Article Text

Access to medical care and its association with physical injury in adolescents: a cross-national analysis
  1. Valerie F. Pagnotta1,
  2. Nathan King2,
  3. Peter D. Donnelly3,
  4. Wendy Thompson4,
  5. Sophie D. Walsh5,
  6. Michal Molcho6,
  7. Kwok Ng7,8,9,10,
  8. Marta Malinowska-Cieślik11,
  9. William Pickett1,2
  1. 1 Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
  2. 2 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
  3. 3 School of Medicine, University of St Andrews, St Andrews, UK
  4. 4 Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ontario, Canada
  5. 5 Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
  6. 6 Department of Children’s Studies, School of Education, University of Galway, Galway, Ireland
  7. 7 Faculty of Education, University of Turku, Turku, Finland
  8. 8 Physical Activity for Health Research Cluster, Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
  9. 9 School of Educational Sciences and Psychology, University of Eastern Finland, Joensuu, Finland
  10. 10 Faculty of Sport and Health Sciences, University of Jyvaskyla, Jyvaskyla, Finland
  11. 11 Department of Environmental Health, Faculty of Health Sciences, Jagiellonian University, Medical College, Krakow, Poland
  1. Correspondence to Valerie F. Pagnotta, Department of Health Sciences, Brock University, St. Catharines, ON L2S 3A1, Canada; vp17ij{at}


Background Strong variations in injury rates have been documented cross-nationally. Historically, these have been attributed to contextual determinants, both social and physical. We explored an alternative, yet understudied, explanation for variations in adolescent injury reporting—that varying access to medical care is, in part, responsible for cross-national differences.

Methods Age-specific and gender-specific rates of medically treated injury (any, serious, by type) were estimated by country using the 2013/2014 Health Behaviour in School-aged Children study (n=209 223). Available indicators of access to medical care included: (1) the Healthcare Access and Quality Index (HAQ; 39 countries); (2) the Universal Health Service Coverage Index (UHC; 37 countries) and (3) hospitals per 100 000 (30 countries) then physicians per 100 000 (36 countries). Ecological analyses were used to relate injury rates and indicators of access to medical care, and the proportion of between-country variation in reported injuries attributable to each indicator.

Results Adolescent injury risks were substantial and varied by country and sociodemographically. There was little correlation observed between national level injury rates and the HAQ and UHC indices, but modest associations between serious injury and physicians and hospitals per 100 000. Individual indicators explained up to 9.1% of the total intercountry variation in medically treated injuries and 24.6% of the variation in serious injuries.

Conclusions Cross-national variations in reported adolescent serious injury may, in part, be attributable to national differences in access to healthcare services. Interpretation of cross-national patterns of injury and their potential aetiology should therefore consider access to medical care as a plausible explanation.

  • cross sectional study
  • ecological study
  • epidemiology
  • adolescent
  • health services
  • child

Data availability statement

Data are available on reasonable request.

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Data are available on reasonable request.

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  • Contributors Building on previous conceptual work by SDW, MM, and PDD, authors VFP, NK, WP, WT, KN, and MM-C collaborated with SDW, MM, and PDD on the conceptualisation and planning of the study. NK and VFP conducted statistical analyses. All authors offered feedback and interpretation of the results. VFP, NK, WP and SDW drafted the manuscript. All authors critically reviewed the article and approved the final manuscript. As senior author, WP takes full responsibility as guarantor.

  • Funding Grant funding for this analysis was provided by the: (1) Centre for Surveillance and Research, Public Health Agency of Canada (6D016-123071/001/SS); 2) Canadian Institutes of Health Research (Project Grant PJT 162237); 3) Polish National Science Centre (2013/09/B/HS6/03438). Corresponding author, Valerie F. Pagnotta, is supported by a CIHR Frederick Banting and Charles Best Canada Graduate Scholarship. The HBSC is a WHO/Euro collaborative study; international coordinator of the 2014 HBSC survey was Dr Candace Currie, University of St. Andrews, Scotland. The international databank manager was Dr Oddrun Samdal, University of Bergen, Norway. The HBSC countries involved in this analysis (current responsible principal investigator) were Albania (G. Qirjako), Armenia (S. Sargsyan), Austria (R. Felder- Puig), Belgium (D. Piette, C. Vereecken), Bulgaria (L. Vasileva), Canada (W. Pickett, J. Freeman), Croatia (M. Kuzman), Czech Republic (M. Kalman), Denmark (M. Rasmussen) Estonia (K. Aasvee), Finland (J. Tynjälä), France (E. Godeau), Germany (P. Kolip), Greece (A. Kokkevi), Greenland (B. Niclasen), Hungary (Á. Németh), Iceland (Á. Arnarsson), Ireland (S. Nic Gabhainn), Israel (Y. Harel-Fisch), Italy (F. Cavallo), Latvia (I. Pudule), Lithuania (A. Zaborskis), Luxembourg (Y. Wagner), Malta (C. Gauci), Macedonia (L. Kostarova Unkovska), Netherlands (W. Vollebergh), Norway (O. Samdal), Poland (J. Mazur), Portugal (M. Gaspar de Matos), Russia (O. Churganov), Slovakia (A. Madarasova Geckova), Slovenia (H. Jericek), Spain (C. Moreno), Sweden (L. Augustine), Switzerland (E. Kuntsche), Ukraine (O. Balakireva) and UK (A. Morgan, F. Brooks; C. Currie; C. Roberts).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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