Author: Huan Linnan
“With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding”, “Good”, “Almost Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report.”
Injury is a leading cause of death for children 1-18 years old in China. This is due to the success of China in reducing child deaths caused by infectious and nutritional causes. Every year, more than 100,000 children die due to various types of injury, almost 1% of the global burden of child deaths. Injury deaths are only the tip of the iceberg. Non-fatal injury, especially permanent disability, imposes huge social burdens on families and results in a large economic burden to society at large.
After 30 years of economic growth, China has reached the stage where addressing child injury is necessary to protect Chinese children’s right to survive and enjoy safe and healthy development. In response to the changing epidemiology of child health, UNICEF has supported child injury prevention (CIP) in China since 2003. In the 2006-2010 Country Program cycle, the CIP project was placed under the Health and Nutrition Program in collaboration with various government counterparts. This was the first ever injury prevention project for UNICEF China.
To evaluate the impact and outcome of the project in terms of:
1. Developing national policies, guidelines and local rules and regulations on CIP.
2. Establishing demonstration projects to test the feasibility of a comprehensive safe school, safe home, and safe community injury prevention model
3. Developing a functional multi-sectoral collaboration mechanism at the pilot sites
4. Building the capacity of CIP for government counterparts and the community at large, for sustainable development
5. Improving safety knowledge and behaviour among parents and children
6. Reducing child injury mortality and morbidity in the pilot areas
7. Developing a school and community-based child injury surveillance system
Both quantitative and qualitative methods were used for evaluating different components of the project. These included document and record review, interviews with project managers from various sectors, field observations, small scale KAP surveys among students and teachers; and analyses of school and community based surveillance data collected over the period 2005-2009.
Evaluation of the Safe Beijing pilot project and its impact on national policy was carried out by a group of injury prevention experts from the Beijing Centre for Disease Control (CDC), Beijing Education Research Institute, and Beijing Institute for Maternal and Child Health (MCH). This team designed the study instruments, conducted quantitative and qualitative surveys, and analysed the data.
Representatives from the health, education, public security, and mass communication (propaganda) sectors of the Beijing Municipal Government and 31 community committees were surveyed and interviewed.
Funding was not available for a large scale end line survey that covered the entire target population, so data from school- and community-based injury surveillance was used to demonstrate changes in injury incidence.
Knowledge and behaviour change were measured by pre- and post tests conducted among 20,000 students who learned from the safety curriculum (“Little Safety Guard”) supplemented by a small scale KAP survey among school students and their parents.
Evaluation of the Jiangxi pilot project was conducted by the Jiangxi Provincial Institute of Chronic Disease. Quantitative methods such as household interviews before and after the intervention, and analysis of school- and community-based injury surveillance were used to measure change in child caregivers’ injury knowledge, attitude and behaviour, and child injury morbidity and mortality.
Document and record review was used to assess local policy and regulation change. Individual / focus group interviews were conducted to assess capacity-building among the project management personnel, establishment of multi-sectoral collaboration mechanisms and introduction of relevant policies. Field visits were also conducted to observe environment modifications in households with children younger than 6, communities and schools. Quality control procedures included: interviewer certification after training, on site supervision, re-interviewing 5% of the respondents, and double data entry data. SPSS 12.0 was used for statistical analysis.
The author of this English report reviewed the evaluation framework and the Chinese language reports, discussed with the evaluation teams and synthesized key components from the two Chinese language evaluation reports provided by the group of injury prevention experts in Beijing and the Jiangxi Provincial Institute of Chronic Disease.
The definition of injury used in the report was: Damage to a person caused by an acute transfer of energy or by sudden absence of heat (hypothermia or oxygen (asphyxiation, drowning). Forms of energy are mechanical (kinetic), thermal, chemical, electrical and radiation. Intentional injures are injuries that are purposefully inflicted, either by the victims themselves (suicide or suicide attempts), or by other persons (homicide and violence). Unintentional injures are classified by the environment causes included drowning, transport (in this report only road traffic accident RTA, was counted), falls, burns/scalds, cuts, poisons, suffocation, electrocution, injury from blunt object, falling objects and animals.
The criteria of injury morbidity for inclusion in the project was an injury incident that caused a child to seek medical care, or caused him/her to miss one day or more of school or kindergarten. For children of preschool age, the minimum criterion for inclusion was an injury event of sufficient magnitude to prevent being able to perform activities of daily life (ADL) such as eating, bathing, and moving.
Findings and Conclusions:
The evaluation found the project had a significant impact at national policy level and provided evidence for reducing child injury from the pilot interventions. The following are highlights of the evaluation:
- The greatest achievement was the integration of CIP into the National Plan of Action for Women and Children (2011-2020). In securing the government’s commitment to CIP at the State Council level, the project embedded child injury in the national agenda which presents opportunities to replicate the CIP program elsewhere in China.
- The project facilitated the development of safety-related policies and regulations in health, education, and road transport at national, provincial and local levels. A series of technical standards and best practices were developed to guide future CIP programs.
- UNICEF and its partners tested both urban and rural implementation strategies in two community-based pilot projects covering approximately 170,000 people. A multi-sectoral collaboration mechanism was developed to address child injury through implementation models of safe school, safe kindergarten, safe home and safe community.
- Surveillance data showed that serious child injury is more prevalent in rural areas. Caretakers of children in rural areas are less educated and generally lack injury prevention knowledge and resources to provide adequate supervision and safe environments. The situation is exacerbated by the large number of "children left behind" whose grandparent caretakers are often illiterate.
- Communication and education programs led to improved awareness, knowledge, skills in parents and caretakers to prevent injury from road traffic, falls, drowning, animal bites, poison and other types of injury. Child participation was a focus of activities in the safe school program to change behaviors and develop safety skills.
- The project developed standards for “Child Safe Home”, “Safe Schools”, “Safe Kindergartens” and “Safe Communities” to identify and remove injury hazards from homes, schools and communities. These interventions focused on separating children from physical hazards in their daily environments, to reduce the risk of drowning, road traffic accidents, falls, burns/scald, poison and animal injuries. The safer physical environment, coupled with behavioral change in parents and children contributed to an overall reduction in child injury.
- Child injury incidence decreased over the life of the project. Specific examples are:
In Jiangxi, for children under 6, injury incidence decreased from 15.5% in 2007 to 7.1% in 2009
(p <0.01). Fatal injury fell from 7 deaths in 2006 to 2 deaths in 2009. For children 7-17, injury
incidence fell from 2.6% in 2008 to 1.8% in 2009 (p <0.01).
In Beijing, for children under 6, injury incidence decreased from 2.8% in 2006 to 1% in 2009.
For school-aged children, non-fatal unintentional injury incidence decreased from 0.9% in 2005
to 0.8% in 2009. The 45% reduction in road traffic injury incidence from 2005 to 2009 was
particularly notable given the number of motor vehicles registered increased 60% in the same
- The likelihood of sustainability is increased by the extensive government buy-in as well as the newly developed injury prevention capacity of local government staff and partners from multiple sectors.
Along with successful experiences, there were challenges and lessons from the project. Two lessons were paramount: the need for government buy-in and multi-sector collaboration. The major challenges were two in number as well: creating a system of clear accountability among individual sectors and establishing a permanent line in the public sector budget.
CIP is greatly under-funded, especially at local government level. To maintain the momentum created by the success of this project, the Government of China should increase the priority for CIP in its development agenda. In particular, more resources are required to expand capacity to prevent drowning, the leading cause of injury mortality, and falls, the leading cause of injury morbidity. Removing drowning and fall hazards and teaching child to swim are effective interventions which require substantial investment.
The evaluation found that UNICEF should continue to advocate on the need to scale up CIP based on the success of the project. Fund raising should focus on CIP in the context of eliminating disparity, and ensuring a child’s right to survival, development and protection.
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