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160 Paediatric Trauma: Epidemiology, Prevention, and Control

be difficult to design a meaningful injury prevention system without We next examine how these general principles of injury prevention
data on injuries and formal injury surveillance systems in place. Some can be applied in the circumstances of road safety and other types of
less-developed countries have some system of collecting information injury prevention.
on injuries, but these are usually unreliable and often underreported. Road Safety
Surveillance systems in sub-Saharan African countries should aim at Prevention strategies for motor vehicle injuries are a complex prob-
upgrading preexisting systems such as police reports of injuries, hospi- lem and require political will to address them. Possible interventions
tal discharge data on injuries, and vital registries, and not seek to create include development of safe road infrastructure, enforcement of speed
entirely new data collection mechanisms. limits on all roads (both rural and urban), and enforcement of the use
Prevention efforts should tackle the various mechanisms of injury of restraints and protective gear such as seat belts and helmets. Specific
in children. These will include prevention or reduction of road traffic interventions include placing children in the back seat of cars, adults
injuries, falls, burns, and drownings, among other injuries. serving as positive role models for children by always wearing their
There is often a misperception that injuries are just due to random seat belts and obeying traffic safety regulations and laws, enforcing the
chance and little can be done to prevent them. However, much can be use of hands-free mobile phones, and enacting laws (and rigorously
done by using the same scientific approach as with any other disease. implementing them) against driving under the influence of alcohol.
This includes: (1) better understanding the extent and nature of the To prevent pedestrian injuries, there is the need to modify the roads
problem through surveillance and research, (2) identifying risk factors, and environment to decrease motor vehicle speeds and increase the
(3) designing prevention programmes that target these risk factors, and number and frequency of “zebra” crossings on busy roads that children
(4) rigorously assessing the results of these prevention programmes are likely to use in going to or from school. To be most effective, such
to determine which are succeeding (and hence should be continued crossings can be augmented with traffic lights and crossing guards
and expanded) and which are not succeeding (so that they can be during peak times when children are crossing the roads. Measures to
discontinued or modified). slow vehicle speeds can include roadway modification (such as speed
A useful tool to assist with designing and carrying out injury bumps) and better police enforcement of speed limits.
prevention strategies is the Haddon matrix. William Haddon proposed Note that many of the strategies that have been successful are based
this classic matrix more than 30 years ago to determine ways to on high-income country experiences. Some of these may be of use in
intervene to decrease morbidity and mortality from traffic injuries. the African context, but some may require considerable modification,
Since then, the matrix has been used as a tool to help in developing and some completely new strategies may need to be developed. A
ideas for preventing injuries of different types. The Haddon matrix major difference in emphasis in prevention efforts is needed, given the
is a grid with four columns (components) and three rows (phases of different aetiologies of traffic-related injuries. In high-income countries,
time). The rows represent different phases of an injury (pre-event, most children who are injured are occupants in private vehicles that
event, and post-event), and the columns represent different influencing crash, so promoting better use of seat belts and car seats or booster seats
factors (host, agent or vehicle of injury, physical environment, and for younger children is an important strategy. In sub-Saharan Africa,
social environment). If a fall from a mango tree is considered, then the however, most children who are injured are pedestrians, so efforts to
pre-event is before the child climbs the mango tree to plug mangos, promote pedestrian safety should especially be emphasized.
the event is the fall from the tree, and the post-event is what happens Prevention for Other Types of Injuries
following the fall, which includes the first aid and/or treatment the
child might (or might not) receive. One should identify, when using Prevention of falls, which in the African subregion includes also falls
the Haddon matrix, the host, agent, and environmental factors that from trees, will consist of advising children to use methods of harvest-
determine whether the event or injuries, along with their particular ing fruits from trees other than climbing them, and to be supervised by
level of severity, occur during different points in time. Successful adults. No child should be left alone unsupervised on the playground,
intervention in injury prevention should take all elements of the in school, or places where the child is likely to fall and be injured.
matrix into account. If these factors are understood, then appropriate Playground equipment should be safe and the surface covering soft to
intervention strategies can be developed. firm to permit safe play and well-cushioned “falls”. Most falls occur at
Injury prevention strategies should be supported by successful home, so supervision by parents or caregivers while the child is play-
interventions that include environmental changes, engineering, ing will go a long way to reducing serious falls that may lead to major
enforcement of legislation, and education (known as the four E’s). injury and hospital visits for either outpatient treatment or admission.
Environmental changes are designed to reduce risk of injury; an example In the case of burns, strategies for prevention include never leaving
is well-designed roads, which can reduce the risk of head-on collisions. children alone around open flames, stoves, and candles; keeping
Engineering changes include the design of vehicles with air bags and matches, all flammable products, and hot liquids (especially hot water
antilock brake systems that reduce the risk of injury. Enforcement of for bathing) away from children; and, as much as possible, restraining
laws requiring the nonuse of alcoholic drinks while driving, the use of children from the kitchen when cooking.
seat belts for all occupants of a vehicle, and the observance of speed Prevention strategies for submersion or drowning include constant
limits will reduce the incidence of road traffic injuries. A broad-based supervision of children around water bodies, not allowing children to
safety education campaign involving adults, children, and stakeholders cross rivers alone for whatever purpose (e.g., attending school or going
(and supported by governments and nongovernmental organisations, or to the farm); emptying water containers or using water containers
NGOs) will produce a safer environment for children. with childproof lids that cannot be easily pried open by an inquisitive
Injury prevention strategies can also be considered as active or child; and using a fence to separate swimming pools and other water
passive. Active interventions rely on actions taken by the child or bodies from children. The use of environmental barriers has been
caregiver (e.g., teaching the child not to climb or jump from high walls advocated by the WHO as the most effective method to prevent
or tables). Passive interventions do not rely on efforts by the individual submersion deaths in all countries, irrespective of the level of income.
to be successful (e.g., child safety caps on medications). Most injury It is also advisable to start swimming exercises for children of all ages,
prevention interventions will have both active and passive elements, and especially after the age of 5 years. Teenagers should be discouraged
the likelihood that an intervention will be successful in preventing injury from drinking and swimming.
is generally inversely related to the amount of individual effort required. Eliminating agricultural injuries will require that children not be
used on farms for either individual or commercial purposes. Child