The Healthy Camp Study Impact Report 2006-2010 Promoting Health and Wellness among Youth and Staff through a Systematic Surveillance Process in Day and Resident Camps
The Healthy Camp Study Impact Report
SPONSOR ACKNOWLEDGEMENT
The Healthy Camp Study was funded by the Markel Insurance Company — an ACA Mission Partner. Since 1977, Markel has been a prominent business member of the American Camp Association. Over the past 33 years, Markel has made a commitment to help make camp a better and safer place for all.
ACA proudly recognizes Markel’s commitment to the health and wellness of youth and staff as demonstrated through their support of initiatives like the Healthy Camp Study.
SPECIAL THANKS TO PARTICIPATING CAMPS From 2006 to 2010, hundreds of day and resident camps were engaged in the Healthy Camp Study, contributing to the success of the project. Although each camp’s name is not listed to protect the confidentiality of the study, the American Camp Association expresses special thanks to all of the health care staff and directors who were committed to this project for one or more years. Without their involvement, the Healthy Camp Study would not have been possible.
ADVISORY COMMITTEE The Healthy Camp Study Advisory Committee was comprised of a team of health care professionals and camp professionals who volunteered to guide the Healthy Camp Study during the five years of the project. ACA sincerely thanks Advisory Committee members for their dedication to the project and their contributions of time, energy, and expertise.
Susan Baird, RN, MPH (Chair)
R. Dawn Comstock, Ph.D.
Linda Erceg, RN, MS, PHN Barry A. Garst, Ph.D.
DD Gass Mary Marugg, RN Natalie McIllvain Marge Scanlin, Ed.D.
Sandra (Sam) Thompson, CPRP Edward (Skip) Walton, MD, FACEP, FAAP Ellen Yard, Ph.D.
ACA extends a special thank you to Ian Garner, Markel Liaison, for his continued support of the Advisory Committee and this project.
© 2011 American Camp Association, Inc.
The Healthy Camp Study Impact Report
TABLE OF CONTENTS Executive Summary. ....................................................................................4 Introduction and Project Overview.................................................................5 Purpose Sample and Response Rates Data Collection Data Analysis Reliability and Validity Project Results.............................................................................................9 Illnesses among youth and staff in day and resident camps Injuries among youth and staff in day and resident camps Making It Better: Interventions for Reducing Injuries and Illnesses in Camp......... 20 Promising Practices for Injury and Illness Prevention........................................ 24 Discussion ............................................................................................... 28 References................................................................................................ 31 Appendix................................................................................................. 32 The Healthy Camp Study was conducted in cooperation with several national partners. Faculty and research assistants from the Center for Research and Policy at Nationwide Children’s Hospital and The Ohio State University provided epidemiology expertise for data collection, analysis, and reporting. The Association and Camp Nurses and the National Recreation and Park Association provided assistance with camp recruitment and the dissemination of the study results. ACA thanks these partners for ensuring the success of the Healthy Camp Study.
The Healthy Camp Study Impact Report 3
EXECUTIVE SUMMARY Both day and resident camps had a very low rate of injuries to campers and staff. The aggregate injury rates for the five study years were .47 injuries per 1,000 camp days for resident camps, and .42 injuries per 1,000 camp days for day camps. (In other words, there was less than one injury in every 2,000 days a camper or staff spent at camp.) These rates did not vary signifi- cantly across the study period. Injuries occurred at simi- lar rates in campers and staff, with overall rates being lower in day campers and day camp staff. There was a trend toward campers being injured more frequently than staff, as would be expected given that campers were a younger, very active population. Data related to Beginning in 2006, and continuing through the sum- the who, what, when, where, and why of an injury are mer of 2010, the American Camp Association undertook explored. Although the camp experience has lower risk a five-year surveillance study of injuries and illnesses in than many other youth activities, the injury data indicate day and resident camps. This project, called the Healthy that many camp injuries can be prevented.
Camp Study, is to date the only example of a long-term illness and injury surveillance study conducted with a The aggregate illness rates for the five study years were representative sample of U.S. summer camps. The pri- 1.23 illnesses per 1,000 camp days for resident camps, mary goal of this descriptive epidemiological study was and .83 illnesses per 1,000 camp days for day camps.
to develop a national benchmark of the rates of injuries An analysis of illness rates for campers and staff in day and illnesses among youth and staff in day and resident and resident camps indicated the following: (a) Camp- camps, against which individual camps could compare ers and staff in both day and resident camps tended their own rates of injuries and illnesses. The secondary to have twice as many illness events than injury events; goal of the Healthy Camp Study was to identify oppor- (b) Day camps tended to have fewer illness events than tunities for prevention and intervention, and to reduce resident camps; (c) Resident campers had more illness the prevalence of injuries and illnesses in camps. events than resident camp staff, and this illness pattern was not replicated among day campers and their staff; A convenience sample of U.S. day and resident camps (d) There was a notable increase in the illness rate for all was selected from the total population of U.S. camps categories except for resident staff in 2009, an increase for each year of the study, ranging from a low of 186 attributed to the national H1N1 outbreak; and (e) There camps to a high of 295 camps. Health care staff at each appears to be an increasing trend in the illness rate over participating camp entered weekly health data about time within both the camper and staff populations.
camper and staff injuries and illnesses (i.e., an adverse event) using an online data entry system called CAMP Four online courses were developed to reduce the prev- RIO™ (Reporting Information Online). A reportable ad- alence of injuries and illnesses in participating camps, verse event for campers was defined as an illness or based on points of intervention identified after the first injury that occurred during a camper’s participation in two years of the study. These courses targeted preven- the camp program (e.g., canoeing), and that removed tion strategies including: coughing and sneezing into an and/or restricted the camper from their normal camp arm or sleeve to reduce the transmission of communica- routine for ≥4 hours for resident camps and ≥1 hour for ble illness, use of appropriate footwear to reduce slips/ day camp. A reportable adverse event for staff was de- trips/falls, use of proper knife handling and storing fined as an illness or injury that occurred during a staff techniques to reduce cuts from knives and other sharp member’s contracted dates, and that removed and/or objects, and appropriate use of protective equipment restricted the staff member from their normal camp re- during camp activities. Approximately 11,300 directors, sponsibilities for ≥4 hours for resident camps and ≥1 staff, and volunteers completed the online courses as hour for day camp. Adverse events were measured a part of either pre-service or in-service training from using rates, an approach common in epidemiological 2008 to 2010. A set of promising practices for injury studies. A “rate” referred to the number of camper and and illness prevention was developed based on the re- staff adverse events that occur during a specified period sults of the study, and on feedback from participating of time which, for this study, was 1,000 camp days. camps regarding improved health care procedures and policies that resulted from study participation.
The Healthy Camp Study Impact Report
INTRODUCTION AND PROJECT OVERVIEW Providing safe, high-quality experiences for chil- and staff at U.S. summer camps, understand risk fac- dren, adolescents, and adults is of paramount impor- tors associated with such adverse events, and identify tance to the camp community. In an era of accountabil- prevention strategies to reduce the incidence of camp ity and high expectations from program participants, injuries and illness. It was also believed that better parents, and the public, the challenge seems to be information about injury and illness adverse events identifying the most effective strategies for program and prevention strategies would help camps improve safety and quality. Over the past 25 years, child- the overall camper experience, improve staff effec- hood injury and illness in the United States has been tiveness, and lower camp healthcare costs.
substantially reduced through the concerted effort of professionals in the areas of health surveillance, inter- The Healthy Camp Study was conducted in coopera- vention, and evaluation (Grossman, 2000). Camps tion with faculty and research assistants from the Cen- can benefit from what has been learned from sur- ter for Research and Policy at Nationwide Children’s veillance programs that have monitored the injuries Hospital and The Ohio State University (OSU), includ- and illnesses that occur in youth and adult programs. ing: R. Dawn Comstock, Ph.D., Associate Professor; The systematic exploration of when, where, and how Ellen E. Yard, Ph.D., Research Associate; Christy Col- creates an opportunity for administrators to improve lins, MA, Research Associate; and Natalie McIllvain, safety by understanding the trends within their own Research Assistant. The study was supported by the program, and by taking proactive approaches to bet- Healthy Camp Advisory Committee, a team of health ter manage risk (Erceg, Garst, Powell, & Yard, 2009). care professionals and camp directors who guided the Healthy Camp Study during the five years of the The American Camp Association® (ACA) provides project (see inside front cover.
an accreditation program for camps, with more than 300 standards related to health, safety, and program- Sample and Response Rates ming. One of these standards requires that camps maintain appropriate record keeping (i.e., health re- All U.S. summer camps were eligible to participate cord logs) of injuries and illnesses (American Camp in the Healthy Camp Study. A convenience sample Association, 2007). The ACA accreditation process of day and resident camps was collected each year has been a driver for injury and illness surveillance, of the study. Attempts were made to collect a repre- as some camps have implemented processes for sentative sample through targeted recruitment, and regularly reviewing health record logs. As a whole, partners including the Association of Camp Nurses however, camps have lacked a reliable surveillance and the National Recreation and Park Association methodology (Erceg, Garst, Powell, & Yard, 2009). were instrumental in the recruitment process. Markel Insurance Company also sent a notice to all of their In 2006, the American Camp Association undertook camps with an invitation to participate in the study.
a five-year surveillance study of injuries and illnesses in day and resident camps. The epidemiological use Day and resident camps were recruited across all of the term “surveillance” referred to the collection of five years of the project. It was important to involve data on who, when, where, and how people became both types of camps in the project because of sev- diseased or injured (Robertson, 2007). The Healthy eral important differences between day and resident Camp Study is, to date, the only implementation of camps with regard to the injury/illness experiences a long-term illness and injury surveillance study in of youth and staff participating in day camps versus a representative sample of U.S. summer camps. By the injury/illness experience of youth and staff par- using a successful methodology, similar to that used ticipating in resident camps. First, day camps typi- in other national injury surveillance projects such cally last roughly 6-8 hours in any given day, while as the National Collegiate Athletic Association In- resident camps operate 24/7 during a camp session.
jury Surveillance System (NCAA ISS), the Healthy Secondly, activities offered during day and resident Camp Study sought to monitor illnesses and injuries camps may differ, with greater numbers of higher risk sustained by summer camp campers and staff, while activities offered by resident camps. And finally, be- identifying risk factors associated with such illnesses cause people live at resident camp, they are placed and injuries. Thus, the purpose of the program was in closer and more prolonged contact with one an- to monitor illness and injury rates among campers other than is typical of the day camp experience.
The Healthy Camp Study Impact Report 5 The sample size for each year of the study reflects the Session length for camps participating in the Healthy number of camps who enrolled in the study (Table 1). Camp Study was defined as short-term (less than 14 Sample sizes ranged from 186 camps (low) to 295 days) and long-term (15 or more days). Using these camps (high). Camps could choose to participate in as definitions, 50 percent of camps self-identified as short- many years of the study as desired. Each year some term, 46 percent as long-term, and 4 percent did not camps chose not to participate. Reasons cited for not respond. Data regarding a camp’s geographic region participating included changes in camp administration was collected: 25 percent of participating camps were or healthcare staff, over-burdened healthcare staff, and in the Mid-Atlantic Region, 24 percent were in the Mid- closing camp due to the economic downturn. The num- America Region, 17 percent were in the Southern Re- ber of camps who submitted usable data for each of gion, 16 percent were in the Northeast Region, and the applicable camp sessions (i.e., the response rate) 15 percent were in the Western Region. International ranged from 140 camps (low) to 180 camps (high)(Ta- camps were excluded from the samples analyzed for ble 1). Because it is common for national injury surveil- this report.
lance studies to collect data from a sample of 100 sites, the sample sizes for each year of the Healthy Camp Data Collection Study were considered robust An online reporting tool called CAMP RIO (Reporting Information Online) was used to perform surveillance of Table 1: Sample Size and Total Number of illness and injuries sustained by campers and staff over Camps Submitting Data for Each Year of the a ten-week period each summer from 2006 through Healthy Camp Study (2006-2010) (and including) 2010 (Figure 1). The epidemiological use of the term “surveillance” referred to the collection Sample Size Response Rate (Day and (Number of Camps of data on who, when, where, and how people become Study Year Resident Camps Submitting Data for Each ill or injured (Robertson, 2007) (Table 2).
Combined) Camp Session) Camps that expressed an interest in participating in the 140 study were first asked to complete a camp demograph- 2006 186 (51 day; 89 resident) ics survey and to designate a “reporter.” Reporters were 160 most often nurses or other health care staff with first 2007 295 (50 day; 110 resident) aid or wilderness first aid certification. After complet- ing the demographics survey, camps were enrolled in 179 2008 236 the study and assigned a unique study ID. Beginning in (40 day; 139 resident) 2007, camps that had participated in a prior year of the 180 study were automatically re-enrolled for the next year 2009 228 (42 day; 138 resident) unless they formally withdrew. Research staff from OSU 163 emailed training packets and CAMP RIO user guides to 2010 200 all enrolled camps, and reporters at these camps were (41 day; 122 resident) asked to contact the researchers if they had any ques- tions. In return for participating, camps that reported Figure 1: CAMP RIO Online Reporting System data were informed that they would receive a copy of a national summary report, along with a camp-specific re- port that they could use to compare patterns of adverse events at their camp to patterns occurring nationally.
Every Monday throughout the ten-week study period (approximately early June through late August), report- ers received an e-mail reminding them to log into CAMP RIO to complete a weekly exposure report and any ap- plicable illness or injury reports. If a camp was not in session during any of the ten weeks, then the camp was asked to log in and report that they were not in session.
Every time a reporter logged into CAMP RIO, they were able to access a screen where they could provide up- dated contact information.
The Healthy Camp Study Impact Report member from their normal camp responsibilities for A reportable adverse event for campers ≥4 hours for resident camps and ≥1 hour for day was defined as an illness or injury that oc- camp.
curred during a camper’s participation in the camp program (e.g., canoeing), and that re- Additionally, for each adverse event reported, report- moved and/or restricted the camper from their ers completed an illness or injury report form that col- normal camp routine for ≥4 hours for resident lected information about the affected individual (e.g., camps and ≥1 hour for day camp. A report- age, gender, etc.), information about the illness (e.g., able adverse event for staff was defined as signs, symptoms, etc.) or the injury (e.g., site, type, an illness or injury that occurred during a staff etc.), and information about the circumstances asso- member’s contracted dates, and that removed ciated with the illness or injury (e.g., date and time and/or restricted the staff member from their of onset, use of protective equipment, etc.) (Table 2).
normal camp responsibilities for ≥4 hours for RIO provided camps with the ability to view all data resident camps and ≥1 hour for day camp. they had reported throughout the study, as well as the option to update reports with information that was not available at the time the initial report was submitted.
Health care staff from each participating camp en- tered the Web-based CAMP RIO system and entered weekly data about camp injuries and illness that met Data Analysis specific definitions for an “adverse event” (Table 2). The Healthy Camp Study was primarily a descrip- A reportable adverse event for campers was defined tive epidemiological study with results reported as as an illness or injury that occurred during a camper’s rates. Two concepts important for understanding the participation in the camp program (e.g., canoeing), results of this study include exposure and rate.
AND that removed and/or restricted the camper from their normal camp routine for ≥4 hours for resident Exposure refers to the length of time a person was at camps and ≥1 hour for day camp. A reportable ad- camp (i.e., how long they were at risk for injury or ill- verse event for staff was defined as an illness or in- ness). Children spending one week at camp had less jury that occurred during a staff member’s contracted exposure than children staying four or more weeks.
dates, AND that removed and/or restricted the staff The same held true for staff; the number of days a Table 2: Types of Data Collected from Participating Camps in the Healthy Camp Study (2006–2010)
- Age and sex WHO • Role at camp (Data about the • Pre-existing chronic health condition person) • Length of time at camp (this season)
- Where the incident happened (included out-of-camp option)
- Name of the activity in which the person was engaged when incident occurred WHEN/ • Time of day the incident occurred and during what week of camp WHERE • Mechanism(s) or object(s) influencing the incident, especially use/non-use of protective (Data about the equipment incident) • How long it took before the person returned to their camp routine
- Relationship of the incident to an existing chronic health condition
- Diagnosis
- Part(s) of body involved WHAT/WHY • Description of primary symptoms experienced (Data about the • Presence of secondary injuries or illnesses as a result of this incident injury/illness • Communicability assessment (for illness) and context) • Credential of professional who treated the injury/illness
- Experience of the data reporter (Had this person been trained to report data?)
- Weather influences (e.g., rain, high humidity, extreme temperatures, altitude)
- Participation in formal safety training preceding incident
The Healthy Camp Study Impact Report 7 staff member worked determined how long that person board, or even over several boards. If the system is valid was exposed to risk of injury or illness. Exposure data (i.e., accurate), then the darts are all aiming for the bulls for each injury or illness was based on the concept of a eye. If it is not valid, then the darts are aiming for the “camp day,” defined as one camper or staff member at wrong point.
camp for one day. Camp days were expressed for both campers and staff. The number of camper camp days Let’s expand this thinking to consider the example of equaled the sum of the number of campers at camp the rate of injury in summer camps. A valid surveillance each day during the past week. For example, if there system will be set up properly and will correctly calcu- were fifty campers on-site five days of the week, twenty late the rate of injury. The Healthy Camp Study maxi- campers on-site on the sixth day and no campers on-site mized validity by utilizing accepted definitions of injury the seventh day, then the camper exposure was 270 and exposure, by having a large variety of camps from camper camp days. The number of staff camp days throughout the United States who participate, and by equaled the sum of the number of staff at camp each using a communication system of automated alerts that day during the past week. For example, if there were let participating camps know if they may have entered fifty staff present all seven days of the week, then the incorrect information.
staff exposure was 350 staff camp days. Exposure data were reported using “per 1,000 camp days.” Still on the topic of the rate of injury in summer camps, let’s consider reliability. A reliable surveillance system Rate refers to the number of adverse events that occurred will reproduce a fairly consistent rate of injury that does during a specified period of time. Although many re- not vary wildly from week-to-week or year-to-year. The search studies report percent change, this study discuss- Healthy Camp Study maximized reliability by having es changes in rates so it is sensitive to both the number of large numbers of participating camps that provided for people at camp and the length of time each person was consistent averages. Also, the use of various incentives there. Using rates instead of percentages is common kept camps involved and reporting for an entire season.
in epidemiological studies. To better understand this Thus, as expected, the Healthy Camp Study has been concept, imagine 1,000 very reliable, and has reported a consistent rate of in- campers and staff stand- jury every year.
Although many research ing in front of you. Now studies report percent imagine that your camp The Healthy Camp Study also benefitted from the use change, this study dis- injury/illness rate per of an established methodology and survey instrument, cusses changes in rates 1,000 camp days was since CAMP RIO was developed based on HS RIO (High so it is sensitive to both 1.5. This means that giv- School RIO), which has been in use for several years as the number of people at en those 1,000 people, a tool for monitoring injuries in high school sports. In camp and the length of 1.5 of them would get addition, the CAMP RIO survey instrument and method- time each person was so injured or ill on this ology were tested in a 2005 pilot study published in Pe- there. Using rates instead day that it pulled them diatrics (Yard, Scanlin, Erceg, Powell, Wilkins, Knox, & of percentages is com- from their camp routine, Comstock, 2006). The pilot study allowed any problem- mon in epidemiological thus meeting the defini- atic questions to be dropped from the survey, and any studies.
tion for inclusion in this methodological issues to be addressed prior to the start study. of the Healthy Camp Study. Interobserver variation was minimized by providing training to the people collecting Reliability and Validity and inputting data, as well as by providing them with a contact phone number to use should questions arise.
Reliability and validity are two important concepts when considering the value of an injury/illness surveil- Because the exact number of U.S. camps is unknown, lance system like the Healthy Camp Study. Reliability data was not collected from a truly random or entirely (sometimes called precision) refers to the repeatability representative sample of U.S. camps. That being said, of a measurement (Robertson, 2007). Validity (some- the Healthy Camp data set is the largest data set of times called accuracy) refers to whether the concept or its kind collected to date, including data representing dimension that one is attempting to measure is actually 5,114,775 camper-days. Large samples increase the re- being measured. To better understand reliability and va- liability of the data in injury/illness monitoring studies.
lidity, let’s consider the example of a dart board. If an In epidemiological research, consistency can provide injury/illness surveillance system is reliable (i.e., precise) evidence of a valid methodology. The consistencies of then the dart hits the same target every time. If it is not the data set across the five years of the study are en- reliable, then the darts end up scattered all over the couraging in this regard.
The Healthy Camp Study Impact Report
PROJECT RESULTS ILLNESSES AMONG PARTICIPANTS AND STAFF IN DAY AND RESIDENT CAMPS Overall Rates of Illness in Day and The overall illness rates for campers and staff at both day and resident camps were calculated (see Figures Resident Camps 2, 3, 4 and 5, specifically the red “Illness Rate” line).
Illness reduces the amount of time campers and When looking at these Figures, note that the range staff have to participate in camp activities. It was on the vertical Y axis — the Rate per 1,000 Camp theorized that a better understanding of camp illness- Days — varies from graph to graph. This is important es would enable the camp community to minimize when interpreting the data. With this in mind, note this problem and, thus, increase the amount of time the following:
campers and staff remained engaged with the camp • Campers and staff in both day and resident camps experience. Consequently, a portion of the Healthy tended to have twice as many illness events than Camp Study sought to describe what illnesses oc- injury events.
curred, the context in which illnesses happened, and • Day camps tended to have better illness rates than to then identify points of intervention. The study also resident camps.
acknowledged that, because campers and staff are • Both day and resident campers had higher illness human, some illness would occur in spite of best in- rates than their corresponding staff group.
tentions. However, if the reality of illness could be • In 2009, a notable increase in the illness rate was tempered with knowledge about factors that influ- found for all categories except resident staff, which enced camp illnesses, camps would be in a better was associated with the H1N1 Influenza outbreak.
position to make the camp experience as illness-free • An increasing trend was identified in the illness as possible. rate over time within both campers and staff.
Figure 2: Rates of Camper Injuries and Figure 4: Rates of Camper Injuries and Illness in Day Camps (2006–2010)* Illness in Resident Camps (2006–2010) Figure 3: Rates of Staff Injuries and Illness Figure 5: Rates of Staff Injuries and Illness in Day Camps (2006–2010)* in Resident Camps (2006–2010) *After 2006 data was collected, the definition of an “adverse event” for day camps was changed from an injury or illness that takes a camper or staff member out of the camp experience for “4 hours or more” to “1 hour or more” for 2007–2010. Thus, the 2006 data for day camps is not available for comparison with subsequent years.
The Healthy Camp Study Impact Report 9 Table 3: Illness/Injury and Camper/Staff Rates per 1000 Camp Days for Day Camp Camper Camper Injury Rate Illness Rate Staff Illness Staff Injury Illness Injury 2006* - - - - - - 2007 0.31 0.45 0.41 0.60 0.30 0.33 2008 0.39 0.62 0.6 0.58 0.42 0.21 2009 0.58 1.13 1.22 0.75 0.61 0.4 2010 0.40 1.19 1.25 0.92 0.44 0.24 Overall 0.42 0.83 0.85 0.71 0.44 0.30 *After 2006 data was collected, the definition of an “adverse event” for day camps was changed from an injury or illness that takes a camper or staff member out of the camp experience for “4 hours or more” to “1 hour or more” for 2007–2010. Thus, the 2006 data for day camps is not available for comparison with subsequent years.
Table 4: Illness/Injury and Camper/Staff Rates per 1000 Camp Days for Resident Camp Camper Camper Injury Rate Illness Rate Staff Illness Staff Injury Illness Injury 2006 0.50 0.98 1.00 0.93 0.54 0.40 2007 0.46 1.00 1.06 0.83 0.48 0.41 2008 0.40 1.10 1.18 0.86 0.41 0.34 2009 0.46 1.57 2.02 0.91 0.53 0.34 2010 0.54 1.34 1.45 1.12 0.57 0.49 Overall 0.47 1.23 1.38 0.93 0.50 0.39 Illness rates became particularly interesting when it was time of day when illness tended to be reported. There noted that campers and staff were more likely to have was, however, a tendency among day camp staff to an adverse illness event while at camp than they were to report more illness on Mondays, whereas resident camp have an injury event. That likelihood was, in fact, almost staff tended to report more illness on Mondays, Tues- double — and, as a result, quite notable (Figures 2–5). days, and Wednesdays than other days of the week.
The gradual increase in the illness rate, coupled with Communicable Illness in Camps the fact that illness was twice more likely to occur than injury in both day and resident camps, prompted an Knowing that illnesses such as the common cold, examination of the kinds of illness that occurred. The sore throat, and flu were the most frequently reported data set indicated that upper respiratory ailments (e.g., raised questions about how illness was passed from common cold, allergy reactions, and sore throat), flu, person to person (i.e., communicability). Based on re- and gastroenteritis were most commonly reported (e.g., ported data, there was a 50/50 split between illnesses met the definition for “adverse event”). It should also that were communicable, as opposed to those that were be noted that some camps reported improved data re- not (Table 5). The prevalence of communicable illness in porting as they became more familiar with the study’s camp means that camps must continue to pay diligent parameters (see Figure 7). This may have contributed to attention to communicable disease control strategies.
more discrete reporting in the vari- Some of these strategies are em- ous illness categories. bedded in “opening day” screen- Campers and staff were more ing processes and expectations likely to have an adverse illness There was no discernable distinc- surrounding personal health behav- event while at camp than they tion in illness reported by males and iors (e.g., effective hand washing, were to have an injury event.
females, nor was there a particular covering coughs/sneezes); however,
The Healthy Camp Study Impact Report Table 5: Illness Communicability among Campers and Staff in Day and Resident Camps (2006–2010) Communicability of Illnesses 2006 2007 2008 2009 2010 Non-communicable illness 57% 58% 48% 41% 51% Communicable illness but not seen in others 18% 19% 16% 14% 16% Communicable illness seen in others 25% 23% 36% 46% 33% these strategies can be ignored by individuals and/ or haphazardly implemented by camps. This impact Strategies That Decrease Potential was aptly demonstrated during the summer of 2009 for Communicable Illnesses in Camp when the H1N1 Influenza outbreak triggered an in- crease in communicable illness, and saw that illness spread to others — with abandons! • Maintain personal resistance — stay well rested, hydrated, and nourished.
In an effort to staunch the spread of influenza-like • “Sneeze in your sleeve” — effectively cover illness — especially during 2009’s H1N1 Influenza coughs and sneezes.
outbreak — the online course, “No Outbreaks Here: • Effectively wash hands and keep them Simple Strategies for Reducing the Spread of Com- away from one’s face.
municable Diseases at Camp” was developed. In • Stay an arm’s length away from one an- addition, infectious disease control strategies were other (maintain social distances).
promoted via online postings to participating camps, • Sleep with the greatest distance between published articles (Appendix E), and key messages heads, including in tents.
delivered at conferences. Efforts to institutionalize • Disperse airborne pathogens by taking ad- those behaviors are ongoing as of the publishing of vantage of moving air (natural or via fans).
this report. • Screen people upon arrival for signs/symp- toms of illness; isolate potential cases.
According to Table 5 (above), there appears to be • Tell parents to keep sick/ill children at a slight upward trend in communicable illnesses that home; provide an alternate start date in are seen in others. This would indicate that directors these situations.
in both day and resident camps should place more ef- • Add a policy that states the camp retains fort in strategies that influence reduce communicabili- the right to refuse admission to someone ty — strategies such as personal protective behaviors who poses a communicable disease threat.
that include staying well rested, effective “opening day” screening, and increased social distance be- chronic condition made it more likely that the person tween people (see sidebar, Strategies That Decrease would get an illness associated with the nature of Potential for Communicable Illnesses at Camp).
the chronic condition (e.g. camper with allergies are more likely to develop a common cold or sinusitis).
Illness Related to Pre-Existing Chronic Knowing this predisposition indicates the need for Conditions camp staff to make sure this susceptible population Along with communicability, it was noted that remains well rested, hydrated, and fed. It may also about 20 percent of reported illness was experienced indicate a need to acknowledge that people with by campers and staff whose illness was related to chronic health conditions are less adept at handling a pre-existing chronic medical condition. This sug- health stressors — such as lack of sleep — than their gests one of two potentials: (a) That the chronic con- generally healthy peers.
dition stressed the individual’s health, thus making them more susceptible to illness; and/or (b) That the Data about communicable disease in camps suggests that directors in both day and resident camps should place more effort in strategies that influence communicability — strategies such as personal protective behaviors that include staying well rested, effective opening day screening, and increased social distance between people.
The Healthy Camp Study Impact Report 11 Onset of Illness Influence of Fatigue on Illness at Camps The study also asked about onset of illness. In both With the start of the 2009 data collection summer, a day and resident camps, the symptoms of most illness question about fatigue was added to the data collection (over 50 percent in each year of the data set) started tool. Specifically, the tool asked the reporter if fatigue when the camper or staff member was at camp. How- was a contributing factor to the illness. Recognizing that ever, at least 3 percent — and one year as high as 20 a reporter’s opinion about the impact of fatigue on ill- percent (day camps, 2006) — of illness started before ness was not a totally reliable factor, that data was not the camper or staff member came to camp. Based on included in this report. Discussion, however, about the data, directors can typically expect that 5–7 percent of impact of fatigue continued to surface and gave rise to the illness that occurs in camp will have started before the content presented in the sidebar, “When Get-Up- the camper or staff member arrives. This information im- and-Go Has Got-Up-and-Went.” pacts screening practices and agreements with parents about keeping ill children at home rather than sending Categories of Illness in Camps them to camp. Illnesses associated with the respiratory tract were most prevalent; these were consistently just over 20 per- cent of the reported illnesses in each year of the data Directors can typically expect that 5–7 percent set. The next most prevalent category, illnesses associat- of the illness that occurs in camp will have ed with the gastro-intestinal tract, ranked a close second started before the camper or staff member and included both infectious and non-infectious gastro- arrives. This information impacts screening intestinal illnesses. All other illness categories were con- practices and agreements with parents about sistently less than 5 percent of the total reports in each keeping ill children at home rather than year; these included allergic reactions, heat-related ill- sending them to camp.
nesses, asthma flares, genital-urinary conditions, and ill- ness associated with ticks.
The Healthy Camp Study Impact Report Comparing Illness Among Campers and What makes a difference to the staff experience of Staff illness may lie more within the camp culture. Function- When examining camp illness experiences, the ing in loco parentis and maintaining client satisfaction study intentionally separated the experience of staff drives the care given to campers. However, camps from that of campers. These two groups have differ- take care of staff in a different way and often sim- ent developmental needs and interact with the camp ply rely on self-care because staff are needed to do program in different ways. From an illness perspec- their job. While a camper with a common cold may tive, however, these differences had less impact on ill- be allowed to take it easy, a staff member with that ness than was anticipated. For example, most camp- same cold is often expected to continue doing their ers and staff are moving through significant physical job. However, if continued job performance isn’t bal- growth and development. This places demands on anced with energy-saving strategies, the staff mem- their bodies to continually replenish reserves asso- ber is likely to deplete coping reserves more quickly, ciated with hydration, nutrition, and sleep (rest). A thus making the staff member more susceptible to situation that depletes those reserves increases the complications of the common cold (e.g., bronchitis, person’s susceptibility to illness regardless of being sinusitis).
a staff member or camper. Adults typically tolerate assaults to reserves better than children, thus tipping illness susceptibility associated with developmental stage toward children (campers).
When Get-Up-and-Go Has Got-Up-and-Went: Fatigue at Camp It’s rare that one can say fatigue actually causes camp population tended to occur in the afternoon, injury or illness. Rather, fatigue is more typically early evening, and on over-night trips. But injuries an element that contributes to injury and illness. It in the day camp sample indicated a greater inci- shares this fame with attributes such as a person’s dence during morning hours.
hydration and nutritional status. In combination, this triad — the absence of fatigue plus good Looking at the impact of fatigue on illness was hydration and nutrition statuses — can make a dif- trickier. Recall that the Healthy Camp data only ference in both a person’s resistance to, as well as counts an illness when it is significant enough to recovery from, injury and illness events. keep a person from their normal camp routine for a given amount of time. With that in mind, Interestingly, both adequate nutrition and hydra- more illness was reported in the resident camp tion have enjoyed attention in the camp com- sample as any given week progressed. Data was munity. We take pride in nutritious meals and the not discrete enough to determine the relationship ubiquitous water bottle appears everywhere — to between long-term resident camper stays and the the point where there’s more concern with being onset of illness. Such was not the case for day over-hydrated than being adequately hydrated camps, where the percent of illness was greater in these days. the earlier part of the week.
But fatigue has remained elusive. Camp profes- Interestingly, fatigue tends to show up in a given sionals anecdotally speak of tired staff and camp- person’s demeanor quicker than in any injury or ers, yet there’s been little that has strategically illness event. Campers and staff become short- addressed this challenge. It’s time to change that. tempered and we speak of someone being “more of a beast than a beauty.” Perhaps if we attend If one subscribes to the classically held belief that to these early signals and appropriately intervene being tired makes it more likely for injury or illness when they occur, we could change the impact of to occur, than one would expect that, as the day fatigue, much the same as we’ve improved nutri- wears on and a person tires, injury and illness tion and hydration states.
would tend to happen. Data from the Healthy Camp Study indicated that injuries in the resident
The Healthy Camp Study Impact Report 13
PROJECT RESULTS INJURIES AMONG PARTICIPANTS AND STAFF IN DAY AND RESIDENT CAMPS When thinking about injuries, data of the type col- Overall Rates of Injury in Day and Resident lected during the Healthy Camp Study can be incred- Camps ibly powerful in identifying areas of risk within camp.
When compared to illnesses, for which a small number The good news is that both day and resident camps of consistently applied interventions can help in preven- have very low rates of camper and staff injuries. Table 4 tion, injuries can happen in any place, at any time. It’s and Table 5 reveal the overall rates of injuries for camp- also important to note that the camp experience is not ers and staff at day and resident camps. The aggregate risk free. Participation in camp includes certain inherent injury rates for the five study years were .47 injuries per risks because of the active nature of the participants, 1,000 camp days for resident camps and .42 injuries terrain, weather, and other characteristics. The key to per 1,000 camp days for day camps. To put this data injury prevention is constant observation and reporting in another way, there was less than one injury in every of incidents, and an ongoing evaluation of the “who, 2,000 days a camper or staff spent at camp. The lower what, when, where, and why” (Table 2) of each inci- rates for day camps likely reflect the shorter time (i.e., dent. Pattern recognition is crucial. Over the five years exposure) any camper or staff member is present on- of data collection, the Healthy Camp Study revealed site. There is simply less time to become injured. These some significant and consistent trends in injuries. It was rates did not vary significantly across the study period.
the critical evaluation of these trends which led the cre- This lack of variation adds weight to any conclusions ation of the specific interventions which are discussed drawn from combining the five years of collected data.
later in this report.
The camp community knows intuitively that the safety of The key to injury prevention is constant observation campers and staff members must be the primary con- and reporting of incidents, and an ongoing cern. It is also clear that parents and other caregivers evaluation of the “who, what, when, where, and are constantly assessing the risk profile of the activities why” of each incident. Pattern recognition is key. in which their children participate and make decisions about their child’s participation based on their conclu- Table 6: Injury Rates for Youth sions. Reassuringly, rates of injury during the camp ex- Participating in Day and Resident Camps perience are significantly lower than most organized Compared with Injury Rates for Youth sports (Table 6). Consider the difference in the “expo- Participating in Common Youth Sports sure” between camp experiences and sports. As a camp (2006–2010)* day may be 24 hours long, and most sports practices and games are only 2–3 hours long, this comparison is Youth Activity Injury Rates** even more powerful. The conclusion: In terms of overall risk of injury, camp is as safe or safer than many activi- Resident Camp 0.50 ties that parents choose for their children.
Day Camp 0.44 Boys’ Football 4.09 In terms of overall risk of injury, camp is as safe or Boys’ Wrestling 2.35 safer than many activities that parents choose for their children.
Girls’ Soccer 2.31 Boys’ Soccer 1.98 Girls’ Basketball 1.80 Boys’ Basketball 1.58 Girls’ Volleyball 1.24 Girls’ Softball 1.15 Boys’ Baseball 1.03 * Rate for camps = chance of 1 child in 1,000 becoming injured during one 24-hour period at camp; Rate for sports = chance of 1 child in 1,000 becoming injured during a practice or a game.
** Morbidity and Mortality Weekly Report, DHHS, Centers for Disease Control, September 29, 2006
The Healthy Camp Study Impact Report Who, What, When, Where, and Why of (Figures 10 and 11). Falling, slipping, or tripping was Camp Injuries by far the most likely mechanism of injury (Figures 12 As noted previously, it is important to assess the and 13). The recognition of lower extremity injuries as who, what, when, where, and why of an injury in the most commonly injured body site, with slip, trip, order to think about ways the injury could have been or fall as the most common mechanism, led to con- prevented. Although it is reassuring to note that the clusion that frequently, campers and staff members camp experience has a lower risk than many other may not be wearing appropriate footwear for the ac- youth activities, many camp injuries can be prevented. tivities they participate in. As a result, the “Footloose:
Camps need to be constantly working to reduce risk Minimizing Slips and Falls at Camp” online course even further. Risk reduction strategies can be ranked was developed as an intervention. The goal was to from least to most powerful. Least powerful are sug- motivate camps to address this common injury issue gestions to be more careful. Staff training is impera- in camps.
tive. However, any educational intervention depends on the individual to not only internalize the informa- Severe, multi-system trauma was rare. Only 9 percent tion and but also put it into practice. Having the staff of injured campers or staff suffered more than one use checklists or standard protocols for an activity, in injury during any single incident.
addition to educational sessions, decreases risk even further. The staff can be engaged to help determine Overall, while most campers or staff who were in- which activities would be amenable to checklist or jured were able to return to camp activities, there protocol creation. were some concerning trends. Some injuries have greater potential for long-term disability than others.
When it comes to illnesses, in general, any healthy One item of significant concern was the proportion of population of children and adults in close proximity injuries to the head and face, most noticeably among to each other would have a similar risk of catching day campers. One third (32.8 percent) of all day an infection. Injuries are different from illnesses in that camper injuries involved the head, face, or neck. As campers and staff differ in their intellectual and mo- day campers tend to be younger, this may have to do tor skills, their understanding of risk, and the activities with the larger head size in proportion to their body, in which they may be participating. It is for these which is present in younger children. Lacerations, reasons that injuries in campers and staff must be bumps and bruises, and broken bones can heal, but evaluated separately. Interventions which might be head injuries can lead to lifelong disability, so their appropriate for campers might not be appropriate prevention is critical.
for staff; the converse is also true.
The study also revealed that staff were more likely Who was injured: As noted previously, injuries oc- than campers to sustain a wound, and that frequently curred at similar rates in campers and staff, with these wounds involved the use of knives during camp overall rates being lower in day campers or day activities and food preparation. Occupational health camp staff. There was a trend toward campers be- and safety experts know that knife-related injuries ing injured more frequently than staff, as would be can be prevented with standardization of practice.
expected given this younger, very active population. Again, this was seen as an opportunity for staff ed- At resident camps, equal numbers of male and fe- ucation and training, and the online course “Knife male campers were injured, while at day camps a Safety: Reducing Sharp Object Injuries at Camp” higher percentage of females than males (55 percent was developed as an intervention.
- 45 percent) were injured. At both resident and day camps, female staff were more likely than male staff
The recognition of lower extremity injuries as to be injured. The underlying cause of this trend is the most commonly injured body site, with slip, unclear.
trip, and fall as the most common mechanism, suggests that campers and staff members were What was injured: Figures 6 and 7 show the most frequently not wearing appropriate footwear.
likely parts of the body to be injured. As would be ex- pected given the young and active camp population, upper and lower extremities were the most common sites of injury. Consistent with this finding, sprains and strains were the most common type of injury reported (continued)
The Healthy Camp Study Impact Report 15 Figure 6: Body Region of Camper and Staff Injuries at Resident Camp, 2006–2010 Campers (n=1,774) Staff (n=739) Head/face/neck, Head/face/neck, 18.5% 23.6% Upper extremity, Upper extremity, 27.1% 30.9% Trunk, Trunk, 8.7% 4.8% Lower extremity, 43.9% Lower extremity, 38.7% Camper Staff Figure 7: Body Region of Camper and Staff Injuries at Day Camp, 2006–2010 Campers (n=502) Staff (n=85) Head/face/neck, 15.4% Head/face/neck, Upper extremity, 32.8% Upper extremity, 27.1% 28.4% Trunk, Trunk, 7.1% 4.4% Lower extremity, 48.2% Lower extremity, 28.4% Camper Staff Figure 8: Distribution of Camper and Staff Injuries at Resident Camp,* 2006–2010 Sprain Blow to Head Broken Bruise/contusion Wound Dislocation Other bone/fracture * “Other” category, which was less than 2 percent of all injuries, consisted of splinters, foreign objects in body, burn/chemical burn, broken or damaged teeth, blow to abdomen, blister, animal bite, chest injury, unknown, undetermined, and non-response.
The Healthy Camp Study Impact Report Figure 9: Distribution of Camper and Staff Injuries Day Camp,* 2007–2010 Sprain Blow to Head Broken Bruise/contusion Wound Dislocation Other bone/fracture * “Other” category, which was less than 2 percent of all injuries, consisted of splinters, foreign objects in body, burn/chemical burn, broken or damaged teeth, blow to abdomen, blister, animal bite, chest injury, unknown, undetermined, and non-response Figure 10: Primary Mechanisms of Camper and Staff Injuries at Resident Camp,* 2006–2010 Fell/tripped/ Hit/struck/ Fall from Cut Crushed Scraped/ Bitten Other slipped kicked height >5ft scratched * “Other” category, of which injuries consisted of less than 2 percent, were being pinched, sunburns, near drowning, stung/insect bite, vehicu- lar accident, jammed fingers, lifting injuries, and increased activity levels leading to soreness Figure 11: Primary Mechanisms of Camper and Staff Injuries at Day Camp,* 2007–2010 Fell/tripped/ Hit/struck/ Fall from Cut Crushed Scraped/ Bitten Stung/bitten Other slipped kicked height >5ft scratched by insect * “Other” category, of which injuries consisted of less than 2 percent, were being pinched, sunburns, near drowning, vehicular accident, jammed fingers, lifting injuries, and increased activity levels leading to soreness.
The Healthy Camp Study Impact Report 17 When did it happen: Resident campers sustained three- In aggregate, most injuries to campers and staff occurred quarters (77.8 percent) of their injuries during their first during planned camp activities (Figures 12 and 13).
week at camp. These findings suggest that unfamiliarity While this finding may at first glance appear discour- with the camp environment may lead to an increased aging, planned activities are the part of the camp day risk of injuries, so staff must have increased vigilance around which most staff training revolves and planned when new campers arrive. Interestingly, resident camp- activities comprise the greatest amount of time during ers sustained almost half of their injuries from noon to which campers are engaged. As a result, it may be 6:00 p.m. This may be related to a time of concentrated possible to reshape the emphasis during staff training to activities in the afternoon, and perhaps campers suffer- more strategically address risk reduction strategies such ing from increasing fatigue as the day progresses. as warming up, correct use of protective equipment, and providing appropriate rest breaks. In addition, re- Resident campers sustained ¾ of their viewing incidents that do occur with staff enables them injuries during the first week of camp. to identify actions that may reduce future potentials.
Figure 12: Portion of the Day of Illness and Injury Onset among Campers and Staff at Resident Camp, 2006–2010 Camper n=1,824 Staff n=770 Figure 13: Portion of the Day of Illness and Injury Onset among Campers and Staff at Day Camp, 2006–2010 Camper n=502 Staff n=85
The Healthy Camp Study Impact Report Of significant concern is the fact that 60 percent of incidents. This could be as simple as marking each resident camper injuries occurred during free time. injury on a map of the camp site. Activities might also This finding has significant implications for staff su- need to be modified based on weather conditions, pervision when campers are not involved in planned terrain, or other characteristics of the playing surface.
activities. Camp directors need to be as aware of what is happening during unscheduled time as they Why did it happen: Determining why an injury oc- are during planned camp activities curred is a difficult question to answer. Every camp must assess where risk is present and create a culture Where did it happen: In most camps, the majority of where the only acceptable practice is a safe practice.
injuries happened on a playing field or court (Table Every incident should be examined fully to determine 7). High velocity activities are the norm in these ar- the root cause. Also, a culture of “shame and blame” eas, so this finding is not surprising. Activities around should be avoided. Campers and staff should feel the waterfront were also a common location where free to come forward and report near misses or un- injuries occurred. Again, adequate supervision is a safe practices before an incident occurs. Staff train- must, especially given the risks associated with some ing is critical; standards, checklists, and protocols waterfront activities. Discovering a pattern related to should be used; and creating high expectations of the physical location on the camp site where injuries care for every child should be the norm.
occur is easier for those camps actively tracking their TABLE 7: Top 10 Activities Associated with Injury in Day and Resident Camps (2006–2010)
CAMPERS STAFF Playing a sport/game 21% Playing a sport/game 17% Other non-sport activity 14% Walking 12% Sedentary (sleeping, sitting) 10% Sedentary (sleeping, sitting) 11% Walking 10% Routine action (hygiene, standing, etc.) 11% Routine action (hygiene, standing, etc.) 9% Horse-related 7% Water-related (non-swimming) 9% Water-related (non-swimming) 6% Running/jogging 8% Instructing/supervising 5% Horse-related 4% Other 5% Biking 4% Camp chore/task 5% Prohibited activity/horseplay 4% Using a knife 3%
The Healthy Camp Study Impact Report 19
“MAKING IT BETTER”
INTERVENTIONS FOR REDUCING INJURIES AND ILLNESSES IN CAMP
- A large number of injuries were the result of trips and falls for both campers and staff. Since data was collect- ed during summer months, the use of sandals, flip-flops, and other less protective footwear came under scrutiny. More discrete questions were added in 2008 to explore the types of footwear being worn in camps. Table 8 shows the additional information that was collected for campers and staff. How might one raise awareness with- in the camp community of how proper footwear choices can reduce injuries associated with slips, trips, and falls?
- Not using protective equipment (when it was appli- cable to a given camp activity) was another element of many injuries. Protective equipment was available but some campers and staff members were not using it, Online Courses for Injury and Illness thus increasing the likelihood that their injuries were sig- Prevention nificant enough to meet the definition of adverse event. How does a camp professional motivate campers and The Healthy Camp Study was implemented to de- staff to consistently use protective equipment? scribe the prevalence and context of the injuries and illnesses that occur at day and resident camps during These questions triggered a series of interventions to the summer months. Prior to this collected data set, the target specific risk areas. The first intervention was a scope of injury-illness incidents within the camp commu- series of online courses designed to educate camp nity was unknown, thus making it difficult to determine professionals (Figure 14). These courses were offered what intervention(s), if any, would improve rates. through ACA’s e-Institute online learning center at www. ACAcamps.org/einstitute/healthycamp. Camps partici- This changed after 2007- the second year of data col- pating in the Healthy Camp Study received free access lection. Consistency in the data sets of 2006 and 2007 to these courses. led the Healthy Camp Study Advisory Committee to pos- • No Outbreaks Here: Simple Strategies for Reducing tulate that collected information was, indeed, reflecting the Spread of Communicable Diseases at Camp the camp experience. With that assumption, the com- • Footloose: Minimizing Trips and Falls at Camp mittee looked more closely at the data in an effort to • Knife Safety: Reducing Sharp Object Injuries at Camp determine potential points of intervention. The following • OUCH: Protective Equipment, What All Staff Should was observed: Know
- Of all reported illness, just under half of the illness Figure 14: American Camp Association’s was communicable. Of the communicable illnesses, ap- Injury and Illness Prevention Online Courses proximately half were seen in others. Was it possible to describe a set of behaviors that would decrease the like- lihood of communicable disease spread among camp- ers and staff, thus increasing the potential for people to enjoy the camp experience rather than getting sick?
- Of the various reported wounds, several resulted from the use of knives, especially among staff. These wounds, severe enough that they took the person from their camp experience for a given time, had potential to impact worker compensation modification rates, as well as limit the ability of people to perform. Might a knife/sharp ob- jects safety program be initiated in an effort to decrease impactful wounds?
The Healthy Camp Study Impact Report TABLE 8: Footwear Worn by Campers and Staff During Slips, Trips, and Falls in 2009 Resident Camps Day Camps Campers Staff Campers Staff Shoes with closed heel and closed toe 75.3% 69.5% 81.5% 60% Shoes with open heel and/or open toe 10.2% 15.3% 9.3% 10.0% Individual was not wearing shoes 10.2% 13.6% 7.4% 20.0% Other 4.2% 1.7% 1.9% 10.0% Total 100% 100% 100% 100% From 2008, when the online courses were first cre- Approximately 11,300 professionals, staff, and ated, to 2010, approximately 11,300 directors, staff, volunteers have been trained on injury and and volunteers accessed the courses. The commu- illness prevention using online interventions nicable disease course elicited most comment be- through ACA’s e-Institute. cause (a) The “sneeze in your sleeve” message was delivered in a humorous way, and (b) Influenza-like illness (H1N1) during summer 2009 threatened the Comments from camp professionals camp experience, thus providing impetus to be as about practices changed as a result protective as possible. However, self-reported an- ecdotal comments (see sidebar) provided evidence of using the online courses for staff that all courses “hit home,” resulting in observable and camper training. behaviors — people used protective equipment, ap- propriate shoes were worn, hand washing increased, “We changed the rules last year to no flip-flops and there were changes in camp policies (e.g., per- . . . and we had only three or four injuries to formance appraisal forms assessed these behaviors, ankles/feet in the last two YEARS! It’s amazing flip-flops were “outlawed,” the courses became part . . . .” of staff orientation).
“All [of the trainings] were incorporated into Dissemination of Promising Practices for risk initiatives. They became part of personnel Injury and Illness Prevention evaluations.” Another intervention focused on publication and “We sneeze every day at the end of singing presentation of the study results along with recom- ‘On Top of Spaghetti’ — but now we do it in mended strategies for injury and illness prevention our sleeves . . . .” . Starting with ACA’s 2007 national conference, at least one session focused on delivering the Healthy “There were comments made throughout the Camp message at national and regional events for summer when a situation arose that related to both ACA and the Association of Camp Nurses the training.” (ACN). Articles appeared in Camping Magazine, The CampLine, and ACN’s CompassPoint. In addi- “On visiting day, we asked the campers to tion, the Healthy Camp Update newsletter became teach their parents how to cough and sneeze an insert for both ACA and ACN. The study was also the right way. . . .” discussed in articles published in peer-reviewed jour- nals including the Journal of Park and Recreation Ad- “. . . lots of hand washing. It was hard to keep ministration (Erceg, Garst, Powell, & Yard, 2009) and soap dispensers full!” Injury Prevention (Appendix D).
The Healthy Camp Study Impact Report 21 The study’s five-year span allowed the Healthy Camp Measuring the Impact of Interventions for Study Advisory Committee to shape a national curiosity Injury and Illness Prevention about camp injury/illness data and the changes that A measure of the interventions’ influence was were possible once one knew and understood the na- achieved via self-report by participating camps. At the ture of injury/illness events. This was largely possible end of the five-year project, all enrolled camps received because, in addition to previously mentioned interven- a request to complete an online survey (via SurveyMon- tions, each camp that contributed data received a cus- key) about their experience in the Healthy Camp Study tom summary report specific to their camp along with and lessons learned from participation. A total of 140 the national report. This made it possible for camps to camps completed the post-study survey, representing a do point-to-point comparisons and to identify both their 30 percent response rate. As indicated by Figure 15, a strengths and weaknesses over time. The custom report number of health care practices were learned through also reinforced study affiliation over the five-year time- participation in the Healthy Camp Study. The most com- frame.
mon responses included
- Importance of washing hands to control communica- One of the goals for the intervention plan was to get ble disease (73.4 percent). both campers and staff to actually practice risk reduc-
- How to monitor injury/illness experience to recognize tion behaviors. Camp leaders are well vested in risk and respond to camper and staff health needs (71.8 assessment, management, and reduction but rare are percent). the opportunities to shape behaviors of staff and camp-
- How to teach staff about their role in camp health ers. The online courses largely delivered this message. care (58.9 percent). Coupled with changes in policy, behaviors arose that
- Reminding staff of the importance of protective equip- should serve camps well into the future as long as those ment (50.0 percent). behaviors become institutionalized.
Figure 15: Changes in Practice Identified by Camps Participating in the Healthy Camp Study (n=134)
The Healthy Camp Study Impact Report Resources for Educating Campers, Parents, and Staff about Injury/Illness Prevention When asked what resources camp leadership planned to continue to use to educate their campers, parents, and staff, 59.8 percent intended to utilize in- formation from the Centers for Disease Control (CDC) Web site (Figure 16). This was closely followed by the Healthy Camp Update (newsletter) (55.9 percent), and resources from ACA’s injury and illness preven- tion Web page (57.1 percent). Figure 16 provides ad- ditional information about resource use.
Figure 16: Injury/Illness Prevention Resources That Camps Planned to Continue to Use to Educate Campers, Parents, and Staff (n=134)
The Healthy Camp Study Impact Report 23
PROMISING PRACTICES FOR INJURY AND ILLNESS PREVENTION Increasingly, camps have been updating their health Promising Practice #3: Camp professionals should con- and safety protocols and practices for the management duct consistent, thorough screening procedures to mini- of communicable diseases and the reduction of inju- mize the potential that ill campers will impact the camp ries. By accessing and incorporating information from community. Screening starts at home when parents de- the Centers for Disease Control, ACA, ACN, and other cide if their children are well enough to attend camp.
related sources, camps are improving their health prac- Parents should be aware of a camp or program’s criteria tices by incorporating new knowledge into their day-to- for inclusion based on a child’s health profile.
day health center operations.
Systems should be in place to document screenings, Camps don’t have to wait for an outbreak to occur to which should include pre-camp conversations regarding update their camp health practices. An important key health concerns. On-site screenings should be conduct- to developing a sound knowledge base about health ed according to a policy, so screenings are consistent.
and safety conditions is careful monitoring of the factors that cause significant injury and illness events in camps.
New information about promising practices of a healthy camp is now available and camps can take advantage of what the camp community has learned to implement Camp professionals said . . .
proactive health care strategies. “[We] instituted more stringent assessments on arrival days. Prior to this year, no temperatures Here are eleven practices you can incorporate into your were checked on incoming campers. This year, camp operations to improve the well-being of campers three were sent home with temperatures greater and staff involved in your program. than 100.” Promising Practice #1: Camp professionals should pro- “Screenings for campers and staff were mote the relative safety of the camp experience to par- improved, additional hand sanitizers were ents, caregivers, and the public. available, and more signage was placed around camp regarding how to stop the spread Research on injury rates from camps and youth sports of germs.” shows that children are less likely to be injured in day and resident camps than in the organized sports in “Parents are given the ‘A Healthy Camp Starts which youth are involved, suggesting that camp staff at Home’ flyer with registration. [Parents] are are trained in safety procedures specific to various ac- keeping the campers home when sick more tivities. By sharing this information, camp staff can reas- often now.” sure parents and other caregivers that staff are trained to conduct activities as safely as possible.
Promising Practice #2: Camp professionals should edu- cate parents/caregivers about their role in injury/illness prevention at camp. A parent flyer is available with key messages for parents (Appendix A).
Camp professionals said . . .
Research indicates that 5-7% of illness actually starts before the child even gets to camp. Consider a parent “We asked the campers to teach their parents policy that directs parents to contact the camp office to how to cough and sneeze the right way. I saw arrange for a delayed start to the child’s camp session campers reprimand their parents for coughing or a switch to another session should this occurs. To into their hands on visiting day.” emphasize parent impact on prevention, consider plac- ing an asterisk next to items on the camp packing list that have a role in injury -illness reduction. This might include items such as appropriate shoes, rain gear, in- sect repellent and sun screen.
The Healthy Camp Study Impact Report Promising Practice #4: Camp professionals should Promising Practice #5: Don’t forget the basics! Remem- regularly evaluate and update their health care prac- ber, the camp experience comes with some unique in- tices and procedures. As outbreaks such as H1N1 In- herent risks such as slips and falls on uneven surfaces fluenza, Norovirus, Lice, etc. occur, camps can access and unfamiliar terrain. These are often very different a range of reliable resources to effectively manage than what children experience in a typical day at these situations. Available resources include existing home. Camp professionals should make closed-toed emergency plans, ACA’s crisis response toolkit, and shoes and protective equipment mandatory for all ACA/ACN/CDC H1N1 response recommendations. applicable activities. No exceptions! Camp profes- sionals should also continue to evaluate slip/trip/fall Controlling infectious disease is the most important hazards.
thing you can do to provide a healthier camp environ- ment. Some simple techniques include: • Before arrival at camp campers and staff should
- Actively promote good hygiene have clear explanations of appropriate footwear for
- Teach proper hand washing camp
- Teach campers and staff the correct way to sneeze • Staff training should include what footwear is ap-
- Require campers and staff to wash their hands be- propriate for what activities fore meals • Systems should be in place to ensure that protective
- Provide hand washing stations at the entrances of equipment is located near where it is to be used eating facilities • Systems should be in place to ensure that protective
- Don’t require sick staff to prepare or serve food equipment is clean, maintained, and in good repair
- Staff should be trained in how to correctly use pro- Since the types of illness found in camps predomi- tective equipment nantly impacted the respiratory and gastro-intestinal (GI) systems, health center staff have solid assessment and care skills associated with these body systems.
Camp professionals said . . .
“We updated our official policy on allowable Camp professionals said . . . footwear at camp.” “We’ve seen a significant increase in the “We changed the rules last year to no flip- number of folks using the appropriate flops during games and absolutely NO bare technique of coughing and sneezing into their feet — and we have had only three or four arm or sleeve.” injuries to ankles/feet in the last two YEARS.
It’s amazing.” “Campers are more aware of communicable diseases and how to keep germs from “[We had] a 100 percent reduction in ankle/ spreading.” foot injuries by implementing shoes only during game time.” “Staff monitored pre-meal hand washing much more closely than in previous years.” “We had a camper come to camp with H1N1 exposure — and thus sent home. So we showed the ENTIRE camp the cough safe video for preventive measures.” “I noticed campers reprimanding each other for not washing hands. That would not have occurred a couple of years ago”
The Healthy Camp Study Impact Report 25 Promising Practice #6: Camp professionals should train Promising Practice #8: Camp professionals should de- both paid and volunteer staff (and campers, if appli- velop staff policies that reinforce how important it is that cable for specific camp activities) how to appropriately staff take proper care of themselves, including getting handle and store knives. Require staff to attend knife sufficient amounts of rest. For example, in 2010 in resi- safety training and demonstrate mastery of the safe use dent camps, more than 17 percent of staff injuries oc- of a knife. curred during days 5–7 of a one-week shift, indicating a potential role of fatigue and/or relaxed safety practices as staff become accustomed to routine. Fatigue is also a Camp professionals said . . . known contributor to illness.
“We introduced a knife safety session into pre- Fatigue tends to show up in a person’s demeanor quick- camp staff training with actual practice.” er than in any other injury or illness event. Campers and staff become short-tempered and weepy. Camp profes- “Kitchen rules and procedures were clarified.” sionals may be able to reduce the impact of fatigue by attending to these early signals and intervening when they occur. (See Appendix B.) Promising Practice #7: Camp professionals should clear- ly define for staff the behaviors that reflect appropriate • Require campers and staff to get appropriate amounts supervision during less structured time. It is sometimes of rest, proper nutrition, adequate breaks, and plenty of helpful in planning the camp day to focus some atten- fluids.
tion on what you see as the goal of free time, what it • Develop staff policies that reinforce how important it can accommodate, what lessons there are to be learned is that they take proper care of themselves. Consider in free time, and then structuring it a little so that those how your policies can be reinforced by language in goals you have identified can happen. Many camps your staff contracts or list of performance expectations.
identify free time as some of the best time spent at camp. For example, insert the expectation, “Staff members are Whether that holds true at your camp can depend on required to manage their personal life so that they re- both planning and execution. mains capable of performing their job.”
- Communicate your free time goals to staff.
- Define for staff the behaviors associated with appro- priate supervision.
- Remind staff that being alert and proactive can stop Camp professionals said . . . incidents before they escalate. It is much easier to pre- “Before I was in the study, I read the article vent things then to try to clean it up later. about fatigue in CampLine. I used it as a way
- Role playing situations during training helps prepare to insist my staff take sleeping and showering your staff. Being “present” but not intrusive is a talent breaks after our overnights. We only have that requires practice. one overnight per camp per year and staff
- Staff may have an “It can’t happen to me” outlook. and campers both try to stay up all night and This can lead to them taking risks during free time that bond. This made me nervous the next day at are not appropriate. Remind staff that their time off still the beach. Now I bring in some fresh ‘subs’ that affects the job if they get hurt. provide lifeguarding the next day at the beach.”
- Supervisors need to continue to monitor staff behavior throughout the summer. Don’t forget to reward the good things staff do.
See the “Discussion” section of this report for additional comments about supervision in camps.
Camp professionals said . . .
“The best a-ha [moment] I saw was when a counselor staff “got it” — injuries can be prevented, and some happen in a predictable pattern, and they already knew the contributing reasons, and could be on the lookout for them.”
The Healthy Camp Study Impact Report Promising Practice #9: As you plan camp activities, Promising Practice #10: Camp professionals should think carefully about the protective equipment that identify ways for closely monitoring injuries and ill- can help reduce the likelihood and severity of injury nesses among campers and staff, and regularly (particularly a head injury) during a slip, trip, or fall. evaluate and update their health care practices and procedures, integrating new and emerging resources.
Think about the surfaces on which camp activities will be played. Take special precautions anywhere po- Maintaining a health record log for visits to your tential hazards are identified. Make “planning for the camp’s health center is a good first step, and it’s worst” a guiding principle for planning camp activi- supported by ACA standards, but there are other ties. Consider this fact: During some study years, pro- ideas you may want to consider. Many resources tective equipment was not being worn in 50 percent are available to inform improved practices and pro- of applicable injury events. Although you might not cedures. These include ACA’s annual summary of think that the use of protective equipment is a problem Hot Line calls with suggested practices, conducting in your camp, be vigilant in your efforts to ensure that a risk audit with the camp’s insurance company, and it is being used by campers and staff when needed. accessing informing from organizations such as the Association of Camp Nurses (www.ACN.org). “Col- lecting and Processing Camp Injury/Illness Informa- tion: How Do I Get Started?” (Appendix C) describes Camp professionals said . . . another option.
“Our adventure staff had more information for their participants about helmets.” You Can Do It! Using a site specific injury and illness monitoring approach (such as ACA’s Healthy Camp “[We reminded] staff to use protective Study) can give you a powerful foundation for evi- equipment, and to remain diligent with dence-based decision making in the areas of health, explaining the rules of the activity as well as wellness, and risk management. Here are several
monitoring the activity.” steps to consider
- Complete a health record log to record injuries and illnesses (as required by ACA Standards).
- Annually review your health center logs to identify where adverse events occur. Identify the patterns of Camp professionals said . . . injury related to specific activities and locations. De- “Having the Healthy Camp Study data as velop specific safety procedures for each camp activ- a foundation reinforced trainings. Had the ity and location where injuries are common. trainings been presented without that data, • Collect additional injury and illness information I don’t think they would have paid as much based on questions asked in the Healthy Camp Study attention.” (Table 2).
- Participate in a national data-collection when avail- able.
- Take advantage of a site-specific reporting tool to more closely monitor injuries and illnesses when Camp professionals said . . . available. “I learned that it takes buy-in from the camp director and staff to have the message of Promising Practice #11: Recognize that both adminis- injury prevention actually acted upon.” tration and frontline staff have responsibility and own- ership in your “healthy camp.” Use available health “Paying attention to our data has resulted data from previous years to inform the current and in campers spending less time in the health upcoming year. Camp stops being fun when some- center, staff having healthier summers, and one gets hurt. ANYONE and EVERYONE can help less out-of-pocket expenses for healthcare prevent injuries and illnesses supplies and medical bills.
The Healthy Camp Study Impact Report 27
DISCUSSION Benefits of Surveillance in Camps seems probable that the high number of participating camps were ACA-accredited, given the recruiting meth- The Healthy Camp Study proved that ongoing sur- ods that were used. These camps might be more aware veillance of injuries and illnesses is not only possible of health, safety, and risk management procedures, and in day and resident camps, but also fruitful. The study may not be representative of the larger population of provided national data which allowed the camp com- camps that may not have access to the same health and munity to benchmark actual rates of camper and staff safety information through ACA.
injuries and illnesses as a comparison for camp-specific adverse events. Given the data provided in this report, Prevention is a key message of the Healthy Camp Study, any individual camp professional could, using the ques- as several opportunities for prevention are highlighted tions provided in Table 2 and the definitions of adverse by the results and the promising practices shared by events provided for campers and staff, monitor injury or participating camps. By engaging parents in the health illness rates in his/her camp. The Healthy Camp Study screening process before camp and by involving them in provided a simple and effective methodology, but other the camp’s overall health promotion efforts, camps can approaches are likely viable. Any camp professional reduce the spread of communicable illness in camps. By that collects camp-specific data on camper and staff requiring close-toed shoes during appropriate camp ac- illnesses and injuries can use their data to develop in- tivities, and enforcing expectations for the use of protec- terventions that improve health and safety. Interventions tive equipment by campers and staff during applicable appropriate for one camp may be different than inter- camp activities, camps can reduce the likelihood of both ventions needed at another camp. foot/toe/ankle injuries and head injuries. By develop- ing an injury/illness monitoring program in camp and The study provided compelling evidence about the rela- engaging administrators and frontline staff in the pro- tive safety of the camp experience, as evidenced by cess, camps can increase their capacity for identifying the very low rates of camper and staff injuries in both problem areas (for example, an activity which results day and resident camps. This is an important marketing in more camper injuries compared with other activities, message for camps to use to attract parents concerned or a time of week in which staff reports of illness seem about the safety of youth settings, and the risks associ- to rise). Based on the Healthy Camp Study, these three ated with sending one’s child away from home for one specific areas of prevention can substantially reduce a or more weeks to attend camp. The finding that camp camp’s experience with injuries and illnesses. Once a is safer than other youth settings is not entirely surpris- camp has addressed those adverse events which are ing. Although data regarding whether or not a camp largely preventable, more resources can be devoted in was ACA-accredited was not analyzed for this study, it response to incidents that are more difficult to control.
The Healthy Camp Study Impact Report Challenges to Monitoring Illness in in the areas applicable to the interventions. So how do we assess the impact of the interventions on camp Camps practices? The qualitative data collected at the end of In an attempt to decrease the rates of illness at each summer via the end-of-summer survey and the camp, it’s important to remember that illness can be end-of-project survey provide evidence of the specific fickle. It doesn’t necessarily have an obvious caus- lessons learned, changes in practice, and “a-ha mo- ative agent like an injury. For example, if someone in- ments” experienced by camps that participated in the jures an ankle from tripping over a root, removing the Healthy Camp Study. So, although the results do not root decreases the potential for that injury to reoccur. indicate, for example, a decrease in the overall rates If, however, that same person complains of a debili- of slips, trips, and falls because of the “Footloose:
tating headache, being sure of causation may not be Minimizing Trips and Falls at Camp “ online course, so easy. Perhaps the person’s hydration status is low which taught staff about proper footwear choices, — or too high. Maybe there’s been extended expo- we did read anecdotes and stories from camp di- sure to sun glare or some other eye strain. Maybe the rectors and health care staff who implemented more headache is actually a symptom of a greater underly- stringent footwear policies and practices and experi- ing problem. Because of this, health center staff need enced positive outcomes as a result. Other data sup- to become super sleuths in an effort to figure out the port that camps were implementing changes in prac- “why?” behind illness, and communicate this informa- tice. Footwear data collected in response to foot/toe/ tion to other camp leaders. Only then can one begin ankle injuries also indicated that more campers and to impact illness rates. staff were wearing appropriate footwear as the study progressed.
In addition, this study only examined those cases that met the definition of adverse event (took the person away from their regular camp activity for one [day Footwear data collected in response to foot/ camps] or four [resident camps] hours). What might toe/ankle injuries indicated that more campers be discovered if one examined the illness complaints and staff were wearing appropriate footwear as that did not meet the study criteria? Seeking care for the study progressed.
minor illness (e.g., slight headache, some joint aches, and a bit of a sore throat) might allow for therapeutic intervention before the minor problem blows up into Another factor that may be influencing the reported a bigger issue. As a result, perhaps the rates of im- rates of injuries and illnesses as the study progressed pactful illness would decrease over time, thus increas- was reporter familiarity with the weekly reporting ing the likelihood that campers and staff continued to tool and the overall process of injury/illness monitor- be engaged in the camp program. ing. As they become more aware of injuries and ill- nesses, and as they became more comfortable using Program Improvement in Camp Policies the CAMP RIO online reporting tool, reporters may have entered greater numbers of adverse events than and Practices they did in previous years of the study. In fact, on The primary purpose of the Healthy Camp Study the end-of-project survey, camps reported improved was descriptive — to describe injuries and illnesses data reporting as they became more familiar with that were occurring within the camp community. the study’s parameters. This may have contributed to However, the study provided an opportunity to de- more discrete reporting in the various illness and in- sign and implement interventions within participating jury categories, thus influencing no reduction in rates.
camps, and to use the surveillance methodology to test those interventions. Finally, the rates of injuries and illnesses are so low that seeing changes in the national data set may be As previously discussed, the rates of adverse events difficult. Individual camps might see a more signifi- remained relatively constant across the five years of cant change.
the study, with the exception of resident camp illness, which spiked in 2009 due to the H1N1 Influenza out- break. Even though multiple interventions were de- veloped (i.e., the online courses) and administered to participating camps, these interventions did not cause a reduction in the rates of injuries and illness
The Healthy Camp Study Impact Report 29 Effective Supervision During Unstructured Consequently, there’s a need for future research into su- pervision, specifically the behaviors that contribute to Time the effectiveness of supervision. For example, if a staff
The results of this study around injuries indicated that member is directed “to supervise the campers during rest free time was an area during which injuries were com- hour,” does that simply mean the staff member is present mon. Additional research is needed to understand the in the cabin? May that staff person fall asleep? What issue of supervision. All too often, camp staff are told if the cabin is a series of rooms — must the counselor to “supervise the campers,” but rarely does someone move among rooms? If so, how frequently? And what describe the behaviors that constitute effective supervi- camper behavior should be noted — conversations? A sion. In addition, there’s an assumption that effective su- camper being out-of-bunk, walking around? What does pervision can reduce or eliminate incidents, especially the counselor do when such behavior is noted? What incidents that result in personal injury. The discrepancy behaviors might be used to describe effective supervi- between the desire for effective supervision and a de- sion of an area during free time? Is it sufficient that the scription of what constitutes effective supervision played staff member simply be in the area? May the person into discussions surrounding the Healthy Camp Study.
read or should their eyes be constantly roving? Does the
The research team wanted to know if supervision, or counselor stay in one area or move around? At what lack thereof, contributed to injury/illness events. How- point should the staff member intercede in risky camper ever, the inability to operationally define supervision behaviors? What are those risky behaviors?!?
was a problem. Simply asking “Was the activity super- vised?” would not have elicited reliable data; we need- One of the better models for supervision behaviors for ed to know the behaviors that constituted supervision.
staff is found in lifeguarding protocols. Aquatic person- nel are trained to be on duty in a manner that describes
The Healthy Camp Study challenges camp pro- their attire, the equipment they carry, the place(s) they fessionals to consider the times and places at are to be, the way they use their eyes, the behaviors that which staff are expected to “supervise” youth and indicate a swimmer in trouble, specific actions to take then explicitly describe the behaviors that consti- in response to an incident, their interface with people tute effective supervision during those times and around them, and the physical space they are respon- at those places.
sible for covering. The Healthy Camp Study challenges Figure 17: Interest in Future Monitoring of Camper and Staff Injuries and Illnesses Identified by Camps Participating in the Healthy Camp Study (n=134)
The Healthy Camp Study Impact Report camp professionals to consider the times and places tional data collection project related to injuries and at which staff are expected to “supervise” youth and illnesses and an interest in collecting their own injury/ then explicitly describe the behaviors that constitute illness information in their own way (46.5 percent).
effective supervision during those times and at those About one-third of the camps (33.3 percent) shared places. that they would take advantage of a CAMP RIO-style reporting tool if one was available.
Future of Injury and Illness Monitoring in The American Camp Association recognizes that Camps there is much more to be learned about injuries and As we look to the future of injury and illness moni- illnesses in camp, but we believe that the Healthy toring in camps, a desired outcome of the Healthy Camp Study has provided a strong foundation and Camp Study would be to empower camps to increase evidence base for what is actually happening in day their capacity for injury and illness surveillance. and resident camps when it comes to the injury and Camps need the capability to access software tools illness experiences of youth and staff. Such an evi- (such as CAMP RIO) for more effective and efficient dence base allows us to make better decisions as a tracking of camper and staff adverse events. In the camp community. Our prevention efforts can be tar- Healthy Camp Study, participating camps received geted. Our intervention strategies can be intentional.
their summary reports once per year (in December). Our camps can be safer. Our youth and staff can be In the future, we envision the need for camps to be healthier. And we can provide even higher quality able to run camp-specific reports at various times camp experiences for all those we serve.
throughout the year for more effective risk manage- ment and healthcare planning. A camp-specific tool that allows camps to add their own health-related questions would be desirable.
On the end-of-project survey, camps were asked how they planned to continue to monitor camper and staff injuries and illnesses (Figure 17). Camps overwhelm- ing indicated (79.8 percent) that they would continue to meet the requirements of ACA Standards. Approxi- mately half of the responding camps (48.8 percent) expressed a desire to continue to participate in a na-
REFERENCES Erceg, L.E., Garst, B.A., Powell, G.M., & Yard, E.E. (2009). An injury and illness surveil- lance program for children and staff: Improving the safety of youth settings. Journal of Park and Recreation Administration, 27 (4), 121-132.
Erceg, L.E. (2008). Staff health does not equal camper health. CompassPoint, 18 (4), 1-4.
Robertson, L.S. (2007). Injury Epidemiology: Research and Control Strategies (3rd. ed).
Oxford University Press. New York.
Walton, E. & Erceg, L. (2005). Health appraisal guidelines for day camps and resident camps (for American Academy of Pediatrics, Committee on School Health, Section on School Health). Pediatrics. 115(6):1770-1773.
The Healthy Camp Study Impact Report 31
APPENDIX A Parent Flyer: “A Healthy Camp Starts at Home” Healthy Camp Industry-Relevant Research for Camp Professionals from ACA 2010 Update A Healthy Camp Starts at Home!
A healthy camp really does start at home. Here are some things you can do to assure your child has a great summer camp experience.
- When children show signs of illness, keep them home. This greatly reduces the spread of illness at camp. Be aware of your camp’s criteria for inclusion in camp.
- Teach your child to sneeze in his/her sleeve, and to wash his/her hands Mission Partner often at camp.
Markel is proud to be an ACA 3. Closed-toed shoes are a requirement for activities such as sports and Mission Partner and sponsor of hiking. This will help avoid slips, trips, and falls, which could cause the ACA Healthy Camp Study.
injuries. Stress to your child the importance of wearing closed-toed shoes to prevent a toe, foot, and/or ankle injury.
- Send enough clothes so your child can wear layers. Mornings can be chilly and by afternoon it will be hot. This enables your child to peel his/her layers off as the weather warms.
- Fatigue plays a part in injuries. If children are going to day camp, ensure they get enough rest at night. If children are going to resident camp, explain that camp is not like a sleepover. Explain to your child that he/she should not try to stay up all night!
- Don’t forget to send sunscreen, and instruct your child how to use sunscreen.
- Please send a reusable water bottle. Your child can refill it frequently during their camp stay. Staying hydrated is very important in the summer.
- The American Camp Association’s® parent-dedicated Web site, www.CampParents.org, provides a wide range of educational resources to help parents make good health-related decisions for children. Building a partnership between you and the camp staff is essential for your child to have the best camp experience possible this summer!
The Healthy Camp Study Impact Report
APPENDIX B Staff Health Does Not Equal Camper Health Originally published in CompassPoint (2008), vol 18 no 4, 1-4.
Linda Ebner Erceg, RN, MS, PHN Twenty-year-old Patsy was diagnosed with mono- nucleosis during her final month at college last May. Acknowledge Differences between Adult Her recovery was uncomplicated. Her physician and Minor Status approved her work at camp and the camp director People of legal age and deemed competent are concurred; it was possible to manage Patsy’s work capable of self-determination in ways society labels assignment to support her continued recovery. But “adult.” Those who are under-age, the minor, are over- she tripped yesterday and slammed belly-down onto seen by parents/guardians — but not in all things.
a hard surface, hard enough to rupture her still en- Minors, for example, often have specific rights — like larged spleen. It was a small tear but enough for the the age they may marry or have access to birth man- physician to keep her overnight in the hospital for agement processes — that are granted by state law.
observation. She’s back at camp today and taking In addition, state law typically specifies at what age it easy. Her parents called the nurse at the camp’s minors may give assent (as opposed to consent) for Health Center this evening. They wanted to know, things such as participating in research, having a pro- “How’s she really doing? Tell us about her ruptured cedure done by a healthcare provider, and applying spleen.” for emancipation. Regardless of age, both adults and minors have an expectation that their personal health Seventeen-year-old Jon worked in the camp kitchen.
information will be held in confidence. And from the As you might suspect, his duties included washing Occupational Health and Safety Administration’s dishes. As he was working at the scrub sink after (OSHA) point of view, OSHA “. . . regulations apply lunch one day, he inadvertently mishandled the blade to all employees regardless of age” (U.S. Department from the slicer; it slipped from his hands, leaving a of Labor, 1999).
very long and deep gash across the palm of his right hand. He got stitches, quite a few of them. He used As a result, a growing number of camps are making his cell phone to call his parents on the way to the a distinction in their health center policies for staff, doctor. Now his mom is on the phone with the camp specifically between staff who are adults and those nurse; she wants to know how he’s doing and what’s who are minors. The overarching distinction is that going to happen now.
staff with adult status can self-determine and are re- sponsible for making their own healthcare decisions.
These situations probably sound familiar to seasoned In addition, adults expect that their interaction with camp professionals. When a staff member gets ill the camp’s healthcare provider — both regarding or injured, the impact of that injury or illness has re- care received and issues discussed — will remain percussions that are different from those of an ill or confidential, specifically between the camp’s health- injured camper. Part of that impact has to do with bal- care provider and the adult staff member.
ancing return-to-work with recovery. Another impact relates to communication: Who needs to know what For minor staff, however, care policies often change.
about the incident, to what extent can that informa- Because parents are still in a custodial relationship tion can be shared, and what are the boundaries to with the child, parents are typically informed and/ those discussions? The question is also colored by the or consulted when the minor staff member gets ill or age of the staff member; those of legal age are adults injured, especially when out-of-camp care is needed.
and, consequently, vested with the privileges of being In addition, input from parents may be sought in the an adult. One such privilege is the right to confidenti- care planning process and information about the mi- ality about one’s health status.
nor’s recovery is shared. Finally, depending on the re- lationship fostered between camp administration and So what’s a camp director and the camp nurse to do?
minor staff members, an expectation of more “care taking” often comes into play.
The Healthy Camp Study Impact Report 33 Camp Health Practices ing practices that they forget to consider the impact of their child’s adult status upon their (the parents’) access Recent revisions in staff health history forms have to information about that child (even the adult ones).
recommended taking an occupational health perspec- Growing up parents is tough! Couple this with a camp tive (Erceg, 2004), reminding staff — whether adult or administration that’s into “taking care of our staff” and minor — that they have been hired to do a job and it’s understandable why critical messages get set at are responsible for managing their health to remain ca- crossed purposes.
pable of doing that job. In addition, job descriptions in- clude essential function statements. For the adult worker, On the other hand, many camps provide a unique bridg- this means that a work supervisor would not have carte ing experience for young adults. There’s an ebb and blanche access to their camp health history or health flow to the transition from being cared for (dependent record. However, there may be exceptions to this gen- child) to self-care. Working at camp often facilitates that eral practice, exceptions that are based on defensible transition. But that facilitation — especially with regard rationale. If so, the camp’s personnel policies make this to personal health information — should be subject to known to staff in writing and prior to hire. boundary-setting practices that are made known from the get-go via written staff policies. One enterprising However, look at the wording of those policies. If the camp recognized that parents of staff can be fickle.
staff member’s work supervisor has access to the staff So the camp’s administrative team wrote a letter to the member’s health form, does it say that in the policy? parents that straightforwardly discussed matters such as Perhaps more importantly, does it explain why? For the their inability to discuss health issues.
adult staff member, such statements are critically impor- tant because their default assumption will be that their health form and record are available only to the camp’s Recommendations from the Society of healthcare providers. If others have access, adult staff Adolescent Medicine members must be told. If the camp has different prac- In 1997, the Society for Adolescent Medicine (SAM) tices for minor staff members — including the camp’s published a position statement that, in this writer’s opin- intent to keep parents informed — those distinctions ion, set forth guidelines for healthcare professionals that should also be clearly stated in the policies. vary from those many camps have in place for minor Also make sure the camp nurse and other camp health- staff. As cited by Ford, English, and Sigman (2004), care providers are briefed about the camp’s policy. the SAM position included the following statements with This is especially important because most nurses come respect to confidentiality of adolescent healthcare, posi- to camp with assumptions about healthcare that are tions that may be at odds with the general operating shaped by their previous experiences. They will assume processes of a given camp:
that an individual’s health information is privileged — all of it — and rightly so. Consequently, the nurse won’t That confidentiality protection is an essential component even think about sharing personal health information of adolescent healthcare. It’s developmentally appropri- with others. The nurse needs to know, maybe even ate to both the maturity level and autonomy of today’s shown, the camp’s written practices, including the dis- adolescent.
tinction between adult and minor staff practices.
Without confidentiality assurances, some adolescents Remember the two situations at the beginning of this will not seek healthcare. Healthcare professionals and article? Both of them included parental requests for in- the entity for which they work should educate adoles- formation. Because camps work closely with parents, cents and their parents about the meaning and impor- it’s easy to forget that a parent’s request for information tance of confidentiality, and the scope of confidentiality is not, necessarily, justification for providing it. Twenty- protection provided by the entity (this includes any lim- year-old Patsy’s parents are a great example; so is the its). In so doing, the entity would also support communi- mom of seventeen-year-old Jon. These parents are ask- cation between adolescents and parents insofar as the ing about their child’s health for all the right reasons. entity’s policies allow.
While Jon’s minor status makes sharing that information possible, Patsy must grant that permission. The entity informs parents that it will follow laws that allow minors to give their own consent/assent to proce- Tactfully saying this to Patsy’s parents, especially when dures that are defined by law.
they may be emotionally stressed over the situation, is tough. In addition, some parents are so into their parent-
The Healthy Camp Study Impact Report Keeping in mind that minor staff and their parents — References as well as many camp health professionals — come American Academy of Pediatrics Committee on Bio- from the greater U.S. culture to the camp setting, some ethics (1995). Informed consent, parental permission, come with the assumptions of that society in place; and assent in pediatric practice. Pediatrics, 95 (2), they expect that practices such as those described 314-317.
above are also in place at camp. What they often discover, however, is a camp’s rather paternalistic “Let Erceg, L.E. (2004). Health histories: What are camps us take care of you” attitude. This value is evidenced (not) asking? CompassPoint, 14 (1), 17-23. Also avail- in some interesting artifacts of the camp world: Staff able online at www.campnurse.org/edcenter/index.
relinquish the responsibility for taking their medica- html tions to someone who sees that they get it on time, Ford, C.F., English, A., & Sigman, G. (2004). Con- someone monitors their night curfew instead of the fidential health care for adolescents: Position paper individual retaining responsibility for getting enough of the Society for Adolescent Medicine. Journal of sleep, and instead of being expected to manage their Adolescent Health, 35 (1).
own recovery process, someone else does it. While U.S. Department of Labor (1999). OSHA has no practices such as these may be explainable from a specific regulations regarding minors. Retrieved 17 camp perspective, they are probably unanticipated October 2008; online at www.osha.gov/pls/os- to non-camp people and, as a result, cause a rub.
haweb/owadisp.show_document?p_id=22820&p_ All one needs do is explain the distinctions and the table=INTERPRETATIONS reason for them.
Linda Erceg, RN, MS, PHN, is Executive Director of the On the other hand, perhaps it’s time for the camp Association of Camp Nurses and Associate Director of community to re-examine some of its practices sur- Health and Risk Management at Concordia Language rounding healthcare of adolescents. Starting with Villages, a year-round program in northern Minnesota.
minor staff members makes good sense since the employee relationship doesn’t have the care-taking connotation of the client (camper) relationship. Most minor staff members have a certain level of matu- rity and they evidence autonomy in their employee status. Might something be gained by treating them more like adults in the health center? It’s an interesting question to chew on.
The Healthy Camp Study Impact Report 35
APPENDIX C
Collecting and Processing Camp Injury/Illness Information
How Do I Get Started?
Linda E. Erceg, RN, MS, PHN You’ve decided that you want to take a look at 5. Then determine what information about each indi- your camp’s injury/illness data and determine what vidual injury/illness incident you want to collect. This it tells you about your camp’s operations, the people is REALLY important since the data set will determine who attend, the staff who work, and the policies you the richness of your data. At minimum, begin by col- may — or may not — have. Maybe you also want to lecting the following information. You can always manage health-associated costs more effectively — add more categories as you learn more about your things like the amount you spend on supplies for your camp’s injury/illness profile.
health center or how to modify your worker compen- a. Information for both campers and staff.
sation insurance. Perhaps you simply want a bench- Consider using a lead column to indicate “C” mark for your camp’s risk management program. for camper and “S” for staff. This will allow Whatever the reason, collecting and analyzing your effective sorting without having to run two camp injury/illness data is important. spreadsheets, which is also an option.
- Name of person: Take care since associating . . . But where does one start? individual names with data has implications. However, you will want to identify “frequent Part 1: Organize the Process fliers” and/or staff with recurring incidents. If
- Appoint someone to oversee the process. This indi- using a computer spreadsheet, one can always vidual doesn’t necessarily have to be the person who hide the name column if need arises. collects the data, but it should be someone who can c. Sex of the individual (male or female). oversee the project and coach other participants. d. Age of the individual.
- Date of injury or illness.
- Determine where you’ll put collected data. If pos- f. Time injury or illness was reported. sible, use a computer spreadsheet program. This can g. Diagnosis. ease the data sorting process but it’s also possible to h. Amount of time before person went back to use plain old paper and pencil. their normal camp routine.
- Cost of care.
- Determine who will collect the raw data. This indi- j. During what activity the incident occurred. vidual should have ready access to the data; conse- k. Where (geographic location) the incident quently, it’s often the camp nurse. But a busy health occurred. center may mean the nurse doesn’t have time to enter information. If that’s the case in your camp, consider 6. The data set about individual incidents should be having an assistant help out, or a staff member who accompanied by another data set about the camp works year-round for camp. population. This information will be needed to run simple statistics later on. Collect this information
- Determine your “case definition.” In other words, about the camp population: what criteria must an injury or illness event meet in a. Total number of campers and total number of order to get entered into your data set? Some people days those campers were at camp. look at all injuries and illnesses, from minor skinned b. Total number of staff at camp and total number knees and splinters to hospitalizations. Others start of days those staff members were at camp. by looking at “significant” data, only those injury/ c. If, during the data collection period, there illness events that were so significant that the person was a significant change in the camp’s health had to be seen by a physician. And still others might behaviors, note that change. You may see data take only the injuries and illnesses for which people reflect the impact of the change. sought care from your health center staff. The point is to select a criteria point that will result in an informa- 7. Decide the source of information for your data set: tive data set for your purposes. a. From the health center log and individual health records?
The Healthy Camp Study Impact Report
- From first aid kit records/notes?
- From insurance claim forms (including worker The resulting number is your camp’s injury/illness rate compensation)? per 1000 camp days for the summer.
- From people at the time of the injury/illness?
- From incident reports? 2. To determine your camp’s staff injury rate:
- Write down the total number of staff at camp
- Determine when you’ll collect the information: at during the summer: the time of the incident? Later on, from records of the b. Write down the total number of days those staff
incident? were at camp
- Multiply line A by line B; this is your total of
- Now that you know what’s going to be collect- “staff days” at camp: ed, design the data collection tool. Create a simple d. Write down the total number of injuries collect spreadsheet into which information can be added. by your data collection process:
Part 2: Collect the Data e. Finally, divide the total number of injuries (line This is the easy part. Have the assigned person D) by the total number of staff days (line C), collect your data as planned in Part 1. Just do it! then multiply by 1000:
The resulting number is your camp staff’s injury rate Part 3: Process Your Raw Data per 1000 camp days for the summer.
Now it’s time to make sense of your data. To do
- To determine your camp staff’s illness rate:
that, take time to understand these terms
- Write down the total number of staff at camp
- Population: This refers to the total number of
during the summer
people in the group being studied. Groups
- Write down the total number of days those staff commonly examined in the camp setting are
were at camp
campers and staff.
- Multiply line A by line B; this is your total of
- Incidence: Simply the number of new cases of an
“staff days” at camp
injury or illness.
- Write down the total number of illnesses
- Rate: A measure that expresses the risk in your collected by your data collection population over a given period of time and in
process
such a way that comparisons between like groups
- Finally, divide the total number of illnesses (line can be made. The constant used to calculate D) by the total number of staff days (line C), injury/illness rates in the camp population is
then multiply by 1000
1000 camp days.
The resulting number is your camp staff illness rate
- Trend: A sense of direction in which data is per 1000 camp days. moving. Injury/illness trends can be observed after three or more years of data collection and
- Calculate the same two rates for your campers by processing. repeating steps #2 and #3 and substituting informa-
- Calculator: Device which, given correct input, tion specific to your campers. For those who are more provides reliable output!
into math, here’s the formula for those steps
- To determine your camp’s injury/illness rate: Number of recorded ill-
- Write down the total number of people nesses and/or injuries (campers and staff) at your camp during a Total number of x 1000 = Rate per 1000 camp days given summer: camper or staff days
- Write down the total number of days all those
people were at camp
- Multiply line A by line B; this is your total of Part 4: What is Your Data Telling You? “camp days”: Begin by looking at your rates. A rate simply tells
- Write down the total number of injuries you, given 1000 of your campers or staff standing in and illnesses recorded during that time front of you, how many of them would have gotten ill period: or injured on a given day. By looking at your camp’s
- Divide the total number of cases (line D) by data over time, you are working with the same popu- the total number of camp days (line C), then lation and compare rates year-to-year. Granted, the multiply that number by 1000: first year you do this, you only have that year’s rates
The Healthy Camp Study Impact Report 37 to consider. But you also have access to the rates col- These and other questions will come to mind as you lected by the Healthy Camp Study. Do your rates come examine your data set. In doing so, remember to revisit close to those of the national study? the reason why you started this process in the first place.
If you are interested in a healthier camp program, con- Compare your staff rates to your camper rates. Is there sider these questions:
a difference? Does that difference make sense to you? A. Does your camp performance appraisal tool What group had the lower rates, campers or staff? A include a statement about the person’s ability to lower rate simply tells you which group had fewer in- keep his/herself healthy enough to do the job?
jury/illness events; it does not tell you why the rate was B. Does your camp performance appraisal tool lower. In other words, a rate is descriptive, not analyti- include a statement about the staff member’s cal. ability to manage his/her cabin/activity to reduce camper injury/illness?
Next, go back to your raw data and sort the data set to C. Does your daily schedule provide adequate rest answer questions like these: for campers and staff?
- Does one sex get ill or injured more than the other? D. Do campers and staff have adequate access to What might that be telling you? water and nutrition to maintain their resilience to
- Is there a particular person who repeatedly gets injury and illness? injured or ill? What implications arise if the person E. Is the health center staff getting camp leadership is a staff member? A camper? involved when some aspect of the camp program,
- Is there a particular age group that gets injured or ill the supplies people are asked to use, the rules more often? What might this suggest? they are asked to follow, or the facility in which
- Look at the date and time during which incidents activity is done seems to cause injury or illness? occur. Do more illnesses occur the longer people are at camp? Do injuries increase as time goes on? Final Thought: Be Realistic! Is there a relationship between time of day and Change takes time. Select one or two areas in which when injury occurs? to direct your change efforts rather than trying to tackle
- Group the diagnosis category. What diagnoses everything all at once. And remember to evaluate your occur most often? Might something be done to efforts. Once one or two things show improvement, add make these less likely to occur? What are the most something else. Before too long, you’ll see a difference. common injuries and illnesses? Does the list change when you sort it for staff as opposed to campers? Also remember to involve your leadership staff. Examine
- Time lost from the program due to injury or illness the time, resources, and personnel available to effect impacts perceived quality of the camp experience change. The more people own this information and are for campers and reflects loss of work productivity for part of the improvement process, the more likely results staff. Might this time be reduced without implicating will be noticed. the quality of health care? Might health center staff change something to make care more effective? Share your successes and challenges by e-mailing Linda Erceg (erceg@campnurse.org).
The Healthy Camp Study Impact Report
APPENDIX D Publications from the Healthy Camp Study Association of Camp Nurses (2007). Healthy camp study completes first year. CompassPoint, 17 (1), 14.
Erceg, L.E. (2007). Golden nuggets from the healthy camp study. CompassPoint, 17 (2), 15.
Erceg, L.E., & Bialeschki, M.D. (2009). Exploring the impact of influenza-like illness: Preliminary survey results.
CompassPoint, 19 (4), 4-5.
Erceg, L.E., Garst, B.A., Powell, G.M., Comstock, R.D. (2008, March/April). How healthy is camp? Exploring early results from the American Camp Association’s surveillance study of injuries and illness. Camping Maga- zine. American Camp Association.
Erceg, L. E., Garst, B.A., Powell, G.M., & Yard, E.E. (2009). An injury and illness surveillance program for children and staff: Improving the safety of youth setting. Journal of Park and Recreation Administration, 27(4), 121-132.
Garst, B. Erceg, E., Baird, S, & Thompson, S. (2010). Ten steps to a healthy camp. Illinois Parks and Recreation Magazine, 41(3), 20-24.
Garst, B. A. & Erceg, L.E., (2010, March/April). Healthy camp ppdate: Promising practices for reducing inju- ries and illnesses in camps. Camping Magazine. American Camp Association.
Garst, B. A. & Erceg, L.E., (2009, March/April). Ten ways to reduce injuries and illnesses in camp. Camping Magazine. American Camp Association.
Goldlust, E., Walton, E., Stanley, R., Yard, E., Garst, B., Comstock, R.D., Erceg, R.C., & Cunningham, R.
(2009). Injury patterns at US and Canadian overnight summer camps: First year of the Healthy Camp Study.
Injury Prevention, 15, 413-417.
Yard, E.E., Scanlin, M.M, Erceg, E.L., Powell, G.M., Wilkins, J.R., Knox, C.L., Comstock, R.D. (2006). Illness and injury among children attending summer camp in the United States. Pediatrics, 118(5), e1342-e1349.
The Healthy Camp Study Impact Report 39 www.ACAcamps.org
The Healthy Camp Study Impact Report