Divided they fall: time to resolve sterile academic disputes that jeopardise child safety efforts

Abstract

Injury is the leading cause of death worldwide for children after their first birthday and is likely to rise up the global league table of premature mortality.1 For every injured child who dies, several hundred are hospitalised and several thousand more live on with varying degrees of discomfort, distress and disability. While a large proportion of these injuries are the result of road accidents, many others occur in either the home or leisure environments. Injury disproportionately affects vulnerable sectors of society such as children, older people and the disadvantaged, thereby contributing to health inequalities.Injury prevention efforts have long been frustrated by disputes that have polarised opinion and diverted attention from the real challenges. Some of these debates may be desirable and even necessary, but many risk becoming sterile and counterproductive. Four are especially troublesome despite appearing superficially benign: concerning terminology, aetiology, strategy and surveillance. All four merit attention in an attempt to ensure their resolution, and failure to do so will pose an additional and avoidable barrier to our collective efforts to improve child safety.Terminology: Accident Or Injury?In recent years, the injury prevention community has eschewed the term 'accident' while almost everyone else persists in using it. The question is does it matter'?The term 'accident' is rapidly becoming obsolete in the scientific and public health literature, where its use is regarded as nurturing archaic and potentially counterproductive notions of unpredictability, randomness and unavoidability. On the other hand, the substitution of 'injury' for 'accident' is often unsatisfactory - the former is an outcome, while the latter is an incident or a series of events. Since prevention depends on unravelling the causal chain of events leading to injury, 'accident' is arguably a more accurate and insightful descriptor of the phenomenon than 'injury' is.'Accident' proved such a problematic word for the British Medical Journal2 that its Editors took the controversial decision in 2001 to banish it from its pages. The journal's view was that this was necessary to counter fatalistic notions of injury. Nevertheless, many members of the public, the media and even some professionals continue to use the term in a way that does not necessarily preclude prevention.3 Stifling their voices will deter many people from expressing valid views and will contribute little to the cause of injury prevention.'Injury' is becoming the common linguistic currency of the global injury prevention community. Where 'accident' continues to be used, practitioners and researchers should be encouraged to display a degree of tolerance rather than a knee-jerk rejection.Aetiology: What Causes Injury - Behaviour Or Environment?As many childhood injuries can be attributed to risk-taking behaviour, logic dictates that behavioural factors should be the main focus, of both aetiological studies and preventive measures. But this would be an oversimplification: human behaviour is partly determined by the environment. If pedestrians are physically separated from traffic by a high barrier, children are less likely to run across the road. Conversely, environment is partly determined by behaviour: parents of toddlers who are especially boisterous will often reorganise potential hazards around the home in such a way as to minimise exposure and risk.Risk taking is difficult to investigate due to its complexity and methodological challenges. The limited research that has been done has proved contradictory. A systematic review of the subject by Thomas et al.4 concluded that 'risk taking behaviour as an umbrella concept cannot be regarded as a useful model to explain accidental injury among young people'.Countermeasures that achieve environmental change are more likely to be effective in preventing injuries than those focusing exclusively on human behaviour. …