The Role of Public Health in Injury Prevention (Policy Briefing # 1

The role of public health in injury prevention

Rationale The scale of the problem Injuries are a leading cause of death and in Injuries are a neglected epidemic in the the 53 countries of the WHO European WHO European Region.1 There is evidence Region there were an estimated 790 000, however that this leading cause of death accounting for 9% of deaths from all and disability can be prevented through causes.5 In the European Union (27 coun- concerted public health action. tries) there were an estimated 252 000 injury deaths, and about a quarter of these are Aim intentional.6,7,8 Deaths are only the tip of the iceberg, and for every injury death there are To define the role of public health in the an estimated 30 hospital admissions, 300 prevention of injuries. emergency department attendances and many thousands more who seek help from Definition of injuries their general practitioner or self treat.8 In the European Union alone, it is estimated that An injury is the physical damage that results there are about 7 million hospital admissions when a human body is suddenly subjected to annually, constituting 8% of all admissions.6 energy in amounts that exceed the threshold of physiological tolerance, or from a lack of The scale of the disabilities that result from one or more vital elements (for example, injuries is not adequately documented. oxygen). The energy could be mechanical, Disability-adjusted life years (DALYs) are thermal, chemical or radiant. It is usual to one way of estimating the non-fatal effects define injuries by intention. The main of injuries, where one DALY is one year of causes of unintentional injuries are road healthy life lost due to premature death or crashes, poisoning, drowning, falls and disability. Injuries were responsible for 14% burns.2,3 Intentional injuries result from vio- of all the DALYs lost in the Region. In peo- lence and can be directed at others ple between 1 and 45 years old, injuries are (interpersonal violence), to the self (self- a leading cause of death. Three out of four directed violence) or at groups (collective injury deaths occur in males. Injuries cause violence).4 Violence is the intentional threat 21% of the deaths but 44% of the DALYs or use of physical force against oneself, lost in people aged 0-29 years (Figure 1). another person or a group or community that results in injury, death, psychological harm, maldevelopment or deprivation.

Figure 1: Percentage of deaths and DALYs lost from all injuries by age in the EuPreoprceeantna Rege gofion dea fothr bos atnhd g DendALeYrs ,l o2s0t02 fr om(So uallrc ien jGuBDries 20 by0 2 version 3) age in the European Region for both genders, 2002 Percentage 35.0 30.0 25.0 20.0 DDA-ALYs LYS 15.0 DeatDeathhss 10.0 5.0 0.0 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+

Age in years

APOLLO Policy briefing: The role of public health in injury prevention Injuries result in high health and social care amounts to 2% of GDP.11 It is likely therefore costs, which are borne not only by society that for all injuries the total societal costs but also by victims and their families. As must be substantial, and investment in injuries affect people when they are poten- evidence-based prevention will be cost- tially most productive, they are a cause of beneficial to society. high economic loss, resulting in high societal costs. These have not been mapped for all The three leading causes of injury death in injuries, but for road traffic injuries alone are the European Region are self-inflicted thought to amount to 2% of the national injuries, road traffic injuries (RTI) and GDP in most European countries.10 Although poisoning (Figure 2). In contrast in the the costs for other injuries have not been European Union, the three leading injury measured, reports from some countries causes are self-inflicted, road traffic and suggest that for domestic violence this falls.

Figure 2: Proportion of deaths from injuries by cause in European Region and European Union for both sexes and all ages

PropoProporrtiont ionf doef dateathsh sfr foromm i innjjuurriieses b byy ca cuaseus ien in ProportPioroporn of dtieaton hosf dfreatomh isn fjurroimes i nbjyur caiesu seby ican u se i n EuropeEauropn Reeagni onReg fionr bofor tbho seth sexxese s2 0200202 ( (GGBD 2002)2002) EuropeEanurop Unieonan Union (Total number of deaths = 790 878) (Average( A25ve2r,a0g00e 2d52ea t0h0s 0fo dre lastht s3 fyoer alars)st 3 years) Total number of deaths = 790,878

RRTITI Other RTI Other 1616%% Other 20%20% 23% 22%

WaWr ar 2% 2% Poisonings Poisonings Violence Poisonings 14%14% 2% 4% VioleViolennccee 9% 9%

FFaallllss Falls 10%10% Self-inflicted 19% FFireiress 25% SelSefl-f-iinnfflilicctedted Fires 3%3% 21% 21% Drownningingss 2% 5% 5% Drownings 3%

Note: Other injuries refer to all other injuries which do not fit into the main categories above. The major part of these are unintentional, and would include causes such as choking, suffocation, strangulation, injury due to impact with a physical object, animal bites etc. Data for the European Union were calculated using the WHO Statistical Information System.

The injury map of Europe (Figure 3) shows income countries.1,13,14 The countries with the inequalities in injury death rates across the lowest rates have achieved this level of the Region and shows that within the Region safety through years of organised efforts of there are some of the highest and lowest society and by acknowledging prevention as rates.12 These differences are also apparent, a societal responsibility. This represents an albeit not to such an extent, when the opportunity for transferring good practice in European Union countries are examined in Europe through networks of policy-makers isolation (Figure 4).6 When taken together and practitioners, but this potential yet death rates in the low- to middle-income remains mainly untapped. countries are 3.7 times higher than in high-

APOLLO Policy briefing: The role of public health in injury prevention 2 Figure 3: Map of European Region showing age standardised death rates from all injuries. Source Health for all mortality database (January 2006)

SDR, External causes of injury and poisoning, per 100000

<= 250 <= 214.29 <= 178.57 <= 142.86 <= 107.14 <= 71.43 Last European Region <= 35.71 available 85.34 No data Min = 0

Figure 4: Map of European Union showing age standardised death rates from all injuries. Source Health for all mortality database (January 2006)

<=28.60 <=42.89 <=57.19 <=71.49 >=85.79

Why has so little action been taken in resources have been dedicated to counter- injury prevention? acting the problem, with relatively little research and development in the field, and Why should such a serious cause of death relatively little media interest. Some coun- and disability have been so neglected by tries have lacked the capacity to mount a society at large? Traditionally injuries have public health response to injury prevention. been perceived as unavoidable occurrences One of the main obstacles in confronting and a science-based approach to prevention injuries is the lack of visibility of the prob- has only been realised in the last few lem.16 In many countries injury surveillance decades.15 As injury prevention has been and ready access to information on the low on the agenda of policy-makers, few extent, causes and consequences of injuries

APOLLO Policy briefing: The role of public health in injury prevention 3 have not been available. This has led to a These initiatives have emphasised injuries failure to appreciate the magnitude of the as a public health priority and although not problem and a lack of involvement by civil legally binding, provide a policy platform society (or those institutions and organis- from which a more systematic and coordi- ations outside of government). As injuries nated approach to injury prevention can be occur in almost any setting, prevention made at a national and local level. This programmes need necessarily to be multi- represents an opportunity for stakeholders sectoral. This requires a clear identification to take the issue of prevention forward in of which sector or body has the lead for Member States. prevention, and without this there has been a consequent lack of ownership. Similarly Prevention effectiveness preventive efforts have been fragmented to date and there is a need for stronger coordi- Major advances have been made in a num- nation and leadership. ber of areas of safety concern, but there is still room for more effective action to reduce Policies prioritising the prevention of the huge toll of injuries in society. Countries injuries and violence with lower injury rates have invested in safety as a societal responsibility, rather than Whereas unintentional injuries and violence delegating this to individuals. Legislation and have received relatively little policy priority in enforcement to ensure safer environments the past, prevention policies have been (e.g. road and housing design, the use of placed firmly on the public health agenda safety equipment) and reduce risk behaviours recently. There have been a number of World (e.g. driving under the influence of alcohol) Health Assembly resolutions and United have been key to changes that affect the Nations General Assembly resolutions general population. Relying solely on media prioritising violence and injury prevention: and educational campaigns without infra- structural and institutional changes shows • WHA49.25: Prevention of violence: little evidence of effectiveness. For example, a public health priority; environmental laws ensuring traffic safety and housing design are thought to have halved • WHA56.24: Implementing the recommen- injury mortality in Sweden over 25 years and dations of the World report on violence reduced inequalities in injuries in different and health; sections of society.21,22 • WHA57.10: Road safety and health; There is a growing body of evidence of • United Nations General Assembly resolu- effective injury and violence prevention tion 58/289: Improving global road safety. strategies and many have been shown to be cost-effective.1,23,24 Cost–outcome studies In Europe injury prevention has also show that investment in safety is a saving received policy priority: for society at large. For example, every €1 invested in child safety seats saves €32; the • Regional Committee resolution EUR/ corresponding savings from other invest- RC54/R3 on Environment and health and ments are €29 for bicycle helmets, €69 for Children’s Environment and Health Action smoke alarms, €19 for home visitation Plan for Europe (CEHAPE) with a regional schemes with parent education against child priority goal on preventing injuries in abuse, €10 for prevention counselling by children;17 paediatricians, and €7 for poison control services.1,23,24 Much of this work comes from • Regional Committee resolution EUR/ the United States of America, and needs to RC55/R9 on Prevention of injuries in the be adapted to European contexts. There is European Region18 evidence from European transport settings • the European Commission complemen- where studies suggest that random breath tary communication and Council recom- testing for driving under the influence of mendation on injury prevention for adop- alcohol would save €36 for every €1 spent, tion in 200619 for road lighting this would save €11, for upgrading marked pedestrian crossings this • the European Commission White Paper would save €14, and widespread use of day European transport policy for 2010: time time driving lights would save €4 for every to decide, and the target to reduce road €1 spent.25 Whereas these results provide traffic injury deaths by 50% by 2010.20

APOLLO Policy briefing: The role of public health in injury prevention 4 the bases for evidence-based action, there The public health approach is a science- is still further research needed to identify based approach, which involves all relevant preventive strategies for a range of injuries, sectors, disciplines and actors and is based such as drowning. on a logical sequence of actions. This involves 4 steps: 1) surveillance to identify the The role of the health sector in uninten- size of the problem, 2) an analysis of risk tional injury and violence prevention factors to identify what are the causes, 3) finding out what works for prevention and The public health approach to unintentional then 4) implementing prevention programmes injury and violence prevention has been on a large scale and evaluating these.1, 15 proposed as the way forward in the Euro- pean Region by both WHO and the Euro- The health sector has a broader role to play Box: Key elements of pean Commission and key elements of the other than just providing evidence-based the Commission com- WHO resolution and Commission communi- services for injuries, violence and rehabilita- munication and WHO cation are summarised in the Box.18,19 tion and this is highlighted below (Figure 5).26 Regional Committee resolution • Developing national plans Figure 5: The role of the health sector and the way forward • Surveillance • Capacity building • Research on effective Public health intervention measures • Risk communication • Sharing evidence- based practice • Creating networks/ syn- ergies/ partnerships Injury surveillance Advocacy • Providing services for victims Research Services

Prevention & control Policy

Evaluation Setting examples

Deaths only provide a small part of the used as well. The sharing of anonymised whole burden of injuries and the health data is central to mounting a multisectoral sector is ideally placed to collect data on response. Research studies and surveys non-fatal injuries on people presenting to can also contribute to a more complete emergency departments and being admitted picture of the prevalence of injuries, the risk to hospital.9 Using these data sources also factors and the longer-term health conse- provides a more complete picture than quences. relying on only one source, e.g. non-fatal road traffic injuries are known to be underes- Part of the science-based approach is timated by police data. Surveillance can also finding out what works in the way of preven- be used to collect data on risk factors for tion, as demonstrated by the cost-effective injuries, and analysis will lead to the identifi- examples above. Such information can be cation of locally relevant factors such as sourced from systematic reviews of evi- alcohol, unsafe consumer products, poverty, dence-based good practice that has been etc. Examples that employ a systematic obtained from experimental scientific stud- methodology include the WHO Injury surveil- ies. The next step is to implement this on a lance guidelines and the EC’s Injury data- broader scale taking local contexts and base project.6,9 Building a complete picture priorities into account. This requires the in an area as diverse as injuries requires development of programmes of implement- that data sources from other sectors be ation that are adequately resourced and with

APOLLO Policy briefing: The role of public health in injury prevention 5 rigorous evaluation to find out whether these Advocating for injury prevention requires programmes are working at a population health professionals to work beyond their level. Public health can contribute to the traditional role in cure and rehabilitation. design and evaluation of programmes where More health professionals need to be other sectors might have the lead. sensitised to this important role in implementing and advocating prevention. Further- With its ready access to reliable surveillance more, as a large employer the health sector data, the health sector can act as a powerful needs to set an example to other sectors by advocate to mobilise opinion and resources putting safety and prevention as a priority for for prevention. By fulfilling its role as a all health care employees regardless of their stakeholder and involving others, public position. health can put safety and injury prevention higher on the policy agenda and contribute There is a need to build capacity to respond to policy formulation. To formulate and to the challenge of prevention in many implement policy for injury prevention countries in view of the relatively recent requires the close and coordinated working history of injury prevention as a field. In this of senior people from different sectors, and respect courses such as the TEACH-VIP an inter-ministerial injury prevention com- course can be used, and public health can mittee is one way of achieving this. Such play a powerful role in building capacity in inter-departmental collaboration can only health and other sectors.27 work if there is ownership of the injury prevention committee by all sectors. When Public health has a central role to play in national plans are formulated these need to tackling the burden of injuries. Working with be owned by all the partners, have realistic other sectors is essential to the way forward goals and timescales, with appropriate and achieving a safer Europe will require resources and clearly identified roles. commitment from practitioners, advocates Achieving this requires that injury prevention and policy-makers. and safety promotion are a priority area for other sectors.

References 7. Petridou ET, et al. Unintentional injury mortality in the European Union: How 1. Sethi D, et al. Injuries and violence in many more lives could be saved? Scand Europe. Why they matter and what can J Public Health (in press). be done. Copenhagen, WHO Regional Office for Europe, 2006. 8. Stone DH, et al. Intentional injury mortality in the European Union: how many 2. Baker SP, et al. The injury fact book. more lives could be saved? Injury Second edition. New York, Oxford Prevention 2006;12:327-332. University Press, 1992. 9. Holder Y, et al. Injury surveillance 3. Peden M, McGee K, Krug E. Injury: a guidelines. Geneva, World Health leading cause of the global burden of Organization, 2001. disease 2000. Geneva, World Health Organization, 2002. 10. Racioppi F, et al. Preventing road traffic injury: a public health perspective for 4. Krug EG, et al. World report on violence Europe. Copenhagen, WHO Regional and health. Geneva, World Health Office for Europe, 2004. Organization, 2002. 11. Walby S. The cost of domestic violence. 5. GBD estimates [web site]. Geneva, London, Women and Equality Unit, World Health Organization, 2002. 2004. (http://www3.who.int/whosis/menu.cfm? path=whosis,burden,burden_estimates,b 12. Mortality by 67 causes of death, age and urden_estimates_2002N accessed April sex (off-line version), supplement to the 2007) European health for all database (HFA- MDB). Copenhagen, WHO Regional 6. Zimmerman N, Bauer R. Injuries in the Office for Europe, 2005 (available at European Union. Summary 2002-2004. http://www.euro.who.int/hfadb). Vienna, Austrian Road Safety Board (KfV), 2006.

APOLLO Policy briefing: The role of public health in injury prevention 6 13. Sethi D, et al. Reducing inequalities in (http://www.ec.europa.eu/health/ injuries in Europe. Lancet 368:2243- ph_determinants/environment/IPP/ 50.2006. documents/com_328_en.pdf, accessed April 2007) 14. Koupilova I, et al. Injuries. In (eds) Tamburlini G, Ehrenstein OV, Bertollini 20. European Commission. White Paper. R. Children’s health and environment: a European transport policy for 2010: time review of evidence. (Environmental to decide (http://ec.europa.eu/transport/ issue report No 29.) Copenhagen, white_paper/index_en.htm) European Environment Agency, 21. Laflamme L. Social inequality in injury 2002,130-140. risks. Stockholm, Sweden’s National 15. Krug E, Sharma G, Lozano R. The global Institute of Public Health, 1998. burden of disease. American Journal of 22. Gustafsson LH. Children in traffic. Some Public Health, 2000,90:523-536. methodological aspects. Paediatrician 16. McKee M, et al. Health policy-making in 1979, 8:181-187. central and eastern Europe: why has 23. Miller TR, Levy DT. Cost-outcome there been so little action on injuries? analysis in injury prevention and control: Health Policy and Planning 2000, 15: eight-four recent estimates for the United 263-269. States. Medical Care 2000, 38:562-582. 17. WHO Regional Office for Europe. Chil- 24. Working to prevent and control injury in dren’s Environment and Health Action the United States. Fact book for the year Plan for Europe (CEHAPE). Copenhagen, 2000. Atlanta, National Center for Injury WHO Regional Office for Europe Prevention and Control, 2000. (http://www.euro.who.int/childhealthenv/ policy/20020724_2 accessed 7 April 25. European Transport Safety Council. 2007) Cost-effective EU transport safety measures. Brussels, ETSC, 2005. 18. WHO Regional Committee for Europe (http://www.etsc.be/documents/ resolution. EUR/RC55/R9 Prevention of costeff.pdf) injuries in the WHO European Region. Copenhagen, WHO Regional Office for 26. Peden M, et al. World report on road Europe, 2005. (http://www.euro.who.int/ traffic injury prevention. Geneva, World eprise/main/WHO/AboutWHO/ Health Organization, 2004. Governance/ resolutions/2005/2005922_1, accessed 27. TEACH-VIP. Users’ Manual. Geneva, April 2007). World Health Organization, 2005. (http://whqlibdoc.who.int/ 19. Communication from the Commission to publications/2005/9241593547.pdf, the European Parliament and the accessed April 2007) Council on Actions for a Safer Europe COM(2006) 328 (Published in September 2007)

Partners

Acknowledgements

Apollo is a project that is co-sponsored by the European Commission in the framework of the Public Health Programme (Grant Agreement 2004119). The project aims to identify strategies and best practices for the reduction of injuries within the EU and is led by the Centre for Research and Preventing of Injuries (CEREPRI) of the University of Athens. This document has been produced by EuroSafe, in collaboration with the WHO European Centre for Environment and Health, within the framework of work package 6 of Apollo.

It has been written by Dr Dinesh Sethi, Technical Officer, Violence and Injury Prevention, WHO European Centre for Environment and Health, WHO Regional Office for Europe. Reviewed by the APOLLO manage- ment team.

APOLLO Policy briefing: The role of public health in injury prevention 7