A small-area population analysis of socioeconomic status and incidence of severe burn/fire-related injury in British Columbia, Canada
Introduction
Burns are a major public health concern. In the US, it has been estimated that the total direct and indirect costs incurred from burn/fire-related injuries are nearly four to six times the total costs of treating many cancers or heart diseases [1]. The most recent national data from Canada on annual costs attributed to burns was $143 million—roughly 1% of the estimated $14.3 billion in direct and indirect costs attributed to all injuries [2]. As in other countries, efforts to address the frequency and severity of burns in Canada have primarily emphasized the most proximal causes of injury, highlighting risks that occur in the kitchen [3], [4], [5], [6], from the misuse of cigarettes or alcohol [7], or resulting from improperly positioned/faulty electrical heaters and wiring [8], while leaving largely underdeveloped any theoretical perspectives of why these risks might vary systematically between socioeconomic groups. Although strategies have emphasized specific populations at an increased risk of burn injury, most notably among Canadian First Nations peoples (see [5], [8], [9]), children (see [4]), or by occupational setting (see [10], [11]), adjustment or direct analysis of more distal social or economic determinants associated with their occurrence have been rather scarce. The absence of these indicators is of critical importance as persons with less control over their employment, household, or social circumstances, coupled with the compounded effect of having a lower income, are less likely to be able to change the factors that elevate risk of injury [12], [13].
Elsewhere, research has shown that linking health outcomes to relative markers of socioeconomic status (SES) illuminates important challenges for health policy regarding the interrelationship between seemingly modifiable behavioral indicators with factors linked to socioeconomic circumstances [14], [15]. Although researchers in Canada have repeatedly documented persistent differences in numerous health outcomes across socioeconomic groups, the rationale for its exclusion here likely parallels prevailing sentiment among prevention epidemiologists that attributes these barriers to data constraints, resources limitations, a lack of generalizability of indicators of SES, as well as the presumption that aspects of SES are not amenable to public health intervention [16], [17].
Using Census and patient data from the provincial trauma registry, our research objective was to (i) investigate the strength in association between SES and risk of severe burn injury in the province of British Columbia (BC), (ii) examine if these variations are generalizable across different geographic regions, which in BC cover a full spectrum of rural, resource-based communities to highly clustered and often socioeconomically divided urban metropolitan centres, and (iii) contextualize our discussion on SES and offer suggestions for future research linking more proximal indicators within the context of SES. In doing so, our research aim is to gain a better understanding of why some populations continually experience higher risks of burn injury than others and contribute to the growing literature on the social determinants of injury.
Researchers from the UK and USA have shown that indicators of increased risk of scalding injury among both children and older adults disproportionately parallel broader factors attributed to individual markers of SES [18], [19], [20]. Runyan et al. previously illustrated that alcohol and poor housing conditions were associated with increased instance of fire injury and mortality—factors which are both known to be further amplified when linked to SES [21], [22], [23]. These conclusions form part of a growing understanding that social factors are a significant characteristic associated of an increased risk of burn injury, with clear outcome variations as one moves stepwise from patient's in the lowest social spectrum upward [15], [20], [24]. Few studies in Canada – albeit with two recent and important exceptions pertaining to occupational-related injuries (see [10], [25]) – have specifically examined the relationship between SES and burn/fire-related injury as the primary research focus. Similarly, of the few past or recent published studies on ecological patterns of burn injuries throughout BC, the most detailed information is published in work-related injury reports, listing burns among the most serious and costly injuries occurring within resource-based occupations throughout the province [11].
Yet, one of the principle findings in health disparities research over the past two decades has been the relationship between individual indicators for a vast array of diseases and health outcomes and their persistent link to social or economic circumstance [26], [27], [28], [29], [30], [31]. In the last decade, these findings have fueled a growing demand to disentangle the determinants of injury, which has been consistently and persistently assessed against individual and contextual measures of income [32], social status [20], education [33], family structure [34], and unemployment [35] using both micro-level and small-area data derived from national censuses. The ensuing research models strive to condense multiple indicators of relative social and economic deprivation into either ‘social’ or ‘material’ constructs—two separate but interconnected dimensions of class or socioeconomic position considered as key determinants of health from the influential findings first published in the UK in the Report of the Working Group on Inequalities in Health, more widely referred to today as The Black Report[36]. This evidence, in turn, is then used to quantify the extent that health disparities parallel larger effects of a socioeconomic hierarchy or stem from the conditions that lead persons sharing similar behaviors that negatively impact disease or health outcomes to cluster in proximity to one another.
Whilst evidence from this model is widely supported, we posit the influences of SES to be more broadly reflective of the conditions that others have referred to as unequal access to opportunities (e.g. education, social and familial connections) and resources (e.g. employment, wealth, safe housing) in an attempt to frame SES in a context that better allows prevention epidemiologists to understand why some populations may continually experience more injuries than others [37], [38]. For instance, persons living in poor and/or overcrowded housing and who depend on the use space heaters may not have the opportunities or the resources that would allow them to eliminate the potential harmful effects of their use, regardless of prevention efforts to minimize these effects. Whilst public health efforts in targeting accessible and tangible factors to reduce the risk of injury is central to ongoing efforts in injury prevention and control, it is equally vital that interventionists also continue to address the broader socioeconomic characteristics associated with the increased prevalence of poor health outcomes [39].
Section snippets
Patient characteristics
This is a retrospective study of adults (age ≥18 years) who were hospitalized from severe burn/fire-related injury between January 1, 2001 and March 31, 2006. Patient records were obtained from the provincial trauma registry (BCTR). The BCTR collects and maintains data on all severe burn injuries (Injury Severity Score [ISS] ≥ 12 and Abbreviated Injury Score [AIS] ≥ 1) from persons admitted directly or indirectly to any of the provinces eight tertiary, level I, and level II trauma centres as well
Results
Between January 1, 2001 and March 31, 2006, for injuries with the mechanism causing the most severe injury categorized as thermal, there were a total of 205 patients treated in hospital for severe burn injury (ISS ≥ 12, AIS ≥ 1) in BC. Of these, 35 records were missing or contained incomplete postal code identifiers, 9 cases were due to hypothermia, and 12 occurred in areas that contained less than 250 persons, leaving 149 records remaining for the analysis. Additionally, Foothills Hospital
Discussion
In this analysis, we examined both incidence of unspecified and subclasses of severe burn/fire-related injuries across both rural and urban areas throughout BC. There was a statistically significant social gradation in unspecified burn injury with each increase in SES disadvantage. When itemized by burn injury mechanism, this relationship was most pronounced among inhalation-related injuries primarily occurring in the home and within urban areas throughout the province. Although persons in the
Conclusion
Despite significant improvements in the prevention and treatment of injuries, premature mortality as a result of sustaining severe injury is the leading causes of death among Canadians under the age of 45 [51]. A limited but growing number of studies within Canada have demonstrated the intransigent relationship between SES and injury disability and mortality (see for example [39], [52], [53], [54]); yet little is still known as to the extent that these indicators are generalizable among severe
Conflict of interest
None.
Acknowledgements
This work was funded by the Michael Smith Foundation for Health Research. The views expressed in this manuscript are those of the authors and not necessarily of the funding agency.
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