1. School of Kinesiology and Health Science Methodologic challenges in preventing playground equipment-related injuries Alison K.Macpherson PhD Linda Rothman, MHSc Colin Macarthur, MBBCh, PhD Andrew Howard, MD MSc FRCSC

2. School of Kinesiology and Health Science Background Playground injuries result in more severe injuries than any other mechanism of common childhood injury (except road traffic) 3313 children visited Ontario Emergency Departments for playground injuries in 2002/03 5 to 9 year old children often injured on playgrounds Severe injuries are usually falls Fall heights > than 1.5 m and poor surfacing main risk factors for injury

3. School of Kinesiology and Health Science A dangerous playground Can fall onto concrete here Falling height >2m here Surfacing in poor condition

4. School of Kinesiology and Health Science Background Most common severe playground injury is upper extremity (UE) fracture 10% of ED injury visits among 5-9 year old Canadian children 1 One of major determinants of playground injury is inadequate surfacing 1 Brown J.A. A comparison of injuries on various types of playground equipment 2 Canadian Institutes of Health Information

5. School of Kinesiology and Health Science Are equipment-related injuries more severe? CHIRPP database was used to identify all fractures occurring on playgrounds seen in the emergency room at the Hospital for Sick Children between 1997 – 2002 Fractures graded as major (i.e., require reduction) or minor (i.e., no reduction required) Examined falls from standing height compared to falls from playground equipment

6. School of Kinesiology and Health Science Fall height and injury severity Falls from playground equipment resulted in a much greater proportion of major fractures than did falls from standing height –The odds of a severe fracture from falling from equipment was 5 times greater than when falling from standing height (OR = 5.03, 95% CI: 3.56, 7.14) 49304Standing height 331408Play equipment Major FracturesMinor Fractures

7. School of Kinesiology and Health Science Injuries sustained from falling from playground equipment are more severe than injuries sustained from standing height falls This research suggested that efforts at injury prevention should examine the safety of playground equipment The Toronto District School Board removed and replaced unsafe playground equipment starting in 2000

8. School of Kinesiology and Health Science Design Randomized Comparison of Wood Fibre versus granitic sand surfaces beneath play equipment Injury Outcomes Vs.

9. School of Kinesiology and Health Science OBJECTIVES Primary Objective: –Upper extremity (UE) fracture rates –Fibar surfacing vs. granite sand surfacing Secondary Objective –Overall playground injury rates, head injury rates –Fibar surfacing vs. granite sand surfacing

10. School of Kinesiology and Health Science METHODS Cluster Randomized –New Playground, New Surface, 19 randomized to Fibar and 18 to sand 37 schools eligible Followed for 2 ½years

11. School of Kinesiology and Health Science METHODS Outcome measures –OSBIE incident reports –Parent telephone interview with consent –Medical record verification Exposure to play equipment measured in spring 2006

12. School of Kinesiology and Health Science 37 schools eligible and randomized n = 15,074 students 19 allocated to receive Fibar wood chip surface -5 discontinued (4 no new play equipment/surface put in, 1 school put in rubber) 18 allocated to receive granite sand surface 4 discontinued (2 refused to participate, 2 no new play equipment/surface put in) 12 received Fibar 2 received granite sand 7 received granite sand 7 received Fibar 12 analyzed Randomized analysis 9 analyzed Cohort analysis 7 analyzed Randomized analysis 19 analyzed Cohort analysis

13. School of Kinesiology and Health Science RESULTS No significant differences in compliant schools and all schools (cohort) in: –Surface installation costs –Exposure to all play equipment (mean student count/minute/school) –# of monkey bars –# of monkey bars > recommended height (2.2m) –# with appropriate depth measured (>7 inches)

14. School of Kinesiology and Health Science RESULTS Total of 259 injuries 44 UE fractures –22 falling onto surface –1 on play equipment (not falling) –46% wrist fractures, ¼ elbow fractures 1 concussion, not on equipment, no hospital admission

15. School of Kinesiology and Health Science RESULTS Compliant SchoolsAll Schools SandFibarSandFibar All Injuries Total106.292.4111.879.8 Falling onto Surface4.923.16.619.8 Other Play Equipment Injuries8.612.310.213.6 UE Fractures Total8.616.28.818.3 Falling onto surface1.28.52.29.7 Other Play Equipment Injuries00.800.7 Crude rates per 1,000 student months

16. School of Kinesiology and Health Science RESULTS Compliant SchoolsAll Schools SandFibarP valueSandFibarP Value All Injuries Total127.2 (45.6,333.7) 101.3 (47.0,212. 9) 0.81144.1 (59.0,334.1) 97.0 (53.7,172.6) 0.53 Falling onto Surface7.3 (1.4,22.6) 25.3 (11.3,54.7) 0.3310.2 (2.5,30.0) 23.0 (11.2, 45.2) 0.17 Other Play Equipment Injuries 9.5 (2.4, 82.1) 9.0 (2.9, 39.9) 0.9514.0 (4.6, 65.9) 10.7 (4.8, 27.4) 0.70 UE Fractures Total8.7 (3.4,17.4) 16.2 (9.5,25.4) 10.3 (3.3, 25.1) 22.7 (12.3,41.3) Falling onto surface1.9* (0.04,6.9) 9.4 (3.7, 21.4) 4.5 (0.26,15.9) 12.9 (5.1, 30.1) Other Play Equipment Injuries** ---- *p<.05, **< 1 events, cannot calculate rates Cluster Analysis: Rate of injury per 100,000 student months

17. School of Kinesiology and Health Science DISCUSSION Cluster analysis : When falling on surface –Injury 3 X greater rate of injury on fibar (randomized) 2 X greater rate on fibar (cohort) –UE Fracture 5 X greater on fibar (randomized) 3 X greater on fibar (cohort) Injury rate lower in all groups than our prior data estimated

18. School of Kinesiology and Health Science CONCLUSION Low overall numbers of injury – highlights success of wide scale intervention of equipment and surface upgrade to meet current safety standards Sand safer in terms of upper extremity fracture and injuries in general

19. School of Kinesiology and Health Science Implication To prevent fractures, use sand! Vs.

20. School of Kinesiology and Health Science ADDITIONAL ANALYSES Relationship between a socioeconomic indicator at the school level and playground injuries

21. School of Kinesiology and Health Science Objective to examine socioeconomic variation in playground equipment prior to and subsequent to equipment replacement

22. School of Kinesiology and Health Science Methods Injury data collected from January 1998- December 1999 and January 2004 – June 2007 (OSBIE incident reports) 374 elementary schools in Toronto, Canada

23. School of Kinesiology and Health Science METHODS Schools categorized into: - pre intervention (before equipment removed) - post intervention (after equipment replaced) All outdoor injuries categorized into: –Non-equipment injuries –equipment injuries Poisson regression used to determine the relationship between injury rates and school SES Comparisons made using injury rate per 1000 student months

24. School of Kinesiology and Health Science SES using Learning Opportunities Index Learning Opportunities Index (LOI) used by school board Based on: family income, proportion of single parent families, housing (detached, apartment buildings), parental education, neighborhood immigration, the number of students at the school who arrived in Canada in the past 5 years, and records of student mobility LOI scores range from 0 (wealthiest) to 0.97 (poorest) Schools with the highest LOI score receive support from the Ministry of Education’s Learning Opportunities Grant to help equalize learning opportunities

25. School of Kinesiology and Health Science Results Pre (January 1998-December 1999) : - 5, 378 injuries were reported by 364 schools Post (January 2004 – June 2007): - 8,380 injuries were reported by 374 elementary schools

26. School of Kinesiology and Health Science Injury rates per 1000 student months pre and post replacement

27. School of Kinesiology and Health Science Relative risk of injury by SES pre and post replacement PrePost All injuries 1.65 (1.50-1.82)2.07 (1.91-2.24) Non-equipment injuries 1.68 (1.50-1.89)2.41 (2.20-2.64) Equipment injuries 1.52 (1.24-1.86)1.13 (0.95-1.32)

28. School of Kinesiology and Health Science Strengths and Limitatations Strengths Standardized data collection Clear time period before and after replacement Limitations SES attributed at the school level Potential variation in threshold for completing incident reports

29. School of Kinesiology and Health Science Discussion There was a change in the SES gradient in school equipment-related injuries subsequent to upgrading the equipment The SES gradient remained for non-equipment injuries Modifying the build environment appears to be an effective way to make schoolyards safer Ongoing research may determine reasons for SES gradient in non-equipment injuries

30. School of Kinesiology and Health Science A Safer Playground for Younger Ages

31. School of Kinesiology and Health Science Conclusion Changing the built environment (upgrading play equipment) can mitigate socio- economic differences in playground equipment injury rates