In an interesting original paper in this issue of the Journal of Epidemiology and Community Health, the question is asked: how radical extinction of poverty would be expected to affect injury incidence and distribution per type and age (see page 899).1 In the authors’ retrospective cohort, there is a statistically significant association between lower mean household income and increased risk of injury in children’s history (especially a clear distinction at the extreme ends of the distribution). This would appear to justify support schemes for disadvantaged families based on experience gained from a variety of studies undertaken in different countries and for different accident types. However, the evaluation of the extent of poverty contribution to injury incidence is anything but simple, owing to the fact that very low-income populations are frequently under-represented in epidemiological studies on account of educational and access restraints. Moreover, the concomitant presence of additional injury risk factors renders it complicated to distinguish the independent role of poverty in injury aetiology. On the other hand, the feasibility of poverty-targeted interventions at national/international scale is questionable because there is no clear evidence that the expected benefit would justify the cost. Recent reports have indicated that strategies focusing on the general population may be more advantageous when combined with those referring to specific priority groups.2^–4

The reduction in the burden of injuries has relied on the implementation of any of two alternative options, namely passive and active measures or, in an optimal scenario, a combination of both. In the first approach, emphasis is placed on behaviour change and promotion of healthy lifestyles and, in the second, on environmental modifications for risk reductions. An alternative approach is the mandatory implementation of public safety measures, which are expected to improve living conditions and lower injury incidence. However, recent experience has shown that this may not always be adequate for a successful injury prevention strategy. Lack of adequate background information on the most frequent causes and sites of childhood injury along with personality characteristics may result in poor adoption of safety measures. Moreover, economic relief measures (eg injury pensions, free installation of protective gear) may not always be as successful interventions as presumably expected, because of lack of awareness and misperceptions on the true causes of injuries, their frequency and preventability, as well as the availability of alternative, safer products in the market.5

An additional important factor in the success of any preventive strategy concerning childhood injuries is parental sensitisation, as parents often tend to underestimate their contribution to accident prevention, placing emphasis on other involved parties, such as the state or the school and environmental factors. Evidently, tailored interventions need to be implemented to convince parents about their key individual role in injury prevention.6 Similarly, it is essential to convince health professionals, especially paediatricians and primary care providers, that injury should be their priority within the context of preventive, diagnostic and therapeutic medicine.7

It has been argued that an effective strategy in childhood prevention should develop realistic expectations in the public. No intervention, however successful, can result in the complete abolition of injuries. Even the most successful intervention strategies so far adopted in childhood injury prevention have only reached a specific maximal improvement rate in morbidity and mortality statistics, recognising a clear distinction between theoretically expected and actually observed outcome. Thus, while childhood injuries are, in a stochastic sense, both predicable and preventable, reduction of their burden is a very demanding task. Therefore, the target population must be able to recognise that best results can only be achieved via the application of all proposed safety measures rather than through a selection of them. Moreover, different guidelines may be applicable for the general public and for specific individuals/special interest groups. For instance, while swimming lessons are a prerequisite for all children, the continuous presence of an adult/lifeguard and the prohibition of access to deep/unfamiliar waters are necessary in order to reduce drowning incidents, especially in high-risk areas.8 Experience from the organisation of information seminars on water safety and prevention of drowning in primary schools has shown that this exercise improves children’s awareness, although the eventual efficacy of the intervention also depends on the social environment (teacher, family).9

The use of all the available technology is another key element in childhood prevention programmes, in which the role of the state can be crucial. For instance, falls can easily be avoided if beds have been equipped with protective bars. Although this may seem to be a high-cost intervention, the benefit far exceeds the purchase and maintenance costs.2

Evaluation of the efficacy of injury prevention strategies is never an easy task. However, it is also the only objective way to accurately determine the effectiveness of implemented actions. For instance, let us examine traffic accidents, the most extensively examined childhood injury subtype. Although the most deadly accidents occur on highways, mainly owing to the high speeds of the vehicles, a large majority of incidents is reported within the city road network. In this context, the adoption of very basic measures, such as the use of a helmet for motorcycle drivers and the use of seatbelts and child restraints in cars, has been shown to have a major impact on injury-related statistics. Experience from the implementation of an information campaign for seatbelt use in Greece has shown that a measurable gain can be achieved, although additional measures, including strict law enforcement, may further improve the efficacy of similar projects.10 In the case of car restraints, an infant car restraint loan pilot project was remarkably successful in Greece.11

It has also been shown that risky driving behaviour increases the likelihood of an accident. Thus, several interventions targeting adolescents, for instance, aim primarily to reduce risky teen driving behaviours or to influence their social norms and then to promote safety measures among them. An integrated intervention strategy should also target these weak points, attempting a wider lifestyle modification.12 The cooperation of different specialists, such as communication experts, psychologists and paediatricians, in a multidisciplinary approach may lead to a most satisfactory outcome. In fact, a survey conducted via the Delphi technique has shown that specialists are generally more confident on population-targeted strategies than on behaviour change procedures.13 Only a protocol that combines all available means of communication and every access opportunity will achieve the required adherence of the participants throughout the study period.

Injury prevention in childhood is a public health priority. Childhood injuries constitute a major morbidity and mortality factor in both developed and developing countries. In fact, childhood injuries are the most important cause of death for the population under 24 years old, while, at the same time, they remain a significant factor in all other age groups. Moreover, accidents are responsible for considerable loss of life expectancy as well as being a significant contributor to reduced overall productivity, as they are associated with both permanent handicap and temporary injury. Consequently, there is growing concern worldwide as to the potential impact of injury on international economy, family planning and social organisation, resulting in a demand for focused and highly effective preventive strategies. As therapeutic options for injuries are rather limited, therefore, no subsequent intervention can be of comparable gain to the actual non-occurrence of such an incident. Such a positive outcome, however, can only be achieved by intensive effort via a combination of accurate state programming and individual sensitisation. The role of low income in this major area of population morbidity and mortality can no longer be ignored. However, complete extinction of poverty appears improbable, and statistical analysis shows that it can only partially justify regional differences in childhood injury incidence. Therefore, a combination of economic, educational and information measures, tailored to the needs of each target population, seems to be the only way of making a difference.14