| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
RESEARCH AND PRACTICE |
Guanmin Chen, Gary A. Smith, Sarah Grim Hostetler, and Huiyun Xiang are with the Center for Injury Research and Policy, Columbus Children’s Hospital and Children’s Research Institute, College of Medicine and Public Health, The Ohio State University, Columbus. Guanmin Chen is also with the Department of Health Statistics, School of Public Health, Wuhan University, Wuhan, China. Shusong Deng is with the Department of Preventive Medicine, Youjiang Medical College for Nationalities, Gangxi, China.
Correspondence: Requests for reprints should be sent to Huiyun Xiang, MD, PhD, Center for Injury Research and Policy, Columbus Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 (e-mail: xiangh{at}pediatrics.ohio-state.edu).
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Objectives. We described nonfatal injuries and calculated injury rates among middle-school and high-school students in Guangxi, China.
Methods. Students were selected using multistage randomizing techniques, and nonfatal injuries in 1840 students from February 2002 to January 2003 were monitored with standardized injury forms. Risk factors for injury were identified in multivariate analyses.
Results. The annual overall injury rate was 32.3 per 100 students. Boys had a significantly higher injury rate than the girls (34.8 vs 30.3 per 100 students), and a significantly higher proportion of injuries in boys was caused by other students (28.1% vs 19.4%). A higher proportion of injuries in girls (40.7%) occurred at home. For both boys and girls, sports were the most common activities associated with injury. Injuries from falls were the leading cause of injury, and extremities were most frequently injured. Gender, age, ethnicity, and family income levels were identified as significant risk factors for injury in multivariate analyses.
Conclusions. Nonfatal injuries in middle-school and high-school students should be recognized as a significant public health concern in China.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Previous studies have estimated that annual injury rates in middle-school and high-school students range from 5 to 50 injuries per 100 students.3,9–11 One study showed that school-aged athletes had a higher injury rate than nonathletes,12 and another study showed substantial differences in injury rates of adolescents by gender and school year.13 However, the majority of school-related injuries occurred in classrooms or on school playgrounds.3,14,15
Results from several studies among middle-school and high-school students indicate that injury type, cause of injury, injured body part, and location of injury vary by student demographics and family socioeconomic status.16–19 An international comparison study of medically attended, nonfatal injuries in adolescents in 24 developed countries across Europe and North America showed a wide range of injury patterns.11 Although epidemiological characteristics of nonfatal injuries in middle-school and high-school students have been well documented in the United States and other developed countries, little has been done in China. We used a large, randomly selected sample of middle-school and high-school students in Baise City, Guangxi Zhuang Autonomous Region of China from February 2002 to January 2003 to conduct a prospective study with the specific aim of investigating nonfatal unintentional injuries. We present results from descriptive epidemiological analyses of nonfatal injuries in this student population with a focus on describing injury characteristics and identifying risk factors for injury.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Study Subjects
Students aged 11 to 18 years were randomly selected in middle and high schools in Baise City, Guangxi Zhuang Autonomous Region of China. Overall, 1855 students were randomly selected from 36 classes in 9 middle and high schools.
Operational Injury Definition
A reportable injury in this study was defined as any injury meeting at least one of the following criteria: (1) an injury for which the student received medical treatment at the school nurse’s office, (2) an injury for which the student received emergency medical care from a doctor at a hospital or a private medical office, (3) an injury for which the student received first aid from his/her parent and missed a half day or more of school or regular activities, or (4) an injury that was not treated but caused the student to miss a half day or more of school or regular activities.
The injury definition criteria, taught during training for the study, were used by school nurses to confirm all injuries. The focus of this study was unintentional injuries; therefore, medically diagnosed child abuse, suicide, and homicide cases were excluded.
Data Collection
Demographic information about the students (e.g., age and gender) and their family (e.g., number of children in the family, family income, marital status, and parents’ education) was collected from the parents at the beginning of the new semester in February 2002 with a survey questionnaire. Students were followed through January 31, 2003. For injuries that occurred at schools, school nurses provided medical treatment and collected detailed information about the injury. Information regarding injuries that occurred outside of the schools was collected during monthly parent–teacher conferences. During these meetings, the teacher asked the parent about any injury that the student experienced in the past month outside of school. If an injury had occurred, the parent reported the injury to a school nurse, who then collected detailed information about the injury from an interview with the parent after the meeting.
Injury data were collected and recorded with Injury Surveillance Survey Forms. These forms recorded the following information for each injury: student’s name and gender, date and time of the injury, cause of the injury, activity when injured, location of the injury, person(s) who caused the injury, body part injured, school days or activities missed because of the injury, and medical advice or treatment received after the injury.
A pilot study was conducted with 45 students at one school in December 2001. Feedback from the pilot study was used to finalize the questionnaire and the Injury Surveillance Survey Form. Before the study, all school nurses and teachers of the selected classes received formal training, which was provided by researchers from the School of Public Health, Wuhan University, Wuhan, China.
Statistical Analysis
The SPSS statistics package (version 11.5)20 was used for all data analyses. Annual injury incidence rates per 100 students were calculated to describe injury incidence by student gender, age group, and ethnicity. Injury incidence rates per 100 students were also calculated by family characteristics, including total number of children in the family, marital status, parents’ education, and monthly family income. According to 2002 local governmental statistics,21 the average monthly household income in Baise City was 2000 Yuan (approximately US$245); therefore, we classified family monthly income into the following three levels: <2000 Yuan, 2000 to 3999 Yuan, and 
4000 Yuan.
We compared injuries between male and female students. Specific injury characteristics compared included cause of the injury, location of the injury, activity when injured, body part injured, person(s) who caused the injury, medical care received after the injury, and school days or activities missed because of the injury.
We used the 
2 statistic to test differences in injury risk among students with different demographics and family characteristics and also the differences in injury characteristics between male and female students. We selected P 
.05 as the significance level. Multivariate logistic regression models were used to control for potential confounding effects of the selected variables.22,23 Odds ratios and associated 95% confidence intervals were calculated.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
Injury Incidence Rates
Student characteristics and injury incidence rates are summarized in Table 1
. Male students had significantly higher injury rates than female students (34.8 vs 30.3 per 100 students; P =.04). Students from nonminority ethnicities (i.e., Han and Zhuang) had almost identical injury rates (31.5 and 31.7 per 100 students). However, the injury incidence rate (45.6 per 100 students) for minority students, including Miao, Bai, Tong, and Yao ethnicities, was significantly higher than that for nonminority students (P =.02). The injury incidence rate decreased with increasing age (i.e., from 41.4 per 100 students aged 11 years to 20.2 per 100 students aged 17–18 years).
|
Overall, approximately one third of students (31.4%) had more than one injury during the study period (Table 2). However, compared with female students, a significantly higher proportion of male students had two or more injuries (P =.03).
|
. For both male and female students, falls were the leading cause of injury. Compared with injuries in male students, a significantly higher proportion of injuries in female students occurred at home (40.7% vs 24.3%) or while working in the house (19.4% vs 3.7%). However, a significantly higher proportion of injuries in male students (36.1% vs 23.1%) occurred during sports activities. Related to this, a significantly higher proportion of injuries in male students was also caused by schoolmates (28.1% vs 19.9%).
|
Logistic Regression Results
Five logistic regression models were fitted to identify risk factors for injury with control for potential confounding effects of selected variables (Table 4). Of all of the significant variables identified in the univariable analyses in Table 1
, only gender, age, and ethnicity were retained in the model, using the method of stepwise autoselection (model 1). After control for ethnicity and age group, male students were significantly more likely than female students to sustain injuries (odds ratio [OR] = 1.25; 95% confidence interval [CI] = 1.02, 1.53). Compared with students aged 17 to 18 years, younger students were significantly more likely to sustain injuries (aged 11–13 years, OR = 1.51; 95% CI = 1.00, 2.26; aged 14–16 years, OR = 2.94; 95% CI = 1.96, 4.42). Consistent with findings in univariable analyses, minority students had approximately a 67% higher risk of injury than Han students (OR = 1.67; 95% CI = 1.05, 2.66).
|
.05, and thus the results are not reported here. |
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
We found an overall annual injury rate of 32.3 injuries per 100 students, which is consistent with injury rates of 5 to 50 injuries per 100 students in previous studies.2,3,9,10,12,24–27 The lower injury rates found in some of these studies are related to study design and injury definition. For example, two previous studies10,26 used data collected by the US National Health Interview Survey but only estimated injury rates for a 3-month recall period. The study conducted by Radelet et al. showed only sports-related injuries.12 Our study methodology was most comparable with the methodology used in previous studies in Shantou City in the Guandong province9 and in the United States.6 During a 1-year follow-up of 2559 students aged 7 to 16 years, the study by Li et al. showed an injury rate of 37.9 injuries per 100 students.9 Using a similar study design, Lenaway et al. monitored nonfatal injuries among 5518 elementary-school to high-school students and found an injury rate of 9.2 per 100 students.6 An international comparison study of medically attended nonfatal injuries among adolescents across 24 developed countries in Europe and North America showed that the annual injury rate among students aged 11 to 15 years varied from 10 to 47 injuries per 100 students in different countries.11 Comparison of injury rates between different injury studies is challenging for many reasons, including different study periods,10,12 different injury definitions,12 and different data collection systems.1,2 According to King et al., it may be more useful to look at the types of injuries by age group and by gender and the circumstances in which injuries occur.11
Our results regarding the leading cause of injury, activity when injured, location of injury, and body part injured among this school population were strikingly consistent with findings from other studies conducted around the world.2,3,10 Our findings and those of previous studies highlight the importance of prevention of sports-related injuries in injury control and prevention programs that focus on students. Around the world, health professionals and public health agencies advocate physical activity to combat the rising epidemic of childhood obesity.28 However, numerous studies have documented the substantial economic and social impact of injuries related to sports, recreation, and exercise.29,30 Parents and students need to recognize that injuries are not an inevitable part of participation in sports but are predictable and preventable. Middle-school and high-school students can harvest the tremendous benefits of physical activity when they play safely. Physical education teachers and coaches in schools need to be aware of the high risk of injury associated with sports activities and should design age-appropriate activities for students to reduce the risk of injury.
The inverse relationship of injury rate and age in our study was different from that found in a previous study.9 Injury rate in the study by Li et al. increased from 18.6 injuries per 100 students for those aged 7 to 9 years to 55.4 injuries per 100 students for those aged 13 to 16 years.9 However, our analysis showed that the injury rate decreased from 41.4 per 100 students aged 11 years to 20.2 per 100 students aged 17 to 18 years. Our results were more consistent with findings from a study conducted in Taiwan3 and from studies conducted among American students.6,7 In Taiwan, students in the ninth grade had the lowest injury rate when compared with students in the seventh and eighth grades. Lenaway et al. also found that American high-school students had a lower injury rate than elementary-school students and middle-school/junior high-school students.6 Differences in injury rate by age are more likely because of changes in student developmental stages and changes in the types of activities in which students participate.31 Analysis of injury rates6 revealed that high-school students were injured more frequently in the gym, middle-school/junior high-school students were injured more frequently on the athletic field, and elementary-school students were injured more frequently on the playground. Our results from multivariate regression analysis also showed that when the confounding effect from other variables was controlled, students aged 14 to 16 years had the highest risk of injury. This might indicate that, in our study, students aged 14 to 16 years participated in different types of activities or had more exposure time to high-risk environments than the students in the other two age groups. Future studies comparing sports/ leisure activities and exposure times to these activities between middle-school and high-school students in China may provide additional useful information.
Differences in injury risk and injury patterns in male and female students of different ethnicity in our study might reflect differences in socioeconomic status, social activities, or urban versus rural residence of the students in China. Our findings indicate that minority students had a higher risk of injury than majority students (higher injury rate and OR) and that socioeconomic background has a major impact on injury risk. With regard to gender, more male students than female students in China participate in aggressive sports activities such as football and basketball, whereas female students are more likely to participate in less aggressive activities such as dancing or performing household chores.32 This difference in social activities may explain the significantly higher proportion of sports-related and leisure activity-related injuries among male students in our study. This is also likely to be the reason why a significantly higher proportion of household injuries occurred among female students. Nevertheless, approximately one third of the injuries among both male and female students occurred in schools, and 28.1% of injuries among male students were caused by other children in schools. These findings have implications for injury-prevention initiatives in schools. As suggested by other researchers,3,7,33 schools are social institutions that have a pivotal role in influencing student behaviors as well as academic and social development. Therefore, school administrators are responsible for monitoring the school environment and providing supervision during class breaks and activities after school.
We used a prospective study design to monitor nonfatal unintentional injuries among middle-school and high-school students in China. This study design allowed us to calculate injury rates and compare relative injury risk in students. We also controlled for potential confounding effects of selected variables by conducting logistic regression analyses, which were seldom used in other studies.3,6,7,9,33 Finally, compared with other studies, our participant completion rate was very good. Nevertheless, our findings are subject to at least two limitations. First, underreporting by parents or students may have occurred, particularly when they were asked to report injuries that occurred during breaks outside of the school. In China, students usually have a 45-day break in July and August. Some parents/students may not remember an injury or the details of an injury that occurred during the school break. Another limitation is that our study was conducted in one city in China; therefore, findings in our study population may not reflect the injury risk and patterns of injury among the entire middle-school and high-school student population of China.
In summary, the results from this large prospective cohort study present an epidemiological overview of characteristics and risk factors for nonfatal unintentional injuries experienced by middle-school and high-school students in Gangxi, China. Our data indicate that the demographics and family characteristics of the students had a significant impact on injury risk and injury patterns among school students. Our findings underscore the importance of injury prevention in schools as well as outside of schools. Nonfatal injuries among middle-school and high-school students should be recognized as a significant public health concern in China.
|
Acknowledgments |
|---|
Human Participant Protection
This research study was reviewed and approved by the Wuhan University School of Public Health. Principals of selected schools signed written consent forms. Parental consent and student assent were obtained before the study.
|
Footnotes |
|---|
Contributors
G. Chen and S. Deng designed the study and collected the original data. G. Chen conducted the data analysis and finished the first draft of the article. H. Xiang participated in the study design, critical review of the article, and revision of the article. G.A. Smith participated in originating the data analysis plan and critically reviewed the article. S.G. Hostetler participated in the data analysis and contributed to the revision of the article. All authors approved the final version of this article.
Accepted for publication July 1, 2004.
|
References |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
|---|
2. Bienefeld M, Pickett W, Carr PA. A descriptive study of childhood injuries in Kingston, Ontario, using data from a computerized injury surveillance system. Chronic Dis Can.1996;17:21–27.[Medline]
3. Yang CY, Yeh YC, Cheng MF, Lin MC. The incidence of school-related injuries among adolescents in Kaohsiung, Taiwan. Am J Prev Med.1998;15:172–177.[CrossRef][Web of Science][Medline]
4. Rivara FP. Pediatric injury control in 1999: where do we go from here? Pediatrics.1999;103:883–888.
5. Feldman W, Woodward CA, Hodgson C, Harsanyi Z, Milner R, Feldman E. Prospective study of school injuries: incidence, types, related factors and initial management. Can Med Assoc J.1983;129:1279–1283.[Abstract]
6. Lenaway DD, Ambler AG, Beaudoin DE. The epidemiology of school-related injuries: new perspectives. Am J Prev Med.1992;8:193–198.[Web of Science][Medline]
7. Sheps SB, Evans GD. Epidemiology of school injuries: a 2-year experience in a municipal health department. Pediatrics.1987;79:69–75.
8. Taketa S. Student accidents in Hawaii’s public schools. J Sch Health.1984;54:208–209.[Web of Science][Medline]
9. Li LP, Wang S, Huang G, Luo JY. A survey on injury incidence in school children in Shantou City, China. Biomed Environ Sci.2003;16:180–186.[CrossRef][Web of Science][Medline]
10. Overpeck MD, Kotch JB. The effect of US children’s access to care on medical attention for injuries. Am J Public Health.1995;85:402–404.
11. King A, Wold B, Tudor-Smith C, Harel Y. The health of youth. A cross-national survey. WHO Re.g., Publ Eur Ser.1996;69:1–222.[Medline]
12. Radelet MA, Lephart SM, Rubinstein EN, Myers JB. Survey of the injury rate for children in community sports. Pediatrics.2002;110:e28.
13. Grimmer KA, Jones D, Williams J. Prevalence of adolescent injury from recreational exercise: an Australian perspective. J Adolesc Health.2000;27:266–272.[CrossRef][Web of Science][Medline]
14. Engstrom K, Laflamme L, Diderichsen F. Equalisation of socioeconomic differences in injury risks at school age? A study of three age cohorts of Swedish children and adolescents. Soc Sci Med.2003;57: 1891–1899.
15. Pickett W, Garner MJ, Boyce WF, King MA. Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents. Soc Sci Med.2002;55:1055–1068.
16. Kramer MD, Lightfoot AC, Knight S, Cazier CF, Olson LM. Classroom injuries in Utah public schools. Acad Emerg Med.2003;10:978–984.[CrossRef][Web of Science][Medline]
17. Junkins EP, Knight S, Lightfoot AC, Cazier CF, Dean JM, Corneli HM. Epidemiology of school injuries in Utah: a population-based study. J Sch Health.1999; 69:409–412.[Web of Science][Medline]
18. Turbeville SD, Cowan LD, Asal NR, Owen WL, Anderson MA. Risk factors for injury in middle school football players. Am J Sports Med.2003;31:276–281.
19. Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas high school basketball. A prospective study among male and female athletes. Am J Sports Med.1999;27:294–299.
20. SPSS base 11.5 application guide. Chicago, Ill: SPSS Inc; 2003.
21. Department of Baise Statistics. Social and economic statistics report 2002. Nanning, China: Guanxi Statistics Bureau; 2002.
22. SPSS regression 11.5 regression model. Chicago, Ill: SPSS Inc; 2003.
23. Daniel WW. Biostatistics: A Foundation for Analysis in the Health Sciences. 7th ed. New York, NY: Wiley; 1999.
24. King MA, Pickett W, King AJ. Injury in Canadian youth: a secondary analysis of the 1993–94 Health Behaviour in School-Aged Children Survey. Can J Public Health.1998;89:397–401.[Web of Science][Medline]
25. Hodgson C, Yacura W, Woodward C, Feldman W, Feldman E. Sequellae of school-related injuries: school and parent perspectives. Can J Public Health.1984;75: 273–276.[Web of Science][Medline]
26. Overpeck MD, Jones DH, Trumble AC, Scheidt PC, Bijur PE. Socioeconomic and racial/ethnic factors affecting nonfatal medically attended injury rates in US children. Inj Prev.1997;3:272–276.
27. Meeuwisse WH, Sellmer R, Hagel BE. Rates and risks of injury during intercollegiate basketball. Am J Sports Med.2003;31:379–385.
28. World Health Organization, Noncommunicable Diseases and Mental Health, Noncommunicable Disease Prevention and Health Promotion. Annual Global "Move for Health" Initiative: A Concept Paper. Geneva, Switzerland: WHO Document Production Services; 2003.
29. Conn JM, Annest JL, Gilchrist J. Sports and recreation related injury episodes in the US population, 1997–99. Inj Prev.2003;9:117–123.
30. Gotsch K, Annest JL, Holmgreen P, Gilchrist J. Nonfatal sports- and recreation-related injuries treated in emergency departments—United States, July 2000–June 2001. MMWR.2002;51:736–740.[Medline]
31. Scheidt P, Harel Y, Trumble A, Jones D, Overpeck M, Bijur P. The epidemiology of nonfatal injuries among US children and youth. Am J Public Health.1995;85: 932–938.
32. Lee MM, Wu-Williams A, Whittemore AS, et al. Comparison of dietary habits, physical activity and body size among Chinese in North America and China. Int J Epidemiol.1994;23:984–990.
33. Limbos M, Peek-Asa C. Comparing unintentional and intentional injuries in a school setting. J Sch Health.2003;73:101–106.[Web of Science][Medline]
This article has been cited by other articles:
|
|
 |
|
  J Mytton, E Towner, M Brussoni, and S Gray Unintentional injuries in school-aged children and adolescents: lessons from a systematic review of cohort studies Inj. Prev., April 1, 2009; 15(2): 111 - 124. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
