Bulletin of the World Health Organization

Three basic convictions: a recipe for preventing child injuries

Ivan Barry Pless a

a. McGill University, 845 Sherbrooke Street West, Montreal, Quebec, H3A 2T5, Canada.

Correspondence to Ivan Barry Pless (e-mail: barry.pless@mcgill.ca).

(Submitted: 21 August 2008 – Revised version received: 29 October 2008 – Accepted: 03 February 2009.)

Bulletin of the World Health Organization 2009;87:395-398. doi: 10.2471/BLT.08.058024


I am sure others have written more profoundly about repetition but I like this quote attributed to Collier: “Constant repetition carries conviction”.1

It seems especially important to write about these convictions in the context of this theme issue for the World report on child injury prevention.2 The Department of Violence and Injury Prevention and Disability at WHO has, in recent years, played an increasingly important role in injury prevention worldwide by providing the strong leadership that the field requires.

My perspectives on the additional requirements needed on top of WHO’s initiatives arise from training as a paediatrician, working as an investigator and editing Injury Prevention since its inception. Since the mid-1960s, I have also witnessed the birth and growth – and occasional demise – of many well-intentioned efforts, ranging from organizations like Safe Kids Worldwide to more modest, local initiatives. Since the “discovery” of injuries as a health problem nearly 50 years ago, we still find far too many studies that are entirely descriptive, or simply repeat findings from other parts of the world. More importantly, there are far too few studies that describe proven interventions, and fewer still that show how or whether a proven intervention works in the real world.

So much for my qualifications to pontificate; my three ingredients are simple but critical if we are genuinely committed to making real progress in preventing children’s injuries and their sequelae. Undoubtedly, other ingredients could be added to this recipe.

Injuries are a health problem

Although many disciplines and many branches of government have important roles to play in preventing childhood injuries, we must hold on to the view that, in the end, injuries are a health problem. This seems so self-evident that it is embarrassing to give examples to support the argument. But, for some inexplicable reason, in most countries injuries are not viewed in this light. Health departments are often disinterested or only pay lip-service to their prevention. So, the reader (or their medical and public health colleagues) needs to be reminded that injuries produce lacerations, broken bones, burned and scalded flesh, clogged airways, damage to vital organs… the list is long and sad. All of these require medical care. Many require long hospital stays. Some end in life-long disability and some are fatal. Consequently, no reasonable person can deny that injuries are a health problem and that this means that health officials must be involved in their prevention as well as in their treatment.

The only element in this proposition that may be debatable is whether it is medicine or public health that should carry the ball. Many of us are convinced it is primarily a public health issue but I will settle for either. As important as AIDS, malaria, and diarrhoeal disease undoubtedly are, injury clearly belongs on WHO’s list of priorities.

Before leaving this point we need to reiterate and acknowledge the contributions made to prevention by housing experts, transport experts, trade and industry, alongside a host of other bodies. Yet it is health that must coordinate these efforts to be certain that none of the injury elements falls between stools and to ensure the high quality of the work of the other contributors. Fire departments do much to prevent home fires and this is at it should be. But if they did not, health departments have the ultimate responsibility for urging them to do so. In fact, “urge” is not a sufficiently strong word. The role that I visualize for health departments is “oversight” – a term that implies that it is with them that “the buck stops” and that they have the moral, and perhaps legislative responsibility, to ensure that all that needs to be done is done. In large part, these ideas echo those in a recent policy forum published in Injury Prevention.3

First recipe ingredient

If you accept this argument, the first step is to persuade your health department to take these responsibilities seriously. This may mean face-to-face meetings with the most senior governmental minister. This is a tall order but the need is equally towering.

Research alone is not the answer

This statement is almost identical to the title of a recent commentary that I wrote on surveillance in which I tried to make the point that surveillance without action is sterile.4 The same holds for research. For intervention research to help prevent injuries, the results need to be implemented. To be sure, not all such research offers findings that lend themselves to action or are worth implementing. But many studies provide results that are encouraging and need to take the critical step from showing that they work in the research setting (efficacy) to the real world (effectiveness). And then, after the latter step is successfully taken, the researcher must confront the huge challenge of persuading the “powers-that-be” (which would usually include health officials) that actions are needed to imbed them in policies, legislation and programmes.

Advocacy is a critical step in this process.5 It is hard to disagree with Gallagher et al. regarding the need to make advocacy a high priority and the ways to do so. Although this is an essential starting point, we must aim higher than just giving injury a “voice”. Somehow, nearly 50 years after the science of injury prevention was established,6,7 the topic still lacks vocal advocates, parent groups and lay organizations, let alone simply a recognizable voice amidst the hubbub of the more noisy diseases.

For the relatively few researchers who are wise enough and fortunate enough to have conducted a solid study and published it in a respected journal, the challenge to which I allude above remains. They must find the time and skill to implement the findings. Too often reluctance to do so (because it is time-consuming and difficult) is rationalized by stating, in effect, “my job is to do the research; it is up to others to act on the findings”. Sometimes this argument is bolstered by the strictures that respected epidemiologists have marshalled against attempting to make policy based on research alone.8 Although some of these points are well-taken, the bottom line remains that far too much of what we know to be effective remains unimplemented.

Some years ago we tried to discover why some public health studies resulted in change and others did not. Through a series of interviews, the notion emerged that, to “cross the bridge from research to action”, a go-between may be needed.9 We called this person a “research broker”. This role (also known as “knowledge broker” or “implementation facilitator”) is now commonly used by funding agencies as part of the knowledge transfer process. Even so, how well knowledge transfer actually works remains to be determined. Whatever the answer, as research funding is reduced, the need to act on what we know becomes more and more urgent.

It is frustrating to read grant applications where an obligatory section addressing “significance” or “relevance” confuses dissemination (e.g. publication, seminars) with implementation. It is equally disheartening to read research papers that conclude with “more research is needed”. More research is always needed, but that is no excuse for paralysis: truly responsible investigators will know when they have a finding that warrants action. The really good ones will invest the time and energy to act. If they do not, the WHO agenda will never move far enough or fast enough.

Second recipe ingredient

Reduce the rhetoric about the need for more research until we have effectively implemented what is known. To do so may require scientists to communicate directly with policy-makers, explaining their findings and what needs to be done.

Governments must respond

Closely related to the preceding items is the need for a structure to facilitate the required activities. I have long argued that all countries require some sort of national centre to achieve this.10 The closest existing example is the National Centre for Injury Prevention and Control within the Centers for Disease Control in the United States of America. Yet even this admirable creation falls short of the mark and lacks clout, for a variety of reasons that are largely political. In most other countries, there exists a mixture of voluntary, nongovernmental organizations such as the Child Accident Prevention Trust, Safe Kids, or, what are essentially, research units.

One step closer to what is needed is the Child Safety Commissioner in Victoria, Australia. As its website11 states, the “Office of the Child Safety Commissioner undertakes research, policy development and resource development that is informed by consultation with government and community stakeholders, including children, and reference to contemporary policy frameworks.” I have since learned that the term “safety” in this context refers mainly to child protection. Hence, even this promising example disappoints. It is, perhaps, worth noting that its counterpart in the United Kingdom – the Children’s Commissioner – has rejected the suggestion that child safety deserves to be high on his agenda and its Every child matters website makes no mention of injuries.12

Other centralized initiatives that are voluntary or quasi-governmental include the Child Accident Prevention Trust, Eurosafe, the European Child Safety Alliance and the European Center for Injury Prevention. The European Child Safety Alliance has done an efficient job of assembling data for an action plan that has many impressive elements, including a country-by-country report card.13 However, this plan distinctively lacks a statement regarding whose job it is to take the steps needed to improve matters. In particular, it makes no mention of the role of health departments. As stated earlier, the key is to have one government department take this responsibility. In spite of my arguments, it may not be the health department. In New Zealand, for example, it is the Minister for the Accident Compensation Corporation who has the responsibility to implement the country’s injury prevention strategy. To its credit, the implementation plan even has some “legislative teeth”.14 But generally the picture is gloomy everywhere and not surprisingly, for obvious reasons, the situation is much worse in developing countries as Mock et al. state.15

In my own country, Canada, in spite of repeated requests and years of lobbying, we are a long way short of the target. On the bright side, what we do have appears to be located in the right place, the Public Health Agency. But, what we find there is but a tiny aspect of injury prevention. The injury part of its website consists of little more than a series of reports and, tellingly, it has not been updated since 2002! Equally astonishing is the virtual absence of any reference to injuries in the Chief Public Health Officer’s most recent annual report.16

What the few governmental bodies involved actually do is certainly encouraging but too often they place most of the burden on other “stakeholders”. In most countries, the situation is far more fragmented and relies almost entirely on voluntary organizations. Most of these groups do admirable work; indeed, many are doing the work that governments should be doing. At the very least, governments should make the work of nongovernmental organizations easier by providing them with more generous funding and by creating a focus for child safety in a national centre. Then, instead of having to battle with 10 government departments and many nongovernmental bodies to act on a particular safety issue, there would be the efficiency and greater effectiveness of “one-stop shopping”.

If you are convinced of the importance of a national focus, located preferably somewhere within the health domain, how can this be achieved? The decision is a political one and politicians respond, in part at least, to what they believe their constituents want, especially when those constituents are noisy and capture the interest of the media. In most countries, families of victims of AIDS, cancer, diabetes and other diseases have succeeded in getting some sort of response from policy-makers and from other members of the public. There is no reason why families of injured children cannot do the same. In fact, they must mobilize in this manner if governments are to take injury prevention seriously.

The task will not be easy for several reasons. First is the lack of industry support that lies behind the poor funding for injury prevention. Pharmaceutical companies have no reason to be concerned about injuries (with the exception of Johnson & Johnson) but it is puzzling that most insurance companies also appear disinterested. Second, we must acknowledge that, as many studies show, families of injured children are disproportionately poor. The heavy burden of organizing to lobby and advocate must compete with other demands. Finally, we need to overcome the barrier that arises from the unintended consequence of injury prevention literature aimed at parents that places most responsibility for prevention on their shoulders. Thus, when a child is injured, parents blame themselves, feel guilty and are unlikely to publicly join advocacy groups. Apart from persuading the sponsors of such unfair, misleading and inaccurate literature to change their message, parents must be convinced that the job of protecting children is not theirs alone. They are entitled to the same help as families who depend on clean water to prevent typhus or on publicly supported immunization programmes to prevent a host of diseases. The reason injury prevention is viewed differently continues to escape me. But this is likely to continue until each of the main points made in this paper are widely accepted, not only by policy-makers but also by the injury prevention community itself.

Third recipe ingredient

Work to create a national centre. Consider doing so by mobilizing or consolidating parent groups. Be prepared to operate at the political level. ■

Competing interests: None declared.