ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Understanding Injury: What are the Indicators?

Ian Pike, PhDCanadian Injury Indicators Team

Director. BC Injury Research and Prevention UnitAsst. Professor, Pediatrics, UBC

Alison Macpherson, PhDCanadian Injury Indicators Team

Associate Professor, Kinesiology and Health Science, York University

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Purpose of this Presentation

• To provide a brief introduction to Injury Indicators and some of the work of the Canadian Injury Indicators Team

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Injury Indicator Definition (Pencheon, 2008)

• Indicators are succinct summary measures that describe as much about a system as possible

• Injury indicators provide a clear signal and help us understand what is happening; they allow us to compare the injury situation between groups and places, and over time

• Indicators are more than measures and signals; they must also drive decision and action (i.e. they inform policy, practice and research)

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Indicators are like a Dashboard

• Car Dashboard has several indicators that are measures that tell you your speed, how much gas you have, engine temp., what gear you are in, engine revs., etc.

Ready reference – easily understood ?Clear signal ? Prompt action ?Monitor the situation and any changes ?

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

There are hundreds of indicators…Which ones are most useful?

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Child and Youth Injury Indicators: Work to Date

Burden of Injuryamong Canadianchildren & youth

National Child and Youth Health Coalition

Initiative

Canadian Injury IndicatorsDevelopment Team:

Child & Youth

The Canadian Injury Indicators Team:

a) Injury Indicators for Canadian Children and Youthb) Injury Indicators for Canadian First Nations and

Inuit Children and Youthc) Injury Policy Indicators and their Associated Risk

Factors and Outcomesd) CIHR Team in Child and Youth Injury Prevention

(grant application submitted)

PreviousResearch

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Canadian Injury Indicators Team

Principals Co-investigators Collaborators

Dr. Alison Macpherson, York Dr. Ronald Barr, UBC Health Canada

Dr. Ian Pike, UBC Dr. Parminder Raina, Mac Safe Kids Canada

Dr. Lynne Warda, UoM Dr. Shelina Babul, UBC SmartRisk Foundation

Dr. Natalie Yanchar, IWK Dr. Ediriweera Desapriya, UBCCanadian Collaborating Centres for Injury Prevention and Control

Ms. Allyson Hewitt, Safe Kids Dr. Colin Macarthur, UoTPublic Health Agency of Canada

Dr. Morad Hameed, UBCCanadian Institute for Health Information

Trauma Association of Canada

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Methods

• Phase 1 – Defining Criteria and Establishing Domains

• Phase 2 – Literature Review

• Phase 3 – Selection of existing indicators and creation of new ones: Expert panel meeting

• Phase 4 – Modified-Delphi Process

• Phase 5 – Specification of Indicators

• Phase 6 – Modified-Delphi II - Broader input through survey

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Criteria (Rigby, et al., 2003)

• Evidence-based, underpinned by research

• Significant burden to society, the family and the individual

• Representative of significant population groups

• Data availability

• Topic amenable to effective action

• Understandable to broad audience

• Regularity and repeatability to enable trend analysis

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

34 Injury Indicators

• Outcome Indicators– e.g. mortality, PYLL, hospitalization

• Health Service Indicators– e.g. diagnosis-specific separation, injury severity at admission, length

of stay

• Risk Indicators– e.g. child restraints, young drivers, drunk driving, rural, residential

swim pools

• Policy Indicators– e.g. GDL, bicycle helmets, playground CSA standards, window guards,

hot water tank

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Definition & Specification of Indicators

• Indicator Definition

• Definition of Relevant Terms

• Justification for this Indicator

• Operational Definition of a Case

• Method of Calculation

• Numerator

• Denominator

• Data sources, availability and quality/years represented

• Units of measurement

• Guide for Use

• Scope of Indicator

• Specification of Data Needed

• Limitations

• How to Use this Indicator

Bicycle Helmet LegislationSport and Rec/Motor Vehicle Domains Indicator #19

Policy

Indicator Definition Percentage of provinces/territories with comprehensive laws requiring use of bicycle helmets that meet the ‘best practice’ helmet laws, currently set by the one enacted in Nova Scotia (2007).

Definition of Relevant Terms

‘Best practice’ means that the following law was adopted based on evidence (see justification for this indicator).Bike Helmet Law:July 1, 1997—Bike helmet use is required for all ages. ($25 fine)May 30, 2002—Anyone using inline skates, scooters and skateboards is required to wear a safety helmet. (minimum $25 fine)

Justification for this indicator

Helmet laws have been shown to be effective in increasing the use of bicycle helmets and reducing the incidence of bicycle-related head injuries (Macpherson et al, 2000). Helmet laws that require bicyclists of all ages to wear helmets, as well as those using in-line skates and scooters, are now considered to be the ‘best practice’ laws. About 50 Canadian children and adolescents die each year from bicycle-related injuries, and 75% of all bicycle-related deaths are due to head injuries. Although the use of helmets can reduce the risk of head injury by 85%, the rate of voluntary helmet use continues to be low (LeBlanc, 2002).

Operational Definition of a Case

Each province/territory is a case.

Method of Calculation (Number of provinces and territories in each category/total number of provinces and territories) x 100

Numerator Province or territory in each category

Denominator Total number of provinces and territories

Data sources, availability and quality/years represented

Provincial legislation is available on relevant web sites.

Units of measurement Number of provinces and territories

Guide for Use Provinces and territories will fall into one of three categories:1.Has a law that meets the current ‘best practice’ law2.Has a law, but it does not meet the current ‘best practice’ specifications3.Does not have a law

Scope of indicator Sex: all children and youthAge: birth to 19 yearsGeographical Area of Interest: Canada, Provinces, Rural/Urban

Specification of data needed

Detailed information on helmet laws.

Limitations This law does not cover heelies. At this time there is not enough evidence to include these in a policy indicator. As well, not all sport helmets are regulated, therefore it is possible to use a helmet and still not protect the head properly. Injuries from the use of non-regulated helmets would skew the injury outcome statistics.

How to Use this Indicator

Ideally bicycle helmet laws would be further developed to compare the following: 1.How many children and youth are injured or killed due to not wearing a helmet while cycling, skateboarding or scootering?2.How many of those injuries and deaths took place in provinces that had a ‘best practice’ helmet law?3.How many of those injuries and deaths took place in provinces with a law that contained only some of the elements of the ‘best practice’ law?4.How many of those injuries and deaths took place in provinces with no law?Separately, it would also be ideal to determine how many children and youth actually wear their helmets while cycling, skateboarding or scootering (could be accomplished through a Risk Factor Survey).

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Injury Indicators for Children and Youth

All Domains Indicators Mortality Rate

Years of Life Lost

Hospital Separations Rate

Overall Health Service Implications Indicators

Diagnosis-Specific Hospital Separations

Hospital Admission, Injury Severity 1

Hospital Admission, Injury Severity 2

Length of Stay in Hospital

Motor Vehicle Injury Indicators

Cost of Motor Vehicle Injuries

Crash Rate

Intersection Crash Rate

Rural Roadways

Drunk Driving

Speed

Young Drivers

Graduated Driver Licensing

Child Restraints

Unrestrained Injuries

Child Restraint Laws

Sport, Recreation, and Leisure Injury Indicators

Bicycle Helmet Laws

Cost of Sport and Recreation Injuries

Percentage of Sport Specific Injuries (Participation Rates)

Requirements that Playgrounds Meet CSA Standards

Legislation Requiring Pool Fencing

Other Policy Indicators Window Guard By-law

Provincial Stand for Hot Water Tap Temp

Violent Crime Rate

Inflicted Childhood Neurotrauma Rate

Suicide Prevention

Anti-Violence/Anti-Bullying Policies

Trauma Care, Quality and Outcomes Indicators

Access to Pediatric Level I Trauma Care/Centre (PTC)

Appropriate Use of Pediatric Level I Trauma Care/Centre (PTC)

Quality of Trauma System

Pre-hospital Transport Time

Presence of a Coordinated Pediatric Trauma System

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Rating of Overall Indicators

Rating of Overall Indicators

0

1

2

3

4

5

6

7

8

9

Mortality rate Dx-specif ic hospitalseparations

Hospital admissionseverity

Hospital separations PYLL Length of stay

Ave

rag

e R

atin

g

Usefulness

Actionability

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Rating of Motor Vehicle Indicators

Motor Vehicle Specific Indicator Ratings

0

1

2

3

4

5

6

7

8

9

Drunk drivercrashes

Unrestrainedpassengers

crashes

Young drivercrashes

Child restraintuse

Motor vehiclecrash rate

Speed relatedcrashes

Cost ofcrashes

Graduatedlicensing

Ruralroadways

Booster seatlaw

Intersectioncrash rate

Ave

rag

e R

atin

g

Usefulness

Actionability

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Rating of Violence Indicators

Violence Ratings

0

1

2

3

4

5

6

7

8

9

Violent crime rates Inflicted childhood neurotraumarate

Schools w ith bullying preventionprograms

Schools w ith suicide preventionprograms

Ave

rag

e R

atin

g

Usefulness

Actionability

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Rating of Policy IndicatorsPolicy Indicator Ratings

0

1

2

3

4

5

6

7

8

9

Presence ofgraduatedlicensing

Bicycle helmetlaw

Presence of abooster seat

law

Presence of apediatric trauma

system

Law requiringplaygrounds to

meet CSAstandards

Legislationrequiring pool

fencing

Provincialstandards for

hot w atertemperature

Window guardby-law s

Ave

rag

e R

atin

g

Usefulness

Actionability

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Results

• From the initial list of 51 indicators, a refined list of 34 indicators was established

• Indicators were grouped into Policy Indicators, Risk Factor Indicators, and Outcome indicators

• In general, indicators related to motor vehicle crashes and

overall injury indicators ranked the highest

• Indicators related to violence and trauma care ranked lower for usefulness and much lower in their ability to prompt action

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Injury Indicators for:First Nations Children and Youth &Inuit Children and Youth

• A parallel process to determine injury indicators for First Nations and Inuit Children and Youth is ongoing

Inuksuit are indicators - different forms have different purposes: e.g. to show directions to travelers, to warn of impending danger, to mark a place of respect, or to act as helpers in the hunting of caribou

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Related Projects: Injury Indicators for First Nations and Inuit children and youth

• Health Canada’s First Nations and Inuit Health Branch supported a parallel development of indicators

• Mirrored same process as original project• 33 indicators defined and specified in the following domains:

- Indicators that will be measured across all injury areas- Animal Bites - Hypothermia/Frostbite- Violent/Inflicted Injury- Burns and Falls- Drowning- Suicide- Motorized Vehicle Collisions

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

MortalityALL DOMAINSIndicator #1

Outcome

Indicator Definition Is the number of deaths due to a specific injury area divided by the total population in a given year, expressed as rates per 100,000 population. Cause-specific First Nations and Inuit child and youth mortality rates according to ICD-10, for all injuries by male, female, and total, stratified by age.

Definition of Relevant Terms

Injury is the damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen. Unintentional injuries are those injuries where there is no intent to do harm. They are typically classified according to the means of their occurrence (e.g., poisoning, burns and scalds, drowning, falls and transport-related). Violent injuries (intentional injuries) resulting in child or youth death are also included in this definition of mortality and are classified according to intentional self-harm, maltreatment, or assault.

Mortality data is based on children and youth killed immediately or dying within 30 days as a result of an unintentional or violent injury.

Justification for this indicator

Injury is a serious public health issue with a major impact on the lives of First Nations and Inuit as it is the number one cause of hospitalization and death among people aged 1-44 years (Health Canada, 1999). Injuries kill more children and young adults than all diseases combined and include both unintentional and intentional injuries. Injuries in children and youth are largely avoidable.

The mortality rate is perhaps the best indication of the burden of severe childhood injury. It is essential to track the mortality rate over time to assess trends in childhood injury.

What are we counting? (definition of a case)

Cases will be identified by the nature of injury codes (ICD-10 S00-T98) and the external cause of injury codes (V01-Y98) recorded in mortality data files.

Where do we get this information / data?

The central Vital Statistics Registry in each province and territory records data from death registrations. Regional offices of the First Nations and Inuit Health Branch (FNIHB), Health Canada have access to vital statistics with a First Nations or Inuit identifier.

What data do we need? Total number of deaths due to injury for all causes for children aged <1, 1-4, 5-9, 10-14, 15-19 and by male, female.

Population of children and youth broken down by age (<1, 1-4, 5-9, 10-14, 15-19), male, female.

Mortality data broken down by external cause of death (ICD-10 Codes V01-Y98).

Method of Calculation (Numerator/Denominator) x 100,000

Numerator Number of deaths stratified by : age, sex, each unintentional injury and each violent injury

Denominator Total resident population stratified by: age and sex. This could be obtained from FNIHB regional offices.

Limitations British ColumbiaData for Registered Indians in British Columbia were gathered through a data linkage with the

British Columbia Vital Statistics Agency. These data includes all Registered Indians, on- and off-reserve combined in British Columbia. Since the BC Vital Statistics Agency use the Status Verification System (SVS) in their linkage, which includes both Registered Indian and Inuit clients, this data file will include some Inuit. The SVS file that the BC Vital Status Agency uses, however, is for all of Canada. This means that Registered Indians (and Inuit) who have moved to British Columbia from elsewhere in Canada would also be captured, if they died or gave birth while living in the province.

AlbertaData for Registered Indians in Alberta were obtained through a manual records match carried

out by the Health Canada regional office in Alberta using the Status Verification System and provincial vital statistics records. In Alberta, the Regional SVS file is used instead of the national list, so information is gathered only for Registered Indians who are members of Alberta bands. Data was gathered for all Registered Indians in Alberta, on- and off-reserve combined, classified using ICD-10 classification.

SaskatchewanData for Registered Indians were extracted from the provincial vital statistics database through

an Aboriginal identifier in the dataset. These data are supplemented with a linkage with the Status Verification System and provincial health records, to include individuals not flagged with an Aboriginal identifier. Saskatchewan Region uses the national version of the SVS, which includes Registered Indians and Inuit from across Canada. Data are broken down by the on- and off-reserve populations, and only the on-reserve population is included in this report. Data are received in ICD-10 classification.

ManitobaData for First Nations are extracted from the provincial vital statistics database using an

Aboriginal identifier. This identifier is voluntary, in that a person must identify themselves as a Registered Indian to the Manitoba Vital Statistics Agency. These individuals are double-checked through a manual records match with the Status Verification System and the provincial dataset. This also identifies Registered Indians who were not flagged in the provincial records. These data are available for the on- and off-reserve populations, though only the on-reserve population is used in this report. Data are reported in ICD-10 format.

No vital stats from OntarioQuebec• The Québec Regional Office does not receive any information from the provincial vital

statistics registry. Reports on vital statistics are received from the communities that are covered under a health control transfer agreement, and entered into a database. The FNIHB regional office does not have the full health information on each death, there is concern that determining the underlying cause of death is not possible. This reporting system covers only communities that have had their health care control transferred from Health Canada (29 of the 41 communities), and none of the off-reserve population is covered.

AtlanticAs with Québec, the FNIHB Atlantic regional office does not receive any information from

the vital statistics registries of any of the Atlantic provinces. Instead, they receive reports on births and deaths from the communities. Information is collected from community health nurses and submitted to the Atlantic regional office using Teleform, a fax-based database application. This system collects information from reserves, and does not cover the off-reserve population. Although the Inuit communities in northern Labrador are not included in this reporting scheme, a small number of Inuit from other communities might be included in these data. The system of reporting deaths to FNIHB is voluntary, and is often based on second-hand information received by the nurse from the family. The number of death reports received by the regional office is believed to be a severe underestimation of the actual number of deaths that occur in the region.

The Territories do not identify FN or Inuit people separately in their vital statistics at all.

How to use this indicator The mortality rate per 100,000 population indicates how many children/youth die from each type of injury each year. An increase in mortality due to a specific injury would indicate the need for more effective injury prevention in that specific area. A decrease in mortality would indicate that the injury prevention strategies in place are working. For example, if it is determined that fewer youth die in ATV crashes from “dry” communities (communities who have prohibited alcohol), a good case could be made for adopting “dry” community policies.

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Injury Indicators for First Nations and Inuit Children and YouthINDICATORS THAT WILL BE MEASURED ACROSS ALL INJURY AREAS

Mortality Rate: Number of deaths due to each injury area

Number of children/youth hospitalized due to each injury area

Number of Substance Use Related Injuries

Number of communities that have culturally appropriate alcohol /drug programs available for community members

Number of self-governing features that exist in the community

ANIMAL BITES Rate of injuries due to dog bites and maulings in a community

Number of communities with Animal Control Services

HYPOTHERMIA/ FROSTBITE

Rate of children and youth who experience hypothermia or frostbite by age

VIOLENT/INFLICTED INJURY

The rate of police calls and charges involving children and youth and related to violent injury

The self-reported rate of inflicted injury (assault) among First Nations/Inuit children and youth (not self-inflicted)

Percentage of violent offenders participating in restorative justice

Availability of fire and ambulance services in a community within a defined response time

Where do falls to children and youth happen (this refers to self-reported falls to children and youth within the last 12 months)

BURNS AND FALLS

Proportion of community members who complete culturally appropriate injury prevention training, by age

Presence of working smoke detectors and tested fire extinguishers in homes

Proportion of self-reported burns to children and youth as well as the self-reported circumstantial details of each case

Presence of a disaster communication plan for community (i.e. Flooding, fires, blizzards, etc.)

DROWNING Number of water rescues by Emergency Response Teams (such as Search and Rescue or Lifesaving Society)

Number of communities with access to water safety education / programs

Enforcement of laws related to water

Number of children and/or youth (ages 0-19) drowning in each body of water type each year

Percentage of children/youth (0-19) enrolled in ‘learn to swim’ programs in a specific year

SUICIDE Access to Mental Health Promotion Programs and Traditional Healing: Number of communities with mental health and wellness promotion programs

The rate of self-reported poor mental health among children and youth

The rate of suicide attempts/self harm among First Nations and Inuit children and youth

The number (rate) of calls to suicide prevention crisis telephone services, by geographical region

MOTORIZED VEHICLE COLLISIONS

Number of motor vehicle collisions involving First Nations or Inuit children and/or youth

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Injury Indicators for First Nations and Inuit Children and Youth (continued)

MOTORIZED VEHICLE COLLISIONS (continued)

Number and proportion of seriously injured or killed First Nations or Inuit occupants (0-19 years of age) who were unrestrained (not wearing a seatbelt)

Youth access to Driver Education Courses – skills for car, snowmobile, boat, and ATV drivers

Percentage and proportion of proper use of child vehicle restraints (carseats) and booster seats

Age and sex of First Nation or Inuit driver and occupants involved in a motor vehicle crashes (including cars, ATVs, and skidoos), as well as road user type

Presence of legislation of minimum age to drive an ATV. Number of provinces and territories with legislation of minimum age to drive an ATV

Number and proportion of seriously injured or killed children and youth (0-19 years of age) who were not wearing a helmet while riding ATVs, snowmobiles, and/or bicycles

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Data for First Nations and Inuit Project

Regional Health Survey

• Directed & implemented by First Nations, in keeping with the First Nation Principles of Ownership, Control, Access and Possession (OCAP)

• Largely standardized sample design• Target population: First Nations communities across Canada• Representative samples at regional and national levels• Locally, individuals were selected within age/gender groups• 283 communities included; 22,602 surveys administered

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

What next?

• Broad feedback on list of indicators – are they useful?- Will they prompt action to prevent injuries? (modified Delphi process)

• Continue to seek data sources (follow up on meeting held December 4th in Ottawa)

• Inclusion of AFN as a partner in CIHR Team in Child and Youth Injury Prevention (STAIR)

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Related Projects: Policy Indicators (CIHR)

GOALS:

• A greater understanding of the elements related to successful injury prevention policies and their interaction with injury risk factors and outcomes

• Improved injury-related policies across Canada

• Reduced injury among Canadian children and youth

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Policy indicators grant

• We will examine differences in policies, risk factors, and outcomes for 4 important injury policies

• Bicycle helmet laws• Graduated driver licensing• Booster seat laws• Pediatric trauma systems

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Example: Bicycle helmet legislation

• Step 1: Evaluate policies across Canada-is there a helmet law? (yes/no)-is it for all ages? (yes/no)-is it enforced? (yes/somewhat/no)-does it cover all roads? (yes/no)

• Step 2: Evaluate helmet use (risk factor)-observational studies this summer in Vancouver, Winnipeg, Toronto, Barrie, Halifax

• Step 3: Examine outcomes -use hospitalization data to examine trends in bicycle-related head injuries across Canada

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

What Now?

• Continue work on policy indicators project

• Build the CIHR Team in Child and Youth Injury Prevention – application submitted to CIHR STAIR grant

• Work toward validation of the indicators

• Work toward making a ‘dashboard’ available through a child and youth injury web portal

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&

Thank you

Acknowledgements

Funding:

Centre for Community Child Health ResearchChild and Family Research InstituteChild Health BCUniversity of British Columbia

ChildYouthHealth

RESEARCH NETWORK

&ChildYouthHealth

RESEARCH NETWORK

&