Unintentional Injuries in Childhood: Results from Canadian Health Surveys

Unintentional Injuries in Childhood:
Results from Canadian Health Surveys
Barry Pless and Wayne Millar
The opinions expressed in this report are those of the authors and contributors and do not
necessarily reflect the official views of Health Canada
Our mission is to help the people of Canada
maintain and improve their health.
Health Canada
For further information, please contact
Paula Hadden-Jokiel
Safe and Supportive Environment
Childhood and Youth Division
Health Canada
Address Locator: 1909C2
Ottawa, Ontario
K1A 1B4
Phone: (613) 954-8836
Fax: (613) 954-5568
E-mail: [email protected]
Published by authority of the Minister of Health
This report was prepared for Health Canada by Barry Pless, Montreal Children’s
Hospital and Wayne Millar, Statistics Canada
For additional copies, please contact:
Publications
Health Canada
Ottawa, Ontario
K1A 0K9
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It can be made available in/on computer diskette/large print/audiocassette/braille upon
request.
Également disponible en français sous le titre
Blessures non intentionnelles chez les enfants – Résultats d’enquêtes canadiennes sur la santé
© Her Majesty the Queen in Right of Canada, represented by the Minister of Public Works and
Government Services Canada, 2000
Cat: H39-523/2000E
ISBN: 0-662-28607-3
Table of Contents
Acknowledgements
...............................................
1
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Organization of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
3
Preamble
Introduction
........................................................
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Social Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Population Health Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Longitudinal Survey of Children and Youth . . . . . . . . . . . . . . . . . .
Health Promotion Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analytic Procedures and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Text References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Survey Overview
5
5
6
7
7
9
10
11
11
12
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15
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
23
30
47
61
63
General Social Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Population Health Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Longitudinal Survey of Children and Youth . . . . . . . . . . . . . . . . . . . . . .
Health Promotion Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Primary Reference List
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Secondary Reference List
69
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79
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
85
Acknowledgements
This report would not have been possible without the effort and cooperation of
a number of individuals who participated in the preparation of this document.
The Health Canada project consultants, Sally Lockhart and Paula Hadden-Jokiel
of the Childhood and Youth Division, were grateful for the tremendous hard work,
dedication and patience of the authors Dr. Barry Pless from the Montreal Children’s
Hospital and Wayne Millar from Statistics Canada, and the tireless efforts of Rolande
Ostiguy, Communications, Health Canada.
The authors are grateful to Barbara Willard, Bonnie Swaine, Judith Marshall,
Diane Léger and Louise Martin for their assistance in the preparation of this report.
Thanks are also due to the many colleagues who responded to a plea on the
Epidemiology and Injury List servers to provide reports from other countries. In
addition, the authors thank Lorie Root for her encouragement and patience, Health
Canada for supporting this work, and finally Yvonne Robitaille and Susan Mackenzie
for reviewing drafts and making constructive suggestions.
1
Preamble
Over the past three decades there has been a growth in concern about
childhood injuries in Canada, as injuries are the leading cause of death in children
and youth in Canada. Groups like the Canadian Institute of Child Health and more
recently, Safe Kids Canada, prompted much of this increased attention by using data
from government surveys. Although such data are rarely as complete as many users
would like, they are, nonetheless, useful. At the very least they provide estimates of the
magnitude of the problem among different sectors of the population. Unfortunately, it
is often not easy to obtain or use these data. This report is intended to help the user by
presenting the results of various surveys in a form and at a level of detail that we
assume will be more helpful than what is normally available.
Worldwide, health surveys have become increasingly popular and important.
Data obtained from the population by this means are used for decision making by
governments and other organizations. The growth in popularity reflects the technical
advances that have been made in the science of sample surveys, as well as the greater
reliance placed on survey data in planning health services and programs.
The principal goal of this report is to describe what has been learned about
childhood injuries from recent Canadian health surveys. Four national populationbased surveys have been analysed to this end – the General Social Survey (GSS), the
National Population Health Survey (NPHS), the National Longitudinal Survey of
Children and Youth (NLSCY), and the Health Promotion Survey (HPS). Information
from these studies is analysed to permit a description of the characteristics of the
children who are injured and the circumstances of their injuries. A secondary goal is to
obtain some further details about possible risk factors. The ultimate objective, of
course, is for these data to help inform policies and programs aimed at prevention.
Finally, we hope that these analyses will underscore some of the shortcomings in
how these surveys deal with the problem of injuries so that these limitations can be
overcome in the future.
Organization of Report
This report begins with a description of the four data sources referred to above.
In the Introduction, we provide a partial review of important health surveys conducted
in other countries and in some Canadian provinces. Some of these are referred to again
in the concluding section. It should be clear that there are many such surveys we have
failed to identify because of limitations in time and resources. This is of little concern,
however, because our goal in this review was not to be comprehensive. Rather, it was to
help situate what is done in Canada in a broader context.
3
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
As will be more fully explained, a major limitation of this review is that we have
the impression that there are many national surveys that either fail to obtain any information about children or, if they do, fail to include information about injuries. It must
also be appreciated that many surveys are not primarily oriented toward health.
Nevertheless, as in the case of the GSS in Canada, even many such omnibus surveys
often include some health questions. The most egregious omissions are those that fail
to include children. Equally puzzling are those that include child health but ignore
injuries.
The section that follows begins by providing some detailed definitions; a general
description of the four Canadian surveys, including a description of the methods by
which they obtained their data; the statistical assumptions and procedures used in the
analyses; and some salient methodological limitations.
The meat of the report is included in the section headed “Results.” It presents
descriptive demographics of childhood injury in each of the surveys under consideration. In each instance, when the data permit, injury occurrence is presented by age,
sex, socio-economic status measures, and geographic characteristics.
In some parts of this section, other correlates of injury in these data sets are presented. These highlight, to the very limited extent that is possible, models of potential
injury predictors. It must be noted that an inherent limitation of most surveys [with
two outstanding exceptions, the NLSCY and the NPHS], is their cross-sectional nature.
This precludes any substantive modelling of true predictors.
In the Discussion, we attempt to draw from the preceding analyses implications
for research and for injury prevention, including health policy initiatives. In this,
the important distinction between initiatives that lie within provincial versus federal
jurisdictions are examined. Recommendations are made for future surveys that will
provide still more useful information on childhood injury.
4
Introduction
Injuries are the major cause of death in childhood. That much is known and
widely acknowledged. Data from vital statistics that are maintained by most countries
have established this sobering fact. Similarly, although hospital discharge statistics
provide a measure of the substantial morbidity arising from injuries in childhood,
hospital data rarely permit a search for risk factors. It is, therefore, to a variety of health
surveys that we turn to learn more about the precursors of these tragic events. We
acknowledge that surveys, as such, even longitudinal studies, are a poor substitute for
well-designed, purpose-built research focussing on specific causal hypotheses. But we
believe survey data are valuable and generally under-utilized. In part, as has been
stated, they are often presented in a manner that makes it difficult for casual or even
more expert users to take full advantage of them. This is one reason for this report.
Regrettably, many health surveys ignore children completely or relegate them to
a secondary status. Equally regrettable is that even when a survey samples children
appropriately and does an otherwise good job in assembling details about their health,
it often fails to include injuries among the array of health problems, or does so only in
a cursory manner.
The four Canadian surveys whose data are examined in this report illustrate
both the advantages and disadvantages in using this method of data collection to
better understand the forces behind childhood injuries and thus enhance their
prevention.
Definitions
Although at first glance it may seem obvious that everyone understands what a
survey is, after consideration the definition of a survey is often not quite so transparent. Therefore, for the purposes of this report we have, somewhat arbitrarily, defined
health surveys as the systematic collection of health or health-related information
from a clearly defined sample of the population. Implicit in the latter phrase is the
critically important element that the data collection is population-based (i.e. that the
denominator is known). It is in this sense that other, seemingly similar, forms of data
collection are best distinguished: surveillance systems, for example, may collect
similar information, but rarely, if at all, in a population-based manner. This is also
typical of most hospital data collection systems. Only in some rare instances
(e.g. where the hospital is isolated and serves a reasonably fixed and defined population), may it be argued that the data from these systems are equivalent to surveys
(i.e. population-based).
5
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Also, in a perhaps arbitrary manner, we have excluded from our review surveys
of other countries (or provinces) which are confined to small communities – and by
small, we have set a cut-off at 100,000 persons. In other words, unless the survey is
conducted on populations larger than this number, we have chosen to ignore it. In
part, this decision is driven by our interest in children (and with a smaller population
base the numbers of children would be insufficient) and our realization that few surveys focus exclusively on children. Instead, the more typical situation is that a sample
of households is drawn and if children are present in the family of the respondent,
proxy information may or may not be obtained about them. Surveys that have been
planned or completed prior to 1985, and those that are topic-specific are not included
(e.g. dental health).
Surveillance systems are often confused with surveys, as are registers. Typically,
neither conforms to the definition laid down above because they are not populationbased. Conversely, however, if a survey is repeated at regular, reasonably closely spaced
intervals, it may serve some of the purposes of a surveillance system. An outstanding
example of this is the National Health Interview Survey in the United States. In spite of
this positive quality, it nevertheless falls short, however, because one of the objectives
of a good surveillance system is that the results are available in a sufficiently short time
period to permit a sharp or sudden increase in events of interest.
Registers exist for many diseases and there are now a number of “trauma
registries.” These are usually oriented toward the assembling of data about serious
injuries – those requiring hospitalization at least. Almost invariably they are, of course,
hospital-based and thus suffer from the same shortcoming as most surveillance
systems – the absence of an identifiable denominator.
It should be noted that although nowadays the term “injury” is preferred to
accidents, the latter word is still in common usage. Moreover, the use of the term
“accidents” varies depending on the survey involved. Although in common parlance
the term is most often associated with physical trauma, in most surveys it includes
poisoning.
Methods
Most surveys, especially those conducted at a national level, collect data from
households. Most often they do so using a sampling procedure that proceeds in several
stages (e.g. from census tract to household). Consequently, they obtain data in
“clusters,” and extrapolating back to the population at large is complex. Invariably,
regardless of the extent of clustering, weighting is required to reconstitute the figures
that would actually exist in the population on which the survey is based. In this report,
the weighted figures are used, with some form of designation of the actual magnitude
of the numbers involved.
6
Introduction
Although telephone surveys have become increasingly popular in recent years,
and often include such techniques as random digit dialing, most seek more information than can be obtained in the time available for a telephone conversation.
Fortunately, two of the four surveys analysed for this report involve face-to-face
interviews with a member of the household. Thus, in these two surveys information
about children (with the exception of older adolescents) is obtained from a parent or
other proxy respondent.
Data Sources
Data relating to the pediatric population (ages 0 to 19) are obtained from a
series of health surveys conducted by Statistics Canada. For the population age 15 to
19, data are more readily available because the majority of health surveys include this
age group. When surveys ask about the prevalence of injuries in the population below
age 15, they may not ask the same questions as posed to the 15 to 19 age group, or the
ages covered by the survey may not encompass the entire pediatric age range.
Consequently, it is usually not possible to provide trend data on various dimensions of
injury over all of the age groups that constitute the pediatric population.
This section presents an overview of four major databases from which injury
statistics in this report are obtained. For each survey, we present information relating
to sample design, sample size and the content of the questions relating to injury.
Because the sampling methods are similar in the various surveys, the approach to the
presentation of estimates is consistent in all the reports. The sources for the estimates
in this report are the 1990 Health Promotion Survey, the 1993 GSS, the 1994-95 NPHS,
(the supplemental questions on the NPHS), and the NLSCY 1994-95. Considerations
relating to data analysis will be addressed at the end of the discussion relating to the
data sources.
General Social Survey
Since 1985, Statistics Canada has conducted the General Social Survey (GSS)
to monitor changes in Canadian society and to provide information on current or
emerging policy issues. The GSS operates on a five-year cycle, each year focussing
on one of five core subjects. Personal risk, which included the incidence and
consequences of “accidents,”1 was the focus in 1988 and again in 1993. (The GSS has
since dropped injury from the personal risk cycle. This issue is being addressed by the
NPHS and the NLSCY.) The main body of the survey was directed at the population
aged 15 and over. In addition, the survey asked a series of questions relating to children
in the household.
1
Terminology used in the survey
7
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
For the primary target population, “accident” screening questions obtained
information relating to the type of “accident.” Four types were identified: motor
vehicle, sports, work, and home. These categories are not mutually exclusive. To
eliminate double counting, the methodology established a hierarchy: motor vehicle,
work, sports, and home “accidents” were assigned in that order. For example, a motor
vehicle accident (MVA) that happened at work was classified as a motor vehicle
accident. The effect of this was to increase the reported incidence of MVAs, while
reducing the incidence of other types. Events that did not fall into one of the four
categories, or for which information was insufficient to make a classification, were
relegated to a residual “unclassified” group. Medical consequences of these injuries
were assessed through a series of questions about whether respondents received medical attention or experienced activity loss/disability days as a result of the injury.
Activity loss days included bed-disability days, which in turn, included hospital days.
GSS questions also probed the economic consequences of injuries
(“accidents”). Personal expenses were measured with questions about financial losses
or extra expenses incurred as a result of the injury. Respondents were also asked if they
had recovered any of these costs from an automobile insurance policy or Worker’s
Compensation. In addition, they were asked to give their best estimate of out-ofpocket expenses (e.g. the deductible on auto insurance claims, legal expenses,
non-insured dental care, extra transportation expenses, prescription drug costs, or
chiropractic or physiotherapy services).
Questions focussed on children under 15 years of age obtained data relating to
injuries in the past 12 months, medical attention for injuries, the number of incidents
requiring medical attention, where the child received medical care, the time of day the
injury occurred, activity at the time of the injury, nature of the injury, parts of the body
injured, and overnight hospital stay.
The 1993 GSS survey is based on a sample of 10,385 households. The response
rate was 82%, if it is assumed that households for which there was no response were
“in scope” (i.e. had at least one eligible member). The population was sampled
by random digit dialing. Sample weights (person weights) were adjusted for
non-response and for differences between the target population and the surveyed
population. Injury weights are assigned weights equivalent to the person weight. The
total number of injuries was calculated by multiplying the number of injuries reported
by each person, by the incident weight, then summing these figures. Further information relating to the 1993 GSS may be found in published reports. (1,2)
8
Introduction
National Population Health Survey
The National Population Health Survey (NPHS) was designed to measure
the health status of Canadians and, in doing so, to expand the knowledge of the
determinants of health. Questions relating to injuries in the NPHS survey were
answered by respondents age 12 and over. Items focussed on injuries were restricted
to those injuries serious enough to limit the respondent’s normal activities. Data were
obtained on the number of injuries in the past year, the type of injury, part of the body
injured, where the injury occurred, the cause of the injury, whether the injury was work
related and the precautions the respondent is taking to prevent injury from happening
again. Although a child could have experienced more than one injury in the past year,
respondents were asked to report only on the most serious injury. Consequently, the
questions relating to type of injury, part of body injured, location of injury and nature
of injury refer to the most serious injury.
Of the 17,626 randomly selected respondents aged 12 and older, 14,786 were
eligible members of the NPHS longitudinal panel. These respondents were also eligible
for the Health Canada supplement. The Health Canada set of supplemental questions
obtained data about where people got information about health and health services. It
also included questions about parents’ awareness of the relative importance of various
diseases as a cause of death in young children. Finally, it asked about sources of information relating to car safety seats, traffic safety, prevention of injury in the home, treatment of a child choking in home, swimming safety, bicycle safety and prevention of
sports injuries. The supplemental questions also expanded the information relating to
bicycling (and tricycling) and helmet use, and the reasons associated with the use of
helmets or seat belts.
The response rate to the Health Canada – sponsored questions was 90.6%. (The
database containing information from the Health Canada supplement as well as data
from the General and Health files pertaining to these respondents is called the
Supplementary file.) The sample size pertaining to youth aged 12 to 19 in the NPHS
supplementary file was 1,373 (678 males and 695 females).
The component of NPHS that is longitudinal will collect information from the
same panel of respondents every two years for up to two decades. The target population of the NPHS consists of household residents in all provinces and territories, except
persons living on First Nations reserves, on Canadian Forces bases or in some remote
areas. An institutional component covers long-term residents of hospitals and
residential care facilities.
NPHS includes a sample of 20,000 households. The base sample sizes in
each province were determined by using an allocation that balances the reliability
requirements at national and regional levels. Some provinces chose to increase the
sample size to increase the utility of the survey. This resulted in a final sample size of
26,430 households. The response rate was approximately 88% of households. Further
information relating to the sample design and methodology of the NPHS may be found
in published documents. (3-5) The final sample size of the NPHS supplemental survey
was 13,378.
9
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
National Longitudinal Survey of Children and Youth
The objective of the National Longitudinal Survey of Children and Youth
(NLSCY) is to develop information for policy analysis and program development on
critical factors affecting the development of children in Canada. More specifically, the
objectives are to determine the prevalence of various biological, social and economic
characteristics and risk factors of Canadian children and youth. In addition, the study
aims to monitor the impact of such factors, life events and protective factors on the
development of children and to provide information to policy and program officials for
use in developing effective policies and programs.
Questions relating to injury are similar to those asked in the NPHS. Data were
obtained on the incidence of injury, type of injury, part of body injured, location of
injury and the cause of the injury. The importance of information relating to injury in
the NLSCY is increased because of the extensive amount of background information
relating to the home, community and school environment of the child. Information
was also obtained on child development, sleep disorder, prescription drug use, use of
alcohol, drugs and cigarettes, and exposure to domestic violence. All of these data are
important for defining the social and physical environment in which a child lives and
are important in understanding the etiology of injury.
Since the purpose of the NLSCY is to follow a representative sample of children
from birth to 11 years into adulthood, the target population for the first data collection
in 1994-95 consisted of Canadian children from birth to 11 years of age. Approximately
25,000 children were included in the first survey. The sampling frame of the Labour
Force Survey was used to design the sample. Although the Labour Force sampling
frame excludes persons living in the Yukon and the Northwest Territories, the sample
includes approximately 2,300 respondents in the territories.
All children under 11 years residing in selected households who are members of
the same economic family are included. For analyses, they are divided into seven age
groups: 0-11 months, 1, 2-3, 4-5, 6-7, 8-9 and 10-11 years. These groupings permit
analysis every two years while maintaining an overemphasis in the youngest groups by
retaining 1-11 months and one-year-olds as separate groups. (6,7)
One component of the NLSCY is integrated with the NPHS. Because both the
NLSCY and the NPHS needed to collect data on the health of Canadian children, it was
decided that a portion of the sample and content of the two surveys would be integrated at the provincial level. Thus, children selected by the NPHS were to be part of
the sample for both surveys. For the integrated portion of the surveys, the intention is
that all of the NLSCY survey instruments will be used to collect information regarding
the children in the sample. The NPHS instruments are used for persons in the sample
who are 12 years of age and over. To ensure comparability, concepts common to both
surveys were achieved through a standard set of questions.
10
Introduction
Health Promotion Survey
The 1990 Health Promotion Survey (HPS) was conducted to update and
expand national and provincial baseline data on the knowledge, attitudes, beliefs,
intentions and behaviour of adult Canadians on a wide range of health promotion
issues. Among the topics included were workplace health, environmental health and
safety. Questions relating to injury prevention included items on seat belt use, helmet
use, use of all-terrain vehicles or snowmobiles in the past 12 months, beliefs and attitudes regarding government involvement in injury prevention, use of an automobile
within two hours of drinking, presence of first aid kits, fire extinguishers and smoke
alarms in the home. Although the sample is restricted to age 15 and over, it is possible
to define households in which children aged 5 or less, 6-11 and 12-14 years are present.
This information can be used to classify households by presence of children and
household characteristics.
The 1990 HPS used a random digit dialing survey method. The target population was all persons 15 years of age and older living in Canada with the following two
exceptions:
1. residents of the Yukon and the Northwest Territories; and
2. full-time residents of institutions.
In order to carry out the sampling, each of the 10 provinces was divided into
strata or geographic areas. Generally, for each province one stratum represented the
census metropolitan areas (CMAs) and the other the non-CMA areas. The sample was
created through the use of two different methods for generating telephone numbers:
the Waksberg method and the elimination of non-working banks method (ENWB). The
final sample of the 1990 HPS was 13,792 respondents. More detail relating to the
sample design, weighting procedures and limitations of the 1990 HPS may be found in
published reports. (8,9)
Analytic Procedures and Principles
None of the surveys listed above is a simple random survey. Instead, the surveys
have complex designs, with stratification and multiple stages of selection, and unequal
probabilities of selection of respondents. Using data from such surveys present
problems to analysts because the survey design and the selection probabilities affect
the estimation and variance calculation procedures. Where surveys use a stratified
design with significant differences in sampling fractions between strata, some areas
may be over-represented in their sample (relative to the population) while other areas
may be under-represented.
11
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Most of the above surveys used stratified design with significant differences
between sampling fractions. This means that the unweighted sample is not representative of the target population. The survey weights must be used when producing
estimates or performing analyses to account for over- or under-representation. While
many analytic procedures found in statistical packages allow weights to be used, the
meaning or definition of the weight in these procedures often differs from that which
is appropriate in a sample survey framework. The result of this is that while in many
cases the estimates produced by the packages are correct, the variances that are
calculated may be almost meaningless.
Because of the large variety of estimates that can be produced from a survey, the
standard deviation is usually expressed relative to the estimate to which it pertains.
The resulting measure, known as the coefficient of variation of an estimate, is obtained
by dividing the standard error of the estimate by the estimate itself and is expressed as
a percentage of the estimate. Screening of survey estimates is done with the approximate sampling variability tables provided in the documentation for each survey.
The goal is to ensure that there are sufficient numbers to result in acceptable variation
coefficients.
In the surveys that involve a cross-sectional design, caution is required in
making causal inferences about the association between variables. Observed associations may reflect differences between cohorts, period effects, differences between age
groups, or a combination of these factors.
Text References:
1. Statistics Canada. General Social Survey – Cycle 3: Personal Risk (1988) – Public Use
Microdata File Documentation and User’s Guide. Catalogue No.12M0003XDB
[Diskette], Ottawa, 1990.
2. Millar WJ. Accidents in Canada, 1988 and 1993. Health Reports 1995;7(2):7-16.
3. Catlin G, Will P. The National Population Health Survey: highlights of initial developments. Health Reports 1992;4:313-9.
4. Tambay JL, Catlin G. Sample design of the National Population Health Survey.
Health Reports 1995;7(1):1-11.
5. Statistics Canada. National Population Health Survey Overview 1994-95. Minister
responsible for Statistics Canada, Minister of Industry, Ottawa, 1995; Catalogue
82-567.
6. Statistics Canada and Human Resources Development Canada. National
Longitudinal Survey of Children: Overview of Survey Instruments for 1994-95, data
collection, Cycle 1. Catalogue 95-02, Ottawa, 1995.
12
Introduction
7. Statistics Canada and Human Resources Development Canada. National
Longitudinal Survey of Children and Youth. Users Handbook and Microdata
Guide. Microdata documentation 89M0015GPE, microdata file 89M001SXDG,
Ottawa, 1996.
8. Health and Welfare Canada. Stephens T, Fowler Graham D., editors. Canada’s
Health Promotion Survey 1990. Technical Report. Ottawa. Minister of Supply and
Services Canada. 1993; Cat. H39-263/2-1990E.
9. Statistics Canada. Health Promotion Survey, 1990, Microdata User’s Guide.
Catalogue 82N0007GPE (Paper: English or French), Ottawa, 1991.
13
Survey Overview
Although an attempt was made to identify the pertinent surveys in other
countries (and provinces in Canada), there was neither enough time nor resources to
permit us to do so comprehensively. Accordingly, this section provides a sample of the
more prominent examples of population-based health surveys to help situate what
has been done in Canada in a broader context.
In 1997, Chronic Diseases in Canada published a comprehensive review of
Canadian Health Surveys by Kendall, Lipskie and MacEachern. It provides a history of
such surveys and shows the shift in focus from basic outcomes to a wide range of
determinants, especially since 1974, the date of the Lalonde report. As they note, the
types of surveys range from occasional cross-sectional surveys, to periodic surveys,
longitudinal surveys, those that are school-based and those based on other subgroups
or specific topics.
Kendall et al. (1997) note in their introduction that surveys have a long history,
dating back to biblical censuses. They emerged in the 1800s as opinion polls used for
political and market research. The origin of the term “survey” is the Latin sur [over] and
videre [see], thus, “oversee.”
As the Kendall paper reminds us, although the focus of the present report is on
national surveys, there are several well-done provincial surveys that provide valuable
and, often, complementary data. In addition, there are commercial surveys. Notably,
few of either of the last two categories, provincial or commercial, address child injuries
in any significant manner.
Among the provincial surveys that have done so are the following: the Ontario
Child Health Survey (1983 and 1987), Enquête Santé Québec (1987), Ontario Health
Survey (1990), and the BC Adolescent Health Survey (1992). It is indicative of the
perceptions of the relative importance of various health problems, that of the
10 provincial surveys that involved children, all had an exclusive focus on drug use. Yet,
using either mortality or hospitalization data as indicators of the relative importance
of injuries versus drugs among children, the evidence suggests that this emphasis on
drugs is misplaced. At the very least, equal attention should be given to injuries, not
only because of the numbers but because of the great potential for prevention.
15
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
In Canada, the first survey devoted exclusively to health was the Canada
Sickness Survey which took place in 1950 and involved a sample of 36,389 respondents
representing all age groups. Between that date and the 1970s when the Nutrition
Canada and Canada Health Surveys took place, there was a series of Labour Force
Surveys on Smoking Habits. The 1978 Canada Health Survey, which included a lifestyle
component for those over 15 years, asked questions about the prevalence of injuries
serious enough to limit normal activities (e.g. location, time, health consequences,
MVA involvement).
The 1983 Canadian Health and Disability Survey examined causes of disability
and included a sample of more than 59,000 children. Similarly, the Canada Health
Attitudes and Behaviours Survey the following year involved a sample of 33,111 children in Grades 4, 7 and 10 and included questions related to safety. The Health and
Activity Limitation Survey of 1986 focussed on disabilities in all age groups, including,
perhaps, their causes. Campbell’s Survey on Well-Being occurred twice, the second
being a follow-up of the 1981 Canada Fitness Survey.
In the 1980s, there was the Canada Fitness Survey and the Canada Health
Knowledge survey – the latter involving children in Grades 4, 7 and 10. This included
several questions on risk behaviours and safety and involved a sample of 28,905 children in each of the provinces. However, although the 1980s saw a sharp increase in the
number surveys (19 in all), only a few included children. And, even among these
injuries were rarely covered.
The same pattern continued into the 1990s. Only 6 involved children. In the
case of some, e.g. NPHS, the involvement of children was minimal in that it only
included those children aged 12 to 19 years. As the authors of two large surveys of
youth, the Canadian Health Knowledge Survey and the Canada Health Attitudes and
Behaviours Survey, sponsored by Health and Welfare in the 1980s, state, these “led to
Canada being invited to join a WHO collaborative study on health behaviours of
school-aged children conducted approximately every four years.” This collaborative
endeavour, involving 32 countries, now represents yet another opportunity to obtain
valuable comparative data on injury occurrence.
To summarize, in Canada, several provinces have conducted one or more
health surveys. Of greatest value and interest are those that have been repeated at least
once. This permits a comparison of changes over time, assuming, of course, that the
basic methods remain the same, including, in particular, the form and structure of
questions. An example is Santé Québec (Quebec Health Survey), conducted first in
1987 and again in 1992. Although the questions addressing injuries were not precisely
identical (as a result of an effort to improve them), a number of useful and illuminating comparisons are available. Finally, the Ontario Health Survey is another such
example. Regrettably, the Ontario Child Health Survey, which included a follow-up
after the original study in 1983, did not include questions about injury.
16
Survey Overview
Since 1957, the United States has conducted a Health Interview Survey annually.
Periodically, this is supplemented by a survey with questions dealing specifically with
the health of children. Both in the main survey, and the supplements, questions about
injuries have been asked. In addition, the United States conducted a Health
Examination Survey which, in 1971, was expanded to include a nutritional component
(the NHANES). The National Ambulatory Medical Care survey may also qualify as a
population-based survey because it involves an attempt to obtain data about medical
visits to a sample of physicians, as does the hospital discharge survey. Two special
reports dealt exclusively with injuries, including those affecting children.
In Britain, an exceptional situation exists. Beginning in 1946, a sample involving
all children born during one week in March was assembled and followed periodically
as a cohort. Subsequently, similar surveys, each involving cohorts of births during the
same time period, were conducted in 1958 and 1970. The positive aspect of these
studies is the repetition of the survey at follow-up intervals varying between several
years (in the case of the 1956 cohort) to longer intervals in the subsequent birth
cohorts. Unfortunately, in each instance, questions about injuries were somewhat
superficial and not always asked in a consistent manner, thus making comparisons
difficult. On the other hand, it is to the great credit of the survey organizers that they
saw fit to include injuries when many today still fail to do so.
Australia has conducted two important surveys that include data on childhood
injury: the National Health Survey (NHS) and the Western Australia Health Survey. The
latter is an “one-off” survey that included children aged only 4 to 16 years, whereas the
former is repeated at regular intervals. The NHS has a filter following a general
question about health conditions that prompted certain defined actions. This leads to
questions about whether they were due to an “accident” (work-related or not); the type
of injury (fractures, dislocations, etc.), the mechanism (MVA, fall, etc.), and the
location. The most recent “accident” is coded based on age, so that somewhat different
questions about the setting apply to those 5 to 14 years and those 15+ years.
The tables below summarize much of what is now known about health surveys
in Canada and several other countries. As stated before, this information is neither
comprehensive nor is it necessarily up-to-date. It does, however, provide a reasonable
overview of where matters stand in the late 1990s.
17
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table SO1 — Canadian Surveys
Survey
Country
Responsible
Organization
Aboriginal
People’s
Survey
Canada
Statistics Canada
National
Aboriginal
Population
Face-to-face
Campbell’s
Survey on
Well-Being
Canada
Canadian Fitness
and Lifestyle
Research Institute
National
SelfAdministered
Questionnaire
0
7+
Canada Health
Canada
Attitude and
Behavior Survey
Social Program
National
Evaluating Group,
Queen’s University
SelfAdministered
Questionnaire
in classroom
0
Grades 1984-5
4,7,10
Community
Risk Factors
Survey
Canada
Laboratory
Centre for
Disease Control,
Health Canada +
10 Community
Health Units
National
Phone survey
0
15 +
1985-1988
General Social
Survey (GSS)
Canada
Statistics Canada
National
Phone survey
(RDD)
2
15 +
4 cycles
Cycle 1–1985
Health and
Social Support
Cycle 3 – 1988
Accidents and
Personal Risk
Cycle 6 –1991
Cycle 8 –1993
Risk & Injury
Health and
Activities
Limitation
Survey (HALS)
Canada
Statistics Canada
National
Household
interview
0
ALL
1986-7
1991-2
Health
Promotion
Survey (HPS)
Canada
Statistics Canada
Health Canada
National
Phone survey
(RDD)
Home (north)
0
15 +
1985
1990
National Alcohol Canada
and Other Drugs
Survey (NADS)
Statistics Canada
Health Canada
National
15 +
1989
National
Longitudinal
Survey of
Children and
Youth (NLSCY)
Statistics Canada
National
Human Resources
Development
Canada (HRDC)
0 – 11
1994
1996
Bi-annual
Canada
Scale
18
Type
<10 – faceto-face
10 – 11 –
SelfAdministered
Questionnaire
Injury
Data1
Ages
Dates
1991 – 92
1996
2
1981 – 88
Survey Overview
Table SO1 — Canadian Surveys (cont’d)
Survey
Country
Responsible
Organization
Scale
National
Population
Health Survey
(NPHS)
Canada
Statistics Canada
National
household
interview
National Survey Canada
on Drinking and
Driving (NSDD)
Statistics Canada
Health Canada
National
Ontario Child
Health Study
Canada
Statistics Canada
McMaster
University
Provincial
Ontario Health
Survey
Canada
Quebec Health
Survey (QHS)
Type
Injury
Data1
2
Ages
Dates
All
1994 –
Longitudinal
16-69
1988
1992
Household
interview
0
4-16
1983
1987
Longitudinal
Ontario Ministry Provincial
of Health and
the Premier’s
Council on Health
Strategy
SelfAdministered
Questionnaire
+ face-to-face
0
12 +
1990
every 5 years
Canada
Quebec Ministry
of Health and
Social Services +
32 community
health
departments
Provincial
Interviewer
questionnaire
2
ALL
1987
1992 – 3
The Canada
Health Monitor
Canada
Price Waterhouse
Syndicated –
multi-scriber
National
Phone survey
1
15+
1988 –
semi-annual
WHO CrossNational Survey
Behaviours of
School-Aged
children
Canada
and
others
WHO
International Teacheradministered
questionnaire
1
11,13,
15
1982 (not
WHO)
1983-84
1985-86
1989-90
1993-4
Every four
years
2
Injury data: 0 = none 1 = minimal 2 = adequate
19
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table SO2 — United States Surveys
Survey
Annual Survey
of Occupational
Injuries and
Illnesses
Country
United
States
Responsible
Organization
Scale
Type
Injury
Data1
Ages
Dates
Bureau of Labor
Statistics,
Department of
Labor, U.S.
government
National
Mailed
questionnaire
copy of Log
Summary of
Occupational
Injuries and
Illnesses
2
No
minimum
age
1971 –
Annual
National
United
Ambulatory
States
Medical Care
Survey (NAMCS)
NCHS, CDC,
PHS, DHHS.
U.S. government
National
Office-based
physicians
1
ALL
1973 –
National Health
and Nutrition
Examination
Survey
(NHANES)
United
States
NCHS, CDC
PHS, DHHS.
U.S. government
National
Household
interview
0
Cycle 1:
1-74 yrs
Cycle 2:
6-74 yrs
Cycle 3:
6 mths
NHANESI:
1971-4
NHANES II:
1976-0
Hispanic
HANES:
1982-84
NHANESI
Follow-up
NHANES III:
1988-94
National Health United
Interview Survey States
(NHIS)
NCHS, CDC,
PHS, DHHS.
U.S. government
National
Household
interview
2
ALL
1957 –
Annual
National
Hospital
Ambulatory
Medical Care
Survey
United
States
NCHS, CDC,
PHS, DHHS
National
OPD records
2
ALL
1991 –
National
Hospital
Discharge
Survey
United
States
NCHS, CDC,
PHS, DHHS
National
Discharge
records
N/A
National
Household
Surveys on
Drug Abuse
United
States
NIDAA
National
Household
interview
N/A
Injury data: 0 = none 1 = minimal 2 = adequate
20
1965 –
12 yrs+
1971 –
The 1991
survey is the
11th in this
series which
began in 1971
Survey Overview
Table SO3 — Other National Surveys
Survey
Country
Responsible
Organization
Scale
Type
Injury
Data1
Ages
Dates
National Survey
of Health &
Development
(1946 Birth
Cohort)
Great
Britain
Medical Research
Council & others
National
Questionnaire
interview and
examination
1–2
0 – 4,7,11
1946 –
Continuing
longitudinal
National Child
Development
Study (1958
Birth Cohort)
Great
Britain
Medical Research
Council & others
National
Questionnaire
interview and
examination
1–2
0 – 4,7,11
1958 –
Continuing
longitudinal.
Child Health
and Education
Study
(1970 Birth
Cohort)
Great
Britain
University of
Bristol, National
Birthday Trust
National
Questionnaire
interview and
examination
1
Birth +
1970 –
Continuing,
longitudinal
General
Household
Survey
Great
Britain
Office of
Population
Censuses and
Surveys
National
Questionnaire
telephone
Topics
vary
ALL
1971
Annual
Continuous
Health Survey
Northern National
Ireland
Safety in the
Home
Australia
Australian Bureau
of Statistics
Community Sup. Australia
of
monthly popuMelbourne lation survey /
questionnaire
1
0-4,
5-14, 15+
National Health
Survey
Australia
Australian Bureau
of Statistics
National
1
5-14, 15+
Western Australia
Health Survey
Australia
Australian Bureau
of Statistics
National
1
4-16
Dunedin Multidisciplinary
Health and
Development
Study
New
Zealand
Medical Research
Council of
New Zealand
Community Questionnaire
interview, exam
1–2
Birth +
1972 – 3
Continuing
longitudinal
Kuwait Child
Health Survey
Kuwait
Gulf Health Survey National
Programme (GHSP)
Questionnaires
examination
0
<6
1987
National Child
Health Survey
United
GHSP
Arab
Emirates,
etc.
National
Questionnaires
examination
0
<6
1987-1989
Nordic
Questionnaire
Scandinavian
?
National
Postal
questionnaires
?
2 – 18
?
“Patient
Survey”
Japan
Ministry of Health
and Welfare
National
In/Out hospital
data
1
ALL
Every 5 years
since ?
Telephone
household
survey
1
<16, 16 +
1988 –
Annual
Enquête sur la
France
Santé et la
Protection Sociale
1983 –
Centre de Recherche National
d’Étude et de
Documentation
en Économie de la
Santé (CREDES)
1992
National Health
Survey
Germany Ministry of Health
and Welfare?
National
Questionnaire
examination
1
ALL
Annual since
1963
National Health
Interview Survey
Netherlands
National
N/A
N/A
N/A
Since 1977?
Central Bureau
of Statistics
Injury data: 0 = none 1 = minimal 2 = adequate
21
Results
General Social Survey – Personal Risk
Canada’s General Social Survey (GSS) began in 1985 and has been repeated at
five-year intervals since then. Its goal is “to monitor changes in Canadian society and
to provide information on current or emerging policy issues.” Each five-year cycle
focusses on one of five core subjects. One of these is “personal risk” which includes the
incidence and consequences of “accidents.” This was the focus of the 1983 and 1993
surveys and the data reported here are derived only from the most recent, 1993, data.
The target population of the GSS is persons aged 15 and over in all provinces but
excluding residents of the Yukon and Northwest Territories and full-time residents of
institutions. Thus, although only those over 15 were interviewed, they were asked to
report on “accidents” involving those under age 14 years. A series of screening
questions was asked to determine if an “accident report” was required. Only events
meeting the follow criteria and occurring in the previous 12 months from the date of
the interview were counted. One or more of:
•
interruption of normal activities for at least half a day;
•
causing out-of-pocket expenses of at least $200; or
•
requiring medical attention from a physician or nurse.
Only four types of “accidents” were identified: motor vehicle, sports, work, and
home. Because these are not mutually exclusive, a hierarchical procedure was followed
in the sequence stated so that, for example, a motor vehicle injury arising when the
victim was at work, would be classified only as “motor vehicle.” As stated earlier,
“accidents” included poisoning and this will not, therefore, be repeated on each of
the tables that follow.
Readers are reminded that the percentages presented in the tables are based on
weighted estimates and that these represent the numbers likely to be found in the
general population. Also, note sums may not total due to rounding. Another important
reminder is that for the GSS as for the other surveys reviewed, invariably some
responses to any question are “don’t know” or the response is not coded for one reason
or another. The proportion of such unusable responses, although low (in the range of
2% to 3%), varies from question to question. The convention of calculating percents
over all categories was followed in this report. In most of the following tables, the
responses for each variable specified are based on just under 3,000 children. (This
represents, when weighted, a population of just over 6 million children under age
15 years.)
23
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Occurrence
In the sample of 2,946 children, 304 under 15 years had been seen by a doctor
for an injury or poisoning in the last 12 months. When weighted to reflect the number
in the general population, this is equivalent to 559,000 injured children or 10% of all
children in this age group. Approximately 102,000 children had more than one injury
in the past year, which is about 2% of all children.
Table 1 – Number and percent of children aged 0-14 years injured in the past year,
by age group, Canada, 1993
Characteristic
Population
(000s)
Number of
injured
(000s)
% of Injured
0-4
2,000
170
9
5-9
1,891
194
10
10-14
1,883
196
10
Total
5,773
559
10
Age group
Source: General Social Survey, 1993
Distribution
More than two thirds of the injured children, 69%, were from urban areas,
similar to the proportion of Canadians actually living in urban communities. In
general, the percent distribution of injured youth reflects their distribution in the
population. Some differences exist, however. For example, boys represent about 51%
of the population of youth, but 58% of the injured. Although children aged 0 to 4
comprise 35% of the population aged 0 to 14, they represented only 30% of the injured
population. There were also some interesting differences in the distribution of injuries
by province. In Newfoundland, Nova Scotia, Alberta and British Columbia, the
proportional distribution of injuries exceeded the proportional distribution of
population. By contrast, the distribution of injuries in Quebec, Ontario and
Saskatchewan were lower than expected based on the population distribution.
24
Results
Table 2 – Percent distribution of population and injuries in the past year, among
children 0-14 years, by selected characteristics, Canada, 1993
Characteristic
Population
(000s)
Number
injured
(000s)
% Distribution
of population
% Distribution
of injured
children
Age group
0-4
2,000
169
35
30
5-9
1,891
193
33
35
10-14
1,883
196
33
35
Total
5,773
559
100
100
Male
2,958
322
51
58
Female
2,815
237
49
42
Urban
3,857
383
67
69
Rural
1,460
157
25
28
456
19
8
3
127
16
2
3
30
—
—
—
Nova Scotia
185
26
3
5
New Brunswick
150
20
3
4
Quebec
1,395
112
24
20
Ontario
2,113
197
37
35
Manitoba
245
23
4
4
Saskatchewan
238
15
4
3
Alberta
606
78
10
14
British Columbia
685
71
12
13
Sex
Rural/Urban
Not stated
Province
Newfoundland
Prince Edward Island
Source: General Social Survey, 1993
Note: — cell size too small to provide a reliable estimate
25
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Month and time
As seen in Table 3, far more injuries occur between April and October than in
other months. This, no doubt, reflects the greater exposure to risks during warm
weather. Similarly, the afternoon peak, when nearly half of all injuries occur, is also
almost certainly a reflection of exposure to risk during that time.
Table 3 – Distribution of injuries among children aged 0-14 years, by month of
injury and time of injury, Canada, 1993
Month/Time
of injury
Number of
injuries
(000s)
% Distribution
of injuries
Month
January/March
101
19
April/June
155
28
July/September
153
28
October/December
138
25
Missing
11
Total
559
100
6:01am to 12 pm
123
22
12.01 pm to 6 pm
275
49
6.01pm to midnight
128
23
12:01am to 6:00 am
4
1
28
5
559
100
Time
Missing
Total
Source: General Social Survey, 1993
Location
As shown in Table 4, over half of all injuries occurred at home (52%). The code
“commercial” refers to locations like restaurants, shopping malls, sports facilities and
commercial buildings.
26
Results
Table 4 – Location where injury occurred, children aged 0-14 years, Canada, 1993
Characteristic
Number of
injuries
(000s)
% Distribution of
injuries by location
Location of injury
Home
290
52
Commercial building
154
28
Public places
87
16
Elsewhere
15
3
Missing
13
2
559
100
Total
Source: General Social Survey, 1993
Activity
Not surprisingly, perhaps, in view of the age group under consideration, nearly
two thirds of all injuries were coded as taking place during “play.” Each of the other
activity categories (personal activities, bicycle, sports, etc.) represent only between 4%
and 6% of the total. (See Table 5.)
Table 5 – Activity when injury occurred, children aged 0-14 years, Canada, 1993
Activity
Number of
injuries
(000s)
Play
% Distribution of
injuries
366
66
Personal activities
21
4
Bicycle
24
4
Sports
34
6
Passenger in vehicle
22
4
Other
82
14
Missing
11
2
559
100
Total
Source: General Social Survey, 1993
27
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Nature of injury
Table 6 shows the nature or type of injury experienced. Notably, over 50%
are clearly minor (e.g. bruises, abrasions, cuts or scrapes). However, most of the
remainder are potentially serious: fractures accounting for 12%, followed by poisoning
(6%), concussions (4%), internal injuries (3%), and burns and scalds (2%).
Table 6 – Type of injury, children aged 0-14 years, Canada, 1993
Type of injury
Number of
injuries (000s)
% of injured
Fracture
65
12
Burn, scald
13
2
Dislocation, sprain, strain
72
13
Bruise, abrasion
107
20
Cut, scrape
174
32
Concussion
22
4
Poisoning
32
6
Internal
14
3
121
22
Other
Source: General Social Survey, 1993
Note: Total of injuries may exceed 100% because of multiple responses to question.
Body part
The information in Table 7 is also disquieting: it suggests that 40% of all injuries
involved the head or neck. Although this does not, of course, mean injuries to the brain
(for, as noted previously, only 4% were said to have suffered a concussion), it is noteworthy.
Table 7 – Part of body injured, children aged 0-14 years, Canada, 1993
Site of injury
Number of
injuries (000s)
Injuries as a percent
of total injuries
14
3
Head or neck
223
40
Upper extremity (shoulder, arms, hands)
139
25
Lower extremity (hip, legs, feet)
134
24
Back or spine
12
2
Trunk
43
8
Eyes
Source: General Social Survey, 1993
Note: Total of injuries may exceed 100% because of multiple responses to question.
28
Results
Site of care
Most of the injured were seen at a hospital (60%) and 10% of those seen initially
at a doctor’s office or clinic were later seen at a hospital. Given that this is a national
sample and that there are only 10 children’s hospitals in Canada, it is not surprising that
the hospital in question was a children’s hospital in only 15% of all cases. As a further
indication of the gravity of many of the injuries reported, however, 9% of the children
who were taken to hospital spent one or more nights as a hospital in-patient.
(See Table 8.) Of the 559,000 children who had experienced an injury in the past
year, 33,000 spent at least one night in hospital. This represents about 6% of all injured
children.
Table 8 – Where injured child received medical care, children aged 0-14 years,
Canada, 1993
Number of injuries (000s)
% Of injured
Location of treatment
Hospital emergency department
335
60
Doctor’s office
113
20
84
15
14
3
Yes
20
10
No
178
90
Yes
48
15
No
307
85
33
9
CHC (clinic)
Not treated
1
Subsequent hospital visit
Treatment in a children’s hospital2
At least one night stay in hospital3
Source: General Social Survey, 1993
Note: 1. If child was taken to a private health professional’s office or a community health clinic
(198,000), the question whether the child went to hospital was asked.
2. The question relating to the type of hospital was asked of all children who were taken to a
hospital facility. Denominator for percentage is all children who were taken to hospital
(355,000).
3. Based on children who were taken to a hospital emergency department or were taken to
hospital after preliminary treatment in another facility. Denominator for percentage is
355,000.
29
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Commentary
The GSS is a potentially important source of information about childhood
injuries. It would be much more helpful, however, if some of the questions and the coding of all questions were adjusted to reflect the world of children and not that of adults.
Despite its shortcomings, it provides a solid estimate of the frequency of injuries over a
broad age range and main patterns of their occurrence. It also calls attention to the
importance of hospitals in general, and children’s hospitals in particular, as a site of care
for these children. Apart from the indication of severity as reflected by hospital use, the
results pertaining to body part and type of injury reinforce the belief that a substantial
proportion of these injuries are potentially serious.
National Population Health Survey
As described earlier, the National Population Health Survey (NPHS) included
questions about injuries that could be answered by those ages 12 and older. Only
injuries of sufficient severity to limit normal activities were included, however. In this
sense, then, the results are not comparable with those described in the previous
section. Of the injuries covered, information was obtained on the number in the past
year, type, body part, location, its cause, whether it was work related, and if any
preventive precautions were taken to avoid another occurrence, including, for
example, helmet use. If a person had more than one injury, information relating to its
type, body part and location referred to the most serious of the injuries.
A set of supplemental questions from Health Canada was added to the NPHS to
obtain data about health and where care was given. Questions also explored parents’
awareness of the causes of death in childhood, sources of information about safety
seats, traffic safety, home injury prevention, swimming, bicycle, and first aid for
choking.
Because the NPHS is longitudinal, it collects information from the same panel
every two years for as long as 20 years. The target population is households in
all provinces and territories, except those on First Nation reserves, Canadian
Forces bases or some remote areas. A total of 26,430 households are included in the
sample (following the procedure described earlier) with a final response rate of
approximately 88%.
Occurrence
The NPHS addressed injuries only among those ages 12 to 19 years. To facilitate
interpretation, the results are reported for the weighted population of those 12 to
14 years and 15 to 19 years. The younger age group represents 39.3% of the total, or
1.3 million adolescents, while the older group is 60.7%, or 2 million adolescents.
30
Results
For the group as a whole, 28.8% reported one or more injuries in the past
12 months. Most (19.5%) had a single incident; 5.6% had two; 3.7% had 3 or more.
Among the younger group 27% reported having an injury (as defined) in the last
12 months; the figure for the older group was quite similar, 29.6%.
The proportions were somewhat different, however, for boys and girls. Thirtytwo percent of the boys aged 12 to 14, and 33% of 15- to 19-year-old boys reported an
injury compared with 22% and 26%, respectively, of the younger and older girls. (See
Table 9.) Note that the percents stated above are based on the whole population:
expressed as a proportion of those injured they would, of course, be quite different. For
example, among the injured population, the percent with a single injury was 68% and
multiple injuries occurred among 32%.
Table 9 – Injuries in the past 12 months among youth 12-19 years, by age and sex,
Canada, 1994/95
Age/Sex
Population
Number of
% Injured
(000s)
injuries (000s)
12-14
1,326
365
27
15-19
2,046
606
30
Total
3,372
971
29
12-14
706
227
32
15-19
1,057
347
33
Total
1,763
574
33
12-14
620
137
22
15-19
989
259
26
Total
1,609
396
25
Both sexes
Males
Females
Source: NPHS,1994/95
Distribution by province
Injuries were more frequently reported by residents of Manitoba and Alberta for
boys, and by those of Saskatchewan and British Columbia for girls. (See Table 10.) The
highest rate was seen in Saskatchewan for boys 15 to 19 years (56%) and the lowest of
the reliable rates (excluding PEI where the numbers are too small), was found for
15- to 19-years-old girls in Newfoundland and 12- to 14-year-old girls in Nova Scotia.
It is difficult to know what to make of these patterns, but the differences seem large
enough to suggest that they are not simply random variations.
31
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 10 – Injuries among youth aged 12-19 years, by province, age, and sex
Canada, 1994/95
12-14
Males
Age group
15-19
12-14
Females
Age group
15-19
Total
Total
Newfoundland
26
31
28
12
10
11
Prince Edward Island
20
23
21
4
18
12
Nova Scotia
44
30
35
10
20
17
New Brunswick
28
29
28
20
18
19
Quebec
22
22
22
14
22
19
Ontario
31
36
34
19
25
23
Manitoba
53
44
48
29
21
23
Saskatchewan
13
56
35
52
40
45
Alberta
40
45
43
29
33
31
British Columbia
48
32
39
40
37
38
Province
Source: NPHS, 1994/95
It is, perhaps, somewhat easier to observe important patterns when the
provinces are grouped into regions, as in the next table. This permits larger aggregations and thus more precision in the estimates. Comparing like with like, that is,
similar age and sex groups, it is noteworthy that the rates in British Columbia are the
highest throughout, with the single exception of 15- to 19-year-old boys, where they
are exceeded by those in the Prairies. Just as striking as this consistency are the large
relative risks between the highest and lowest regions. In the case of 12- to 14-year-old
boys, those in British Columbia have more than twice the risk of being injured than
those in Quebec; the same is true for the Prairies compared to Quebec for the older
boys. For girls the differences are even greater – younger teenagers in British Columbia
have nearly three times the risk of those in the Atlantic region or Quebec, and nearly
twice the risk when British Columbia rates are compared with those in Atlantic Canada
for the older girls. (See Table 11.)
32
Results
Table 11 – Injuries among youth aged 12-19 years, by region, age and sex, Canada,
1994/95
12-14
Males
Age group
15-19
12-14
Females
Age group
15-19
Total
Total
Atlantic
32
29
30
14
17
16
Quebec
22
22
22
14
22
19
Ontario
31
36
34
19
25
23
Prairies
36
47
42
34
31
32
British Columbia
48
32
39
40
37
38
Region
Source: NPHS, 1994/95
Urban vs rural
There is considerable interest and debate about whether urban children have
more or fewer injuries than those living in rural areas. Table 12 reveals that for older
but not younger boys, those in rural areas have higher rates. For girls, the pattern is
reversed. There is no generally accepted explanation for the higher rural rates,
although there are several theories. For example, it is assumed that the rural environment is more dangerous, and especially so if youth in rural areas are working on farms,
either those of their families or others. Moreover, although motor vehicle crashes may
be less frequent in rural areas, their consequences may be more serious because
of higher speeds and less readily available emergency medical services. Why these
explanations apply to some age-sex groups but not others remains unexplained.
33
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 12 – Injuries in the past 12 months among youth aged 12-19 years, by
rural/urban status, sex and age, Canada, 1994/95
Age/Sex
Population
Number of
(000s)
injuries
(000s)
% Injured
Both sexes
Urban
12-14
1,056
297
28
15-19
1,670
485
29
Total
2,727
782
29
12-14
263
67
25
15-19
365
118
32
Total
627
185
29
12-14
562
185
33
15-19
863
265
31
Total
1,425
450
32
12-14
141
42
29
15-19
188
81
43
Total
329
123
37
12-14
495
111
23
15-19
807
221
27
Total
1,302
332
26
12-14
121
25
21
15-19
177
37
21
Total
298
62
21
Rural
Males
Urban
Rural
Females
Urban
Rural
Source: NPHS,1994/95
34
Results
Nature or type of injury
As shown in Table 13 below, for both sexes and both age groups the dominant
injury was coded as a sprain or strain. This involved 12.3% of the total population,
followed by fracture, 5.8%, and cuts or scrapes, 2.2%. All other types of injuries
occurred less often except those labelled “ill-defined” and “other.” These basic patterns
are the same in all four age and sex groups.
Table 13 – Percent injured by nature of injury, youth aged 12-19 years, by age,
Canada, 1994/95
Nature of injury
Population (000s)
12-14
Age group
15-19
Total
1,326
2,046
3,372
—
—
—
Fractures
6.9
5.1
5.8
Burns/Scalds
0.1
1.0
0.6
Dislocation
1.0
2.4
1.9
12.1
12.5
12.3
Cut/Scrapes
1.8
2.5
2.2
Bruise
2.4
1.3
1.7
Concussion
0.7
0.2
0.4
Poisoning
—
—
—
Internal injuries
—
0.7
0.4
2.4
3.6
3.1
Multiple injuries
Sprain/Strains
Other
Source: NPHS, 1994/95
Note: Denominator for rates is the total population within each age group.
— cell size too small to provide a reliable estimate
In Table 14 and those that follow in this section, the data are also displayed as
percentages of all those who are injured in the weighted sample. Viewed in this
context, the importance of fractures, dislocations, concussions, burns, scalds and
multiple injures (i.e. all those likely to be serious) is seen in a different light: together
they represent 33% of boys’ injuries and 28% of all injuries to girls (data not shown).
35
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 14 – Percent distribution of injuries among youth aged 12-19 years, by
nature of injury, Canada 1996/97
Nature of injury
Total injuries (000s)
12-14
Age group
15-19
Total
365
606
971
—
—
—
25.2
17.2
20.2
Burns/Scalds
0.2
3.2
2.1
Dislocation
3.8
8.2
6.5
44.1
42.1
42.8
Cut/Scrape
6.6
8.3
7.6
Bruise
8.7
4.3
6.0
Concussion
2.6
0.6
1.3
Poisoning
—
—
—
Internal injuries
—
2.3
1.4
8.8
12.1
10.9
Multiple injuries
Fractures
Sprain/Strains
Other
Source: NPHS, 1994/95
Note: Denominator is the population within each age group who experienced an injury.
— cell size too small to provide a reliable estimate
Although it is true that 40% to 50% of all injuries are strains and sprains which
may be regarded as not serious, nevertheless, as stated above, there is a substantial
proportion with concussions and fractures. The former occurs far more often among
boys, but the latter are equally frequent in both sexes (data not shown).
Distribution by body part
Injuries involving the lower extremities were most common, 13.6%, followed by
upper extremity injuries. Arms or hands were involved in 6% of youth injuries. Back or
spine injuries occurred among 3% of youth. (See Table 15.) The percent distribution of
injuries reflect the prevalence by body site. The lower extremity (hips, legs or feet) was
most often involved in 48%, upper extremity (shoulder, arms, hands) in 26%; and the
back, spine or trunk in 14%. This general pattern is consistent in all the age/sex
sub-groups (data not shown).
36
Results
Table 15 – Body part injured, youth aged 12-19 years by age, Canada, 1994/95
Age Group
Site of injury
12-14
15-19
Total
1,326
2,046
3,372
Multiple
—
—
—
Eyes
—
—
0.4
Head
1.8
1.3
1.5
Neck
—
0.7
0.9
Shoulder
1.2
1.7
1.5
Arms/Hands
7.5
5.0
6.0
—
—
—
Legs /Feet
13.1
14.0
13.6
Back/Spine
1.4
4.2
3.1
Trunk
0.7
1.1
0.9
Other
—
—
—
Population (000s)
Hip
Source: NPHS, 1994/95
Note: Denominator for rates is the total population within each age/sex group.
— cell size too small to provide a reliable estimate
Most injuries involve arms and legs in adolescents of both sexes, although boys
are more often affected than girls. For some reason, arms are more often injured in the
12- to 14-year-olds than in 15- to 19-year-olds of both sexes. The excess of head
injuries among boys is noteworthy, however, and in this case the sex differences are
larger than for most other body parts (data not shown).
37
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 16 – Percent distribution of injuries among youth aged 12-19, by body part
injured, by age, Canada, 1994/95
Age group
Site of injury
12-14
15-19
365
606
971
Multiple
—
—
—
Eyes
—
—
0.4
Head
6.5
4.4
5.2
Neck
—
2.5
3.2
27.2
17.0
20.9
—
—
—
Legs /Feet
47.7
47.2
47.4
Back/Spine
5.2
14.3
10.9
Trunk
2.7
3.6
3.3
Other
—
—
—
100.0
100.0
100.0
Total injuries (000s)
Arms/Hands
Hip
Total
Total
Source: NPHS, 1994/95
Note: Denominator for rates is the total population within each age/sex group.
— cell size too small to provide a reliable estimate
Distribution by locale
The coding of locale was not entirely appropriate for children. Assuming that
“industrial location” was equivalent to place of work, the dominant locales for injuries
in the total population aged 12 to 19 years were recreational facilities (15.5%), home
(6%), and on streets, about 3%. (See Table 17.) The distribution of injuries among children who were injured (Table 18), varied, predictably, by the age of the child. About
54% of all injuries occurred in a recreational facility, followed by 20% in the home, and
about 10% in the street. Among children aged 12 to 14, about 25% of injuries occurred
in the home, compared to 19% in the 15 to 19 age group.
38
Results
Table 17 – Location of injury, youth aged 12-19 years, by age, Canada,1994/95
Age group
Location
12-14
15-19
Total
1,326
2,046
3,372
Home
6.7
5.5
6.0
Farm
—
—
0.4
15.7
15.4
15.5
Street
1.7
3.7
2.9
Public building
2.5
2.3
2.4
Industrial location
—
0.6
0.4
Other
—
1.6
1.2
Population (000s)
Recreational facility
Source: NPHS, 1994/95
Note: Denominator for this table is the total population within each age group.
— cell size too small to provide a reliable estimate
Table 18 – Percent distribution of injuries by location of injury, youth aged
12-19 years, by age, Canada, 1994/95
Age group
Location
12-14
15-19
365
606
971
24.5
18.7
20.9
—
—
1.3
57.0
52.0
53.9
Street
6.0
12.3
10.0
Public building
9.2
7.9
8.4
Industrial location
—
2.0
1.2
Other
—
5.5
4.2
Don’t know
—
—
—
100.0
100.0
100.0
Number injured (000s)
Home
Farm
Recreational facility
Total
Source: NPHS, 1994/95
Note: Denominator for this table is youth who experienced an injury in the past year.
— cell size too small to provide a reliable estimate
39
Total
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
The patterns by sex are, again, interesting. Even in adolescence, girls have more
injuries than boys in the home, whereas the reverse is true for recreational injuries,
which are, presumably, for the most part, sports related (data not shown).
Distribution by external cause
Here again, the coding is based on adult mechanisms, so that categories like
natural environment, corrosive, and machinery are somewhat difficult to interpret.
Nonetheless, it is notable that falls clearly predominate. The next largest category is
struck, followed by MVA. Although this latter proportion may appear small, it
represents over 56,000 victims! It is also noteworthy that the injury rates due to MVAs
increases sharply in both sexes between the two age groups (data not shown).
Table 19 – External cause of injury among youth aged 12-19 years, by age,
Canada, 1994/95
Age group
External cause
12-14
15-19
Total
1,326
2,046
3,372
—
2.2
1.7
15.5
12.4
13.6
Struck
4.9
4.2
4.5
Assault
—
0.7
0.5
Environmental
—
1.0
0.9
Cut
—
—
0.3
5.1
8.7
7.3
Population (000s)
Motor vehicle accident
Fall
Other
Source: NPHS, 1994/95
Note: Denominator for this table is the total population within each age group.
— cell size too small to provide a reliable estimate
The other category includes injuries from corrosive products, machinery,
poisoning, fires and residual categories for which the cell count was too low to yield
reliable estimates.
The distribution of injuries by external cause of injury indicates that about 47%
of all injuries were attributable to falls compared to 16% for accidental strikes and 6%
for MVA. There are age differences in the distribution of injuries. Among youth aged 12
to 14, 56% of all injuries were associated with falls compared to 42% in the 15 to 19 age
group. (See Table 20.)
40
Results
Table 20 – Percent distribution of injuries among youth aged 12-19, by age and
external cause of injury, Canada, 1994/95
Age group
Location
12-14
15-19
365
606
971
—
7.3
5.8
Fall
56.4
41.9
47.3
Struck
17.9
14.3
15.7
Assault
0.4
2.3
1.6
Environmental
—
3.4
3.1
Cut
—
—
1.1
18.5
29.5
25.4
100.0
100.0
100.0
Number injured (000s)
Motor vehicle accident
Other/Don’t know
Total
Total
Source: NPHS, 1994/95
— cell size too small to provide a reliable estimate
The other category includes injuries from corrosive products, machinery,
poisoning, fires and residual categories for which the cell count was too low to yield
reliable estimates.
It is unclear from the preceding table how many of these injuries are workrelated. This is, however, an important problem that has begun to receive increasing
attention worldwide. Respondents who experienced an injury in the past year were
asked, “Was this a work-related injury?” From Tables 21 and 22, it appears that about
3% of this age group responded “yes” – they were injured at work, (i.e. about 5% of
all those injured). The problem is, not surprisingly, much greater among older
adolescents, and twice as great for boys than girls.
41
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 21 – Work-related injury among youth aged 12-19 years, by age and sex,
Canada, 1994/95
Age/Sex
Population
(000s)
Number injured
in work-related
activity (000s)
% Injured
Both sexes
12-14
1,326
—
—
15-19
2,046
52
1.6
Total
3,372
53
2.5
12-14
706
—
—
15-19
1,057
38
3.6
Total
1,763
38
2.1
12-14
620
—
—
15-19
989
14
Total
1,609
15
Males
Females
Source: NPHS, 1994/95
— cell size too small to provide a reliable estimate
42
1.5
Results
Table 22 – Work-related injury among youth aged 12-19, by age and sex, Canada,
1994/95
Characteristic
Population
(000s)
Number
injured
(000s)
Number injured
in work-related
activity
Work-related
as % of all
injured
12-14
1,326
365
—
—
15-19
2,046
606
52
9
Total
3,372
971
53
5
12-14
706
227
—
—
15-19
1,057
347
37
11
Total
1,763
574
38
7
12-14
620
137
—
—
15-19
989
259
14
5
Total
1,609
396
15
2
Age group
Both sexes
Males
Females
Source: NPHS, 1994/95
— cell size too small to provide a reliable estimate
Distribution by income
Many reports, including several from Canada, have called attention to a strong,
linear relationship between income and injuries, especially among children. That
relationship suggests that children from low-income families have many more
injuries, including fatalities, than those from wealthy families. In light of this, the
results seen in Table 23 are puzzling: among 12- to 14-year-old boys the pattern is
curvilinear, with highest rates found for both the poor and the rich. Among both male
and female 15- to 19-year-olds, however, the pattern is the reverse of what is expected:
rates are highest for the rich, not the poor. This needs to be examined more carefully.
One possible explanation is that wealthier youth have more access to cars and other
dangerous recreational vehicles or equipment, including skis, snowboards, in-line
skates, snowmobiles, etc.
43
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 23 – Injuries among youth aged 12-19 years, by household income, and sex,
Canada, 1994/95
Sex/Household
income
Population
(000s)
Number injured
(000s)
% Injured
Both sexes
Lowest
625
174
28
Lower middle
1,072
275
26
Upper middle
974
287
29
Highest
524
187
36
Missing
178
48
27
Lowest
338
118
35
Lower middle
559
156
28
Upper middle
476
154
32
Highest
304
123
40
Missing
86
24
28
Lowest
287
56
20
Lower middle
513
119
23
Upper middle
498
133
27
Highest
220
65
29
Missing
92
24
26
Males
Females
Source: NPHS, 1994/94
Bicycle injuries
Bicycle injuries are important because they can have serious consequences and
because the use of helmets can prevent many of these consequences. Unfortunately,
many accounts of these injuries fail to use bike ownership or actual use as a measure
of exposure. Most children ride bicycles or tricycles. In 1994/95, 62% of parents with a
child aged 12 or younger reported that their child rode a bicycle or tricycle. The
percentage ranged from 59% in Quebec to 66% in British Columbia. (See Table 24.)
Rural or urban residence had little relationship to bicycle or tricycle use, but differences by household income were notable.
44
Results
Use of bicycle helmets differed depending on where they lived. Nationally, 58%
of parents reported that their child who rode a bicycle or tricycle always wore a helmet,
but the figure varied from 44% in the Prairies to 65% in Ontario and British Columbia.
Use rates were relatively lower in rural areas. Whereas 59% of parents in urban communities reported that their child always wore a helmet, the figure was 34% in rural
areas. Differences in helmet use by household income were also striking. Of children
in the highest income households, 69% wore helmets, compared to 50% or less in the
two lowest income groups. (See Table 24.)
Table 24 – Bicycle* use and helmet use, children aged 12 and younger by region,
rural/urban residence, and household income, Canada, 1994/95
Parents of …
Child 12
and
younger †
Children
use
bicycle
Bicycle
use
rate
Child
always wore
helmet
Helmet
use rate
(000s)
(000s)
% of
population
(000s)
% of
bicycle
users
5,883
3,619
62
2,084
58
Atlantic
463
288
62
168
58
Quebec
1,441
844
59
428
51
Ontario
2,267
1,405
62
912
65
Prairies
990
607
61
268
44
British Columbia
723
474
66
309
65
799
518
65
177
34
2,793
1,684
60
990
59
Lowest
235
119
51
60
50
Lower-middle
819
470
57
204
43
Middle
1,799
1,119
62
602
54
Upper-middle
2,036
1,242
61
786
63
801
534
67
368
69
Total
Region
Rural/Urban ††
Rural
Urban
Household
income ‡‡
Highest
Source: NPHS, 1994/94
* bicycle refers to two- and three-wheelers (tricycle)
† Based on information provided by parents of children aged 12 and younger; does not reflect the
population aged 12 and younger.
†† Rural/Urban does not sum to total because of a category added to ensure confidentiality.
‡‡ Income does not sum to total because of a “not stated” category which is not shown.
45
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
In 1994/95, 1.85 million teenagers aged 12 to 19 were bicycle riders. Cycling
declined from 62% at ages 12 to 14 to 49% at ages 15 to 19. Teenage boys were more
likely than girls to be cyclists. Rates of helmet use among teenagers were much lower
than among children, and fell sharply among older teenagers. At ages 12 to 14, 16% of
cyclists always wore a helmet, but by ages 15 to 19, the percentage was just 8%. Overall,
the rate of helmet use by teenage boys was somewhat higher than that for girls. (See
Table 25.)
Table 25 – Bicycle use and helmet use, among youth aged 12 and older, by sex and
age group, Canada, 1994/95
Age/Sex
Population
Bicycle
users †
Bicycle
rate
Helmet
users ‡
Helmet
use rate
(000s)
(000s)
% of
population
(000s)
% of
bicycle
users
12-14
1,312
820
62
133
16
15-19
2,088
1,029
49
85
8
Total
3,400
1,849
54
218
12
12-14
686
508
74
105
21
15-19
1,082
637
59
42
7
Total
1,771
1,145
65
197
17
12-14
626
312
50
28
9
15-19
1,006
391
39
43
11
Total
1,632
703
43
51
7
Both sexes
Males
Females
Source: NPHS, 1994/95
† Based on respondents who cycled in the past three months.
‡ Bicycle users who always wear a helmet.
46
Results
National Longitudinal Survey of Children and Youth
This survey represents a sharp departure from most other health surveys undertaken in Canada (and, elsewhere, for that matter). With the exception of the NPHS,
most other health surveys are cross-sectional whereas the design of the NLSCY is longitudinal. Through a complex sampling procedure, described in detail in the following
section, it is intended to follow the growth, health, and development of a representative sample of children from infancy to adulthood. In this respect, the NLSCY is similar to the British Birth Cohorts and the U.S. National Longitudinal Survey of Youth, and
is certain to provide equally valuable information.
Survey methodology
To select a representative sample of Canadian children the original target
population (Cycle 1) was children from birth to age 11. The starting point was a household from three possible sources, labelled the Main Component, the Integrated
Component, and the Territories Component. For cycle 1, the main requirement was to
select households with children 0 to 11 years of age. To find such families (about 26%
of all), a link was made to Statistics Canada’s Labour Force Survey. This survey is
conducted monthly and obtains information about all household members from a
representative sample. Households with children that were recently in that sample
served as the basis for the Main Component and from this approximately
12,900 households were selected. As the Labour Force Survey excludes the Yukon and
Northwest Territories, a special “Territories” Component was added. Finally, because
both the NLSCY and the NPHS needed to collect data on the health of Canadian
children, it was decided that a portion of the sample and content of the two surveys
would be integrated for the 10 provinces. Thus, children selected by the NPHS were
part of the sample for both surveys (the Integrated Component).
Once a sample of households was selected, one child in the specified age group
was randomly selected followed by up to four others from the same family. The
sampling procedure was constructed to yield a sufficiently large sample in each of the
provinces to ensure acceptable estimates in each of seven age groups: 0 to 11 months,
ages 1, 2 to 3, 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years. The goal was to permit new
analyses every two years for each of these age cohorts and at the same time to
maintain an emphasis on those younger than age 2.
Most provinces had a sample between 1,000 and 2,000; Quebec and Ontario had
4,000 and 6,000, respectively. In each single-year age group the sample was, likewise,
about 1,800 except for the 0- to 1-year-olds, where the number was 2,227, and the
1- to 2-year-olds, where it was 2,469. At each successive wave, or cycle, those previously in the sample were revisited; newborns were replaced; and, eventually, those
“graduating” will be dropped.
47
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Unfortunately, at the time this report was being completed, the results of the
second cycle were not available for analysis. Consequently, the data reported here are,
in one respect, similar to those from other surveys in this report, while in another
respect they are fundamentally different. They are similar insofar as they describe a
sample of children at a single point in time. The sampling scheme is, however,
basically different because it is not based on a sample of households but rather on
families with children, and the design is clearly longitudinal. Thus, much of the information collected is intended to provide a baseline for information to be collected later
on the same child.
Questions related to injury occurrence were part of a “buy-in” by Health
Canada. The exact wording of the filter used was: “The following questions refer to
injuries, such as a broken bone, bad cut or burn, head injury, poisoning or sprained
ankle, which occurred in the past 12 months, and were serious enough to require
medical attention by a doctor, nurse, or dentist. In the past 12 months was the child
injured?” At a later point, the parent is asked “How many times was he/she (the child)
injured?” and the questions that follow referred to the most serious injury (e.g. what
type of injury did he/she have – broken or fractured bones, burn or scald, etc.?)
The sampling design for the first wave only included children up to age 11 years.
A total of 22,831 children were included in this wave, with 46% between birth and
4 years of age; 38.8% between 5 and 9 years; and 15% ages 10 or 11 years. In part
because of this age distribution, all responses to questions about injury were given by
a proxy respondent. In most cases this was a parent, usually the mother. The weighted
estimates yield a population of over 4.7 million children.
Overview of injuries
Of the 4.7 million children aged 0 to 11, 10.2% experienced at least one injury
during the previous year. This estimate represents about 468,000 children. Among
both boys and girls the injury rate increased with age and in every age group, the
prevalence was higher among boys than among girls. Overall, 11% of boys experienced
an injury compared to 9% of girls. (See Table 26.)
48
Results
Table 26 – Number and percent of children aged 0-11 years injured in the past
year by age and sex, Canada, 1994/95
Age/Sex
Population
(000s)
Number injured
(000s)
% Injured
Both sexes
0-4 years
1,931
166
8.6
5-9 years
1,898
191
10.1
777
111
14.3
4,605
468
10.2
0-4 years
992
96
9.7
5-9 years
963
109
11.3
10-11 years
396
59
14.8
2,352
264
11.2
0-4 years
939
69
7.4
5-9 years
934
83
8.8
10-11 years
380
53
13.9
2,254
204
9.1
10-11 years
Total
Males
Total
Females
Total
Source: National Longitudinal Survey of Children and Youth, 1994/95
The leading types of injury were cuts, scrapes or bruises (40.3%), fractures
(23.7%), sprains or strains (12.3%), and other (7.2%). This pattern is similar to that
found in the other surveys.
Among those children who experienced an injury in the past year, injuries
involving the arms or legs accounted for 45% while the face, head or neck accounted
for another 30%.
Most injuries involved falls (53%), followed by sports (14%). (It is not clear how
a fall during sports would be coded, but these categories are mutually exclusive.)
Notably, only 3% of all injuries were MVA, divided almost equally between passengers,
pedestrians and bicyclists. Also of note, intentional injuries were reportedly rare; 2% of
the total were said to have been assaulted, and a further 1% were intentionally injured
in some other way. In light of the age distribution of the sample, it is not surprising that
most injuries (34%) occurred in the home (data not shown).
49
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Cause of injury by age
In Table 27 the distribution by cause of injury is shown for each of the age
groups. As in all such tables that follow, the figures shown are the percent of children
in each age group whose parents reported an injury during the past 12 months.
Table 27 – External cause of injury among children aged 0-11 years by age group,
Canada, 1994/95
Age group
5-9 years
0-4 years
Number injured (000s)
10-11 years
Total
165
191
111
467
MVA-Passenger
—
—
—
0.8
MVA-Pedestrian
—
—
—
0.5
MVA-Bicyclist
—
—
—
0.7
Other bicyclist
1.4
5.9
3.9
3.8
57.9
47.5
39.0
49.2
Sports
—
13.6
37.7
15.1
Assault
2.2
3.3
—
2.3
Scalds
4.6
—
—
3.0
Fire/Flames
—
—
—
0.2
Accidental poisoning
—
—
—
—
Intentional poisoning
—
—
—
—
Intentional injury
—
—
—
1.4
3.5
3.4
2.1
3.1
Other
21.2
19.6
13.7
18.7
Total
100.0
100.0
100.0
100.0
External cause of injury
Falls
Natural/Environment
Source: National Longitudinal Survey of Children and Youth, 1994/95
— cell size too small to provide a reliable estimate
One noteworthy feature in this table is that there appear to be few strong age
gradients. The only injury showing a definite increase with age is that related to sports;
several others (i.e. pedestrians, falls and poisoning) show an inverse relationship, with
the highest proportion of each occurring among the youngest age group and the
smallest among the older children. There are also some instances where the relationship is curvilinear; the highest rates occurring among the 5- to 9-year-olds. These
include motor vehicle passengers, bicyclists and assaults.
50
Results
Type of injury by age
Using weighted data to examine variations by age group shows some striking
variations for fractures, sprains and strains. These are seen proportionately more often
with increasing age, whereas, for example, the opposite is true for burns and scalds,
and, to a lesser extent for dislocations. (See Table 28). It seems reasonable to assume
that most of these variations can be accounted for by differences in exposure to risk in
these age groups.
Table 28 – Percent distribution of injuries among children aged 0 to 11 years,
type of injury by age group, Canada, 1994/95
0-4
Age group
5-9
165
10-11
Total
191
111
467
12.6
24.9
38.2
23.7
Burn/Scald
7.6
4.2
—
4.6
Dislocation
6.7
1.1
—
2.9
Sprain/Strain
6.1
11.1
23.7
12.3
49.0
40.9
26.6
40.3
Concussion
4.5
4.4
1.7
3.8
Poisoning
0.9
—
—
0.6
—
—
—
0.6
Dental
2.9
4.3
2.3
3.3
Other
9.1
7.1
4.4
7.2
—
—
—
—
100.0
100.0
100.0
100.0
Number injured
Type of injury
Fracture
Cut/Scrape/Bruise
Internal
Multiple
Total
Source: National Longitudinal Survey of Children and Youth, 1994/95
— cell size too small to provide a reliable estimate
Body part by age
In Table 29, the body parts injured are shown by the same age groupings. The
body part grouping has some overlap (e.g. arms/legs vs legs/feet) and this needs to be
kept in mind. Respondents were asked, “For the most serious injury, what type of
injury did he/she have?”
51
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 29 – Percent distribution of injuries among children aged 0-11, by body part
injured, Canada, 1994/95
0-4
Age group
5-9
135
Eyes
10-11
Total
157
100
392
2.2
—
—
1.3
Face
28.6
18.0
6.2
18.7
Head/Neck
22.9
15.5
5.0
15.4
Arms/Hands
24.0
31.6
40.0
31.1
Legs/Feet
15.1
23.8
37.1
24.2
—
—
—
1.5
Trunk
1.0
2.3
—
2.1
Shoulder
4,6
5.9
—
5.1
Hip
—
—
—
—
Multiple sites
—
—
—
—
100.0
100.0
100.0
100.0
Number injured (000s)
Body part
Back/Spine
Total
Source: National Longitudinal Survey of Children and Youth, 1994/95
— cell size too small to provide a reliable estimate
Note: The question relating to the site of the injury was asked only of children who suffered a fracture,
burn or scald, dislocation, sprain or strain, or cut, scrape or bruise.
One striking age-related pattern revealed in the table above is the proportion of
injuries involving the head (including eyes, head and neck). The pattern is strongly
inverse; that is, the younger the child the greater the proportion of all injuries involving
the head. The distribution of injuries among the youngest age group probably reflects
the hazards associated with learning to walk. Among children age 0 to 4 years, about
29% of injuries involved the face and 23% the head or neck. Among those ages 5 to 9,
injuries to the arms or hands accounted for about 32% of all injuries, and among 10to 11-year-olds 40% of injuries were to the arms/hands and 37% to the legs or feet.
Place of injury by age
Table 30 shows the distribution of injuries in each age group according to the
place where the injury reportedly occurred. Again, the reader is cautioned that these
categories do not appear to be mutually exclusive and some arbitrary decisions were
made in the coding.
52
Results
Table 30 – Percent distribution of injuries among children aged 0-11, by age group
and place injury occurred, Canada, 1994/95
0-4
Age group
5-9
10-11
Total
165
191
111
467
Home
57.7
21.5
12.2
32.1
Outside home
16.4
22.4
23.2
20.5
Other private residence
10.0
10.9
3.8
8.9
4.3
18.6
27.0
15.5
—
9.9
19.9
9.2
3.6
3.0
—
2.7
—
4.9
4.5
3.6
Other park or play ground
2.0
3.0
4.0
2.9
Other location
3.3
5.9
4.7
4.7
100.0
100.0
100.0
100.0
Number injured (000s)
Place injury occurred
School/Day care
Sports facility
Other public building
Sidewalk or road
Total
Source: National Longitudinal Survey of Children and Youth, 1994/95
— cell size too small to provide a reliable estimate
The patterns are very largely related to age: the youngest age group having the
greatest proportion of injuries in the home, while outside home, school or neighbourhood are more often seen among older children. This, no doubt, reflects exposure to
risk and little more.
Sociodemographic factors
Figure 1 shows what appears to be a tendency for the rate of injuries to occur
with greater frequency with age. The rate rises sharply from 5% for those 0 to 1 years
old to 14% for the 10- to 11-year-olds. But when these trends are examined in two-year
increments, it seems that after the age of 2 there is little further increase each year. As
noted previously, the age-related patterns are of greater importance than any
age/sex combinations. The generally higher injury rate among boys is consistent with
previous research.
53
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Figure 1 – Percent of children aged 0-11 years,
injured in the past year, by age and sex
20
16
12
Males
Females
8
4
0
0-1
year
2-3
4-5
6-7
8-9 10-11
years years years years years
Age Group
National Longitudinal Survey of Children and Youth 1994-95
Table 31 showing injury rates by province is intriguing.
Table 31 – Number and percent of children aged 0-11, injured in the past year, and
percent distribution of injured children by province, Canada, 1994/95
Province
Population
(000s)
Number
injured
(000s)
% Injured
% Of injured
by province
Newfoundland
89
9
9.7
1.9
Prince Edward Island
23
2
7.5
0.5
Nova Scotia
144
18
12.4
3.1
New Brunswick
115
10
9.0
2.5
Quebec
1,091
102
9.3
23.7
Ontario
1,761
173
9.8
38.2
Manitoba
180
16
9.0
3.9
Saskatchewan
170
19
11.3
3.7
Alberta
470
50
10.7
10.2
British Columbia
562
69
12.3
12.2
4,605
468
10.2
100.0
Canada
Source: National Longitudinal Survey of Children and Youth, 1994/95
54
Results
Bearing in mind that the national average is 10.2%, it is evident that children in
certain provinces, generally those in the west, are injured more often than those in the
east, with the exception of Nova Scotia. Compared with the province with the lowest
rate, Prince Edward Island (7.5%), the rate in British Columbia is 60% higher. It is difficult to explain why this is so but may reflect greater exposure because of climatic conditions, or sharply different provincial prevention policies.
A related, but contrasting finding is that pertaining to rural vs urban differences.
Unlike many of the results pertaining to hospitalizations reported by Hodge and Pless
(1995), in the case of injuries the rate is 10.3% for those in urban areas compared with
9.7% for those in rural areas – essentially identical.
Injury and income adequacy
Table 32 shows no apparent relationship between reported injuries and income
adequacy. This is striking. In fact, unexpectedly, those in families with the lowest
income adequacy actually have a lower proportion with injuries than any of the other
income bracket families. The most likely explanation is that those in higher income
families are more often exposed to risk (e.g. through greater opportunities to participate in sports).
Table 32 – Percent of youth aged 0 to 11 years, injured in the past year by
household income adequacy, Canada, 1994/95
Rank of
household income
Population
(000s)
Number of
injured (000s)
% Injured
in past year
Lowest
120
9
7.2
Lower middle
715
76
10.6
Middle
1,452
151
10.4
Upper middle
1,615
160
9.9
704
73
10.3
Highest
Source: National Longitudinal Survey of Children and Youth, 1994/95
Note: Household income was missing for 68,000 children.
Another social measure often judged to be a risk factor for childhood injury is
single parenthood. In the NLSCY, the rate of injuries for those in two-parent families is
9.8%; for those living with one parent it is 12.2%. Bearing in mind the lack of relationship between income and injury as shown previously, it cannot be concluded that
single parenthood is a proxy or correlate of low income. Other factors must be at work.
55
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Injury and parent education
The same is true for parent education – that is, there is no evidence of the
gradient that might be expected. However, parent education is, of course, highly
correlated with income.
Although the differences are small and likely to be insignificant, it is worth noting that the expected educational gradient is reversed; unlike the results reported by
Wilkins et al. (1990), these figures, like those for income, suggest that rates are higher
in families where the parent is better educated. (See Table 33.) The differences in the
prevalence of injury between the two studies could have been due to the study design
in that the Wilkins study employed an ecological design.
Table 33 – Percent of youth aged 0 to 11 years injured in the past year, by mother’s
education, Canada, 1994/95
Mother’s
education
Population
(000s)
Number of
injured (000s)
% Injured
in past year
Less than high school
755
71
9.4
High school
817
77
9.4
Some post secondary
1,307
140
10.7
College/university
1,719
179
10.4
7
—
—
Not stated
Source: National Longitudinal Survey of Children and Youth, 1994/95
Note: The level of education refers to the person most knowledgeable about the child. In the
majority of cases it was the mother.
Other correlates of injury
Although, as stated, at the time of writing, data from the second wave of the
NLSCY were not available, in time it will be possible to take full advantage of this
powerful longitudinal design. This will permit a thorough examination of predictors or
risk factors for injury in a scientifically acceptable manner. At present, however, the
best that can be done to mine this rich resource is to examine cross-sectional relationships with other variables. It must be emphasized that in doing so we are not testing
hypotheses and, accordingly, no statistical tests are reported. These analyses are basically exploratory or hypothesis generating; nothing more. They are made possible by
the fact that the NLSCY included a large number of questions about other social and
health problems. It was not unreasonable to explore any possible relations between
these and the occurrence of injury.
56
Results
Medication
Perhaps the most direct (i.e. most plausible relationship), is with Attention
Deficit Disorder with Hyperactivity (ADDH). This common problem has often been
shown to be associated with injury occurrence, as has over-activity alone. ADDH is
commonly treated with the drug Ritalin. In the NLSCY population, the parents of 1%
(54,200) of children in the population said that their child was being treated with
Ritalin. Thus, not unexpectedly, the prevalence of injury among those who were taking
this medication was higher (14%) than among those who were not taking it (10%). (See
Table 34.) What cannot be concluded from this is the direction of the effect; that is,
whether the occurrence of injury prompted the diagnosis of ADDH and thus the
prescription for Ritalin, or whether without the use of Ritalin the rate of injury would
be much higher.
A popular misconception is that children with epilepsy are more likely to
experience injuries. As most children with this disorder receive anti-convulsants, the
relationship was examined. Among children who used epilepsy medication, the
prevalence of injury was 18% compared to 10% among children who did not use
epilepsy medication.
The possibility that each of the above represents a reporting bias is raised by
the fact that when the general question was asked, “Does child take any other medication?,” to which nearly 4% of parents said, “yes,” a similar but smaller elevation was
noted for children who had been injured: 13% versus 10%.
Table 34 – Rates of injury among children aged 0-11 years, by the use of selected
medications, Canada, 1994/95
% of children injured
Medication use
Children with
medication
Children who
do not use
medication
Relative
risk
Use of asthma inhalants
15
10
1.50
Use of Ritalin
14
10
1.40
Use of anti-convulsants
18
10
1.80
Use of any other medication
13
10
1.30
Source: National Longitudinal Survey of Children and Youth, 1994/95
Note: Although the survey also asked about the use of tranquilizers, cell counts were too small to
yield reliable estimates.
57
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Diseases
The likelihood of an association between the occurrence of injuries and any
specific disease or condition, with the exception of those listed above, (i.e. ADDH and
epilepsy) is remote. Nevertheless, we explored such possible associations.
The most common of the diseases reported in a general population survey is
allergy of one sort or another. About 14% of the children experienced allergies. Among
those children who had allergies, 14% experienced an injury in the past year compared
to 10% of those children who did not have allergies. A similar difference was seen in the
case of bronchitis. About 3% of children were diagnosed with bronchitis. Among
children with bronchitis, 15% suffered an injury in the past year compared to 10% of
children who did not have bronchitis. (See Table 35.)
For heart condition, the rates are 19 vs 10 (RR 1.9). The lack of any biological or
psychological explanation for these findings suggests they are spurious or due to a
reporting bias.
Table 35 – Rates of injury among children aged 0-11 years, by selected diseases or
conditions, Canada, 1994/95
% of children injured
Disease/Condition
Children with
disease
Children
without
disease
Relative
risk
Allergies
14
10
1.40
Bronchitis
15
10
1.50
Heart condition
19
10
1.90
Learning disability
18
12
1.50
Emotional problems
24
12
2.00
Limited in normal activity
14
10
1.40
Any worry or unhappiness in past year
15
9
1.66
Mental handicap
8
10
0.80
Other conditions
13
10
1.30
Source: National Longitudinal Survey of Children and Youth, 1994/95
Note: The survey also asked about the prevalence of cerebral palsy, epilepsy and kidney disease,
but the cell counts were too small to yield reliable estimates.
58
Results
For those with learning disability or other conditions the rates are again elevated,
with relative risks (RRs) of 1.5 and 1.3, respectively, whereas for those with emotional
problems the elevation is striking, revealing a RR of 2.1. It is difficult to know what to
make of these findings and the reader is again cautioned that as these are observational,
cross-sectional data, no temporal or causal interpretation can be assumed. Nevertheless,
it is possible to speculate that some diseases may be protective if they prompt the child
or parents to be more cautious. Similarly, as in the case of those with emotional problems, many of which are likely to be of the “acting out” variety, including over-activity,
there is some literature that suggests a causal interpretation (i.e. that such children are
more likely to be injured).
The reverse in the case of the many disorders with elevated relative risks in the
range of 1.5 is also plausible; that is, it is possible, but unlikely, that in some cases the
disease may be indirectly the result of an injury. Although not everyone would agree that
all the conditions listed in the table are “diseases.” In the usual sense, assuming the term
applies, it would not be surprising if injuries led to emotional problems, limitations in
normal activities, worries and unhappiness, and possibly even mental handicap.
Limitations of activity
The data from this set of analyses are also used to examine the relationship
between various measures of limitation of activities or disability. Bearing in mind that
these measures are correlated with the diseases described above, whatever the
relationship may be, if any, is likely to be accounted for by the underlying disease
resulting in the disability reported. Overall, 13.7% of children reported to be limited in
their normal activity had been injured in the previous year, compared to 10% of those
who had no such limitations. In this case, however, it is even more likely that the injury
was responsible for the reported limitations in activity.
General health and well-being
A small but interesting gradient is evident when ratings of general health
are considered. Only 8% of children whose health was considered to be excellent
experienced an injury in the past year, compared to 10% among children with very
good health, 12% among those whose health was good or fair and 16% among those
whose health was poor.
Repeated injuries
In the NLSCY, a special set of analyses compared children who were injured
more than once in the past year with those who had no injury or only one. It is likely
that this was prompted by the view still held by some that there are children who are
“accident prone” and that this could be supported if a consistent relationship was
found with other variables.
59
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
As Table 36 indicates, the basic demographics show that for both sexes, 8.6% of
the population had a single injury requiring medical attention while another 1.5% had
more than one such injury. The rate of the latter increased with age, from 1% in the
0 to 4 age group, to 1.2% among youth aged 5 to 9, rising to 3.3% in youth aged 10 to 11
years.
Table 36 – Percentage of youth aged 0-11 years with more than one injury in the
past year, by age, sex and selected characteristics, Canada, 1994/95
Characteristic
Males
Females
Both sexes
0-4 years
1.6
0.5
1.1
5-9 years
1.4
1.1
1.2
10-11 years
3.8
2.3
3.3
Atlantic
2.7
1.3
2.0
Quebec
2.1
0.5
1.3
Ontario
1.7
1.2
1.5
Prairies
1.5
1.1
1.3
British Columbia
2.1
2.2
2.1
Rural
2.0
1.2
1.6
Urban
1.4
0.9
1.1
Less than high school
1.7
1.5
1.5
High school
1.5
1.1
1.1
Some post high school
2.2
1.5
1.5
Two parents
1.7
1.2
1.5
One parent
3.0
0.7
1.8
Lowest/Lower middle
2.4
1.2
1.8
Middle
1.5
0.9
1.2
Upper middle
1.8
1.5
1.7
Highest
2.1
0.7
1.4
Total
Age
Region
Rural/Urban
Education of mother
College/University
Family structure
Household income
Source: National Longitudinal Survey of Children and Youth, 1994/95
60
Results
These data suggest some tantalizing hypotheses but prove little. Apart from the
powerful effect of age, and the expected higher repeat injury rates among boys, there
are higher rates in the Atlantic Provinces and British Columbia; for those in rural areas,
and no clear trends with parental status or education. In the absence of information
about personality or emotional status, the “accident-prone” issue could not be
explored further.
Health Promotion Survey (HPS)
This survey, which took place in 1990, involved only youth 15 to 19 years.
Respondents were asked to describe many health-promoting behaviours, several of
which relate to injury prevention. The sample comprised 1,010 respondents aged 15
to 19.
The profile of the weighted sample, representing nearly 2 million youth
(n=1,842,253) is as follows: 51.2% were males, 24.1% were residents of Quebec, 36.5%
residents of Ontario, and 11.2% residents of British Columbia. The other provinces
account for an average of 3% to 4% each.
The income quartile of over one half (52.6%) of the respondents was not known.
Most of the remainder were “lower middle”, (26.3%), followed by lowest (13.2%), with
8% falling into the “upper middle” or highest income quartiles. The frequency of
various self-reported health behaviours for male and female adolescents are shown in
Table 37.
To assess safety in the home, respondents were asked “Do you have the following in your home: a first aid kit, a smoke detector, a fire extinguisher?” The survey also
asked respondents “Do you have a household member trained in first aid?”
Respondents were asked about their driving behaviour: “How often do you wear
seatbelts when your ride in a car?” Response options were always, most of the time,
sometimes, rarely and never. With regard to the use of alcohol while driving, a question
was asked, “In the past 12 months, how many times have you driven within two hours
after drinking any amount of alcohol?” Safety on snowmobiles was assessed by asking
respondents “Have you driven an all-terrain vehicle (ATV) or snowmobile in the last
12 months?” If the response was yes, respondents were asked “How often do you use
seatbelts when you ride in a car?” Again, the response options were always, most of the
time, sometimes, rarely or never.
61
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 37 – Injury prevention behaviours, among youth aged 15-19 years,
by sex, Canada, 1990
Preventive measure
Population
(000s)
Number
who report
yes
(000s)
% Who
report
yes
Both sexes
Has smoke alarm in house
1,842
1,600
87
Has fire extinguisher in house
1,842
1,117
61
Has first aid kit in house
1,842
1,207
66
Someone in house is trained in first aid
1,842
1,082
59
1,842
1,245
68
1,227
1,070
87
1,842
769
42
763
445
58
Has smoke alarm in house
944
858
91
Has fire extinguisher in house
944
595
63
Has first aid kit in house
944
627
66
Someone in house is trained in first aid
944
544
58
Always uses seatbelt when driving
944
607
64
Did not drive within two hours of drinking 1
682
568
83
ATV /snowmobile use in past year
944
509
54
Wore helmet on ATV or snowmobile 2
503
314
62
Has smoke alarm in house
899
742
83
Has fire extinguisher in house
899
521
58
Has first aid kit in house
899
580
65
Someone in house is trained in first aid
899
538
60
899
638
71
545
503
92
899
260
29
260
131
50
Always uses seatbelt when driving
Did not drive within two hours of drinking
1
ATV /snowmobile use in past year
Wore helmet on ATV or snowmobile
2
Males
Females
Always uses seatbelt when driving
Did not drive within two hours of drinking
1
ATV /snowmobile use in past year
Wore helmet on ATV or snowmobile
2
Source: Health Promotion Survey, 1990
Notes: 1. Based on youth who had a driver’s licence
2. Based on youth who used an ATV or snowmobile in the past year.
62
Results
Several points in these data merit comment. First, as self-reports, it must be
assumed that these are somewhat exaggerated estimates. Despite this, they tell a
cautionary tale. Perhaps surprisingly, the message that appears to have sunk in most is
that pertaining to drinking and driving! Only (13%) admitted to having driven in the
last 30 days within 2 hours of having an alcoholic drink. Not surprisingly, this proportion was much higher among young men (17%) than young women (8%). On the other
hand, the percentage reporting that they “always” used a seat belt was disappointing –
only 68% overall. The figure for men (64%) was lower than that for women (71%) and
these rates are actually lower than some recent observational surveys suggest. The
combination of low seat belt use and inexperience puts these drivers at higher risk.
In light of these findings, it was not surprising to find that among those youth
who rode on an all-terrain vehicle or snowmobile in the last year, only 58% stated that
they always wore helmets. Unexpectedly, this figure was lower for girls (50%) than boys
(62%). Perhaps the girls are more often passengers and thus feel less exposed to risk.
Two questions addressed fires and burns. The first asked if there was a smoke
alarm in the home and nearly 87% said there was – somewhat higher in men’s homes
than women’s. The second asked about a fire extinguisher and one was reportedly
available in 61% of homes.
There were also two questions about first aid: 66% of respondents said their
home had a first aid kit but more importantly, only 59% said that somebody in the
household was trained in first aid. Surprisingly perhaps, the percentage was higher for
females (60%) than for males (58%).
Discussion (Prepared by Barry Pless)
Most of the national surveys described in this report were sponsored by various
branches in Health Canada (previously, Health and Welfare Canada), and conducted
by Statistics Canada. Similarly, the provincial surveys tend to have been sponsored by
Departments or Ministries of Health and the data collected by these same departments. In light of largely health department sponsorship, at both the national and
provincial level, it is unfortunate that so little attention has been paid to the injury
problem. It suggests that health departments, federal and provincial, still have difficulty accepting that injuries are every bit as much a health problem as drug taking,
AIDS or various infectious diseases.
63
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
What have we learned?
The surveys covered in this report provide a picture of childhood injury in
Canada that is unlike that available from any other source. Of the alternatives, the
most similar is the result provided by Canadian Hospitals Injury Reporting and
Prevention Program (CHIRPP) – a collaboration project between Health Canada and
16 hospital emergency departments which collects and analyses information on the
circumstances of injuries (Health and Welfare Canada, 1993; Mackenzie and Pless,
1999). Although this surveillance system, covering all children’s hospitals (and several
others) provides far more contextual and demographic information than either of the
main alternatives, vital statistics data and those from hospital discharges, it is fundamentally different in one important respect. The difference lies in the extent to which
the data are representative of all injured children. CHIRPP data only reflect injuries
treated in children’s hospital emergency departments and those at six other hospitals.
These may differ from those treated in general hospitals, as well as those treated in
other settings such as private offices or community clinics. The CHIRPP data certainly
differ from those pertaining to injuries that were never seen or treated by a physician.
Despite the important advantage that survey data provide with respect to their
representativeness and the opportunity to relate injuries to other data obtained in the
same survey, it is apparent that each of the surveys covered by this report has major
limitations. As will be argued later, it should be evident that much can be learned from
a national, purpose-built survey of childhood injuries.
Despite this need, the surveys described in this report cannot be dismissed.
They provide valuable information that should be used immediately to influence
future preventive activities.
To summarize, Table 39 gives the main findings from each of the surveys used in
this report.
64
Results
Table 39 – Summary of survey characteristics, injury estimates, selected surveys,
Canada, 1990, 1993 and 1994/95
HPS*
GSS**
NPHS
NLSCY
1990
1993
1994/95
1994/95
15 to 19
0 to 14
12 to 19
0 to 11
Size of sample
1,010
2,946
1,847
22,831
Population
1,814
5,773
3,372
4,673
Total injured
N/A
559
971
468
Injury rate (%)
N/A
10
28.8
10.2
Main site
N/A
Home
Recreation
day care
Home, school
Main injury
N/A
Cut, scrape
sprain, strain
Cut, scrape
Main type
N/A
Fall
Fall
Fall
Year
Age group
(Note: All are household surveys
* HPS did not ask about injury in the past year; injury questions did not provide estimates of
prevalence but only to preventive behaviour.)
** GSS included an estimated 5.7 million children under 15 of whom 559,000 were seen by a doctor
for poisoning or injury.
The first message is that no matter which survey data are used, at least 10% of
Canadian children are injured each year and that this represents, in raw numbers,
nearly 500,000 children. Second, the greatly increased rate of injury among adolescents is striking and important because this age group often falls between the gaps; too
old for pediatricians and too young for internists or family doctors. Third, although
many injuries are not severe (cuts, scrapes, sprains and strains), most require medical
care and thus expense, and a significant proportion are much more serious. Third, the
main type or mechanism of injury is a fall. More attention needs to be given to how
these injuries can be prevented, along the lines of the recently conducted playground
studies in Quebec. (Lesage et al. 1995). Finally, the home and recreational sites being
the main place of occurrence, preventive strategies need to be focussed on methods by
which both can be effectively made safer, with preference, perhaps, to new regulatory
mechanisms.
We also know a great deal from a wide variety of other studies. Many of these are
population-based surveys, while others are ad hoc studies. An attempt to summarize
their principal features and main results is shown in Tables 1 and 2 in the Appendix. It
should be noted, once again, that this is neither exhaustive nor as up-to-date as we
would like. Nonetheless, it provides a good opportunity to learn from the findings of
others.
65
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
In general, a number of basic messages are shown repeatedly. They include the
magnitude of the injury problem; the dominance of certain sub-groups defined by age,
sex and other characteristics; the possibly important role of behaviour and temperament; the dangers associated with certain environmental situations (day care, work
conditions, etc.). These are but a few examples of what has been learned from the work
of others. The survey data are generally less focussed on specific questions, but have
the great advantage of being, by definition, population-based. In contrast, the ad hoc
studies are rarely population-based but provide, because of the purpose-built designs,
results of great value. The most sensible way to approach these diverse sources of
information about childhood injuries is to view them as complementary.
What more do we need to know?
Much more needs to be learned about childhood injuries (or injuries in any age
group, for that matter) in order to plan and implement the most effective prevention
programs. By far the most important set of data that are needed are those that help
estimate exposure to risk for each of the major causes of injury. Only with such information can the role of other risk factors be clearly determined. For example, the
pervasive sex difference is most likely to represent differences in exposure to risk
between boys and girls. But if this is not so – if, for example, boys are no more likely to
ride bicycles than girls and nevertheless experience more injuries – this is a vitally
important piece of information.
The example above reveals the challenge in measuring exposure to risk. In the
first place, although the difference is a subtle one, it is nevertheless important to
acknowledge that the extent to which an activity is engaged in is not necessarily the
same as the extent to which the child is exposed to risk. For example, while street
crossings may be the best possible easily obtained measure of risk for pedestrian
injury, it has been persuasively argued that actual risk in this situation is present only
when the child or driver must take certain actions to avoid injury. Despite this important distinction, data on hours (or days) of activity are an essential first step toward
measuring exposure.
The difficulty arises in having a metric similar to streets crossed for other risky
situations such as exposure to hot water, flames or drowning. Nonetheless, should
a major survey of child injury be launched, much attention must be given to this
too-often neglected, but extremely important component.
Another often missing item of information is the extent of supervision provided.
This, too, is far from easy to remedy but if we are ever to resolve the debate about how
much can reasonably be expected from enhanced supervision, we must do our best to
obtain such information.
66
Results
Certainly, some means of obtaining a better understanding of the dangers in the
child’s environment, both within the home and in the neighbourhood, must be found
and incorporated into future surveys. The ecological fallacy is well known and emerges
often in national surveys. This is the assumption that characteristics of, say, the census
tract in which the child lives apply to the individual family. To remedy errors arising
from this fallacy, more direct information about the environment must be obtained.
To accomplish all of this, or even a large part of it, serious consideration must
be given to the creation of a national survey focussed exclusively on child injury. The
precedent clearly exists for such a survey, and the problem of injury is of much greater
magnitude than that of drugs, for example, to which much attention has been paid in
recent years.
What needs to be done?
As deficient as the survey data we now have may be, and as important as more
and better surveys may be, what needs to be done to diminish the number and severity
of childhood injuries is to make more effective use of existing information. Inaction at
the program or policy level cannot be excused by the argument that the data are insufficient. Certainly, any argument that Canada must first replicate studies or surveys
from other countries before it take action, is unacceptable. On the other hand, it is
equally unacceptable to assume that as long as a neighbouring country such as the
United States continues to obtain child injury data, there is no need for Canada to
do so.
Ideally, national surveys should be both complementary – adding to what
others provide – and confirmatory – replicating what others have found. Striking the
balance between the two will not be easy. But the fact remains that sufficient information is now available from surveys and other observational and occasionally experimental designs to provide a solid basis for action.
The decision to take that action is a matter of political will in most instances,
whether the level at which programs are needed are national, provincial or local. That
will should be heavily moved by the data from the surveys reported here that clearly
show the extent of morbidity related to injury in childhood. The level of morbidity far
exceeds that arising from many other childhood disorders to which far more attention
has been paid in the past. That attention is expressed in terms of funds available
for research, for prevention programs, and in terms of willingness to make tough
decisions that may not always have popular support.
67
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
An example of the latter is bicycle helmet legislation. As a by-product of this
initiative, Dr. Millar and I examined in greater detail the frequency of head injury,
bicycle and helmet use, (Millar & Pless, 1997). In doing so, we also obtained data from
each of the provinces about legislation. At the time of writing, only two provinces in
Canada require child bicyclists to be helmeted. This is surprising, to say the least,
in light of the abundant evidence from part of the United States and Australia, for
example, showing the efficacy and effectiveness of helmets in reducing head injuries
among child bicyclists.
In the end, much of what needs to be done will be an uphill struggle unless and
until health departments accept responsibility for the implications of these findings.
Until the health community gives major priority to this significant health issue,
children will continue to be injured at these alarming rates.
68
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83
Appendix
Table 1 – Population-based Surveys: National or State/Provincial
Ref. No*
Author
Source
Site
N
Age
Key Results
Bijur, PE (1986)
British Birth Cohort
Britain
11,966
0-5 years
Aggression and over-activity independently
associated with injuries
51
Landman, PF (1987)
Telephone survey to
day care centers
Maryland
18,728
children
2-6 years
Yearly injury rate of 11.3%; no reduction in
injury rates in licensed day care
96,97
Smith, GA (1995, 1996) National Electronic
USA
Injury Surveillance
System (US Consumer
Product Safety
Commission [PSC]
75,200
<15 years
shopping
cartrelated
injuries
Children <5 yrs at highest risk (20%
greater); mostly head and neck injuries,
important cause of morbidity for under
5 age group
78,81
Rivara, FP (1985, 1997) US NCHS Mortality
Multiple Cause of
Death tapes
(1991-1993),
CPSC National
Electronic Injury
Surveillance System
(1990-1993) (NEISS)
USA
<19 years
Child farm injury deaths down but ED
injuries up, farm injuries are a major
problem
49
Kopjar, B (1996)
Norway
Approximately
100,000
Incidence of unintentional home injury
highest among preschoolers (51 per 1,000)
not accounted for by awake time at home
85
5
*See Primary Reference List
Prospective, ongoing
injury registration
system
Ref. No*
Author
Source
Site
N
Age
Key Results
86
105
Waller, AE (1993)
Health Statistical
Services
New
Zealand
634
0-14
years
47
Klauber, MR (1986)
Random digit-dialing
telephone survey
San Diego
1,213
<14 years Education is positively associated with
poisoning, and income is negatively
associated with burns; children of
caretakers working outside the home do
not have higher rates than others, few
differences in caretaker attitudes – may
reflect having had an injury, rather than
factors preceding it.
6
Bijur, PE (1995)
Child Health
Supplement, NHIS
(1988)
USA
11,840
5-17
years
Sports account for 36% of total injuries
59
MacKeller, A (1995)
Australian Bureau of
Statistics
Western
Australia
462
0-14
years
Mortality rates highest for motor vehicle
accidents (5.1); drowning (2.9) mortality of
Aboriginal children nearly 4 times greater
than non-Aboriginals
63,64
Mercier, C (1995, 1996) Admissions to
hospital burn units
and pediatric surgery
units
France
687
0-5
Boys (59.3%) <36 months burned in kitchen
(62.4%) with hot fluids (73%) or bathroom
(16.2%) by tap water. Flame burns (8.7%)
from flammable products
98
Sosin, DM (1996)
USA
603
injuries
0-14
Most frequent cause was a fall, followed by
an MVA and adverse effects of drugs and
biologics
*See Primary Reference List
National Health
Interview Survey
Children more likely to die in house fires
than any other thermal injury event; 2/3 of
hospitalizations are due to hot water, rates
for children are higher than overseas
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 1 – Population-based Surveys: National or State/Provincial (cont’d)
Table 1 – Population-based Surveys: National or State/Provincial (cont’d)
Ref. No*
Author
Source
Site
N
11
Brown, EM (1994)
Ontario Health
Survey (1990)
Ontario
60,972
12
Bussing, R (1996)
National Health
Interview Survey
(1988)
USA
11,630
24
DuRant, RH (1997)
Massachusetts Youth
Risk Behavior Survey
27
Fraser, JJ Jr (1996)
31
48
Age
Key Results
20% had one or more visits to emergency
department in past 12 months; subgroups
with increased emergency department use
after adjustment
Massachu- 3,054
setts
High
school
students
Weapon carrying at school more strongly
associated with violence and use of
substances. A subgroup of students have
been victimized at school
Child Health
Supplement of the
National Health
Interview Survey
(1988)
USA
7,470
10-17
years
Most frequent in older adolescents, males,
whites and in Midwest. Most were cuts,
sprains, strains and broken bones, head
injuries. Injury is an important factor in
morbidity
Harel, Y (1994)
Child Health
Supplement of the
National Health
Interview Survey
(1998)
USA
17,110
0-17
years
Varying recall periods affect epidemiology.
Recall 1 and 3 mos recommended
Kogan, MD (1995)
Longitudinal Follow- USA
up (1991) to the
National Maternal and
Infant Health Survey
8,145
0-3
years
Preschool-age present different
pattern of fatal vs injuries
*See Primary Reference List
Appendix
Rates higher in white than African-American
or Hispanic children, behavioural problems
risk for unintentional injuries among three
ethnic groups; prevention strategies should
target behavioural disorders
87
0-14
Ref. No*
Author
Source
Site
N
Age
Key Results
Li, G (1996)
Nationwide Personal
Transportation
Survey, National
Center for Health
Statistics
USA
2,333
0-14
years
Males higher death rate from bicycling than
females, a greater exposure and case fatality
4
Bijur, P (1988)
British Birth Cohort
Britain
10,394
5-10
years
Boys’ behaviour at 5 strongly predictive of
injuries subsequent 5 years than girls’
behaviour;
The odds of injuries resulting in
hospitalization in boys with high aggression
scores 2.4 times that of boys with low scores
52
Larson, CP (1988)
Telephone interviews
re injury histories
Montreal
918
children
0-3
years
Three maternal factors (single, unemployed,
smoking), and absence of younger sibling
increase risk from 20% to 60%
82
Roberts, IG (1994)
New Zealand
Household Travel
Survey
New
Zealand
56
Li, G (1995)
National Pediatric
Trauma Registry
USA
43
Jolly, DL (1993)
National Injury
Surveillance Unit
data
Melbourne,
Brisbane
88
57
*See Primary Reference List
Road crossings greater for girls;
pedestrian exposure increases with age;
5-9 yr-olds, lowest income bracket, cross
50% more roads;
sex difference injury rates not explained by
differences in exposure
2,333
patients
0-14
years
54% of bicycle accidents head injury;
mental disorders, no helmet; increased risk;
high-risk groups
Low-income area significant. Predictor
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 1 – Population-based Surveys: National or State/Provincial (cont’d)
Table 1 – Population-based Surveys: National or State/Provincial (cont’d)
Ref. No*
Author
Source
Site
N
Age
Key Results
108
Williams, BC (1990)
National Center for
Health Statistics,
WHO
USA,
Canada,
England,
Wales,
France,
Netherlands,
Norway
Mortality increasing only in USA (MVA &
homicide);
excess mortality < 5 yrs and > 14 yrs;
behavioural strategies inadequate
94
Sellar, C (1991)
Hospital inpatient
records
Oxford
Regional
Health
Authority
19,427
children
91
Schappert, SM (1997)
National Hospital
Ambulatory Medical
Care Survey (1992)
USA
36,271
patient
visits
357 visits per 1,000 persons
1/3 visits injury related (falls)
103
Swigonski, NL (1995)
National Maternal and USA
Infant Health Survey
(1988)
10,868
mothers
Adequacy of prenatal care not predictive of
injury
92
Scheidt, PC (1995)
Child Health
Supplement, NHIS
(1988)
17,110
children
2,772
injuries
<5 years
at time
of first
admission
89
USA
0-17
years
Number more than one accident greater
than expected if accidents random;
at one yr follow-up, 4-5 yr-olds were
least likely and < 1 yr-olds most likely to
have further admissions
Injury rate: 27 per 100 children (adjusted
to 1 mo. recall);
adolescents highest;
25% had medically attended injury
each yr
*See Primary Reference List
Appendix
Ref. No*
Author
Source
Site
N
Age
90
61
Malek, M (1991)
1) Massachusetts
Statewide Childhood
Injury Prevention
Project and 2) Health
Data Institute
58
Lowry, R (1996)
Youth Risk Behaviour USA
Survey supplement to
NHIS (1992)
6,321
12-17
years
63% of adolescents reported 2-5 risk
behaviours
2
Baker, SP (1994)
Consumer Product
Safety Commission,
hospital surveillance
58,480
head
injuries
< 25
years
Large number and high rate of head
injuries, multipurpose helmets valuable
Nowjack-Raymer,
RE (1996)
Child Health
Supplement, NHIS
(1991)
USA
Bijur, PE (1996)
British Birth Cohort
Britain
1915 case- 0-17
control
years
pairs
Cognitive deficits associated with multiple
mild head injury due to social and personal
factors
Schober, SE (1988)
Workers’
compensation claims
to Supplementary
Data System of
Bureau of Labor
Statistics
24 states
23,823
claims
Injury rates 16-17 yrs: 12.6 males,
6.6 females per 100 full-time employees;
not adequate protection
69
7
93
*See Primary Reference List
Massachu- 1) 87,000 0-19
setts
children years
Key Results
Mean hospital. Cost $5,094, ED care $171;
cost increases with age
Football only sport where majority used
mouthguards and headgear;
differences in use not consistent across
sports;
multifaceted initiatives needed
< 18
years
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 1 – Population-based Surveys: National or State/Provincial
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Ref. No*
Author
Source
Site
N
Age
Key Results
Kendrick, D (1993)
Hospital admissions
Nottingham
Health
District
342 pairs < 5 yrs
44
Jordan, EA (1993)
Home interviews
Baltimore
MD
363
children
(68 exp
inj)
97
Smith, GA (1996)
Emergency dept.
records
62 children 4 months
– 10 years
Falling out of cart (58%), cart tip-overs
(26%); cart tip-overs most frequent in < 1 yr
68
Mott, A (1994)
A&E dept. records
Cardiff
178
children
Mean 7.5 yrs; 105 fell from equipment;
125 surface injuries; high fracture rate on
modern park playgrounds
30
Hahn, YS (1988)
Hospital admission
for head injuries
Chicago
738 head 0-16
injuries years
43.1% of patients were < 3 yrs; mostly falls
28
Gofin, R (1993)
Primary care clinics –
forms filled out by
physicians
0-15
years
62
McLoughlin, E (1990)
89
Sarhadi, NS (1995)
91
46
3 months, Children of mothers with home safety
15 months information by 3 mos had lower risk of
injury
Differences between lower and middle class
neighbourhoods in rate of injury; place of
treatment; referral to hospital
USA
1,461
deaths
Scotland
51,530
inpatients
0-19
years
“Cost of burn injury” approx. $3.5 billion;
47% killed in house fires 0-4 yrs;
need solutions to “kitchen” scald and
gasoline burns
Burn rates highest in < 15 yr-olds (43.7%);
pattern of admission changed; fall in
admissions in ages
Appendix
*See Primary Reference List
Hospital inpatient
records
Injuries at A&E dept predict admissions
Ref. No*
Author
Source
Hu, X (1993)
Emergency room
injury surveillance
program
67
Morrow, SE (1996)
Hospital records of
burn victims
34
Heaton, PA (1996)
A&E dept. records
40
Hu, X (1997)
80
Age
Key Results
0.18
years
Falls most common (51%);
hazards in child’s psychological and
motor development
449
patients
< 16
years
Burn type, size and mortality rate did not
differ between urban and rural children;
Mortality: burn size, < 4 yr, inhalation
New
Zealand
372
patients
< 15
years
58% male, 66% preschoolers; burns
significant statistical difference. Morbidity;
tap water scalds severe and preventable
Hospital discharge
records and coroner’s
records
Metro
Toronto
11,024
non-fatal
injuries,
133 fatal
injuries
Rivara, FP (1993)
Hospital discharges
Washington
74
Pegg, SP (1978)
Hospital records
Brisbane
17
Christoffel, KK (1993)
USA
71
Parker, DL (1994)
Cross-sectional
survey
*See Primary Reference List
Metro
Toronto
N
1,538
patients
92
37
Site
Falls leading cause of non-fatal injury;
international leading cause fatal;
non-fatal and fatal rates dropped over 6 yrs;
MVA and drownings increased
< 19
years
382
burns
Falls nearly 33% admissions, patients
younger; 25% of fatal & 42% of preschoolers
sustained head injury; annual
Burns disproportionate. Common in
children; 70% normal active children
< 4 yrs
Leading causes of injury deaths for US
adolescents are MVA and homicide
Minnesota 3,051
10th-12th Females: rural 12, urban 13 per 100,000 hrs
graders
worked. Males: rural 20, urban 16 per
100,000 hrs worked; ongoing medical
problems; 26% injured workers; previous
estimates of adolescent work-related injury
may be low
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Ref. No*
90
Author
Source
Site
N
Age
Key Results
Sceats, J (1989)
A&E dept. records
Waikato –
New
Zealand
Australia
50,000
< 15
years
Attendance rates for injury highest for
infants, then 10-14 yrs; very high rate
attendance Maori infants; falls for
< 10 yrs, sports 10-14 yrs
Watkins, J (1996)
Retrospective study
injuries treated at
sports injuries clinic
London
394
injuries
5-17
years
45.2% females, peak females 13-14 yrs,
males 15-16 y rs; 50% acute, 49.5% chronic
1
Backx, FJ (1989)
Questionnaires to
students, large scale,
population-based
survey
Holland
7,468
students
791
injuries
8-17
years
Injury rate: organized sports (62%), phys ed
classes (21%), unsupervised (17%); highest
rates basketball, field hockey; high risk
group: 15-16 yr-old boys, high sports
activity index, played mainly contact team
sports
8
Boyce, WT (1989)
Recurrent injuries in
school district
population,
prospective
surveillance system
California
54,874
6-18
students, years
573 recurrent
injuries
Small group sustain disproportionate % of
injury; majority experience transient
periods of enhanced risk
88
Santer, LJ (1991)
Interviews with care
givers, medically
indigent urban
children
Chicago
133
Need for prevention focussed on
low-income urban families
54
Leland, NL (1994)
Record review of
injury logs in day
care programs
95
Simon, PA (1994)
Hospital discharge
data and burn unit
admission logs
106
93
Children with disabilities higher rates
Denver
122
< 5 years
Developmental stage important determinant of risk and type of burn; 6 mos –
2 yrs at increased risk of severe burn
Appendix
*See Primary Reference List
< 6 years
Ref. No*
Author
Source
Site
USA
N
Age
Key Results
Briss, PA (1994)
Interviews with
directors of day care
centres
138,404
Most injuries (51%) on the playground;
day care centre rates relatively low and
many minor
41
Jaquess, DL (1994)
Parent questionnaires
and reports
50
Children with behaviour problems may be
predisposed to injuries; behaviour change
strategies to reduce injury risk and target
children for prevention
16
Chang, A (1989)
Injury incidents in
day care centres
(Los Angeles Unified
School District)
Los
Angeles
423
< 5 years
Relative risk boys and girls was 1.5:1;
younger boys highest rate and older girls
lowest; the majority minor; medical
attention in only 12.8%; 75% preventable
20
Davidson, LL (1988)
Hospital records
UK
951
5-8 years
Increased risk for boys and discipline
problems; predicted relationships between
overactive behaviour; decreased concentration and rate not found
50
Kotch, JB (1993)
Hospital records
New
Zealand
< 5 years
528 hospitalized injuries involving playground equipment, 145 day care injuries;
home and day care injuries of equipment
differences
75
Peterson, L (1993)
Interviews with
mothers and children
USA
14
Carter, YH (1993)
General practice who
presented at hospital
North
Staffordshire
94
10
*See Primary Reference List
Children report more injuries than mothers;
children recalled far fewer and mothers
recalled slightly; fewer events than reported
in biweekly interviews; fewer near injury
than actual injury events reported
511
children
< 5 years
Most fall (56%) at home (79%); younger
mothers more likely to have sibling injured
the previous year; doubt value of safety
equipment and knowledge alone in
prevention
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Ref. No*
Author
Source
Site
N
Age
Key Results
95
76
Price, JH (1997)
Pediatric residence
programs
USA
209
Fewer than half believed firearm issues
should have high priority in residence
programs
83
Ruch-Ross, HS (1993)
Questionnaires to
pediatricians
USA
1,201
80% of pediatricians who provide health
supervision discuss helmet use; most
important predictor of helmet counselling
was experience with injured children
23
Dunne, RG (1992)
Street-crossing and
vocabulary tests
administered to
parents
25
Evans, SA (1997)
Postal survey
Lanarkshire
Health
Board area
39
Hu, X (1996)
Telephone survey
Metro
1,516
Toronto
and Barrie
63,64
Mercier, C (1995, 1996) Hospital admissions
France
to burn units and
pediatric surgery units
937
Typical burn patient boy (61.6%), 2 yrs,
scald burn (64.1%) in kitchen (56.2%)
26
Finvers, KA (1996)
CHIRPP
699
3-16 years Risk of head injury significantly greater
when helmet not worn
107
Weiss, BD (1986)
Observation of
students arriving at
schools
468
University bicyclists wear helmets more
often than younger bicyclists
Parents’ expectations for their children’s
pedestrian skills are least accurate for 5 and
6 yr-olds; mismatch decreases with age;
inaccurate expectations may be target for
prevention
3 years
Differences injury experience of children
from more and less affluent backgrounds
not due to differences in parental attitude,
knowledge, or practice of home safety
Parents aware of childhood injury; need to
be educated about specific risks
Appendix
*See Primary Reference List
5-10
years
Ref. No*
Author
Source
Johnston, C (1994)
Police-reported car
crashes
22
Dickson, DG (1997)
Regular visits of data
collectors to physicians,
dentists, and hospitals
78
Rivara, FP (1985)
Census tracts
Injury statistics
70
Overpeck, MD (1995)
73
Paulson, JA (1988)
N
USA
Memphis
210
injuries
Age
3
86
Greater involvement in care crashes and less
use of restraints explains the 64% higher
rate of injury for 3 yr-olds than for infants
< 7 yrs
Annual rate of 124 per 1,000 children under
7 yrs; two or more injuries 10%; highest
rate 2 yr-olds; 2 yr-old boys 75% higher
than other age/sex group
0-14
years
Injured child most often: male, age 7.
3 yrs; crossing between intersections,
2-7 PM; census tracts with injuries twice the
% of nonwhite population, lower incomes,
more children in female-headed
households, below poverty level, greater
crowding
For children without medical coverage, 30%
of all injuries and 40% of serious injuries
may not be attended by MD
USA
Banco, L (1994)
Chart review of first
Hartford
visits of burn patients Connecticut
Samuels, RH (1996)
Survey of orthodontic UK and
practitioners
Eire
*See Primary Reference List
Key Results
0-14
years
96
42
Site
Adolescent
109 visits < 18
years
Leading cause of death; road most
dangerous environment; alcohol/drugs
contrib. factors; schools – nonfatal sports
injuries; home – adolescent, injuries less
common; Farm – understudies
Contact burns, scalds, flames/explosion,
cigarettes, electrical; contact burns higher
for < 11 yrs
Injuries due to orthodontic face-blows
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Ref. No*
Author
Source
Site
87
Samuels, RH (1996)
Questionnaires to
dental practitioners
UK and
Eire
38
Hu, X (1995)
Random digit dialing
telephone survey and
analysis of hospital
discharge records
Metro
Toronto
Williams, JM (1997)
Self-complete
questionnaire school
survey
Scotland
77
Ray, JG (1995)
Retrospective chart
review of inpatient
burn cases
19
Currie, CE (1996)
Self-completed
questionnaire in
schools
9
Brison, RJ (1988)
Collision fatalities
Washingrecords (State death
ton
certificates, coroners’
reports, police records)
Ruta, D (1993)
A&E dept. records
109
97
84
Age
1117
respondents,
859 users
Key Results
33 injuries with orthodontic face-blows
5-17
years
Boys higher rates (8.1 vs. 3.4 per 100,000);
bicycle-related injuries associated more
with exposure than distance ridden
4,710
11, 13,
15 years
Socio-economic status affects injury events
and risk behaviour
Hamilton,
Ontario
50
patients
< 5 years
2/3 consumption or prep of food or hot
liquids, 1/3 flame burns or bath tub scalds;
significant difference in surface area and
days spent in the BTU to agent involved;
infants and toddlers disproportionate burn
victims
Scotland
4,710
11, 13,
15 years
41.9% reported medically attended injury;
1/3 moderate or severe; incidence and
distribution consistent with estimates
based on other data sources
< 5 years
Factors in collision age dependent;
pedestrian fatality < 5 yrs occur when
child backed over in the driveway
Aberdeen,
Scotland
91 cases
24.4% all nonfatal injuries sustained by
passenger prevented if all children
restrained; 49.5% of head injuries and 48.4%
of face injuries preventable
Appendix
*See Primary Reference List
N
Ref. No*
Author
Source
Site
N
Age
98
36
Holloway, M (1994)
Hospital records
Ranwick,
49
New South children
Wales,
Australia
21
Davis, JM (1993)
Trauma registry and
retrospective chart
review
Boston
142
patients
Serious sports injuries in ED mostly male
teenagers, fractures of extremities
35
Hijar-Medina,
MC (1995)
Hospital records
Mexico
City
350 casecontrol
pairs
Protective effect on severity when mother
worked outside home; no differences in sex
and age; mother < 24 yrs and low schooling
significant risk of major injuries
29
Gunn, WJ (1991)
National telephone
survey
USA
171
poisonings
No poisonings during out-of-home child
care; out-of-home child care no increased
risk of injury (maybe lower risk)
55
Lesage,D. (1995)
Playground survey
254 playgrounds
Montreal
53
Layne, LA (1994)
Emergency
dept. records
National
sample of
emergency
depts.
37,405
occupational
injuries
85
Sacks, JJ (1989)
Injury reports from
day care centres
Atlanta
5,300
(143
injuries)
*See Primary Reference List
1 mo. –
8 years
Key Results
Retinal hemorrhage and unconsciousness
on admission were with poor outcome;
cerebral edema associated with severe
motor disability; lowest SES was risk factor
One of two pieces of playground equipment
was installed on protective surfaces that did
not conform to Canadian standards
14-17
years
Injury rate: 7.0 males, 4.4 females per 100
(full-time employees); lacerations to hand
or finger; majority in retail trade
(e.g. restaurants)
1.77 injuries per 100,000 child hours in day
care; lowest rate in infants, highest rate in
2 yr-olds 33% of falls on playground
Unintentional Injuries in Childhood: Results from Canadian Health Surveys
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Table 2 – Non-Population Based Surveys: Local, Ad-Hoc
Ref. No*
Author
18
Cooper, SP (1989)
110
Winn, DG (1991)
Source
Cause-of-death
information
Site
Texas
N
Age
Key Results
0-19
years
34% of deaths; 46% involve MV, 22%
intentional
< 5 years
Differences in pedestrian injury events
between toddlers (0-2 yrs) and
preschoolers (3-4 yrs); toddlers more
non-traffic events: (vehicles backing up);
preschoolers more traffic sites: crossing/
darting/mid-block
*See Primary Reference List
99
Appendix

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