The Scottish Health Survey 2011 - volume 2: children

2 Accidents

Paul Bradshaw

SUMMARY

• In 2009/2011 combined 16% of boys and 12% of girls aged 0-15 reported having had at least one accident in the previous year where advice was sought from a doctor, nurse or other health professional, or which required a visit to hospital, or time to be taken off school.
• Boys had a significantly higher accident rate than girls in the 2009/2011 period (20 per 100 persons compared with 14 per 100 persons).
• There was a significant reduction in the accident rate for children aged 2-15 between 1998 and 2009/2011 from 21 per 100 to 18 per 100.
• Accident rates were not significantly associated with socio-economic classification, equivalised household income or Scottish Index of Multiple Deprivation.
• The most common cause of accidents for boys and girls was a fall, slip or trip (52%). These were particularly common for children aged 0-7 (67%).
• 38% of accidents to children occurred in the home or garden. This was a particularly likely accident location for children aged 0-7 (62%).
• The most commonly mentioned injuries were swelling or tenderness in some part of the body (30% of accidents); cuts or grazes (27%) and bruising, pinching or crushing (23%).
• Children aged 8-15 were more likely than those aged 0-7 to have experienced broken bones (27% compared with 11%), while the youngest age group were more than twice as likely as the oldest to have experienced cutting or grazing (41% compared with 18%).
• Boys were more likely than girls to have suffered broken bones (23% compared with 18%), whereas girls were more likely to have suffered bruising, pinching or crushing (25% compared with 21%).

2.1 INTRODUCTION

Figures for hospital admissions and deaths caused by accidents are reported by ISD Scotland.^[1] In 2009/10, there were 8,511 emergency hospital admissions among children in Scotland as a result of accidents, accounting for one in seven of all emergency admissions for those aged under 16 years.^[2] At all ages, boys are more likely than girls to have an emergency hospital admission following an accident. Deaths from accidents are thankfully rare - 16 were recorded in 2010 (the most recent year for which figures are available) - and administrative statistics suggest both deaths and hospital admissions caused by accidents have reduced in the last ten years. For example, compared with 2009/10, in 2002/03 there were almost twice as many deaths (31) and around 2,500 more emergency hospital admissions among children under 16 resulting from accidental injury.^[3] However, accidents constitute a more common cause of death in children than in adults. Figures based on the 2002-2006 period showed that injuries were the leading cause of deaths among children aged 5-9 and 10-14, and among all children aged 1-14 in Scotland.^[4] Deaths from accidents among children in Scotland also show marked socio-economic inequalities. In the 2006-2010 period, the standardised mortality ratio was 54.7 in the least deprived area quintile compared with 119.3 in the most deprived quintile.^[2]

The 2008 report of the Ministerial Taskforce on Health Inequalities Equally Well included a recommendation to target children from disadvantaged areas who are at greater risk of road traffic accidents.^[5] Initiatives to reduce the incidence and severity of accidents in childhood focus on multiple settings, including the home (e.g. recent campaigns raising awareness of the risks of blind cords), outdoor play spaces, and roads and pavements. The Scottish Government works with a number of partner agencies to reduce accidents (the Royal Society for the Prevention of Accidents, the Child Accident Prevention Trust, Scottish Accident Prevention Council), and supports an annual child safety week to disseminate messages about accident prevention.

This chapter presents trends over time in accident rates, since 1998. It then looks in more detail at differences in accident rates by age and sex, and by socio-demographic characteristics. Participants were asked to report information about the cause, location and resulting injury (if any) of their most recent accident; figures on these aspects are also presented.

2.2 METHODS AND DEFINITIONS OF MEASUREMENT

2.2.1 Accident classification and recall period

The term 'accident' covers a very broad range of events from the extremely serious through to the relatively trivial. In order to concentrate on events which are most salient to those monitoring health in Scotland, the definition of 'accident' used in the Scottish Health Survey (SHeS) is any accident where advice was sought from a doctor, nurse or other health professional, or which caused time to be taken off school.

Participants were asked to recall any accidents they had had in the 12 months prior to the interview which fitted this definition.^[6] Accident rates, however, are based only on those accidents about which advice was sought from a doctor or which required a visit to hospital.

All those who reported having at least one accident of this kind were then asked detailed questions about the nature and cause of the most recent accident. The reference period of 12 months before the interview was chosen so as to be sufficiently long to generate details of enough accidents for analysis, yet short enough for participants to be able to remember accurate details about their most recent accident.

2.2.2 Coverage of accidents

The survey covers most, but not all, accidents to children. Since SHeS collects data directly from participants, fatal accidents are excluded. In addition, there will be under-representation of accidents that lead to long-term hospitalisation. For these reasons, the accident rates presented in this chapter can best be described as non-fatal accident rates for the household population. These rates will be slight under-estimates of the true accident rates for children because of the exclusions. However, since the great majority of accidents do not lead to long-term stays in hospitals, the downward bias should be small.

2.2.3 Accident rates and weighting to compensate for selection bias

The incidence of accidents to children is presented in terms of 'annual accident rates per 100 persons'. That is, the mean number of accidents over a 12 month period multiplied by 100.

Although participants were asked to specify the total number of accidents they had had over the period 12 months before the interview, detailed information was collected for only the most recent accident. This selection process leads to the over-representation of accidents occurring to children for whom accidents are relatively uncommon events, and this over-representation could, in principle at least, bias the survey estimates. For example, a child who had three accidents in the last year would contribute only as much information as a child who had just one accident. To avoid such bias, analyses that use the detailed data on the most recent accident use an additional 'accident weight', which is multiplied to the more general survey weight. The 'accident weight' per child is calculated as equal to the total number of accidents reported by that child in the 12 month reference period. In practice relatively few children reported having had two or more accidents, so the impact of the accident weight on estimates is fairly small.

2.2.4 Data collection years

The same information about accidents was collected in the 1998 and 2003 surveys. From 2008, the accidents module was asked biennially, and was included in the 2009 and 2011 surveys. It is next due to be asked in 2013. As many of the figures are based only on those children who had an accident, to increase the sample size available for analysis data from the 2009 and 2011 surveys have been combined to enable more robust estimates to be presented.

2.3 TRENDS IN ACCIDENT RATES SINCE 1998

Accident rates per 100 persons for 1998, 2003 and 2009/2011 combined, by age and sex are shown in Table 2.1. As infants aged 0-1 were not included in the 1998 survey, comparisons between the years are restricted to children aged 2-15.

Between 1998 and 2009/2011 combined, there was a significant reduction in the accident rate for children aged 2-15 from 21 per 100 persons to 18 per 100. The rate remained largely unchanged between 1998 and 2003, before reducing slightly in 2009/2011. The apparent reductions since 1998, in the accident rate for boys and girls separately were not statistically significant. In each survey year, the accident rate for girls has been lower than for boys.

The significant decline in accidents among children aged 2-15 reflects reductions in deaths and emergency hospital admissions among children under 16 resulting from accidental injury as seen in administrative health and population statistics between 2002/03 and 2009/10.^[1],[7]
Table 2.1

2.4 ACCIDENTS IN THE PREVIOUS YEAR, 2009 AND 2011 COMBINED BY AGE AND SEX

The remainder of this chapter focuses on accidents in 2009/2011 combined among children aged 0-15. Both the number of accidents and accident rates by age and sex are shown in Table 2.2.

In 2009/2011, 16% of boys and 12% of girls reported having had at least one accident where advice was sought from a doctor, nurse or other health professional, or which caused time to be taken off school. Just 3% of boys and 1% of girls had two or more accidents in the previous 12 months. Boys had a significantly higher accident rate than girls (20 per 100 persons compared with 14 per 100) and the highest accident rates were for boys aged 14-15 (37 per 100).
Table 2.2

2.5 ACCIDENT RATES BY SOCIO-DEMOGRAPHIC FACTORS

Tables 2.3 to 2.5 present accident rates for all children aged 0-15 by socio-economic classification (NS-SEC of the household reference person), equivalised household income and the Scottish Index of Multiple Deprivation (SIMD) (descriptions of each of these measures are available in the Glossary at the end of this volume).

2.5.1 Socio-economic classification (NS-SEC)

2009/2011 accident rates by NS-SEC are shown in Table 2.3. There was no clear relationship with NS-SEC and the accident rate for children living in managerial and professional households was the same as for those living in semi-routine and routine households (17 per 100 persons).
Table 2.3

2.5.2 Equivalised household income

The 2009/2011 accident rates by equivalised household income quintile are shown in Table 2.4. As with NS-SEC, there was no significant relationship between accident rates and household income. Indeed, the accident rate was very similar across all the income groups and the rate for children aged 0-15 in the lowest household income quintile was the same as that for those in the highest quintile (16 per 100 persons).
Table 2.4

2.5.3 Scottish Index of Multiple Deprivation (SIMD)

Two measures of SIMD are being used throughout this report. The first, which uses quintiles, enables comparisons to be drawn between the most and least deprived 20% of areas and the intermediate quintiles. The second contrasts the most deprived 15% of areas with the rest of Scotland (described in the tables as the "85% least deprived areas").

Combined 2009/2011 accident rates by SIMD quintile are shown in Table 2.5. For children aged 0-15, the accident rate was slightly lower (but not significantly) for those living in the least deprived areas compared with those living in the most deprived areas (16 per 100 persons compared with 19 per 100). Accident rates did not consistently increase in line with deprivation - for example the rate for children aged 0-15 living in areas in the 4^th quintile was equal to that for children living in areas in the most deprived quintile (19 per 100).

The pattern is similar when the accident rate for children living in the 85% least deprived areas in Scotland was compared with that for those living in the 15% most deprived areas. The accident rate for children living in both areas was almost identical (17 per 100 persons for children in the 85% least deprived areas and 18 per 100 for those in the most deprived 15% of areas in Scotland). Whilst there were some large differences within specific age groups - for example, the accident rate for children aged 11-15 living in the 85% least deprived areas was higher than for those of the same age living in the most deprived 15% of areas (26 per 100 persons compared with 18 per 100) - these differences were not significant.
Table 2.5

2.6 CHARACTERISTICS OF ACCIDENTS, 2009 AND 2011 COMBINED

2.6.1 Causes of accidents

Participants who had at least one accident in the twelve months prior to interview were asked to describe the cause of the most recent accident and interviewers coded responses using the following options:

• hit by a falling object
• fall, slip or trip
• road traffic accident
• sports or recreational accident
• use of tool of implement, or piece of electrical or mechanical equipment
• burn or scald
• animal or insect bite or sting
• another person (including attacks).

Some caution is needed in the interpretation of the data on cause of accident derived from this interviewer coding. What is coded in individual cases will depend firstly upon how the participant describes the accident and secondly on how the interviewer interprets that description. For example, an accident in which a child sprains their ankle when playing football may be described as a fall by one participant ("I fell and sprained my ankle") or as a sporting accident by another ("I sprained my ankle when I was out playing football"). If the participant describes the accident to the interviewer as 'I fell and sprained my ankle' then some interviewers may code this as a fall or slip automatically whereas others may probe further, establish that the informant was playing football at the time of the fall, and code it as a sports accident. Interviewers were briefed to code more than one cause per accident if appropriate, the intention being to collect as full a description of the accident as possible in order to avoid misclassification. One implication of the ambiguity in coding is that accident rates cannot be readily derived for different types of accident.

Table 2.6 shows the causes of accidents, by age and sex for 2009/2011 combined. The most common cause of accident for boys and girls was a fall, slip or trip (52% of accidents). The only exception was among boys aged 8-15 for whom a sports or recreational accident was most common (47%). Falls, slips and trips were particularly common among children aged 0-7 (67% of accidents) though this cause reduced with age. In contrast, sports and recreational accidents increased with age; from 7% of accidents among children aged 0-7 to 41% of accidents among those aged 8-15. From the age of eight, boys were more prone to sports and recreational accidents than girls. 47% of boys aged 8-15 reported having such an accident, considerably higher than the 29% of girls who also did so.
Table 2.6

2.6.2 Locations of accidents

The location of the most recent accident by age and sex for 2009/2011 combined is presented in Table 2.7. The patterns for locations of accidents by age and sex are similar to those seen in relation to causes of accidents, reflecting both the fact that location and cause are related and that lifestyles and activities vary by age and sex.

The most common location for an accident was in a home or garden (38% of accidents), though many also occurred in a place used for sport, play or recreation (31%). A home or garden was a particularly likely accident location for younger children. 62% of accidents among children aged 0-7 took place here compared with 19% of accidents to children aged 8-15. Older children were considerably more likely to have an accident away from home, particularly in places for sports or recreation. 44% of the accidents to children aged 8-15 occurred in places for sports or recreation. Among older children, boys were more likely than girls to have had an accident outside of a home or garden. 87% of accidents to boys aged 8-15 happened somewhere other than a home or garden compared with 72% of accidents to girls in the same age group.
Table 2.7

2.6.3 Types of injury

Participants were asked to describe the injuries caused by their most recent accident using twelve categories of injury which were presented to them on a card; interviewers were briefed to probe for more than one kind of injury where appropriate:

• broken bones
• dislocated joints
• losing consciousness
• straining or twisting a part of the body
• cutting, piercing or grazing a part of the body
• bruising, pinching or crushing a part of the body
• swelling or tenderness in some part of the body
• something stuck in the eye, throat, ear or other part of the body
• burning or scalding
• poisoning
• other injury to internal parts of the body
• animal or insect bite or sting.

The distribution of types of injury by age and sex for 2009/2011 combined is shown in Table 2.8. The most common injury reported for all children who had an accident in the previous year was swelling or tenderness (30%), with cuts or grazes also relatively common (27%). Bruising, pinching or crushing (23%), broken bones (21%) and straining or twisting (19%) were less common, but occurred considerably more often than dislocation (5%) or burning or scalding (3%).

Boys were more likely than girls to suffer broken bones - particularly among those aged 8-15 - and swelling or tenderness. In contrast, girls were more likely to suffer bruising, pinching or crushing (25% compared with 21%). The oldest age group were more likely than the youngest to have experienced broken bones (27% compared with 11%), straining or twisting (29% compared with 2%) and swelling or tenderness (34% compared with 23%). The youngest age group however, were more than twice as likely as the oldest to have experienced cutting or grazing (41% compared with 18%).
Table 2.8