care, health and development Child: Original Article bs_bs_banner
doi:10.1111/cch.12140
Childhood psychosocial development and fatal injuries in Gauteng, South Africa K. Pretorius and A. Van Niekerk Safety and Peace Promotion Research Unit, Medical Research Council–University of South Africa, Tygerberg, Western Cape, South Africa Accepted for publication 6 March 2014
Abstract
Keywords adolescence, child development, infant, injury, preschool, psychosocial factors Correspondence: Karin Pretorius, MA, Safety and Peace Promotion Research Unit, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa E-mail: [email protected]
Background In South Africa, injuries are the third leading cause of death and disability. Children are especially susceptible to unintentional injuries, especially pedestrian injuries, burns and drowning. Injury risk is informed by children’s exposure to adverse environmental circumstances, and individual capacities dependent on developmental maturity. Boys are at greater risk than girls. This study investigates the incidence of fatal childhood injuries as well as sex differences across psychosocial development stages. Methods Data on fatal injuries in Gauteng, South Africa’s most populous province, were obtained from the National Injury Mortality Surveillance System. The analysis drew on Erikson’s psychosocial theory of development which was used to create meaningful age groups. Age-specific population data from the 2011 Census were used to calculate rates, and significant differences were determined through the generation of risk ratios and confidence intervals. Results There were 5404 fatal injuries among children in Gauteng from 2008 to 2011. The average age of victims was 8.9 years, and the majority male (65.6%). In infancy, the mortality rates for all injuries and non-traffic unintentional injuries were significantly higher than for the other age groups. Burns were the most common cause of death in infancy and early childhood. Pedestrian injuries accounted for a third of mortality in preschool and school age, and homicide rates were significantly higher in adolescence than in the other developmental stages. For injuries in general, boys had significantly higher mortality rates than girls in all age groups except preschool. The only instance where the mortality rate for girls was significantly higher than for boys was for adolescent ingestion poisoning suicides. Conclusions The exposure to environmental and social risks is differentially moderated with maturing age and levels of autonomy. The sex of the child also informs risk. The nature of these risks is important when considering child injury prevention strategies.
Introduction Injuries in adults and children are a major global health concern because of the extent of mortality and morbidity (Peden et al. 2008; World Health Organization 2008). The average global rate of injury mortality is 86.9 per 100 000 population, and in South Africa it is 157.8 (Murray et al. 2001; Bradshaw et al. 2003b), the latter a reflection of compounded contextual factors, including poverty and inequality, insufficient basic infrastructure, and
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inadequate law enforcement (Seedat et al. 2009). Children are a vulnerable group at high risk for injury mortality and morbidity; many who survive a serious injury are left with disabilities, at times with life-long personal and social consequences (Peden et al. 2008; Seedat et al. 2009; Towner & Mytton 2009). The main causes of childhood injury mortality across the world are similar, with the most common due to traffic, drowning, burns, falls or poisoning injuries (Towner & Mytton 2009). The leading causes of injury may, however, vary by context, with
35
Continued growth of formal operational thinking, complex abstractions
Identity vs. Role Confusion: Need to gain certainty about own characteristics, social identity and values Peer group Find own identity, establish philosophy of life, experimentation Puberty; sexual maturity. Industry vs. Inferiority: Need a sense of competency Initiative vs. Guilt: Begin to independently explore his/ her world Autonomy vs. Shame and Doubt: should be able to do certain tasks by themselves
Basic family Exploration of immediate environment, modelling behaviour of parents Improvement in hand-eye co-ordination Learning gender roles, improvement in language, increase in memory span
School and neighbourhood Gain knew knowledge & skills engage in social interactions Improvement in elegance of movement (e.g. sports) Abstract reasoning, logical use of symbols, operational thought
Adolescence School age
traffic, falls and burn injuries the leading causes in Pakistan (Razzak et al. 2004); falls, traffic crashes and burns in China (Jiang et al. 2010); and road traffic and thermal injuries in India (Kanchan et al. 2009). In South Africa, almost a third of the population is younger than 15 years, with 23% of all deaths in children aged 5 to 14 years due to injury, especially pedestrian injury, passenger injury, drowning, burns and firearm-related injury (Burrows et al. 2010). Children’s vulnerabilities to injury stem from exposure to hazardous environmental conditions and individual vulnerability as a result of specific physical, psychological and behavioural attributes. Children living in poverty are at higher risk for injury due, for example, to cramped living conditions, informal housing conditions, lack of safety equipment, and compromised supervision (Garzon 2005; Peden et al. 2008). Injury risk is further significantly influenced by a child’s development status (Rivara 1995; Schieber & Thompson 1996; Linnan et al. 2007; Jiang et al. 2010), with children’s capacities and ability to engage with their environment characterized by varying cognitive, emotional and physical capabilities (Piaget 1969; Louw et al. 1998). These still maturing capacities impact differentially upon injury risk exposure (Peden et al. 2008).
Preschool
K. Pretorius and A. Van Niekerk
Early childhood
36
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
Source: Adapted from Dewey 2004; Erikson 1963; Louw et al. 1998, Piaget 1969.
Cognitive abilities
Reflex action, Sucking, biting, grasping Recognizing objects, memory acquisition Physical abilities
Walking, talking, dressing and feeding self Symbolic language, imagination, basic judgements and decisions
Primary caregiver Positive, loving care received & basic needs met Most significant relationship Important tasks/activities
Parents/caregivers Master basic skills (walk, talk, toilet training)
Trust vs. Mistrust: need a predictable and supportive world Erikson’s psychosocial phase
Infancy
Developmental psychology refers to ‘the scientific study of changes in human behaviours and mental activities as they occur over a lifetime’ (Bukatko & Daehler 2011, p. 5). Jean Piaget’s developmental theory describes cognitive development via children’s interactions with their environment, which is influenced by factors such as physical maturation, experience, practice and social interaction (Piaget 1971, cited in Louw et al. 1998). Erik Erikson’s theory of psychosocial development considers the personal, emotional and social development of the individual. Ginsburg (1992) maintains that Erikson’s psychosocial stages ‘may be a useful heuristic approach for childhood injury investigators to consider’ (p. 95), and describes common childhood injuries in terms of Erikson’s developmental phases, including development-specific child behaviour and parenting practices. Erikson divided the lifespan into eight stages, with the first five stages describing childhood, namely: infancy, early childhood, preschool age, school age and adolescence (Dewey 2004; Harmon 2005). Erikson highlighted the interaction between increasing individual capabilities and an expanding social environment, with each development stage characterized by a dominant psychosocial crisis (see Gines et al. 1998; Louw et al. 1998). Table 1 presents the five psychosocial development phases of childhood, as
Table 1. Childhood development phases
Theories of child development
Childhood psychosocial development and fatal injuries 37
well as the main tasks and physical and cognitive abilities as described by Erikson and Piaget’s theories. The infancy stage is characterized by a psychosocial crisis of basic trust versus mistrust. Infants are helpless and dependent on the caregiver to protect and provide for them, and need to develop a feeling of basic trust. Incorporation, i.e. taking in of food and love, is considered an important social behaviour (Louw et al. 1998). In the early childhood phase, the psychosocial crisis is autonomy versus shame and doubt. The child develops skills which contribute towards growing independence, such as toilet training, and caregivers need to encourage independence and show compassion with regard to failures. In the preschool phase, the psychosocial crisis is initiative versus guilt. Children have a greater degree of freedom and greater access to society and socialization influences, with gender roles becoming clearer. In school age, children continue to master various skills and seek to succeed at what they do. They become competitive with their peers, with industry versus inferiority forming the dominant psychosocial crisis. During adolescence, the child experiences identity versus role confusion, or an identity crisis. This is often a period of experimentation, as the adolescent seeks to establish their social identity, values and goals. As children progress through these developmental stages, they gain and improve upon various abilities, but may still experience risk appraisal and response limitations that would expose them to injury. For example, in early childhood, a child can make basic decisions (based, e.g. on personal preferences), but cannot yet adequately assess potential sources of danger, while their increased curiosity about their environment and tendency and increasing capacity to explore puts them at greater risk (Gilbride et al. 2006; Jiang et al. 2010). There is a paucity of analysis of serious child injury and mortality by developmentally meaningful age categories, which would strengthen understandings of injury exposure and is required for developmentally relevant child safety interventions. The aim of this paper is therefore to investigate the occurrence of injury mortality in children by meaningful age groups, defined according to a leading psychosocial development theory. The paper also investigates the contributions of the child’s sex to injury mortality within these age groups.
Methodology
is the smallest province in the country (primarily urban) with the greatest population density, as well as the second highest proportion of deaths of the nine provinces (Statistics South Africa 2012; South African Government Information 2014). In 2007, the fatal injury rate for children younger than 15 years in Gauteng was 31.7 per 100 000 population (Swart et al. 2012).
Data sources Injury data Injury mortality data for Gauteng were obtained from the National Injury Mortality Surveillance System (NIMSS). The NIMSS has full coverage of Gauteng with the exception of Pretoria. Data for four consecutive years (1 January 2008 to 31 December 2011) were obtained for 0- to 19-year-old victims (cases where age was unknown were excluded). The NIMSS produces and disseminates descriptive epidemiological information on deaths due to non-natural causes detailing, where available, the deceased’s age, sex, population group, scene of injury, apparent manner and circumstances of death. Information is collected by the police and pathologists at each forensic pathology facility (Matzopoulos et al. 2002). Age categories were based on Erikson’s psychosocial stages. The Erikson age ranges for each phase are as follows: 0–1 year (infancy), 1–3 years (early childhood), 3–6 years (preschool), 6–12 years (school age) and 12–19 years (adolescence) (see Louw et al. 1998; Dewey 2004; Harmon 2005). There is some overlap across these categories; NIMSS data records age in single years, therefore the ranges were adjusted so that each individual age (in years) could be assigned to only one developmental phase as follows: 0–1 year (infancy), 2–3 years (early childhood), 4–6 years (preschool), 7–12 years (school age) and 13–19 years (adolescence).
Denominator data Age-specific population data for Gauteng were obtained from the 2011 South African Census. The same data were obtained for Pretoria and then subtracted from the Gauteng totals in order to match the sample population.
The study uses a retrospective, cross-sectional design.
Data analysis Setting The study focuses on Gauteng, where 19.4% of South African children live (Statistics South Africa 2011). Geographically, this
Descriptive statistics and cross-tabulations were run on the total sample, as well as each age group, using SPSS (version 20), in order to report on fatality frequencies for each developmental
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
38
K. Pretorius and A. Van Niekerk
Table 2. Sample characteristics by age group (developmental phase), Gauteng 2008–2011
Sex Male Female Race†‡ Black White Coloured Asian/Indian Apparent manner of death† Road traffic-related Other unintentional Homicide Suicide Main external causes Pedestrian Burns Drowning Passenger Blunt force Poisoning Sharp force Total fatal injuries
Infancy % (n)
Early childhood % (n)
Preschool % (n)
School age % (n)
Adolescence % (n)
Total % (n)
57.0 (647) 43.0 (488)
58.7 (424) 41.3 (298)
61.2 (394) 38.8 (250)
63.7 (484) 36.3 (276)
74.6 (1568) 25.4 (533)
65.6 (3517) 34.4 (1845)
90.1 (1026) 5.3 (60) 2.7 (31) 1.9 (22)
87.8 (635) 7.5 (54) 2.6 (19) 2.1 (15)
92.2 (595) 5.0 (32) 1.7 (11) 1.1 (7)
91.3 (695) 4.2 (32) 2.8 (21) 1.7 (13)
83.1 (1746) 10.1 (212) 4.4 (92) 2.4 (51)
87.5 (4697) 7.3 (390) 3.2 (174) 2.0 (108)
18.5 (127) 64.6 (443) 16.6 (114) N/A
33.8 (202) 55.6 (332) 10.1 (60) N/A
46.9 (261) 41.2 (229) 11.5 (64) N/A
50.9 (348) 32.3 (221) 13.7 (94) 2.8 (19)
30.6 (575) 10.3 (194) 35.7 (672) 19.4 (364)
34.4 (1513) 32.2 (1419) 22.8 (1004) 8.7 (383)
6.5 (60) 23.5 (218) 9.4 (87) 5.0 (46) 4.5 (42) 8.5 (79) 0.9 (8) 1170
20.6 (141) 24.9 (170) 16.8 (115) 5.3 (36) 4.4 (30) 5.6 (38) 1.8 (12) 724
31.9 (198) 14.0 (87) 13.4 (83) 6.4 (40) 6.8 (42) 5.6 (35) 1.0 (6) 645
32.8 (241) 12.0 (88) 13.1 (96) 8.8 (65) 5.2 (38) 2.7 (20) 2.3 (17) 762
12.5 (251) 3.9 (78) 3.0 (60) 8.0 (161) 9.6 (193) 7.0 (142) 13.0 (262) 2103
17.9 (891) 12.9 (641) 8.9 (441) 7.0 (348) 6.9 (345) 6.3 (314) 6.1 (305) 5404
†Percentages reflect totals where sex, race, manner of death and external cause were known. ‡The terms ‘White’, ‘Black’ and ‘Coloured’ do not signify inherent characteristics, but rather refer to demographic markers that stem from the apartheid era.These markers are still used in South Africa for their historical significance, and refer to people of European, African and mixed (African, European and/or Asian) ancestry respectively (Parry et al. 2004).
age group by sex, race, apparent manner and external cause of death. The age-adjusted death rates were computed for each age group by dividing the number of events (deaths) by the population total of the same age group, and then multiplying by a constant of 100 000. This results in an age-specific death rate (ASDR) per 100 000 population for each age group. For the purpose of calculating rates, 2011 mortality data were used, as these were the latest available data at the time of publication and corresponds with the latest Census data (2011). For the descriptive statistics, data from 2008 to 2011 were used (years were not compared). The descriptive statistics refer to all injuries irrespective of apparent manner (e.g. unintentional versus intentional), while the rates were focused on the main injury types for each apparent manner (e.g. unintentional burns, but not homicide burns). We compared the mortality rates for different injury types across the developmental stages, and used the age group with the highest incidence rate as the reference group. To identify statistically significant differences between these rates, we used risk ratios with 95% confidence intervals, which were calculated using SPSS (version 21). The two-tailed P values from the Fisher’s Exact Test were used because of the small sample sizes. Sex differences with regard to mortality rates within each developmental stage were also analysed.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
Results Sample characteristics The total number of fatal injuries to children during the period of 2008 to 2011 was 5404. Table 2 displays the frequency of fatalities according to developmental age group, by sex, race, manner and external cause of death. The majority of fatal injuries were to males, with the proportion of male mortality increasing between infancy and adolescence. The ratio of male to female injuries overall was 1.9:1. For the total sample, the majority of fatalities (87.5%) occurred among Black children/ adolescents. Road traffic-related injuries, non-traffic unintentional injuries and intentional injuries (i.e. violence and suicide) each comprised of a third of all child mortality. In infancy and early childhood, more than half of fatalities were due to non-traffic unintentional injuries. Road traffic injuries accounted for the largest proportion of deaths in the preschool and school age groups, and in adolescence, homicides accounted for just over a third of deaths. The most common external cause of injury in infancy was burns, followed by drowning, and in early childhood it was burns followed by pedestrian injuries. In the pre-
Girls
4 2 0 Infancy
Early Preschool Childhood
School Adolescence Age
Figure 1. Sex difference in 2011 overall injury mortality rates, by age
group.
0.47–0.93 0.35–0.84 0.37–1.43 0.06–0.12 0.03–0.12 0.06–0.25 – – – – – – 0.44–0.60 0.66 0.55 0.72 0.09 0.06 0.12 1.00 1.00 1.00 1.00 1.00 1.00 0.52 1.52 0.87 0.40 0.64 0.16 0.15 1.99 0.36 0.80 0.61 1.30 0.97 6.34 0.013 0.096 0.334 0.000 0.000 0.000 0.000 0.002 0.000 0.000 0.000 0.000 0.000 0.44–0.91 0.44–1.05 0.34–1.40 0.10–0.18 0.06–0.19 0.12–0.42 0.17–0.39 0.08–0.63 0.02–0.23 0.14–0.60 0.02–0.16 0.03–0.22 0.22–0.33 0.63 0.68 0.70 0.13 0.11 0.22 0.25 0.22 0.07 0.29 0.06 0.08 0.27 1.45 1.09 0.38 0.97 0.27 0.29 0.50 0.08 0.06 0.18 0.08 0.08 3.32 0.235 0.640 0.548 0.000 0.000 0.006 0.000 0.033 0.000 0.003 – – 0.000 0.54–1.15 0.56–1.41 0.35–1.70 0.23–0.41 0.16–0.44 0.24–0.79 0.18–0.49 0.08–0.93 0.02–0.34 0.11–0.70 – – 0.33–0.50 0.79 0.89 0.78 0.30 0.26 0.43 0.30 0.28 0.08 0.28 – – 0.41 1.80 1.41 0.43 2.24 0.66 0.56 0.60 0.10 0.07 0.17 N/A ″ 4.98 – – – 0.009 0.624 – 0.001 0.016 0.037 0.084 – – 0.002 – – – 0.57–0.92 0.61–1.31 – 0.28–0.72 0.02–0.96 0.22–0.97 0.20–1.09 – – 0.62–0.90 1.00 1.00 1.00 0.72 0.89 1.00 0.44 0.13 0.46 0.46 – – 0.75 2.29 1.59 0.55 5.32 2.27 1.29 0.88 0.05 0.37 0.28 N/A ″ 9.17 0.063 0.037 0.839 – – 0.400 0.000 – 0.000 0.007 – – – 0.42–1.02 0.31–0.97 0.40–2.07 – – 0.45–1.37 0.14–0.48 – 0.01–0.42 0.07–0.74 – – –
95% CI RR RR P value IR 95% CI
P value§ IR
RR
95% CI
P value IR
RR
95% CI
School age Preschool Early childhood
†Comparison of age groups across columns. ‡Incidence rate estimated at the number of injuries per 100 000 population. §Fisher’s Exact Test, two-tailed. Significant values indicated in bold. RR, risk ratio; CI, confidence interval.
Boys
6
0.66 0.54 0.91 1.00 1.00 0.78 0.26 0.00 0.06 0.23 – – 1.00
8
RR
10
IR‡
12
Infancy
14
Table 3. Distribution of injuries by age group†
16
95% CI
Table 3 displays the injury mortality rates by developmental age group for 2011. The mortality rates for injuries in general as well as non-traffic unintentional injuries were significantly higher in infancy than in the other developmental phases. In early childhood, road traffic fatalities (in general) were significantly higher than in school age and adolescence, but not significantly higher than in infancy and preschool. In adolescence, the rates for overall homicide, as well as firearm and sharp object homicide specifically, were significantly higher than in the other age groups. Figure 1 illustrates the sex differences in injury mortality rates for each developmental phase. Overall, boys had higher death rates than girls in all developmental age groups, although in preschool this difference was not statistically significant. In adolescence, boys had significantly higher mortality rates than girls for the majority of injury types, with the exception of unintentional burns (P = 0.754) and passenger deaths, with the latter having a higher rate among girls and bordering on significance with a P-value of 0.051. Firearm homicides in adolescent boys were more than 10 times the rate than for adolescent girls (P < 0.001). There was only one instance where the mortality rate for girls was significantly higher than for boys, namely suicide-related ingestion poisoning (P < 0.05). Detailed results are presented in Table 4.
Road traffic 1.51 Pedestrian 0.86 Passenger 0.51 Other unintentional 7.36 Burns 2.54 Drowning 1.01 Homicide 0.51 Firearms 0.00 Sharp 0.05 Blunt 0.14 Suicide N/A Hanging ″ All fatal injuries 12.27
Injury mortality rates
P value IR
Adolescence
P value
school and school age groups, pedestrian injury became the most common type of fatality. Sharp force injuries were the most common fatalities in adolescence, followed by pedestrian injuries. The youngest suicide victim was 8 years old, and the average age of suicide victims was 16.7 years. The most common method was hanging (66.8%) followed by ingestion poisoning (19.6%).
0.021 0.007 0.351 0.000 0.000 0.000 – – – – – – 0.000
Childhood psychosocial development and fatal injuries 39
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
RR
P value‡
1.74 1.28 0.46 1.24 0.23 0.46 0.54 0.04 0.08 0.23 0.11 0.11 0.00 4.06
1.16 0.90 0.31 0.72 0.32 0.12 0.47 0.12 0.04 0.12 0.04 0.04 0.00 2.54
0.67 0.70 0.68 0.58 0.73 0.26 0.88 0.33 0.51 0.51 0.34 0.34 0.00 0.62
0.42–1.06 0.41–1.21 0.28–1.67 0.32–1.02 0.26–2.12 0.07–0.91 0.41–1.89 0.03–3.14 0.05–5.64 0.13–2.04 0.04–3.28 0.04–3.28 – 0.46–0.85
95% CI
2.55 1.83 0.46 6.44 2.87 1.75 1.20 0.09 0.64 0.28 N/A ″ ″ 11.08
IR (girls)
0.086 0.222 0.504 0.066 0.604 0.035 0.845 0.370 1.00 0.508 0.625 0.625 – 0.003
P value
2.03 1.37 0.65 4.18 1.60 0.86 0.56 0.00 0.09 0.29 N/A ″ ″ 7.19
RR 0.80 0.75 0.70 0.65 0.56 0.48 0.47 – 0.15 0.99 – – – 0.65
95% CI 0.46–1.39 0.38–1.49 0.22–2.22 0.44–0.94 0.31–1.01 0.22–1.06 0.18–1.23 – 0.02–1.18 0.20–4.89 – – – 0.49–0.86
2.04 1.42 0.25 0.91 0.19 0.28 3.24 0.65 1.43 1.00 1.76 1.50 0.10 9.22
2.08 1.72 0.46 2.87 0.73 0.79 0.40 0.13 0.07 0.07 N/A ″ ″ 5.59
IR (boys)
Preschool
0.99 0.33 0.56 0.38 0.13 0.03 0.72 0.06 0.15 0.22 0.85 0.44 0.35 3.45
IR (girls)
P value 0.480 0.487 0.578 0.024 0.060 0.087 0.167 – 0.070 1.00 – – – 0.003
IR (boys)
RR
0.297 0.238 1.00 0.232 0.106 0.832 0.344 – – 1.00 – – – 0.030
IR (boys)
IR (girls)
95% CI 0.33–1.33 0.19–1.36 0.26–2.78 0.56–1.12 0.37–1.08 0.37–1.97 0.11–1.69 – – 0.05–5.62 – – – 0.59–0.97 Adolescence
0.66 0.51 0.85 0.82 0.63 0.85 0.44 – – 0.51 – – – 0.76
School age
1.20 0.59 0.47 6.66 1.98 0.95 0.28 0.00 0.00 0.10 N/A ″ ″ 10.50
IR (girls)
IR (boys)
1.81 1.15 0.55 8.08 3.13 1.10 0.64 0.00 0.09 0.19 N/A ″ ″ 13.81
IR† (boys)
†Incidence rate estimated at the number of injuries per 100 000 population. ‡Fisher’s Exact Test, two-tailed. Significant values indicated in bold. RR, risk ratio; CI, confidence interval.
Road traffic Pedestrian Passenger Other unintentional Burns Drowning Homicide Firearms Sharp Blunt Suicide Hanging Ingestion poisoning All fatal injuries
Road traffic Pedestrian Passenger Other unintentional Burns Drowning Homicide Firearms Sharp Blunt Suicide Hanging Ingestion poisoning All fatal injuries
Early childhood
Infancy
Table 4. Distribution of fatal injuries by age group and gender
IR (girls)
0.48 0.23 0.44 0.42 0.68 0.11 0.22 0.10 0.11 0.22 0.48 0.29 0.27 0.37
RR
1.52 1.12 0.40 1.63 0.61 0.34 0.80 0.07 0.07 0.27 N/A ″ ″ 4.40
RR
95% CI 0.43–1.25 0.35–1.22 0.29–2.59 0.34–0.93 0.35–2.01 0.15–1.20 0.19–1.31 0.05–5.60 0.06–16.25 0.03–2.20 – – – 0.57–1.09
0.32–0.74 0.12–0.46 0.19–1.01 0.21–0.82 0.19–2.34 0.01–0.89 0.14–0.35 0.02–0.41 0.04–0.27 0.10–0.50 0.30–0.76 0.16–0.52 0.08–0.97 0.30–0.47
95% CI
0.73 0.65 0.87 0.57 0.83 0.42 0.49 0.51 1.00 0.25 – – – 0.79
P value
0.001 0.000 0.051 0.012 0.754 0.022 0.000 0.000 0.000 0.000 0.002 0.000 0.034 0.000
P value
0.281 0.212 1.00 0.028 0.824 0.144 0.164 1.00 1.00 0.215 – – – 0.164
40 K. Pretorius and A. Van Niekerk
Childhood psychosocial development and fatal injuries 41
Discussion This Gauteng study reported that, for all childhood injuries considered, infants had the highest mortality rates, consistent with international research (Runyan et al. 2005; Linnan et al. 2007). The overall mortality concentration in infancy thereafter steadily declines with age, only to increase again in adolescence, consistent with other South African findings (Donson 2009). The childhood injury mortality rates were driven by unintentional injuries that were not traffic-related, which were also most prominent in infancy. In infancy, burns were the most common cause of injury mortality, followed by drowning. This is consistent with reports from other settings, for example, the leading cause of injury death for Chinese children younger than 3 years was also burn-related (Jiang et al. 2010), as it was for non-fatal injuries in Canadian infants (Flavin et al. 2006). The psychosocial crisis in infancy, according to Erikson (1963), is that of trust versus mistrust; a reflection of the highly dependent relationship between the infant and caregiver. The quality of this relationship is impacted upon by infant temperament and parenting behaviour, which may interact and influence one another, and contribute to injury risk (Schwebel et al. 2004). For example, positive parenting is related to a reduced risk of injury, while a difficult temperament of an infant may negatively interact with the caregiver’s parenting style and impair the quality of care. Inappropriate parenting, supervision and other adult behaviours may contribute to fatal injuries in infancy (Ginsburg 1992; Morrongiello et al. 2004). The second highest occurrence of overall injury mortality occurred in early childhood. Burns were again the most common type of injury, followed by pedestrian-related injury. This is consistent with international studies, e.g. from Kuwait, where children younger than five are at a significantly higher risk of fatal burns (Sharma et al. 2006); from India (e.g. Kanchan et al. 2009) which have reported toddlers and preschool children at a greater risk of burn injuries, and other South African burn research (e.g. Van Niekerk et al. 2004). Although the incidence of childhood burn injury is much higher in low- and middle-income countries (LMIC), studies from high-income countries (HIC) have also shown that children younger than five are also at greatest risk to burns in these settings, although at much lower rates (Papp et al. 2008; Spinks et al. 2008; WHO 2008). The South African and international examples (e.g. Kanchan et al. 2009; Jiang et al. 2010) have attributed this elevated exposure to hazards in the home environment, as especially manifest in LMIC settings, and to the natural tendency to increasingly engage in exploratory behaviour, combined with a limited, still developing ability to assess dangerous situations. This is consistent with Erikson’s
autonomy versus doubt phase (early childhood), when children are eager to explore their surroundings (see Gines et al. 1998). Children who overestimate their abilities are more likely to sustain an injury due to such judgements (Ginsburg 1992; Schwebel 2004). Children in the more mature preschool phase are still naturally curious about their physical environment, but have greater experience and skills with which to assess and engage potentially harmful or risky situations, in the home but increasingly in the road environment (Garzon 2005; Jiang et al. 2010). In the Gauteng school age group, traffic-related injuries became the most common type of injury, accounting for about half of school age deaths (50.9%). The incidence of these injuries was not significantly higher than rates in the other groups, with road traffic injury a substantial concern across the developmental spectrum. Traffic accidents were also among the leading causes of injuries in children aged between 6 and 14 years in China (Jiang et al. 2010) and in India (Kanchan et al. 2009), and in many countries affiliated to the Organization for Economic Co-operation and Development (mostly highincome countries), where traffic-related injuries are the leading cause of death in children up to 14 years old (OECD 2004). Jiang and colleagues (2010) reported that the proportion of traffic accidents increased as children got older. Despite increasing experience, and physical and cognitive capacities, school age children’s egocentricity may put them at an increased risk for pedestrian injuries, as they may assume that drivers are aware of their presence, or overestimate their own still developing ability to negotiate traffic environments (Schieber & Thompson 1996). The World Health Organization (2008) has reported that the leading cause of death in 15- to 19-year-olds is road trafficrelated, with higher mortality rates found in HICs. In Gauteng, road traffic injuries were the second leading cause of death in adolescence, closely following homicide, which accounted for more than a third of all fatal injury in this group. The relative concentration of homicides in adolescence is echoed elsewhere, e.g. in a Brazilian study (Arnold et al. 2002) and in Canada (Sauvageau & Racette 2008). Overall, in the present study, firearm homicide rates were generally lower than those for sharp and blunt object homicides, a reflection of the more limited access and availability of firearms. This is in contrast with the Canadian study, where the vast majority of child homicides were firearm-related (Sauvageau & Racette 2008), although in the Brazilian study there was an equal number of firearm and sharp force injuries in child and adolescent homicides (Arnold et al. 2002). Mathews and colleagues (2012) have reported that nearly two-thirds of South African teenage homicide victims (15- to 17-year-olds) are killed by someone known
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to them, with male adolescents typically killed by a male acquaintance. Erikson has indicated that peers play the most influential role during the adolescent developmental phase (see Gines et al. 1998). In adolescence, suicide is the third leading manner of death. One of the vulnerabilities that play a role in self-destructive behaviour in adolescence is that of impaired social problem-solving (Hawton et al. 2012). Some studies maintain that males are more likely to opt for more violent or irreversible methods of suicide, and females are more likely to opt for poisoning (Brent et al. 1999; Denning et al. 2000; Mutlu et al. 2010; Callanan & Davis 2011). This is reflected in the present study, where girls had significantly higher rates than boys for ingestion-poisoning suicides. Research across numerous countries has indicated that childhood injuries are at a higher frequency and severity among boys than girls, whether unintentional, intentional, fatal or non-fatal (Bartlett 2002; Bradshaw et al. 2003a; Mattila et al. 2004; Razzak et al. 2004; Runyan et al. 2005; Mytton et al. 2009; Towner & Mytton 2009; Burrows et al. 2010; Jiang et al. 2010). Schwebel (2004) has reported that boys act more impulsively than girls, a behavioural tendency associated with unintentional injuries (Schwebel & Barton 2005). In general, the socialization of boys and girls is considered to significantly contribute to risk-taking behaviour, for example, girls are more likely to be cautioned and viewed as vulnerable (Morrongiello & Lasenby-Lessard 2007). The present study found that boys overall sustained more fatal injuries than girls, at a ratio of 1.9:1. Kanchan and colleagues (2009) also reported more cases among boys, at a ratio of 2.1:1, as did Jiang and associates (2010), with a ratio of 2.2:1, although in the latter girls were more likely to be injured through traffic accidents and burns. In the present Gauteng study, gender differences were most pronounced in adolescence, e.g. firearm homicide rates for adolescent boys were just over 10 times that for girls, significantly greater than a national study which found boys’ homicide rates to be five times higher than girls (Mathews et al. 2013). The Gauteng findings therefore share similarities with the international research in both LMIC and HIC settings. However, there are variations especially to the distribution of the main causes of child injury mortality by country income status and local contexts.
important for the design of prevention interventions that are developmentally appropriate (Roberts et al. 1995; Munro et al. 2006; Jiang et al. 2010). For example, environmental contributors to pedestrian injuries may include the traffic volume in residential areas (Roberts et al. 1995), but a child’s developmental maturity influences his or her pedestrian skills when it comes to challenges such as planning a route, detecting traffic and making judgements about potential danger (Schieber & Thompson 1996). The present study illustrates how injury risk varies through childhood, highlighting relevant sex differences within each developmental stage, and illuminating developmental considerations that prevention strategies should take into account to strengthen impact.
Key messages • In Gauteng, South Africa, infants are at the highest risk for injury mortality in general, as well as unintentional (nontraffic) injuries. They are also at higher risk of burn injuries than the older age groups. Strategies for prevention of unintentional injuries in children should encompass a strong focus on this vulnerable age group. • In early childhood, road traffic injury rates are significantly higher than that of children in the school age and adolescent groups. Interventions centred on child road safety should not focus solely on school-going children, but should take the early childhood phase into account as well. • The most common fatal injuries in preschool and school age were related to road traffic. Preschool boys are at a higher risk of unintentional injuries than girls, and school age boys are at a higher risk of drowning. • Homicide rates in adolescents are significantly higher than the younger age groups. Adolescents tend to engage in risk-taking behaviour and may be more likely to expose themselves to situations which put them at risk of violent injury. Interventions should take psychosocial factors into account, especially with regard to boys. • Boys are at higher risk of injury mortality than girls, with the exception of adolescent suicide by ingestion poisoning. The differences between boys’ and girls’ injury mortality rates were most pronounced in adolescence.
Conclusion The international child injury prevention research has emphasized the contribution of the environment to injuries. The contribution of individual vulnerability, as informed by the capacities and abilities defined through developmental stages is
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doi:10.1111/cch.12140
Childhood psychosocial development and fatal injuries in Gauteng, South Africa K. Pretorius and A. Van Niekerk Safety and Peace Promotion Research Unit, Medical Research Council–University of South Africa, Tygerberg, Western Cape, South Africa Accepted for publication 6 March 2014
Abstract
Keywords adolescence, child development, infant, injury, preschool, psychosocial factors Correspondence: Karin Pretorius, MA, Safety and Peace Promotion Research Unit, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa E-mail: [email protected]
Background In South Africa, injuries are the third leading cause of death and disability. Children are especially susceptible to unintentional injuries, especially pedestrian injuries, burns and drowning. Injury risk is informed by children’s exposure to adverse environmental circumstances, and individual capacities dependent on developmental maturity. Boys are at greater risk than girls. This study investigates the incidence of fatal childhood injuries as well as sex differences across psychosocial development stages. Methods Data on fatal injuries in Gauteng, South Africa’s most populous province, were obtained from the National Injury Mortality Surveillance System. The analysis drew on Erikson’s psychosocial theory of development which was used to create meaningful age groups. Age-specific population data from the 2011 Census were used to calculate rates, and significant differences were determined through the generation of risk ratios and confidence intervals. Results There were 5404 fatal injuries among children in Gauteng from 2008 to 2011. The average age of victims was 8.9 years, and the majority male (65.6%). In infancy, the mortality rates for all injuries and non-traffic unintentional injuries were significantly higher than for the other age groups. Burns were the most common cause of death in infancy and early childhood. Pedestrian injuries accounted for a third of mortality in preschool and school age, and homicide rates were significantly higher in adolescence than in the other developmental stages. For injuries in general, boys had significantly higher mortality rates than girls in all age groups except preschool. The only instance where the mortality rate for girls was significantly higher than for boys was for adolescent ingestion poisoning suicides. Conclusions The exposure to environmental and social risks is differentially moderated with maturing age and levels of autonomy. The sex of the child also informs risk. The nature of these risks is important when considering child injury prevention strategies.
Introduction Injuries in adults and children are a major global health concern because of the extent of mortality and morbidity (Peden et al. 2008; World Health Organization 2008). The average global rate of injury mortality is 86.9 per 100 000 population, and in South Africa it is 157.8 (Murray et al. 2001; Bradshaw et al. 2003b), the latter a reflection of compounded contextual factors, including poverty and inequality, insufficient basic infrastructure, and
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inadequate law enforcement (Seedat et al. 2009). Children are a vulnerable group at high risk for injury mortality and morbidity; many who survive a serious injury are left with disabilities, at times with life-long personal and social consequences (Peden et al. 2008; Seedat et al. 2009; Towner & Mytton 2009). The main causes of childhood injury mortality across the world are similar, with the most common due to traffic, drowning, burns, falls or poisoning injuries (Towner & Mytton 2009). The leading causes of injury may, however, vary by context, with
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Continued growth of formal operational thinking, complex abstractions
Identity vs. Role Confusion: Need to gain certainty about own characteristics, social identity and values Peer group Find own identity, establish philosophy of life, experimentation Puberty; sexual maturity. Industry vs. Inferiority: Need a sense of competency Initiative vs. Guilt: Begin to independently explore his/ her world Autonomy vs. Shame and Doubt: should be able to do certain tasks by themselves
Basic family Exploration of immediate environment, modelling behaviour of parents Improvement in hand-eye co-ordination Learning gender roles, improvement in language, increase in memory span
School and neighbourhood Gain knew knowledge & skills engage in social interactions Improvement in elegance of movement (e.g. sports) Abstract reasoning, logical use of symbols, operational thought
Adolescence School age
traffic, falls and burn injuries the leading causes in Pakistan (Razzak et al. 2004); falls, traffic crashes and burns in China (Jiang et al. 2010); and road traffic and thermal injuries in India (Kanchan et al. 2009). In South Africa, almost a third of the population is younger than 15 years, with 23% of all deaths in children aged 5 to 14 years due to injury, especially pedestrian injury, passenger injury, drowning, burns and firearm-related injury (Burrows et al. 2010). Children’s vulnerabilities to injury stem from exposure to hazardous environmental conditions and individual vulnerability as a result of specific physical, psychological and behavioural attributes. Children living in poverty are at higher risk for injury due, for example, to cramped living conditions, informal housing conditions, lack of safety equipment, and compromised supervision (Garzon 2005; Peden et al. 2008). Injury risk is further significantly influenced by a child’s development status (Rivara 1995; Schieber & Thompson 1996; Linnan et al. 2007; Jiang et al. 2010), with children’s capacities and ability to engage with their environment characterized by varying cognitive, emotional and physical capabilities (Piaget 1969; Louw et al. 1998). These still maturing capacities impact differentially upon injury risk exposure (Peden et al. 2008).
Preschool
K. Pretorius and A. Van Niekerk
Early childhood
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Source: Adapted from Dewey 2004; Erikson 1963; Louw et al. 1998, Piaget 1969.
Cognitive abilities
Reflex action, Sucking, biting, grasping Recognizing objects, memory acquisition Physical abilities
Walking, talking, dressing and feeding self Symbolic language, imagination, basic judgements and decisions
Primary caregiver Positive, loving care received & basic needs met Most significant relationship Important tasks/activities
Parents/caregivers Master basic skills (walk, talk, toilet training)
Trust vs. Mistrust: need a predictable and supportive world Erikson’s psychosocial phase
Infancy
Developmental psychology refers to ‘the scientific study of changes in human behaviours and mental activities as they occur over a lifetime’ (Bukatko & Daehler 2011, p. 5). Jean Piaget’s developmental theory describes cognitive development via children’s interactions with their environment, which is influenced by factors such as physical maturation, experience, practice and social interaction (Piaget 1971, cited in Louw et al. 1998). Erik Erikson’s theory of psychosocial development considers the personal, emotional and social development of the individual. Ginsburg (1992) maintains that Erikson’s psychosocial stages ‘may be a useful heuristic approach for childhood injury investigators to consider’ (p. 95), and describes common childhood injuries in terms of Erikson’s developmental phases, including development-specific child behaviour and parenting practices. Erikson divided the lifespan into eight stages, with the first five stages describing childhood, namely: infancy, early childhood, preschool age, school age and adolescence (Dewey 2004; Harmon 2005). Erikson highlighted the interaction between increasing individual capabilities and an expanding social environment, with each development stage characterized by a dominant psychosocial crisis (see Gines et al. 1998; Louw et al. 1998). Table 1 presents the five psychosocial development phases of childhood, as
Table 1. Childhood development phases
Theories of child development
Childhood psychosocial development and fatal injuries 37
well as the main tasks and physical and cognitive abilities as described by Erikson and Piaget’s theories. The infancy stage is characterized by a psychosocial crisis of basic trust versus mistrust. Infants are helpless and dependent on the caregiver to protect and provide for them, and need to develop a feeling of basic trust. Incorporation, i.e. taking in of food and love, is considered an important social behaviour (Louw et al. 1998). In the early childhood phase, the psychosocial crisis is autonomy versus shame and doubt. The child develops skills which contribute towards growing independence, such as toilet training, and caregivers need to encourage independence and show compassion with regard to failures. In the preschool phase, the psychosocial crisis is initiative versus guilt. Children have a greater degree of freedom and greater access to society and socialization influences, with gender roles becoming clearer. In school age, children continue to master various skills and seek to succeed at what they do. They become competitive with their peers, with industry versus inferiority forming the dominant psychosocial crisis. During adolescence, the child experiences identity versus role confusion, or an identity crisis. This is often a period of experimentation, as the adolescent seeks to establish their social identity, values and goals. As children progress through these developmental stages, they gain and improve upon various abilities, but may still experience risk appraisal and response limitations that would expose them to injury. For example, in early childhood, a child can make basic decisions (based, e.g. on personal preferences), but cannot yet adequately assess potential sources of danger, while their increased curiosity about their environment and tendency and increasing capacity to explore puts them at greater risk (Gilbride et al. 2006; Jiang et al. 2010). There is a paucity of analysis of serious child injury and mortality by developmentally meaningful age categories, which would strengthen understandings of injury exposure and is required for developmentally relevant child safety interventions. The aim of this paper is therefore to investigate the occurrence of injury mortality in children by meaningful age groups, defined according to a leading psychosocial development theory. The paper also investigates the contributions of the child’s sex to injury mortality within these age groups.
Methodology
is the smallest province in the country (primarily urban) with the greatest population density, as well as the second highest proportion of deaths of the nine provinces (Statistics South Africa 2012; South African Government Information 2014). In 2007, the fatal injury rate for children younger than 15 years in Gauteng was 31.7 per 100 000 population (Swart et al. 2012).
Data sources Injury data Injury mortality data for Gauteng were obtained from the National Injury Mortality Surveillance System (NIMSS). The NIMSS has full coverage of Gauteng with the exception of Pretoria. Data for four consecutive years (1 January 2008 to 31 December 2011) were obtained for 0- to 19-year-old victims (cases where age was unknown were excluded). The NIMSS produces and disseminates descriptive epidemiological information on deaths due to non-natural causes detailing, where available, the deceased’s age, sex, population group, scene of injury, apparent manner and circumstances of death. Information is collected by the police and pathologists at each forensic pathology facility (Matzopoulos et al. 2002). Age categories were based on Erikson’s psychosocial stages. The Erikson age ranges for each phase are as follows: 0–1 year (infancy), 1–3 years (early childhood), 3–6 years (preschool), 6–12 years (school age) and 12–19 years (adolescence) (see Louw et al. 1998; Dewey 2004; Harmon 2005). There is some overlap across these categories; NIMSS data records age in single years, therefore the ranges were adjusted so that each individual age (in years) could be assigned to only one developmental phase as follows: 0–1 year (infancy), 2–3 years (early childhood), 4–6 years (preschool), 7–12 years (school age) and 13–19 years (adolescence).
Denominator data Age-specific population data for Gauteng were obtained from the 2011 South African Census. The same data were obtained for Pretoria and then subtracted from the Gauteng totals in order to match the sample population.
The study uses a retrospective, cross-sectional design.
Data analysis Setting The study focuses on Gauteng, where 19.4% of South African children live (Statistics South Africa 2011). Geographically, this
Descriptive statistics and cross-tabulations were run on the total sample, as well as each age group, using SPSS (version 20), in order to report on fatality frequencies for each developmental
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Table 2. Sample characteristics by age group (developmental phase), Gauteng 2008–2011
Sex Male Female Race†‡ Black White Coloured Asian/Indian Apparent manner of death† Road traffic-related Other unintentional Homicide Suicide Main external causes Pedestrian Burns Drowning Passenger Blunt force Poisoning Sharp force Total fatal injuries
Infancy % (n)
Early childhood % (n)
Preschool % (n)
School age % (n)
Adolescence % (n)
Total % (n)
57.0 (647) 43.0 (488)
58.7 (424) 41.3 (298)
61.2 (394) 38.8 (250)
63.7 (484) 36.3 (276)
74.6 (1568) 25.4 (533)
65.6 (3517) 34.4 (1845)
90.1 (1026) 5.3 (60) 2.7 (31) 1.9 (22)
87.8 (635) 7.5 (54) 2.6 (19) 2.1 (15)
92.2 (595) 5.0 (32) 1.7 (11) 1.1 (7)
91.3 (695) 4.2 (32) 2.8 (21) 1.7 (13)
83.1 (1746) 10.1 (212) 4.4 (92) 2.4 (51)
87.5 (4697) 7.3 (390) 3.2 (174) 2.0 (108)
18.5 (127) 64.6 (443) 16.6 (114) N/A
33.8 (202) 55.6 (332) 10.1 (60) N/A
46.9 (261) 41.2 (229) 11.5 (64) N/A
50.9 (348) 32.3 (221) 13.7 (94) 2.8 (19)
30.6 (575) 10.3 (194) 35.7 (672) 19.4 (364)
34.4 (1513) 32.2 (1419) 22.8 (1004) 8.7 (383)
6.5 (60) 23.5 (218) 9.4 (87) 5.0 (46) 4.5 (42) 8.5 (79) 0.9 (8) 1170
20.6 (141) 24.9 (170) 16.8 (115) 5.3 (36) 4.4 (30) 5.6 (38) 1.8 (12) 724
31.9 (198) 14.0 (87) 13.4 (83) 6.4 (40) 6.8 (42) 5.6 (35) 1.0 (6) 645
32.8 (241) 12.0 (88) 13.1 (96) 8.8 (65) 5.2 (38) 2.7 (20) 2.3 (17) 762
12.5 (251) 3.9 (78) 3.0 (60) 8.0 (161) 9.6 (193) 7.0 (142) 13.0 (262) 2103
17.9 (891) 12.9 (641) 8.9 (441) 7.0 (348) 6.9 (345) 6.3 (314) 6.1 (305) 5404
†Percentages reflect totals where sex, race, manner of death and external cause were known. ‡The terms ‘White’, ‘Black’ and ‘Coloured’ do not signify inherent characteristics, but rather refer to demographic markers that stem from the apartheid era.These markers are still used in South Africa for their historical significance, and refer to people of European, African and mixed (African, European and/or Asian) ancestry respectively (Parry et al. 2004).
age group by sex, race, apparent manner and external cause of death. The age-adjusted death rates were computed for each age group by dividing the number of events (deaths) by the population total of the same age group, and then multiplying by a constant of 100 000. This results in an age-specific death rate (ASDR) per 100 000 population for each age group. For the purpose of calculating rates, 2011 mortality data were used, as these were the latest available data at the time of publication and corresponds with the latest Census data (2011). For the descriptive statistics, data from 2008 to 2011 were used (years were not compared). The descriptive statistics refer to all injuries irrespective of apparent manner (e.g. unintentional versus intentional), while the rates were focused on the main injury types for each apparent manner (e.g. unintentional burns, but not homicide burns). We compared the mortality rates for different injury types across the developmental stages, and used the age group with the highest incidence rate as the reference group. To identify statistically significant differences between these rates, we used risk ratios with 95% confidence intervals, which were calculated using SPSS (version 21). The two-tailed P values from the Fisher’s Exact Test were used because of the small sample sizes. Sex differences with regard to mortality rates within each developmental stage were also analysed.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
Results Sample characteristics The total number of fatal injuries to children during the period of 2008 to 2011 was 5404. Table 2 displays the frequency of fatalities according to developmental age group, by sex, race, manner and external cause of death. The majority of fatal injuries were to males, with the proportion of male mortality increasing between infancy and adolescence. The ratio of male to female injuries overall was 1.9:1. For the total sample, the majority of fatalities (87.5%) occurred among Black children/ adolescents. Road traffic-related injuries, non-traffic unintentional injuries and intentional injuries (i.e. violence and suicide) each comprised of a third of all child mortality. In infancy and early childhood, more than half of fatalities were due to non-traffic unintentional injuries. Road traffic injuries accounted for the largest proportion of deaths in the preschool and school age groups, and in adolescence, homicides accounted for just over a third of deaths. The most common external cause of injury in infancy was burns, followed by drowning, and in early childhood it was burns followed by pedestrian injuries. In the pre-
Girls
4 2 0 Infancy
Early Preschool Childhood
School Adolescence Age
Figure 1. Sex difference in 2011 overall injury mortality rates, by age
group.
0.47–0.93 0.35–0.84 0.37–1.43 0.06–0.12 0.03–0.12 0.06–0.25 – – – – – – 0.44–0.60 0.66 0.55 0.72 0.09 0.06 0.12 1.00 1.00 1.00 1.00 1.00 1.00 0.52 1.52 0.87 0.40 0.64 0.16 0.15 1.99 0.36 0.80 0.61 1.30 0.97 6.34 0.013 0.096 0.334 0.000 0.000 0.000 0.000 0.002 0.000 0.000 0.000 0.000 0.000 0.44–0.91 0.44–1.05 0.34–1.40 0.10–0.18 0.06–0.19 0.12–0.42 0.17–0.39 0.08–0.63 0.02–0.23 0.14–0.60 0.02–0.16 0.03–0.22 0.22–0.33 0.63 0.68 0.70 0.13 0.11 0.22 0.25 0.22 0.07 0.29 0.06 0.08 0.27 1.45 1.09 0.38 0.97 0.27 0.29 0.50 0.08 0.06 0.18 0.08 0.08 3.32 0.235 0.640 0.548 0.000 0.000 0.006 0.000 0.033 0.000 0.003 – – 0.000 0.54–1.15 0.56–1.41 0.35–1.70 0.23–0.41 0.16–0.44 0.24–0.79 0.18–0.49 0.08–0.93 0.02–0.34 0.11–0.70 – – 0.33–0.50 0.79 0.89 0.78 0.30 0.26 0.43 0.30 0.28 0.08 0.28 – – 0.41 1.80 1.41 0.43 2.24 0.66 0.56 0.60 0.10 0.07 0.17 N/A ″ 4.98 – – – 0.009 0.624 – 0.001 0.016 0.037 0.084 – – 0.002 – – – 0.57–0.92 0.61–1.31 – 0.28–0.72 0.02–0.96 0.22–0.97 0.20–1.09 – – 0.62–0.90 1.00 1.00 1.00 0.72 0.89 1.00 0.44 0.13 0.46 0.46 – – 0.75 2.29 1.59 0.55 5.32 2.27 1.29 0.88 0.05 0.37 0.28 N/A ″ 9.17 0.063 0.037 0.839 – – 0.400 0.000 – 0.000 0.007 – – – 0.42–1.02 0.31–0.97 0.40–2.07 – – 0.45–1.37 0.14–0.48 – 0.01–0.42 0.07–0.74 – – –
95% CI RR RR P value IR 95% CI
P value§ IR
RR
95% CI
P value IR
RR
95% CI
School age Preschool Early childhood
†Comparison of age groups across columns. ‡Incidence rate estimated at the number of injuries per 100 000 population. §Fisher’s Exact Test, two-tailed. Significant values indicated in bold. RR, risk ratio; CI, confidence interval.
Boys
6
0.66 0.54 0.91 1.00 1.00 0.78 0.26 0.00 0.06 0.23 – – 1.00
8
RR
10
IR‡
12
Infancy
14
Table 3. Distribution of injuries by age group†
16
95% CI
Table 3 displays the injury mortality rates by developmental age group for 2011. The mortality rates for injuries in general as well as non-traffic unintentional injuries were significantly higher in infancy than in the other developmental phases. In early childhood, road traffic fatalities (in general) were significantly higher than in school age and adolescence, but not significantly higher than in infancy and preschool. In adolescence, the rates for overall homicide, as well as firearm and sharp object homicide specifically, were significantly higher than in the other age groups. Figure 1 illustrates the sex differences in injury mortality rates for each developmental phase. Overall, boys had higher death rates than girls in all developmental age groups, although in preschool this difference was not statistically significant. In adolescence, boys had significantly higher mortality rates than girls for the majority of injury types, with the exception of unintentional burns (P = 0.754) and passenger deaths, with the latter having a higher rate among girls and bordering on significance with a P-value of 0.051. Firearm homicides in adolescent boys were more than 10 times the rate than for adolescent girls (P < 0.001). There was only one instance where the mortality rate for girls was significantly higher than for boys, namely suicide-related ingestion poisoning (P < 0.05). Detailed results are presented in Table 4.
Road traffic 1.51 Pedestrian 0.86 Passenger 0.51 Other unintentional 7.36 Burns 2.54 Drowning 1.01 Homicide 0.51 Firearms 0.00 Sharp 0.05 Blunt 0.14 Suicide N/A Hanging ″ All fatal injuries 12.27
Injury mortality rates
P value IR
Adolescence
P value
school and school age groups, pedestrian injury became the most common type of fatality. Sharp force injuries were the most common fatalities in adolescence, followed by pedestrian injuries. The youngest suicide victim was 8 years old, and the average age of suicide victims was 16.7 years. The most common method was hanging (66.8%) followed by ingestion poisoning (19.6%).
0.021 0.007 0.351 0.000 0.000 0.000 – – – – – – 0.000
Childhood psychosocial development and fatal injuries 39
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
RR
P value‡
1.74 1.28 0.46 1.24 0.23 0.46 0.54 0.04 0.08 0.23 0.11 0.11 0.00 4.06
1.16 0.90 0.31 0.72 0.32 0.12 0.47 0.12 0.04 0.12 0.04 0.04 0.00 2.54
0.67 0.70 0.68 0.58 0.73 0.26 0.88 0.33 0.51 0.51 0.34 0.34 0.00 0.62
0.42–1.06 0.41–1.21 0.28–1.67 0.32–1.02 0.26–2.12 0.07–0.91 0.41–1.89 0.03–3.14 0.05–5.64 0.13–2.04 0.04–3.28 0.04–3.28 – 0.46–0.85
95% CI
2.55 1.83 0.46 6.44 2.87 1.75 1.20 0.09 0.64 0.28 N/A ″ ″ 11.08
IR (girls)
0.086 0.222 0.504 0.066 0.604 0.035 0.845 0.370 1.00 0.508 0.625 0.625 – 0.003
P value
2.03 1.37 0.65 4.18 1.60 0.86 0.56 0.00 0.09 0.29 N/A ″ ″ 7.19
RR 0.80 0.75 0.70 0.65 0.56 0.48 0.47 – 0.15 0.99 – – – 0.65
95% CI 0.46–1.39 0.38–1.49 0.22–2.22 0.44–0.94 0.31–1.01 0.22–1.06 0.18–1.23 – 0.02–1.18 0.20–4.89 – – – 0.49–0.86
2.04 1.42 0.25 0.91 0.19 0.28 3.24 0.65 1.43 1.00 1.76 1.50 0.10 9.22
2.08 1.72 0.46 2.87 0.73 0.79 0.40 0.13 0.07 0.07 N/A ″ ″ 5.59
IR (boys)
Preschool
0.99 0.33 0.56 0.38 0.13 0.03 0.72 0.06 0.15 0.22 0.85 0.44 0.35 3.45
IR (girls)
P value 0.480 0.487 0.578 0.024 0.060 0.087 0.167 – 0.070 1.00 – – – 0.003
IR (boys)
RR
0.297 0.238 1.00 0.232 0.106 0.832 0.344 – – 1.00 – – – 0.030
IR (boys)
IR (girls)
95% CI 0.33–1.33 0.19–1.36 0.26–2.78 0.56–1.12 0.37–1.08 0.37–1.97 0.11–1.69 – – 0.05–5.62 – – – 0.59–0.97 Adolescence
0.66 0.51 0.85 0.82 0.63 0.85 0.44 – – 0.51 – – – 0.76
School age
1.20 0.59 0.47 6.66 1.98 0.95 0.28 0.00 0.00 0.10 N/A ″ ″ 10.50
IR (girls)
IR (boys)
1.81 1.15 0.55 8.08 3.13 1.10 0.64 0.00 0.09 0.19 N/A ″ ″ 13.81
IR† (boys)
†Incidence rate estimated at the number of injuries per 100 000 population. ‡Fisher’s Exact Test, two-tailed. Significant values indicated in bold. RR, risk ratio; CI, confidence interval.
Road traffic Pedestrian Passenger Other unintentional Burns Drowning Homicide Firearms Sharp Blunt Suicide Hanging Ingestion poisoning All fatal injuries
Road traffic Pedestrian Passenger Other unintentional Burns Drowning Homicide Firearms Sharp Blunt Suicide Hanging Ingestion poisoning All fatal injuries
Early childhood
Infancy
Table 4. Distribution of fatal injuries by age group and gender
IR (girls)
0.48 0.23 0.44 0.42 0.68 0.11 0.22 0.10 0.11 0.22 0.48 0.29 0.27 0.37
RR
1.52 1.12 0.40 1.63 0.61 0.34 0.80 0.07 0.07 0.27 N/A ″ ″ 4.40
RR
95% CI 0.43–1.25 0.35–1.22 0.29–2.59 0.34–0.93 0.35–2.01 0.15–1.20 0.19–1.31 0.05–5.60 0.06–16.25 0.03–2.20 – – – 0.57–1.09
0.32–0.74 0.12–0.46 0.19–1.01 0.21–0.82 0.19–2.34 0.01–0.89 0.14–0.35 0.02–0.41 0.04–0.27 0.10–0.50 0.30–0.76 0.16–0.52 0.08–0.97 0.30–0.47
95% CI
0.73 0.65 0.87 0.57 0.83 0.42 0.49 0.51 1.00 0.25 – – – 0.79
P value
0.001 0.000 0.051 0.012 0.754 0.022 0.000 0.000 0.000 0.000 0.002 0.000 0.034 0.000
P value
0.281 0.212 1.00 0.028 0.824 0.144 0.164 1.00 1.00 0.215 – – – 0.164
40 K. Pretorius and A. Van Niekerk
Childhood psychosocial development and fatal injuries 41
Discussion This Gauteng study reported that, for all childhood injuries considered, infants had the highest mortality rates, consistent with international research (Runyan et al. 2005; Linnan et al. 2007). The overall mortality concentration in infancy thereafter steadily declines with age, only to increase again in adolescence, consistent with other South African findings (Donson 2009). The childhood injury mortality rates were driven by unintentional injuries that were not traffic-related, which were also most prominent in infancy. In infancy, burns were the most common cause of injury mortality, followed by drowning. This is consistent with reports from other settings, for example, the leading cause of injury death for Chinese children younger than 3 years was also burn-related (Jiang et al. 2010), as it was for non-fatal injuries in Canadian infants (Flavin et al. 2006). The psychosocial crisis in infancy, according to Erikson (1963), is that of trust versus mistrust; a reflection of the highly dependent relationship between the infant and caregiver. The quality of this relationship is impacted upon by infant temperament and parenting behaviour, which may interact and influence one another, and contribute to injury risk (Schwebel et al. 2004). For example, positive parenting is related to a reduced risk of injury, while a difficult temperament of an infant may negatively interact with the caregiver’s parenting style and impair the quality of care. Inappropriate parenting, supervision and other adult behaviours may contribute to fatal injuries in infancy (Ginsburg 1992; Morrongiello et al. 2004). The second highest occurrence of overall injury mortality occurred in early childhood. Burns were again the most common type of injury, followed by pedestrian-related injury. This is consistent with international studies, e.g. from Kuwait, where children younger than five are at a significantly higher risk of fatal burns (Sharma et al. 2006); from India (e.g. Kanchan et al. 2009) which have reported toddlers and preschool children at a greater risk of burn injuries, and other South African burn research (e.g. Van Niekerk et al. 2004). Although the incidence of childhood burn injury is much higher in low- and middle-income countries (LMIC), studies from high-income countries (HIC) have also shown that children younger than five are also at greatest risk to burns in these settings, although at much lower rates (Papp et al. 2008; Spinks et al. 2008; WHO 2008). The South African and international examples (e.g. Kanchan et al. 2009; Jiang et al. 2010) have attributed this elevated exposure to hazards in the home environment, as especially manifest in LMIC settings, and to the natural tendency to increasingly engage in exploratory behaviour, combined with a limited, still developing ability to assess dangerous situations. This is consistent with Erikson’s
autonomy versus doubt phase (early childhood), when children are eager to explore their surroundings (see Gines et al. 1998). Children who overestimate their abilities are more likely to sustain an injury due to such judgements (Ginsburg 1992; Schwebel 2004). Children in the more mature preschool phase are still naturally curious about their physical environment, but have greater experience and skills with which to assess and engage potentially harmful or risky situations, in the home but increasingly in the road environment (Garzon 2005; Jiang et al. 2010). In the Gauteng school age group, traffic-related injuries became the most common type of injury, accounting for about half of school age deaths (50.9%). The incidence of these injuries was not significantly higher than rates in the other groups, with road traffic injury a substantial concern across the developmental spectrum. Traffic accidents were also among the leading causes of injuries in children aged between 6 and 14 years in China (Jiang et al. 2010) and in India (Kanchan et al. 2009), and in many countries affiliated to the Organization for Economic Co-operation and Development (mostly highincome countries), where traffic-related injuries are the leading cause of death in children up to 14 years old (OECD 2004). Jiang and colleagues (2010) reported that the proportion of traffic accidents increased as children got older. Despite increasing experience, and physical and cognitive capacities, school age children’s egocentricity may put them at an increased risk for pedestrian injuries, as they may assume that drivers are aware of their presence, or overestimate their own still developing ability to negotiate traffic environments (Schieber & Thompson 1996). The World Health Organization (2008) has reported that the leading cause of death in 15- to 19-year-olds is road trafficrelated, with higher mortality rates found in HICs. In Gauteng, road traffic injuries were the second leading cause of death in adolescence, closely following homicide, which accounted for more than a third of all fatal injury in this group. The relative concentration of homicides in adolescence is echoed elsewhere, e.g. in a Brazilian study (Arnold et al. 2002) and in Canada (Sauvageau & Racette 2008). Overall, in the present study, firearm homicide rates were generally lower than those for sharp and blunt object homicides, a reflection of the more limited access and availability of firearms. This is in contrast with the Canadian study, where the vast majority of child homicides were firearm-related (Sauvageau & Racette 2008), although in the Brazilian study there was an equal number of firearm and sharp force injuries in child and adolescent homicides (Arnold et al. 2002). Mathews and colleagues (2012) have reported that nearly two-thirds of South African teenage homicide victims (15- to 17-year-olds) are killed by someone known
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
42
K. Pretorius and A. Van Niekerk
to them, with male adolescents typically killed by a male acquaintance. Erikson has indicated that peers play the most influential role during the adolescent developmental phase (see Gines et al. 1998). In adolescence, suicide is the third leading manner of death. One of the vulnerabilities that play a role in self-destructive behaviour in adolescence is that of impaired social problem-solving (Hawton et al. 2012). Some studies maintain that males are more likely to opt for more violent or irreversible methods of suicide, and females are more likely to opt for poisoning (Brent et al. 1999; Denning et al. 2000; Mutlu et al. 2010; Callanan & Davis 2011). This is reflected in the present study, where girls had significantly higher rates than boys for ingestion-poisoning suicides. Research across numerous countries has indicated that childhood injuries are at a higher frequency and severity among boys than girls, whether unintentional, intentional, fatal or non-fatal (Bartlett 2002; Bradshaw et al. 2003a; Mattila et al. 2004; Razzak et al. 2004; Runyan et al. 2005; Mytton et al. 2009; Towner & Mytton 2009; Burrows et al. 2010; Jiang et al. 2010). Schwebel (2004) has reported that boys act more impulsively than girls, a behavioural tendency associated with unintentional injuries (Schwebel & Barton 2005). In general, the socialization of boys and girls is considered to significantly contribute to risk-taking behaviour, for example, girls are more likely to be cautioned and viewed as vulnerable (Morrongiello & Lasenby-Lessard 2007). The present study found that boys overall sustained more fatal injuries than girls, at a ratio of 1.9:1. Kanchan and colleagues (2009) also reported more cases among boys, at a ratio of 2.1:1, as did Jiang and associates (2010), with a ratio of 2.2:1, although in the latter girls were more likely to be injured through traffic accidents and burns. In the present Gauteng study, gender differences were most pronounced in adolescence, e.g. firearm homicide rates for adolescent boys were just over 10 times that for girls, significantly greater than a national study which found boys’ homicide rates to be five times higher than girls (Mathews et al. 2013). The Gauteng findings therefore share similarities with the international research in both LMIC and HIC settings. However, there are variations especially to the distribution of the main causes of child injury mortality by country income status and local contexts.
important for the design of prevention interventions that are developmentally appropriate (Roberts et al. 1995; Munro et al. 2006; Jiang et al. 2010). For example, environmental contributors to pedestrian injuries may include the traffic volume in residential areas (Roberts et al. 1995), but a child’s developmental maturity influences his or her pedestrian skills when it comes to challenges such as planning a route, detecting traffic and making judgements about potential danger (Schieber & Thompson 1996). The present study illustrates how injury risk varies through childhood, highlighting relevant sex differences within each developmental stage, and illuminating developmental considerations that prevention strategies should take into account to strengthen impact.
Key messages • In Gauteng, South Africa, infants are at the highest risk for injury mortality in general, as well as unintentional (nontraffic) injuries. They are also at higher risk of burn injuries than the older age groups. Strategies for prevention of unintentional injuries in children should encompass a strong focus on this vulnerable age group. • In early childhood, road traffic injury rates are significantly higher than that of children in the school age and adolescent groups. Interventions centred on child road safety should not focus solely on school-going children, but should take the early childhood phase into account as well. • The most common fatal injuries in preschool and school age were related to road traffic. Preschool boys are at a higher risk of unintentional injuries than girls, and school age boys are at a higher risk of drowning. • Homicide rates in adolescents are significantly higher than the younger age groups. Adolescents tend to engage in risk-taking behaviour and may be more likely to expose themselves to situations which put them at risk of violent injury. Interventions should take psychosocial factors into account, especially with regard to boys. • Boys are at higher risk of injury mortality than girls, with the exception of adolescent suicide by ingestion poisoning. The differences between boys’ and girls’ injury mortality rates were most pronounced in adolescence.
Conclusion The international child injury prevention research has emphasized the contribution of the environment to injuries. The contribution of individual vulnerability, as informed by the capacities and abilities defined through developmental stages is
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 1, 35–44
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