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School of Kinesiology and Health Science
Methodologic challenges in preventing playground equipment-related injuries
Alison K.Macpherson PhD Linda Rothman, MHSc
Colin Macarthur, MBBCh, PhDAndrew Howard, MD MSc FRCSC
School of Kinesiology and Health Science
Background• Playground injuries result in more severe
injuries than any other mechanism of common childhood injury (except road traffic)
• 3313 children visited Ontario Emergency Departments for playground injuries in 2002/03
• 5 to 9 year old children often injured on playgrounds
• Severe injuries are usually falls• Fall heights > than 1.5 m and poor surfacing
main risk factors for injury
School of Kinesiology and Health Science
A dangerous playground
Can fall onto concrete here
Falling height >2m here
Surfacing in poor condition
School of Kinesiology and Health Science
Background• Most common severe
playground injury is upper extremity (UE) fracture
• 10% of ED injury visits among 5-9 year old Canadian children1
• One of major determinants of playground injury is inadequate surfacing
1 Brown J.A. A comparison of injuries on various types of playground equipment
2 Canadian Institutes of Health Information
School of Kinesiology and Health Science
Are equipment-related injuries more severe?
• CHIRPP database was used to identify all fractures occurring on playgrounds seen in the emergency room at the Hospital for Sick Children between 1997 – 2002
• Fractures graded as major (i.e., require reduction) or minor (i.e., no reduction required)
• Examined falls from standing height compared to falls from playground equipment
School of Kinesiology and Health Science
Fall height and injury severity • Falls from playground equipment resulted in a much
greater proportion of major fractures than did falls from standing height
– The odds of a severe fracture from falling from equipment was 5 times greater than when falling from standing height (OR = 5.03, 95% CI: 3.56, 7.14)
49304Standing height
331408Play equipment
Major FracturesMinor Fractures
School of Kinesiology and Health Science
• Injuries sustained from falling from playground equipment are more severe than injuries sustained from standing height falls
• This research suggested that efforts at injury prevention should examine the safety of playground equipment
• The Toronto District School Board removed and replaced unsafe playground equipment starting in 2000
School of Kinesiology and Health Science
Design• Randomized Comparison of Wood Fibre versus granitic sand surfaces
beneath play equipment• Injury Outcomes
Vs.
School of Kinesiology and Health Science
OBJECTIVES
• Primary Objective:– Upper extremity (UE) fracture rates – Fibar surfacing vs. granite sand surfacing
• Secondary Objective– Overall playground injury rates, head injury rates – Fibar surfacing vs. granite sand surfacing
School of Kinesiology and Health Science
METHODS
• Cluster Randomized– New Playground, New
Surface, 19 randomized to Fibar and 18 to sand
• 37 schools eligible
• Followed for 2 ½years
School of Kinesiology and Health Science
METHODS
• Outcome measures– OSBIE incident
reports– Parent telephone
interview with consent
– Medical record verification
• Exposure to play equipment measured in spring 2006
School of Kinesiology and Health Science
37 schools eligible and randomizedn = 15,074 students
19 allocated to receive Fibar wood chip surface
-5 discontinued (4 no new play equipment/surface put in, 1 school put in rubber)
18 allocated to receive granite sand surface
4 discontinued (2 refused to participate, 2 no new play equipment/surface put in)
12 received Fibar
2 received granite sand
7 received granite sand
7 received Fibar
12 analyzedRandomized analysis
9 analyzed Cohort analysis
7 analyzedRandomized analysis
19 analyzedCohort analysis
School of Kinesiology and Health Science
RESULTS
• No significant differences in compliant schools and all schools (cohort) in:– Surface installation costs– Exposure to all play equipment (mean student
count/minute/school)– # of monkey bars– # of monkey bars > recommended height (2.2m)– # with appropriate depth measured (>7 inches)
School of Kinesiology and Health Science
RESULTS
• Total of 259 injuries
• 44 UE fractures– 22 falling onto surface– 1 on play equipment (not falling)– 46% wrist fractures, ¼ elbow fractures
• 1 concussion, not on equipment, no hospital admission
School of Kinesiology and Health Science
RESULTS
Compliant Schools All Schools
Sand Fibar Sand Fibar
All Injuries
Total 106.2 92.4 111.8 79.8
Falling onto Surface 4.9 23.1 6.6 19.8
Other Play Equipment Injuries
8.6 12.3 10.2 13.6
UE Fractures
Total 8.6 16.2 8.8 18.3
Falling onto surface 1.2 8.5 2.2 9.7
Other Play Equipment Injuries 0 0.8 0 0.7
Crude rates per 1,000 student months
School of Kinesiology and Health Science
RESULTS
Compliant Schools All Schools
Sand Fibar P value Sand Fibar P Value
All Injuries
Total 127.2 (45.6,333.7)
101.3 (47.0,212.9)
0.81 144.1(59.0,334.1)
97.0 (53.7,172.6)
0.53
Falling onto Surface 7.3 (1.4,22.6)
25.3 (11.3,54.7)
0.33 10.2(2.5,30.0)
23.0 (11.2, 45.2)
0.17
Other Play Equipment Injuries
9.5(2.4, 82.1)
9.0 (2.9, 39.9)
0.95 14.0 (4.6, 65.9)
10.7(4.8, 27.4)
0.70
UE Fractures
Total 8.7 (3.4,17.4)
16.2 (9.5,25.4)
10.3 (3.3, 25.1)
22.7 (12.3,41.3)
Falling onto surface 1.9* (0.04,6.9)
9.4 (3.7, 21.4)
4.5(0.26,15.9)
12.9(5.1, 30.1)
Other Play Equipment Injuries**
- - - -
*p<.05, **< 1 events, cannot calculate rates
Cluster Analysis: Rate of injury per 100,000 student months
School of Kinesiology and Health Science
DISCUSSION• Cluster analysis : When falling on surface
– Injury• 3 X greater rate of injury on fibar (randomized)• 2 X greater rate on fibar (cohort)
– UE Fracture• 5 X greater on fibar (randomized) • 3 X greater on fibar (cohort)
• Injury rate lower in all groups than our prior data estimated
School of Kinesiology and Health Science
CONCLUSION
• Low overall numbers of injury– highlights success of wide scale intervention of
equipment and surface upgrade to meet current safety standards
• Sand safer in terms of upper extremity fracture and injuries in general
School of Kinesiology and Health Science
ADDITIONAL ANALYSES
• Relationship between a socioeconomic indicator at the school level and playground injuries
School of Kinesiology and Health Science
Objective
• to examine socioeconomic variation in playground equipment prior to and subsequent to equipment replacement
School of Kinesiology and Health Science
Methods
• Injury data collected from January 1998-December 1999 and January 2004 – June 2007 (OSBIE incident reports)
• 374 elementary schools in Toronto, Canada
School of Kinesiology and Health Science
METHODS
Schools categorized into:- pre intervention (before equipment removed) - post intervention (after equipment replaced)All outdoor injuries categorized into:
–Non-equipment injuries–equipment injuries
Poisson regression used to determine the relationship between injury rates and school SES Comparisons made using injury rate per 1000 student months
School of Kinesiology and Health Science
SES using Learning Opportunities Index
• Learning Opportunities Index (LOI) used by school board • Based on: family income, proportion of single parent
families, housing (detached, apartment buildings), parental education, neighborhood immigration, the number of students at the school who arrived in Canada in the past 5 years, and records of student mobility
• LOI scores range from 0 (wealthiest) to 0.97 (poorest)• Schools with the highest LOI score receive support from
the Ministry of Education’s Learning Opportunities Grant to help equalize learning opportunities
School of Kinesiology and Health Science
Results
• Pre (January 1998-December 1999) :- 5, 378 injuries were reported by 364 schools
• Post (January 2004 – June 2007): - 8,380 injuries were reported by 374 elementary schools
School of Kinesiology and Health Science
Injury rates per 1000 student months pre and post replacement
0
0.5
1
1.5
2
2.5
All injuries Non-equipment
Equipment
Pre
Post
School of Kinesiology and Health Science
Relative risk of injury by SES pre and post replacement
Pre Post
All injuries 1.65 (1.50-1.82) 2.07 (1.91-2.24)
Non-equipment injuries
1.68 (1.50-1.89) 2.41 (2.20-2.64)
Equipment injuries
1.52 (1.24-1.86) 1.13 (0.95-1.32)
School of Kinesiology and Health Science
Strengths and Limitatations
Strengths
• Standardized data collection
• Clear time period before and after replacement
Limitations
• SES attributed at the school level
• Potential variation in threshold for completing incident reports
School of Kinesiology and Health Science
Discussion
• There was a change in the SES gradient in school equipment-related injuries subsequent to upgrading the equipment
• The SES gradient remained for non-equipment injuries
• Modifying the build environment appears to be an effective way to make schoolyards safer
• Ongoing research may determine reasons for SES gradient in non-equipment injuries
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