Measuring exposure to injury risk in schoolchildren aged 11-14

Road traffic injuries to children during the school commute in Hyderabad, India: cross-sectional survey

BACKGROUND

India is motorising rapidly. With increasing motorisation, road traffic injuries are predicted to increase. A third of a billion children travel to school every day in India, but little is known about children's safety during the school commute. We investigated road traffic injury to children during school journeys.

METHODS

We conducted a cross-sectional survey in Hyderabad using a two-stage stratified cluster sampling design. We used school travel questionnaires to record any road injury in the past 12 months that resulted in at least 1 day of school missed or required treatment by a doctor or nurse. We estimated the prevalence of road injury by usual mode of travel and distance to school.

RESULTS

The total sample was 5842 children, of whom 5789 (99.1%) children answered the question on road injury. The overall prevalence of self-reported road injury in the last 12 months during school journeys was 17% (95% CI 12.9% to 21.7%). A higher proportion of boys (25%) reported a road injury than girls (11%). There was a strong association between road injury, travel mode and distance to school. Children who cycled to school were more likely to be injured compared with children who walked (OR 1.5; 95% CI 1.2 to 2.0). Travel by school bus was safer than walking (OR 0.5; 95% CI 0.3 to 0.9).

CONCLUSIONS

A sixth of the children reported a road traffic injury in the past 12 months during school journeys in Hyderabad. Injury prevention interventions should focus on making walking and cycling safer for children.

What is the Relationship between Risky Outdoor Play and Health in Children? A Systematic Review

Risky outdoor play has been associated with promoting children’s health and development, but also with injury and death. Risky outdoor play has diminished over time, concurrent with increasing concerns regarding child safety and emphasis on injury prevention. We sought to conduct a systematic review to examine the relationship between risky outdoor play and health in children, in order to inform the debate regarding its benefits and harms. We identified and evaluated 21 relevant papers for quality using the GRADE framework. Included articles addressed the effect on health indicators and behaviours from three types of risky play, as well as risky play supportive environments. The systematic review revealed overall positive effects of risky outdoor play on a variety of health indicators and behaviours, most commonly physical activity, but also social health and behaviours, injuries, and aggression. The review indicated the need for additional “good quality” studies; however, we note that even in the face of the generally exclusionary systematic review process, our findings support the promotion of risky outdoor play for healthy child development. These positive results with the marked reduction in risky outdoor play opportunities in recent generations indicate the need to encourage action to support children’s risky outdoor play opportunities. Policy and practice precedents and recommendations for action are discussed.

Social deprivation as a risk factor for fractures in childhood

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. These findings have important implications for public health and preventative measures.

Roadway characteristics and pediatric pedestrian injury

Changing the built environment is a sound, but often underutilized approach to injury control. The authors reviewed the literature and conducted a meta-analysis to synthesize the evidence on the association of roadway characteristics with risk of pediatric pedestrian injury. To synthesize the data, they converted results to odds ratios based on direct results or abstracted outcomes and used Bayesian meta-analytic approaches by modeling outcomes as the logit of a normally distributed set of outcomes with vague prior distributions for the central measure of effect and its variance. On the basis of 10 studies of roadway features restricted exclusively to pediatric populations, the synthesized effect estimate for the association of roadway characteristics with pedestrian injury risk was 2.5 (95% credible interval: 1.8, 3.2). The probability of a new study showing an association between the built roadway and pediatric pedestrian injury was nearly 100%. The authors concluded that the built environment is directly related to the risk of pedestrian injury. This review and meta-analysis suggests that even modest interventions to the built roadway environment may result in meaningful reductions in the risk of pediatric pedestrian injury.

Socioeconomic status and injury risk in children

Research has consistently shown that low socioeconomic status (SES) is associated with an increased risk of poor health and death in adults and children. Studies from around the world have shown an inverse relationship between SES and childhood injury morbidity and mortality. For example, compared with children with high SES, children with low SES are at an increased risk of death from pedestrian collisions, fires, falls and drownings, and at an increased risk of hospitalization from recreation or play injuries. Research from England and Wales shows that these disparities in mortality between high and low SES children may be widening over time. This paper provides an overview of the literature on the relationship between SES and childhood injury morbidity and mortality, outlines the postulated mechanisms for this relationship, and highlights some intervention studies targeted to low SES children.

Are safety-related features of the road environment associated with smaller declines in physical activity among youth?

This study examined how objective measures of the local road environment related to safety were associated with change in physical activity (including active transport) among youth. Few longitudinal studies have examined the impact of the road environment on physical activity among children/adolescents in their neighborhoods. Participants were children aged 8-9 years (n = 170) and adolescents aged 13-15 years (n = 276) in 2004. Data were collected in 2004 and 2006 during follow-up of participants recruited initially in 2001 from 19 primary schools in Melbourne, Australia. Walking/cycling to local destinations was parent-reported for children and self-reported by adolescents. Moderate-to-vigorous physical activity (MVPA) during nonschool hours was recorded using accelerometers. Road environment features in each participant's neighborhood (area within 800 m radius of their home) were measured objectively using a Geographical Information System. Linear regression analyses examined associations between road features and changes in active transport (AT) and MVPA over 2 years. Children's AT increased but MVPA levels decreased in both age groups; on average, younger girls recorded the greatest declines. The number of traffic/pedestrian lights was associated with DeltaAT among younger girls (B=0.45, p=0.004). The total length of walking tracks (in meters) was associated with AT among younger girls (B = 0.0016, p = 0.015) and adolescent girls (B = 0.0016, p = 0.002). For adolescent boys, intersection density was associated with AT (B = 0.03, p = 0.030). Slow points were associated with MVPA among younger boys before school (B = 1.55, p = 0.021), while speed humps were associated with MVPA among adolescent boys after school (B = 0.23, p = 0.015). There were many associations for adolescent girls: for example, the total length of local roads (B = 0.49, p = 0.005), intersection density (B = 0.05, p = 0.036), and number of speed humps (B = 0.33, p = 0.020) were associated with MVPA during nonschool hours. Safety-related aspects of the built environment are conducive to physical activity among youth and may help stem age-related declines in physical activity. Passive road safety interventions may promote AT and physical activity among less active girls, in particular.

Environmental correlates of children's active transportation: a systematic literature review

This systematic review investigated the environmental (physical, economic, socio-cultural and political) correlates of active transportation (AT) among young people aged 5-18 years to better inform the promotion of active living. Greater distance, increasing household income and increasing car ownership are consistently associated with lower rates of AT among children. Having a non-white ethnic background has a convincing positive association with AT. Having recreation facilities and walk or bike paths present are possibly associated with higher rates of AT. Further research requires longitudinal and intervention studies, utilizing multi-level design methodologies and objective measures of environmental attributes.

Injury risk in young psychiatric outpatients: an 11-year follow-up of 302 adolescents

BACKGROUND

Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients.

SUBJECTS AND METHODS

Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation.

RESULTS

Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation.

CONCLUSION

Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.

Participation in sports clubs is a strong predictor of injury hospitalization: a prospective cohort study

The aim of this prospective cohort study was to investigate the nature and risk factors of injuries leading to hospitalization. A cohort of 57 407 Finns aged 14-18 years was followed in the Hospital Discharge Register for an average of 10.6 years, totaling 608 990 person-years. We identified 5889 respondents (10.3%) with injury hospitalization. The most common anatomical location was the knee and shin (23.9%), followed by the head and neck (17.8%), and the ankle and foot (16.7%). Fractures (30.4%) and distortions (25.4%) were the most common injury types. The strongest risk factor for injury hospitalization was frequent participation in sports clubs [hazard ratio (HR) in males 1.8; 95% confidence interval (CI): 1.7-2.0 and in females 2.3; 95% CI: 1.9-2.7], followed by recurring drunkenness (HR 1.6; 95% CI: 1.4-2.7 in males and 1.4; 95% CI: 1.2-1.6 in females) and daily smoking (HR 1.4; 95% CI: 1.3-1.5 in males and 1.43 95% CI: 1.2-1.5 in females). The association between injuries and sports clubs participation remained after adjusting for sociodemographic background, health, and health behaviors. Health behavior in adolescence, particularly sports club activity, predicted injury hospitalization. Preventive interventions directed toward adolescents who participate in sports clubs may decrease injury occurrence.

An association between socioeconomic, health and health behavioural indicators and fractures in young adult males

The aim of this survey study with 7,083 male respondents was to examine the association between socioeconomic, health and health behavioural risk indicators and fractures. In the multivariate regression model, fractures were associated strongest with frequency of drunkenness, regular sports training, frequent use of health care services and obesity.

INTRODUCTION

Little is known about the risk factors for fractures in young adults. Our aim was to identify the association between socioeconomic background, health and health behaviours and fractures.

METHODS

The survey sample comprised 7,378 conscript males (median age 19), of which 7,083 (96%) answered. The outcome was self-reported fracture. Associations between 20 background variables and fractures were analysed with logistic regression.

RESULTS

Altogether 2,456 (34.7%) participants reported fracture(s) during their lifetime. The most common anatomical locations of fracture were the forearm, the hand and the ankle. The strongest risk indicators for fractures were frequent drunkenness (OR 1.7; 95% CI: 1.3-2.0), regular sports training (OR 1.6; 95% CI: 1.3-1.9), frequent use of health care services (OR 1.5; 95% CI: 1.3-1.8) and obesity (OR 1.5; 95% CI: 1.2-1.9).

CONCLUSIONS

This is among the first studies to describe risk indicators for fractures in young adults. The strongest risk factors for fractures were associated with health damaging behaviour, high-intensity physical activity and use of health care services. Of socioeconomic background factors, only living in the capital city area was associated with fractures. Preventive measures should be targeted at the males frequently using health care services or actively participating in sports.

Socio-economic distribution of environmental risk factors for childhood injury

OBJECTIVE

Childhood injury remains the single most important cause of mortality in children aged between 1-14 years in many countries. It has been proposed that lower socio-economic status (SES) and poorer housing contribute to potential hazards in the home environment. This study sought to establish whether the prevalence of observed hazards in and around the home was differentially distributed by SES, in order to identify opportunities for injury prevention.

METHODS

This study was a cross-sectional, random sample survey of primary school children from 32 schools in Brisbane. Interviews and house audits were conducted between July 2000 and April 2003 to collect information on SES (income, employment and education) and previously identified household hazards.

RESULTS

There was evidence of a relationship between prevalence of household environmental hazards and household SES; however, the magnitude and direction of this relationship appeared to be hazard-specific. Household income was related to play equipment characteristics, with higher SES groups being more likely to be exposed to risk. All three SES indicators were associated with differences in the home safety characteristics, with the lower SES groups more likely to be exposed to risk.

CONCLUSION

The differential distribution of environmental risk factors by SES of household may help explain the SES differential in the burden of injury and provides opportunities for focusing efforts to address the problem.

Relationships between child, family and neighbourhood characteristics and childhood injury: a cohort study

There has been little research into the role of neighbourhood effects in childhood injury. We report results from a cohort study, comprising 1717 families (2357 children aged 0-7 years) registered at 47 general practices in Nottingham, UK. Multi-level Poisson regression examined relationships between electoral ward (neighbourhood), family and child characteristics and medically attended injury rates. Primary care attendance rates were higher for children in rented accommodation and those aged 2-3 years. An n-shaped relationship was found between geographical access to services and the primary care attendance rate. Accident and Emergency (A&E) department attendance rates were higher amongst boys, children in rented accommodation, with a teenage mother, aged 2-5 years and living in wards with a higher number of parks and play areas. They were lower for children whose families had a smoke alarm. Hospital admission rates were higher amongst children living in more deprived wards and wards with higher violent crime rates. They were lower in children whose families had smoke alarms, stair gates and stored sharp objects safely. Primary care and A&E attendance rates varied significantly between families. Variation between wards in the A&E attendance rate was explained by family characteristics. We conclude that characteristics of wards, families and children are associated with medically attended childhood injury rates. This study did not find a neighbourhood effect for A&E attendances that could not be explained by family level characteristics. Studies with greater power and a measure of injury severity independent of health service utilisation are needed to explore the relationship between neighbourhood effects and more severe injuries. The greater variation in injury rates vary between families than between neighbourhoods suggests reducing inequalities in injury rates may be achieved more effectively by focussing prevention at families rather than neighbourhoods, but in practice interventions at both levels are likely to be necessary.

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

OBJECTIVE

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

DESIGN

Cross-sectional survey.

SETTING

Barcelona (Spain).

METHODS

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

RESULTS

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

CONCLUSION

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

Characteristics of ice hockey-related injuries treated in US emergency departments, 2001-2002

OBJECTIVE

Ice hockey, a popular sport in some regions, has potential for injury due to the velocities of players, pucks, and sticks. Previous studies conducted worldwide have shown that the rate of injury increases as the size and the speed of players increase, as well as when checking is allowed. However, national data about the annual number and types of injuries among ice hockey players are lacking. Data from previous studies were collected from regional tournaments, collegiate teams, local emergency departments (EDs), and different countries. The purpose of this article is to examine ice hockey injuries using a national US database to determine the age distribution of total injuries, injury types, and body regions injured, with a particular focus on ice hockey players <18 years old.

METHODS

Data regarding ice hockey-related injuries treated in US EDs between January 1, 2001, and December 31, 2002, were extracted from the National Electronic Injury Surveillance System (NEISS). Data considered included age, gender, race, injury diagnosis, and body region injured. Ice hockey-related injury cases were identified using the consumer product code for ice hockey and the narrative description of the incident in NEISS.

RESULTS

An estimated 32,750 individuals with ice hockey-related injuries were treated in US EDs in 2001-2002, including >18,000 youths <18 years old. The number of injuries peak through adolescence (ages 12-17; 47% of all injuries). Males experienced 90% of all injuries. A very small percentage of individuals were hospitalized after injury (1.2% of individuals <18 years old; 0.5% of individuals > or =18 years old). The incidence of head injuries increased as age decreased, although the trend was not statistically significant. The upper extremity (44%) accounted for the highest total percentages of body regions injured for youths <18 years old, and trunk (14%) and facial injuries (10%) represented the smallest total percentages. Players > or =18 years old had significantly more lacerations than younger players (38% of injuries for 18- to 24-year-olds; 25% for 25- to 34-year-olds; 50% for 35- to 44-year-olds compared with 19% for 6- to 11-year-olds and 14% for 12- to 17-year-olds).

CONCLUSIONS

Adolescents had the greatest number of ice hockey-related injuries treated in NEISS hospital EDs in 2001-2002; thus, ongoing efforts to develop injury prevention strategies should focus on this age group. Players < or =17 years old had a lower percentage of lacerations compared with all older players and a higher percentage of upper extremity injuries. The percentage of individuals hospitalized after injury was very low, yet youths <18 years old had twice the percentage of hospitalization after injury compared with individuals > or =18 years old. Males experienced the vast majority of all ice hockey-related injuries, with females representing a higher percentage of injuries among youths than among adults. Children and adults alike can reap the physical fitness and social benefits from ice hockey, when they are able to avoid predictable and preventable injuries.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Children at play: the death and injury pattern in New South Wales, Australia, July 1990-June 1994

OBJECTIVES

To describe and to understand the pattern of play-related deaths and injury (excluding organized sports) among children in New South Wales (NSW), Australia.

METHODOLOGY

This study utilized a state-wide prospective surveillance data collection of paediatric traumatic deaths and injuries at the Royal Alexandra Hospital for Children. Deaths and injury cases were selected from the NSW Trauma Death Registry and Childsafe NSW database. Information including basic demographics, the surrounding circumstances of death and injury incidents, and the required treatment was collected.

RESULTS

There were 30 play-related deaths and 92 drownings over the 4-year period. The male to female ratio was about 2:1. Excluding drowning, which has been reported elsewhere, and sports, the leading causes of play-related deaths were burns (eight) and asphyxiation (eight). An average of 6444 presentations to the emergency departments per year were recorded with sex ratio and age distribution pattern similar to the deaths. The home was the most common place (55.5%) of play-related injury, specifically the living and sleeping area. Falls, both under and above 1 metre, were the most common causes of injury (50.9%). The leading mechanism was cuts and lacerations (21.2%). Nearly one-third (32.7%) of all injuries were to the head, with face, cheek, forehead and scalp as the most common injured body part. Significant associations between place of injury, injured body parts and age were observed.

CONCLUSIONS

Play-related injury is common among children, and in some cases causes severe injury and death. To tackle the problem of play-related deaths and injuries, a holistic approach is suggested. This includes the provision of a safe environment, supervision by parents, education of children and detailed data collection.

Injury control strategies: extending the quality and quantity of data relating to road traffic accidents in children

This review describes how an extended database of information can provide the opportunity to go beyond the traditionally distinct health, engineering, and education initiatives in order to identify the effectiveness of more overarching policies for injury control. Such information can be used to raise awareness and to encourage community participation in designing a road traffic accident prevention strategy.

Children's exposure to traffic and pedestrian injuries

OBJECTIVES

The purpose of this study was to estimate children's exposure to traffic (number of streets crossed) and to determine the role of exposure in pedestrian injury.

METHODS

Questionnaires were distributed to a random sample of 4080 first- and fourth-grade children in 43 Montreal schools.

RESULTS

When analyzed by police district, injury and exposure rates were positively correlated (r2 = 0.53). Crossings were similar by sex but increased with age and were inversely related to socioeconomic status.

CONCLUSIONS

These results suggest that although children's exposure to traffic could be reduced by transporting them to school, a more reasonable prevention strategy involves environmental changes.

Traumatic injuries among university students in Finland

A questionnaire dealing with the incidence of traumatic injuries was sent to 1,000 randomly selected 3rd-year university students in Finland; 617 students responded adequately. Of those, 177 (28.7%) reported a combined total of 281 accidents and 323 separate injuries requiring medical or dental treatment during the preceding 3 years. The accidents resulted in 1,061 days of official sick leave, and one third of the accidents caused permanent sequelae to the affected students. Almost half of all accidents had been sustained during sports activities and 14% in traffic. Only 0.5% of the accidents were classified as having occurred in the university environment or during activities directly related to studies. Alcohol was involved in 10.1% of the accidents; 45% of the injuries affected the lower extremities, and 22% the upper extremities. Most of the injuries were related to the students' active lifestyles and keen interest in sports.

Accidents among high school pupils in Israel: a recurrent disease?

Accidents are unexpected events usually producing injury. Many victims of trauma have a history of recurrent accidents. This study is a preliminary effort to verify the hypothesis that accidents may be considered as a recurrent disease in certain families; these children and families belong to a 'high risk group'. Two-hundred seventy-nine high school pupils participated in the study. Every pupil had experienced 1.7(+/- 1.7) mild to serious injuries that necessitated medical treatment during the years of elementary and high school. The geographical location of accidents was as follows: 26.4% were on the road; 23.1% occurred at school; 28.6% were associated with sport activities; and 22% occurred at home. The prevalence of injuries among boys was higher than among girls. A correlation was found between the number of accidents of the pupils and those of close family members, suggesting that these children and families are prone to accidents and form a 'high risk group'. The knowledge of accident and injury prevention did not change significantly during high school studies. The principal source of knowledge of accident and injury prevention of the pupils were the media: TV (98.8%), newspapers: (65.6%), and radio (58.1%). The contribution of physicians and nurses to this knowledge was very slight (16.5%). These families should be a target population; an educational program should be organized and transmitted by the media; family meetings with educational advisors, physicians and nurses should take place at school, especially for these target families. As a preventive measure for all, and especially to the high risk group, we would suggest that high school pupils work for 1-3 months in rehabilitation centers in which they can see the consequences of accidents and thereby gain an understanding of the effects of injury on the patient and his family.

Socioeconomic status and adolescent injuries

Injuries are the major cause of morbidity among children and adolescents in developed countries, but there is a lack of consensus on the relationship between socioeconomic status and risk of injuries. A self-complete questionnaire survey, to gather information on non-fatal injuries and sociodemographic details, was administered in schools during April-June 1994 to a national sample of 4710 Scottish adolescents aged 11, 13 and 15 years. Although there was no evidence of a socioeconomic gradient in the total incidence of medically attended injuries among adolescents, based on the Registrar General's classifications of paternal occupation and a composite measure of family affluence, marked socioeconomic variation in the circumstances in which injuries occurred was observed. There were also socioeconomic differences in the extent and type of risk behaviours reported by adolescents, indicating differential rates of risk exposure. The finding that socioeconomic status affects the kinds of injury events adolescents experience and levels of risk behaviour has implications for the design of injury prevention strategies.

Road traffic accidents: early psychological consequences in children and adolescents

BACKGROUND

Although road traffic accidents are a major cause of injury and death in children and adolescents, research into their psychological consequences consists mainly of case reports.

METHOD

A prospective study was made of young road traffic accident victims: 57 subjects, aged 5-18 years, who had been injured in road traffic accidents, and their parents, were interviewed 2-16 days post-accident and re-examined after 12-15 weeks.

RESULTS

Post-accident stress symptoms occurred at both times. There was a decrease of symptom severity between the two interviews, but at the later time, 14% still suffered from moderate or severe post-traumatic stress disorder, 17% from serious traffic-related fears, and parents reported increased mood disturbance in their children compared with the pre-accident period. High levels of distress during and immediately after the accident were associated with severe post-traumatic stress symptoms.

CONCLUSIONS

There is an urgent need for healthcare staff working with children and adolescents involved in road traffic accidents to be aware of the potential psychological consequences and the importance of the immediate accident experience on subsequent coping.

Child pedestrian injury rates: the importance of "exposure to risk" relating to socioeconomic and ethnic differences, in Auckland, New Zealand

STUDY OBJECTIVE

To examine how child pedestrian exposure to risk, as measured by the mean number of streets crossed, varies according to indices of material disadvantage and ethnic group.

DESIGN

A questionnaire on pedestrian exposure to risk was distributed to children for completion by parents and return to school. Children from 40 schools were selected using a probability cluster design.

SETTING

The Auckland region of New Zealand.

SUBJECTS

Questionnaires were distributed to 3388 pupils of whom 2873 (85%) completed and returned the questionnaire.

RESULTS

The mean number of streets crossed was 2.19 (95% confidence interval 1.82, 2.56) at age 6 years and 2.80 (2.42, 3.17) at age 9 years. The mean number of streets crossed for boys (2.57 (2.15, 2.98)) was similar to that for girls (2.38 (2.05, 2.72)). The mean number of streets crossed by Pacific Island children was 4.87 (4.01, 5.73), more than twice the number crossed by children of predominantly European origin (1.90 (1.65, 2.15)). Children from families without a car crossed an average of 5.34 (4.35, 6.34) streets, compared with 2.90 (2.50, 3.31) streets for children from families with one car, and 1.97 (1.65, 2.29) streets for children from families with two or more cars.

CONCLUSION

There are large differences in pedistrian exposure to risk in relation to ethnic group and levels of car ownership. These differences may explain ethnic and socioeconomic differentials in child pedestrian injury rates.

Incidence and distribution of injury among schoolchildren aged 11-15

OBJECTIVES

To measure the incidence and age and sex distribution of self reported experience of injuries in the preceding 12 month period among a representative national sample of Scottish schoolchildren and to validate the findings against other data sources.

DESIGN

Self completed questionnaire administered in schools, April-June 1994.

SUBJECTS

4710 pupils aged 11, 13, and 15 years drawn from a representative sample of 270 classes with returns from 224 classes (83.2% completion rate).

OUTCOME MEASURES

Number, type, site, and severity of injuries reported.

RESULTS

41.9% of pupils reported a medically attended injury, with injury incidence significantly higher in boys than in girls. Using the abbreviated injury scale (maximum abbreviated injury score) one third of injuries were either moderate or severe.

CONCLUSION

The incidence and distribution of self reported injury is consistent with estimates based on other data sources thus confirming the utility of this method of injury surveillance in this age group.

Population-based incidence of injuries among preschoolers

A population survey was conducted to determine the incidence of injuries among preschoolers and their risk factors. A systematic sample (15%, n = 4540) of families with at least one child aged 0-5 years in 1991 living in the Canton of Vaud (Switzerland) received a mailed questionnaire in February 1992. There were 5827 eligible children in the sample. The response rate was 67.5% after two recall mailings. Injuries were defined as those from all causes with at least one physician contact in 1991. The overall incidence was 224 injuries per 1000 children (95% CI [= confidence intervall]: 211-237); 188 per 1000 children were injured over 1 year (95% CI: 176-200, n = 746), of whom 16.5% (n = 123) had 32 injuries. Falls represented 66% of all injuries, followed by burns (8%) and poisonings (5%). The proportion of hospitalized cases was 4.8% and the population incidence of hospitalization due to injury was 10.8/1000 children. Socioeconomic factors did not influence the occurrence of injuries.

CONCLUSION

The measured incidence of injuries among preschoolers is among the highest in developed countries. Practitioners could contribute more effectively to injury prevention through routine information and counselling of parents from all social backgrounds.

A case-control study of child bicycle injuries: relationship of risk to exposure

In order to assess the relationship of the risk of injury requiring hospital attendance in children riding bicycles to sociodemographic factors and to measures of exposure, a population-based case-control study is being undertaken in a large area of suburban Melbourne, Australia. Particular attention is given to the measurement of individual exposure in several dimensions. Analysis of interim data from 109 cases and 118 controls shows that 51% of injuries occurred while the child was playing rather than making a trip on the bicycle and only 22% involved another vehicle. Boys used bicycles more commonly than girls but there was minimal evidence of an increased risk of injury in boys, adjusting for exposure. There was no evidence for an age trend in injury risk, but children from families in the lowest income category were at significantly increased risk. Exposure measures showed complex patterns of association with injury risk. Estimated time spent riding was more closely associated with risk than distance travelled, with an odds ratio of 2.2 (95% confidence interval 1.1-4.2) for children riding for more than 3 hours per week compared to children riding less than 1 hour. Riding more than 5 km on the sidewalk was also associated with increased risk (odds ratio 3.1, 95% CI 1.1-8.5). The elevated risk associated with sidewalk riding may be due to difficulties in negotiating uneven surfaces. The case-control study provides an ideal design for this type of investigation but valid and reliable measurement of exposure is difficult.

Child pedestrian deaths: sensitivity to traffic volume--evidence from the USA

STUDY OBJECTIVE

In case centred epidemiological studies, traffic volume has been shown to be a potent risk factor for child pedestrian injuries. Nevertheless, over the past two decades child pedestrian death rates have fallen in many countries despite large increases in traffic volumes, suggesting that other factors are responsible for the long term decline in death rates. This study aimed to investigate the relationship between short term changes in traffic volume and child pedestrian death rates.

DESIGN

The relationship between child pedestrian death rates and traffic volume in the USA for the period 1970-88 was investigated. Trends in death rates and in traffic volume were removed by the time series method of differencing.

RESULTS

After removing the long term trends, there was a close relationship between the year to year variation in traffic volume and the year to year variation in the child pedestrian death rate. Most notably, in the two periods when traffic volume actually fell, the falls in the child pedestrian death rate were considerably larger than those seen at any other time. Overall, decelerations in the rate of increase in traffic volume were accompanied by accelerations in the rate of decline in the child pedestrian death rate.

CONCLUSION

While other factors may determine long term trends in child pedestrian death rates, they are very sensitive to short term changes in traffic volume. Public policy changes which limit the growth in traffic volume have the potential to accelerate the decline in child pedestrian death rates.

Methodologic issues in injury case-control studies

In this paper some methodological problems particularly relevant to case-control studies of injury are illustrated by reference to previous childhood injury case-control studies. In contrast to studies of disease, where 'person time' constitutes the observational experience of interest, in injury studies person time engaged in a particular activity to often more appropriate. The implications for the definition of the study base are discussed. The potential for hospital admission bias in injury case-control studies is considered along with potential strategies for avoiding it. The importance of errors in exposure measurement, including those arising from inappropriate induction time assumptions, are illustrated. Finally, the potential for bias resulting from the combination of etiologically unrelated injury outcomes into a single outcome measure is illustrated and discussed.