Association between childhood fatal injuries and socioeconomic position at individual and area levels: a multilevel study

Socioeconomic differences in the perception of inequalities in healthcare utilization and health in South Korea

This study investigated the lay perception of inequalities in society, healthcare utilization, and health in Korea. We also examined the association between socioeconomic status (SES) and perception of inequalities. Data from an online survey on the perception of health and healthcare inequalities related to cancer conducted between October 19, 2021, and November 12, 2021, were used. Data of 3,769 participants aged 20 to 74 years from 17 provinces were analyzed. We examined the perceived level of inequalities according to SES or residential area using frequency analysis, a t-test or analysis of variance (ANOVA), multiple linear regression analysis, and multiple logistic regression analysis. The mean score for perception of social inequality was 5.99 [Standard Deviation (SD) = 1.95] and that for perception of healthcare utilization inequality was 4.75 (SD = 1.96). The perception rate of health inequality according to SES and residential area was approximately 59 % and 61 %, respectively. Higher the income level, lower the level of perception of social inequalities β = -0.22, p < 0.01). Higher the education level, higher the level of perception of healthcare utilization inequalities (β = 0.21, p < 0.01). Higher the education level, higher the level of perception of health inequalities according to SES or residential area [adjusted odds ratio (aOR): 2.33 (95 % CI: 1.48, 3.66); aOR: 2.73 (95 % CI: 1.73, 4.31)]. Socioeconomic inequalities were observed in the perception of inequalities in healthcare utilization and health. Policymakers should establish policies to bridge the gap between perceived healthcare utilization inequalities and health inequalities. Future research should investigate the perception of healthcare utilization and health inequalities.

Access to medical care and its association with physical injury in adolescents: a cross-national analysis

BACKGROUND

Strong variations in injury rates have been documented cross-nationally. Historically, these have been attributed to contextual determinants, both social and physical. We explored an alternative, yet understudied, explanation for variations in adolescent injury reporting-that varying access to medical care is, in part, responsible for cross-national differences.

METHODS

Age-specific and gender-specific rates of medically treated injury (any, serious, by type) were estimated by country using the 2013/2014 Health Behaviour in School-aged Children study (n=209 223). Available indicators of access to medical care included: (1) the Healthcare Access and Quality Index (HAQ; 39 countries); (2) the Universal Health Service Coverage Index (UHC; 37 countries) and (3) hospitals per 100 000 (30 countries) then physicians per 100 000 (36 countries). Ecological analyses were used to relate injury rates and indicators of access to medical care, and the proportion of between-country variation in reported injuries attributable to each indicator.

RESULTS

Adolescent injury risks were substantial and varied by country and sociodemographically. There was little correlation observed between national level injury rates and the HAQ and UHC indices, but modest associations between serious injury and physicians and hospitals per 100 000. Individual indicators explained up to 9.1% of the total intercountry variation in medically treated injuries and 24.6% of the variation in serious injuries.

CONCLUSIONS

Cross-national variations in reported adolescent serious injury may, in part, be attributable to national differences in access to healthcare services. Interpretation of cross-national patterns of injury and their potential aetiology should therefore consider access to medical care as a plausible explanation.

Maternal socioeconomic position and inequity in child deaths: An analysis of 2012 South Korean birth cohort of 466,636 children

Background

Inequalities in child mortality occur via interactions between socio-environmental factors and their constituents. Through childhood developmental stages, we can observe changing patterns of mortality. By investigating these patterns and social inequalities by cause and developmental stage, we aim to gain insights into health policies to reduce and equalize childhood mortality.

Methods

Using vital statistics, we examined the Korean birth cohort of 2012, including all children born in 2012 up to five years of age (N = 466,636). The dependent variables were all-cause and cause-specific mortality by developmental stage (i.e., neonatal, post-neonatal, and childhood). A Cox proportional hazard regression model was built to compare child mortality according to maternal education. The distribution of inequalities in cause-specific mortality by child age was calculated using the slope index of inequality (SII).

Results

Inequalities in child mortality due to maternal education occur during the neonatal period and increase over time. After adjusting for covariates, the Cox proportional hazard models showed that "injury and external causes" (HR = 2.178; 95% CI = [1.283-3.697]) and "unknown causes" (HR = 2.299; 95% CI = [1.572-3.363]) in the post-neonatal period, and "injury and external causes" (HR = 2.153; 95% CI = [1.347-3.440]) in the childhood period significantly contributed to socioeconomic inequalities in child mortality. For each period, the leading causes of inequality were identified as follows: "congenital" (96.7%) for the neonatal period, "unknown causes" (58.2%) and "injury and external causes" (28.4%) for the post-neonatal period, and "injury and external causes" (56.5%) for the childhood period.

Conclusion

We confirmed that the main causes of death in mortality inequality vary according to child age, in accordance with the distinctive context of child development. Strengthening the health system and multisectoral efforts that consider families' and children's needs according to spatial contexts (e.g., home, community) may be necessary to address the social inequalities in child health.

Study on the Causes, Types, and Mechanisms of Childhood Injuries-Age and Disease Specificity

INTRODUCTION

To clarify the causes, types, and mechanisms of injuries in children, we collected injury cases and analyzed their causes.

METHODS

During the 3-year period from 2013, we collected injury cases from three sources: nursery schools and kindergartens (A), emergency clinics of hospitals (B), and schools and a clinic for the developmentally disabled (C), using a format designed by Safe Kids Japan.

RESULTS

In all, 383 cases were collected during the 3-year period. The causes of the injuries in group A were crashes, falls, and so on. The types of injuries were cuts, bruises, fractures, injuries of teeth, etc. Dislocations and abrasions were prominent in nursery school children (aged less than 3 years) and bone fractures were prominent in kindergarten children aged more than 3 years.Group B consisted of 144 cases. The most common causes of injuries were falls, traffic accidents, and so on, and the types of injuries were fractures, abrasions, sprains, etc. The incidence of fractures was particularly high and 50% of the accidents were bicycle accidents.Group C consisted of 41 cases. Although the age distribution was similar to that of group B, the types of accidents and injuries were similar to those of group A.The Bodygraphic Injury Surveillance System (BISS) analysis showed that groups A and C were similar, that is, injuries occurred mainly to the head, whereas in group B, the extremities were mainly affected.

CONCLUSIONS

We analyzed the causes, types, and mechanisms of childhood injuries. The BISS may help to clarify the mechanisms of injuries in childhood.

Effect of socioeconomic deprivation on outcomes of diabetes complications in patients with type 2 diabetes mellitus: a nationwide population-based cohort study of South Korea

INTRODUCTION

This study aimed to examine the effect of socioeconomic deprivation on the outcomes of diabetes complications in patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

We conducted a cohort study using claims data and 2005 national census data. We included of 7510 patients newly diagnosed with T2DM from 2004 to 2012 and aged 40 years or above. We excluded participants who had onset of diabetes complications and hospitalization within 1 year after initial onset T2DM, aged less than 40 years and with missing covariates. We used the regional socioeconomic deprivation index and classified study participants into five categories according to the quintile distribution. We calculated the adjusted HR and 95% CI for hospitalization related to diabetes complications and all-cause mortality by applying Cox proportional hazards model and the adjusted subdistribution hazards model.

RESULTS

The percentages of participants in the first quintile (least deprived) to fifth quintile (most deprived) were 27.0%, 27.9%, 19.5%, 14.8%, and 10.8% for socioeconomic deprivation; 25.4%, 28.8%, 32.4%, 34.6%, and 37.6% for hospitalization due to diabetes complications; 1.3%, 2.1%, 2.5%, 2.9%, and 3.6% for deaths from diabetes complications; and 5.7%, 7.2%, 9.7%, 9.7%, and 13.1% for deaths from all causes, respectively. Participants with higher socioeconomic deprivation had a higher HR for hospitalization and mortality from all-cause and diabetes complications. These associations were the strongest among men and participants in their 40s in hospitalization related to diabetes complications, 50s in diabetes complications-specific mortality and 50s and 60s in all-cause mortality.

CONCLUSIONS

Patients with T2DM with high socioeconomic deprivation had higher hospital admission and mortality rates for diabetes complications than those with low deprivation. We cannot fully explain the effect of socioeconomic deprivation on diabetes outcomes. Therefore, further studies are needed in order to find underlying mechanisms for these associations.

Multiple-scale spatial analysis of paediatric, pedestrian road traffic injuries in a major city in North-Eastern Iran 2015-2019

Background

Paediatric, pedestrian road traffic injuries (PPRTIs) constitute a major cause of premature death in Iran. Identification of high-risk areas would be the primary step in designing policy intervention for PPRTI reduction because environmental factors play a significant role in these events. The present study aims to determine high-risk areas for PPRTIs at three different geographical scales, including the grid network, the urban neighbourhood and the street levels in Mashhad, Iran during the period 2015–2019.

Methods

This cross-sectional retrospective study was based on all pedestrian accidents with motor vehicles involving children (less than 18 years of age) between March 2015 and March 2019 in the city of Mashhad, which is the second-most populous city in Iran. The Anselin Local Moran’s I statistic and Getis-Ord Gi* were performed to measure spatial autocorrelation and hotspots of PPRTIs at the geographical grid network and neighbourhood level. Furthermore, a spatial buffer analysis was used to classify the streets according to their PPRTI rate.

Results

A total of 7390 PPRTIs (2364 females and 4974 males) were noted during the study period. The children’s mean age was 9.7 ± 5.1 years. Out of the total PPRTIs, 43% occurred on or at the sides of the streets, 25 of which labelled high-risk streets. A high-high cluster of PPRTI was discovered in the eastern part of the city, while there was a low-low such cluster in the West. Additionally, in the western part of the city, older children were more likely to become injured, while in the north-eastern and south-eastern parts, younger children were more often the victims.

Conclusions

Spatial analysis of PPRTIs in an urban area was carried out at three different geographical scales: the grid network, the neighbourhood and the street level. The resulting documentation contributes reliable support for the implementation and prioritization of preventive strategies, such as improvement of the high-risk streets and neighbourhoods of the city that should lead to decreasing numbers of PPRTIs.

Parental offending and children's emergency department presentations in New South Wales, Australia

OBJECTIVES

Children whose parents have a history of criminal offending may be at risk of higher rates of emergency department (ED) presentation, along with other adverse health outcomes. We used data from a large, population-based record linkage project to examine the association between maternal and paternal criminal offending and the incidence of ED presentations among child offspring.

METHODS

Data for 72 772 children with linked parental records were drawn from the New South Wales Child Development Study. Information on parental criminal offending (spanning 1994-2016) and child ED presentations (spanning 2005-2016; approximately ages 2-12 years) was obtained from linked administrative records. Cox proportional hazards regression analyses were conducted to examine the association between parental offending and the incidence of children's ED presentations for any reason and for physical injury, while accounting for important covariates.

RESULTS

Child rates of ED presentation, particularly for physical injury, were higher among those with parental history of criminal offending, after adjusting for covariates. The magnitude of the association was higher for paternal criminal offending (ED presentation for any reason: HR=1.44 (95% CI 1.41 to 1.48); physical injury: HR=1.70 (95% CI 1.65 to 1.75)) than maternal criminal offending (any reason: HR=0.99 (95% CI 0.95 to 1.03); physical injury: HR=1.05 (95% CI 1.00 to 1.10)).

CONCLUSION

Children of parents, particularly of fathers, with a history of criminal offending have an increased incidence of ED presentation, including for potentially avoidable physical injury. These findings require replication and further research to understand the mechanisms underlying these associations.

The impact of neighborhood socioeconomic disparities on injury

OBJECTIVES

To examine the relationship between neighborhood socioeconomic level (NSEL) and injury-related hospitalization.

METHODS

The National Trauma Registry (INTR) and the National Population Census (NPC), including NSEL, were linked by individual identity number. Age-adjusted logistic regression predicted injury hospitalization. Mantel-Haenszel  X² was used for linear trends. NSEL was divided into 20 clusters.

RESULTS

The population comprised 7,412,592 residents, of which 125,829 (1.7%) were hospitalized due to injury. The injury hospitalization rate was at least 42 per 10,000 per year. Except for the very low SEL, an inverse relationship between NSEL and all-cause injury was found: 46.1/10,000 in cluster 3 compared to 22.9/10,000 in cluster 20. Hip fracture-related hospitalizations among ages 65 + decreased as SEL increased (2.19% o in cluster 2 compared to 0.95% in cluster 19). In comparison with Jews, non-Jews were 1.5 times more likely to have an injury-related hospitalization [OR 1.5 (95% CI 1.50-1.55)].

CONCLUSIONS

The INTR and the NPC were successfully linked providing individual and injury hospitalization data. The outcomes confirm the strong relationship between injury mechanism and NSEL.

The effect of contextual factors on unintentional injury hospitalization: from the Korea National Hospital Discharge Survey

Background

It has been suggested that health risks are affected by geographical area, but there are few studies on contextual effects using multilevel analysis, especially regarding unintentional injury. This study investigated trends in unintentional injury hospitalization rates over the past decade in Korea, and also examined community-level risk factors while controlling for individual-level factors.

Methods

Using data from the 2004 to 2013 Korea National Hospital Discharge Survey (KNHDS), trends in age-adjusted injury hospitalization rate were conducted using the Joinpoint Regression Program. Based on the 2013 KNHDS, we collected community-level factors by linking various data sources and selected dominant factors related to injury hospitalization through a stepwise method. Multilevel analysis was performed to assess the community-level factors while controlling for individual-level factors.

Results

In 2004, the age-adjusted unintentional injury hospitalization rate was 1570.1 per 100,000 population and increased to 1887.1 per 100,000 population in 2013. The average annual percent change in rate of hospitalizations due to unintentional injury was 2.31% (95% confidence interval: 1.8–2.9). It was somewhat higher for females than for males (3.25% vs. 1.64%, respectively). Both community- and individual-level factors were found to significantly influence unintentional injury hospitalization risk. As community-level risk factors, finance utilization capacity of the local government and neighborhood socioeconomic status, were independently associated with unintentional injury hospitalization after controlling for individual-level factors, and accounted for 19.9% of community-level variation in unintentional injury hospitalization.

Conclusion

Regional differences must be considered when creating policies and interventions. Further studies are required to evaluate specific factors related to injury mechanism.

Impact of participant attrition on child injury outcome estimates: a longitudinal birth cohort study in Australia

BACKGROUND

Longitudinal research is subject to participant attrition. Systemic differences between retained participants and those lost to attrition potentially bias prevalence of outcomes, as well as exposure-outcome associations. This study examines the impact of attrition on the prevalence of child injury outcomes and the association between sociodemographic factors and child injury.

METHODS

Participants were recruited as part of the Environments for Healthy Living (EFHL) birth cohort study. Baseline data were drawn from maternal surveys. Child injury outcome data were extracted from hospital records, 2006-2013. Participant attrition status was assessed up to 2014. Rates of injury-related episodes of care were calculated, taking into account exposure time and Poisson regression was performed to estimate exposure-outcome associations.

RESULTS

Of the 2222 participating families, 799 families (36.0%) had complete follow-up data. Those with incomplete data included 137 (6.2%) who withdrew, 308 (13.8%) were lost to follow-up and 978 families (44.0%) who were partial/non-responders. Families of lower socioeconomic status were less likely to have complete follow-up data (p<0.05). Systematic differences in attrition did not result in differential child injury outcomes or significant differences between the attrition and non-attrition groups in risk factor effect estimates. Participants who withdrew were the only group to demonstrate differences in child injury outcomes.

CONCLUSION

This research suggests that even with considerable attrition, if the proportion of participants who withdraw is minimal, overall attrition is unlikely to affect the population prevalence estimate of child injury or measures of association between sociodemographic factors and child injury.

Spatial distribution of child pedestrian injuries along census tract boundaries: Implications for identifying area-based correlates

Census tracts are often used to investigate area-based correlates of a variety of health outcomes. This approach has been shown to be valuable in understanding the ways that health is shaped by place and to design appropriate interventions that account for community-level processes. Following this line of inquiry, it is common in the study of pedestrian injuries to aggregate the point level locations of these injuries to the census tracts in which they occur. Such aggregation enables investigation of the relationships between a range of socioeconomic variables and areas of notably high or low incidence. This study reports on the spatial distribution of child pedestrian injuries in a mid-sized U.S. city over a three-year period. Utilizing a combination of geospatial approaches, Near Analysis, Kernel Density Estimation, and Local Moran’s I, enables identification, visualization, and quantification of close proximity between incidents and tract boundaries. Specifically, results reveal that nearly half of the 100 incidents occur within roads that are also census tract boundaries. Results also uncover incidents that occur on tract boundaries, not merely near them. This geographic pattern raises the question of the utility of associating area-based census data from any one tract to the injuries occurring in these border zones. Furthermore, using a standard spatial join technique in a Geographic Information System (GIS), these points located on the border are counted as falling into census tracts on both sides of the boundary, which introduces uncertainty in any subsequent analysis. Therefore, two additional approaches of aggregating points to polygons were tested in this study. Results differ with each approach, but without any alert of such differences to the GIS user. This finding raises a fundamental concern about techniques through which points are aggregated to polygons in any study using point level incidents and their surrounding census tract socioeconomic data to understand health and place. This study concludes with a suggested protocol to test for this source of uncertainty in analysis and an approach that may remove it.

Relationship between socioeconomic status and accessibility for endoscopic resection among gastric cancer patients: using National Health Insurance Cohort in Korea: poverty and endoscopic resection

BACKGROUND

Gastric cancer is one of the most common types of cancer among patients in Korea. We measured the inequity in accessibility to endoscopic mucosal/submucosal resection (EMR) for early and curable gastric cancer treatment among different income classes in patients diagnosed from late 2011 to 2013.

METHODS

Data were obtained from the National Health Insurance Cooperation Claim Data from patients diagnosed from late 2011 until the end of 2013, to provide a total of 1,671 patients with newly diagnosed carcinoma in situ of gastric and gastric cancer among 1,025,340 enrollees. Multiple logistic regression analysis was conducted to investigate the associations between independent variables and the rate of treatment with EMR.

RESULTS

Among 1671 gastric cancer patients, 317 (19.0 %) subjects were treated with EMR. The 'lowest' income group was associated with a statistically significant lower rate of EMR treatment [odds ratio (OR) = 0.55, 95 % confidence index (CI) 0.34-0.89] compared to the 'highest' income group. The ORs for the 'low-middle' and 'middle-high' income groups were both higher than for the reference group, although these were not significantly different. According to the subgroup analysis by gender, rate of EMR treatment of 'lowest' income group (OR = 0.37, 95 % CI 0.18-0.74) was significantly lower only among men.

CONCLUSION

In conclusion, we suggest that although universal health insurance in Korea has covered EMR treatment since August 2011, patients from the lowest income group are less likely to receive this treatment. Thus, we need to detect more eligible early-stage gastric cancer and treatment for individuals of low socioeconomic status.

Positive correlation between regional emergency medical resources and mortality in severely injured patients: results from the Korean National Hospital Discharge In-depth Survey

OBJECTIVES

In South Korea, injury is a public health problem due to its high incidence and high mortality. To improve emergency medical systems, the government announced plans to increase the emergency medical resources for each region. This study investigated the association between regional emergency medical resources and mortality during hospitalization in severely injured inpatients.

METHODS

To analyse mortality for severely injured inpatients, we used the Korean National Hospital Discharge In-depth Survey data, consisting of 18,621 hospitalizations from 2005-2012. Generalized estimating equations were analysed to examine the association between mortality during hospitalization and both individual and regional variables.

RESULTS

Mortality during hospitalization occurred in 913 (4.9%) cases. Patients in regions with a higher number of emergency departments (odds ratio [OR]=0.94, 95% confidence interval [CI]: 0.91-0.98), a higher number of ambulances (OR=0.99, 95% CI: 0.98-0.99), and a higher number of registered nurses per emergency department (OR=0.88, 95% CI: 0.83-0.94) had a lower risk of mortality during hospitalization.

CONCLUSIONS

Our findings suggest that regional emergency medical resources are associated with a lower risk of mortality during hospitalization in severely injured patients. Thus, health care policymakers need to determine the proper distribution of emergency medical resources for each region and the function of emergency departments to provide a superior quality of emergency medical services to patients.

Infant and toddler drowning in Australia: Patterns, risk factors and prevention recommendations

Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioural factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. Recent studies link high socio-economic status and drowning, in contrast to earlier studies. Cardiac arrhythmias, epilepsy and autism are strong risk factors for drowning incidents. Prevention strategies have substantially lowered drowning rates. While legislation-compliant pool fencing substantially reduces drowning risk, compliance levels are low, and penalties are minor. Active supervision education for parents and carers is an effective drowning prevention strategy. Bystanders provide basic life support in only 30% of cases; strategies to increase training uptake are needed. Fencing costs should be a mandatory inclusion for pool installations, with high penalties for non-compliance. Basic life support training should be compulsory for pool owners, and tax incentives should be used as a lever to increase training uptake.

Socioeconomic Inequality in mortality using 12-year follow-up data from nationally representative surveys in South Korea

Background

Investigations into socioeconomic inequalities in mortality have rarely used long-term mortality follow-up data from nationally representative samples in Asian countries. A limited subset of indicators for socioeconomic position was employed in prior studies on socioeconomic inequalities in mortality. We examined socioeconomic inequalities in mortality using follow-up 12-year mortality data from nationally representative samples of South Koreans.

Methods

A total of 10,137 individuals who took part in the 1998 and 2001 Korea National Health and Nutrition Examination Surveys were linked to mortality data from Statistics Korea. Of those individuals, 1,219 (12.1 %) had died as of December 2012. Cox proportional hazard models were used to estimate the relative risks of mortality according to a wide range of socioeconomic position (SEP) indicators after taking into account primary sampling units, stratification, and sample weights.

Results

Our analysis showed strong evidence that individuals with disadvantaged SEP indicators had greater all-cause mortality risks than their counterparts. The magnitude of the association varied according to gender, age group, and specific SEP indicators. Cause-specific analyses using equivalized income quintiles showed that the magnitude of mortality inequalities tended to be greater for cardiovascular disease and external causes than for cancer.

Conclusion

Inequalities in mortality exist in every aspect of SEP indicators, both genders, and age groups, and four broad causes of deaths. The South Korean economic development, previously described as effective in both economic growth and relatively equitable income distribution, should be scrutinized regarding its impact on socioeconomic mortality inequalities. Policy measures to reduce inequalities in mortality should be implemented in South Korea.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0341-9) contains supplementary material, which is available to authorized users.

Inequalities in Hospitalized Unintentional Injury Between Aboriginal and Non-Aboriginal Children in New South Wales, Australia

OBJECTIVES

To quantify inequalities in rates of unintentional injury-related hospitalizations between Australian Aboriginal and non-Aboriginal children.

METHODS

We used linked hospital and mortality data to construct a retrospective whole-of-population birth cohort including 1,124,717 children born in the state of New South Wales, Australia, between July 1, 2000 and December 31, 2012. We adjusted hazard ratios (HRs) of first injury hospitalization for geographic clustering and individual- and area-level factors.

RESULTS

Aboriginal children were 1.6 times more likely than were non-Aboriginal children to be hospitalized for an unintentional injury. The largest inequalities were for poisoning (HR = 2.7; 95% CI = 2.4, 3.0) and injuries stemming from exposure to fire, flames, heat, and hot substances (HR = 2.4; 95% CI = 2.1, 2.7). Adjustment reduced the inequality for all unintentional injury overall (HR = 1.4; 95% CI = 1.3, 1.4) and within leading injury mechanisms.

CONCLUSIONS

Australian Aboriginal children suffer a disproportionately high burden of unintentional injury.

Child injury: Does home matter?

This study examined the relationship between home risk and hospital treated injury in Australian children up to five years old. Women with children between two and four years of age enrolled in the Environments for Healthy Living (EFHL): Griffith Birth Cohort Study were invited to complete a Home Injury Prevention Survey from March 2013 to June 2014. A total home risk score (HRS) was calculated and linked to the child's injury related state-wide hospital emergency and admissions data and EFHL baseline demographic surveys. Data from 562 households relating to 566 child participants were included. We found an inverse relationship between home risk and child injury, with children living in homes with the least injury risk (based on the absence of hazardous structural features of the home and safe practices reported) having 1.90 times the injury rate of children living in high risk homes (95% CI 1.15-3.14). Whilst this appears counter-intuitive, families in the lowest risk homes were more likely to be socio-economically disadvantaged than families in the highest risk homes (more sole parents, lower maternal education levels, younger maternal age and lower income). After adjusting for demographic and socio-economic factors, the relationship between home risk and injury was no longer significant (p > 0.05). Our findings suggest that children in socio-economically deprived families have higher rates of injury, despite living in a physical environment that contains substantially fewer injury risks than their less deprived counterparts. Although measures to reduce child injury risk through the modification of the physical environment remain an important part of the injury prevention approach, our study findings support continued efforts to implement societal-wide, long term policy and practice changes to address the socioeconomic differentials in child health outcomes.

Reliability of the American Community Survey for unintentional drowning and submersion injury surveillance: a comprehensive assessment of 10 socioeconomic indicators derived from the 2006-2013 annual and multi-year data cycles

BACKGROUND

Our objective was to evaluate the reliability and predictability of ten socioeconomic indicators obtained from the 2006-2013 annual and multi-year ACS data cycles for unintentional drowning and submersion injury surveillance.

METHODS

Each indicator was evaluated using its margin of error and coefficient of variation. For the multi-year data cycles we calculated the frequency that estimates for the same geographic areas from consecutive surveys were statistically significantly different. Relative risk estimates of drowning-related deaths were constructed using the National Center for Health Statistics compressed mortality file. All analyses were derived using census counties.

RESULTS

Five of the ten socioeconomic indicators derived from the annual and multi-year data cycles produced high reliability CV estimates for at least 85 % of all US counties. On average, differences in socioeconomic characteristics for the same geographic areas for consecutive 3- and 5-year data cycles were unlikely to be caused by sampling error in only 17 % (5-89 %) and 21 % (5-93 %) of all counties. No indicator produced statistically significant relative risk estimates across all data cycles and survey years.

CONCLUSIONS

The reliability of the annual and multi-year county-level ACS data cycles varies by census indicator. More than 75 % of the differences in estimates between consecutive multi-year surveys are likely to have occurred as a result of sampling error, suggesting that researchers should be judicious when interpreting overlapping survey data as reflective of real changes in socioeconomic conditions. Although no indicator predicted disparities in drowning-related injury mortality across all data cycles and years, further studies are needed to determine if these associations remain consistent at different geographic scales and for injury morbidity.

Contextual Determinants of Childhood Injury: A Systematic Review of Studies With Multilevel Analytic Methods

BACKGROUND

The definition of injury that underpins the contemporary approach to injury prevention is an etiological definition relating to bodily damage arising from transfer of energy to tissues of the body beyond the limits compatible with physiological function. Causal factors proximal to the energy transfer are nested within a more complex set of contextual determinants. For effective injury control, understanding of these determinants is critical.

OBJECTIVES

The primary aims of this study were to describe the area-level determinants that have been included in multilevel analyses of childhood injury and to quantify the relationships between these area-level exposures and injury outcomes.

SEARCH METHODS

We conducted a systematic review of peer-reviewed, English-language literature published in scientific journals between January 1997 and July 2014, reporting studies that employed multilevel analyses to quantify the eco-epidemiological causation of physical unintentional injuries to children aged 16 years and younger. We conducted and reported the review in accordance with the PRISMA guidelines.

SELECTION CRITERIA

We included etiological studies of causal risk factors for unintentional traumatic injuries to children aged 0 to 16 years. Methodological inclusion criteria were as follows: Epidemiological studies quantifying the relationship between risk factors (at various levels) and injury occurrence in the individual; Studies that recognized individual exposure and at least 1 higher level of exposure with units at lower levels or microunits (e.g., individuals) nested within units at higher levels or macrounits (e.g., areas or neighborhoods); Injury outcomes (dependent variable) examined at the individual level; and Central analytic techniques belonging to the following categories: multilevel models, hierarchical models, random effects models, random coefficient models, covariance components models, variance components models, and mixed models. We combined criteria from the checklist described by the Cochrane Effective Practice and Organization of Care Review Group with factors in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, and we used several quality assessment items from other injury-related systematic reviews to create a quality assessment checklist for this review.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and selected analysis features for the included studies by using preformatted tables. They extracted information as reported in the articles. We determined statistical significance of estimates and effects by using the conventional threshold, P < .05. Any differences in the information extracted were resolved by discussion between authors and by specifically rereading and rechecking the facts as reported in the relevant articles. We tabulated results from the final multilevel model(s) in each of the included articles with key aspects summarized in text. Interpretations of the results and identification of key issues raised by the collated material are reported in the Discussion section of this article.

MAIN RESULTS

We identified 11,967 articles from the electronic search with only 14 being included in the review after a detailed screening and selection process. Nine of the 14 studies identified significant fixed effects at both the area and individual levels. The area-level variables most consistently associated with child injury rates related to poverty, education, employment, and access to services. There was some evidence that injury rates were lower in areas scoring well on area-level summary measures of neighborhood safety. There was marked variation in the methods used and in the mapping of measured variables onto the conceptual model of ecological causation. AUTHOR CONCLUSIONS: These results help establish the scope for the public policy approach to injury prevention. More consistent reporting of multilevel study results would aid future interpretation and translation of such findings.

Disparities in Children's Blood Lead and Mercury Levels According to Community and Individual Socioeconomic Positions

We aimed to examine the associations between blood lead and mercury levels and individual and community level socioeconomic positions (SEPs) in school-aged children. A longitudinal cohort study was performed in 33 elementary schools in 10 cities in Korea. Among a total of 6094 children included at baseline, the final study population, 2281 children followed-up biennially, were analyzed. The geometric mean (GM) levels of blood lead were 1.73 μg/dL (range 0.02–9.26) and 1.56 μg/dL (range 0.02–6.83) for male and female children, respectively. The blood lead levels were significantly higher in males, children living in rural areas, and those with lower individual SEP. The GM levels of blood mercury were 2.07 μg/L (range 0.09–12.67) and 2.06 μg/L (range 0.03–11.74) for males and females, respectively. Increased blood mercury levels were significantly associated with urban areas, higher individual SEP, and more deprived communities. The risk of high blood lead level was significantly higher for the lower individual SEP (odds ratio (OR) 2.18, 95% confidence interval (CI) 1.36–3.50 in the lowest educational attainment of the father), with a significant dose-response relationship observed after adjusting for the community SEP. The association between high blood lead levels and lower individual SEP was much stronger in the more deprived communities (OR 2.88, 95% CI 1.27–6.53) than in the less deprived communities (OR 1.40, 95% CI 0.76–2.59), and showed a significant decreasing trend during the follow-up only in the less deprived communities. The risk of high blood mercury levels was higher in higher individual SEP (OR 0.64, 95% CI 0.40–1.03 in the lowest educational attainment of the father), with a significant dose-response relationship noted. Significant decreasing trends were observed during the follow-up both in the less and more deprived communities. From a public health point-of-view, community level intervention with different approaches for different metals is warranted to protect children from environmental exposure.

Maternal Beliefs and Socioeconomic Correlated Factors on Child Mortality from Drowning in Caspian Sea Coastline

OBJECTIVE

To investigate maternal beliefs, practices about causes and determinant factors on drowning and maternal socioeconomic correlated factors on child mortality from drowning.

METHODS

From March 2005 to March 2009, in a register-based cohort study and household survey, individual records utilizing drowning registry data of northern Iran were enrolled.   Mothers (n=276) who responded to multiple questions in a household survey were included. The patterns, interrelationships and effects of socioeconomic correlated factors on child mortality were analyzed.

RESULTS

A significant difference in relation to mother's educational level and age and family income distribution was noticed. Participants in household survey also reported that establishment of a multi-sectorial collaboration, integration of public health messages into local television, additional rescue stations and lifeguard, hazard environment fencing, increasing adult supervision, more support on increasing swimming ability among the children were all effective on reducing of drowning death.

CONCLUSION

Due to the high rate of drowning in children and lack of attention among olders, a greater emphasis should be placed on educating mothers to assist a better supervision on their children.

Does a geographical context of deprivation affect differences in injury mortality? A multilevel analysis in South Korean adults residing in metropolitan cities

BACKGROUND

This study aimed to examine whether the socioeconomic context of urban areas affects differences in adult mortality from injuries in the districts of all seven South Korean metropolitan cities, after adjusting for individual demographic and socioeconomic indicators.

METHODS

Two different sets of data were used in this study: (1) the National Death Registration data from 2003 to 2008; and (2) the National Census in 2005. Variables for individual characteristics were gender, age, residential area and educational level. A geographic deprivation index was calculated based on the Carstairs Index. Multilevel Poisson regression models were used to analyse the relationship between area deprivation levels and injury mortality.

RESULTS

Greater mortality risks of traffic accidents, falls, suicide and all injuries were found in the elderly, the less educated and men, compared with their counterparts. The most deprived districts were at greater risks of death due to traffic accidents (risk ratio (RR)=1.34; 95% CI 1.05 to 1.73), falls (RR=1.63; 95% CI 1.20 to 2.20), suicide (RR=1.09; 95% CI 1.01 to 1.17) and all injuries (RR=1.14; 95% CI 1.07 to 1.22) compared with the least deprived districts, even after individual level socioeconomic variables were controlled for. However, area level deprivation did not show cross level interactions with the individual level education in estimating fatal injury risks.

CONCLUSIONS

Both contextual and compositional effects of socioeconomic status on injury mortality among urban areas in South Korea should be considered in allocating resources for injury prevention.

Global health: injuries and violence

Injury and violence rank among the leading causes of death worldwide, with more than 5 million deaths annually, representing a significant portion of the global burden of disease. This article examines how injury and violence relate to global health using recent global burden of disease data and selected key studies and databases, and further explores risk factors and intervention initiatives that address unintentional and intentional injuries. The article serves as a call to action to enhance understanding of the growing burden of injury and violence, especially in low-income and middle-income countries, where more than 90% of injuries occur.

Child health and maternal stress: does neighbourhood status matter?

The purpose of this cross-sectional questionnaire study was to explore neighbourhood-level differences in health behaviour, maternal stress and sense of coherence, birth weight, child health and behaviour, and children's television watching habits. In total, 2006 pairs of Swedish mothers and children, aged approximately 20 months, from the general population participated in the study. A total of 1923 lived in neighbourhoods of average socioeconomic status in six counties, and 83 in a high-status neighbourhood in one of the counties. Data were collected in 2002-2003 and 2004-2005 through the Child Health Services. Socio-demographic confounders were adjusted for in multiple logistic regressions (maternal age, country of birth, education, marital status and parity). Compared with their counterparts in average neighbourhoods, mothers in the high-status neighbourhood were less frequently smokers and had been breastfeeding their children more. They felt less stress from social isolation and had a higher sense of coherence. All these differences except lower social isolation were non-significant after adjusting for socio-demographic characteristics. Privileged mothers felt more restricted by their parenting tasks (unadjusted comparison), and more privileged children were frequent television watchers. Child birth weight, health and behaviour were no better in the privileged than in average neighbourhoods. This paper adds to previous knowledge by showing that status-based geographic differences in important parenting and health parameters can be non-significant in an equitable society such as Sweden, where all families with young children have access to free high-quality health services. Individual characteristics could provide better explanations than neighbourhood status.

Safety practices in relation to home ownership among urban Mexican immigrant families

We examined home safety hazards, comparing renter- to owner-occupied housing among urban, immigrant Mexican families.

METHODS

Interviews and home inspections were conducted among urban, Spanish-speaking immigrant families with children. We estimated weighted hazard prevalence and used logistic regression to compare owner- and renter-occupied homes. Of 313 eligible households, 250 (80%) enrolled. Respondents were predominantly Mexican-born (99%), low income (72.6%) and lower education (92.3%). Most homes had fire, burn, fall, poisoning, electrocution and fire escape hazards, including high tap water temperatures (76.4%; 95% CI: 69.0, 83.7%), no working smoke alarms (60.0%; 51.3, 68.8%), slippery bathtub/shower surfaces (58.7%; 49.9, 67.5%), blocked fire escape routes (55.9%; 47.2, 64.5%) and child-accessible medications (71.0%; 60.1, 81.3%). After adjustment for sociodemographics, fire escape (OR = 8.8; 95% CI: 2.8, 27.7), carbon monoxide poisoning (OR = 2.9; 1.4, 6.2) and drowning (OR = 3.5; 1.3, 9.4) hazards were more likely in owner- than renter-occupied homes. Housing age and type explained most differences. Many urban, immigrant Spanish-speaking families live in unsafe homes. For this population, housing safety programs should be targeted based on housing age and type rather than tenure.

[Development of composite deprivation index for Korea: the correlation with standardized mortality ratio]

OBJECTIVES

The aims of this paper were to develop the composite deprivation index (CDI) for the sub-district (Eup-Myen-Dong) levels based on the theory of social exclusion and to explore the relationship between the CDI and the standardized mortality ratio (SMR).

METHODS

The paper calculated the age adjusted SMR and we included five dimensions of social exclusion for CDI; unemployment, poverty, housing, labor and social network. The proxy variables of the five dimensions were the proportion of unemployed males, the percent of recipients receiving National Basic Livelihood Security Act benefits, the proportion of households under the minimum housing standard, the proportion of people with a low social class and the proportion of single-parent household. All the variables were standardized using geometric transformation and then we summed up them for a single index. The paper utilized the 2004-2006 National Death Registry data, the 2003-2006 national residents' registration data, the 2005 Population Census data and the 2005-2006 means-tested benefit recipients' data.

RESULTS

The figures were 115.6, 105.8 and 105.1 for the CDI of metropolitan areas (big cities), middle size cities and rural areas, respectively. The distributional variation of the CDI was the highest in metropolitan areas (8.9 - 353.7) and the lowest was in the rural areas (26.8 - 209.7). The extent and relative differences of deprivation increased with urbanization. Compared to the Townsend and Carstairs index, the CDI better represented the characteristics of rural deprivation. The correlation with the SMR was statistically significant and the direction of the CDI effects on the SMR was in accordance with that of the previous studies.

CONCLUSIONS

The study findings indicated mortality inequalities due to the difference in the CDI. Despite the attempt to improve deprivation measures, further research is warranted for the consensus development of a deprivation index.

20 Years of Research on Socioeconomic Inequality and Children's-Unintentional Injuries Understanding the Cause-Specific Evidence at Hand

Injuries are one of the major causes of both death and social inequalities in health in children. This paper reviews and reflects on two decades of empirical studies (1990 to 2009) published in the peer-reviewed medical and public health literature on socioeconomic disparities as regards the five main causes of childhood unintentional injuries (i.e., traffic, drowning, poisoning, burns, falls). Studies have been conducted at both area and individual levels, the bulk of which deal with road traffic, burn, and fall injuries. As a whole and for each injury cause separately, their results support the notion that low socioeconomic status is greatly detrimental to child safety but not in all instances and settings. In light of variations between causes and, within causes, between settings and countries, it is emphasized that the prevention of inequities in child safety requires not only that proximal risk factors of injuries be tackled but also remote and fundamental ones inherent to poverty.

GIS and injury prevention and control: history, challenges, and opportunities

Intentional and unintentional injury is the leading cause of death and potential years of life lost in the first four decades of life in industrialized countries around the world. Despite surgical innovations and improved access to emergency care, research has shown that certain populations remain particularly vulnerable to the risks and consequences of injury. Recent evidence has shown that the analytical, data linkage, and mapping tools of geographic information systems (GIS) technology provide can further address these determinants and identify populations in need. This paper traces the history of injury prevention and discusses current and future challenges in furthering our understanding of the determinants of injury through the use of GIS.

Parental socioeconomic status and unintentional injury deaths in early childhood: consideration of injury mechanisms, age at death, and gender

The aim of this study was to determine whether the socioeconomic status (SES) of parents influences early childhood unintentional injury deaths for different injury mechanisms and the gender and age at death of the child. Study design is a population-based retrospective study. Death certificate data from 1995 to 2004 were linked to birth certificate data from 1995 to 1996 for each child who died when aged < or = 8 years. Parental age, birth order, marital status, residence area, educational level, and occupation were used as indices for SES. Cox proportional-hazards analysis was employed. Our results indicate that nonmetropolitan residence, low parental education level, and a father working in a nonadministrative job or as a farmer were associated with a higher risk of death from injury for both boys and girls. A mother aged younger than 20 years and parents working in manual jobs were associated with a higher risk in boys only. The risks of some socioeconomic factors (low parental education and a father working in a manual job or as a farmer) were evident for children aged 1-4 years. The risks of rural residency tended to increase in older children, and the risk of injury from having a mother aged younger than 20 years increased for younger children. The risks of childhood injury deaths from traffic accidents, falls, and fire/burns were associated with the SES of the parents. Younger parents were associated with higher risks of injury deaths from traffic accidents (hazard ratio [HR]: father, 7.9; mother, 1.9) and falls (HR: father, 2.0; mother, 2.5). A father working as a farmer was associated with a higher risk of childhood injury death from fire/burns (HR = 4.0). In conclusion, the parental SES risk profiles of childhood injury deaths varied with the age and gender of the child, and with the injury mechanism. Therefore, reducing excess injury deaths during early childhood requires preventive efforts targeted at high-risk parents, and based on injury mechanism and on the gender and age of the child.

Social determinants of child and adolescent traffic-related and intentional injuries: a multilevel study in Stockholm County

Several significant developmental and socialisation processes in the life of children and adolescents take place in the area where they live. The extent to which they can feel and be safe in this environment is an important component of the success of those processes. This study highlights the independent contribution of neighbourhood and individual-level demographic and socioeconomic attributes to child and adolescent injuries. All individuals between the ages of 7 and 16 years living in Stockholm County in January 1998 (n=184 545) were followed up for their injuries during a five-year period considering injuries sustained as a pedestrian/cyclist/motor-vehicle rider and intentional injuries (violence-related and self-inflicted). A series of two-level logistic regressions were conducted to examine the association between the occurrence of injuries and individual (compositional) characteristics nested into parish of residence as well as contextual characteristics. For children and adolescents living in Stockholm County, contextual socioeconomic and social attributes of their place of residence were significant for injuries sustained as motor-vehicle riders but not for those sustained as pedestrians/cyclists or those inflicted intentionally. In the latter case, only the highest concentration of social benefit recipients was associated with significantly higher odds ratios. This emphasises that each injury mechanism has its own socioeconomic and social pathway, where contextual and compositional factors come into play to varying degrees.

Regional and social differences concerning overweight, participation in health check-ups and vaccination. Analysis of data from a whole birth cohort of 6-year old children in a prosperous German city

Background

Studies on health inequalities still focus mostly on adults. Research about social disparities and health in children is slowly increasing, also in Germany, but these studies are mostly restricted to individual social variables derived from the parents to determine social class. This paper analyses the data of the medical check-up prior to school enrolment to determine differences concerning overweight, participation in health check-ups and immunization; it includes individual social variables but also regional variables describing the social environment of the children.

Methods

The dataset includes 9,353 children who started school in 2004 in Munich, Germany. Three dependent variables are included (i.e. overweight, health check-ups, vaccinations). The individual level social variables are: children's sex, mother tongue of the parents, Kindergarten visit. On the small scale school district level, two regional social variables could be included as well, i.e. percentage of single-parent households, percentage of households with low educational level. Associations are assessed by cross tables and regression analyses. The regional level variables are included by multilevel analyses.

Results

The analyses indicate that there is a large variation between the school districts concerning the three dependent variables, and that there is no district with very 'problematic values' for all three of them (i.e. high percentage of overweight, low levels of health check-ups and vaccinations). Throughout the bivariate and multivariate analyses, the mother tongue of the children's parents shows the most pronounced association with these dependent variables; i.e. children growing up in non-German-speaking families tend to be more overweight and don't visit preventive check-ups as often as children of German-speaking parents. An opposite association can be seen concerning vaccinations. Regional level influences are present as well, but they are rather small when the individual level social variables are controlled for.

Conclusion

The dataset of the medical check-up prior to school enrolment offers a great opportunity for public health research, as it comprises a whole age cohort. The number and scope of variables is quite limited, though. On one hand, it includes only few variables on health or health related risks. On the other, it would be important to have more information from the region where the children live, e.g. the availability of community and health care services for parents and children, social networks of families with children, areas where children can play outside, traffic noise and air pollution. Despite these shortcomings, the need for specific interventions can already be derived from the data analyzed here, e.g. programs to reduce overweight in children should focus on parents with a mother tongue other than German.

Individual factors explain neighbourhood variations in accidents to children under 5 years of age

Previous studies have identified possible neighbourhood-level influences on the risk of injuries to preschool children, but none have had sufficient data at both household and area level to explain these neighbourhood effects. We used data from the Avon Longitudinal Study of Parents and Children, which recruited over 14,062 children at birth in the former county of Avon, UK, and collected information about accidents, as well as extensive social, health and developmental data throughout the first 5 years of life. This information was combined with census and geographical data in order to identify neighbourhood influences on accident risks and then attempt to explain these using multilevel regression modelling. A small but statistically significant amount of between-neighbourhood variance in accident risk was found, with neighbourhood intraclass correlation coefficients of 0.82% for any accident, and 0.84% for accidents resulting in injury requiring medical attention. This was entirely accounted for by a variety of child, parental and household level variables. Independent risk factors for both outcomes were children who were developmentally more advanced or displayed greater conduct and behavioural problems, mothers who were of younger age, who were without work, who were smokers, whose partners were unemployed or drank alcohol excessively, and households in which there had recently been adverse life events, or which were under financial stress. The mother's perceptions of neighbourhood quality also explained some of the risks for any accident, but not for medically attended accidents, and this was a variable that operated at the level of individual households rather than at the level of neighbourhoods. The implications of this study are that differences in accident risk between neighbourhoods are explained by geographical clustering of similar types of children, families and households. Interventions should focus more on parental factors and household social circumstances than on the physical environment or community based risks. However, many of these factors are those most resistant to modification without broader societal change.

Host factors and childhood injury: the influence of hyperactivity and aggression

OBJECTIVE

This study examined the association between hyperactivity, aggression, and unintentional childhood injury among a cohort of children aged 5-12 years. Participants were recruited utilizing a two-tier randomization process from primary schools in Brisbane, the capital city of Queensland, Australia. Information on hyperactivity and aggression was collected by trained interviewers using a semi structured questionnaire and episodes of injury were reported by parents using an injury event report form. Eight hundred and seventy-one children were recruited into the study of which 811 (93%) completed the full 12 months of follow-up. All subsequent analysis was limited to the children who were retained for the full study period.

METHODS

One hundred and twenty-one children were categorized as hyperactive and 48 as aggressive. Boys were nearly twice as likely as girls to be categorized as hyperactive or aggressive, although this difference was not statistically significant for aggression. Lower socioeconomic status (SES) as measured by household income was also associated with aggression while more children from middle SES households as measured by both household income and maternal education were hyperactive compared with children from either low or high SES households.

RESULTS

After adjusting for key confounding factors, children with high hyperactivity scores had an increased risk of all injuries (OR 1.98, 95% CI 1.48-2.64) and medically treated injuries (OR 1.56, 95% CI 1.01-2.43). Male gender was also a significant predictor of injury. Initiatives to prevent childhood injuries should take into account that child temperament may act as a mediating factor in the injury pathway.

CONCLUSION

Further research is necessary to determine the success of preventive efforts in higher risk children who may react to their environment in a substantially different manner compared with less hyperactive children.

[Health inequalities in Korea: current conditions and implications]

OBJECTIVES

The aim of this study is to summarize the current conditions and implications of health inequalities in South Korea.

METHODS

Through a literature review of empirical studies and supplementary analysis of the data presented in the 1998, 2001, and 2005 KNHANEs, we evaluated the extent and trends of socioeconomic inequalities in both health risk factors, such as smoking, physical activity, and obesity, and outcomes, such as total mortality, subjective poor health status by self-reports and metabolic syndrome. Relative risks and odds ratios were used to measure differences across socioeconomic groups, and the relative index of inequality was used to evaluate the changes in inequalities over time.

RESULTS

We found clear inequalities to various degrees in most health indicators. While little change was observed in mortality differences over time, the socioeconomic gaps in risk factors and morbidity have been widening, with much larger differences among the younger population.

CONCLUSIONS

Socioeconomic inequalities are pervasive across various health indicators, and some of them are increasing. The trends in socioeconomic inequalities in health should be carefully monitored, and comprehensive measures to alleviate health inequalities are needed, especially for young populations.