The Relationship Between Social Problems And Injuries: Implications

For Policy And Practice

Angus H Thompson, PhD.Alberta Centre for Injury Control & Research

University of Alberta

Canadian Conference on Injury Prevention & Safety Promotion. Ottawa, Canada, November 24, 2003

ACKNOWLEDGEMENTS

Kathy L Belton

Co-DirectorAlberta Centre For Injury Control & Research

Kim Borden

Data AnalystAlberta Centre For Injury Control & Research

Source: Thompson AH, Borden K, Belton KL. (2003). The Relationship Between Unintentional & Intentional Injuries Across Alberta’s Health Regions. Unpublished manuscript.

DO UNINTENTIONAL AND INTENTIONAL INJURIES BELONG

TOGETHER?

Unintentional and intentional injuries involve very different contexts and interventions

“Traditional public health injury control does not apply to violence.”

L.Fisher

ARGUMENTS AGAINST

“Whatever the form, in the end an injury is a health problem”

B. Pless

“... the evidence on shared risk factors among intentional and unintentional infant deaths warrants ‘convergence’ of effort rather than the compartmen-talization engendered by separation.”

Overpeck and McLoughlin

ARGUMENTS FOR

• SII predicts later mortality due to natural causes, unintentional injuries, & violence

• Common parental factors exist for a variety of infant injury deaths, regardless of intent

• There is a relationship between falls, suicidal behaviour, & disease

• There is an overlap among predictors of death by suicide, accidents & natural causes.

EVIDENCE FOR

THE

CANADIAN SOCIAL

PROBLEM INDEX

(SPI)

MurderAttempted Murder

AssaultSexual assault

SuicideRobberyDivorce

Alcoholism

SPI COMPONENTS

SOCIAL PROBLEM INTERCORRELATIONS ACROSS PROVINCES: 1971/1981

Att.Murder Assault Rape Robbery Divorce Suicide

Alco-Holism

Homicide .91/.90 .47/.50 .58/.69 .71/.61 .65/.66 .47/.81 .43/.82

AttemptedMurder .36/.24 .58/.44 .80/.61 .56/.48 .38/.79 .43/.59

Assault .23/.73 .26/.00 .76/.54 .41/.30 .17/.63

Rape .84/.35 .71/.68 .68/.34 .76/.83

Robbery .72/.67 .63/.66 .75/.65

Divorce .77/.70 .68/.77

Suicide .79/.66

80

100

120

140

160S

PI

BC AB SK MN ON PQ NB NS PEI NF

SPI VALUES FOR CANADIAN PROVINCES: 1956, 1976, & 1996

1956 1976 1996

Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51

Social Problem Index Values For

Alberta RHA’s in Comparison to

Canadian 1956 Values

1991 1997

1. Chinook 160 151

2. Palliser 155 147

3. Headwaters 152 150

4. Calgary 148 145

5. RHA #5 152 148

6. David Thompson 156 151

7. East Central 148 143

8. WestView 158 149

9. Crossroads 168 152

10. Capital 153 146

11. Aspen 159 157

12. Lakeland 155 161

13. Mistahia 165 151

14. Peace 159 153

15. Keeweetinok 203 177

16. Northern Lights 173 161

17. Northwestern 192 174

Alcohol Abuse

Drug Abuse Divorce

Unem- ployment

Suicide attempt Felony

Spouse Abuse

Child Abuse

Schizophrenia

Mania

Depression

Dysthymia

Phobia

Panic Disorder

Obsessive Compulsive

Antisocial Personality

OR < 5 OR 5 - 9.9 OR 10+

THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS

Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian Journal of Psychiatry 40, 15 – 20.

ECOLOGICAL EVIDENCE FROM

ALBERTA’S HEALTH REGIONS

METHOD

• Comparison of injury rates (hospitalizations) across Alberta’s 17 health regions (in 1999)

•Analysis of the level of association among intentional and unintentional injuries

• Principal components analysis to search for an independent intentional injury factor

Unintentional InjuriesAdverse Effects (Medical)Adverse Effects (Drug)FallsMotor Vehicle CrashOverexertion /StrainLate Injury EffectsPoisonStruck Object /PersonNatural /Env. CausesSports RelatedCutting/PiercingSuffoc'n Foreign Body

MachineryFire/ Scalding Bike - Non-TrafficUndetermined IntentPedestrian - Non TrafficDrowningFirearm (Unintentional)Legal InterventionOther InjuryOther Transp. RelatedUnspec.Cause of InjuryIntentional InjuriesSuicide AttemptAssault

ALBERTA INJURY GROUPINGS

Unintentional InjuriesAdverse Effects (Medical)Adverse Effects (Drug)FallsMotor Vehicle CrashOverexertion /StrainLate Injury EffectsPoisonStruck Object /PersonNatural /Env. CausesSports RelatedCutting/PiercingSuffoc'n Foreign Body

MachineryFire/ Scalding Bike - Non-TrafficUndetermined IntentPedestrian - Non TrafficDrowningFirearm (Unintentional)Legal InterventionOther InjuryOther Transp. RelatedUnspec.Cause of InjuryIntentional InjuriesSuicide AttemptAssault

ALBERTA INJURY GROUPINGS

Unintentional InjuriesAdverse Effects (Medical)Adverse Effects (Drug)FallsMotor Vehicle CrashOverexertion /StrainLate Injury EffectsPoisonStruck Object /PersonNatural /Env. CausesSports RelatedCutting/PiercingSuffoc'n Foreign Body

MachineryFire/ Scalding

Other InjuryOther Transp. RelatedUnspec.Cause of InjuryIntentional InjuriesSuicide AttemptAssault

ALBERTA INJURY GROUPINGS

Unintentional InjuriesAdverse Effects (Medical)Adverse Effects (Drug)FallsMotor Vehicle CrashOverexertion /StrainPoisonStruck Object /PersonNatural /Env. Causes

Sports RelatedCutting/PiercingSuffoc'n Foreign Body MachineryFire/ Scalding

Intentional InjuriesSuicide AttemptAssault

RETAINED INJURY GROUPINGS(91.7% of Injury Hospitalizations)

INTERCORRELATIONS OF THE RETAINED INJURY GROUPINGS

Suic Att MVCs Falls Poison Asslt Suffoc Fire

Nat /Env

AdvEff Medic.

AdvEff Drugs Mach Struck Cut Sport

Motor Vehicle

Falls

Poison .60+ p < .01

Assault .47-.59 p < .05

Suffocat’n/Foreign Body .30-.46

Fire/Scalding

Natural/Environmental

Adverse Effect-Medical

Adverse Effect-Drugs

Machinery

Struck Object/Person

Cutting/Piercing

Sports Related

Overexertion/Strain

Note: 48 of 105 comparisons were significant at p < 5%

(r = 0.81)

PRINCIPLE COMPONENTS ANALYSIS

Factor1 2 3

Eigenvalue 6.9 2.6 1.4

Variance 45.8% 17.2% 9.6%

Suicide .85 -.20 -.24

Motor Vehicle .67 .16 -.39

Falls .87 -.31 .16

Poison .77 .49 .04

Assault .74 -.53 .00

Suffocation/Foreign Body .48 -.30 .06

Fire/Scalding .59 .59 -.34

Natural/Environmental .89 .19 .33

Adverse Effects-Medical .51 -.40 -.11

Adverse Effects-Drugs .48 -.10 .77

Machinery .76 .03 -.37

Struck Object/Person .83 -.09 .17

Cutting/Piercing .50 -.55 -.25

Sports Related .42 .79 -.14

Overexertion/Strain .48 .57 .37

SOCIAL PROBLEMS AND INJURIES

Suicide 0.72Assault 0.89

Falls 0.75Adverse Effects-Medical 0.65

Cutting/Piercing 0.51Struck Object /Person 0.50

Motor Vehicle 0.49Machinery 0.46

Natural /Env. Causes 0.43Poison 0.23

Fire/ Scald 0.22Suffoc'n Foreign Body 0.17Adverse Effects-Drugs 0.14

Overexertion /Strain -0.16 Sports Related -0.19

CORRELATIONS BETWEEN THE SPI AND THE RETAINED INJURY GROUPINGS

SPI AlcoholismSexual Assault

Child Negl/Abuse

Suicide Attempt 0.72 0.82 0.75 0.76Assault 0.89 0.83 0.83 0.66

Falls 0.75 0.73 0.69 0.49Adverse Effects-Medical 0.65 0.41 0.65 0.50

Cutting/Piercing 0.51 0.49 0.54 0.25Struck Object /Person 0.50 0.52 0.44 0.40

Motor Vehicle 0.49 0.78 0.61 0.52Machinery 0.46 0.50 0.54 0.51

Natural /Env. Causes 0.43 0.63 0.38 0.36Poison 0.23 0.49 0.29 0.43

Fire/ Scald 0.22 0.33 0.24 0.56Suffoc'n Foreign Body 0.17 0.25 0.15 0.18Adverse Effects-Drugs 0.14 0.42 0.06 -0.09

Overexertion /Strain -0.16 0.21 -0.22 -0.22 Sports Related -0.19 0.10 -0.10 0.23

CORRELATIONS BETWEEN SELECTED SPI COMPONENTS AND RETAINED INJURY GROUPINGS

REVISITS TO THE EMERGENCY ROOM AFTER

SELF-INFLICTED INJURY

UTILIZATION OF THE EMERGENCY DEPARTMENT AFTER SELF-INFLICTED INJURY

Source: Colman I, Dryden DM, Thompson AH, Chahal AM, Borden K, Rowe BH, Voaklander DC. In press. Academic Emergency Medicine.

• Record-linkage study of individuals admitted to an Edmonton ER for SII in fiscal year 1995/96

• Comparison groups were those admitted for asthma and a random selection of the remaining patients

• Groups were matched on age and sex, and were of equal size (n = 478)

• Groups were compared on readmissions to any regional ER over the subsequent three years

PROPORTION RETURNING TO THE ER WHO WERE INITIALLY ADMITTED FOR EITHER SII, ASTHMA OR "OTHER" REASONS

0%

5%

10%

15%

20%

25%

30%

Self-inflicted Injury Unintentional Injury Assault

REASON FOR RETURN

SII Group

Asthma Group

Other

WHAT DOES IT MEAN?

• They do, at least at the ecological level.

• Proximal vs Distal: There may be less commonality in the proximal case, but this needs to be investigated.

• The association among social problems, mental illness, and injuries is suggestive of a common underlying, contributing cause.

DO INTENTIONAL AND UNINTENTIONAL INJURIES BELONG TOGETHER?

SOME POSSIBILITIES

1. Child Development

2. Child Development

3. Child Development

SOME POSSIBILITIES

• Parenting & Supervision

• Community Self-Efficacy

• Social Capital (Democracy)

The End

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