THE INJURY FREE COALITION FOR KIDS OF CHICAGO: A COMMUNITY-BASED APPROACH TO INJURY PREVENTION-Child's Doctor Spring 2001.

The Injury Free Coalition for Kids of Chicago: A Community-Based Approach to Injury Prevention

Karen Sheehan, MD, MPH

aSpring 2001

THE EPIDEMIOLOGY OF CHILDHOOD INJURY

At the beginning of the 21st Century, injury is the most serious public health problem that children face.[1] Injury is the leading cause of death for children over 1 year of age, exceeding the combined total of deaths from all other causes.[2] In 1997, nearly 19,000 children and adolescents younger than 20 years old died as the result of injuries.[3]

Mortality data provide an incomplete picture of the burden of injury. For every injury death, it is estimated that there are approximately 18 hospitalizations and 233 emergency department visits.[4] Each year approximately 1 in 4 children experience an injury that is severe enough to require medical attention, missed school, and/or bed rest.[5]

Injury rates vary depending on the age and gender of the child, family income, and race/ethnicity. For example, drowning injuries in younger children tend to occur in swimming pools while adolescent drowning injuries are more likely to occur in open water and be associated with alcohol use.[6] Males tend to be injured more than females, although this ratio is narrow for younger children and widens in adolescence.[3] Poor children are twice as likely as nonpoor children to receive injuries from all causes and 4.5 times as likely to receive assault injuries.[7] Minority children are most likely to be injured, but it is not known if racial disparities might be a result of the confounding effects of socioeconomic status. Besides sociodemographic characteristics, other factors affect injury rates. For example, the prevalence of the threat in the community (e.g., backyard swimming pools, kerosene heaters), and access to and use of environmental countermeasures (e.g., car seats, smoke detectors) play important roles in injury incidence.[8]

THE FIVE “E’s”

It is critical to understand the epidemiology of injury because it can help provide direction in planning and implementation of prevention programs. One conceptual framework, promoted since the 1950s, that can be used to design an injury prevention intervention utilizes the “three E’s”—education, enforcement, and engineering.[9] Adding two more “E’s”—environment and evaluation—to the historic trio provides an even richer framework for intervention structure.

Education strategies are used to increase knowledge about safer behaviors and decrease risky behaviors. Used alone, education strategies are often not effective in preventing injury, because although they may increase knowledge, they do not guarantee a behavioral change. However, when used with the other “E’s,” they can enhance injury prevention efforts. Enforcement—or legal regulation—is another tool that can be used to prevent injuries. Legislation can lead to changes in individual behavior, such as requiring the use of seat belts, or changes in industry standards, such as requiring children’s sleepwear be fire retardant. Engineering is considered the most effective of the three “E’s” because it provides automatic, passive protection to large groups of people. Engineering examples include narrowing the space between crib slats to avoid head entrapment and using shatterproof glass in automobiles.[10]

In addressing childhood injury, it is helpful to consider another “E,” the environment. The environment where they live and play affects the safety of all children, but it is especially true for the urban poor who often lack safe play areas and appropriate adult supervision. An unsafe environment is the most likely reason that poor children have significantly higher injury rates than nonpoor children.[7]

Also, no injury prevention effort should be complete without an evaluation component—the fifth “E.” It is critical to evaluate prevention strategies because some efforts that would seem to prevent injury actually may cause harm. One study that evaluated the effectiveness of Mr. Yuk stickers in discouraging children from ingesting hazardous substances found that children who were taught that these stickers meant “do not touch” actually were more likely to touch the Mr. Yuk labeled containers.[11]

HARLEM HOSPITAL INJURY PREVENTION PROGRAM (HHIPP)

Although injuries are a leading cause of mortality and morbidity in this country, hospitals, while providing acute trauma care and rehabilitation to injury victims, have historically done little to prevent injuries. This has been changing slowly as individual physicians and nurses have begun to go beyond the hospital setting to prevent injuries so that fewer children would experience a trauma ward. In the late 1980s, Dr. Barbara Barlow, a pediatric trauma surgeon at Harlem Hospital in New York City, began a community-based effort that works to decrease injuries through modifying the physical and social environment of urban youth. An evaluation component was built into the prevention effort so that the effects of the intervention could be measured. The conceptual framework that illustrates HHIPP’s injury prevention approach is shown in the Figure.[12]

Figure Data-based model for change. Epidemiologic information, coupled with community awareness, ultimately results in specific programs designed to deal with concerns arising from children’s physical and social environments. Outcome data from the programs are incorporated to effect further changes.

HHIPP HIGHLIGHTS

To reduce the disproportionate burden of injury that children in Harlem experience, HHIPP developed two types of injury prevention activities: 1) educational programs, and 2) creating safe environments—both physical and social. The programs were implemented through the collaboration of 26 other organizations including the Little League, the New York City Department of Transportation, and the Black United Fund. Surveillance data were used to assess the effectiveness of HHIPP activities.

Educational programs

Harlem Safety City: The goal of the Safety City program is to improve knowledge and behavior of traffic safety. Developed by the Department of Transportation, the program includes a puppet theatre company which travels to all Harlem elementary schools (kindergarten through fourth grade) and gives instruction in safe street-crossing behavior to all third-grade students in a full-sized model street. During the intervention period (which involved the creation of safe play areas and traffic safety education, i.e., the Playground Injury Prevention Project, the Safety City Program, and other supervised after-school activities), a recent study demonstrated that traffic injuries among school-aged children decreased by 36% (unadjusted).[13]

Safe environments

Playground Injury Prevention Project: Analysis of the surveillance data showed that many of Harlem’s children were injured on playgrounds. A survey of the community’s playgrounds found that the playgrounds were neglected, unsafe, and havens for drug dealers. Armed with these data, HHIPP staff relentlessly lobbied city officials to repair existing playgrounds. Eventually the Parks Department and the Board of Education, with the assistance of private grant support, renovated 35 park and school playgrounds. To save on costs and to attain a sense of community ownership, community children and parents helped in playground design and construction with several of the playground projects. Law enforcement officers worked with the community to police the playgrounds to keep them free from drugs. One year after the intervention, Harlem Hospital Trauma Registry Data showed a 12% decrease in emergency department visits for playground injuries.[14]

USING SURVEILLANCE TO EVALUATE THE HHIPP

Prior to founding the Harlem Hospital Injury Prevention Program (HHIPP) in 1988, Dr. Barlow and colleagues spent 5 years developing the Northern Manhattan Injury Surveillance System (NMISS), which tracks severe injuries of children (defined as those resulting in hospitalization or death) in Harlem and surrounding communities. They found that the injury rate of children and adolescents from Central Harlem (1,141/100,000)[12] (their targeted area) was substantially higher than that of Northern Manhattan (846/100,000), Ohio (518/100,000), and the entire country (656/100,000).[15]

One study of the HHIPP used data collected from the NMISS surveillance system to test whether the incidence of severe injury declined during the intervention period (1989–1991) compared to the pre-intervention period (1983–1988). The evaluation of the HHIPP showed there was a positive effect from the HHIPP approach in decreasing injuries. There was a 44% reduction in injury risk for targeted injuries in school-aged children in Central Harlem during the intervention period.[17]

THE INJURY FREE COALITION FOR KIDS

Harlem Hospital Injury Prevention Program’s unique approach—integrating the environmental and evaluation focus—with the traditional approaches to injury prevention (education, enforcement, and engineering) produced such impressive outcomes that the HHIPP has become a model for urban community injury prevention.[16,17] With funding from the Robert Wood Johnson Foundation (RWJF) beginning in 1994, the program has been replicated in eight cities across the country—Pittsburgh, Chicago, Kansas City, St. Louis, Atlanta, Los Angeles, Philadelphia, and Dallas—and renamed the Injury Free Coalition for Kids (IFCK). To be considered to be an outreach site, each applicant site had to

be located in a pediatric trauma center in a high-risk urban community,
have program site directors “who have a passion for controlling injury,”
have capacity to leverage RWJF seed money to raise other funds and in-kind support,
demonstrate willingness by the hospital to partner with community groups, and
have access to local injury surveillance data.[16]

Each site is unique depending on the communities they serve and the individual strengths they had prior to joining the Coalition. The sites, however, share a vision to reduce injury through creating physical and social environments for children and using local data to guide and evaluate program efforts. The rest of this article is devoted to the activities based at Children’s Memorial Hospital.

CHILDREN’S MEMORIAL HOSPITAL

In 1995, Children’s Memorial Hospital was the third hospital to join the IFCK. Although Injury Free Coalition for Kids of Chicago (IFCKC) works with many community organizations, its primary partner is the Chicago Youth Programs (CYP). CYP provides preventive health care, tutoring, mentoring, after-school activities, and college preparation classes to at-risk youth in three Chicago communities. The injury prevention focus of the Coalition complemented CYP’s well-developed programming aimed at providing safe social environments for at-risk youth.

History of the Chicago Youth Programs

CYP (then named the Cabrini Green Youth Program) was founded in 1984 when a group of Northwestern University (NU) medical students walked into Cabrini Green, a housing project notorious for its poverty and violence, and simply asked a few children if they wanted to play basketball.

For the next few years, CYP provided a few hours of safe play and tutoring to Cabrini Green children on Saturday mornings in donated space in a NU dormitory until it became clear to the volunteers that good intentions were not enough. Several of the girls became pregnant and one of the boys was shot and killed in a gang-related activity. Volunteers recognized that, while a once-a-week program helped some children, it was inadequate to make a significant difference in most of the children’s lives. The activities of CYP were moved to the Cabrini Green community and additional activities were offered to increase contact with the children. The Saturday session was redesigned to focus on recreation and mentoring, a separate evening of tutoring was added, and other sports activities (such as tennis, basketball, and ballet) were implemented.

Over time, art programs, computer classes, and science activities have been incorporated into the weekly schedule. New activities were incorporated when a volunteer or group had a specific interest; for example, the Japan American Society, wanting to work with inner city youth, partnered with the CYP to sponsor a judo class. Substantial changes were made in teen programming based on suggestions made by adolescent participants. Scholarships are provided for trade school and college. A community board was formed, and by parental request, a parent-run evening preschool was established to increase school readiness in preschool children and enhance parenting skills. Medical care is provided to those without physicians. Over the years the program has evolved so that each child receives a developmentally appropriate, comprehensive set of services. For example, a six-year-old participant might attend tutoring on Mondays, judo class on Tuesdays, clinic (if needed) on Wednesdays, and the recreation/mentoring program on Saturdays.

In 1995, the Cabrini Green Youth Program model was replicated in Washington Park (WPYP) on Chicago’s south side and the name changed to the Chicago Youth Programs. In 1998, a third site was added in the Uptown community (UCYP), an ethnically diverse neighborhood on Chicago’s north side. Currently CYP serves 150 children in Cabrini Green, 150 children in Washington Park and 68 children in Uptown. Five hundred volunteers (which now include working professionals in addition to students) provide services to the children at about 20 sites. All of the physical space is donated.

Injury Free Coalition for Kids of Chicago Program Highlights

Children Teaching Children: In Harlem, poor children are more likely to be involved with violence than nonpoor children.[7] Similar results were found in Cabrini Green. Through a self-report survey in 1995, 146 young children (ages 7 through 13 years) living in Cabrini Green reported high exposure to community violence. Forty-two percent of the children had seen someone shot, and 37% had seen someone stabbed. Twenty-one percent of the 146 children lived with someone who had been shot; 16% lived with someone who had been stabbed. Almost all of the subjects (90%) felt safe at home. Two-thirds of the children were not afraid to play outside, but almost half (43%) worried about getting hurt at school.[18]

In the early 1990s, CYP developed Children Teaching Children (CTC), a peer mentoring program in which older children teach younger children about various health issues through games, skits, and rap music. With funding from the Emergency Medical Services for Children program, Injury Free Coalition for Kids of Chicago evaluated CTC as a means of violence prevention. Changes in attitude, behavior, and injury rates for the younger children were compared to changes in other Cabrini Green children who were matched to the cases on age, sex, and census tract. Children who received CTC lessons showed a decrease in their attitudes that support violence and no change in aggressive behavior. In contrast, the control children demonstrated an increase in both attitudes that support violence and an increase in aggressive behavior.[19]

KidStART: KidStART is a secondary prevention program that uses the visual arts as a means to increase self-esteem (a known protective factor against the effects of violence) in youth who have been exposed to violence. Funded by the Illinois Violence Prevention Program, IFCKC is evaluating the effectiveness of KidStART in increasing self-esteem, decreasing aggressive behaviors, and reducing the negative psychological effects of violence to children at the three CYP locations and a Boys and Girls Club site.

Parent-Run Evening Preschool (PREP): Through PREP, which was founded by parents and CYP staff in the early 1990s, parents become involved in their child’s education through the supervised operation of evening preschool activities. Funding received from the Healthy Tomorrows Partnership for Children Program this year has been used to expand PREP to include two additional sites and to study its effectiveness. The goal of PREP is to improve parenting skills and to enhance school readiness in preschool children. Experiencing poor parenting and early school failure have been associated with an increased use of violence in later childhood. By improving parenting skills and school readiness, it is hoped that future violence can be avoided. Specific objectives are: 1) improving parenting attitudes and child-rearing behaviors, 2) increasing maternal self-esteem, and 3) preparing children cognitively and emotionally for school.

Chicago Youth Programs Clinic: Founded in 1993, the Chicago Youth Programs Clinic based at Children’s Memorial Hospital provides medical care with a special emphasis on injury prevention to CYP participants. The Clinic employs a unique approach to delivering health care. We believe that to make a significant difference in children’s lives, it is not enough to place a stethoscope on a child’s chest once a year. Thus, the doctors and medical students who provide their medical care also play in the gym with the children, tutor them, and take them on trips. This approach helps develop trust between the families and the health care workers.

Playground Initiative: Through a citywide initiative and funding from the Illinois General Assembly and the support of the Center of Childhood Safety, we have formed a local coalition with Chicago Public Schools, the Chicago Park District, and Friends of the Park to create awareness of playground safety and develop standards for maintenance and supervision. This past summer we used the National Program for Playground Safety playground survey to assess potential hazards in over 100 playgrounds in mostly low-income Chicago neighborhoods. This “report card” will be used to set priorities for the citywide task force. In addition, there is a paucity of playgrounds in low-income neighborhoods. We have completed one community-built playground in Cabrini Green and have plans to build or repair five more in inner city neighborhoods over the next year.

Emergency Department Surveillance Data: To assess our efforts, we developed an emergency department population-based[20] injury surveillance system to describe the incidence and mechanism of nonfatal injuries among children living in Cabrini Green. (Most emergency department surveillance systems are injury-specific). It is critical to have local data for accurate, meaningful assessment. For example, in most inner-city communities, pedestrian injury is more common than motor vehicle occupant injury. In Cabrini Green, for reasons that are not entirely clear, more children are injured as passengers in cars than as pedestrians. Our efforts are therefore focused on training community leaders to teach others in their community how to properly restrain children in cars.

Other Coalition Activities

Safe-at-Home Boxes: In June 2000, 5,000 Safe-at-Home boxes were distributed to families that are served by IFCK sites. Sponsored by the Allstate Foundation, the boxes contained home safety items including outlet covers, poison control information, home safety checklists, and safety door latches. The boxes were distributed in various ways. In Chicago, where the national kick-off occurred, the boxes were distributed through local clinics and a parenting program in the Chicago Public Schools. We hope this will become a yearly event.

Collaborative Research: Three sites—Kansas City, Los Angeles, and Chicago—have collaborated on one research project that explored adolescents’ thoughts and feelings on the role of the emergency health care provider in violence prevention.[21] Future collaborative research projects among the sites are being planned.

FUTURE DIRECTIONS

Over the next 5 years, the Injury Free Coalition for Kids plans to expand by adding 30 more trauma hospitals in partnership with their local communities in order to further decrease childhood injury. In addition, the Coalition has partnered with the National Association of Children’s Hospitals and Related Institutions (NACHRI) to help provide technical assistance to the new sites. NACHRI envisions that IFCK programs will become a benchmark for their member institutions. With these efforts, we hope all children will grow up healthy and injury-free.

REFERENCES

1. Bonnie RJ, Fuclo CE, Liverman CT, eds. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: National Academy Press; 1999.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 10 leading causes of death, United States 1997, all races, both sexes. National Center for Health statistics annual mortality tapes. Available on line at www.cdc.gov/ncipc/osp/states/101c97.htm

3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. US injury mortality statistics. National Center for Health Statistics annual mortality tapes. Available on line at www.cdc.gov/ncipc/osp/usmort.htm

4. Burt CW, Fingerhut LA. Injury-related visits to hospital emergency departments: United States, 1992–1995. National Center for Health Statistics, Centers for Disease Control and Prevention. Vital Health Statistics. January 1998;13:1–76.

5. Danesco ER, Miller TR, Spicer RS. Incidence and costs of 1987–1994 childhood injuries: demographic breakdowns. Pediatrics. 2000;105(2). URL: www.pediatrics.org/cgi/content/full/105/2/e27

6. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Drowning prevention. Available on-line at www.cdc.gov/ncipc/factsheets/drown.htm

7. Durkin MS, Davidson LL, Kuhn L, O’Connor P, Barlow B. Low-income neighborhoods and the risk of severe pediatric injury: a small-area analysis in northern Manhattan. Am J Public Health. 1994;84:587–592.

8. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Childhood injury fact sheet. Available on-line: www.cdc.gov/ncipc/factsheets/childh.htm

9. Widome MD. Remembering as we look ahead: the three E’s and firearm injuries. Pediatrics. 1991;88:379–382.

10. Deal LW, Gomby DS, Zippirioli L, Berman R. Unintentional injuries in childhood: analysis and recommendations. In: The Future of Children: Unintentional Injuries in Childhood. 2000;10:4–17.

11. Vernberg K, Culver-Dickinson P, Spyker DA. The deterrent effect of poison-warning stickers. Am J Dis Child. 1984;138:1018–1020.

12. Laraque D, Barlow B, Durkin M, Heagarty M. Injury prevention in an urban setting: challenges and successes. Bull NY Acad Med. 1995;72(1):16–30.

13. Durkin MS, Laraque D, Lubman I, Barlow B. Epidemiology and prevention of traffic injuries to urban children and adolescents. Pediatrics. 2000;103(6) URL:www.pediatrics.org/cgi/content/full/103/6/e74

14. Laraque D, Barlow B, Davidson L, Welborn C. Central Harlem playground injury project: a model for change. Am J Public Health. 1994;84(10):1691–1692.

15. Davidson LL, Durkin MS, O’Connor P, Barlow B, Heagarty MC. The epidemiology of severe injuries to children in northern Manhattan: methods and incidence rates. Paediatr Perinat Epidemiol. 1992;6:153–165.

16. Robert Wood Johnson Foundation. National Program Report: Dissemination of a Model Injury Prevention Program for Children and Adolescents. Available on-line: www.rwjf.org/health/injurye.htm

17. Davidson LL, Durkin MS, Kuhn L, O’Connor, Barlow B. The impact of the Safe Kids/Healthy Neighborhoods Injury Prevention Program in Harlem, 1988 through 1991. Am J Public Health. 1994;84:580–586.

18. Sheehan K, DiCara J, LeBailly S, Christoffel KK. Children’s exposure to violence in an urban setting. Arch Pediatr Adolesc Med. 1997;151:502–504.

19. Sheehan K, DiCara JA, LeBailly S, Christoffel KK. Adapting the gang model: peer mentoring for violence prevention. Pediatrics. 1999;104:50–54.

20. Zuckerbraun NS, Powell EC, Sheehan KM, Parks K, Uyeda A, Barlow B. Community injury surveillance: an emergency department based model. Presented at the American Academy of Pediatrics, Section of Emergency Medicine Annual Meeting, Chicago, October 2000.

21. Dowd DM, Seidel JS, Sheehan K, Barlow B, Bradbard S. Teenagers’ perceptions of personal safety and the role of the emergency health care provider. Ann Emerg Med. 2000:36:346–350.

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