theroleofhealth education inchildhoodinjury …...injuryprevention 1995; 1: 53-58 reviewarticle...

Injury Prevention 1995; 1: 53-58

REVIEW ARTICLE

The role of health education in childhood injuryprevention

EML Towner

In the debate about the relative merits ofdifferent preventive strategies in injury preven-tion, environmental changes, and legislationare often regarded as superior and moreeffective approaches to those involving healtheducation. Stone, for example, has suggestedthat an inverse proportion law operates, withpreventive activities receiving official supportin inverse proportion to their effectiveness.'socio-environmental change is costly, radicaland unpredictable and is consequently unat-tractive to politicians, in contrast to healtheducation which is, 'cheap, generally uncon-troversial and safe'.' Roberts et al support thisviewpoint: 'It is unclear what part, if any,educational health promotion messages haveplayed in the reduction of accidents',2 as doesSibert: 'The evidence that these [educationalcampaigns] are effective is unconvincing' andin most cases, effective solutions 'involveenvironmental changes'.3 Within the authors'definitions of health education their commentshave some validity, but what is their definitionof health education? This review contends thatmany criticisms of health education are basedon a narrow view ofwhat it can contribute. Forexample, Roberts et al question whether healtheducation is effective for parents, but later intheir arguments advocate that knowledge oflocal lay opinion and citizens' safe keepingstrategies could be fruitfully used 'to provideinformation and education, not only for otherparents, but for decision makers in local andcentral government'.2 Education is rejected inthe first instance and advocated in the second.In supporting the superiority ofenvironmentaland legislative interventions, the wider pro-cesses of education are largely ignored.This paper seeks to demonstrate that health

education has a wider role than one solelydirected at individualised behaviour change.Health education underpins both legislativeand environmental measures. My goal is to setthe scene by summarising different ideologiesthat underlie contrasting models of healtheducation and the principles of education thatfacilitate effective teaching and learning. Iexamine the range of available strategies fordifferent injury types, and assess whethereducational programmes focused on individ-uals or groups can be effective in promotingsafety or preventing injuries by comparing thecharacteristics of ineffective and effective prog-rammes. The processes by which legislationand environmental measures are introduced arethen described and issues related to education

of professionals, policy makers, and the widercommunity are discussed.

Models of health educationWhitehead considers that health education isone component of the overall process of healthpromotion 'which encompasses actions to pro-tect or enhance health, including legal, fiscal,educational and social measures' but thateducation for health is a crucial component 'tolay the foundations before other componentscan come into play'.4The criticisms of health education described

earlier relate specifically to the traditional'preventive' model, in which people are per-suaded to adopt healthy lifestyles. But, inaddition to individual decision making, educa-tion can also be directed at professionals, atlobbying and advocacy, at changing the politi-cal agenda, and at general awareness. Whichmodels of health education encompass these?Tones and Tilford characterise the different

philosophies, ideologies, and values of threebroad models of health education as 'preven-tive', 'radical', or 'empowerment' models.5 It isbeyond the scope ofthis review to discuss thesemodels in detail, but a briefsummary follows todemonstrate the breadth of approachesavailable within a health education framework.

(1) The preventive model is an individuallyfocused and medically dominated form ofhealth education. It tends to be politically andideologically favoured in an era of individ-ualised culture. It provides people with in-formation on which they are expected to act,assuming individual responsibility for theirown health. This model seeks approvedbehavioural outcomes and has been criticisedbecause of its tendency to blame the victim.

(2) The radical model, in contrast, is morecollectivist in outlook. It is an environmental'upstream' model that challenges the view thatthe individual is to blame for his/her ownhealth. It stresses social and environmental,rather than individual factors. It seeks socialchange rather than individual change and isinvolved in critical consciousness raising,breaking free of uncritical acceptance ofcausality.

(3) Within empowerment models, process ismore important than outcomes. Value is placedon 'voluntarism', in which the learner mustunderstand the process by which he or she islearning. It enhances self esteem and a willing-ness to take control.5

Department of ChildHealth, University ofNewcastle upon Tyne

Correspondence to:DrEML Towner, ChildhoodInjury Prevention andPromotion of Safety(CHIPPS) Programme,Community Child Health,5th Floor, Aidan House,Sunderland Road, GatesheadNE8 3EP.

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These three models stem from differentideologies and philosophies of society thatinitially seem to be diametrically opposed. Inpractice, however, there are a number of over-laps.5 Each model could also give rise todifferent educational methods: the preventiveto a more didactic style of presentation, theradical and empowerment models to moreexploratory learning methods. But again, anoverlap can occur between these methods.

What are the principles of educationthat facilitate effective teaching andlearning?Modern educational theory emphasises thelearning of processes and minimises the learn-ing of facts.6 Minds are not empty vessels to befilled with facts. Education needs to becarefully structured to take individuals andgroups through the learning process in aneffective and motivating way. Educators needto build from the known to the unknown; fromthe simple to the complex. Learning is moreeffective when it is organised in a spiral inwhich issues are revisited in increasing depth astime goes on, rather than in a linear series of'one off' experiences.7 People learn best whenexperiences are brought together and reinforceone another - when topics are not tackled inisolation but used in a coordinated manner, andwhen different learning experiences comple-ment each other. When people engage activelyin the learning process they are more likely tobe influenced by it.The educational task needs to be right for the

learner: it needs to take into account thelearner's stage of development. It should alsostart from where people are emotionally and beconcerned with self esteem and relationshipskills. The social context of the learner- theirsocial background, for example - can have aprofound effect on their response to education.These educational principles can be applied

both to individuals, whether they are parents,children, policy makers, to groups of profes-sionals, or the public.

Available strategies for differentinjury typesUnintentional injury is not homogenous.Childhood injuries occur in the home, road,and leisure environments and encompass awide range of causes and possible counter-measures.89 For some injury types, a widerange of countermeasures are possible, thoughnot always put into action. Pedestrian injuries,for example, can potentially be preventedthrough a range of techniques, including trafficcalming measures, changes in land use, trans-port policies, provision of school crossing pat-rols, speed restrictions, and also througheducational programmes directed at the child,or -car driver. For other injuries, such asdrownings in the bath tub, 'passive' environ-mental or legislative approaches are not possi-ble and educational/training approaches are theonly ones available.

Just concentrating on those injury types forwhich there are 'proved', effective environ-

mental or legislative interventions means thatother areas may be neglected.

Educational programmes:characteristics of unsuccessful andsuccessful programmesOver the years, there have been a number ofeducational interventions directed at behaviourchange in parents and children. What are thecharacteristics ofthose campaigns that are mostsuccessful and those that are not succesful?Examples of campaigns that have not proved

to be effective include those reported by Min-chom et al,'0 Dershewitz et al," Schlesinger etal," and McLoughlin et al." In a home safetycampaign in Cardiff directed at parents, nosignificant improvement in injury rates couldbe detected. However the campaign was short,it was traditional in style, comprising leaflets,posters, speakers at local organisations, and oneoff sessions in schools. Penetration levels wererelatively low, and baseline and follow up datacollected over a short period.'0A community wide home safety campaign

directed at parents of young children in Rock-land County in the US, showed no significantgains in terms of reduced injury rates.'2 Theprogramme involved neighbourhood discus-sion groups and identified hazards and preven-tive methods appropriate for each age group.Pless and Arsenault considered these educa-tional techniques to be 'state of the art' andpenetration to the population was high and theyconsequently believe that the conclusions fromthis study are sobering in relation to healtheducation.'4 In both this and a later campaign,"Ihowever, which involved personalised adviceand provision of free home safety devices, therange of messages was great. This led theauthors to conclude that household injurycontrol was too broad a field for health educa-tion to be effective.

Project Burn Prevention, a large campaignconducted in the US by McLoughlin et al,"reported knowledge gains but no reduction inburn injuries or severity in the long term. Theauthors provide a very useful critique of thestudy. They feel the programme 'addressed toomany topics for persistent learning about anytopic to occur, or for learning to motivatechanges in behaviour related to burn preven-tion'."3 Moreover, the duration of the prog-ramme may not have been long enough forpersistent learning to take place. An importantissue also raised was that 'demonstration pro-jects awarded by competitive process andfunded by contracts to accomplish an objectiveof a Federal agency, will rarely have as a majorgoal to meet the express primary needs of thecommunity'."3 Here, the community was thesite, not the source, of the programme.

In these studies where educational interven-tions were not effective: the nature of theprogramme may not have been suited to thetarget group; the number ofmessages too great;the duration too short; or the source of theprogramme inappropriate.Turning to campaigns where some successes

have been achieved, one home safety campaign

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attempted to address two of the above issues(namely advice that was often inappropriateand too diffuse)."5 This campaign was con-ducted in a disadvantaged community in New-castle, England; it compared the effects of amass media campaign, the BBC Play it Safeseries, with a mass media campaign combinedwith targeted advice by health visitors duringplanned home visits using home safetyknowledge and actions of families as endpoints. Nine per cent ofthe first ofthese groupsof families (the control group) made somephysical changes to make their homes safer,compared with 60% of the second (theintervention group). The authors of the studybelieve that the advice given was small, specific,and concrete: the severely disadvantagedfamilies responded because the education wasappropriate to their immediate needs."5

In the road safety field, difficulties can alsoarise because ofthe complexity ofthe educationand training tasks. Rivara et al have estimatedthat road crossing can involve up to 26 differenttasks to negotiate traffic.'6 Some training pro-grammes targeted on clearly defined road cros-sing skills have, however, been demonstrated tobe effective. Thomson et al in Glasgow, Scot-land have developed programmes to trainyoung children to find safe places to cross theroad.'7 There is a need, however, for small scaleexperimental studies such as these to beextended into wider operational programmeswhere parents can help to transmit the skills.These studies are continuing in Glasgow.An example of a small scale behavioural

programme developed into a larger scaleversion comes from the US: Roberts et al usedbehavioural procedures, involving rewards,modelling, prompting, and feedback in twoschools in an experimental programme expand-ed to a larger operational programme in 25schools.'8 What was important in this study wasthe use of rewards (stickers, car bumper strips,and prizes of pizza dinners): over 60% ofchildren wore seatbelts compared with 18%before the programme and when these incen-tives were withdrawn, the compliance declinedto 49%. The authors felt that 'basic inform-ation and publicity on passenger safety arehelpful, but inefficient to achieve great impacton behaviour. The clear and dramatic effect ofrewards lend credence to the use of incentivesto motivate safety behaviour'.'8 Petersonbelieves that 'feedback, rewards and behav-ioural rehearsal are extremely important tothe success of educational programmes and areto be preferred to didactic and passive

' 19measures .It has been possible to demonstrate

effectiveness in single measure interventions,such as increasing seat belt use or bicyclehelmets, within 'closed' systems such asschools. A bicycle helmet campaign in Seattlein the US, included the main ingredients thatcharacterised the most successful interven-tions.20 The age group of this campaign wasnarrow, the campaign had a single aim (increas-ing helmet wearing rates), and the educationalmethods employed, which ranged from massmedia to targeted one to one counselling,

reinforced one another. The campaign alsoaddressed the issue of cost of helmets by avariety of subsidies.Many successful campaigns, in addition to

having an educational component, increase useof a particular item of safety equipment byimproving its availability and reducing its cost.An often quoted study is the Children can'tflycampaign in New York, where a variety ofapproaches were adopted including a massmedia campaign, individual education, andhome inspection.2' A key factor was that freewindow bars were provided, and in many cases,fitted, where children were at risk. The authorsreported a 50% decline in falls from windowsin the Bronx area, 31% city wide, and a 35%decline in mortality due to these falls. Successcan be greatest when a combination of ap-proaches: educational and environmental areadopted.

In addition, there are other possibly fruitfularea of research. These include improvingdriver behaviour, which 'has never been anareas of emphasis either in Europe or in theUnited States'.22 In Nottingham, England,Thompson et al measured vehicle speeds out-side junior schools and the distance betweenthe car and the kerb.23 Drivers' speed andposition in the road were unaffected by thepresence of children by the roadside. Evenlarge groups of child pedestrians had the effectof reducing mean speeds by only one mile anhour. Vehicle drivers were not prepared for theunpredictable behaviour of child pedestrians.Howarth believes that 'pedestrian safety couldbe most effectively increased by measuresaimed at increasing the responsibility of driversfor avoiding more accidents'.24The more widespread use of behavioural

methods involving rewards and behaviouralrehearsal could be considered'8 19 as could theuse ofmethods such as 'children helping child-ren',25 and 'community mothers'26 which havebeen applied in other areas ofhealth education.

The role of education in legislationIt has often been stressed that legislation is aneffective solution in injury prevention. But itdepends on whether the legislated action is asingle, one off event that offers passive protec-tion to the vulnerable recipient or whether itrequires repetitive action. Examples of theformer include product design, such as theredesign of front loading washing machines toavoid chest scalds in young children,27 orredesign of products associated withsuffocation and strangulation-such as ref-rigerators, infant cribs, and plastic bags.28Examples of legislation that require repetitiveaction include bicycle helmet wearing, seatbeltwearing, and the use of infant car safety seats.Intermediate between the two ofthese are childresistant containers to prevent poisonings andfencing for domestic swimming pools. Bothoffer a degree of passive protection when usedcorrectly (putting the lids back on containersand closing the gates of the swimming poolfences).

Education has a role in the process of imple-

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menting legislation by influencing policymakers and changing public opinions. Legisla-tion can happen overnight, but usually takes a

long time to achieve: Pearn notes that 'it took 22years after the discovery of poisoning by lead-containing paints before Queensland was

reluctantly dragged to the point of introducingsafety legislation which would protect child-

'29ren . 9 What is involved is a process of trying toget people to believe that there is a problem,that it is a higher priority, that it is possible todo something about it, and that legislationwould be effective.The process of implementing legislation can

be illustrated by Katcher's experience in Wis-consin, USA, in implementing a programme toprevent tapwater scald injuries reported inNational Committee for Injury Prevention andControl 1989.2 Having established by localstudies that a problem and solution existed,Katcher believed at the outset that the mosteffective intervention was state or nationalregulations requiring manufacturers to set allnew water heaters at a maximum temperatureof 120- 130°F. Initially however there was littlesupport for such regulations in Wisconsin or atfederal level. From 1982-5, Katcher focusedon educational interventions, targeting medicalprofessionals to convey the message ofeducating parents about the dangers of exces-

sive hot water. Katcher's 1985 efforts to initiatestate legislation failed, but over the next twoyears a strong lobbying group of medical andnursing professionals and state legislators per-suaded the Assembly and Senate to pass the Billin 1987. Similar laws were then passed inFlorida and Washington. This was then used toapproach water heater industry leaders to urgethe adoption of voluntary standards. Withinthis process, Katcher concentrated on activitiesin areas where success was most likely: educa-tion campaigns directed at professionals andparents when the political climate would notsuppport a legislative intervention, advocacy toenable passage of the water heater law, and theWisconsin legislation as leverage for nationalvoluntary standards.0

Stone, in his critique of health education,states that 'thousands of lives were lost duringthe years of fruitless political lobbying beforeseatbelt wearing was made compulsory'.' In theUK, the first parliamentary questions relatingto mandatory front seat belts in cars was raisedin 1959. The first formal proposal was made in1973, but legislation was not approved until19813' This period of 22 years did not repres-

ent 'fruitless lobbying' but a slow and difficultprocess of understanding what the issue was

and overcoming objections, such as loss ofpersonal freedom. Legislation does not takeplace in a vacuum divorced from any learningprocess. Factors contributing to the success ofthis measure included the support of profes-sional groups, police, medical, community andacademics (all taking time). These groups were

able to gain considerable attention from themedia in a campaign to bring the issue toparliament. A television documentary Thegreatest epidemic of our time viewed by half thepopulation of the country, was shown a week

before the vote in parliament and had a power-ful effect.3"

Education is important in influencing thedevelopment ofpolicy and resulting legislation,by influencing public opinion before suchlegislation and in maintaining compliance withlegislation when passed. Before bicycle helmetlegislation came into effect in Victoria, Aust-ralia in 1990, there had been a 10 year campaignto promote helmet use through bicycle helmetpromotion in schools, mass media publicity,support by professional organisations and com-munity groups, bulk purchase schemes, andgovernment rebates for helmet purchases. InMelbourne, there had been a steady increase involuntary helmet use from 1983-90-5% -70% in primary schoolchildren and2%-20% in secondary school pupils. Afterlegislation, these rates increased to 70-90%.*32'The strategies and activities necessary toachieve the ultimate goal were multi-facetedand involved support from a wide range ofcommunity and professional organisations'. Itis important in seeking the introduction ofsimilar measures to recognise the need for sucha widely based approach and the need forpatience and perseverance.

Proponents of political intervention seem toassume that the introduction of legislation is allthat is needed, but for this to be effective inpractice requires a high level of acceptance andappreciation of the value of the legislation: thistherefore includes some form of education. Inthe US, all states have laws requiring thatyoung children be restrained in cars, but Wil-son and Shock report that 'observationalstudies show that about one fifth of infantpassengers still ride unrestricted on the lap ofanother occupant'.33 Maintaining a climate ofopinion in which child safety seats are deemedimportant, and reminding parents of the con-tinued need for using these seats, as well asusing them correctly, requires continued massmedia and individual education campaigns.Political culture has an important impact onpublic acceptance ofpolicy choices. After legis-lation, seat belt usage in Britain has beenaround 95% whereas in the US, seat belt usagehas been much lower and there are considerablevariations between states. Leichter argues thatBritish political culture has historically beenmore deferential than the more individualisticculture of the US.3'

Sociopolitical climates do not stay still. InBritain and elsewhere in Europe, there is apolitical will that favours the relaxation ofregulations and legislative controls on businessactivities, and these have included a range ofsafety measures. A continued process of educa-tion is required to persuade decision makersabout the effectiveness of measures and toretain the political will to sustain legislation.

The role of health education inenvironmental changeCritics of health education suggest thatenvironmental changes are more significant inpreventing injury, but what has been the pro-cess by which large scale environmental

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measures, such as area wide urban safetyschemes to reduce road traffic accidents, havebeen introduced? Dissemination of scientificreports among professional groups, lobbying ofdecision makers, initiation of experimentalstudies, and wider application of effectivemeasures are all parts of the process. Largescale demonstration studies are expensive andtime consuming: the Transport and RoadResearch Laboratory in Britain set up theUrban Safety Project to evaluate urban safetyschemes in five towns in England.34 Eachscheme cost £250 000 and the project tookplace over seven years. The 13% reduction inaccidents resulting from the scheme led to anational strategy for urban safety management.Ward points out, however, that local area safetyschemes only work effectively if local peoplehave been involved in setting the agenda for theschemes.35 The sophistication of the engineer-ing measures was not matched by the consulta-tion process with the public. Consultationoften resulted in safety considerations beingcompromised in favour of access. Greater localacceptance of schemes might have beenachieved by greater public consultation and useof the media to explain the benefits theseschemes would bring to local populations andperhaps even greater reductions in accidentsmight have occurred.9

Education of professionals, policymakers, and the wider communityThe issues discussed so far in this paper havebrought into focus the importance of educatingprofessionals to prepare them for their role ineducation for health and to alert them to thewider social issues of making the environmentsafer. In the UK health visitors are the onlyprofessionals who have long term regular con-tact with families from soon after the birth of achild. The Newcastle study, referred to earlier,ofhealth visitor home visits demonstrated theireffectiveness in influencing families to improvethe safety of their homes. But there are manycompeting demands on health visitors' time. Inaddition, Laidman found that when she studiedthe role of health visitors in injury prevention,their knowledge was 'little better than thepublic they serve' and she identified a numberof communication problems.36 A trainingresource for health visitors was subsequentlydeveloped to address the issues raised. Thisstressed not only work with individual families,but also work at a community level, supportinglocal groups in campaigns for saferenvironments.37 This training resource hasbeen widely used and disseminated, but unfor-tunately no funds have been allocated toevaluate its impact at a local level.

In the study of Corkerhill, Glasgow referredto earlier, Roberts et al contrast the preventiveambitions for safety of health professionalsworking in the area and citizens' groups livingin the area.2 The citizens' groups focused onhousing, whereas the professionals were moremodest and focused solidly on education: 'wehave to educate them, the parents, that thehome is really the most unsafe place you can

be'.2 The educational tasks here would includewidening the professionals' horizons aboutdifferent strategies of injury prevention, in-creasing their skills in local advocacy work, andlearning about citizens' conceptions of need intheir area.The community wide programme of injury

prevention in Falkoping, Sweden prioritisedthe education of policy makers and healthworkers.38 Results of an injury surveillancesystem were used to stimulate local interest inthe programme from professionals and thepublic alike. 'Local injury data are necessary togain the support of local authority organisa-tions and the population, who may not believethat the problem exists in their community'. 38The Falkoping programme also relied on areference group or 'healthy alliance' drawnfrom a wide range of health, local authority,voluntary, and community agencies to coor-dinate and plan the prevention activities. Thismodel of community based programmes hasbecome the basis for the WHO's Safe Com-munities programme,39 and has also beenadopted in a number of other areas such as theIlawarra area of New South Wales,40 and theSafe Kids Healthy Neighbourhood injuryprevention programme in Harlem.4'

Involving the community through the mediawas well demonstrated by Schelp in Falkoping,Sweden where local journalists were involvedin the planning group.38 Safety promotingmessages need to be introduced into how themedia report on injury 'which often dwells onbizarre or gruesome aspects of individualcases'.42 In reporting on individual cases, 'whatis missing is the depiction of injuries as under-standable, predictable and in many casespreventable, events'.3o Resulting for this is 'thevast majority of legislators, governors, com-missioners, physicians, nurses, lawyers and thegeneral public [who] continue to view injuriesof acts of fate'.30

Lescohier points to an expansion of the roleof education to alter the public perception ofrisk in order to change social norms, for exam-ple, in relation to drinking and driving. Thework of grass roots organisations, such asMothers Against Drunk Driving (MADD) hasreceived a great deal of media attention andhelped to influence local communities.42Both 'top down' and 'bottom up' approaches

can help alter social norms in relation to safety.In the work in Corkerhill, Glasgow withcitizens' groups, parents already exercised arange of preventive actions. There is a need toconsult those whose day to day lives are areservoir of effective safe keeping strategies anduse this in education as appropriate.2

ConclusionWhitehead, in surveying the wider scene ofhealth education, has concluded that most ofthe activity has been concerned with individuallifestyles and that 'there has been a neglect ofeducation concerned with social and environ-mental influences on health and a relativeneglect of education directed at local andnational policy makers as opposed to the

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general public'.4 This can be echoed in the fieldof injury prevention and safety promotion.What this article has sought to illuminate is thisbroader definition of health education and itsimportance in injury prevention, as a found-ation for both environmental change and legis-lation.There are still many gaps in our knowledge

of how best to influence policy makers, profes-sionals, children, parents, and the wider com-munity. Very few evaluated studies ofinterventions pay any attention to measuringprocess. It is important to be able to identifysuccessful and unsuccessful components ofcampaigns and understand why a programmeworks in specific circumstances or localities andnot in others. Only then can we transport thoseeffective components to other areas and to leamfrom earlier mistakes. There has been a falsedistinction between the role of health educa-tion, environmental measures, and legislation:in practice the three are interlinked and theirsynergistic effect is important. The challenge isto make the educational process more effectivein all the contexts in which it takes place.

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