Elsevier

The Lancet

Volume 363, Issue 9427, 26 June 2004, Pages 2172-2179
The Lancet

Series
Strengthening the prevention and care of injuries worldwide

https://doi.org/10.1016/S0140-6736(04)16510-0Get rights and content

Summary

The global burden of injuries is enormous, but has often been overlooked in attempts to improve health. We review measures that would strengthen existing efforts to prevent and treat injuries worldwide. Scientifically-based efforts to understand risk factors for the occurrence of injury are needed and they must be translated into prevention programmes that are well designed and assessed. Areas for potential intervention include environmental modification, improved engineering features of motor vehicle and other products, and promotion of safe behaviours through social marketing, legislation, and law enforcement. Treatment efforts need to better define the most high-yield services and to promote these in the form of essential health services. To achieve these changes, there is a need to strengthen the capacity of national institutions to do research on injury control; to design and implement countermeasures that address injury risk factors and deficiencies in injury treatment; and to assess the effectiveness of such countermeasures. Although much work remains to be done in high-income countries, even greater attention is needed in less-developed countries, where injury rates are higher, few injury control activities have been undertaken, and where most of the world's population lives. In almost all areas, injury rates are especially high in the most vulnerable sections of the community, including those of low socioeconomic status. Injury control activities should, therefore, be undertaken in a context of attention to human rights and other broad social issues.

Introduction

Injury is one of the leading causes of death in children and working-aged adults in almost every country. There are more than five million injury-related deaths every year, as well as a tremendous burden of disability and economic loss;1, 2, 3, 4 yet, little attention is given to injury. In high- income countries, research expenditures for injury are small compared with those for cancer and cardiovascular disease.5 The situation is even more pronounced in less-developed countries. External assistance to the health sector of less-developed countries was US$2–3 per disability adjusted life year (DALY) lost to major infectious diseases such as HIV/AIDS and malaria, but only $0·06 per DALY lost to injury.6

Part of this neglect might stem from the fact that the solutions lie outside the usual frameworks of health care. Part may also stem from a sense of fatalism, that injuries are caused by bad luck and that little can be done to prevent them. However, the experience of most high- income countries over the past 40–50 years has been that, in fact, injury rates can be lowered and the consequent morbidity and mortality can be reduced.5, 7, 8 Part of the success has been achieved through advances in transport systems, housing construction, and industrial machinery. However, much has been accomplished by the application of scientific methods of injury prevention and control.7, 8, 9

The largest gains are to be made in less-developed countries, where rates of injury-related death are highest4, 10 (table and figure), where there have been limited applications of scientific methods of injury control, and where most of the world's people live. Improvements are needed across a range of injury control activities, encompassing surveillance, prevention, and treatment. For all of these, progress can be made by applying or adapting some of the interventions that have been effective in high-income countries. However, there is an important role for new research to identify and elucidate injury risk factors and to rigorously assess the effectiveness of injury control policies in less-developed countries.11, 12, 13, 14

In this review, we discuss what is known and what new information is needed. This includes both basic research to elucidate injury risk factors and operations research to decide how best to implement and assess policies to promote safety in different societies worldwide. The major focus of this review is to identify ways in which current injury prevention and treatment could be strengthened, especially in less-developed countries.

Section snippets

Surveillance

All too often, injury control activities in both high-income nations and less-developed countries have been done without adequate assessment of their effectivness.9, 15 Data on the extent and characteristics of injuries should be collected in every country. Such follow-up assessment would allow better targeting of interventions and assessment of their success or failure. Most high-income countries have formal surveillance systems, such as the Fatality Analysis Reporting System (PARS)16 for

Prehospital care

Most injury-related deaths occur before any chance of treatment, indicating the importance of prevention in all countries. The proportion of prehospital deaths seems to increase with decreasing economic status. For example, 81% of injury deaths occurred in the field in Kumasi, Ghana compared with 59% in Seattle, USA.94 Based on the site of death of most injury victims, development of prehospital emergency medical services (EMS) could be more effective in reducing death rates than would

Trauma system organisation

Efforts to strengthen injury treatment worldwide can build on trauma system organisation in place in several high-income contries. Part of such organisation entails trauma service verification, involving a review of hospitals' completeness for clinical services (human resources), physical resources, and administrative functions, such as quality improvement. Such verification is provided by professional organisations,120 while governments designate which hospitals should fill the roles of trauma

Essential trauma care

Improvements in injury treatment could probably be brought about through better organisation along the lines of trauma system planning. WHO and the International Society of Surgery have a project underway to elucidate what treatment capabilities should be available in hospitals of varying levels in countries at varying economic levels. The collaborative Essential Trauma Care Working Group has developed a list of injury treatment services that are deemed essential and/or desirable in different

Capacity for injury control

All the efforts for surveillance, prevention, and treatment of injuries that we have discussed require a certain level of resources and legal authority within institutions such as universities, road safety agencies, and ministries of health. Because road traffic is such a great cause of injury, the role of road safety agencies merits special attention. In most countries, there is a need for a sufficiently funded government department, with adequate and appropriately trained staff, and with

The way forward

Much can be done to lower the huge global burden of death and disability from injury by improved application of scientifically-based evidence on injury control, and strengthened surveillance, prevention, and treatment. Current efforts, especially those in less-developed countries, could be enhanced by addressing various research and policy issues (panel), but more human resources, finances, and legal authority are needed. Furthermore, injury-control workers need to be versed in advocacy and

Search strategy

Studies selected for this review were identified from MEDLINE. We also used articles from the grey literature and journals from Mexico, Malaysia, and Ghana that are not MEDLINE referenced. These included unpublished documents, institutional and government reports, and conference proceedings. We considered any article addressing the subject of injury in any country. Studies were included or excluded on the basis of their contribution to the principal question of how the current scenario of

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