Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Household and Recreational Injuries in Adults

Overview
In the 1979 Canadian Task Force report, home and recreational injuries< 1> were acknowledged to constitute an important proportion of accidents. At that time there was insufficient literature on the subject to justify a recommendation on scientific grounds. While there is currently fair evidence upon which to implement some legislative measures, there remains insufficient evidence to clarify the effectiveness of individual counselling by physicians (C Recommendations). Three other chapters deal with unintentional injuries in children (Chapter 28), the elderly (Chapter 76), and those due to motor vehicle accidents (Chapter 44).

Burden of Suffering
Approximately 9,000 Canadians die annually of unintentional injuries, about 5% of all deaths. This review focuses on the seven leading causes of death from household and recreational injuries, namely, falls (21%), drownings (6.4%), burns and fire-related injuries (4.8%), suffocation (4.7%), poisonings (4.7%), bicycle/sports-related deaths (1.7%), and firearms (0.7%).<2> Because many of these injuries occur in the younger age groups the societal burden due to loss of productive years from prolonged dependency due to disabilities, and due to acute care (7.9% of all hospital days), is considerable. In 1989 injuries were the second highest cause of potential years of life lost (PYLL) before 65 years of age in Canada. The impact of these injuries is felt far beyond the injured person; family members, employers, health care systems and the community are affected. The individual and family burden of suffering is large in comparison to other types of unintentional injury because third party insurance is seldom in effect, and many of the financial obligations must be borne directly. Injury is probably the most under-recognized major public health problem facing the nation today, and the study of injury presents unparalleled opportunities for reducing morbidity and mortality and for realizing significant savings in both financial and human terms – all in return for a relatively modest investment.<3> Table 1 summarizes the mortality and morbidity rates for various types of adult injury. A brief description of the risk factors associated with each of the leading causes of unintentional injury in adults follows.

Falls
There were 2,100 deaths due to falls in 1988.<2> Falls were second only to motor vehicle traffic accidents among the leading causes of accidental death in Canada and were by far the leading cause of hospitalization for treatment of accidental injuries. Female exceeded male deaths, and falls resulting in serious injury or death were much more frequent among those aged 55 and over.<4>

Drowning
429 Canadians drowned in 1987, including 135 in boating accidents. Nearly one-quarter of drowning victims were youths 15-24 years of age. Drowning-site profiles varied by age and sex but also by climate and the accessibility of natural bodies of water and pools. Contributing factors were inability to swim, swimming outside patrolled areas, unfamiliarity with the beaches, pre-existing medical conditions and consumption of alcohol.<5> A review of Ontario coroners’ reports showed that the young adolescent male was at particular risk of drowning. Among 263 deaths by drowning for young adults, males outnumbered females 3 to 1 and alcohol and/or drugs were detected in nearly 20% of victims.<6> For more information on problem drinking consult Chapter 42. In deaths involving boats, canoes and sail boats, only 25% of the drowning victims were wearing a personal flotation device or life-jacket. Diving, surfing and water skiing also account for a portion of spinal injuries.

Burns, Scalds and Fire-Related Deaths
There were 402 deaths among Canadians caused by fire and flames in 1988.<2> In 1987 there were 30,735 residential fires in Canada (including hotels), causing property damage of $382 million. Studies from the early 1980s indicated that cigarette smoking was associated with about half of residential fire deaths. The number of residential fires has declined continuously since 1980. This reduction in fires has been attributed to better education, more widespread use of smoke detectors, and fewer people smoking.<7>

Poisoning
Of the 424 fatal poisonings in Canada in 1987, most were by drugs and medications (58%); 23% were by solid and liquid substances, and 19% by gases and vapours.<4> Thirty-one percent were among persons aged 25-34;<4> the majority of these deaths (particularly where drugs and medication are involved) would be self-inflicted. Canadian poison control centre data indicates that in 1986 there were 103,459 poisoning cases and 365 deaths (a 0.35% case fatality rate).<8>

Suffocation
Almost two-thirds of the 415 Canadian deaths by suffocation in 1987 resulted from inhalation and aspiration of food; 62% were in adults over 55 years of age.<4>

Bicycle and Other Sports-Related Injuries
There were 139 fatal pedal cycle injuries in Canada in 1987 and 86% of the casualties were male.<4> In a Calgary study, 67% of 107 patients hospitalized for bicycle-associated injuries had craniocerebral trauma; 20% overall involved a collision between bicycle and automobile.<9> Contusions, abrasions, open and crushing wounds and fractures were also common. Another study found that the most common sports and leisure activities resulting in death between 1982-88, were swimming (152 deaths), horse riding (117 deaths), motor sports (95 deaths), air sports (92 deaths among adults) and fishing (86 deaths). When the number of participants and hours of activity were taken into account, air sports, mountaineering, motor sports and horse riding were found to be the most hazardous activities – 10 to 100 times more hazardous than ball games or water sports.<10>

Firearms
There were 60 deaths by firearms in Canada each year in 1987 and 1988.<4> Elevated mortality rates for males aged 15-24 were documented in a study that found almost one-third of unintentional shooting deaths were hunting-related and that young hunters appeared to be at greatest risk of injury. There is some evidence (grade III) that keeping guns in the home unloaded and locked away reduces unintentional deaths among children.<11>

Alcohol and Drug Use in Association With Injury
Several studies from different countries have demonstrated that alcohol is an important contributing factor in many injury deaths, especially among adults. Higher proportions of positive alcohol readings occurred among home accident victims (p<.001) than among a comparison group of accident patients admitted to the same Boston hospital emergency service. Approximately half of several thousand deaths by drowning reviewed by autopsy in Auckland, Sacramento County, Baltimore, and Geelong, Australia showed evidence of alcohol consumption.<12>

Effectiveness of Prevention Maneuvers
During the past decade numerous descriptive studies concerning home and recreational injuries have been published. More important however, is the steady stream of experimental and quasi-experimental studies demonstrating that unintentional injury and death are not random, unpredictable events, but are predictable and preventable<13> and must be looked upon as being a disease whose prevention must be approached scientifically. One model for organizing preventive measures for unintentional injury and death is the Haddon Matrix,<14> named after a leading thinker in injury control. Three widely adopted approaches to interventions for accidental injury arising from this model are described in greater detail; namely, public health education, environmental legislation, and individual counselling.

1. Public Health Education – Health professionals who wish to direct their efforts toward a major cause of death can give effective leadership to programs to prevent drowning by counselling patients that alcohol increases the hazard of water sports.<12> The well known dictum "do not drink and drive" also applies to water recreational activity in the modification, "do not drink and dive."
2. Legislative/Environmental – As influential as physicians may be with patients, they can have a far greater impact on promoting home safety by discussions with legislators, who in turn can modify the environment through building codes and safety legislation (see Table 2, Chapter 76 on Injuries in the Elderly). For example, barriers, bicycle paths and other design features that separate the cyclist from traffic and pedestrians or remove through-traffic are effective measures for reducing bicycle-related injuries.<15> In general, modifying the environment appears to be more effective than trying to change human behaviour.
3. Individual Counselling – While the evidence that physician counselling is effective in preventing injuries is inconclusive in some areas, minor reductions in injury rates would have major public health benefits. The evidence for these activities will be presented sequentially for each major type of home and recreational injury in adults.

Suffocation
A review of before and after studies of programs teaching the Heimlich maneuver were reported to have resulted in 10-45% reductions in choking deaths.<17> The 1985 Health Promotion Survey in Canada found that only 34% of respondents indicated they knew how to administer CPR and/or the Heimlich maneuver.

Bicycle and Sports-Related Injury
A case-control study of injuries among bicycle riders experiencing crashes in greater Seattle showed that safety helmets reduced the risk of head injury by 85% (odds ratio 0.15; 95% confidence interval (CI): 0.07-0.29) and of brain injury by 88% (odds ratio 0.12; 95% CI: 0.04-0.40).<18> These results are confounded by the fact that those who choose to wear helmets would tend to have a different overall attitude toward safety; however, the physics of crashing suggest that helmet wearing is advisable.<19> In a survey of 894 South Australian bicycling enthusiasts, 197 had crashed and struck their head or helmet within the previous 5 years; a significant association was found between helmet use and reduced severity of head injury (p<0.005) which persisted (p<0.05) after adjustment for crash severity. Based on a cohort of 100 consecutive head injuries in Portsmouth, it was estimated that the wearing of safety helmets would prevent at least half of the minor head injuries and reduce the seriousness of major injuries sustained in cycle accidents.

Although bicycle helmets have been shown to reduce the rate of head and brain injuries from bicycle mishaps, the use of helmets is still uncommon. Educational programs promoting helmet use have shown no impact on the proportion of helmet wearers in a school age population.<20> Helmet design, peer pressure, lack of availability, and cost have been found to be reasons for non-use.

Alcohol and Substance Abuse Intervention for Prevention of Injuries
Alcohol testing and history taking in all cases of accidental injury has been suggested. When alcohol and/or other drugs are implicated in an injury, a number of expert groups have recommended that the connection should be authoritatively communicated to the patient with follow-up to self-help groups. This strategy is based on preliminary evidence that an appeal to fear fortifies adolescent intentions to eschew alcohol. The effectiveness of counselling regarding substance abuse to reduce recreational injury rates has not been evaluated.

Recommendations of Others
The "Year 2000 Injury Control Objectives for Canada" recommend that individual counselling be targeted particularly towards high-risk groups; namely, families with young children, the socio-economically disadvantaged, aboriginal people, situations where alcohol and/or substance abuse is suspected, and the elderly living alone.<21>

The American Academy of Pediatrics, based on expert opinion, makes the following recommendations concerning bicycle helmet use:<22>

1. Physicians should inform parents and patients of the importance of wearing bicycle helmets and the dangers of riding without a helmet.
2. Retail outlets should be urged to carry approved, inexpensive helmets that are available at the time of purchase of the bicycle.
3. The Consumer Product Safety Commission should develop mandatory, uniform safety standards for bicycle helmets.
4. Coalitions of physicians, parents, and community leaders should be encouraged to develop and support community-based programs to promote bicycle safety and helmet usage.
5. The popular media should be urged to depict the helmeted bicycle rider on television, in advertisements and in promotional materials.

In 1989, the U.S. Preventive Services Task Force recommended the following: "Patients who use alcohol or other drugs should be warned against engaging in potentially dangerous activities while intoxicated. It may be clinically prudent to provide counselling on other measures to reduce the risk of unintentional household or environmental injuries from falls, drowning, fires or burns, poisoning, bicycle collisions, sports and firearms."<23>

Conclusion and Recommendations
There is fair evidence (grade II-2) that bicycle helmet use for those who ride the roadways reduces the rate of head injury and death<19> (B Recommendation). There is fair evidence (grade II-2) that not drinking while being involved in water recreational activities reduces the rate of drowning among young adults<12> (B Recommendation). There is some evidence (grade III) that keeping guns in the home unloaded and locked away reduces unintentional deaths among children<11> (C Recommendation). There is some evidence (grade III) that adults learning the Heimlich maneuver can reduce deaths due to suffocation (C Recommendation). Expert opinion (grade III) evidence suggests that many patients seen by clinicians could potentially benefit from counselling to modify their accident prone behaviors. In actual practice, however, it is not known how effectively clinicians can alter these behaviors. Since unintentional injuries represent a leading cause of death and nonfatal injury, even modest successes through clinical interventions could have major public health value. Counselling is most relevant for those at increased risk of injury, such as adolescents and young adults, persons who use alcohol or other drugs. The optimal frequency for counselling patients about unintentional injury has not been determined and is left to clinical discretion.

Unanswered Questions (Research Agenda)
The Haddon Matrix for generating countermeasures provides a model for planning research. Most of the "energy vector" and "physical environment" aspects involve environmental design/engineering. Improving post-event performance is the domain of both formal and informal health care delivery systems. Provincial, regional, and local health care delivery effectiveness must constantly be assessed by quality assurance methods, and areas of poor performance must be addressed. An example of this process is the setting of the Year 2000 Injury Control Objectives.<15,21> The "social environment" sector is primarily the jurisdiction of the political/legislative institutions in our society but is greatly influenced by public pressure. The norms, values, and laws of our society must be constantly re-evaluated and revised as a better understanding of the balance between individual and corporate rights/privileges is derived. The "human" sector presents a major challenge for behavioral medicine (e.g., medication prescribing practices in the elderly). Much remains to be learned about lifestyle patterns and behaviour change strategies. It is in this last area that individual practitioners spend most of their time and energy. The "timing" of health education messages, the effectiveness of different motivational techniques, the counselling skills required by health care providers, and the most conducive atmosphere for anticipatory care, all require further elucidation.

Evidence
This review deals with household and recreational injuries without considering occupational or aviation related injuries. These limitations were incorporated in the MEDLINE search strategy: accidents as a major MESH heading under the subheadings diagnosis, economics, epidemiology, law and jurisprudence, mortality, prevention and control, standards and trends; and not aviation, occupational or traffic accidents. References were identified for the years 1981 – November 1992. Other sources included Statistics Canada, Health and Welfare Canada, the Insurance Bureau of Canada.

This review was initiated in January 1991 and recommendations were finalized by the Task Force in June 1993.

Full Citation
Elford RW. Prevention of household and recreational injuries in adults. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 526-37.