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sustainability
Article
Effect of the Safe Fall Programme on Children’s
Health and Safety: Dealing Proactively with
Backward Falls in Physical Education Classes
Luis Toronjo-Hornillo 1, *, Óscar DelCastillo-Andrés1ID , María del Carmen Campos-Mesa 1ID ,
Víctor Manuel Díaz Bernier 1and María Luisa Zagalaz Sánchez 2ID
1
Facultad de Ciencias de la Educación, Universidad de Sevilla, 41013 Sevilla, Spain; ocastillo@us.es (Ó.D.-A.);
mccampos@us.es (M.d.C.C.-M.); victormd2007@gmail.com (V.M.D.B.)
2Faculty of Humanities and Education Sciences, University of Jaén, 23071 Jaén, Spain; lzagalaz@ujaen.es
*Correspondence: ltoronjo@gmail.com; Tel.: +34-619-23-1176
Received: 22 March 2018; Accepted: 10 April 2018; Published: 13 April 2018
Abstract:
The aim of this study is to show that the implementation of the Safe Fall programme
in physical education classes can help to reduce the negative effects of unintentional backward
falls in the adolescent population, by teaching them how to protect themselves when falling.
A quasi-experimental research design was applied in a sample of 120 children (M = 15.1 years,
SD = 2.45), attending a secondary school in Seville (Spain). Data was collected on an ad hoc
observation scale INFOSECA (which records five basic elements during a backward fall: position
of the neck, the hands, the trunk, the hips, and the knees), applying descriptive, correlational, and
contrast statistics. The criteria for considering statistical significance was p< 0.05 in McNemar ’s test.
The data indicates that learning safe and protected ways of falling backward is possible through the
implementation of the Safe Fall programme, and no differences were found in terms of gender.
Keywords: falls; childhood; prevention; education; school health
1. Introduction
The study of falls among the school population has attracted a great deal of social interest in
terms of public health, safety, and the protection of minors, becoming an important component of
intervention in developed societies throughout the world. This interest in the study of fall-induced
injuries and their consequences has been reflected in studies published in high-impact Spanish and
international journals in the area of psychology and public health [1–6].
The World Health Organisation [
7
], drew attention to the fact that falls represent the
second-leading cause of death from unintentional injuries among minors throughout the world.
In Spain, different studies [
3
,
8
–
10
] have presented falls as the third most common cause of death from
unintentional injuries among this population (approximately 13% of child mortality). In first place are
traffic accidents (23.7%), followed closely by drownings (20%). In the context of Andalusia, a previous
study [
11
] pointed out that falls represent 4.3% of accidental deaths at that age, and of these falls
26% take place at school. Likewise, a study supported by the Spanish Association of Pediatrics and
Primary Health Care [
12
] pointed out that falls are the main cause of unintentional injury in children
under 14. The figures from Spain tie in with those of the European Child Safety Alliance [
13
] at an
international level. To give an idea of what this costs in terms of health care, the USA reports an annual
health expenditure of 50 billion dollars associated with fall-related injuries in children from 0 to 14
years [8].
Sustainability 2018,10, 1168; doi:10.3390/su10041168 www.mdpi.com/journal/sustainability
Sustainability 2018,10, 1168 2 of 8
The scientific community has reacted in Spain [
8
,
10
–
12
] and internationally [
2
,
4
,
14
] with
preventive programmes that, from a multisector approach [
6
], partially solve the problem of falls,
as children will continue to have falls since it is in their nature to do so [15].
To provide a response to fall-related issues in children beyond mere prevention programmes,
something not found in the specialized literature on falls, this study presents a proactive educational
programme, Safe Fall [
16
], which introduces the teaching of safe and protected ways of falling to
schoolchildren as an adapted physical activity to be included in physical education (PE) classes.
The programme is in line with proposals of the WHO internationally, and the Ministry of Health in
Spain [
17
] encouraging multisector programmes designed to minimize fall-related injuries. Interest in
the Safe Fall programme amongst future health and education professionals was underlined by a
recent study amongst this group showing great demand for training in this area [18].
Safe Fall has been designed to minimize the consequences of injuries from unintentional falls in
schoolchildren through group work on movements, balance, and basic and specific motor abilities.
Above all, it focuses on automating movements to ensure children protect themselves in the event of
an unintentional fall. The programme also aims to bolster the competencies of specialists in PE, sports,
and health in more protected and safer ways of falling. This is an addition to current programmes
focusing on fall-prevention; it gives teachers an important and innovative, proactive tool with which
they can teach children in PE classes how to fall more safely.
The aim of this study is to show that the implementation of the Safe Fall programme can help
reduce the consequences of unintentional backward falls in schoolchildren by teaching them motor
responses that are associated with less harmful ways of falling.
2. Materials and Methods
With an explanatory objective, and from a positivist paradigmatic approach, a quantitative
methodology based on the experimental method was adopted to apply a pretest–posttest
quasi-experimental research design.
2.1. Sample
Sample selection was performed using incidental sampling [
19
], with the final sample consisting
of 120 schoolchildren whose ages ranged from 12 to 17 years (M = 15.1 years, SD = 2.45), all attending
a private, but partially publicly-funded, secondary school in Seville (Spain). Information was
collected from 1st, 2nd, and 3rd year students (26.8%, 23.3%, and 23.3%, respectively) in compulsory
secondary education, and the rest (26.6%) were in their first year of baccalaureate studies during the
2016/17 school year. By gender, 54.2% were male and 45.8% female.
2.2. Process
The study intervention period lasted 5 weeks, from 17 April to 19 May 2017. Empirical data
were collected using the INFOSECA ad hoc observation scale (Information Scale on Safe Ways of
Falling) (Appendix A). A video-graphic record was made of each student for of the pretest and posttest
for subsequent analysis by 5 independent experts, plus the principal investigator. The experts were
previously trained to collect data as follows: each of them viewed 10 execution models at different
time points (twice in a row, every two days, for a total of 5 training sessions). On the collected data,
the level of reliability intra-evaluators for this scale presents a value for the Kappa index of 0.95 for the
neck variable, 0.99 for the hands, 0.93 for the trunk variable, 0.87 for the hip, and 0.88 for the knees.
Later, it was established that the level of reliability between evaluators for this scale presents a value
for the Kappa index of 0.93 for the neck variable, 0.98 for the hands, 0.75 for the trunk variable, and
0.82 and 0.84 for the hip and knees, respectively. Pupils’ parents or tutors were informed about the
implementation characteristics of the programme and gave their informed consent for the study.
The design of the resulting instrument meant that 5 fundamental elements to be taken into account
during the process of a safe and protected backward fall would be recorded dichotomously (on a
Sustainability 2018,10, 1168 3 of 8
nominal scale, either well executed or badly executed): first, protect the head (reduces the frequency
and/or intensity of the blow to the neck on the ground); second, avoid using hands to break the fall
(reduces the frequency and/or intensity of the support of the upper limbs on the ground); third, roll up
into a ball (progressively increases the surface of the impact on the ground); fourth and fifth, bend the
hips and the knees (reduces the height of the fall and helps in rolling up into a ball). Content validity
was demonstrated via the conjugation of two fundamental perspectives: the theoretical review about
the state of the question and the assessment of two judo specialists who were experts in falls.
The pretest was done only once by each student and it recorded pupils’ spontaneous motor
response to a sudden backward fall. The programme was then implemented in three phases as part
of P.E. classes. First was a theoretical presentation about falls and their consequences at school age
(1 h), which consisted of a practice session, Level I in the gym, on the specific techniques of Safe Fall
(the content of the 50 min practical lesson consisted of a presentation of the positions to be avoided in
the event of a fall, presenting to the students which positions are protected and safe in the event of
a fall, and a battery of exercises and games to allow them to practice but also to encourage them to
think about the information and the aforementioned items). In the 10 successive sessions (within the
warm-up of the physical education class) two 5 min exercises or one 10 min exercise were performed,
so the total time spent was 10 min per 10 sessions. These last exercises are chosen in a sequence and,
depending on their level of difficulty at the teacher’s discretion, adjusting to the learning progressions
established in the program, reviewing some known exercises and introducing new ones depending on
the level of student achievement. After the implementation of the Safe Fall programme, a posttest was
conducted to collect the assimilated motor response to a sudden backward fall (Appendix A). Again,
to collect this data, each student performed the test once (posttest).
Data was analyzed with the statistical package IBM SPSS v24 (IBM, New York, NY, USA) in a
Mac environment. Descriptive, correlational, and contrast statistics were applied. The criteria for
considering statistical significance was p< 0.05 in McNemar’s test. The gender contrast was determined
via a Student’s t-test.
3. Results
The following section presents the main results of the study, in relation to learning protected and
safe ways of falling backward. First, general descriptive information was provided. The application
of contrast statistics confirmed the impact of the programme: the assimilation of the protected fall
procedure was positive.
3.1. Backward-Fall Mechanization Routines for Secondary and Baccalaureate Students
Table 1illustrates performance results before and after the application of the programme. The data
reflect that, before the application of the programme, less than a third of the sample bent their neck for
protection in the fall (10.8%) and there were even lower values (less than 1%) for subjects who did not
use hands to minimize the impact for upper limbs on the ground.
As for rolling up, the safety position, which increases the surface area hitting the ground, the data
show that only 15% of the students did this correctly before the implementation of the programme. To
this last figure, another notable figure can be added: not one student bent their upper limbs during the
fall. The descriptive analysis concluded that 1.6% of the students correctly bent their knees during the
unintended backward fall as a measure of safety and protection.
As Figure 1shows, after the application of the Safe Fall programme, the posttest shows results
that are clearly different from those obtained in the pretest (the students had correctly learnt each of the
five technical movements involved in a safe and protected backward fall, with this being particularly
notable in the variables of bending the neck and using hands).
Sustainability 2018,10, 1168 4 of 8
Table 1.
Statistics on assimilation of variables for safe and protected backward falls (* p< 0.05 in
McNemar test; N = number of subjects; X2= chi square).
Pretest N Posttest N X2p
Yes No Yes No
Bending the neck 13 107 107 * 13 105.009 0.000
Using hands 1 119 106 * 14 104.009 0.000
Rolling up 18 102 85 * 35 65.015 0.000
Bending hip 0 120 86 * 34 84.012 0.000
Bending knees 2 118 109 * 11 105.009 0.013
Figure 1.
Effects of the program on the competence of pupils to assimilate a safe and protected
backward fall.
3.2. Effects of the Programme on the Competence of Secondary and Baccalaureate Pupils to Assimilate a Safe
and Protected Backward Fall
Contrast statistics (chi-square and bilateral exact significance) were applied to determine whether
there were significant differences because of the application of the Safe Fall programme and not due to
chance (Table 1). The pairs of data were analyzed from the pretest and posttest for each of the recorded
direct variables by applying McNemar’s exact test (p< 0.05).
Regarding the five direct variables of protection and safety proposed in the study for a sudden
backward fall, Figure 1shows an increase in the correct protection position for students in all the
variables after the application of the programme. The proportion of students who bent their neck in a
sudden fall was 10.8% before the application of the programme and 89.2% afterwards. In this case,
McNemar’s test presented a (bilateral) exact significance below 0.05 (Table 1). This figure indicates
that pupils improved their ability to bend their necks in the fall from what they had learnt in the Safe
Fall programme.
On the action of not putting their hands on the ground during the fall, the percentage of students
who did this correctly before the programme was 0.8%, compared to the 99.2% who did perform
it correctly after implementation [(bilateral) exact significance = 0.00]. For the rolling up variable,
the proportion of students who did perform this correctly before the programme was 15.0%, compared
to the 85.0% afterwards [(bilateral) exact significance = 0.00]. The bending of the hip was done
incorrectly by all students before the programme, compared to the 100.0% afterwards [(bilateral) exact
significance = 0.00]. Finally, the bending of knees variable was done correctly by 1.7% of the sample
before the Safe Fall programme, with this figure dropping to 98.3% after implementation [(bilateral)
exact significance = 0.013]. As the McNemar test presented a (bilateral) exact significance below or
Sustainability 2018,10, 1168 5 of 8
equal to 0.01 in all the direct variables, there is a 99% probability of not being mistaken when affirming
that this improvement is due to the Safe Fall programme and not to chance.
Differences of the effect of the programme in terms of the pupils’ gender were examined using a
Student’s t-test for contrast. No significant statistical differences were found for this variable, showing
that the programme was equally effective for boys and girls.
4. Discussion
The proposal for implementation of the Safe Fall programme constitutes a step forward for fall
prevention programmes [
4
,
8
,
10
,
12
,
14
] as it responds in a preventive and proactive way to the problem
for public health and safety posed by backward falls in the school population. It responds to calls
from the WHO [
7
], at an international level and the Ministry of Health [
17
] in Spain, for the design of
effective prevention programmes, which are extensive and versatile, in order to eliminate the factors
that lead to falls and reduce the severity of the injuries that do occur, with the latter being possible by
teaching children how to protect themselves and minimize their injuries when they do fall [16].
The Safe Fall programme is coherent with child safety in the event of falls as it teaches the process
of falling backward by automating protective motor actions for specific parts of the body that are more
often injured in falls [3,8–10]: the head, the upper limbs, and the hip or lower limbs, amongst others.
Child development between 12 and 17 years brings with it more dynamic and complex
physical-sport activities from a motor point of view (e.g., Parkour, mountain biking, and climbing),
and this leads to an increase in the number and type of falls endured [
15
,
20
]. Together with this, in
developed countries, children at this age become involved in more sporting activities, and many of
them have an inherently high risk of injury [
3
,
10
]. The development of basic motor skills, work on
turning, learning how to balance, and general dynamic coordination worked on through the theoretical
basics of motor tasks proposed in the Safe Fall programme [
16
] prepare children to react in the event
of a sudden backward fall and to impact in a safer and more protected way, as has been demonstrated
in the study.
It is vital to establish the factors and circumstances that come into play in a fall [
13
,
15
], to lay
out the appropriate methodological development to enable the automation of protected ways of
falling backward. The results of this study are coherent with the more frequent types of injuries [
3
,
21
]
and show that it is possible to avoid or reduce, for example, the intensity of the impact of the head
against the ground, thereby preventing the most serious type of injury produced by a fall [8].
No significant differences were found in terms of gender after the implementation of the
programme, which proves the programme is suitable for both boys and girls, despite the formers’
greater tendency to experience falls [12].
Learning a safe and protected way of falling backward using the Safe Fall programme has a direct
influence on the main cause of injuries among children [
11
–
13
]. It should be noted that there is no
proactive and specific programme in the world that teaches school-age children to fall in a safe and
protected way.
The Regional Government of Andalusia [
11
] found that 26% of children’s falls occur at school. As a
result, given the need to train secondary school teachers [
18
] in the specific area of falls, this programme
has been designed as a useful and practical tool for future education and health professionals working
with adolescents.
The implementation time of this research made it possible to verify that an assimilation of motor
gestures that allows students to fall safely. Regarding the length of the programme, one of the
premises of its success is the individuals’ long-term continuity of physical activity. It is necessary to
continue with new longitudinal studies that center their objective in assessing the minimum time
of implementation of the programme needed to guarantee the automation of the protective motor
gestures or the persistence of the gestures learned through the programme. Likewise, new lines of
research that look at, for example, the number and severity of injuries caused in a school population as
a consequence of an unintentional fall, before and after the implementation of the Safe Fall programme,
Sustainability 2018,10, 1168 6 of 8
are proposed. This would allow for a prediction of the transfer of the learned motor gestures to
other contexts.
It must be mentioned as one of the limitations of the study that not many references were found
in the literature [
22
] that would allow us to contrast the results obtained with the Safe Fall programme
with another on a regional, state, or international level and to enable a meta-analysis of data.
In light of these results, the programme could be extended to include specific exercises to learn
to fall sideways and forward. Likewise, ad-hoc observation scales will have to be developed and
validated to record the learning of safe and protected ways of falling in these directions. In turn,
the results of the study open new study perspectives whose hypotheses have not been considered here.
Thus, a correlation between learning a safe and protected way of falling and raising the self-confidence
of students when performing motor activities in PE classes needs to be established.
5. Conclusions
The conclusions stemming from this study show that, by using the Safe Fall programme in P.E
classes, it is possible to teach adolescent secondary school students techniques for falling backward in
a safe and protected way. In turn, the Safe Fall programme responds proactively to the call from the
WHO for the implementation of education programs based on fall-related research.
It responds in this way to the overall objective of reducing the risk and severity of injuries
produced by a sudden fall backward.
Author Contributions:
Luis Toronjo-Hornillo conceived and designed the experiments; Óscar DelCastillo-Andrés
performed the experiments, analyzed the data, and wrote the paper; Víctor Manuel Díaz Bernier
reagents/materials/analysis tools; María Luisa Zagalaz Sánchez performed the experiments and contributed
reagents/materials/analysis tools.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix
•crouching position (buttocks slightly clear of the floor)
•wrists held by a classmate
Sustainability 2018,10, 1168 7 of 8
•
position of imbalance with the trunk angled forward while the classmate holds on to the wrists
(they will later let go without warning to provoke the backward fall)
When the classmate lets go of the wrists, the observer records on the following table whether the
subject performed the actions in the different areas.
References
1. Alcalde Tirado, P. Miedo a caerse. Rev. Esp. Geriatr. Gerontol. 2010,45, 38–44. [CrossRef] [PubMed]
2.
Baker, R.; Orton, E.; Tata, L.J.; Kendrick, D. Epidemiology of poisonings, fractures and burns among 0–24 year
olds in England using linked health and mortality data. Eur. J. Public Health
2016
,26, 940–946. [CrossRef]
[PubMed]
3.
González Pacheco, N.; Marañón Pardillo, R.; Storch de Gracia Calvo, P.; Campos Calleja, C.; Mojica Muñoz, E.;
Rodríguez Sáez, M.J. Accidentes de bicicleta atendidos en los Servicios de Urgencias. Estudio multicéntrico.
An. Pediatr. 2014,80, 242–248. [CrossRef] [PubMed]
4.
Kalina, R.M.; Mosler, D. Risk of Injuries Caused by Fall of People Differing. In Advances in Human Factors in
Sports, Injury Prevention and Outdoor Recreation; Ahram, T., Ed.; Springer: Cham, Switzerland, 2017; p. 603,
ISBN 978-3-319-60821-1.
5.
Pérez, E.A.; Sobrino, R.; Estrada, O.; Chillón, R. Intervención mediante feedback auditivo para la mejora del
equilibrio en mujeres que realizan actividad física. RPD 2014,2, 327–335.
6.
Scholtes, B.; Schröder-Bäck, P.; Förster, K.; MacKay, M.; Vincenten, J.; Brand, H. Multi-sectoral action for
child safety-a European study exploring implicated sectors. Eur. J. Public Health
2017
,27, 512–518. [CrossRef]
[PubMed]
7.
World Health Organization. Falls. Descriptive note 344. Available online: http://www.who.int/
mediacentre/factsheets/fs344/es/ (accessed on 21 March 2018).
8.
Esparza, M.J.; Mintegi, S. Guía Para Padres Sobre la Prevención de Lesiones no Intencionadas en la Edad Infantil;
Asociación Española de Pediatría, Fundación MAPFRE: Madrid, Spain, 2016; ISBN 978-84-608-6366-3.
9.
Jiménez de Domingo, A.; Rubio García, E.; Marañon Pardillo, R.; Arias Constanti, V.; Frontado Haiek, L.A.;
Soriano Arola, M.; Oliveras, F.R.; García, C.R.; Ferrer, G.E.; Romero, J.L.; et al. Epidemiología y factores de
riesgo de las lesiones por caídas en niños menores de un año. An. Pediatr.
2017
,86, 337–343. [CrossRef]
[PubMed]
10. Soriano, M. Accidentes Infantiles; Junta de Andalucía, Consejería de Empleo: Jaén, Spain, 2008.
11.
Ruiz Beníteza, B.; Soriano, M.; Cabrera León, A. Prevención de la accidentalidad infantil en Andalucía:
Aprender a crecer con seguridad. An. Pediatr. 2010,73, 249–256. [CrossRef] [PubMed]
12.
Guzmán, A.; Manjón, R.; Hernández, J. Accidentes en la Población Infantil Española; Fundación MAPFRE:
Madrid, Spain, 2014; ISBN M-15281-2014.
13.
European Child Safety Alliance: Child Safety Report Card. How Safety Conscious Are. European Countries
towards Children. Available online: http://www.childsafetyeurope.org/publications/info/child-safety-
report-cards-europe-summary-2012.pdf (accessed on 21 March 2018).
Sustainability 2018,10, 1168 8 of 8
14.
Morrongiello, B.; Corbett, M. Parents’ perspectives on preschool children’s in-home falls: Implications for
injury prevention. Vulnerable Child. Youth Stud. 2016,11, 136–145. [CrossRef]
15.
Savitsky, B.; Aharonson-Daniel, L.; Giveon, A. Variability in pediatric injury patterns by age and ethnic
groups in Israel. Ethn. Health 2007,12, 129–139. [CrossRef] [PubMed]
16.
DelCastillo-Andrés, O.; Toronjo-Hornillo, L.; González-Campos, G.; Toronjo-Urquiza, M.T. Propuesta de
intervención “Safe Fall”: Prevención de lesiones en escolares mediante formas seguras y protegidas de caer.
JSHR 2017,9, 137–142.
17.
Ministerio de Sanidad, Servicios Sociales e Igualdad. Informe anual del Sistema Nacional de
Salud. Ministerio de Sanidad. Available online: https://www.msssi.gob.es/estadEstudios/estadisticas/
sisInfSanSNS/tablasEstadisticas/InfAnualSNS2016/Informe_Anual_SNS_2016_completo.pdf (accessed on
21 March 2018).
18.
Campos-Mesa, M.C.; Corral-Pernía, J.; Chacón-Borrego, F.; Castañeda-Vázquez, C. Need to introduce
teaching of safe and protected teacher training techniques (Safe Fall). JSHR 2017,9, 115–120.
19. Salkind, N. Métodos de Investigación; Prentice Hall: Englewood Cliffs, NJ, USA, 1999.
20.
Bena, A.; Farina, E.; Orengia, M.; Quarta, D. Promotion of safety culture in Italian schools: Effectiveness of
interventions on student injuries. Eur. J. Public Health 2016,26, 587–592. [CrossRef] [PubMed]
21. Gelfman, M.G.; Ledesma, J.; Hauier, F.; Volonté, P.; Orbe, G.; Fiorentino, J.A. Trauma por caída de altura en
pediatría. Arch. Argent. Pediatr. 2005,103, 414–419.
22.
Errington, G.; Evans, C.; Watson, M.C. Searching for sustainability within public health policy: Insights from
an injury prevention perspective. Eur. J. Public Health 2016,27, 334–339. [CrossRef] [PubMed]
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