【作者】 沈敏；

【导师】 杜玉开；

【作者基本信息】 华中科技大学 ， 儿少卫生与妇幼保健学， 2009， 博士

【摘要】 研究目的系统评价儿童意外伤害预防干预的方法及效果；探讨当前经济和社会模式下农村留守儿童和非留守儿童意外伤害流行特征及影响因素；评价健康教育对农村儿童意外伤害预防的效果及存在问题，探讨建立以健康信念模型为理论基础的农村儿童意外伤害干预模式。为有效开展农村儿童意外伤害干预提供理论基础。研究方法第一部分采用系统评价的方法，检索国内外数据库中关于儿童意外伤害干预的研究，按纳入条件筛选相关文献进行总结归纳和Meta分析。Meta分析采用ReviewManager5．0软件进行统计分析。第二部分采用定量研究方，对儿童意外伤害特征及相关因素进行面对面现场调查研究。第三部分采用教育干预，对某小学进行伤害特征和伤害认知的干预前后对照研究。统计分析采用SAS9．0统计软件进行描述性分析、χ~2检验、多因素非条件logistic回归等方法进行统计分析。第四部分采用健康信念模型构建儿童意外伤害干预模型。研究结果1、第一部分：共检索出1410篇相关文献，符合纳入条件的共55篇。干预的伤害类型包括儿童家庭常见意外伤害、机动车意外伤害、自行车相关的意外伤害、行人安全和运动安全等；以儿童和青少年为干预对象的最多占69％，以儿童及其父母或家庭为干预对象有13篇(占23．6％)。儿童家庭常见意外伤害主要以提高父母相关的伤害预防意识和家庭环境改变的教育和工程干预；机动车安全主要以提高儿童及其父母对儿童安全座椅使用的教育和工程干预；儿童行人安全主要以改变儿童行走和过马路安全意识教育和技能培训；自行车伤害主要评价立法干预对增加儿童自行车头盔的使用，降低头损伤的发生。Meta分析结果显示，强制儿童使用自行车头盔可使儿童头盔使用增加2．44倍(OR=3．44，95％CI：3．13-3．79)，自行车相关的头损伤发生的风险约下降50％(OR=0．52，95％CI：0．40，0．66)。2、第二部分结果(1)留守率：共调查学生3019人，男女性别比为1．52：1。留守儿童共1182人，总留守率为39．15％，男、女生留守率分别为39．92％、37．98％。(2)伤害发生率：总的伤害发生率为17．19％(95％CI：15．46-18．92％)。男女生伤害发生率分别为21．75％(95％CI：19．86-23．64％)和10．28％(95％CI：8．88-11．66％)，差异具有显著性(χ~2=66．89，p＜0．001)。留守儿童伤害发生率是非留守儿童的2倍，分别为25．29％(95％CI：23．30-27．30％)和11．98％(95％CI：10．49-13．47％)。(3)伤害特征：前三位伤害类型为跌落伤、机械伤和动物咬伤。留守儿童伤害发生地点前三位分别是家中、学校、道路，分别占31．99％、25．59％和23．91％；非留守儿童为学校、家中和道路，分别为30．00％、27．23％和25．45％。伤害发生时的活动主要是：游戏或玩耍、走路、骑自行车或坐机动车和做家务等；留守儿童伤害平均治疗费用(201元)低于非留守儿童(448元)。(4)伤害发生的影响因素：按伤害类型分别进行影响因素分析，儿童跌落伤的危险因素是年龄增加(OR=2．16)、做家务(OR=3．34)、没有好朋友(OR=4．84)和住处靠近江河湖泊(OR=3．45)；保护因素是母亲年龄增加(OR=0．84)和从不参与打架(OR=0．40)。按年龄分层，5-12岁组的儿童没有好朋友(OR=3．12)和住处靠近江河湖泊(OR=2．78)会增加跌落伤发生的危险。13-15岁组儿童，女生(OR=0．36)、性格类型为中间型(相对于外向型OR=0．27)和喜欢与同学／朋友一起(OR=0．30))是保护因素，监护人是祖父母的儿童比监护人是父母的儿童跌落伤发生的风险增加3．26倍(OR=3．259)。机械伤的危险因素有非独生子女(OR=2．49)，保护因素是年级上升(OR=0．71)和家庭人口数多(OR=0．59)。按年龄分层后5-12岁儿童性别为女性(OR=0．17)、家庭人口数较多(OR=0．32)为保护因素，而非独生子女(OR=18．83)、学习成绩差(OR=2．99)为危险因素。13-15岁年龄组中女生(OR=7．06)是危险因素。动物伤害的危险因素为性格类型为内向(OR=4．47)和监护人为母亲(OR=4．38)。3、第三部分结果：采用健康教育对某小学进行意外伤害干预，干预后对伤害认知的正确率均有所提高，但伤害发生率从14．29％上升到27．14％。留守儿童前三位伤害为动物伤害、跌落、溺水和道路交通伤害。非留守儿童伤害类型为跌落、动物伤害和溺水。4、第四部分结果：应用健康信念模型的行为改变理论为基础构建农村儿童意外伤害干预模式：通过提高儿童青少年对伤害易感性、伤害严重性、预防伤害的益处和采取预防行动的障碍的认知；采用健康教育、行为和生活技能培训干预措施，结合学校的安全行为规范条例，建立以健康信念模式为理论基础的儿童意外伤害干预模式。研究结论教育、技能训练、强制干预和工程干预是儿童意外伤害预防的主要干预措施湖北省麻城市农村儿童意外伤害发生率较高，留守儿童高于非留守儿童，伤害类型以跌落、机械伤和动物咬伤为主，影响因素与伤害类型、监护人类型、儿童性格等因素有关。以学校为基础进行儿童意外伤害健康教育，可提高伤害相关的认知。以健康信念模型为理论基础的儿童意外伤害干预模式，将为中国农村儿童意外伤害预防提供理论基础。更多还原

【Abstract】 Objectives: To evaluate the effectiveness of the intervention on unintentional injuriesamong children and adolescents using systematic review, to analysis the epidemiologicalcharacteristics and influencing factors of unintentional injuries among children in ruralChina, to discuss the pilot intervention effectiveness in a rural primary school, and toexplore the intervention model based on behavior change theory of Health Belief Model(HBM) for childhood unintentional injuries, to reduce the prevalence of childhoodunintentional injuries and to promote Safe Kids in rural China.Methods: Systematic review was applied to evaluate the effectiveness of theinterventions of unintentional injuries among children and adolescents. Meta-analyses wereused to analysis the effectiveness of bicycle helmet legislation to reduce the incidence rateof bicycle related head injury and to increase helmet use. The search strategy was made toretrieve the linkage-database, including Pubmed、Embase、Web of Science、Proquest, andJournals of Chinese Medical Association, China Academic Journals Net Database,Wanfang Data Information System, and VIP Information System. Meta-analyses wereprocessed by Review Manager 5.0 Software. Quantitative studies were used in Part 2 andPart 3. Questionnaires of unintentional injuries characteristics and injury knowledge wereused to interview children of left-behind and children living with 2 parents in 6 ruralschools. Data analysis was analyzed on SAS 9.0 statistic software.Discriptive methods, Chi-square tests, and Logistic regression model were used.Results:1. Part 1: Out of1410 prescreened articles, 112 were potentially relevant to the topicand 55 were finally included in the review. All were published articles. Of the 55 studies, 8were obtained by other related review articles. 10 were obtained the full articles fromexperts in USA. 27 were random controlled trials, 15 were controlled before after studies,10 were interrupted time series studies, and 3 were quai-experimental designs. The maintypes of unintentional injuries include: home injuries, motor-related injuries, bicycle relatedinjuries, pedestrian injuries and playground injuries. The participants were mainly childrenand adolescents, accounted for 69%, and children and their parents, accounted for 23.6%.The intervention of home injuries, including burning and scald, fall, and poisoning, etc,often aimed at increasing parents’ awareness of injury prevention, the safety kits use andhome risk environment modification. Education, engineering and safe training were used asintervention methods. Parenting interventions, most commonly provided as part ofmulti-faceted interventions to improve a range of child (often maternal health) outcomesappear to be effective in reducing self-reported or medically attended injury among youngchildren. Motor-related injuries were often aimed at increase the use of safety equipment ofchildren, such as safe seats, booster seats. Children’s pedestrian safety intervention oftenapplied pedestrian skill training to teach children and adolescents to walk in the right wayand in safe behavior, and cross the road correctly. Playground safety campaign in schoolreduced children’s risk behavior and increased teachers’ supervision on children bybehavior training. Bicycle helmet legislations were implemented in many developedcountries to reduce bicycle related injuries. While the effectiveness of bicycle helmetlegislation varied, all studies demonstrated higher proportions of helmet use followinglegislation targeted to children and adolescents. The effectiveness was evaluated bymeta-analyses that helmet legislation could reduce the bicycle related head injury almost 50% (OR=0.52, 95% CI: 0.40 to 0.66) and increase the helmet use 2.44 times (OR=3.44,95% CI: 3.13 to 3.79) than those of no helmet legislation.2. Part2(1) The proportion of left-behind children in rural primary and middle school: Thetotal number of participants was 3019 students. The sex ratio was 1.52:1. The number ofleft-behind children was 1182, of which, 727 were boys and 455 were girls. The overallproportion of left-behind children was 39.15%, and that of male and female were 39.92%and 37.98% respectively, there was no significant difference (χ~2= 1.14, p=0.28).(2) The injury prevalence rate: the overall injury prevalence rate was 17.19% (95% CI:15.46-18.92%). That of boys was 2 times than that of girls, were 21.75% (95% CI:19.86-23.64%) and 10.28% (95% CI: 8.88-11.66%) respectively, there was significantdifference (χ~2=66.89, p＜0.001) between boys and girls. The injury prevalence rate of leftbehind children was 25.29%, twice than that among children living with 2-parentS. Maleleft-behind children had the highest prevalence rate, 31.64% (95% CI: 29.50-33.80%), andthat of female left-behind children was 15.16% (95% CI: 13.50-16.80%).(3) Injury characteristics: Falls, mechanic injuries and animal bites were the samethree leading types of injuries for different supervisor, such as no parent at home, motheronly, father only and 2-parents,. The mechanic injuries were stab and cuts. The first threeleading locations of injury occurrence for left-behind children were home (31.99%), school(25.29%) and road (23.91%), and that of children living with 2-parents were school(30.00%), home (27.23%) and road (25.45%). The activities when the injury occurred wereplaying (left behind children/children with 2-parents: 40.4%/44.09%) and riding bicycle ormotor vehicle (left behind children/ children with 2-parents: 13.18%/12.46%). But theproportion of doing housework among left behind children was 12.46%, higher than that ofchildren living with 2-parents. The portion of sports related injuries was 9.09%. About73.74% of left-behind children suffered maltreatment, higher than that of children living with 2-parents (58.18%), there was significant difference (χ~2=13.86, p=0.0002). Theaverage cost of injuries for left behind children was 201 Yuan, and that of children livingwith 2-parent was 448 Yuan.(4) The influencing factors for injury: the factors affected injury prevalence wasanalyzed by type of injury. The results showed that risk factors related to falls were ageincreasing (OR=2.16), doing housework (OR=3.34), no good friend (OR=4.84) and homenear river or lake (OR=3.447), protective factors were mother’s age increasing (OR=0.84)and never fighting (OR=0.40). When controlled age by 5-12 years, 13-15 years and 16-18years, risk factors for 5-12 years old children were no good friend (OR=3.12) and homenear river or lake (OR=2.78); risk factors for 13-15 years old children were no parents athome (OR=3.26), protective factor was female (OR=0.36).The risk factors of mechanic injuries were non-singleton (OR=2.49), protective factorswere grade increasing (OR= 0.71) and big household (OR=0.59). After Controlling age,protective factors for 5-12 years old children were female (OR=0.17) and big household(OR=0.32). Non-singleton (OR=18.83) and underachieving in study (OR=2.988) were riskfactors for mechanic injuries. And for 13-15 years children the risk factor was female(OR=7.06).The factor increasing the risk hazard for animal bite was diffidence personality(OR=4.474) and mother as caregiver (OR=4.385). After controlled age, the risk factor for13-15 years old children was found, that was mother as caregiver (OR=28.327).3. The result of Part 3: The injury prevalence of left-behind children increased from18.47% before intervention to 46.67% after intervention. Those of children living with2-parents increased from 7.84% to 14.91% after intervention. The first leading injuries wereanimal bite, falls, drowning and road traffic injuries among left-behind children, those forchildren living with 2-parents were falls, animal bites and drowning. The length of stay inhospital increased from 1.3 days to 5 days for left-behind children, the average medical cost increased from 156 Yuan to 665 Yuan, however the average medical cost decreased from418 Yuan to 183 Yuan for children living with 2-parents.4. The results of Part 4. To construct the intervention model based on behavior changetheory-Health Belief Model to prevent unintentional injuries for rural children. Throughpromote the awareness of injury susceptibility, injury severity, benefits and barriers toprevent injury, education, behavior and living skill training and home and schoolenvironment modification were applied, combined with safety behavior regulation, todevelop peer help and teacher supervision for left-behind children, construct theintervention model of unintentional injuries for rural children, and to make children safe.Conclusions: There are well rounded intervention methods and reliable effectivenessfor childhood unintentional injuries. Health education, training, legislation, and engineeringwere the main methods. The main types of injuries for children were home injuries, bicyclerelated injuries, motor-vehicle injuries, and pedestrian injury, etc. Rural children have highinjury prevalence rate, especially among left-behind children. The first three leadinginjuries were falls, mechanic injuries and animal bites. The influencing factors were variedby types of injuries and children’s age. There was significant association between types ofguardian and injury type. Education could not reduce the prevalence rate; we shoulddevelop a comprehensive intervention model to reduce the occurrence of unintentionalinjuries, to increase the awareness of prevention and cognition to injury; training should beused to elevate the safe behavior and living skills for the children. The intervention modelbased on Health Belief Model should be developed to reduce injury occurrence.更多还原