Social Determinants Associated with Pediatric Burn Injury: A Population-Based, Case-Control Study

Association Between Social Determinants of Health and Concussion Among High School Students in the United States

We examined the association between social determinants of health and the likelihood of sustaining a concussion among adolescents. Participants in this cross-sectional study were 7164 high school students who completed the 2021 Adolescent Behaviors and Experiences Survey (52.7% girls; mean age = 16.0 years, SD = 1.2; age range 12-18 years). Logistic regression was used to determine which social determinants of health variables were associated with a self-reported history of concussion from playing a sport or being physically active over the past year. One in 10 adolescents (n = 716; 10.0% total; 11.8% of boys, 8.3% of girls) reported sustaining a concussion during the past year. Seven of 10 adolescents (70.3%) reported experiencing at least 1 of 8 negative social determinants of health. A multivariable logistic regression was statistically significant (P < .001), indicating that the negative social determinants of health were associated with having sustained a concussion during the past year; the model explained 12.5% (Nagelkerke R2) of the variance in concussion. Controlling for all other predictors, sports participation (odds ratio [OR] = 3.72, medium effect), housing instability (OR = 3.25, small-medium effect) and limited English language proficiency (OR = 3.05, small-medium effect) were the strongest independent predictors of sustaining concussion within the past year. Adolescents who lived in a neighborhood where there is violence (OR = 1.78, small effect), who were bullied (OR = 1.57, very small effect), and who experienced food insecurity (OR = 1.36, very small effect) were more likely to have sustained a concussion. Research is needed to understand the nature of these determinant-injury associations. Whether social determinants of health are associated with specific treatment and rehabilitation needs, and time to recover following concussion, should be examined with prospective studies.

Mental and physical health disorders following paediatric traumatic injury: a population-based longitudinal study in Manitoba, Canada

IMPORTANCE

Paediatric traumatic injury (PTI) is a leading cause of hospitalisation among children. Little is known about subsequent mental and physical health disorders while accounting for pre-injury health.

OBJECTIVE

To compare pre-injury and post-injury mental and physical disorders in survivors of PTI with an uninjured matched cohort from the general population. This study hypothesised injured youth will have increased rates of mental and physical disorders relative to matched uninjured youth in the post-injury period.

DESIGN

Retrospective longitudinal cohort study using linked administrative health data to examine paediatric patients hospitalised for injury between 1 January 2004 and 31 December 2016, measured 2 years pre-injury and 2 years post-injury.

SETTING

Population-based study in Manitoba, Canada.

PARTICIPANTS

Youth<18 years old who survived to discharge after an injury requiring hospitalisation in the study period (n=9551) were matched 1:5 (age, sex and region) to youth from the general uninjured population (n=47 755).

EXPOSURES

PTI that required hospitalisation.

MAIN OUTCOMES AND MEASURES

Mental disorders (anxiety, depression and substance use) and physical disorders (arthritis, cancer, diabetes, gastrointestinal, hypertension and total respiratory morbidity) were measured at physician visits and hospitalisations 2 years pre-injury and post-injury. Generalised estimating equations were used to estimate adjusted rate ratios (ARR).

RESULTS

This study examined 9551 in the injured cohort and 47 755 matches in the uninjured cohort. Injured individuals had increased ARRs for all mental disorders (p<0.0006) pre-injury (anxiety=1.30 (95% CI, 1.16 to 1.47); depression=2.00 (95% CI, 1.73 to 2.32); substance use=4.99 (95% CI, 3.08 to 5.20); any mental disorder=1.50 (95% CI, 1.37 to 1.66)) and post-injury (anxiety=1.66 (95% CI, 1.51 to 1.82); depression=2.87 (95% CI, 2.57 to 3.21); substance use=3.25 (95% CI, 2.64 to 3.99); any mental disorder=1.90 (95% CI, 1.76 to 2.04)). For physical disorders, injured individuals had increased ARRs (p<0.0006) pre-injury for arthritis (1.50 (95% CI, 1.39 to 1.60)), cancer (1.97 (95% CI, 1.35 to 2.88)), gastrointestinal (1.12 (95% CI, 1.06 to 1.18)) and any physical disorder (1.14 (95% CI, 1.11 to 1.18)). Post-injury, the injured had higher ARRs (p<0.0006) for arthritis (2.02 (95% CI, 1.91 to 2.15)), cancer (1.97 (95% CI, 1.35 to 2.88)), diabetes (1.76 (95% CI, 1.33 to 2.32)), gastrointestinal (1.19 (95% CI, 1.12 to 1.27)), hypertension (2.36 (95% CI, 1.83 to 3.06)) and any physical disorder (1.33 (95% CI, 1.29 to 1.37)). Comparing the pre-injury and post-injury periods, ARRs for injured showed a difference over time for all mental disorders except substance use and all physical disorders except gastrointestinal and total respiratory morbidity compared with matched uninjured. Greater injury severity was associated with two times greater ARR for developing any mental health disorder, and the injured had three times the ARR for dying by suicide (p<0.0006).

CONCLUSIONS AND RELEVANCE

Child survivors of traumatic injury had increased relative rates of mental and physical disorders compared with a matched uninjured cohort. These findings support targeted intervention strategies for this population at the time of hospitalisation.

Workplace Injury and Mental Health Outcomes

Importance

Workplace injury is a widespread problem that impacts mental health and quality of life and places a substantial burden on employers and the health care system.

Objective

To determine whether mental disorder rates differ following workplace injury compared with injuries outside the workplace.

Design, Setting, and Participants

This retrospective cohort study assessed individuals hospitalized for an injury requiring surgery between January 1, 2002, and December 31, 2018, with a 2-year follow-up period using population-based administrative data in Manitoba, Canada. Analyses were completed June to July 2021. This study compared 2 cohorts: individuals with a workplace injury matched 1:5 on sex, age, geographical region, and surgical procedure code with individuals with a nonworkplace injury in the general population.

Exposure

Traumatic physical injury that required surgery with anesthetic.

Main Outcomes and Measures

The outcome of interest was a diagnosis of mental disorder (anxiety, depression, substance abuse, suicide attempt, and any mental disorder), measured 2 years prior to and following injury.

Results

In this cohort study, 7556 individuals (mean [SD] age, 44.8 [13.3] years; 5721 [75.7%] male; 4624 individuals [61.2%] with urban residence; 4545 individuals [60.1%] with low income) with a workplace injury were compared with 28 901 matches from the general population. The workplace cohort had lower rates of all mental disorders (anxiety: adjusted rate ratio [ARR], 0.82; 95% CI, 0.77-0.87; depression: ARR, 0.78; 95% CI, 0.72-0.84; substance abuse: ARR, 0.63; 95% CI, 0.55-0.72; suicide attempt: ARR, 0.28; 95% CI, 0.11-0.70; and any mental disorder: ARR, 0.82; 95% CI, 0.78-0.86; all P < .0006) before their injury and for depression (ARR, 0.89; 95% CI, 0.82-0.95) and substance abuse (ARR, 0.83; 95% CI, 0.73-0.94) after their injury. The group × care period interaction term was significant for anxiety (P < .0001) and any mental disorder (P < .0001), suggesting that individuals with workplace injuries had worse mental disorder outcomes over time than individuals with nonworkplace injuries.

Conclusions and Relevance

This cohort study found that the mental health trajectory from the preinjury to postinjury period was worse for individuals with a workplace injury compared with those injured outside the workplace. These findings suggest that there may be features unique to the workplace and/or injury claims and compensation processes that contribute to this pattern, which warrant further examination.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury

INTRODUCTION

Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children.

METHODS

We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay.

RESULTS

2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56).

CONCLUSION

Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns.

TYPE OF STUDY

Retrospective study LEVEL OF EVIDENCE: Level III.

Routinely collected burn clinical data in Canada: Determining the knowledge gap

Unlike other developed countries that hold national burn registries to monitor burn injury and care, Canada relies on single-centre secondary datasets and administrative databases as surveillance mechanisms. The objective of this study was to determine the knowledge gap faced in Canada for not having a dedicated burn registry. A comprehensive scoping review was conducted to identify the burn literature that has arisen from secondary datasets in Canada. Literature of all study designs was included with the exception of case reports and cases series. Once data extraction was concluded, a thematic framework was constructed based on the information that arose from nations that hold national burn registries. Eighty-eight studies were included. Twelve studies arose from national datasets, and 18 from provincial databases, most of which were from Ontario and British Columbia. Only seven studies were conducted using a combination of Canadian units' single-centre datasets. The majority of included studies (58%) resulted from non-collaborative use of single-centre secondary datasets. Research efforts were predominantly conducted by burn units in Ontario, British Columbia, Manitoba and Alberta. A significant number of the included studies were outdated and several provinces/territories had no published burn data whatsoever. Efforts should be made towards the development of systems to surveil burn injury and care in Canada. This study supports the development of a nation-wide burn registry to bridge this knowledge gap.

Investigating social determinants of child health and their implications in reducing pediatric traumatic injury: A framework and 17-year retrospective case-control study protocol

INTRODUCTION

Traumatic physical injuries are the number one cause of hospitalization and death among children in Canada. The majority of these injuries are preventable. The burden from injury can be reduced through prevention programs tailored to at-risk groups, however, existing research does not provide a strong explanation of how social factors influence a child's risk of injury. We propose a theoretical framework to better understand social factors and injury in children and will examine the association between these social factors and physical traumatic injury in children using large population-wide data.

METHODS AND ANALYSIS

We will examine data from 11,000 children hospitalized for traumatic physical injury and 55,000 matched uninjured children by linking longitudinal administrative and clinical data contained at the Manitoba Centre for Health Policy. We will examine 14 social determinants of child health measures from our theoretical framework, including receipt of income assistance, rural/urban status, socioeconomic status, children in care, child mental disorder, and parental factors (involvement with criminal justice system, education, social housing, immigration status, high residential mobility, mother's age at first birth, maternal Axis I mental disorder, maternal Axis II mental disorder and maternal physical disorder) to identify groups and periods of time when children are at greatest risk for traumatic physical injury. A conditional multivariable logistic regression model will be calculated (including all social determinant measures) to determine odds ratios and adjusted odds ratios (95% confidence interval) for cases (injured) and controls (non-injured).

ETHICS AND DISSEMINATION

Health Information Privacy Committee (HIPC No. 2017/2018-75) and local ethics approval (H2018-123) were obtained. Once social measures have been identified through statistical modelling, we will determine how they fit into a Haddon matrix to identify appropriate areas for intervention. Knowing these risk factors will guide decision-makers and health policy.

Social determinants of alcohol-related traumatic injury in young adults: a scoping review protocol

INTRODUCTION

Limited research examines alcohol-related injury in the context of social determinants of health (SDoH) to guide effective intervention and prevention programmes. SDoH are non-medical factors that impact health such as income, housing and childhood environment. This scoping review aims to explore the role SDoH in childhood have in alcohol-related injury in young adults.

METHODS AND ANALYSIS

The scoping review process will be guided by the methodology framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews Guidelines (PRISMA-ScR). The PubMed and SCOPUS databases will be systematically searched. Studies of various designs and methodologies (published in English since 1 January 2000) that examine certain SDoH of interest in relation to alcohol-related injury in adults aged 18-25 years old will be considered for inclusion in this review. Two reviewers will screen all articles identified from the databases independently. Titles and abstracts will be reviewed based on the initial search and included if eligibility criteria are met. Duplicate articles will be removed and full texts will be examined to create a final list of included studies. Any disagreements on the inclusion of any articles will be resolved through discussion and consultation with a third reviewer if necessary.

ETHICS AND DISSEMINATION

As this research does not involve human subjects, ethics approval is not required. The results of this study will be summarised quantitatively through numerical counts and qualitatively through a narrative synthesis. The results from this review will address an important literature gap and inform the development of targeted prevention programmes for alcohol-related injury.

REGISTRATION NUMBER

This protocol is registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/MYEXA).

Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines

We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.

Evaluating the Impact of a Paediatric Burn Club for Children and Families Using Group Concept Mapping

Access to burn camps and clubs is cited as an essential element for children following a burn injury. In the Northern Regional Burns Service, this takes the form of a club run by a multidisciplinary team, offering residential camps and family day trips. In this service evaluation, Group Concept Mapping was used to evaluate the perception of the club by staff, children and families. Opportunistic sampling was used to seek responses to the following prompts: "The challenges for children and families after a burn injury are…" and "The role of The Grafters Club is…". The results indicate that participants perceived the club to be effective at addressing body image and confidence issues for the children but highlighted an unmet parental expectation that the club would also facilitate the sharing of experiences, normalisation of emotional reactions, and processing of guilt and other psychological distress for parents. When taken concurrently with pre-existing evidence in the literature base, it is proposed that a club model of psychosocial support for children and families could provide an accessible and informal opportunity for parental support that may be less subject to barriers perceived with traditional formal psychological support.

What Fuels the Fire: A Narrative Review of the Role Social Determinants of Health Play in Burn Injuries

Social determinants of health (SDOH) are the conditions where people live, learn, work, and play that affect their health and quality of life. There has been an increasing focus on the SDOH in the field of medicine to both explain and address health outcomes. Both the risk of burn injuries and outcomes after burns have been found to be associated with multiple aspects of the SDOH. This narrative review seeks to explore the main domains of the social determinants of health, reiterate their importance to the general and burn injury population, examine each's association with risks of burn injuries and burn-related outcomes, and provide an overview of the current burn research landscape that describes the social determinants of health.

Physical Rehabilitation and Mental Health Care after Burn Injury: A Multi-Nation Study

While remarkable improvements have been made to acute hospital burn care in recent decades, it is not matched by improvements in post-acute care, including physical rehabilitation and mental health. Progress in acute hospital treatment of burn survivors now highlights the next important step-addressing care once a patient leaves intensive treatment and is discharged to the community. Long-term physical rehabilitation and mental health services are vital to improving quality of life for burn survivors. Using qualitative methods, we apply the adapted Reeve framework to assess and compare post-acute physical rehabilitation and mental health care across thirteen countries on six continents. Twenty semi-structured interviews were conducted with burn surgeons and rehabilitation specialists. One major theme that emerged was the importance of training and resources to the quality of post-acute care. This exploratory study suggests the value of investing scarce resources in a range of low-cost interventions to improve follow-up burn care. One intervention identified here is short-term training in post-acute rehabilitation and mental health to upgrade and standardize best clinical practices to address as-yet unmet post-discharge needs of burn survivors.