Articles

Effective interventions for unintentional injuries: a systematic review and mortality impact assessment among the poorest billion Andres I Vecino-Ortiz, Aisha Jafri, Adnan A Hyder

Summary

Background Between 1990 and 2015, the global injury mortality declined, but in countries where the poorest billion live, injuries are becoming an increasingly prevalent cause of death. The vulnerability of this population requires immediate attention from policy makers to implement effective interventions that lessen the burden of injuries in these countries. Our aim was two-fold; first, to review all the evidence on effective interventions for the five main types of unintentional injury; and second, to estimate the potential number of lives saved by effective injury interventions among the poorest billion. Methods For our systematic review we used references in the Disability Control Priorities third edition, and searched PubMed and the Cochrane database for papers published until Sept 10, 2016, using a comprehensive search strategy to find interventions for the five major causes of unintentional injuries: road traffic crashes, falls, drowning, burns, and poisoning. Studies were included if they presented evidence with significant effects sizes for any outcome; no inclusions or exclusions made on the basis of where the study was carried out (ie, low-income, middle-income, or high-income country). Then we used data from the Global Burden of Disease 2015 study and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved among the poorest billion by these evidence-based injury interventions. We estimated results for 84 countries where the poorest billion live. Findings From the 513 papers identified, 47 were eligible for inclusion. We identified 11 interventions that had an effect on injury mortality. For road traffic deaths, the most successful interventions in preventing deaths are speed enforcement (>80 000 lives saved per year) and drink-driving enforcement (>60 000 lives saved per year). Interventions potentially most effective in preventing deaths from drowning are formal swimming lessons for children younger than 14 years (>25 000 lives saved per year) and the use of crèches to supervise younger children (younger than 5 years; >10 000 lives saved per year). We did not find sufficient evidence on interventions for other causes of unintentional injuries (poisoning, burns, and falls) to run similar simulations.

Lancet Glob Health 2018; 6: e523–34 International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (A I Vecino-Ortiz PhD, A Jafri PhD, Prof A A Hyder PhD); and Institute of Public Health, Universidad Javeriana, Bogota, Colombia (A I Vecino-Ortiz) Correspondence to: Prof Adnan A Hyder, International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA [email protected]

Interpretation Based on the little available evidence, key interventions have been identified to prevent lives lost from unintentional injuries among the poorest billion. This Article provides guidance to national authorities on evidence-based priority interventions that can reduce the burden of injuries among the most vulnerable members of the population. We also identify an important gap in knowledge on the effectiveness and the mortality impacts of injury interventions. Funding Partly supported by the Fogarty International Center of the US National Institutes of Health (Chronic Consequences of Trauma, Injuries, Disability Across the Lifespan: Uganda; #D43TW009284). Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.

Introduction As a result of the rapid wave of urbanisation, demographic and nutritional transitions, economic growth, and technological change, the epidemiological profile of most countries has been moving from communicable diseases to non-communicable diseases and injuries.1 However, while the global burden of injuries has decreased by 31% in the past 20 years, the injury burden due to road injuries and falls in sub-Saharan Africa and southeast Asia has increased by 10–50%,2 showing how improvements in the injury burden have not been equitably distributed. Specifically, unintentional injuries are a growing concern. Deaths caused by unintentional injuries comprise 10% of all deaths in www.thelancet.com/lancetgh Vol 6 May 2018

low-income and middle-income countries, compared with intentional injuries that cause 3% of all deaths in these countries.3 In low-income and middle-income countries, efforts to generate a regulatory and societal response to unin­ tentional injuries, and to strengthen safety infra­ structure often lag behind an accelerated development rate, leading to an increased risk of injury.1,4–7 Highincome countries followed the same process decades ago, but with smaller populations than low-income and middle-income countries have nowadays, and with less complex systems than are in development now; hence, it is much more complex initiating effective interventions in these resource-limited settings. e523

Articles

Research in context Evidence before this study The burden of unintentional injuries is increasing in low-income and middle-income countries compared with other more traditional causes of disease burden. Low-income and middle-income countries comprise 91% of deaths and 94% of disability-adjusted life-years lost because of unintentional injuries; these countries also have most of the population that belong to the poorest billion. Despite the relevance of this subject, no studies appear to have determined which evidence-based interventions should be prioritised to reduce the burden of unintentional injuries for those living in extreme poverty. Added value of this study Our study is the first large-scale investigation that reviews all the available evidence on effective interventions for the five main types of unintentional injury and that estimates

For the Lancet NCDI Poverty Commission website see http://www.ncdipoverty.org/

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The long-term cost of injuries in low-income and middle-income countries include adverse effects on health and productivity, and the resulting pressure on social systems. The annual gross domestic product, for example, has been shown to decrease by 1–3% because of road traffic injuries alone,7,8 and this loss would be even greater if other unintentional injuries were taken into account. Many chronic conditions are multifactorial and the marginal effect of a single intervention is seldom evident, thereby requiring more complex and diagonal programmes and interventions.9 In the field of injury, a single intervention aimed at the prevention and control of a risk factor can have a substantial effect on an entire target population. For example, in road injuries, a single intervention aiming to reduce average speeds or increase helmet use can lead to important reductions in both the frequency and severity of road injuries.10 The Lancet’s Non-Communicable Disease and Injury (NCDI) Poverty Commission has committed to facilitating the prioritisation of evidence-based, countrylevel investments to reduce the burden of chronic conditions and unintentional injuries among the poorest billion.11 In this Article, we provide evidence on the potential mortality effects that a set of interventions to prevent unintentional injury could have on the poorest billion people, living in 84 countries across the world.11 These countries also have few tools and resources to deal with such a burden and, therefore, are in greatest need of rigorous prioritisation tools to define where to devote intervention investments.12 The aim of this study was two-fold; first, to review all the evidence on effective interventions for the five main types of unintentional injury; and second, to estimate the potential number of lives saved by effective injury interventions among the poorest billion. This study will

potential lives saved by a set of injury interventions for those living in extreme poverty. We estimated the potential mortality impact of selected evidence-based interventions for each of the 84 countries where the poorest billion live. Implications of all the available evidence This study builds on existing work to review all evidence on effective interventions for the five main types of unintentional injury, and to estimate the potential gains in terms of lives saved from a set of evidence-based injury interventions. We expect this study to help inform policy makers to prioritise unintentional injury interventions in the countries where the poorest billion live. We also found that the evidence on the effect of injury interventions on mortality is sparse and call for global researchers to strengthen efforts to study this field.

provide tools to prioritise injury interventions for national and global health organisations.

Methods

Search strategy and selection criteria First, we did a literature review to find the effect sizes for all unintentional injury interventions for which the data showed any significant effect on mortality (ie, p