns. We outline the importance of play as a necessary ingredient for healthy child development and review the evidence for arguments supporting the need for outdoor risky play, including: (1) children have a natural propensity towards risky play; and, (2) keeping children safe involves letting them take and manage risks. Literature from many disciplines supports the notion that safety efforts should be balanced with opportunities for child development through outdoor risky play. New avenues for investigation and action are emerging seeking optimal strategies for keeping children “as safe as necessary,” not “as safe as possible.” This paradigm shift represents a potential for epistemological growth as well as cross-disciplinary collaboration to foster optimal child development while preserving children’s safety.

Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review.

Objective: To identify risk factors for unintentional injuries due to falls in children aged 0–6 years. Design: A systematic review of the literature. Methods: Electronic databases from 1966 to March 2005 were comprehensively searched to identify empirical research that evaluated risk factors for unintentional injuries due to falls in children aged 0–6 years and included a comparison group. Results: 14 studies met the inclusion criteria. Studies varied by the type of fall injury that was considered (ie, bunk bed, stairway, playground or infant walker) and with respect to the quality of evidence. In general, major risk factors for the incidence or severity of injuries due to falls in children included age of the child, sex, height of the fall, type of surface, mechanism (dropped, stairway or using a walker), setting (day care v home care) and socioeconomic status. Conclusion: Despite a high burden, few controlled studies have examined the risk and protective factors for injuries due to falls in children aged 0–6 years. The only study to examine falls from a population health perspective suggests that age, sex and poverty are independent risk factors for injuries due to falls in children.

What is the Relationship between Risky Outdoor Play and Health in Children? A Systematic Review

Risky outdoor play has been associated with promoting children’s health and development, but also with injury and death. Risky outdoor play has diminished over time, concurrent with increasing concerns regarding child safety and emphasis on injury prevention. We sought to conduct a systematic review to examine the relationship between risky outdoor play and health in children, in order to inform the debate regarding its benefits and harms. We identified and evaluated 21 relevant papers for quality using the GRADE framework. Included articles addressed the effect on health indicators and behaviours from three types of risky play, as well as risky play supportive environments. The systematic review revealed overall positive effects of risky outdoor play on a variety of health indicators and behaviours, most commonly physical activity, but also social health and behaviours, injuries, and aggression. The review indicated the need for additional “good quality” studies; however, we note that even in the face of the generally exclusionary systematic review process, our findings support the promotion of risky outdoor play for healthy child development. These positive results with the marked reduction in risky outdoor play opportunities in recent generations indicate the need to encourage action to support children’s risky outdoor play opportunities. Policy and practice precedents and recommendations for action are discussed.

Position Statement on Active Outdoor Play

A diverse, cross-sectorial group of partners, stakeholders and researchers, collaborated to develop an evidence-informed Position Statement on active outdoor play for children aged 3–12 years. The Position Statement was created in response to practitioner, academic, legal, insurance and public debate, dialogue and disagreement on the relative benefits and harms of active (including risky) outdoor play. The Position Statement development process was informed by two systematic reviews, a critical appraisal of the current literature and existing position statements, engagement of research experts (N = 9) and cross-sectorial individuals/organizations (N = 17), and an extensive stakeholder consultation process (N = 1908). More than 95% of the stakeholders consulted strongly agreed or somewhat agreed with the Position Statement; 14/17 participating individuals/organizations endorsed it; and over 1000 additional individuals and organizations requested their name be listed as a supporter. The final Position Statement on Active Outdoor Play states: “Access to active play in nature and outdoors—with its risks— is essential for healthy child development. We recommend increasing children’s opportunities for self-directed play outdoors in all settings—at home, at school, in child care, the community and nature.” The full Position Statement provides context for the statement, evidence supporting it, and a series of recommendations to increase active outdoor play opportunities to promote healthy child development.

Unintentional injuries in school-aged children and adolescents: lessons from a systematic review of cohort studies

Objectives: To critically synthesise current knowledge of the patterns of injuries and risk factors for injury in school-aged children, to summarise the evidence and support effective child injury prevention initiatives. Design: Systematic review. Selection criteria and methods: Prospective cohort studies reporting unintentional injuries in healthy children aged 5–18 years were identified by searching 15 electronic databases and additional grey literature sources. A narrative synthesis was conducted of papers meeting quality criteria, with risk factors analysed at individual, family and environmental levels. Limitations of existing evidence were considered. Results: 44 papers from 18 different cohort studies met the inclusion criteria. There were broad and consistent patterns of injury across time and place. Male sex, psychological, behavioural and risk-taking behaviour problems, having a large number of siblings, and a young mother were all associated with increased injury occurrence across more than one cohort and setting. Conclusions: Descriptive epidemiology and risk factors for injury were derived from prospective cohort studies, but few studies used the full potential of their design. Opportunities to use repeated measures to assess temporal changes in injury occurrence, and the exploration of risk factors, particularly those related to the child’s environment, have rarely been undertaken. Few studies were conducted in low/middle-income countries where the burden of injury is greatest. These findings should be considered when planning future research and prevention initiatives.

Evidence into practice: combining the art and science of injury prevention

Objectives: To bring together scientific evidence of what works in injury prevention with the knowledge and experience of practitioners, using a case study of smoke alarm installation from England. Design: There is good evidence of strategies to reduce injuries but less is known about the art of translating those strategies to implementation in real-world settings. England’s Health Development Agency developed a structured process applicable to many public health fields, which integrates practitioner knowledge into the evidence base and reflects local contexts. The multistep process includes convening structured field meetings with local practitioners and policy makers, which focus on a mapping exercise of strategies, policies, targets, and funding streams related to childhood injury prevention, and barriers and facilitators relating to implementation of specific interventions. Setting: Meetings were held in six venues across England with 98 participants from a range of professional backgrounds and sectors. Results: The collective knowledge of participants provided many local insights unlikely to emerge in conventional research. Discussion topics covered key partners and sectors to include when planning a program; national policies and programs that could be used to drive the agenda; potential sources of funding; the importance of providing and installing appropriate smoke alarms; targeting of programs; and suggestions for gaining access to hard-to-reach populations. Conclusion: This methodology represents an efficient way of gaining insight necessary for successful implementation of evidence based programs. It may be particularly useful in lower and middle income countries, serving to translate evidence into the local contexts and circumstances within which practitioners operate.

Child motor vehicle occupant and pedestrian casualties before and after enactment of child restraint seats legislation in Japan.

Problem. Prevention of injuries to child passengers is a significant public health priority, as motor vehicle-related injuries remain a leading cause of death for children in Japan. The purpose of compulsory child restraint seats legislation in April 2000 was to reduce the number of child passengers killed or injured in motor vehicle crashes. Methods. The objectives of this preliminary evaluation are to measure the effectiveness, benefits and usage of safety seats for child passengers aged 1–5 years by analysing the child casualty data for the period of 1997–2002. Population and vehicle miles travelled based injury and fatality rates were used to compare before and after legislation trends in child casualties. Results. Despite overall increases in the use of child restraint seats (as observed by different national surveys), overall casualty rates in motor vehicle occupants in the 1–5 year age group did not change (fatalities and serious injuries) or even increased (minor injuries). Conclusions. Casualties among restrained children have not decreased since the law came to effect in the year 2000, perhaps because of incorrect usage of the seats. Given that exposure to crash environments is increasing, traffic safety advocates and public health community need to be aware of the importance of child restraints as a means of reducing the likelihood of injury. It is necessary to implement effective community-based child safety seat campaigns to disseminate the information on appropriate restraint use and to increase efforts to enforce the existing legislation.

Men on Fathering in the Context of Children’s Unintentional Injury Prevention

Injuries are a leading cause of death for children, and parental safety behaviors are fundamental to child injury prevention. Fathers’ perspectives are largely absent. Our novel research connects masculinities, fathering, and childhood injury. Sixteen fathers of children aged 2 to 7 years in two Canadian urban settings participated in photo-elicitation interviews detailing activities they enjoyed with their children and concerns regarding child safety. Participants described how elements of risk, protection, and emotional connection influenced their approach to fathering as it related to injury prevention. Most men considered engaging children in risk as key to facilitating development and described strategies for protecting their children while engaging in risk. Many men identified how the presence of an emotional connection to their children allowed them to gauge optimal levels of risk and protection. There exists a tremendous opportunity to work with fathers to assist in their efforts to keep their children safe.

The Advocacy in Action Study a cluster randomized controlled trial to reduce pedestrian injuries in deprived communities

Background Road trafficrelated injury is a major global public health problem. In most countries, pedestrian injuries occur predominantly to the poorest in society. A number of evaluated interventions are effective in reducing these injuries. Very little research has been carried out into the distribution and determinants of the uptake of these interventions. Previous research has shown an association between local political influence and the distribution of traffic calming after adjustment for historical crash patterns. This led to the hypothesis that advocacy could be used to increase local politicians knowledge of pedestrian injury risk and effective interventions, ultimately resulting in improved pedestrian safety. Objective To design an intervention to improve the uptake of pedestrian safety measures in deprived communities. Setting Electoral wards in deprived areas of England and Wales with a poor record of pedestrian safety for children and older adults. Methods Design mixedmethods study, incorporating a cluster randomized controlled trial. Data mixture of Geographical Information Systems data collision locations, road safety interventions, telephone interviews, and questionnaires. Randomization 239 electoral wards clustered within 57 local authorities. Participants 615 politicians representing intervention and control wards. Intervention a package of tailored information including maps of pedestrian injuries was designed for intervention politicians, and a general information pack for controls. Outcome measures Primary outcome number of road safety interventions 25months after randomization. Secondary outcomes politicians interest and involvement in injury prevention cost of interventions. Process evaluation use of advocacy pack, facilitators and barriers to involvement, and success.

Injury hospitalizations due to unintentional falls among the Aboriginal population of British Columbia, Canada: incidence, changes over time, and ecological analysis of risk markers, 1991-2010

Background Aboriginal people in British Columbia (BC) have higher injury incidence than the general population. Our project describes variability among injury categories, time periods, and geographic, demographic and socio-economic groups. This report focuses on unintentional falls. Methods We used BC’s universal health care insurance plan as a population registry, linked to hospital separation and vital statistics databases. We identified Aboriginal people by insurance premium group and birth and death record notations. We identified residents of specific Aboriginal communities by postal code. We calculated crude incidence and Standardized Relative Risk (SRR) of hospitalization for unintentional fall injury, standardized for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. We tested hypothesized associations of geographic, socio-economic, and employment-related characteristics with community SRR of injury by linear regression. Results During 1991 through 2010, the crude rate of hospitalization for unintentional fall injury in BC was 33.6 per 10,000 person-years. The Aboriginal rate was 49.9 per 10,000 and SRR was 1.89 (95% confidence interval 1.85-1.94). Among those living on reserves SRR was 2.00 (95% CI 1.93-2.07). Northern and non-urban HSDAs had higher SRRs, within both total and Aboriginal populations. In every age and gender category, the HSDA-standardized SRR was higher among the Aboriginal than among the total population. Between 1991 and 2010, crude rates and SRRs declined substantially, but proportionally more among the Aboriginal population, so the gap between the Aboriginal and total population is narrowing, particularly among females and older adults. These community characteristics were associated with higher risk: lower income, lower educational level, worse housing conditions, and more hazardous types of employment. Conclusions Over the years, as socio-economic conditions improve, risk of hospitalization due to unintentional fall injury has declined among the Aboriginal population. Women and older adults have benefited more.