The Relationship Between Social
Problems And Injuries: Implications
For Policy And Practice
Angus H Thompson, PhD.
Alberta Centre for Injury Control & Research
University of Alberta
Canadian Conference on Injury Prevention & Safety
Promotion. Ottawa, Canada, November 24, 2003
ACKNOWLEDGEMENTS
Kathy L Belton
Co-Director
Alberta Centre For Injury Control & Research
Kim Borden
Data Analyst
Alberta Centre For Injury Control & Research
DO UNINTENTIONAL AND
INTENTIONAL INJURIES BELONG
TOGETHER?
Source: Thompson AH, Borden K, Belton KL. (2003). The Relationship
Between Unintentional & Intentional Injuries Across Alberta’s
Health Regions. Unpublished manuscript.
ARGUMENTS AGAINST
Unintentional and intentional injuries
involve very different contexts and
interventions
“Traditional public health injury
control does not apply to violence.”
L.Fisher
ARGUMENTS FOR
“Whatever the form, in the end an injury is a health
problem”
B. Pless
“... the evidence on shared risk factors among
intentional and unintentional infant deaths warrants
‘convergence’ of effort rather than the compartmentalization engendered by separation.”
Overpeck and McLoughlin
EVIDENCE FOR
• SII predicts later mortality due to natural
causes, unintentional injuries, & violence
• Common parental factors exist for a variety
of infant injury deaths, regardless of intent
• There is a relationship between falls,
suicidal behaviour, & disease
• There is an overlap among predictors of
death by suicide, accidents & natural causes.
THE
CANADIAN SOCIAL
PROBLEM INDEX
(SPI)
SPI COMPONENTS
Murder
Attempted Murder
Assault
Sexual assault
Suicide
Robbery
Divorce
Alcoholism
SOCIAL PROBLEM INTERCORRELATIONS ACROSS PROVINCES: 1971/1981
Homicide
Attempted
Murder
Assault
Rape
Robbery
Divorce
Suicide
Att.
Murder
Assault
Rape
Robbery
Divorce
Suicide
AlcoHolism
.91/.90
.47/.50
.58/.69
.71/.61
.65/.66
.47/.81
.43/.82
.36/.24
.58/.44
.80/.61
.56/.48
.38/.79
.43/.59
.23/.73
.26/.00
.76/.54
.41/.30
.17/.63
.84/.35
.71/.68
.68/.34
.76/.83
.72/.67
.63/.66
.75/.65
.77/.70
.68/.77
.79/.66
SPI VALUES FOR CANADIAN PROVINCES: 1956, 1976, & 1996
160
SPI
140
120
100
80
BC
AB
SK
MN
1956
ON
1976
PQ
NB
NS
PEI
NF
1996
Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for
Canada. Canadian Journal of Psychiatry 46, 45-51
Social Problem Index Values For
Alberta RHA’s in Comparison to
Canadian 1956 Values
1991
1997
1. Chinook
160
151
2. Palliser
155
147
3. Headwaters
152
150
4. Calgary
148
145
5. RHA #5
152
148
6. David Thompson 156
151
7. East Central
148
143
8. WestView
158
149
9. Crossroads
168
152
10. Capital
153
146
11. Aspen
159
157
12. Lakeland
155
161
13. Mistahia
165
151
14. Peace
159
153
15. Keeweetinok
203
177
16. Northern Lights 173
161
17. Northwestern
174
192
THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN
THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS
Alcohol
Abuse
Drug
Abuse
Divorce
UnemSuicide
ployment attempt
Felony
Spouse
Abuse
Child
Abuse
Schizophrenia
Mania
Depression
Dysthymia
Phobia
Panic
Disorder
Obsessive
Compulsive
Antisocial
Personality
OR < 5
OR 5 - 9.9
OR 10+
Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian
Journal of Psychiatry 40, 15 – 20.
ECOLOGICAL
EVIDENCE FROM
ALBERTA’S
HEALTH REGIONS
METHOD
• Comparison of injury rates (hospitalizations)
across Alberta’s 17 health regions (in 1999)
•Analysis of the level of association among
intentional and unintentional injuries
• Principal components analysis to search
for an independent intentional injury factor
ALBERTA INJURY GROUPINGS
Unintentional Injuries
Adverse Effects (Medical)
Adverse Effects (Drug)
Falls
Motor Vehicle Crash
Overexertion /Strain
Late Injury Effects
Poison
Struck Object /Person
Natural /Env. Causes
Sports Related
Cutting/Piercing
Suffoc'n Foreign Body
Machinery
Fire/ Scalding
Bike - Non-Traffic
Undetermined Intent
Pedestrian - Non Traffic
Drowning
Firearm (Unintentional)
Legal Intervention
Other Injury
Other Transp. Related
Unspec.Cause of Injury
Intentional Injuries
Suicide Attempt
Assault
ALBERTA INJURY GROUPINGS
Unintentional Injuries
Adverse Effects (Medical)
Adverse Effects (Drug)
Falls
Motor Vehicle Crash
Overexertion /Strain
Late Injury Effects
Poison
Struck Object /Person
Natural /Env. Causes
Sports Related
Cutting/Piercing
Suffoc'n Foreign Body
Machinery
Fire/ Scalding
Bike - Non-Traffic
Undetermined Intent
Pedestrian - Non Traffic
Drowning
Firearm (Unintentional)
Legal Intervention
Other Injury
Other Transp. Related
Unspec.Cause of Injury
Intentional Injuries
Suicide Attempt
Assault
ALBERTA INJURY GROUPINGS
Unintentional Injuries
Adverse Effects (Medical)
Adverse Effects (Drug)
Falls
Motor Vehicle Crash
Overexertion /Strain
Late Injury Effects
Poison
Struck Object /Person
Natural /Env. Causes
Sports Related
Cutting/Piercing
Suffoc'n Foreign Body
Machinery
Fire/ Scalding
Other Injury
Other Transp. Related
Unspec.Cause of Injury
Intentional Injuries
Suicide Attempt
Assault
RETAINED INJURY GROUPINGS
(91.7% of Injury Hospitalizations)
Unintentional Injuries
Adverse Effects (Medical)
Adverse Effects (Drug)
Falls
Motor Vehicle Crash
Overexertion /Strain
Poison
Struck Object /Person
Natural /Env. Causes
Sports Related
Cutting/Piercing
Suffoc'n Foreign Body
Machinery
Fire/ Scalding
Intentional Injuries
Suicide Attempt
Assault
INTERCORRELATIONS OF THE RETAINED INJURY GROUPINGS
Suic
Att
MVCs
Falls
Poison
Asslt
Suffoc
Fire
Nat
/Env
AdvEff AdvEff
Medic. Drugs
Mach
Struck
Cut
Motor Vehicle
Falls
Poison
.60+
p < .01
Assault
.47-.59
p < .05
Suffocat’n/Foreign Body
.30-.46
Fire/Scalding
Natural/Environmental
Adverse Effect-Medical
Adverse Effect-Drugs
Machinery
Struck Object/Person
Cutting/Piercing
Sports Related
Overexertion/Strain
Note: 48 of 105 comparisons were significant at p < 5%
Sport
(r = 0.81)
PRINCIPLE COMPONENTS ANALYSIS
1
Eigenvalue
Variance
Suicide
Motor Vehicle
Falls
Poison
Assault
Suffocation/Foreign Body
Fire/Scalding
Natural/Environmental
Adverse Effects-Medical
Adverse Effects-Drugs
Machinery
Struck Object/Person
Cutting/Piercing
Sports Related
Overexertion/Strain
Factor
2
3
6.9
2.6
1.4
45.8%
17.2%
9.6%
.85
.67
.87
.77
.74
.48
.59
.89
.51
.48
.76
.83
.50
.42
.48
-.20
.16
-.31
.49
-.53
-.30
.59
.19
-.40
-.10
.03
-.09
-.55
.79
.57
-.24
-.39
.16
.04
.00
.06
-.34
.33
-.11
.77
-.37
.17
-.25
-.14
.37
SOCIAL PROBLEMS
AND INJURIES
CORRELATIONS BETWEEN THE SPI AND
THE RETAINED INJURY GROUPINGS
Suicide
Assault
0.72
0.89
Falls
Adverse Effects-Medical
Cutting/Piercing
Struck Object /Person
Motor Vehicle
Machinery
Natural /Env. Causes
Poison
Fire/ Scald
Suffoc'n Foreign Body
Adverse Effects-Drugs
Overexertion /Strain
Sports Related
0.75
0.65
0.51
0.50
0.49
0.46
0.43
0.23
0.22
0.17
0.14
-0.16
-0.19
CORRELATIONS BETWEEN SELECTED SPI COMPONENTS AND
RETAINED INJURY GROUPINGS
Suicide Attempt
Assault
SPI
0.72
0.89
Alcoholism
0.82
0.83
Sexual
Assault
0.75
0.83
Falls
Adverse Effects-Medical
Cutting/Piercing
Struck Object /Person
Motor Vehicle
Machinery
Natural /Env. Causes
Poison
Fire/ Scald
Suffoc'n Foreign Body
Adverse Effects-Drugs
Overexertion /Strain
Sports Related
0.75
0.65
0.51
0.50
0.49
0.46
0.43
0.23
0.22
0.17
0.14
-0.16
-0.19
0.73
0.41
0.49
0.52
0.78
0.50
0.63
0.49
0.33
0.25
0.42
0.21
0.10
0.69
0.65
0.54
0.44
0.61
0.54
0.38
0.29
0.24
0.15
0.06
-0.22
-0.10
Child
Negl/Abuse
0.76
0.66
0.49
0.50
0.25
0.40
0.52
0.51
0.36
0.43
0.56
0.18
-0.09
-0.22
0.23
REVISITS TO THE
EMERGENCY ROOM AFTER
SELF-INFLICTED INJURY
UTILIZATION OF THE EMERGENCY DEPARTMENT
AFTER SELF-INFLICTED INJURY
• Record-linkage study of individuals admitted to an
Edmonton ER for SII in fiscal year 1995/96
• Comparison groups were those admitted for asthma and
a random selection of the remaining patients
• Groups were matched on age and sex, and were of equal
size (n = 478)
• Groups were compared on readmissions to any regional
ER over the subsequent three years
Source: Colman I, Dryden DM, Thompson AH, Chahal AM, Borden K, Rowe BH,
Voaklander DC. In press. Academic Emergency Medicine.
PROPORTION RETURNING TO THE ER WHO WERE INITIALLY ADMITTED FOR
EITHER SII, ASTHMA OR "OTHER" REASONS
30%
25%
20%
SII Group
Asthma Group
15%
Other
10%
5%
0%
Self-inflicted Injury
Unintentional Injury
REASON FOR RETURN
Assault
WHAT DOES IT
MEAN?
DO INTENTIONAL AND UNINTENTIONAL
INJURIES BELONG TOGETHER?
• They do, at least at the ecological level.
• Proximal vs Distal: There may be less
commonality in the proximal case, but
this needs to be investigated.
• The association among social problems,
mental illness, and injuries is suggestive
of a common underlying, contributing cause.
SOME POSSIBILITIES
1. Child Development
2. Child Development
3. Child Development
SOME POSSIBILITIES
• Parenting & Supervision
• Community Self-Efficacy
• Social Capital (Democracy)
The End
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