Chapter 7: The Health of Canada's Young People: a mental health focus – Injury

Injury

by William Pickett

What is injury?

Injury is defined as any physical harm to the body caused typically by an external force. The most common causes of injury are physical forces, and in young people these often happen while playing sports, during motor vehicle collisions, while cycling, or during physical fights (Molcho et al., 2006). Injuries can also include poisoning and ingestions, as well as burns.

Why does injury matter?

Injury is recognized as a leading public health issue in populations of young people around the world (Peden et al., 2008). This is certainly the case in Canada. Injuries are also costly to society in terms of health care expenditures and time lost from productive activities for both adolescents and the adults who care for them when they are injured (Ameratunga, 2009; Leitch, 2007; Peden et al., 2008).

Possible relationships between injury and mental health

While injuries may cause obvious physical health effects such as pain and disability, the extent to which injuries may relate to mental health is not well known. This is a relatively new area of research. Recovery from injury can be a challenging process. Not only may injured youth experience ongoing pain and inconvenience, they may be prevented from engaging in their usual activities such as sports, music, and other recreational activities. These life changes are not trivial, and they may take a significant emotional toll. It is also possible that a young person's mental health status may impact risks for injury, (i.e., those who are suffering from emotional problems may be more prone to injury through a variety of risk-taking and other mechanisms). For these reasons, it is important to examine associations between various types of injury and mental health.

What are we reporting in this chapter?

In this chapter, we report on the percentage of students who experience at least one injury in a year, on the percentage of those who experience multiple injuries, and on the seriousness of these injuries. We define injuries as any injury event reported in the last 12 months that resulted in treatment by a doctor or nurse. One year represents the standard time period over which it is believed that young people can recall their injury experiences accurately (Harel et al., 1994).We define serious injuries as those that resulted in significant medical treatment such as the placement of a cast, stitches or an overnight admission to hospital. We also describe injuries leading to at least five days missed from school or usual activities. We describe patterns of injury by grade level and gender, and whether the serious injury problem appears to be getting better or worse compared with past HBSC surveys. Common activities and locations of injury are highlighted. Finally, the burden of injuries is reported in terms of time lost from school or other usual activities. We also examine some key behaviours that are known to protect young people from injury, or alternatively, cause great harm. Key protective behaviours include bicycle helmet use, and helmet use while operating ATVs, snowmobiles, and dirt bikes. The key risk behaviours examined were riding in a car or other motor vehicle operated by someone who had been drinking or using drugs, or alternatively driving a car or other motor vehicle under the same conditions. Finally, we examine injury in relation to the four standard indicators of mental health.

Description of the injury problem

The size of the injury problem in Canada

7.1 Students reporting an injury requiring medical treatment, by grade and gender (%)

[Click to enlarge Figure 7.1]

Figure 7.1 shows the overall proportions of students who reported at least one injury in the past 12 months. Across the grades, 42 to 47% of boys reported experiencing at least one injury requiring medical treatment, compared to 35 to 40% of girls. In every grade, boys reported more injuries than girls. There was no strong observable pattern in the occurrence of injuries across the five grades.

7.2 Students reporting multiple injuries, by grade and gender (%)

[Click to enlarge Figure 7.2]

Some young people reported experiencing more than one injury over the course of a year, and this is shown in Figure 7.2. Reports of multiple injuries ranged from 20 to 26% for boys and 16 to 21% for girls. In general, there were no strong increases or decreases in the occurrence of injury across the different grades. These patterns were quite similar to past cycles (e.g., 2006) of the HBSC.

7.3 Students reporting one or more serious injuries requiring significant medical treatment, by grade and gender (%)

[Click to enlarge Figure 7.3]

Figure 7.3 shows that at each grade level, a greater proportion of boys (18 to 22%) compared to girls (13 to 17%) reported a serious injury requiring placement of a cast, stitches, surgery, or an overnight admission to hospital in the past 12 months.

Impact of injury on young people's lives

7.4 Missing one or more days from school or usual activities due to an injury, by grade and gender (%)

[Click to enlarge Figure 7.4]

The impact of students' injuries extends beyond their immediate physical consequences. In 2010, about 1 in 4 students typically missed one or more days of school or other usual activities due to an injury, with slightly higher percentages reported by boys in the older grades (Figure 7.4). There were no strong age-related patterns observed for girls.

7.5 Missing five or more days of school or usual activities due to an injury, by grade and gender (%)

[Click to enlarge Figure 7.5]

Between 6 to 10% of students reported missing a week or more of school or usual activities due to an injury (Figure 7.5).

Trends in injury over time

7.6 Injuries resulting in five or more days lost from school or usual activities reported over the last five cycles of the HBSC Survey, by grade and gender (%)

[Click to enlarge Figure 7.6]

Trends in the occurrence of serious injuries reported by young people are summarized in Figure 7.6. There was no clear trend in the occurrence of reported injuries across the five HBSC survey cycles representing 16 years. This is despite the fact that injury has been recognized as an important public health issue in Canada, and considerable resources have been put into prevention efforts. This is of obvious concern to public health officials in Canada.

7.7 Total days missed of school or usual activities due to an injury per 1000 students per year, by grade and gender

[Click to enlarge Figure 7.7]

Figure 7.7 describes the burden of injury in the HBSC sample, estimated per 1000 participating students. Cumulatively, these injury events resulted in an enormous amount of time lost to students in all grades.

How are young people injured?

Injuries to young people occurred during many different activities. Figures 7.8 to 7.10 show that sports and recreational activities including walking or running, biking and skating are leading causes of injury. While fighting injuries are less common, the effects of violence on mental health will likely be more serious than the effect of recreational injuries due to the emotional impact of the violent event. Similarly, while motor vehicle injuries and occupational injuries account for smaller percentages in all age groups, they are still notable because they can be traumatic and disabling, thereby affecting the mental health of the victim.

7.8 Leading activities that result in injury to Grade 6 students, by gender (% of all activities; note: percentages do not add to 100%)

[Click to enlarge Figure 7.8]

7.9 Leading activities that result in injury to Grade 8 students, by gender (% of all activities; note: percentages do not add to 100%)

[Click to enlarge Figure 7.9]

7.10 Leading activities that result in injury to Grade 10 students, by gender (% of all activities; note: percentages do not add to 100%)

[Click to enlarge Figure 7.10]

Where are young people injured?

Table 7.1 shows that the leading places where injuries to young people occurred include sports facilities or fields (21 to 41%), and at school during regular hours (12 to 19%). Injuries at sports facilities appeared to increase in older grades, while injuries that happened at home or in schools declined with age.

Which activities lead to the most serious injuries?

Figure 7.11 shows that the types of injury-causing activities most likely to lead to significant medical treatment (any of placement of a cast, stitches, or an overnight admission to hospital) include motor vehicle injuries, cycling injuries, and fighting. This is consistent with what is known about major causes of adolescent injury that result in death and hospitalization. While less common than sports injuries, these types of injury are important due to their relative severity.

7.11 Injuries requiring significant medical treatment, by activity (%)

[Click to enlarge Figure 7.11]

Risk and protective factors

Helmet use

There were large differences observed in the use of helmets while cycling (Figure 7.12). While about 60% of Grade 6 cyclists wore a helmet most or all of the time, less than 20% of Grade 10 students reported this protective behaviour. Percentages of adolescents reporting bicycle helmet use were roughly equivalent between boys and girls in all age groups. Figure 7.13 suggests that while proportions of young people reporting helmet use were generally consistent between populations from urban and rural areas, lower proportions of reported use were observed in smaller urban centres among Grade 8 participants.

7.12 Students wearing a bicycle helmet most or all of the time when cycling in the last 12 months, by grade and gender (%)

[Click to enlarge Figure 7.12]

7.13 Students wearing a bicycle helmet most or all of the time when cycling in the last 12 months, urban vs. rural schools (%)

[Click to enlarge Figure 7.13]

Figure 7.14 shows that the majority of young people reported use of a helmet most or all of the time when they were riding motorized vehicles such as snowmobiles, dirt bikes, and all-terrain vehicles. However, substantial proportions of these students (21-46%) did not report helmet use and this risk behaviour increased in the older age groups. This pattern was similar for boys and girls. The pattern of responses to this question were quite similar in urban versus rural respondents.

7.14 Students wearing a helmet most or all of the time when riding other vehicles (e.g., snowmobile, ATV, dirt bike) in the last 12 months, urban vs. rural schools, by grade (%)

[Click to enlarge Figure 7.14]

Drinking, drug use and driving

7.15 Students reporting riding in a car or other vehicle driven by someone who had been drinking alcohol or using drugs in the past 30 days, (% of Grade 9 and 10 students)

[Click to enlarge Figure 7.15]

Driving a motor vehicle while under the influence of alcohol or drugs is an obvious and serious cause of major injury in Canada. Therefore, it is disturbing to see that substantial proportions of boys and girls reported riding in a motor vehicle driven by someone who had been using drugs or alcohol in the past 30 days. Figure 7.15 presents the percentages for Grade 9 and 10 students, who reported this behavior most frequently. This was especially a problem in rural student populations.

7.16 Grades 9 and 10 students reporting driving a vehicle after drinking alcohol or using drugs in the past 30 days, urban vs. rural schools, by gender (%)

[Click to enlarge Figure 7.16]

Equally disturbing are the proportions of Grade 9 and 10 students who reported driving a motor vehicle when they had been drinking alcohol or using drugs. Again, the highest reports of this behaviour were observed among boys in rural areas (Figure 7.16). However, 15% of girls from small urban centres also reported this behaviour, which was considerably higher than those from large urban centres.

Injury and mental health

For many different reasons, it is possible that young people who report injuries may also report different types of mental health experiences, both positive and negative. On the one hand, injuries can cause pain and suffering. Prolonged experiences with pain can take a toll, and potentially have consequences in terms of poorer levels of mental health. On the other hand, relationships between specific types of injury and the mental health indicators are affected by the context in which the injury occurred.

An injury that occurred during a fight or other act of violence will have obvious detrimental effects on a young person's mental health. This may, however, be an artifact of the violent encounter, and not necessarily the injury itself. On the other hand, an injury that occurred during physical activity (including sports) may have positive relations with mental health outcomes, as the positive effects of this activity may outweigh any negative consequences of the injury itself.

Figure 7.17 demonstrates that girls reporting injuries also reported increases in the most negative responses on the emotional problem scale. Both boys and girls reporting injuries also reported higher scores on the behavioural problem scale (Figure 7.18). This suggests that overall, injury experiences are associated with some negative aspects of mental health.

7.17 Students reporting high levels of emotional problems, by days missed due to injury, by gender (%) ¹

[Click to enlarge Figure 7.17]

7.18 Students reporting high levels of behavioural problems by days missed due to injury, by gender (%)

[Click to enlarge Figure 7.18]

When these relationships are broken down for specific types of injury, quite a different pattern emerges.

Higher rates of emotional well‑being are associated with the reporting of a physical activity injury (Figure 7.19), most likely attributable to the benefits of exercise and participation in sports.

7.19 Students reporting high levels of emotional well‑being by days missed due to physical activity injury, by gender (%)

[Click to enlarge Figure 7.19]

When injuries caused by fighting were examined (Figure 7.20), strong relationships were observed between boys with injuries caused by fighting and higher scores on the emotional problem scale, while the pattern observed among girls was less consistent. Emotional well‑being also appeared to decline in association with reports of fighting injuries among boys, whereas no such pattern appeared among girls (Figure 7.21).

7.20 Students reporting high levels of emotional problems by days missed due to fighting injury, by gender (%)

[Click to enlarge Figure 7.20]

7.21 Students reporting high levels of emotional well‑being by days missed from school or usual activities due to fighting injury, by gender (%)

[Click to enlarge Figure 7.21]

7.22 Students reporting high levels of behavioural problems by whether they have ridden in a car with an impaired operator, by gender (%)

[Click to enlarge Figure 7.22]

Finally, it is clear that some indicators of negative mental health, such as the behavioural problem scale, can be linked with risk-taking behaviours that have very serious consequences. For example, strong relationships were observed between those with a high score on the behavioural problem scale and drinking and driving behaviours, such as riding in a car or other vehicle while the operator was impaired (Figure 7.22).

What young people thought about these findings

While young people appreciated the importance of injury as a public health problem, their views on its relative importance might vary somewhat from adults, especially adult professionals who are responsible for the development of injury prevention programs. The immediate consequences of injuries in terms of pain, suffering, and inconvenience seem to be understood, at least conceptually. Nevertheless, the long-term costs of injury in terms of its effects on society, or even its immediate effects on mental health, are less well understood. As a priority, it seemed that many youth attending the workshop ranked injury behind other leading public health issues (e.g., obesity, physical inactivity, violence), in terms of the need for urgent government action.

In addition, there are many obvious and well-established risk-taking behaviours that can lead to injury. Some of these include drinking and driving or riding in a vehicle with an impaired driver. Others include non-use of helmets while riding bicycles or other recreational vehicles such as snowmobiles, ATVs, and dirtbikes. Many young people that responded to the HBSC in Canada reported recent engagement in such risky behaviours, despite what is known about such risks and their effects on injury. There is a consequent need to redouble efforts to educate young people about the importance of preventing injury in their young lives, and how to manage and prevent the overt risk-taking that can lead to trauma.

Summary and implications

Commentary

The descriptive findings that appear in this chapter mirror those found in previous HBSC cycles and reports. Injury remains a leading public health priority in terms of the prevalence of injury events reported, and the extent and consistency of the problem observed in groups of young people across the country. Injury also exacts a significant toll in terms of the numbers of young people who seek formal medical care from the health care system, and in terms of the extensive amount of time lost to school or other usual activities. These facts are well understood by Canadian authorities, including the Public Health Agency of Canada which has identified injury as one of its leading priority health issues during recent years (Leitch, 2007; Public Health Agency of Canada, 2009).

What is new in the 2010 HBSC Study is the documentation on a population basis of some key risk-taking behaviours that have the potential to result in major injury. Substantial proportions of students in Grade 9 and 10 (e.g., up to 25% of rural boys) report the recent operation of a car or other vehicle after consuming alcohol. Even higher proportions (25% to 33%) of young people report riding in a car or other vehicle driven by someone who had been drinking or using drugs. While the majority (about 60%) of Grade 6 children report wearing a helmet while cycling at least most of time, this drops to only 20% by the time young people enter Grade 10. And about 45% of Grade 10's report at least some non-use of helmets while riding on other recreational vehicles such as ATVs or snowmobiles. All populations of young people seemed to share in these risks. Efforts to prevent young people from engaging in these known and obvious risks remain a leading priority for the prevention of major injury in Canada.

While some forms of injury may take an important toll on the mental health of young people, it is also clear that the causal relationship between injuries and mental health outcomes is not always straightforward. Injury can lead to poor mental health outcomes. Poor mental health outcomes can also lead some young people to take increased risks leading to injury. Exploratory analyses of these relationships, such as those presented in this chapter, require confirmation in longitudinal studies to sort out the correct temporal sequence. It is also clear that context plays a role in the nature and effects of these relationships. Injuries that occur in different settings and contexts might have very different effects on standard indicators of mental health. These do not represent clear-cut relationships, and the context in which the injury occurred seems to matter.

In summary, injury remains a leading public health priority among populations of young people in Canada. This chapter provides simple descriptive insights into the ongoing nature of this problem in our country. It also points to some obvious priorities for prevention that were documented during the 2010 HBSC cycle.

References

• Ameratunga, S. (2009). Which pill should we take? Bulletin of the World Health Organization, 87:399.
• Harel, Y., Overpeck, M.D., Jones, D.H., Scheidt, P.C., Bijur, P.E., Trumble, A.C. & Anderson, J. (1994). The effects of recall on estimating annual nonfatal injury rates for children and adolescents. American Journal of Public Health, 84:599-605.
• Leitch, K. (2007). Reaching for the top: A report by the advisor on healthy children and youth. Ottawa:
  Ministry of Health Canada.
• Molcho, M., Harel, Y., Pickett, W., Scheidt, P.C., Mazur, J., Overpeck, M.D. & HBSC Violence and Injury Writing Group (2006). The epidemiology of non fatal injuries among 11, 13 and 15 year old youth in 11 Countries: Findings from the 1998 WHO-HBSC cross national survey. International Journal of Injury Control and Safety Promotion, 13:205-211.
• Peden, M., Oyegbite, K., Ozanne-Smith, J., Hyder, A.A., Branche, C., Rahman, F., AKM, Rivara, F. & Bartolomeos, K. (2008). World Report on Child Injury Prevention. Geneva: WHO and UNICEF.
• Public Health Agency of Canada (2009). Child and youth injury in review, 2009 edition - Spotlight on consumer product safety. Ottawa: Government of Canada.

1. 25% of boys who did not see a doctor or nurse for an injury in the past 12 months report relatively high levels of behavioural problems, compared with 27% of boys who saw a doctor or nurse for an injury in the last 12 months, but missed fewer than 5 days of school or other usual activities due to the injury. A full explanation of how to interpret the figures that relate to mental health is provided in Chapter 1.