Deaths from injury in children and employment status in family: analysis of trends in class specific death rates
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38875.757488.4F (Published 13 July 2006) Cite this as: BMJ 2006;333:119
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This paper, sadly, includes no surprises to anyone working in an
inner city area, but could offer a useful additional measure of the
effectiveness of community based parenting programmes.
The discussions in the paediatric ward based multidisciplinary
meetings in this inner city hospital too often highlight the correlation
described in this paper. A small increase in our sensitivity to indicators
of difficulties in parenting would threaten to deluge local CAMH services,
yet a relatively small but ongoing intervention at this stage is likely to
be protective in the future.
Poverty distorts parenting, including its protective and supervisory
functions. It emphasises any inherent weaknesses in parenting in a way
that more affluent families with difficulties can guard against in a
number of financially based ways.
The studies after the Bristol floods showed the correlation of
physical injury following emotional trauma. Are some or many of these
parents traumatised sufficiently by the difficulties of their day to day
lives to pass on the effects down the generations? This would fit with
what we see week to week on the ward. It seems quite possible that being
able to assess the parents of children on the ward for more subtle signs
of mental distress and there being a service that could support them
sufficiently intensively as individuals and parents would help.
Yet being more sensitive to lower clinical thresholds, and thereby
inevitably less specific, is not what is required from CAMHS services at
present. We are increasingly pressurised to go down the route of only
assessing and treating more extreme pathology, which often means shutting
the door after the horse has bolted and disappeared over the horizon.
Will the intervention of Sure Start programmes across the country be
shown to reduce these statistics? What about the range of other parenting
programmes on offer? Is what we are doing across the statutory and
voluntary sectors effective or are we just trying to push water uphill in
the face of the level of deprivation and lack of opportunity and hope?
It would be heartening to see more hopeful statistics than these, but
some we could believe in.
Competing interests:
None declared
Competing interests: No competing interests
The study on children from the poorest families in England and Wales
facing greater risks of dying from injury matches our observation of the
same in underdeveloped countries. Financial considerations affect the
treatment of serious cases of trauma among poor children in developing
countries.
In cases of children with serious and life-threatening injuries the
treatment costs are exorbitant. There are public hospitals in countries
like India which provide high standards of healthcare to cases of trauma
to patients of all sections of society. These services are availed only by
the economically poorer sections since the other social classes suspect
the efficacy of such publicly funded health systems.
Facilities like CT-guided surgery are available only at major private
hospitals. Supramajor surgeries are performed only in major public
hospitals and tertiary private hospitals. The latter are beyond the reach
of the poorer sections of society. Therefore, the poor do not manage to
make use of the facilities provided by such private hospitals. Hence the
survival of poor children from accidental injuries is much less than the
fortunate one's in developing countries.
Competing interests:
None declared
Competing interests: No competing interests
Understanding inequalities in injury deaths
Edwards et al.1 examine the rates of death of children from injuries
according to socioeconomic group in England and Wales during the period
2001-2003 and find extremely high ratios of the rates in the lowest
socioeconomic group to those in the highest. The authors deem the
continued existence of a socioeconomic gradient surprising in light of the
recent declines in rates and the low absolute numbers of deaths. Due to
problems with comparability of data for different periods, the authors do
not assess whether socioeconomic differences are narrowing or widening.
But the continued existence of large socioeconomic difference for
increasingly rare outcomes ought not to be surprising. Moreover, in all
likelihood, during the period of declining injury death rates, the
socioeconomic differences were in fact increasing, for that is generally
what occurs when an adverse outcome declines. The basis for these
observations lies in the statistical tendency whereby, when two groups
differ in their susceptibility to an outcome, the rarer the outcome, the
greater the relative difference in experiencing it (though the smaller the
relative difference in avoiding it).2-6. The tendency is the consequence
of the facts that progress in eliminating adverse outcomes is almost
invariably a matter of restricting those outcomes to the point where only
the most susceptible segments of the overall populations continue to
experience them, and that disadvantaged groups make up higher proportions
of each increasingly more susceptible segment of the overall population
than they do of the preceding one.
For the same reason, we can expect that further efforts to reduce
injuries, assuming they are successful, may well increase relative
socioeconomic differences in injuries even when the efforts seem
particularly aimed at the disadvantaged. A study published last year in
the American Journal of Public Health is illustrative.7 The authors
examined changes in socioeconomic differences in rates of Sudden Infant
Death Syndrome (SIDS) in the United States as a result of the Back to
Sleep Program. The program, which was aimed at educating the public about
the advantages of having infants sleep on their backs, was deemed by the
authors as one expected to reduce health inequalities since there would be
few barriers to universal implementation of the recommendations. Yet the
study found that, while SIDS decreased substantially for all groups,
socioeconomic differences in SIDS rates increased. In fact, however, the
increase in those differences was just what one should expect as the
result of a program like this that serially restricted avoidable SIDS
mortality to the very most disadvantaged segments of the population – on
the way, one would hope, to the complete elimination of SIDS.
This does not mean that by promoting healthy living a society is
doomed to increase health inequalities. Rather, it means that some
rethinking is warranted concerning the utility of measuring inequalities
in terms of ratios of rates of experiencing adverse outcomes.
References
1. Edwards P, Green J, Roberts I, Lutchmun S. Deaths from injury in
children and employment status in family: analysis of trends in class
specific death rates. BMJ, doi:10.1136/bmj.38875.757488.4F (published 7
July 2006).
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2006;19(2):47-51. In press.
3. Scanlan JP. Measuring health disparities. J Public Health Manag
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(http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=641470).
4. Carr-Hill R, Chalmers-Dixon P. The Public Health Observatory
Handbook of Health Inequalities Measurement. Oxford: SEPHO; 2005
(http://www.sepho.org.uk/extras/rch_handbook.aspx).
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(http://www.jpscanlan.com/images/Race_and_Mortality.pdf).
6. Scanlan JP. Divining difference. Chance. 1994;7(4):38-9, 48.
7. Pickett KE, Luo Y, Lauderdale DS. Widening social inequalities
in risk for sudden infant death syndrome. Am J Public Health 2005;95:97-81
Competing interests:
None declared
Competing interests: No competing interests