Adolescent Injury Deaths and Hospitalization in Canada: Magnitude and Temporal Trends (1979–2003)

Article Outline

• Abstract
• Methods
• Results
• Discussion
• References
• Copyright

Abstract 

Purpose

To understand the magnitude and the national trends of mortality and hospitalization due to injuries among Canadian adolescents aged 15–19 years in 1979–2003.

Methods

Data on injury deaths and hospitalizations were obtained from the national Vital Statistical System and the Hospital Morbidity Database. Injuries were classified by intent and by mechanism.

Results

In 15–19-year-olds, 75.6% of all deaths and 16.6% of all hospitalizations were attributed to injuries. Unintentional and self-inflicted injuries accounted for 70.2% and 24.1%, respectively, of total injury deaths as well as 72.6% and 17.4%, respectively, of total injury hospitalizations. The main causes for injury were motor vehicle traffic-related injury (MVT), suffocation, firearm, poisoning, and drowning for injury deaths; and MVT, poisoning, fall, struck by/against, and cut/pierce for injury hospitalizations. Mortality and hospitalization rates of total and unintentional injuries decreased substantially, whereas those of self-inflicted injuries decreased only slightly, with a small increase in females. Rates also decreased for all causes except suffocation, which showed an increasing trend. Males had higher rates for all intents and causes than females, except for self-inflicted injury hospitalization (higher in females). The territories and Prairie Provinces also had higher ones of total injuries and self-inflicted injuries than in other provinces.

Conclusions

Injury is the leading cause of deaths and a major source of hospitalizations in Canadian adolescents. However, prevention programs in Canada have made significant progress in reducing injury mortality and hospitalization. The graduated driver licensing, enforcement of seat-belt use, speed limit and alcohol control, and Canadian tough gun control may have contributed to the decline.

Keywords: Adolescent, Injury, Trend, Unintentional, Intentional, Mortality, Hospitalization

Risk-taking and novelty-seeking are characteristics of adolescents: search for identity, belief in invincibility, search for independence, curiosity, strong influence of peer groups, impulsiveness, and experimentation [1]. These characteristics may modify an adolescent's perception of risk and his/her understanding of the consequences of particular behaviors. They are more likely to engage in risky behaviors such as drinking and driving, social drug use, aggressive behaviors, and ignoring accepted safety practices; they view these risk behaviors as exciting and rewarding [1], [2], [3]. These risk-taking behaviors make them more vulnerable to injury [2], [4], [5], [6].

Injury is recognized internationally as the major threat to adolescent health [7]. It is the leading cause of death and a major source of morbidity, disability, and excess health expenditures in adolescents in western countries [7]. According to a report in the United States, the total and average cost of injuries in adolescents aged 15–19 years was estimated to be US$92 billion and US$17,700, respectively, including medical care, lost future work, and quality of life [8].

To understand the burden and magnitude of injuries in Canadian adolescents, we examined mortality and hospitalization rates due to injury among adolescents at the national level, as well as the national trends of mortality and hospitalization rates of both total and cause-specific injuries from 1979 to 2003. These analyses would guide prevention efforts and help us set program priorities.

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Methods 

People in late adolescence were chosen as the study population mainly because driving becomes a means of transportation as well as a recreational activity in this age group, when they are still developing motor skills and decision-making skills.

Annual mortality data were obtained from the national Vital Statistics System at Statistics Canada. The Vital Statistics System is a statutory and computer-based register that covers the entire Canadian population. The central Vital Statistics Registry in each province and territory provides data of death registrations to Statistics Canada. The death database includes data on demographic factors, province of residence, date of death, underlying cause of death (classified into the World Health Organization's International Statistical Classification of Diseases and Related Health Problems), province or territory where death occurred, place of accident (available from year 1991), and autopsy, if available.

Because the registration of deaths is a legal requirement in each Canadian province and territory, reporting is virtually complete. Under-coverage may occur because of late registration. For example, the number of cases by late registration for 1996, 6 years after the year of death (accumulated late records), represents approximately 400 deaths or .2% of the total records (http://www.statcan.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=3233&lang=en&db=IMDB&dbg=f&adm=8&dis=2). Duplicate death registrations are identified as part of the regular processing operation on each provincial and territorial subset as well as through additional inter-provincial checks. The accuracy of the database is maximized by checking at the provincial/territorial and Statistics Canada's level. The quality of the data capture and the data coding is evaluated annually and on an irregular basis through comprehensive studies.

The source of data for injury hospitalizations is the Hospital Morbidity Database (HMD), managed by the Canadian Institute for Health Information (CIHI). CIHI receives all acute care, convalescence, and chronic hospital discharge data from Canadian general and allied special hospitals, submitted through the Discharge Abstract Database or via the provincial Ministries of Health in Manitoba and Quebec. Data are standardized in HMD to include demographic, diagnostic, and intervention data on all Canadian inpatient separations. This HMD includes overnight hospital discharges only and excludes outpatients. However, no data on hospitalizations are available for the Northwest Territories and the Yukon before 1994. E-codes are available only: from 1986 for Prince Edward Island (but not available in 1990); from 1994 for full code for New Brunswick (available for three-digit ICD codes from 1981–1987); and from 1983 for British Columbia (BC) (abbreviated three-digit ICD codes used for 1981 and 1982). To present long-term trends, we excluded Prince Edward Island, New Brunswick and the Territories from our study for hospitalization rates and selected data from 1986 to 2002.

Injuries were coded according to the International Classification of Disease, ninth revision (ICD-9), and tenth revision (ICD-10). Mortality data have been classified using ICD-9 from 1979 to 1999 and ICD-10 from 2000 to 2003. Hospitalization data have been classified using ICD-9 from 1979, and ICD-10-CA from 2001 by Newfoundland and Labrador, Prince Edward Island, Nova Scotia, Saskatchewan (partial), BC, and the Yukon; from 2002 by Ontario, Saskatchewan (remainder), Alberta, the Northwest Territories, and Nunavut; in 2003 by New Brunswick. We grouped injuries by intent (unintentional, self-inflicted [suicide], assault, legal intervention/war, and undetermined), and by mechanism (cut/pierce, drowning, fall, fire/hot object or substance [burning], firearm, machinery, all transport including motor-vehicle traffic [MVT], natural/environmental, poisoning, struck by/against, suffocation, among others) (www.cdc.gov/mmwr/pdf/rr/rr4614.pdf and www.cdc.gov/nchs/data/ice/icd10_transcode.pdf) . Abnormal reactions and complications of medical care (E870–E879.9) and adverse effects of the therapeutic use of drugs (E930.0–E949.9) were excluded from the injuries in this study.

To minimize the impact of change in coding system from ICD-9 to ICD-10 on the rate estimates, grouping of external causes were modified as in the ICD-9 and ICD-10 Transition Matrix developed by the Health Statistics and Epidemiology Division at the Public Health Agency of Canada, based on ICD-9 and ICD-10 external cause matrices available at http://www.cdc.gov/nchs/about/otheract/ice/projects.htm#Reporting%20Frameworks. For example, fracture, cause unspecified was included in the category of fall in ICD-9 but is coded to X59 (exposure to unspecified factor) in ICD-10, therefore, fracture, cause unspecified was excluded from falls for the period of 1979 to 1999 to be compatible with ICD-10. Cases with ICD-9 codes E830 and E832 (drowning unintentional) were moved to the category of water transport-related injury; E924.1 and E961 (burning) were moved to poisoning; E958.7 and E988.7 were moved from scald due to hot object or substance to other specified/not elsewhere classified (NEC); E958.6 and E988.6 (air crash) were moved from other and unspecified transport (self-inflicted and undetermined) to other specified/NEC self-inflicted (X83) and undetermined (Y33); E846 was moved from other specified classifiable to land transport, other (unintentional) because there is an equivalent in ICD-10 transport codes (V83); E847–E848 were moved from other specified, classifiable to other, and unspecified transport; E904.0 was moved from natural/environmental, unintentional to other specified, classifiable, assault (neglect and abandonment, Y06). E958.3 and E988.3 were moved from natural/environmental self-inflicted and undetermined to other specified/NEC, respectively; E958.4 and E988.4 were moved from other specified, classifiable to other specified/NEC; E990 and E994 were moved from other classifiable, legal intervention/war to burning, legal/war and to other and unspecified transport legal intervention/war, respectively.

Annual population estimates were taken from Statistics Canada's annual demographic statistics (available at http://www.statcan.ca/Daily/English/050629/d050529d.htm).

Secular trends in mortality and hospitalization rates of total and cause-specific injuries from 1979 to 2003 were estimated by negative binomial regression models, using the annual rates for various intents or mechanisms. The average annual percent change was derived from the regression coefficients of these models during the described periods.

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Results 

During the study period (1979 to 2003), injury deaths in adolescent males and females aged 15–19 years accounted for an average of 79.6% and 65.0% of all deaths, respectively. From 1986 to 2003, injury hospitalizations in this age group accounted for an average of 31.0% and 9.3% of all hospitalizations in males and females, respectively. These proportions did not change significantly over the period (Figure 1).

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• Figure 1. 

  Injury deaths and hospitalizations as proportion of all deaths and hospitalizations, adolescents (15–19 years), Canada, 1979–2003.

Between 1979 and 2003, deaths due to unintentional and self-inflicted injuries accounted for an average of 70.2% and 24.1% of total injury deaths, respectively (Table 1). During this period, mortality rates for total injuries and injuries of four intents decreased by various degrees . Similar trends were observed in both males and females, except for the mortality from self-inflicted injuries showing a small increase in females (data not shown). Males' rate of total injuries was, on average, three times higher than females'; and rates were all higher among males than among females for mortalities from all intents (data not shown).

Table 1. Annual deaths and mortality rates (per 100,000 population) due to injury, by intent, adolescents aged 15–19 years, Canada, 1979–2003

AAPC = average annual percent change; CL = confidence limit.

The most common causes of injury death were MVT-related injuries, firearm, suffocation, poisoning, drowning, fall, and burning (Table 2). Rates of mortality from MVT , firearm poisoning, drowning, and fall all decreased. However, rates of deaths due to suffocation increased 104.5%. These trends were seen in both males and females (data not shown). Our data also indicated that the increase in deaths from suffocation was mainly due to the increase in deaths from self-inflicted suffocation. This accounted for 86.0% of total suffocation deaths (89.9% for males and 80.2% for females), and rates of self-inflicted suffocations increased by 178.4% from 2.6 in 1979 to 7.1 in 2003 (147.1% for males and 318.7% for females) (data not shown). From all causes, especially from firearms, males had higher mortality rates than females.

Table 2. Mortality rates (per 100,000 population) due to injury, by mechanism, adolescents aged 15–19 years, Canada, 1979–2003

MVT = were motor vehicle traffic-related injury; AAPC = average annual percent change; CL = confidence limit.

Between 1986 and 2003, an average of 72.6%, 17.4%, 7.0%, and 3.0% of total injury hospitalizations was caused by unintentional injuries, self-inflicted injuries, assaults, and injuries of undetermined intent, respectively, with decreasing trends for hospitalizations due to these injuries (Table 3). Males had higher rates than females for all intents except for self-inflicted injuries, where rates were 2.5 times higher in females than in males (data not shown). Hospitalizations for unintentional and self-inflicted injuries accounted for 81.0% and 8.1%, respectively, of total injury hospitalizations in males, whereas they accounted for 57.9% and 33.9%, respectively, in females. Rates of hospitalizations from all intents showed decreasing trends in both males and females, with a small decrease (11.5%) for self-inflicted injuries in females.

Table 3. Hospitalization rates (per 100,000 population) due to injury, by intent, adolescents aged 15–19 years, Canada, excluding NB, PEI, territories, 1986–2003

MVT, poisoning, struck by/against, fall, and cut/pierce were the main causes of injury hospitalizations from 1986–2003 (Table 4). Over the study period, annual hospitalization rates demonstrated a decreasing trend for all causes of injuries except for suffocation. These trends were observed for both males and females, whereas the rates for suffocation increased 14.9% for males and 136.6% for females. Males had higher rates than females for injuries of all mechanisms except poisoning, where females had about 2.4 times higher rate than males (data not shown). For males, an average of 20.9%, 18.1%, 17.4%, 9.7%, and 6.9% of total injury hospitalizations were caused by MVT, struck by/against, fall, poisoning, and cut/pierce, respectively. The corresponding numbers for females were 21.2%, 5.7%, 11.6%, 38.1% and 4.8%, respectively (data not shown).

Table 4. Hospitalization rates (per 100,000 population) due to injury, by mechanism, adolescents aged 15–19 years, Canada, excluding NB, PEI, territories, 1986–2003

MVT = were motor vehicle traffic-related injury; AAPC = average annual percent change; CL = confidence limit.

There were some differences in injury mortality and hospitalization rates between provinces or the territories (data not shown). Mortality rates of total injuries and suicide were the highest in the territories and lowest in Ontario, whereas total injury rates in Prairie Provinces were higher than in Atlantic Provinces, and suicide rates were higher in the Prairies and Quebec than in the Atlantic and BC. Hospitalization rates of total, unintentional, self-inflicted injuries and assault were comparable in the Prairie, BC, and the territories (except the rates of self-inflicted injuries were much higher in the territories than in the Prairies and BC) but higher than in other provinces.

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Discussion 

Our study showed that from 1979 to 2003, injury was the leading cause of deaths and a major source of morbidity in Canadian adolescents aged 15 to 19 years. We also found that mortality and hospitalizations due to total and unintentional injuries decreased substantially in both adolescent males and females; but for self-inflicted injuries, they decreased on a smaller scale or even increased slightly. The leading cause of injury deaths for both genders was MVT-related injuries, followed by firearm, suffocation, poisoning, drowning, and fall for males; and by suffocation, poisoning, firearm, drowning, and fall for females. The main causes of hospitalizations were MVT, struck by/against and fall for males, and poisoning, MVT, and fall for females. We have seen decreasing trends in rates of mortality and hospitalization from all causes of injuries except from suffocation.

The finding of substantial decreases in mortality rates of total injuries and unintentional injuries in Canadian adolescents is in accordance with those reported by other countries, such as Finland [9], Sweden [10], England and Wales [11], the United States [12], Israel [13], and Mexico [14]. The total injury mortality rates in Canadian adolescents were higher than those in Finnish adolescents during the same period, but were close in 2002 [9]. Therefore, from 1979 to 2002, the injury mortality rates in Canadian adolescents declined faster than in Finland. However, the Canadian rates were lower than rates in New Zealand (for the period 1986–1995) [6], and in the USA (in 1990–2002) [12].

Canadian rates of injury hospitalizations among adolescents aged 15–19 years were lower than New Zealand's national rate in 1987–1996 [15], and urban rate in 1989–1993 [16]. Canadian rates were also lower than those in Sweden [17], Australia [18], and France [19]. However, although rates in Canada were higher than in California for 1997 [20], they were similar to the rate based on 1987 National Hospital Discharge Survey in the United States [21].

Although the mortality and hospitalization rates of total and unintentional injuries have declined significantly, those of self-inflicted injuries decreased slightly or even increased. This situation is similar to most other developed countries, such as in Finland [9], New Zealand [22], Sweden [10], [17], England and Wales [11], the United States [12], Mexico [14], and Israel [13]. In most industrialized countries including Canada, suicide ranks as the second leading cause of deaths among adolescents [7]. In Canada, suicides were responsible for an average of 19.2% of total deaths among 15–19-year-olds during the study period (12.8% in 1979 and 21.9% in 2003) (data not shown). Although the higher suicide rates in the prairies and territories (especially among males) than in other provinces could be linked to the higher rate of gun ownership in these places [23], our data indicate that rate of suicides by firearm decreased from 6.6 in 1979 to 1.5 in 2003, whereas by suffocation it increased from 2.6 to 7.1, suggesting a partial replacement effect. A study also indicated a substitution of methods for suicide after firearms became less available due to implementation of a firearm act in 1991 [24]. Data in the United States suggests that the enactment of gun laws to keep firearms from youths and the increasing use of antidepressants in the treatment of pediatric depression has contributed to the decline in the youth suicide rate [25]. However, we do not have data to confirm whether antidepressants use is a factor in the small reduction of self-inflicted injuries in Canada.

We found that although males were more than four times as likely to die from suicide attempts as females, females were more likely to attempt suicide, a situation similar to those in the United States [26] and New Zealand [6]. The reason for the gender difference in self-inflicted injury mortality and hospitalization is not fully understood. One possible reason might be related to the method of suicide. Our data and, similarly, that from New Zealand [6] indicated that males were more likely to use lethal methods such as firearm and hanging, whereas females more often used drugs (data not shown). Suicidal behavior may be associated with a complex array of factors including social and educational disadvantage, childhood and family misfortune, individual and personal vulnerabilities, exposure to stressful life events and circumstances, and social isolation, substance abuse and mental illness, with the strongest risk factors as mental and substance abuse disorders [27], [28]. A review found that school-based suicide prevention programs focusing on behavioral change and coping strategies in the general school population indicated lowered suicidal tendencies, improved ego identification and coping skills, whereas programs focusing on skill training and social support for at-risk students were effective in reducing risk factors and enhancing protective factors, with limited evidence indicating that no single intervention appeared to be effective in reducing suicide rates [28]. Therefore, suicidal prevention strategies need to be multifaceted, with priorities on improvement in recognition, treatment, and management of adolescents with mental and substance abuse disorders.

The considerable reduction in injury deaths and hospitalizations among adolescents demonstrated Canada's success in preventing adolescent injury deaths and hospitalizations. The reason behind the decline is multifactorial, such as educational campaigns, community safety programs, legislation and federal safety regulations, improved enforcement of rules and regulations, graduated driver licensing, increased use of seat belts and helmets, improved road conditions, better vehicle design and maintenance, and increased use of residential smoke detectors [2], [29], [30], [31], [32], [33], [34], [35], [36], [37]. Since 1994, nine Canadian provinces and one territory (Ontario and Nova Scotia in 1994, New Brunswick in 1996, Quebec in 1997, British Columbia and Alberta in 1998, Newfoundland in 1999, Prince Edward Island and Yukon in 2000, and Manitoba in 2003) have introduced one or more elements of graduated licensing. Significant reductions in new driver collision rates have been reported for the graduated licensing programs in Nova Scotia (19%) (37% reduction over the first 3 years of program for young drivers), BC (26%) and Ontario (31%) [38]. The early introduction of graduated licensing in Ontario and Nova Scotia may have played a role in their relatively lower hospitalization rates of MVT-related injuries than in other provinces. Studies on other countries also demonstrated the effectiveness of graduated driver licensing in reducing the crash rates of young drivers ([29], [32]).

Improved enforcement of speed limits, seat belt use, and blood alcohol concentration limits (zero for young or novice drivers and .05–.08 g/dL for more experienced drivers) may have contributed to the reduction in road traffic deaths and serious injuries [29], [37]. Studies in several countries found that enforcement of speed limits by police officers reduced road traffic deaths and serious injuries by 6%, and speed cameras or radar reached a 14% reduction [29]. Studies also indicate that publicizing the presence of speed cameras or radar increase compliance with speed laws and reduce the incidence of crashes and injury considerably [29]. Mandatory seatbelt use has been shown to be one of the greatest success stories of road injury prevention [2], [29], [35]. Studies have shown that wearing seatbelts can reduce the risk of all injuries by 40% to 50%, of serious injuries by 43% to 65%, and of fatal injuries by 40% to 60% [29]. Random breath testing, disqualification from driving after failing a test or refusing to summit to a test, and publicizing enforcement (mass media campaigns that increase public perception of the risk of being caught, reduce public acceptance of drinking and driving, and increase public acceptance of enforcement) also contribute to the reduction in alcohol-related road traffic injuries [2], [29], [34], [37].

Alcohol is a contributing factor to not only motor vehicle traffic injuries, but also to suicides, assaults, and drowning [6]. School-based and multi-faceted community-based alcohol and drug prevention programs [37], and emergency department screening and brief intervention programs [6] have been shown to be effective in reducing alcohol use and related injuries.

The decline may also be a result of improvement and expansion of passive preventive measures, such as 911 access, availability and quick response of paramedic services, surgical techniques, technological advances such as airbags and cell phones, trauma treatment centers, burn treatment centers, and regional poison control centers [29], [39]. The finding of comparable hospitalization rates but much lower mortality rates in the prairies than in the territories may suggest the effectiveness of passive prevention.

The tough gun control legislation in Canada may also attribute to the substantial decline of firearm deaths and hospitalizations. Studies found that gun death rates were highly correlated to the rate of gun ownerships and access both internationally and within Canada [23], [40], [41], and provinces with higher rates of gun ownership (such as the territories and the Prairies) had higher rates of gun deaths and injuries [23].

Limitations of this study deserve discussion. First, an individual can be admitted to a hospital more than once for the treatment of the same injuries and that injury discharge data are the number of discharges or deaths after admission for treatment of injuries. Therefore, these numbers do not represent either the number of injuries that led to the discharges or the number of injured people who were discharged from hospitals. Because hospitalized injuries represent a relatively small proportion of all nonfatal injuries, the hospitalization rates do not reflect the real picture of injury incidence. However, hospitalized injuries are generally more severe, are related to higher medical costs than those treated in outpatient clinics or at home, and are widely used to measure the burden of injury.

There are some differences between ICD-9 and ICD-10. Therefore, the change from ICD-9 to ICD-10 for cause-specific coding for death and hospitalization during our study period may cause the rates to increase for some types of injuries and to decrease for others. The difference in year of adopting ICD-10 by provinces and territories may also account for the difference in provincial or territory rate. Although modifications were made on the grouping of injuries, there might be some minor changes unaccounted for.

Because the registration of deaths in each province and territory is mandatory, missing data would be minimal. However, we could not rule out the possibility of misclassification (miscoding) of injuries by intent and cause. But the degree of misclassification of injuries by intent and by cause is unknown. In addition, we only selected teenagers in late adolescence; therefore, we could not assess the overall magnitude of injury problems in the whole teenage stage. Another limitation is the lack of information on socioeconomic status. Availability of this information would be helpful to determine whether there is any difference in the extents of injury problem between various levels of socioeconomic status.

In summary, injury has been the leading cause of adolescent deaths in Canada during 1979–2003. Canada has made remarkable progress in reducing injury mortality and hospitalization among adolescents, with substantial decreases for total injuries, unintentional injuries, and injuries of most mechanisms. However, little progress has been made for self-inflicted injuries, and more targeted prevention strategies are needed to tackle the problem. More efforts should be made to further reduce injuries among Canadian adolescents. Increasing the legal minimum drinking age (such as to 21 years of age in the United States) and driving age (from 15/16 to 18 years, as in Europe) will be beneficial. For self-inflicted injuries, an innovative, comprehensive multi-sectoral approach, including both health and nonhealth sectors, e.g. education, labor, police, justice, religion, law, politics, the media is needed to effectively deal with adolescent suicide problem. Programs on strengthening family/community support, improving skills in problem solving, conflict resolution, and nonviolent handling of disputes, and reducing alcohol and drug use should also be considered.

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