Near miss and minor injury information — can it be used to plan and evaluate injury prevention programmes?
Introduction
Unintentional injuries occurring in the home environment disproportionately effect the health of every child from the age of 1 year and onwards. Evidence of the impact of injuries to children's health is provided by the statistics which show that unintentional injuries accounted for 218 deaths in children aged 0–4 years in 1995 (ONS, 1997). The overwhelming majority of unintentional injuries are however non-fatal. In England and Wales in 1995 approximately 545 000 children aged 0–4 years suffered an unintentional injury which caused them to attend an accident and emergency department (HASS, 1995). Within the primary health care setting 1 in 8 children in a general practice population will attend a surgery because of an injury (ONS, 1997, RCGP, 1995). Home is the locality in which the majority of injuries that require children under 5 years to be admitted to hospital occur (Alwash and McCarthy, 1988).
Reducing the incidence and severity of childhood injuries is recognised as a public health priority (DOH, 1996). Information on mortality from injuries collected by national injury surveillance systems such as the Office of National Statistics (ONS) and Police ‘Stats 19’ system, is used to determine priorities for prevention. At the local level, accident and emergency departments, general practice records and local coroners records provide sources of information (Benson, 1993).
Although death is clearly an important outcome of injury, injury related fatalities are relatively rare, representing less than 1% of all treated injuries (Guyer and Gallagher, 1985). Their rarity and the wide variation in injury epidemiology between communities limits the use of mortality data in planning and evaluating local injury prevention programmes (Graitcer, 1987, Pless, 1992, DOH, 1993, Marsh and Kendrick, 1995, Benson, 1995, Stone and Doraiswamy, 1996).
Morbidity data, as measured by attendances at accident and emergency departments, provides an enormous amount of information regarding childhood injuries which is useful and important in monitoring the effectiveness of prevention initiatives. However the addition of non-fatal injuries, still only represents the ‘tip of the iceberg’ of injuries occurring in a community (Walsh and Jarvis, 1992, Marsh and Kendrick, 1995, Benson, 1995). This ‘iceberg’ of morbidity prevents a simple conclusion being drawn merely from medical attendances as an evaluation of prevention programmes (Alwash and McCarthy, 1988).
None of the information presently available provides a complete picture of childhood injuries with important gaps in our knowledge remaining such as, the absence of information on childhood injuries which do not report for medical attention-minor injuries (Benson, 1993) and those in which no injury occurred, ‘near misses’ (Peterson et al., 1993). Minor injuries and near miss incidents occur at a higher rate than more severe injuries and it would be useful if information from the study of these more common incidents could be used for injury prevention purposes (Laughery and Vaubel, 1993).
If it can be shown that the causes of potential injury producing events (near misses) and injury producing events are similar, then the planning of prevention efforts aimed at reducing all injuries could benefit from this additional information source (Laughery and Vaubel, 1993). For such information to have any relevance to the evaluation of intervention strategies it is also necessary to establish how well knowing a child had a near miss and/or minor injury predicts the likelihood of that child having a future injury which requires medical attention. If the predictive value of such information is high, then researchers conducting intervention programmes, can, by using near miss and minor injuries as an outcome measure, evaluate the effectiveness of their programmes over shorter time periods using smaller populations.
Although in the field of childhood injury research little work has been done on the relationship between non-injury and injury producing events, studies carried out in the occupational setting have shown a consistent relationship between these incidents (Lees and Laundry, 1989).
Measuring such incidents is difficult because they do not, by definition, report to the health service and therefore can only be measured by self-reports from parents. Retrospective studies have been carried out using questionnaire postal surveys (Spencer et al., 1954) and interview methods Peterson et al. (1993), however the results of such studies strongly rely on the assumption that parents can recall such events accurately (Harel et al., 1994). The use of diaries as a data collection method in health and social research has been increasing (Corti, 1993, Gibson, 1995) mainly because they have very high rates of compliance and produce detailed information whilst reducing the problem of recall error (Gibson, 1995).
In the field of childhood injuries no previous diary based research appears to have been undertaken using parents of children aged under 5 years to record such information. The purpose of the study therefore was: to use information recorded by parents using a diary method to compare the circumstances surrounding near miss and minor injuries recorded in the diary with those recorded on medically attended injuries and asses the relationship between the occurrence of near miss and minor injuries with future medically attended injuries.
Section snippets
Setting
The diary study was set within the context of a controlled intervention project based in 18 randomly selected practices and 18 matched control practices in Nottinghamshire.
Study population
The controlled intervention study population included all children registered with each of the 36 practices on June 30th 1995 and aged between 3 and 12 months. A total of 2152 questionnaires were mailed to the parents of the children selected (1124 in the intervention group, 1028 in the control group). The 1594 (823 from the
Response rates
Overall 434 diaries were sent out and 236 (54%) parents returned a completed diary, five could not be entered into the analysis as the reference number had been removed. A total of 231 (53%) diaries were analysed.
Characteristics of responders and non-responders
The only significant difference shown between responder and non-responder groups was that non-responders were less likely to have access to a car (Table 1). The practice Jarman scores for both groups lay within a similar range (responders 25.63–44.79, non-responders 26.17–43.52).
Discussion
The main focus of the study was to establish whether the circumstances surrounding near miss and minor injuries were similar to those of medically attended injuries. Overall, analysis of the data revealed a common pattern of causal factors between the three incident categories. The descriptions given by parents regarding the circumstances surrounding these incidents may be useful in planning prevention programmes. However there did not appear to be a strong relationship between the occurrence
Conclusion
Although some differences were found in the causal factors surrounding non-injury and injury producing events, overall, similar patterns in the circumstances surrounding the incidents were demonstrated. These findings suggest the causation of all injury and non-injury incidents may be similar. The numbers in this study were to small to see whether specific injury mechanisms predict future injuries of the same type and to make an accurate assessment of the relationship between near miss, minor
Acknowledgements
We would like to thank Trent Regional Health Authority, NHS Executive for funding the project. Our thanks go to Dr Dove, Consultant in Accident and Emergency Medicine and the Department of Information Management and Technology for help in accessing the manual records. Finally we would like to thank all of the parents who participated in the project by completing a diary.
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