Environmental Approaches to Injury Prevention

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Environmental Approaches to Injury Prevention

• Susan P. Baker, MPH
• Johns Hopkins Center for Injury Research and
  Policy

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Unintentional and Intentional Injury

• Common approaches are often appropriate
  regardless of intent
• shootings personalized weapons would prevent
  some injuries regardless of intent
• poisonings the reduced carbon monoxide content
  of cooking gas lowered both unintentional and
  suicidal death rates

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Passive (automatic) protection is needed because
those at greatest risk of injury are

• Young children
• Teenage males
• Elderly people
• Intoxicated people
• Namely, the people whose behavior is hardest to
  change.

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• Unintentional Poisoning Death Rates from Carbon
  Monoxide, U.S. 1947-79
• The period when states gradually converted to
  non-poisonous natural gas an example of passive
  protection and its effects.

Deaths/100,000
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Correlation Between Hazardous Driving
and
Self-protectionLESS SEATBELT USE IF

• High speed
• High risk situations
• following too closely
• running red lights
• Nighttime
• Young drivers
• Alcohol-impaired drivers

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People take risks because of

• Economic pressure
• Productivity pressure
• Competition pressure
• Peer pressure
• Time pressure

They will often choose speed and convenience.
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The safest way must be the easiest way,or people
will make a hazardous choice.
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These Sri Lankans are crossing the river using
the safe walkway because it is easier than
fighting the traffic.
Photo by SP Baker
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Injuries Among the Hopi IndiansSimpson et al.
JAMA 2491873-76, 1983

• Population based study all Hopis treated in the
  two relevant IHS hospitals
• The authors read the hospital discharge records
• Visited homes, villages to examine setting
• Circumstances that were revealed
• Falls from roofs
• Hangings in jail
• Kids falling from pickup trucks
• Single-vehicle crashes narrow, winding steep
  roads without shoulders or guardrails

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The hazardous environment of a Hopi village.

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Baltimores beautiful Harborplace. The white
areas between these bricks are just for
decoration.
Photo by SP Baker
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Nearby, similar white areas mark a change in
level.
What happens if someone is looking upward?
Photo by SP Baker
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As I puzzled over how best to illustrate the
hazard, I heard a sudden cry.
Photo by SP Baker
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Photo by SP Baker
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Residential facilities for the elderly are an
environment where there are an exceptional number
of high-risk people needing protection
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The water temp at this retirement home was 180
degrees hot enough to poach eggs.
Photo by SP Baker
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The cabinets were so high that someone would
need to stand on a chair or stepstool to reach
them. The sharp corner of the hood over the
stove was at eye level
Photo by SP Baker
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After her forehead healed, she put the bandaid
on the sharp corner in case she hit it again.
Photo by SP Baker
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Photo by SP Baker
She was 92 years old, and like most seniors did
not lift her feet high with each step. If she
were to trip, there was no railing and the
surface was hard cement.
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To call attention to the tripping hazard, a
WHITE stripe -- unlikely to be noticed by
anyone with poor eyesight.
Photo by SP Baker
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One of these held glue, the other had eyedrops.
Some people who needed eyedrops did not see
well. Some glued their eyelids shut. The glue
manu- facturers should have predicted that and
used another shape.
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Deaths in Housefires

• The leading cause of injury death among children
  in some cities.
• Often they are ignited by smoldering cigarettes
  (cigarettes can be designed to reduce the
  likelihood that they will ignite fabric)

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55 Housefire Deaths in BaltimoreRecord Review
Showed.

• 31 (56) in cigarette-ignited fires
• 12/31 (39) not the smokers of the cigarettes
• BAC gt.10 in half of cigarette-ignited fires
• Highest rates were in low-income areas

Mierley and Baker, JAMA 2491466-8,1983
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40 Fatal Housefires in Baltimorevs. Median
Rental Value Quintile
EXPECTED OBSERVED
QUINTILE
1 8 10
2 8 13
3 8 8
4 8 5
5 8 3
Mierley and Baker, JAMA 2491466-8,1983
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The sign is hard to read from ground level.
Photo by AJ Saah
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Even if it could be read, this might
not discourage a young climber
Photo by AJ Saah
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...especially one inspired by nearby
climbing equipment.
Photo by AJ Saah
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OSHA might require someone working at this
height to have some form of protection. We just
say Be careful, Timmy, and dont push.
Photo by SP Teret
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This slide is built into a hill. It is steep
enough to give a child a good ride, but even a
fall from the top is not likely to cause injury.
Photo by SP Baker
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Walkers place toddlers at high risk of falls
down stairs. Heres a low-risk alternative.
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Pacifiers like the one at left were small enough
to enter a childs airway. CPSC eventually
banned them.
Photo by SP Baker
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Some foods place children at high risk of choking.
Photo by SP Baker
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Foods that Caused Death of U.S. Children

• 17 hot dogs/sausages
• 9 peanuts/nuts
• 8 grapes
• 6 carrots
• 4 beans
• 4 hard candies

Harris, Baker et al JAMA 2512231-2235, 1984.
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Characteristics of FoodsLikely to Cause Fatal
Choking

• Smooth
• Hard or tough
• Small
• Airway-sized
• Round
• Pliable
• Cohesive

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If the water is gt120 F and mom has to answer the
phone, disaster can result.
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Effectiveness varies inversely with frequency or
amount of effort e.g. - To Protect A Child From
Scalding
Resulting Protection
Prevent discharge gt120 F
MAX
Adjust valve on heater
Watch child
MIN
MAX
MIN
Frequency or Amount of Effort
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Should there be a committee that screens the
safety of baby/toddler products before they go on
the market?
Will this encourage the caretaker to leave for a
moment?
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Messages such as this are too often unseen or
ignored.
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Whose Decisions Determine Injury?

• Designers
• Administrators
• Legislators
• Regulators
• Architects
• City planners

Therefore we need to educate the decision-makers.
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Drownings in Australia, Ages 1-4Two cities with
similar ratios of pools but different fencing
regs.
Pools /100 homes Drownings /100,000 children
Canberra (no fencing) 9 2.7
Brisbane (fencing mandated) 8 0.3
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Airbag regulations followed years of work by
scientists and advocates. (Initial deaths of
unrestrained children resulted in design changes.)
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Findings re Compact Pickup Trucks

• Children in 2nd row of compact pickups
• Higher risk of injury than front row occupants
• Predominantly head injuries
• Higher injury risk than children in 2nd row of
  other vehicles
• Higher risk of contact
• Higher risk of injury given contact
• Design of vehicles is decided by manufacturers
  who can be influenced by data.

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Injuries to Child Passengers by Vehicle
TypeFrequency of AIS 2 head injuriesWinston et
al. JAMA 287,1147-1152, 2002
PUpickup
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Photo by AL Dannenberg
Look closely do you think warnings work??
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Contributors

• Andrew L. Dannenberg, MD
• U.S. Centers for Disease Control
• Alfred J. Saah, MD
• Merck Research Labs
• Stephen P. Teret, JD
• Johns Hopkins School of Public Health