Unintentional injuries in children of Danish and foreign-born mothers

Health care utilisation for treatment of injuries among immigrants in Norway: a nationwide register linkage study

Background

Previous research has generally found lower rates of injury incidence in immigrant populations than in native-born populations. Most of this literature relies on mortality statistics or hospital data, and we know less about injuries treated in primary health care. The aim of the present study was to assess use of primary and secondary care for treatment of injuries among immigrants in Norway according to geographic origin and type of injury.

Methods

We conducted a nationwide register-based cohort study of all individuals aged 25–64 years who resided in Norway as of January 1st 2008. This cohort was followed through 2014 by linking sociodemographic information and injury data from primary and secondary care. We grouped immigrants into six world regions of origin and identified immigrants from the ten most frequently represented countries of origin. Six categories of injury were defined: fractures, superficial injuries, open wounds, dislocations/sprains/strains, burns and poisoning. Poisson regression models were fitted to estimate incidence rate ratios separately for injuries treated in primary and secondary care according to immigrant status, geographic origin and type of injury, with adjustment for sex, age, county of residence, marital status and socioeconomic status.

Results

Immigrants had a 16% lower incidence of injury in primary care than non-immigrants (adjusted IRR = 0.84, 95% CI 0.83–0.84), and a 10% lower incidence of injury in secondary care (adjusted IRR = 0.90, 95% CI 0.90–0.91). Immigrants from Asia, Africa and European countries outside EU/EEA had lower rates than non-immigrants for injuries treated in both primary and secondary care. Rates were lower in immigrants for most injury types, and in particular for fractures and poisoning. For a subset of injuries treated in secondary care, we found that immigrants had lower rates than non-immigrants for treatment of self-harm, falls, sports injuries and home injuries, but higher rates for treatment of assault, traffic injuries and occupational injuries.

Conclusions

Health care utilisation for treatment of injuries in primary and secondary care in Norway was lower for immigrants compared to non-immigrants. Incidence rates were especially low for immigrants originating from Asia, Africa and European countries outside EU/EEA, and for treatment of fractures, poisoning, self-harm and sports injuries.

Social inequalities in unintentional childhood injury incidence suggest subgroup identification and differentiation in the municipal planning of preventive efforts

Aims: This registry-based study examined differences according to socio-economic factors in the incidence of unintentional childhood injuries involving main injury types. Methods: All children aged 0-15 years living in the municipality of Odense were followed from January 1 2006 to December 31 2010 (n=176,585). Injury outcome (n=27,745) was defined as visits to the local emergency department. Cohort data were transferred to Statistics Denmark and linked with socio-economic registry data based on unique personal identification numbers. Results: Children aged 10-15 years were at the highest risk for any injury (incidence rate ratio (IRR)=1.14), traffic injury (IRR=5.89) and sports injury (IRR=49.58) compared to children aged 0-4 years. Girls were at lower risk for any injury (IRR=0.85) and higher risk for sports injury (IRR=1.11) and home injuries (IRR=1.12) compared to boys. Children of parents with the lowest household income were at the highest risk for any injury (IRR=1.19) and traffic injury (IRR=2.16) compared to children of parents with the highest group. Children of parents with primary education were at the highest risk of any injury (IRR=1.22) and the lowest risk of traffic injury (IRR=0.80) and sports injury (IRR=0.75) compared to children of parents with tertiary education. Immigrants and descendants were at lower risk for any injury (IRR=0.75 and 0.79, respectively) and sports injury (IRR=0.81 and 0.68, respectively) compared to Danish children. Conclusions: Injury risk varied with socio-economic factors in a Danish municipal setting. The effect varied between specific injury types. Social and ethnic background is important in establishing targeted preventive efforts, but some aspects of selection bias may occur.

The impact of parental migration on injuries among left behind young people aged 10 years to 24 years in Botswana

There has been little evidence of the relationship between children and absence of parents in Botswana literature; and it is still the case that absence of parents increases the risk of injuries to their children. The aim of this study is to investigate the impact of parental migration among left behind young people aged 10 years to 24 years in Botswana and examine patterns of injuries from immigrant families. This is a population-based crosssection from which a dataset was created by compiling data from two different sources for the period of 2010 to 2015. All the variables were transformed into natural logarithms so as to avoid outliers and normalize the variables. All statistical modeling was carried out using Statistical Analysis System version 6.1. Left behind young people were associated with higher risk of injuries especially in motor vehicle accidents 391(40%), fire 264 (27%), and burns 162 (16%) except for drowning, machinery and poisoning. Parental migration is the most important issue in the total number of injuries. Correlation coefficient shows that non-left behind, the greater the chance to be classified under the poisoning cases (r = 0.888) and is lower compared to the left behind (r = 0.471). This study shows clearly that injuries take an insufficiently high toll on children's health and on society. Additionally, if parental migration trends continue, Botswana's burden of injuries are expected to rise in the next 10 years.

Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study

BACKGROUND

Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.

METHODS

Population-based, cross-sectional study of children and youth (0-24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.

RESULTS

There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).

INTERPRETATION

The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

The shrinking health advantage: unintentional injuries among children and youth from immigrant families

BACKGROUND

Immigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury.

METHODS

Population-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0-5 years, intermediate: 6-10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries.

RESULTS

999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants.

CONCLUSIONS

Risk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development.

Risk of firearm injuries among children and youth of immigrant families

BACKGROUND

Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth.

METHODS

We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008-2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations.

RESULTS

We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7-13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2-4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1-8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5-6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4-0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0-2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries.

INTERPRETATION

Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.

Unintentional injuries in children and youth from immigrant families in Ontario, Canada: a population-based cross-sectional study

BACKGROUND

Unintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth.

METHODS

We performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status.

RESULTS

Annualized injury rates were 11 749 emergency department visits per 100 000 population, 267 hospital admissions per 100 000 population and 12 deaths per 100 000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr).

INTERPRETATION

Rates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.

A scoping review of female disadvantage in health care use among very young children of immigrant families

Preference for sons culminates in higher mortality and inadequate immunizations and health care visits for girls compared to boys in several countries. It is unknown if the negative consequences of son-preference persist among those who immigrate to Western, high-income countries. To review the literature regarding gender inequities in health care use among children of parents who migrate to Western, high-income countries, we completed a scoping literature review using Medline, Embase, PsycINFO and Scopus databases. We identified studies reporting gender-specific health care use by children aged 5 years and younger whose parents had migrated to a Western country. Two independent reviewers conducted data extraction and a quality assessment tool was applied to each included study. We retrieved 1547 titles, of which 103 were reviewed in detail and 12 met our inclusion criteria. Studies originated from the United States and Europe, using cross-sectional or registry-based designs. Five studies examined gender differences in health care use within immigrant groups, and only one study explored the female health disadvantage hypothesis. No consistent gender differences were observed for routine primary care visits however immunizations and prescriptions were elevated for boys. Greater use of acute health services, namely emergency department visits and hospitalizations, was observed for boys over girls in several studies. Studies did not formally complete gender-based analyses or assess for acculturation factors. Health care use among children in immigrant families may differ between boys and girls, but the reasons for why this is so are largely unexplored. Further gender-based research with attention paid to the diversity of immigrant populations may help health care providers identify children with unmet health care needs.

Physical performance and 25-hydroxyvitamin D: a cross-sectional study of pregnant Swedish and Somali immigrant women and new mothers

BACKGROUND

Severe vitamin D deficiency can impair muscle strength. The study aims were to examine physical performance in the hands and upper legs, and analyze plasma 25-hydroxyvitamin D (25(OH)D) concentrations in women with presumably low (veiled, Somali-born) and high levels (unveiled, Swedish-born).

METHODS

Women (n=123, 58% Swedish) enrolled at a Swedish antenatal clinic, latitude 60° N, were recruited. Plasma 25(OH) D was analyzed, measured as nmol/L, then categorized as <10 = undetectable, 10-24, 25-49, 50-74 or >75. Muscle strength was tested: maximal hand grip strength (in Newtons, N), and upper leg performance (categorized as able/unable to perform squatting, standing on one leg, standing from a chair, and lifting their hips). Social and anthropometric data were collected. Non-parametric statistics tested the data for differences in their ability to perform the tests across 25(OH)D categories. Undetectable values (<10 nmol/L) were replaced with '9' in the linear correlation statistics. A final main effect model for grip strength (in N) was calculated using stepwise linear regression for independent variables: country of birth, 25(OH)D levels, age, height, weight, physical activity, lactation status, parity, and gestational age.

RESULTS

Somali participants (35%) had 25(OH)D levels of <10 nmol/L, and 90% had <25 nmol/L; 10% of Swedish participants had <25 nmol/L of 25(OH)D, and 54% had <50 nmol/L. Somali women had a relatively weak grip strength compared with Swedish women: median 202 N (inter-quartile range 167-246) vs. median 316 N (inter-quartile range 278-359), respectively. Somali women were also weak in upper leg performance: 73% were unable to squat, 29% unable to stand on one leg, and 21% could not lift their hips (not significant across 25(OH)D categories); most Swedish women could perform these tests. In the final model, grip strength (N) was significantly associated with 25(OH)D levels (B 0.94, p=0.013) together with Somali birth (B -63.9, p<0.001), age (B 2.5, p=0.02) and height (B 2.6, p=0.01).

CONCLUSIONS

Many Somali women had undetectable/severely low 25(OH)D concentrations and pronounced hand and upper leg weakness; grip strength was strongly associated with 25(OH)D. Maternity health care personnel should be aware of this increased frequency and manage care accordingly.

Are there differences in injury mortality among refugees and immigrants compared with native-born?

BACKGROUND

The authors studied injury mortality in Denmark among refugees and immigrants compared with that among native Danes.

METHOD

A register-based, historical prospective cohort design. All refugees (n=29, 139) and family reunited immigrants (n=27, 134) who between 1 January 1993 and 31 December 1999 received residence permission were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities due to unintentional and intentional injuries were identified based on ICD-10 diagnosis. Sex-specific mortality ratios were estimated by migrant status and region of birth, adjusting for age and income and using a Cox regression model after a median follow-up of 11-12 years.

RESULTS

Compared with native Danes, both female (RR=0.44; 95% CI 0.23 to 0.83) and male (RR=0.40; 95% CI 0.29 to 0.56) refugees as well as female (RR=0.40; 95% CI 0.21 to 0.76) and male (RR=0.22; 95% CI 0.12 to 0.42) immigrants had significantly lower mortality from unintentional injuries. Suicide rates were significantly lower for male refugees (RR=0.38; 95% CI 0.24 to 0.61) and male immigrants (RR=0.24; 95% CI 0.10 to 0.59), whereas their female counterparts showed no significant differences. Only immigrant women had a significantly higher homicide rate (RR=3.09; 95% CI 1.11 to 8.60) compared with native Danes.

CONCLUSIONS

Overall results were advantageous to migrant groups. Research efforts should concentrate on investigating protective factors among migrants, which may benefit injury prevention in the majority population.

Mothers' knowledge of domestic accident prevention involving children in Baghdad City

Background: Accidental injuries are the most common cause of death in children over the age of one. Every year, millions of children are permanently disabled or disfigured because of accidents. Objective: To assess the level of knowledge of women with respect to children's domestic accidents, and to determine its association with some demographic factors. Method: This cross-sectional study was conducted in both sides of Baghdad City during the period from April through to August 2013. The targeted population were women attending the primary health care centers (PHCCs). A random sample of 20 PHCCs was taken through a stratified random sampling technique by dividing Baghdad City into its two main parts Karkh and Russafa. Ten centers were then chosen from each sector by a simple random sampling technique. A well-structured questionnaire was developed that constituted of questions on four main types of accidents involving children (poisoning by chemicals and detergents, electric shock, injuries from sharp instruments in the kitchen, and burns). Results: The total number of women enrolled in this study was 1032 aged from 15–50 years. The results revealed that only 9.2% of the mothers acquired a good level of knowledge in prevention of injuries from chemicals and detergents, and more than 90% were found to have poor knowledge. The same was found regarding knowledge about preventing electrical accidents caused by power sockets and electrical appliances where only 10.2% of the mothers were found to have a good level of knowledge. The results were not much better regarding accidents caused by fire, only 11.6% of the mothers scored well. With respect to dealing with accidents caused by sharp instruments in the kitchen, only 6.3% of the mothers obtained a score that indicated a good level of knowledge. Older mothers were statistically found to have a better level of knowledge than younger mothers. Higher educated mothers' were statistically associated with a lower level of knowledge in accident prevention. Mothers with more children and those whose children had previously been involved in an accident were found to have a better level of knowledge. Conclusion: It can be concluded from this study that women in Baghdad are poorly educated about how to protect their children against domestic accidents.

Register-based studies on migration, ethnicity, and health

Introduction: Researchers in Denmark have unique possibilities of register-based research in relation to migration, ethnicity, and health. This review article outlines how these opportunities have been used, so far, by presenting a series of examples. Research topics: We selected six registers to highlight the process of how migrant study populations have been established and studied in relation to different registers: The Danish Cancer Registry, the Danish Central Psychiatric Research Register, the Danish National Patient Register, the Danish National Health Service Register, the Danish Injury Register, and the Danish Medical Birth Register. Conclusion: Our paper documents the unique opportunities to study migration, ethnicity, and health through Danish national registers. Our examples show that in Denmark ‘‘country of birth’’ is the most commonly used measure. It renders information on whether the person is an immigrant or not, and on ethnic background. Data on migration background (i.e. refugee status vs. family reunification, etc.) is more difficult to obtain and therefore less used. It has been debated if ethnicity should be registered upon using health services; however, some consider it discriminatory. Although, we do not register ethnicity in relation to use of health care in Denmark, our possibilities of linkage between population registers and registers on diseases and healthcare utilisation appear to render the same potentials.