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Abstract
To report public health practitioners’ perceptions of injury prevention in Changsha, China. We undertook a cross-sectional study at Changsha, Hunan, China. An anonymous self-reported survey was conducted to ascertain the proportion of respondents who answered negatively to questions about the value of injury prevention. Over 20% of respondents answered ‘unpreventable’ or ‘don't know’ to whether injuries from natural environmental disaster, homicide/assault, poisoning, animal bite, cut/pierce, suffocation and electric current were preventable. More than 40% of respondents answered ‘no’ or ‘don't know’ to whether the prevention of injuries from homicide/assault, cut/pierce, fall, suicide/self-harm, drowning, road traffic crash and fire/burn belonged to the job of public health. Only 48% of respondents supported building a division/office within the Centers for Disease Control and Preventions at all levels. Many public health practitioners in Changsha had misperception about injury prevention. Education and training are needed to correct their misperception.
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Introduction
Although injuries are the fifth leading cause of death in China,1 injury control has received little support from the government and has been excluded from the list of public health priorities.2–4 The current state of injury control in China is very similar to that in the USA three decades ago when injuries were not widely recognised as a public health problem.5 A widely circulated explanation among the injury prevention community in the USA was that people believed that injuries are not preventable.5 This also applies to China and may explain why injury control has not been listed as a priority in public health.
The global injury control community has for many years believed that: (1) most injuries are preventable; and (2) injury prevention belongs in public health. These conclusions, however, may not be evident to public health practitioners in China because injury prevention is absent from public health education in almost all medical colleges and universities.3
Public health practitioners are primarily responsible for the surveillance and control of infectious and parasitic diseases, poisoning, nutritional diseases and diseases due to radiation and environmental pollution, public health emergencies, health education and health promotion, laboratory tests, and vaccination at the local level in China.6 Misperceptions about injury prevention could explain why injury control rarely receives the support of government or the attention of the funders in China.
Early studies examined public perceptions about the word ‘accident’7 as well as effective strategies to prevent death from common injuries,8 parents’ perceptions, attitudes and behaviours toward child safety,9 and the attitudes of older persons toward falls and injury prevention.10 These studies also provided important evidence on the promotion of injury prevention in some countries. Girasek11 also stressed the importance of risk communication science to the development of injury prevention. However, no one has studied public health practitioners’ perceptions of injury prevention. To examine the perceptions of public health practitioners about injury prevention in China, we conducted a cross-sectional survey at Changsha.
Methods
Study subjects
Because (1) the 32 Chinese province-level Centers for Disease Control and Prevention (CDC) do not have an office responsible for injury prevention except for Shanghai and Guangxi12 and (2) few active CDC employees have received education or training in injury prevention,13 the perception of Changsha CDCs public health practitioners likely reflects the perceptions of the majority of public health practitioners in China.
Changsha is the capital city of Hunan Province, China, including a municipal CDC and nine district CDCs at Changsha. The target public health practitioners were employees of the municipal CDC and nine district CDCs. We aimed to sample a third of all CDC employees at Changsha. We generated a convenience sample; questionnaires were distributed to all practitioners who were present on the day of the survey.
Survey questionnaire
Because there is no Chinese version questionnaire for the assessment of injury prevention perceptions, we developed the survey questionnaire based on early reports in other countries5 ,14 and tested it through a pilot survey of 10 public health practitioners. Unlike the other questionnaires, we did not use a 5-point scale14 or a 0–100 scale5 in the formal questionnaire to quantify perceptions because the pilot test showed that study subjects found it difficult to respond to in this manner. Pilot test participants suggested that in addition to ‘yes’ and ‘no’, the option ‘don't know’ should be included. Sociodemographic variables were included in the survey questionnaire.
Three questions were used to evaluate perceptions of injury prevention:
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Are the following injuries preventable? The options were ‘mostly preventable’, ‘unpreventable’ and ‘don't know’.
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Should prevention of the following injuries be the job of public health? The options were ‘yes’, ‘no’ and ‘don't know’.
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Should a division or office be established to take charge of injury control within CDC at all levels? The options were ‘yes’, ‘no’ and ‘don't know’.
Data collection
Because it was hard to convene all employees of the municipal CDC and nine district CDCs to complete the survey, we asked a senior officer at the municipal CDC to help coordinate the survey. At the municipal CDC, the senior officer sent the questionnaires to the professional divisions (non-administrative and non-logistic) and asked the employees who were present at the office to complete the self-reported questionnaire. For the survey at each district CDC, the municipal senior officer sent the questionnaires to each district CDC and asked the administrative division to help to distribute the questionnaires to the employees at meeting time and to collect the questionnaires when they were completed. After 1 week, the senior officer collected the completed questionnaires from the municipal and district CDCs.
The decision to take part in the survey completely depended on the employees themselves. All questionnaires were self-administered by public health practitioners anonymously. This study was approved by the Central South University Ethics Committee and informed consent was obtained before proceeding with the questionnaire. The survey was completed at the Changsha CDC and subordinate CDCs by paper questionnaire between 10 March and 17 March 2012.
Statistical analysis
The collected data were entered and analysed using Microsoft Excel 2010. Frequencies and percentages were used to measure the participants’ perceptions of injury prevention.
Results
A total of 279 public health practitioners participated in the survey, with a valid response rate of 98%. Forty-five per cent were men and 12% had received a master's degree or higher education.
From 10% to 46% of respondents answered ‘unpreventable’ or ‘don't know’ when asked whether most injuries were preventable for homicide/assault, poisoning, animal bite, cut/pierce, suffocation, electric current, fall, suicide/self-harm, road traffic crash, drowning and fire/burn (figure 1). Seventy-eight per cent of respondents answered ‘no’ or ‘don't know’ when asked if injuries due to natural environmental disasters were preventable.
Percent of respondents who answered ‘unpreventable’ or ‘don't know’ to ‘whether the following injuries are mostly preventable’.
Over 40% of respondents answered ‘no’ or ‘don't know’ when asked if the prevention of injuries from homicide/assault, cut/pierce, fall, suicide/self-harm, drowning, road traffic crash and fire/burn was within the scope of public health practice (figure 2). Approximately 90% of respondents regarded the prevention of animal bites (89%) and poisoning (92%) as within the domain of public health.
Percent of respondents who answered ‘no’ or ‘don't know’ to whether the prevention of following injuries belonged to the job of public health.
Fifty-two per cent of respondents did not agree that it was necessary to establish a division or office within the CDCs of all levels in China to take charge of injury control, with a 95% CI of 46% to 58%.
The results of subgroup analysis were not included because they were very similar to the results for all study subjects.
Discussion
This was the first study to examine the perception of injury prevention among public health practitioners in China. We found that (1) many respondents answered ‘unpreventable’ or ‘don't know’ when asked if most injuries were preventable, especially injuries due to natural environmental disaster (78%) and homicide/assault (45%); (2) more than 40% answered ‘no’ or ‘don't know’ when asked whether the prevention of injuries from homicide/assault, cut/pierce, fall, suicide/self-harm, drowning, road traffic crash and fire/burn was within the purview of public health; and (3) only 48% of respondents supported building an injury prevention division within CDCs at all levels in China.
These results were similar to those among 943 adult Americans (56% of whom agreed that 'fatal accidents’ were preventable).5 A larger proportion (84%) of 5282 New Zealanders agreed that ‘most injuries are preventable’.14
Our findings emphasise the fact that many public health practitioners in China have misconceptions about injury prevention. This may be due to the lack of education and training in injury prevention in China. To date, most colleges and universities have not developed injury prevention courses for medical students.3 At present, only two provinces (Shanghai and Guangxi) have a division/office that is responsible for injury prevention.12 There are few training programmes related to injury prevention at the central and provincial level since injury prevention is not included in the routine job of CDCs. Based on the latest statistics by Duan, the Director of the Office of Injury Prevention and Control, China Disease Prevention and Control Center, there are at most 1000 public health practitioners of CDCs at all levels who have received injury prevention training.13
The extent of misconceptions about injury prevention is exemplified by the fact that 78% of respondents did not agree that injuries in natural disasters were preventable. In fact, many deaths due to disasters can be avoided when appropriate preventive measures and treatment are taken. A retrospective analysis showed that most deaths of the Wenchuan earthquake were due to cardiopulmonary arrest, severe craniocerebral injury, haemorrhagic shock, and crush syndrome; many deaths could have been prevented by strengthening onsite emergency medical resources, speeding-up triage and equipping responders with professional, portable medical equipment.15 Public health officials and practitioners can intervene in advance of and after disaster to reduce postdisaster injuries. The safety of homes and the work environment can be improved by building standards that require use of safer materials.16 Measures to prevent earthquake-induced injuries include securing appliances, securing hanging items on walls or overhead, turning off utilities, storing hazardous materials in safe, well ventilated areas and checking homes for hazards such as windows and glass that might shatter.16
Erroneous beliefs are impediments to injury prevention.17 To change the misconception of public health practitioners, the central government of China could: (1) include injury prevention in the education of medical students; (2) provide training in injury prevention to active public health practitioners; and (3) assign the leading role of injury prevention to the health sector. In most of the world, the health sector is given the leadership role in injury prevention.18 However, in China injury prevention has never been clearly assigned as the responsibility of government departments at the central level, making public health practitioners erroneously believe that injury prevention does not belong in public health. Four kinds of roles of the health sector that are suggested by the WHO (leadership role, catalytic role, coordinating role and supportive role),18 could be a basis for China to allocate the responsibility for injury prevention to the health sector.
Our findings were limited by the selection of the study sample and the survey questionnaire. First, the study subjects, a convenience sample, may not be a representative sample of Changsha public health practitioners, and cannot represent all public health practitioners in China. Second, the survey questionnaire was based on three-option questions, and could not provide a quantitative assessment of injury prevention perceptions to be compared with other published studies.5 ,14 In addition, the self-administration of survey questionnaires may have some influence on the results although the survey was anonymous and took less than 5 min.
In conclusion, many public health practitioners in China have erroneous perceptions about the preventability of injury and do not regard injury prevention as within the job of public health. In order to promote injury prevention in China, education and training should be provided to medical students and to active public health practitioners.
What is already known on this subject
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That injuries are mostly preventable is widely known at the global injury control community.
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It has been recognised throughout the world that injury prevention belongs within the job of public health.
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Nothing is known about the perception of injury prevention among public health practitioners of China.
What this study adds
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Many public health practitioners disagreed with or did not know that ‘most injuries are preventable’.
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Many public health practitioners disagreed with or did not know that ‘the prevention of injuries belongs to the job of public health’.
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Only 48% of respondents were in favour of establishing a division/office within CDCs at all levels in China.
A move in the right direction
In the province of Ontario, the fine for distracted driving has been increased from $C 125 to $C 225. This totals $C 280 when all surcharges are included. If a driver decides to go to court to fight a ticket and loses, the total would be about $C 500. If the driver is judged to have endangered others because of distraction, the fine could be as high as $C 2000 with 6 demerit points or 6 months in jail or both or 2 years with license suspension. (Noted by IBP)
And one in the wrong direction
A California appeals court has decided that reading a hand-held cellphone map while driving is legal. The court reversed the case of a man ticketed for looking at a map on his smartphone while stuck in traffic. The driver challenged the US$ 165 fine because he was stationary and an appellate court concluded that the law does not apply to looking at maps on mobile phones, only to ‘listening and talking’. (Noted by IBP)
Hearse used in distracted driving campaign
Toronto police use a hearse and the slogan ‘That Text or Call Could End It All’ to warn drivers about the dangers of texting. Since 2011, over 55 000 distracted driving charges have been laid. It is also illegal for drivers to look at display screens unrelated to driving. (Noted by IBP)
Mouthguards in sport injury prevention
Orofacial injuries are 1.5–2 times greater when a mouthguard is not worn during many sports. The cost to treat a lost front tooth can reach $C 10 000, yet a custom-fitted device can be as cheap as $C 50. Many sports could benefit from mandatory mouth protection. (Noted by IBP)
More brain trauma from MMA versus other martial arts
A study based on medical records and videos from 844 bouts of professional mixed martial arts (MMA) notes that about a third end in knockout or technical knockout. This is a higher rate of brain trauma than in boxing or other martial arts. It is even greater than American football and ice hockey. New York is the only state that prohibits MMA bouts. (Noted by IBP)
Acknowledgments
This study was supported by the 2009 New Century Scholar Support Program of the Ministry of Education of China (NCET-10-0782) and funded in part by Grant Number R49CE001507 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. We also thanked Mr Tianmu Chen from Changsha CDC very much for his support in data collection.
References
Footnotes
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Contributors AT and XTZ participated in the design and data analysis, and the writing the paper. SPB helped explain the results and improve the paper. GH led the project design and implementation of the research and contributed to the writing of the paper.
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Funding The 2009 New Century Scholar Support Program of the Ministry of Education of China.
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Competing interests None.
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Patient consent No.
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Ethics approval The Central South University Ethics Committee.
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Provenance and peer review Not commissioned; externally peer reviewed.