Volume:9
Issue:2
Year:
2009
Abstract
This research aimed to study children’s accidents and compare sexes’ accidents in a northern part of Greece, Thrace. Specifically, it examined whether there was a correlation between each risk factor that was used in the research, and the dependent variables: 1. minor accidents, 2. serious accidents that required Emergency Room attendance (ER accidents), 3. serious accidents that lead to hospital admission (admission accidents). 1,516 high school children completed an anonymous questionnaire regarding the cause, the activity before the accident, the place, and result of their accident.
The results indicated that sex, grade, mother’s studies, father’s studies and nationality were important risk factors for minor injuries. It appears that young boys (7th grade), immigrants and the children whose parents received higher education were at greater risk of having minor injuries. Sex (girls had OR: .5; CI .4-.63) and nationality (immigrants had OR: 2.75; CI 1.82-4.16) continued to be important risk factors for E.R. accidents. Only sex was an important risk factor in admission accidents. Girls had OR .436 (CI .245-.774, p=.004). Sex and nationality were found important for ER accidents but only sex was important for admission accidents.
Although many surveys examine risk factors and accidents, this has gone a little further examining risk factors that account for serious injuries which lead to an E.R. or a hospital admission. As major accidents may result in serious health problems or even disability, attention should be paid to the risk factors found.
Key words: Accident; children; environmental health; emergency room; hospital admission; injury; safety.
Introduction
Annually, more than 790,000 people die of unintentional injuries in Europe (Petridou, et al., 2005), which represents 15% of all deaths from injuries worldwide. Studies show that the mortality rate in Europe is about 90 deaths per 100,000 residents, while in the U.S.A. the corresponding number is 53 per 100,000 (Roberts, 2005). Non fatal injuries account for a big public health problem; it is estimated that more than 15 million injuries in Europe need medical care in a hospital, while about 6 million years of life are lost because of post-traumatic disability (Centre for Research and Prevention of Injuries, 2005). Although the EU is described as one of the safest regions in the world, much space for improvement concerning accidents still exists. Since May 2004, when the EU consisted of 15 members, the Standard Death Rate (SDR) from injuries was roughly 39 deaths per 100,000, while after the integration of 10 new countries, it went up considerably to 45 deaths per 100,000 (Ministry of Health and Social Solidarity, 2008). More specifically, statistics about children show that Sweden, the United Kingdom, Italy and the Netherlands are at the top of a table with the least children's deaths from injuries. Sweden has a low annual number of deaths from injuries (intentional and unintentional): 5.2/100,000 children, for ages of 1-14 years and during the period 1991-1995 (Ekman, et al., 2005). Most children's fatal injuries were recorded in Portugal, which had a double rate compared to the pre-mentioned countries (Unicef, 2001).
Injuries are the main cause of death in children (0-14 yrsold), adolescents and young persons (15 until 24 years) (Centre for Research and Prevention of Injuries, 2005; EU Council, 2007; European Union Council, 2006; Ministry of Health and Social Solidarity, 2008). Fortunately, fatal injuries in the EU-25 present a downturn. From 1994 till 2003, the SDR for all kinds of injuries were reduced from 53 to 43 deaths per 100,000 residents (European Association for Injury Prevention and Safety Promotion, 2006).
The main causes of lethal accidents for the 29 countries – members of the Organisation for Economic Cooperation and Development (OECD), for ages of 1-14 years old during 1991-1995, were: 41% accidents on the street (pedestrian, cyclist, passenger), 15% drownings, 14% intentionally caused, 7% fire accidents, 4% falls, 2% poisonings, 1% gun accidents, and 16% other accidents (Unicef, 2001 ).
Accidents are connected to various types of activity and take place at different settings, as in the house, at school and in the street (NHS, Quality Improvement Scotland, 2004). The place where children had accidents most often was their school (inside or in the yard), where almost 1/3 of all children had suffered an accident. It is remarkable that more than 1/3 of young men (15-24 years old) were injured in an athletic centre (or gymnasium), while the respective injuries of young women were far lower (Hellenic Ministry of Health and Welfare, 2003). In Canada, 38% of 5-9 year-old children had domestic accidents while older children (10-14 years old) had a lower percentage for domestic accidents (23%). The latter had injuries during their playing outside (15%) and on the street (15%) (Health Canada, 1999).
Injury intensifiers
It was calculated that one third of accidents can be anticipated under the existing standards of prevention (Chang, et al., 2004; Dessypris, et al., 2002). Risky behaviour was found to predict in an important degree consequent injuries (Bijttebier, et al., 2003). The difficult work appears to be the adoption of these preventive measures diminishing risky behaviour. Boys are often involved in risky behaviours (Health Canada, 1999). In a research study in Finland, boys had a slightly higher percentage of injuries compared to girls (odds ratio, OR: 1,33; 95% CI) (Mattila, et al., 2004).
Most researchers agree that male sex, early adolescence, minority groups and low social economic status are the predominant risk factors for children’s accidents (Haynes, et al., 2003; Otters, et al., 2005; Unicef, 2001). Boys generally face more and more severe accidents (NHS, Quality Improvement Scotland, 2004; North Carolina Institute of Medicine, 2000). Nationality and family income were recognized as important risk factors (Chen, et al., 2005; Karr, et al., 2005). In a review of 57 different studies that examined the relation of socio-economic level (Social Economic Status-SES) and accidents, it was found that accidents are related to SES (MacKay, et al., 1999).
Injuries affect disproportionately the most vulnerable children and adolescents (Unicef, 2001). Moreover, the continuous loss of children and adolescents because of injuries is a critical demographic and economic issue (European Child Safety Alliance, 2009). Family reasons are intensifiers (e.g. low income, overcrowding, low level of parents’ education, young mother, a family with many children) (Reading, et al., 1999). Although some agree that a risk factor is the low level of education the parents have, it was found that parental levels of education had no effect in falls for boys but increased the risk of falls for girls (Faelker, et al., 2000). Environmental reasons can escalate the number of deaths from injuries, (e.g. traffic/ too many vehicles, unfavourable living conditions, direct access of houses in busy streets of dense circulation, inadequate supervision of children) (Reimers & Laflamme, 2005).
Minority children that live in poor neighborhoods have to face a more dangerous environment around them. Children from many-membered families or working children are at greater risk of accidents than their agemates (Bartlett, 2002). This can be explained since these children live in stifling neighborhoods, with no safe playing areas or safe places of recreation (MacKay, et al., 1999). Nationality (not western children OR=.67, 95%CI) and low socio-economic level (OR=1.39; 95% CI) were also related to accidents in 12-17 year-olds in Denmark (Otters, et al., 2005). In the same research, it appeared there was an increased danger of injuries for younger children (0-4 years) with many siblings (> or = 3 siblings, OR=1,57; CI =95%). Minorities usually have bigger rates of mortality because of the increased levels of poverty and low levels of education, low employment and income (Ministry of Health and Social Solidarity, 2008). While poverty was more generally a risk factor for unintentional accidents in a research study in Vietnam, it appeared to act protectively for accidents in school and it did not increase the odds ratio for street accidents (Thanh, et al., 2005). Similarly, in a study in Stockholm, the low socio-economic status of families had a protective effect for 10-19 yearold boys in traffic and athletic accidents (Faelker, et al., 2000) but was a risk factor for falls. Additionally, the levels of education and the economic resources of each family did not have an effect on falls for boys but increased the danger of falls for girls. In Sweden, the research of Engstrom, et al., (2002) showed that accidents were not related with the socio-economic differences for 0-4 yr olds.
Children of small provincial areas faced a bigger risk of accidents or deaths (National SAFE KIDS Campaign - NSKC, 2004; Washington State Department of Health Maternal and Child Health Assessment, 2006). On the contrary, some other researchers reached contradicting results. People living in cities faced a higher risk than people living in rural areas in Tanzania (Moshiro, 2005). Similarly, living in urban areas was found to be a powerful risk factor for accidents in all ages (0-17) (Otters, et al., 2005). Other risk factors were the family background of illnesses or insufficient supervision during the children’s playing, which at least doubled the danger (Wazana, 1997).
Indeed, accidents are the main cause of children’s death all over the world, even if an important percentage of these deaths can both be foreseen and predicted (Department of Hygiene and Epidemiology, 2004). In a study by the Greek Ministry of Health about the Greek population, more than 19% of the accidents were related to children from 10 to 19, 14% to 5-9 year-old children and 16% were the accidents for younger children (0-4 y.). A great percentage of accidents were related to children in their teens, which is worryingly high for the total population (Hellenic Ministry of Health and Welfare, 2003). In Greece, the distribution of deaths per type of accident, age-related group and sex were as follows: the main cause of accidents for 5-9 year olds were traffic-related accidents; similar were the results for 10-14 yr-olds. Boys had more accidents (60%) in both age groups (Ministry of Health and Social Solidarity, 2008). Generally most injuries and most serious ones are traffic related for children in their teens.
Purpose
The purpose of this research was to study children’s accidents and find out their causes in the region of Thrace, Greece. Specifically, whether there was a correlation between each risk factor that was used in the research, and the dependent variables: 1. minor accidents, 2. serious accidents that required emergency room attendance (ER accidents), 3. serious accidents that lead to hospital admission (admission accidents). Moreover, another purpose was to compare the accidents of sexes in the area.
Method
1,516 high school children (52% boys, 48% girls) from 11 schools in Thrace completed an anonymous questionnaire. Before it was handed out to children, the Greek Ministry of Education gave the permit for the researchers to get into schools and carry on with it. Moreover, each parent gave their written consent that they allowed their child to participate in the study. The children’s rights were fully protected at each step of the research. The questionnaire was created by the research team. Some of the questions had to do with the children’s demographic information (e.g. “Do you live in a city?” or “Do you live with both your parents?”) and they had to circle the answer that was correct for them. Some other questions asked them to answer directly (e.g. “How many times have you been to the ER during the last six months?”). Then, children who had an accident during the specific period of time were asked to describe the most serious one, which led them to the ER or to admission. After all the necessary instructions, they were advised to give information about the cause of the accident, the exact activity the children participated just before the accident occurred, the place it happened and finally the result of their accident. All children were advised to answer truthfully and they were given all the clarifications needed. The process took about 45 min. for each class and then children handed the questionnaires back. All the information was coded for data entry and analysed using SPSS (version 10). Descriptive statistics of the sexes were obtained, chi-square statistics and odds ratio (OR) were calculated between independent variables (age, sex, etc.) and the dependent ones (minor accidents, ER admission).
Results
Descriptives of boys
Some descriptive statistics concerning the cause of the accident, the activity they engaged in at the time of the accident, the place of the accident and the result of it, are presented in Table 1.0. The major causes of accidents for boys was accidents on a bike /motorbike, falls as they were walking or running, and various sport-related accidents. Just before the accident occurred, most boys stated that they were freely playing with no adult’s supervision (parent or teacher) while one out of four young men was riding a motorbike or bicycle at the time of the accident. A relatively large percentage of boys were injured in an organised athletic activity, either at school (physical education class, school matches etc.), or at organised sport clubs under the supervision of their coach/physical education teacher. Most boys’ accidents happened on the street, while a great percentage of them took place in an athletic centre (gymnasium) or at their school. After the accident, the majority of boys were looked after by a teacher or a relative, while four out of 10 were brought to a hospital ER either for treatment or countercheck. The percentage of boys that needed admission in a hospital was twice the girls’ percentage.
Descriptives for girls
Girls had high numbers of accidents for falls, sportrelated accidents, cuts/piercing with sharp objects and burns/scalds. Worrying was the high percentage of girls (more than one out of three) that stated they did nothing in particular at the time the accident occurred (slicing bread or going down the stairs etc.), as about one out of five was injured during their unsupervised playtime. Besides that, about one girl out of seven was injured, under the supervision of their coach/physical education teacher, during an organised athletic activity at school or at an organised sport clubs. Girls were mostly injured at home, although a relatively large percentage of them were injured on the street or at school. The great majority of girls received first aid for their injuries from a teacher or a relative, while many fewer girls than boys needed to be taken to a hospital for treatment, or to have been admitted.
Injuries in general, minor ones
It appeared that the relative danger of injury generally for non-native children is increased. Thus, the odds ratio (OR) for non-native children (immigrants) is more than three times compared to the natives in Thrace. Children, whose parents had received higher education, also appeared to have higher odds. Grade appeared to be connected with the existence of accidents and more specifically, children in 7th grade had more odds to be injured compared to the next two grades.
Sex, as expected, had a high correlation to accidents. Thus, girls had about half odds compared to boys. No other variable (living in a city or village, living with one or both parents, being an only child or not) was found to be statistically important for minor children injuries (p<.05). All the necessary information is shown in Table 2.0.
Serious injuries-transport to ER or hospital admission
Fewer variables were connected and seemed important when talking about serious accidents that resulted in a hospital ER or in admission. The probability of a child being brought into the ER of a hospital in combination with all the variables was examined and is presented in Table 3.0. Immigrants continued to have higher probability (OR=2.7) to be taken to a hospital ER compared to natives. So, nationality seems to be important. Another important variable was sex. It seemed that girls presented half the probability of being transferred to a hospital E.R. It should also be mentioned that a tendency appeared for children with siblings. They appeared to have less possibility (.7) of being brought to an ER, even though ‘p’ was not statistically important but close enough (p=.067).
Finally, the probability of a child being admitted to a hospital in combination to all the variables was examined but only sex appeared to be connected. No other variable appeared to be statistically important. Boys continued being in greater danger of being admitted in a hospital, and more specifically their relative danger was twice the danger girls had, as girls had odds ratio .436 (C.I. =.245-.774, p=.004).
Discussion
Sex
As it was expected from literature, there were certain variables that could worsen the fact that children might have an accident. It is already well documented that sex is an intensifier (NHS, Quality Improvement Scotland, 2004; North Carolina Institute of Medicine, 2000; Unicef, 2001). The present research also confirms that boys are in greater danger of accidents than girls. Moreover sex was the only variable that was connected to all three dependent variables we examined. It was an intensifier for accidents in general, ER accidents and accidents resulting in admission. Girls had half the odds for an accident (serious or minor) compared to boys, having all the other variables the same (Haynes, et al., 2003; Otters, et al., 2005). So it is of great importance to talk to boys and try to protect them by showing all the dangers around them. They were mostly injured on motorcycles/bicycles, mainly because they didn’t wear helmets. It would be interesting to mention first, that legislation in Greece obliges motorcyclists to wear a helmet but most of the times they don’t, and next, that there is no law to oblige pedal cyclists to wear one. This is worrying if we consider that the majority of accidents boys had, could have been prevented if all children realised the danger and wore helmets. Recently, a preventive approach towards accidents was developed. It includes the “3 Es” from the words Education/behaviour, Engineering/ technology, Enforcement/legislation. It has been documented that the technology approach is more effective than legislation and that education is the least effective. Modifying the environment where people work, live or play – through technology or public policy – appears to be the most effective way for injury reduction. Education – a well informed public – plays an important role in this objective, specifically when it is accompanied by technology and legislation (Alaska Adolescent Health Advisory Committee, 1997). In interventionist research at schools, communities and municipalities, it was found that education was effective in the use of bicycle helmets or seat belts but didn’t help in the reduction of adolescents’ risky behaviour, or driving and alcoholism (Klassen, et al., 2000). In any case, programmes for the reduction of injuries should include changes in the behaviour of the particular crowd of the region it is aimed at, so that they cover the existing needs and resolve the particular problems of residents in that area.
Immigrants
Another risk factor was nationality. Non-natives were in greater danger both for minor and ER accidents. It was shown that immigrants had OR about three times compared to natives. It may be the many hours their parents were working to improve their life and/or the riskier kind of life those children were leading (as most of the time their parents weren’t home), that brought about so many accidents. Minorities are really in greater danger of suffering from an accident as most literature suggests (Bartlett, 2002; MacKay, et al., 1999) although in another research there were some opposite results since it was shown that minorities were less prone than western children (Otters et al., 2005).
Living in a family with many children/living with one parent
Living with one parent or in a many membered family were not intensifiers. It was not established that many children in a family may be a risk factor as literature showed (Otters, et al., 2005; Wazana, 1997), although there seemed to be a tendency for children with siblings to have fewer ER accidents. This could be explained by the fact that older children in Greece are used to taking care of or babysitting their younger siblings, and most of the time are great at it. Consequently, efficient supervision of their young siblings may result in fewer accidents. Moreover, someone would assume that when one parent lives with the child, they are forced to work more and thus pay less attention to their child. This assumption was not established, though. It seems that, before the parent leaves home, they have already made arrangements for the good care of their children (supervised by nannies, grandparents or siblings) to make sure they will be safe. Grade was also connected to minor accidents but not serious ones (ER accidents or admissions).
Parents’ educational level
Although the literature showed that parents with low levels of education had children with more accidents (Faelker, et al., 2000), it was the opposite that this study found. It seems that when both parents have higher levels of education, their children are in greater danger of having a minor accident. That could be because the majority of people in Greece study one thing, but work in another. Highly educated and thus well paid jobs are few. As a result, the job they usually find is inferior to their studies and as a consequence they have to work more hours in environments that are lower than they deserve according to the studies. Sometimes they have to work straight from one job to another to make their living. That results in many hours of absence from home, leaving children alone.
Place where children live
There was no correlation between the place children lived and their having accidents. Although some researchers found that children in urban areas suffer most from accidents (Moshiro, 2005; Otters, et al., 2005), some others claimed the opposite (National SAFE KIDS Campaign – NSKC, 2004).This study, though, found no link between the place children lived and the injuries they had.
Conclusions
It appears that:
Young boys (7th grade), immigrants and the children whose parents received higher education were at greater risk of having minor injuries
Boys are in greater danger of both minor and major accidents (ER accidents or admissions)
Minorities – immigrants – suffered more injuries, both minor and major
Apart from the above, no other variable was statistically important for major accidents, so no other risk factor was found for ER accidents or accidents resulting in hospital admissions.
Although many surveys examine risk factors and accidents, this has gone a little further in examining risk factors that account for serious injuries which lead to an E.R. or a hospital admission. As major accidents may result in serious health problems or even disability, attention should be paid to the risk factors connected to those serious accidents.
References
Alaska Adolescent Health Advisory Committee (AHAC) (1997). Unintentional Injury Among Adolescents. Adolescent Health Research Updates. Suppl. to the Adolescent Health Plan, 2, 1- 8.
Bartlett S N (2002). The problem of children’s injuries in low income countries: a review. Health Policy and Planning, 17(1), 1-13.
Bijttebier P, Vertommen H and Florentie K (2003). Risk-taking behaviour as a mediator of the relationship between children's temperament and injury liability. Psychol Health, 18(5), 645 – 653
Centre for Research and Prevention of Injuries (CEREPRI) (2005) Burden of fatal injuries in the European Union: Report of the Task Force on Burden of Injuries. Working Party on Injuries and Accident, Athens.
Chang J T, Morton S C, Rubenstein L Z, Mojica W A, Maglione M, Suttorp M J, Roth E A & Shekelle R G (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. BMJ, 328, 680-683.
Chen G, Smith G, Deng S, Hostetler S & Xiang H (2005). Nonfatal injuries among middle-school and high-school students in Guangxi, China. American Journal of Public Health, 95(11), 1989-95.
Department of Hygiene and Epidemiology (2004). Brief report of CEREPRI activities, University of Athens.
Dessypris N, Petridou E, Skalkidis Y, Moustaki M, Koutselinis A & Trichopoulos D (2002). Countrywide estimation of the burden of injuries in Greece: a limited resources approach. J Cancer Epidemiol Prevention, 7, 123-129.
Ekman R, Svanstrom L & Langberg B (2005). Temporal trends, gender, and geographic distributions in child and youth injury rates in Sweden. Injury Prevention, 11(1), 29-32.
Engstrom K, Diderichsen F & Laflamme L (2002). Socioeconomic differences in injury risks in childhood and adolescence: a nation-wide study of intentional and unintentional injuries in Sweden. Injury Prevention, 8(2), 137-42.
EU Council (2007). Constitution of council on 31 May 2007 regarding to the prevention of injuries and the promotion of safety. Official Newspaper of the European Union, 50 (C164/01).
European Association for Injury Prevention and Safety Promotion (2006). Injuries in the European Union: Statistics summary 2002-2004.Vienna. Available at: EUROSAFE http://ec.europa.eu/health/ph_determinants/environment/IPP/documents/InjuriesEU_sum_en.pdf [accessed 10/08/09]
European Union Council (2006). Proposal for a council recommendation on the prevention of injury and the promotion of safety. Commission of the European Communities. Brussels, 329.
Faelker T, Pickett W and Brison R (2000). Socioeconomic differences in childhood injury: a populationbased epidemiologic study in Ontario, Canada. Injury prevention, 6(3), 203-8.
Haynes R, Reading R & Gale S (2003) Household and neighbourhood risks for injury to 5-14 year old children. Social science and medicine, 57(4), 625-36.
Health Canada (1999). Healthy Development of children and youth, Ottawa, Ontario (1999). Healthy Development of children and youth, Ottawa, Ontario
Hellenic Ministry of Health and Welfare (2003). Annual European Home and Leisure Accident Surveillance Report, Centre for Research and Prevention of Injuries among the young, CEREPRI, Greece.
Karr C, Rivara F and Cummings P (2005). Severe injury among Hispanic and non-Hispanic white children in Washington state. Public health reports, 120(1), 19-24.
Klassen T P, MacKay J M, Moher D, Walker A and Jones A L (2000). Community-based injury prevention interventions. Future Child, 10(1), 83-110
MacKay M, Reid D C, Moher D and Klassen T (1999). Systematic review of the relationship between childhood injury and socio-economic status. Published by authority of the Minister of Health (from: www.hcsc.gc.ca/hppb/childhood-youth).
Mattila V, Parkkari J, Kannus P and Impela A (2004). Occurrence and risk factors of unintentional injuries among 12 to 18-year-old Finns – a survey of 8,219 adolescents. European Journal of epidemiology, 19(5), 437-44.
Ministry of Health and Social Solidarity (2008). National action plan for Public Health: National action plan for accidents, 2008-2012. Athens.
Moshiro C (2005). The epidemiology of injuries in an urban and two rural areas of Tanzania: a populationbased study, Philosophiae Doctor (PhD) Thesis, Centre for International Health University of Bergen, Norway.
National SAFE KIDS Campaign (NSKC) (2004). Children at Risk Fact Sheet, Washington (DC): NSKC.
NHS, Quality Improvement Scotland (2004). Health Indicators Report: A focus on children, Scotland. Available online at: www.nhshealthquality.org/nhsqis/files/2004%20Health%20Indicators%20Report.pdf [accessed 10/08/09].
North Carolina Institute of Medicine (2000). Comprehensive Child Health Plan: 2000-2005, Task Force Report to the North Carolina Department of Health and Human Services.
Otters H, Schellevis F, Damen J, van der Wouden J, van Suijlekom-Smit L & Koes B (2005). Epidemiology of unintentional injuries in childhood: a populationbased survey in general practice. The British Journal of General Practice, 55 (517), 630-3.
Petridou E, Alexe D M, McDaid D, Segui-Gomez M and the Task Force on Burden of Injuries (BOI) of the European Commission Working Party on Accidents and Injuries (WP-AI) (2005). Burden of Fatal Injuries In The European Union. Report prepared for the European Commission, DG SANCO. Athens, Greece.
Reading R, Langford I, Haynes R & Lovett A (1999). Accidents to preschool children: comparing family and neighbourhood risk factors. Soc Sci Medicine, 48(3), 321-30.
Reimers A, Laflamme L (2005). Neighbourhood social and socio-economic composition and injury risks. Acta Paediatr, 94(10), 1488-94.
Roberts I (2005) Trauma care research and the war on uncertainty. BMJ, 331,1094-1096.
Thanh N, Hang H, Chuc N, Byass P & Lindholm L (2005). Does poverty lead to non-fatal unintentional injuries in rural Vietnam?, International Journal of Injury Control and Safety Promotion,12(1), 31-7.
Unicef (2001). A league table of child deaths by injury in rich nations, Innocenti report card, Is.2, Innocenti Research Centre, Florence.
Washington State Department of Health Maternal and Child Health Assessment (2006). Maternal and Child Health Data and Services Report. Available at: www.doh.wa.gov/cfh/mch/mch_assessment/mchdatareport/mch_datareport_2006.pdf [accessed 10/08/09]
Wazana A (1997). ‘Are there injury-prone children? A critical review of the literature’. Canadian J Psychiatry, 42, 602–610.