Socioeconomic status and adolescent injuries

Child drowning mortality in Israel: Trends and measures for prevention

INTRODUCTION

In this study, we use the media-based database of Beterem-Safe Kids Israel, to provide a 15-year review of unintentional fatal childhood drowning in Israel, between 2008 and 2022.

METHOD

It total, we identified 257 cases of child mortality due to drowning during this period.

RESULTS

Our results demonstrate a gradual rise in childhood mortality due to drowning, from 72 cases in 2008-2012, to 85 cases in 2013-2017, and to 100 cases in 2018-2022. Especially worth noting is the increase in childhood drowning in domestic swimming pools. We point to a link between low socioeconomic status and cases of drowning, showing that the risk of drowning extends beyond a mere matter of caregiver inattention. We recommend a series of regulatory and legislative steps to reduce fatal childhood drowning, including fencing built around domestic swimming pools, extending lifeguard activity hours, adding declared beaches, forming programs of safe behavior in water environments for adolescents, and establishing swimming lessons during the 2nd grade, for all populations. We further recommend that a special focus will be put in municipalities situated at the bottom of the socioeconomic index.

From unequal injuries to unequal learning? Socioeconomic gradients in childhood concussions and the impact on children's academic performance

Previous research identifies stark socioeconomic disparities in child injuries, yet research on the repercussions hereof on other aspects of children's lives remains sparse. This paper tests whether social gradients in minor traumatic brain injuries (mTBIs or concussions) contribute to corresponding inequalities in children's academic performance. Previous research on this topic is mostly based on small samples and confounded by non-random selection into experiencing mTBIs. We improve on prior research by using high quality, large N, administrative registry data. Further, we control for selection into having an mTBI via comparing the test score progression of children having an mTBI with children who experience an mTBI in later years (staggered difference-in-differences). Based on Danish ER/hospital records and national test score data, we find that children from families with lower earnings and less education are more likely to experience an mTBI and that having an mTBI negatively correlates with reading test scores. However, comparing present with future mTBI cases, we show that having an mTBI within a year before a test does not negatively affect children's reading scores. Our findings suggest that negative correlations between mTBIs and academic performance more likely reflect socioeconomic gradients in mTBI incidents rather than a direct causal effect. Further, socioeconomic gradients in mTBI incidents do not significantly contribute to corresponding disparities in academic performance.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

INTRODUCTION

Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions.

METHODS

A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status).

RESULTS

Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls).

DISCUSSION

Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified.

CONCLUSION

This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Influence of High School Socioeconomic Status on Athlete Injuries during the COVID-19 Pandemic: An Ecological Study

Background

It is presently unclear how the cessation of high school sport has affected injury incidence at different socioeconomic levels. The COVID-19 pandemic may have disproportionately affected athletes of lower socioeconomic status, potentially increasing injury risk in this population.

Purpose

To 1) Describe athlete injury incidence prior to and during the 2019-2020 and 2020-2021 school years in high school athletes by socioeconomic status; 2) Investigate the association between socioeconomic status and injury incidence in high school athletes.

Study Design

Ecological Study.

Methods

High schools were matched between the 2019-2020 and 2020-2021 school years. All athletes from all sports were included. High school socioeconomic status was determined by the school district median household income. Socioeconomic strata were defined as <$30,000, $30,000-50,000, $50,001-100,000, and >$100,000. Injury incidence proportion with 95% confidence interval (95% CI) was calculated for each academic year. Mixed effects negative binomial models with robust errors were performed to assess the association between the incidence proportion ratio and high school median household income. Six states and 176 high schools were included (2019-2020: 98,487 athletes; 2020-2021: 72,521 athletes).

Results

Injury incidence increased in three of four socioeconomic strata during the 2020-2021 year (<$30,000: 2019-2020: 15.6 (13.1-18.1), 2020-2021: 26.3 (23.1-29.6); $30,000-50,000: 2019-2020: 7.8 (7.1-8.6), 2020-2021: 14.9 (13.8-15.9); $50,001-100,000: 2019-2020: 15.1 (14.7-15.4), 2020-2021: 21.3 (20.9-21.8); >$100,000: 2019-2020: 18.4 (18.1-18.8), 2020-2021: 17.3 (16.8-17.7)). An association was observed between injury incidence ratio and log median high school household income in 2019-2020 [1.6 (1.1-2.5)] but not 2020-2021 [1.1 (0.8-1.6)] school years.

Conclusions

Athletes from lower socioeconomic high schools reported increased injury incidence compared to higher socioeconomic high schools during the 2020-2021 academic school year. These results highlight the increased COVID-19 pandemic vulnerability in athletes from lower socioeconomic high schools. High school sport stakeholders should consider how abrupt sport stoppage can affect lower socioeconomic athletes.

Level of Evidence

2.

The association between improved standard of living and paediatric burns

INTRODUCTION

In the "Children's Hospital Zagreb Referral Centre for Paediatric Trauma of the Ministry of Health Republic of Croatia (MHC)" we observed a significant decline in the number of both hospitalised and ambulatory treated paediatric patients with burn injuries in the period from 2011 to 2018. Our hypothesis is that this decline could be either due to the decline of the paediatric population of Croatia or due to the economic growth and the improvement in the standard of living that Croatians have enjoyed in the past decade.

MATERIALS AND METHODS

In this observational study, we analysed data on the numbers of patients treated due to burn injuries from January 2011 to December 2018 in the Children's Hospital Zagreb Hospital. Indicators of standard of living and population size estimates were obtained from Eurostat and the Croatian Bureau of Statistics. Associations between the proportion of people with poor standard of living and the number of treated patients were analysed with logistic regression models.

RESULTS

Percentage of the population with low housing standards, percentage of Croatians with low level of education, percentage of children that live in jobless households, and percentage of children at risk of poverty and social exclusion were predictors of the rate of hospital admissions, ambulatory treated patients and total number of treatments. The slight decrease in the rate of treated patients was interrupted with notable decline in 2014 followed by the slight increase in 2015. Over following years, the rate did not change remarkably.

CONCLUSION

Apart from the decline of the paediatric population of Croatia, it is reasonable to assume that the improvement in the standard of housing, level of education and employment rate as well as the reduction in the risk of poverty and social exclusion in children had a notable contribution to the decline in the rate of paediatric burns in the observed period.

Sports injuries patterns in children and adolescents according to their sports participation level, age and maturation

Background

Growth can make young athletes more vulnerable to sports injuries. Increased knowledge about injury profile and its predictors is an important part of an overall risk management strategy but few studies have produced information.

Methods

Information about injury profile and sports participation (SP) level was obtained by LESADO and RAPIL II questionnaires. They were distributed to 651 participants aged between 10 and 18 years attending four schools. Maturity measures were evaluated through maturity offset (MO) and Tanner-Whitehouse III method. Bivariate analysis was used to identify the set of candidate predictors for multinomial logistic regression analysis that was used to determine significant predictors of injury type and body area injury location.

Results

Regarding injury type predictors recreative boys had more chances of having a sprain or a fracture than a strain. Also, recreative and scholar girls had more chances of having a sprain than a strain. As MO decreased, the chances of girls having a strain or a fracture when compared to sprains were higher. For body area location boys with 10–11 years were more likely to have upper limbs injuries than boys of other ages. This was also confirmed by MO. Spine and trunk injuries were more likely to occur in federate and no sports participation girls.

Conclusions

Injury type and body area injury location differed significantly by SP level, age group and MO.

Can Injuries Be Predicted by Functional Movement Screen in Adolescents? The Application of Machine Learning

ABSTRACT

Karuc, J, Mišigoj-Duraković, M, Šarlija, M, Marković, G, Hadžić, V, Trošt-Bobić, T, and Sorić, M. Can injuries be predicted by functional movement screen in adolescents? The application of machine learning. J Strength Cond Res 35(4): 910-919, 2021-This study used machine learning (ML) to predict injuries among adolescents by functional movement testing. This research is a part of the CRO-PALS study conducted in a representative sample of adolescents and analyses for this study are based on nonathletic (n = 364) and athletic (n = 192) subgroups of the cohort (16-17 years). Sex, age, body mass index (BMI), body fatness, moderate-to-vigorous physical activity (MVPA), training hours per week, Functional Movement Screen (FMS), and socioeconomic status were assessed at baseline. A year later, data on injury occurrence were collected. The optimal cut-point of the total FMS score for predicting injury was calculated using receiver operating characteristic curve. These predictors were included in ML analyses with calculated metrics: area under the curve (AUC), sensitivity, specificity, and odds ratio (95% confidence interval [CI]). Receiver operating characteristic curve analyses with associated criterium of total FMS score >12 showed AUC of 0.54 (95% CI: 0.48-0.59) and 0.56 (95% CI: 0.47-0.63), for the nonathletic and athletic youth, respectively. However, in the nonathletic subgroup, ML showed that the Naïve Bayes exhibited highest AUC (0.58), whereas in the athletic group, logistic regression was demonstrated as the model with the best predictive accuracy (AUC: 0.62). In both subgroups, with given predictors: sex, age, BMI, body fat percentage, MVPA, training hours per week, socioeconomic status, and total FMS score, ML can give a more accurate prediction then FMS alone. Results indicate that nonathletic boys who have lower-body fat could be more prone to suffer from injury incidence, whereas among athletic subjects, boys who spend more time training are at a higher risk of being injured. Conclusively, total FMS cut-off scores for each subgroup did not successfully discriminate those who suffered from those who did not suffer from injury, and, therefore, our research does not support FMS as an injury prediction tool.

The influence of behavioural and socioeconomic factors on the community injury rates of adolescents assessed by the south Korean emergency medical services: an ecological approach

Background

Aim of this study is to determine if peer group risk behaviors and neighbourhood socioeconomic status (SES) would ecologically affect injury incidence according to place and gender among adolescents (aged 13–15) in South Korea.

Methods

Three variables from the Korea Youth Risk Behavior Survey (2014) were used to represent peer group risk behaviours; current alcohol consumption (cAlc), the experience of violence or bullying (VicVB), and having undergone education for injury prevention (Edu-IP). The Korea Census Data (2010) was used for neighborhood SES; the degree of urbanization, the proportion of high educational attainment, and the proportion of low residential environment. The nationwide and regional Incidence-Rates of Injury assessed by EMS (IRI-EMS) were calculated according to age and gender based on the number of injuries from EMS record (2014). A linear regression model was used to examine associations.

Results

The nationwide total and inside-school IRI-EMS were 623.8 and 139.3 per 100,000 population, respectively. The range of the regional IRI-EMS showed a maximum of about 4 times the difference from 345 to 1281 per 100,000 population depending on the region. The low residential environment had a significant effect on the increase of total IRI-EMS (β = 7.5, 95% CI 0.78–14.21). In the case of boys, the IRI-EMS inside-school was increased as the percentage of VicVB was higher (β = 17.0, 95% CI 1.09–32.91). In the case of girls, the IRI-EMS outside-school was increased in rural compared to urban location (β = 211.3, 95% CI 19.12–403.57).

Conclusion

The incidence rate of outside-school was higher than that of inside-school, and incidence rate of boys was higher than that of girls. Peer group risk behaviors were significant only in the injury of boys. Among the SES factors, rural area was a significant factor in girls, especially outside-school injury. Moreover, the rate of households not in an apartment was significant in all outside-school injury and outside-school injury of boys.

Our study suggests that among native South Korean adolescents, neighbourhood SES and peer group risk behavior have different effects depending on the injury context such as place of occurrence or gender.

An epidemiological evaluation of fractures and its determinants among Lebanese schoolchildren: a cross-sectional study

The purpose of this study is to establish the prevalence and determinants of fractures among 974 Lebanese schoolchildren aged 8-18. Fractures might be less common in the Lebanese pediatric population compared to western populations. Male gender and high SES are independent risk factors for fractures, while 25(OH)D and BMI have no impact.

PURPOSE

To establish the prevalence of fractures among Lebanese schoolchildren and its relationship with age, gender, BMI, 25 hydroxyvitamin D (25(OH)D) levels, and socioeconomic status (SES).

METHODS

In this cross-sectional study, 974 Lebanese schoolchildren aged 8-18 years old, mean age 13.37 ± 2.92 (508 boys and 466 girls), were recruited from 10 schools with different SES. For each participant, a questionnaire was used to collect data regarding history of fractures. Serum 25(OH)D was also measured.

RESULTS

The prevalence of Lebanese children sustaining ≥ 1 fracture was 16.9% and was higher in boys compared to girls (22.2% vs 11.1%, p < 0.0001). A 71.3% of fractures were localized in the upper limbs and 20% of participants had at least one displaced fracture. Children who sustained a fracture had a non-significant higher BMI compared to those without (p = 0.096). The percentage of children with fractures was higher in children from high SES compared to those from middle and low SES (respectively 23.3% vs. 16.3% and 13.8%, p < 0.0001). Fractures occurred at a younger age in girls compared to boys, but this difference was non-significant (p = 0.13). 25(OH)D levels were significantly higher in children with fractures compared to those without (p = 0.017). Finally, female gender was protective against upper limb fractures (p = 0.009). In a logistic regression analysis, male gender and high SES were independently associated with fractures, while BMI and 25(OH)D were not.

CONCLUSION

Our study demonstrates that the prevalence of fractures in the Lebanese pediatric population might be lower than western populations. It also confirms that male gender and high SES are independent risk factors for fractures, while 25(OH)D and BMI were not independently associated with fracture risk.

Socioeconomic variation in injury hospitalisations in Australian children ≤ 16 years: a 10-year population-based cohort study

BACKGROUND

Childhood injury remains a significant public health problem responsible for significant morbidity and mortality. However, injury has been found to increase with socioeconomic disadvantage for some injuries. The current study examines the 10-year epidemiological profile of injury hospitalisations of children ≤16 years by socioeconomic status for different age group and select types of injury.

METHOD

A retrospective analysis of injury hospitalisations of children aged ≤16 years using linked hospitalisation and mortality records during 1 July 2002 to 30 June 2012 was conducted. Negative binomial regression was used to calculate incidence rate ratios (IRRs) for injury hospitalisation rates by socioeconomic disadvantage quintile.

RESULTS

There were 679,171 injury hospitalisations for children aged 0-16 years in Australia. Children in more disadvantaged socioeconomic quintiles were more likely to be hospitalised for an injury sustained by: assault (IRR range 1.40 to 3.64), poisoning (IRR range 1.29 to 1.36), heat and hot substances (IRR range 1.07 to 1.34), and pedestrian collisions (IRR range 1.06 to 1.54) than children in advantaged socioeconomic quintiles.

CONCLUSIONS

Findings support the notion that the risk of injury hospitalisation among children differs according to socioeconomic gradient and has implications for childhood injury prevention. Policy makers should consider socioeconomic differences in the design of injury prevention measures, particularly measures directed at modifying the built environment and home-based interventions.

Socioeconomic status, gender, and burn injury: A retrospective review

Burn injury rates appear to be influenced by socioeconomic status (SES) and gender globally, but the impact of poverty and gender on burn injury has not been studied in a developed country. This study was a retrospective chart review conducted at a regional burn center in the Southwest US that included 340 patients with TBSA burns >15%. SES was determined using zip code and US census data. The distribution of mechanism of injury was significantly different by gender (χ²(6) = 36.14, p < 0001), but not significantly different by SES (χ²(12) = 19.68, p = 0.073). Burn rates in women was found to have a significant and linear increase (χ² = 13.8513, p = 0.001) with increasing poverty. Women had higher frequencies of being burned at home, and men had higher frequencies of being burned at work. While poverty did not appear to increase the risk of burn injury overall in a mixed population, it was associated with a significant increase in the risk of burn injury in women. Thus, strategies for decreasing risk factors should be targeted toward low SES females and the working male.

A new version of the HBSC Family Affluence Scale - FAS III: Scottish Qualitative Findings from the International FAS Development Study

A critical review of the Family Affluence Scale (FAS) concluded that FAS II was no longer discriminatory within very rich or very poor countries, where a very high or a very low proportion of children were categorised as high FAS or low FAS respectively (Currie et al. 2008). The review concluded that a new version of FAS - FAS III - should be developed to take into account current trends in family consumption patterns across the European region, the US and Canada. In 2012, the FAS Development and Validation Study was conducted in eight countries - Denmark, Greenland, Italy, Norway, Poland, Romania, Slovakia and Scotland. This paper describes the Scottish qualitative findings from this study. The Scottish qualitative fieldwork comprising cognitive interviews and focus groups sampled from 11, 13 and 15 year-old participants from 18 of the most- and least- economically deprived schools. These qualitative results were used to inform the final FAS III recommendations.

An evaluation of the impact of 'Lifeskills' training on road safety, substance use and hospital attendance in adolescence

PURPOSE

To evaluate if attendance at Lifeskills, a safety education centre for children in Year 6 (10-11 years), is associated with engagement in safer behaviours, and with fewer accidents and injuries, in adolescence.

METHODS

The sample are participants in the Avon Longitudinal Study of Parents and Children who attended school in the Lifeskills catchment area in Year 6; 60% attended Lifeskills. At 14-15 years, participants (n approximately 3000, varies by outcome) self-reported road safety behaviours and accidents, and perceived health effects and use of alcohol, cannabis, and tobacco. Additional outcomes from linkage to Hospital Episodes Statistics were available for a sub-sample (n=1768): hospital admittance (for accident-related reason, from 11-16 years) and A&E attendance (for any reason, from approximately 14-16 years).

RESULTS

Children who attended Lifeskills were more likely to report using pedestrian crossings on their way to school than children who did not attend (59% versus 52%). Lifeskills attendance was unrelated to the ownership of cycle helmets, or the use of cycle helmets, seat belts, or reflective/fluorescent clothing, or to A&E attendance. Use of cycle helmets (37%) and reflective/fluorescent clothing (<4%) on last cycle was low irrespective of Lifeskills attendance. Lifeskills attendance was associated with less reported smoking and cannabis use, but was generally unrelated to perceptions of the health impact of substance use.

CONCLUSIONS

Lifeskills attendance was associated with some safer behaviours in adolescence. The overall low use of cycle helmets and reflective/fluorescent clothing evidences the need for powerful promotion of some safer behaviours at Lifeskills and at follow-up in schools.

Use of geographic information systems to assess the error associated with the use of place of residence in injury research

Background

In any spatial research, the use of accurate location data is critical to the reliability of the results. Unfortunately, however, many of the administrative data sets used in injury research do not include the location at which the injury takes place. The aim of this paper is to examine the error associated with using place of residence as opposed to place of injury when identifying injury hotspots and hospital access.

Methods

Traumatic Brian Injury (TBI) data from the BC Trauma Registry (BCTR) was used to identify all TBI patients admitted to BC hospitals between January 2000 and March 2013. In order to estimate how locational error impacts the identification of injury hotspots, the data was aggregated to the level of dissemination area (DA) and census tract (CT) and a linear regression was performed using place of residence as a predictor for place of injury.

In order to assess the impact of locational error in studies examining hospital access, an analysis of the driving time between place of injury and place of residence and the difference in driving time between place of residence and the treatment hospital, and place of injury and the same hospital was conducted.

Results

The driving time analysis indicated that 73.3 % of the injuries occurred within 5 min of place of residence, 11.2 % between five and ten minutes and 15.5 % over 20 min. Misclassification error occurs at both the DA and CT level. The residual map of the DA clearly shows more detailed misclassification.

As expected, the driving time between place of residence and place of injury and the difference between these same two locations and the treatment hospital share a positive relationship. In fact, the larger the distance was between the two locations, the larger the error was when estimating access to hospital.

Conclusions

Our results highlight the need for more systematic recording of place of injury as this will allow researchers to more accurately pinpoint where injuries occur. It will also allow researchers to identify the causes of these injuries and to determine how these injuries might be prevented.

Socioeconomic status and the incidence of child injuries in China

Injuries are the major cause of morbidity among children and one of the leading causes of death for children ages 1-17 years in developing countries. Of particular importance is whether child injuries are equally distributed across all socioeconomic groups and the implications of this question for child injury prevention, but there is a lack of research on the relationship between socioeconomic status and risk of child injuries in developing countries, including China. This study used a provincially-representative, population-based sample of 98,385 Chinese children under age 18 to investigate the relationships between socioeconomic status (SES) and child injuries. Despite the lack of a SES gradient in the overall incidence of nonhospitalized injuries, evidence of SES disparity was found for the overall incidence of H/PD injuries (injuries resulting in hospitalization or permanent disability) and fatal injuries. The odds of getting injured in the poorest wealth quintile were about 1.3 and 3.5 times greater than the odds found in the richest wealth quintile for H/PD and fatal injuries respectively. Further analyses showed that the associations between SES and injuries varied by type and severity of injury, and across different life stages. The findings have important implications for identifying at-risk populations and the optimal times for interventions to reduce different types and severity levels of child injuries.

Trends and socioeconomic correlates of adolescent physical fighting in 30 countries

BACKGROUND AND OBJECTIVES

No recent international studies provide evidence about its prevalence, trends, or social determinants of physical fighting in adolescents. We studied cross-national epidemiologic trends over time in the occurrence of frequent physical fighting, demographic variations in reported trends, and national wealth and income inequality as correlates.

METHODS

Cross-sectional surveys were administered in school settings in 2002, 2006, and 2010. Participants (N = 493874) included eligible and consenting students aged 11, 13, and 15 years in sampled schools from 30 mainly European and North American countries. Individual measures included engagement in frequent physical fighting, age, gender, participation in multiple risk behaviors, victimization by bullying, and family affluence. Contextual measures included national income inequality, absolute wealth and homicide rates. Temporal measure was survey cycle (year).

RESULTS

Frequent physical fighting declined over time in 19 (63%) of 30 countries (from descriptive then multiple Poisson regression analyses). Contextual measures of absolute wealth (relative risk 0.96, 95% confidence interval 0.93-0.99 per 1 SD increase in gross domestic product per capita) but not income inequality (relative risk 1.01, 95% confidence interval 0.98-1.05 per 1 SD increase) related to lower levels of engagement in fighting. Other risk factors identified were male gender, younger age (11 years), multiple risk behaviors, victimization by bullying, and national homicide rates.

CONCLUSIONS

Between 2002 and 2010, adolescent physical fighting declined in most countries. Specific groups of adolescents require targeted violence reduction programs. Possible determinants responsible for the observed declines are discussed.

Adolescent involvement in anti-social and delinquent behaviours: predicting future injury risk

The purpose of this study was to challenge the broadly based focus of injury prevention strategies towards concern with the needs of young adolescents who engage in multiple anti-social and delinquent behaviours. Five hundred and forty 13-14-year olds reported on injuries and truancy, violence, illegal road behaviours, drug, and alcohol use. Engagement in these behaviours was found to contribute to the likelihood of an injury. Those engaging in the most anti-social and delinquent behaviours were around five times more likely to report medically-treated injuries in the past three months. Their likelihood of future injury was 1.8 times more likely when they were followed up three months later. The engagement in multiple delinquent and illegal behaviours thus significantly increased the likelihood of injury and identifies a particularly vulnerable group. The findings also suggest that reaching these young people represents a key target for change strategies in injury prevention programs.

Pattern of fractures across pediatric age groups: analysis of individual and lifestyle factors

Background

Knowledge of the epidemiology of children's fractures is essential to develop preventive strategies. The aim of this study was to analyze the individual/lifestyle determinants of fractures across pediatric age groups.

Methods

A cross-sectional study was performed in the first six months of 2008 through questionnaire on a sample of children from an outpatient clinic for pediatric fractures. Differences in gender, anatomic site, circumstances and location of fracture occurrence, behavioural lifestyle, and calcium intake were investigated among three different age classes (pre-school children, school children, and adolescents).

Results

The sample consisted of 382 subjects (2-14 years of age) sustaining a fracture after low or moderate trauma. Males were at a higher risk of fractures than females; greater than two-thirds of injuries occurred after low-energy trauma and the upper limb was more frequently involved. With increasing age, the male/female ratio and time spent in sports participation increased (p < 0.001), while calcium intake and time spent in sedentary behaviors decreased (p < 0.001 and < 0.003, respectively). Gender discordance existed in pre-school children with respect to the anatomic location, and in school children and adolescents with respect to the dynamics. In the adolescent group, males were more physically active and also more sedentary than females. Fractures most frequently occurred in homes (41.6%), followed by playgrounds and footpaths (26.2%), sports facilities (18.3%), and educational facilities (13.9%), with gender differences existing only in adolescence. Twenty-three percent of the subjects sustained one or more fractures in the past. The percentage of recurrent fractures increased with age (p = 0.001), with a similar trend in both genders.

Conclusions

Gender differences were shown in the prevalence of injuries, characteristics, and circumstances across ages. These differences may be explained by the related changes in behaviors, together with attending different places. Individual and lifestyle factors can in part explain the variability in the occurrence of fractures and can also address targeted preventive strategies.

The role of community in pediatric injury

Cultural variations between communities may impact injury rates, especially among children. We conducted a retrospective study of three communities in Israel using data from the Israel National Trauma Registry (1998-2007). Pediatric injury hospitalization rates in urban communities with varied levels of socio-economic status (low, medium, and high) were compared for all injuries and cause-specific injuries. Age-standardized and age-specific rates were calculated. Age-standardized injury hospitalization rates were lowest for the low socio-economic status (SES) community (299.7, 95% confidence interval [CI] 289.8-309.6) compared to the medium SES (658.2, 95% CI 629.1-687.3) and high SES (443.7, 95% CI 422.2-465.3) communities. Similar rates were observed for injuries from falls, transportation, accidental striking and intentional causes. For example, rate ratios for falls were 149.1 (95% CI 142.0-156.2), 340.8 (95% CI 319.5-362.1) and 245.7 (229.9-261.5) in the low, medium and high SES communities, respectively. Deviations from these overall trends were noted, however, for pedestrian injuries and burns that were relatively higher in the low SES community and injuries from motorized vehicles that were greater among children living in the high SES community. These results suggest that strong social capital is associated with reduced pediatric injury risks regardless of community wealth. However, targeted interventions for reducing injuries in at-risk populations that rely solely on injury rates may omit culturally distinct communities and overlook their uneven burden to the trauma care system.

Safety standards and socioeconomic disparities in school playground injuries: a retrospective cohort study

Background

Playground injuries are fairly common and can require hospitalization and or surgery. Previous research has suggested that compliance with guidelines or standards can reduce the incidence of such injuries, and that poorer children are at increased risk of playground injuries.

Objective

The objective of this study was to determine the association between playground injury and school socioeconomic status before and after the upgrading of playground equipment to meet CSA guidelines.

Methods

Injury data were collected from January 1998-December 1999 and January 2004 - June 2007 for 374 elementary schools in Toronto, Canada. The objective of this study was to investigate the effect of a program of playground assessment, upgrading, and replacement on school injury rates and socio-economic status. Injury rates were calculated for all injuries, injuries that did not occur on equipment, and injuries on play equipment. Poisson regression was performed to determine the relationship between injury rates and school socio-economic status.

Results

Prior to upgrading the equipment there was a significant relationship between socio-economic status and equipment-related injuries with children at poorer schools being at increased risk (Relative risk: 1.52 [95% CI = 1.24-1.86]). After unsafe equipment was upgraded, the relationship between injury and SES decreased and was no longer significant (RR 1.13 [95% CI = 0.95-1.32]).

Conclusions

Improvements in playground equipment can result in an environment in which students from schools in poorer neighbourhoods are no longer at increased risk of injuries on play equipment.

Area socioeconomic status and childhood injury morbidity in New South Wales, Australia

OBJECTIVE

To explore the relationship between child injury morbidity and socioeconomic status.

DESIGN

A cross-sectional analysis of routinely collected hospital separation data for unintentional injury for the period 1999/2000-2004/2005.

SETTING

All statistical local areas of New South Wales (NSW), Australia

SUBJECTS

110 549 unintentional injury-related hospital separations for NSW children aged 0-14 years.

MAIN OUTCOME MEASURE

Adjusted incidence rate ratios (IRRs) for hospital separations for unintentional injury (for all injury and by individual injury mechanisms) by quintile of socioeconomic disadvantage for children aged 0-14 years.

RESULTS

There was no clear relationship between socioeconomic status and injury when all injury mechanisms were combined. However, children in the more disadvantaged quintiles were more likely to be hospitalized than children in the least disadvantaged quintile for the following injury mechanisms: motor cycle (point estimates for IRRs across the socioeconomic status quintiles ranged from 2.95 to 4.02 relative to the least disadvantaged quintile), motor-vehicle occupant (IRR range 1.33-2.27), pedestrian (IRR range 1.43-2.54 for ages 0-4 years), pedal cyclist (IRR range 1.30-1.50), fire and burns (IRR range 1.37-2.00), and poisoning (IRR range 1.32-1.91). Similarly, hospital separation rates for foreign body, other transport, and pedestrian (aged 5-9 years) injuries were also greater, but the differences were not statistically significant across all quintiles. These injury mechanisms accounted for about 25% of the hospital separations.

CONCLUSIONS

The relationship between relative socioeconomic disadvantage and injury risk in NSW children is strongest for transport-related injuries, fires and burns, and poisoning. Interventions that address these specific injury mechanisms may help to reduce the disparity between high and lower socioeconomic groups.

Social and economic factors associated with the risk of burn injury

Socioeconomic status (SES) factors have been associated with the risk of burn, but the relative significance of these findings across populations and cultures is not known. The purpose of this literature synthesis was to determine: (1) which SES factors have been associated with burn risk; (2) whether these factors are generalizable across studies; and (3) which of these factors are modifiable. A search of studies of SES and burn risk published between January 1992 and September 2006 yielded 34 pertinent studies. SES risk factors were placed into categories pertaining to ethnicity, income, family structure, education, occupation, residence, and general SES. SES factors associated with increased risk included: ethnicity (non-white), low income, large families, single parents, illiteracy, low maternal education, unemployment, job loss, substandard living conditions, not owning a home, not having a telephone, and crowding. The lack of standard definitions for SES, as well as the heterogeneity of study populations and outcome variables, limits the generalizability of these results. However, the results confirm that several SES factors are associated with increased risk of burn and provide a template of factors to be considered when studying burn populations.

Gender differences in adolescent injury characteristics: A population-based study of hospital A&E data

OBJECTIVES

To investigate patterns of adolescent home/leisure injury serious enough to require hospital attendance.

STUDY DESIGN

Population-based analysis of data collected by the Home and Leisure Accident Surveillance System (HASS/LASS).

METHODS

Study subjects were 0-17 year old residents of Airdrie and Coatbridge, Lanarkshire, Scotland, who attended Monklands Hospital Accident and Emergency (A&E) Department with a home/leisure injury during calendar years 1996-1999. Male to female relative risk ratios (M:F RRRs) for A&E attendance, fracture and hospital admission, stratified into sports and non-sports injuries, were calculated. Sports injuries were further analysed by specific sports and by whether the sports activity was organized or informal. Data were analysed in age groups corresponding to children's stage of schooling.

RESULTS

The M:F RRR for non-sports A&E attendances remained constant throughout childhood (1.35, 95% CI 1.30-1.39 in 0-17 year olds), whilst that for sports attendances increased sharply with age (2.50, 95% CI 0.89-7.02 in 0-4 year olds, increasing to 8.11, 95% CI 6.27-10.51 in 16-17 year olds). Of sports injury attendances, 50.3% were football-related. Football was overwhelmingly the main cause of boys' sports injury in both the organized and informal sports injury categories. When football injuries were excluded from the analysis, the widening teenage gender gap in injury risk disappeared. There was no significant gender difference in teenagers' rates of A&E attendance for injuries sustained during compulsory school physical education (PE), suggesting a dose-response relationship between sports participation and injury risk.

CONCLUSIONS

This study found significant gender inequalities in adolescent injury risk, which were largely attributable to boys' football injuries. Focusing prevention efforts on making football safer would, then, be a sensible strategy for reducing the overall burden of adolescent injury and for reducing sex inequalities in injury risk; however further research is needed to understand how the risks differ between organized and informal football. These findings are also interesting because of what they suggest about teenage girls' lack of participation in sport and habitual physical activity. This is clearly of public health concern because of the links between physical inactivity and a range of health problems.

Multilevel analysis of associations between socioeconomic status and injury among Canadian adolescents

STUDY OBJECTIVE

To determine the contribution of individual and area level measures of socioeconomic status (SES) to the occurrence of various injury types among Canadian adolescents.

DESIGN AND SETTING

Cross sectional Canadian data were used from two sources: (1) the 2001/02 health behaviour in school aged children survey (individual level SES measures, injury measures), and (2) the 2001 Canada census of population (area level SES measures). Injury outcomes included: medically treated injury, injury hospitalisation, sport/recreational injury, and fighting injury. Multilevel logistic regression models were used to examine individual and area level SES measures as potential determinants of adolescent injury.

PARTICIPANTS

7235 students in grades 6-10 from 170 schools across Canada.

MAIN RESULTS

Associations between SES and injury were identified for each injury outcome examined, although a clear direction of association was not present for the overall measure of medically treated injury. In general, lower SES was associated with increased risk for hospitalised and fighting injury. Higher SES was associated with increased risks for sport/recreational injury. Independent contributions of individual and area level measures of SES were seen for hospitalised and fighting injury.

CONCLUSIONS

Associations between SES and adolescent injury exist; however, the direction of these relations becomes more apparent with particular indicators of SES and when homogenous injury outcomes are evaluated.

The regional differences in prevalence, medical expenditures and risk factors for injury in Taiwanese teenagers

Background

Injury is the leading cause of death in teenagers worldwide. In Taiwan, people in mountainous areas have a 4 to 8 years shorter life span than the general population. Injury among teenagers is likely a major cause. The objective of this study was to investigate the regional differences in the prevalence, the risk factors, and the medical expenditures for injury among Taiwanese teenagers.

Method

An equal probability national sample was used. In addition, representative samples from mountainous areas and offshore islands were used. Only those who aged between 12 and 21 years, and signed the consent form permitting us to link their National Health Insurance (NHI) claim data were included in the analysis. Injury-related visits and expenditures in outpatient services were extracted from the NHI data. Logistic regression was used to examine the factors associated with injury. For those who had injury related outpatient visits, mixed model was used to examine the factors associated with medical expenditures accounting for multiple visits by the same individual.

Results

The prevalence of nonfatal injury was around 30% of teenagers in Taiwan. It was 10% higher in mountainous areas. Factors associated with injury were those who lived in mountainous areas (adjusted odds ratio [OR]: 1.7; 95%; confidence interval [CI]: 1.3–2.3), males (OR: 1.3; 95%; CI: 1.1–1.6), older teens (18–21 years old), and those with risk behavior were positively associated with injury. These factors were also associated with the number of injury-related outpatient visits. However, teenagers in mountainous areas did not spend more on medical care than those who lived in metropolitan Taiwan.

Conclusion

Around 30% of the teenagers were injured in a year, not including the dead. Each of the injured spent at least 851.4NTD (~27USD) for outpatient visits. The scope of the problem was not trivial. Hazardous environments and high-risk behaviors were the universal causes. In remote areas, lack of medical resources was another possibility. Empowering local people to design prevention programs according to their needs is recommended.

Social equalization in youth: evidence from a cross-sectional British survey

BACKGROUND

A number of studies have suggested that social inequalities in health disappear or are attenuated in early adolescence possibly due to changing risk exposures. The present study examines social equalization in youth in a representative sample of British households with children aged 0-18 years.

METHODS

Secondary analysis of a cross-sectional survey of a representative sample of British households with children and youth with parent-reported less than good health, long-standing illness, and chest problems as outcomes.

RESULTS

Data were available on 15 756 children aged 0-18 years in 8541 households in the third sweep (2001) of the British government's Families and Children Study. Parent-rated health status, long-standing illness, and chest problems all showed social patterning among children who were 0-11 years of age. Among 12- to 14-year-olds, the social gradients in these outcomes noted in childhood associated with income, social class, and education were lost but inequalities in parent-rated health status and long-standing illness but not chest problems persisted associated with measures of household work status and wealth. Among 15- to 18-year-olds, income inequalities appeared to reassert themselves, particularly among girls, but gradients by maternal education noted among 0- to 11-year-olds were absent in both sexes. Inequalities persisted with measures of household worklessness and wealth.

CONCLUSIONS

In this cross-sectional study, the social equalization in youth was noted for some health outcomes and by some measures of socioeconomic status but not for others. Inequalities in parent-rated health status and long-standing illness persist among young people in workless households and those experiencing severe material hardship.

Cross national study of injury and social determinants in adolescents

OBJECTIVES

To compare estimates of the prevalence of injury among adolescents in 35 countries, and to examine the consistency of associations cross nationally between socioeconomic status then drunkenness and the occurrence of adolescent injury.

DESIGN

Cross sectional surveys were obtained from national samples of students in 35 countries. Eight countries asked supplemental questions about injury.

SETTING

Surveys administered in classrooms.

SUBJECTS

Consenting students (n = 146 440; average ages 11-15 years) in sampled classrooms. 37 878 students (eight countries) provided supplemental injury data.Exposure measures: Socioeconomic status (material wealth, poverty) and social risk taking (drunkenness).

OUTCOME MEASURES

Specific types and locations of medically treated injury.

RESULTS

By country, reports of medically treated injuries ranged from 33% (1060/3173) to 64% (1811/2833) of boys and 23% (740/3172) to 51% (1485/2929) of girls, annually. Sports and recreation were the most common activities associated with injury. High material wealth was positively (OR>1.0; p<0.05) and consistently (6/8 countries) associated with medically treated and sports related injuries. Poverty was positively associated with fighting injuries (6/8 countries). Drunkenness (social risk taking) was positively (p<0.01) and consistently (8/8 countries) associated with medically treated, street, and fighting injuries, but not school and sports related injuries.

CONCLUSION

The high prevalence of adolescent injury confirms its importance as a health problem. Social gradients in risk for adolescent injury were illustrated cross nationally for some but not all types of adolescent injury. These gradients were most evident when the etiologies of specific types of adolescent injury were examined. Prevention initiatives should focus upon the etiologies of specific injury types, as well as risk oriented social contexts.

Socioeconomic status and non-fatal injuries among Canadian adolescents: variations across SES and injury measures

Background

While research to date has consistently demonstrated that socioeconomic status (SES) is inversely associated with injury mortality in both children and adults, findings have been less consistent for non-fatal injuries. The literature addressing SES and injury morbidity among adolescents has been particularly inconclusive. To explore potential explanations for these discrepant research findings, this study uniquely compared the relationship across different measures of SES and different causes of injury (recreation versus non-recreation injuries) within a sample of Canadian adolescents.

Methods

The sample included adolescent participants (aged 12 to 19 years) in the Canadian 1996–1997 cross-sectional National Population Health Survey (n = 6967). Five SES measures (household income, two neighbourhood-level proxy measures, two parental indicators) were examined in relation to three injury outcomes (total, recreation, and non-recreation injuries) using multivariable logistic regression.

Results

Among males, a clear relationship with injury was observed only for a parental SES index, which was positively associated with total and recreation injuries (odds ratios for the highest versus lowest SES category of 1.9 for total and 2.5 for recreation injuries). Among females, there was some evidence of a positive relationship between SES and injuries, particularly for a neighbourhood-level education measure with total and recreation injuries (odds ratios of 1.7 for total and 2.0 for recreation injuries).

Conclusion

The results suggest that differences related to the measures of SES chosen and the causes of injury under study may both contribute to discrepancies in past research on SES and non-fatal injuries among adolescents. To clarify the potential SES-injury relationship among youth, the findings emphasize a need for a greater understanding of the meaning and relevance of different SES measures for adolescents, and for an exploration of the pathways through which SES may be related to injury risk.

Socioeconomic status and health: do gradients differ within childhood and adolescence?

Socioeconomic status (SES) gradients may not be static across the lifespan, but instead may vary in strength across different life stages. This study examined the periods in childhood when SES and health relationships emerge and are strongest among US children. Data came from the National Health Interview Survey, 1994, a cross sectional, nationally representative sample of 33,911 US children ages 0-18. Parents were asked about family SES and child health status. Global health measures included overall ratings of child health, activity and school limitations. Acute conditions included childhood injuries and respiratory illnesses. For all global child health measures, lower family SES was associated with poorer child health in a gradient fashion (P < .001); these differences did not vary across age. For specific conditions, interaction effects of SES with age were found (P < .05). Interaction effects revealed that for injury and acute respiratory illness, expected SES gradients (lower SES with poorer outcomes) were evident during adolescence. In contrast, respiratory illness had a reverse SES gradient in early childhood. In sum, for global child health measures, associations of lower SES with poorer health throughout childhood suggest that factors that do not change with age (e.g., health care quality) may best explain overall health status. However, for acute conditions, the relationship between low SES and poor child health appears most consistently during adolescence. This suggests that normal development-related changes during adolescence, such as increasing peer group affiliation, may help explain these gradients. These patterns are important to understand for optimally timing interventions to reduce SES disparities in US children's health.

Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland

BACKGROUND

With the increase in the amount of medical data handled by emergency units, advances in computerisation have become necessary. New computer technology should have a major influence on accident analysis and prevention and the quality of research in the future.

OBJECTIVES

To investigate the occurrence of sports related maxillofacial injuries using a newly installed relational database. To establish the first sports trauma database in Switzerland.

METHODS

The Qualicare databank was used to prospectively review 57 248 case histories of patients treated in the Department of Emergency Medicine between January 2000 and December 2002. Pre-defined key words were used to collect data on sports related maxillofacial injuries.

RESULTS

A total of 750 patients with maxillofacial injuries were identified. Ninety (12%) were sports related maxillofacial fractures. Most (27%) were sustained during skiing and snowboarding, 22% during team sports such as soccer or ice hockey, and 21% were from cycling accidents. Sixty eight per cent of the cyclists, 50% of the ice hockey players and soccer players, and 48% of the skiers and snowboarders had isolated fractures of the midface. Fractures of the mandible were noted predominantly in contact sports.

CONCLUSIONS

Computerisation of trauma and emergency units and the introduction of customised software can significantly reduce the workload of researchers and doctors. The effective use of new computer technology should have a considerable influence on research and the quality of future prospective and retrospective studies.

Injury morbidity in an urban and a rural area in Tanzania: an epidemiological survey

Background

Injuries are becoming a major health problem in developing countries. Few population based studies have been carried out in African countries. We examined the pattern of nonfatal injuries and associated risk factors in an urban and rural setting of Tanzania.

Methods

A population-based household survey was conducted in 2002. Participants were selected by cluster sampling. A total of 8,188 urban and 7,035 rural residents of all ages participated in the survey. All injuries reported among all household members in the year preceding the interview and resulting in one or more days of restricted activity were included in the analyis.

Results

A total of 206 (2.5%) and 303 (4.3%) persons reported to have been injured in the urban and rural area respectively. Although the overall incidence was higher in the rural area, the incidence of major injuries (≥ 30 disability days) was similar in both areas. Males were at a higher risk of having an injury than females. Rural residents were more likely to experience injuries due to falls (OR = 1.6; 95% CI = 1.1 – 2.3) and cuts (OR = 4.3; 95% CI = 3.0 – 6.2) but had a lower risk of transport injuries. The most common causes of injury in the urban area were transport injuries and falls. In the rural area, cuts and stabs, of which two thirds were related to agriculture, formed the most common cause. Age was an important risk factor for certain types of injuries. Poverty levels were not significantly associated with experiencing a nonfatal injury.

Conclusion

The patterns of injury differ in urban and rural areas partly as a reflection of livelihoods and infrastructure. Rural residents are at a higher overall injury risk than urban residents. This may be important in the development of injury prevention strategies.

Individual and contextual effects in injury morbidity in Barcelona (Spain)

OBJECTIVE

To determine the relationship between socioeconomic level (measured through individual educational level and material deprivation in the areas of residence) and injury morbidity in different age groups and in males as well as in females.

DESIGN

Cross-sectional survey.

SETTING

Barcelona (Spain).

METHODS

The study population included all cases over the age of 19 who, as a result of an injury (motor vehicles injuries, falls, hits and cuts), were admitted to the emergency departments of the six main hospitals of the city during the years 1990-1991. Age- and sex-specific morbidity rates were calculated for each educational level and each cause of injury. The contextual variable included was the proportion of unemployment in each neighbourhood. Multilevel Poisson regression models were fitted.

RESULTS

Morbidity rates were higher in males, in young people and for lower educational levels. Results from the multilevel models show that, at contextual level, neighbourhoods with more unemployment present a higher risk of injuries. At individual level, after adjusting for contextual variables, the risk of sustaining injuries was higher among young men and women for all injury causes except falls among women where the risk was higher in the elderly; among both men and women, the risk of sustaining injury was higher in the population with lower educational level (RR = 1.79, 95% CI = 1.73-1.86 in men; RR = 2.12, 95% CI = 2.04-2.21 in women). This trend was also observed separately for traffic injuries, falls, hits and cuts.

CONCLUSION

Our results provide information about individual and contextual social inequalities in injury morbidity, the highest risks of injury occur in individuals of lower educational level and who reside in the more private neighbourhoods. These results underscore the need to implement injury prevention strategies not only at the individual level, but also to tailor them to the socioeconomic position of the population.

Evidence on equalisation in health in youth from the West of Scotland

Many studies report few socioeconomic (SES) differences in health in youth, a pattern contrasting with that of health inequalities in childhood and adulthood. This paper focuses on the child-youth transition to examine the hypothesis of equalisation in health over this period. Specifically, we test two hypotheses: (a) that equalisation is more likely for health state measures (physical and malaise symptoms and accidents) than health status ([limiting] longstanding illness and self-rated health) or health potential (height), and (b) that the patterning of health over this period is similar between occupational (social class) and non-occupational (deprivation, housing tenure and family affluence) SES measures. Data are derived from the West of Scotland 11 to 16 cohort, followed from late childhood (aged 11) through early (13) to mid (15) adolescence. The results showed very little evidence of SES differences in (limiting) longstanding illness at any age for both sexes, while self-rated health exhibited some differentiation, and height (as expected) consistent gradients throughout. By contrast, among males evidence of equalisation was found for both physical and malaise symptoms and pedestrian road traffic accidents (RTAs). Among females, equalisation was confined to specific physical symptoms, pedestrian RTAs, sports injuries and burns/scalds, while for malaise symptoms a reverse gradient at age 11 strengthened with age. These patterns were generally unaffected by the SES measure used. We conclude that while some of the evidence is consistent with the equalisation hypothesis, it needs extending to accommodate patterns of no SES differences, and particularly reverse gradients, in childhood. These patterns may reflect the increasingly pervasive influence of youth culture, suggesting that in the UK the boundary between childhood and youth should be set at an earlier age. This in turn suggests that international comparisons have considerable analytic potential for identifying the conditions under which equalisation does and does not occur.

Equalisation of socioeconomic differences in injury risks at school age? A study of three age cohorts of Swedish children and adolescents

The objective of the study was to investigate whether there is equalisation of socioeconomic differences in injury risks among Swedish children and adolescents. Equalisation was defined as a reduction in relative differences in risks between socioeconomic groups. All Swedish children and adolescents aged 5-19 in 1990 were grouped into three age cohorts and allocated to four household socioeconomic statuses, considering boys and girls separately. Each cohort was then followed up over a 5-year period (1990-1994) with regard to three injury diagnosis groups (as registered in the national Hospital Discharge and Causes of Death registers) with documented socioeconomic differences: injuries due to traffic, interpersonal violence, and self-infliction. The Relative Index of Inequality was used to measure the magnitude of relative socioeconomic differences, for each year of observation. Where applicable, relative risks were computed in order to see whether equalisation benefited all socioeconomic groups. Tendencies of equalisation were found among girls for two of the diagnosis groups: in traffic injuries for the youngest cohort (aged 5-9 in 1990) and in the case of self-inflicted injuries within the two older cohorts (10-14 and 15-19, in 1990). In conclusion, this study provides limited evidence of equalisation in injury risks between socioeconomic groups among Swedish adolescents. Equalisation appears to be a gender-specific phenomenon, that is, among girls, and manifests itself around the age of 5-13 in traffic-related injuries, when girls are in first and second levels of compulsory school, and later on in self-inflicted injuries. Given the economic recession in Sweden at the time of the study period, whether the equalisation processes are attributable to school, peer group and youth culture effects-as hypothesised by West-is debatable, particularly in the case of self-inflicted injuries.

Behavioural characteristics and accidents: findings from the Health Survey for England, 1997

This study analysed the relationship between major and minor accidents, and major accidents involving a moving vehicle, and behavioural and emotional factors in children, aged 4-15 years, using the Strengths and Difficulties Questionnaire (SDQ), and adjusting for demographic, socio-economic and family type factors. Data from a large representative national sample of about 6000 children were analysed using simple and multiple logistic regression. The analysis shows that the prevalence of SDQ scales, such as hyperactivity and conduct disorder were significantly higher in boys, lower social classes and step- and single-parent families. After adjusting for the demographic, socio-economic and family type factors, children who scored borderline or high for hyperactivity were almost two times more likely to report having major accidents. Children who scored high for hyperactivity and emotional symptoms were one and a half times more likely to report having minor accidents. For major accidents involving moving vehicles, the relationships with the behavioural and emotional factors were generally stronger than for major accidents in general. Hyperactivity, in particular, was significantly associated with the occurrence of major and minor accidents, and major accidents involving moving vehicles. The behavioural risk factors were significantly more common in the lower social classes, families receiving benefits and step- and single-parent families.

The relationship between traumatic dental injuries and adolescents' development along the life course

Few models have been proposed to explain the aetiology of traumatic dental injuries. Those that have, focus on risk factors at present stage of life. The contribution of risk factors for dental injuries at different stages of life needs to be investigated.

OBJECTIVES

To test the relationship between life course experiences and the occurrence of traumatic dental injuries in adolescents.

METHODS

A cross-sectional survey was used to collect data retrospectively. Out of a total number of 764 eligible 13-year-old-adolescents enrolled in private and public schools located in urban areas in the town of Cianorte, Brazil, 652 (85%) agreed to participate in the study. They were interviewed and examined for traumatic dental injuries by two trained dental epidemiologists using validated criteria. The interviews collected information on socioeconomic circumstances, family related variables, school grade and anthropometric measures (height and weight).

RESULTS

Adolescent boys, those from non-nuclear families, those reporting high levels of paternal punishment and those who were at lower grades at school for their age were more likely to experience dental injuries than girls, adolescents from nuclear families, those reporting low levels of paternal punishment and those who were at higher grades at school.

CONCLUSION

It was concluded that adolescents who experienced adverse psychosocial environments along the life course had more traumatic dental injuries than their counterparts who experienced more favourable environments.

Risk factors for childhood major and minor head and other injuries in a nationally representative sample

OBJECTIVE

To assess the relationship between demographic, socioeconomic, family type and behavioural factors and childhood major and minor head and other injuries.

DESIGN, SUBJECTS AND SETTING

A cross-sectional study, on a large nationally representative sample of 5913 children aged 4-15 years (Health Survey for England, 1997).

MAIN OUTCOME MEASURES

Frequency of major and minor head and other injuries.

RESULTS

There were no significant associations between any of the socioeconomic factors and family type and major and minor injuries, except for major head injuries in children who lived in families receiving more than one social or financial benefit. Boys were 1.5 times more likely to suffer major head and other injuries than girls. Older children were significantly more likely to experience major and minor other injuries, but less likely to have major and minor head injuries, compared to younger children. High scores for conduct disorder and emotional symptoms were significant risk factors for other major injuries, while high scores for hyperactivity and conduct disorder were significantly related to major and minor head injuries. The risk factors assessed were often stronger for major than for minor injuries, and stronger for head than other injuries.

CONCLUSION

Boys and children who exhibit certain behavioural problems such as high levels of hyperactivity were significantly more likely to report major and minor injuries affecting the head region.

Socioeconomic variation in injury in children and older people: a population based study

OBJECTIVES

To compare hospital admission rates for all causes and specific causes of injury in children and the elderly by a measure of economic deprivation.

STUDY DESIGN

All emergency admissions for Welsh residents from 1997-99 were located to one of 865 electoral tracts, which were grouped into fifths using a measure of socioeconomic deprivation. Standardised admission rates for all ages and 0-14, 15-75, and 75+ year groups for each quintile were calculated with 95% confidence intervals.

RESULTS

There were 90 935 admissions in a population of 2.84 million yielding a crude admission rate of 1601/100 000/year and a standardised rate of 1493/100 000. The ratio of admissions in deprived and affluent areas varied with category of injury and age group. In general, socioeconomic variations in injury rates were much smaller in older people than in children with the exception of pedestrian related injuries where the rates were similar. The largest variations were for injuries sustained in assaults or self inflicted.

CONCLUSIONS

The relationship between socioeconomic position and injury varies by cause and age group. This should be considered when developing area based preventive interventions or monitoring the effectiveness of policies to reduce inequalities in injury occurrence.

Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents

This study used the Canadian version of the World Health Organization-Health Behaviour in School-Aged Children (WHO-HBSC) Survey to examine the role of multiple risk behaviours and other social factors in the etiology of medically attended youth injury. 11,329 Canadians aged 11-15 years completed the 1997-1998 WHO-HBSC, of which 4152 (36.7%) reported at least one medically attended injury. Multiple logistic regression analyses failed to identify an expected association between lower socio-economic status and risk for injury. Strong gradients in risk for injury were observed according to the numbers of multiple risk behaviours reported. Youth reporting the largest number (7) of risk behaviours experienced injury rates that were 4.11 times (95% CI: 3.04-5.55) higher than those reporting no high risk behaviours (adjusted odds ratios for 0-7 reported behaviours: 1.00, 1.13, 1.49, 1.79, 2.28, 2.54, 2.62, 4.11; p(trend) < 0.001). Similar gradients in risk were observed within subgroups of young people defined by grade, sex, and socio-economic level, and within restricted analyses of various injury types (recreational, sports, home, school injuries). The gradients were especially pronounced for severe injury types and among those reporting multiple injuries. The analyses suggest that multiple risk behaviours may play an important role in the social etiology of youth injury, but these same analyses provide little evidence for a socio-economic risk gradient. The findings in turn have implications for preventive interventions.

Injury inequalities: morbidity and mortality of 0-17 year olds in Israel

BACKGROUND

To determine whether there are inequalities in the incidence of fatal and non-fatal unintentional injuries among Jewish and Arab children in Israel.

METHODS

A nationwide random sample of injured children aged 0-17 attending emergency rooms (ER) during one year was selected (n = 11 058). The number of cases was weighted to 365 days and rates and odds ratios (OR) were calculated. Logistic regression was performed to study the OR of hospitalization in the total population and among Jews and Arabs controlling for independent variables.

RESULTS

The incidence of ER admissions among the Jews was 752.6/10 000 (95% CI: 738.1-767.1), 1.5 times higher than among the Arabs (492.8/10 000, 95% CI: 472.8-512.8). However, the rate of hospitalization was 1.1 times higher among Arabs than among Jews and the mortality rate was 3.2 times higher among Arabs than among Jews.

CONCLUSIONS

The differences in injury rates for fatal and non-fatal injuries may be due to differences in the severity of injuries or in the use of services by the two populations. A study is underway to elucidate this point.

Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7

OBJECTIVE

To determine the relation between morbidity from injury and deprivation for different levels of injury severity and for different injury mechanisms for children aged 0-14 years.

DESIGN

Cross sectional survey of routinely collected hospital admission data for injury 1992-7.

SETTING

862 electoral wards in Trent Region.

SUBJECTS

21 587 injury related hospital admissions for children aged 0-4 years and 35 042 admissions for children aged 5-14.

MAIN OUTCOME MEASURES

Rate ratios for hospital admission for all injuries, all injuries involving long bone fracture, and all injuries involving long bone fracture requiring an operation; rate ratios for hospital admission for six types of injury mechanism divided by quintiles of the electoral wards' Townsend scores for deprivation. Rate ratios calculated by Poisson regression, with adjustment for distance from nearest hospital admitting patients with injuries, rurality, ethnicity, and percentage of males in each electoral ward.

RESULTS

Both total number of admissions for injury and admissions for injuries of higher severity increased with increasing socioeconomic deprivation. These gradients were more marked for 0-4 year old children than 5-14 year olds. In terms of injury mechanisms, the steepest socioeconomic gradients (where the rate for the fifth of electoral wards with the highest deprivation scores was > or =3 times that of the fifth with the lowest scores) were for pedestrian injuries (adjusted rate ratio 3.65 (95% confidence interval 2.94 to 4.54)), burns and scalds (adjusted rate ratio 3.49 (2.81 to 4.34)), and poisoning (adjusted rate ratio 2.98 (2.65 to 3.34)).

CONCLUSION

There are steep socioeconomic gradients for injury morbidity including the most common mechanisms of injury. This has implications for targeting injury prevention interventions and resources.

Social class gradients in health during adolescence

STUDY OBJECTIVE

To review existing data on social class gradients in adolescent health and to examine whether such gradients exist in new data concerning US adolescents.

DESIGN

Review of relevant publications and unpublished data; regression analyses using adolescent self reported health status data to determine whether there are gradients by social class, using three classes categorised by adolescent reported parental work status and education.

PARTICIPANTS

Adolescents of ages 11-17.

MAIN RESULTS

Findings from the literature indicate the presence of social class gradients in some but not all aspects of adolescent health. Results from new data showed social class gradients in several domains of health and in profiles of health. The likelihood of being satisfied with one's health, of being more resilient (better family involvement, better problem solving, more physical activity, better home safety), having higher school achievement, and of being in the best health profiles were significantly and progressively greater as social class rose. Moreover, the probability of being in the poorest health profile type group was progressively higher as social class declined.

CONCLUSIONS

The review of existing data and the new findings support the existence of social class gradients in satisfaction with one's health, in resilience to health threats, in school achievement, and in being in the best health overall (as manifested by the health profiles composed of four major domains of health). The study had two especially notable findings: (1) the paucity of studies using the same or similar indicators, and (2) the consistent existence of social class gradients in characteristics related to subsequent health, particularly intake of nutritional foods and physical activity. The sparseness of existing data and the different aspects of health investigated in the relatively few studies underscore the need for (1) the development of conceptual models specifically focused on adolescent health and social class; (2) additional inquiry into the measurement of social class and adolescent perceptions of class; (3) inclusion of contextual variables in study design; and (4) longitudinal cohort studies to better understand the specific determinants of health during adolescence.

Recreational injury and its relation to socioeconomic status among school aged children in the US

OBJECTIVES

This study described epidemiologic patterns of recreational injuries among school aged children in the US and assessed the relation of these patterns to socioeconomic status.

METHODS

Combined data from the 1997-98 National Health Interview Surveys for 38 458 children aged 6-17 years regarding non-fatal recreational injury episodes that received medical attention, reported by a household adult, were analysed. Logistic regression analysis was used to assess the association between recreational injury and socioeconomic status while controlling for confounding factors.

RESULTS

The annualized rate of recreational injury was 91.2 episodes per 1,000 children, with an increased risk associated with a higher family income status or being non-Hispanic white. For children from not poor families, most injury episodes occurred in sport facilities, whereas for children from poor and near poor families, most occurred outside the home.

CONCLUSION

Recreational injury is a significant health problem for school aged children in the US. Non-Hispanic white children and children from affluent families are at increased risk of recreational injury.

Socioeconomic differences in children's health: how and why do these relationships change with age?

The effects of socioeconomic status (SES) on health are well documented in adulthood, but far less is known about its effects in childhood. The authors reviewed the literature and found support for a childhood SES effect, whereby each decrease in SES was associated with an increased health risk. The authors explored how this relationship changed as children underwent normal developmental changes and proposed 3 models to describe the temporal patterns. The authors found that a model's capacity to explain SES-health relationships varied across health outcomes. Childhood injury showed stronger relationships with SES at younger ages, whereas smoking showed stronger relationships with SES in adolescence. Finally, the authors proposed a developmental approach to exploring mechanisms that link SES and child health.

Socioeconomic differences in childhood injury: a population based epidemiologic study in Ontario, Canada

OBJECTIVE

To determine whether risks for childhood injury vary according to socioeconomic gradients.

DESIGN

Population based, retrospective study. The percentage of individuals living below the poverty line (described ecologically using census data) was the primary measure of socioeconomic status.

SETTING

Catchment area of a tertiary medical centre that provides emergency services to all area residents. Area residents aged 0-19 years during 1996 were included.

OBSERVATIONS

Injuries that occurred during 1996 were identified by an emergency department based surveillance system. The study population was divided into socioeconomic grades based upon percentages of area residents living below the poverty line. Multiple Poisson regression analyses were used to quantify associations and assess the statistical significance of trends.

RESULTS

5894 childhood injuries were identified among 35380 eligible children; 985 children with missing socioeconomic data were excluded. A consistent relation between poverty and injury was evident. Children in the highest grade (indicating higher poverty levels) experienced injury rates that were 1.67 (95% confidence interval 1.48 to 1.89) higher than those in the lowest grade (adjusted relative risk for grades 1-V: 1.00,1.10,1.22,1.42, 1.67; Ptrend < 0.001). These patterns were observed within age/sex strata; for home, recreational, and fall injuries; and for injuries of minor and moderate severities.

CONCLUSIONS

Socioeconomic differences in childhood injury parallel mortality and morbidity gradients identified in adult populations. This study confirms that this health gradient is observable in a population of children using emergency department data. Given the population based nature of this study, these findings are likely to be reflected in other settings. The results suggest the need for targeted injury prevention efforts among children from economically disadvantaged populations, although the exact requirements of the optimal prevention approach remain elusive.

Unintentional injury mortality and socio-economic development among 15-44-year-olds: in a health transition perspective

Injury imposes one of the greatest health risks in terms of mortality and morbidity among 15-44-y-olds. There is evidence that socio-economic development (SED) is related to injury risk, but the findings are inconsistent. We aimed to study the magnitude, pattern and relative importance of unintentional injury mortality (UIM) in relation to SED in this age group. Cross-sectional data on UIM by age-sex specific groups were obtained for 54 countries from the World Health Statistics Annuals 1993-1995. The relationship between UIM and SED (measured in gross national product (GNP) per capita) was studied using two methods: (1) with regression analysis, and (2) by categorizing the data into four income-based country groups and then comparing the differences in their mean values. The results were: (1) UIM rates were inversely correlated with GNP per capita and the relationship became stronger with increasing age (r=-0.22 for both sexes in the 15-24-y-olds, r=-0.65 for males, r=-0.54 for females in the 35-44-y-olds); (2) there was an increase in UIM rates between low-income and lower-middle-income countries (LoMIC), but a decrease between LoMIC and upper middle-income (UpMIC), and finally also a significant decrease between UpMIC and high-income countries in most age-sex groups (ie P<0.005 for males, P<0.05 for females in the 35-44-y-olds). The highest rates of UIM were in LoMIC for all age-sex groups. Male rates were consistently higher than female in all age groups. In conclusion, SED was inversely related to UIM. There was an initial positive relation between GNP per capita and UIM, which became negative with increasing GNP per capita. We also found a health transition that had taken place in all country groups.