Progress towards Regional Priority Goal II - on accidents, injuries and physical activity.

In a recent global comparison of child mortality, Sweden shows the lowest rate within the high income countries (HIC), at 5.2/100 000 children, with a comparable rate in the United States of America of 14.1/100 000.  Bergman and Rivara (1991) reported almost equal rates for groups of children in Sweden and the United States for the period 1957-9; thirty years later, however, United States rates were almost unchanged, whereas Sweden's rates have fallen from around 47 to 6/100,000 (1-4 year olds) and from 18 to 7/100,000 (5-14 year olds).  

Children's injuries are a national health priority in Sweden.  The Swedish Government enacted a special commission for the promotion of childhood safety in the early 2000s. After the establishment of this commission, responsibility for oversight of children's safety promotion activities was delegated to the Swedish Rescue Services Agency, SRSA. 

Leading causes of unintentional injuries for children

Injury is by far the most common cause of death among children aged one year or more. From an extremely high level of injuries to children, with as many as 450 children under 15 dying due to accidents during 1954, Sweden has shown a unique trend. In 2000, there were just 49 injury-related child deaths.

The number of hospital discharges due to injuries for children aged 0-20 years in Sweden hovered at six per thousand between 1987 and 2000.

For more specific information on childhood injuries, please refer to the Injury Prevention article above, based on The Swedish Child Injury Atlas. A national action plan has been in effect for the past 40 years, in one form or another. Current responsibility for enactment of the latest plan has been delegated to the Swedish Rescue Services Agency. 
 

Surveillance systems

In Sweden, there are two universal, legally mandated surveillance systems in place to monitor childhood injuries. Injury fatalities are captured by the Swedish National Board of Health and Welfare, Epidemiology Centre in Stockholm. The childhood mortality data capture mortality by age group, sex, injury cause, and setting, using International Classification of Diseases 10 (ICD-10) categorizations for injuries occurring 1997 onwards.  Nonfatal childhood injuries that require hospitalization are also documented by age group, sex, cause of injury.  Voluntary injury registries are also in place in about 50% of the 21 Swedish county councils (Landsting)- these systems use Nordic Medico Statistico Committee (NOMESCO) categorization schemes.

Basic information about injury location includes information on the child's legal residence, but information on actual injury location is not always available. One obvious drawback for hospital-based surveillance systems is that information on less serious injuries is not available. Less severe injuries are often, but not universally, captured using the voluntary European Home and Leisure Accident Surveillance System (EHLASS).  Approximately 6% of the Swedish population resides in areas that report to EHLASS.  Trend data for fatal injuries and nonfatal injury hospitalizations is available. ICD 10 information is available beginning with 1987. 

Accidents on the way to and from school

Information on injuries occurring to children on their way to and from schools is not available per se. Mortalities that occur in this circumstance would be collected by the Swedish National Board of Health and Welfare, via hospital reports, as would be hospitalizations under such circumstances. However, no special surveillance system is in place to capture injuries occurring while children are in transit. NOMESCO categories, as used by voluntary surveillance systems in about half of Sweden's county councils, may allow for better investigation and surveillance of injuries occurring to children while they go to and from schools. 

Steps taken to reduce the burden of unintentional injuries among children

Sweden regards injury as a public-health problem, and also as something for society as a whole to control. This was made clear as early as in the 1950s in national policy statements. This policy led to a societal approach to the promotion of safety through the development of preventive strategies, such as injury surveillance, information, and education and environmental improvement, and also product-safety development. The so-called Joint Committee for the Prevention of Accidents to Children was set up as far back as in 1954. The Committee was succeeded by the National Child Environment Council, and later by the Children's Ombudsman and - for two years - the Child Safety Commission. The Swedish Rescue Services Agency is now responsible for the National Safety Promotion Programme, one of whose tasks is to promote child safety.

Challenges and constraints

One challenge is that Sweden lacks universal information on nonfatal injury events. 

Recent polices and measures

There are currently 15 WHO-designated Safe Communities in Sweden- all of these programmes provide childhood injury prevention programmes. See also the Karolinska Institute. There is one designated Safe School, which is in Källby Gård, Götene Municipality in southwest Sweden.  All children in Sweden have universal access to health care, including visits from public health district nurses and visits to paediatricians, most of whom provide injury prevention information, along with other public health services to children and their families. Information specific to newborns is provided to expectant parents by midwifes, including information on safe transport of children, and child-proofing houses. 

Traffic safety

There is mandatory use of car child restraints and bicycle helmets for children up to 15.  Sweden has enacted a national policy of Zero Vision, which states that should be no traffic-related deaths or severe injuries within the nation. As such, traffic environments now make frequent use of calming devices, including separate trails and walkways, and better pedestrian crossings. There is compulsory use of helmets for all drivers and passengers on mopeds and motorbikes.

Drowning prevention

Primary school age children are provided with compulsory swimming lessons throughout most of Sweden.  Lifeguards are posted in most outdoor swimming areas and public beaches. There is a system of voluntary loans for personal floatation devices, although the use of such is not compulsory for children in Sweden.

Poisoning prevention

There is a national poison control centre in Stockholm, Giftinformationcentralen, which provides local authorities and hospitals, and members of the public, including parents, with information on dangerous chemicals and medicines. Swedish homes are equipped with a locked safe box, where people must store prescription medicines.  Child safety locks are found on most medicines and chemicals. Schools that instruct pupils on subjects involving exposure to toxic elements, including home economics, chemistry, and woodworking classes, must be properly ventilated.

Fall prevention

Minimum height policies vary by location, but most windows come equipped with locks and maximum opening to prevent falls. All balconies have vertical bars-indoor railings must be 110 cms high.  Stairwells must have at least one handrail. Stairs with open spaces must have enclosed risers, so that people do not trip while using them. Children's playgrounds must have soft material underneath, to minimize injuries from falls.

Burns prevention

There is compulsory setting of thermostats for heating and water systems.  Smoke detectors are not mandatory.  Children's clothes are supervised by the Swedish Consumer Agency, which requires that they be fire-retardant.   

NGOs and other sectors and organizations involved

Swedish safety promotion activities are multi-sectoral, and usually involve the participation of mandatory and voluntary organizations. Injury prevention programmes are often implemented by local authorities, in cooperation with regional groups, guided by national programmes.  Some NGOs that regularly sponsor or participate in childhood injury programmes on national or regional levels include:

• NTF - The National Society for Road Safety, a non governmental organisation which works to improve road safety. NTF is an umbrella organisation and consists of 24 county road safety federations, 70 national, interest and professional organisations and hundreds of local voluntary associations. The national network is made up of thousands of people working to help you contribute to safer roads
• Red Cross
• Swedish LIfe Saving Society

Industry partners include e.g. national  insurance companies, bicycle helmet manufacturers, and major automotive industries, including Volvo and Saab. 

Research

There is a large body of peer-reviewed research that evaluates the implementation of injury prevention activities around Sweden.  Research efforts include injury mapping and analysis of surveillance data, process and outcome evaluations, and descriptions of the development of Sweden's national policies for injury prevention.  Studies include general information on childhood injury prevention on national and local levels, and specific reports on injuries occurring in various environments, including home and leisure time locations, schools, and traffic. There is a large body of studies describing injury prevention activities for children on bicycles, or who are passengers in motor vehicles.   Recent studies on Swedish childhood injuries have focused on social inequalities that are associated with such events.

Physical activity

There are more children who are physically active today (2001) than during previous surveys (1997, 1993, 1989, 1985) according to the statistics from the Swedish National Institute of Public Health. Boys 11 years old 44 per cent, 13 years 42 % and 15 years 40%. Girls 11 years 26 per cent, 13 years 27 % and 15 years 23 % who are training at least four times a week during their leisure time (Figur sidan 326 i Folkhälsorapporten 2005 från Socialstyrelsen)

About 65 per cent of children 7 - 15 years of age are engaged in sports and PA, according to a survey by the Swedish Sports Confederation 2004 (Barn och ungdomars idrottande, RF 2004)

There seems to have been no recent change in young people's level of sports activities, although the scale of sedentary activities has increased in recent years. There have been no comparable data on the physical activity of children and young people over the last twenty years or so. The studies that have been presented mostly concern sports activities. The Statistics Sweden (SCB) Living Conditions Surveys show that the proportion of 16-24 year-olds participating in sports indoors and outdoors during the period 1982-1999 changed only slightly (SCB 2005, in Swedish). A study of training for schoolchildren, both organised and spontaneous, does not indicate any significant changes between 1985 and 2001 (Danielsson 2003, in Swedish). Changed training routines/frequency does not seem to explain the increase in obesity. Neither is this anticipated since physical activity is only carried out as training to a very limited extent.

Sedentary activities: watching TV

The scale of sedentary activities has however increased in recent years. A study of children's TV-watching habits reported that 97 per cent of children between 9 and 16 years old watched TV for an average of two hours a day in 1999. More recent figures indicate that 19 per cent of boys and 17 per cent of girls aged 11-15 years watch TV at least 4 hours a day on weekdays. The corresponding figures for weekends were 40 per cent of boys and 33 per cent of girls. The use of computers and computer games has also increased over the last twenty years.

Overweight, obesity and physical activity

Among 18 to 20 per cent of all 10-year-olds are either overweight or obese (appr. 4 % ). It is a growing public health problem. A study in the north of Sweden, Umeå shows that overweight has doubled between 1986 and 2001, but gone up 5 times regarding obesity (from 1,2 per cent to 6 per cent)

There are no national studies available on how many children presently meet the recommended daily dose of physical activity (60 minutes per day), but WHO 2004 Health Behaviour in School-aged Children shows that boys training in the leisure time four times a week are 33 per cent and girls 27 per cent. A comparison between European countries is made.

Another study Compass (Community-based study of physical activity, life style and self-esteem in Swedish school children), FHI 2004 shows that among 15-year-olds in the Greater Stockholm area, 64% of girls and 78% of boys achieved the recommended 60 minutes of at least moderate physical activity per day. It is probable that not more than 20 per cent of the grown-up population meets the recommended daily dose of at least 30 minutes of PA (Kallings, Lena FHI-rapport 2002:6) 11.2% of the girls and 14.5% of the boys were found to be overweight, and 3.3% of girls and 3.7% of boys were obese. Obesity was more than three times as common among girls with a less educated mother than among those with a higher educated mother; for boys, it was almost twice as common for those with a less educated mother.

Adolescents of Swedish background were overweight or obese to a lesser extent than those with a foreign or immigrant background. 14.6% of young people with an immigrant background and 14.6% of those with a foreign background were overweight, which can be compared with a proportion of 11.7% among adolescents of Swedish origin. Obesity was also found to be more common among adolescents of foreign background (4.6%), and of immigrant background (4.4%), than among those of Swedish origin (2.8%). Girls and boys were sedentary for, on average, 4.6 hours and 4.9 hours respectively during weekdays after school. Both boys and girls watched TV or video for an average of 2.1 hours per day on weekdays.Young people with a lower educated mother, those in cramped accommodation, and those with immigrant background devoted the most time to sedentary activities.

Physical activity is carried out mostly within facilities provided by the municipality and as members of one or several of the NGO`s eg. in the Sports Confederation or one of the many organizations for outdoor life (environment, fauna, skiing etc).

According to a survey by RF, the Swedish Sports Confederation, in 2004, the most popular sports among girls were football 28%, riding 21 %, swimming 13 %, aerobics 13 % and handball 10% - and among boys football 56%, in-door-bandy 23%, icehockey 12%, handball 9% and swimming 8%.

There is a survey of levels of physical activity by children carried out every four years by the Swedish Institute of Public Health.

Actions to support  children becoming more physically active

There are several national initiatives:

• NCFF - The National Centre for Enhancement of Physical Activity among Children and Adolescents, is commissioned by the Government to address these matters by cooperating with other national authorities and towards local schools. NCFF have had a project running since 2005 to get as many schoolclasses as possible to take part in a walking-competition. Another project is to develop the dancing as such within the school day. This is also a joint project with many contributors.
  
• The National School Curriculum was amended in 2004 to give every child the right to physical activity during each day at school. This has to be followed- up by every single school.
• NGOs are collaborating with local schools and providing their services during the working hours of the day such as aerobics, out-door-activities, fishing.
• The National Government has asked SIPH for a National Plan to enhance PA and was given this in 2005 and is now putting some of the 79 initiatives into action

Transport

16,6 per cent of the young people reported that they never walked or cycled to school, and 16,3 per cent that they never walked or cycled during leisure time.

The Swedish Road Administration has a national strategy and programme to enhance cycling and walking as means of transport. They have also put into action a specific national plan to help children have a more physically active and safer way to school. Many more parents are concerned with the safety of the children and tend to drive them by car to school and leisure activities. Noise, big roads, speed and more vehicles are considered to obstruct a more physically active lifestyle.

There is no national campaign other than that of September 22 "leave your car", but there are local ones to reduce speed-limits in residential areas to 30 km/h.

School settings

More children are physically active at school today (from 1985 to 2001), but this applies mostly to those involved in many kinds of organized activities. On the other hand there are studies showing children of 10, 13 and 16 being less physically active spontaneously. The every day PA has decreased in favour of the more organised forms of PA.

Many universities have training programmes for teachers to learn out-door education and skills. 80 municipalities have out-door-schools  (Naturskolor) and there are some initiatives by NGO`s to give young children skills for out-door-life during school hours (Ur-och-Skur-skolor). The subject of sports and physical activity and health is getting more and more involved in other subjects.

In 2003 the Swedish National Agency for Education began to inspect municipal and independent schools throughout the country. They are about to set up qualifications for physical activity.Many books have been written together with children to promote out-door-games during recess time. Other tutorial books have been published to help teachers enhance PA among very young children at pre-schools.

Leisure time

Attractive local environments and access to open spaces increase physical activity. The National Government has given an assignment 2005 to Movium at SLU - the Swedish University of Agricultural Sciences - to give directive solutions on how to promote PA by changing school-yards. The SNIPH was also given a governmental task in 2005 to examine both out-door and in-door environments in order to make people more inclined to be physically active in the neighbourhood.
It is assumed that children as a group have difficulties to address their own rights and wishes.  One study (Pia Björklid) shows that the freedom of motion is restricted by traffic and urbanization in general. The environmental aspects are therefore important. There are many studies showing the health benefits of being outdoors.

Leading actors in promoting physical activity among children

There are many actors on the national level:

• The Swedish Institute of Public Health SNIPH
• Movium within the Swedish University of Agricultural Sciences
• NCFF as mentioned above as a focal point
• The Swedish Road Administration
• The local Municipalities must take the lead and get the support from the national authorities.

NGOs, civil society and other sectors actively involved in physical activity promotion

In Sweden these sectors are involved a great deal, especially within the Sports Confederation and those enhancing out-door life within the umbrella-organisation FRISAM. Most educational bodies are concerned and sometimes involved i.e. courses and teaching programmes and there is a wide range of non-governmental teaching organisations providing studies in various forms on the topic of health and PA promotion. It must be said that we are in the middle of a boom regarding initiatives to promote physical activity and healthy habits. Many new jobs are being formed eg. Health-coaches at work-places. The media is doing series on eating habits, training and well-being. It could be stated that physical activity is the top priority of our time at the present moment.

All sectors have been made aware of the situation with over-weight and obesity, the growing number of employees on sick-leave, a larger number of people especially women suffering of distress. And the knowledge that physical activity can make a lot of difference in prevention. A review of health promotion activities at the municipal level in Sweden showed that 26 out of a total of 290 municipalities had an action plan for physical activity and only 13 had one for healthy dietary habits. This highlights the great need for the development of community-based measures to promote healthy dietary habits and increased physical activity.

SLU Swedish University of Agricultural Sciences are doing research on the propision of exercise-enhancing and supportive settings 
     

Transport to school

The Swedish Road Administration (Thomas Larsson) and perhaps MSU - the Swedish National Agency for School Improvement  are involved with information on the mode of transport that children use on their way to schoolthis.

A study called SKOLBARNENS RESEKEDJOR (Swedish Road Administration, 2003) ARS P0479 regarding children´s mode of transport to school has given the following results:
By walking   37%
By bicycle   29%
By school bus  13%
By public transport 4%
By taxi    2%
Driven by private car  19%
No answer   1%

There are more children in Sweden in comparison with the United Kingdom who walk or cycle to school.