Using threshold analysis to assess the robustness of public health intervention recommendations from network meta-analyses: application to accident prevention in households with children under five.

BACKGROUND: In the appraisal of clinical interventions, complex evidence synthesis methods, such as network meta-analysis (NMA), are commonly used to investigate the effectiveness of multiple interventions in a single analysis. The results from a NMA can inform clinical guidelines directly or be used as inputs into a decision-analytic model assessing the cost-effectiveness of the interventions. However, there is hesitancy in using complex evidence synthesis methods when evaluating public health interventions. This is due to significant heterogeneity across studies investigating such interventions and concerns about their quality. Threshold analysis has been developed to help assess and quantify the robustness of recommendations made based on results obtained from NMAs to potential limitations of the data. Developed in the context of clinical guidelines, the method may prove useful also in the context of public health interventions. In this paper, we illustrate the use of the method in public health, investigating the effectiveness of interventions aiming to increase the uptake of accident prevention behaviours in homes with children aged 0-5. METHODS: Two published random effects NMAs were replicated and carried out to assess the effectiveness of several interventions for increasing the uptake of accident prevention behaviours, focusing on the safe storage of other household products and stair gates outcomes. Threshold analysis was then applied to the NMAs to assess the robustness of the intervention recommendations made based on the results from the NMAs. RESULTS: The results of the NMAs indicated that complex intervention, including Education, Free/low-cost equipment, Fitting equipment and Home safety inspection, was the most effective intervention at promoting accident prevention behaviours for both outcomes. However, the threshold analyses highlighted that the intervention recommendation was robust for the stair gate outcome, but not robust for the safe storage of other household items outcome. CONCLUSIONS: In our case study, threshold analysis allowed us to demonstrate that there was some discrepancy in the intervention recommendation for promoting accident prevention behaviours as the recommendation was robust for one outcome but not the other. Therefore, caution should be taken when considering such interventions in practice for the prevention of poisonings in homes with children aged 0-5. However, there can be some confidence in the use of this intervention in practice to promote the possession of stair gates to prevent falls in homes with children under 5. We have illustrated the potential benefit of threshold analysis in the context of public health and, therefore, encourage the use of the method in practice as a sensitivity analysis for NMA of public health interventions.

Evaluating the citywide Edinburgh 20mph speed limit intervention effects on traffic speed and volume: A pre-post observational evaluation.

OBJECTIVES: Traffic speed is important to public health as it is a major contributory factor to collision risk and casualty severity. 20mph (32km/h) speed limit interventions are an increasingly common approach to address this transport and health challenge, but a more developed evidence base is needed to understand their effects. This study describes the changes in traffic speed and traffic volume in the City of Edinburgh, pre- and 12 months post-implementation of phased city-wide 20mph speed limits from 2016-2018. METHODS: The City of Edinburgh Council collected speed and volume data across one full week (24 hours a day) pre- and post-20mph speed limits for 66 streets. The pre- and post-speed limit intervention data were compared using measures of central tendency, dispersion, and basic t-tests. The changes were assessed at different aggregations and evaluated for statistical significance (alpha = 0.05). A mixed effects model was used to model speed reduction, in the presence of key variables such as baseline traffic speed and time of day. RESULTS: City-wide, a statistically significant reduction in mean speed of 1.34mph (95% CI 0.95 to 1.72) was observed at 12 months post-implementation, representing a 5.7% reduction. Reductions in speed were observed throughout the day and across the week, and larger reductions in speed were observed on roads with higher initial speeds. Mean 7-day volume of traffic was found to be lower by 86 vehicles (95% CI: -112 to 286) representing a reduction of 2.4% across the city of Edinburgh (p = 0.39) but with the direction of effect uncertain. CONCLUSIONS: The implementation of the city-wide 20mph speed limit intervention was associated with meaningful reductions in traffic speeds but not volume. The reduction observed in road traffic speed may act as a mechanism to lessen the frequency and severity of collisions and casualties, increase road safety, and improve liveability.

Equity as the fourth 'E' in the '3 E's' approach to injury prevention.

The education, engineering and enforcement (3 E's) approach to injury prevention is grounded in assumptions that it is effective for everyone; however, evidence demonstrates that it fails to consider opportunities for all populations to experience safe and injury-free lives. In this way, the 3 E's approach does not support health equity in the injury prevention field. In this brief report, we argue that a fourth E, equity, must also be used with the 3 E's approach to injury prevention.

Child Housing Assessment for a Safe Environment (CHASE): a new tool for injury prevention inside the home.

OBJECTIVE: To develop a tool to assess the safety of the home environment that could produce valid measures of a child's risk of suffering an injury. METHODS: Tool development: A four-step process was used to develop the CHASE (Child Housing Assessment for a Safe Environment) tool, including (1) a literature scan, (2) reviewing of existing housing inspection tools, (3) key informants interviews, and (4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with paediatric injury. Retrospective case-control study to validate the CHASE tool: Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban paediatric emergency department in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Standard (HQS) and the CHASE tool to each enrollee's home, and we compared scores on individual and summary items between cases and controls. RESULTS: Twenty-five items organised around 12 subdomains were included on the CHASE tool. 71 matched pairs were enrolled and included in the analytic sample. Comparisons between cases and controls revealed statistically significant differences in scores on individual items of the CHASE tool as well as on the overall score, with the cases systematically having worse scores. No differences were found between groups on the HQS measures. CONCLUSION: Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future study of the CHASE inspection tool in a prospective trial would help assess its efficacy in preventing injuries and reducing medical costs.

[Analysis of the determinants of cost savings in traffic accidents on interurban roads in Spain]. / Análisis de los factores determinantes del ahorro de costes en accidentes de tráfico en la red de carreteras de España.

OBJECTIVE: The increase in traffic accidents depends on multiple factors; it generates an economic and public health problem that must be analyzed jointly by agents involved in road safety. The aim of the work was to quantify the effect of various factors in the cost savings due to traffic accidents on interurban roads in Spain. METHODS: It was analyzed, through a lineal regression with panel data model and in the period 2000-2017, how different factors affected cost savings due to the risk of mortality or injury avoided on Spanish interurban roads. RESULTS: A 1% increase in traffic volume led to a reduction in costs per MVKT (million vehiclekilometres travelled) of €162.46 referring to the risk of mortality, €115.32 for serious injuries and €10.10 for mild injuries. This increase in unemployment caused a cost reduction of €31.43, €10.76 and €0.98, respectively. The same increase in the investment in replacement implied a reduction of these costs of €11 for any risk. A 1% increase in the ageing index led to an increase in costs of €276.83 in terms of mortality risk and €257.49 in terms of injury. Foreign tourism generated a cost of more than €40 for any risk. A 1% increase in GDP per capita led to an increase in costs of €155.50, €138.09 and €8.21 for defined risks. The points driving license led to an increase in costs of €785.50 per MVKR when referring to mortality risks. CONCLUSIONS: Determining factors for cost savings: motorization rate, unemployment rate and investment in replacement interurban roads. Determining factors that increased costs: expiry of the effect of the penalty - points driving licence, ageing index of the population, increase in GDP or proportion of foreign travelers.

OBJETIVO: El incremento de los accidentes de tráfico depende de múltiples factores, generando un problema económico y de salud pública que debe ser analizado conjuntamente por los agentes intervinientes en la seguridad vial. El objetivo del trabajo fue cuantificar el efecto de diversos factores determinantes en el ahorro de costes por accidentes de tráfico en vías interurbanas en España. METODOS: Se analizó, a través de un análisis de regresión mediante datos de panel referidos al período 2000-2017, cómo afectaban diferentes factores al ahorro de costes por cada riesgo de mortalidad o lesividad evitado en las vías interurbanas españolas. RESULTADOS: El aumento del 1% del volumen de tráfico conllevó una reducción de costes por MVKR (millón de vehículos-kilómetros recorridos) de 162,46€ refiriéndonos al riesgo de mortalidad, 115,32€ para lesividad grave y 10,10€ para leve. El aumento en el desempleo supuso una reducción de costes de 31,43€, 10,76€ y 0,98€, respectivamente. Idéntico incremento de la inversión en la reposición implicó una reducción de estos costes de 11€ para cualquier riesgo. El aumento del 1% del índice de envejecimiento comportó un aumento de costes de 276,83€ hablando del riesgo de mortalidad y de 257,49€ si hablamos de lesividad. El turismo extranjero generó un coste superior a los 40€ para cualquier riesgo. El aumento del 1% del Producto Interior Bruto (PIB) per cápita conllevó un aumento de costes de 155,50€, 138,09€ y 8,21€ para los riesgos anteriormente definidos. El permiso de conducción por puntos condujo a un incremento de costes de 785,50€ por MVKR al referirnos a los riesgos de mortalidad. CONCLUSIONES: Los factores condicionantes del ahorro de costes son el volumen de tráfico, la tasa de paro y la inversión en reposición. Los factores condicionantes del incremento de costes son la caducidad del efecto del permiso de conducción por puntos, el índice de envejecimiento, el incremento del PIB y la proporción de conductores extranjeros.

Expediting cataract surgery in New Zealand is cost-effective for falls prevention and improving vision-so what might be the next steps?

Multifactorial individual assessment with interventions tailored to the individual's risk factors can reduce the rate of falls and risk of fractures. Assessment of vision is one key aspect of multifactorial assessment and first eye cataract surgery reduces the rate of falls. We recently modelled the impact of expediting first eye cataract surgery in New Zealand for falls prevention (Boyd et al Injury Prevention). The model used was the same model used for previous modelling of home safety assessment and modification and community exercise programmes. This study found that expedited cataract surgery was highly cost-effective by generating a quality-adjusted life-year (QALY) for NZ$10,600 (95%UI: NZ$6,030-15,700). Routine cataract surgery itself (relative to no such surgery being available) was even more cost-effective at $4,380 per QALY gained, when considering vision benefits and falls prevention benefits. In this viewpoint article, we discuss the potential next steps for expediting cataract surgery and further improving its cost-effectiveness in the New Zealand setting.

America's Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 6: Social Factors.

Although previous articles in the series have focused on the key players in our health care system, even larger factors that impact the cost and outcome of the nation's health lie in areas that are not traditionally thought of as "health care." Diet and exercise play a huge role in longevity and well-being. The best health care systems are unable to do much to lower deaths from firearms and motor vehicle crashes. Changing our focus from health care institutions to how to better support patients in the community will both lower cost and improve satisfaction. We need to learn how to better integrate patients' wishes into end-of-life care to provide more humanistic as well as less expensive care.

Integration of hazard rectification efficiency in safety assessment for proactive management.

OBJECTIVE: Safety assessment is crucial for the development of continuous improvement strategies. However, most studies assess construction safety with cross-sectional information and thus management tends to be passive. This study proposes an evidence-based methodology incorporating hazard rectification efficiency for project safety assessment. METHOD: First, we theoretically introduced hazard rectification efficiency as a proxy for hazard exposure. Later, based on set-pair analysis, we proposed a safety assessment model that incorporates hazard occurrence and rectification efficiency. Subsequently, we collected site investigation records from seven building projects in Qingdao, Shandong. The data were used to develop a safety performance index (SPI) with the proposed model and a default model. The results were compared and discussed according to industrial practices for validation purposes. RESULTS: The proposed model provides conservative indications of project safety performance; more importantly, the index calculated with the model provides advance warning when necessary. In the proposed method, in terms of the SPI, hazard and rectification indicators provide actionable information to address failures and improve safety conditions. IMPLICATIONS: This research describes a new perspective (rectification efficiency) for safety assessment, which supplements the current body of knowledge on safety assessment. The proposed index, SPI, promotes the adoption of proactive hazard identification, monitoring, and control in construction.

Net-societal and net-private benefits of some existing vehicle crash avoidance technologies.

Most light-duty vehicle crashes occur due to human error. Many of these crashes could be avoided or made less severe with the aid of crash avoidance technologies. These technologies can assist the driver in maintaining control of the vehicle when a possibly dangerous situation arises by issuing alerts to the driver and in a few cases, responding to the situation itself. This paper estimates the societal and private benefits and costs associated with three crash avoidance technologies, blind-spot monitoring, lane departure warning, and forward-collision warning, for all light duty passenger vehicles in the U.S. for the year 2015. The three technologies could collectively prevent up to 1.6 million crashes each year including 7200 fatal crashes. In this paper, the authors estimated the net-societal benefits to the overall society from avoiding the cost of the crashes while also estimating the private share of those benefits that are directly affecting the crash victims. For the first generation warning systems, net-societal benefits and net-private benefits are positive. Moreover, the newer generation of improved warning systems and active braking should make net benefits even more advantageous.

Ethical considerations for the design and implementation of child injury prevention interventions: the example of delivering and installing safety equipment into the home.

INTRODUCTION: Public health ethics is a growing field of academic interest but ethical discussion of injury prevention seems to have received limited attention. Interventions that promise to be effective are not necessarily-without explicit justification-'good' and 'right' interventions in every sense. This paper explores public health ethics in the context of child injury prevention with the objective to initiate interdisciplinary dialogue on the ethics of child safety interventions. METHOD: A framework of seven public health ethics principles (non-maleficence, health maximisation, beneficence, respect for autonomy, justice, efficiency and proportionality) were applied to an intervention to promote child safety in the home. RESULTS: Preventing child injury in the home is ethically challenging due to the requirement for the state to intervene in the private sphere. Non-maleficence and beneficence are difficult to judge within this intervention as these are likely to be highly dependent on the nature of intervention delivery, in particular, the quality of communication. Respect for autonomy is challenged by an intervention occurring in the home. The socioeconomic gradient in child injury risk is an important factor but a nuanced approach could help to avoid exacerbating inequalities or stigmatisation. Equally, a nuanced approach may be necessary to accommodate the principles of proportionality and efficiency within the local context. CONCLUSION: We conclude that this intervention is justifiable from an ethical perspective but that this type of reflection loop is helpful to identify the impact of interventions beyond effectiveness.

School Area Road Safety Assessment and Improvements (SARSAI) programme reduces road traffic injuries among children in Tanzania.

PURPOSE: To determine the impact of a paediatric road traffic injury (RTI) prevention programme in urban Sub-Saharan Africa. SETTING: Dares Salaam, Republic of Tanzania. METHODS: Household surveys were conducted in catchment areas around 18 primary schools in Dar es Salaam, Republic of Tanzania; the catchment areas were divided into control and intervention groups. Collected data included basic demographic information on all school-aged household members and whether or not they had been involved in an RTI in the previous 12 months, and, if so, what the characteristics of that RTI were. Based on these findings, a separate road safety engineering site analysis and consultation with the communities and other stakeholders, an injury-prevention programme was developed and implemented, consisting of infrastructure enhancements and a site-specific educational programme. The programme was initially implemented at the intervention schools. After 1 year, data were collected in the same manner. The control group received the same intervention after follow-up data were collected. RESULTS: Data were collected on 12 957 school-aged children in the baseline period and 13 555 school-aged children in the post-intervention period, in both the control and intervention communities. There was a statistically significant reduction in RTIs in the intervention group and a non-significant increase in RTI in the control group. The greatest reduction was in motorcycle-pedestrian RTI, private vehicle-pedestrian RTI and morning RTI. CONCLUSION: The programme demonstrated a significant reduction in paediatric RTI after its implementation, in very specific ways. This study demonstrates that for a reasonable investment, scientifically driven injury-prevention programmes are feasible in resource-limited settings with high paediatric RTI rates.

The impact of vessel speed reduction on port accidents.

Reduced-speed zones (RSZs) have been designated across the world to control emissions from ships and prevent mammal strikes. While some studies have examined the effectiveness of speed reduction on emissions and mammal preservation, few have analyzed the effects of reduced ship speed on vessel safety. Those few studies have not yet measured the relationship between vessel speed and accidents by using real accident data. To fill this gap in the literature, this study estimates the impact of vessel speed reduction on vessel damages, casualties and frequency of vessel accidents. Accidents in RSZ ports were compared to non-RSZ ports by using U.S. Coast Guard data to capture the speed reduction effects. The results show that speed reduction influenced accident frequency as a result of two factors, the fuel price and the RSZ designation. Every $10 increase in the fuel price led to a 10.3% decrease in the number of accidents, and the RSZ designation reduced vessel accidents by 47.9%. However, the results do not clarify the exact impact of speed reduction on accident casualty.

Cost-effectiveness of raising alcohol excise taxes to reduce the injury burden of road traffic crashes.

BACKGROUND: Alcohol is an important risk factor for road transport injuries. We aimed to determine if raising alcohol taxes would be a cost-effective intervention strategy for reducing this burden. METHODS: We modelled the effect of a one-off increase in alcohol excise tax (NZ$0.15 (US$0.10)/standard drink) on alcohol consumption in New Zealand, using price elasticities to determine change in on-trade and off-trade sales of beer, cider, wine, spirits and ready-to-drink products. We simulated change in alcohol-attributable motor vehicle and motorcycle injuries, by age, sex and ethnicity, over the lifetime of the current population, and from changes in injuries, we determined changes in costs of health care, productivity, crime and vehicle damage. RESULTS: The modelled increase in tax led to a net 4.3% reduction in pure alcohol consumption and a 27% increase in excise tax revenue. Lifetime population health improved by 640 quality-adjusted life years (95% uncertainty interval: 450 to 860) and costs of treating transport injuries reduced by NZ$3.6 million ($0.88 million to $6.8 million), although this was countered by a $3.8 million ($2.9 million to $4.8 million) increase in costs of treating other diseases. Health care costs were far outweighed by a $240 million ($130 to $370 million) reduction in lost productivity, crime and vehicle damage costs. Cost-effectiveness was not highly sensitive to price elasticity values, discount rates or time horizons for measurement of outcomes. CONCLUSION: Raising alcohol excise tax in this high-income country would be highly cost-effective and could lead to substantial cost-savings for society.

Economic evaluations of strategies to prevent sports and recreational injury among children and adolescents: a systematic review.

OBJECTIVE: To identify, summarise and critically assess studies reporting costs and consequences of sport and recreation injury prevention strategies among children and adolescents. DESIGN: Systematic review. METHODS AND DATA SOURCES: We searched MEDLINE (Ovid), EMBASE, CINAHL, Pubmed, Econlit and SPORTDiscus and PEDE. Included studies were peer reviewed full economic evaluations or cost analyses of sport/recreation injury prevention among children and adolescents≤18 years of age. The Pediatric Quality Appraisal Questionnaire was used for quality assessment. RESULTS: The initial search yielded 1896 unique records; eight studies met inclusion criteria. Six studies were related to injury prevention in the context of recreation, two were related to sports. For recreation studies in cycling and swimming: costs per head injury averted was US$3109 to $228 197; costs per hospitalisation avoided was US$3526 to 872 794; cost per life saved/death avoided was US$3531 to $103 518 154. Sport interventions in hockey and soccer were cost saving (fewer injuries and lower costs). Global quality assessments ranged from poor to good. Important limitations included short time horizons and intermediate outcome measures. CONCLUSIONS: Few rigorous economic evaluations related to sport and recreation injury prevention have been conducted. The range of estimates and variation in outcomes used preclude specific conclusions; however, where strategies both improve health and are cost saving, implementation should be prioritised. Future economic evaluations should incorporate time horizons sufficient to capture changes in long-term health and use utility-based outcome measures in order to capture individual preferences for changes in health states and facilitate comparison across intervention types.

Effectiveness of an app-based intervention for unintentional injury among caregivers of preschoolers: protocol for a cluster randomized controlled trial.

BACKGROUND: Each year, over 15,000 preschoolers die from unintentional injuries in China. Many interventions proven to work in other nations have not been implemented nationwide in China. The rapid popularity of smartphones offers an opportunity to overcome this limitation and disseminate evidence-based interventions to the large population of China. This study aims to assess the effectiveness of an app-based intervention for caregivers of preschoolers to prevent unintentional injury among young Chinese children. METHOD: A single-blinded, 6-month, parallel-group cluster randomized controlled trial with 1:1 allocation ratio will be conducted in Changsha, China. In total, 2626 caregivers of preschoolers ages 3-6 years old who own a smartphone will be recruited from 20 preschools. Clusters will be randomized at the preschool level and allocated to either the control group (routine education plus app-based parenting education excluding unintentional injury prevention) or the intervention group (routine education plus app-based parenting education including unintentional injury prevention). The app-based injury prevention program was developed based on the Theory of Planned Behavior, the Haddon Matrix, the Mobile Learning framework, and a needs assessment. Data collection will be conducted at baseline, 3-month, and 6-month follow-up via app-based survey plus printed questionnaire survey. The primary outcome measure is unintentional injury incidence among preschoolers in the past 3 months. Secondary outcome measures include economic losses due to unintentional injury in the past 3 months, the Incremental Cost-Effectiveness Ratios (ICERs), and parent's attitudes and behaviors concerning supervision to prevent preschooler unintentional injury in the past week. An intention-to-treat approach will be used to evaluate outcome measures. Chi-square tests will examine differences for outcome measures between groups at each time point and generalized estimation equations (GEE) will test the overall effectiveness of the app-based intervention. Missing outcome data will be imputed using the Expectation Maximization algorithm (EM). DISCUSSION: This trial will examine evidence concerning the effectiveness of an innovative app-based intervention for caregivers of Chinese preschoolers. If effective, the app-based intervention could offer an effective population-based intervention option to cost-effectively promote unintentional injury prevention in countries and regions where injury control is under-supported. TRIAL REGISTRATION: ChiCTR-IOR-17010438 . Registered 15 January 2017.

Use of evidential reasoning and AHP to assess regional industrial safety.

China's fast economic growth contributes to the rapid development of its urbanization process, and also renders a series of industrial accidents, which often cause loss of life, damage to property and environment, thus requiring the associated risk analysis and safety control measures to be implemented in advance. However, incompleteness of historical failure data before the occurrence of accidents makes it difficult to use traditional risk analysis approaches such as probabilistic risk analysis in many cases. This paper aims to develop a new methodology capable of assessing regional industrial safety (RIS) in an uncertain environment. A hierarchical structure for modelling the risks influencing RIS is first constructed. The hybrid of evidential reasoning (ER) and Analytical Hierarchy Process (AHP) is then used to assess the risks in a complementary way, in which AHP is hired to evaluate the weight of each risk factor and ER is employed to synthesise the safety evaluations of the investigated region(s) against the risk factors from the bottom to the top level in the hierarchy. The successful application of the hybrid approach in a real case analysis of RIS in several major districts of Beijing (capital of China) demonstrates its feasibility as well as provides risk analysts and safety engineers with useful insights on effective solutions to comprehensive risk assessment of RIS in metropolitan cities. The contribution of this paper is made by the findings on the comparison of risk levels of RIS at different regions against various risk factors so that best practices from the good performer(s) can be used to improve the safety of the others.

Human rights-based approach to unintentional injury prevention.

Unintentional injury remains an important global public health issue, and efforts to address it are often hampered by a lack of visibility, leadership, funding, infrastructure, capacity and evidence of effective solutions. The growing support for a socioecological model and a systems approach to prevention-along with the acknowledgement that injury prevention can be a byproduct of salutogenic design and activities-has increased opportunities to integrate unintentional injury prevention into other health promotion and disease prevention agendas. It has also helped to integrate it into the broader human development agenda through the Sustainable Development Goals. This growing support provides new opportunities to use a human rights-based approach to address the issue. The human rights-based approach is based on the idea that all members of society have social, economic and cultural rights and that governments are responsible and accountable for upholding those rights. It incorporates a systems approach, addresses inequity and places an emphasis on the most vulnerable corners of humanity. It also leverages legal statutes and provides organisations with the opportunity to build existing international goals and benchmarks into their monitoring efforts. This paper describes the approach and highlights how it can leverage attention and investment to address current challenges for unintentional injury.

Fall Prevention Hits Stumbling Blocks.

Implementation of efforts to screen older people for fall risk-and to intervene before falls occur-have been scattershot at best. Ongoing studies of fall prevention called STRIDE (Strategies to Reduce Injuries and Develop Confidence in Elders) might change that. The studies look at whether clinicians can implement a fall-prevention program across rural, urban, and suburban treatment settings.

Vehicular Hyperthermia-A Highly Preventable and Potentially Fatal Problem.

A child dying of heat injury due to being left unattended in a motor vehicle is a needless tragedy. Each year in the United States an average of 38 children mostly younger than age 2 years die of vehicular hyperthermia, frequently the result of a parental lapse of attention and not intentional neglect. Serious illness results quickly from exposure to rising heat within the passenger compartment, even on days when the temperature is fairly moderate. Prevention is paramount in addressing this problem and can best be accomplished by a combination of technological means, such as passive warning systems, laws that make leaving a child in a car alone illegal, and public education campaigns. [Pediatr Ann. 2018;47(3):e88-e90.].

Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study.

BACKGROUND: Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin. METHODS: Population-based, cross-sectional study of children and youth (0-24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries. RESULTS: There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84). INTERPRETATION: The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.