Public Health (1991), 105, 113-120
© The Society of Public Health, 1991
School Accidents During a Three School-Years Period in a S w e d i s h M u n i c i p a l i t y L. Schelp 1"2, R. Fkman 2'3 and I. Fahl 3
1National Board of Health and We/fare, Stockholm, 2Karo/inska Institute, Department of Social Medicine, Kronan Health Centre, Sundbyberg, 3prirnary Health Care, Lidkdping, Skaraborg County, Sweden
The aim of this study was to analyse the scope and nature of accidents that occurred at school as a basis for countermeasures. There were a total of 204 school accidents during the three school-years period, causing 222 injuries. Accidents during breaks and physical education were most common (85%). Fractures (24%), wounds (21%), sprains/strains (15%) and dental injuries (14.5%) were the dominating types of injuries. The site of injury was most commonly the upper extremity (22%), head and neck (18.5%), and lower extremity. Accidents during breaks dominated in age-group 7-12 years, while sports accidents were most common in age-group 13-19 years. Surveillance of school accidents on the municipal level is needed as a base-line for countermeasures as well as the evaluation of their effects.
Introduction Accidents are the leading cause of death a m o n g the age group attending school. Due to their c o m m o n occurrence, accidents in children have been studied in recent years fairly extensively, and from various points of view. Only rarely has attention been paid to school accidents. The vast majority of accidents in the school p r o g r a m m e result in injuries rather than death. They cause, however, fairly frequent absences from school and form a considerable part of the school physician's and school nurse's daily work. t'2 As m a n y authors have observed, 37 school accidents account for 10-30% o f all accidents a m o n g school pupils. Most studies have described the medical consequences o f school accidents. Further information on these accidents occurring in children is needed and can be helpful in indicating directions for preventive efforts. The present study was undertaken to provide a description of school accidents in a local municipality.
Objectives This article is p a r t o f a b r o a d e r e p i d e m i o l o g i c a l s t u d y o f all a c c i d e n t cases l e a d i n g to a n y c o n t a c t for t r e a t m e n t with the p r i m a r y o r s e c o n d a r y h e a l t h c a r e services in a defined p o p u l a t i o n a n d g e o g r a p h i c a l area. T h e a i m was to a n a l y s e the n a t u r e a n d s c o p e o f accidents t h a t o c c u r r e d at s c h o o l as a basis for c o u n t e r m e a s u r e s . T h e q u e s t i o n s t h a t are o f interest include: when, where, a n d h o w s c h o o l accidents occur, which i n d i v i d u a l s o r g r o u p s are affected, a n d which types o f accidents a r e the m o s t c o m m o n . T h i s Study is p a r t o f a c o m m u n i t y - o r i e n t e d i n t e r v e n t i o n p r o g r a m m e in S k a r a b o r g C o u n t y . Correspondence to: Dr Lothar Schelp, National Board of Health and Welfare (F), S- 106 30 Stockholm, Sweden.
L. Schelp et al.
114
Definitions In this study, an accident is defined as a sudden unexpected series of undesired occurrences in interplay between individual, object and environment which leads to personal injury) School accident means an accident which has occurred during school hours, during activities organised by the school outside its premises and on the way to or from the school. Only accidents for which the victim has been treated by a doctor or dentist are included. Material
Study area The study area is the Lidk6ping Municipality in S k a r a b o r g County in western Sweden, comprising rural areas, more densely populated areas and an urban population centre. Its total geographical area is 689 sq kin. The n u m b e r of schools during the study period was 20.
Study population During the study period, the average municipal population was 35,122 inhabitants corresponding to 13% of the County population. The study population consists of pupils aged 7-19 years. The average distribution o f the pupils a m o n g different levels in school is shown in Table I. The compulsory school age in Sweden extends from seven to sixteen years, or to completion o f ninth form. Methods Since 1978 a continuous, population based, surveillance system covering all emergency admittances and including accident cases exist in the study area. The model for surveillance as well as validity and reliability aspects have been described earlier. 9 In this study, however, a different method has been tested. School accidents were also registered at the school health office in the respective school by school nurses and by teachers. Insurance data regarding oral t r a u m a have been added from the compulsory school insurance in the study area. Table I
School accidents by school level, sex and average number of pupils (1985-1988)
Level in school Junior (7-9 yrs) Intermediate (10-12 yrs) Upper (13 15 yrs) Secondary (16-19 yrs) Total
Male
Female
Total
%
Number of pupils
%
20
9
29
14
1,189
22
49
35
84
41
1,323
25
25
27
52
25
1,403
26
29
!0
39
20
1,472
27
123
81
204
100
5,387
100
School Accidents in Sweden
115
This article describes only accidents which resulted in injuries for which the pupils have been treated by a doctor at health centres and hospitals or by a dentist. Excluded are injuries treated by the victim himself or which have been treated only by nurses or care units other than the medical care centres in the study area. In order to obtain better knowledge and detailed m a p p i n g o f school accidents the victims were interviewed by means of a standardised questionnaire. The form included 16 items and covered such factors as the pupil's age and sex, place, time and type o f accident, location and type o f lesion, school type and level, degree o f supervision, circumstances and objects involved as well as a free-text description of the event. All patients admitted to the health care facilities and registered for a school accident took part in the investigation. There was no drop-out. The study period referred to includes three years f r o m August 1, 1985 to July 31, 1988. A school year comprised 36 weeks. School accidents were recorded during the a u t u m n term, which started on August 15 and ended on December 20, and during the spring term, from J a n u a r y 7 to June 8. In February the pupils had one week winter vacation. School was from M o n d a y to Friday.
Results There were a total of 204 school accidents during the three school-years period, causing 222 injuries (incidence 14/1,000 pupils/year), Table I shows the distribution by sex and school level. Sixty per cent of the victims were males and 40% females. High incidence show males and females on the intermediate level (21.2/1,000 pupils/year) and the upper school level (12.3/1,000 pupils/year). School accidents occurred most c o m m o n l y in September, October and N o v e m b e r and from February through March. Table II shows the situation in which the accident occurred. Accidents during breaks and physical education were most c o m m o n (85%). Accidents during breaks dominated in age-group 7-12 years, while sports accidents were most c o m m o n in age-group 13-19 years. Eleven accidents occurred on the way to and from school and as much during excursions organised by the school. Others include accidents during classroom instructions and handicraft. I n d o o r environments accounted for 106 accidents and outdoor environments for 98 accidents. Information on the type of injury is presented in Table III. The most c o m m o n injuries were fractures (24%), wounds (21%), sprains and strains (15%) and dental injuries (14.5%). Nineteen fractures were located to the radius, ulna and fingers, 12 to the humerus and shoulder and nine to the tibia and ankle. The majority of wounds were located to the head. The site of injury was most c o m m o n l y the upper extremity (22%) (Table IV). The rest consisted of injuries to the head and neck (18.5%) and to the lower extremity (16%). One hundred and fifty-seven victims were referred and treated at hospital departments, 16~were treated at health centres and 31 by a dentist. There were 92 accidents during breaks resulting in 102 injuries. The school yard was the most c o m m o n scene of accidents. Threequarters o f these accidents involved pupils from the junior (23%) and intermediate level (50%). The sex distribution showed a predominance o f males (58 accidents) on all school levels in comparison to females (34 accidents). In 65% o f the cases o f specified accident mechanism, a fall was the cause of injury (on the same level 50%) during breaks. In 25% o f the cases, the pupil was struck by another pupil. The site of injury was most c o m m o n l y the upper extremity. Seventy per cent of the school accidents occurred when there was no supervision by an adult or a member o f the staff.
L. Schelp et al.
116
The type of injury is described in Table V. Wounds (23.5%) and fractures (22.5%) dominated. Sixty-two per cent of the wounds were to the head and neck. There were 81 sports accidents during physical education resulting in 83 injuries. Sixty-nine per cent involved pupils from the upper (39%) and secondary (30%) level, compared to the junior (8%) and intermediate (23%) level. Females dominated on the upper school level (13-15 years) and males on the secondary school level (16~19 years). Table VI shows sports accidents by activity. The majority of the injuries were attributed to gymnastics (21%)--specifically the bars and vaulting horse were the most c o m m o n sports equipment involved--soccer and other types o f ball sports. The type of injury in shown in Table V. Fractures (27.7%) dominated, followed by sprains and strains (24%).
Table II
School accidents by situation and school level
Situation
Level in school Junior/Intermediate (7-12 yrs) Number Percentage
Break Sports From and to school Other Total
Upper/Secondary (13-19 yrs) Number Percentage
67 25 9 12
59 22 8 l!
25 56 2 8
113
100
91
Table III
27.5 61.5 2.2 8.8 100
Total Number
Percentage
92 81 II 20
45 40 5 10
204
100
School accidents by type of injury
Type of injury
Number
Percentage
Fractures Wounds Sprains/strains Dental injuries Contusions Concussions Eye injuries Lacerations Dislocations Animal bites Internal injuries (abdomen) Other injuries
53 47 33 32 16 12 9 9 7 2 1
24.0 21.0 15.0 14.5 7.0 5.5 4.0 4.0 3.0 1.0 0.5
1
0.5
Total
222
100
School Accidents in Sweden Table IV
School accidents by site of injury
Site o f injury
Number
Percentage
49 42 36 32 23 21 10 7 2 2
22.0 18.5 16.0 24.5 10.5 9.5 4.5 3.0 1.0 0.5
Wrist, hand, finger Head, neck Lower leg, foot, ankle Tooth Upper leg, knee Shou2der, arm Eye Upper part of the body Lower part of the body Inner organ Total
Table V
222
Break Number
Total
100
School accidents during break and sports by type of injury
Type of injury
Fractures Arm, shoulder Hand, wrist, finger Foot, leg Clavicle Skull Face Upper leg Wounds Dental injuries Sprains, strains Contusions Concussions Lacerations Dislocations Other injuries
117
23
Sports
Percentage
Number
22.5
Percentage
23
27.7
8
9.7
8 20 3 3 5 6 7
9.7 24.1 3.6 3.6 6.0 7.2 8.4
(2) (11) (7)
(20) (8) (2) (1) (l) (1)
(2) (1) 24 17 13 8 7 4 6
202
23.5 16.6 12.7 7.8 7.0 4.0 5.9 100
83
100
L. Schelp et al.
ll8 Table V!
Activity
Sports accidents by activity Number
Percentage
Gymnastics Soccer Basketball Skiing Running High jump Indoor hockey Volleyball Handball Swimming Cycling Other ballsports Other sports
17 12 9 6 3 3 3 2 2 1 1 11 11
21.0 15.0 ! 1.0 7.0 4.0 4.0 4.0 2.5 2.5 1.0 1.0 13.5 13.5
Total
81
100
Discussion
Adequate surveillance of school accidents provides the basis for determining prevention strategies. The objective of this study was to analyse the scope and nature o f accidents that occurred a m o n g a well-defined background population (7 19 years) as a basis for countermeasures. Since accidents requiring medical examination affect the pupil's schoolwork much more than do the slight scratches and strains treated by the school nurse, attention was paid mainly to the injuries o f those children who were treated by doctors at Health Centres, Casualty Departments and by dentists. This means that the actual incidence of school injuries is greater than that found in the present study, especially when minor injuries are concerned. However, the number o f reported accidents in the three school-years period gives a good indication of the types o f accidents and resulting injuries occurring at school. Although the majority of children, who were injured at school, returned after a short period o f absence, there is a need for accident prevention in school children. Sixty per cent of the victims were males and 40% females. This is very similar to the results presented by other investigations 6"~°'~ which were confined to age-groups from 6-14 years of age. Accidents during breaks and physical education were most c o m m o n (85%). Similar results were presented by Ranch Aalberg et al. 1986 (87%) in a Danish study. These figures were higher than reported by Jacobsson et al. from an intervention area of accidents in Sweden? The way to and from school accounted for 5% o f the accidents and has to be further improved. The most c o m m o n types o f all school injuries were fractures (24%), wounds (21%), sprains and strains (15%). Fractures are considered important because they take up considerable time and resources o f the health care system. Other studies show that fractures account for 11-32% of all injuries. 5'6'~°Wounds were mainly the result of fails on the same level from tripping, slipping and stumbling and to pushes against building elements and some were caused by using tools. Little attention has been paid to dental injuries before. In this study they accounted for 14.5% of all injuries. As reported by other authors injuries to the extremities and to the head were most common. 6
School Accidents in Sweden
119
Twenty-two to fifty-seven per cent of all school accidents are reported to occur during breaks. 5'6"7'j2 In this study the frequency rates a m o n g school children were higher in unorganised activities on the school yards than any other area o f school. Ninety-two accidents (45%) during breaks resulted in 102 injuries. Seventy-three per cent o f the victims belonged to the junior and intermediate school level. In 25% the injury was caused 'unintentionally' by another pupil. Only in 30% o f the cases there was some kind of supervision by an adult. Perhaps this is an area where teachers could consider extending their normal out-of-class supervision in an attempt to reduce this figure. Play, brawling and aggression are not easy to differentiate. Studies on intentional violence at schools show that these account for 7 13% o f all injuries. ~3,~4 As in other studies o f childhood accidents, falls have been shown to be the most c o m m o n type of accident, s,~5 Sports accidents during physical education accounted for 40% of all school accidents. These accidents were more frequent a m o n g pupils from the upper and secondary school level (aged 13 years and over). Other studies show a distribution o f sports injuries during physical education between 30M4%. 5"6"16 In this study females dominate on the upper school level (13-15 years) and males on the secondary school level (16-19 years). These results do not confirm similar injury rates for males and females reported by Tursz and Crost. J6 Surveillance o f school accidents is needed as a basis for intervention p r o g r a m m e s as well as the evaluation o f their effects. Countermeasures based on the local accident pattern at schools have been implemented including: safety training of children at compulsory schools, education o f teachers, safety rounds, increased pupil involvement from all school levels in safety decision-making, warming up before physical education etc. Safety training and education can be thought of as a part of the broader field o f health education and should be integrated as much as possible with the health education curriculum. Emphasis on accident prevention can be included in every subject. Safety rounds are useful since m a n y teachers and administrators are not totally aware of all the potential hazards. It remains to be seen, from further study, whether or not changes in environment, equipment or tuition could reduce the number of school accidents.
Acknowledgements This study has been funded by the County Council of Skaraborg and supported by the National Board of Health and Welfare.
References 1. ArsdeIl, W. R., Roghmann, K.J. & Nader, P. R. (1972). Visits to an elementary school nurse. Journal of School Health, 42, 142. 2. McKevitt, R. K., Nader, P. R., Williamson, M. C. & Berrey, R. (1977). Reasons for health office visits in an urban school district. Journal of School Health, 47, 275. 3. Berfenstam, R. (1979). Prevention of childhood accidents in Sweden. With special attention to the work of the joint committee for prevention of accidents. Acta Paediatrica Scandanavica (Suppl.), 275, 88. 4. Maddocks, G. B., Sibert, J. R. & Brown, B. M. (1978). A four week study of accidents to children in South Glamorgan. Public Health, 92, 171-176. 5. Jacobsson, B., Bek-Jensen, H. & Jansson, B. (1986). One year's incidence of school accidents and their severity in a Swedish municipality. Scandinavian Journal of Primary Health Care, 4, 213217.
120
L. Schelp et al.
6. Ranch Aalberg, J., Beier-Holgersen, R, & Jensen, S. (1986). Accidents in schoolchildren. A prospective investigation of accidents in primary schools, Ugeskr Lceger, 148, 913-914. (In Danish). 7. Sillanp~i~i, M., Tcrho, P., Westeren, H, & Pisirici, H. (1983). Accidents in school children: epidemiologic, aetiologic and prognostic consideration. Acta Paediatrica Hungariea, 24, 119130. 8. Schelp, L. (1987). Epidemiology as a Basis for Evaluation o f a Community Intervention Programme on Accidents. Thesis. Sundbyberg. 9. Schelp, L. & Svanstr6m, L. (1987). A model for registration and mapping of accident cases in health care. Scandinavian Journal of Primary Health Care, 5, 91-99. 10. Langley, J. D., Silva, P.A. & Williams, S. M. (1981). Primary school accidents. New Zealand Medical Journal 94, 336-339. l 1. Dale, M., Smith, M., Weil, J. & Parrish, H. (1969). Are schools safe?--Analysis of 409 student accidents in elementary schools, Clinical Pediatrics, 8, 294-296. 12. Liimatianen-Lamberg, A. E. & Elfing, J. (1982). Accidents in Finnish schools 1980. Finnish Board of Education. 13. Johnsson, C.J., Carter, A.P., Harlin, V.K. & Zoller, G. (1974). Student injuries due to aggressive behavior in the Seattle public schools during the school year 1969-70. American Journal o f Public Health, 64, 904-906. 14. Hultin, H. & Kilpinen, C. (1985). Unfiille, die absichtlich durch einen anderen Schiller in Grundschulen in Finnland und in der Waldorf-Schule in Helsinki verursacht worden sind. (International School Accidents comparing regular compulsory schools and Waldorf Schools in Finland.) OffGesundheitswes, 47, 61-64. 15. Langley, J.D. & Silva, P.A. (1979). Falls--the most common accident experienced by New Zealand children. Accident Compensation Commission Report, 6, 6244. 16. Tursz, A. & Crost, M. (1986). Sports-related injuries in children. American Journal o f Sports Medicine, 14, 294-299.
© The Society of Public Health, 1991
School Accidents During a Three School-Years Period in a S w e d i s h M u n i c i p a l i t y L. Schelp 1"2, R. Fkman 2'3 and I. Fahl 3
1National Board of Health and We/fare, Stockholm, 2Karo/inska Institute, Department of Social Medicine, Kronan Health Centre, Sundbyberg, 3prirnary Health Care, Lidkdping, Skaraborg County, Sweden
The aim of this study was to analyse the scope and nature of accidents that occurred at school as a basis for countermeasures. There were a total of 204 school accidents during the three school-years period, causing 222 injuries. Accidents during breaks and physical education were most common (85%). Fractures (24%), wounds (21%), sprains/strains (15%) and dental injuries (14.5%) were the dominating types of injuries. The site of injury was most commonly the upper extremity (22%), head and neck (18.5%), and lower extremity. Accidents during breaks dominated in age-group 7-12 years, while sports accidents were most common in age-group 13-19 years. Surveillance of school accidents on the municipal level is needed as a base-line for countermeasures as well as the evaluation of their effects.
Introduction Accidents are the leading cause of death a m o n g the age group attending school. Due to their c o m m o n occurrence, accidents in children have been studied in recent years fairly extensively, and from various points of view. Only rarely has attention been paid to school accidents. The vast majority of accidents in the school p r o g r a m m e result in injuries rather than death. They cause, however, fairly frequent absences from school and form a considerable part of the school physician's and school nurse's daily work. t'2 As m a n y authors have observed, 37 school accidents account for 10-30% o f all accidents a m o n g school pupils. Most studies have described the medical consequences o f school accidents. Further information on these accidents occurring in children is needed and can be helpful in indicating directions for preventive efforts. The present study was undertaken to provide a description of school accidents in a local municipality.
Objectives This article is p a r t o f a b r o a d e r e p i d e m i o l o g i c a l s t u d y o f all a c c i d e n t cases l e a d i n g to a n y c o n t a c t for t r e a t m e n t with the p r i m a r y o r s e c o n d a r y h e a l t h c a r e services in a defined p o p u l a t i o n a n d g e o g r a p h i c a l area. T h e a i m was to a n a l y s e the n a t u r e a n d s c o p e o f accidents t h a t o c c u r r e d at s c h o o l as a basis for c o u n t e r m e a s u r e s . T h e q u e s t i o n s t h a t are o f interest include: when, where, a n d h o w s c h o o l accidents occur, which i n d i v i d u a l s o r g r o u p s are affected, a n d which types o f accidents a r e the m o s t c o m m o n . T h i s Study is p a r t o f a c o m m u n i t y - o r i e n t e d i n t e r v e n t i o n p r o g r a m m e in S k a r a b o r g C o u n t y . Correspondence to: Dr Lothar Schelp, National Board of Health and Welfare (F), S- 106 30 Stockholm, Sweden.
L. Schelp et al.
114
Definitions In this study, an accident is defined as a sudden unexpected series of undesired occurrences in interplay between individual, object and environment which leads to personal injury) School accident means an accident which has occurred during school hours, during activities organised by the school outside its premises and on the way to or from the school. Only accidents for which the victim has been treated by a doctor or dentist are included. Material
Study area The study area is the Lidk6ping Municipality in S k a r a b o r g County in western Sweden, comprising rural areas, more densely populated areas and an urban population centre. Its total geographical area is 689 sq kin. The n u m b e r of schools during the study period was 20.
Study population During the study period, the average municipal population was 35,122 inhabitants corresponding to 13% of the County population. The study population consists of pupils aged 7-19 years. The average distribution o f the pupils a m o n g different levels in school is shown in Table I. The compulsory school age in Sweden extends from seven to sixteen years, or to completion o f ninth form. Methods Since 1978 a continuous, population based, surveillance system covering all emergency admittances and including accident cases exist in the study area. The model for surveillance as well as validity and reliability aspects have been described earlier. 9 In this study, however, a different method has been tested. School accidents were also registered at the school health office in the respective school by school nurses and by teachers. Insurance data regarding oral t r a u m a have been added from the compulsory school insurance in the study area. Table I
School accidents by school level, sex and average number of pupils (1985-1988)
Level in school Junior (7-9 yrs) Intermediate (10-12 yrs) Upper (13 15 yrs) Secondary (16-19 yrs) Total
Male
Female
Total
%
Number of pupils
%
20
9
29
14
1,189
22
49
35
84
41
1,323
25
25
27
52
25
1,403
26
29
!0
39
20
1,472
27
123
81
204
100
5,387
100
School Accidents in Sweden
115
This article describes only accidents which resulted in injuries for which the pupils have been treated by a doctor at health centres and hospitals or by a dentist. Excluded are injuries treated by the victim himself or which have been treated only by nurses or care units other than the medical care centres in the study area. In order to obtain better knowledge and detailed m a p p i n g o f school accidents the victims were interviewed by means of a standardised questionnaire. The form included 16 items and covered such factors as the pupil's age and sex, place, time and type o f accident, location and type o f lesion, school type and level, degree o f supervision, circumstances and objects involved as well as a free-text description of the event. All patients admitted to the health care facilities and registered for a school accident took part in the investigation. There was no drop-out. The study period referred to includes three years f r o m August 1, 1985 to July 31, 1988. A school year comprised 36 weeks. School accidents were recorded during the a u t u m n term, which started on August 15 and ended on December 20, and during the spring term, from J a n u a r y 7 to June 8. In February the pupils had one week winter vacation. School was from M o n d a y to Friday.
Results There were a total of 204 school accidents during the three school-years period, causing 222 injuries (incidence 14/1,000 pupils/year), Table I shows the distribution by sex and school level. Sixty per cent of the victims were males and 40% females. High incidence show males and females on the intermediate level (21.2/1,000 pupils/year) and the upper school level (12.3/1,000 pupils/year). School accidents occurred most c o m m o n l y in September, October and N o v e m b e r and from February through March. Table II shows the situation in which the accident occurred. Accidents during breaks and physical education were most c o m m o n (85%). Accidents during breaks dominated in age-group 7-12 years, while sports accidents were most c o m m o n in age-group 13-19 years. Eleven accidents occurred on the way to and from school and as much during excursions organised by the school. Others include accidents during classroom instructions and handicraft. I n d o o r environments accounted for 106 accidents and outdoor environments for 98 accidents. Information on the type of injury is presented in Table III. The most c o m m o n injuries were fractures (24%), wounds (21%), sprains and strains (15%) and dental injuries (14.5%). Nineteen fractures were located to the radius, ulna and fingers, 12 to the humerus and shoulder and nine to the tibia and ankle. The majority of wounds were located to the head. The site of injury was most c o m m o n l y the upper extremity (22%) (Table IV). The rest consisted of injuries to the head and neck (18.5%) and to the lower extremity (16%). One hundred and fifty-seven victims were referred and treated at hospital departments, 16~were treated at health centres and 31 by a dentist. There were 92 accidents during breaks resulting in 102 injuries. The school yard was the most c o m m o n scene of accidents. Threequarters o f these accidents involved pupils from the junior (23%) and intermediate level (50%). The sex distribution showed a predominance o f males (58 accidents) on all school levels in comparison to females (34 accidents). In 65% o f the cases o f specified accident mechanism, a fall was the cause of injury (on the same level 50%) during breaks. In 25% o f the cases, the pupil was struck by another pupil. The site of injury was most c o m m o n l y the upper extremity. Seventy per cent of the school accidents occurred when there was no supervision by an adult or a member o f the staff.
L. Schelp et al.
116
The type of injury is described in Table V. Wounds (23.5%) and fractures (22.5%) dominated. Sixty-two per cent of the wounds were to the head and neck. There were 81 sports accidents during physical education resulting in 83 injuries. Sixty-nine per cent involved pupils from the upper (39%) and secondary (30%) level, compared to the junior (8%) and intermediate (23%) level. Females dominated on the upper school level (13-15 years) and males on the secondary school level (16~19 years). Table VI shows sports accidents by activity. The majority of the injuries were attributed to gymnastics (21%)--specifically the bars and vaulting horse were the most c o m m o n sports equipment involved--soccer and other types o f ball sports. The type of injury in shown in Table V. Fractures (27.7%) dominated, followed by sprains and strains (24%).
Table II
School accidents by situation and school level
Situation
Level in school Junior/Intermediate (7-12 yrs) Number Percentage
Break Sports From and to school Other Total
Upper/Secondary (13-19 yrs) Number Percentage
67 25 9 12
59 22 8 l!
25 56 2 8
113
100
91
Table III
27.5 61.5 2.2 8.8 100
Total Number
Percentage
92 81 II 20
45 40 5 10
204
100
School accidents by type of injury
Type of injury
Number
Percentage
Fractures Wounds Sprains/strains Dental injuries Contusions Concussions Eye injuries Lacerations Dislocations Animal bites Internal injuries (abdomen) Other injuries
53 47 33 32 16 12 9 9 7 2 1
24.0 21.0 15.0 14.5 7.0 5.5 4.0 4.0 3.0 1.0 0.5
1
0.5
Total
222
100
School Accidents in Sweden Table IV
School accidents by site of injury
Site o f injury
Number
Percentage
49 42 36 32 23 21 10 7 2 2
22.0 18.5 16.0 24.5 10.5 9.5 4.5 3.0 1.0 0.5
Wrist, hand, finger Head, neck Lower leg, foot, ankle Tooth Upper leg, knee Shou2der, arm Eye Upper part of the body Lower part of the body Inner organ Total
Table V
222
Break Number
Total
100
School accidents during break and sports by type of injury
Type of injury
Fractures Arm, shoulder Hand, wrist, finger Foot, leg Clavicle Skull Face Upper leg Wounds Dental injuries Sprains, strains Contusions Concussions Lacerations Dislocations Other injuries
117
23
Sports
Percentage
Number
22.5
Percentage
23
27.7
8
9.7
8 20 3 3 5 6 7
9.7 24.1 3.6 3.6 6.0 7.2 8.4
(2) (11) (7)
(20) (8) (2) (1) (l) (1)
(2) (1) 24 17 13 8 7 4 6
202
23.5 16.6 12.7 7.8 7.0 4.0 5.9 100
83
100
L. Schelp et al.
ll8 Table V!
Activity
Sports accidents by activity Number
Percentage
Gymnastics Soccer Basketball Skiing Running High jump Indoor hockey Volleyball Handball Swimming Cycling Other ballsports Other sports
17 12 9 6 3 3 3 2 2 1 1 11 11
21.0 15.0 ! 1.0 7.0 4.0 4.0 4.0 2.5 2.5 1.0 1.0 13.5 13.5
Total
81
100
Discussion
Adequate surveillance of school accidents provides the basis for determining prevention strategies. The objective of this study was to analyse the scope and nature o f accidents that occurred a m o n g a well-defined background population (7 19 years) as a basis for countermeasures. Since accidents requiring medical examination affect the pupil's schoolwork much more than do the slight scratches and strains treated by the school nurse, attention was paid mainly to the injuries o f those children who were treated by doctors at Health Centres, Casualty Departments and by dentists. This means that the actual incidence of school injuries is greater than that found in the present study, especially when minor injuries are concerned. However, the number o f reported accidents in the three school-years period gives a good indication of the types o f accidents and resulting injuries occurring at school. Although the majority of children, who were injured at school, returned after a short period o f absence, there is a need for accident prevention in school children. Sixty per cent of the victims were males and 40% females. This is very similar to the results presented by other investigations 6"~°'~ which were confined to age-groups from 6-14 years of age. Accidents during breaks and physical education were most c o m m o n (85%). Similar results were presented by Ranch Aalberg et al. 1986 (87%) in a Danish study. These figures were higher than reported by Jacobsson et al. from an intervention area of accidents in Sweden? The way to and from school accounted for 5% o f the accidents and has to be further improved. The most c o m m o n types o f all school injuries were fractures (24%), wounds (21%), sprains and strains (15%). Fractures are considered important because they take up considerable time and resources o f the health care system. Other studies show that fractures account for 11-32% of all injuries. 5'6'~°Wounds were mainly the result of fails on the same level from tripping, slipping and stumbling and to pushes against building elements and some were caused by using tools. Little attention has been paid to dental injuries before. In this study they accounted for 14.5% of all injuries. As reported by other authors injuries to the extremities and to the head were most common. 6
School Accidents in Sweden
119
Twenty-two to fifty-seven per cent of all school accidents are reported to occur during breaks. 5'6"7'j2 In this study the frequency rates a m o n g school children were higher in unorganised activities on the school yards than any other area o f school. Ninety-two accidents (45%) during breaks resulted in 102 injuries. Seventy-three per cent o f the victims belonged to the junior and intermediate school level. In 25% the injury was caused 'unintentionally' by another pupil. Only in 30% o f the cases there was some kind of supervision by an adult. Perhaps this is an area where teachers could consider extending their normal out-of-class supervision in an attempt to reduce this figure. Play, brawling and aggression are not easy to differentiate. Studies on intentional violence at schools show that these account for 7 13% o f all injuries. ~3,~4 As in other studies o f childhood accidents, falls have been shown to be the most c o m m o n type of accident, s,~5 Sports accidents during physical education accounted for 40% of all school accidents. These accidents were more frequent a m o n g pupils from the upper and secondary school level (aged 13 years and over). Other studies show a distribution o f sports injuries during physical education between 30M4%. 5"6"16 In this study females dominate on the upper school level (13-15 years) and males on the secondary school level (16-19 years). These results do not confirm similar injury rates for males and females reported by Tursz and Crost. J6 Surveillance o f school accidents is needed as a basis for intervention p r o g r a m m e s as well as the evaluation o f their effects. Countermeasures based on the local accident pattern at schools have been implemented including: safety training of children at compulsory schools, education o f teachers, safety rounds, increased pupil involvement from all school levels in safety decision-making, warming up before physical education etc. Safety training and education can be thought of as a part of the broader field o f health education and should be integrated as much as possible with the health education curriculum. Emphasis on accident prevention can be included in every subject. Safety rounds are useful since m a n y teachers and administrators are not totally aware of all the potential hazards. It remains to be seen, from further study, whether or not changes in environment, equipment or tuition could reduce the number of school accidents.
Acknowledgements This study has been funded by the County Council of Skaraborg and supported by the National Board of Health and Welfare.
References 1. ArsdeIl, W. R., Roghmann, K.J. & Nader, P. R. (1972). Visits to an elementary school nurse. Journal of School Health, 42, 142. 2. McKevitt, R. K., Nader, P. R., Williamson, M. C. & Berrey, R. (1977). Reasons for health office visits in an urban school district. Journal of School Health, 47, 275. 3. Berfenstam, R. (1979). Prevention of childhood accidents in Sweden. With special attention to the work of the joint committee for prevention of accidents. Acta Paediatrica Scandanavica (Suppl.), 275, 88. 4. Maddocks, G. B., Sibert, J. R. & Brown, B. M. (1978). A four week study of accidents to children in South Glamorgan. Public Health, 92, 171-176. 5. Jacobsson, B., Bek-Jensen, H. & Jansson, B. (1986). One year's incidence of school accidents and their severity in a Swedish municipality. Scandinavian Journal of Primary Health Care, 4, 213217.
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6. Ranch Aalberg, J., Beier-Holgersen, R, & Jensen, S. (1986). Accidents in schoolchildren. A prospective investigation of accidents in primary schools, Ugeskr Lceger, 148, 913-914. (In Danish). 7. Sillanp~i~i, M., Tcrho, P., Westeren, H, & Pisirici, H. (1983). Accidents in school children: epidemiologic, aetiologic and prognostic consideration. Acta Paediatrica Hungariea, 24, 119130. 8. Schelp, L. (1987). Epidemiology as a Basis for Evaluation o f a Community Intervention Programme on Accidents. Thesis. Sundbyberg. 9. Schelp, L. & Svanstr6m, L. (1987). A model for registration and mapping of accident cases in health care. Scandinavian Journal of Primary Health Care, 5, 91-99. 10. Langley, J. D., Silva, P.A. & Williams, S. M. (1981). Primary school accidents. New Zealand Medical Journal 94, 336-339. l 1. Dale, M., Smith, M., Weil, J. & Parrish, H. (1969). Are schools safe?--Analysis of 409 student accidents in elementary schools, Clinical Pediatrics, 8, 294-296. 12. Liimatianen-Lamberg, A. E. & Elfing, J. (1982). Accidents in Finnish schools 1980. Finnish Board of Education. 13. Johnsson, C.J., Carter, A.P., Harlin, V.K. & Zoller, G. (1974). Student injuries due to aggressive behavior in the Seattle public schools during the school year 1969-70. American Journal o f Public Health, 64, 904-906. 14. Hultin, H. & Kilpinen, C. (1985). Unfiille, die absichtlich durch einen anderen Schiller in Grundschulen in Finnland und in der Waldorf-Schule in Helsinki verursacht worden sind. (International School Accidents comparing regular compulsory schools and Waldorf Schools in Finland.) OffGesundheitswes, 47, 61-64. 15. Langley, J.D. & Silva, P.A. (1979). Falls--the most common accident experienced by New Zealand children. Accident Compensation Commission Report, 6, 6244. 16. Tursz, A. & Crost, M. (1986). Sports-related injuries in children. American Journal o f Sports Medicine, 14, 294-299.
