Ministry of Health and Social Affairs in co-operation with Ministry of Children and Family Affairs, Ministry of Defence, Ministry of Justice, Ministry of Education, Research and Church Affairs, Ministry of Local Government and Labour, Ministry of Cultural Affairs, Ministry of the Environment, Ministry of Transport and Communications

Short report

Plan of action 1997-2002 - prevention of injuries at home, school and recreation

Contents

Plan of action Part I

• Chapter 1 Introduction
• Chapter 2 Objectives
• Chapter 3 Outcomes and means

Background documentation - facts and data Part II

• Chapter 4 Unintentional injuries
• Chapter 5 Registration of unintentional injuries
• Chapter 6 Prevention of injuries: experience to-date
• Chapter 7 Means and Challenges
• Chapter 8 Ministries involved

Plan of action Part I

Chapter 1 Introduction

In its handling of the Report to the Storting (Norwegian Parliament) no. 37 (1992-93) Challenges in health promotion and preventive efforts, cfr. Innst.S. nr. 118 (1993-94), the Storting agreed to focus nationally on four areas in prevention and health promotion.

The prevention of injuries is one of these areas. Close co-operation between sectors, professional groups and levels of public administration is a necessary prerequisite in the prevention of unintentional injuries.

Plan of Action 1997-2002 prevention of injuries at home, school and recreation has been prepared by the Ministry of Health and Social Affairs in co-operation with the following eight other ministries:

• Ministry of Children and Family Affairs
• Ministry of Defence
• Ministry of Justice
• Ministry of Education, Research and Church Affairs
• Ministry of Local Government and Labour
• Ministry of Cultural Affairs
• Ministry of the Environment
• Ministry of Transport and Communications

This publication represents a short report of the Plan of Action 1997-2002 prevention of injuries at home, school and recreation, intended to include goals and the means to reach them (part I) and background documentation - facts and data (part II). The Plan of Action is a co-ordinated presentation of the participating ministries' contributions in the field. The goal is that this work will contribute to a reduction in the number of injuries and the consequences that injuries have both for the individual and for society.

The prevention of accidents that can lead to personal injury is the purpose of the Plan of Action.

The Plan covers injuries at home, school and during recreation. Injuries sustained during working hours and in traffic are discussed in the plan with respect to the overall personal injury panorama, but are not dealt with explicitly in this Plan of Action.

Goals and initiatives outlined in the plan have been formulated based on the responsibilities of, and means available to the different participating ministries. At the same time it is important to emphasise that injury prevention efforts at the municipal level, those carried out by voluntary organisations and by private enterprises are essential in order that results can be achieved. These efforts must be encouraged.

An accident refers to a sudden, unintentional, and unplanned event, characterised by the sudden release of an external force or impact that can result in a bodily injury. An injury is the concrete, demonstrable result of an accident. Personal injuries are the result of the sudden or acute impact upon the body of physical factors in an amount or size that exceeds the tolerance level of the human body. The Plan of Action covers human activities, factors in the person's environment or surroundings such as product defects, the actual injury incident and the consequences there of. The goal of the Plan of Action is the prevention of accidents that can result in personal injury.

Developments that reflect safety and security are the goals of preventive efforts. Their ultimate effects must also be evaluated with respect to the developmental needs of the individual. For example, it is only natural for children to kick balls and climb trees. Methods to improve safety might include the use of leg pads or providing a foundation that is as secure as possible, while at the same time not preventing or obstructing a child's development.

The goal of providing for a secure development is an important basis for injury prevention. Injury prevention must be active and not result in pacifying the individual.

Chapter 2 Objectives

The Storting agreed to focus on the national goal in this area in connection with its handling of the Report to the Storting no. 37 (1992-93) Challenges in health promotion and preventive efforts :

• By the year 2002 the co-ordinated planning and development of a positive attitude towards safety measures at all levels of decision making and in all sectors will result in the reduction in the number of injuries that result in death, hospital admission and medical treatment due to accidents.

This is the main goal of the Plan of Action.

Two additional objectives have been formulated for the Plan of Action:

1. Injury deaths will be reduced by at least 25% from 1980 to the year 2000.
2. Injuries that result in hospital admission and medical treatment will be reduced by at least 10% from 1993 to the year 2002.

The stated objective to reduce injury deaths is in accordance with goals set by the World Health Organisation in this area.

In actual numbers these objectives imply a reduction of injuries at home, school and during recreation by about
100 injury deaths in relation to the 1980 level
30 000 injuries in relation to the 1993 level

Taking as a basis the cost of injuries to society in 1989, in the form of production loss, treatment costs, medicine, rehabilitation etc., the Plan of Action estimates the following costs (in 1995 NOK) for home, school and recreational injuries:

Production loss per injury death: 640000 NOK
Cost per personal injury: 23000 NOK

It is then possible that the full realisation of the two stated objectives could result in an annual gross economic profit to society of

• 64 mill. NOK following the reduction in number of injury deaths (objective I)
• 690 mill. NOK following the reduction in number of injured (objective II)

It should be noted that the figures presented here are subject to a degree of uncertainty. In addition, it must be clearly understood that the economic assessments are a part of the decision making process. They are meant to supplement, and not replace those decisions covering ethics, politics and health promotion in the area of injury prevention. The purpose of prevention is not first and foremost to save money, but to improve standards of health and quality of life.

Chapter 3 Outcomes and means

Both outcomes and the means to reach them have been formulated for the prevention of injuries in homes, schools and during recreation. In addition, more general goals have been formulated. The means or resources that are outlined here include information, improved competence, co-operative measures, research and development as well as the influence of legal, regulative and economic factors.

The prevention of injuries requires that specific initiatives be set in motion. Through the support of several ministries working co-operatively, chances are that these measures will be successful.

In the list below, the ministry named first has the administrative responsibility. Other participating ministries are listed (in parentheses) thereafter.

Abbreviations:

3.2. Home

3.2.1. Prevention of injuries at home (i.e. injuries in and around the place of residence)

3.2.2. Prevention of injuries in special-care residences, old-age and nursing homes

3.2.3. Prevention of fires at home

3.3. Schools and day-care centres

3.3.1. Prevention of injuries at school

3.3.2. Prevention of injuries at day-care centres and playgrounds

3.4. Recreation and leisure

3.4.1. Prevention of injuries during recreation (including injuries at sea, on lakes and rivers)

3.4.2. Prevention of sports injuries

3.4.3. Prevention of pedestrian (non-traffic) injuries

The Ministry of Transport and Communications' document "Traffic safety towards the year 2000" covers work in the area of traffic safety. The document represents a collaborative effort between the Ministry of Justice, Ministry of Education, Research and Church Affairs and Ministry of Health and Social Affairs together with the Directorate of Public Roads, and will be followed-up by these institutions. Particular emphasis will be placed on:

1. The Ministry of Transport and Communications will undertake an evaluation of traffic regulations and road signs for cyclists.
2. The Ministry of Transport and Communications will evaluate immediate solutions for improved passage for cyclists in heavily trafficated areas. Efforts directed towards both the physical and attitude changing effects in "cycle-cities" will be assessed. A number of information programmes are relevant in this area, for example, to increase the use of bicycle helmets.

3.5. Other areas, general means

A number of outcomes and means are independent of arena.

Central authorities can also co-ordinate initiatives in many arenas in the prevention of injuries.

Background documentation - facts and data Part II

Chapter 4 Unintentional injuries

Between 450,000-500,000 unintentional injuries require medical treatment each year. Of these, 55,000 are admitted to hospital, and approximately 1,800 result in death. 10 % of all hospital beds at any given time are occupied by patients with unintentional injuries.

Falls are the single most important causes of unintentional injury deaths. The majority of such deaths are falls on the same level among those over 75 years of age. Injuries at home, school and during recreation dominate as arenas for unintentional injury deaths in all age groups with the exception of those 15-24 years, where traffic accidents account for 65% of all unintentional injury deaths.

Unintentional injury deaths have decreased by 19% from 1980 to 1993, due primarily to a decrease in traffic accidents, but also in some years to fewer falls among the elderly (despite increases in both traffic density and number of elderly). During this period additional efforts have been made in the area of traffic safety, improved housing standards, more emphasis placed on safety through the legal system as well as through specific efforts.

Injuries at home, school and during recreation in all age groups dominate among those unintentional injuries that do not result in death. These account for 70-95% of all unintentional injuries. Overall the highest prevalence of injuries occur among children and youths aged 10-20 years. Gender differences show that boys and men have the highest prevalence up to 50 years of age, at which point accidents among women predominate. 22% of all injury diagnoses are fractures.

Looking closer at the injury arena, those associated with sports and training activities dominate among youths and young adults up to 30 years of age. Apart from these, injuries in and around the home predominate in all age groups, in particular among the youngest and the oldest.

Injuries at home are most often characterised by falls among both children and the elderly. 52% of home accidents among those over 65 years result in fractures.

95% of injuries in old-age and nursing homes are the result of falls, and almost half of these injuries are diagnosed as hip fractures. Electrical tools and parts of buildings are often seen to play a part in injuries among adults. Circa 50 fires annually result in fatalities; house fires are the cause of approximately 50 deaths and 170 injuries yearly.

Injuries at school account for 5% of all injuries, i.e. annually 22,500 school children receive treatment as a result of injuries. 26% of injuries sustained during school hours occur in the school building, 36% on the school grounds and 42% in the gymnasium/sports complex. Sprains are the most common diagnoses. 40-50% of injuries to teeth occur at school.

Playground equipment is implicated in approximately 30% of injuries among small children in day-care centres and playgrounds.

Injuries during leisure/recreation account for 3% of all injuries, the majority of these are connected to activities in and around open water as well as hiking in the outdoors. 198 persons drowned in 1993, the main reasons being alcohol, suicide, ship wreck/boat capsizing, rough and/or cold weather. Sports injuries account for 15.4% of all injuries and this is the most common injury arena among those 10-20 years of age. Ball and ski sports predominate in both number of injuries and number of participants. Half of all falls on sidewalks and roads due to snow and ice results in fractures.

Injuries related to specific products are distributed in the population in the same way as injuries in general.

It has been calculated that unintentional injuries cost society ca. 25 billion NOK annually (treatment, production loss and damage to property). Costs for medical treatment up to one year after an injury are calculated at 1.55 billion NOK annually, 36% of these costs are related to injuries at home.

Chapter 5 Registration of unintentional injuries

Deaths due to unintentional injuries and discharges from hospital are registered by the Central Bureau of Statistics. Based on injury registration at 4 selected hospitals and emergency departments, the National Institute of Public Health is able to calculate national estimates for injuries that require medical treatment. A number of additional institutions are also active in the registration of injuries in different areas and for different purposes.

Improved co-operation between those active in the area of injury registration is desired. A system for national personal injury statistics can lead to the establishment of national statistics based on all existing registers.

Chapter 6 Prevention of injuries: experience to-date

In the USA efforts made to prevent home injuries among children have resulted in a 31% reduction in mortality due to falls from windows; this due to better information on health hazards, home visits by housing inspectors and the distribution of free window locks.

During the period 1985-1993 in town of Harstad there was a 10% reduction in fractures due to fall injuries among the elderly. Women aged 65-79 years experienced a 29% reduction in injury fractures occurring in the home. Among men, a reduction of injury fractures in trafficated areas during the winter of almost 50% was recorded. These results seen in Harstad were achieved through the efforts at the local level where the public, private and voluntary sectors actively took part. Work was based on local injury data and consisted of various enterprises, including the distribution of information and the removal of "injury traps" in the home. Individual/personal safety equipment such as non-slip foot wear was made readily available, and the elderly were encouraged to make use of them.

Another investigation looked at the frequency of falls among a specific group of elderly, and instituted measures directed towards a combination of risk factors including the adjustment of medications. The frequency of falls was thus reduced by 12% in this group of elderly over 70 years. A study in France demonstrated that a calcium and Vitamin D3 supplement reduced the risk of fractures among elderly by 25-30% over three years.

An attempt has been made in Denmark to prevent sports injuries. The frequency of injuries was reduced by an average of 25% by means of providing better health information in combination with adequate time spent warming up and stretching out. Ski injuries dominate among non-organised sports. Considerable headway has been made in this area by focusing on improved inspection of equipment.

It has been demonstrated that smoke detectors can prevent over 80% of fire-related personal injuries, including deaths.

A wide ranging prevention programme carried out in the municipality of Harstad resulted in a decrease in burn injuries among children by over 50% over a 7 year period. The programme comprised information on burn prevention in schools, information programmes directed at childcare workers, safety stops on hot waterfaucets and information to the parents of children who have experienced burn injuries.

Experience shows that there does not exist an automatic relationship between knowledge, attitudes and behaviour with respect to the prevention of injuries. Generally, it could be said that health information has an effect on the individual's knowledge and under- standing, but to a lesser degree on their behaviour. The most promising programmes will be those where engagement and interest in injury prevention occurs at the local level.

Accidents were reduced from 218 in 1980 to 59 in 1988 in the small municipality of Værøy. Injury prevention programmes included the provision of information, education and home visits.

The town of Falköping in Sweden achieved an injury reduction of approximately 30% in the course of three years by means of local injury prevention initiatives. These results in Falköping were possible through the provision of information, educational aids and alterations made in the physical environment, e.g. the building of bicycle paths.

Chapter 7 Means and Challenges

The prevention of injuries can be initiated through political resolutions made centrally, or alternatively, work can be based more on decisions arrived at locally. Efforts can be directed towards the entire population, or towards certain high risk groups. The goals of injury prevention programmes can be general in nature or they can be focused on more specific injury arenas. Different combinations and overlapping of the above axes will, of necessity, occur. Above all, the Plan of Action is not meant to alter the individual's own responsibility for his/her own safety.

Public injury prevention initiatives are performed under state, county or municipal auspices. The state sector takes on those tasks that are best solved on the national level. This is accomplished with the help of laws and regulations. More indirect implementation of desired policy is achieved through economic and educational means. State agencies at the county level also have their own important responsibilities with respect to injury prevention.

Health care services can be said to influence 10% of the population's health. The remaining 90% falls under conditions that the health care services alone are unable to influence, such as standard of living and social support. Close co-operation between all interested sectors is essential in order to attain results.

The municipalities are responsible for the planning and execution of initiatives at the local community level. The most comprehensive efforts in injury prevention must occur at the local level, in munici- palities around the country, and by individuals - where they live, work and play.

It is important that the value represented by the voluntary sector be recognised and made use of in the collaboration across sectors. A large proportion of the work done in injury prevention is addressed either outside of the public sector, or in collaboration with other sectors. Through it's history of competence and activities, the voluntary sector has significant resources that are of use in injury prevention.

Co-operative bodies or agencies for the various participants and sectors involved in injury prevention can be an important tool in the co-ordination and strengthening of prevention efforts. This requires a clear mandate that reflects both the desires of the members involved and the goals of the collaboration.

Industry and private enterprise have an important role to play in injury prevention. The responsibility of the private sector is to ensure that products put on the market do not represent a risk of injury. The private sector can, by imparting their experience in the area of safety to other sectors, be an important partner in the development of a positive attitude towards safety measures.

In the municipality of Årdal, injury prevention has taken the form of a project-oriented collaboration, "Årdal thinks safety", between the municipality, the private sector and voluntary organisations. One of the conclusions of the work to-date is that efforts in prevention cross the boundaries between sectors.

An employee who has suffered an injury will have an effect upon the employer regardless of when or where the injury occurred. For this reason the private sector contributes actively in the prevention of injuries at home and during recreation.

The strength in local initiatives lies in the fact that they are rooted in real life experiences and they have the ability to call on large resources through the commitment and contributions of the local inhabitants themselves. Experience has shown that goal-oriented prevention based on a knowledge of local injury statistics and the use of a wide range of actions gives measurable effects. These findings should be shared with other municipalities to stimulate injury prevention activities.

In the municipality of Alvdal a collaboration has been established between those responsible for maintenance of chimneys (chimney sweeps) and the local health authorities. The chimney sweeps give out information and instructions on prevention of injuries at home, at the same time as technical standards of chimneys are checked. In smaller municipalities, where the chimney sweep is known among the local inhabitants, the sweep can act as a "safety consultant" for the community in a new and interesting way.

The Ministry of Children and Family Affairs has subsidised projects in municipalities that have developed methods for incorporating the contributions made by children and youths to municipal planning and to the formulating of efforts, as well as injury prevention initiatives.

All public school children and youths in the munic- ipality of Klepp have been asked where the municipality should use 800,000 NOK for street lighting. The municipality will follow the priorities outlined by the "municipal student council".

Using a method called "Child step", children mark on a map places where they think it is dangerous to walk, play or hang out. These can be, for example, places where there is little protection against traffic or playgrounds where equipment should be either repaired or removed.

In addition, work in the area of crime prevention shows clear parallels with injury prevention, and provides examples of successful co-operation across sectors.

In Skien, a formal collaboration has been established between the municipality and the police force (CLM= co-ordination of local measures). The purpose of this is to prevent criminality among children and youths.

The municipality of Rakkestad has implemented a successful CLM collaboration. The actual form of the collaboration is emphasised as a good basis for injury prevention initiatives in the municipality.

The World Health Organisation (WHO) has, through the concept Safe Community, taken the consequences of the fact that the work of injury prevention must be organised across the different sectors involved. Specific criteria have been established and must be met before a community can be approved as a Safe Community.

A Norwegian secretariat for Safe Communities has been established. One of its responsibilities is to assist communities in the development of initiatives directed at local injury prevention, and to establish a national network of municipalities that are active in the area of injury prevention.

To date, Harstad is the only municipality in Norway to be given the status of Safe Community. Harstad has documented a reduction in fall injuries among the elderly, burn injuries among children and traffic injuries in general. The community can also claim to have increased the public's awareness of and belief in injury prevention. Harstad makes use of local injury data in a goal-oriented approach to these problems.

The Plan of Action for the Prevention of Injuries will defeat its own purpose if the individual's responsibility for his/her own safety is not stressed. We are responsible for our own safety and security, that our homes are reasonably safe, we are responsible for the supervision of our children, and responsible for ourselves when we go hiking in the mountains. These are responsibilities that will not be assumed by the public sector. The responsibility of the individual is however regulated by means of a number of laws and regulations in, for example, insurance and penal legislation.

Risk and vulnerability analysis is a working method for the systematic mapping of events that can represent risks or hazards for people, things of economic value and important social functions. The analysis consists of the mapping of causes of undesired events, the likelihood that they will occur and an overview of implemented preventive measures. In addition, a resource analysis is carried out, i.e. a discussion to show the positive resources that are available and can be built upon. Finally the analysis is followed by a political decision as to which injury prevention counter-measures will be initiated locally, and the way in which the initiatives will be followed-up.

A risk and vulnerability analysis can form the basis of a model for goal-oriented working procedures in local injury prevention. The starting point is an analysis of vulnerability on the local level, and counter-measures take the form of injury prevention and injury limitation. The analysis must result in political action and follow-up in order to reduce the level of vulnerability in the local community, and in this way the work can contribute to the development of a positive attitude towards safety locally.

Regulations relating to environmental impact assessment, in accordance with the planning and building legislation (PBL), establish that notification must be made (including a description of possible effects) before going ahead with large projects, if it is thought that these activities will have substantial consequences for the environment, natural resources and society. Some of these consequences are significant to injury prevention, such as discharges to the air or water, noise, radiation, and risks of explosion, all of which can be hazardous to health. The regulations relating to environmental impact assessment in PBL will result in placing greater weight on the consequences for the environment, natural resources and society through planning and development. Furthermore, the regulations call for an account to be made of the activities' essential impact on the environment, natural resources and society in the construction phase, operational phase, in the event of an accident and in the event of a possible shut down.

Prevention is also assessed in connection within the framework of the physical planning of the municipality. One of the overall goals in the regional planning and area policy is to ensure health, prosperity, security and a good standard of living for the population. These goals will again form the basis of the municipality's regional planning. Both the prevention and the reduction of injuries form one of the themes that is assessed under projects connected to road building and/or improvement in all road and traffic planning. According to the planning and building regulations it is possible to mark off areas that are potentially dangerous to the general public; for example high voltage electrical power lines, shooting ranges and areas considered to be susceptible to either landslide or flood. Further initiatives include, for example, the restriction of airports and ensuring that drivers have a clear view of roads and that hidden access ways are clearly marked.

It is also important to look at the National political directives for strengthening the interest of children and youths in planning as a tool to secure for these groups access to nature in their local environment where they can, through play, experience physical proficiency and competence with respect to the natural environment, and develop a positive attitude to the natural environment including the assessment of any potential dangers. Emphasis must be placed on ensuring that outdoor areas connected to day-care centres and schools also allow for this type of learning experience.

The goals of injury prevention are firstly associated with established welfare policies. Economy is also an important factor, especially for the municipalities. They finance their injury prevention initiatives through creating municipal political priorities within a fixed economic framework consisting of tax revenues, duties and transfers of capital.

Earmarked subsidies can contribute to emphasising a priority area. A municipality can increase its efforts in a particular area following an increase in earmarked national subsidies. In an investigation, the amount that a municipality was willing to invest in preventive efforts was assessed through the municipality's accounts. A relationship was found between national subsides and the municipality's use of its own resources for prevention. The overall municipal investment in preventive efforts increased by 2.09 NOK for each NOK that the municipality received in subsidies from the state.

Different levels of administration have economic responsibility for different services that are relevant for injury prevention. Within the health services, the county administration is responsible for hospitals, while social security payments are the responsibility of the state. With respect to injuries, prevention is thus the responsibility of the municipality, while the county administration is responsible for treating those who have received unintentional injuries. The munici- palities carry much of the expenses for preventive measures, such as sanding/salting icy sidewalks and ensuring that playgrounds are safe. The county administration must ultimately take over those expenses if the municipality does not set high enough priority on the prevention of injuries. In the same way injury prevention initiatives in the municipality will lead to a savings at the national level in the form of reduced expenses for sick benefits.

Through the National Insurance the state contributes to cover a considerable portion of fees that go to doctor's and physiotherapist's curative treatment functions in the municipalities. The administration of this through municipal budgets will be a considerable incentive to the preventive efforts made by the municipality. A trial arrangement with financial co-operation between different levels of administration, with the goal of stimulating preventive efforts depends upon municipalities indicating their wish to participate.

Economic measures can both stimulate behaviours that increase safety, and act to impede certain factors that increase risk. Such measures are used both by the public and private sectors. An example of such a measure is the fee for failure to use a helmet when driving a motorcycle or moped in traffic, and the fee for failure to wear a seat belt in a car.

Almost 40 % of all automobile drivers killed in road accidents are influenced by alcohol and/or drugs at the time of the accident. The high price of alcohol, resulting from taxes imposed, is meant to make alcohol less attractive. Limited access through the retail monopoly system acts as an additional barrier. The connection between these alcohol policies and the goals of injury prevention are thus well illustrated.

Economic benefits of being accident free are a part of the comprehensive insurance and bonus point systems of insurance companies.

Chapter 8 Ministries involved

Nine ministries are responsible for the Plan of Action, and for implementing the interdepartmental initiatives for the prevention of unintentional injuries. In the following table the responsible authorities and collaborators are listed according to the different injury arena classifications.

The Ministry of Children and Family Affairs' responsibility with respect to the prevention of injuries is concentrated in the area of product safety and consumer services. The Ministry is also responsible for policies regarding day-care centres, children, youths and families.

The Ministry of Defence priorises the prevention of injuries within its area of responsibility. Knowledge and understanding of the prevention of injuries can be taken up among recruits to compulsory military service, a group that represents a large part of the youth cohort.

The Ministry of Justice has the responsibility for laws governing insurance and compensation; laws that generally have prevention as a goal. The Ministry's responsibility for the police force also covers the preventive efforts undertaken in this area, including the care and safety of those incarcerated.

The Ministry of Education, Research and Church Affairs has, through the school system, the responsibility for an important health promotion and injury prevention arena in the local environment.

The Ministry of Local Government and Labour, in addition to its responsibility with respect to the work force, also has responsibility for building safety, fire, electrical and explosive protection.

The Ministry of Cultural Affairs' responsibility for sports includes the organisation of physical activity for the general population. Measures to improve safety through physical activity, including sports, fall under this heading.

The Ministry of the Environment is responsible for the preparing adapting/organising of regional planning, therein local political means for strengthening local planning. The Ministry also has a responsibility for the possibilities open to the public with respect to use of the outdoors, and for the prevention of injuries due to chemical exposure.

The Ministry of Transport and Communications has the responsibility for traffic safety.

The Ministry of Health and Social Affairs is responsible for prevention, treatment and rehabilitation within the areas of health and social services. This Ministry has in addition been given the role of initiator in health promotion and injury prevention.

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