Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children

Socioeconomic variables and fracture risk in children and adolescents: a population-based study from northern Sweden

OBJECTIVES

Previous studies have investigated the association between socioeconomic characteristics and fractures among children, producing different results. In a population-based study, we previously found an increased risk of fractures among children living in an urban municipality compared with rural municipalities. This study aimed to evaluate the importance of socioeconomic variables for the incidence of fractures among 0-17 year olds.

SETTING, DESIGN AND OUTCOME MEASURE

We present a longitudinal, observational study of a population 0-17 years of age. Data from an injury database were linked with additional socioeconomic data for the population at risk. These were 55 758 individuals residing within the primary catchment area of a regional hospital in northern Sweden. Using the number of fractures as the outcome, we fitted a generalised linear mixed model for a Poisson response with socioeconomic variables at the family level as independent variables while controlling for age, sex and place of residence.

RESULTS

We found a significant association between higher levels of family income and the risk of fracture, rate ratio 1.40 (1.28-1.52) p<0.001 when comparing the highest income quintile to the lowest as well as the number of siblings and the risk of fracture. Children with one or two siblings had a rate ratio of 1.28 (1.19-1.38) p<0.001 when compared with children with no siblings. Parents' educational level and having a single parent showed no significant association with fractures. The previously observed association between municipalities and fracture risk was less pronounced when taking family-level socioeconomic variables into account.

CONCLUSION

Our results indicate that children from families with higher income and with siblings are at greater risk of sustaining fractures.

Patient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury

OBJECTIVE

To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level sociodemographic characteristics.

STUDY DESIGN

Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004-2008. Home addresses were geocoded to determine census block group and associated sociodemographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between sociodemographic characteristics and admission or transfer among injury-related ED visits.

RESULTS

Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2,833676 successfully geocoded visits, 700,821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty.

CONCLUSIONS

Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Sociodemographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries.

Incidence of fractures among children and adolescents in rural and urban communities - analysis based on 9,965 fracture events

BACKGROUND

Previous work has explored the significance of residence on injuries. A number of articles reported higher rates of injury in rural as compared to urban settings. This study aimed to evaluate the importance of residency on the occurrence of fractures among children and adolescents within a region in northern Sweden.

METHODS

In a population based study with data from an injury surveillance registry at a regional hospital, we have investigated the importance of sex, age and place of residency for the incidence of fractures among children and adolescents 0-19 years of age using a Poisson logistic regression analysis. Data was collected between 1998 and 2011.

RESULTS

The dataset included 9,965 cases. Children and adolescents growing up in the most rural communities appeared to sustain fewer fractures than their peers in an urban municipality, risk ratio 0.81 (0.76-0.86). Further comparisons of fracture rates in the urban and rural municipalities revealed that differences were most pronounced for sports related fractures and activities in school in the second decade of life.

CONCLUSION

Results indicate that fracture incidence among children and adolescents is affected by place of residency. Differences were associated with activity at injury and therefore we have discussed the possibility that this effect was due to the influence of place on activity patterns. The results suggest it is of interest to explore how geographic and demographic variables affect the injury pattern further.

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.

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.

Possible geographical barriers to trauma center access for vulnerable patients in the United States: an analysis of urban and rural communities

OBJECTIVE

To study whether traditionally vulnerable populations have worse geographic access to trauma centers.

DESIGN

A cross-sectional analysis using data from the American Hospital Association Annual Survey from 2005 linked with zip code-level data from the US Census. We used a multinomial logit model to examine the odds of having difficult as opposed to easy access to trauma centers for a given subgroup of vulnerable populations.

SETTING AND PARTICIPANTS

Population in rural and urban communities as defined by zip codes in the United States.

MAIN OUTCOME MEASURES

Each community's distance to the nearest trauma center (levels I-III).

RESULTS

In urban areas, 67% of the population had easy access to trauma centers and 12% had difficult access compared with 24% and 31% in rural areas, respectively. Areas with higher shares of the following vulnerable population groups had higher risks (odds ratios) of facing difficult access to trauma center services in 2005: foreign born in urban areas (1.65 for a medium share and 2.18 for a high share [both P < .01]); African American in urban and rural areas (1.25 for a medium share and 1.35 for a high share, respectively [both P < .05]); and near-poor in urban and rural areas (1.52 [P < .05] and 1.69 [P < .01] for a high share, respectively).

CONCLUSIONS

A significant segment of the US population (representing 38.4 million people) does not have access to trauma care within 1 hour of driving time. Moreover, certain vulnerable groups are at higher risk than others for worse access to trauma centers. Stakeholders and health care planners should consider these factors in the development of trauma systems because a mismatch of potential need and access could signal inefficiencies in the delivery of care.

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.

Unemployment rates and trauma admissions

In this article, we tested the hypothesis that the number and demographic characteristics of admissions to our trauma center were related to unemployment rates. The correlation study was conducted at The American College of Surgeons-verified level I trauma center in our area (New Orleans, Louisiana). It included all trauma admissions. Monthly unemployment rate data from our area were obtained from the Bureau of Labor Statistics. The hospital trauma registry supplied trauma emergency room admissions and demographic data. Mean daily trauma admissions were calculated for each month. Pearson correlations were used for statistical analysis. Over 24,000 trauma admissions occurred over a six-year period. Unemployment rates correlated with penetrating trauma admissions (r = 0.50; p < 0.001). Interestingly, unemployment rates inversely correlated with total trauma admissions (r = -0.73; p < 0.001), blunt trauma admissions (r = -0.81; p < 0.001), and ratio of blunt-to-penetrating trauma admissions (r = -0.82; p < 0.001). Higher percentage of male patients (r = 0.66; p < 0.001), percentage of African-American patients (r = 0.53; p < 0.001), and mortality (r = 0.56; p < 0.001) correlated positively with higher unemployment rates. We concluded that as unemployment rates decrease, emergency room penetrating trauma admissions decrease, while total and blunt trauma admissions increase. As the socioeconomic status (measured by unemployment rates) of the community changes, so do the demographic make-up and mortality of the trauma population. Our findings suggest that during times of economic hardships, certain population groups are at higher risk for trauma. Prevention should be aimed accordingly.

Incidence and Nature of Farm-related Injuries among Children Aged 6-15 during a 10-year Period in One Region in Poland

The health risks among children in "new" and "old" members of the European Union seem to be different. Farms are the most frequent place of injuries among children living in rural areas in Poland. Our aim is to present data on the farm-related injuries conditions among children aged 6-15 in one large region in Poland. The analysis has been made on the basis of information collected from the Farmers' Insurance Fund in Włocławek, which registers all farm-related injuries reported within the Włocławek Province. Over the 10-year study period 449 injuries were recorded (1.29 injuries per 1000 person-years). Among all victims there were 132 girls (29.4% of the total) and 317 boys. 14-year-old children fell victims of injuries most frequently (20.0% of all injuries). The highest number of injuries was recorded during the summer season. The injuries resulted mainly from falls or slips (47.2%) and falling from high altitudes (22.9% of all injuries). Individual and unattended works accounted for 37.5% of cases while 30.4% of all injuries happened while children were assisting in the work performed by adults. The sites were farm facilities (29.0%), farmyard (23.8%), around farm facilities (13.1%), pastures and meadows (11.1%), fields (9.1%), roads leading to houses or farm facilities (7.6%) and home (6.2%). We conclude that 13-15-year-old boys falling during an individual unattended work or while assisting in the work performed by adults, inside and around farm facilities, and during summer months, were the most frequent victims of injuries on farms. Information obtained in this study may be helpful in developing and implementing injury prevention strategies tailored to the Central-Eastern European agricultural realities.

Psychological determinants of risk taking by children: an integrative model and implications for interventions

OBJECTIVES

To draw on empirical findings of the psychological factors that cause elementary-school children to engage in risky play behaviors that can lead to injury, with the aim of developing an integrative model that can support intervention-program planning.

METHODS

An extensive review of literature on this topic was conducted, determinants of risk taking for which there was empirical support were identified, and results were synthesized to create an integrative model of children's risk taking.

RESULTS

Research on risk taking in children is limited, but the findings support the importance of examining child, family and socio-environmental factors to understand children's risk-taking behaviors.

CONCLUSIONS

Development of a model outlining the determinants of risk behaviors can provide a foundation for initiatives that aim to reduce such behaviors and prevent childhood injuries.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries 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 improve a range of safety practices or reduce injury rates 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 in increasing home safety practices or reducing child injury rates and whether the effect varied by social group.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, DARE, ASSIA, Psychinfo and Web of Science, plus a range of relevant web sites, conference proceedings and bibliographies. We contacted authors of included studies and surveyed a range of organisations.

SELECTION CRITERIA

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

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 simultaneoulsy combined in meta-regressions by social and demographic variables.

MAIN RESULTS

Eighty studies were included; 37 of which were included in at least one meta-analysis. Twenty-three (62%) were RCTs and 12 (32%) included in the meta-analysis provided IPD. Home safety education was effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.35, 95% CI 1.01 to 180), functional smoke alarms (OR 1.85, 95% CI 1.24 to 2.75), storing medicines (OR 1.58, 95% CI 1.18 to 2.13) and cleaning products (OR 1.63, 95% CI 1.22 to 2.17) out of reach, syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) and poison control centre numbers accessible (OR 3.66, 95% CI 1.84 to 7.27), fitted stair gates (1.26, 95% CI 1.05 to 1.51), socket covers on unused sockets (OR 3.73, 95% CI 1.48 to 9.39) and storing sharp objects out of reach (OR 1.52, 95% CI 1.01 to 2.29). There was a lack of evidence that interventions reduced rates of thermal injuries, poisoning or a range of injuries. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety education provided most commonly as one-to-one, face-to-face education, in a clinical setting or at home, especially with the provision of safety equipment is effective in increasing a range of safety practices. There is a lack of evidence regarding its impact on child injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment was less effective in those at greater risk of injury.

Lower rates of emergency department injury visits among Latino children in the USA: no association with health insurance

BACKGROUND AND OBJECTIVE

Latino children have lower rates of injury visits to emergency departments (EDs) than non-Latino white and African American children. This study tests the hypothesis that this difference reflects health insurance status.

DESIGN

Secondary analysis. Patients/

SETTING

Children under 19 years of age visiting EDs in the USA, sampled in the National Hospital Ambulatory Medical Care Survey of EDs (NHAMCS-ED) from 1997 to 2001.

MAIN OUTCOME MEASURES

Rates of ED injury visits; ED injury visit rates by race/ethnicity stratified by health insurance and adjusted for other covariates; subtypes of injury visits; and procedures and hospital admissions by race/ethnicity.

RESULTS

Injuries accounted for >56 million, or 40.5%, of total ED visits among pediatric patients. Injury visits occurred at lower rates for Latino children (9.9 per 100 person years) than non-Latino white and African American children (16.2 and 18.3, respectively), although total ED visit rates were similar. Regardless of health insurance status, Latino children had lower rates of injury visits than non-Latino white and African American children. Latino children had lower rates of the three major subtypes of injury visits (sports, accidental falls, struck by/between objects). Latino children had similar rates of procedures and hospital admissions to non-Latino white children.

CONCLUSIONS

Irrespective of their insurance status, Latino children have lower rates of ED injury visits in the USA than non-Latino white children. Possible reasons for this difference include different healthcare seeking behavior or different injury patterns by race/ethnicity, but not differences in health insurance status or barriers to accessing ED care.

Identified attention-deficit/hyperactivity disorder and medically attended, nonfatal injuries: US school-age children, 1997-2002

OBJECTIVE

To determine the medically attended, nonfatal injury rate among children 6-17 years of age ever and never identified with attention-deficit/hyperactivity disorder (ADHD).

METHODS

An analysis was performed of parentally reported injury episodes during the past 3 months and current demographic characteristics of 3,741 sample children ever identified with ADHD and 48,243 never identified with ADHD in the 1997-2002 National Health Interview Surveys.

RESULTS

The annualized rate of injury was 204 episodes per 1,000 among children with ADHD compared with 115 episodes per 1,000 among children without ADHD. Injury episode rates were higher for children with ADHD regardless of age, sex, or health insurance. Logistic regression, which controlled for confounding risk factors, showed a robust association between ADHD and injury. The adjusted odds ratio (OR) for ADHD (OR(adj) = 1.83) was similar to the ORs for other important predictors of injury, such as male sex (OR(adj) = 1.45), older age (OR(adj) = 1.50), and private health insurance (OR(adj) = 1.44). Children with other health conditions had an increased odds for injury (OR(adj) = 1.51 for children with other developmental disorders and OR(adj) = 1.53 for children with physical disorders). Characteristics of injury episodes were generally similar for children with and without ADHD.

CONCLUSIONS

Results from a large, nationally representative sample indicate that children ever identified with ADHD were more likely to have a medically attended, nonfatal injury than children never identified with ADHD. The increased odds of injury among children with ADHD could not be attributed to other confounding risk factors. Children with ADHD may benefit from targeted injury prevention efforts.

Psychological symptoms and nonfatal unintentional injuries among Chinese adolescents: a prospective study

PURPOSE

To describe patterns of nonfatal unintentional injuries and investigate the association of psychological symptoms with injury risk among adolescents in Guangxi, China.

METHODS

Adolescents were selected from middle and high school students in Baise City, Guangxi, China. Psychological symptoms at baseline were measured using SCL-90-R and nonfatal unintentional injuries that occurred among participants were recorded using a standardized injury surveillance questionnaire. Annual injury rates per 100 adolescents by adolescents' demographic and family characteristics were calculated. Student's t-test and the Chi-square test were used to test differences in mean raw scores of SCL-90-R subscales and injury rates. Relative risks and odds ratios of injury with 95% confidence intervals were calculated in univariate analyses and multivariate logistic models.

RESULTS

A total of 1474 middle and high school students finished the study. Of them, 442 reported nonfatal unintentional injuries during the study period, resulting in an annual injury rate of 30.3 per 100 adolescents. Boys had a significantly higher injury rate than girls (32.6% vs. 27.4%). Injury rate decreased as the adolescents' age increased. Compared with adolescents who were not injured, the injured adolescents had higher average raw scores of all subscales of SCL-90-R, with an exception of the subscale for hostility. All SCL-90-R subscales factors, except those for hostility and phobia, were associated with injury risk. After confounding effects of age, gender, and ethnicity were controlled using logistic regression models, SCL-90-R subscales for somatization (OR = 2.00, 95% CI 1.52-2.63), obsessive-compulsiveness (OR = 2.10, 95% CI 1.71-2.58), interpersonal-sensitivity (OR = 1.66, 95% CI 1.34-2.06), depression (OR = 2.00, 95% CI 1.59-2.51), anxiety (OR = 2.08, 95% CI 1.62-2.66), and psychoticism (OR = 1.60, 95% CI 1.26-2.03) were significantly associated with an elevated injury risk.

CONCLUSION

Psychological symptoms are associated with an elevated risk of nonfatal unintentional injury among middle and high school students. Mental health services, such as psychological counseling, may help reduce the risk of nonfatal unintentional injuries among Chinese adolescents.

Nonfatal injuries among middle-school and high-school students in Guangxi, China

OBJECTIVES

We described nonfatal injuries and calculated injury rates among middle-school and high-school students in Guangxi, China.

METHODS

Students were selected using multistage randomizing techniques, and nonfatal injuries in 1840 students from February 2002 to January 2003 were monitored with standardized injury forms. Risk factors for injury were identified in multivariate analyses.

RESULTS

The annual overall injury rate was 32.3 per 100 students. Boys had a significantly higher injury rate than the girls (34.8 vs 30.3 per 100 students), and a significantly higher proportion of injuries in boys was caused by other students (28.1% vs 19.4%). A higher proportion of injuries in girls (40.7%) occurred at home. For both boys and girls, sports were the most common activities associated with injury. Injuries from falls were the leading cause of injury, and extremities were most frequently injured. Gender, age, ethnicity, and family income levels were identified as significant risk factors for injury in multivariate analyses.

CONCLUSIONS

Nonfatal injuries in middle-school and high-school students should be recognized as a significant public health concern in China.

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.

Identification of risk factors for non-fatal child injury in a rural area: Keokuk County Rural Health Study

OBJECTIVE

To identify risk factors for non-fatal injury among rural children.

DESIGN

Cross sectional health interview survey, 1994-98.

SETTING

A rural Iowa county, not adjacent to a metropolitan area.

SUBJECTS

Stratified, random sample of households, including all resident children and adults.

MAIN OUTCOME MEASURES

Injury episodes in the past 12 months among children aged 0-17 years and the parental and child characteristics associated with these episodes.

RESULTS

Of the 621 children in participating households, 137 or 22.1% were injured during the past 12 months. Children age 5-17 on a sports team were 1.88 times (95% confidence interval (CI) 1.07 to 3.31) more likely than other children to be injured. Children age 12-17 who binge drink were 3.50 times (95% CI 1.31 to 9.50) more likely than other children to be injured. Compared with children not on sports teams, girls on teams were 2.26 times (95% CI 1.02 to 5.13) more likely while boys on teams were 1.60 times (95% CI 0.71 to 3.68) more likely to have an injury episode. Compared with children who did not binge drink, girls binge drinking were 8.11 times (95% CI 1.52 to 43.33) more likely while boys binge drinking were 2.19 times (95% CI 0.70 to 6.84) more likely to have an injury episode.

CONCLUSIONS

Local studies such as this can provide useful clues regarding the etiology of injury. Some known and some new potential risk factors including behavioral aspects for childhood non-fatal injury in a very rural area were investigated. It is planned to address these cross sectional findings in future longitudinal follow up of this population.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Injury in children of low-income Mexican, Mexican American, and non-Hispanic white mothers in the USA: a focused ethnography

Several studies indicate that rates of serious pediatric injury are higher among Hispanics than among non-Hispanic whites in the USA. To investigate possible contributory factors, we interviewed 50 Mexican, 30 Mexican American, and 30 non-Hispanic white mothers in their own homes in the same low-income neighborhoods of Southern California. Mothers were identified via door-to-door canvassing in areas with high rates of pediatric injury. We observed household conditions and behaviors and obtained a detailed family history, including accounts of any occurrence of serious injury in a child under 5 years old, the highest-risk age group for pediatric injury. Results show that Mexican families were poorer, less educated, and lived in more hazardous and crowded conditions than did families in the other two groups. Nevertheless, they benefited from strong family bonds and a cultural tradition in which responsible older children typically supervise younger siblings. In contrast, a number of Mexican American and white mothers had been abused as children and were estranged from their own mothers; hence they lacked support and models of good parenting. There was much less self-reported smoking, drug use, and mental dysfunction among the Mexican mothers and their male partners as well as much less excessively active and/or aggressive behavior among their children. The nature of the injuries reported by the various groups seemed to reflect these differences. Appropriate interventions for each group are discussed. The study illustrates the importance of using ethnographic methods to examine the context of pediatric injury at the household level.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

OBSERVATIONS

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

RESULTS

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

CONCLUSIONS

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

High-risk periods for childhood injury among siblings

OBJECTIVE

To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling.

DESIGN

Retrospective cohort.

SETTING

King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years).

OUTCOME MEASURES

The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use.

RESULTS

. There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56-1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk:.57; 95% confidence interval:.07-2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 21/2 months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children.

CONCLUSIONS

Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.