Socioeconomic status and the occurrence of fatal and nonfatal injury in the United States

Explaining the Persistence of Health Disparities: Social Stratification and the Efficiency-Equity Trade-off in the Kidney Transplantation System

Why do health disparities persist when their previous mechanisms are eliminated? Fundamental-cause theorists argue that social position primarily improves health through two metamechanisms: better access to health information and technology. I argue that the general, cumulative, and embodied consequences of social stratification can produce another metamechanism: an efficiency-equity trade-off. A case in point is kidney transplantation, where the mechanisms previously thought to link race to outcomes--ability to pay and certain factors in the kidney allocation system--have been greatly reduced, yet large disparities persist. I show that these current disparities are rooted in factors that directly influence posttransplant success, placing efficiency and racial/ethnic equity at cross-purposes.

Suicides, homicides, accidents, and other external causes of death among blacks and whites in the Southern Community Cohort Study

Prior studies of risk factors associated with external causes of death have been limited in the number of covariates investigated and external causes examined. Herein, associations between numerous demographic, lifestyle, and health-related factors and the major causes of external mortality, such as suicide, homicide, and accident, were assessed prospectively among 73,422 black and white participants in the Southern Community Cohort Study (SCCS). Hazard ratios (HR) and 95% confidence intervals (CI) were calculated in multivariate regression analyses using the Cox proportional hazards model. Men compared with women (HR = 2.32; 95% CI: 1.87-2.89), current smokers (HR = 1.74; 95% CI: 1.40-2.17), and unemployed/never employed participants at the time of enrollment (HR = 1.67; 95% CI 1.38-2.02) had increased risk of dying from all external causes, with similarly elevated HRs for suicide, homicide, and accidental death among both blacks and whites. Blacks compared with whites had lower risk of accidental death (HR = 0.46; 95% CI: 0.38-0.57) and suicide (HR = 0.55; 95% CI: 0.31-0.99). Blacks and whites in the SCCS had comparable risks of homicide death (HR = 1.05; 95% CI: 0.63-1.76); however, whites in the SCCS had unusually high homicide rates compared with all whites who were resident in the 12 SCCS states, while black SCCS participants had homicide rates similar to those of all blacks residing in the SCCS states. Depression was the strongest risk factor for suicide, while being married was protective against death from homicide in both races. Being overweight/obese at enrollment was associated with reduced risks in all external causes of death, and the number of comorbid conditions was a risk factor for iatrogenic deaths. Most risk factors identified in earlier studies of external causes of death were confirmed in the SCCS cohort, in spite of the low SES of SCCS participants. Results from other epidemiologic cohorts are needed to confirm the novel findings identified in this study.

Do neighborhood demographics, crime rates, and alcohol outlet density predict incidence, severity, and outcome of hospitalization for traumatic injury? A cross-sectional study of Dallas County, Texas, 2010

BACKGROUND

Unintentional injury leads all other causes of death for those 1 to 45 years old. The expense of medical care for injured people is estimated to exceed $406 billion annually. Given this burden on the population, the Centers for Disease Control and Prevention consistently refers to injury prevention as a national priority. We postulated that exposure to crime and the density of alcohol outlets in one's neighborhood will be positively associated with the incidence of hospitalization for and mortality from traumatic injuries, independent of other neighborhood characteristics.

METHODS

We conducted a cross-sectional study with ecological and individual analyses. Patient-level data for traumatic injury, injury severity, and hospital mortality due to traumatic injury in 2010 were gathered from the Dallas-Fort Worth Hospital Council Foundation. Each case of traumatic injury or death was geospatially linked with neighborhood of origin information from the 2010 U.S. Census within Dallas County, Texas. This information was subsequently linked with crime data gathered from 20 local police departments and the Texas Alcoholic Beverage Commission alcohol outlet dataset. The crime data are the Part One crimes reported to the Federal Bureau of Investigation.

RESULTS

The proportion of persons 65 years old or older was the strongest predictor of the incidence of hospitalization for traumatic injury (b = 12.64, 95% confidence interval (CI) 8.73 to 16.55). In turn, the incidence of traumatic injury most strongly predicted the severity of traumatic injury (b = 0.008, 95% CI 0.0003 - 0.0012). The tract-level unemployment rate was associated with a 5% increase in the odds of hospital mortality among hospitalized trauma patients.

CONCLUSIONS

Several neighborhood characteristics were associated with the incidence, severity, and hospital mortality from traumatic injury. However, crime rates and alcohol outlet density carried no such association. Prevention efforts should focus on neighborhood characteristics such as population density, mean age of the residents, and unemployment rate, regardless of crime rates and alcohol outlet density.

Prevalence of epilepsy--an unknown quantity

The incidence, prevalence, and mortality of epilepsy vary across countries with different economies. Differences can be explained by methodological problems, premature mortality, seizure remission, socioeconomic factors, and stigma. Diagnostic misclassification-one possible explanation-may result from inclusion of patients with acute symptomatic or isolated unprovoked seizures. Other sources of bias include age and ethnic origin of the target population, definitions of epilepsy, retrospective versus prospective ascertainment, sources of cases, and experienced and perceived stigma. Premature mortality is an issue in low-income countries (LICs), where treatment gap, brain infections, and traumatic brain injuries are more common than in high-income countries (HICs). Death rates may reflect untreated continued seizures or inclusion of acute symptomatic seizures. Lack of compliance with antiepileptic drugs has been associated with increased risk for death, increased hospital admissions, motor vehicle accidents, and fractures in poor communities. Epilepsy is a self-remitting clinical condition in up to 50% of cases. Studies in untreated individuals from LICs have shown that the proportion of remissions overlaps that of countries where patients receive treatment. When the identification of patients is based on spontaneous reports (e.g., door-to-door surveys), patients in remission may be less likely to disclose the disease for fear of stigmatization with no concurrent benefits. This might lead to underascertainment of cases when assessing the lifetime prevalence of epilepsy. In LICs, the proportion of people living in poverty is greater than in HICs. Poverty is associated with risk factors for epilepsy, risk for developing epilepsy, and increased mortality. The high incidence and prevalence of epilepsy found in LICs is also observed in low income individuals from HICs. Epileptogenic conditions are associated with an increased mortality. This may partly explain the difference between incidence and lifetime prevalence of epilepsy in LICs. Poverty within LICs and HICs could be a preventable cause of mortality in epilepsy.

Home safety education and provision of safety equipment for injury prevention (Review)

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD. There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92). Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96). Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Korean Youth Risk Behavior Surveillance Survey

This study investigated the association between in-school students’ part-time work and 1-year suicide attempts in Korea. The authors analyzed Korean Youth Risk Behavior Surveillance data (2008), which included 75 238 samples that represent Korean middle and high school students. Multiple logistic regression analysis was performed to investigate the association between part-time work and suicide attempt during the past 1 year, controlled by sociodemographic, school-related, lifestyle, and psychological factors. Among high school students, there was no association between part-time work and suicide attempts. However, part-time work was associated with suicide attempts significantly among middle school students (odds ratio = 1.59; 95% confidence interval = 1.37-1.83). Despite the limitation that details of the part-time work were not included in this study, it was found that middle school students’ part-time work may increase suicide attempts, and the circumstances of Korean adolescents’ employment, especially that of younger adolescents, would need to be reconsidered to prevent their suicide attempts.

Study on the trend and disease burden of injury deaths in Chinese population, 2004-2010

Injuries are a growing public health concern in China, accounting for more than 30% of all Person Years of Life Lost (PYLL) due to premature mortality. This study analyzes the trend and disease burden of injury deaths in Chinese population from 2004 to 2010, using data from the National Disease Surveillance Points (DSPs) system, as injury deaths are classified based on the International Classification of Disease-10(th) Revision (ICD-10). We observed that injury death accounted for nearly 10% of all deaths in China throughout the period 2004-2010, and the injury mortality rates were higher in males than those in females, and higher in rural areas than in urban areas. Traffic crashes (33.79-38.47% of all injury deaths) and suicides (16.20-22.01%) were the two leading causes of injury deaths. Alarmingly, suicide surpassed traffic crashes as the leading cause of injury mortality in rural females, yet adults aged 65 and older suffered the greatest number of fatal falls (20,701 deaths, 2004-2010). The burden of injury among men (72.11%) was about three times more than that of women's (28.89%). This study provides indispensible evidence that China Authority needs to improve the surveillance and deterrence of three major types of injuries: Traffic-related injury deaths should be targeted for injury prevention activities in all population, people aged 65+ should be encouraged to take individual fall precautions, and prevention of suicidal behavior in rural females should be another key priority for the government of China.

The social side of accidental death

Mortality from unintentional injuries, or accidents, represents major and understudied causes of death in the United States. Epidemiological studies show social factors, such as socioeconomic and marital status, relate with accidental death. But social theories posit a central role for social statuses on mortality risk, stipulating greater relevance for causes of death that have been medically determined to be more preventable than others. These bodies of work are merged to examine deaths from unintentional injuries using 20years of nationally representative survey data, linked to prospective mortality. Results indicate that socially disadvantaged persons were significantly more likely to die from the most preventable and equally likely to die from the least preventable accidental deaths over the follow-up, compared to their more advantaged counterparts. This study extends our knowledge of the social contributors to a leading cause of death that may have substantial implications on overall disparities in length of life.

Socioeconomic disparity in inpatient mortality after traumatic injury in adults

BACKGROUND

Prior studies have demonstrated that race and insurance status predict inpatient trauma mortality, but have been limited by their inability to adjust for direct measures of socioeconomic status (SES) and comorbidities. Our study aimed to identify whether a relationship exists between SES and inpatient trauma mortality after adjusting for known confounders.

METHODS

Trauma patients aged 18-65 years with an Injury Severity Scores (ISS) of ≥9 were identified using the 2003-2009 Nationwide Inpatient Sample. Median household income (MHI) by zip code, available by quartiles, was used to measure SES. Multiple logistic regression analyses were performed to determine odds of inpatient mortality by MHI quartile, adjusting for ISS, type of injury, comorbidities, and patient demographics.

RESULTS

In all, 267,621 patients met inclusion criteria. Patients in lower wealth quartiles had significantly greater unadjusted inpatient mortality compared with the wealthiest quartile. Adjusted odds of death were also higher compared with the wealthiest quartile for Q1 (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.06-1.20), Q2 (OR, 1.09; 95% CI, 1.02-1.17), and Q3 (OR, 1.11; 95% CI, 1.04-1.19).

CONCLUSION

MHI predicts inpatient mortality after adult trauma, even after adjusting for race, insurance status, and comorbidities. Efforts to mitigate trauma disparities should address SES as an independent predictor of outcomes.

Vulnerable roadway users struck by motor vehicles at the center of the safest, large US city

BACKGROUND

Road safety constitutes an international crisis. In 2010, 11,000 pedestrians and 3,500 bicyclists were injured by motor vehicles in New York City. This study aims to identify the demographics, behaviors, injuries, and outcomes of vulnerable roadway users struck by motor vehicles in New York City's congested central business district and surrounding periphery.

METHODS

A prospective, descriptive study of pedestrians and bicyclists struck by motor vehicles and treated at a Level I regional trauma center was performed. Data were collected between December 2008 and June 2011 by interviewing patients and first responders supplemented with imaging and outcomes variables. Main outcome measures included patient demographics, behavior patterns, scene-related data, Injury Severity Score (ISS), and outcomes including mortality. Multivariate ordinal logistic regression modeling was performed to isolate effects of predictor variables on outcome of ISS categories.

RESULTS

Injured pedestrians (n = 1,075) and bicyclists (n = 382) differ by age (p < 0.001), sex (p < 0.001), ethnicity/race (p < 0.001), and involved motor vehicle type (p < 0.001). Pedestrians sustain more severe/critical injuries (p < 0.001) and hospital admissions (p < 0.001). Bicyclists are more commonly struck by taxis (p < 0.001) and infrequently wear helmets (29.6%). Variables associated with low ISS include bicycling (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.29-0.63), above normal body mass index (AOR, 0.73; 95% CI, 0.54-0.99), Latino (AOR, 0.65; 95% CI, 0.46-0.94) or black (AOR, 0.63; 95% CI, 0.41-0.96) ethnicity/race, and struck by a taxicab (AOR, 0.50; 95% CI, 0.33-0.76) or turning vehicle (AOR,0.49; 95% CI, 0.34-0.70). Variables associated with high ISS include alcohol (AOR, 2.71; 95% CI, 1.81-4.05), age less than 18 years (AOR, 1.73; 95% CI, 1.05-2.86), hearing impairment (AOR, 2.24; 95% CI, 1.24-4.03), and struck by a truck or bus (AOR, 1.91; 95% CI, 1.18-3.10). Mortality was 1.2%.

CONCLUSION

Injured pedestrians and bicyclists represent distinct entities. Prevention modalities must be tailored accordingly with a focus on high-risk subgroups and compliance with traffic laws. Studying fatality or admissions data fail to capture the extent of the epidemic.

LEVEL OF EVIDENCE

Prospective epidemiologic study, level II.

Depression as a psychosocial consequence of occupational injury in the US working population: findings from the medical expenditure panel survey

BACKGROUND

Empirical evidence describing the psychosocial consequences of occupational injury is still limited. The effect of occupational injury on depression might pose unique challenges in workers compared with other kinds of injury. This study aimed to assess the differential impact of workplace injury compared with non-workplace injury on depression over time, and to identify the potential risk factors associated with post-injury depression in the US working population.

METHODS

Using pooled panel data from the Medical Expenditure Panel Survey 2000-2006, a total of 35,155 workers aged 18-64 years who had been followed for about 18 months in each panel were analyzed. Injuries in the 4-5 months before baseline, and subsequent depression incidence during follow-up, were identified using ICD-9 codes for the medical conditions captured in personal interviews. A discrete time-proportional odds model was used.

RESULTS

A total of 5.5% of workers with occupational injury at baseline reported depression at follow-up, compared with 4.7% of workers with non-occupational injury and 3.1% of workers without injuries. Those with occupational injuries had more severe injuries and required longer treatment, compared with those with non-occupational injuries. Only 39% of workers with workplace injuries were paid Workers' Compensation (WC). The association between injury and depression appeared to be stronger for workplace injury, and the adjusted odds ratio for depression was 1.72 for those with occupational injury (95% CI: 1.27-2.32), and 1.36 for those with non-occupational injury (95% CI: 1.07-1.65) compared with the no-injury group, after controlling for relevant covariates. Occupational injury was associated with higher odds of developing depression over time. WC as a source of medical payment was associated with 33% higher odds of developing depression (95% CI: 1.01-1.74). Part-time work, shorter job tenure, and long working hours were independently associated with post-injury depression risk.

CONCLUSIONS

Workers with occupational injury were more likely to become depressed than those with non-occupational injury. The psychosocial consequences of occupational injury, including depression, deserve further exploration to adequately support those injured at work. This finding also emphasizes a need for early intervention to reduce the burden of depression associated with occupational injury.

Unintentional Injuries among School-Aged Children in Palestine: Findings from the National Study of Palestinian Schoolchildren (HBSC-WBG2006)

Purpose. This study describes the nonfatal injuries among adolescents in Palestine. Methods. The 2006 Palestinian Health Behaviour in School-aged Children (HBSC) is a cross-sectional survey. Students of grades 6, 8, 10, and 12 completed a modified version of the international HBSC questionnaire, resulting in 15,963 students (47.3% boys and 52.7% girls) included in this study (56.9% from the West Bank and 43.1% from Gaza). Results. Of the total 15,963 adolescents, 47.6% were injured, with boys (53.5%) being statistically higher than girls (42.1%) (P<0.001). The prevalence of those injured more than once decreased by age and was also found significantly higher in boys than in girls (27.3% and 17.9%, resp.) (P<0.001). Children living in low FAS families showed significantly lower ratios of injuries than those living in moderate and high FAS families (P<0.001). Injuries while biking were significantly higher among boys (46.3%) than girls (41.7%) (P<0.001), and injuries while walking/running were more prevalent among girls (32.5%) than boys (28.0%) (P<0.001). Conclusion. Despite these considerably high rates, injury remains relatively underappreciated. Results of this study are useful to develop a national injury prevention program aimed at enhancing the safety of Palestinian adolescents.

Association between alcohol screening scores and mortality in black, Hispanic, and white male veterans

BACKGROUND

Scores on the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire are associated with mortality, but whether or how associations vary across race/ethnicity is unknown.

METHODS

Self-reported black (n = 13,068), Hispanic (n = 9,466), and white (n = 182,688) male Veterans Affairs (VA) outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1 to 4, 5 to 8, and 9 to 12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity.

RESULTS

Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1 to 4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p = 0.0022). Hispanic and white patients with scores of 0, 5 to 8, and 9 to 12 had significantly increased risk of death compared to those with scores of 1 to 4; Hispanic ORs: 1.93, 95% CI 1.50 to 2.49; 1.57, 1.07 to 2.30; 1.82, 1.04 to 3.17, respectively; white ORs: 1.34, 95% CI 1.29 to 1.40; 1.12, 1.03 to 1.21; 1.81, 1.59 to 2.07, respectively. Black patients with scores of 0 and 5 to 8 had increased risk relative to scores of 1 to 4 (ORs 1.28, 1.06 to 1.56 and 1.50, 1.13 to 1.99), but there was no significant increased risk for scores of 9 to 12 (ORs 1.27, 0.77 to 2.09). Post hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity.

CONCLUSIONS

Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically tailored feedback regarding medical consequences of drinking.

Outcome measurements in major trauma--results of a consensus meeting

BACKGROUND

The NHS Outcomes Framework for England has identified recovery from major injury as an important clinical area. At present, there are no established outcome indicators. As more patients survive major trauma, outcomes will need to be measured in terms of morbidity and not mortality alone.

OBJECTIVE

To make recommendations for a selection of outcome measures that could be integrated into National Clinical Audit data collection and form part of clinical governance requirements for Regional Trauma Networks (RTNs) and measures by which RTNs are held to account by government. Specific focus was given to acute care and rehabilitation for both adults and children.

METHOD

A Multiprofessional, multidisciplinary expert group reviewed the current evidence on outcome measures for major trauma in the adult and children's populations, informed by a systematic review carried out jointly by the Trauma Audit and Research Network (TARN) and the Cochrane Injuries Group. A structured discussion covered functional and quality of life outcome measures as well as patient experience and indicators such as return to work, education and social dependency.

RESULTS

For the adult population the group agreed with the in-hospital performance and hospital discharge measures recommended in the TARN and Cochrane systematic review. Concerning longer-term outcome indicators, the group suggested the use of the Glasgow Outcome Scale - Extended (GOS-E) and European Quality of Life 5D (EQ-5D) with consideration to be given to the World Health Organisation Quality of Life survey (WHO-QoL). For patients who had ongoing inpatient rehabilitation needs the group thought the measurement of the Rehabilitation Complexity Scale (RCS) and Functional Independence Measure (FIM) were important in total brain injury and, the American Spinal Injury Association Impairment Scale (ASIA) and Spinal Cord Independence Measure (SCIM) in spinal cord injury. For children the group recommended the use of the King's Outcome Scale for Childhood Head Injury (KOSCHI) and Paediatric Quality of Life measure (Peds-QL) preferably at multiple intervals following injury to take into account effects on development.

CONCLUSION

Specific recommendations were made for the use of outcome measures in adults and children with major trauma and those with complex rehabilitation needs following injury. More work on outcome measures in major trauma is needed especially for children. There are currently no robust measures of patient experience for use in major trauma. The importance of data linkage to allow measurement of non-clinical outcomes such as return to work, maintainence of education and societal dependency was emphasised by the group. A system for recording outcomes should be piloted post injury and at 6 and 12 months, with those still requiring inpatient rehabilitation after this time having longer follow up.

Effect of preexisting musculoskeletal diseases on the 1-year incidence of fall-related injuries

Objectives

People who have chronic diseases, as well as gait imbalance or psychiatric drug use, may be susceptible to injuries from falls and slips. The purpose of this study was to evaluate the effect of musculoskeletal diseases on incidental fall-related injuries among adults in Korea.

Methods

We analyzed data from the 4th Korea National Health and Nutrition Examination Survey (2007-2009), which are national data obtained by a rolling survey sampling method. The 1-year incidence of fall-related injuries was defined by health service utilization within the last year due to injury occurring after a slip and fall, and musculoskeletal diseases included osteoarthritis, rheumatoid arthritis, osteoporosis, and back pain. To evaluate the effects of preexisting musculoskeletal diseases, adults diagnosed before the last year were considered the exposed group, and adults who had never been diagnosed were the unexposed group.

Results

The weighted lifetime prevalence of musculoskeletal disease was 32 540 per 100 000 persons. Musculoskeletal diseases were associated with a higher risk of fall-related injury after adjustment for sex, age, residence, household income, education, occupation, visual disturbance, paralysis due to stroke, and medication for depression (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.03 to 1.93). As the number of comorbid musculoskeletal diseases increased, the risk of fall-induced injuries increased (p-value for trend <0.001). In particular, patients who had any musculoskeletal condition were at much higher risk of recurrent fall-related injuries (OR, 6.20; 95% CI, 1.06 to 36.08).

Conclusions

One must take into account the risk of fall-related injuries and provide prevention strategies among adults who have musculoskeletal diseases.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Spatial clusters of suicide in the municipality of São Paulo 1996-2005: an ecological study

BACKGROUND

In a classical study, Durkheim mapped suicide rates, wealth, and low family density and realized that they clustered in northern France. Assessing others variables, such as religious society, he constructed a framework for the analysis of the suicide, which still allows international comparisons using the same basic methodology. The present study aims to identify possible significantly clusters of suicide in the city of São Paulo, and then, verify their statistical associations with socio-economic and cultural characteristics.

METHODS

A spatial scan statistical test was performed to analyze the geographical pattern of suicide deaths of residents in the city of São Paulo by Administrative District, from 1996 to 2005. Relative risks and high and/or low clusters were calculated accounting for gender and age as co-variates, were analyzed using spatial scan statistics to identify geographical patterns. Logistic regression was used to estimate associations with socioeconomic variables, considering, the spatial cluster of high suicide rates as the response variable. Drawing from Durkheim's original work, current World Health Organization (WHO) reports and recent reviews, the following independent variables were considered: marital status, income, education, religion, and migration.

RESULTS

The mean suicide rate was 4.1/100,000 inhabitant-years. Against this baseline, two clusters were identified: the first, of increased risk (RR=1.66), comprising 18 districts in the central region; the second, of decreased risk (RR=0.78), including 14 districts in the southern region. The downtown area toward the southwestern region of the city displayed the highest risk for suicide, and though the overall risk may be considered low, the rate climbs up to an intermediate level in this region. One logistic regression analysis contrasted the risk cluster (18 districts) against the other remaining 78 districts, testing the effects of socioeconomic-cultural variables. The following categories of proportion of persons within the clusters were identified as risk factors: singles (OR=2.36), migrants (OR=1.50), Catholics (OR=1.37) and higher income (OR=1.06). In a second logistic model, likewise conceived, the following categories of proportion of persons were identified as protective factors: married (OR=0.49) and Evangelical (OR=0.60).

CONCLUSIONS

This risk/ protection profile is in accordance with the interpretation that, as a social phenomenon, suicide is related to social isolation. Thus, the classical framework put forward by Durkheim seems to still hold, even though its categorical expression requires re-interpretation.

The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health's commitment to social justice makes it a natural fit with intersectionality's focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.

Unemployment and mortality: a comparative study of Germany and the United States

OBJECTIVES

We examined the relationship between unemployment and mortality in Germany, a coordinated market economy, and the United States, a liberal market economy.

METHODS

We followed 2 working-age cohorts from the German Socio-economic Panel and the US Panel Study of Income Dynamics from 1984 to 2005. We defined unemployment as unemployed at the time of survey. We used discrete-time survival analysis, adjusting for potential confounders.

RESULTS

There was an unemployment-mortality association among Americans (relative risk [RR]=2.4; 95% confidence interval [CI]=1.7, 3.4), but not among Germans (RR=1.4; 95% CI=1.0, 2.0). In education-stratified models, there was an association among minimum-skilled (RR=2.6; 95% CI=1.4, 4.7) and medium-skilled (RR=2.4; 95% CI=1.5, 3.8) Americans, but not among minimum- and medium-skilled Germans. There was no association among high-skilled Americans, but an association among high-skilled Germans (RR=3.0; 95% CI=1.3, 7.0), although this was limited to those educated in East Germany. Minimum- and medium-skilled unemployed Americans had the highest absolute risks of dying.

CONCLUSIONS

The higher risk of dying for minimum- and medium-skilled unemployed Americans, not found among Germans, suggests that the unemployment-mortality relationship may be mediated by the institutional and economic environment.

Injury risk and severity in a sample of Maryland residents with serious mental illness

OBJECTIVE

Adults with serious mental illness experience premature mortality and heightened risk for medical disease, but little is known about the burden of injuries in this population. The objective of this study was to describe injury incidence among persons with serious mental illness.

METHODS

We conducted a retrospective cohort study of 6234 Maryl and Medicaid recipients with serious mental illness from 1994-2001. Injuries were classified using the Barell Matrix. Relative risks were calculated to compare injury rates among the study cohort with injury rates in the United States population. Cox proportional hazards modeling with time dependent covariates was used to assess factors related to risk of injury and injury-related death.

RESULTS

Forty-three percent of the Maryland Medicaid cohort had any injury diagnosis. Of the 7298 injuries incurred, the most common categories were systemic injuries due to poisoning (10.4%), open wounds to the head/face (8.9%), and superficial injuries, fractures, and sprains of the extremities (8.6%, 8.5%, and 8.4%, respectively). Injury incidence was 80% higher and risk for fatal injury was more than four and a half times higher among the cohort with serious mental illness compared to the general population. Alcohol and drug abuse were associated with both risk of injury and risk of injury-related death with hazard ratios of 1.87 and 4.76 at the p<0.05 significance level, respectively.

CONCLUSIONS

The superficial, minor nature of the majority of injuries is consistent with acts of minor victimization and violence or falls. High risk of fatal and non-fatal injury among this group indicates need for increased injury prevention efforts targeting persons with serious mental illness and their caregivers.

The social patterning of deaths due to assault in Scotland, 1980-2005: population-based study

Objectives

The objectives of this study were to explore the extent of the social gradient for deaths due to assault and its impact on overall inequalities in mortality and to investigate the contribution to assault mortality of knives and other sharp weapons.

Design

An analysis of death records and contemporaneous population estimates was conducted.

Setting

The authors investigated the social patterning of homicide in Scotland.

Participants

This study included deaths between 1980 and 2005 due to assault.

Main measurements

Death rates were standardised to the European standard population. Time trends were analysed and inequalities were assessed, using rate ratios and the slope index of inequality, along axes defined by individual occupational socioeconomic status and area deprivation.

Results

An increase in mortality due to assault was most pronounced at ages 15–44 and was steeper among assaults involving knives. The death rate among men in routine occupations aged 20–59 was nearly 12 times that of those in higher managerial and professional occupations. Men under 65 living in the most deprived quintile of areas had a death rate due to assault 31.9 times (95% CI 13.1 to 77.9) that of those living in the least deprived quintile; for women, this ratio was 35.0 (4.8 to 256.2). Despite comprising just 3.2% of all male deaths between 15 and 44 years, assault accounted for 6.4% of the inequalities in mortality.

Conclusions

Inequalities in mortality due to assault in Scotland exceed those in other countries and are greater than for other causes of death in Scotland. Reducing mortality and inequalities depends on addressing the problems of deprivation as well as targeting known contributors, such as alcohol use, the carrying of knives and gang culture.

Does doxycycline protect against development of Clostridium difficile infection?

BACKGROUND

Receipt of antibiotics is a major risk factor for Clostridium difficile infection (CDI). Doxycycline has been associated with a lower risk for CDI than other antibiotics. We investigated whether doxycycline protected against development of CDI in hospitalized patients receiving ceftriaxone, a high-risk antibiotic for CDI.

METHODS

We studied adults admitted to an academic county hospital between 1 June 2005 and 31 December 2010 who received ceftriaxone to determine whether the additional receipt of doxycycline decreased the risk of CDI. Patients were followed from first administration of ceftriaxone to occurrence of CDI or administrative closure 30 days later.

RESULTS

Two thousand three hundred five unique patients comprising 2734 hospitalizations were studied. Overall, 43 patients developed CDI within 30 days of ceftriaxone receipt, an incidence of 5.60 cases per 10 000 patient-days. The incidence of CDI was 1.67 cases per 10 000 patient-days in those receiving doxycycline, compared to 8.11 per 10 000 patient-days in those who did not receive doxycycline. In a multivariable model adjusted for age, gender, race, comorbidities, hospital duration, pneumonia diagnosis, surgical admission, and duration of ceftriaxone and other antibiotics, for each day of doxycycline receipt the rate of CDI was 27% lower than a patient who did not receive doxycycline (hazard ratio, 0.73; 95% confidence interval, .56-.96).

CONCLUSIONS

In this cohort of patients receiving ceftriaxone, doxycycline was associated with lower risk of CDI. Guidelines recommend this combination as a second-line regimen for some patients with community-acquired pneumonia (CAP). Further clinical studies would help define whether doxycycline-containing regimens should be a preferred therapy for CAP.

The association between insurance status and emergency department disposition of injured California children

OBJECTIVES

This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.

METHODS

Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age.

RESULTS

Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06).

CONCLUSIONS

Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.

Pesticide use and fatal injury among farmers in the Agricultural Health Study

PURPOSE

To assess whether pesticide use practices were associated with injury mortality among 51,035 male farmers from NC and IA enrolled in the Agricultural Health Study.

METHODS

We used Cox proportional hazards models adjusted for age and state to estimate fatal injury risk associated with self-reported use of 49 specific pesticides, personal protective equipment, specific types of farm machinery, and other farm factors collected 1-15 years preceding death. Cause-specific mortality was obtained through linkage to mortality registries.

RESULTS

We observed 338 injury fatalities over 727,543 person-years of follow-up (1993-2008). Fatal injuries increased with days/year of pesticide application, with the highest risk among those with 60+ days of pesticide application annually [hazard ratio (HR) = 1.87; 95% confidence interval (CI) = 1.10, 3.18]. Chemical-resistant glove use was associated with decreased risk (HR = 0.73; 95% CI = 0.58, 0.93), but adjusting for glove use did not substantially change estimates for individual pesticides or pesticide use overall. Herbicides were associated with fatal injury, even after adjusting for operating farm equipment, which was independently associated with fatal injury. Ever use of five of 18 herbicides (2,4,5-T, paraquat, alachlor, metribuzin, and butylate) were associated with elevated risk. In addition, 2,4-D and cyanazine were associated with fatal injury in exposure-response analyses. There was no evidence of confounding of these results by other herbicides.

CONCLUSION

The association between application of pesticides, particularly certain herbicides, and fatal injuries among farmers should be interpreted cautiously but deserves further evaluation, with particular focus on understanding timing of pesticide use and fatal injury.

Impact of socioethnic factors on outcomes following traumatic brain injury

BACKGROUND

Ethnic minorities and low income families tend to be in poorer health and have worse outcomes for a spectrum of diseases. Health care provider bias has been reported to potentially affect the distribution of care away from poorer communities, minorities, and patients with a history of substance abuse. Trauma is perceived as a disease of the poor and medically underserved. Minorities are overrepresented in low income populations and are also less likely to possess health insurance leading to a potential overlapping effect. Traumatic brain injury (TBI) is a predominant cause of mortality and long-term morbidity, which imposes a considerable social and financial burden. We therefore sought to determine the independent effect on outcome after TBI from race, insurance status, intoxication on presentation, and median income.

METHODS

A 5-year retrospective chart review of admitted trauma patients aged 18 years and older to a Level I trauma center. Zip code of residency was a surrogate marker for socioeconomic status, because median income for each zip code is available from the US Census. Charts review included race, insurance status, mechanisms of trauma, and injuries sustained. Outcomes were placement of tracheostomy, hospital length of stay (HLOS), leaving Against Medical Advice (AMA), and discharge to home versus rehabilitation and mortality.

RESULTS

A total of 3,101 TBI patients were included in the analyses. Multivariable logistic and proportional hazard regression analyses were undertaken adjusting for age, gender, Injury Severity Score, and mechanism. Rates of tracheostomy placement were unaffected by race, median income, or insurance status. Race and median income did not affect HLOS, but private insurance was associated with shorter HLOS and intoxication was associated with longer HLOS. Neither race nor intoxication affected rates of AMA, but higher income and private insurance was associated with lower rates of AMA. Non-Caucasian race and lack of insurance had significantly lower likelihood of placement in a rehabilitation center. Mortality was unaffected by race, increased in intoxicated patients, was variably affected by median income, and was lowest in patients with private insurance.

CONCLUSIONS

An extremely complex interplay exists between socioethnic factors and outcomes after TBI. Few physicians would claim overt discrimination. Tracheostomy, the factor most directed by the surgeon, was unbiased by race, income, or insurance status. The likelihood of placement in a rehabilitation center was significantly impacted by both race and insurance status. Future prospective studies are needed to better address causation.

Influence of social and material individual and area deprivation on suicide mortality among 2.7 million Canadians: a prospective study

BACKGROUND

Few studies have investigated how area-level deprivation influences the relationship between individual disadvantage and suicide mortality. The aim of this study was to examine individual measures of material and social disadvantage in relation to suicide mortality in Canada and to determine whether these relationships were modified by area deprivation.

METHODS

Using the 1991-2001 Canadian Census Mortality Follow-up Study cohort (N = 2,685,400), measures of individual social (civil status, family structure, living alone) and material (education, income, employment) disadvantage were entered into Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for male and female suicide mortality. Two indices of area deprivation were computed - one capturing social, and the other material, dimensions - and models were run separately for high versus low deprivation.

RESULTS

After accounting for individual and area characteristics, individual social and material disadvantage were associated with higher suicide mortality, especially for individuals not employed, not married, with low education and low income. Associations between social and material area deprivation and suicide mortality largely disappeared upon adjustment for individual-level disadvantage. In stratified analyses, suicide risk was greater for low income females in socially deprived areas and males living alone in materially deprived areas, and there was no evidence of other modifying effects of area deprivation.

CONCLUSIONS

Individual disadvantage was associated with suicide mortality, particularly for males. With some exceptions, there was little evidence that area deprivation modified the influence of individual disadvantage on suicide risk. Prevention strategies should primarily focus on individuals who are unemployed or out of the labour force, and have low education or income. Individuals with low income or who are living alone in deprived areas should also be targeted.

Status and risk factors of unintentional injuries among Chinese undergraduates: a cross-sectional study

Background

Injuries affect all age groups but have a particular impact on young people. To evaluate the incidence of non-fatal, unintentional, injuries among undergraduates in Wenzhou, China, assess the burden caused by these injuries, and explore the associated risk factors for unintentional injuries among these undergraduates, we conducted a college-based cross-sectional study.

Methods

Participants were selected by a multi-stage random sampling method, and 2,287 students were asked whether they had had an injury in the last 12 months; the location, cause, and consequences of the event. The questionnaire included demographic and socioeconomic characteristics, lifestyle habits, and the scale of type A behaviour pattern (TABP). Multivariate logistic regression models were used; crude odds ratios (ORs), adjusted ORs and their 95% confidence intervals (CIs) were estimated, with students having no injuries as the reference group.

Results

The incidence of injuries among undergraduates in Wenzhou was 18.71 injuries per 100 person-years (95%CI: 17.12~20.31 injuries per 100 person-years). Falls were the leading cause of injury, followed by traffic injuries, and animal/insect bites. Male students were more likely to be injured than female students. Risk factors associated with unintentional injuries among undergraduates were: students majoring in non-medicine (adjusted OR: 1.53; 95% CI: 1.19-1.96); type A behaviour pattern (adjusted OR: 2.99; 95% CI: 1.45-6.14); liking sports (adjusted OR: 1.86; 95% CI: 1.41-2.45).

Conclusions

Injuries have become a public health problem among undergraduates. Falls were the major cause of non-fatal injury. Therefore, individuals, families, schools and governments should promptly adopt preventive measures aimed at preventing and controlling morbidity due to non-fatal injury, especially among students identified to be at high-risk; such as male students with type A behaviour pattern who like sports.

Influence of socioeconomic status on trauma center performance evaluations in a Canadian trauma system

BACKGROUND

Trauma center performance evaluations generally include adjustment for injury severity, age, and comorbidity. However, disparities across trauma centers may be due to other differences in source populations that are not accounted for, such as socioeconomic status (SES). We aimed to evaluate whether SES influences trauma center performance evaluations in an inclusive trauma system with universal access to health care.

STUDY DESIGN

The study was based on data collected between 1999 and 2006 in a Canadian trauma system. Patient SES was quantified using an ecologic index of social and material deprivation. Performance evaluations were based on mortality adjusted using the Trauma Risk Adjustment Model. Agreement between performance results with and without additional adjustment for SES was evaluated with correlation coefficients.

RESULTS

The study sample comprised a total of 71,784 patients from 48 trauma centers, including 3,828 deaths within 30 days (4.5%) and 5,549 deaths within 6 months (7.7%). The proportion of patients in the highest quintile of social and material deprivation varied from 3% to 43% and from 11% to 90% across hospitals, respectively. The correlation between performance results with or without adjustment for SES was almost perfect (r = 0.997; 95% CI 0.995-0.998) and the same hospital outliers were identified.

CONCLUSIONS

We observed an important variation in SES across trauma centers but no change in risk-adjusted mortality estimates when SES was added to adjustment models. Results suggest that after adjustment for injury severity, age, comorbidity, and transfer status, disparities in SES across trauma center source populations do not influence trauma center performance evaluations in a system offering universal health coverage.

Mortality from road traffic accidents in Switzerland: longitudinal and spatial analyses

Road traffic accidents (RTA) are an important cause of premature death. We examined socio-demographic and geographical determinants of RTA mortality in Switzerland by linking 2000 census data to RTA mortality records 2000-2005 (ICD-10 codes V00-V99). Data from 5.5 million residents aged 18-94 years, 1744 study areas, and 1620 RTA deaths were analyzed, including 978 deaths (60.4%) in motor vehicle occupants, 254 (15.7%) in motorcyclists, 107 (6.6%) in cyclists, and 259 (16.0%) in pedestrians. Weibull survival models and Bayesian methods were used to calculate hazard ratios (HR), and standardized mortality ratios (SMR) across study areas. Adjusted HR comparing women with men ranged from 0.04 (95% CI 0.02-0.07) in motorcyclists to 0.43 (95% CI 0.32-0.56) in pedestrians. There was a u-shaped relationship with age in motor vehicle occupants and motorcyclists. In cyclists and pedestrians, mortality increased after age 55 years. Mortality was higher in individuals with primary education (HR 1.53; 95% CI 1.29-1.81), and higher in single (HR 1.24; 95% CI 1.05-1.46), widowed (HR 1.31; 95% CI 1.05-1.65) and divorced individuals (HR 1.62; 95% CI 1.33-1.97), compared to persons with tertiary education or married persons. The association with education was particularly strong for pedestrians (HR 1.87; 95% CI 1.20-2.91). RTA mortality increased with decreasing population density of study areas for motor vehicle occupants (test for trend p<0.0001) and motorcyclists (p=0.0021) but not for cyclists (p=0.39) or pedestrians (p=0.29). SMR standardized for socio-demographic and geographical variables ranged from 82 to 190. Prevention efforts should aim to reduce inequities across socio-demographic and educational groups, and across geographical areas, with interventions targeted at high-risk groups and areas, and different traffic users, including pedestrians.

Children hospitalized with lower extremity fractures in the United States in 2006: a population-based approach

OBJECTIVE

The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006.

METHODS

Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under "Injury and Poisoning (800-999)." Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance.

RESULTS

There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals.

CONCLUSIONS

This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine causality of the associations found including increased mortality risk for this population at rural and non-teaching hospitals.

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.

Sociodemographic factors associated with aggressive driving behaviors of 3-wheeler taxi drivers in Sri Lanka

Little is known about the nature and scope of aggressive driving in developing countries. The objective of this study is to specifically examine the sociodemographic factors associated with aggressive driving behavior among 3-wheeler taxi drivers in Sri Lanka. Convenience samples of 3-wheeler taxi drivers from Rathnapura, Ahaliyagoda, Sri Lanka were surveyed from June to August 2006. Analyses included bivariate and multivariate logistic regression. Drivers with less than high school education were 3.5 times more likely to drive aggressively (odds ratio [OR] = 3.46; 95% confidence interval [CI] = 1.08, 11.1). Single drivers were 9 times more likely to run red lights (OR = 8.74; 95% CI = 2.18, 35.0), and being single was a major risk factor for drunk driving (OR = 4.80; 95% CI = 1.23, 18.7). Furthermore, high school completers were 4 times more likely to bribe a policeman (OR = 4.27; 95% CI = 1.23, 14.9) when caught violating the road rules. Aggressive driving and risk-taking behavior are amenable to policy initiatives, and preventive programs targeted at key groups could be used to improve road safety in Sri Lanka. This study demonstrates that aggressive driving behavior is associated with sociodemographic factors, including the level of education, marital status, and other socioeconomic factors. Hence, economic factors should be addressed to find solutions to traffic-related issues. It will be the government's and policy makers' responsibility to try and understand the economic factors behind risky road behavior and bribe-taking behavior prior to legislating or enforcing new laws.

A population-based study of repetitive traumatic brain injury among persons with traumatic brain injury

PRIMARY OBJECTIVE

The objective was to estimate and compare the hazards of repetitive traumatic brain injury (RTBI) events as a function of the index TBI severity, in a cohort of TBI hospital discharges include in the South Carolina Traumatic Brain Injury Follow-up Registry.

RESEARCH DESIGN

Retrospective cohort.

METHODS AND PROCEDURES

There were 4357 persons with TBI who were followed from the index hospital discharge through 31 December 2005 for RTBI events through the statewide hospital discharge (HD) and emergency department (ED) records. Prentice, Williams, Peterson total time/conditional probability model (PWP-CP) for recurrent events survival analysis was used to assess RTBI as a function of index TBI severity.

MAIN OUTCOMES AND RESULTS

Index TBI severity approached significance in its relationship with RTBI, with persons with a severe index TBI experiencing events at a higher rate than those with a mild/moderate index TBI. Among the other covariates evaluated, epilepsy/seizure disorder, race, gender, payer status, cause of injury and having a prior history of TBI were associated with RTBI.

CONCLUSIONS

While TBI severity approached significance with RTBI, other variables, such as epilepsy/seizure disorder, seem to have a more significant relationship with RTBI.

A population-based analysis of neighborhood socioeconomic status and injury admission rates and in-hospital mortality

BACKGROUND

Research indicates that neighborhood socioeconomic status (N-SES) is inversely related to injury and injury-related mortality. We hypothesized that injury-related hospitalization rates would vary by N-SES and that N-SES would be related to in-hospital mortality.

STUDY DESIGN

Adults (age 18 to 84 years) living in Shelby County, TN, were eligible for the study. Addresses of adults admitted to the only Level I trauma center in the county from 1996 to 2005 were geocoded and matched to 1 of 214 census tract groups. Census tract groups were divided into quintiles based on percent of the population living below the poverty level (lowest to highest income N-SES). Crude injury admission rate ratios (CIRR) and 95% confidence intervals (CI) were calculated. Multivariable logistic regression was used to determine if N-SES was associated with in-hospital mortality.

RESULTS

Compared with the highest N-SES, those in the lowest N-SES suffered significantly higher rates of blunt (CIRR 5.74; 95% CI 5.35, 6.15) and penetrating injuries (CIRR 20.98; 95% CI 18.03, 24.42). On multivariable logistic regression analysis, compared with the highest N-SES, decreasing N-SES was not associated with in-hospital mortality for blunt (high-middle [0.90; 95% CI 0.57, 1.44]; middle [1.22; 95% CI 0.78, 1.87]; low-middle [0.89; 95% CI 0.58, 1.39]; lowest [0.67; 95% CI 0.42, 1.08]); or penetrating injury (high-middle [1.35; 95% CI 0.48, 3.81]; middle [2.77; 95% CI 0.99, 7.25]; low-middle [1.44; 95% CI 0.55, 3.74]; and lowest [1.03; 95% CI 0.39, 2.73]).

CONCLUSIONS

N-SES was inversely related to crude injury rates for all mechanisms. However, in-hospital mortality was not associated with N-SES level.

Intelligence in early adulthood and subsequent risk of assault: cohort study of 1,120,998 Swedish men

OBJECTIVE

To examine the association between low intelligence (IQ) and increased risk of assault. Previous studies have been relatively small, have not adjust for socioeconomic status, and have not examined method-specific assaults.

METHODS

Cox proportional hazards regression was used to explore IQ associations with assault by any means and by four specific methods in a large prospective cohort of 1,120,988 Swedish men. Study members had IQ measured in early adulthood and were well characterized for socioeconomic status in childhood and adulthood. Men were followed-up for an average of 24 years, and hospital admissions for injury due to assault were recorded.

RESULTS

A total of 16,512 (1.5%) men had at least one hospital admission for injury due to assault by any means during follow-up. The most common assault was during a fight (n = 13,144), followed by stabbing (n = 1,211), blunt instrument (b = 352), and firearms assaults (n = 51). After adjusting for confounding variables, lower IQ scores were associated with an elevated risk of hospitalization for assaults by any means (hazard ratio per standard deviation decrease in IQ, 1.51; 95% confidence interval, 1.49, 1.54) and for each of the cause-specific assaults: fight: 1.48 (1.45, 1.51); stabbing: 1.68 (1.58, 1.79); blunt instrument: 1.65 (1.47, 1.85); and firearms: 1.34 (1.00, 1.80). These gradients were stepwise across the full IQ range.

CONCLUSIONS

Low IQ scores in early adulthood were associated with a subsequently increased risk of assault. A greater understanding of mechanisms underlying these associations may provide opportunities and strategies for prevention.

Suicide in selected occupations in Queensland: evidence from the State suicide register

OBJECTIVE

Prior research has suggested an association between suicide and certain occupations. The aim of the present study was to report on suicide rates in selected occupations in Queensland (QLD).

METHOD

Suicide mortality data from the QLD Suicide Register and population data from the Australian Bureau of Statistics were obtained for the period 1990-2006. Suicide rates were calculated for each occupational group and compared to rates within the general population (15-64 year age group) and the employed population of QLD.

RESULTS

There was significantly higher risk of suicide for male subjects in the agricultural, transport and construction sectors of QLD. High suicide rates were also found in female nurses, artists, agricultural workers and cleaners, while education professionals (of both genders) appeared at lower risk.

CONCLUSIONS

The significantly higher suicide rates for employees of the agriculture, construction, and transport industries indicate a need for further research into the occupation-specific conditions and individual or other social-environmental factors that may accentuate suicide risk within these professions. Use of higher quality occupational data is also warranted in future studies.

School resources, resource allocation, and risk of physical assault against Minnesota educators

To investigate the relation between schools' resource levels (i.e., annual per student expenditures), school resource allocations, and physical assault (PA) against Minnesota's educators, a study was conducted from the two-phase Minnesota Educators' Study (MES) that incorporated school-level fiscal and demographic data from the Minnesota Department of Education (MDE). The MES examined a randomly selected cohort of employed, state-licensed kindergarten through grade 12 educators. From mailed questionnaires, response rates for both Phase I (comprehensive data collection on violent events) and Phase II (case-control) were 84%. Cases experienced a work-related PA event in the previous 12 months; controls reported no assaults. Based on the school in which they worked the most time and available MDE school-level data, together with MES questionnaire data, analyses were conducted on 238 cases and 640 controls. Multivariate analyses, using directed acyclic graphs to guide selection of confounders, suggested that increased spending (i.e. resources) was associated with decreased risk of PA. Analyses further suggested that the highest quartiles of resource allocations, compared with the lowest quartiles (referents), were associated with decreased risks of PA for: district level administration; regular instruction; special education; student activities and athletics; and pupil support services expenditures. Associations between increased resource allocations to student activities expenditures and decreased risks of PA were the strongest. For example, an allocation greater than 5% of the total annual per student expenditure to student activities programming (referent, less than 0.04%) was associated with a decreased risk of PA (OR=0.30, 95% CI: 0.12, 0.77). Results suggested that allocations of school resources (i.e., expenditures) to key program areas such as student athletics and extracurricular activities may reduce risk of work-related PA against educators. Research to further explore the nature of the relations between disparities in school resources and spending, resource allocations, and PA will be important to the continued development of relevant prevention strategies.

Trends in educational differentials in suicide mortality between 1993-2006 in Korea

PURPOSE

This study aims to examine how inequalities in suicide by education changed during and after macroeconomic restructuring following the economic crisis of 1997 in South Korea.

MATERIALS AND METHODS

Using Korea's 1995, 2000, and 2005 census data aggregately linked to mortality data (1993-2006), relative and absolute differentials in suicide mortality by education were calculated by gender and age among Korean population aged 35 and over.

RESULTS

Average annual suicide mortality rates have steadily increased from 1993-1997 to 2003-2006 in almost all sociodemographic groups stratified by gender, age, and education. Based on the relative index of inequality (RII) and slope index of inequality (SII), educational differentials in suicide mortality generally increased over time in men and women aged 45 years+. Although RII did not increase with year among men and women aged 35 - 44 years, SII showed a significantly increasing trend in this age group.

CONCLUSION

These worsening absolute inequalities in suicide mortality indicate that the governmental suicide prevention policy should be directed toward socially disadvantaged groups of the Korean population.

Does level of social capital predict perceived health in a community?--A study of adult residents of low-income areas of Francistown, Botswana

This study explores and describes the relationships among neighbourhood characteristics, social capital, and health outcomes among low-income urban residents in Francistown, Botswana. Using an explanatory correlational research design to explore the relationships among the study variables, data were collected from 388 low-income urban residents in Francistown, Botswana. The study further examined the role of social capital on the environmental quality for the overall health and quality of life and the psychological, physical and level of independence domains of health. Several studies have explored these relationships but currently no study has explored this relationship in Africa and Botswana in particular. Selected concepts from social capital theory and stress theory were used as a conceptual framework. Using linear and multiple regression models, results of the study showed that social capital did not correlate with the overall health and quality of life and the level of independence domain of health but positively correlated with psychological well-being. Social capital negatively predicted physical health. Hierarchical moderated multiple-regression analyses were conducted to examine the moderating role of social capital. To the contrary, social capital did not moderate the effects of chronic community stressors on all health outcomes. Social capital, however, moderated the effects of the poor environmental quality on level of independence and physical health outcomes but not on the psychological and overall health and quality of life. These results underscore the importance of considering the role of social capital, especially in low-income communities.

The role of socioeconomic indicators on non-alcohol and alcohol-associated suicide mortality among women in Finland. A register-based follow-up study of 12 million person-years

This study was to analyse the effects and interrelationships of three socioeconomic indicators--education, occupation-based social class and income--on non-alcohol and alcohol-associated suicide mortality among women in Finland. The register data used comprised the 1990 census records linked to the death register for the years 1991-2001 for women who were 25-64 years old in 1990. Adjusted relative mortality rates and the relative index of inequality (RII) were estimated using Poisson regression. The study population experienced 1926 suicides, of which 563 (29%) had alcohol intoxication as a contributory cause. The age-adjusted effects of education on non-alcohol associated suicide were modest, while social class and income related inversely and strongly. The effect of social class was partly mediated by income, and social class explained income differences to some extent. The associations between these socioeconomic indicators and alcohol-associated suicide were stronger, and following adjustment for each other large effects were left for education, social class and income. Further adjustment for living arrangements had little effect on socioeconomic differences in both types of suicide, but practically all of the effects of income and some of education and social class were mediated by employment status. In conclusion, current material factors are hardly the main underlying drivers of socioeconomic differences in suicide among Finnish women. Low social class proved to be an important determinant of suicide risk, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set.

Ethical and legal issues in emergency research: barriers to conducting prospective randomized trials in an emergency setting

INTRODUCTION

As in any area of medicine, clinical trials are crucial to the advancement of trauma care and the establishment of evidence-based guidelines. This work identifies consent regulations that impede advances in trauma resuscitation research and examines several ethical issues underlying current policies in the United States which regulate how clinical trials are conducted in an emergency setting. Trauma is a leading cause of mortality in the U.S. Minorities and those in low socioeconomic groups are subject to a disproportional amount of traumatic injuries and have worse treatment outcomes than non-minority individuals. Current regulations guiding consent requirements in emergency research were enacted to protect such vulnerable populations from exploitation. Ironically, these same regulations also serve as barriers to clinical trials in trauma research, thus depriving these same vulnerable groups from the benefits of advances in trauma care.

METHODS

A literature review was conducted on areas affecting emergency medical research including: informed consent, socioeconomic and racial disparities, federal regulations in trauma research and biomedical ethics.

RESULTS

In the ten year period following the passage of the FDA's Common Rule (21 CFR 50.24) in 1995, 21 published emergency research studies were conducted under the waiver of informed consent. Misconceptions regarding federal regulations and cumbersome internal review board approval processes are frequently cited as significant barriers to conducting prospective randomized trials in the emergency setting.

CONCLUSIONS

Given the history of past abuses in medical research, the principle of maintaining autonomy of choice is of paramount importance. However, trauma resuscitation is unique in that patients are either unconscious or of limited mental capacity at the time treatment is required, and thus the standard of informed consent is unable to be achieved as in other areas of medicine. While this paradox was recognized by the FDA in 1995 with the creation of an exception to the requirement for informed consent in emergency research (the "Common Rule"), the wording of this exception is ambiguous, and has consequently deterred trauma investigators from pursuing valuable research endeavors. In particular, the language requiring "community consultation" and demonstration that existing treatments are "unproven or unsatisfactory" have been identified as the most problematic terms to satisfactorily address by those aiming to conduct trauma research. It is imperative that the current exemptions to the Common Rule be more thoroughly operationalized, so that greater advancement in emergency medicine research can be promulgated, while concurrently maintaining a high standard of protection for the rights of trauma patients.

Suicide and potential occupational exposure to pesticides, Colorado 1990-1999

A number of occupational studies have reported high rates of suicide among selected occupations, including farmers. Limited work has focused on occupational exposures that may increase the risk of suicide. The purpose of this study is to describe suicide among individuals potentially exposed to pesticides through their occupation. Data from Colorado death certificate files for the period 1990-1999 were obtained. Eligible records were those individuals who were Colorado residents at the time of death who had an occupation listed on their death certificates. Cases had suicide listed as the primary cause of death on the death certificates. The comparison group included Colorado residents who died from any cause during the same period other than cancer, mental disorders and injuries. A total of 4,991 suicide deaths were included and a total of 107,692 other deaths served as the comparison group. Occupations considered pesticide exposed included: veterinarians; pest control occupations; farmers and farm workers; farm managers and supervisors; marine life cultivators; nursery workers; groundskeepers and gardeners; animal caretakers; graders, sorters and inspectors of agricultural products; and forestry workers, supervisors and loggers. All other occupational categories were coded as unexposed. Logistic regression was used to compare the groups, separately for males and females. After controlling for age, race, Hispanic ethnicity, years of education, and marital status, males who were in pesticide exposed occupations had higher odds of suicide (odds ratio 1.14; 95% confidence interval 0.97, 1.34) and females in pesticide exposed occupations also had higher odds of suicide (odds ratio 1.98; 95% confidence interval 1.01, 3.88).

IQ in early adulthood, socioeconomic position, and unintentional injury mortality by middle age: a cohort study of more than 1 million Swedish men

The authors evaluated the little-examined association between intelligence (IQ) and injury mortality and, for the first known time, explored the extent to which IQ might explain established socioeconomic inequalities in injury mortality. A nationwide cohort of 1,116,442 Swedish men who underwent IQ testing at about 18 years of age was followed for mortality experience for an average of 22.6 years. In age-adjusted analyses in which IQ scores were classified into 4 groups, relative to the highest scoring category, the hazard ratio in the lowest was elevated for all injury types: poisonings (hazard ratio (HR) = 5.82, 95% confidence interval (CI): 4.25, 7.97), fire (HR = 4.39, 95% CI: 2.51, 7.77), falls (HR = 3.17, 95% CI: 2.19, 4.59), drowning (HR = 3.16, 95% CI: 1.85, 5.39), and road injury (HR = 2.17, 95% CI: 1.91, 2.47). Dose-response effects across the full IQ range were evident (P-trend < 0.001). Control for potential covariates, including socioeconomic position, had little impact on these gradients. When socioeconomic disadvantage—indexed by parental and subject's own occupational social class—was the exposure of interest, IQ explained a sizable portion (19%–86%) of the relation with injury mortality. These findings suggest that IQ may have an important role both in the etiology of injuries and in explaining socioeconomic inequalities in injury mortality.