Relationships between child, family and neighbourhood characteristics and childhood injury: A cohort study

Abstract

There has been little research into the role of neighbourhood effects in childhood injury. We report results from a cohort study, comprising 1717 families (2357 children aged 0–7 years) registered at 47 general practices in Nottingham, UK. Multi-level Poisson regression examined relationships between electoral ward (neighbourhood), family and child characteristics and medically attended injury rates. Primary care attendance rates were higher for children in rented accommodation and those aged 2–3 years. An n-shaped relationship was found between geographical access to services and the primary care attendance rate. Accident and Emergency (A&E) department attendance rates were higher amongst boys, children in rented accommodation, with a teenage mother, aged 2–5 years and living in wards with a higher number of parks and play areas. They were lower for children whose families had a smoke alarm. Hospital admission rates were higher amongst children living in more deprived wards and wards with higher violent crime rates. They were lower in children whose families had smoke alarms, stair gates and stored sharp objects safely. Primary care and A&E attendance rates varied significantly between families. Variation between wards in the A&E attendance rate was explained by family characteristics. We conclude that characteristics of wards, families and children are associated with medically attended childhood injury rates. This study did not find a neighbourhood effect for A&E attendances that could not be explained by family level characteristics. Studies with greater power and a measure of injury severity independent of health service utilisation are needed to explore the relationship between neighbourhood effects and more severe injuries. The greater variation in injury rates vary between families than between neighbourhoods suggests reducing inequalities in injury rates may be achieved more effectively by focussing prevention at families rather than neighbourhoods, but in practice interventions at both levels are likely to be necessary.

Introduction

Injuries are the most common cause of death in childhood (Roberts, DiGuiseppi, & Ward, 1998) and the social gradient for deaths from injury is steeper than that for any other cause of death in childhood.(Botting, 1995) Social gradients are particularly steep for deaths caused by fire and flames, pedestrian injury, cyclist injury, falls and poisoning (Roberts, 1997) and there is evidence that the difference in death rates between the more and less advantaged is increasing. There are also steep social gradients for admissions to hospital in childhood for pedestrian injury, burns and scalds and poisoning (Hippisley-Cox et al., 2002) and little evidence that gradients in hospital admissions following severe traffic injury are reducing (Coupland et al., 2003).

In recent years there has been increasing interest in examining the effect of where people live as well as their individual characteristics on health behaviours and health outcomes (Diez Roux, 2001; Duncan, Jones, & Moon, 1998; Pickett & Pearl, 2001; Reijneveld, 2002) The role of neighbourhood effects in childhood injury would seem particularly relevant as characteristics of the neighbourhood such as traffic volume, the quality of housing, the availability of safe play areas or off street parking may be causally related to childhood injury (Cubbin, LeClere, & Smith, 2000; O’Campo, Rao, Gielen, Royalty, & Wilson, 2000; Reading, Langford, Haynes, & Lovett, 1999, Soubhi, 2004) Furthermore, if there is evidence of a neighbourhood effect this would provide support for the use of neighbourhood level interventions as well as interventions directed at the level of children and families to prevent injury.

There has been little work in this area related to childhood injury. Two recent UK studies investigated the relationship between the Townsend score of social areas, individual level characteristics and secondary care attendances for injury. (Haynes, Reading, & Gale, 2003; Reading et al., 1999) An increasing level of deprivation of the social area was associated with an increasing odds of injury. There was a small but significant amount of unexplained variation in the injury rates for children aged 0–4 years between social areas but most of the unexplained variation was at child level. They suggested that the area level effects may be explained by road safety measures, housing conditions, access to amenities or cultural attitudes to child safety and supervision.

One study in the USA (O’Campo et al., 2000) examined the relationship between neighbourhood characteristics and risk of events with injury-producing potential amongst children aged 0–4 years. Higher rates of events with injury producing potential were associated with younger parental age and with poorer quality housing. The authors postulated that the area effect may be explained by children living in structurally dangerous homes or playing in or around dilapidated housing. A second study from Canada (Soubhi, 2004) using self-reported data from the National Longitudinal Survey of Children and Youth found that neighbourhood problems and parental perceptions of having a difficult child were associated with a higher odds of injury amongst children less than 2 years of age, whilst positive and consistent parenting was associated with a lower odds of injury for children above 2 years of age. Neighbourhood cohesion was associated with a lower odds of injury only amongst children who were perceived as “difficult” and neighbourhood disadvantage was associated with a higher odds of injury only amongst children with aggressive behaviour. The author concludes that intervening at the level of the neighbourhood would be insufficient to reduce injury rates if parenting and child behaviour were not also addressed.

It is possible that unmeasured child or family level characteristics known to be associated with childhood injury, (Erens, Primatesta, & Gillian Prior, 2001; Tobin, Milligan, Shukla, Crump, & Burton, 2002) individual level measures of socio-economic disadvantage (Agran, Winn, Anderson, & Del Valle, 1998; Alwash & McCarthy, 1988; Faelker, Pickett, & Brison, 2000; Pomerantz, Dowd, & Buncher, 2001) or safety practices (Azizi, Zulkifli, & Kassim, 1994; DiGuiseppi, Roberts, & Li, 1998; Elkington, Blogg, Kelly, & Carey, 1999; Marshall et al., 1998; Petridou et al., 1998; Runyan, Bangdiwala, Linzer, Sacks, & Butts, 1992; van Rijn, Bouter, Kester, Knipschild, & Meertens, 1991) could explain the area level effects found in these studies. In addition, area characteristics could provide direct explanations for variations in injury rates. This study was therefore undertaken to examine the relationships between a range of area, family and child characteristics and medically attended unintentional injury in childhood. An examination of the utility of safety practices in predicting childhood injury will be presented elsewhere.