Differences in cause-specific patterns of unintentional injury mortality among 15–44-year-olds in income-based country groups

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Abstract

Objectives: The aim of the present study was to investigate the cause-specific patterns of unintentional injury mortality among 15–44-year-olds in various income-based country groups, and to analyze which specific causes contribute the most to the unintentional injury mortality in each country group. Materials and methods: Cross-sectional data on the five most common causes of unintentional injury mortality by age–sex specific subgroups were compiled for 57 countries from the World Health Statistics Annuals for the year 1993 (1991–1994 if information for 1993 was unavailable). Data were categorized into four income-based country groups according to their gross national product (GNP) per capita for the year 1993. The differences between means and rate ratios of low, lower-middle, and upper-middle income countries were calculated by comparing them with those of the high-income countries. Regression analysis was performed to determine the trends in the direction of income for each specific cause of unintentional injury mortality by age–sex. Results: For any of the specific causes of unintentional injury mortality there was an inverse relationship between mortality rates and GNP per capita except for motor vehicle traffic (MVT) among the 15–24-year-old age group. MVT accidents were the most common cause and contributed 26–77% of all unintentional injury mortality. The second most common cause was poisoning in all country groups except low-income countries where drowning dominated for males and mixed causes for females. Upper-middle income countries represented the highest MVT mortality in all age–sex subgroups except among 15–24-year-old females for which high-income countries displayed the highest rate. For other causes, lower-middle income represented the highest rates with a few exceptions. In the 15–24-year age group, the rate ratio of motor vehicle traffic mortality was higher in high-income countries compared to low-income countries, while in the 35–44-year age group, all other country groups showed a higher rate ratio than high-income countries. Drowning for males and burns for females in the low and middle-income countries were significantly higher than in high-income countries.

Introduction

Today, injuries are recognized as an important public health problem not only in developed countries, but also in many developing countries where injuries are gradually becoming one of the major causes of death (Bangdiwala and Anzola-Perez, 1990, Bangdiwala et al., 1990, Rahman et al., 1998). As a means for understanding the extent of the problem and method of controlling accidents and injuries, numerous studies have been conducted in developed countries, but few in developing countries. In many developing countries, the victims of injuries are still too often blamed for their injuries; in road traffic accidents, it is the drivers who are invariably blamed for the accidents. The World Health Organization predicts that by the year 2020, injuries will be responsible for more deaths, disability, and morbidity combined than communicable diseases. Currently, injuries account for one in seven healthy life years lost world-wide; by 2020, they will account for one in five with low and middle-income countries bearing the brunt of this increase (Zwi et al., 1996) Among injury deaths, unintentional injuries are responsible for more death and disability. Globally, unintentional injuries cause as many Disability Adjusted Life Years Lost (DALYs) as diarrhea, and more than those lost from cardiovascular disease, malignant neoplasm, or vaccine-preventable childhood infections (Michaud and Murray, 1994). The relative importance of injuries is not only related to an absolute increase in injury, but also, in many countries, to an overall decline in mortality rates and to the increasing proportion of adults who are at higher risk for injuries (Mosley et al., 1990).

Injuries impose one of the greatest health risks in terms of mortality and morbidity among adolescents and young adults (15–44-year-olds). In 1990, in developing regions of the world, injuries among males aged 15–44 years led to 55 million DALYs lost in the world, with over one-third of DALYs lost from all causes coming from this sex and age group (Murray et al., 1994). When only premature deaths are considered and calculated by Years of Potential Life Lost (YPLLs), injuries lead all other causes (Rodriquez and daMotta, 1989). In the United States, unintentional injury mortality is the leading cause of death among 15–44-year-olds of all races and both sexes (Singh and Yu, 1996). Studies in developing countries also reveal the importance of this age group for the risk for injury deaths, with examples including Zimbabwe (Zwi et al., 1996), Bangladesh (Fauveau et al., 1989), and Egypt (Grubb et al., 1988).

The economic discrepancy between rich and poor countries is enormous. There is now evidence that lower socio-economic status is related to injury risk, but the results are non-linear and inconsistent (Berger and Mohan, 1996, Laflamme, 1998). One of the important measures of socio-economic development is gross national product (GNP) per capita. GNP per capita has been found to be inversely related to unintentional injury deaths among 1–14 (Plitponkarnpim et al., 1999a, Plitponkarnpim et al., 1999b) and 15–44-year-olds (Ahmed and Andersson, 2000). However, the relationship is not that straightforward, and development does not always directly reduce the injury mortality. In Taiwan, where the status of the country during the period 1960–1977 moved from that of developing to developed status, unintentional injuries rose from the seventh to the third leading cause of death, and the annual injury mortality rate increased from 39 to 57 per 100 000 population (Selya, 1980). Söderlund and co-workers describe an initial positive correlation between GNP per capita and road traffic accidents, which becomes negative with increasing GNP per capita (Söderlund and Zwi, 1995). Road traffic and other transport-related accidents are the most common cause of unintentional injury mortality in most countries (Söderlund and Zwi, 1995, Odero et al., 1997). Developed countries have long experienced motor vehicle traffic accidents as a major killer. Even in developing countries, these accidents are increasing rapidly: in Sri-Lanka, motor vehicle traffic mortality increased from 3 to 11 per 100 000 males from 1960 to 1983 (Smith and Barss, 1991). Other common causes of unintentional injury mortality are poisoning, drowning, burns, and falls.

The aim of the present study was to investigate the cause-specific pattern of unintentional injury mortality among 15–44-year-olds in income-based country groups, and to analyze which specific causes contribute the most to the unintentional injury mortality in each country group.

Section snippets

Source of data and study population

World Health Statistics Annuals 1993–1996 were used as the source of data (World Health Organization, 1994–1996). Data for all countries reporting to the World Health Statistics Annuals 1993–1996 were reviewed. Data for 1993 or the closest preceding or subsequent year in the period of 1991–1994 (if information for 1993 was unavailable) were collected. Some countries were excluded due to small population size (less than 1 million), out-dated data (before 1991), or lack of information about

Results

Fig. 1 shows aggregated unintentional injury mortality rates among 15–44-year-olds in the 57 countries. The unintentional injury mortality rates started to increase in the countries with a GNP per capita income of more than US$1000. The mortality rates then gradually declined when GNP per capita income reached approximately US$5000.

Table 2 depicts the mean rates of the five most common specific causes of unintentional injury mortality in four income-based country groups by age and sex

GNP per capita and wealth

GNP per capita was used to classify the countries and the intention was to choose GNP as a proxy for the countries’ developmental status. Other parameters could also be added to the analysis, such as income disparity, gross domestic product, exports, the level of external debts, vehicle ownership, the number of vehicles per capita, energy or newspaper consumption, women's literacy, etc. Income disparity could be one of the most suitable alternatives. For the analysis of MVT accident mortality,

Conclusion

Motor vehicle traffic accidents were the most common cause of injury death and contributed the most to the unintentional injury mortality rates among 15–44-year-olds in all country groups. In the 15–24-year age group, HICs displayed a higher risk of MVT mortality than was the case in LICs, while in the 35–44-year age group, all other country groups showed a higher risk of MVT mortality than the HICs. Poisoning mortality could be used as a sensitive indicator of unintentional injury mortality

Acknowledgements

The authors wish to thank Karen Leander, Department of Public Health Sciences, Karolinska Institutet, for her excellent efforts in correcting the English manuscripts.

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