Public Health
(1990), 104, 171-182
© The Societyof Public Health, 1990
Geographical and Social Variations in M o r t a l i t y Due to Childhood Accidents in England and Wales 1975-1984 J. G. Avery] J. N. Vaudin, 2 J. L. F l e t c h e r 2 a n d J. M. W a t s o n ~
1South Warwickshire Health Authority, Warwick CV34 4DE, 2Department of Geography, Coventry Polytechnic, Coventry CV1 5FB
An analysis was made of the death rates from accidents in children aged 0-14 by health districts in England and Wales during the five year periods 1974-79 and 1980-84. Death rates were generally higher in the north and west of England and lower in the south and east. Rates were higher in urban areas than in rural areas. There was a more than fivefold difference between the highest and lowest rates by districts during both periods. There was a very strong correlation with social deprivation. Greater efforts are required to reduce unnecessary deaths and disability from childhood accidents. The lessons already learned in many parts of the world must now be put into much wider use and practice in the United Kingdom.
Introduction In 1985 the European region of the World Health Organisation set a series of targets I for health improvement which included a 25% reduction in the death rate due to accidents. Since accidents are the biggest killer of children over the age of I in the UK 2 there is ample justification to give them special priority. With the decline in infectious diseases, accidents now present one o f the major challenges for prevention during the remaining years of the century. Wide social class variations in accident experience 3"4 make this even more imperative. A number o f studies on the geographical distribution of accidents and diseases in Britain have shown up the overall disadvantages experienced by people living in the north of the country. 5'6 In the absence of any similar studies on deaths from childhood accidents, we undertook a detailed analysis by health regions and districts. This paper highlights the serious mortality from childhood accidents and the continuing high degree of health inequality existing in Britain today.
Methods The annual number of deaths from injury, poisoning and violence (ICD codes E800-E999) in children aged between 0 and 14 years was obtained from the OPCS official death returns by district of usual residence over a ten-year period. Using these data and the
Correspondence: Dr J, G. Avery, Director of Public Health, South Warwickshire Health Authority, Westgate House, Market Street, Warwick CV34 4DE.
172
J. G. A very et al.
corresponding population estimates, the death rates from childhood accidents were calculated for two five-year periods, 1975-79 and 1980-84. A five-year death rate was chosen to smooth out any biases due to single major accidents resulting in clusters of childhood deaths. Because o f the small numbers involved and the limited age range of the study, death rates were used in preference to standardised mortality ratios. Test standardisation in a range of districts gave no indication that this would have made any significant difference to the results. In the first five-year period there were difficulties with boundary changes and population estimates being unavailable in 50 of the health districts. In such cases a death rate based on a two- or three-year period was calculated and used in the analysis. For each five-year period the mean annual death rate, standard deviation and 95% confidence limits were calculated. A note was made of all districts where any annual death rate was more than two standard deviations above the mean and/or where the five-year death rate was more than 20 per 100,000 population. The District Medical Officers of these districts were contacted to ascertain from their local knowledge whether there had been any relevant incidents in which clustering of fatal childhood accidents had occurred. In order to illustrate secular trends, the annual death rate for each region was plotted for each of the years 1975 to 1984. The geographical distribution of child accident mortality was mapped out by district for each five-year period using four score categories relating to the mean annual death rate per 100,000 children. Comparisons were made between the twenty two districts in the West Midlands for each of the two five-year periods using the standard Yates performance indicator histograms. 7 Finally the death rate for each district during 1980-84 was plotted against the Jarman 8 score using this as an index of social deprivation. 8 A similar plot was made for the West Midlands region. Correlation coefficients were calculated and analysis of variance performed in order to demonstrate the influence of social deprivation on the death rate. Note: Jarman 8 is a composite of eight indicators which attempts to identify under-privileged areas with particular emphasis on the very young. The higher the indicator the greater the degree of deprivation. The index gives weightings to eight factors from the 1981 census which include under 5's, single parents, the unskilled, the unemployed, overcrowding, change of address and ethnic minority. The only factor not directly relevant to children is that of pensioners living alone.
Results
Comparison of death rates between regions The death rates by NHS health regions in England and Wales for the two periods are shown in Figure 1. The rates were generally higher in the North and N o r t h West and Midlands of England compared with the South and South East. The rates in the North East Thames and South East Thames regions were raised above the general level in the South due to the influence o f high rates in several inner-city L o n d o n districts. In contrast, the lower rates in Mersey were due to the strong influence o f several low rate districts (e.g. Wirral, Southport) off-setting the relatively higher rates of the Liverpool urban areas. The death rates for all health regions showed an overall decline during the ten-year period. Nearly all of the northern regions of England along with Wales were above the
Mortality Due to Childhood Accidents
Northern North Western Yorkshire Mersey Trent West Midlands Oxford South Western Wessex East Anglia NW Thames NE Thames SW Thames SE Thames England Wales England and Wales
1975-79
1980-84
12.31 15.63 12.82 11.00 13.00 12.36 11.14 8.90 11.00 11.00 11.28 11.66 11.07 12.26 11.82 12.59 12.05
12.06 I 1.57 11.82 10.10 10.00 11.18 9.88 7.45 9.00 9.63 9.42 10.43 9.07 11.20 10.20 10.74 10.33
173
Figure 1 Childhood accident death rates by NHS health regions in England and in Wales 1975-79 and 1980-84.
national average all or most of the time (Figure 2). In contrast, the southern regions were generally below the national average with the four more urban Thames regions being nearer to the national norm than the other more rural regions (Figure 3).
Comparison of death rate by districts The death rates by districts for each of the two periods are shown in Figures 4 and 5. During both periods the highest rates of all were found in the inner-city areas of Birmingham, Manchester and London and in some o f the medium sized industrial towns of the N o r t h and the Midlands. The lowest rates were found in the predominantly rural areas o f the South West and South o f England and of East Anglia. Rural areas elsewhere in parts of the Midlands, the N o r t h and Wales were generally low. In spite o f these very strong geographical variations, there were some notable exceptions. Bristol and Liverpool and their surrounding districts had relatively low rates in both periods. Newcastle and its immediate surroundings were generally low apart from South Tyneside. Leeds and Sheffield were also relatively low for cities with a population around half a million. The outer London boroughs tended to be low in comparison with their inner city neighbours. The only localities in the south o f England with rates higher than the national average were the large towns. Swindon was very high in the 1975-79 period, but much lower in the second five years. Other high areas in the south during the first period included Brighton, Eastbourne, Hastings, Chichester, Salisbury and Cambridge, whilst West Norfolk was high during both periods. Dyfed's high rate in 1975-79 was explained by a high number of deaths (17) in a small population in three of the five years.
174
J. G. A very et al. 20
20
---
\
N. Western
---
\
\
16
Mersey
.....
W.
-----
Trent
------
Yorkshire
.......
Northern
-
-
Midlands
16
Wales England/Wales
o o
d
::,,
O
~-~- 12
-
12
03
~ 75
76
I
L
77
78
J
J
79 80 Year
L_ 81
I 82
__L
r4 83
84
Figure 2 Child accident death rates for Northern England (1975-1984).
The district enquiries revealed that there was only one district in which there was a clustering of deaths. This was South West D u r h a m where there was a definite cluster of three separate house fires during the 1980's resulting in 9 child deaths. House fires and multiple vehicle occupant road traffic accidents are the most c o m m o n reasons for the deaths of several children at one time. A detailed analysis by districts in the West Midlands (Figures 6 and 7) showed a more than three-fold difference in 1975-79 and a more than five-fold difference in 1980-84 between the districts with the highest rates and those with the lowest rates. In both periods the districts with the lowest rates were predominantly rural areas or the more affluent urban areas like .Solihult and N o r t h Birmingham. The districts with the highest rates were the inner city districts of Birmingham and the urban areas of the West Midlands conurbation, all being localities with the highest degrees of social deprivation. Similar patterns were seen in the other regions of England with the overall difference between the highest and lowest districts being over five-fold in 1975-79 and over six-fold in 1980-84.
175
Mortality Due to Childhood Accidents - 20
20
---
- -
- -
- -
S.
Wessex
- - - - -----
16
S.W.
......... ........ --
--
-
-
--
Thames
S.E.
Thames
N.E.
Thames
N.W. E.
S
o" o v~)
Western
Oxford
16
Thames
Anglia
England/Wales
12
12
..!= i/3 /23
X
~ 75
'
~ 76
_ 77
~ 78
I
I
I
79
80
81
_ I 82
J~
I
83
84
t4I
Year
Figure 3 Child accident death rates for Southern England (1975 1984).
Correlation between death rate and social deprivation
The scattergram for England 1980-48 (Figure 8) shows a wide range of death rates in relation to the Jarman 8 indices, A strong correlation between death rate and social deprivation is shown in the highly significant correlation coefficient of 0.56. An even stronger correlation with a coefficient of 0.79 is shown in the scattergram for the West Midlands (Figure 9).
Discussion This study highlights the very wide geographical variation in mortality from childhood accidents in England and Wales. Similar variations have been found in morbidity. The third national cohort study9 of children born between 5-11 April, 1970 found that children aged 0 4 living in the north and north-west of England had a greater likelihood of accidents compared with those in the south and south-east,
J. G. A very et al.
176
CHILD ACCIDENT DEATH RATE BY N.H.S. HEALTH DISTRICTS IN ENGLAND AND WALES 1975-79 Child accident deaths per 100,000 per annum 1975-1979 Northern 0
~20
~
Kilometres 100
k,
and over
15-19
J ILess than 10 h J
Wesl ' East Anglia Oxford
London
South Western
North West Thames.~, ~J , C.~North East Thames South West Thamesq
(1990), 104, 171-182
© The Societyof Public Health, 1990
Geographical and Social Variations in M o r t a l i t y Due to Childhood Accidents in England and Wales 1975-1984 J. G. Avery] J. N. Vaudin, 2 J. L. F l e t c h e r 2 a n d J. M. W a t s o n ~
1South Warwickshire Health Authority, Warwick CV34 4DE, 2Department of Geography, Coventry Polytechnic, Coventry CV1 5FB
An analysis was made of the death rates from accidents in children aged 0-14 by health districts in England and Wales during the five year periods 1974-79 and 1980-84. Death rates were generally higher in the north and west of England and lower in the south and east. Rates were higher in urban areas than in rural areas. There was a more than fivefold difference between the highest and lowest rates by districts during both periods. There was a very strong correlation with social deprivation. Greater efforts are required to reduce unnecessary deaths and disability from childhood accidents. The lessons already learned in many parts of the world must now be put into much wider use and practice in the United Kingdom.
Introduction In 1985 the European region of the World Health Organisation set a series of targets I for health improvement which included a 25% reduction in the death rate due to accidents. Since accidents are the biggest killer of children over the age of I in the UK 2 there is ample justification to give them special priority. With the decline in infectious diseases, accidents now present one o f the major challenges for prevention during the remaining years of the century. Wide social class variations in accident experience 3"4 make this even more imperative. A number o f studies on the geographical distribution of accidents and diseases in Britain have shown up the overall disadvantages experienced by people living in the north of the country. 5'6 In the absence of any similar studies on deaths from childhood accidents, we undertook a detailed analysis by health regions and districts. This paper highlights the serious mortality from childhood accidents and the continuing high degree of health inequality existing in Britain today.
Methods The annual number of deaths from injury, poisoning and violence (ICD codes E800-E999) in children aged between 0 and 14 years was obtained from the OPCS official death returns by district of usual residence over a ten-year period. Using these data and the
Correspondence: Dr J, G. Avery, Director of Public Health, South Warwickshire Health Authority, Westgate House, Market Street, Warwick CV34 4DE.
172
J. G. A very et al.
corresponding population estimates, the death rates from childhood accidents were calculated for two five-year periods, 1975-79 and 1980-84. A five-year death rate was chosen to smooth out any biases due to single major accidents resulting in clusters of childhood deaths. Because o f the small numbers involved and the limited age range of the study, death rates were used in preference to standardised mortality ratios. Test standardisation in a range of districts gave no indication that this would have made any significant difference to the results. In the first five-year period there were difficulties with boundary changes and population estimates being unavailable in 50 of the health districts. In such cases a death rate based on a two- or three-year period was calculated and used in the analysis. For each five-year period the mean annual death rate, standard deviation and 95% confidence limits were calculated. A note was made of all districts where any annual death rate was more than two standard deviations above the mean and/or where the five-year death rate was more than 20 per 100,000 population. The District Medical Officers of these districts were contacted to ascertain from their local knowledge whether there had been any relevant incidents in which clustering of fatal childhood accidents had occurred. In order to illustrate secular trends, the annual death rate for each region was plotted for each of the years 1975 to 1984. The geographical distribution of child accident mortality was mapped out by district for each five-year period using four score categories relating to the mean annual death rate per 100,000 children. Comparisons were made between the twenty two districts in the West Midlands for each of the two five-year periods using the standard Yates performance indicator histograms. 7 Finally the death rate for each district during 1980-84 was plotted against the Jarman 8 score using this as an index of social deprivation. 8 A similar plot was made for the West Midlands region. Correlation coefficients were calculated and analysis of variance performed in order to demonstrate the influence of social deprivation on the death rate. Note: Jarman 8 is a composite of eight indicators which attempts to identify under-privileged areas with particular emphasis on the very young. The higher the indicator the greater the degree of deprivation. The index gives weightings to eight factors from the 1981 census which include under 5's, single parents, the unskilled, the unemployed, overcrowding, change of address and ethnic minority. The only factor not directly relevant to children is that of pensioners living alone.
Results
Comparison of death rates between regions The death rates by NHS health regions in England and Wales for the two periods are shown in Figure 1. The rates were generally higher in the North and N o r t h West and Midlands of England compared with the South and South East. The rates in the North East Thames and South East Thames regions were raised above the general level in the South due to the influence o f high rates in several inner-city L o n d o n districts. In contrast, the lower rates in Mersey were due to the strong influence o f several low rate districts (e.g. Wirral, Southport) off-setting the relatively higher rates of the Liverpool urban areas. The death rates for all health regions showed an overall decline during the ten-year period. Nearly all of the northern regions of England along with Wales were above the
Mortality Due to Childhood Accidents
Northern North Western Yorkshire Mersey Trent West Midlands Oxford South Western Wessex East Anglia NW Thames NE Thames SW Thames SE Thames England Wales England and Wales
1975-79
1980-84
12.31 15.63 12.82 11.00 13.00 12.36 11.14 8.90 11.00 11.00 11.28 11.66 11.07 12.26 11.82 12.59 12.05
12.06 I 1.57 11.82 10.10 10.00 11.18 9.88 7.45 9.00 9.63 9.42 10.43 9.07 11.20 10.20 10.74 10.33
173
Figure 1 Childhood accident death rates by NHS health regions in England and in Wales 1975-79 and 1980-84.
national average all or most of the time (Figure 2). In contrast, the southern regions were generally below the national average with the four more urban Thames regions being nearer to the national norm than the other more rural regions (Figure 3).
Comparison of death rate by districts The death rates by districts for each of the two periods are shown in Figures 4 and 5. During both periods the highest rates of all were found in the inner-city areas of Birmingham, Manchester and London and in some o f the medium sized industrial towns of the N o r t h and the Midlands. The lowest rates were found in the predominantly rural areas o f the South West and South o f England and of East Anglia. Rural areas elsewhere in parts of the Midlands, the N o r t h and Wales were generally low. In spite o f these very strong geographical variations, there were some notable exceptions. Bristol and Liverpool and their surrounding districts had relatively low rates in both periods. Newcastle and its immediate surroundings were generally low apart from South Tyneside. Leeds and Sheffield were also relatively low for cities with a population around half a million. The outer London boroughs tended to be low in comparison with their inner city neighbours. The only localities in the south o f England with rates higher than the national average were the large towns. Swindon was very high in the 1975-79 period, but much lower in the second five years. Other high areas in the south during the first period included Brighton, Eastbourne, Hastings, Chichester, Salisbury and Cambridge, whilst West Norfolk was high during both periods. Dyfed's high rate in 1975-79 was explained by a high number of deaths (17) in a small population in three of the five years.
174
J. G. A very et al. 20
20
---
\
N. Western
---
\
\
16
Mersey
.....
W.
-----
Trent
------
Yorkshire
.......
Northern
-
-
Midlands
16
Wales England/Wales
o o
d
::,,
O
~-~- 12
-
12
03
~ 75
76
I
L
77
78
J
J
79 80 Year
L_ 81
I 82
__L
r4 83
84
Figure 2 Child accident death rates for Northern England (1975-1984).
The district enquiries revealed that there was only one district in which there was a clustering of deaths. This was South West D u r h a m where there was a definite cluster of three separate house fires during the 1980's resulting in 9 child deaths. House fires and multiple vehicle occupant road traffic accidents are the most c o m m o n reasons for the deaths of several children at one time. A detailed analysis by districts in the West Midlands (Figures 6 and 7) showed a more than three-fold difference in 1975-79 and a more than five-fold difference in 1980-84 between the districts with the highest rates and those with the lowest rates. In both periods the districts with the lowest rates were predominantly rural areas or the more affluent urban areas like .Solihult and N o r t h Birmingham. The districts with the highest rates were the inner city districts of Birmingham and the urban areas of the West Midlands conurbation, all being localities with the highest degrees of social deprivation. Similar patterns were seen in the other regions of England with the overall difference between the highest and lowest districts being over five-fold in 1975-79 and over six-fold in 1980-84.
175
Mortality Due to Childhood Accidents - 20
20
---
- -
- -
- -
S.
Wessex
- - - - -----
16
S.W.
......... ........ --
--
-
-
--
Thames
S.E.
Thames
N.E.
Thames
N.W. E.
S
o" o v~)
Western
Oxford
16
Thames
Anglia
England/Wales
12
12
..!= i/3 /23
X
~ 75
'
~ 76
_ 77
~ 78
I
I
I
79
80
81
_ I 82
J~
I
83
84
t4I
Year
Figure 3 Child accident death rates for Southern England (1975 1984).
Correlation between death rate and social deprivation
The scattergram for England 1980-48 (Figure 8) shows a wide range of death rates in relation to the Jarman 8 indices, A strong correlation between death rate and social deprivation is shown in the highly significant correlation coefficient of 0.56. An even stronger correlation with a coefficient of 0.79 is shown in the scattergram for the West Midlands (Figure 9).
Discussion This study highlights the very wide geographical variation in mortality from childhood accidents in England and Wales. Similar variations have been found in morbidity. The third national cohort study9 of children born between 5-11 April, 1970 found that children aged 0 4 living in the north and north-west of England had a greater likelihood of accidents compared with those in the south and south-east,
J. G. A very et al.
176
CHILD ACCIDENT DEATH RATE BY N.H.S. HEALTH DISTRICTS IN ENGLAND AND WALES 1975-79 Child accident deaths per 100,000 per annum 1975-1979 Northern 0
~20
~
Kilometres 100
k,
and over
15-19
J ILess than 10 h J
Wesl ' East Anglia Oxford
London
South Western
North West Thames.~, ~J , C.~North East Thames South West Thamesq
