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Assessing the effects of societal injury control interventions
Karlstad University, Faculty of Health, Science and Technology (starting 2013), Centre for Public Safety. Karlstad University, Faculty of Health, Science and Technology (starting 2013), Department of Environmental and Life Sciences. (Centre for Public Safety)ORCID iD: 0000-0002-1189-9950
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Injuries have emerged as one of the biggest public health issues of the 21th century. Yet, the causal effects of injury control strategies are often questioned due to a lack of randomized experiments. In this thesis, a set of quasi-experimental methods are applied and discussed in the light of causal inference theory and the type of data commonly available in injury surveillance systems. I begin by defining the interrupted time series design as a special case of the regression-discontinuity design, and the method is applied to two empirical cases. The first is a ban on the sale and production of non-reduced ignition propensity (RIP) cigarettes, and the second is a tightening of the licensing rules for mopeds. A two-way fixed effects model is then applied to a case with time-varying starting dates, attempting to identify the causal effects of municipality-provided home help services for the elderly. Lastly, the effect of the Swedish bicycle helmet law is evaluated using the comparative interrupted time series and synthetic control methods. The results from the empirical studies suggest that the stricter licensing rules and the bicycle helmet law were effective in reducing injury rates, while the home help services and RIP cigarette interventions have had limited or no impact on safety as measured by fatalities and hospital admissions. I conclude that identification of the impact of injury control interventions is possible using low cost means. However, the ability to infer causality varies greatly by empirical case and method, which highlights the important role of causal inference theory in applied intervention research. While existing methods can be used with data from injury surveillance systems, additional improvements and development of new estimators specifically tailored for injury data will likely further enhance the ability to draw causal conclusions in natural settings. Implications for future research and recommendations for practice are also discussed.

Abstract [en]

Injuries have emerged as one of the biggest public health issues of the 21th century. Yet, the causal effects of injury control strategies are rarely known due to a lack of randomized experiments. In this thesis, a set of quasi-experimental methods are discussed in the light of causal inference theory and the type of data commonly available in injury surveillance systems. I begin by defining the identifying assumptions of the interrupted time series design as a special case of the regression-discontinuity design, and the method is applied to two empirical cases. The first is a ban on the sale and production of non-fire safe cigarettes and the second is a tightening of the licensing rules for mopeds. A fixed effects panel regression analysis is then applied to a case with time-varying starting dates, attempting to identify the causal effects of municipality-provided home help services for the elderly. Lastly, the causal effect of the Swedish bicycle helmet law is evaluated using a comparative interrupted time series design and a synthetic control design. I conclude that credible identification of the impact of injury control interventions is possible using simple and cost-effective means. Implications for future research and recommendations for practice are discussed.

Place, publisher, year, edition, pages
Karlstad: Karlstads universitet, 2016. , 59 p.
Series
Karlstad University Studies, ISSN 1403-8099 ; 2016:23
Keyword [en]
causal inference, epidemiology, injury, time series analysis, impact evaluation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Risk and Environmental Studies
Identifiers
URN: urn:nbn:se:kau:diva-41204ISBN: 978-91-7063-701-8 (print)OAI: oai:DiVA.org:kau-41204DiVA: diva2:916360
Public defence
2016-05-19, Eva Erikssonsalen, 21A342, Karlstad, 13:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Civil Contingencies Agency
Available from: 2016-04-29 Created: 2016-04-01 Last updated: 2016-08-25Bibliographically approved
List of papers
1. Investigating the effect of banning non-reduced ignition propensity cigarettes on fatal residential fires in Sweden
Open this publication in new window or tab >>Investigating the effect of banning non-reduced ignition propensity cigarettes on fatal residential fires in Sweden
2016 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 26, no 2, 334-338 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:Annually, 100 people die as a result of residential fires in Sweden and almost a third of the fatal fires are known to be caused by smoking. In an attempt to reduce the occurrence of these events, reduced ignition propensity (RIP) cigarettes have been developed. They are designed to reduce the risk of fire by preventing the cigarette from burning through the full length when left unattended. In November 2011, a ban was introduced, forbidding the production and sale of all non-RIP cigarettes in all member states of the European Union, including Sweden.

METHODS:Monthly data on all recorded residential fires and associated fatalities in Sweden from January 2000 to December 2013 were analyzed using an interrupted time series design. The effect of the intervention [in relative risk (RR)] was quantified using generalised additive models for location, shape and scale.

RESULTS:There were no statistically significant intervention effects on residential fires (RR 0.95 [95% CI: 0.89-1.01]), fatal residential fires (RR 0.99 [95% CI: 0.80-1.23]), residential fires where smoking was a known cause (RR 1.10 [95% CI: 0.95-1.28]) or fatal residential fires where smoking was a known cause (RR 0.92 [95% CI: 0.63-1.35]).

CONCLUSION:No evidence of an effect of the ban on all non-RIP cigarettes on the risk of residential fires in Sweden was found. The results may not be generalisable to other countries.

Place, publisher, year, edition, pages
Oxford University Press, 2016
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Risk and Environmental Studies
Identifiers
urn:nbn:se:kau:diva-34774 (URN)10.1093/eurpub/ckv180 (DOI)000374479200025 ()26428480 (PubMedID)
Available from: 2014-12-12 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
2. The effect of stricter licensing on road traffic injury events involving 15 to 17-year-old moped drivers in Sweden: a time series intervention study
Open this publication in new window or tab >>The effect of stricter licensing on road traffic injury events involving 15 to 17-year-old moped drivers in Sweden: a time series intervention study
2015 (English)In: Accident Analysis and Prevention, ISSN 0001-4575, E-ISSN 1879-2057, Vol. 83, 154-161 p.Article in journal (Refereed) Published
Abstract [en]

This study aimed to evaluate and quantify the effect of the introduction of the AM driving license on non-fatal moped-related injuries in Sweden. With the introduction of the new license category in October 2009, prospective moped drivers are now required to pass a mandatory theory test following a practical and theoretical course. In addition, obtaining a license to operate a moped is now considerably more costly.

METHODS:Time series intervention analysis on monthly aggregated injury data (1st Jan 2007-31st Dec 2013) was performed using generalized additive models for location, shape and scale (GAMLSS) to quantify the effect size on injury events involving teenage (15-17 years) moped drivers, while controlling for trend and seasonality. Exposure was adjusted for by using the number of registered mopeds in traffic as a proxy.

RESULTS:The introduction of AM license was associated with a 41% reduction in the rate of injury events involving 15-year-old moped drivers (IRR 0.59 [95% CI: 0.48-0.72]), and a 39% and 36% decrease in those involving 16-year-old (IRR 0.61 [95% CI: 0.48-0.79]) and 17-year-old drivers (IRR 0.64 [95% CI: 0.46-0.90]), respectively. The effect in the 15-year-old stratum was decreased roughly by half after adjusting for exposure, but remained significant, and the corresponding estimates in the other age groups did not change noticeably.

CONCLUSIONS:This study provides quasi-experimental evidence of an effect on non-fatal moped-related injuries as a result of stricter licensing rules. Only part of the effect could be explained by a reduction in the number of mopeds in traffic, indicating that other mechanisms must be studied to fully understand the cause of the reduction in injuries.

Keyword
Injury control; Intervention; Licensing; Policy; Road traffic injuries
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Risk and Environmental Studies
Identifiers
urn:nbn:se:kau:diva-34771 (URN)10.1016/j.aap.2015.07.022 (DOI)000362135400015 ()26276538 (PubMedID)
Available from: 2014-12-12 Created: 2014-12-12 Last updated: 2017-12-05Bibliographically approved
3. Can the provision of a minor home help service for the elderly population reduce the incidence of fall-related injuries?: A quasi-experimental study of the community-level effects on hospital admissions in Swedish municipalities
Open this publication in new window or tab >>Can the provision of a minor home help service for the elderly population reduce the incidence of fall-related injuries?: A quasi-experimental study of the community-level effects on hospital admissions in Swedish municipalities
2016 (English)In: Injury Prevention, ISSN 1353-8047, E-ISSN 1475-5785, Vol. 22, no 6, 412-419 p.Article in journal (Refereed) Published
Abstract [en]

Background

Fall-related injuries are a global public health problem, especially in elderly populations. The effect of an intervention aimed at reducing the risk of falls in the homes of community-dwelling elderly persons was evaluated. The intervention mainly involves the performance of complicated tasks and hazards assessment by a trained assessor, and has been adopted gradually over the last decade by 191 of 290 Swedish municipalities.   

Methods

A quasi-experimental design was used where intention-to-treat effect estimates were derived using panel regression analysis and a regression-discontinuity (RD) design. The outcome measure was the incidence of fall-related hospitalizations in the treatment population, the age of which varied by municipality (≥65 years, ≥67 years, ≥70 years or ≥75 years).

Results

We found no statistically significant reductions in injury incidence in the panel regression (IRR 1.01 [95% CI: 0.98-1.05]) or RD (IRR 1.00 [95% CI: 0.97-1.03]) analyses. The results are robust to several different model specifications, including segmented panel regression analysis with linear trend change and community fixed effects parameters.

Conclusions

It is unclear whether the absence of an effect is due to a low efficacy of the services provided, or a result of low adherence. Additional studies of the effects on other quality of life measures are recommended before conclusions are drawn regarding the cost-effectiveness of the provision of home help service programs.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2016
Keyword
falls, injury prevention, quasi-experiment, time series analysis, econometric analysis
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Risk and Environmental Studies; Public Health Science
Identifiers
urn:nbn:se:kau:diva-41145 (URN)10.1136/injuryprev-2015-041848 (DOI)000390591200007 ()27016460 (PubMedID)
Funder
Swedish Civil Contingencies Agency
Available from: 2016-03-29 Created: 2016-03-29 Last updated: 2017-08-10Bibliographically approved
4. The effect of the Swedish bicycle helmet law for children: An interrupted time series study
Open this publication in new window or tab >>The effect of the Swedish bicycle helmet law for children: An interrupted time series study
2014 (English)In: Journal of Safety Research, ISSN 0022-4375, E-ISSN 1879-1247, Vol. 51, 15-22 p.Article in journal (Refereed) Published
Abstract [en]

Previous population-based research has shown that bicycle helmet laws can reduce head injury rates among cyclists. According to deterrence theory, such laws are mainly effective if there is a high likelihood of being apprehended. In this study, we investigated the effect of the Swedish helmet law for children under the age of 15, a population that cannot be fined. Method  An interrupted time series design was used. Monthly inpatient data on injured cyclists from 1998–2012, stratified by age (0–14, 15 +), sex, and injury diagnosis, was obtained from the National Patient Register. The main outcome measure was the proportion of head injury admissions per month. Intervention effect estimates were obtained using generalized autoregressive moving average (GARMA) models. Pre-legislation trend and seasonality was adjusted for, and differences-in-differences estimation was obtained using adults as a non-equivalent control group. Results There was a statistically significant intervention effect among male children, where the proportion of head injuries dropped by 7.8 percentage points. There was no evidence of an intervention effect on the proportion of head injuries among female children. Conclusion According to hospital admission data, the bicycle helmet law appears to have had an effect only on male children.

Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2014
Keyword
helmet law, cyclist, accident, injury rate, children, patient, swedish
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Science
Identifiers
urn:nbn:se:kau:diva-30119 (URN)10.1016/j.jsr.2014.07.001 (DOI)000345723400003 ()25453172 (PubMedID)
Available from: 2013-11-22 Created: 2013-11-22 Last updated: 2017-12-06Bibliographically approved
5. The Effects of Bicycle Helmets and Helmet Legislation on the Severity of Children’s Head Injuries
Open this publication in new window or tab >>The Effects of Bicycle Helmets and Helmet Legislation on the Severity of Children’s Head Injuries
(English)Manuscript (preprint) (Other academic)
National Category
Economics Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Science
Identifiers
urn:nbn:se:kau:diva-41153 (URN)
Available from: 2016-03-29 Created: 2016-03-29 Last updated: 2016-05-09Bibliographically approved

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