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Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: A population-based cross-sectional study
Abstract
Background
Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.
Methods
Population-based, cross-sectional study of children and youth (0–24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.
Results
There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).
Interpretation
The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.
... These preventive measures attempt to mitigate the injury burden on the refugee community and reduce the demand for fragile and limited health care and rehabilitation services in host countries [17,28,29]. This study aligns with existing literature and confirms the high prevalence of injuries among the refugee populations in Lebanon [19,30,31]. A recent local study indicated the high proportion of medical care services provided to adult Syrian refugees suffering from injuries, compared to local residents in Lebanon [19,30,31]. ...
... This study aligns with existing literature and confirms the high prevalence of injuries among the refugee populations in Lebanon [19,30,31]. A recent local study indicated the high proportion of medical care services provided to adult Syrian refugees suffering from injuries, compared to local residents in Lebanon [19,30,31]. Moreover, regional studies reported that injuries were the leading cause of hospitalization among the refugee population compared to host community [32]. ...
... Moreover, regional studies reported that injuries were the leading cause of hospitalization among the refugee population compared to host community [32]. This discrepancy in injury rates was confirmed by various studies examining the risk of injuries among refugees globally; a Canadian study reported an increased rate of motor vehicle injuries, poisoning, suffocation, and overall injury-related hospitalization and mortality among individuals seeking asylum or refugees [30]. A comparable study conducted in Denmark revealed high rates of fatal injuries among refugees [33]. ...
Background
Refugees are prone to higher risks of injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and to examine injury characteristics, risk factors, and outcomes.
Methods
We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the ‘Surgeons Overseas Assessment of Surgical Need (SOSAS)’ tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.
Results
750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value = 0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs. 13.3%, p value = 0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.
Conclusions
Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching about heating and cooking safety practices.
... Each year, millions of people sustain non-fatal injuries that require emergency department (ED) visits and hospitalizations, impacting individuals' health and exerting financial pressure on health care systems [3]. The interplay of multiple intrinsic factors (eg, age, gender, education, socio-economic status) and extrinsic factors (eg, external environment, available and accessible health care service) strongly impact the frequency and severity of individual injuries [4][5][6][7][8]. Major discrepancies in the distribution of the global burden of injury-related mortality and morbidity are noted, with a substantial human and economic impact in low-and middle-income countries (LMICs) [9]. ...
... Consistent with existing studies, a predominance of male injuries in both resident and refugee communities was noted, with a slightly larger proportion of injuries among male refugees (68.7% vs 61.8%) [7,27]. The refugees' male workforce exposure to hazardous occupations in industrial or construction sites may increase their vulnerability to injuries. ...
... In particular, refugees mostly work as construction workers in Lebanon, with hazardous work environments and an evident lack of proper safety measures adopted at construction and industrial sites [29][30][31][32]. Similar evidence has been noted in a recent Canadian study indicating that refugees and recent immigrants have a higher risk of occupational safety hazards as they are less likely to receive information on safety and health or undergo formal job training [7]. Refugees typically performed more physically demanding jobs without the use of proper safety protection gears, which increase their risk for injury [24]. ...
Background:
Refugees are susceptible to various types of injury mechanisms associated with their dire living conditions and settlements. This study aims to compare and characterize the emergency department admissions due to physical trauma and injuries among local residents and refugees in greater Beirut.
Methods:
This epidemiological study analyzes injury incidence and characteristics of patients presenting to Emergency Departments of 5 sentinel hospitals between 2017 and 2019. Using the WHO Injury Surveillance Guidelines and Pan-Asia Trauma Outcomes Study form, an injury data surveillance form was designed and used in hospital settings to collect data on injuries. Chi-square test analysis was performed to compare differences in injury characteristics between local residents and refugees. Regression models were constructed to assess the effect of being a refugee on the characteristics of injuries and outcomes of interest.
Results:
A total of 4847 injuries (3933 local residents and 914 refugees) were reported. 87.4% of the total injuries among refugees were sustained by the younger age groups 0-45 years compared to 68.8% among local residents. The most prevalent injury mechanism was fall (39.4%) for locals and road traffic injury (31.5%) for refugees. The most injured body part was extremities for both populations (78.2% and 80.1%). Injuries mostly occurred at home or its vicinity (garden or inside the camp) for both populations (29.3% and 23.1%). Refugees sustained a higher proportion of injuries at work (6%) compared to locals (1.3%). On multivariate analysis, refugee status was associated with higher odds of having an injury due to a stab/gunshot (odds ratio (OR) = 3.392, 95% confidence interval (CI) = 2.605-4.416), having a concussion injury (OR = 1.718, 95% CI = 1.151-2.565), and being injured at work (OR = 4.147, 95% CI = 2.74-6.278). Refugee status was associated with increased odds of leaving the hospital with injury-related disability (OR = 2.271, 95% CI = 1.891-2.728)].
Conclusions:
Injury remains a major public health problem among resident and refugee communities in Beirut, Lebanon. Refugees face several injury-related vulnerabilities, which adversely affect their treatment outcomes and long-term disabilities. The high prevalence of occupational and violence-related injuries among refugees necessitates the introduction of targeted occupational safety and financial security interventions, aiming at reducing injuries while enhancing social justice among residents.
... A., 2018 [36] n = 999, 951-total number of immigrants 153, 822-refugees 846, 129-nonrefugees Unintentional injuries among immigrant and refugee children/ The majority of immigrants were from South Asia and East Asia and the Pacific. The largest proportion of Cross-sectional population-based survey using linked health, administrative and immigration data There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee migrants, respectively. ...
... In addition to the aforementioned health problems, one of the reasons for the need for urgent medical care is unintentional injuries. Refugee immigrants have a 20% higher rate of unintentional injuries compared to non-refugee immigrants [36]. Surgical care in refugee children also includes routine surgical problems such as inguinal hernia and appendicitis, non-war-related injuries and gynaecological problems [16]. ...
Background:
After the invasion of Ukraine, neighbouring countries were forced to find systemic solutions to provide medical care to those fleeing the war, including children, as soon as possible. In order to do this, it is necessary to know the communication problems with refugee minors and find proposals for their solutions.
Methods:
A systematic review of the literature from 2016 to 2022 was conducted according to PRISMA criteria.
Results:
Linguistic diversity and lack of professional readiness of teachers are the main constraints hindering the assistance of refugee children in schools. Problems during hospitalization include lack of continuity of medical care and lack of retained medical records. Solutions include the use of the 3C model (Communication, Continuity of care, Confidence) and the concept of a group psychological support program.
Conclusions:
In order to provide effective assistance to refugee minors, it is necessary to create a multidisciplinary system of care. It is hoped that the lessons learned from previous experiences will provide a resource to help refugee host countries prepare for a situation in which they are forced to provide emergency assistance to children fleeing war.
... Therefore, we think that work-related injuries are similarly more common in refugee children in the present study. Causes of injuries in refugee children differ due to socioeconomic conditions, traditional behaviors, and different living conditions during or after the migration [15]. Duramaz et al. showed that some of the refugees treated in Turkey due to firearm injuries [16]. ...
... The literature has been stated that difficult living conditions are the basis of injuries (burn traumas, fractures, deaths and psychological problems, etc.) in refugee children [3,4,11,15]. Although we could not concretely examine the reasons that increase the frequency of high-energy trauma-related injuries in refugee children in our study, we think that those reasons should be considered as a whole. ...
PurposeSeveral factors affect injury types in childhood. The aim of the study was to evaluate the musculoskeletal injury types, treatment modalities, and demographic characteristics of refugee children and to reveal the differences from native children.MethodsA total of 1297 patients (897 females, 400 males) treated in our clinic between January 2014 and January 2019 were included in the study. The mean age of the patients was 8.9 ± 5.1 in refugees and 7.5 ± 4.6 in the native group (range, 0–18 years). The patients were evaluated in terms of age, gender, mechanism of injury, location and type of fracture, presence of accompanying injuries, surgical technique, complications, and treatment modalities.ResultsThe trauma mechanism differed significantly between the groups, high-energy traumas such as falling from a height, fight/assault injury, gunshot injury, and work injury were found more frequently in the refugee group (p = 0.001). The rates of CRIF, ORIF, graft/flap surgery, and hospitalization time were observed to be significantly higher in the refugee group (p = 0.013). No significant difference was observed between groups in terms of demographic distribution, injury location, and complications.Conclusion
This population-based, cross-sectional study emphasizes that the refugee children have different injury mechanisms. Improved living conditions may reduce musculoskeletal injury in this population.
... 21 In one study the patients presented with the complaint suggestive of head injury, fractures, skin injuries and burn injuries. 20,25 The common cause of head injury was assault however, the motor vehicle accidents were less prevalent (probably due to limited access in refugee camps). 20 Although studies have tried to identify the causes of traumatic brain injury and recognized TBI as a significant cause of morbidity but the details are restricted by paucity of published data and further most of these studies are restricted to single center studies. ...
... Studies have further highlighted, refugee patients population usually prefer to use emergency services instead of regular outpatient's services, as these are easily available, affordable and accessible. 20,25 ...
Background and objectives. Due to marked increase in violence, the world is facing problem of refugee population either as a source of refugee population or shelter provider. These refugee population is exposed to prolonged physical and emotional distress over years, may result into spectrum of neuropsychiatric disease conditions including traumatic brain injury (TBI). Although trauma is one of the major events faced by refugee population, the exact details of the injuries still not documented and there is paucity of published literature; further these injuries may be recorded as unspecified.
Methods. The present article is intended to provide a theoretical overview of existing knowledge and gaps on trauma and injuries in the refugee population. Authors analysed all relevant articles available on PubMed and Medline using the keywords: “Refugee”, “Traumatic Brian Injury”, “Head Injury”.
Results. There is a gap in knowledge for this particular demographic population. They suffer a wide range of physical and emotional to social traumatic events. The most common cause of head injury was assault; however, motor vehicle accidents were less prevalent, and there is an ongoing struggle for resources to fulfil basic needs leading to health care taking a backseat. There is high prevalence of post-traumatic stress disorder. Many of the refugees are settled in relative economically poorer countries which further add to the burden of a nation already besotted with internal requirements. There is a need for international collaboration to tackle unique problem.
Conclusion. Authors recommend urgent need to handle the root causes responsible for the generation of refugee population and at the same time it is necessary to identify the epidemiology, patterns, management challenges and consequences of injuries and barriers to seek and provide care in refugee population.
... more injuries compared to their non-refugee immigrant counterparts (47). Given differential injury risk exposure among immigrant population, it is critical to collect and analyse disaggregated data by ethnocultural groups to identify speci c risk and protective factors within each community (48). ...
Background Despite existing prevention initiatives, preventable unintentional home injuries remain a significant public health concern in Canada, and are often influenced by the social determinants of health. This study identified dissemination-area-level hotspots of unintentional home injuries resulting in hospitalizations across British Columbia (B.C.), Canada, from 2015 to 2019, and it’s examined their relationship with multiple deprivation indexes. Methods Unintentional home injury hospitalization data from B.C., Canada, (2015–2019) were obtained from the Discharged Abstract Database. These data were then linked with dissemination area (DA) level data and the Canadian Index of Multiple Deprivation (CIMD) for B.C. Spatial autocorrelation was assessed using Moran's I, and hotspot analysis was performed using the Getis-Ord Gi* statistic. Crude injury rates for each DA were calculated. Geospatial and bivariate analysis were examined using ArcGIS Pro. Results Between 2015 and 2019, the annual rate of unintentional home injuries leading to hospitalization in B.C. was 256.5 per 100,000 population. Unintentional home injuries leading to hospitalizations in B.C. were significantly clustered (Moran’s I = 0.05, z-score = 38.53, and p-value = 0.000). A total of 1,183 hotspots and 3,130 cold spots across DAs in B.C. were identified. Significant hotspots (99% CI, z-score > 2.58) were found in the southern B.C. region, especially across Thompson-Okanagan region and Vancouver Island, indicating that higher unintentional home injury rates were clustered in urban areas and larger population centres. In urban hotspots, bivariate analysis showed a positive relationship between unintentional home injury rates and economic dependency, residential instability, and situational vulnerability, and an inverse relationship with ethnocultural composition. Conclusion This geospatial analysis identified urban clusters in B.C. with higher unintentional home injury rates, particularly in areas of socioeconomic deprivation. These findings provide valuable insights into high-risk areas for implementing tailored injury prevention programs and policies.
... 3 Remarkably, 76% of the 30.4 million refugees globally residing in LMICs, experience amplified vulnerability due to a multitude of obstacles associated with their living and working conditions, and resulting in injuries including occupational injuries, road injuries, and interpersonal violence. [3][4][5][6] The risk of various injuries increases due to the nature of labor they endure in hazardous working places such as working in agricultural fields adjacent to major highways which increase their occupational injuries and nearly doubles their road traffic mortality risk compared to local residents. [7][8][9][10] Regional conflicts and war heighten injury risks and increase the incidence of gunshot wounds, traumatic brain injury and psychological trauma. ...
Background
The global refugee crisis presents a major public health challenge, with Syrian refugees in Lebanon facing a heightened injury burden. This population experiences 2.5 times more occupational injuries, with 1 in 5 suffering burns and 1 in 30 sustaining conflict-related injuries, among other trauma types. This study explores refugee injuries to inform targeted interventions and policies.
Methods
This study builds on the Surgeons Overseas Assessment of Surgical Need framework to explore injured refugees’ perspectives and barriers to healthcare access. An ethnographic-inductive approach was employed, combining direct participation and thematic analysis of interviews. The interviews were conducted in colloquial Arabic with a sample of adult Syrian refugees with unmet surgical or healthcare needs and took place in participants’ dwellings, following an interview guide, and were audio-recorded, transcribed, and analyzed using thematic analysis.
Results
A total of 17 participants were included. Findings indicate participants live with family members in suboptimal dwellings, have unsustainable work conditions, strained community relationships, and sustained injuries from violence, occupations, and war. The healthcare they have received seemed inadequate, delayed, and limited to specific services, leading to incomplete recovery and adverse impacts on their quality of life.
Conclusions
Syrian refugees in Lebanon face significant challenges in accessing equitable healthcare for injuries, resulting in prolonged suffering, incomplete recovery, and financial difficulties. Lebanon’s privatized healthcare system, combined with insufficient humanitarian support, exacerbates these barriers. Addressing these issues requires a multifaceted approach, including subsidized healthcare programs, mobile medical units in refugee-dense areas, targeted injury prevention initiatives, and expanding mental health services for injured refugees.
... En primer lugar, respecto al uso de urgencias asociado a barreras de acceso a servicios de salud que afectan particularmente a población migrante irregular [14,45], es preciso fortalecer los mecanismos que a nivel regional garanticen cobertura sanitaria y acceso a Salud de niños, niñas y adolescentes migrantes de América Latina y el Caribe servicios de prevención y promoción de salud de niños, niñas y adolescentes migrantes. Esto, de manera independiente de la condición migratoria en que se encuentren ellos y/o sus padres, de modo de reducir el uso de urgencias y hospitalizaciones evitables [46], y aumentar la cobertura de los programas preventivos. Acciones intersectoriales coordinadas con el sector educación son clave en la disminución de brechas de afiliación. ...
The presence of children and adolescents in migratory flows is growing in Latin America and the Caribbean. Little is known about migration's effects on these groups' health. This article aims to investigate the evidence available on the access and use of healthcare services by migrant children and adolescents in Latin America and the Caribbean. We seek to explore the role of social determinants of health at different levels in the health conditions of these groups. Also, to identify potential recommendations for healthcare systems and public policy to address them. For this purpose, a narrative review of 52 publications was carried out based on a search of scientific literature in the Web of Science and Google Scholar databases. Five relevant topics were identified: use of emergency care associated with lack of healthcare access, preventive services, and other social determinants of health; exposure to preventable infectious diseases; mental health; sexual and reproductive health; and vaccinations and dental health. We conclude that the evidence shows the need to address the inequities and disadvantages faced by migrant children from a perspective of social determinants of health and policies that consider health as a human right regardless of the migratory status of children and adolescents, as well as that of their parents or primary caregivers.
... Within young individuals with LMM, substantial disparity between migrants, particularly refugees and native-born have been reported in numerous studies (4)(5)(6)(7). Exposure to trauma and adversities, uncertainties of settlement and post-migration living difficulties make young refugees particularly vulnerable and more susceptible to adverse health outcomes and poor social integration when compared to their native-born peers (4,8,9). As in many European countries, and also worldwide, the population of refugees increased in recent decades (8, 10), understanding the relation between health status and LMM among young refugees is of critical importance. ...
Background
Common mental disorders (CMDs), multimorbidity, and refugee status are associated with poor labor market outcome. Little is known about how these factors interact in young adults.
Objective
We aimed to i) investigate whether the association of CMDs and multimorbidity with labor market marginalization (LMM) differs between refugee and Swedish-born young adults and ii) identify diagnostic groups with particularly high risk for LMM.
Methods
This longitudinal registry-based study included individuals aged 20–25 years followed from 2012 to 2016 in Sweden (41,516 refugees and 207,729 age and sex-matched Swedish-born individuals). LMM was defined as granted disability pension (DP) or > 180 days of unemployment (UE). A disease co-occurrence network was constructed for all diagnostic groups from 2009 to 2011 to derive a personalized multimorbidity score for LMM. Multivariate logistic regression was used to estimate odds ratios of LMM in refugee and Swedish-born youth as a function of their multimorbidity score. The relative risk (RR, 95% CI) of LMM for refugees with CMDs compared to Swedish-born with CMDs was computed in each diagnostic group.
Results
In total, 5.5% of refugees and 7.2% of Swedish-born with CMDs were granted DP; 22.2 and 9.4%, respectively received UE benefit during follow-up. While both CMDs and multimorbidity independently elevated the risk of DP considerably in Swedish-born, CMDs but not multimorbidity elevated the risk of UE. Regarding UE in refugees, multimorbidity with the presence of CMDs showed stronger estimates. Multimorbidity interacted with refugee status toward UE (p < 0.0001) and with CMDs toward DP (p = 0.0049). Two diagnostic groups that demonstrated particularly high RR of UE were schizophrenia, schizotypal and delusional disorders (RR [95% CI]: 3.46 [1.77, 6.75]), and behavioral syndromes (RR [95% CI]: 3.41 [1.90, 6.10]).
Conclusion
To combat LMM, public health measures and intervention strategies need to be tailored to young adults based on their CMDs, multimorbidity, and refugee status.
... [23][24][25] The variation seen in seeking a medical consultation for the different types of injuries may be attributable to factors such as injury severity, general awareness, household income/education and health care access. 13,23,26,27 ...
This work provides an overview of injury patterns in Canadian children and youth aged 1 to 17 years. Self-reported data from the 2019 Canadian Health Survey on Children and Youth were used to calculate estimates for the percentage of Canadian children and youth who experienced a head injury or concussion, broken bone or fracture, or serious cut or puncture within the last 12 months, overall and by sex and age group. Head injuries and concussions (4.0%) were the most commonly reported, but the least likely to be seen by a medical professional. Injuries most frequently occurred while engaging in sports, physical activity or playing.
... Moreover, injuries were the leading cause of hospitalization among refugees, accounting for nearly 19.8% of hospitalizations compared to 14.9% among the host community (29). This discrepancy in injury rates has been documented in various countries; a Canadian study reported an increased rate of motor vehicle injuries, poisoning, suffocation, and overall injury-related hospitalization and mortality among refugees (27). A similar study conducted in Denmark revealed high rates of fatal injuries among refugees (30). ...
Background: Refugees are prone to injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and examine injury characteristics, risk factors, and outcomes.
Methods: We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the ‘Surgeons Overseas Assessment of Surgical Need (SOSAS)’ tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.
Results: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value=0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs 13.3%, p-value=0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.
Conclusions: Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching heating and cooking safety practices.
... The percent of the population that are visible minorities and recent immigrants together form the "ethnic concentration" index of the ON-Marg. These factors were examined separated for this study as the two populations have different associations with injury as well as transportation patterns (Kunaratnam et al., 2022;Saunders et al., 2018b). The proportion of recent immigrants (immigrated between 2011 and 2016, the five years prior to the census) and visible minorities by CT were extracted from the 2016 Canadian census (CHASS, 2020). ...
Background
Important inequities in child pedestrian-motor vehicle collisions (PMVC) have been observed. The mechanism through which social dimensions influence child PMVC is not well understood, nor is the role of the roadway-built environment.
Methods
The relationship between area-level social dimensions (material deprivation, proportion recent immigrants, proportion visible minority) and police-reported child PMVC between 2010 and 2018 in Toronto, Canada was examined using multivariable negative binomial regression models, controlling for built environment covariates.
Results
All social dimensions were significantly associated with child PMVC, including material deprivation (Incidence Rate Ratio (IRR–adjusted): 1.31, 95 % Confidence Interval (CI): 1.22–1.40), recent immigrant proportion (IRR adjusted: 1.58, 95 %CI: 1.30–1.92, per 10 % increase), and visible minority proportion (IRR adjusted: 1.09, 95 %CI: 1.05–1.12, per 10 % increase). Built environment features did not attenuate these associations.
Conclusion
This study provides evidence of social inequalities in child PMVC, suggesting a need to target traffic safety interventions towards the most socially marginalized areas.
... The percent of the population that are visible minorities and recent immigrants together form the "ethnic concentration" index of the ON-Marg. These factors were examined separated for this study as the two populations have different associations with injury as well as transportation patterns (Kunaratnam et al., 2022;Saunders et al., 2018b). The proportion of recent immigrants (immigrated between 2011 and 2016, the five years prior to the census) and visible minorities by CT were extracted from the 2016 Canadian census (CHASS, 2020). ...
... Similarly, a Canadian study showed that the risk of unintentional injury for children with poor family nancial status was 1.67 times that of children with good family nancial status [25] . Furthermore, Saunders et al. [26] conducted a survey of 999,951 people aged 0-24 who immigrated to Canada and found that the incidence of unintentional injuries among refugees was 1.20 times (95% CI: 1.40, 1.62) that among non-refugees. This may be related to the poor living environment which leads fewer protective factors and poor supervision and management from family members for the children with CP. ...
In recent years, the incidence of accidental injuries among disabled children increased, including children with cerebral palsy(CP). However, there are few reports on the characteristics and risk factors of unintentional injuries in children with cerebral palsy. Therefore, we collected 117 children with CP as the research objects, and analyzed the characteristics and influencing factors of unintentional injuries of them to provide effective preventive measures and reduce the incidence of accidental injuries in children with CP. Results reveal that the incidence of once unintentional injuries in children with CP in the past 3 months was 32.47%, and the incidence of re-injury was 3.4%, which was lower than that of normal or disabled children. In addition, our research also found that the causes of unintentional injuries of children with CP were mainly fall. The injured parts were mainly lower limbs and head and neck. The injuries mainly occured indoors, and most unintentional injuries occurred during when resting, sleeping or relaxing. Multivariate logistic regression analysis of this study found that girls, low family income and less time with their parents were risk factors for unintentional injuries in children with CP.
... Sosyoekonomik dezavantajlar, daha spesifik olarak söylemek gerekir ise düşük gelir ve ebeveynlerdeki düşük eğitim seviyesi; çocukluk çağındaki travmalar için önemli bir risk faktörü kabul edilmektedir (2)(3)(4). Bununla birlikte, göçmen ve mülteci statüsü de dahil olmak üzere diğer sosyal kırılganlıklar daha az incelenmiştir ve bunların yaralanma riski üzerindeki etkileri henüz tam olarak ortaya konulamamıştır (5). Yıllar içinde giderek artan göçmenlik olgusunun travma üzerindeki rolüne etki eden bu faktörler aydınlatılabilirse, çocuklarda ve gençlerde hedefe yönelik travma önleme planlamaları da yapılabilecektir. ...
Introduction:In recent years, Turkey has become a destination for many Syrian refugees due to the civil war. The objective of our study was to describe the epidemiological characteristics of injuries among refugee children admitted to our tertiary clinic and compare them with Turkish children.Methods:This retrospective study was conducted between December 2013 and December 2017. Syrian refugees were compared with the local population according to the epidemiology of the trauma. Data on age, gender, trauma mechanism, trauma type, first referral center, transfer status, affected body region, affected organ, injury severity score, hospitalization in intensive care unit and pediatric surgery clinic, need for mechanical ventilation and operation, and clinical course were noted.Results:Four hundred fifteen Turkish citizens and 46 Syrian refugees were enrolled. The median age was similar (8 and 9; respectively) (p=0.815), but there were more boys among the refugees (65.3% and 80.4%; respectively) (p=0.025). The causes of trauma, type of trauma, transfer status, affected body region, need for mechanical ventilation, need for operation, and discharge status were similar between the groups. Lung trauma was more common in refugees than in Turkish patients (21.7% and 9.6%, respectively) (p=0.018). The rate of admission to intensive care unit was higher among Syrian children (p0.05).Conclusion:The findings suggest that the injury characteristics were similar between refugees and local children. We suppose that the higher incidence of intensive care unit admission among refugees was due to the fact that lung injury and high energy trauma mechanisms such as fall from heights or motor vehicle accident were more common in Syrian refugee children. We suggest that preventive measures and parenteral education would contribute to decrease the prevalence of traumatic injuries.
... The study reported a 20% higher rate of unintentional injury in refugee youth compared with non-refugee immigrant youth for most causes of injury, with notably higher rates of motor vehicle injuries, poisonings, suffocation and scald burns. 66 However, to our knowledge, there are no studies that provide data on the prevalence of disability or its effect on the health and development of children on the move. ...
Background
Europe has experienced a marked increase in the number of children on the move. The evidence on the health risks and needs of migrant children is primarily from North America and Australia.
Objective
To summarise the literature and identify the major knowledge gaps on the health risks and needs of asylum seeking, refugee and undocumented children in Europe in the early period after arrival, and the ways in which European health policies respond to these risks and needs.
Design
Literature searches were undertaken in PubMed and EMBASE for studies on migrant child health in Europe from 1 January 2007 to 8 August 2017. The database searches were complemented by hand searches for peer-reviewed papers and grey literature reports.
Results
The health needs of children on the move in Europe are highly heterogeneous and depend on the conditions before travel, during the journey and after arrival in the country of destination. Although the bulk of the recent evidence from Europe is on communicable diseases, the major health risks for this group are in the domain of mental health, where evidence regarding effective interventions is scarce. Health policies across EU and EES member states vary widely, and children on the move in Europe continue to face structural, financial, language and cultural barriers in access to care that affect child healthcare and outcomes.
Conclusions
Asylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ from children in the local population. Major knowledge gaps were identified regarding interventions and policies to treat and to promote the health and well-being of children on the move.
Background:
This study investigated the quality of inpatient care provided to Afghan immigrants in Iran during the COVID-19 pandemic (February 2019 to March 2021). For this purpose, the services received by Afghan immigrants were compared with those received by Iranian citizens.
Methods:
Two emergency services (traumas with 8080 victims and 8,686 patients hospitalized with severe COVID-19 infection) were taken into consideration. The records of all patients, including the Afghan immigrants, in two referral hospitals in Kerman were reviewed, and the main variables were the length of hospitalization (LoH), intensive care unit (ICU) admission rate, and death rate. Quantile regression, multiple logistic regression, and Cox regression were used to analyze the data.
Results:
The median and interquartile range of LoH for Afghan and Iranian nationals admitted due to traumas were 3.0±4.0 and 2.0±4.0, respectively (P<0.01). Moreover, the chance of Afghan nationals being admitted to the ICU (38%, odds ratio=1.38; 95% confidence interval [CI]=1.12; 1.69) and the hazard of death (60%, hazard rate=1.60; 95% CI=1.03; 2.49) were higher compared to Iranian nationals, which is statistically significant. However, no significant differences were observed between the COVID-19 patients from the two nationalities in terms of the median LoH, the odds of being admitted to the ICU, and the hazard of death due to COVID-19.
Conclusion:
Afghan nationals admitted to the hospital due to traumas were more likely to be admitted to ICUs or die compared to Iranian citizens. It seems that Afghan patients who had traumas went to the hospitals with more serious injuries. There was no difference between Afghan and Iranian patients in terms of COVID-19 consequences. Following the findings of this study, it seems that justice in treatment has been fully established for Afghan patients in Iran.
This study describes the extent, quality and cultural appropriateness of current research on the health conditions of refugee children aged 0-6 years settled in high-income countries. A systematic review was conducted, including original articles published on the health conditions experienced by refugee children. A total of 71 papers were included. The studies varied considerably in their research design, population characteristics and health conditions. Studies included information on 37 different health conditions, with the majority non-communicable diseases, in particular growth, malnutrition and bone density. Although the studies identified a wide range of health issues, a coordinated effort to prioritise research on particular health topics was lacking, and health conditions studied do not align with the global burden of disease for this population. Additionally, despite being rated medium-high quality, most studies did not describe measures taken to ensure cultural competency and community involvement in their research. We suggest a coordinated research effort for this cohort, with greater emphasis on community engagement to improve the evidence-base of the health needs of refugee children after settlement.
Cet article fournit un aperçu des profils de blessures subies par les enfants et les jeunes canadiens de 1 à 17 ans. Les données autodéclarées tirées de l’Enquête canadienne sur la santé des enfants et des jeunes (ECSEJ) de 2019 ont servi à calculer les estimations du pourcentage d’enfants et de jeunes canadiens qui ont subi un traumatisme crânien ou une commotion cérébrale, une fracture ou une fêlure ou encore une coupure ou une perforation grave au cours des 12 derniers mois, en général et selon le sexe et le groupe d’âge. Les traumatismes crâniens et les commotions cérébrales (4,0 %) sont les blessures les plus fréquemment déclarées, mais les moins susceptibles d’être évaluées par un professionnel de la santé. Les blessures ont lieu le plus souvent lors de la pratique d’un sport, d’une activité physique ou d’un jeu.
In recent years, the immigration of Venezuelan citizens to the Republic of Colombia has increased1. Although some research has shown a difference in the presentation of medical conditions in these individuals, there are still no studies evaluating the epidemiology of trauma in this population2,3. The objective of the present study was to compare the characteristics of trauma in the native Colombian population versus the Venezuelan immigrant population using the Institutional Trauma Registry of the Hospital Universitario de Santander (RITHUS) in its first year of implementation.
In recent years, the immigration of Venezuelan citizens to the Republic of Colombia has increased1. Although some research has shown a difference in the presentation of medical conditions in these individuals, there are still no studies evaluating the epidemiology of trauma in this population2,3. The objective of the present study was to compare the characteristics of trauma in the native Colombian population versus the Venezuelan immigrant population using the Institutional Trauma Registry of the Hospital Universitario de Santander (RITHUS) in its first year of implementation.
Purpose:
Study purpose was to describe the child safety injury experiences, injury prevention behaviors and educational needs of immigrant Vietnamese women on Jeju Island, and to explore associations among those factors.
Methods:
A descriptive correlational study was conducted using structured questionnaires to collect data from immigrant Vietnamese women who visited a multicultural centers on Jeju Island from January to April, 2017.
Results:
Data from 60 women were analyzed. They were 28.2±5.5 years old, had resided in Korea for 40.6±31.1 months, and had 1.5±0.6 children on average. In total, 51.7% had previous injury prevention education, 68.2% had experienced child safety injuries, and 95.0% wanted to receive education on how to prevent child safety injuries. The mean total score of child injury prevention behaviors was 27.33±17.79, and that variable was associated with a longer duration of formal education (t=2.41, p=.021) and with women's experiences of child safety injury (t=5.97, p<.001).
Conclusion:
Immigrant Vietnamese women experienced a higher frequency of child safety injuries and needed educational opportunities to prevent these injuries. Further research is necessary to develop the essential content and effective methods for education on child safety injury prevention among this unique multicultural population.
Background
Homicide is an extreme expression of violence that has attracted less attention from public health researchers and policy makers interested in prevention. The purpose of this study was to examine the socioeconomic gradient of homicide and to determine whether risk differs by immigration status.
Methods
We conducted a population-based cohort study using linked vital statistics, census and population data sets that included all deaths by homicide from 1992 to 2012 in Ontario, Canada. We calculated age-adjusted death rates for homicide by material deprivation quintiles, stratified by immigration status. Count-based negative binomial regression models were used to calculate unadjusted and adjusted rate ratios with predictors of interest being age, urban residence, material deprivation and immigration status. A subanalysis containing immigrants only examined the effect of time since immigration and immigration class.
Results
There were 3345 homicide deaths registered between 1992 and 2012. Relative to low material deprivation areas, age-adjusted rates of homicide deaths in high materially deprived areas were similar among refugees (RR: 48.49; 95% CI 36.99 to 62.45) and long-term residents (RR: 47.67; 95% CI 44.66 to 50.83), but were slightly lower for non-refugee immigrants (RR: 38.53; 95% CI 32.42 to 45.45). Female refugees experienced a 1.31 (95% CI 0.88 to 1.94) higher rate and male refugees experienced a 1.23 (95% CI 0.90 to 1.67) higher rate of homicide victimisation compared with long-term residents. In an immigrant only analysis, the risk of homicide among refugees increased with duration of residence.
Conclusions
Given the large area-level, socioeconomic status gradients observed in homicides among refugees, community-level and culturally appropriate prevention approaches are important.
Local efforts in global health are a rising area of focus as multigenerational immigrant communities continue to grow in the United States. Immigrant and refugee children are at risk for poor health outcomes due to environmental, social, economic, and individual factors that contribute to inequities in participation within the health care system. This case-based reflection brings to light specific manifestations of the aforementioned factors. Addressing these barriers will promote health equity and allow children, regardless of background, to reach their full potential.
Unintentional injury remains an important global public health issue, and efforts to address it are often hampered by a lack of visibility, leadership, funding, infrastructure, capacity and evidence of effective solutions. The growing support for a socioecological model and a systems approach to prevention—along with the acknowledgement that injury prevention can be a byproduct of salutogenic design and activities—has increased opportunities to integrate unintentional injury prevention into other health promotion and disease prevention agendas. It has also helped to integrate it into the broader human development agenda through the Sustainable Development Goals. This growing support provides new opportunities to use a human rights-based approach to address the issue. The human rights-based approach is based on the idea that all members of society have social, economic and cultural rights and that governments are responsible and accountable for upholding those rights. It incorporates a systems approach, addresses inequity and places an emphasis on the most vulnerable corners of humanity. It also leverages legal statutes and provides organisations with the opportunity to build existing international goals and benchmarks into their monitoring efforts. This paper describes the approach and highlights how it can leverage attention and investment to address current challenges for unintentional injury.
Background
Ontario, the most populous province in Canada, has a universal healthcare system that routinely collects health administrative data on its 13 million legal residents that is used for health research. Record linkage has become a vital tool for this research by enriching this data with the Immigration, Refugees and Citizenship Canada Permanent Resident (IRCC-PR) database and the Office of the Registrar General’s Vital Statistics-Death (ORG-VSD) registry. Our objectives were to estimate linkage rates and compare characteristics of individuals in the linked versus unlinked files. Methods
We used both deterministic and probabilistic linkage methods to link the IRCC-PR database (1985–2012) and ORG-VSD registry (1990–2012) to the Ontario’s Registered Persons Database. Linkage rates were estimated and standardized differences were used to assess differences in socio-demographic and other characteristics between the linked and unlinked records. ResultsThe overall linkage rates for the IRCC-PR database and ORG-VSD registry were 86.4 and 96.2 %, respectively. The majority (68.2 %) of the record linkages in IRCC-PR were achieved after three deterministic passes, 18.2 % were linked probabilistically, and 13.6 % were unlinked. Similarly the majority (79.8 %) of the record linkages in the ORG-VSD were linked using deterministic record linkage, 16.3 % were linked after probabilistic and manual review, and 3.9 % were unlinked. Unlinked and linked files were similar for most characteristics, such as age and marital status for IRCC-PR and sex and most causes of death for ORG-VSD. However, lower linkage rates were observed among people born in East Asia (78 %) in the IRCC-PR database and certain causes of death in the ORG-VSD registry, namely perinatal conditions (61.3 %) and congenital anomalies (81.3 %). Conclusions
The linkages of immigration and vital statistics data to existing population-based healthcare data in Ontario, Canada will enable many novel cross-sectional and longitudinal studies to be conducted. Analytic techniques to account for sub-optimal linkage rates may be required in studies of certain ethnic groups or certain causes of death among children and infants.
Background:
Although immigrants tend to be healthier than the Canadian-born population when they arrive, subgroups, notably different immigration categories, may differ in health and health care use. Data limitations have meant the research has seldom focused on category of immigrant-economic, family or refugee. A newly linked database has made it possible to study acute care hospitalization by immigration category and source region.
Data and methods:
The Immigrant Landing File-Hospital Discharge Abstract Linked Database (n = 2.6 million) was used to derive sex-specific crude and age-standardized hospitalization rates (ASHRs) per 10,000 population for all-cause and leading causes of hospitalization during the 2006/2007-to-2008/2009 period.
Results:
Economic class immigrants had lower all-cause ASHRs than did their family class or refugee counterparts. Male refugees had high ASHRs overall and for circulatory diseases, digestive diseases, injury, and cancer. Female differences by immigrant class were less pronounced. All-cause ASHRs (excluding pregnancy) rose with years since arrival in Canada for male and female immigrants. Immigrants from East Asia had the lowest ASHRs; those from the United States, the highest.
Interpretation:
Although hospital use is an imperfect indicator of health status, this study supports an initial healthy immigrant effect and its subsequent decline. Marked differences emerged among immigrant subgroups with some, notably refugees and immigrants from the United States, having significantly higher hospitalization rates overall and for leading causes, compared with other groups.
Background:
Guidelines recommend children and young people participate in at least 60 min of physical activity (PA) every day, however, findings from UK studies show PA levels of children vary across ethnic groups. Since parents play an instrumental role in determining children's PA levels, this article aims to explore parental views of children's PA in a multi-ethnic sample living in a large city in the North-West of England.
Methods:
Six single-ethnic focus groups were conducted with 36 parents of school-aged children (4 to 16 years) with a predominantly low socio-economic status (SES). Parents self-identified their ethnic background as Asian Bangladeshi (n = 5), Black African (n = 4), Black Somali (n = 7), Chinese (n = 6), White British (n = 8) and Yemeni (n = 6). Focus group topics included understanding of PA, awareness of PA guidelines, knowledge of benefits associated with PA and perceived influences on PA in childhood. Data were analysed thematically using QSR NVivo 9.0.
Results:
Parents from all ethnic groups valued PA and were aware of its benefits, however they lacked awareness of PA recommendations, perceived school to be the main provider for children's PA, and reported challenges in motivating children to be active. At the environmental level, barriers to PA included safety concerns, adverse weather, lack of resources and lack of access. Additional barriers were noted for ethnic groups from cultures that prioritised educational attainment over PA (Asian Bangladeshi, Chinese, Yemeni) and with a Muslim faith (Asian Bangladeshi, Black Somali, Yemeni), who reported a lack of culturally appropriate PA opportunities for girls.
Conclusion:
Parents from multi-ethnic groups lacked awareness of children's PA recommendations and faced barriers to promoting children's PA out of school, with certain ethnic groups facing additional barriers due to cultural and religious factors. It is recommended children's PA interventions address influences at all socio-ecological levels, and account for differences between ethnic groups.
Pediatric burn injuries are one of the leading causes of preventable morbidity and mortality in Sub-Saharan Africa. Research on the complex system of social, economic and cultural factors contributing to burn injuries in this setting is much needed.
We conducted a prospective questionnaire-based analysis of pediatric burn patients presenting to the Hospital Central de Maputo. A total of 39 patients were included in the study. Interviews were conducted with the children's caretakers by two trained medical students at the Eduardo Mondlane Medical School in Maputo with the aid of local nursing staff.
Most burns occurred from scald wounds (26/39) particularly from bathwater, followed by fire burns (11/39). Burns occurred more frequently in the afternoon (16/39) and evening (16/39). Over one quarter of burns (9/33) occurred in the absence of a caretaker. One-third (12/36) of participants attempted to treat the burn at home prior to bringing the child into the hospital, and roughly two-thirds (24/37) reported using traditional remedies for burn care. The average household had just 2 rooms for an average of 5 family members. Most burns were second degree (25/37).
Prevention efforts in this setting are much needed and can be implemented taking complex cultural and social factors into account. Education regarding regulation of water temperature for baths is important, given the prevalence of scald burns. Moreover, the introduction of low-cost, safer cooking technology can help mitigate inhalation injury and reduce fire burns. Additionally, burn care systems must be integrated with local traditional medical interventions to respect local cultural medicinal practices.
This study examines challenges faced by refugee new parents from Africa in Canada. Refugee new parents from Zimbabwe (n = 36) and Sudan (n = 36) were interviewed individually about challenges of coping concurrently with migration and new parenthood and completed loneliness and trauma/stress measures. Four group interviews with refugee new parents (n = 30) were subsequently conducted. Participants reported isolation, loneliness, and stress linked to migration and new parenthood. New gender roles evoked marital discord. Barriers to health-related services included language. Compounding challenges included discrimination, time restrictions for financial support, prolonged immigration and family reunification processes, uncoordinated government services, and culturally insensitive policies. The results reinforce the need for research on influences of refugees' stressful experiences on parenting and potential role of social support in mitigating effects of stress among refugee new parents. Language services should be integrated within health systems to facilitate provision of information, affirmation, and emotional support to refugee new parents. Our study reinforces the need for culturally appropriate services that mobilize and sustain support in health and health related (e.g., education, employment, immigration) policies.
Although injuries related to sports and recreation represent a significant burden to children and youth, few studies have examined the descriptive epidemiology of sports-related injury since 2005, and some sports such as ringette have not been evaluated to date. The primary purpose of this study was to provide the descriptive epidemiology of sports-related injuries treated in emergency departments for children and youth aged 5 - 19.
A retrospective data analysis was performed using data from the Canadian Hospitals Injury Reporting and Prevention Program [CHIRPP] from fiscal years (April - March) 2007/08 to 2009/10. CHIRPP is a computerized information system designed by the Public Health Agency of Canada that collects information about injuries to people evaluated in emergency departments across 11 pediatric hospitals and 5 general hospitals in Canada. Thirteen sports or activities were analyzed (baseball, basketball, cycling, football, ice hockey, lacrosse, ringette, rugby, skiing, sledding, snowboarding, soccer, and volleyball). Descriptive statistics, including frequency by sport, age and sex, as well as the percent of concussions within each sport were calculated.
Out of a total of 56, 691 reported sports and recreational injuries, soccer accounted for the largest proportion of injuries with 11,941 reported cases over the 3 year time period. Of these, approximately 30% were fractures. The 10 - 14 year age group reported the greatest proportion of injuries in 10 out of the 13 sports analyzed. In addition, males reported a greater number of overall injuries than females in 11 out of the 13 sports analyzed. The largest percentage of concussions was reported in ringette; these injuries accounted for 17.1% of overall injuries within this sport.
Injury prevention programs in Canada should focus on improving evidence-based programs to reduce the burden of injuries in all sports.
Background:
Injury risk during childhood and adolescence vary depending on socio-economic factors. The aim of this study was to study if the risk of fatal and non-fatal unintentional injuries among foreign-born children was similar across parental educational level or not.
Methods:
In this retrospective cohort study we followed 907,335 children between 1961 and 2007 in Sweden. We established the cohort by linkage between Swedish national registers including cause of death register and in-patient register, through unique Personal Identification Numbers. The main exposure variable was parental (maternal and paternal) educational level. The cohorts was followed from start date of follow-up period, or date of birth whichever occurred last, until exit date from the cohort, which was date of hospitalization or death due to unintentional injury, first emigration, death due to other causes than injury or end of follow-up, whichever came first. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) by Cox proportional hazards regression models.
Results:
Overall, we found 705 and 78,182 cases of death and hospitalization due to unintentional injuries, respectively. Risk of death and hospitalization due to unintentional injuries was statistically significantly 1.48 (95% CI: 1.24-1.78) and 1.10 (95% CI: 1.08-1.12) times higher among children with lowest parental educational level (9 years and shorter years of study) compared to children with highest parental educational level (+13 years of study). We found similar results when stratified our study group by sex of children, by maternal and paternal educational level separately, and injury type (traffic-related, fall, poisoning, burn and drowning).
Conclusions:
It seems injury prevention work against unintentional injuries is less effective among children with low parental education compared with those with higher parental education. We recommend designing specific preventive interventions aiming at children with low parental education.
Childhood injury is the second leading cause of death for infants aged 1--5 years in the United Kingdom (UK) and most unintentional injuries occur in the home. We explored mothers' knowledge and awareness of child injury prevention and sought to discover mothers' views about the best method of designing interventions to deliver appropriate child safety messages to prevent injury in the home.
Qualitative study based on 21 semi-structured interviews with prospective mothers and mothers of young children. Mothers were selected according to neighbourhood deprivation status.
There was no difference in awareness of safety devices according to mothers' deprivation status. Social networks were important in raising awareness and adherence to child safety advice. Mothers who were recent migrants had not always encountered safety messages or safety equipment commonly used in the UK. Mothers' recommended that safety information should be basic and concise, and include both written and pictorial information and case studies focus on proactive preventive messages. Messages should be delivered both by mass media and suitably trained individuals and be timed to coincide with pregnancy and repeated at age appropriate stages of child development.
The findings suggest that timely childhood injury-related risk messages should be delivered during pregnancy and in line with developmental milestones of the child, through a range of sources including social networks, mass media, face-to-face advice from health professionals and other suitably trained mothers. In addition information on the safe use of home appliances around children and use of child safety equipment should be targeted specifically at those who have recently migrated to the United Kingdom.
Cycling is a major activity for adolescents in Canada and potential differences exist in bicycling-related risk and experience of injury by population subgroup. The overall aim of this study was to inform health equity interventions by profiling stratified analytic methods and identifying potential inequities associated with bicycle-related injury and the use of bicycle helmets among Canadian youth. The two objectives of this study were: (1) To examine national patterns in bicycle ridership and also bicycle helmet use among Canadian youth in a stratified analysis by potentially vulnerable population subgroups, and (2) To examine bicycling-related injury in the same population subgroups of Canadian youth in order to identify possible health inequities.
Data for this study were obtained from the 6th cycle (2009/10) of the Health Behaviour in School-aged Children (HBSC) study, which is a general health survey that was completed by 26,078 students in grades 6--10 from 436 Canadian schools. Based on survey responses, we determined point prevalence for bicycle ridership, bicycle helmet use and relative risks for bicycling-related injury.
Three quarters of all respondents were bicycle riders (19,410). Independent factors associated with bicycle ridership among students include being male, being a younger student, being more affluent, and being a resident of a small town. Among bicycle riders, 43% (95%CI +/- 0.60%) reported never wearing and 32% (+/- 0.57%) inconsistently wearing a helmet. Only 26% (+/-0.53%) of students reported always wearing a bicycle helmet. Helmets were less frequently used among older students and there were also important patterns by sex, geographic location and socioeconomic status. Adjusting for all other demographic characteristics, boys reported 2.02-fold increase (95% CI: 1.61 to 1.90) and new immigrants a 1.35-fold increase (95%CI: 1.00 to1.82) in the relative risk of bicycling-related injury in the past 12 months, as compared to girls and students born in Canada. The relative risk of injury did not vary significantly by levels of socioeconomic status.
Troubling disparities exist in bicycle use, bicycle helmet use and bicycling-related injuries across specific population subgroups. Bicycle safety and injury prevention initiatives should be informed by disaggregated analyses and the context of bicycle-related health differences should be further examined.
Background
The authors studied injury mortality in Denmark among refugees and immigrants compared with that among native Danes.
Method
A register-based, historical prospective cohort design. All refugees (n=29 139) and family reunited immigrants (n=27 134) who between 1 January 1993 and 31 December 1999 received residence permission were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities due to unintentional and intentional injuries were identified based on ICD-10 diagnosis. Sex-specific mortality ratios were estimated by migrant status and region of birth, adjusting for age and income and using a Cox regression model after a median follow-up of 11–12 years.
Results
Compared with native Danes, both female (RR=0.44; 95% CI 0.23 to 0.83) and male (RR=0.40; 95% CI 0.29 to 0.56) refugees as well as female (RR=0.40; 95% CI 0.21 to 0.76) and male (RR=0.22; 95% CI 0.12 to 0.42) immigrants had significantly lower mortality from unintentional injuries. Suicide rates were significantly lower for male refugees (RR=0.38; 95% CI 0.24 to 0.61) and male immigrants (RR=0.24; 95% CI 0.10 to 0.59), whereas their female counterparts showed no significant differences. Only immigrant women had a significantly higher homicide rate (RR=3.09; 95% CI 1.11 to 8.60) compared with native Danes.
Conclusions
Overall results were advantageous to migrant groups. Research efforts should concentrate on investigating protective factors among migrants, which may benefit injury prevention in the majority population.
Playground injuries are fairly common and can require hospitalization and or surgery. Previous research has suggested that compliance with guidelines or standards can reduce the incidence of such injuries, and that poorer children are at increased risk of playground injuries.
The objective of this study was to determine the association between playground injury and school socioeconomic status before and after the upgrading of playground equipment to meet CSA guidelines.
Injury data were collected from January 1998-December 1999 and January 2004 - June 2007 for 374 elementary schools in Toronto, Canada. The objective of this study was to investigate the effect of a program of playground assessment, upgrading, and replacement on school injury rates and socio-economic status. Injury rates were calculated for all injuries, injuries that did not occur on equipment, and injuries on play equipment. Poisson regression was performed to determine the relationship between injury rates and school socio-economic status.
Prior to upgrading the equipment there was a significant relationship between socio-economic status and equipment-related injuries with children at poorer schools being at increased risk (Relative risk: 1.52 [95% CI = 1.24-1.86]). After unsafe equipment was upgraded, the relationship between injury and SES decreased and was no longer significant (RR 1.13 [95% CI = 0.95-1.32]).
Improvements in playground equipment can result in an environment in which students from schools in poorer neighbourhoods are no longer at increased risk of injuries on play equipment.
In an earlier population based surveillance study of pediatric injuries, the rate of Hispanic children injured as pedestrians was 63/100,000 compared with 17/100,000 for non-Hispanic white children. The present study was designed to examine the effect of family, social, and cultural factors on the rate of pedestrian injury in a population of Hispanic children in the southwestern US.
A case-control study of pedestrian injuries among Hispanic children. The sample consisted of 98 children 0-14 years of age hospitalized as a result of a pedestrian injury and 144 randomly selected neighborhood controls matched to the case by city, age, gender, and ethnicity. Cases were compared with controls using conditional logistic regression; in the study design the odds ratio (OR) estimates the incidence rate ratio.
The following family and cultural variables were associated with an increased risk of injury: household crowding (OR = 2.8, 95% confidence interval (CI) 1.1 to 7.1 for 1.01-1.5 persons per room, compared with < or = 1.0 persons per room), one or more family moves within the past year (OR 2.2, 95% CI 1.2 to 4.1), poverty (OR 1.9, 95% CI 1.1 to 3.3), and inability of mother (OR 3.6, 95% CI 1.3 to 10) or father (OR 5.6, 95% CI 1.5 to 20) to read well. However, children in single parent households and children whose parents did not drive a car, had less education, or were of rural origin, did not have an increased rate of injury.
These results have implications for childhood pedestrian prevention efforts for low income, non-English speaking Hispanic populations, and perhaps for other immigrant and high risk groups. Prevention programs and materials need to be not only culturally sensitive but also designed for those with limited reading skills. In addition, environmental interventions that provide more pedestrian friendly neighborhoods must be considered.
Changes to Canadian Standards Association (CSA) standards for playground equipment prompted the removal of hazardous equipment from 136 elementary schools in Toronto. We conducted a study to determine whether applying these new standards and replacing unsafe playground equipment with safe equipment reduced the number of school playground injuries.
A total of 86 of the 136 schools with hazardous play equipment had the equipment removed and replaced with safer equipment within the study period (intervention schools). Playground injury rates before and after equipment replacement were compared in intervention schools. A database of incident reports from the Ontario School Board Insurance Exchange was used to identify injury events. There were 225 schools whose equipment did not require replacement (nonintervention schools); these schools served as a natural control group for background injury rates during the study period. Injury rates per 1000 students per month, relative risks (RRs) and 95% confidence intervals (CIs) were calculated, adjusting for clustering within schools.
The rate of injury in intervention schools decreased from 2.61 (95% CI 1.93-3.29) per 1000 students per month before unsafe equipment was removed to 1.68 (95% CI 1.31-2.05) after it was replaced (RR 0.70, 95% CI 0.62-0.78). This translated into 550 injuries avoided in the post-intervention period. In nonintervention schools, the rate of injury increased from 1.44 (95% CI 1.07-1.81) to 1.81 (95% CI 1.07-2.53) during the study period (RR 1.40, 95% CI 1.29-1.52).
The CSA standards were an effective tool in identifying hazardous playground equipment. Removing and replacing unsafe equipment is an effective strategy for preventing playground injuries.
Studies evaluating the effectiveness of bicycle helmet legislation often focus on short term outcomes. The long term effect of helmet legislation on bicycle helmet use is unknown.
To examine bicycle helmet use by children six years after the introduction of the law, and the influence of area level family income on helmet use.
The East York (Toronto) health district (population 107,822) was divided into income areas (designated as low, mid, and high) based on census tract data from Statistics Canada. Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) from April to October in the years 1995-1997, 1999, and 2001. The frequency of helmet use was determined by year, income area, location, and sex. Stratified analysis was used to quantify the relation between income area and helmet use, after controlling for sex and bicycling location.
Bicycle helmet use in the study population increased from a pre-legislation level of 45% in 1995 to 68% in 1997, then decreased to 46% by 2001. Helmet use increased in all three income areas from 1995 to 1997, and remained above pre-legislation rates in high income areas (85% in 2001). In 2001, six years post-legislation, the proportion of helmeted cyclists in mid and low income areas had returned to pre-legislation levels (50% and 33%, respectively). After adjusting for sex and location, children riding in high income areas were significantly more likely to ride helmeted than children in low income areas across all years (relative risk = 3.4 (95% confidence interval, 2.7 to 4.3)).
Over the long term, the effectiveness of bicycle helmet legislation varies by income area. Alternative, concurrent, or ongoing strategies may be necessary to sustain bicycle helmet use among children in mid and low income areas following legislation.
The aim of this study was to examine the effect of household income on unintentional injury mortality in children and to model the potential impact of eradicating income poverty as an injury prevention strategy.
A national retrospective cohort study linking census to mortality records carried out in New Zealand during a 3-year period following the 1991 census and including children aged 0-14 years on census night. The main outcome measures are odds ratios (ORs) for unintentional injury death by equivalised household income category and proportional reductions (population-attributable risk) in unintentional injury mortality from modelled scenarios of nil poverty.
One-third of children lived in households earning less than 60% of the national median household income. Age-adjusted odds of death from unintentional injury were higher for children from any income category compared with the highest, and were most elevated for children from households earning less than 40% of the national median income (OR 2.81, 95% CI 1.73 to 4.55). Adjusting for ethnicity, household education, family status and labour force status halved the effect size (OR 1.83, 1.02 to 3.28). Thirty per cent of injury mortality was attributable to low or middle household income using the highest income category as reference. Altering the income distribution to eradicate poverty, defined by a threshold of 50% or 60% of the national median income, reduced injury mortality in this model by a magnitude of 3.3% to 6.6%.
Household income is related to a child's risk of death from unintentional injury independent of measured confounders. Most deaths attributable to low income occur among households that are not defined as "in poverty". The elimination of poverty may reduce childhood unintentional injury mortality by 3.3% to 6.6%.
BACKGROUND: Unintentional injury is a frequent reason for emergency department visits and is the leading cause of death for Canadian children. Injury is associated with a number of socio-demographic variables but it is not known whether being an immigrant changes this risk.
OBJECTIVES: To examine the association between family immigrant status and unintentional injury; and to test this relationship within immigrants by refugee status.
DESIGN/METHODS: Retrospective population-based cross-sectional study of children ages 0 to 14 years residing in Ontario, Canada from 2008 to 2012, using linked health administrative databases and Citizenship and Immigration Canada’s Permanent Resident Database. The main exposure was immigration status (immigrant or child of an immigrant vs. Canadian born). Secondary exposure was refugee status. Main outcome measure was unintentional injury events (emergency department visits, hospitaliza-tions, deaths), annualized. Data were analyzed using Poisson regression models to estimate risk ratios (RR) for unintentional injuries.
RESULTS: There were 11 464 317 injuries per year. Non-immigrant children sustained 12051 injuries/100 000 and immigrants had 6837 injuries/100 000, annually. In adjusted models, immigrants had a significantly lower risk of injury compared with non-immigrant children (RR 0.60; 95% confidence interval [CI] 0.57, 0.63). Overall, the most materially deprived neighbourhood quintile was associated with a higher rate of injury (RR 1.13; 95% CI 1.07, 1.02, quintile 5 vs. 1) whereas within immigrants, material deprivation was associated with a lower rate of injury (RR 0.96; 95% CI 0.94, 0.98, quintile 5 vs. 1). Other predictors of injury included age (0 to 4 years: RR 0.84; 95% CI 0.81, 0.88; 5 to 9 years: RR 0.70; 95% CI 0.67, 0.73), male sex (RR 1.30; 95% CI 1.26, 1.35), and rural residence (RR 1.50; 95% CI 1.43, 1.57). Injury rates were lower in immigrants across all types of unintentional injuries. Within immigrants, refugees had a higher risk of injury compared with non-refugees (RR 1.12; 95% CI 1.10, 1.14). This risk was particularly high for motor vehicle accidents (RR = 1.58; 95% CI 1.46, 1.71) and scald burns (RR 1.23; 95% CI 1.11, 1.35).
CONCLUSION: Risk of unintentional injury is lower among immigrants compared with Canadian-born children. These findings support a healthy immigrant effect. Socioeconomic status has a different effect on injury risk in immigrant and non-immigrant populations, suggesting alternative causal pathways for injuries in immigrants. Risk of unintentional injury is higher in refugees versus non-refugee immigrants, highlighting a population in need of targeted injury prevention strategies.
To characterize physical and mental health in trauma exposed refugees by describing a population of patients with regard to background, mental health history and current health problems; and to identify pre- and post-migratory predictors of mental health.
All patients receiving treatment at the Psychiatric Trauma Clinic for Refugees in Copenhagen from April 2008 to February 2010 completed self-rating inventories on symptoms of PTSD, depression and anxiety as well as level of functioning and quality of life before treatment. Then, associations of pre and post migratory factors with mental health were explored using linear and logistic regression and Pearson's correlation coefficients.
Among the patients, the prevalence of depression, somatic disease, pain, psychotic symptoms co-existing with PTSD and very low level of functioning was high. Persecution, being an ex-combatant and living currently in social isolation were significantly associated with PTSD arousal symptoms and self-reported pain.
New treatment modalities should seek to address all of the symptoms and challenges of the patients including psychotic and somatic symptoms and social isolation, and studies of treatment effect should clarify all co-morbidities so that comparable populations can be included in treatment evaluation studies.
Introduction
Many unintentional injuries to young children occur in the home. The current study examines the relation between family socioeconomic and sociodemographic factors and risk factors for home injury.
Methods
Presence of household hazards was examined in 80 families with toddler-aged children. Parental ability to identify household hazards in pictures was also assessed. ANOVAs and Pearson product–moment correlations examined the relationship between presence of household hazards, knowledge to identify hazards, and factors of yearly family income, parental age, parental education, parental marital status, child ethnicity, and the number of children living in the home.
Results
A greater number of hazards were found in the homes of both the lowest and highest income families, but poorer knowledge to identify household hazards was found only among parents of the lowest income families and younger parents. Across family socioeconomic status, parent knowledge of hazards was related to observed household hazards.
Conclusions
The relationship between family income and risk for injury is complex, and children of both lower and higher SES families may be at risk for injury.
Practical applications
While historically particular focus has been placed on risk for injury among children in low income families, injury prevention efforts should target reducing presence of household hazards in both high and low SES families.
Unscheduled return visits (URV) to the emergency department (ED) may be an important quality indicator of performance of individual clinicians as well as organisations and systems responsible for the delivery of emergency care. The aim of this study was to perform a rapid evidence assessment policy-based literature review of studies that have looked at URVs presenting to the ED. A rapid evidence assessment using SCOPUS and PUBMED was used to identify articles looking at unplanned returns to EDs in adults; those relating to specific complaints or frequent attenders were not included. After exclusions, we identified 26 articles. We found a reported URV rate of between 0.4% and 43.9% with wide variation in the time period defined for a URV, which ranged from 24 h to undefined. Thematic analysis identified four broad subtypes of URVs: related to patient factors, to the illness, to the system or organisation and to the clinician. This review informed the development of national clinical quality indicators for England. URV rates may serve as an important indicator of quality performance within the ED. However, review of the literature shows major inconsistencies in the way URVs are defined and measured. Furthermore, the review has highlighted that there are potentially at least four subcategories of URVs (patient related, illness related, system related and clinician related). Further work is in progress to develop standardised definitions and methodologies that will allow comparable research and allow URVs to be used reliably as a quality indicator for the ED.
Cycling is a popular past-time among children and adults and is highly beneficial as a means of transport and obtaining exercise. However, cycling related injuries are common and can be severe, particularly injuries to the head. Bicycle helmets have been advocated as a means of reducing the severity of head injuries, however voluntary use of helmets is low among the general population. Bicycle helmet laws mandating their use have thus been implemented in a number of jurisdictions word-wide in order to increase helmet use. These laws have proved to be controversial with opponents arguing that the laws may dissuade people from cycling or may result in greater injury rates among cyclists due to risk compensation. This review searched for the best evidence to investigate what effect bicycle helmet laws have had. There were no randomised controlled trials found, however five studies with a contemporary control were located that looked at bicycle related head injury or bicycle helmet use. The results of these studies indicated a positive effect of bicycle helmet laws for increasing helmet use and reducing head injuries in the target population compared to controls (either jurisdictions without helmet laws or non-target populations). None of the included studies measured actual bicycle use so it was not possible to evaluate the claim that fewer individuals were cycling due to the implementation of the helmet laws. Although the results of the review support bicycle helmet legislation for reducing head injuries, the evidence is currently insufficient to either support or negate the claims of bicycle helmet opponents that helmet laws may discourage cycling.
Population-based health surveys are increasingly popular sources of data on injury occurrence. Self-reported surveys can yield estimates of the total incidence of non-fatal injuries while simultaneously capturing a rich repository of contextual data that may be informative for exploring determinants of injury risk. Although survey data are rarely recognised as complete, several researchers have expressed concerns about the sensitivity and validity of self-reported injury data, questioning whether captured cases are representative of the population experience of injury, particularly among children and youth. The present study sought to compare the population incidence of paediatric injury estimated from self-reported survey responses to those documented by a complete-capture health service utilisation database among Ontario children.
Injury incidence rates documented from the National Longitudinal Survey of Children and Youth and the National Population Health Survey were compared with those reported in Canada's National Ambulatory Care Reporting System for Ontario youth aged 0-19 years for fiscal year 2002/3, stratified by the child's age and geographical location of residence.
The two self-reported health surveys underestimated the population incidence of injury among Ontario children by at least 49% and 53%, respectively. Systematic errors exist in survey data capture such that injuries in infants and preschoolers (<4 years of age) and urban residents were most likely to be missed by the population health surveys.
Injury incidence estimated through self-report is not representative of the population burden and experience of paediatric injury for Ontario children, and may produce biased estimates of risk when analysed as independent sources of data.
The purpose of this study was to assess physical activity preferences (PAP) in preadolescent children. 191 Latino and White children (M = 11.9, SD = +/- 0.7) participated. Demographic, anthropometric, and PAP measures were employed. Both Latino and White children reported water play, basketball, and bicycling as their most preferred activities while indoor chores were least preferred. Compared with Latino, White children reported a higher preference for baseball/softball. Exploratory factor analysis of PAP measure indicated a three-factor solution: free play, sports, and exercise. Multiple linear regression models revealed that PAP varied as a function of ethnicity, gender, age, and body mass index.
To explore socio-cultural influences on migrant mother decisions and beliefs regarding co-sleeping as a risk factor for sudden infant death syndrome (SIDS).
Semi-structured interviews with five Indian-born women in a socio-economically disadvantaged suburb in the south-west of Sydney were conducted between September and December 2007. Transcripts were analysed using principles of discourse analysis.
Discourse analysis revealed that SIDS-related decisions and beliefs about co-sleeping as a risk factor for SIDS are constructed amid competing discourses of motherhood and child health. Mothers are either actively or unconsciously deciding how they negotiate or resist dominant Western discourses of motherhood and child health to make 'the best' health-related decisions for their children. Participants resisted acknowledging child sleep practices recommended by health practitioners, particularly recommendations to put to sleep the baby in its own cot. This resistance was expressed by constructing messages as 'inapplicable' and 'inappropriate'. Co-sleeping was constructed as a highly valued practice for its physical and social benefits to the child, mother and family by facilitating child security, breastfeeding, bonding and family connectedness.
This study illustrates how decisions and behaviour are shaped by socio-cultural influences embedded in discourses and context. It also shows that in-depth investigation through a social constructivist lens is particularly useful for investigating influences on knowledge acquisition, interpretation and implementation among migrant groups. A greater appreciation of the social meanings and ideologies attached to behaviours can help to ensure that the correct messages reach the correct populations, and that child health outcomes can be achieved and maintained both for overseas and Australian-born populations.
A case-control study examined, primarily, the association between booster seat laws and fatalities among children in frontal collisions and, secondarily, the association between booster seat laws and reported restraint use, and restraint use and child fatalities. Children who died in a crash in the US were cases, and children who survived a fatal crash were controls. Subjects were child passengers (4-8 years old) in the Fatality Analysis Reporting System Database, 1995-2005. In states with a booster seat law, children were less likely to die than in states without a law (OR 0.80; 95% CI 0.66 to 0.98). They were also more likely to be restrained (adjusted OR 1.59; 95% CI 1.21 to 2.09) and were more likely to be correctly restrained (adjusted OR 4.44; 95% CI 3.18 to 6.20). It is concluded that booster seat laws are associated with a decrease in child deaths and an increase in correct restraint use among children involved in a fatal crash in the USA.
Unintentional injuries in children of foreign-born mothers were studied and compared with those in children of Danish-born mothers.
A population of 173,504 children living in 32 municipalities in Denmark was followed from 1998 to 2003. Detailed information on childhood unintentional injuries from hospital records was linked to register data on parents' education, country of origin, income, family type, etc. Poisson regression was used to analyse differences in injury risk between children of different origins.
We found 133,649 injuries, of which 15,389 occurred in children of foreign-born mothers. The injury rates in children of Western and non-Western origin were 0.83 (0.70-0.98) times and 0.84 (0.79- 0.90) times that of children of Danish-born mothers, respectively. The difference was largest in children of families with unemployed parents. The injury rate in girls of non-Western origin was 29% lower than in girls of Danish origin, while the rate in boys of non-Western origin was only 5% lower than in boys of Danish origin. This gender difference was particularly pronounced for sports and traffic injuries. Children of non-Western origin had a three-fold higher rate of burns caused by hot water, tea or oil than children of Danish origin.
Prevention of injuries in children of non-Western origin should especially focus on scalds from tea, oil, and hot water.
Several significant developmental and socialisation processes in the life of children and adolescents take place in the area where they live. The extent to which they can feel and be safe in this environment is an important component of the success of those processes. This study highlights the independent contribution of neighbourhood and individual-level demographic and socioeconomic attributes to child and adolescent injuries. All individuals between the ages of 7 and 16 years living in Stockholm County in January 1998 (n=184 545) were followed up for their injuries during a five-year period considering injuries sustained as a pedestrian/cyclist/motor-vehicle rider and intentional injuries (violence-related and self-inflicted). A series of two-level logistic regressions were conducted to examine the association between the occurrence of injuries and individual (compositional) characteristics nested into parish of residence as well as contextual characteristics. For children and adolescents living in Stockholm County, contextual socioeconomic and social attributes of their place of residence were significant for injuries sustained as motor-vehicle riders but not for those sustained as pedestrians/cyclists or those inflicted intentionally. In the latter case, only the highest concentration of social benefit recipients was associated with significantly higher odds ratios. This emphasises that each injury mechanism has its own socioeconomic and social pathway, where contextual and compositional factors come into play to varying degrees.
To describe the home-based injury prevention practices used by low-income mothers of Mexican descent with their preschool children.
A descriptive qualitative study with convenience sampling of mothers (n=9) who are of Mexican descent and have preschool children.
Data collection consisted of ethnographic interviews supplemented by focused home observations.
2 themes emerged from the data: the spectrum of physical proximity and the use of injury prevention technology. The spectrum of physical proximity reflected the degree of physical closeness (i.e., supervising children, watching children closely, and being after children) that the mothers used to manage injury risk in their children. Children who were perceived as curious or restless, or too young were judged by the mothers as being prone to injury and requiring more maternal physical closeness. The participants used the injury prevention technology recommended by the experts despite their limited economic resources. However, this group of mothers used the spectrum of physical proximity as the main tool to prevent child injuries in their home.
These findings provide an insight into the attitudes and behaviors of low-income, Mexican mothers toward injury prevention in the home. Awareness of these attitudes and behaviors will allow for the creation of interventions that take into account this maternal perspective.
In less than a year, the World Health Organization (WHO) and the United Nations Children’s Fund will release the first ever World report on child injury prevention . It is expected that the report will become a milestone in the child injury prevention field, and will provide an opportunity to focus attention on the issue and generate additional action on the part of governments and their partners. Readers of Injury Prevention are already contributing to the development of the report and can play an important role in its launch and follow-up.
Child injuries are a global public health problem. According to the WHO’s Global Burden of Disease data, around 875 000 children under the age of 18 years died as a result of injury or violence in 2002. Injuries are a leading cause of death for all children after their first birthday. Beyond the fatalities, for every child who dies, there are several thousand children who live on with varying degrees of disability.
For all the main …
Immigration overview - permanent and temporary residents: Citizenship and Immigration Canada
- Figures Facts
Injury surveillance guidelines. Geneva: World Health Organization
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