Prévention des traumatismes

Transcription

Catégorie B
Gouvernement du Québec
Ministère de la Santé et des Services sociaux
Service de Formation-réseau
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Table des matières
1.
Les traumatismes au Québec. Mme Ginette Beaulne, DSC de l'Hôpital général de Montréal.
Texte principal: (remis lors de la présentation)
Texte complémentaire: Les accidents au Canada: décès et hospitalisation..
2.
L'approche privilégiée en prévention des traumatismes (Injury Control). Dr. Bruce Brown,
DSC de l'Hôpital Charles-Lemoyne.
Texte principal: Orientation privilégiée en prévention des traumatismes.
Textes complémentaires:
Injuries Are no Accident.
Conference on the Prevention of Motor Vehicle Crash Injury.
Injury: Conceptual Shifts and Preventive Implications.
3.
Planification et programmation selon l'approche de la prévention des traumatismes appliquée
à la problématique des blessures sportives et récréatives. M. Guy Régnier» Régie de la sécurité
dans les sports au Québec.
•
>
Texte principal: L'approche de la Santé Publique pour la prévention des traumatismes: application
aux traumatismes récréatifs et sportifs.
Texte complémentaire: Le sport...à vos risques!
4.
Présentation d'une intervention en Montérégie sur les casques protecteurs pour les jeunes
cyclistes. Mme Céline Farley, DSC Charles-Lemoyne.
Texte principal: Résumé de l'évaluation de la première année d'implantation du programme «Mon
Vélo-casque c'est sauté!».
Texte complémentaire: Les traumatismes reliés aux accidents de bicyclette: Problématique, nature
des traumatismes et mesures d'intervention.
5.
Connaissance-surveillance des traumatismes. Mme Yvonne Robitaille, DSC de l'Hôpital général
de Montréal.
Texte principal: (remis lors de la présentation)
Texte complémentaire: Public Health Surveillance in the United States.
6.
Stratégies d'intervention proposées par Haddon.
Texte principal: The Basic Strategies for. Reducing Damage From Hazards of all Kinds.
7.
Planification et programmation selon l'approche de la prévention des traumatismes appliquée
à la problématique des chutes chez les personnes âgées. Mme Jennifer O'Loughlin, DSC de
l'Hôpital général de Montréal.
Texte principal: Danish Medical Bulletin - Les chutes.
Texte complémentaire: Falls in the Elderly.
8.
Présentation d'intervention sur la violence conjugale. Mme Hélène Cadrin, DSC de Rimouski.
Texte principal: La violence conjugale.
Texte complémentaire: État de la santé des femmes et des enfants victimes de violence.
9.
Présentation d'intervention sur la problématique dès blessures par armes à feu. M. Antoine
Chapdelaine» DSC de l'Hôpital de l'Enfant-Jésus.
Texte principal: Contrôle des armes à feu.
Texte complémentaire: Le contrôle des armes à feu: une question de santé publique.
10.
Bibliographie.
11.
Inventaire des organismes oeuvrant en prévention des traumatismes.
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MONTREAL H1J2K9
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formation
en
Prévention
Texte
réseau
des
traumafismes
principal
«Les traumatismes
au Québec»
^
(Mme Ginette Beaulne, DSC de {'Hôpital général de
Montréal)
NATURE, PROFIL DÉMOGRAPHIQUE
ET FACTEURS DE RISQUES
Ginette Beaulne
Robert Choinière
Département de santé communautaire
Hôpital général de Montréal
FORMATION EN PRÉVENTION DES TRAUMATISMES
CAHIER DU PARTICIPANT
Montréal, le 20 février 1991
1
CONTENU DE CE CAHIER :
1)
DÉFINITION D'UN TRAUMATISME
2)
LES TRAUMATISMES : UN PROBLÈME DE SANTÉ PUBLIQUE
3)
PROFIL DÉMOGRAPHIQUE DES TRAUMATISMES AU QUÉBEC
4)
CRITÈRES DANS LE CHOIX DES PROBLÉMATIQUES
5)
PRINCIPALES CATÉGORIES DE TRAUMATISMES ET FACTEURS DE
RISQUE
6)
BIBLIOGRAPHIE
7)
RÉFÉRENCES SUPPLÉMENTAIRES CONCERNANT LES ÉTUDES SOCIOÉCONOMIQUES
8)
ARTICLES DE RÉFÉRENCES
9)
LISTE DES AUTEURS DU LIVRE LES TRAUMATISMES AU QUÉBEC,
COMPRENDRE POUR PRÉVENIR
10)
CAHIER DE PRESSE
2
1. DÉFINITION D'UN TRAUMATISME
DÉFINITION
ACCIDENT VERSUS TRAUMATISME
TRAUMATISME INTENTIONNEL VERSUS NON INTENTIONNEL
DÉFINITION
LÉSIONS CORPORELLES QUI RÉSULTENT :
•
D'UNE EXPOSITION À UNE FORME D'ÉNERGIE
PHYSIQUE (thermique, mécanique, électrique, chimique
ou de radiation)
•
DE L'ABSENCE D'ÉLEMENTS ESSENTIELS TELS QUE
L'OXYGÈNE OU LA CHALEUR
ACCIDENT VERSUS TRAUMATISME
•
ACCIDENT :
ÉVÉNEMENT
DANGEREUX
•
TRAUMATISME : BLESSURE
ACCIDENT
POTENTIELLEMENT
RÉSULTANT
D'UN
TRAUMATISME INTENTIONNEL VERSUS NON INTENTIONNEL
INTENTIONNEL
•
ACTE DE VIOLENCE ENVERS SOI OU AUTRUI
NON INTENTIONNEL
•
INVOLONTAIRE
2.
LES TRAUMATISMES : UN PROBLÈME
DE SANTÉ PUBLIQUE
2.1
NATURE, AMPLEUR ET CONSÉQUENCES
SUR LA SANTÉ
2.2
OUTILS D'ANALYSE ET D'INTERVENTION
EN SANTÉ PUBLIQUE
5
2.1
NATURE, AMPLEUR ET CONSÉQUENCES
Nature, ampleur
•
Traumatismes touchent l'ensemble de la population
•
La santé : témoin des dommages causés par les traumatismes
•
3 945 décès par année; une réalité quotidienne dont témoignent les
journeaux (cahier de presse ci-joint)
Conséquences
•
Études économiques réalisées au Québec1
Camirand du MSSS (1983, 1985) évalue le coût des
traumatismes pour l'année 1980-1981 à 1,43 $ milliards (en $
1989) soit; 356 $ millions (2,5%) en coût direct, 456 $ millions
en coût indirect de morbidité (32%) et 613 $ millions (43%) en
coût indirect de mortalité
Bordeleau de la SAAQ (Société d'assurance automobile du
Québec) évalue le coût des traumatismes routiers à plus de
2,5 $ milliards (en $ de 1985). Ainsi, il estime à 835 $ millions
le coût attribuable à la perte de productivité, à 144 $ millions
les coûts médical et paramédical, à 560 $ millions le coût de
prévention et à 1,2 $ milliard la perte attribuable aux dommages
matériel
Sicard et Daigle ont pour la RSSQ (Régie de la sécurité dans
les sports) estimé le coût des traumatismes récréatifs et sportifs
en 1987, à 184 $ millions dont 51 $ millions en coût direct et
133 $ millions en coût indirect
•
Étude économique de Rice et collaborateurs : Cost of Injury
En 1985, on comptait 57 millions de victimes de traumatismes
aux États-Unis. Le coût de ces traumatismes est évalué à près
de 158 $ milliards dont 45 $ milliards (29%) en coût direct,
65 $ milliards (41%) en coût indirect de morbidité et 48 $
milliards (30%) en coût indirect de mortalité
•
Ce qui s'évalue difficilement
Souffrance, préjudice esthétique, changement de carrière ou de
mode de vie, effets sur la famille, etc.
Voir bibliographie à la fin du document.
OUTILS D'ANALYSE ET D'INTERVENTION EN SANTÉ PUBLIQUE
Les traumatismes : un problème que l'on peut prévenir
•
Collecte et analyse : qui, quand, comment, où ...
•
Identification de groupes à risques
•
Compréhension de la "dynamique" des traumatismes
•
Conception ou implantation de mesures préventives
3. PROFIL DÉMOGRAPHIQUE DES
TRAUMATISMES
3.1
FAITS SAILLANTS
8
3.1
FAITS SAILLANTS
•
Les décès et les hospitalisations ne représentent qu'une faible proportion de
l'ensemble des conséquences attribuables aux traumatismes ayant un effet
sur la qualité de la vie.
•
Au Québec, les traumatismes constituent la troisième grande cause de décès
(8% en 1987), devancés seulement par les maladies de l'appareil circulatoire
(41%) et les tumeurs (28%).
•
Entre 1 et 45 ans, les traumatismes forment la première cause de décès et
sont responsables d'au moins un décès sur trois. Chez les jeunes âgés de
15 à 24 ans, plus de trois décès sur quatre sont dus aux traumatismes.
•
À partir de 25 ans, l'importance relative des traumatismes diminue
rapidement avec l'âge, pour représenter moins de 3% de l'ensemble des
décès chez les personnes de 65 ans et plus. A l'inverse, le taux de
mortalité par traumatisme augmente rapidement après 65 ans.
•
En éliminant la mortalité par traumatisme, l'espérance de vie de la population
québécoise augmenterait de 1,4 an. En comparaison, la disparition des
décès par maladie de l'appareil circulatoire et des décès par tumeur
entraîneraient respectivement des gains de 4,3 ans et de 3,4 ans.
•
Les traumatismes arrivent au premier rang pour les années potentielles de
vie perdues dans la population âgée de 15 à 64 ans.
•
Alors que le taux de mortalité toutes causes était presque réduit du tiers
durant tes cinquante dernières années, le taux de mortalité par traumatisme
est demeuré relativement stable. L'importance relative des traumatismes a
donc subi une hausse importante, passant de 5% à 8%.
•
Le taux de mortalité par traumatisme observé récemment au Québec est
inférieur à celui des pays scandinaves, à celui des États-Unis et à celui de
la France. Il est toutefois supérieur à celui du Canada, de l'Ontario, de
l'Angleterre, des Pays-Bas et du Japon, même si ces populations sont plus
âgées que celle du Québec.
•
Les suicides (30%) et les traumatismes routiers (28%) forment les deux
principales causes de mort violente. Ils sont suivis de loin par les chutes
(9%), les homicides (3%) et les incendies et brûlures (2%).
•
Chez les enfants de moins de 15 ans, les véhicules à moteur et les piétons
représentent les deux principales catégories de décès par traumatisme.
Dans le groupe des 15-24 ans, les véhicules à moteur arrivent au premier
rang tandis qu'entre 25 et 64 ans, ce sont les suicides qui prennent la
première place. Finalement, chez les personnes âgées de 65 ans et plus,
les chutes forment la catégorie la plus importante de traumatisme.
•
Le dixième des hospitalisations de courte durée pour maladie sont dues aux
traumatismes. Cette cause arrive au 5e rang des maladies.
•
Chez les fëmmes, le taux d'hospitalisation par traumatisme diminue
légèrement entre 0 et 45 ans, pour ensuite augmenter rapidement. Chez les
hommes, les variations selon l'âge sont moins grandes. Avant 65 ans, les
hommes présentent des taux plus élevés que les femmes, tandis qu'après,
c'est l'inverse qui se produit.
•
De 1980-1981 à 1987-1988, les taux d'hospitalisation par traumatisme ont
légèrement augmenté au Québec.
•
Les chutes représentent la principale cause d'hospitalisation par traumatisme
chez les enfants de moins de 15 ans. Dans la population âgée de 15 à 24
ans, les chutes et les véhicules à moteur forment les deux premières
catégories, tandis qu'à partir de 25 ans, ce sont les chutes qui arrivent au
premier rang.
•
Les accidents sont à l'origine de limitations à long terme, principalement chez
les jeunes et chez les hommes. Chez les hommes âgées de 15 à 44 ans,
plus de la moitié des limitations à long terme sont d'origine accidentelle. Ce
n'est qu'à partir de 65 ans que l'importance des limitations dues aux
traumatismes est plus élevée chez les femmes que chez les hommes
Référence principale :
Robitaille, Y., R. Choinière, F. Camirand. 1991.
Dans Les traumatismes au Québec, Comprendre
pour prévenir. Chap 2.
Répartition des décès par traumatisme,
selon la cause, Québec, 1987
N = 3 945
Piétons
Cyclistes 1,0% 4»3 %
Chutes 9,0 %
Incendies
et brûlures
2,5 %
NON INTENTIONNELS
66,7 %
Véhicules à moteur
22,8 %
Intoxications 1,1 %
Suicides 29,9%
INTENTIONNELS
33,3 %
Autres 25,9 %
(dont 2,8 % sont
des noyades)
Homicides
3,4 %
Tiré du Livre «Les traumatismes au Québec comprendre pour prévenir, 1991»
4. CRITÈRES DE CHOIX DES
PROBLÉMATIQUES
4.1
FOCUS DE PRÉVENTION :
CATÉGORIE DE TRAUMATISMES
NATURE DES BLESSURES
GROUPE D'ÂGE
LIEUX DE SURVENUE
4.2
FRÉQUENCE ET GRAVITÉ
4.3
PRÉOCCUPATION DU MILIEU/MOMENTUM
12
4.1
FOCUS DE PRÉVENTION
PRINCIPALES CATEGORIES DE TRAUMATISMES ET CODES E DE LA
CLASSIFICATION INTERNATIONNALE DES MALADIES (CIM)
CATÉGORIES DE TRAUMATISMES
TRAUMATISMES INTENTIONNELS ET
NON INTENTIONNELS
CODES E CORRESPONDANTS
E 800-E 999
NON INTENTIONNELS
TRANSPORT
Occupant de véhicules à moteur
Motocycliste
Cycliste
Piétons
Autres
• Train
. Aérien
• Non circulation
. Autres
E 810-819
810-819
810-819
810-819
800-809
840-845
820-829
810-819 (.5,.8,.4)
NOYADES
Liées aux embarcations
Non liées aux embarcations
830,832
910
INTOXICATIONS
Solides/liquides
Gas/vapeurs
850-866
867-869
CHUTES
880-888
INCENDIES ET BRÛLURES
Feu et flammes
Substance/objet chauds
890-899
924
AUTRES NON INTENTIONNELS
Armes à feu
Agents physiques du milieu
Aspiration/suffocation
Corps étranger
Choc (frappé), compression (écrasé)
Machinerie
Instruments tranchants/perforants
Autres...
(.0..1..9)
(.2, .3)
(.6)
(.7)
922
900-909
911 -913
914-915
916-918
919
920
13
INTENTIONNELS
SUICIDE ET TENTATIVE
Substances solides ou liquides
Gas/vapeur
Pendaison
Submersion
Armes à feu
E 950-959
950
951-952
953 (.0)
954
955 (.0-.4)
HOMICIDE ET ATTENTAT
Pendaison/strangulation
Armes à feu
Instrument tranchant ou perforant
E 960-969
963
965 (.0-.4)
966
Sources :
Yvonne Robitaille, regroupement inspiré de :
Baker (1984) The Injury Fact Book, p. 278.
Langiey & McLoughlin (1989) Injury Mortality and Morbidity in New
Zealand. Acc Anal & Prev, vol. 21, pp. 243-254.
NATURE DES BLESSURES
PRINCIPALES CAUSES MÉDICALES DES DÉCÈS PAR TRAUMATISMES
•
Fractures du crâne (13,9%)
•
Traumatismes au thorax (12,9%)
•
Autres introcrâniens (12,5%)
•
Intoxications médicamenteuses (6,5%)
•
Intoxications non-médicamenteuses (6,3%)
•
Fractures des membres inférieurs (6,1%)
•
Fractures du cou (4,0%)
•
Autres (37,8%)
GROUPES D'ÂGE
•
Enfants
•
Jeunes adultes
•
Adultes
•
Personnes âgées
UEUX DE SURVENUE
•
Route
•
Lieux de travail
•
Lieux récréatifs ou sportifs
•
Domicile
•
Autres : lieux publics, institutions, etc.
15
5.
PRINCIPALES CATÉGORIES DE TRAUMATISMES
ET FACTEURS DE RISQUES*
5.1
FACTEURS DE
TRAUMATISMES
RISQUE
COMMUNS
À
PLUSIEURS
5.2
FACTEURS DE RISQUE PROPRES À DES CATÉGORIES
SPÉCIFIQUES DE TRAUMATISMES
(Référence principale de cette section : Les traumatismes au Québec,
Comprendre pour prévenir (en voie de publication).
16
5.1
FACTEURS DE RISQUE COMMUNS À PLUSIEURS TRAUMATISMES
Âge : Jeunes adultes, personnes âgées
Sexe : surmortalité et surmorbldlté masculine
Consommation d'alcool (voir références citées dans la bibliographie)
•
Environ 50% des conducteurs qui décèdent d'un traumatisme routier
•
30 à 50% des décès par brûlures
•
Environ 50% des décès par noyades liés aux embarcations
•
Environ 10% des décès par chutes
Niveau socio-économique : milieux défavorisés
TAUX DE MORTALITÉ DES PERSONNES LES PLUS DÉFAVORISÉES
RAPPORTÉ À CELUI DES PERSONNES LES PLUS FAVORISÉES (Wilkins)
•
Homicides : 5 fois plus élevé
•
Incendies : 4 fois plus élevé
•
Intoxications : 4 fois plus élevé
•
Noyades : 2,5 fois plus élevé
•
Suicide : 2 fois plus élevé
•
Traumatismes routiers : 1.7 fois plus élevé
(piétons : 1,8 fois selon Pless enfants à Montréal : 4 fois)
17
5.2
FACTEURS DE RISQUE PROPRES À DES CATÉGORIES SPÉCIFIQUES
DE TRAUMATISMES
TRAUMATISMES ROUTIERS
AMPLEUR : FAITS SAILLANTS
•
Il y a en moyenne annuellement 203 265 traumatismes routiers de
tous genres (SAAQ)
•
1ère cause de décès pour chacun des groupes d'âge quinquennaux
entre 1 et 25 ans chez les hommes et entre 1 et 30 ans chez les
femmes
•
Au cours de la période 1985-1987, on dénombre une moyenne
annuelle de 1 183 décès attribuables aux traumatismes routiers se
répartissant comme suit 839 occupants de véhicule à moteur, 115
motocyclistes, 159 piétons, 36 cyclistes et 34 autres ou non précisés
(SAAQ)
•
En 1987, on dénombre 10 974 hospitalisations suite à un traumatisme
routier (Med-ECHO)
•
Au Québec, les piétons âgés de moins de 15 ans et de 65 ans et
plus constituent chacun 21 % des victimes de la route (SAAQ)
FACTEURS DE RISQUE : EXEMPLES
OCCUPANTS DE VEHICULE A MOTEUR
INDIVIDU
•
Consommation d'alcool et de drogues
•
Âge et expérience de conduite
•
Excès de vitesse
18
TECHNOLOGIE/ENVIRONNEMENT
•
Véhicule et équipements
Entre 4.5% et 13% des accidents sont liés à un facteur
mécanique (Treat et Waller)
Taux d'utilisation de la ceinture de sécurité à l'avant le
plus élevé en Amérique du Nord soit entre 85% et 90%
(1990)
Toutefois, un des taux d'utilisation de DRE (Dispositifs de
retenu pour enfants) les plus bas au Canada
Coussins gonflables disponibles surtout dans les automobiles de plus
de 18,000. $
•
Environnement routier
contributif dans 35% des accidents routiers
Topographie (routes, abords), éclairage, signalisation, etc.
CYCLISTES (Céline Farley)
MOTOCYCLISTES
INDIVIDU
•
Expérience de conduite, perceptibilité du motocycliste
•
Grosseur de la cylindrée, conditions physiques de la route (scarifiage,
trous, etc.)
PIÉTONS
INDIVIDU
•
Taux de létalité chez les 65 ans et plus : 2,5 fois plus élevé que celui
des moins de 15 ans
•
Limites normales du développement psycho-moteur d'un enfant le
place à risque
•
Diminution des capacités sensorielles et physiques place les personnes
âgées à risque
•
Visibilité du piéton
•
Consommation d'alcool
•
Environnement :
Milieu urbain ; Montréal 50 % des traumatismes pjétons, 25 %
des décès
La signalisation, le marquage de la chaussée, le temps
de traverse etc.
•
Conception des véhicules à moteurs
20
INCENDIES ET BRÛLURES
•
En 1987, 99 décès et 332 hospitalisations attribuables aux incendies
et brûlures par flamme
•
En 1987, 924 hospitalisations pour brûlures de toutes sortes avec un séjour
total moyen de 19 jours (séjour total moyen ensemble traumatismes = 12.8
jours)
•
La plupart des décès sont attribuables aux incendies et 86 % de ceux-ci
surviennent à domicile principalement suite à l'inhalation de fumée.
•
La plupart des hospitalisations dues aux brûlures parmi lesquelles la
catégorie brûlures par eau et liquides chauds est la plus fréquente
FACTEURS DE RISQUES : EXEMPLES
INDIVIDU
•
Groupes à risque : enfants (0-4 ans), personnes âgées, personnes
handicapées, personnes socio-économiquement défavorisées
•
Tabagisme et consommation d'alcool dans les décès par incendies
•
Bâtiments vétustes/Conception des bâtiments modernes
•
Température de l'eau chaude domestique dépassant 55 °C
•
Inflammabilité des vêtements (personnes âgées)
INTOXICATIONS NON INTENTIONNELLES
•
En 1987, on compte 45 décès et 901 hospitalisations attribuables aux
intoxications non intentionnelles
•
En 1988, le Centre antipoison du Québec s'est occupé de 27 354 cas
d'intoxications dont la majorité était qualifiée non intentionnelle
FACTEURS DE RISQUES : EXEMPLES
INDIVIDU
•
Groupe à risque : 0-4 ans
•
Surveillance parentale
•
Équipement de protection déficient (adultes)
•
Peu de produits commerciaux et industriels ainsi que des produits
antiparasitaires à usage domestique vendus dans des contenants
sécuritaires
•
Non respect de la «loi sur la pharmacie»
•
Produits fréquemment impliqués dans les consultations au centre
antipoison : parfum, eau de cologne, plantes et alcool méthylique chez
les plus jeunes ; monoxyde de carbone et chlore à piscine chez les
adultes
TRAUMATISMES LIÉS AU TRAVAIL
AMPLEUR ; FAITS SAILLANTS
•
En 1987, la CSST a ouvert 217 291 dossiers d'indemnisation dont
215 744 pour causes "d'accidents" (traumatismes) et 1 547 pour
causes de maladies. On compte pour cette même année 131 décès.
FACTEURS DE RISQUE : EXEMPLES
•
Très grande diversité due au fait que cette catégorie regroupe
plusieurs types de traumatismes
•
Très nombreux et variés selon le type de traumatismes. Toutefois on
les classe généralement en 5 grandes catégories : les facteurs liés au
matériel, au milieu, à l'organisation, à la tâche et aux individus
•
Parallèle entre l'approche privilégiée en santé au travail soit "les
interventions à la source" et celle privilégiée en prévention des
traumatismes soit la promotion de "mesures passives" orientées vers
les solutions technologiques et environnementales. Les interventions
à la source touchent principalement les facteurs de risque liés au
matériel, au milieu, et à l'organisation
23
TRAUMATISMES ATTRIBUABLES AUX CHUTES (présentés par Jennifer
O'Loughlln)
TRAUMATISMES ATTRIBUABLES AUX
SPORTIVES (présentés par Guy Régnier)
ACTIVITÉS
RÉCRÉATIVES
ET
TRAUMATISMES INTENTIONNELS (présentés par Antoine Chapdelaine et
Hélène Cadrln)
24
r
(
\
6.
BIBLIOGRAPHIE
25
6.
BIBLIOGRAPHIE
1.
Les traumatismes au Québec, Comprendre pour prévenir. 1991. Publications
du Québec (en voie de publication).
2.
Smith, G.S. et J.F. Kraus. 1988. «Alcohol and residential, recreational and
occupational injuries : A review of the epidemiologic evidence». Annual
Review of Public Health, 9, pp. 99-121.
3.
Patteta, M.J. et P.W. Biddinger. 1988. «Characteristics of drowning deaths
in North Carolina». Public Health Reports, 103, pp. 406-411.
4.
Dougherty, G., B. Pless et R. Wilkins. 1990. «Social class and the occurence
of traffic. Injuries and deaths in urban children». Canadian Journal of Public
Health, 81, pp. 204-209.
5.
Wilkins, R., A. Owen et A. Brancker. 1989. «Évolution de la mortalité selon
le revenu dans les régions urbaines du Canada entre 1971 et 1986». Health
Reports, 1.2, pp. 137-174.
6.
Riley, R., P. Padden. 1989. «Les accidents au Canada : décès et
hospitalisation». Health Reporte, 1.1, pp. 23-50.
7.
Lacroix, D. 1988. Synthèse sur les accidents de la route impliquant des
piétons, 1982-1986. Rapport de recherche. Québec, Régie de l'assurance
automobile du Québec.
The National Committee for Injury Prevention and Control. 1989. Injury
Prevention : meeting the challenge, a summary. 26 p.
7. RÉFÉRENCES SUPPLÉMENTAIRES :
ÉTUDES SOCIO-ÉCONOMIQUES
ÉTUDES SOCIO-ÉCONOMIQUES RELATIVES
AUX TRAUMATISMES
- Quelques références -
Sicard, C. et B. Daigle. Avril 1990. Analyse des coûts socio-économiques associés à
la morbidité et à la mortalité d'origine sportive et récréative au Québec en 1987. TroisRivières, Régie de sécurité dans les sports du Québec. 143 p.
Bordeleau, B. 1988. évaluation des coûts de l'insécurité routière au Québec. Québec,
Direction des études et analyses, Régie de l'assurance automobile du Québec.
Camirand, F. 1983. Les coûts de la maladie au Québec en 1980-1981. Québec, gouv.
du Québec, Conseil des affaires sociales et de la famille.
Rice, D.P., E.J. MacKenzie et coll. 1989. Cosf of Injury in the United States. Report to
the Congress. San Francisco, Institue for Health and Aging. University of California and
Injury Prevention Center, The Johns Hopkins University.
Lawson, J.J. 1989. The Valuation of Transport Safety. Ottawa, Transports Canada.
Lawson, J.J. 1978. The Cost of Road Accidents and their Application in Economic
Evaluations of Safety Programs. Ottawa, Transports Canada.
8. ARTICLES DE RÉFÉRENCES
Changes in Mortality by Income in
Urban Canada from 1971 to 7986*
Evolution de la mortalité selon le revenu
dans les régions urbaines du Canada entre
1971 et 1986*
Russell Wilkins, O w e n A d a m s et A n n a Brancker
Russell Wilkins. Owen Adams
and A n n a Brancker
Abstract
Résumé
The reduction
of socio-economic
inequities
in
health is now an explicit ob/ective of health policy m
Canada.
This study examines changes in mortality by
income m urban Canada from 1971 to 7986 m terms of
both relative and absolute differences between mcome
groups.
La réduction des inégalités socio-économiques
sur le
plan de la santé est aujourd'hui
un objectif explicite de la
politique du Canada en matière de santé. Dans la présente
étude, nous examinons l'évolution
de la modalité selon le
revenu dans les régions urbaines du Canada entre 1971 et
7986. ef nous analysons les écarts observés en chiffres
absolus et en chiffres relatifs.
Street address information
as shown on death
certificates
was used to code census tract of usual
place of residence for deaths occurring to residents of
Canada's Census Metropolitan Areas (CMAs) in 1971
and 1986. After exclusion of residents of health care
institutions.
73,995 deaths were included in the study
for 1971. and 88.129 for 1986. These deaths were
analyzed by income qumtile (based on census tract
incidence
of tow income), age. sex, and cause of
death.
L'adresse
au domicile
indiquée sur les certificats
de
décès nous a permis d'identifier le secteur de recensement
du heu de résidence.
Cela a été fait pour l'ensemble des
résidents des régions métropolitaines
de recensemenr (RMR)
du Canada qui sont décédés
en 1971 ou 7986.
Après
exclusion des personnes dont le lieu de résidence était un
établissement
de
soins
de
santé
(centre
d'accueil
d'hébergement,
unité ou hôpital de soins prolongés),
notre
étude a porté sur 73,995 décès pour l'année 7977 et sur
88.129 décès pour l'année 1986. Ces décès ont été analysés
selon le qumtile de revenu (établi à partir du pourcentage
de
personnes a faible revenu dans le secteur de recensement) et
en fonction de l'âge, du sexe et de la cause de décès.
In 1971. the difference in life expectancy at birlh
between the highest and lowest income quintiles was
6.3 years for men and 2.8 years for women. By 1986,
these differences had decreased to 5.6 years for men
and 1.8 years for women.
However, relative mortality
(lowest compared to highest mcome qumtile) at most
ages changed on/y slightly over the i5 years. Relative
infant mortality, for example, was 1.97 in 1971 and
1.82 m J 986.
En 1971, l'écart d'espérance
de vie à la naissance entre
le qumtile de revenu le plus élevé et le qumtile le plus bas
était de 6.3 années pour les hommes et de 2.8 années pour
les femmes. En 7986. l'écart avait diminué a 5.6 années pour
les hommes et a 1.8 années pour les femmes.
Toutefois,
dorant la période 1971-1986. la mortalité relative (du qumtile
de revenu le plus bas par rapport au plus elevé) dans
l'ensemble
des groupes
d'âge a très peu changé.
Par
e*emp/e. pour la mortalité
infantile, le rapport entre les
qumtiles extrêmes était de 1.97 en 1971 et de 1.82 en 7986.
In 7986. 21*'* of total potential years of lite lost
(PYLL) prior
to age 75 could
be attributed
to
differences
m qumtile death rates compared to rates
for the highest income quintile. Approximately 45% of
this "excess" PYLL was for persons under 45 years of
age. in 1971. the comparable figure was 678©.
En 1986. 21% des années potentielles
de vie perdues
(APVP) avant l'âge de 75 ans étaient attribuables
aux
inégalités de mortalité selon le revenu, le taux de chaque
quintile étant comparé au taux du quintile de revenu le plus
élevé. En 7986. environ 45% de cet -exces- provenait du
groupe
de personnes
âgées
de. moms de 45 ans.
comparativement à 67% en 1971. .
Pmdmgs
of a /omt study undertaken
by me
Planning
3nd information
Branch.
Health and
Canada,
and
tne
Canadian
Centre
for
information.
Statistics
Canada.
hcy
Welfare
Heaim
Résultats d'une étude faite en collaboration
oar 'a Direction
de
ia oo htiQue. des planifications
et de : m formation
oe Santé et
Bier.-étre
social Canada,
et le Centre canadien
d'information
sur la santé de Statistique
Canada.
Health Reports. Volume i. Number 2 - Rapports sur la sante. volume i . numéro 2
Page 171
in 1966. the maiot causes of death contributing
to
mcome
inequalities
m mortality
were:
circulatory
diseases,
accounting
tor 2 5 % 0/ excess PYLL related
to qumtile
differences:
accidents,
poisonings
and
violence,
accounting
for about /7%. and
neoplasms,
accounting
for 15%. Respiratory
diseases,
ill-defmed
conditions,
metabolic
diseases
and
perinatal
conditions
each contributed
6 - 7 % of excess PYLL.
En
1986. les principales
causes
de deces
ayant
contribue
aux inégalités de mortalité selon le revenu
etaient
les suivantes: les maladies de l'appareil circulatoire
( 2 5 % des
APVP attnbuabies
aux inégalités),
les traumatismes
('7°»)
et
les tumeurs (I50'o).
Les maladies de l'appareil
respiratoire,
les états morbides
mal définis, les maladies
du
systeme
endocrinien
et les causes permatales
représentaient
dans
chaque cas 6 % ou 7% des APVP attnbuabies
aux
inégalités
de mortalité selon le niveau de revenu.
From 191" to 1986. m terms of
age-standardized
mortality rates (ASMRs) for all ages, certain causes of
death
showed
increased
mortality
together
with
greater
inequality
by income,
especially
for
males:
these causes included lung cancer, suicide,
metabolic
diseases
other
than
diabetes,
and
ill-defmed
conditions.
Other causes of death showed either little
change
or less
inequality
by income
but
higher
ASMRs:
these included
breast cancer,
colon
and
rectal
cancer,
arterial
diseases,
alcoholism,
mental
disorders,
and diseases
of the nervous
system.
Finally, for many causes of death. ASMRs
declined
while income. inequality
diminished:
these
included
congenital
anomalies,
perinatal
conditions,
infectious
diseases,
uterine (including
cervical) cancer,
stomach
cancer,
diabetes,
respiratory
diseases,
digestive
system diseases,
cirrhosis
of the liver, motor
vehicle
traffic accidents
(for occupants
and pedestrians),
and
accidental
poisonings,
drownings,
and fires.
Pour la penode de 1971 a 1986. les taux de
mortalité
normalisés
selon l'âge (TMNA). pour l'ensemble
des
groupes
d'âge, montrent que pour certaines causes de décès, il y a eu
augmentation
des taux de mortalité
et accroissement
des
inégalités de mortalité selon le revenu, en particulier
chez les
hommes.
Il s'agit des causes de décès suivantes: le cancer
du poumon,
les suicides,
les maladies
metabohques
(â
l'exclusion du diabète) et les états morbides
mal définis.
Pour
d'autres causes de décès, on a observe peu de
changements
ou une reduction dans les écarts de mortalité selon te revenu,
mais des hausses des taux normalises
selon l'âge,
il s'agit
des causes de décès suivantes: le cancer du sem. le cancer
du gros intestin et du rectum,
les maladies
des
arteres.
l'alcoolisme,
les troubles mentaux et les maladies du
système
nerveux.
Enfin, pour plusieurs
causes de deces. il y a eu
diminution
à la fois des taux normalisés
selon l'âge et des
écarts de mortalité selon le revenu,
il s'agit des causes
de
décès suivantes:
les anomalies
congénitales,
les
causes
périnatales,
les maladies infectieuses,
le cancer de l'utérus (y
compris le col de l'utérus), le cancer de l'estomac,
le diabète,
les maladies respiratoires,
les maladies du système
digestif,
la cirrhose
du foie, les accidents
de la route (piétons
et
occupants
des véhicules), les empoisonnements
accidentels,
les noyades et les
incendies.
Introduction
Introduction
" H e a l t h for All by the Year 2 0 0 0 " is a long-term
goal shared by all m e m b e r states of the World Heaith
Organization (WHO), including Canada (1).
Within
d e v e l o p e d countries, socio-economic inequalities m
health are increasingly seen as impediments to the
attainment of this goal (2). Health and Welfare Canada
has
identified
the
reduction of
socio-economic
inequities as a high priority for health promotion in
C a n a d a (3.4). Similar objectives have b e e n endorsed
by p r o v i n c i a l g o v e r n m e n t bodies (5-7). associations of
health professionals (8-10). as well as local health units
across Canada <11-13>.
••La santé pour tous d ' i c i l'an 2000» est ('objectif à long
terme que visent le Canada (1) et tous les autres p a y s
m e m b r e s de l'Organisation mondiale d e la santé (OMS). Dans
les pays industrialisés, o n se rend c o m p t e d e plus en plus q u e
les inégalités socio-économiques sur le plan d e la santé
constituent un obstacle à la realisation d e cet objectif (2).
C'est pour cette raison q u e Santé et Bien-être social C a n a d a a
décidé, dans le cadre d e son p r o g r a m m e d e p r o m o t i o n d e la
santé, d'accorder la priorité à la réduction d e c e s inégalités
(3.4). Différents organismes provinciaux (5-7) et associations
de professionnels de la santé (8-10) d e m ê m e q u e d i v e r s e s
unités d e santé publique a travers le Canada ( 1 1 -13)
poursuivent des objectifs semblables.
N u m e r o u s studies have d o c u m e n t e d the nature
a n d extent of inequalities in health in other countries,
f r o m b o t h cross-sectional and longitudinal perspectives.
The extensive international literature on this
s u b j e c t has recently been reviewed ( 1.14.15). and new
work c o n t i n u e s to appear (16-23). in Canada, a small
but g r o w i n g n u m b e r of studies have d o c u m e n t e d
inequalities m mortality a m o n g socio-economic groups.
T h e s e include cross-sectional studies of occupational
mortality (24-26). national ecological studies based on
Oans des pays autres q u e le Canada, de n o m b r e u s e s
études transversales et longitudinales ont été faites sur la
nature et l'importance d e s inégalités sociales sur le pian d e la.
santé. La plupart de c e s études ont été passées en revue
dernièrement (1.14.15) et de nouvelles études continuent d e
paraître ( 16-23). Au Canada, quelques travaux ont été faits sur
les différences dans les taux d e mortalité selon le niveau
socio-économique, il y a eu des é t u d e s transversales d e la
mortalité par profession (24-26), des e t u d e s - e c o i o g i q u e s nationales selon
la
catégorie
socio-economique
des
Page 130
Heal 1 h Reports. Volume 1. Number 2 -
ftaopofts
su» 13 same, volume ' " u m e r o 2
T A B L E 7.
M o r t a l i t y b y C a u s e of D e a t h : A g e - s t a n d a r d i z e d M o r t a l i t y R a t e s ( A S M R ) f o r A l l I n c o m e O u i n t i l e s
C o m b i n e d , a n d R e l a t i v e M o r t a l i t y of Q u i n t i l e 5 C o m p a r e d t o Q u i n t i l e 1, b y S e x , U r b a n C a n a d a , 1971
a n d 1986 ( c o n t i n u e d o n n e x t p a g e ) .
Molality (ASMR t 100.000) - MonaMe (TMNA « 100.000)
AH causes
infectious
Neoplasms
Lung cancer
Other cancers
Stomach cancer
Colon and rectal cancer
Pancreatic cancer
Breast cancer
Uterine (mci. cervical) cancer •
Ovarian cancer
Prostate cancer
Brajn cancer
Leukemias
Metabolic
Diabetes meiietis
Blood diseases
Mental disorders
Alcoholism
Nervous system
Circulatory
Ischemic heart
Cerebrovascular
Arterial
Respiratory
influenza
Pneumonia
Bronchitis, emphysema, asthma
Other respiratory
Digestive system
Cirrhosis Of liver
Genitourinary
Complications of pregnancy
Skm diseases
Musculoskeletal
Congenital anomalies
Perinatal conditions
in-defined conditions
Accidents, poisonings, violence
Motor vehicle traffic accidents
Pedestrian accidents
Suicide
Other accidents
Palls
Fires
Drownings
Homicides
Poisonings
Vota
Male - Hommes
Total
Diseases
1971
1986
714.4
4.7
164.7
31.8
131 3
12.5
24 2
9.0
15.6
589.6
3.8
174.9
44 2 /
128.8
7.9
23.4^
8.9
16.8
...
••
• •
--
86-71
1971
1986
838.6
5.4
184.5
54.9
128.3
15.3
238
10.6
2 '
676 3
40
194.1
C4.0
128.4
9.3
24.0
9.6
.2 •
81
75
105
117
100
61
101
91
1 14
••
••
4.4
6.2
16.4
10.8
2.3
5.9
2.5
10 4
241.8
150.0^
39.6 ^
52.3
40.0 /
.5
14.6
20.
4.8
23.0
9.0
8.1
.5
2.2
5.0
4.7
8.0
42.5 J
10.7
1.9
13.3
18.4*
5.8
1.2
.9
19
1.5
89
107
71
41
181
71
57
44
100
68
75
57
41
90
37
••
••
s
2.1
7.1
11.4 •
4.4
59.8
18.7
4.4
13.3
27.2
7.7
2.1
2.3
2.1
3.9
83
81
106
139
98
63
97
99
107
V
114
99
97
76
134
215
103
138
69
64
'59
102
96
34
77
124
96
82
78
89
••
3.9
6.2
16.9
14.2 •
1.7
2.7
2.4
7.5
351.9
233.1
67.3
51.5
41.6
1.6
18.6
16.1
5.0
28.1
11.5
9.1
86-71
Female - Femmes
••
15.9
- 4.9
6.8
16.0
13.2
1.6
3.6
3.6
8.6
405.6
290.3
63.1
522
56.0
1.4
22.3
26.3
6.1
34.2
15.3
11.4
••
.4
1.7
7.9
139
5.4
82.2
26.7
5.7
18.6
36.3
8.2
2.2
3.9
2.9
4.9
-
•
18.4
53
7.2
18.2
11.0
2.2
6.9
3.9
11.4
273.6
183.0
35.2
554
49.7
.3 '
16.4
27.4
5.7
25.7
12.5
9.0
116
108
105
113
83
134
188
108
133
67
63
56
106
89
21
74
104
93
75
82
79
••
.4
1.3
52
58
93
59.5
14.9
2.3
20.4
24.0
62
1.5
1.4
2.5
1.9
97
81
66
41
172
72
56
40
110
66
75
68
35
85
39
1971
1966
36 71
592.3
3.9
144.9
9.5
133.7
9.7
24.5
7.4
30.5
11 2
9.5
506.6
3.6
156.6
25.2
129 3
65
22.7
8.2
32.6
66
8.2
86
90
108
266
97
67
93
111
107
59
87
2.9
5.6
17.8
15.1
1.8
1.9
13
6.4
299.0
177.3
71.2
50.6
27.2
1.8
15.3
6.2
4.0
22.2
7.9
6.8
.4
.6
2.5
6.2
9.0
3.5
38.1
11.1
3.1
8.3
18.3
7.2
2.1
.8
1.3
2.9
3.6
5.2
14 8
10.7
24
5.0
1.1
9.4
211.3
1 18.4
43.7
49.2
30.7
8
12.8
13.0
4.0
20 4
5.6
72
124
93
83
71
135
265
88
146
71
67
61
97
113
44
84
212
102
92
71
106
5
3.1
49
3.7
6.8
26.2
6.6
1.6
6.5
13.0
5.4
9
5
13
i 0
84
124
78
41
197
69
59
51
79
71
76
••
4 5
64
100
35
tor A$MRs. * indicates coefficient of variation (CV) > 16 7*n,ie
indicates CV > 33 3\. For ratios. •• indicates Cv of numerate or
denominator > 33 3*, (data supressedi Ht both ASMR s and ratios - indicates value not applicable, indicates data suppresteo oec au se of
high CV
Page ' 5 2
Health Reports. Volume i. Number 2 - Rapports sur la sante. volume i. numéro 2
Page17
T A B L E A U 7.
M o r t a l i t é s e l o n la c a u s e d e d é c é s : T a u x d e m o r t a l i t é n o r m a l i s é s e l o n l ' â g e ( T M N A ) . e n s e m b l e d e s
q u i n t i l e s d e r e v e n u , et m o r t a l i t é r e l a t i v e d u q u i n t i l e S c o m p a r é e a u q u i n t i l e 1. s e l o n le s e x e d a n s
l e s r e g i o n s u r b a i n e s d u C a n a d a e n 1971 et 1986 ( s u i t e d e la p a g e p r é c é d e n t e ) .
Relative mortality pOO * 0 5 01) - Mortalité relative OOO < 0 5 - Q i l
Total
1971
1986
132
154
122
169
109 •
109
100
94
103
136
226
119'
155
112
133
104
94
90
Maie - Hommes
Female - Femmes
86'71
1971
t986
.86.71
1971
96
68
103
109
98
82
97
100
115
151
374
130
160
119
129
117
100
152
190
140
187
122
105
119
107
100
51
108
117
102
81
101
107
121
132
107
132
105
139
92
87
90
205
85
••
104
90
106
142
(36
14S
376
589
168
127
133
106
127
180
84
176
194
194
230
331
146
94
88
126
161
133
139
232
533
104
122
122
118
125
135
79
118
156
123
167
221
146
90
98
119
113
97
95
62
90
62
97
92
111
99
75
94
67
80
63
73
67
100
102
106
103
127
117.
84
480
686
194
137
141
107
156
207
101
206
209
225
252
372
162
100
99
136
207
147
136
288
579
128
135
134
142
133
167
98
• 94
132
162
125 '
162
60
84
66
99
95
133
85
81
139
198
142
222
259
158
68
94
63
88
70
98
85
136
158
189
263
173
115
246
152
228
170
530
258
398
430
170
111
132
171
259
172
97
178
210
202
132
440
256
517
'403
199
82
83
90
98
100
64
72
138
89
78
83
99
130
94
163
178
191
318
185
123
234
179
238
222
840
302
315
414
102
179
173
303
188
99
207
212
245
195
391
279
549
495
63
101
90
95
102
80
89
118
103
88
47
92
174
119
Not*
••
66
109
157
156
306
232
••
1986
113
124
107 .
147
100
123
85
83
100
176
79
••
77
118
120
122
143
176
Maiaoïes
86'71
94
94
100
111
95
89
93
96
111
86
94
••
116
108
77
78
47
76
••
139
114
121
106
103
134
77
137
138
155
199
267
121
83
m
111
103
120
103
60
98
92
97
117
77
98
108
105
121
164
136
72
78
68
61
61
112
123
137
187
191
147
97
272
106
208
122
114
99
170
212
143
94
146
209
146
86
93
72
91
111
97
97
53
196
70
70
299
65
..
460
Toutes causes
infectieuses
Tumeurs
Cancer du poumon
Autres cancers
Cancer de l'estomac
Cancer grosmstesun/rectum
Cancer du pancréas
Cancer du sein
Cancer de l'uterus
Cancer des ovaires
Cancer de la prostate
Cancer du cerveau
Leucémie
Métaboliques
Diabète sucré
Ou sang
Troubles mentaux
Alcoolisme
Ou systeme nerveux
Circulatoires
ischémiques du coeur
Cérebro-vascuiaires
Maladies des artères
Respiratoires
Influença
Pneumonie
Bronchite, emphyseme. asthme
Autres maladies respiratoires
Digestives
Cirrnose du (oie
Genuo-urmajres
Complications de grossesses
Peau et tissu sous-cutané
Osteo-articulai res
Anomalies congénitales
Causes permataies
Etats morpides mai définis
Traumatismes
Accidents véhiculés-moteurs
Accidems piétons
Suicides
Autres accidents
Chutes
incendies
Noyades
Homicides
Empoisonnements
Pour .es TMNA i astensQue t') <nd>Que Que 'e coefficient se variation 'CV) > >6
tandis Que 'es deu* points t i inc/Quent un Cv > 33 J*.
p
Pour 'es rapports 'es deu« points ( \ indiquent Que >e Cv j u numérateur ou du dénominateur
> 33 3•• idonnees suoprtmeesi
rur 'es TMNA
et les rapports, 'es deu» tirets
>ndiQuent une valeur non-apphcapie et tes deu t points I ) mdiQuent une donnée supprimée a
d un
d'eve
Health Reports. Vo'ume
<•••
Nymfcei 2 - Rapports sur la santé, volume i, numéro 2
c tuse
CV
Page iS3
Cnart 6
Graphique 8
Excess PYLL (0-74) Related to Income
Differences. Urban Canada,
1971 and 1986
Part des APVP (0-74) attribuables aux inégalités
selon le revenu,dans les régions urbaines
du Canada en 1971 et 1986
By age g r o u p
Par g r o u p e d ' â g e
1971
1986
By cause of death
Par cause de décès
1971
i—r
1986
i — r
Accidents
Traumatismes
Circulatory
Circulatoires
Circulatory
Circulatoires
Perinatal
Pennatales
Respiratory
Respiratoires
Neoplasms
Tumeurs
Respiratory
Respiratoires
Neoplasms
Tumeurs
III-defined
Mai-defmies
Congenital
Congénitales
Metabolic
Métaboliques
Digestive
Digestives
Pennatai
Pennatales
Other
Autres
Other
Autres
Accidents
Traumatismes
0
5
10
15
20
25
°e oi total excess / ••« du total annbuabies
Page '58
30®'<
5
10
15
% oi total excess /
Health Reooriv Volume 1. Number ? -
flaooorts
20
25
30*
du total attnouabies
sur la « n i e . ,oium e i numéro 2
Chart 9
Graphtque 9
Excess PYLL (0-74) Related
to Income Differences,
Part des APVP (0-74) attribuables aux inégalités
selon le revenu, dans les
Urban Canada. 1986
régions urbaines du Canada. 1986
Ages 1*14 years / de 1 à 14 ans
Age < 1 year/ < 1 an
Perinatal
Pérmataies
Accidents
Traumatismes
Congenital
Congemtaies
Respiratoires
D»gestrve
Digestives
Infectious
infectieuses
iii-deimed
Mai-defmies
Other
Autres
Other
Autres
Respiratory
0
10
20
30
40
0
50*«
t0
Accidents
Traumatismes
Circulatory
Circulatoires
Metabolic
Métaboliques
NeopJasms
Tumeurs
Circulatory
Circulatoires
Accidents
Traumatismes
iiidefmed
Mai-defmes
Respiratory
Respiratoires
Digestive
Digestives
Digestive
Digestives
Other
Autres
Other
Autres
10
20
% of total excess •
30
40
50'
du total annbuabies
Heaith'Reports. Volume i. Number 2 - Rapports sur la santé, volume i. numéro 2
30
40
50*
% du total attnbuabies
Ages 45-74 years / de 45 a 74 ans
Ages 25-44 years / de 2S a 44
0
20
% of total excess
% oi total excess / % du total attribuables
•:•>:<•.",
0
••
>''•/
,•
;',' <' S*:-}xo^ftv
10
20
30
50 (
40
% of total excess ' % du total attnbuabies
Page ' 5 9
T A B L E 9.
E x c e s s P Y L L ( 0 - 7 4 ) R e l a t e d t o I n c o m e D i f f e r e n c e s , b y A g e G r o u p . Sex, a n d M o s t I m p o r t a n t C a u s e s
o f D e a t h (ICO C h a p t e r s ) . U r b a n C a n a d a , 1971 ( e x p r e s s e d as % o f T o t a l E x c e s s P Y L L (0-74) f o r a g e
g r o u p a n d sex).
-
T A B L E A U 9.
P a r t d e s A P V P a t t r i b u a b l e s a u x i n é g a l i t é s s e l o n le r e v e n u , s e l o n l e g r o u p e d ' â g e et le s e x e , p o u r
l e s p r i n c i p a l e s c a u s e s d e d é c è s ( c h a p i t r e s d e la CIM), d a n s l e s r é g i o n s u r b a i n e s d u C a n a d a e n
1971 ( e x p r i m é c o m m e % d u t o t a l d e l ' e x c é d a n t d e s A P V P (0-74) d u g r o u p e d ' è g e s e x e ) .
T
°taJ
Maie - Hommes
Female - Femmes
Ages 0*74 years
de 0 a 74 ans
Accidents
Circulatory
Perinatal
Respiratory
Neoplasms
Congenital
Digestive
Other
24.9
17.1
15.4
84
7.6
7.0
6.9
12.7
Traumatismes
Circulate. - s
Périnataes
Respiratoires
Tumeurs
Congénitales
Digestives
Autres
Accidents
Circulatory
Perinatal
Neoplasms
Respiratory
Digestive
Congenital
Oiher
27 4
18.3
15.2
8.5
7.2
6.6
. 6.5
10.3
Traumatismes
Circulatoires
Périnatales
Tumeurs
Respiratoires
Digestives
Congénitales
Autres
Accidents
Perinatal
Circulatory
Respiratory
Congenital
Digestive
Metabolic
Other
19.7
160
14.7
11.1
8.1
7.7
65
16.2
Age < 1 year
moins de 1 an
Perinatal
Congenital
Accidents
Respiratory
Nervous syst.
Other
50.2
179
10.4
9.9
3.1
8.5
Pénnataies
Congénitales
Traumatismes
Respiratoires
Syst nerveux
Autres
Perinatal
Congenital
Accidents
Respiratory
Nervous syst.
Other
54.6
183
11 1
78
3.7
4.5
Pénnataies
Congénitales
Traumatismes
Respiratoires
Syst nerveux
Autres
Perinatal
Congenital
Respiratory
Accidents
m-defined
Other
43.5
17.3
13.2
9.2
48
12.0
Ages 1*14 years
63.3
10.3
9.7
96
5.5
1.6
Traumatismes
Congénitales
Respiratoires
Métaboliques
Syst nerveux
Autres
Accidents
Congenital
Nervous syst
Metabolic
Respiratory
Other
68.5
8.7
8.0
6.6
4.0
42
Traumatismes.
Congénitales
Syst nerveux
Métaboliques
Respiratoires
Autres
Accidents
Respiratory
Metabolic
Congenital
Neoplasms
Other
54 2
198
14 8
13.2
6.5
•8.5
A g e s 15-24 years
69.9
8.8
8.3
4 7
3 2
5.1
Traumatismes
Congénitales
Circulatoires
Syst nerveux
Digestives
Autres
Accidents
Nervous syst
Neoplasms
Congenital
Circulatory
Other
75.9
13.0
8.2
8.0
76
•12.7
Traumatismes
Syst nerveux
Tumeurs
Congénitales
Circulatoires
Autres
Accidents
Respiratory
Congenital
Circulatory
Digestive
Other
59.2
. 10.6
10.3
9.7
8.2
2.0
Page \72
Traumatismes
Respiratoires
Congénitales
Circulatoires
Digestives
Autres
de 25 à 44 ans
44.3
16.9
10.2
5.6
5.4
15.6
Traumatismes
Circulatoires
Digestives
Respiratoires
Syst nerveux
Autres
Accidents
Circulatory
Digestive
Respiratory
Nervous syst
Other
50.3
17.7
9.9
5.5
3.8
12.8
Traumatismes
Circulatoires
Digestives
Respiratoires
Syst nerveux
Autres
A g e s 45-74 years
Circulatory
Neoplasms
Digestive
Accidents
Respiratory
Other
Traumatismes
Respiratoires
Métaboliques
Congénitales
Tumeurs
Autres
de 15 à 24 ans
Ages 25-44 years
Accidents
Circulatory
Digestive
Respiratory
Nervous syst.
Other
Pénna taies
Congénitales
Respiratoires
Traumatismes
Mal définies
Autres
de i a 14 ans
Accidents
Congenital
Respiratory
Metabolic
Nervous syst.
Other
Accidents
Congenital
Circulatory
Nervous syst
Digestive
Other
Traumatismes
Pérmataies
Circulatoires
Respiratoires
Congénitales
Digestives
Métaboliques
Autres
Accidents
Circulatory
Digestive
Nervous syst
Respiratory
Other
30.4
21.8
10.9
9.0
5.7
222
-
36.5
16.9
11.7
10.9
102
11.8
Circulatoires
Tumeurs
Digestives
Traumatismes
Respiratoires
Autres
Circulatory
Neoplasms
Accidents
Digestive
Respiratory
Other
36.5
19.8
12.2
11.7
10.5
9.3
Circulatoires
Tumeurs
Traumatismes
Digestives
Respiratoires
Autres'
Traumatismes
Circulatoires
Digestives
Syst nerveux
Respiratoires
Autres
de 45 à 74 ans
Circulatory
Neoplasms
Digestive
Respiratory
Metabolic
Other
36.5
16.2
11 8
9.3
9.2
170
Circulatoires
Tumeurs
Digestives
Respiratoires
Métaboliques
Autres
Health Reports. Volume ». Number 2 - Rapports sur «a santé, volume i . numéro 2
T A B L E 10.
E x c e s s P Y L L (0-74) R e l a t e d t o I n c o m e D i f f e r e n c e s , b y A g e G r o u p . S e x . a n d M o s t I m p o r t a n t C a u s e s
of D e a t h (ICO c h a p t e r s ) . U r b a n C a n a d a . 1986 ( e x p r e s s e d a s % o f t o t a l e x c e s s P Y L L (0-74) f o r a g e
g r o u p a n d sex).
T A B L E A U 10. Part d e s A P V P a t t r i b u a b l e s aux i n é g a l i t é s s e l o n le r e v e n u , s e l o n le g r o u p e d ' â g e e t le sexe, p o u r
l e s p r i n c i p a l e s c a u s e s d e d é c è s ( c h a p i t r e s d e la C I M ) , d a n s l e s r é g i o n s u r b a i n e s d u C a n a d a e n
1986 ( e x p r i m é e c o m m e % d u t o t a l d e s A P V P (0-74) d u g r o u p e d ' â g e - s e x e ) .
Total
Maie - Hommes
Female - Femmes
%
%
de 0 à 74 ans
Ages 0*74 years
25.0
17,2
14.7
. 7.6
7.2
6.8
6.0'
15.5
Circulatory
Accidents
Neoplasms
Respiratory
iil-defmed
Metabolic
Perinatal
Other
Circulatoires
Traumatismes
Tumeurs
Respiratoires
Mai définies
MetaboiiQues
Périnatales
Autres
Circulatory
Accidents
.Neoplasms
Metabolic
Respiratory
ill-defined
Digestive
Other
24.1
18.5
16.1
78
7.0
6.0
5.6
14.9
Circulatoires
Traumatismes
Tumeurs
Métaboliques
Respiratoires
Mai définies
Digestives
Autres
Circulatory
Accidents
ill-defined
Neoplasms
Respiratory
Perinatal
Digestive
Other
28.1
13.2
109
10.3
9.6
9.5
5.6
12.8
moins de 1 an
Age < 1 year
40 3
24 8
16.9
8.3
3.8
5.9
Perinatal
Accidents
Congenital
Respiratory
Infectious
Other
Périnatales
Traumatismes
Congénitales
Respiratoires
infectieuses
Autres
Perinatal
Accidents
Congenital
Respiratory
iil-defmed
Other
35.0
24 0
22.8
7.3
5.0
5.9
Périnatales
Traumatismes
Congénitales
Respiratoires
Mal défîmes
Autres
Perinatal
Accidents
Respiratory
infectious
Neoplasms
Other
52.6
26.6
10.8
7.2
4.5
•1.7
29.3
23.1
15.6
11.7
9.8
10.5
Accidents
Congenital
Respiratory
Digestive
m-defined
Other
Traumatismes
Congénitales
Respiratoires
Digestives
Mai définies
Autres
Accidents
Neoplasms
Congenital
Respiratory
Digestive
Other
29.7
29.1
23 3
76
58
45
Traumatismes
Tumeurs
Congénitales
Respiratoires
Digestives
Autres
infectious
Metabolic
m
27.4
24.0
m
m
m
.m
de 15 à 24 ans
33.7
20.3
20.0
133
•12 5
0.2
Respiratoires
Métaboliques
Tumeurs
Circulatoires
Digestives
Autres
Neoplasms
Respiratory
Accidents
Metaboic
Digestive
Other
28.7
23 2
15.8
13.7
13.5
51
Tumeurs
Respiratoires
Traumatismes
Metabdiques
Digestives
Autres
Respiratory
iil-defmed
Metabolic
Blood
•
Other
62.5
42.8
38.6
28.5
.Respiratoires
Mai définies
Métaboliques
Du sang
•
-72.4
Autres
de 25 â 44 ans
Ages 25-44 years
Accidents
Metabolic
Circulatory
in-defined
Digestive
Other
infectieuses
Métaboliques
m
•
m
Ages 15-24 years
44 5
14.7
1V5
6.5
5.7
17 1
Traumatismes
Métaboliques
Circulatoires
Mal définies
Digestives
Autres
Accidents
Metabolic
Circulatory
m-defined
Digestive
Other
43 l
19 7
10 5
5 1
4 5
171
Traumatismes
Métaboliques
Circulatoires
Mai defmies
Digestives
Autres
Accidents
Circulatory
ill-defined
Neoplasms
Digestive
Other
48.4
14.4
10.6
9.0
89
8.7
Traumatismes
Circulatoires
Mal définies
Tumeurs
Digestives
Autres
de 45 â 74 ans
Ages 45-74 years
Circulatory
Neoplasms
Accidents
Respiratory
Oigestive
Other
Périnatales
Traumatismes
Respiratoires
infectieuses
Tumeurs
Autres
de 1 a 14 ans
Ages 1-14 years
Respiratory
Metabolic
Neoplasms
Circulatory
Digestive
Other
Circulatoires
Traumatismes
Mai défîmes
Tumeurs
Respiratoires
Périnatales
Digestives
Autres
39 8
233
8.9
7 4
68
13.8
Circulatoires
Tumeurs
Traumatismes
Respiratoires
Digestives
Autres
Circulatory
Neoplasms
Accidents
Respiratory
Digestive
Other
38 5
24 4
92
77
72
13.0
Circulatoires
Tumeurs
Traumatismes
Respiratoires
Digestives
Autres
Circulatory
Neoplasms
Accidents
Respiratory
Metabolic
Other
43.8
20.0
8.1
6.5
62
15.4
Circulatoires
Tumeurs
Traumatismes
Respiratoires
Métaboliques
Autres
numerator of oercentage based on fewer than 5 e*cess deaths »n age-se* grouo
numérateur du pourcentage base sur moins de S (feces dans 'e groupe d'àge-se»e
Health Reports. Volume i. Number 2 - Rapports sur la sante. volume i. numéro 2
Page 171
neighborhoods, rather than concentrated m "poor •
neighborhoods as they were m i 971. then the
disparities between qumtiles - as measured m this type
of study - would have diminished, even m the absence
of changes <n relative mortality at the individual level.
However, because the overall incidence of low income
was nearly the same m 1986 as it had been in 1971.
and the percentage of persons poor m each quintile
was also similar m both years, the observed changes m
mortality by quintile are unlikely to be accounted for by
changes in the composition of the qumtites
une periode relativement longue Par exemple, si en 1986 les
logements des pauvres avaient ete plus également répartis
dans les quartiers plutôt q u e d être concentres seulement dans
certains quartiers, c o m m e c'était le cas en 1971. les écarts
entre les qumtiles de revenu - de la façon dont nous les avons
mesures dans cette étude - auraient ete moms importants,
même en l'absence de changements dans la mortalité relative
chez les particuliers. Toutefois, c o m m e la frequence des cas
de faible revenu était presque la m ê m e en 1986 qu'en i 9 7 i . et
comme le pourcentage de pauvres dans chaque quintile était
à peu près égal les deux annees. les variations dans les écarts
de mortalité selon le quintile de revenu ne sont probablement
pas dues a des changements dans la composition des
quintiles.
Conclusion
Conclusion
According to these data, the disparity m all-cause
mortality between income quintiles in Canada appears
to have diminished from 1971 to 1986
Over that
period, the disparity in life expectancy at birth between
i n c o m e qumtiles 1 and 5 decreased from 4.6 to 3.7
years.
However, the difference remaining between
i n c o m e qumtiles was still over twice as large as the
disparity m life expectancy among Canada's five
geographic regions.
Regional disparities in life
expectancy declined from over five years in 1941 to
about three years in 1956. two years in 1971, and 1.5
years m 1986 (78.79).
Thus, disparities in life
expectancy between income quintiles in 1986 were
about as large .as regional disparities had been in the
early 1950s. Still, substantial progress has been made
in reducing both types of disparity.
D'après les données, l'écart de mortalité selon le revenu
(toutes causes de décès confondues) semble avoir diminué
entre 1971 et 1986. Durant cette periode. l'écart d'espérance
de vie a la naissance entre les qumtiles 1 et 5 est tombe de
4.6 à 3.7 annees.
Toutefois, l'écart qui subsiste entre les
qumtiles est plus de deux fois supérieur a r écart d'esperance
de vie entre les cinq régions du Canada, l ' é c a r t d'espérance
de vie entre les regions est passe d'un peu plus de cinq
années en 1941. a environ trois années en 1956. puis a deux
années en 1971 et à 1.5 année en 1986 (78.79). Ainsi, l'écart
d'espérance de vie entre les quintiles en 1986 était presque
aussi considérable que l'était l'écart entre les régions au début
des années 50. Quoi qu'il en soit, d'importants progrès ont
été réalisés vers une réduction d e ces deux types d'écarts.
Between 1971 and 1986. males gained an average
of 3.2 years of life expectancy, compared to an
average gain of 2.0 years for women. The advantage
in favor of w o m e n was thus narrowed by 1.2 years. On
the other hand, the differences between income
quintiles were reduced more among women (1 0 years)
than a m o n g men (0.7 years).
De 1971 à 1986. les h o m m e s ont gagné en moyenne 3.2
années d'espérance d e vie. et les femmes. 2 années.
L'avantage des f e m m e s sur les h o m m e s a donc été réduit d e
1 2 annees durant cette période. Cependant, les écarts de
mortalité selon le quintile de revenu ont davantage diminué
chez les femmes (1.0 année) que chez les hommes (0.7
année).
Thus the data on changes in mortality by income
in urban Canada from 1971 to 1986 generally indicate
diminishing absolute differences in mortality between
i n c o m e quintiles together with a persistence of relative
inequalities in mortality. In 1986 as in 1971. the higher
the percentage of population poor in the neighborhood,
the higher the mortality. This was true for all-cause
mortality and. with few exceptions, for cause-specific
mortality at most ages.
En résumé, les données sur les changements dans la
mortalité selon le revenu dans les régions urbaines du Canada
durant la période 1971-1986 indiquent qu'en termes absolus il
y a eu réduction des inégalités de mortalité selon le revenu,
mais qu'en termes relatifs les inégalités persistent. En 1986.
comme en 1971. plus le taux d e pauvreté était étévé dans un
quartier, plus le taux d e mortalité y était elevé aussi. Cette
constation vaut pour les causes d e décès considérées
globalement et pour la majorité des causes de décès prises
individuellement dans la plupart des groupes d'âge.
In terms of changes from 1971 to 1986. when
particular causes of death are examined individually,
there are indications both of clear successes and of
evident failures to attain the goal of the best possible
health for all Canadians regardless of income.
For
m a n y causes of death, mortality rates fell and
inequalities by income were reduced from 1971 to
1986. but for other causes of death, results were either
Quant aux changements survenus entre 1971 et 1986.
l'examen de chacune des causes d e deces révélé que les
efforts du Canada pour assurer la santé de tous les citoyens,
quel que sott leur revenu, ont atteint leur but dans certains cas.
mais ont echoue dans cértams autres. Pour plusieurs causes
de deces. il y a eu baisse des taux de mortalité et des
inégalités de mortalité selon le revenu durant la periode de
1971 a 1986.
Mais pour d'autres causes de deces. les
Page \72
Health Reports. Volume ». Number 2 -
Rapports sur «a santé, volume i. numéro 2
References
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Page17
Health Reports. Volume i . Number 2 - Rapports sur la sante. volume i . numéro 2
Social Class and the Occurrence of Traffic Injuries
and Deaths in Urban Children
GEOFFREY DOUGHERTY,
MD, MSc. FRCPC. 1
I. BARRY PLESS,
This paper examines motor vehicle traffic accident
deaths and injuries to pedestrians and bicyclists (ICD-9
codes E813-E814) aged 0-14 years, by income quintile of
area of residence. It is based on 92 deaths in urban
Canadain 1981, 69deathsin Montreal during the period
1979-1983. and 1,133 injuries which resulted in hospital
care or police reports in Montreal in 1981. For injuries in
Montreal, the pattern of socio-economic inequality in the
annual incidence rates by quintile was very pronounced,
completely regular and highly significant. The rate of
injury to children living in the poorest neighbourhoods
was four times that of children living in the least poor
neighbourhoods. For both sexes, inequalities were much
more pronouncedfor pedestrians compared to bicyclists.
For deaths in Montreal and all of urban Canada, the
inequality in the rates did not follow such a consistent
pattern across the income quintiles, nor were the
differences statistically significant in most cases, but the
rates for each sex were consistently highest in the poorest
income quintile. Socio-economic inequalities in the rates
of death and injury were greater in girls than in boys. The
results are discussed in the context of theories of etiology
and strategies for prevention.
A
fter the first year of life, injuries and deaths due to
accidents, poisonings and violence account for
substantial morbidity, and by far, the greatest loss of life in
childhood. Among these, motor vehicle traffic accidents
(MVTAs) are the Largest single group. 1
1. Department of Epidemiology and Biostatistics. McGill University. Community
Pediatric Research. Montreal Children's Hospital.
2. Health Care Section. Health Division. Statistics Canada. Formerly with the
Department of Community Health. Montreal General Hospital.
*The views of this author are his own and not necessarily those of his current or former
employers.
Address for correspondence I reprints: Geoffrey Dougherty. M.D.. Montreal
Children's Hospital. 2300 Tupper Street. Montreal. Quebec H3H IP3.
204
MD. FRCPC. 1
RUSSELL WILKINS,
MLrb 2 *
Cet article traite des décès et blessures que subissent les
piétons et cyclistes âgés de 0 à 14 ans, causés par les
accidents de la route (CIM-9 codes E813-E814), par
quintiles de revenus du lieu de résidence. Il est basé sur 92
décès en milieu urbain au Canada en 1981, 69 décès à
Montréal entre 1979 et 1983, et 1.133 blessures ayant
nécessité des soins hospitaliers ou ayant fait l'objet d'un
rapport de police à Montréal en 1981. Le profil
d'inégalité socio-économique des taux d'incidence
annuels était très marqué, parfaitement régulier et très
significatifpour les blessures enregistrées à Montréal. Le
taux de blessures subi par les enfants habitant dans les
quartiers les plus défavorisés était quatre fois plus élevé
que celui des enfants vivant dans les quartiers lés moins
défavorisés. Pour les deux sexes, les inégalités étaient
beaucoup plus marquées chez les piétons que chez les
cyclistes. Quant aux taux de mortalité, par quintiles de
revenus, à Montréal et pour tout le Canada urbain, les
inégalités ne présentent pas un profil aussi constant. Bien
que les taux de mortalité dans la catégorie la plus
défavorisée étaient toujours plus élevés, pour les deux
sexes, les différences n'étaient généralement pas
statistiquement significatives. Les inégalités socioéconomiques, au niveau des taux de mortalité et
blessures, étaient plus marquées chez les filles que les
garçons. Les résultats sont discutés dans le contexte des
théories étiologiques et des stratégies de prévention.
Childhood injury is linked to social and environmental
factors. However, the causal pathways are not well understood. 25
The now widely accepted generic model of causality
includes facilitating features, exposure to injurious forces and
modifying factors.2-6 The study of subgroups may elucidate
these elements.
One such subgroup is the children of disadvantaged
families.7
We present data on rates of injury and death to child
pedestrians and bicyclists due to MVTAs in Canada's largest
Vol. 81, May/June 1990
TABLE I
Population and income characteristics of the areas of residence for the quintiles
as defined in each of the three studies, Montreal and urban Canada, 1981
Montreal deaths
Urban Canada deaths
Pop.
Quintile
Q l (rich)
Q2
Q3
Q4
Q5 Ipoorl
Total
27.0
23.6
16.1
I I.I
100.0
Median
household
income
$33.147
27.281
22.956
19.236
14.209
24.650
Pop.
c-r
18.8
21.3
20.9
18.4
20.5
100.0
Montreal injuria
Povertv
r,
Pop.
10.5
18.6
20.4
20.0
19.8
19.7
20.1
100.0
r
22.0
29.9
43.0
24.9
Povertv
c
7.6
|7.|
24.4
33.9
49.8
26.5
N'ote: Population aged 0-14 sears. Po\eny among children aged 0-17 yean..
cities in the late 1970s and early 1980s. We contend that
inequalities in c h i l d h o o d M V T A injury and death rales are a
fundamental by-product of social class disparities, and that
urban physical and social environments fail to provide an
adequate level of protection to the children of disadvantaged
families.
METHODS
We reanalyzed data on the occurrence of motor vehicle
traffic accidents to pedestrians and bicyclists ( I C D - 9 codes
E813-E8I4) aged 0-14 years f r o m three studies which
examined differences in the rates of injuries and deaths by
income* quintile. 8 - 9 - 10
D e n o m i n a t o r data were taken f r o m the 1981 Census of
C a n a d a . " U r b a n Canada and M o n t r e a l death data were
obtained f r o m Statistics Canada and the Population Registry
of the Quebec Bureau of Statistics, respectively. M o n t r e a l
injurv data were obtained f r o m a m o n i t o r i n g system
established in eight general hospitals and t w o children's
hospital emergency departments to identify all children seen
as a result o f M V T A s as well as f r o m police reports of
M V T A s resulting in injury to children.
M o n t r e a l injuries and urban Canada deaths were assigned
to census tracts based on the home address of the victim.
M o n t r e a l deaths were assigned to health and social services
districts ( C L S C s ) based o n the postal code and municipality
reported o n the death certificate. ( S e e A p p e n d i x I).
Income quintiles were defined in each study as follows: For
the study o f u r b a n Canada deaths in 1981, census tracts were
ranked by median household income as reported on the
census, and one fifth o f the ranked tracts were allocated to
each quintile. For the study o f M o n t r e a l deaths in 1979-1983.
40 C L S C s were ranked according to the rate of poverty in
1981 a m o n g children under 18 years o f age, and the service
districts were divided so as to allocate approximately one fifth
of the 1981 census p o p u l a t i o n aged 0-14 to each quintile. ( See
A p p e n d i x II). For the M o n t r e a l injuries study, the 450 census
tracts were ranked by their rate o f poverty among children
under 18. The census tracts were sub-divided so as to allocate
a p p r o x i m a t e l y one fifth o f the 1981 census population aged 014 to each o f five quintiles.
May/June 1990
A n n u a l incidence rates were calculated by dividing the
number of events (deaths or injuries) by the person-years of
exposure, which was taken as the mid-year census population
multiplied by the number of years of observation (one in the
case of deaths in urban Canada and injuries in Montreal, and
five in the case of deaths in Montreal).
For the annual incidence rates. 95 e ? confidence intervals
(CIs) were calculated.' 2 Tests were performed for the
significance of the difference between the rates in quintiles 5
and 1. and for the difference between quintile 5 and all other
quintiles together. 12
T o compare the relative rates among quintile*. between
sexes and across the studies, an index of relative rates ua<
calculated as 100 times the rate in a particular quintile dis idei
by the rate in all quintiles together.
RESULTS
Table I shows population size and income characteristics of
the quintiles as defined for each of the three studies. For the
urban Canada deaths study, the lowest quintile of census
tracts included about 109c of all children aged 0-14 years,
while each quintile for the M o n t r e a l deaths and injuries
studies included approximately 20% of all children in that age
range. M e d i a n household income for the quintiles of the
urban Canada deaths study varied f r o m S14.209 to $33.147.
The rate of poverty among children in each quintile varied
from
to 50% in the M o n t r e a l injury study ( based on census
tracts), and f r o m I 1% to 43% in the M o n t r e a l deaths study
(based on larger and relatively less homogeneous C L S C
districts).
Table I I presents the findings of the three studies of socioeconomic disparities in pediatric traffic accidents. Figure I
shows the index by income quintile and sex for each of the
three studies.
In urban Canada as a whole, the gradient of rates was
nearly continuous for boys but no clear trend was evident for
quintiles 1-4 in girls. The index was 160 for poor boys and 239
for poor girls. The difference in death rates between quintiles 1
and 5 was statistically significant for both sexes together but.
due to the small number of events, not for boys and gir
separately..
205
TABLE II
Motor vehicle accident deaths or injuries to pedestrians and cyclists aged 0-14 years,
by income quintile of area of residence. Montreal and urban Canada. 1981
Study
Quintile •
Males
Q l (rich)
Q2
Q3
Q4
Q5 (poor)
Total
Females
Q l (rich)
Q2
Q3
Q4
Q5 (poor)
Total .
Total
Q l (rich)
Q2
Q3
Q4
Q5 (poor)
Total
Injuries. Montreal. 19X1
Deaths. Montreal. 1979-19X3
Deaths, urban Canada. 1981
73 .
107
134
164
261
234(185-296)
149 (288-424)
446(375-530)
546 (467-638)
850(751-961)
48
7"»
• 92
113
l"6
152.650
739
484 (450-521 )
100
93
61
83
94
169
29.635
28.980
29.030
28.885
29,355
29
51
68
95
151
98 167-143)
176(132-233)
234(183-299)
329(268-404)
514(437-605)
36
65
87
122
190
2.6 (1.7-4.0)
100
145.885
394
270(244-298)
100
(2.6-7.6)
(1.5-5.3)
(1.7-5.8)
(1.5-5.8)
(3.6-8.9)
116
75
83
79
148
60.865
59.620
59,085
58.910
60.055
102
158
202
259
412
168 (138-204)
265 (226-311)
342 (297-393)
440 (389-497)
686(622-756)
44
70
90
116
181
3.9 (3.0-4.9)
100
298.535
1.133
380(358-402)
100
11
x
X •
6
13
6.4(3.4-11.8)
4.1 (1.9-8.5)
4.2 (1.9-8.6)
3.6 (1.5-8.2)
7.0 f 3.9-12.3)
127
82
S3
71
138
31.230
30.640
30.055
30.055
30.700
IK2.239
46
5.0 (3.7-6.8)
100
60
III
71
83
239
32.522
37.290
36.410
32.065
35.880
4
}
4
4
8
2.5 (0.8-6.8)
1.6 (0.4-5.1)
T "> (0.7-6.0)
(0.8-6.9)
2.5
4.5 (2? 1-9.2)
2.2 (1.5-3.1)
100
174.167
23
II
23
25
14
19
1.7
3.0
3.7
3.1
6.0
(0.9-3.2)
(1.9-4.6)
(2.5-5.6)
(1.7-5.3)
(3.7-9.6)
54
92
115
95
186
66.911
76.040
74.665
65.685
73.105
15
11
12
10
21
4.5
2.9
3.2
3.0
5.7
'92
3.2 (2.6-4.0)
100
356.406
69
323.459
394.860
344.700
234J20
162.310
7
14
20
10
II
2.2 (0.9-4.7)
3.5 (2.0-6.1)
5.8 (3.6-9.1)
4.3 (2.2-8.1)
6.8(3.6-12.5)
51
S3
137
101
160
34.3X9
38.750
38.255
33.620
37.225
1.459.485
62
4.2 (3.3-5.5)
100
307.380
374.615
327.400
223.230
154.620
4
9
5
4
8
1.3 (0.4-3.6)
2.4 (1.2-4.7)
1.5 (0.6-3.8)
1.8 (0.6-4.9)
5.2(2.4-10.6)
1.387.245
30
630.875
769.457
672.100
457.350
316.930
2.846.730
Rate (951 C.l.) Index
Rate (95'V C.l.) Index Population Events
Rate (950' C.l.) Index 1 'opulaiion Fu-nts
Population Events
Note: I C D - 9 codes E 8 I 3 - E 8 I 4 for deaths. Average a n n u a l rales per 100.000 population. Quintiles tor u r h a n Canada deaths based o n median household income i n census tract ol
residence. Quintiles for M o n t r e a l deaths based on rate o f poverty among children aged 0-17 \ears in C L S C o l residence. Quintiles tor M o n t r e a l injuries based on rate o l
poverty a m o n g c h i l d r e n aged 0-17 years in census tract o f residence. Injuries reported to police or resulting in hospital admission or outpatient emergency care.
TABLE III
Motor vehicle accident injuries to pedestrians and cyclists aged 0-17 years, by income
quintile of census tract of residence, by type of accident. Island of Montreal, 1981
Events
Rate (951 C.l.)
Index
Events
Rate ( 9 5 1 C.l.)
Index
31.230
30.640
30.055
30.055
30.700
43
77
90
130
213
138 (101-187)
251 (200-316)
299(242-370)
433 (363-516)
694 (605-795)
38
69
83
120
192
30
30
44
34
48
96 (66-139)
98 (67-142)
146(108-198)
113 (80-160)
156(117-209)
• 79
80
120
93
128
152.650
553
362(333-394)
100
186
122(105-141)
100
29.635
28.980
29.030
28.885
29.355
20
45
59
85
145
67 (42-106)
155(115-210)
203 (156-264)
294 (237-366)
494(418-583)
28
64
84
121
204
9
6
9
10
6"
30
21
31
35
20
(15-60)
(8-48)
(15-61)
(18-66)
(8-47)
111
76
113
126
75
145.885
354
24.1(218-270)
100
40
27
(20-38)
100
60.865
59.620
59.085
58.910
60.055
63
122
149
215
358
104 (80-133)
205(171-245).
252(214-297)
365 (319-418)
596(537-662)
34
67
83
120
196
39
36
53
64 ( 46-89)
60 (43-85)
90 (68*118)
75 (55-101)
90 (68-118)
85 '
80
118
99
119'
298.535
907
304(285-324)
76
100
Population
Males
Q l (rich)
Q2
Q3
Q4
Q5 (poor)
•Total
Females
Q l (rich)
Q2
Q3
Q4
Q5 (poor)
Total
Total
Q l (rich)
Q2
QJ
Q4
Cyclists
Pedestrians
Study
Quintile
.
Q5 (poor)
Total
. 100
44
54
226
(66-86)
Note: Injuries reported to police or resulting in hospital admission or outpatient emergency care, Income quintiles based on raie of poverty among children aged 0-17in census iraci
of residence. Rates per 100.000 population.
F o r deaths t o c h i l d pedestrians a n d bicyclists in M o n t r e a l ,
the pattern o f i n e q u a l i t y d i d not f o l l o w a consistent pattern
across
the
income
quintiles.
nor
were
statistically s i g n i f i c a n t , b u t t h e rates f o r
consistently
206
highest
in
the
poorest
most
income
differences
b o t h sexes
quintile.
were
The
difference
i n d e a t h rates b y q u i n t i l e
was not
statistically
s i g n i f i c a n t f o r e i t h e r b o y s o r g i r l s , o r f o r b o t h sexes t o g e t h e r .
For injuries in M o n t r e a l , the pattern of
inequality
in the annual
incidence
rates
socio-economic
by quintile
was
p r o n o u n c e d a n d c o n t i n u o u s . T h e rate o f i n j u r y t o c h i l d r e n
Vol.81,May/June
/ y
Deaths, Urban Canada. 1 9 8 1
Injuries, Pedestrians, Montreal, 1981
Cyclists
150
100
50
0
•///'///Y//'/,
''//jV/A'/s/m
1
2 3 4
5
1
2 3 4
5
1
2
3 4 5
Income Quintile
Figure 2.
Index
of
relative
rates o f
injury
in
traffic
accidents, s h o w i n g pedestrians and bicyclists separately,
c h i l d r e n aged 0 - 1 4 , ' M o n t r e a l . 1981.
DISCUSSION
Evidence from the three Canadian studies
1 2
3
4 5
1
2
3 4 5
1
2
3 J
T h e lack o f statistical significance in m a n y categories in t
5
differences between death rates by income q u i n t i l e is not
Income Quintile
Figure I.
surprising, given the small n u m b e r o f deaths. T h e death rates
I n d e x o f relative rates o f death and i n j u r y in
by q u i n i i l e d i d n o t . in most cases, f o l l o w the same regular
t r a f f i c accidents a m o n g pedestrians and bicyclists aged 0-
progression f r o m low t o high as d i d the injuries in M o n t r e a l ,
14. by income q u i n t i l e o f area o f residence. M o n t r e a l and
but the pattern o f death rates w o u l d have, been strongly
u r b a n C a n a d a . 1981.
affected by a change in the occurrence or classification o f only
a few deaths. M o r e o v e r , differences in the way in w h i c h the
l i v i n g in the poorest n e i g h b o u r h o o d s was slightly m o r e t h a n 4
limes t h a t o f c h i l d r e n in the least p o o r n e i g h b o u r h o o d s (686
vs.
168, 100.000).
The
rates
increased
consistently
with
p o v e r t y . F o r b o t h boys a n d girls, the difference in the rates o f
i n j u r y by q u i n t i l e was statistically significant (at the 95%
confidence level) i n all cases.
T h e rate r a t i o c o m p a r i n g the poorest q u i n t i l e to all other
quintiles was 2.0 f o r deaths in u r b a n C a n a d a , 1.7 f o r deaths in
M o n t r e a l , and 2.3 f o r injuries in M o n t r e a l . I n all three studies,
the rate r a t i o c o m p a r i n g the poorest q u i n t i l e to the least p o o r
was greater f o r girls t h a n f o r boys.
T a b l e I I I and Figure 2 present the findings f o r injuries in
M o n t r e a l s h o w i n g accidents t o pedestrians separately f r o m
accidents t o bicyclists. F o r pedestrians, the i n j u r y raies were
nearly 6 times higher (596 vs. 104/100,000) in the poorest t h a n
in the least p o o r n e i g h b o u r h o o d s . These differences were
statistically significant at the 9 5 % confidence level and again
were greater in girls t h a n in boys. F o r bicyclists, however,
there was no consistent trend.
May/June 1990
quintiles were defined in each study might have had some
effect o n the patterns. Nevertheless, the findings for deaths
were consistent w i t h those for injuries in i h a i the poorest
q u i n t i l e always showed the highest death rates for boys and
girls in b o t h M o n t r e a l a n d u r b a n Canada.
W h y was a steep n e i g h b o u r h o o d income q u i n t i l e gradient
in c h i l d h o o d t r a f f i c injuries apparent for pedestrians, but not
for bicyclists? Injuries and deaths were always tabulated o n
the basis o f place of residence rather t h a n place o f occurrence,
but the risk o f i n j u r y and death w o u l d have been substantially
related t o the c o n d i t i o n s prevailing in the n e i g h b o u r h o o d
where exposure actually occurred. It is likely that y o u n g
bicyclists were more apt t o be exposed t o risk outside of their
o w n n e i g h b o u r h o o d or local area, whereas y o u n g pedestrians
were m o r e likely t o be exposed near home, a l t h o u g h some
recent studies based o n pediatric emergency r o o m case series
dispute this p o i n t . 1 1 Vehicle occupants w o u l d be even m o r e
likely t o be exposed l o risk at a greater distance f r o m h o r
and data f r o m o u r studies ( n o t s h o w n here) c o n f i r m that th<
207
or
result o f this deleterious c o m b i n a t i o n are M V T A i n j u r y and
injuries t o c h i l d vehicle occupants in M o n t r e a l or all o f u r b a n
death rates in poorer c h i l d r e n that are 2-6 times those for the
Canada. T h i s p a r t i c u l a r f i n d i n g suggests a relatively greater
more affluent.
was v i r t u a l l y
no socio-economic
gradient
l o r deaths
the
This f i n d i n g appears to be true for b o t h deaths and injuries,
n e i g h b o u r h o o d o f residence (unsafe streets, lax enforcement
and is robust to the differences in methods and spectrum of
o f speed limits, lack o f parks or other safe places to play) as
geographic settings of the three studies examined. It appears
opposed
risk-taking
that u r b a n physical and social environments fail to provide an
behaviours o f the c h i l d r e n or their parents. O n the other hand,
adequate level o f p r o t e c t i o n to the c h i l d r e n o f disadvantaged
importance
to
of
the
the
environmental
personal
characteristics
characteristics
or
of
the lack o f social class gradient in the rates o f i n j u r y or death
families. Subsequent research in this exceptionally vulnerable
to c h i l d vehicle occupants m i g h t also be related in part to
s u b - g r o u p should acknowledge this web of causation, so that
lower vehicle o w n e r s h i p o r usage a m o n g the parents of poor
preventive strategies can take account o f the multifaceted
children. S i m i l a r l y , a d i f f e r e n t i a l rate o f bicycle ownership by
human
income has been suggested by some.
children,
and
physical antecedents
A n analysis o f the M o n t r e a l i n j u r y data by 5-year age g r o u p
o f traffic
accidents
to
APPENDIX I
showed that the relative risks for c h i l d r e n aged 0-4 (most
F o r the u r b a n C a n a d a study, deaths o c c u r r i n g to residents
frequently under the direct responsibility o f their parents) was
m u c h less t h a n that for c h i l d r e n aged 5-14 ( m o r e frequently
of
not under the direct supervision of their parents). I n o u r
manually assigned to a census tract based o n the f u l l home
o p i n i o n , this and the other evidence presented here does not
address o f the v i c t i m , using a variety o f geographic reference
support
materials."
the
"inadequate
parenting"
hypothesis
as
an
e x p l a n a t i o n o f socio-economic inequalities in deaths and
Canada's
23 largest
census
metropolitan
areas
were
Deaths in the M o n t r e a l m o r t a l i t y study were assigned to
injuries t o c h i l d pedestrians and bicyclists.
local c o m m u n i t y health and social service districts ( C L S C s )
Evidence from other studies
death certificate. F o r the d e f i n i t i o n of each service district in
based o n the postal code and m u n i c i p a l i t y reported o n the
N u m e r o u s earlier studies have s h o w n various measures o f
terms o f postal codes and municipalities, see Wilkins. 2 5
social class t o be correlated w i t h the occurrence of injuries as a
F o r the M o n t r e a l injuries study, place o f residence of
w h o l e ; deaths due t o accidents, p o i s o n i n g or violence: and.
accident victims was collected using the f u l l m a i l i n g address.
m o r e recently, t o M V T A injuries and deaths. 7 , U J 5
17
I n a separate clerical o p e r a t i o n , w h e n necessary, the six-digit
These observations, like ours, may be related t o a c o m p l e x
postal code c o r r e s p o n d i n g to each home address was f o u n d ,
i n t e r a c t i o n o f characteristics o f lower class families and the
based o n the C a n a d a Postal Code D i r e c t o r y o f address
levels o f risk inherent to the n e i g h b o u r h o o d s in w h i c h they
ranges. Statistics Canada's Postal Code C o n v e r s i o n File 26
live. F o r e x a m p l e , c h i l d r e n in p o o r families may experience
increased stress.
was then used t o determine the census tract c o r r e s p o n d i n g to
each postal code. A few recently added postal codes not
1819 20
A child's insecurity and anxiety are increased by f a m i l y
disturbance a n d accidents are m o r e frequent a m o n g such
present in the C o n v e r s i o n File were m a n u a l l y a t t r i b u t e d to a
census tract, based o n m a p location o f the address.
c h i l d r e n . - C h i l d r e n i n single parent families are m o r e likely to
A P P E N D I X II
have accidental injuries in the first 5 years of life t h a n c h i l d r e n
l i v i n g w i t h t w o parents. 2 3
C h i l d r e n were classified as p o o r or n o n - p o o r according to
an
the income o f their families. Families l i v i n g in poverty were
i m p o r t a n t role. R i v a r a a n d Barber's recent study o f c h i l d h o o d
those whose t o t a l income in the year preceding the census was
Neighbourhood
characteristics
also
clearly
play
pedestrian injuries f o u n d t h a t a n u m b e r o f indices related to
below the Statistics C a n a d a l o w - i n c o m e c u t - o f f for
lower social class — race, household income, female head o f
relevant f a m i l v size. T h e 1980 low income cut-offs were as
household, c r o w d i n g and, i n p a r t i c u l a r , housing density
follows:
were all h i g h l y related t o the occurrence o f i n j u r y . F u r t h e r , i he
$20.375. respectively, for families o f 2. 3 . 4 . 5 . 6 and 7 or more
action o f the d r i v e r was j u d g e d t o be partly responsible tor the
persons. 27
7
$9.436. S12.622. SI4.545.
SI6.949,
518.511
the
and
event in at least 219- o f cases. Baker et al 24 f o u n d that 4 6 ' ; ol
drivers were j u d g e d t o have been negligent and 5 8 0 o f these
Acknowledgements
had p r i o r dangerous d r i v i n g records.
I he three >tudies on vihich this paper is based were funded in pari bv the Minister»: de
et des Services S o c i a u * d u Québec (Quebec Ministrv o f Health and Social
Seruce-i. the Conseil de la Santé ei des Service-» Sociaux du M o n t r é a l - M é t r o p o l i t a i n
i M o n t r e a l Regional C o u n c i l ol Health and Social Services», the \ j u o n a l Health
Research Development Program «Health and Wellare Canada), and the McCïillM o n t r e u l C h i l d r e n ' " Hospital Research Institute.
CONCLUSION
These results, together w i t h those o f others suggest t h a i
l.i Sjihc
poorer c h i l d r e n , f o r various reasons, are m o r e likely to be
exposed t o risks o f i n j u r y , b o t h " s e l f - i m p o s e d " (stress-related
r i s k - t a k i n g behaviour) a n d " e x t e r n a l l y i m p o s e d " ( l i v i n g in
substantially m o r e dangerous u r b a n environments). The net
208
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I. IMesslB. Morbidity and mortality among the young.In: Hoekelnian RA.
ed. Primary Pediatric Care. St. Louis: CV Mo>by. 198". pp. 20-7.
Vol.81,May/June
2. Rivara FP. Epidemiology of childhood injuries. I. Review of current
research and presentation of conceptual framework. Am J Dis Child
1082: 136: 399-405.
3. Guver B. Gallagher SS. An approach to the epidemiology of childhood
injuries. Pediair Clin Sorth Am 1985; 32: 5-15.
4. Gustation LH. Childhood accidents. ScandJ Soc Med 1977; 5: 5-13.
5. Suchman EA. A conceptual analysis of the accident phenomenon. In:
Behavioral Approaches to Accident Research. New York: Association
tor the Aid ol Crippled Children. 1961. pp. 26-47.
6. Haddon W. Energv damage and the ten countermeasure strategies. J
Trauma 1973; 13: 321-31.
7. Rivara FP. Barber M. Demographic analvsis of childhood pedestrian
injuries. Pediatrics 1985: 76: 375-81.
8. Doughert\ G. Socioeconomic differences in pediatric mortality in urban
Canada 1981. Research Report Series. Ottawa: Health and Welfare
Canada. 1988. (in press).
9. Wilkins R. Dossier décès: compilations par CLSC et DSC. Région 6A
(Montréal-métropolitain. 1979-1983). Montréal: Department of
Community Health. Montreal General Hospital. 1988 (in press).
10. Pless IB. Verreault R. Arsenault L. et al. The epidemiology of road
accidents in childhood. Am J Public Health 1987; 77: 358-60.'
11. Statistics Canada. Census Tract Profile Series A. 1981 Census of Canada
(catalogue 95-918). Ottawa: Minister of Supplv and Services Canada.
1982.
12. Fleiss JL. Statistical Methods for Rates and Proportions. 2nd ed. New
York: Wiley and Sons. 1981.
13. Selbsl SM. Alexander D. Ruddv R. Bicvcle-related injuries. Am J Dis
Child 1987: 141: 140-4.
14. Macfarlane A. Fox J. Child deaths from accidents and violence.
Population Trends 1978: 12: 22-7.
15. Iskrant AP. Joliet PV. Accidents and Homicide. Cambridge: Harvard
l'ni\ersil\ Press. 1968.
16. Baker SP*. O'Neill B. Karpf RS. eds. The Injury Fact Book. Lexington:
Lexington Books. 1984: pp. 206-7.
17. Barancik J I. Chatterjee BF. Greene YC.et al. Northeastern Ohio trauma
studv: I. Magnitude of the problem. Am J Public Health 1983:73:74651.
18. Husband P. Hinton PE. Families of children with repeated accidents.
Arch Dis Child 1972: 47; 396-400.
19. Padilla ER. Rohsenow DJ. Bergman AB. Predicting accident trequencv
in children. Pediatrics 1976: 58: 223-6.
20. Brown GW. Davidson S. Social class, psychiatric disorder of mother,
and accidents to children. Lancet 1978: I: 378-80.
21. Marcus I M . WilM>n W. Kraft I. et al. An interdisciplinary approach to
accident patterns in children. Monogr Soc Res Child Dev I960: 25: 3-79.
22. Manheimer Dl. Mellinger GD. Personalis characteristics of the child
accident repealer. Child Dev 1967: 38: 491-513.
23. Bijur PE. Stewart-Brown S. Butler N. Child behavior and accidental
injurv in II.966 preschool children. Am J Dis Child 1986: 140: 487-92.
24. Baker SP. Robertson LS, O'Neill B. Fatal pedestrian collisions • driver
negligence. Am J Public Health 1974: 64: 318-25.
25. Wilkins R. Dossier population: Compilations du recensement de 1981
par CLSC et DSC. Région 6A (Montréal-métropolitain). Montreal:
Regroupement des départements de santé communautaire du Montréalmétropolitain ( R D S C M M ) . septembre 1987.
26. Statistics Canada. User's Guide for the Canada Conversion File
(revised). Small Area Data Programme. Ottawa: Statistics Canada.
1986.
27. Statistics Canada. Economic families in private households: income and
selected characteristics, (catalogue 92-937). Ottawa: Minister of Supplv
and Services Canada. 1984. Table A. p. xxv.
28. Race KEH. Evaluatingpedestriansafetyeducalionmaterialsforchildren
ages five to nine. 1988: 58(7): 277-8.
29 Guver B. Talbot A M . Pless IB. Pedestrian injuries to children and vouih
Pediair Clin Sorth Am 1985: 32: 163-75.
30. Organization for economic cooperation and development: traffic salet>
of children. Report prepared by an OECD scientific expert group. Paris.
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1982: 14: 315-22.
Received: August 12. 1988
Accepted: November 25. 1988
May/June 1990 1606
Ann. Rev. Public Health. 1988. 9.-99-/2/
Copyright © 1988 by Annual Reviews lite. All rights reserved
ALCOHOL AND RESIDENTIAL,
RECREATIONAL, AND
OCCUPATIONAL INJURIES: A Review
of the Epidemiologic Evidence
Gordon S. Smith
The Injury Prevention Center, John's Hopkins School of Hygiene and Public Health,
6IS North Wolfe Street, Baltimore, Maryland 21205
Jess F. Kraus
Division of Epidemiology, School of Public Health, University of California, Los
Angeles, California 90024
INTRODUCTION
The association of alcohol with injuries has been known since some of the
earliest recorded history. On one ancient Egyptian papyrus the following
remarks about the role of alcohol and injuries appeared (71):
Make not thyself helpless in drinking in the beer shop. For will not the words of thy report
repeated slip out from thy mouth without thy knowing thai thou hast ottered them? Falliog
down thy limbs will be broken, and no one will give thee a hand to help thee up.
While both ancient historical and present day literature strongly associate
alcohol and injuries, the exact role of alcohol in the causation of injuries is
often unclear. Many popular myths surround the use o f intoxicating agents.
For example, at the turn of the century, alcohol was widely praised for its
ability to provide the needed stimulation for long and arduous work (16).
Even today alcohol is commonly associated with providing the stimulation for
work, and when friends are asked over to help paint the house or to a "moving
99
0163-7525/88/0510-0099S02.00
-S3
lOu
ALCOHOL AND
SMITH & KRAUS
party/' alcohol is commonly provided, both as a reward to friends for their
hard work and to "stimulate the work." It is only recently that breweries have
begun to halt the practice of providing free beer to employees for consumption
on the premises during working hours (L. Wallack, personal communication).
These brief examples illustrate the common confusion and misinformation
surrounding the use of alcohol, especially its role in association with injuries.
Many hundreds o f articles* commentaries, and reports are published annually in the literature on the role of alcohol in human injury occurrence.
Almost all are devoted to the hazards associated with motor vehicle use, and
to a lesser extent, with suicide, homicide, and domestic violence (29, 30, 48,
49, 76). The role of alcohol involvement in other exposures is largely
overlooked. However, the ingestion of alcohol prior to or during other human
activities is widespread and suggests that injuries associated with those activities may be related also to alcohol. To date most prevention efforts directed at
alcohol-related injuries have devoted their attention to drunk driving (62, 73).
It is commonly believed that if we can just keep people out of automobiles,
o f f the streets, and let them drink in the safety of their own home, they w i l l be
less of a danger to themselves and others.
In this paper we review the role of alcohol in residential, recreational, and
occupational settings, and suggest why these situations present very different
environments in which to control alcohol-related injuries. We specifically
exclude motor vehicle injuries, except for those involving some off-road
vehicles used in recreational activities, and all intentional injuries (homicide,
suicide, domestic violence, etc). We include a discussion of most domestic,
occupational, recreational, water, and air transport injuries, except when the
vehicles involved are used for commercial purposes. Recreational injuries
include those occurring during leisure time activities, hobbies, organized or
unorganized individual or group sports and athletics. Although we do not
discuss injuries associated with motor vehicles and violence in detail in this
paper, some reference to them w i l l be necessary, since such injuries feature
some of the same principles as those which apply to home and occupational
injuries, and they have been the subject of considerably more research.
METHODS AND MATERIALS
This review summarizes the relevant English language literature on the
subject o f alcohol and nonvehicular injuries published since 1960. Articles in
peer-reviewed journals or government reports (when available) were examined. The information selected was restricted to reports from North Americân and European countries and from Australia. Information from previously
published review articles was generally not included unless original data were
cited in that review.
101
Scientific information on alcohol as it relates to many specific types of
activities could not be located and simply may not exist or is so obscure that it
could not be located in two leading university libraries or through a search of
M E D L I N E (National Library of Medicine) and the Clearinghouse for Alcohol
Information (National Institute on Alcohol Abuse and Alcoholism). If information on other specific activities was identified during the literature
search but the original article could not be located or an English translation
could not be found, this fact was so stated. This review summarizes certain
relevant findings, including a brief description of the study population, the
results found, and the authors' opinions on méthodologie concerns that should
be considered when assessing the results from the paper.
In order to achieve comparability in blood alcohol concentrations (BAC)
between studies, all values have been converted to the international standard
o f milligrams of alcohol per deciliter (100 ml) of blood (mg/dl). Levels of
B A C above 50 mg/dl have been shown to significantly impair performance,
and levels above 100 mg/dl (0.1%) exceed the legal limit to drive an automobile in most states. No comparable "legal limits" exist outside the transportation area.
FINDINGS
Alcohol and Injury Risk
Alcohol has a recognized association with all types of injuries, espécially the
more severe and fatal ones. A review of mortality studies of men who were
alcohol-dependent ("alcoholics") or heavy drinkers found that their overall
risk of death due to "accidental" causes ranged from 2.5 to 8 compared to men
in the general population (58). Another study found alcoholics to have a
relative risk o f dying from falls of 16, a relative risk of 10 for bums and fires,
4.5 to 5 for motor vehicle accidents, and 2 to 3 for industrial "accidents," as
compared to thé general population (15).
As is true with other alcohol-related diseases (e.g. cirrtiosis), there is a
dose-response relationship; that is, as alcohol consumption increases so do
both the risk and the severity of disease or injury. While these findings appear
to have been substantiated for motor vehicle injuries (9, 15a, 22, 28, 39), it is
unknown whether the same relationships hold for other injuries. Teenagers
and the elderly appear to be more susceptible to the effects of even moderate
amounts o f alcohol (27, 83). It has been suggested that even low BACs may
significantly contribute to death from drowning and may even be associated
with some "as yet undetermined" physiological response potentiated by alcohol (55). More research is needed into the role of low and moderate levels of
alcohol and its risks in nonmotor vehicle situations, especially in adolescents
and elderly people.
ALCOHOL AND INJURIES
109
102 . SMITH & KRAUS
Residential
Injuries
Residential injuries (those occurring in the home or surrounding environment)
cause more than one fifth of all unintentional trauma deaths and approximately one third of all disabling injuries. It is estimated that in 1982 some 25
million injuries. 3.2 million of which are disabling, and about 21,000 deaths
occur annually in the residential environment (51 ). These injuries are responsible for more than $10 billion in wage loss, medical and health insurance
expenses, and fire loss ( 5 i ) . About 6400 of residential deaths are from falls,
4100 from burns and fires, 3100 due to poisoning. 2300 from suffocation,
1100 from unintentional firearm injuries, and a further 4000 from other causes
such as drowning, being struck by falling objects, and electrocution.
The limited available studies suggest that alcohol is a significant factor in
unintentional residential injuries. Although huge gaps exist in our knowledge
of residential injuries, there is reasonable evidence in even early studies to
suggest that alcohol may be a strong contributing factor in their causation. A
study of 108 deaths in Sacramento, California from 1965 through 1967 found
alcohol was present in about half of the residential injury fatalities in persons
aged 15 or older (77, 78). BACs of 100 mg/dl or higher were found in 37% of
the 108 deaths, and detectable alcohol was found in the blood of 42% of the
injury fatalities. Only 18% of those who died from other causes had detectable
BACs. A significant finding was that most patients with positive BACs had
had an earlier diagnosis of, or at least one indication of, problem drinking.
A study by Wechsler et al (80) of 620 home-injured persons presenting to
an emergency room in Boston found 11% to have a BAC of 10-50 mg/dl and
a further 11 % to have a level 50 mg/dl or greater on testing with a breathalyzer. Detectable blood alcohol levels were found in only 9% of patients presenting for other reasons, with only 3% about 50 mg/100 dl. The relationship
remained significant even after adjusting for age, sex, and socioeconomic
status o f persons in each group. However, these were ill patients and may not
necessarily represent the status of well people at home. There was little
difference in the degree of involvement of alcohol by cause of residential
injury. Males injured at home were twice as likely to have positive blood
alcohols, with 32% o f males and only 15% of females having positive
breathalyzer tests. The only indicator of injury severity in the paper was head
injuries, in which 30% of people had alcohol involvement.
While it is assumed that the same relationship of increasing severity of
injury with increasing BAC seen in motor vehicle crashes can be applied to
home injuries, this relationship has not been well documented. There is a need
to implicate more clearly the role of alcohol in home injuries, and to select a
control group more representative of people in their home environment.
A limited amount of data are available on the role of alcohol and certain
specific injuries. For example, alcohol involvement has been hypothesized as
a major contributing factor in suffocation deaths, especially those due to
inhaled food particles (44), although the exact role of alcohol has not been
adequately studied. Injuries for which specific information is available are
falls, bums, poisoning, and hypothermia; these are discussed specifically in
the following sections.
HALLS Falls are the most common cause of home injury. They were
responsible for some 11,600 fatalities in the US in 1982, of which about half
occurred in the home. The rates are highest in the elderly, with 66% of fatal
home falls occurring in persons age 75 years or over. The number may be
even higher because of the underreporting of fall-related deaths in the elderly.
Brenner (8) found alcohol-dependent persons to be 16 times more likely than
the general population to die from a fall. Waller (77, 78) found that alcohol
was involved in seven out of ten fatalities from falls occurring within four
hours of injury. Limited data are available to suggest that the severity of
injury is related to BAC. Head injuries to pedestrians resulting from falls on
ice were frequently associated with alcohol, whereas other kinds of falls were
not (41). In a review of hospital emergency room records for 1975 in
Washington state. 10% of 1740 persons with Tall injuries had alcohol use
recorded in the emergency mom record, as did 22% of 7K fall "repeaters"
(persons who experienced and sought médical care for more than one injury
during Ihe one-year period) (2.M. Although this study had no control group
and relics entirely on mention of alcohol in the record (which is believed to be
grossly underTcporicd). il illustrates at least that alcohol was noted as a feature
in many falls. One sludy in emergency rooms where BAC was actually
measured found that alcohol was detected in 23% of persons treated for falls
(80).
Epidemiological studies yielding estimations of risk from alcohol and falls
are lacking. Typical of the problems of many studies is one by Haberman &
Baden (20). They reported that 41% of 54 fall victims had BACs of 100 mg/dl
or greater. However, BACs were only available in half the cases in the study,
with no information available on the others. Studies such as these illustrate the
need for further detailed research, including case-control studies, to further
delineate the role of alcohol in falls. One of the few controlled studies of
alcohol and falls is that done in Finland by Honkanen et al (24). They found
that 53% of 313 adults injured by falls in public places occurring between
3:00 and 11:00 P.M. had evidence of alcohol involvement. Only 15% of
control pedestrians matched for time, site, and sex had detectable BAC. The
study found a steadily increasing risk of injury with increasing BACs. Similar
studies have not been done concerning falls in the home.
BURNS AND HIRES A total of 6016 deaths from bums and fires were
reported in the Uniied States for 1980 (4), a figure that does not include the
estimated annual 500 due to arson or "suspicious circumstances" or the
I Oh .
ALCOHOL AND INJ
SMITH & KRAUS
post-crash fires in transportation crashes. An estimated 90,000 people are
admitted to hospital for treatment for bums each year, requiring over a million
days of hospitalization. The elderly and disabled persons are at highest risk.
Alcohol has been recognized as a major contributing factor in fire-related
deaths. A case-control study by Ducik & Ghezzo (13) of house fires found
that in the serious house fires group, the single most important variable was
the number of alcohol users residing in the affected building (more in households in which fire occurred). A study of adult bum victims admitted to
hospital found 61% of 83 patients had a positive BAC (34). Those persons
burned in nonindustrial settings had more frequent positive blood alcohol
levels and a higher mortality rate. A similar study by MacArthur & Moore
(37) found that 36% of hospitalized bum victims had been drinking. Attempts
to quantify the prevalence of alcohol involvement among victims in these
studies is precluded by the incomplete recording of such information in the
hospital record. One study found that in hospitalized bum victims, over 50%
of the charts showed no mention of either smoking or alcohol use (35).
The role o f alcohol in fatal bums has been studied more extensively.
However, there are problems in many of these studies in that data on blood
alcohol concentrations at the time of the fire are often not available, since
many victims die some time after the incident and blood alcohol tests were not
done on admission to the hospital. The bodies of fire victims are sometimes so
badly burned that determination of BAC is not possible. Of 55 fatalities from
house fires in Baltimore in a 14-month period from 1973-1974. blood alcohol
data were available on only 34 cases (35). Of these cases. 11 (32%) had BACs
over 150 mg/dl, but no mention is made of the time interval from the fire to
blood collection, although 42 of the 52 fatalities are known to have died
within the first 24 hours. Waller (77) found that 64% of 22 persons over 15
years of age who died in house fires had a BAC of over 100 mg/dl. Haberman
& Baden (20) found 40% of the 28 fire victims they studied in New York City
to have a B A C of 100 mg/dl or higher. A more recent study of 55 house fire
deaths in Baltimore found that of 35 persons aged 15 years or over on whom
B A C could be measured within 4 hours of the fire, 13 (39%) had a B A C of
100 mg/dl or higher (43). O f those who died in cigarette-related house fires,
11 (50%) had a B A C of 100 mg/dl or higher compared to only 2 of 11 ( 18%)
o f those who died in fires from other causes.
There is a strong relationship between alcohol and fires because of the
association between alcohol and smoking. The typical history of alcoholrelated fires is of the intoxicated smoker who falls asleep holding a burning
cigarette. The cigarette often falls unnoticed into bedding or furniture, which
may smolder for hours (40). People are either killed by the toxic fumes or by
smoke or flames when the house catches fire. Those intoxicated are less likely
to be roused by the smoke and will succumb to carbon monoxide or be less
able to escape the flames. Smoke alarms are known to be effective in alerting
>
105
people to the smoke, but their effectiveness at arousing intoxicated persons is
unknown. The most effective means of preventing fire related injuries in this
situation is through the use of self-extinguishing smoking materials, wider use
of flame-retardant bedding and upholstery, and heat-activated sprinkler systems (43).
POISONING AND HYPOTHERMIA Poisonings were responsible for a total of
10,942 deaths in 1980, of which 4331 were classified as unintentional (4). A
total of 385 deaths due to acute alcohol poisoning was reported in 1980, with
a peak at age 50. The acute alcohol poisoning rate for males is about three
times that for females, with blacks and native Americans having the highest
rates. Southern states such as North Carolina have alcohol-poisoning rates ten
times the national average, and rates are highest in low-income areas (4).
Acute alcohol poisoning is also a significant cause of hospitalization, with
admission rates among Maryland teenagers being twice as high among whites
than among blacks (70). The problem of acute alcohol poisoning is poorly
understood and deserves further attention.
Poisoning by other means both intentional and unintentional is often associated with alcohol use. For example, alcohol intoxication has been associated
with carbon monoxide poisoning from motor vehicle exhaust (3). Alcohol can
also potentiate the systemic effects of many drugs, thus contributing to an
overdose death. For example, the interaction of alcohol and opiates may
significantly contribute to heroin overdose deaths (63. 66).
Alcoholism and alcohol also greatly increase the risk of both exposurerelated hypothermia and frostbite ( 14. 26. Kl ). A study of 63 exposure-related
hypothermia deaths in the District of Columbia found detectable blood alcohol levels in 69% of victims, with 48% above 150 mg/dl, a level that
significantly interferes with normal thermoregulation (36). Deaths among the
homeless are likely to be highly correlated with alcohol, and hypothermia
deaths are likely to increase with the current acceleration in the problem of
homelessness.
Recreational
Injuries
DROWNING Almost all reports that specify B A C in persons who have
drowned fail to indicate the nature of the aquatic activity involved. Papers that
deal with persons who drowned during occupational activities (e.g. seamen)
are discussed below under occupational injuries. It should be noted that
reports that failed to indicate the activity involved could include persons not
engaged in recreational or leisure time activities. By and large, persons who
drown include those who were swimming, fishing, boating, or engaged in
other related activities. A summary of the features of the reports discussed is
shown in Table I.
i
;
SMITH & KRAUS
Table I
Selected features of reports on drowning and alcohol
Authorts)
(references)
Date of Persons tested/
report persons eligible
Percentage
positive
BAC
Remarks
Metropolitan
Life Ins. Co. (42)
1968
16/?
20
Includes persons drowned at
home, age 15-24
Press ai al (59)
1968
828/1201
18
Findings based on coroners'
data plus history of ingestion
for cases in 5 states,
1965-66. BAC levels not
reported.
Waller (77)
1972
17/?.
30
Persons BAC tested less than 6
hr. Cases 1965-1967.
Sacramento County aged 15
yrs + . BAC > 0 mg/% =
positive.
Dict7. and Baker ( I I )
1974
45/?
47
BACs not reported in drownigs
s 12 hr post event,
1968-1972. Maryland BAC
s 0.03% - positive
Haberman & Baden
(20)
1978
19
53
Cases in New York City.
1974-1975. BAC s*. 10%
equals positive lest.
.Berkelman cl al (6)
1985
13
77
Fulton County. Georgia eases
24-64 yr age. BAC 5s
0.01% equals positive.
1981-1982 cases.
Alha el al < la)
(Finland)
1970
156/511
83
1967 cases.
Gicnscn (19)
(Norway)
1970
86/350
20
Annual estimate of cases, all
ages. % positive BAC based
on 86 of 350 cases.
Plucckhahn (57)
1972
22/45
36
Plueckhahn (56)
1975
56/79
66
Drownings in Geelong Dist..
Australia. Persons one
age= 15, 1967-1971,
1959-1974. BAC > 0 gm/100
ml = positive.
One o f the earliest US reports on alcohol use and drowning was published
by the Metropolitan Life Insurance Company in 1968 (42). This brief report,
covering 16 drownings, showed positive BACs in 20% of the cases (Table I)
(42). Those tested were persons aged 15-64 years and, as implied, the limited
findings pertain to persons insured by this insurance company. BAC levels
were not specified.
107
Press and associates in 1968 reported on 1,201 drownings in a 12-month
period ending June 30, 1966 in Colorado, Florida, Illinois, New York, and
North Carolina (59). Alcohol exposure was determined by history, and no
B A C data were reported. History of alcohol ingestion was positive for 149 of
828 cases (18%). Activities included swimming, boating, fishing, diving, and
related activities, but analyses by type of exposure and alcohol use were not
reported. Reported findings on alcohol use in the absence of blood analysis
must be suspect.
In a 1972 report using coroner's cases, Waller (77) found that 30% of 17
drowning victims in Sacramento County. California during 1965-1977 had
measurable blood alcohol levels; 24% had a BAC of greater than 99 mg/dl.
Alcohol use by type o f water activity was not reported.
Haberman & Baden (20) reported on the BACs of 19 persons who drowned
in New York City in 1974 or 1975. Fifty percent of these cases had a B A C of
100 mg/dl or higher. The type of exposure (e.g. boating) was not reported.
Dietz & Baker ( I I ) reviewed coroner's data on all drownings in the state of
Maryland during 1972. Forty-five cases, 15 years of age or older, who had
blood tests for alcohol, were selected for study. Cases involving submersion
while an occupant in a land vehicle, or where the person was submerged for
12 or more hours, were excluded. Forty-seven percent of the group had a
positive B A C ranging from 30 to 260 mg/dl. There was no difference in
gender or race in the proportion with or without a positive alcohol determination. Data on age were available, hut the numbers were too small for
meaningful analysis. Alcohol was not involved in any drowning that occurred
before noon. Two persons who drowned in a bathtub had evidence of alcohol,
and alcohol was involved in 11 of 14 swimming deaths. Six drownings were
from occupational exposures; one had a positive BAC. Five drownings
occurred from exposure to flood waters; three of these persons had positive
BACs.
Drownings in Fulton County, Georgia (which includes the city of Atlanta),
reported to the medical examiner's office during 1981 and 1982, were studied
by Berkelman and colleagues (6). A toxic screen of blood was performed on
all persons over 14 years o f age when the specimen had been obtained within
six hours of death. O f 19 cases, nine (69%) showed positive BACs of
100
mg/dl. It was noteworthy that none of the six who were aged 15-24 years had
evidence of alcohol ingestion. Specifics of the aquatic exposures were not
reported.
Plueckhahn (57) reported on BACs in a group of 14 persons who drowned
while swimming in the Geelong district of Victoria, Australia during 19671971. Six (43%) o f the 14 cases over age 14 had a positive BAC and five of
these had a blood alcohol level of 150 mg/dl or higher. Twelve of the 14 cases
were males; none o f the females had been drinking. The author speculated
that intoxication with immersion could contribute to an acute laryngeal spasm
108
. SMITH & K R A U S
or a vasovagal reflex. Plueckhahn further cautions against swimming after
consuming more than one or two beers or after a heavy meal or heavy
exercise. The evidence for the warning was not given. Finally, Plueckhahn
notes the high frequency of cases over age 25 in his study series and warns
further that those over age 25 should take heed of his warning. The failure to
compare the cases with the population who swim, by age (or any other
factor), detracts from the value of his warning.
In a later report. Plueckhahn (56) provides data on BAC in 56 adults age 17
years and older who drowned in the Geelong district. 1959 to 1974. Forty-five
of these persons had drowned while swimming and 28 of these (62%) had a
positive blood alcohol test ( > l mg/dl); 42% had a BAC of 100 mg/dl or
higher. Details of the swimming exposures were not reported.
A report from Norway in 1970 (19) gives BAC or alcohol ingestion
information on 86 of the total estimated number of drownings in Norway for
1960-1964. plus cases from 1950-1959 and 1965-1968 in Bergen. The case
series included occupational and nonoccupational exposures. The positive
B A C was estimated at about 20% and over 40% of the positive cases had
BACs of more than 200 mg/dl.
The first reported incident of an alcohol-related skin-diving or scuba-diving
drowning involving alcohol is recorded by Webster (79) when he noted a case
who had drowned while diving and who "was known to have had a few
beers." No other reports could be located that included information on alcohol
use among persons who drowned during this water activity.
Plueckhahn (57) reported in 1972 on 37 drownings in Geelong, Australia
involving watercraft incidents. Only three of these persons had BAC determinations, two were positive. In a second report (56), Piueckhahn reported
on 11 persons, average age 16, who drowned while boating. Nine of the 11
had a positive B A C and seven of these had BACs more than 100 mg/dl.
Factors descriptive of the boating incidents were not reported.
In a report from Finland. Penttila et al (53) showed that about 30% of all
occupants of motorboats tested in a section of the Gulf of Finland during the
summer of 1978 had a positive breath test for alcohol. Among those with a
breath test, only 1% had a blood alcohol level in excess of the legal limit of
150 mg/dl for water traffic in Finland. Age-specific findings were not reported. The results were important, nonetheless, as they documented for the
first time the widespread use of alcohol in the motor-boating population.
Findings are important also in establishing standards against which to compare B A C levels in persons who drown while boating.
In a 1983 report (50) sponsored by the National Transportation Safety
Board, recreational boating safely and alcohol were extensively studied. This
report claimed that over 50 million persons participate in various recreational
boating activities on at least eight days per year, ln the five-year period
109
1978-1982, almost 28.000 boating accidents were reported by the US Coast
Guard. There were 6467 deaths and 11,994 injuries. O f these "accidents"
only 592 (2%) were events in which alcohol was involved and in which
fatalities resulted.
In a boating survey in 1976 (50), the US Coast Guard found that almost
40% of boating occupants claimed to carry alcoholic beverages on board. The
proportion of boats with drinking drivers was not determined. The US Coast
Guard report (50) cited other unpublished reports from North Carolina,
Maryland, California, and South Carolina in which alcohol was reported to be
involved in about two thirds to three fourths of related injuries and drownings.
A recent survey (50) by the National Transportation Safety Board has
shown that all but two states in the US have laws prohibiting the operation of
marine vessels while the driver is under the influence of alcohol. In only 11 of
the states with such laws are levels of "intoxication" by BAC defined.
SNOWMOBILING Although many fewer participants engage in snowmobiling than in skiing, more reports have documented the.hazards of alcohol use
in the former than in the latter. Mongé & Reuter (45) claimed that their study
of 267 Minnesota and Wisconsin patients involved in snowmobile accidents
showed 22% in the first winter of the survey and 14% in the second winter of
the survey to have evidence of alcohol ingestion. Half of those hospitalized
for their injuries admitted having consumed alcohol prior to operating the
vehicle. No BACs were ascertained and alcohol use was determined by a
questionnaire administered in the emergency room.
ln one of the best designed epidemiological studies undertaken on the
subject of injuries and snowmobiles. Waller & Lambom (74) investigated the
problem in northern Vermont during the 1971-1972 and 1972-1973 seasons.
The researchers had attempted, by use of a mail survey, to describe the
population of snowmobiles in the predominantly rural county of Chittenden.
Injured persons were identified while in the emergency department of the
Medical Center Hospital of Vermont. About 2.3 per 100 snowmobilers per
year were injured. The injured differed from non injured snowmobilers in that
the former were twice as likely to have reported that they had been drinking
and drinking heavily just before their injury event. The higher the speed, the
greater the chance the operator of the snowmobile had been drinking. Blood
alcohol levels were not, determined in this research project.
SKIING The scientific literature on skiing is extensive. Studies of skiing
injuries have been common since the classic study by Haddon, Elison &
Carrol (21). Although the investigators acknowledged the likely involvement
of alcohol in skiing injuries, no objective determination of alcohol was made,
probably for logistical or technical reasons. No other reports could be located
1613
SMITH & KRAUS
thai addressed alcohol and skiing injuries, although the use of alcohol is
widely observed before and during skiing activities.
SPECTATOR SPORTS Alcohol, mostly beer and wine, is available for purchase at a large number of spectator sports events in Western countries! In the
US, beer is readily available at baseball, football, basketball games, and at
horse races. W o r l d w i d e , alcohol has long been available at soccer games and
other popular spectator events. Zuska (82) reports a 1964 episode when
d r i n k i n g fans rioted in Lima, Peru after a referee's unfavorable decision at a
soccer game. Over 5000 were injured and 318 died. He also reports a
professional football game in 1976 in Foxboro, Massachusetts, where drunken fans disrupted the gaine by throwing bottles, running onto the field, and
participating in many fights. Thirty were injured, t w o died o f heart attacks,
and almost 50 were arrested. More recently, at a soccer game in Brussels,
Belgium in 1985, many deaths occurred when drunken fans rioted, resulting
in spectators being crushed or trampled to death. Sanctions were levied
against the British for the riot, much to the national embarrassment o f that
country.
Many other events of similar nature, with varying results, have occurred,
all related to alcohol abuse immediately before or during sporting events. The
extent of the problem has recently prompted the US American and National
Baseball leagues to consider lor institute) policies prohibiting the sale of
alcoholic beverages, or specifying the designation of alcohol-free areas in
some baseball facilities.
Similar episodes have occurred in public transport when fans, either in
anticipation of or lo celcbrate a victory in competitive.sports, have displayed
public drunkenness. Commercial airlines have adopted policies that can result
in termination of flights mid-route when such public displays have gone out of
control. Some element of blame, however, must rest with the airlines themselves—they provide unlimited alcohol for consumption on almost all flights!
ORGANIZED SPORTS The literature on competitive individual or team sports
and injuries is extensive, yet there are no data on the role of alcohol in these
injuries. While use o f alcohol by high school or college athletes before or
during competitive events is strictly controlled by schools and supervising
organizations, the endorsement o f alcoholic products by professional athletes
or competitors extends implicitly the use o f alcohol by athletes and others.
Alcoholic beverages are consumed with relish during many other kinds o f
leisure time or recreational activities. It is not uncommon to see widespread
use of these beverages in local, state, or federal parks or beaches, campgrounds. or other public places. Many local police agencies prohibit use of
alcoholic beverages in such places, but enforcement is lax or difficult.
ALCOHOL AND INJURIES 121
Aeronautical Activities
GENERAL AVIATION About 25% o f general aviation air miles are flown for
recreational or leisure purposes (54). Concern over alcohol use and crashes of
private, general aviation aircraft is not new. Aarens and associates ( I ) noted
in their 1978 unpublished report that early warnings on the harmful effects of
alcohol use when flying appeared in the early 1900s. Harper & Albers (23) in
their 1964 report documented the association of alcohol with private aircraft
crashes. Their data [from Federal Aviation Administration ( F A A ) records)
showed that o f 158 pilots killed in crashes in the United States who were
tested for blood alcohol, over 35% had an alcohol level in excess or equal to
15 mg/dl blood (Table 2). Noteworthy was the fact that the group of 158
tested represented only one third of all general aviation pilots killed in the US
in 1963. Bias in sample selection for blood alcohol tests must be considered in
evaluating this finding. Nonetheless, student pilots, those with only about 300
f l y i n g hours, and those involved in night crashes were ovenepresented in the
positive alcohol pilot group compared to the overall general aviation fatal
accident population. A comparison o f the tested group with pilots not involved in crashes was not attempted.
Gibbons et al (18) attempted to control for selection bias in his study o f
private aircraft pilots by limiting the study group to those tested for B A C soon
after the crash. The investigators found private pilots aged 45-54 who had
crashed while flying at night to have higher levels o f B A C than pilots who had
crashed during the daytime. In 1963 general-aviation crashes, testing of those
pilots who died (30% of the total) revealed measurable BACs (2* 15 mg/dl) in
31 % (Table 2). with about 80% of these having BACs of 100 mg/dl or higher.
Information on flying-exposure hours by age o f pilots and hours of flights was
not reported for all pilots, so the meaning o f the B A C finding could not be
properly interpreted.
Using US F A A data, Dille & Morris (12) reported on BACs in private
aircraft pilots who were killed in crashes in the western region of the US from
1964-1965. Over 20% of the pilots tested (83 o f 122 fatals) showed positive
BACS ( ^ 30 mg/dl blood), and about 30% o f these had BACs of 250 mg/dl
blood or higher.
Ryan & Mohler (65) summarized fatal crash data from the US Federal
Aviation Administration for 1963-1971 (Table 2). Almost 5100 general
aviation crashes involving over 10,500 deaths were evaluated. B A C test
results were available on about 53% o f the pilots who died. The annual
percentage with a positive blood alcohol level o f 15 mg/dl blood or higher
ranged from 18 to 43% over this nine-year period. Data on blood tests were
supplied by local coroners and the proportion tested who had blood alcohol
tests six or more hours post-crash was not reported.
Lacefteld and colleagues (33) reported alcohol tests o f 1345 pilots killed in
A L C O H O L A N D IN112
S M I T H & KRAUS
Table 2
Selected studies of general aviation crashes and alcohol in pilots
5
113
d i d not give evidence to support their assertion. Those tested were claimed t o
Publication
date
Authorfs)
Number tested/
number fatalities
Percentage
positive
BAC
an unbiased sample. Positive B A C s were f o u n d in 18% o f the pilots tested.
B r o w n & Lane c l a i m e d that impairment by alcohol was probably a factor in
about 9 % o f accidents in w h i c h v a l i d pilot B A C s were obtained.
Remarks
Ryan & M o h l e r (64) expanded the US case series f r o m 1971 to include the
Harper & Albers
(23)
1964
158/477
35
Gibbons at at (18)
1966
61/76
31'
BAC 3* 15 mg/100 ml. crashes
in Southwest US. 1965-1966
Dille & Moms (12)
1967
83/122
21
BAC » 30 mg/100 ml. crashes
in US Western region. Nov.
1964-Oct. 1965
Ryan & Mohler (65)
1972
4515/8070
27'
Lacefield at al (33)
1975
1345/?
9*
Brown & l-ane (7)
Ryan & Mohler (64)
BAC » 15 mg/llX) ml. all US
crashes. 1963.
BAC 2* 15 mg/100 ml. all US
crashes. 1963-1971
BAC s* SO mg/100 ml. all
reported US crashes.
1968-1974
1977
138/213
18"
BAC ^ 15 mg/100 ml. all
Australian crashes.
1962-1975
1979
735/2456
15'
BAC » >5 mg/100 ml, all US
reported crashes. 1972-1976
years 1972 t h r o u g h 1976 (Table 2). The four-year average o f positive B A C
for those pilots tested showed that 15% had B A C s greater than o r equal t o
15 m g / d l b l o o d . T h i s figure was considerably less than the nine-year average figure o f 2 7 % reported by the authors for pilots tested i n fatal crashes
i n the U S f r o m 1963-1971. T h e authors concluded that the eight-hour abstinence regulation f r o m the U S National Transportation Safety Board (to
c o m m e n c e December 5 , 1970) reduced alcohol consumption i n pilots but
increased the relative proportion o f heavy d r i n k i n g and f l y i n g pilots (i.e.
the percentage o f pilots w h o crashed and had B A C s i n excess o f 150 m g / d l
was increased).
OTHER AERONAUTICAL RECREATIONAL ACTIVITIES: PARACHUTING (SKY
DIVING), BALLOONING, GLIDING, AND HANG-GLIDING
T h e number o f
persons w h o engage i n various aeronautical activities other than general
aviation is u n k n o w n because certification or licensure is not required except
f o r operation o f gliders. T h e literature o n deaths or injuries o n this subject is
p i t i f u l l y small; in fact, o n l y a handful o f
reports
c o u l d be located that
document i n j u r y occurrence in persons w h o participate in these forms o f
' U n w e i g h t e d average over years indicated.
recreational
activities. O n l y one report ( 10) ( f r o m California) was located that
mentioned alcohol and fatal injuries in hand-gliding. T w e n t y percent o f those
general aviation crashes f r o m 1968-1974 in the US. Data were f r o m the
w h o crashed and were tested had positive blood alcohol levels. The report on
A v i a t i o n T o x i c o l o g y Laboratory o f the F A A C i v i l Aeromedical
the B A C finding appeared t o be anecdotal and was not evaluated further by
Institute.
Tissue and b l o o d samples were provided by local medical examiners. Find-
the
researcher.
ings are reported at 5 0 mg/dl and above, a level considered by the National
T h e findings cited above are intriguing and suggest that d r i n k i n g and f l y i n g
Transportation Safety Board to be a possible contributing factor to the cause
in general aviation can be as hazardous as d r i n k i n g and operating a land
o f the crash. A l t h o u g h the findings are not representative o f all private aircraft
vehicle i n terms o f crashes. Y e t , an important unanswered question
pilots k i l l e d i n crashes, the data suggest that f r o m 5 to 17% o f pilots had B A C
W h a t p r o p o r t i o n o f all pilots i n general noncommercial aviation fly after
i n excess o f 50 m g / d l (Table 2).
c o n s u m i n g alcohol? N o published data exist o n this question but an i n f o r m a l
B r o w n & Lane ( 7 ) studied the problem o f alcohol use and fatal general
remains:
estimate p r o v i d e d by the A i r c r a f t Owners and Pilots Association is less than
a v i a t i o n crashes i n Australia f r o m 1962 to 1975 (Table 2). Data o n B A C s
1% ( R é f . I , p. 79). M o r e i n f o r m a t i o n o n this question is essential i f accurate
o r i g i n a t e d f r o m the A i r Safety Investigation Branch o f the Australian Depart-
estimates o f risk o f crashes i n v o l v i n g alcohol are t o be made.
ment o f Transportation. B l o o d samples were obtained f r o m each state's
Despite the numerous flaws in methodology in studies o f alcohol i n private
designated aviation pathologist. O f the 259 pilots w h o crashed, 35 survived
aircraft crashes, the evidence seems t o point t o an a l a r m i n g p r o b l e m , largely
the c r a s h . a n d I I were
unassessed. T h e effect o f alcohol in performance and judgement i n motor-
n o t
f o u n d :
h e n c e
213 bodies were available for testing,
but an additional 63 pilots could not be evaluated because no v a l i d blood
vehicle operation has l o n g been k n o w n . Less w e l l
sample
rapid absorption o f alcohol at simulated h i g h altitudes (demonstrated in recent
could
be obtained
due to gross decomposition
or
destruction/
incineration o f the b o d y . B r o w n & Lane claimed that there was no reason t o
believe those not tested were different f r o m those tested, but the researchers
recognized
studies ( 1 0 ) | , c o m p o u n d i n g an already hazardous situation.
is the more
I. .
S M I T H & KRAUS
A L C O H O L A N D INJUKIK»
Occupational Injuries
115
uted in at least half o f the total number o f cases . " A b o u t half o f all drownings
T h e exact number o f work-related fatalities or injuries is u n k n o w n . The
and homicide v i c t i m s were intoxicated. H o w e v e r , the author fails to mention
N a t i o n a l Safety C o u n c i l reports about 13,000 deaths and a m i l l i o n injuries
the source o f the data and whether or not blood alcohol measurements were
that occurred i n 1980 (51). The US Department of L a b o r , Bureau o f L a b o r
obtained.
Statistics reports considerably fewer (32). A recent report f r o m the Centers f o r
L i t t l e is k n o w n about the role o f alcohol in nonfatal occupational injuries.
Disease C o n t r o l ( N I O S H ) suggest an average o f between 6 0 0 0 and 7000
In the study b y Wechsler el al ( 8 0 ) , among patients injured at w o r k and
w o r k - r e l a t e d i n j u r y deaths per year f r o m 1980 through 1984 (8a). A b o u t a
admitted to the emergency r o o m ,
t h i r d o f all w o r k - r e l a t e d injuries are due to transportai ion-related crashes,
breathalyzer. H o w e v e r , o n l y 5 % o f those measured had readings greater than
w h i c h are not discussed in detail in this paper.
50 m g / d l . T h e highest rate o f detection o f alcohol was in ages 2 4 - 4 5 ( 1 9 % )
A l c o h o l abuse and alcoholism have been clearly identified as a problem i n
16% had blood alcohol detectable by
and in males ( 1 7 % versus 10% in females).
the occupational setting ( 16). T o date, most studies have directed attention t o
T h e findings for nonvehicular occupational injuries are in marked contrast
the alcohol-dependent w o r k e r and his identification, so that treatment pro-
t o other injuries. There have been few explanations offered f o r this apparent
grams may be initiated. T h e role o f alcohol and work-related injuries has been
l o w involvement o f alcohol in occupational injuries. It has been suggested
p o o r l y or i n s u f f i c i e n t l y studied. The results are at times c o n f l i c t i n g , and the
that other employees may cover for an intoxicated w o r k e r and frequently
d e f i n i t i o n s used o f t e n unclear. A study by Shain (68) found alcoholics to be
provide protection for h i m , thus resulting in less injuries than may be ex-
t w o t o three times more l i k e l y than other employees t o be i n v o l v e d in w o r k
pected (8). H o w e v e r , another plausible reason has to be that few people drink
accidents. A n o t h e r study, comparing 72 alcoholic employees w i t h a control
prior to or d u r i n g their normal e m p l o y m e n t . A national survey by Q u i n n &
g r o u p , f o u n d no relationship between alcoholism and involvement in w o r k
Shepard (60) f o u n d that each year, w h i l e about 2 5 % o f workers sustain some
injuries d u r i n g the f i v e years preceding and one year f o l l o w i n g diagnosis (69).
sort o f i n j u r y on the j o b , only 2 % o f the w o r k i n g population can be expected
T h e r e have been f e w studies o f alcohol involvement in work-related injur-
to d r i n k o n the j o b o n any g i v e n day. There is a need f o r more research into
ies. " G i v e n the well-established relationships between blood alcohol levels
the role o f alcohol and work-related injuries. One factor that has not been
and poor c o o r d i n a t i o n , faulty judgement, and lengthened reaction t i m e , it is
explored is the role o f post-alcohol hangover and the possible resulting
plausible that alcohol often contributes t o accidents at w o r k " (72). H o w e v e r ,
inattentiveness as a c o n t r i b u t i n g factor in occupational injuries.
the studies t o date have failed to demonstrate that alcohol is a major factor in a
substantial p r o p o r t i o n o f work-related injuries. Its contribution t o nonvehicular occupational deaths appears to be o n the order of o n l y 3 to 4 % . In a study
o f alcohol use a m o n g workers at seven railroad companies, o n l y 4 % o f all
reported injuries i n v o l v e d alcohol (38). A n informal review o f medical exa m i n e r records for occupational traumatic deaths in West V i r g i n i a indicated
that o n l y 4 % showed significant blood alcohol levels (67). A study by Baker
el al ( 5 ) f o u n d 11% o f a l l 85 occupational fatalities tested to have a blood
O n e o f the major barriers to the study o f occupational injuries in general has
been the poor quality o f data available. T h i s has been w e l l summarized by
Baker et al (5):
The scientific investigation of occupational injuries and death is difficult not only because
there is no single complete source for readily identifying cases, but also because important
data are commonly absent. Injured workers, for example, are not generally tested for BACs
and in many jurisidctions. alcohol tests are not routine even for fatalities:
a l c o h o l concentration greater or equal t o 80 mg/dl. H o w e v e r , a m o n g those
k i l l e d in road vehicles, 14% had a high B A C . and o n l y 3 % o f 30 other
SUMMARY AND PUBLIC HEALTH IMPLICATIONS
occupational fatalities had a B A C 3* 80 m g / d l . A recent study o f 41 occupational fatality deaths in A l l e g h e n y County found four deaths ( 1 0 % ) t o have
detectable B A C w i t h o n l y one ( 2 % ) over 100 mg/dl ( 1 4 0 m g / d l compared to 2
less than 10 m g / d l , and I case 45 mg/dl) (52).
A number o f studies have attempted to document the frequency o f alcohol use
i n residential or occupational environments and in recreational activities. Yet
there is a notable absence o f epidemiological findings for many specific kinds
O n e particular occupational group identified as being at particularly high
o f aquatic or f l y i n g exposures such as scuba d i v i n g or water s k i i n g , as w e l l as
risk o f alcohol-related i n j u r y fatality is seamen. A review by A m e r (2) o f all
a total absence o f any i n f o r m a t i o n o n alcohol and injuries involved i n a very
N o r w e g i a n seaman deaths reported f r o m 1957-1964 found a mortality rate o f
large number o f human activities such as h i k i n g , c a m p i n g , j o g g i n g , or b i k i n g
2.8 per 1000 for male seamen i n foreign trade, of w h i c h 2 8 % were due t o
and organized sports o f all types.
drowning.
The
study
reports that at
least one third o f all v i c t i m s
of
"accidental 1 ' death were " m o r e or less intoxicated" and that " a l c o h o l con tri b -
T h e quality o f the existing data o n nonmotor vehicle unintentional injuries
is beset b y numerous shortcomings and methodological flaws. Some studies
116
117
SMITH & KRAUS
do not report the levels o f blood alcohol concentrations, while others rely on
questionnaires or anecdotal reports from witnesses to describe alcohol use.
This was found most predominantly in studies attempting to document alcohol
use in submersion fatalities or in aviation crashes. The value of these
nonobjective measures is doubtful. Better attempts to quantify alcohol use are
needed.
A second related problem is the practice of some investigators to make
generalizations to the broad population, based on material obtained from a
limited number o f cases. This practice is found in studies of recreation injuries
because only a small proportion of fatal injuries are associated with leisure
time and recreational pursuits. Hence, one limiting factor in published data is
the inability to obtain and report relevant alcohol information on nonfatal
injuries. Attempts have been made to document the degree of alcohol use in
the general population o f persons participating (exposed) in such recreational
activities (as in the case o f general aviation studies in the US and boating
studies from Norway); however, by and large such information is totally
devoid o f data on levels o f exposures involved.
Although it has been documented that alcohol plays a substantial role in
injuries occurring in and about the home, some of the activities in the
residential environment can also be considered leisure-time or recreational.
The failure to identify specific external causes of injury or specific potentially
dangerous activities in the home has hampered any meaningful research in
this direction. In addition, though some general studies are available, a failure
to subcategorize inherently hazardous activities in public places has thwarted
attempts to determine the role of alcohol in these environments. Similar
problems exist for studies o f the use of alcohol and injuries resulting from
falls. Again, the external causes have been categorized globally without
reference to the nature o f the activity associated with the injury, and much
better delineation and subclassification is obviously necessary before
meaningful data on these environments and alcohol use w i l l be forthcoming.
Similar problems exist in the occupational setting, where current studies
suggest that aside from occupational-related motor vehicle injuries, alcohol is
only involved in about 3 to 4% of other occupational fatalities. However,
most studies have only small numbers, and more research is needed to
document the role o f alcohol in both fatal and nonfatal occupational injuries.
Despite the numerous methodological problems with present studies, there
is considerable evidence that alcohol is involved with a wide variety o f
residential and recreational activities. A number of injury studies have shown
B A C levels similar to those found in motor vehicle injuries. Several studies
have also suggested that the dose response for alcohol and severity of injury
found for motor vehicle injuries also apply to other injuries. A case control
study o f alcohol and falls clearly demonstrated an association between B A C
and the risk o f fall injuries. Though much basic data are lacking, the degree of
alcohol involvement in the different types of injuries appears to vary considerably. Drownings, for example, show a high association with alcohol, yet
occupational injury fatalities only rarely appear related to alcohol.
Legal issues notwithstanding, there is a need for the testing for alcohol of
all injured patients and to have better recording of alcohol involvement in
medical records. This would improve both the clinical evaluation and management o f the patient (17), and provide the data necessary for sound clinical,
epidemiologic, and intervention studies on alcohol. The study by Levine &
Radford (35) o f hospitalized house fire victims found that neither smoking nor
alcohol use was mentioned in the chart, despite the high association of both of
these with house fires. As part of a recent study of brain injuries, Kraus et al
(31 ) found that only 17% of adults over the age of 15 who were injured during
sport or recreational activities were BAC-tested; among the 17% tested, 36%
had blood alcohol levels in excess o f 100 mg/dl. These figures represent only
brain-injury cases in which the importance o f the knowledge of B A C for
proper clinical assessment is well recognized. However, testing rates did
increase in response to the increasing severity of injury, to 100% of those
involved in fatal spurt-recreational-related injuries being tested.
Waller (75) has clcarly identified drunk driver; as having been known as
problem drinkers. Unknown, however, is whether the problem drinker has a
history of recurrent admission to the emergency room for earlier nonmotorvehic le-related trauma, or whether recurrent trauma victims are likely to be
problem drinkers. If such findings are replicated for nonvehicular injuries,
then these people should be the target o f intensive interventions aimed both at
controlling drinking and at reducing the environmental hazards in which the
person lives. Could actions by taken to modify a problem drinker's home to
reduce the likelihood o f injury? Once having identified these high-risk people,
what is the most effective way either to reduce their drinking or to reduce its
health consequences? There is a need to study these aspects in more detail and
to determine whether such people could have been identified earlier as being
at risk. However, the value o f any of these means can only be realized if
injured persons are tested for B A C when they are injured rather than waiting
until they end up as fatalities in the coroner's office. As a matter of public
policy, better distribution of information through federal, state, and existing
agencies on the role of blood alcohol on risk o f injury outside the highway
setting is timely and needed.
There is a need to bring together researchers studying the control of alcohol
use and injury epidemiologists who have directed most of their attention to
controlling the external environmental factors involved in injury etiology.
Many of the injury prevention interventions such as the design of stairs,
automatic fire sprinklers in houses, and other measures w i l l reduce all injur-
118
ALCOHOL A N D INJURIES
S M I T H & KRAUS
ies, regardless o f alcohol involvement. Just as the airbag w i l l prevent deaths
t o d r i v e r s o f automobiles regardless o f their B A C s , other environmental
m o d i f i c a t i o n s , such as
flame-retardant
materials and fire-safe cigarettes, w i l l
prevent deaths f r o m alcohol-related house fires without attempting t o control
a l c o h o l c o n s u m p t i o n , a m u c h more d i f f i c u l t proposition. A l t h o u g h alcohol
use may increase the risk o f becoming injured, taking advantage o f the
t e c h n o l o g y u n d e r l y i n g many currently available interventions w i l l reduce
injuries regardless o f the degree o f alcohol involvement.
M a n y methods t o reduce alcohol-related injuries have been based o n m o t o r
v e h i c l e injuries and a i m at isolating the intoxicated person f r o m the h i g h - r i s k ,
i n j u r y - p r o d u c i n g e n v i r o n m e n t , particularly the highway. Drunk d r i v i n g laws
( 6 2 ) and interventions directed at the availability of alcohol ( 4 6 , 4 7 ) p r i m a r i l y
focus o n preventing the intoxicated person from d r i v i n g ; presumably it is
assumed that i f this is done, the person is " s a f e . " H o w e v e r , as this paper
illustrates, alcohol has a significant involvement i n other injuries, such as
burns o r d r o w n i n g s , so that simply getting intoxicated persons o f f the highw a y and h o m e safely does not prevent them f r o m being injured.
Although
alcohol
use in occupational settings is controlled and dis-
couraged, there is little control over alcohol use i n other environments. For
e x a m p l e , certain w i n t e r sports activities (e.g. skiing) take place o n private
p r o p e r t y ; though owners may be legally liable for alcohol use a m o n g these
leisure-time and recreational participants, there does not appear t o be m u c h
e f f o r t to c o n t r o l alcohol use. In fact, the use o f alcohol is often actively
promoted in
recreational
settings, w i t h ready availability and
promotion
t h r o u g h the mass media. Federal, state, o r local agencies have laws or
j u r i s d i c t i o n over the control o f access to alcohol d u r i n g some o f these
activities, yet little i n f o r m a t i o n is available concerning h o w these agencies
coordinate i n f o r m a t i o n o n the hazards involved, or enforce adherence to rules
and regulations. For e x a m p l e , empirical data document h i g h alcohol use by
spectators at sporting events. Disasters at these events i n recent decades are
w e l l d o c u m e n t e d , yet efforts have been made only recently to control the
amounts o f alcohol distributed, beginning w i t h regulations f r o m the National
Baseball League that w i l l prohibit or at least l i m i t the sale o f alcoholic
beverages i n baseball parks.
Recent prevention efforts at c o n t r o l l i n g the availability o f alcohol, such as
restricting sales in hazardous environments and reducing consumption
t h r o u g h price increases t o reflect the true social costs o f its use, are but a f e w
examples o f the broad social policies toward alcohol control that need t o be
considered (61). I f these are combined w i t h other environmental measures
directed at reducing hazardous exposures, such as wearing o f protective life
vests or increasing fire safety, we w o u l d expect to reduce much o f the current
burden o f alcohol o n nonmotor vehicle unintentional injuries.
119
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63. Rultenber. A. J..Luke.J. L. 1984. Heroin-related deaihs: New epidemiologic
insights. Science 226:14-20
64. Ryan. L . Mohler. S. 1979. Current role
of alcohol as a factor in civil aircraft
accidents. Aviat. Space Environ. Med.
50:275-79
65. Ryan. L . Mohler. S. 1972. Intoxicating
liquor and the general aviation pilot in
1971. Aerosp. Med. 43:1024-26
66. Samkoff. J. S . Baker. S. P. 1982. Recent trends in fatal poisoning by opiates
in the United States. Am. J. Public
Health 72:1251-56
67. Sanderson. L. 1983. Unpublished analysis of West Virginia médical examiner
records on job-related traumatic deaihs.
NIOSH Div. Safely Res.
68. Shain. M. 1982. Alcohol, drugs and
safety: An updated perspective on problems and their management in the
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239-46
69. Trice. H M. 1965. Alcoholic employees: A comparison of psychotic,
neuroitc. and "normal" personnel. J.
Occup Med. l7(.*):94-99
70. Trinkoff. A. M.. Baker. S. P. 1986.
Poisoning hospitalizations and deaihs
among children and teenagers. Am. J.
Public Health 76:657-60
71. US Dept. Heailh. Educaiion Welfare.
1980. ABC Laws. Alcohol Health and
Research World 4(2) Washington DC:
Alcohol, Drug Abuse and Mental Heailh
Admin. US GPO
72. US Dept. Health and Human Services.
121
1983. Chapt. VI. Adverse social consequences of alcohol use and alcoholism. Natl. Inst. Alcohol Abuse and
Alcoholism. In Alcohol and Health 5th
Special Report to the US Congress, from
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Traffic Safely Ed. 20(l):7-8. 34
9. LISTE DES AUTEURS DU LIVRE
LES TRAUMATISMES AU QUÉBEC, COMPRENDRE
POUR PRÉVENIR
30
LES TRAUMATISMES AU QUÉBEC
COMPRENDRE POUR PRÉVENIR
(en voie de publication pour 1991)
LISTE DES AUTEURS
PAR CHAPITRE
CHAPITRE 1 :
TRAUMATISMES
ORIENTATION
PRIVILÉGIÉE
EN
PRÉVENTION
DES
M. Bruce Brown
DSC, Hôpital Charles LeMoyne
M. Richard Massé
DSC, Hôpital général de Montréal
CHAPITRE 2 : IMPORTANCE DES TRAUMATISMES
MORTALITÉ, HOSPITALISATIONS, INCAPACITÉS
Mme Yvonne Robitallle
M. Robert Cholnldre
M. François Camirand
Ministère de la Santé et Services sociaux
CHAPITRE 3 : LES TRAUMATISMES ROUTIERS
M. Robert Bourbeau
Université de Montréal (démographie)
Mme Solange Charest
DSC, C.H. régional de Rimouski
Mme Claire Laberge Nadeau
Université de Montréal (CRT)
Mme Dominique Lesage
AU
QUÉBEC
:
31
M. Claude Dussault
Société de l'assurance automobile du Québec
Mme
Marie-France
Joly
Université
de Montréal
(médecine sociale et préventive)
ENCARRE : LES TRAUMATISMES DOMESTIQUES
M. Guy Régnier
Régie de la sécurité dans les sports
CHAPITRE 4 : LES TRAUMATISMES DUS AUX CHUTES
Mme Esther Létourneau
Bureau de la Statistique du Québec
Mme Jennifer O'Loughlin
Mme Yvonne Robitaille
CHAPITRE 5 : LES TRAUMATISMES DUS AUX INCENDIES ET AUX
BRÛLURES
M. Slobodan Ducic
Université de Montréal (médecine sociale et préventive)
CHAPITRE 6 : LES INTOXICATIONS
M. Guy Sanfaçon
Centre Anti-Poison du Québec
M. René Biais
Centre Anti-Poison du Québec
CHAPITRE 7 : LES TRAUMATISMES RÉCRÉATIFS OU SPORTIFS
M. Claude Slcard
Régie de la sécurité dans les sports du Québec
32
M. Yvan Chalifour
La Société canadienne de la Croix-Rouge
M.
André
Delisle
DSC,
Hôpital
Hôtel-Dieu de St-Jérôme
CHAPITRE 8 : LES TRAUMATISMES LIÉS AU TRAVAIL
M. Michel Pérusse
Université Laval (sciences sociales)
CHAPITRE 9 : ACTES DE VIOLENCE : SUICIDES, PARASUICIDES, HOMICIDES
ET VOIES DE FAIT
M. Richard Boyer
Hôpital Louis-H Lafontaine (recherche)
Mme Louise Langeller-BIron
Université de Montréal (criminologie)
CHAPITRE 10 : LA PRÉVENTION TERTIAIRE
M. André Lavofe
DSC, Cité de la santé de Laval
M. Pierre Lapolnte
Société de l'assurance automobile du Québec
M.
YvesdePoirier
Centre
réadaptation Lucie-Bruneau
Mme Elizabeth Riley
Institut de réadaptation de Montréal
CHAPITRE 11 : L'APPROCHE
TRAUMATISMES
ÉCONOMIQUE
M. Claude Fluet
Université du Québec (sciences économiques)
EN
PRÉVENTION
DES
33
CHAPITRE 12 : LES INSTITUTIONS : LE RÔLE DE L'INTERSECTORIALITÉ
M. Pierre Gosselin
DSC, Hôpital de l'Enfant-Jésus
M. Antoine Chapdelaine
DSC, Hôpital de l'Enfant-Jésus
M. Pierre Marc Johnson
Université McGill (médecine, éthique et droit)
Directrice de la rédaction :
Mme Ginette Beaulne
34
10. CAHIER DE PRESSE SUR
LES TRAUMATISMES
Fillette de 6 ans tuée sous les yeux de son père
Elle a été écrasée par l'autobus scolaire qui venait de la ramener d'une excursion de ski
MARTIN PELCHAT
• Sous les yeux de son père, u n e f i l l e t t e
de six ans a p é r i écrasée p a r u n a u t o b u s
d'écoliers hier a p r è s - m i d i s u r l ' a v e n u e
Walpole, à Ville Mont-Royal.
La petite C a t h e r i n e K h o u z a m r e v e n a i t
d ' u n e excursion de s k i à laquelle p a r t i c i pait également son f r è r e l o r s q u ' e l l e a été
happée, peu avant 17 h , face a u d o m i c i l e
de ses parents au 592 W a l p o l e .
La j e u n e K h o u z a m venait d e descendre
de l'autobus. Selon les e n q u ê t e u r s d u dist r i c t 31 d u service dé p o l i c e d e la C U M , i l
semble que le c h a u f f e u r a pensé q u ' e l l e
avait déjà traversé la r u e et i l a f a i t m a r che avant sans la v o i r .
« Les deux enfants sont descendus p o u r
se r e n d r e à leur d o m i c i l e et le c o n d u c t e u r
a vu le jeune garçon d e l ' a u t r e côté d e la
rue, de raconter le d i r e c t e u r Jean-Claude
L e r o u x , d u S P C U M . Il a présumé q u ' i l e n
était d e m ê m e p o u r la j e u n e f i l l e . »
C a t h e r i n e K h o u z a m a d ' a b o r d été f r a p pée par lu r o u e a v a n t d u v é h i c u l e , p u i s a
été écrasée sous la r o u e a r r i é r e d r o i t e .
Son père S h a f i k , q u i venait d ' ê t r e tém o i n d e l ' a c c i d e n t , a vite fait de-la prend r e dans ses bras p o u r la t r a n s p o r t e r a u
salon de sa résidence, o ù les a m b u l a n ciers d ' U r g e n c e s Santé n ' o n t c e p e n d a n t
p u que constater le décès.
L'agent |ean D e l a u n i è r e , d e la section
enquêtes-accidents, s'est v u c o n f i e r le
dossier et a u m o m e n t d e m e t t r e sous
>resse, a u c u n e i n f o r m a t i o n c o n c e r n a n t
e chauffeur n'avait filtré. U n officier a
s i m p l e m e n t i n d i q u é que l ' a u t o b u s é t a i t
m u n i de tous les é q u i p e m e n t s réglementaires, soit d u système de rétroviseurs êt
de feux.
f
M. Khouzam comprenait cependant
m a l c o m m e n t sa f i l l e avait p u échapper à
l ' a t t e n t i o n d u c o n d u c t e u r et q u e s t i o n n a i t
l ' a t t i t u d e des m o n i t e u r s q u i p r e n a i e n t
place à b o r d d e l ' a u t o b u s .
« I l y avait c i n q m o n i t e u r s assis dans
l ' a u t o b u s et ils n ' o n t pas fait traverser les
e n f a n t s , a-t-il déclaré. C'est la troisième
fois que m a f i l l e faisait le voyage et à chaque fois ils la faisaient traverser la rue.
Pas cette fois-ci.»
Déjà huit victimes
Cet accident ajoute a u b i l a n r o u t i e r
déjà l o u r d des p r e m i è r e s heures de ce
w e e k - e n d . O n d é n o m b r e déjà h u i t victimes.
V e n d r e d i , u n c o u p l e d e K i r k l a n d Lake,
e n O n t a r i o et l e u r f i l l e t t e d e t r o i s m o i s
o n t p e r d u la vie lorsque leur c a m i o n n e t t e
a été e m b o u t i e p a r u n c a m i o n - r e m o r q u e
à A r n t f i e l d , en A b i t i b i .
La Sûreté d u Québec a révélé h i e r
l ' i d e n t i t é des t r o i s victimes. I l s'agit de
François L a v o i e , 24 ans. d e son épouse
L i n e . 19 ans c l leur f i l l e t t e S t é p h a n i e .
À p r e m i e r e vue, la chaussée glissante
e x p l i q u e r a i t la c o l l i s i o n e n t r e leur cam i o n n e t t e ei u n c a m i o n - r e m o r q u e d o n t
lu c o n d u c t e u r . S y l v a i n C a m e r o n . 27 un»,
de T a c h e r e u u . e n A h i i i b i . n'a subi m i e
des blessures legeres.
h il O u i u o u a i * . d e u x a c c i d e n t s m o r t e l *
sont s u r v e n u s v e n d r e d i , l a i s a n l t r o i s
m o r t s . Lu aussi lu chaussée enneigée semble e n être a l ' o r i g i n e . Solange Renaud.
57 ans. d u Luc-des-lles. a p e r d u la vie a
S a i n t - A i m é d u Lac-des-Hes. L i n ma. l a
brecque, 8 2 uns de S t u r g e o n halls en O n t a r i o , e l C a r o l e G u u v r c a u , 24 u i u , de.
H u l l , o n t uussi été tuées à Bryson.
E n f i n L u c i e n n e Jacob. 76 ans, d e SaintGeorges-de-Beauce, a p é r i dans u n e c o l l i sion v e n d r e d i a p r è s - m i d i sur la r o u t e 173
à la s o r t i e sud de Saint-Georges.
vie, M m e Marena le ddit
à la rapidité d ' i n t e r v ^ i tion des sapeurs MicËe!
Charbonneau, Raoul
Boudreau, Normaed
Sanscoucy et Yvan Brunelle q u i o n t p é r . * t r ~
dans le brasier dès leur
arrivée.
Ils ont trouvé la mal
heureuse inconsc!t-r.!>
sur le plancher de ia cuisine.
Selon le sapeur M i chel Charbonneau. elle
s o u f f r e de brûlures au
corps et d'une blessure a
la téte.
JÉ3DO0OAL PS MIL.y //-0*2-ff
Photo Yvon TREMBLAY
Des sapeurs donnent de l'oxygène à la victime.
Grièvement blessée
(YC) — Une femme a été grièvement
blessée dans un incendie, hier soir, dans le
quartier Âthuosic.
La victime. Ananciata
M a r e n a , 79 ans, a étéc o n d u i t e au centre des
grands brûlés de l'hôpital Hôtel-Dieu.
Si elle est encore en
Selon l'officier M j r A u d a r t . du servue :
p r é v e n t i o n des incc-n
dies, il a fallu plus de 1<
minutes à une ambulan
ce d ' U r g e n c e s - S a n t é
pour arriver sur place.
Le feu a éclaté vers 21
h 42 et a été c o n t r ô l é
vers 22 h 30. Le bungalow est une perte totale.
A 12 ANS,
SUR
SON
AMI DE
m
en compagnie de sa
sceur. pour tout raconter
aux enquêteurs.
Entretemps, une ambulance et un médecin
d'Urgences Santé
avaient été dépêchés sur
?'est écroulé tout.en chez ia voisine en lui les lieux.
sang, entre la cuisine et criant d'appeler la poliTransfusions
le salon. sous le regard ce. ce qu'elle a fait.
sanguines
Il s'est plus tard rendu
ahuri de ses copains !
Après avoir tenté l'imAffolé, le garçon qui de lui-même au poste 55
n"iiî '.irt î'ffil p é p i t e de la police de la CUM. possible pour limiter
Deux tout leunes garçons de 11 et 12 on», qui avalent consommé de la bière en présence de fillettes d e leur âge, ont vécu,
jeudi, une expérience dramatique, l'un des garçons* atteintpar
Foutre d'une aéchorge de plombs do calibre 12. Hsque autourd*hul de perdre à jamais l'usage d'une jambe.
Il était environ
15 h 45. jeudi, lorsque le
coup de feu a retenti.
<*Ân« una résidence privée du quartier Pointa*
flux-Trembles, à Montréal.
En vertu des dispositions prévues par la Loi
sur la protection de la
jeunesse, il nous est in*
terdit de publier quelque
détail qui serait de nature à identifier les enfants
impliqués dans ce drama.
D a été imp*—thU par
ailleurs. de confirmer
que1 les enfanta se trouvaient seuls i la maiann.
comme cela semble être
le cas, lorsque le drame
s'est produit.
Le Journal de Montreal a nfriPTn™1"1 appris
qu'après avoir consommé une certaine quantité
de bière, le plus jeune .
des deux garçons, ches
lequel le groupe d'enfanta s'était réuni, est allé chercher le fusil quelque part 4 * w t la maison.
Selon le témoignage
des deuz fillettes alors
dans la cuiaine, le garçon
s'est ensuite approché
du salon, où se trouvait
son
de 12 ans,
puis il a chargé l'arme et
l'a pointée en direction
de celui-ci, pour une raison qui n'a pas été rêvé*
lé*.
Atteint
aux genoux
Cest la garçon de 12
an» qui sa serait ensuite
emparé de Tanne et qui
aurait U t feu en pointant le canon du fusil
rers son axnL
:
A t t e i n t violemment
par une puissante charge
de plombs dans les genoux, renïant'dtaTU àûtf
l'hémorragie dont il était
victime, lea secouristes
ont conduit le jeune
blessé à l'hôpital Maisonneuve-Rosemont. où
son état aurait nécessité
des transfusions sanguines.
Aux dernières nouvel*
'les, les médecins n'étaient pas sûrs de pouvoir sauver la jambe du
garçon, gravement blessé.
L'enquête, dans cette
affaire, a été menée par
le sergent-détective
Pierre Saint-André, du
bureau des enquêtes cri-,
minjdw et l'agent JeanJacques Hétu. de Police
jeunesse, au poste 55.
Le lieutenant-détective Normand Coulombe a
cependant indiqué
q u ' a u c u n e a c c u s a t i o n ne
sera vraisemblablement
p o r t é e c o n t r e le g a r ç o n
de l'J a n s . c o m p t e t e n u
d e s c i r c o n s t a n c e s d e l'inc i d e n t et du j e u n e âge
des individus impliqués.
Les policiers ont
n é a n m o i n s saisi, au dom i c i l e de la v i c t i m e . !e
fusil d e c a l i b r e 12 utilisé
à cette occasion, ainsi
q u ' u n e a u t r e «arme à feu.
Yvon TREMBLAY
Un plus lourd
Une automobile n'a pas fait le poids, dans
la nuit de mercredi à hier, à la suite d'une
collision avec une remorqueuse munie d'une plate-forme. Par chance, malgré d'importants dommages matériels, le conducteur de l'automobile, qui portait sa ceinture
de sécurité, a subi des blessures mineures.
L'accident est survenu vers 1 h à l'angle des
boulevards Taschereau et Curé*Poirier.
Une glissade
tragique
Presse Canadienne
'
RIVltREMALBAIE
m Un adolescent de 14 ans, Éric
Tremblay, est mort enseveli dans
la neige hier à Rivière-Malbaie,
dans le comté de C h a r l e v o i x .
Deux compagnons de jeu. dont
son frère. lean-Rock. 10 ans. s'en
sont tirés indemnes.
Les trois amis glissaient sur une
pente d'une vingtaine de metres
qui surplombe un ruisseau. Au
sommet, la neige avait pris la forme d'une lame sous l'effet; du
veni.
«l'étais avec lean-Kock. Nous
remontions. Éric descendait et la
neige a dévalé derrière lui», a expliqué Sébastien Harvey, âgé également de 14 ans.
Le jeune Harvey n'a pas été
complètement enseveli puisqu'il
s'est retrouvé avec la tète et le
bras droit hors de le neige.
«l'ai quand même eu de la difficulté à me dégager, a-t-il raconté. La neige était pesante».
Il a cherché ses compagnons
quelques instants, «l'entendais
sourdement crier fean-Rock mais
je n'ai jamais pu le localiser», a-til raconté. Il est ensuite allé chercher du secours.
Le jeune lean-Rock a été retrouvé non loin de l'endroit où
Sébastien avait roussi a s'en sortir. Il a été conduit au centre hospitalier de Lu Malbaie mais son
état n'inspire aucune crainte.
Quant à Eric, il a ctc localisé environ deux heures après la mesaventure. Les efforts pour le réanimer ont été vains.
Le mur s'effondre
Un ouvrier est passé à quelques pouces d'être enseveli sous des tonnes de pierres,
hier, lorsque le mur de béton qu'il s'efforçait de démolir s'est soudainement affaissé
sur lui. L'accident est survenu au deuxième
étage d'un édifice commercial situé au 474,
rue Sainte-Catheriine ouest, vers 10 h. L'effondrement a eu pour effet de déclencher le
système de gicleurs des commerces situés à
l'étage plus bas. C'est pourquoi les pompiers ont été appelés sur les lieux.
J&jïaml
Photo Normand JOUCCEUR
Huit morts accidentelles
/'rc"»itr Cjnddienne
• Au moins huit personnes
oni connu une fin tragique au
Québec durani la fin de semaine. selon les rapports de police
disponibles, hier, en milieu de
soiree.
Cinq accidents de la circulalion ont fait chacun un mort,
lu pratique de la motoneige a
ravi une victime et un homme
a rendu l'âme plusieurs heures
après qu'une explosion se fut
produite dans un atelier. La
huitième victime a été retrouvée sans vie. gelée.
• C'est hier, vers 13 h, qu'un
adepte du ski de fond a trouvé
le corps gelé d'un homme de
31 ans en bordure d'un sentier
de motoneige aux limites de
Beauport et Charlesbourg. La
victime, une personne portée
disparue vendredi, souffrait de
problèmes d'ordre psychologique. Le corps ne portait aucune trace de violence.
Pour ce qui est de la tragédie
de motoneige. elle est survenue, encore une fois, au Sague-
nay—Lac-Saint-lean : Sylvain
Hébert, àgéé de 26 ans et domicilie à Rivière-Eternité, dans
le Bas-Saguenay. est mort lorsqu'il a été écrasé par son engin. Selon des témoignages, le
motoneigiste filait à grande vitesse et a heurté une lame de
neige durcie de un mètre de
haut; l'engin a fait un bond
dans les airs et un tour sur luimême pour ensuite retomber
sur son pilote. L'accident s'est
produit vers 14 h 15, samedi,
sur les eaux glacées de la rivière Saguenay.
Une lonquiéroise de 67 ans.
Jeannette Verville, a succom-
bé aux blessures qu'elle s'est
infligées samedi, vers I I h.
lors d'une spectaculaire collision impliquant son automobile et un camion-citerne d'une
compagnie pétrolière â une intersection achalandée de la
route 170 à lonquière. Un des
deux conducteurs a omis vraisemblablement d'effectuer
correctement un arrêt obligatoire.
Michel Garon, de Beauport,
a péri samedi, vers 14 h 30,
lorsque son véhicule a percuté
violemment un poteau supportant des panneaux de signalisation en bordure de l'autoroute
de la Capitale à Québec. L'automobile de la victime circulait â grande vitesse. L'homme
aurait eu 46 ans après-demain.
Une collision frontale, survenue vers 2 h 50, sur la route
354 près de Saint-Alban, à michemin entre Québec et TroisRivières, a coûté la vie à M a r i o
Delisle. âgé de 22 ans et domicilié à Saint-Ubald. Un des
deux conducteurs aurait été
aveuglé par les phares de la
voiture venant en sens inverse
et circulant au milieu de la
chaussée. .
Vers 20 h 05. vendredi, sur
la route 207 à Saint-Isidore,
sur la Rive-Sud, Cécile Demers-Gervais a péri dans une
une collision entre deux véhicules venant à sens inverse; la
victime demeurait â Saint-Isidore même et elle avait célébré, il y a une quinzaine de
jours, son 79e anniversaire.
Une collision entre une automobile et un autobus de la
compagnie Orléans Express,
en début de soirée, vendredi, a
fait un mort: Cécile LavoieMorissette, une résidente de
Donnacona âgée de 51 ans.
L'accident, qui a causé également des blessures à quatre
passagers de l'autocar, est survenu sur la route 138 à CapSanté, une petite localité située à une trentaine de kilomètres à l'ouest de Québec ; i l
se serait p r o d u i t à la suite
d'une fausse manoeuvre de la
conductrice.
Finalement, André Morissette. âgé de 49 ans, a succombé. durant la soirée de vendredi. au centre des grands brûlés
de l'Hôtel-Dieu de Montréal,
aux brûlures et blessures qu'il
s'était infligées, quelques heures auparavant, lors de l'explosion qui a secoué la remise à
proximité de sa demeure de
Saint-Pie, non loin de SaintHyacinthe.
j&u&jk- œ. MC Capotage
Un homme et une femme ont été blessés, en fin de soirée, samedi,
lors d'un accident de la circulation survenu sur la route 131, près de
Lavaltrie, sur la Rive-Nord du Saint-Laurent. L'accident s'est produit lorsque le conducteur d'une camionnette a perdu la maîtrise du
volant. Le véhicule a capoté pour finir sa course dans un fossé. Les
blessés ont été transportés au Centre hospitalier régional de Lanaudière, à Joliette.
Deux morts
sur les
routes
• Un homme de 45 ans. Michel
Garon, de Beauport. a perdu la
vie hier' après-midi lorsque son
véhicule a violemment percuté
un poteau de signalisation sur
l'autoroute de la Capitale, à Québec.
L'homme, qui aurait vraisemblablement perdu le contrôle de
son automobile, est décédé sur le
coup.
Par ailleurs, une collision frontale a fait un mort. M a r i o Delisle,
22 ans. dans la nuit de vendredi à
samedi. L'accident est survenu
sur la route 354 à 2 h 50, à SaintAlban, dans le comté de Portneuf.
f
I n c e n d i e t r a g i q u e si
la rue Vinu
]
Une femme meurt
ASPHYXIEE
redonner un souffle de vie, mais ce n'était pas le
cas», explique M. Lussier.
Morte
•Après une quinzaine de minutes d'efforts, j'ai
remis M"" Schachuk entre les mains des ambulanciers et d'un médecin d'Urgences Santé. Ils
ont poursuivi les tentatives de réanimation durant un certain temps, mais la pauvre femme
était morte*, ajoute-1-il.
Les efforts héroïques d'un pompier, qui o donné la respiration artificielle à une
Le pompier Lussier ne tarde jamais à se porter
femme asphyxiée dans un incendie, n'ont pas été suffisants pour lo ramener à la vie.
volontaire pour tenter de sauver la vie des gens.
Cet incendie mortel s'est produit vers 2 h 4 5 hier matin, dans une maison à loge«J'ai perdu mon enfant de trois ans, en 1985, a la
ments du 5 5 0 rue Viau, à Montréal.
ment voisin, inoccupé et dont la porte.était ou- suite d'une maladie. Depuis ce temps, je suis daLa maison contenait six logements, mais un
porté à tout essayer pour sauver la vie
verte. Il semble bien qu'a moitié asphyxiée, elle vantage
seul était habité. Liliane Schachuk, 44 ans, était
des autres», explique-t-il.
se soit trompée de direction.
l'unique locataire.
Ça fait une dizaine de fois qu'il donne ainsi la
Selon toute vraisemblance, M"* Schachuk auTentatives de réanimation
respiration artificielle. «Une seule fois, j'ai sauvé
rait fumé au lit et se 9erail endormie avec sa cigaDeux pompiers l'ont découverte dans l'appar- quelqu'un. Il s'agissait d'un jeune homme, en
rette. Les flammes ont couvé un bon bout de
tement concerné et se sont empressés de la sortir
1987. lors d'un incendie sur la nie dè La Salle,
temps avant de mettre le feu aux draps.
à l'extérieur. C'est par la suite que le pompier près de Hochelaga. Je l'ai ranimé, mais malheuM"" Schachuk s'est réveillée et aurait réussi,
Jean Lussier, de la caserne 45, est intervenu pour reusement, il était brûlé sur plus de 80 pour cent
malgré la fumée, à se rendre dans un appartetenter de lui lui sauver la vie.
de son corps et il est décédé une semaine plus
•J'étais au premier étage lorsque j'ai vu mes tard*, rappelle M. Lussier.
deux confrères descendre, avec M™ Schachuk
Pompier blessé lors
dans leurs bras. J'ai dit a mon officier que j'allais
d'un 2* incendie
leur donner un coup de main et je suis sorti deLes d o m m a g e s s o n t évalués a e n v i r o n
horç.
100 000 $. L'incendie, qui a nécessité une deuxiè«A l'extérieur, j'ai enlevé mon masque et mon
casque et j'ai commencé à lui donner le bouche-à- me alerte, a été tout d'abord maîtrisé à 3 h 10,
bouche, pendant que mon collègue, Yves Har- mais pour une raison inconnue, les flammes ont
jailli de nouveau au bas d'un mur du troisième
noia, lui faisait des massages cardiaques.
«Aucun de ses signes vitaux ne fonctionnait. étage, vers 10 h 30.
Les pompiers sont retournés sur place et lors
Sans relâche, Yves et moi avons continué les tentatives de réanimation. Un autre collègue, qui vé- de l'opération, le capitaine Georges-Henri Da;
viault
a fait une chute d'un étage et a été blessé
rifiait son pouls, a cru percevoir un battement.
•A ce moment, j'ai arrêté la respiration artifi- légèrement au dos. Incident qui a nécessité un sécielle, afin de vérifier si on avait enfin réussi a lui jour à l'hôpital Saint-Michel.
Pholo» Yves f ABI
Le p o m p i e r J e a n Lussier d o n n e le boucheà - b o u c h e à l a victim e , p e n d a n t q u e son
confrère, Yves H a r nois, lui f a i t des massages cardiaques. La
maison à l o g e m e n t s ,
o ù l'incendie a éclaté, n'était habitée
que par la victime,
â g é e d e 4 4 ans.
Jo rnée de ski funeste
UN CHAUFFEUR
D'AUTOBUS
PERD LA VIE
DE
2 3 - G I ' 9/
Le conducteur d'un autobus o été tué, tandis que cinq de ses
i ? . P a s s o 9 e r s e f u n camionneur ont été blessés, à la suite d'une
collision frontale survenue dans une courbe, hier vers 9H30, sur
la route Notre-Dame-de-la-Merci, à l'intersection du chemin Gagné, à Saint-Côme, à 55 kilomètres au nord dé Joliette.
son de solutés déstinés à
une dialyse. Il répétait
sans cesse qu'elle devait
être livrée sans faute à
Saint-Félix-de-Valois.
Le chargement a élé placé à bord d'une ambulance.
M m ' Danielle Boisvert-Montambault, 34
ans. a souffert d'une
fracture ouverte du fémur. Son mari. Lester
Montambault. .19 ans,
du 1200, 9* rue SaintMalo, à Sainte-Marthedu-Cap, s'en est tiré avec
une blessure à un genou.
Johanne Lafontaine,
35 ans. du 6825. boulevard Parent, à Troia-Rivières, a écopé d'un léger
Des techniciens-ambulanciers ont prodigué les premiers soins à M " * Danielle Boisvert-Montambauh qui a subi une fracture ouverte «lu fémur.
traumatisme crânien.
Paul D i a m o n d . 49
a n s . du 601, c h e m i n
Sainte-Marguerite, à
P o i n t e - d u - L a c , s'est,
plaint de malaises au dos
et au cou.
Son épouse, Rolande
Courteau, 45 ans. a subi
toires Abbott Ltèe, Clauune fracture de l'huméde Nadon, :i2 ans, de la
rus et une blessure légère
rue Rlie. à Saint-Hubert,
à l'épaule droite.
a subi une fracture ouverte à une jambe.
Selon le directeur des
services professionnels
Selon des témoins sur
du centre hospitalier réles lieux de la collision, il
gional de Lanaudière,
s'inquiétait, m al pré sa
M. Gilles Martin, quatre
souffrance, de sa cargaides six victimes devaient
recevoir leur congé quelques heures après leur
admission à l'hôpital.
Les trois autres passagers, dont l'identité n'a
pas été dévoilée, ont pu
quitter l'hôpital presque
immédiatement, n'ayant
pas subi de blessures. On
imagine qu'ils ont cependant suhi un traumatisme nerveux.
Aucune chance
La collision frontale a
élé d'une violence peu
commune.
Tout le devant de l'autobus a été replié comme
un accordéon.
I<e conducteur n'a eu
aucune chance. Il a été
écrasé sur son siège par
Des techniciens d'Ambulance Joliette ont dû utiliser des pinces de désincarcération pour dégager le
le tableau de bord et le
corps de M. Gaboury de l'amas de métal tordu. On peut voir (à gauche) que le tracteur du camion a
volant.
subi des dommages importants.
Les techniciens-ani-,
Iâ victime a été identifiée comme étanl M.
Léonard Gnhoury. AM
an», du :i2S, 120' Avenue. à Shawinigan-Sud.
Il était au volant de
l'nutobus de la compagnie Rell-Horizon. dont
les bureaux sont niKiés
au 400. me Dessureault.
à Cap-de-la-Madeleinc.
Le décès de M. finboury a été constaté au
centre hospitalier régional de l*anaudière.
I«ea aîx blessés onl élé
conduits au même hôpil al. Cinq v é h i c u l e s
d'Ambulance Juliette
ont servi au transport
des blessé».
I>e camionneur de la
compagnie /,•>.« labora-
bulanciers ont dû utiliser des pinces de désincarcération afin de le dégager de l'amas de métal
tordu.
Les passagers ont été
évacués par une fenêtre
latérale de l'autobus.
Le tracteur du camion
a également subi desdommages importants.
En c e t t e j o u r n é e
splendide, les passagers
de l'autobus se proposaient du bon temps au
centre de ski de ValSaint-Côme.
L'accident mortel est
survenu à environ un kilomètre et demi au sud
de la station de ski.
L'enquête est menée
par la Sûreté du Québec,
détachement de Juliette.
Selon nos informations,
des spécialistes en reconstitution d'événement de la Sûreté du
Québec se sont rendus
au Garage Chaput, à Joliette, pour y examiner
les deux véhicules impliués dans cet accident
e la route.
3
l e s possogers de l'outobus qui n'ont pas é t é
trop sérieusement blessés ont pensé à récupérer leurs skis. Par ailleurs, des patrouilleurs du
centre de ski Val-Saint-Côme sont venus prêter
main-forte a u * techniciens-ambulanciers.
i
V
5-year-ôld boy
pulled from pool
Richard Theriault. the 5-year-oldtreating four near-fatal drowning
boy pulled from the bottom' of Vervictims last week. Official Hélène St.
dun's Thernen Park pool Sundav. Hitaire did not have exact figurés,
died late last night after spendingbut said the number of victims seen
two days in intensive care at Montby the emergency department al>
real Children's Hospital, a nursinways
g
increases dramaucally during
supervisor told The Gazette
a heat wave.
Both Montreal Urban Community Bo il eau said statistics oo the Dumpolice and the Labor Department ber of children under $ who drown
are investigating the incident.
haven't been compiled butte'snoMVC Sgt. Det_ Gerard Bordeleauneed many more cases than ia the
of Station 22 in Verdun said herepast.
will be a coroner's inquest tnto theThe number of backyard<pool
drowning, as in any other accidentad
leaths across the province a oo the
death "especially with people of that
rise. too. he said, ln 1984 pool deaths
age."
accounted for 4 per cent of drownVerdun Mayor Raymond Savard ings. In 1986. Boileau said about IS
said he was saddened by tbe news o
f cent of the drownings occmied
per
the death, but maintained that lifein backyard pools.
guards at the pool did their jobs andTbe number of public pool drownwere not responsible.
ings remained eoosunt at about four
Red Cross officials said yesterdayor five per year, be said.
that the Dumber of swimming acciBut he said in most cases, public
dents and drownings involving youngpools
are safe, as long as there is
children are increasing
"From our point of view drowningproper surveillance.
is the up of the iceberg. ' Alain BoSome
i- ba then said this week that
leau. water-safetv director at the at the Verdun pool lifeguards were
Red Cross, said in an interview. raUïer
.listthan
ening to music in lawo chairs
For every person who dies. Boilooking out for people's
leau said, another eight to 10 survive safety, and Thériault had to be renear-drownings in which they suffer
ty
another swimmer,
some degree of permanent damage
According to the police report his
due to lack of oxygen. About three* mother had been looking for him for
quarters are children.
about 15 minutes before be was
St*. Justine Hospital reported found in tbe pool
ÉTUDES SOCIO-ÉCONOMIQUES RELATIVES
AUX TRAUMATISMES
- Quelques références -
Sicard, C. et B. Dalgle. Avril 1990. Analyse des coûts socio-économiques associés à
la morbidité et à la mortalité d'origine sportive et récréative au Québec en 1987. TroisRivières, Régie de sécurité dans les sports du Québec. 143 p.
Bordeleau, B. 1988. Évaluation des coûts de l'insécurité routière au Québec. Québec,
Direction des études et analyses, Régie de l'assurance automobile du Québec.
Camirand, F. 1983. Les coûts de la maladie au Québec en 1980-1981. Québec, gouv.
du Québec, Conseil des affaires sociales et de la famille.
Rice, D.P., EJ. MacKenzie et coll. 1989. Cost of Injury in the United States. Report to
the Congress. San Francisco, Institue for Health and Aging. University of California and
Injury Prevention Center, The Johns Hopkins University.
'
Lawson, J.J. 1989. The Valuation of Transport Safety. Ottawa, Transports Canada.
Lawson, J.J. 1978. 777e Cost of Road Accidents and their Application in Economic
Evaluations of Safety Programs. Ottawa. Transports Canada
1
2
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Statistics Statistique
Canada Canada
CSTK CAMClOî DTSffCSMASCSf St» IA 5AOT
I,
No. 1
Malaffo canfio-fcsculafres
Accidents Cancan Incidence,tepiiallsatensetdécès
Tuberculose
Canada
Accidents in Canada: Mortality and
Hospitalization .
"* '
Les accidents au Canada: décès et
hospitalisation
R. Riley, P. Paddon
R. Riley et P. Paddon
Abstract
Résumé
For Canadians under 45. accidents are the
leading causa of both death and hospitalization. For
the Canadian population as a whole, accidents rank
fourth as a cause of death. after cardiovascular
disease (CVD), cancer and respiratory disease.
Les accidents sont toujours la principale cause de décès
et d'hospitalisation chez les personnes de moins de 45 ans.
Pour tous les groupes d'âge, les accidents occupent la
quatrième place pour toutes les causes de décès, après les
maladies cardio-vasculaires. le cancer et les maladies
respiratoires.
This article analyzes accident mortality and
hospitalization in Canada using age-specific rates.
age-standardized mortality rates (ASMR), and
potential years of life lost (PYLL).
Au Canada, les statistiques des accidents qui entraînent
la mort ou l'hospitalisation sont établies selon les taux par
âge, les taux dé mortalité normalisés selon l'âge et les années
potentielles de vie perdues (APVP).
The six major causes of accidental death for
men are motor vehicle traffic accidents (MVTA), falls,
drowning, fires, suffocation and poisoning. For
women, the order is slightly different: MVTA. falls,
fires, suffocation, poisoning and drowning.
Les six principales causes de décès accidentels, chez les
hommes, sont les accidents de la circulation impliquant des
véhicules à moteur, les chutes, les noyades, les incendies,
l'asphyxie et l'empoisonnement. Chez les femmes, les causes
de décès varient un peu: les accidents de la circulation
impliquant des véhicules à moteur, les chutes, les incendies,
l'asphyxie, l'empoisonnement et les noyades.
From 1971 to 1986. age-standardized mortality
rates (ASMR) for accidents decreased by 44% for
men and 39% for women. The. largest decrease
occurred in the under 15 age group.
De 1971 à 7936. par contre, le taux comparatif de
mortalité a diminué de 44% selon l'âge chez les hommes et
de 39% chez les femmes. La plus forte baisse a été observée
chez Jes enfants de moins de 15 ans.
Accidents accounted for 11.5% of total hospital
days in 1985. and 8% of hospital ' discharges.
Because young people have the highest rates« of
accidental death, potential years of life lost (PYLL)
are almost as high for accidents as for
cardiovascular disease, although CVD deaths
outnumbered accidental deaths by almost five to
one in 1985.
Lès accidents représentent 17.5% de toutes les journées
d'hospitalisation en 1985. comparativement à 21% pour les
maladies cardio-vasculaires et 8% pour le cancer. On
enregistre chez les jeunes les taux de décès accidentels les
plus élevés, aussi le nombre d'APVP attribuable aux accidents
est-il presque aussi élevé que celui des maladies cardiovasculaires. Les décès dus aux maladies cardio-vasculaires
dépassent cependant de cinq fois les décès accidentels en
1985.
Introduction
Introduction
Accidents in Canada are a leading cause of
death arid hospitalization. The majority result f r o m
motor vehicle traffic accidents, falls, fires, drownings,
and poisonings. Accidents occur primarily on our
roads and highways, in our h o m e s , and affect every
age g r o u p from infants to the elderly.
Les accidents sont une d e s principales causes d e décès
et d'hospitalisation au Canada. Les plus fréquents sont les
accidents d e là circulation impliquant d e s véhicules à moteur,
les
chutes,
les
incendies,
les
noyades
et
les
e m p o i s o n n e m e n t s . Les accidents se produisent surtout sur
nos routes et dans nos foyers, et touchent tous les segments
d e la population canadienne, d e s nouveau-nés jusqu'aux
personnes âgées.
This paper examines accidents in Canada using
mortality and hospital morbidity statistics provided, to
Statistics
Canada
by
the
provinces.
Some
international
comparisons
are
also
presented.
Mortality
trends
and provincial
variations
are
reviewed, as well as hospitalization patterns. Agestandardized rates, age-specific rates, and potential
Le présent d o c u m e n t examine les accidents qui se
produisent au Canada à partir d e s d o n n é e s sur la mortalité et
la morbidité hospitalière que fournissent les provinces à
Statistique Canada. Des c o m p a r a i s o n s avec d'autres p a y s sont
également présentées. Les tendances et les différences entre
les provinces au chapitre d e la mortalité sont examinées, d e
m ê m e que- les caractéristiques d e l'hospitalisation. Les taux
Health Reports. Volume t. Number » - Rapports sur la same, volume i, numéro t
Page 23
years of life lost are analyzed to determine trends,
patterns, and the frequency of accidents that results
in death and hospitalization.
normalisés selon l'âge, les taux par âge et les année
potentielles d e vie perdues (APVp) sont les mesures qui o u
permis, dans cette analyse, de déterminer les tendances, les
caractéristiques et la fréquence des accidents qui entraînent la
mort et l'hospitalisation.
Method
Méthode
In the health field most authors would agree with
the following definition: "an accident is an event, it
occurs abruptly, is potentially harmful, is independent
of h u m a n volition, and has a cause outside the
individual" 1 . Consequently this definition excludes
deliberate acts of violence, suicide, homicide and
maltreatment. This definition was used to select
accidents from the Supplementary Classification of
External Causes of Injury and Poisoning (E-codes),
Dans le domaine de la santé, .la plupart des auteurs
s'entendent sur la définition du terme "accidents", à savoir
qu 7 il s'agit d'un événement imprévu et soudain qui p e u t
représenter un danger, qui est indépendant de la volonté
humaine, dont la cause est extérieure à la personne et qui
entraîne une btessure 1 . En conséquence, cette définition exclut
tes actes de violence délibérés, les suicides, les homicides et
les mauvais "traitements. En partant d e cette définition, des
catégories d'accidents ont été choisies dans la classification
supplémentaire des accidents et des empoisonnements selon
la cause extérieure (rubriques E) d e la
Classification
International Classification of Diseases (ICD). World
Health Organizations. For this study on accidents the
E-codes E-800-E949 were selected, excluding E870E879.
Data on accident mortality are based on the vital
statistics data base of the Health Division of Statistics
Canada. T h e mortality period studied is 1951-1986
and covers the ten provinces. Age-standardized
mortality rates (ASMR) for males and females were
calculated based on the 1971 census population of
Canada as the standard. Age-specific mortality rates
for both sexes were also computed. In comparing the
importance of major caiises of death one measure
used is potential years of life lost (PYLL) between the
ages of 0 and 75. The PYLL indicator'provides a
statistical expression to the harsh reality of death at
an early age. The mortality data for the international
comparisons were taken from the World
Health
Statistics
Annual published by the World Heajth
Organization 3 .
Accidents
resulting in hospitalization
were
derived from the Statistics Canada hospital morbidity
statistics program. The data consist of a count of
inpatient discharges during the year from general
and allied special hospitals. Since a patient may be
admitted to a hospital and discharged several times
during a_year. the data are a count of discharges
rather than individual persons. Emergency visits and
outpatient data are not reported. In recent years, the
reporting of E-codes has improved considerably.
Provincial reporting of E-codes was examined for
1
Tursz. A. Spidemiological Studies of Accident Morbidity
in Children
and
Young People:
Problems
of
Methodology• Wo rid Health Statistics Quarterly, volume
39. No. 3. 7986.
2
3
Manual of the Intemaoonai Classification of Statistical
Classification of Diseases, Injuries and Causes of
Oeath. World Health Organization Geneva. 1987.
World Health S/a&sûcs. World Health Organization.
Geneva. '966.
Page 24
internationale des maladies (CIM) de l'Organisation mondiale
de la santés. Les rubriques E800 à E949 ont été retenues pour
la présente étude, à l'exception des rubriques E870 à E879.
Les données sur la mort par accident sont tirées de la
base de données de ta statistique de l'état civil de la Division
de la santé de Statistique Canada. L'étude d e la mortalité porte
sur les années 1951 à 1986, par intervalles de cinq ans. et vise
les dix provinces. Les taux de mortalité normalisés selon l'âge
pour les h o m m e s et tes femmes ont été calculés à partir des
données d u recensement de la populaton canadienne d e 19T'
Les taux de mortalité par âge pour les h o m m e s et les femm
ont également été calculés. Le nombre d'années potentiel
de vie perdues (APVP) entre 0 et 75 ans est une des mesures
qui ont permis d e comparer l'importance des principales
causes de décès. Cet indicateur exprime d e façon statistique
la dure réalité des décès en bas âge. Pour les comparaisons
•faites avec d'autres pays, des données sur la mortalité ont été
tirées de
Annuaire de statistiques sanitaires mondiales
publié par l'Organisation mondiale de la santé 3 .
Les données sur les accidents entraînant l'hospitalisation
ont été tirées d u programme de la morbidité hospitalière de
Statistique Canada. Elles représentent le nombre de départs
de malades hospitalisés des hôpitaux généraux et spécialisés
pendant l'année. Étant donné qu'un malade peut être admis à
l'hôpital et recevoir son congé plusieurs fois au cours d ' u n e
m ê m e année, les données correspondent au nombre de
départs plutôt qu'au nombre d e malades. Les données sur les
visites à l'urgence et sur les patients externes ne sont pas
déclarées. Ces dernières années, une nette amélioration quant
à la. déclaration des accidents des rubriques E a été observée.
'
Tursz. A. Spidemiological
Studies of Accident Morbidity in
Children and Young People: Problems of Methodology. World
Health Statistics Quarterly, Volume 39. No. 3. 1986.
2 Manual
of the international
Classification
of
Statistical
Classification of Diseases, injuries and Causes of Death. World
Health Organization Geneva. 1987.
3
World Health Statistics. World Health Organization. Geneva. 1986.
Health Reports. Volume i . Number i - Rapports sur la santé, volume t. numéro '
nine provinces (excluding Prince Edward Island) and it
was estimated that 9 0 % of the E - c o d e s were reported.'
Les déclarations d'accidents d e s r u b r i q u e s , E d e toutes les
provinces (à l'exception d e
rïlé-du-Prince-Édouard)
ont été
étudiées. L ' e x a m e n d e ces dossiers provinciaux, a révélé
qu'environ 9 0 % des accidents des rubriques E ont été
déclarés.
Results
Résultats
INTERNATIONAL COMPARISONS
COMPARAISONS AVEC D'AUTRES PAYS
M o r t a l i t y R a t e s f o r Six C o u n t r i e s
Taux d e mortalité d a n s six p a y s
A c o m p a r i s o n of mortality rates a m o n g six
countries for the five leading causés of accidental
deaths in 1985 s h o w e d Canada s e c o n d for deaths from
accidental poisonings and fires (Chart l ) . Canada was
in the m i d d l e for the remaining leading causes, that is.
motor vehicle traffic accidents, drownings, and falls.
These rankings w e r e very similar to 1982 international
data for these countries.
Si l'on c o m p a r e les taux d e mortalité pour les cinq
principales causes d e décès accidentels en 1985. on constate
que le Canada vient au d e u x i è m e rang pour les décès causés
par des incendies (graphique 1 ). Le Canada o c c u p e le rang du
milieu pour les autres causes principales, c'est-à-dire lès
accidents d e la circulation impliquant d e s véhicules à moteur,
les noyades et les chutes. Cet ordre d ' i m p o r t a n c e est très
semblable à celui d e 1982.
A g e - S p e c i f i c M o r t a l i t y R a t e s f o r Six C o u n t r i e s
Taux de mortalité par â g e d a n s six pays
In all countries mortality rates for motor vehicle
traffic accidents w e r e highest for the age g r o u p s 15-24
and 75 and over (Chart 2). For Canada, the U.S..
Austria, and G e r m a n y rates p e a k e d at ages 15-24;
while in England a n d Japan rates were highest for
those 75 and over.
Les taux d e mortalité par accident d e la circulation
impliquant d e s véhicules à moteur sont les plus élevés chez
les groupes d e 15 à 24 ans et d e 75 ans et plus dans tous les
pays (graphiquè. 2). A u Canada, aux États-Unis, en Autriche et
en Allemagne, les taux atteignent leur s o m m e t chez les
groupes d e 15 à 2 4 ans. tandis q u ' e n Angleterre et au Japon,
les taux les plus élevés se situent chez les groupes d e 75 ans
et plus.
•
Mortality rates for falls were far higher in the older
population in all countries. The Canadian rate for falls
was 128 deaths per 100.000 for the 75 and over group,
ranking Canada third. T h e highest rate in this age
group was reported for Austria (239 per 100.000) and
the lowest for Japan (38 per 100.000).
Dans tous les pays, les taux d e mortalité due aux chutes
les plus élevés se trouvent chez les gens âgés. Au Canada, le
taux de mortalité par chute est d e 128 d é c è s pour 100.000
habitants chez les personnes d e 75 ans et plus, ce qui place le
Canada au troisième rang pour c e g r o u p e d'âge. Le taux le
plus élevé dans c e g r o u p e d ' â g e est celui d e l'Autriche (239
pour 100.000) et le plus bas. celui d u Japon (38 pour 100,000).
Age-specific rates for drownings were highest for
children 1-4 in all countries, e x c e p t Japan. Rates
levelled off thereafter except in Japan where the rate
increased sharply at older ages.
Dans les six pays, les taux d e mortalité par âge pour les
noyades sont le plus élevés chez les jeunes d e 1 à 4 ans. Les
taux se stabilisent pour les autres groupes d'âge, sauf au
Japon, où ils augmentent rapidement chez les personnes
âgées.
.
In all six countries age-specific mortality rates for
accidents c a u s e d by fires were highest a m o n g thé
older population. Accidents c a u s e d by fires were
highest a m o n g the older population. For Canada.
England and G e r m a n y the s e c o n d highest rate was in
the very y o u n g a g e d 1-4. In 1985 in Canada, s o m e o n e
75 or older was ten times m o r e likely to die in a fire
than a 25 to 34 year old. The e x c e s s risk of d y i n g in a
fire at older ages c o m p a r e d with persons ages 2 5 - 3 4 is
even greater in Japan, with a rate 18 times higher, and
England and Wales with a rate 16 times higher in those
a g e d 75 years and over.
Les taux d e mortalité par âge pour les accidents causés
par des incendies sont plus élevés chez les personnes âgées.
A u Canada, en Angleterre et en Allemagne, c e sont ensuite
chez les très jeunes enfants d e 1 à 4 ans. Eh 1985. au Canada,
une personne de 75 ans et plus était quatre fois plus
susceptible d e mourir dans un incendie q u ' u n e personne d e
25 à 34 ans. Le risque plus g r a n d d e mourir dans un incendie
q u e courent les personnes âgées par rapport aux personnes
d e 25 à 34 ans est encore plus remarquable au Japon, où le
taux est dix-huit fois plus élevé, et en Angleterre et au pays d e
Galles, où le taux est seize fois plus élevé chez les personnes
d e 75 ans et plus.
Health Reports. Volume 1. Number i - Rapports sur la santé, volume i. numéro i
Page 25
Chart 1
Graphique 1
Accidents, Mortality Rates, by Selected Countries. 1985
Accidents, taux de mortalité, pour certains pays, 1985
Rate per 100,000 population - Taux pour 100.000 habitants
M o t o r Vehicle Traffic A c c i d e n t s
A c c i d e n t s d e la circulation impliquant des véhicules à moteur
Drownings - N o y a d e s
Japan _ _ _ _
Japon
United States
États-Unis
CANAOA
CANAOA
Federal Republic
of Germany
Réoublioue fédérale
d'Allemagne
Austria - Autriche - -
- -
Federal Republic
of Germany
Réoublioue fédérale * •
d'Allemagne
Japan - Japon
England and Wales
Angleterre oays de
Galles
England and Wales _
Angleterre pavs de
Galles
I
25
0.5
Faits - C h u t e s
Fires « Incendies
Austna - Autriche • - -
United States
États-Unis
Federal Republic
Of Germany
République fédérale ~~
d'Allemagne
CANAOA
l
I
I
I
1.5
2.0
2.5
3.0
—
England and Wales
Angleterre pays de
Galles
England and Wales _ .
Angleterre pays de
Galles
CANAOA
Japan - Japon
United States
États-Unis
Federal Republic
of Germany
Réoublioue fédérale
d'Allemagne
Japan
Japon
Austna
_
Autriche
1
I
1.0
25
i
I
I
I
I
0.5
1.0
1.5
2.0
2.5
Poisonings - Empoisonnements
United States
Etats-Unis
CANAOA
England and Wales
Angleterre pays de
Galles
Austna
Autriche
Japan - Japon - •
Federal Republic
of Germany
République federate
d'Allemagne
Page 26
I
I
I
I
I
0.5
1.0
1.5
2.0
2.5
Health Reports. Volume i Number i - Rapports sur la santé, volume t. numéro i
Graphique 2
Chart .2
Accidents, Age-specific Mortality Rates, by Selected Countries, 198S
Accidents, taux de mortalité par âge, pour certains pays, 1985
Rate per 100.000 population - Taux pour 100.000 habitants
Motor Vehicle Traffic Accidents
Accidents de la circulation impliquant
des véhicules à moteur
Legend - Légende
Canada
Austria
Autnche
England
Angleterre
Germany
Allemagne
Japan
Japon
<1
i
5-14
i 25-34 i .45-54 i 65-74 '
1-4
15-24
35-44
55-64
75'
Age groups - Groupes d'âge
250 r-
Fires - Incendies
Falls - Chutes
200
150
100
50
< 1
<1
i
5-Î4
i 25-34 I 45-54 I 65-74
1-1
15-24
35-44
• 55-64
75
i
5-14, ' 25-34 " 45-54 i 65-74 «
1-4
15-24
35-44
55-64
75;
Age groups * Groupes d'âge
Drownings - Noyades
i
5-14
i 25-34 i 45-54 ' 65-74
1-1
15-24
35-44
55-64^
75 +
Health Reports. Volume t. Number i - Rapports sur la santé, volume i. numéro i
Poisonings r Empoisonnements
4 r-
<1
v
i
5-14
i 25-34 • 45-54 i .65-74 1
1 -i
15-24
35-44
55-64
75 +
Page 27
Age-specific mortality rates for poisonings were
lowest in the under IS g r o u p . For those 15 and over
the rates w e r e higher but with wider variations between
the six countries c o m p a r e d to other types of accidents.
i
. •
Pour les e m p o i s o n n e m e n t s , les taux d e mortalité par àg
les plus bas s'observent chez les personnes de m o i n s de .1.
ans. Chez tes groupes d e 15 ans et plus, les taux sont
généralement plus élevés, mais les écarts entre les six p a y s
sont plus grands c o m p a r a t i v e m e n t
aux autres
genres
d'accidents.
Canada and the United States
Canada et États-Unis
The distribution of age-specific mortality rates for
motor vehicle traffic accidents was similar across the
age g r o u p s w h e n c o m p a r i n g Canadian and American
data (Chart 3). For the 15 to 2 4 age group, m e n were
three times m o r e likely , to die from a motor vehicle
traffic accident than w o m e n . Three times m o r e likely to
die from a motor vehicle traffic accident than w o m e n .
For both sexes, rates were highest in the age groups
15-24 and 75 + .
La répartition d e s taux d e mortalité par âge pour les
accidents d e la circulation impliquant d e s véhicules à moteùr
est très similaire d a n s tous tes g r o u p e s d ' â g e lorsque l'on
c o m p a r e les données pour (e C a n a d a et les États-Unis
(graphique 3). Les h o m m e s d e 15 à 2 4 ans sont plus d e trois
fois plus suscepti6les d e mourir dans un accident d e la
circulation que les. f e m m e s du. m ê m e g r o u p e d ' â g e . Chez les
deux sexes, les taux étaient les plus élevés pour les groupes
d ' â g e d e 15-24 ans et d e 75 ans et plus.
In Canada and the United States, deaths from fallso c c u r r e d m o s t frequently in the 75 and over age g r o u p
for both sexes. Rates were considerably higher for
m e n in all age g r o u p s until age 75 and over.
Les décès causés par d e s c h u t e s surviennent te plus
f r é q u e m m e n t chez les h o m m e s et les f e m m e s d e 75 ans et
plus, aussi bien au Canada qu'aux États-Unis. Les taux pour
les h o m m e s sont b e a u c o u p plus élevés dans tous les g r o u p e s
d'âge, sauf les groupes d e 75 ans et plus.
For all age g r o u p s mortality rates for drownings
were considerably higher for m e n ' than w o m e n .
Canadian rates for male d r o w n i n g s m a t c h e d U.S.
patterns although rates for m e n were slightly h i g h e r in
the United States. Death rates from drownings were
highest for both countries in the 1-4 age groups. The
s e c o n d highest rate was in the age group 15-24 in the
U:S., and the age g r o u p 7 5 + in Canada. Second
highest rate was in the age g r o u p 15-24 in the U.S..
a n d the age g r o u p 75 + in Canada. Females with
considerably lowest rates followed similar age patterns
as males in- both countries. Both in Canada and the
United States d e a t h rates from fires were higher for
m e n than w o m e n , and for. both ; sexes, rates were
highest in the 1-4 age g r o u p and the 75 + age group.
Les taux d e mortalité par âge pour les noyades
accidentelles chez les h o m m e s au Canada sont très près d e s
taux correspondants observés aux États-Unis (graphique 3).
Bien que les taux enregistrés c h e z les h o m m e s soient
légèrement-plus élevés aux États-Unis, les taux les plus élevés
pour les noyades accidentelles se trouvent, dans les d e r *
pays, chez les jeunes d e 1 à 4 ans puis chez les personnes c
15 à 2 4 ans aux États-Unis et d e 75 ans et plus au Canad
Les groupes d ' â g e d e s f e m m e s , chez qui les taux d e mortalité
étaient b e a u c o u p m o i n s élevés, se rapprochaient d e s groupes
d ' â g e d e s h o m m e s dans les deux pays. Tant au Canada
qu'aux États-Unis, les taux d e mortalité c a u s é e .par les
incendies étaient plus élevés c h e z les h o m m e s q u e c h e z les
f e m m e s ; pour les deux sexes, les taux étaient plus élevés chez
tes jeunes d e 1 à 4 ans et chez tes personnes d e 75 ans et
plus.
in Canada a n d . the United States the average
mortality rates for poisonings were approximately t w i c e
as high for m e n as for w o m e n over the age of 14. The
largest differences in rates for males and females
o c c u r r e d in the 2 5 - 3 4 g r o u p , w h e r e the rate for males
was three times higher in Canada and four times
higher in the U.S.
Au Canada et aux États-Unis, les taux d e mortalité m o y e n s
pour tous tes âges due aux e m p o i s o n n e m e n t sont environ
deux fois plus élevés chez tes h o m m e s q u e c h e z les f e m m e s
âgés d e plus d e 14 ans. O n o b s e r v e te-ptus g r a n d écart entre
les h o m m e s et les f e m m e s dans te g r o u p e d e s 2 5 à 34 ans.
où le taux est trois fois plus élevé chez les h o m m e s .
CANADIAN TRENDS
TENDANCES DANS CANADA
Leading Causes of Death and Hospitalization
Principales causes de décès et d'hospitalisation
Accidents in C a n a d a are a major cause of death
and hospitalization for all ages. For the Canadian
population as a whole, accidents ranked fourth as a
cause of death, after cardiovascular disease, cancer
and respiratory disease. However their importance
varies great|y at different stages of life. In 1966. 1976.
and 1986 (Chart 4) accidents were the leading cause of
death for p e r s o n s under 45 years of age. From 45 to
64. accidents were outranked only by cardiovascular
Bien q u ' a u Canada les accidents soient une importante
cause de décès et d'hospitalisation dans tous les g r o u p e s
d'âge. Pour tous tes groupes d ' â g e , les accidents o c c u p a i e n t
la quatrième place d e toutes les c a u s e s ' d e décès, après tes
affections cardio-vasculaires.' le cancer et tes
troubles
respiratoires./La place qu'ils o c c u p e n t varie c o n s i d é r a b l e m e n t
seion les différentes étapes d e la vie. Un e x a m e n des six
principales causes d e d é c è s pour 1966. 1976 et 19
(graphique 4) montre que les accidents sont la principe
Page 28
Health Reoorts. Volume 1. Numoer 1 - Rapports sur la santé, volume i . numéro i
Chart 3
Graphique 3
-
Accidents, Age-specific Mortality Rates, by Sex, Canada and U.S.A., 1985
Accidents, taux de mortalité par âge, selon le sexe, Canada et États-Unis, 1985
Ram per 100.000 population - Taux pour 100.000 habitants
Accidents de ia circulation impliquant
Legend - Légende
Canada - Maie
Canada - Homme
Canada - Female
Canada - Femme
U.S.A. - Male
États-Unis - Homme
U.S.A. - Female
États-Unis - Femme
<1
i
5-14
I 25-34 I 45-54 • 65-74
1-4
15-24
35-14
55-64
75
Fails - Chutes
140
120
10
100
8
80
Fires - Incendies
12
6
60
4
40
2
20
0
«
<1
•
0
'
i
5-14
» 25-34. » 45-54 • 65-74 '
1-4
15-24
35-44
55-64
75
<1
l
1-i
Age groups * Groupes d'âge
! 5-14
î 25-34 " 45-54 i 65-74 1
1-4
15-24
35-44
55-64
75
• 25-34
l 45-54 • 65-74 «
15-24 '
35-44
55-64
75
Drownings - Noyades
<1
5-14
1
.i
1-4
t. 25-34
45-54 • 65-74 1
15-24
• 35-44
55-64
75
5-14
Page 29
Health Reports. Volume ». Number i - Rapports sur la santé, volume t. numéro l
Chan 14
Graphique 14
Five Leading Causes of Death, by Age, Canada, 1966, 1976, 1986
Cinq principales causes de décès, selon l'âge, Canada, 1966, 1976, 1986
Under 45 years
Moins de 45 ans
CODES
Number of deaths
Nombre de décès
B
7.000 i -
6.000
5.000
r•
Accidents
2
Cancer
3
Cardiovascular diseases
Maladies cardio-vasculare
4
Suicides
5
Pneumonia and influenza
Pneumonie et gnppe
6
Perinatal
Affections pènnatales
7
Liver disease and cirrhosis .
Maladie du foie et cirrhose
8
Bronchitis and emphysema
Bronchite et emphysème
9
Diabetes
Diabète
4.000
3.000
2.000
1.000
0
1976
1966
1986
45-64 years
45-64 ans
65 years and over
65 ans et plus
Number of deaths
Number of deaths
Nombre de décés
Nombre de décès
20.000 r-
70,000
60.000
15,000
50.000
40.000
10.000
30.000
20.000
5.000
10.000
|i_8
•
1966
Page 30
• '
'4
Ë h .
1976
1986
2'
1966
Health Reports. Volume i. Number t -
HmL
1976
T£b
1986
Rapports sur la santé, volume t. numéro i
disease and cancer. For the 65 and over age group,
accidents ranked fourth and fifth a m o n g deaths. The
rank-order of hospitalizations following an accident was
similar to that for deaths (Chart 5). For persons under
45. accidents w e r e the leading cause. They were the
fourth leading cause in the 45-64 group, and the third
leading cause for the age g r o u p 65 and over.
cause d e d é c è s c h e z les personnes d e moins d e 45 ans. Dans
le groupe des 45 â 6 4 ans. ils viennent au troisième rang,
après les maladies cardio-vasculaires et le cancer, tandis que
chez les personnes d e 65 ans et plus, ils occupent la
quatrième et c i n q u i è m e place. L'ordre d ' i m p o r t a n c e d e s .
causes d'hospitalisation est très s e m b l a b l e à celui des causes
de décès (graphique 5). Chez les personnes d e moins de 45
ans. les accidents sont la principale cause d'hospitalisation, ils
constituent la quatrième cause d'hospitalisation chez les
personnes d e 45 à 64 ans et la troisième chez celles de 65
ans et plus.
Potential years of life lost (PYLL) provide a useful
statistical indicator of premature death, because
heavier weight is g i v e n to deaths at younger ages. The
contrast b e t w e e n cardiovascular disease and accidents
using PYLL (between 0 a n d 75 years) illustrates this
point (Chart 6). Although in 1986 deaths from
cardiovascular disease (34.1% of deaths) o u t n u m b e r e d
those from accidents (7.2?'o of deaths) by nearly 5 to 1,
they both were very close in terms of PYLL. In
addition. PYLL for accidents were almost two-thirds of
the PYLL for cancer..
Si l'on examine la mortalité sous l'angle des années
potentielles d e vie perdues, on obtient un bon indicateur des
d é c è s prématurés, puisque c e calcul donne plus d e poids aux
d é c è s en bas âge. La différence entre les A P V P (entre 0 et 75
ans) attribuables aux affections cardio-vasculaires et les APVP
attribuables aux accidents le prouve (graphique 6). Bien qu'en
.1986 le n o m b r e d e d é c è s attribuables aux affections cardiovasculaires (34.1% des décès) ait été environ cinq fois
supérieur à celui d e s décès causés par des accidents (7.2%
d e s décès), ces deux causes sont responsables d'un n o m b r e
d ' A P V P très semblable. En outre, les A P V P imputables aux
décès accidentels correspondent à près des deux tiers des
APVP imputables au cancer.
Mortality Trends
From 1951 to 1986. mortality rates (ASMR) for
accidents have d e c r e a s e d both for males and females
(Chart 7). No a p p r e c i a b l e change o c c u r r e d during the
first two d e c a d e s after 1951; however., from 1971 to
1986 the age-standardized mortality rate d e c r e a s e d - b y
4 4 % for m e n (from 78 to 4 4 per 100.000 population)
and by 3 9 % . for w o m e n (from 33 to 20 per 100.000
population). The A S M R for m e n during the 1951-1986
period was always at least twice the rate for w o m e n ,
the ratio ranging f r o m 2.2 to 2.6.
Tendances de la mortalité
L'examen des taux comparatifs d e mortalité selon l'âge
pour les accidents qui se sont produits entre 1951 et 1986
• révèle une baisse tant chez les h o m m e s que chez les f e m m e s
(graphique 7). Ce taux n'a presque pas varié entre 1951 et
1971. Cependant, entre 1971 et 1986. il a diminué de 4 4 %
chez les h o m m e s (de 78 à 44 décès pour 100.000 habitants)
et d e 3 9 % chez les f e m m e s (de 33 à 20 décès pour 100.000
habitants). Entre 1951 et 1986. le taux comparatif d e mortalité
selon l'âge chez les h o m m e s était toujours au moins le double
d u taux d e mortalité chez les f e m m e s . " l e ratio variant d e 2.2 à
2.6.
A provincial c o m p a r i s o n of the A S M R for accidents
in 1966. 1976. and 1986 showed decreases in all
provinces (Chart 8). In 1966. the A S M R was highest in
New Brunswick. British C o l u m b i a and Nova Scotia and
lowest in Newfoundland. Ontario and Manitoba. In
1986. the A S M R was highest in Saskatchewan. British
C o l u m b i a a n d Prince Edward Island and lowest in
Newfoundland. Ontario and Nova Scotia. From 1966 to
1986 the largest decreases in the A S M R were in
Newfoundland. N o v a Scotia, and Prince Edward Island,
each showing a reduction of over 5 0 % . , T h e A S M R for
Quebec closely followed the national A S M R . which
d e c r e a s e d b y 2 0 % from 1966 to 1976 and by 3 4 %
from 1976 to 1986.
Si l'on c o m p a r e les taux comparatifs d e mortalité selon
l'âge pour les accidents dans les différentes provinces en
1966. 1976 et 1986. on observe des baisses dans toutes l e s .
provinces (graphique 8). En 1966. les taux les plus élevés
étaient c e u x du Nouveau-Brunswick. d e la
ColombieBritannique et d e la Nouvelle-Ecosse, tandis que tes plus bas
étaient ceux d e Terre-Neuve, d e l'Ontario et du Manitoba. En
1986, la Saskatchewan, la Colombie-Britannique et l'île-duPrince-Édouard affichaient les taux les plus élevés, alors que
Terre-Neuve. l'Ontario et la Nouvelle-Ecosse présentaient les
taux les plus bas. Entre 1966 et 1986. les plus fortes baisses
du taux comparatif de mortalité selon l'âge se sont produites à
Terre-Neuve, en Nouvelle-Ecosse et à lïle-du-Prince-Édouard.
où il a baissé d e plus d e 5 0 % . Au Québec, le taux comparatif
d e mortalité selon l'âge suivait d e très près le taux enregistré
pour l ' e n s e m b l e du pays, lequel a diminué d e 2 0 % entre 1966
e u 976 et d e 3 4 % de 1976 à 1986.
The age-specific mortality rates for accidents were
higher for males in all age g r o u p s (Chart 9). Rates for
males d e c l i n e d over the 1951-1986 period in ail age
groups. .For w o m e n , however, not all age g r o u p s
showed a decline, that is. the age groups 15-24 and
25-44' showed
moderate
increases. The
largest
Les taux d e mortalité par âge pour les accidents sont plus
élevés c h e z les h o m m e s dans tous les groupes d ' â g e
(graphique 9). Entre 1951 et 1986. les taux de mortalité par
âge chez les h o m m e s ont diminué dans tous les groupes
d'âge. Ce n'est pas le cas chez les f e m m e s , où les taux de
mortalité chez les groupes d e 15 à 24 ans'et de 25 à 44 ans
Health Reports. Volume ». Number i - Rapports sur la same, volume i. numéro ?
Page•»'
Chan 14
Graphique 14
Five Leading Causes of Hospitalization, by Age, Canada, 1985
Cinq principales causes d'hospitalisation, selon l'âge, Canada, 1985
Number of discharges
Nombre de départs
COOES
250,000 i—
Accidents
Diseases of musculoskeletal system
Maladies du systeme ostéomuscuiaire
200.000
Mental disorders
Troubles mentaux
150.000
Diseases of nervous system
Maladies du système nerveux
100.000
Bronchitis, emphysema, and asthma
Bronchite, emphysème et asthme
Cancer
50.000
Maladies cardto-vasculaires
45-64
Under 45
Moins de 45
65 and over
65 et plus
Age - Age
Chart 6
Graphique 6
Deaths and Potential Years of Life Lost, by Major Causes, Canada, 1986
Décès et années potentielles de vie perdues, selon les principales causes, Canada, 1986
Number of deaths
Nombre de dècès
40.000
30.000
20.000
Potential Years of Life Lost1
Années potentielles de vie perdues1
100.000
I
200.000
I
300.000
_ I
400.000
I
500.000
I
Cancer
Maladie cardio-vascuiaires
Accidents
Suicides
Pennatal2
Affections pénnataJes2
Congenital anomalies
Anomalies congénitales
Respiratory diseases
Maladies respiratoires
1
Between ages of 0 and 75. - Entre 0 et 75 ans.
2 Excludes stillbirths. - Ne comprend pas les mortinaissances.
Page
30
Health Reports. Volume i. Number t - Rapports sur la santé, volume t. numéro i
Graphique 7
Chart 7
Accidental Deaths, Age-standardized Mortality Rates (ASMR) by Sex, Canada,1951-1986
Décès accidentels, taux comparatifs de mortalité selon l'âge, seion le sexe, Canada, 1951-1986
ASMR per 100.000 population
Taux comparaofsde mortalité normalisés
selon l'âge pour .100.000 habitants
ASMR per 100.000 population
Taux comparatifs de mortalité normalisés
seion l'âge pour 100.000 habitants
—1100
100
r—
1951
1956
1961
1966
Chart 8
1971
1976
1981
1986
Graphique 8
Accidental Deaths, Age-standardized Mortality Rates (ASMR), by. Province, Canada,
1966, 1976, 1986
Décès accidentels, taux comparatifs de mortalité selon l'âge, par province, Canada, 1966, 1976, 1986
Rate per 100.000 population
Taux pour 100.000 habitants
80*1—
—i
80
—
60
—
40
—
20
• 0
Health Reports. Volume t. Number l - Rapports sur la santé, volume i, numéro i
Page 33
Graphique
Accidental Deaths, Age-speciflc Mortality Rates, by Age and Sex, Canada, 1951-1986
Décès accidentels, taux de mortalité par âge, selon l'âge et le sexe, Canada, 1951-1986
Maie - Hommes
Female - Femmes
150 r -
60 r-
50
.0-4.
5-14
40
15-24
25-44
30
45-64
20
10
I
19S1 1956 1961 1986
1971 1976 1961 1986
19S1 1956 1961 1966
I
1971 1976 1981 1986
Chart 10
Graphique 10
Percentage of Accidental Deaths to All Causes of Deaths, by Age and Sex, Canada, 1951-1986
Décès accidentels en pourcentage de toutes les causes de décès, selon l'âge et le sexe, Canada, 19511986
.
Maie - Hommes
Female - Femmes
Percentage
Pourcentage
Percentage
Pourcentage
80 i -
60 r -
50
60
•
0-4
Ë3 5-14
40
^
15-24
M
25-44
40
30
M 45-64
H
65 +
20
20
y yi
10
i
L
1951 19S6 1961 1966 1971 1976 1981 1986
Page 34
h
1951 1956 1961 1966'1971 1976 1981 1986
Heailh Reports. Volume i. Number i - Rapports sur la santé, volume l. numéro
declines in rates were for children under 15. For
example, from 1951 to 1986. rates decreased by 75%
for children under 5. c o m p a r e d to 3 9 % for all ages. For
those 5 - 1 4 the decrease was 7 1 % for b o y s and 5 3 %
for girls. During this same period rates were highest for
seniors (65 and over) and lowest for children 5-14.
ont c o n n u des augmentations modérées. Les baisses les plus
importantes d e s taux d e mortalité par âge sont survenues chez
les groupes d e moins d e 15 ans. Par e x e m p l e , de 1951 à
1986. les taux d e mortalité par âge ont d i m i n u é d e 7 5 % chez
les jeunes d e m o i n s de 5 ans. par rapport à 3 9 % pour
l'ensemble des groupes d'âge. Chez les jeunes de 5 â 14 ans.
la diminution a été d e 7 1 % chez les garçons et de 5 3 % chez
les filles. Entre 1957 et 1986. les taux d e mortalité les plus
élevés ont été o b s e r v é s chez les personnes d e 65 ans et plus
et les taux les plus bas. chez celles de 5 à 14 ans.
From 1951 to 1986. accidental deaths, as a
percentage of total deaths a m o n g m e n decreased from
8 . 3 % in 1951 to 5.9% in 1986. For w o m e n , the
percentages declined from 3.9% to 3.6%. However,
rates varied greatly a m o n g age groups (Chart 10). For
males, the 15-24 g r o u p had the largest p e r c e n t a g e s
accidentai deaths throughout the period, ranging from
53.2% in 1951 to a 1966 peak of 7 2 . 9 % to 5 4 % in
1986. For females in this age group the percentages
were 16.6% in 1951. peaking at 5 1 . 0 % in 1971. and
decreasing to 4 3 . 4 % in 1986:
Les d é c è s accidentels, en pourcentage d e toutes les
causes de d é c è s , sont passés d e 8 . 3 % en 1951 à 5 . 9 % en
1986 chez les h o m m e s , et d e 3.9% à 3.6% chez les f e m m e s .
Cependant, il y a d e grands écarts entre les groupes d'âge
(graphique 10). Chez les h o m m e s , le plus fort pourcentage d é
décès accidentels par rapport à toutes les causes d e d é c è s au
cours de cette période se situe chez les groupes de 1 5 à 24
ans. allant d e 5 3 . 2 % en -1951 à un s o m m e t d e 72.9% en 1966
et retombant à 5 4 % en 1986. Les taux pour les f e m m e s d u
m ê m e âge sont d e 16.6% en 1951. atteignent un s o m m e t de
5 1 . 0 % en 1971 et diminuent à 43.4% en 1986.
T h e A S M R for the six leading causes of accidental
death were considerably higher for males during the
period 1951-1986 with the exception of falls from 19511961 when the A S M R were higher for females (Chart
11).. T h e A S M R for motor vehicle traffic accidents for
m e n increased by 4 2 . 8 % from 1951-1966 and then
d e c r e a s e d by 4 8 . 1 % from 1966-1986. For w o m e n ,
there was a 6 4 . 8 % increase from 1951 to 1966 and a
3 9 . 0 % decrease from 1971 to 1986. T h e A S M R for
falls d e c r e a s e d b y 56.4% from 1951 to 1986 for
w o m e n and by 4 9 . 2 % for men. For this same period,
d r o w n i n g s s h o w e d a decrease of 6 5 . 9 % in the A S M R
for w o m e n , and 73.7% for men. The A S M R for fires
fluctuated d u r i n g the period 1951-1976 for m e n . From
1976-1986. however, it d e c r e a s e d , by 4 7 . 8 % . For
w o m e n the A S M R decreased by 4 0 . 6 % from 1951 to
1986. From 1951 to 1971 the A S M R for poisonings
s h o w e d an increase of 3 8 . 9 % for males and then a
decrease of 5 6 . 4 % from 1971 to 1986. This pattern
was s o m e w h a t similar for females but with a m u c h
higher increase
141.2% from 1951 to 1971
followed by a decrease of 6 2 . 8 % from 1971 to 1986.
Les taux comparatifs de mortalité selon l'âge pour les six
principales causes d e décès' étaient b e a u c o u p plus élevés
chez les h o m m e s entre 1951 et 1986. sauf pour ce qui est des
chutes entre 1951 et 1961. où les taux d e mortalité étaient plus
élevés chez les f e m m e s (graphique 11). Si l'on considère les
accidents d e la circulation impliquant d e s véhicules à moteur,
le taux comparatif d e mortalité selon l'âge pour les h o m m e s a
augmenté d e 4 2 . 8 % entre 1951 et 1966. puis a diminué d e
4 8 . 1 % entre 1966 et 1986. Chez les f e m m e s , le taux d e
mortalité a a u g m e n t é d e 6 4 . 8 % entre 1951 et 1966 et diminué
d e 3 9 . 0 % d e 1971 à 1986. Les taux comparatifs de mortalité
selon l'âge pour les chutes ont baissé d e 5 6 . 4 % chez les
f e m m e s entre 1951 et 1986; chez les h o m m e s , la diminution a
été d e 4 9 . 2 % . A u cours de la m ê m e période, les. taux d e
mortalité pour les noyades ont diminué d e 6 5 . 9 % chez les
f e m m e s , tandis q u e chez les h o m m e s , la diminution a été d e
73.7%. Les taux d e mortalité pour les incendies ont fluctué
chez les h o m m e s entre 1951 et 1976. mais ils ont baissé d e
4 7 . 8 % entre 1976 et 1986. Chez l e s ' f e m m e s . ils ont diminué
d e 40.6% entre 1951 et 1986. Entre 1951 et 1971. les taux
comparatifs d e mortalité selon l'âge pour l ' e m p o i s o n n e m e n t
observés chez les h o m m e s ont augmenté d e 38.9%. puis ils
ont diminué d e 5 6 . 4 % entre 1971 et 1986. Ces pourcentages
ressemblent à ceux enregistrés chez les f e m m e s , quoiqu'ils
aient c o n n u une augmentation b e a u c o u p plus forte (141.2%)
entre 1951 et 1971. puis une diminution d e 6 2 . 8 % de 1971 à
1986.
While the majority of accidental deaths o c c u r r e d
on road and highway, most other accidental deaths
o c c u r r e d in the h o m e (Table 1). Excluding traffic
accidents, residential institutions such as hospitals,
prisons and nursing h o m e s rank next after the h o m e .
This pattern held for four of the leading causes of nontraffic accidental deaths. For drownings, however, only
a small proportion occurred in the h o m e environment.
"Other specified sites" (lakes, rivers, oceans, ponds
and s w a m p s ) accounted for 4 0 % of drownings.
Accidental d r o w n i n g s at h o m e increased from 4 % in
1966 to 17% in 1986. During the same period,
drownings in other specified sites d e c r e a s e d from 5 6 %
to 4 0 % .
Après la route, le d o m i c i l e est le principal lieu où
surviennent les d é c è s accidentels (tableau 1). Si l'on fait
exception des accidents d e la, circulation, les établissements
résidentiels c o m m e les hôpitaux, tes prisons et les maisons d e
soins infirmiers viennent au d e u x i è m e rang. Cette répartition
vaut pour quatre des principales causes d e décès accidentels
hors d e la voie publique. Pour les noyades, cependant, la
proportion d e celles qui se produisent au foyer est minime.
Dans 4 0 % d e s cas. elles surviennent dans "d'autres endroits
d é t e r m i n é s " , n o t a m m e n t .des lacs, des rivières, la mer. d e s
étangs, d e s
marais', etc.
La proportion
de
noyades
accidentelles survenues au foyer est passée d e 4 % en 1966 à
17% en 1986, tandis que la proportion d e noyades survenues
dans "d'autres endroits d é t e r m i n é s " est passée d e 5 6 % à
4 0 % au cgurs d e la m ê m e période.
Page•»'
Graphique 14
Chan 14
Six Leading Causes of Death due to Accidents, Age-standardized Mortality Rates (ASMR), by Sex,
Canada, 1951-1986
Six principales causes de décès attribuabies aux accidents, taux comparatifs de mortalité selon l'âge,
selon le sexe, Canada, 1951-1986
Maie
Hommes
50 f -
Accidenta de la circulation impliquant
Female
Femmes
Ftres - Incendies
5 r-
40
30
20
10
1951
1956
1961
1966
1971
1976
1981
1986
Falls - Chutes
1951
1956
1961
1966
1971
1951
1956
1981
1986
Orownings - Noyades
1951
5 r-
1*.
1966
1971
1976
1981
1986
Suffocation - Asphyxie
4 r-
1976
1961
1956
1961
1966
1971
1 $76
1981
1986
12
10
8
6
4
2
0
1951
Page 30
1956
1961
1966
1971
1976
1981
1986
1951
1956
1961
1966
1971
1976
1981
1$
TABLE 1.
Percentage Distribution of Deaths for Leading Non-transport Accidents, by Place of Occurence,
Canada. 1966. 1976, 1986
TABLEAU 1. Répartition en pourcentage des décès par principales causes d'accidents non liés au transport
selon le lieu, Canada, 1966,1976.1986
Fails
Drownings
Fire
Suffocations
Poisoning
Chutes
- Noyades
incendies
Asphyxies
Empoisonnements
1966 1976 1986
1966 1976 1986
1966 19761986
1966 1976 1986
1986 1976 1986
Total
Place
Endroit
1966 1976 1986
43
38
43
45
Farm - Ferme
i
3
1
1
Mines or Quarry - Mine ou carrière
1
1
0
1
industrial Place or Premises Endroit industriel ou immeuble
4
5
1
6
3
Place for Recreation or Sport Terrain de ieux ou de sport
1
2
1
0
1 0
Street or Highway - Rue ou grande
• route
2
3
Public Building - Immeuble public
1
Residential Institution résidentiel
8
8
11
7
5
4
18
15
7
4
5
14
18
30-
21
26
Home - Habitation
Établissement
Water Transport - Transport par
eau
Other Specified - Autres {à spécifier)
.Place Not Specified - Endroit non
spécifié
1
3
1
2
40
4
8
1 0
36
2
2
1'
0
1
1,
0
1
1
1
2
9
2
-
2
3
2
0
0
17
0
85
83
.90
1 1
5
1
0
0
2
2"
2
0
0
0
1
3
- 17
19
19
0
0
1
2
4
27
23
30
2
56
48
40
3
3
37
7
8
8
2
5
1
0
56
40
36
58
55
62
1
1
i
1
2
2
t
1
1
0 - 0
2
1
2
3
1
1
0
0
1
1
-
0
2
0
0
1
4
3
2
1
2
2
3
2
2
11
8
11
t
1
3
1
3
5
2
8
9
3
6
24
d0
45
22
20
25
In 1986. a c c i d e n t s c a u s e d the loss of c l o s e to
2 0 0 . 0 0 0 potential y e a r s of life for m a l e s , m o r e than
t h r e e t i m e s that of f e m a l e s (66.013). M T V A w e r e
r e s p o n s i b l e for 5 6 % of P Y L L for m a l e s a n d 6 3 % of
P Y L L for f e m a l e s (Chart 12). T h e rank-order for
a c c i d e n t a l c a u s e s Of P Y L L is q u i t e similar to the ranko r d e r of t h e c a u s e s of a c c i d e n t a l death's b e f o r e a g e 75.
En 1986. les a c c i d e n t s o n t c a u s e la p e r t e d e près d e
2 0 0 . 0 0 0 a n n e e s p o t e n t i e l l e s d e v i e c h e z les h o m m e s , soit p l u s
d e trois fois p l u s q u e c h e z les f e m m e s (66:013). On attribue
aux a c c i d ë n t s d e la c i r c u l a t i o n i m p l i q u a n t d e s v é h i c u l e s à
m o t e u r 5 6 % d e s A P V P c h e z les h o m m e s et 6 3 % c h e z les
f e m m e s ( g r a p h i q u e 12). L ' o r d r e d ' i m p o r t a n c e d e s d i f f é r e n t s
t y p e s d ' a c c i d e n t s e n n o m b r e d ' A P V P est a s s e z s e m b l a b l e à
celui d e s c a u s e s d e d é c è s a c c i d e n t e l s avant l ' â g e 75 a n s .
Mortality and Hospitalization.
Mortalité et hospitalisation
In
1985, 8 . 9 5 3
accidental
deaths
occurred;
r e p r e s e n t i n g 4 . 9 % of all d e a t h s ( T a b l e 2). A c c i d e n t s
accounted
for
290.799
hospital
discharges
and
4.761.331
hospital
days,
representing
8.1%
of
d i s c h a r g e s a n d 1 1 . 5 % of h o s p i t a l d a y s . M e n w h o d i e d
f r o m or w e r e h o s p i t a l i z e d for a c c i d e n t s a c c o u n t e d for
c o n s i d e r a b l y h i g h e r p r o p o r t i o n s of all d e a t h s a n d
hospitalizations t h a n w o m e n , h o w e v e r they s p e n t a
similar p r o p o r t i o n of d a y s in h o s p i t a l (Chart 13).
En 1985. les 8 . 9 5 3 d é c è s a c c i d e n t e l s r e p r é s e n t a i e n t 4 . 9 %
d e tous les d é c è s (tableau 2). C e t t e m ê m e a n n é e , o n a i m p u t é
aux a c c i d e n t s 290.799" d é p a r t s d e s hôpitaux et 4 , 7 6 1 . 3 3 1
j o u r n é e s d ' h o s p i t a l i s a t i o n , c e q u i r e p r é s e n t a i t 8 . 1 % d e tous les
d é p a r t s e t 1 1 . 5 % d e toutes les j o u r n é e s d ' h o s p i t a l i s a t i o n . Le
nombre d'hospitalisations
attribuables
aux a c c i d e n t s
en
p o u r c e n t a g e d e tous les d é c è s et d e toutes les hospitalisations
est b e a u c o u p p l u s é l e v é c h e z les h o m m e s q u e c h e z les
f e m m e s ( g r a p h i q u e 13). b i e n q u e le p o u r c e n t a g e d e j o u r n é e s
d ' h o s p i t a l i s a t i o n soit p r e s q u e le m ê m e c h e z les h o m m e s et les
femmes.
Page•»'
Graphique 14
Chan 14
Percentage of Deaths and Hospitalizations due to Accidents to Total Deaths and Hospitalizations,
by Age, Canada, 1985 x
Décès et hospitalisations attribuables aux accidents en pourcentage du nombre total de décès et
d'hospitalisations, selon l'âge, Canada, 1985
Percentage
Pourcentage
Percentage
Pourcentage
60 r -
Deaths
Décès
60
Hospital discharges
Départs des hôpitaux
H 50
Hospital days
Journées d'hospitalisation
-
40
-
30
-
20
-
10
.0
15-24
Graphique 15
Chart 15
Percentage of Deaths and Hospitalizations due to Accidents, by Age and Sex,
Canada, 1985
Pourcentage des décès et des hospitalisations attribuables aux accidents, selon l'âge et le sexe,
Canada, 1985
Hospital discharges
Départs des hôpitaux
Deaths
Décès
4.6%
691
3.0%
t4.r
24.0%
10.9'
16.9%
15.5%
21.2*
46.3%
27.5%
15.2'
Female
Femmes
Maie
Hommes
•
Under 5
Moms de 5 ans
Page 30
5-14 yèars
5-14 ans
17.0%
Female
Femmes
Maie
Hommes
^
15-24 years
15-24 ans
25-44 years
25-44 ans
45-64 years
45-64 ans
Health Reports. Volume i. Number t -
i 65 years and over
' 65 ans et plus
Rapports sur la santé, volume t. numéro i
TABLE 3.
Ten Leading Causes of Death and Hospitalization due to Accidents, Canada. 1985
TABLEAU i3. Dix principales causes d'accidents entraînant la mort et l'hospitalisation, Canada. 1985
Maie
Hommes
Percent
Female
Pourcentage
Femmes
• Percent
"
Pourcentage
Death - Oécès.
1
2
3
4
5
6
7
8
9
10
Motor Vehicle Traffic Accident Accidents de la circulation impliquant
Fall - Chutes
Drowning -Noyades
Fire - Incendies
Suffocation - Asphyxies
Poisoning - Empoisonnements
Machinery - Machines
Struck by Falling Object - Chocs par
chute d'un obiet
Excessive Cold - Froid excessif
Motor Vehicle Nontraffic Accident Accidents de véhicules à moteur
hors de la voie publique
Total
1
47.2
14.8
8.3
5.4
4.7
3.7
1.8
1.8
1.6
2
3
4
5
6
7
8
9
1.5
10
Motor Vehicfe Traffic Accident —
des véhicules a moteur
Fail - Chutes
Fire - Incendies
Drowning - Noyades
Late Effects of injury - Séquelles de
blessures
Therapeutic Drug - Médicaments
thérapeutiques
Motor Vehicle Nontraffic Accident
Accidents de véhicules à moteur
Excessive Cold - Froid excessif
Total
90.8
42.7
32.4
5.5
5.1
3.7
3.2
1.3
0.9
0.8
0.8
96.4
Hospital Discharges - Départs des hôpitaux
1
2
3
4
5
6
7
8
9
10
Fall - . Chutes
Motor Vehicle Traffic Accident Accidents.de la circulation impliquant
Striking Against or Struck Chocs actils ou passifs
,
thérapeutiques
Late Effects of injury - Séquelles de
blessures
Overexertion - Surmenage
Cutting or Piercing Object - Objets
tranchants ou perforants
Other Road Vehicle - Autres véhicules
routiers
Motor Vehicle Nontraffic Accident Accidents de véhicules à moteur
31.1
1
2
15.2
3
Total
83.7
7.6
6.3
4
5
5.7
'4.8
.6
7
4.0
3.3
6
9
2.9
10
Fall - Chutes
thérapeutiques •
Motor Vehicle Traffic Accident Accidents de la circulation impliquant
Late Effects of injury - Séquelles de :
blessures
Overexertion - Surmenage .
Sinking Against or Struck - Chocs
actifs ou passils
Other Road Vehicle - Autres véhicules
routiers
Cutting or Piercing Object - Objets
tranchants pu perforants
Hot Object - Objets brûlants
49.4
12.9
Total
91.7
11.0
4.2
3.8
2.8
2.7
2.2
1.5
1.2
2.8
Page •» '
A listing of accidents by age and sex for the four
leading causes of deaths, and hospitalizations are
shown in Table 4. T h e rank-order showed considerable
variation, by age.' sex, and whether the accident,
resulted in death or hospitalization. For example, for
ages 45-64. the first leading cause of accidental death
was M V T A . whereas for hospitalization it was falls, with
M V T A ranking third.
Le tableau 4 donne une liste d'accidents par âge et ps
sexe, pour les quatre principales causes d e décès e
d'hospitalisation. L'ordre d'importance d e c e s accidents varie
c o n s i d é r a b l e m e n t en fonction, de l'âge et du sexe et selon
qu'ils ont entraîné un décès ou une hospitalisation. Par
e x e m p l e , chez les personnes d e 45 à 64 ans. les accidents d e
la circulation impliquant des véhicules à moteur sont la
principale cause d e d é c è s accidentels, alors que ces accidents
figurent au troisième rang des causes d'hospitalisation, la
p r e m i è r e étant les chutes.
The age distribution of deaths and hospitalizations
varied by accident t y p e (Chart 16). The curve for
M V T A peaked for deaths and hospital discharges in
the 15 to 24 age g r o u p with the rate for males
approximately three times that for females. The curve
for falls for both sexes was very similar for deaths and
hospitalizations, with large increases after age 64. For
poisonings, the age-specific rates were quite different
for deaths and hospitalizations. Death rates started low
and rose with age. whereas' the hospitalization rates
started off high with under age 4. decreased at 5-14,
and then rose again gradually.
La répartition par âge des décès et d e s hospitalisations
varie en fonction du genre d'accident, c o m m e le m o n t r e le
graphique 16. La c o u r b e d e s accidents d e la route impliquant
des véhicules à moteur atteint son s o m m e t pour les décès et
les hospitalisations chez les personnes d e 15 à 2 4 ans. le taux
pour les h o m m e s étant environ trois fois supérieur à celui d e s
f e m m e s . La courbe des chutes, pour les h o m m e s et les
f e m m e s , est très semblable
pour
lès d é c è s et
les
hospitalisations, les taux augmentant fortement après 64 ans.
Pour c e qui est des empoisonnements, les taux par âge sont
assez différents pour les décès et les hospitalisations. Les taux
d e mortalité par âge augmentent avec l!âge. tandis q u e les
taux d'hospitalisation sont élevés chez les jeunes d e moins d e
4 ans, d i m i n u e n t chez ceux d e 5 à 14 ans. puis augmentent
graduellement dans les groupes d ' â g e supérieurs.
The rates for accidents resulting in deaths or
hospitalizations were higher for males than females,
e x c e p t for hospitalizations for w o m e n ages 65 + (Table
5).. For death and hospitalization rates, the ratio of
males to females was highest in the two age g r o u p s
between . 15 and. 4 4 (Table 6). In particular, ages 25-44
s h o w e d a male-female ratio of 4.0 for deaths, and for
15-24 years, the male-female ratio for hospitalizations
was 2.7.
Les taux d'accidents entraînant la m o r t ou l'hospitalisation
sont plus élevés chez les h o m m e s que c h e z les f e m m e s , sauf
pour c e qui est du taux d'hospitalisation chez les f e m m e s d e
plus d e 65 ans (tableau 5). En c e qui c o n c e r n e les taux d A
mortalité et d'hospitalisation, le ratio h o m m e s - f e m m e s est plu
élevé dans les deux groupes d ' â g e situés entre 15 et 44 an
(tableau 4). Plus particulièrement, le ratio h o m m e s - f e m m e s
c h e z les personnes d e 25 à 44 ans est d e 4.0. pour les décès,
et c h e z les personnes d e 15 à 24 ans. le ratio h o m m e s f e m m e s pour l'hospitalisation est de 2.7.
The average length of stay in hospital varied by
sex, age. and t y p e of accident. The average stay was
12.4 d a y s for m e n and m u c h longer. 22.0 days, for
w o m e n . F o r both m e n and w o m e n under 45. the
average stay was under 10 d a y s (Chart 17): However,
after age 44. average stays increased sharply to 38.9
d à y s for males over 74 years of age. and 47.1 d a y s for
females. The longest length of average hospital stay
for falls. 18.7 d a y s for m e n and 29.3 days for w o m e n
(Chart 18.)
.
La d u r é e - m o y e n n e du séjour à l'hôpital varie selon le
sexe, l'âge et le genre d'accident. Pour tous les groupes
d'âge, la durée m o y e n n e est d e 12.4 jours pour les h o m m e s et
d e 22 jours pour les f e m m e s . Pour les h o m m e s et les f e m m e s
d e m o i n s d e 45 ans. la durée m o y e n n e du séjour est d e moins
d e dix jours (graphique 17). Cependant, chez les personnes d e
.plus d e 4 4 ans. la durée m o y e n n e d u séjour a u g m e n t e
c o n s i d é r a b l e m e n t , pour passer à 38.9 jours chez les h o m m e s
d e plus d e 74 ans et â 47.1 jours chez les f e m m e s du m ê m e
g r o u p e d'âge. Les plus longs séjours à l'hôpital pour les
chutes sont d e 18.7 jours pour les h o m m e s et de 29.3 jours
pour les f e m m e s (graphique 18).
\
Page -J2
Health Reports. Volume t. Number i - Rapports sur la santé, volume t. numéro t
TABLE 4.
Four Leading Causes of Death and Hospitalization, by Age and Sex, Canada. 1985
TABLEAU 4. Quatre principales causes de décès et d'hospitalisation, selon l'âge et le sexe. Canada. 1985
Deaths
Hospitalizations - Hospitalisations
Décès
Female - Femmes
Maie - Hommes
Female - Femmes
.Male -.Hommes
Age Under 4 - Momsde 4 ans
Fire - Incendies
Drowning - Noyades
22
21
MVTA - ACVM
30
•18
MVTA - ACVM
19
Fire - Incendies
18
18
Drowning - Noyades
14
TOTAL
80
TOTAL
80 -
Fail - Chutes
Poisoning - Empoisonnements"*
Hot object - Objets
brûlants
Therapeutic Drugs Médicaments
thérapeutiques
34. - Fall
Chutes
Poisoning - £mpoi21
sonnements
"7
Therapeutic Drugs Médicaments
. thérapeutiques
7
Hot object - Objets
brûlants
i
37
22
7
7
69
TOTAL
73
Fail - Chutes
Sinking against or
• struck - Chocs
. actifs ou passifs
Other road vehicle Autres véhicules
routiers
MVTA - ACVM
38
*4
-11
12
11
Fall - Chutes
MVTA - ACVM
Othér road vehicle Autres véhicules
routiers
Sinking against or
struck - Chocs
actifs ou passifs
TOTAL'
75
TOTAL
75
17
29
MVTA - ACVM
Fall - Chutes
Therapeutic Drugs Médicaments thérapeutiques
Late effects of drugs • Séquelles des médicaments
31
19
TOTAL
66
TOTAL
Age 5 - H ans
MVTA - ACVM
Drowning - Noyades
Fire - Incendies
Suffocation - Asphyxies.
TOTAL
51
14
8
5
78
MVTA - ACVM
Drowning - Noyades
Fire - Incendies
TOTAL
68
12
10
2
92
14
-
1
1
9
Age 15 - 24 ans
MVTA - ACVM
Drowning - Noyades
Fire - Incendies
Fall - Chutes
TOTAL
72
7
3
3
85
MVTA - ACVM
Fire - Incendies
Poisoning - -Empoisonnements
Drowning - Noyades
TOTAL
77
7
4
3
91
Fall - Chutes
MVTA - ACVM
Late effects of injury . Séquelles de blessures
TOTAL
9
9
64
10
6
r
Paqe 43
Health Reports. Volume i. Number i - Rapports sur la same..volume i . numéro 1
TABLE 4.
Four Leading Causas of Death and Hospitalization, by Age and Sex, Canada, 1985
-
Concluded
TABLEAU 4. Quatre principales causes de décès et d'hospitalisation, suivant l'âge et le sexe,~
Canada, 1985 - fin '
Deaths ' - Décès
Maie - Hommes
Hospitalizations -
Female* - Femmes
Male - Hommes
/
Hospitalisations
Female - Femmes
Age 25 - 44 ans
%
-
M VTA - ACVM
Drowning - Noyades
Fire - Incendies
"
TOTAL
% '70
7
5
MVTA - ACVM
Fire
Incendies
Poisoning - Empoi- x sonnements
5
Drowning - Noyades
4
53
10
73
7
TOTAL
88
»
Fall - Chutes
MVTA - ACVM
Late effects of injury
Séquelles de blessures
TOTAL
%
21
17
3
9
56
r«
Fall - Chutes
MVTA - ACVM
Late effects of injury
Séquelles de blessures
27
19
TOTAL
68
t
15
7
J
Age 45 - 64 ans
MVTA - ACVM
Fall - Chutes
Drowning - Noyades
36
14
10
7
MVTA - ACVM
'Fall - Chutes
Fire - Incendies
Poisoning * Empoisonnements
56
11
8
7
34
Fall - Chutes
Therapeutic Drugs Médicaments thérapeu10
tiques.
MVTA
ACVM
10
Overexertion - Surmenage 8
t
TOTAL
67
TOTAL
82
%
%
Fire - incendies
46
23
S
5
84
TOTAL
TOTAL
62
Fall - Chutes
MVTA - ACVM
Late effects of injury Séquelles de blessures
47
TOTAL'
81
18
11
5
Age 65 and over - 65 ans et plus
-
Fall - Chutes
MVTA - ACVM
%
% ^
%
%
Fail - Chutes
MVTA - ACVM
Fire
incendies
TOTAL
66
' 17
6
2
91
%
Fall - Chutes
Theraoeutic Drugs
Médicaments thérapeutiques
M VTA r AÇVM
Poisoning'- Empoi- sonnemerits
59
TOTAL
85
17
6
3
%
FaJI - Chutes
M VTA - ACVM
TOTAL
71
" 14
3
2
90
)
Page 44
Health Reports. Volume t. Number i - Rapports sur la santé, volume i. numéro i
Graphique 16
Chart 18
Age-specîfic Rates. Deaths and Hospitalizations due to Accidents; by Leading Causes and Sex, Canada. 1985
Taux par âge, décès et hospitalisations attribuables aux accidents, selon les principales causes
et le sexe. Canada. 1985
'
Rate per 100.000 population - Taux pour 100.000 haoitants
Motor Vehicle Traffic Accidents,
Age-specific Hospital Discharge Rates
Accidents de la circulation impliquant des véhicules,
à moteur, taux de dépans des hôpitaux par âge
Motor Vehicle Traffic Accidents.
Age-specific Mortality Rates
des véhicules à moteur, taux de mortalité par âge
a
500 r*
50 ( 40
Maie
Hommes
30
Female
Femmes
(
Maie
Hommes
Femaie
Femmes
20
10
Under 4
Moins de 4
S-14
•
15-24
25-14
45*64
65 •
Under 4
Moins de 4
3
^
5-14
15-24
25-44
15-24
25-44
45-64
65 +
Falls, Age-specific Hospital Discharge Rates
Chutes, taux de départs dés hôpitaux par âge
Falls. Age-specific Mortality Rates
Chutes, taux de mortalité par âge
Under 4
Moins de 4
5-14
Under 4
Moins de 4
45-64
5-14-
15-24
25-44
45-64
6S +
Poisoning, Age-specif te Hospital Discharge Rates
Empoisonnements,
taux de départs des hôpitaux par âge
Poisoning, Age-specific Mortality Rates
Empoisonnements, taux de mortalité par âge
Maie
Hommes
Female
Femmes
Under 4
Moins de 4
i
5-14
15-24
25-44
45-64
Under 4
Moins de 4
65
,
Health Reoorts. Volume 1. Number i - Râoports sur la santé, volume i. numéro 1
•
5-14
15-24 '
25-w
45-64
65 +
Page 45
Chan 14
G r a p h i q u e 14
Hospitalizations due to Accidents, by Average Length of Stay, Age and Sex, Canada, 1985
Hospitalisations attribuables aux accidents, selon la durée moyenne du séjour, l'âqe et te sexe,
Canada, 1985
Age - Age
Under 1
Moins de 1
Maie
Hommes
Female
Femmes
ssag^
•
.
I
10
20
30
40
50
Number of days - Nombre de jours
C h a r t 18
. G r a p h i q u e 18
Hospitalizations Due to Accidents, by Average Length of Stay for Leading Causes of Accidents,
Canada, 1985
Hospitalisations attribuables aux accidents, selon la durée moyenne du séjour et les principales causes
d'accidents, Canada, 1985
E CODES
833-835,
880-888
Fall - Chutes
810-819
Motor vehicle traffic accidents - Accidents de la.
circulation impliquant des véhicules à moteur
917
Striking against, etc. - Chocs contre
930-949
Therapeutic drug
Médicaments thérapeutiques
927
Overexertion
Surmenage
920
Cutting object, etc.
- - — - — ...
Instruments tranchants, etc.
850-869
Poisoning
'- - —
Empoisonnements
"///'///////////////////À
y-
„
_„
- -
_„
_
n Maie
_.
® Hommes
826-829
'Other road vehicle
Autres véhiculés routiers
-
...
!
820-825
Motor vehicle nontraffic accident - Accidents de
véhicules â moteur hors de la vote publique
/ / / / y" ' " / / / / / / " A
924
Hot substance, etc.
Substances brûlantes
V///// ' / / / / / / / / / / / / / / / / / / / / / / / / / / z / / / /
n Female
^ Femmes
20
Average length of stay - Durée moyenne du séjour.
Page 30
TABLE 5.
Age-specific Rates. Deaths' and Hospitalizations due to Accidents, by Age and Sex, Canada. 1985
TABLEAU 5. Taux par âge, décès' et hospitalisations attribuables aux accidents, selon l'âge et le sexe, Canada,
1985
.
•' ,
,
.
.
,
Under 4
Moins de 4 -
Deaths*- Décès
M-H
F
49.0
.23.0
•
Age - Âge
• 5-14
15-24
15.4
8.4
64.9
18.8
Î9.5
12.3
25-44
~
45.9
. 11?4
45.7
17.9
116.8
88.4
1,205.5
834.5
2.257.1
3,118.0
•
v, ' • . . .
Hospital Discharges Départs des hôpitaux
M - H 1.368.0
F
949.4
'
- Pour 100.000
Per 100.000 Population
1.250.1
950.1
1.170.4
645.2
1.682.1
632.5
*
1.167.4
491.9-
habitants
i
TABLE 6.
Accidents, Ratio of Male to Female Mortality Rates and Hospitalization Rates. Canada, 1985
TABLEAU 6. Accidents, ratio hommes-femmes. taux de mortalité et d'hospitalisation, Canada, 1985 .
Age - Âge
Total
15-24
1.6
1.a
3.5
4.o"
-1.3
1.8
2.7-
2.4 ,
Under 4
Moins'de 4
Deaths - Décès
2.1 '
Hospital Discharges Departs des hôpitaux
1-4
0
,
5-14
.
25-44
' 45-64
• 65 •
2.6
1.3
1-4
0.7
.
r
/ - \
Page «l 7
Health Reports. Volume t. Numder 1 - Raoports sur la santé, volume i..numéro i
Discussion
Discussion
The analysis of mortality, and hospitalization from
accidents demonstrates that despite decreases in
accidents during the period 1971 to 1986. they are still
a leading cause of death and hospitalization. Accidents
d u r i n g the period 1971 to 1986. they are still a leading
c a u s e of death and hospitalization. The General Social
Survey (GSS). c o n d u c t e d by Statistics Canada in 1988.
found that one in five Canadians (3.8 million persons)
reported having had at least one accident d u r i n g the
1987 calendar year with 4 5 % of these accidents
requiring s o m e kind of hospital care 4 . Potential years
of life lost from âccidents s h o w e d they are only b e h i n d
cardiovascular disease and cancer. .Given the n u m b e r
of deaths, hospitalizations and PYLL. accidents are as
serious a health risk as cardiovascular disease and
cancer.
L'analyse d e la mortalité et de l'hospitalisation dues aux
accidents m o n t r e q u ' e n dépit d e la baisse d e s accidents
observée entre 1971 et 1986. ceux-ci sont t o u j o u r s ' u n e cause
importante d e d é c è s et d'hospitalisation. L'enquête sociale
générale, m e n é e par Statistique Canada en 1988. a révélé
q u ' u n Canadien sur cinq (3.8 millions d e personnes) a déclaré
avoir éu au moins un accident pendant l'année civile 1987.
4 5 % d e s cas ayant i m p l i q u é d e s soins hospitaliers 4 . Le
n o m b r e d ' A P V P attribuables aux accidents place ces derniers
au troisième rang après les affections cardio-vasculaires et le
cancer. Étant d o n n é le n o m b r e de décès, d'hospitalisations et
d ' A P V P attribuables aux accidents, ces derniers constituent,
d u point d e vue d e la santé, un p r o b l è m e aussi grave q u e les
affections cardio-vasculaires et le cancer.
International ratings placing Canada in the high to
m i d d l e range for accidents indicates the serious nature
of the p r o b l e m for this country.. The analysis of the
age-specific rates for the leading causes of accidents
s h o w e d striking similarities in alt countries, attesting to
universal patterns. In the c o m p a r i s o n of Canada with
the U.S.. males p r e d o m i n a t e d in all five leading causes
of accidental death.
Le fait que. par rapport à d'autres pays, le Canada ait un
n o m b r e d ' a c c i d e n t s plutôt élevé témoigne d e la gravité d u
p r o b l è m e . L'analyse d e s taux par âge pour les principales
causes d'accidents m o n t r e d e s similitudes frappantes, qui
prouvent qu'il existe un lien entre l'âge et le genre d ' a c c i d e n t
dans tous les pays. La comparaison entre les d o n n é e s
canadiennes et américaines montre la p r é d o m i n a n c e d e s
h o m m e s , dans les cinq principales causes d e
décès
accidentels.
T h e decline in accidents between 1971 a n d 1986
has been largely attributable to decreases in motor
vehicle traffic accidents. However M V T A still account
for m o r e than half of accidental deaths. T h e GSS
survey results showed t h a t . M V T A a c c o u n t e d for o n e
out of three accidents .reported in 1987 4 . T h e d e c l i n e in
M V T A over the last two d e c a d e s is attributable to
m a n y factors. A proliferation of safe driving courses
c o m b i n e d with reduced insurance rates to participants
have m e a n t that y o u n g drivers are now m u c h better
trained than in the 50's and 60's. In addition, d u r i n g the
70's and 80's public awareness c a m p a i g n s on the
danger of drinking and driving were introduced along
with increased law enforcement programs. Dangér of
drinking and- driving were introduced along with
incréased law e n f o r c e m e n t programs. In 1987 a survey
f o u n d that 4 7 % of current drinkers reported having had
o n e or m o r e accidents c o m p a r e d with 2 7 % "of non?
drinkers. T h e rate of traffic offences and fatalities for
driving while impaired have b e e n steadily d e c l i n i n g
over the last decade^.
La baisse des accidents enregistrée entre 1971. et 1986
était attribuable en g r a n d e partie â la diminution d e s accidei
d e la circulation impliquant des véhicules â moteur. C e p e n d ;
ces 'derniers sont toujours la cause d e plus d e ta moitié c . .
d é c è s accidentels. Les résultats d e l'ESC révélaient que
A C V M représentaient un accident sur trois en 1987 4 . La baisse
du. n o m b r e d ' A C V M depuis 20 ans est attribuable à d e
nombreux facteurs. La généralisation d e s cours d e c o n d u i t e
défensive par les c o m p a g n i e s d'assurance-automobile et les
tarifs réduits offerts aux conducteurs qui ont suivi ces c o u r s
font que. d e nos jours, les jeunes conducteurs connaissent
b e a u c o u p mieux la conduite automobile défensive que c e
j i ' é t a i t le cas dans les années 1950 et 1960. En outre, au cours
'des années 1970 et 1980. les responsables en matière d e
promotion d e la santé ont fait des efforts considérables pour
sensibiliser davantage le public aux dangers d e la c o n d u i t e
automobile e n état d'ébriété et un plus g r a n d n o m b r e d e
p r o g r a m m e s d'application d e la loi ont été m i s sur pied. En
1987. une enquête a révélé q u e 4 7 % des b u v e u r s actuels ont
déclairé avoir eu un accident ou plus, par rapport à 2 7 % d e s
non^buveurs. Les taux d'infraction au c o d e d e la route et
d'accidents mortels attribuables à la conduite avec facultés
affaiblies ont d i m i n u é de façon constante d e p u i s dix ans 5 .
4
5
General Social Survey. Preliminary
Data. Cycle• 3:
Personal Risk. Statistics Canada. 1989.
Statistics on Alcohol and Drug Use in Canada and Other
Countries. Data available by 1988. Volume I: Statistics on
Alcohol Use. Compiled by M. Adrian. P. Jull. P. Williams.
•Alcoholism and Drug Addiction Research
Foundation.
1989.
Page 48
4
5
General Social Survey. Preliminary Data. Cycle 3: Personal Risk.
Statistics Canada. 1989.
Statistics on Alcohol and Drug, Use in Canada and Other
Countries. Data available by 1988. Volume I: Statistics on Alcohol
Use. Compiled by M. Adrian. P. Juil. R. Williams. Alcoholism and
Drug Addiction Research Foundation. 1989.
Health Reports. Volume i. Numfter i - Rapoorts sur la same, volume i, numéro i
In addition to improvements in safe driving skills
and attitudes, modern cars are better designed to
protect occupants. Seatbelt use in particular has been
instrumental in reducing the incidence of mortality 6 . In
addition, improved highway engineering has resulted in
better
driving
conditions 7 .
Despite
these
improvements. M V T A continue to be a leading cause
of accidental death and injury for young adults.
Outre l'amélioration des compétences et des attitudes en
matière de conduite défensive, les automobiles récentes sont
plus sécuritaires. Soulignons particulièrement
l'utilisation
accrue des ceintures de-sécurité qui a favorisé la réduction de
l'incidence de la mortalité 6 - l ' e n v i r o n n e m e n t aussi changé
grâce â l'amélioration de la conception technique des routes,
qui s'est traduite par de meilleures conditions de conduite 7 .
Cependant, malgré toutes ces" améliorations, les accidents de
la circulation impliquant des véhicules à moteur demeurent
une des principales causes de décès accidentels et de
blessures chez les jeunes adultes.
The overall decline of the A S M R for falls,
drownings, fires, suffocations, and poisonings, may be
in part attributed to the improvements in occupational
safety standards, as well as to an heightened public
awareness of safety practices in our homes, schools,
offices
and
recreational
facilities.
Also., safety
regulations and practices have improved for boating
and water sports, fire prevention, children's furniture
and toy design, and general sporting activities. The
improvement and more frequent use of safety
protection equipment for high risk accident occupations
as well as sporting activities are most
likely
contributing factors in the reduction of accidental
deaths. Most medications and dangerous substances
now have locking mechanisms to assist in preventing
their opening by the very young. Moreover, advances
in medical knowledge, practices, and technology
undoubtedly contribute to the reduction in accidental
injuries resulting in death.
La baisse du taux comparatif de mortalité selon l'âge pour
les chutes, les noyades, les empoisonnements, les incendies
et les asphyxies peut être attribuée en partie à"l'amélioration
des normes de sécurité du travail et à la sensibilisation accrue
d u public à l'égard de la sécurité dans les foyers, les écoles,
les lieux de récréation et les bureaux publics. En outre, des
améliorations ont été apportées aux règlements et aux usages
relatifs à la sécurité en ce qui concerne la navigation de
plaisance et les sports nautiques, la prévention des incendies,
la conception de meubles et de jouets pour, enfants et les
activités sportives en général. L'amélioration et l'utilisation
fréquente de l'équipement et du matériel' de protection pour
les métiers et les activités sportives où les risques d'accidents
sont élevés réduisent de toute évidence le nombre de décès
accidentels. La plupart des médicaments et des substances
dangereuses sont maintenant offerts dans des contenants
munis de mécanismes de verrouillage empêchant les très
jeunes enfants de les ouvrir. Enfin, les progrès réalisés dans le
domaine des connaissances, des pratiques et des techniques
médicales sont un autre facteur qui contribue â la réduction
des blessures accidentelles entraînant la mort.
An important demographic factor in accidents is
sex. The higher rates for male mortality
and
hospitalization from accidents may partly-be attributed
to the predominance of males in higher accident risk
occupations., In addition, differences in behaviour
between the sexes exposes them to greater accident
risks especially among children and young adults. For
example it is generally accepted that males engage in
more hazardous activities than females. For M V T A it
has been shown that not only d o males drive more
often than females while impaired and/or without a
seatbelt. they also are faster drivers .and more often
violate traffic laws. 8
Le sexe des personnes est un des principaux facteurs
démographiques à considérer dans l'examen des accidents.
Les taux plus élevés de mortalité et d'hospitalisation dus aux
accidents chez les h o m m e s sont en partie attribuables à la
• prédominance des h o m m e s dans les professions comportant
des risques élevés d'accidents. De plus, il y a entre les deux
sexes des différences de comportement qui exposent l'un o u
l'autre à de plus grands risques d'accidents, surtout chez les
enfants et les jeunes adultes. Par exemple, il est reconnu que
les garçons, plus q u e les filles, participent â des activités
dangereuses et exigeantes sur le plan physique. En ce qui
concerne les accidents de la circulation impliquant des
véhicules à moteur, il a été prouvé que les hommes non
seulement conduisent plus souvent que les femmes avec des
facultés affaiblies ou sans porter la ceinture de sécurité, mais
conduisent également plus vite et enfreignent plus souvent le
code de la route 8 .
s
Wiltons. K. The major causes of death among young
a,dults: trends from 1926 to 1985. Chronic Diseases in
Canada. Volume 10. No. 1. 1989: 3-7.
7
Millar. W. Motor vehicle traffic accident mortality in
Canada. 1921- 1984. Am. J. Prev. Med. 1988: 4: 220-230.
9 Waldron. I. Sex differences• in illness
incidence,
prognosis and mortality: issues and evidence. Soc. Sci.
Med. 1985; 17: 1107-1123.
s
Wiltons. K. The major causes of death among young adults:
trends from >926 to 1985.. Chronic Diseases m Canada, volume
10. No. 1. 1989: 3-7.
7
Millar. W. Motor vehicle traffic accident mortality in Canada. 19211984. Am. J. Prev. Med. 1988: 4: 220-230.
8 Waldron. I. Sex differences in illness incidence, prognosis and
mortality: issues and evidençe. Soc. Sci. Med. 1985: 17: 1107•
1123.
Health Reports. Volume i. Number i - Rapports sur la same, volume i. numéro i
Page 49
Age is another important d e m o g r a p h i c factor
affecting accidental mortality and hospitalization rates.
The age distribution for these rates varied with the
different types of accidents. For M V T A the age group
15-24 had the highest rates. This relationship is. most,
likely due to their high risk driving practices.
L'âge est un autre facteur d é m o g r a p h i q u e importan
influe sur les taux d'hospitalisation et d é mortalité, d u e s
accidents. La répartition par âge pour ces taux varie selon le
t y p e d'accident. Pour les accidents d e la circulation impliquant
des véhicules à moteur, les taux les plus élevés se situent
c h e z les personnes âgées d e 15 à 2 4 ans. C e fait est sans
aucun doute attribuable au c o m p o r t e m e n t à risque élevé d e s
personnes d e c e g r o u p e dans leur façon d e conduire.
The elderly had the highest rate for falls and the
longest stays in hospitals. The physical vulnerability of
the elderly often results in m o r e severe fractures and
longer periods for the m e n d i n g of bones and tissues.
Osteoporosis is m o r e c o m m o n in the elderly and
frequently contributes to the severity of the injury and
recovery period. S o m e studies suggest that changes in
the central nervous s y s t e m affect the sense of balance
in older people. 9
Les personnes âgées {65 ans et plus) ont le taux d e
chutes le plus élevé et la durée d e séjour à l'hôpital la plus
longue. La fragilité p h y s i q u e d e s personnes âgées se traduit
souvent par d e s fractures plus graves et par de plus longues
périodes d e guérison d e s os et des tissus. L'ostéoporose. plus
fréquente chez les personnes âgées, peut ajouter à la gravité
d ' u n e blessure et rendre la guérison plus difficile. Selon
certaines études, l e s ' c h a n g e m e n t s dans le s y s t è m e nerveux
central d e s gens âgés affectent leur sens d e l'équilibre^
For poisonings, the low death rates a n d high
hospitalization rates f o r ' c h i l d r e n under four m a y b e
partially attributed to the effective utilization of the
poison control p r o g r a m s offered in our hospitals. The
high death rate in the older age groups m a y be due to
the misuse of therapeutic drugs and m e d i c a m e n t s .
En c e q u a trait aux e m p o i s o n n e m e n t s , les faibles taux d e
mortalité et les taux élevés d'hospitalisation chez les enfants
de m o i n s d e 4 ans peuvent être' attribuables à l'utilisation
efficace des p r o g r a m m e s d e lutte anti-poisons offerts dans nos
hôpitaux. Le tûx d e mortalité élevé dans les groupes d age
supérieurs peut s'expliquer par la mauvaise utilisation des
médicaments.
/
Conclusion
Conclusion
Accidents resulting in death or hospitalization are a
major risk to Canadians of all ages and from al) walks
of life. In potential years of life lost d u e to premature
death, accidents are only surpassed by cardiovascular
disease a n d cancer. If death is not the o u t c o m e , the
serious aftermath of .an accident m a y be severe trauma
and life-long disability. The magnitude of accidents
underlines the n e e d for research into strategies for
prevention.
Les accidents entraînant l'hospitalisation ou la
c o n s t i t u e n t - u n danger important pour les Canadiens d e
âge et d e toute condition sociale. En ce qui concerns
années potentielles d e vie perdues en raison d ' u n d é c è s
prématuré, les accidents viennent au troisième rang, après les
affections cardio-vasculaires et le cancer. Et si un accident
n'entraîne pas la mort, il peut avoir c o m m e c o n s é q u e n c e
l'invalidité permanente. Devant l'ampleur des
accidents
entraînant la mort ou l'hospitalisation, on se doit d e poursuivre
la r e c h e r c h e de m e s u r e s préventives".
More detailed data is available in Standard Table '
number 21. To order, see page 79.
Des d o n n é e s plus détaillées sont disponibles dans le
tableau normalisé, n u m é r o 21. Pour c o m m a n d e r , voir page 79.
9
*
Boucher, C. Falls in the home. The Med. Offic. 1979: 102:
194-195.
Pa<
*°
Boucher.
C. Falls in the home. The Med. Offic.
1979• 102- 194-
195.
50
Health Reports. Volume i . Number 1— Rapports sur la santé, volume i. numéro
(
I
formation
en
Prévention
réseau
des
traumatismes
\
Texte principal
de
référence
«L'approche
privilégiée
(Injury
Control>
.en' prévention
des
(Dr Bruce Brown, Département
de santé communautaire,
Hôpital
traumatismes
Charles-Lemoyne).
Chapitre I
\
Orientation
Extrait
Les
traumatismes
privilégiée
en prévention
fraumatismes
du volume
au
(en voie
Québec
de
: comprendre
des
publication)
pour
prévenir
I
formation
en
Prévention
Texte
principal
réseau
des
de
traumatismes
référence
«Planificatlàn
et' programmation
selon
l'approche
de la
prévention,
des traumatismes
appliquée
à la
problématique
des chutes
chez les personnes
âgées»
_
(Mme Jennifer O'Loughlin, DSC de l'Hôpital généraI de Montréal)
DANISH MEDICAL BULLETIN
Pmwiw
Erik Jutt
APHL ISS? - VOL 34 SJPPUMEHrr s a 4
EDITOB2AL ADDSESSs
TR0NSHJEMSGÀB8 9. DE-210Û CÛPEÛUGHN3, ^BT^MARf
^nifth Mcdcil AnodstïQK
Medial Fieolxy of Copttfcagcfi:
MkEŒI Fwwhy fff ÂriwB
Quilib Ositul AitwirifliE
l t s A i m d i i l u of Diuilili ]
NStoeaJ Bond of Kafeft ef Desm&fk:
U*Bi»t BÉ^wppII ftuHtffli
Edk Hofat, Eikfl Hofavy, Po«l R&
B a Ibnald. Oto M m t Stem Walter
Jflfftt Fttsdif
AndEBVSfik
J u l n p s Ptadbotj
NttltoHlbt
ACKNOWLEDGEMENTS
SUMMARY
This report is the product of an international work «roup con- Although falls among tbe elderly cany high costs to individuals
vened wHw the trngplCfi9 of the fffllA*^ Tnrwrrmj|flmn| Wanlf^ and sodecy. the prevention of falls in later life has not received
and Aging Program co study how to prevent fans by the elderly. adequate anentfonfromhealth care professionals. The prevaThis group consisted of as Ergonomist. Robert O. Andres. lence of falls appears to involve roughly one-third of persons
Ph*D., Department of Exerdsefaïence,Unfeerslty of Massa» aged 65 and over, and theriskof falling and suffering serious
chaser»,.UÂ^ a Geriatrician, Bema/tfSSSMJD., Char- injury increases substantially op to the eighth decade of life.
les Hayward Professor of Geriatric MedioneTuniveniry of The proportion of falls which result in fracture is low, but the
Birmingham* United Kingdom; and a Neurologist, Jergen absolute number of olda* people who suffer fractures U high
Worm-Pmnon. M.D., Chief, Uznvershy Department of Neu- and places heavy demands on health care systems. Even falls
rology, Oeffiofte Hospital, Heflerop, Denmark.
which result in no physical injury often have serious sodal amJ
During die
sages of the group's work, Theresa Rode* psychological consequences for the dderiy, including loss 0
bough» KLD., National
of Aging,
Mary* confidence and restrictions in mobility, and high proportion,
land. U&A». joined the group and assisted in preparation of of older people report fears of falling. ~
the final report.
There is a need to .provide accurate information about the
Mary Jo Gibson. International Federation on Ageing, Wash- causes and prevention of falls in later life. Falls are not part
ington» D.C« U.S-A-, wrote thereportfor the-work group. of the normal aging process. Rather, they are due to underlying
Sfliwml îitiHvtilijah
rha worlf group by providing eon.physical Aînesses, medications,
environmental
saltation, reading drafts of the report, offering suggestions, often In interaction..
and in soma cases mpwf,*ng with the group.
This report provides an overview of the elderly population
These individuals
MarkAbrams» FIlD.» Age Con- atriskof falling and suffering serious injury, some of the reacern, London, UJC^ Jacob Brody, M.D., School of Public sons older people fan, and the mrrhodt to prevent falls which
Health, University of Illinois, Chicago, U.S.A.; John Bud, have been developed in both community and institutional set- Former Director. MRC Injuries Unit. Birmingham Acddem tings. In addition, it suggests some of die practical steps which
Hospital. UJC: Moniçue Esnard* League of Red Cross Sodécan be taken by health and sodal care professionals and by
dés, Geneva, Swioerland; Maria Fetter, MJ}.t Hôpital de Ge- older people and their families in order to prevent falls.
riatrie, Geneva, Switzerland; Sharon Gamaehe, National Sa* Empirical knowledge about the causes of falls by the elderly
fety Council, Chicago. Illinois,
Ann Jackson, Consu- and the most effective methods of prevention remains nmifdmer Safety Unit, London. U-K-; Jeenia Knyser-Joriss. Ph-D- Major barriers to research have been the lade of a dear deflntUniversity of California, San Francisco. California. U.SJL; Hôb oi a rail ana me tact tnai xaiis are not indudetfin medial—
Georges Lambert, Cense International de Gérontologie So- dligBMfic mdlcrm lr ft w t t i w m ^ ^ that fall* W W f ^ H l
entity in Index Medlcns and in the International Clascials, Paris, France; Diane LenK MSN, Grace Hospital, De» a
troit, Michigan, U.SJL; David Mcçfadyen. HJD» World He- sification of Diseases Xth Revision. To fadlitate future campa*
on faQs, a définition of a fell is proalth Organization, Denmark: Bspeih Modem, RgvalJadefy risons of research
posed.
for the Prevention of Accidents. UJC.;
Department of Geriatric Medidne, University oTB&ingham,
The report tmderscoresihai the causes of falls are very diffo*
UJC.; Chariotte Nusberg, International Federation on Ageing, rent for persons of varying ages, health status, and levels of
Washington. D.C.; Claude Romer, M.D-, World Health Orga- mobility. While the many risk factors for falls are not yet
nization, Denmark: Sendee St*ffl, College of Nursing, Ari-known, poor health status, especially chrome illness, impaired
zona State University, Tempe, Arizona, U.S.A.; Rem TIdeik- mobility and postural instability, and a history of prior falls
soar.MLDu&.Arthur Kay. MJ>.. Falls and Immobility Clinic.
have been assodarfd with theriskof falling. Balance, the al
MouâPsinai\ledical Center,- New York, New York, U.S.A.; lity to prevent falls upon displacement, can be impaired by d
Mary<nrteïtiJ M-D-, Yale-New Haven Hospital, New Haven, ease or ag^related changes la a number of anatomical strucConnerttarffU.S.A.; Bruno VeBas, M*D., Centre Hospitaller tures, by medications which reduce thdr effident functioning,
Regional da Toulouse, France; G&sfe Wolf~KlebiP
Jew^ and by environmentalftgrafts.
ish Institute for Geriatric Care, New Hyde Park, New York,
Steps to hdp prevent falls which can be taken by health and
New York, U . S j L
social care professionals are suggested. "Rmmv older people's
JOUUBÔmKHtl
MOO
ta^^d dc fmpefir las caidas al desplazsrse. podri
Pwmote the earlyrestorationof
and
M prevention programs in
aroldy afhsfch ore settings « described. It Is noted that
some V dm ad hoe measures currently used to m m am, los prohlamaa
as the
ofsuspeaed
physical and
tnttona.
areuse
now
of ebanfcalrestraimsB
ingesting the risk ofsome^S
faffing.
tew*
necesarios a teguif por d p.
P«Pte Mid their families can take «psdallzado desŒvidos sodalm y sanidad para de esn
to prevent Wis. including good basic sdf-ore and steps to rela rchablltaidàn pararajtaurarel eqnilflnio y la maMIIc
duce horns hamthi m
rtu
». . .
bambunmg «bat w do if a fen shonld occur. Programs to que ios morfmientos de Ios ancfanos podrin cnnbTd
d o n » o U l También se deseriben qanples de prot
beBa
SET*
by national parafapedirlas caidas es dHversosIuganMMitariofc&
V0hmtai7
«saltations serving the elderly, serodo quealgimasdalasmcdldas
aad sdf-hdp groups of older people are described.
ft, J « ! i ^ 0 r t
b? identifying several important isina « . ^ t o s t t t n d o n a , pa» la prmsdta deeaidaa.»
forftoureresearch on falls in later
fife.
^ ^ >w<b moderators Qdas y qtdmicos, ahoraMiêd
»«nfacausa del auaeno deriesgode caidas. TamWto
praoudoncj a jeguir per loi ancianos y sus fa
para podîmpedir las caidas, indnyendo los puntosfc
w a « M andado de si mismo. y
lascaûîas •
ofcrtcnIosaiasa.LosandanossebenefldarindenhŒ
Wfflr en caso da que sucediese una erfda. Se deseriben lo
Aunqne lascaidas en los anrianoj cuestan grandes cantidado OT«as » majorar la s^îuridad . osa, S S S J
consaios nadonale, de seguridad. por orgaaixaaones vo
«nia
rt tereera edad no hareabido la'atenddn adecnada de la
ï®
'êteowetosdesaaidad.LascaidassnrganconfrecneB).
'"Tr"""
Z ^ U ! ! f l ! l , m " w t w amterciodelas pwoaas coapwadidas
mn Ios65 aaos « adelante. y ambo, el riesgo de «SSay &
? " i n f Q r m a P«Voniona varios pantos ir
graves anmmtnn sustanoalmente a partir de las
ftmm, d. las c i d J Œ d „
P«Mas octogwws. Aunqne proporaonalmenta d mnnaw Penndo da vida crdinaria del hombre.
que sn&en fracturas es eJevado y por to tanto existe
por la parte de fa «teanas de sanidad. Indnso
las caidas sin lesion» fl&as eon W n d a p w d u œ S
« ^ d a , end a m b i ^ soda! y p s t a d w H S j S E
* « f *p »O »B ^®e d*èa a5 snado a- n*o s rienemledo
de movfailen^
y t m etawdo
a las e a t
Es nocesario propordnnar la lnformari<Sn exacta sobra las
tote oddas . los andanos y. como
™ a o J ^ ? a a P , « e ' W p « M o deandanidad normal. Sbo.
que se producen per eansa de enfermedades fbicss. medical
ne^y probto»ambientales. con f r e e u e n d S s ^ , 0 ^
btanas sonfaflnendadosemre sL
non^D ^nfornietfede como fû de propordonar una opinion g^
njnlê los andanos conriesgode caida y con Issxono graves,
dgna*^de las raaone por las que Ios andanos se caaTyk»
to itamuaones. Ademàs. sugïert * metfidas prtafcas n e c e j
rte « tomar por el penmrni espedaHado da sanidad. por Ios
^
*
P « *
-
»•*« las caidas en los ancianos
ague limitado, asf como les métodos mas eHeaces para preve«to to fata de una defïniaôn epedfte sob« la
^ aidas no estén inclnidas en Ios fndte <te
seanreyuauag como una enfermwnri WrnitifiBdaendrndicademe.
iona j o la Oaàfîcadôn Intemacional de Enfernwdadts Di-
SOMMAIRE
LES CHUTES
B t o q w t e chutecoutot chbts aux individus et à la so.
la prévôn des dmtes parmi les personnes
âgées n'a tm
une attention
..
"T 3 1***?
iwhK»» t — « = a paît ae» professionnels de la :
"«de Plus de «5 ans. a 1, risque des chutes « des b
wav» a^nente progressivement Jusqu'à l'âge de 80 ans.
5U un petit pourcentage total des chutes produisent d* fa
««««
«ouffrent des f r a a
« t r i s âcvé;mêmeles c h u » sans blessures physiques p r ^
X ^ q u e to perte,de «nflanca a» soi. « la Kmitatiot
flaisieuogran
nés âgées qnl ontplus,
peur da
chutes.
pourcentage des
^
d J ! ^ 0 1 ® 8 ? ! ^ f o m ° T ' , i a f o n M f o n exacte sur les eai
taictates^parml
les p e r w n n o âgées, et comment les
fc
P« paxtie du procasus nonnal de
aab proviennent de l'interaction des maladies p t a S ^ .
rwtente m é d i ™ .
«
d«
C
7
S
Ce rapport donnes des informations générales sur les mm.
« leurs risques à l'égard d - d S T i ^
ainsi que les facteurs qui contribuent aux chutes
s g f a d b H D t e t t peuvent employer pour empêcher Icschut
n ^ Z ^ T T ^ w p i r « w les chutes chez le,
^
« ^ « a i n d que les m e s u r a les plus efficaces p o J é * £
«bre las caidas. se propone una deflnldôn sobre
les mdtt duôstiques de médidne ont fait de grands c
Este informe subraya que las causastfclas caidas son mny
Prônas de difetantes edades. estado de s ^ u ï ffl^t àla «chocte. n est «commandé que les e h ^ i e
-y aifargrtas mveles de movimxento. Mientras que todavla no se ^ ^ c o i n m a m j e maladie dans l'Index Media»et to
flores dcriesgode caida. un esta<£fc U n e ^ S ? ^ I^madonale d« Matadte,. Dbdèm* Editic
c ^ h a n . i d o a s o c h S ^ L ' S ^ ^
SOuUgne
«° 8
« n » de chutes sont divines
« m a i e s v a r i a s selon l'âge, r é t a i de santé, et le
VeL Si SnndcaotNo. Â/Apn
S
m
^ÂWnùOe. Bfaaqoeroiiii'ait pat moon MentiBétonsta « « f e ^ M U p . ^ , ffn ^ toluljmL
•a®*®* <papeuv«« provoqua do chutes, la mauvaise santé. pendeneeT^ ™rTT mrnmnntil outfit loved «me-jinde"«QHBtértdnto.arinsta,
iUthough for eider p e ^ and «bdr famines
amtfirion,
teSt
ÏÏ'^
^ r r r ^ r ^ , ^ ^ t e e d m m B f a ^toques*» elderly p a ^ a b o » their ««perfa»» of E ^
fflfrtnm.qucsrelatifsan vftg- Falls are part of commonecpetiencnthroug^HfeTthatm
__ x.
.
, —
I^'i^HMM ««ça pssvoi coan-
g^sottd.imedrate,oaûsouagnél%iportttCBd8larafr
HHtatlon prompte pour'restaurer i'équflîbrc et la mobilité. Le
-—
_
• H M M M awqnjr mi
on at rtomtmrmr wiodte. 4 unrisquefie*and 17 p < ^ o f n ^ wfflsuffa-aHp f r a W ^ Conieu-
' l
i
S
^
En nlm. Im
X
S
^
^
^
«.IT
^
^
r
^
, F " ™111"5 «
OfganisationsvolootairesQmaito
^ ^ ^ t h l ' ^ amy high sod^^wefluiadM.
SWY and long-tana healthcare. In ttoUA, the «momiecost
"H HPfracturestobeen estimated âbonrl^bllSn
falls without
s sInRbothstheaUnited
s BBngdom
s aandsFrtmce,
iss
s
®faimportant to emphasize that the great majority of older
people do not sustain salons physical Injuriafromfalls. De»
FOREWORD
spile this faa^ higfa proportions of the elderly reportfanof
*ndsisoneof a series of initiatives by the Kellogg Izztsnational ^ ^ ^ a recaitaudyiof persons aged 75 and over in a com.
0ver 0xM hJ
Programme on^Health and Aging with which the Worid Health
7
« rt C36<%) of those who had
Organization (WHO) has been assodatecL Hie current work
ÏÏTfcîSlî^Sf
'
*
« » P«« *
programme of two of the Organization's programmes, on Acd- ^™^ftousiyfellen (Taxent W86b). Such data emphasident Preveition and Health of the Elderly, makes provision far f«Jûeneed to put fcHsin perspective by providing accurate
gMng practical rtcoimnrnrTiitions to WHO member conmriei
on accident prevention in the elderiy. The present publication J i • J x r ^ 0 T °
* * f a z a Œ« and even some health care
provides this with respect to the problem offoilsin later life. S T r ^ f ^ f ! ?
^ « « « ^ y attrîbuto faHiia® to »oM aê ItThe manuscript was prepared by a smafl working group and
fatalisticattftu&s need to be ounmred, since falls
reviewed by them together with the WHO secretariatfac£neva T ? ? a î 1 0 ^ p f r V ô f ^ ^
P ^ - Rather, they are
u 1986.
— c u e to underlying physical illnesses, medications, œvironmen_
tal haasds, and social factors, often in Interaction.
FaDs
The publication of the product of this Working Gronp m the
teve been defined as êvents which lead to the coaDamsh Medical Bulletin special Gerontological supplément so- «to™ subject coming torestinadvertently on the ground» The
nes should serve to diminish unnecessary sufferingfromfalls
of the event is the key to the variation in the significance
among the world's elderiy people.
of falls. At one carane, a resolute bur imprudent elderly man
ÇJ Romer MD MPH. Chief
p a 8 C e n d s ft s h a k y l a d d a r ' extends his head backwards, reaches
zsxssssssssssss
Sgu^SiSzssssa^
World Health Organimion
urganuaaon
tolrh
INTRODUCTION
Falls are the mostfrequentand serious home acddem involving
the elderly. Everyone involved with older people Is famflS
with their fear of M l n 8 M d of tte serions e ^ ™ "
ma, resultfroma fall, t i e consequences Z
S
indignity and embarrassment of sprawling on the ground with torn
doth*, a split shoppy bagâadjf braised
to»
nesd
for prolonged hospitalization following a fracture of the femur. From the perspective of the older penon, falls are painful
andfrighteningand may lead to loss of «aflïenee. « s t S Z ^
la mobility, depression: and death. Even if the fan
MT»!
dsnca tn thalr ability to engage in routine physical and sodal
may feel guilty that they did not prevent the fan and co«cDaasih Madis) BaltMfn
as a consequence, but he is eaamially a Bt person and his
I» not likely to suffer seriously. Al the other «trane,
a weak, malnourished, ffl old person walks slowly across tbe
room; her legs gwe way and udown she goes.® Perhaps the su».
tamtaleinjury, bot may be so shocked and weakened by the
K
^
d
^ f j f ^
^ 0 0 ^ floor f o r h o u "
B a ^ ^ e ^ o ^ f e . t f ^ ^
« K ^ S S ^ ^ S E ? 1 T l ^ T ï**0'
S S S X ^ ^ ^ ^ J f E " *
weD as t h r t r t n ^ w . ^ ^
consequences of falls, as
S £
h t a ^ i S S - S T
"
i Z S o B S e S ^ ^ l
^
^
^
H ^ S ^ ^ ^ S T ^
^Jf^,,
? professionals as wen as older people
t l S ^ ^ L S ^ l S ^
p^,^^^
r e t a f v B l y
perieaces of many nations in preventing h*™» and traffic ac> L THE POPULATION AT BISK OF FALLING AN
cidents â general, however* suggest that similar approaches
s BEING SERIOUSLY INJURED: AN OVERVIEW
nay be effective in developing fail prevention programs for ithe
t
A. How Frequently Do FaBs Occurf
drfrrty.
h g>fh
^
ffî difflfflff
gpfrf
This report has been wrlttea in the hope thai »
and so- Th^ magnfriirf» nf th+
cial care professionals and others working with and for theêW miologfcai data on falls by the elderly areft""'"**,and studi
of older persons living in the community usually rdy upon t
deriy wffl give new «"P1""^8 to vntiT***"*^ the
and
d
^ subject'srecall*leading to a probable under-reporting of t
methods of preventing faQs among the elderly. It will provide
an overview of the ddoiy population atriskoffanmgand of|f actual prevalence of falls. However, the prevalence of falls
suffering serious injury, some of the reasons why older people the horns appears to involve roughly one-third of posons agi
M» and the sethods developed in community and fr*ffmT*')ftfll
65 and ova- {perry, 1982). A major study of M s conductr
d
to prevent falls,
in New Zealand, for example»
« that about onc-thL
Of the population aged 65findover had experienced one
more falls in the
year, with thisfigureriringto ;
Definittone of FttJBtt$m
Evoyone aknowM what a fall b, yet every «gtewtWfe paper on most one half of persons aged 80 and over (CampbeQ a <
„ 1981). Other studies in the U X show ewmpraH* rat
the subject opens with a different definition* ^nntmmr to aA
egy tha er^pceots of change of position of the body and lack |fof XExtan-SmUH. 1977; Pmdham & Evans, 1981). Similarly»
* France, it is mrlnwffd that 2045 percent of persons aged
intentionJo doso. Researches differ in how thev treat, fog
k and over have one or more faQs each year (Vdka, 1985).
example, a ML mm a chair; a fall out of a chair; a fan which
Many of the studies on falls have bem conducted in instxt
f
results from loss of consciousness or the onset of 1 stroke or
an epileptic attack; a fan resulting from a violent blow; orT tional settings, where the frequency of falls is reported to
o*
simply the situation in which a person ts found lying on theg considerably hiflftf than that among those living in
homes (fieny, 1981; Perry, 1983). Residents In institutior
k
ground unable to explain how he got there. Hie causes and concare facilities are typically in poorer health and havemôrem
r
séquences offiaHsin such different wwiifftfatiww vary greatly.
It Is important not so much to strive after a form of words£ bEtyhnpainnnns which hicreise the likelihood of a fafl-Inc
which coven every situation, as for each researcher to declare8 dnion, "«ffi'mtjttnnl care fadlMes are not always
which of these tjwBitwgfnm^fceâs induded m his definition mmirnhn the occurrence offalls,-andresidmts must adjust
and which ho has rrdirdnl Reados ere then hi a position to9 unfamiliar environments.
ôîfliwfr» tftf1 Bgî^ffwi of the îrymt findings.
1. B. How Frequently Do Falls Resuk bt Serious Physical Injur
Werecommendthat inreportingstudies of the dinxcal significance and conxfarw of falls in old age, research workerss The great majorfry of falls by the dderiy do not result in seric
physical Injury. In France, VeBa (1985)reportsthat only :
7
might agree to the use of the following definition; or. if they
j iwiceir of faSs by older posons result ln a fracture, and c
prefer a different one, to state the deviations from our proposal
other ten percent in injuries withoutfracture.Similarly, Cry
which they have adopted and their reasons for doing $0. •
and colleagues (1977) report that six percent of faOs by eldc
Canadians living is residentialflwmTTmft^fltfnmremit In fix
Proposed Definition of aFoB
tures, of which one percent arefraeturesto the proximal fam
3 fo ? fYfl* ^'fî^
a person coming to rest in1 (hip). In Oreax Britain as wdL less than one percent of all fa
advertently on the ground or otSx Tower level and 'ôther than- among those aged 65 and over has been estimated to result
tf a'cdnêqucnce 01 Plii
following:
—
hip fractures {Baker, 1985).
Sustaining a violent blow.
Although the proportion of falls with fracture is low, the 2
Loss of finntrimnnrtt
solute
number of those who «periencefracturesis high. Wh:
Sadden onset of paralysis, as in a stroke.
the
literature
is contradictory, several European saches also i
An epfleptxo seizure»
dicate a steady increase hi the Incidence of hip fraetures in 1
cent years (JohntU et
1984). In Nottingham, for otamp •
the numbers of older people admitted to orthopédie units wi
foc&ireg of the proximal femur (hip) increased at an anus
rate of 6-10 percent between 1971 and lttO, while the popu!
tion aged 65 and over increased at a rate of only two perce
(fffeffoafc 1983). Finally, falls can result in injuria oth» th:
. fractures. Even those falls whichresultIn no physical inju
often have serious sodal and psychological consequmces (s
section ILD. below).
C. Who Is ax Greatest Risk ofFaBlng?
A broad body of research ^T^TI that advanced age is ass
dated with an hxereased risk of falling and that both tha ri
of falling and of suffering serious physical injury increases su
standally up to the eighth décade of life ÇMàssey, 1985).
The data suggest that most fans occur a**»™ g older wome
Of course; there are Car more women than men within the gee
ral older population m most nations and particularly amnng ^
very old. However, even when age adjustments are'made, old
women experience significantly more falls
do older mi
. (Prudhnm £ Evans* 1981). Olds- women are alio more like
to be single (e.g. widowed or separated and living alone). >
though researchresultsoa whether marital status per ie Is as&tiated with highr rates of falling have
(Mossey, 1985),researchesin both new 7«land and Fran
4
VOL U Suppteaest No. 4/Apdl
xo : 44
AND
£pide»
.radies
on the
it the
ills in.
> aged
'ucted
-third
<ne or
to alet at,
rates
iy, à
ed 65
5)istitii"
to be
r own
donal
< moin ad*
ted to
ust to
erious
ilysbc
id anGryfé
Idetly
femur
a fans
ioll m
iea^
While
Isoinhi r^
•mple,
s with
•mntql
jpula? than
injury
* (see
asso»
,e risk
ssnb-
ngthe
older
men
likely
). Alictoty
•
i-
«
;
I
V
j.
••
t
i
U914 WO* X0U2
diiiA uaeflonrreai -»-»-» ueptaaq^QiomKiKi
ua uug
report that elderiy women IMng atone are at significantly grea- Tnrtrtffncc of 14)fractures,possibly as a consequence of unpt^
terriskof faffing and being injured {CampbeU ttal, 1981; Ve£*
tected falls ((£zmnwrp«0/. 1979; iteimn <& Strûuihtàs, 1985).
/as, 1985).
Evidence thatfracturesmay be the result of violent, unpro
The manyriskfactors for falls are not yet known, and some tected falls comesfromGreat Britain and ECUSB. In recent sni
older people who escperience multiple falls have the same ftmc-dies in both countries, older people who sufferedfracturesw «
donal capability as those who have not fallen. However, a more active and more likely to have fallen outside onto the hard
number of charaaerisdes have been found to be
ground. Those who were less active and fdl more slowly inside
with theriskof falling. These include poor
ct*ma
their homes did not sustainfractures,but were more prone to
daily chronic Alness. impaired mobiKtyandpostural stability', further falls iAOenârker et at, 1986; ftea et ah 1985.).
anH â history orpSoi falls, illfttopledl&fnmil wUi
moo-witinsSIêmSSou^ utidi may add to thdr diffi.
culties in sustaining balance. Among the diseases common m
this highriskgroup are arthritis in the lower
stnictural E. What are thé Major Consequences of Falls?
4Ueasg_gfthe fee, and visual utfoawmenti Not oaiyiretHS Falls may result in * number of physical injuries, «*-»»
fagfrtr»friftiwrtwaiiyattnrLrf «rfift tfltt ffefc-'ftf ÛSÎBg, but the
greater the number of disabilities, the greater the risk of fhlHng soft tissue
(bruising and lacerations)
(Tirwsl et aL, 1980). Hence, theriskof Ming becomes a seframures (of the hip, wrist, and other bones)
rious problem whan multiple HiâKntft^ involving multiple
trauma to the nervous system (rare, but very serious)
functions, interfere with the person's ability to compensate:
hypothermia, dehydration, and pneumonia after a »long
Sea.
Fafli occur when a person undertakes an activity which requires collection of an unexpected displacement and lacks the
Both hipfracturesand what has been termed the along lie* (reqipndfy to correct the displacaneut in the available
an hour after
Those who might be atriskof falling were they to continue in maining on the ground or floor for more
a
fan)
are
««gyfatwrf
with
high
mortality
rates
^
« ^ g the dtheir former activities, therefore, generally slow down and reduce therisksthey might otherwise take. Nonetheless, they re- deriy. The mortality rate of those who have suffoed a fracmain vulnerable to small irregularities in their environment tured hip may be 12-20 percent higher than that of persons of
since, as balancefonctionVtTTnn impaired, there is a ten* similar age and gender who have not, with most of these deaths
deney for Calls to oceur with less and less provocation. Among occurring in the first four months following the fracture.
active individuals, a high proportion offellsoccurs outdoors (Çummingr et al, 1985). Hipfracturesalso are a leading cause
disability among the elderiy; nm^lily llilll iil HiiîjM'UiiM
or at points of.ha2ard. Among the severely ritahlwl, a high of
never recover normalflnctioirfnfl^fcbmmJiigfer a/Tim). In
proportion of Îb
indoors and in less ^mwrjoH» sur- the U.S., the avenge length of nift fin liin fi n mm îmiin
roundings.
in acute care hospitals is three weeks, longer than for any othi
diagnosis (Maker é Harvey, 1985).
D. Who is at Greatest Risk of Serions Physical Injury?
The along lies is a marker of weakness» illness, and yyfa'
It Is generally aggyf jMt women of advance! age OS years and isolation. British studies ^fontf that half of those who lie on
over)_are most llkalv ^ •fïïffgr ^"CTJTflfrVflfaft-injuryfroma thefloorfor an hour .or longer die within six months, even if
faE. In the United Kingdom, women aged 75 anaôvô>
thereis no direct physical injuryfromthe fall {WBdetal. 1981).
represent about Va of the population aged 65 and over, accountComplications associated with the long lie include hypotherfor over half of the hospital-treated fans among the elderly po- mia, bnmgh<wjm»mw/wi«g and dehydration, an of which can
lead £0 death (Mitchell, 1984* Data from Francs suggest that
pulation (Abrams, 1984).
Many types of serious fractures are characterized by Inci- long fies are not uncommon. In Toulouse, ten of fortydence rates that rise with age and are greater among olds eight elderiy patients hospitalized for falls had been on the
women then older men. This general pattern is observed for ground for one hour or more, and one for three days {VeOas,
of the followingfracture****** pm^fmai few m (hip); Hfc* 1985).
tal forearm (wrist); proximal humerus (upper arm); and pelvis
An important point Is that even if a fall does not result in
(Melton £ RIggs, 1985). In tbe U;S., UJC., and Scandanavta, Physical injury, it can lead to other serious consequences. The
.female hip fracture patients aged 75 and over outnumber males Shock of Ming may generate the fear of falling again, which
by approximately between two and three to one iEvans & at, may lead to amdety, loss of confidence, sodal withdrawal, and
1979; Kruetzfdd et ah 1984). The increase in the fnrirVnct of restrictions in daily activities. In a study conducted In a US.
hip fractures
white females begins around age 40 and community, in which high proportions of older persons reporw
of
with this fear said It
doubles with eachfiveto six years offifethereafter in an expo» ted fears of faiHng,. 40
nential curve (firody et al, 1984b).
had led them to restrict their basic daily activities {Unetti,
1986b). In a French study, slightly more older people who fdl
r Osteoporosis, which is more common among women than
men, appears to be an important contributing factor to the in their homes were found at six month follow-up to have rehigher incidence of fractures among women (Cummings et al, stricted their activities than had a control group of those who
1985). Men also experience age-related Inoeases in osteoporo- had not fallen. In the institutionalized sample, the falls were
sis andfractures.Recant "normal hospital data from the U.S. awndntrd with behavioral disorders such as agitated behavior
are now showingfracturesof the hip and other bones to be a and mood disturbances among 13 percent of those followed
significant problem among males aged 75 and ever as well as (VeUasetai, 1985).
•among females (fiaker and Harvey, 1985).
Not only older people themselves but theirfa^flfr*often reIn addition to the fact that bone loss predisposes to fractures,spond with ansety to falls. It is not uncommon for famff
another important part of the problem may be age-related re* to become »overproteedve« and attempt to restriet-thdr ole
ductions in protective responses to falls such as extending a. relative's autonomy (Yong, 1984). In
the famSt, „
hand to break the impact (Meltan and Riggs, 1985). Tbe inci-reaction may even lead to unnecessary institutionalization. In
dence of Colles (wrist)fracturespeaks-among women in their Toulouse, France, a shocking 39 percent of 295 persons aged
mid 70s, after which It plateaus or declines (Fofcft, l983;JaueR 70 end over who had fallen but suffered no
physical
etaL 1982); this has been attributed to d» loss of the protective Injury, were
upon their family's request
reflflc in falling. After age 70, there is a steep Increase in the (Albarede A Vettas. 1985).
IL THEREASONS OLDER PEOPLEFAIX:'AN
OVERVIEW
t. a movement such as walking Is planned and initiated;
II. an mwmmed or unpercrived hasard Is encountered an
When physicians ask older people who havefatlrmto explain
distorts the pattern of movement:
why they fen, they often are told:
UL the body is displaced beyond hs support base;
»I just feD<c
IV. the corrective mechanism Is delayed or
»I must have tripped».
V.' the paint of no return has passed* and the patient fells.
»My legs gave way mdcr me«.
Balance, the ability to prevent falls Upon displacement. rdû
oils floor came np and hie mea.
upon the proper functioning of a number offlfMtomlcalstrut
»I lost my balances
tu*es. It can be impaired by disease or agc-idated dianges i
^Something
over men.
any one of these structures, by drugs which reduce then- efr
Such comments illustrate the difficulties physicians, other dent functioning, and by avironmeutal factors. Fqrh of the:
health care professionals, and xeaeaicU workers confront in in* three challenges to balance form the subject matter of this ser
terpretingthe anses offellsbased on tbe reports of the victims, tioa.
who may be
faffr»*^
forgetful or 3L*)
Another problem Is that circumstances surrounding the falls A. Dbeattnatd CcmSdom
are often not spfrîfîrri m recordkeeping systms within institu- Tinea Tirfaarv *y*tprji^
normal postural balancer vfatqr
tions. It is very important to attempt to establish what the per- vestibularftmcdon,and proprioception. These system an pre
son was doing at the time of the falL For emmple, the cause vine important sensory information abônt orientation in spaa
of a fall which challenges twinnr» control (such as standing on Diseases in these systems, as wdl as other conditions wide
a step ladder) is quite differentfromone which occurs during contribute to impairments ln balance among the elderly, a:
slow and habitual movement (such as transferring from a discussed below.
chair). The latter
much greater impairment in the balance mrvhfinh""J. Visual System
Mauy investigators have recognized various types of faQs due Visual problems are obvious. Important contributors to fel
to differing causa and have adopted different terms to desoibe among tbe eldsiy. There is an inoeasing incidence in later ifc
these events. Campbell sad his colleagues (1981), for
of structural diseases of the eye (such as
glgnfOTWfl an
have distinguished between »pattern« or recurrent falls and retinopathy), and such visual disorders can impair the abflfc
aoocasionakc falls among the elderly. »Paoenw falls were as- to judge an imminent faQ and to take appropriate and speco
sessed as being caused primarily by disorders in postural stabi- corrective action.
lity or balance, nuher than external influences; they more com-. Misinterpretation of spatial Information, «««ft as the narrn
monly occuzred among persons aged 80 and over who had more of ground surfaces or misjudgement of distance are not alw*<.
functional disabilities and morefctip«inn«ninhi mobility.
the result of eye diseases. The use of visual information ab
Those who experienced »occasional« falls were generally can be impaired by age-related deficits in visual acuity, «strie
younger, m better health, and more active, and hence exposed non of the visualfield,increased susceptibility to glare, an
to more environmental hazards. They fell ln circumstances poorer depth perception iStelmch & WorringHam. 1985). I
which would make most fit persons liable to falL shntta» cha« addition, there may be an age-related deficit in gaze stabSir:
racteristics have been used in identifying groups of older peoplewhich canresultin visual disorientation (JUebawitz & Shupe
who are at Ugh and lowrisksfor falls (Isaacs, 1985).
In essence, such categories are efforts to discriminate beIn a community-based study of older adults in the Unite
tween two ends of a continuum in which intrinsic and extrin- States, Tobts and his colleagues (1985) found significant is
sic factors play greater and lesser roles In ^"Kng falls by older painnents in the visual perceptual abilities offenvictims. Con
people. They clearly are not intended to describe the wide pared with those who had not fallen, fan victims showed a Iai
range of falls «petia&ced by older people, in which both Intrin- fier error fr ggflhtfrhrng the true vcrticaf and h5Kz5rairtE&
sic and extrinsic factors usually interact. As these categories whojuffged £ftg wnrffi fall* <Um*A
laggf g ^ r . TBeâl
suggest, the causes of faQs are very different for people of vary- tHBrs postulate that the relatively greats- dependence on visas
ing ages, health status, and levels of mobility. It is also true sources among the ddcriy generally and some faQers sped
that the same person may fan at differenttimesfor different flcany may develop in response to Impairment of feslback o:
reasons.
posture and gait from the kinesthetic and vestibular systems a
One common thread linking many studies is that poor health a rank of age and chronic health problems. This greater depes
status and mobility problems are strongly assodated with the dence upon environmentalcues in maintaining posture and gai
frequency of falls by the elderly {Perry, 1982). Many studies suggests that ambiguous or misleading environmental mfor
also have indicated that olds persons taking certain types of motion can. predispose older adults to Calling.
mftrifcaTfnrn are at much higherriskof falling. Environmental It even has been hypothesized that part of the explanatior
hazards contribute to falls by some older people, espedally of the large gender differences in thefrequencyoffellsmay l>
those who are younger and more active. For those elderly per- related to a sex difference in receptivity to optical information
sons with impaired balance, who tend to avoid the chaDmigmg e.g., women may take longer to detect body sway (Owen
environment of the outside world and may become confmcd to 1985). Similarly, Overall (1985) observes that when visual ant
their homes or institutions, minor but unexpected iragnlarities postural information conflict women are more »ffdd depes
in the environment become hazardous. For the purposes of pre- dent«, Le., they rely more heavily on the spatial framcworl
vention, h is important to consider factors aworifttcd both with provided by vision.
the person and the environment, often in interaction.
2. Vestibular System
While the multiple reasons why older people fall are not yet
wen understood, it Is clear thai impairments in balance and gait Vestibular disorders, particularly when asymmetrical, may band troublesome to the dderiy. Although agc-relatei
are not normal aspects of aging. The sequence of evens in a common
changes affecting vestibular function have not been wfddy stu
fan sometimesfollowsthe following pattern:
died, they may be important since the vestibular apparat*
hdps to keep the head and neck in vertical position and affect
mwhawinns needed to do sofêtelmach£ Wor
•) For a Br of qumJum wfaieh <as be pari m obtain the most iaformsthe
ioncorrective
whea
quaitanliiE cMgr pattatt wfaotawhad falls: see seaton IZL A. ringfuutL 1985).
6
VoL StSuppttBMai No. 4/Aprfl 19
f •UP
i.
and
J. Proprioceptive Disorders •
"••ft
"Y
•2
lis.'
dies
raesta
iffi*iese
sec- j
• »
X,
^
Ion,
pro*
ice.
lfch •f
are
*
falls
life
and *
-Ofay
*dy ï*
mre
/ays
also
lieand
-
tity,
i
Jted
im9m*
lartose
mal
edon
;as
cnor- "
ton
-be
at,
4ld
saut
be
•£d
tn*
'.US
as
or-
i
fl. Effects of MeOeattans and Alcohol
^proprioceptors In oovfol joints may give misleading
Information about tbe position and movement or tbe bead in It is not dear whether the falls that have been assodated with
spao&. Diseases in weight-bearing joints in tbe lower Cmbs may some medications are due to the medications thonselves or to
contribute to error hi foot placement. Distorted or painibl feet the illnesses for which they have been presaibed. Research re*** poorlyfittingshoes may gtve misleading information on suits on the relationship between medications and falls among
the nature of ground emmet and produce errors during the the elderiy have been somewhat contradictory. However, some
types of drugs do appear to increase thefrequencyof falls
swing phase.
^ ^
among the elderly. Older persons taking multiple medications
lu a recent study of ftlls by olte people in intermediate ore are at particular risk (Macdonald. 1985).
feeffities in the UA, TmatA and her colleagues (1986) found Those drugs which reduce mental alcrtnen and the speed of
that deceased knee strength and symptoms during a neck exar transmission within the central nervous system m particular
woadonwere assodated withfelling.Subjects with sensations have been implicated as contributors to falls. For example, in
of staggering or Imbalance during ncck grange of motions a British study of older people who feU at home, fallen were
testing WOT dghr times more likely tofiaflthan those withom more likely to have taken hypnotics, tranquflizen, and seda.
such symptoms, çrte frequent finite of decreased knee
Some studio also
strength also lends support to the comment often
by
laveshown a link between tricyclic antidepressants and M s
people who have fallen that their »fcoee gave out«.)
1981). Antihypertensive drugs and dinretia are
As yet there are little dam on ageteiaicd deficits in proprio"«ribtto» i» falls. (Macdonald,
ception. However, some evidence «1
th^t th*** 2it ^
apparaît if the movement in question is preselected by the 1985). Knowledge about variationsfromdrug to drug w S
sutfett, but problems occur if the movements are unexpected majordrug groups» however, is fer from adequate.
or forced (ftelmach and Worringham, 1985).
^
^
^
s « patients where alcohol appear, to have
been a contributing factortothe falL In a stndy offallsby oldor
people m the United State resulting in injury, eight perçoit of
4. Functioned Disruption of Central Processing
Even when there is no disorder in end-organfonction,pro- the falls werc attributed to alcohol use (IWaller, 1978b). Howblems can be experienced in the coitral processing of informa- ever, one study in Great Britain found no assodation between
tionfromthese pcriphsal structures. Vision, vestibular seasap alcohol and falls (PrutOtam é Evans, 1981
The effects of medications on balance are summarized in
tion, and proprioception all interact centrally. These immc. Appendix
B.
tions can be disrupted by aging or disease, resulting in balance
control defîdn. Disruptions in vestibulooealar'rafles», vesti- C. Environmental Factors
bulospinal function and balance performance have been wen
rfftnimimird for patinns with peripheral and/or central
dpitate many falls in older people. While dangers in the exter<Honnsbia and Éra&r, 1982), Adaptive protocols [Nashner,
nal environment appear to be more important csuses of falls
1977), which require changes in sensorimotor organization may
prove to be most useftxl for deciphering central postural control increasmg importance for those in advanced age and in health,
dysfunction. .
who tend to restrict their activities in the outside world.
Few would deny that the external environment, with its fast
moving vehicles. Irregular ground surfaces, blinking "g>»t. and
3. Disorders of Perfusion
thefike,is often unsafe for the general population and espeMomentary disturbances of perfusion, cspcdaQy of the hind cially for the dderfy. In a British study of 100 healthy people
brain and upper cord» may suffice to impair muscle tone long aged 65*74, most of the falls which occurred over a one-year
enough for a fan to occur. Reduced perfusion, when effort Is period were due to escounten with external environmental ha«rted, may result from constrictive lesions redndng canflac ards, and imprudence or errors in perception. (Gabeil et aL
output. Impaired baroreceptor function may reduce perfusion in preparation).
when there is ai postural ^««gf •
However, it is in the familiar but often very dangerous home
fanaient hypotension due to impaired regulation of syste- environment where most older people, and particularly the very
mic blood pressure is one common process thought to
and those in poor health, spend most of thdr time. Loose
falls by the elderiy. With advancing age, there is
^ old
rugs, unstablefarnirare,poor lighting, unsafe stairs, and the
dine in. homeostatic capacity, which
that seemingly
aU pose significantrisksto the unwary. (For a detailed list
minor changes, such as changes in posture as well as acute HI* IDce
of the steps that can be taken to reduce home hazards, see pp.
ness, or a new medication, may threaten blood piaaui'e stabi- 21).
lity and pxedpltate a fan
1985).
Moreover, what once was not an environmental hamrd to a
In the United Kingdom, largefluctuationsin blood presure healthy person of relatively young age may become one in adwithout any symptoms during a 24 hour period have been vancedage and m health- For example, elderiy people often fen
found among both older and younger people with previously
unexplained falls (Jsaaa, 1985). A key issue
to be the to appreciate a sman but critical decline m their ability to prevent a fan and continue to perform familiar but now more difspeed of the change in blood pressure and the ability of cerebral ficult tasks. Standing on steps to change a light bulb, which involves an unstable position and loss of eye conma with the
pafrslon to adapt. However, this is very difficult to measure. ground, is a good example and
the importance of
considering the redprocal relationship between the faHer and
6, Structural Changes
the environment.
Of the many environmental factors which predispose the el*
Changes in the cerebral cortex exert relatively slight effects on
balance. Pyramidal tract disorders affect the patterning of gait deriy to fells, problems in foot-ground contact appear to be
and may weaken supporting limbs. Extra-pyramidal disorders espedaUy important. Such problems arisefromImproperly fitgravely alter the sequencing of padng and may also impair the ting shoes, irregular ground surfaces, and low slip resistance
• of correction
wmwimn
Meypuig
fMuiomCerebellar
sua impaidisorders
r correctivebetween the foot and surface. In a study offellsby the elderiy
Speed
after
displacement.
mechanisms. Weakness and wasting of musdes disturb the sta^ in a rural northern dimata in the UA , for sample, one third
HHty of support and delay the effectiveness of conceivemes- o f the treated falls involved icy or wet surface or rough ground;
sages.
many of these falls oamied on public streets or sidewalks
Danish MerftaJ Boilcda
(Waller, 1978a). Faulty footwear, such as sfippers, also bas IZL THE METHODS OF PREVENTING FALLS
ben fmrtfrarrri is several British studies as a major cause of As tbe above review of some of the known and postulated cas»
falls by Older people (GabeH ex al; Kinsman, 1983).
ses of falls attests, it dearly !s not r^rfMe to prevent ag f»n*
Falls by the elderly, particularly those of advanced age, fre- byflieelderly. In tha tm rif aw llmiwi »mpit4<»*l
quently tttmr dnriug
«mpia aw^ famflforrfaflyactivities about the cause of falls, ad hoe measures have sometimes beet
as rising from a chair or getting out of bed. Improperiy de» developed which are now suspected of resulting in more falls.
signed chairs, which slope or are too high or too low, may be For example, efforts to prevent (alls In Institutional setting
contributing factors, as are beds which are too high. low, or through the use of physical and chemical restraints often retch
soft.
in both reduced mobility and loss of personal autonomy. Thi
Stair accidenta have been found to be more common among attanpt by some families to limit an olds- relative's activitie
the young elderly (65-74) than those of advanced age (Abrams, is another example of a weU
but misguided effort te
1984), who are less likely to use stairs or to do so very cautious- prevent falls.
ly. Although the elderly have fewer « ^ " f f than those hi
Both research evidence and common
however, «ngg^r
other age groups because of less frequeu usa, those
that it is possible to prevent falls by the elderly through me
which do occur are much more serious. In the U.S., 85 percent, tfaods which do not undermine mobiBty or amûffuiy. Severs
of all deaths attributed to stair
an among persons different groups, rnrhtrting health care professionals, olde
aged 60 and older {Archea, 1985). Most of the serious aeddents people and their families, and planners and architects, are al
occur on descent, and visual impairments have been implicated appropriate a>f*i|f!KfB for information on the steps thst can b
as a cause. Olds people may for example, have difficulty judg» taken to pwv*nifaTlcIn fotmv fM»
lug the si2e of the tread bdow. It has been observed that stair
It Is Important to bear in mind that
• people of vwyinj
accidents are oftex not simply dne to human imprudence, but ages, health, status, and mobility levels fan for different res
to ârchitecturally triggered human erronc (Ardiea, 1985).
sons. Although there are few data evaluating the efficacy of va
While older people use escalators lessfrequentlythan do the rious preventive approaches with different subgroups of old?
young, they are disproportionately involved in escalator fan ac- people, it may be useful to distinguish between those method
cidents. Some of these falls may be due to jostling by other which may prove to be more effective with two broad group
riders. However, repeating optical partons on escalator treads of the elderly: older people who are at high ortowriskof fal
can cause a visual depthfllusioa,resulting in disorientation Jlna._The high nsk group mouses individuals with impair»
(Co/in & Lastly. 1985). Such optokinetic patterns, which also mobility and stability, multiple pathologies,
k^rt^n^ 0
occur on tile and floor surfaces, may be important contributors prior falls. They are usually, but not always, aged 75 or older
to falls among the elderiy.
For this group, a particularly useful approach may be througi
For a summary of some of the environmental factors affec- action by health ore professionals. Physicians, for «««plr
ting balance, see Appendix C*
need to identify and treat reversible medical conditions tha
have contributed to falls, identify impairments In gait and be
D. A Nate an Sadd out Behavioral Factors
lance, and hdp to improve >«Tant» through activity programs
There is very liale information available on thiffldnl and beha- better nntrirlon, and good general care. Older persons who ar
vioral factors which may predispose the elderly to fans. Some at low risk Of falling are those who arc adive, ^general!
investigators, however, have observed that
and emotio- healthy, and usually but not always under age 75. Since thi
nal status may influence mobility, inrhr/Hwg ggj^ balance and group experiences approximately one half of allfracturesof thawareness of and desire to manoeuvo in the environment femur, small Improvements in their balance tould be vey effet
('Jtnetti, 1986a). Since mobility itw^rfftw» have been found totive En reducing the total number of fall-related injuries. Fo
be important predictors of falls (TTnatti et al. 1986; WUdetal,this group, exercise and activity programs, programs to im
1981), mental and emotional status may be at
indirectly provo balance, and education regarding environmental hazard
A9tnri*t*A with falls.
in the home seen particularly appropriate.
Some empirical evidence indicates that the fear of falling Is Of course, k is also important to educate all older people, in
common among both the elderly who have etperienced fen* dudtng the young and healthy, to recognize that a fan may b.
and those who have not and that this fear often leads to restric- an early sign of illness which should be reported to their physi
tions in dally activities (Tbutti, 1986b). Probably for some in- dans for identification and treatment. At the same to fc
dividuals, the reduced mobility in turn précipitâtes other falls. necessary to encourage all older people,
ê vey ok
An interesting example of the interaction between sodal and and chronically disabled, to remove home hazards and to re
physical factors in causing falls comes from a study of Institu- main as active as possible. Distinguishing between chose pre
tionalized women with dementia CBrody et al, 1984a). Those ventive approaches likely to be most effective with group;
women who showed the least decline In their sodal relationships and mads more efforts to
comunication were which a n high and lowriskfor Tans is not intended to promott
found to Tan the mostfrequency.Since these women also had »dtfaa-/or« approaches, but simply to suggest where rdativd:
experienced abrupt dedines in their physical vigor, it is prasthle greate emphasis may need to be placed.
thdr attempts to m?intnfn sodal Interaction presented them , Soate of the steps to prevent falls that can be taken by profe*
with more opportunities to faH. Such data point to the need for aionals, older people, and thdr families, along with example,
a delicate balance between protecting the institutionalized el- of fan prevention programs that have been rmpWipm^ ^
derly who arc vulnerable to falls and fostering their sense of community and institutional serings, follow.
mastery and independence.
A. Steps To Be Taken by Health and Sodal Care Profession
i. CGnkal Evaluation of the Causes of Falis
The importance of a thorough clinical evaluation of older persons who have experienced falls cannot be overemphasised. A
follmfly be a symptom of a disease and calls for a thorough
examination. Because falls which do not result In injury are
often notreported,physidans need to activdy inquire about
fells during routine physical examinations and consultations
8
VOL S4 Snpfilirmtn No. VApril IC87
with older patients. Physidans who deal with injuries (rem falls madefromthis test, which also provides a rough measure of
should osore that an adcqoato assessment of the eansa of tha speed of gait and skiD on turning. Sway on standing can be totfall has been made.
ed by observation and alight tmeqwi ml tap on the sternum,
Whenever circumstances permit, a detailed history should be which notmaOy nrnim little or no response.
taken. Falling episodes, however, are often followed by shock, This simpte-nGet Up and Goa test has been found to be a
forgetfulness, and fatigue, and physicians often must
most as reliable as laboratory tests of gait and balance (Methhs
the nmTimnm information with a minimum
r of quo* etai 1986)*
tiens. If cimiiiimncrt do not permit taldng a
y
during the Initial examination, the following questions are use*, ° Two other clinically uscftxl tests (one for gait and one for balance) that require no eqidpmat and little training may be
ftik
found in Appendix D. Hiese «performance cneuted* HsittrtWhere were you?
mentsreflectthe position changes and gait maneuvers used du«
What were you doing?
ring normal daily activities (7Sxefl& 1986a). Difficulty on rising
Did you know you were going to M ?
and sitting down, instability onfirststanding, and short, disHow did you get up?
continuous steps were the itons on these tests winch best sepaWhesa ponible, coinfotmants should be queried about the cir- rated persons who feQrecurrentlyfromthose who did not
cumstances surrounding theft!LPgtf«w«B çhonHftlyftbe que* (Pnetti et ai, 1986).
tfftftsrfflhnnfany BfdîffltïftTW, M ^tfl flg fllCOhOl,ttfly
have taken within the prior 24 hours and how long they remai- A. Boston* Tests of Balance
ned on theflooror ground.
The dinial balance tests mentioned above can be quite useful
An in-depth history of prior faQs and the circumstances In for nwnriag balance poformance of individual elderiy pap
which they occurred should be obtained. In «MM™»w the pa- tienta. However, many more sophisticated tests of balance are
tient's levels of mobility and confidence in their balance should now being applied to investigate global balance control mechabe assessed, a.g. by asking them howfrequentlythey leave thdr nisms. One example is the balanee testing in the spaee programs
home and cross the street or, If institutionalized, leave their of the O.S. ÇAndenon etal, 1984) and of France (Oementetai,
room. The number ofrisksa patient taka is a crude inverse in* 1984), which involves adaptation to andfroma wdghtless environment. Adaptive protocols are also being applied in clinical
dicator of the probability of further falls.
Fflfnhffrtriflfl what thm paft-ff g^rçflftmflfg fh* rh*e afthm foTJ
research situations Qfashur, 1983), and wffl lead to a better
will hdp the physidan determine wheths: 1) it occurred as a re- undemanding of the disruptions in central processing mensult of imprudent movement but near normal balance or 2) me- tioned previously. These techniques require complot tostrudical factors and an impaired balance
were the ral clinical settings. For areviewof the balance poformance
major contributors to thefialLThe activity in which the patient tests,fromsimple clinical procedures to complex computer-as*
was engaged at the time of the fall can be classified according to
the challenge Itrepresentsto balance. For example, walking or sistcd procedures, including the rdadve costs of these tests,
r se
risingfroma chair is less challenging than rmehing to a high Appendix E.
shelf, which in tun is less chaHmging than running or bicy- J. Exercise and Other Programs to Improve Balance
cling. Systems of classification found usefhl in the epidemio- Another approach to the prevention offellsis to improve the
logy of industrial accidents might be applied in thefixtureepi- physicalfitness,agffity, and speed of response of older people
demiology of falls (Strandberg, 1983).
through exercise programs. Such programs aim to improve
nxusde tone, strengthen bones, and enhance confidence. The
2. Tests of Balance
pnernl health benefits of exercise programs for the elderly are
increasingly bebg recognized. Exercise programs have demona, Clinical Tests of Balance
Tests of balance should be routinely performed with all elderiy strated positive effects on the musde strength,flexibility,and
parieim who have experienced falls. The simpler tots a n also cardiovascular and respiratory systems of older people (Smith
be usefully performed with those who have not fallen, but who & Serf ass, 1981). In addition, exerdse programs for older people have been found to have sodal and psychological benefits
may hove undetected impairments of balance
Examples of balance tests «inch can be easily and quickly con- (MacPhason, 1986).
ducted by any health care professional follow.
Exercise programs for the elderly have proliferated rapidly in
recent
yeare in many nations, and a mowing number of trained
° Observe the patient's way of entering and moving around the
professionals are designing such programs for older persons.
room. Ask him/her to stand upright without support, with feet Sevoal good resources which illustrate simple omises for separallel and as close together as possible. Then ask hzm/hw to niors are now available (see, for «ample, Blkkard, 1986).
dose the eyes, raise the arms horizontal^, and walk a few steps Although tha efficacy of exerdse programs forfellprévent i f has not yet been demonstrated, the approach appears pro*
ded if needed. Anyone who can perforin this maneuver without xmsrng. Such programs combat the inactivity and loss of mobitaking steps to the side to maintain an upright position has per- lity that are though t to predispose the elderly to falls. It Is possifectly normal balance. If balance appears to be impaired in any
way, ask him/her to walk hed-to-toe along a line (actual or We, for example, for a relatively fit older person who has fallen
Imaginary) and turn around, observing how MImr* is main- to succumb to a vidous cycle of loss of confidence and reduced
tained during movement. The
should note any com- mobility, which in turn preeipates another felL In addition,
plaints about feeling unsteady, as well as swaying that is correc- age-related deficits in the speed of corrective movements, which
ted by the patient. This test may be most appropriate for pari- reduce the ability to prevent or protect from an imminent falL
ante —"
**
© Observe the patient's posture In a chair, ask hm/har to rise,dies, for example, have shown that the time to complete :
walk a short distance, and come back and sit down. Observe movement is much longer for old inactive subjects than othc
groups. In gâterai, the evidence seems to suggot that adults
this sequence of movements for any deviationfroma eonfidat who engage in physical exerdse react more rapidly than sedennormal performance (such as undue slowness, hesitancy, ab? f imparable ages CStelmach é Worrii^ham,
normal movements of trunk or upper limbs, staggering or 1985). Such data under score the potential which ocerdse prostumbling). Most of tha common neurological tfiagnoses can be grams may hold for dm prevention offen$by the dderiy.
Danish MoffeaJ TTiitTutîn
4» General Measures
Cos* history
,
Carefully assmtim medications takca by older patients and Mrs. Satth Is a widew, aaed 85. She sufiasfromPadin*n s eae»
mmaaTThrirre
and
poor
eyesight.
She
often
stusUes
aad
sometime
their patterns of alcohol use. (For a listing of the drugs whidi
both in and vat ef ha bouse. She has bees to the casualty depan
have been implicated as contributors to f&Hs, please see Appen- falls
meat several doss. Luckfly she has nottartherself mndi, apart fee
ds* B). Cautions attention» for example, must be paid to the breaking tworibsen one ecaslon and
severe braising or
precarious nature of blood presnre regulation in older patients another. Ha- daughter is aged 60 and lives is a flat some aille
away. Her gnsal practitioner, sodal worker and neighbours m eon
so as not to induce hypotension and falls p-frfffc 1985).
ceraed that she mightraftera sere sofonsfracture,had fsjmy or bi
o Encourage older patients who have Men to resume their found by the home hdp Meg on thefloordead form bypodrennk
daily activities as soon as possible.
Mo. Smith is cduaa&t to leave her heme *>rtt,vTqh it Is an eld heuu
full ef obstacles and has steps down m an outside tote.
o Reinforce the importance of wearing properlyfittedshoes
with soles of adequate slip resistance. low broad beds, and heel Response
cups Or straps to avoid foot movement in the shoe.
a. Assess Mrs. Smith's
(drags for arthritis ant
Parkinson's disease).
o Stress the importance of wearing presafption eyeglasses as
instructed
b. Request a domfdHany (home) visit by a geriatrician and oc
eopational therapist to assess functional ability in Mrs
° Distribute information to older patients on how to reduce
Smith's own environment.
home hazards.
c. Rcfe Mrs, Smith fbr day hospital aztodance in order to assess her vision aad general medical condition and to providt
5. RehahiStation
0
physiotherapy
aimed at improving gait and balance.
After a fan, the movements of an older person may change
d.
Try
to
persuade
Mrs. Smith to reduce some of the hazard:
and he/she may need rehabilitation in order to prevent farthff
ïo
her
home,
including
selling or loaning some of her furniMs. Retraining of conscious and tmconsdous control of
ture, finng loose carpet, getting a commode, and
motor functions to regain
is normally overlooked.
easy-co-grasp
down to the MTH*.
CarefUly planned exerdse programs may be usefuL
e. Discuss with Mrs. Smith the possibility of moving into a
Q There is a great temptation to give a partent an assistive demore protected environment, such as sheltered housing, or
vice for stabilization, such as a walking aid. Whfle a few neurt> help her arrange for supportive home care services.
logical conditions dictate the need for «^h devices, this dedSioa Should not be made Iigfatly. Aids do not allow correct sensory input and may undermine «««mpm to restore normal ba* 7. Steps to Promu Falls in Institutions
lance.
In con&daing ways to prevent fails in institutions, it Is important to recognize that the environmental needs of the resident
o if assistive devices arcrfffpmdnecessary, make certain they and the needs of the institution may be in conflict. For examare sized correctly and "parfaits are-instructed in their proper pie, institutional care staiT need to have the residents in higher
use. One British study found that only 22% of walking sticks
used by a sample of the elderly had been measured. Of these H beds in ordo- to perform their duties without strain, but resiwere si2ed incorrectly - usually too long (Salisbury MuUey,dœts need lower beds in order to get out of them safdy and
easily. While beds with variable heights are in widespread use,
1982).
they are usually controlled by the nursing staff. Carpeting
o Particularly for those older patients who have been confined would hdp reduce injuriesfromfalls, but is difficult to keep
to bed or chair, it is important to promote early restoration of dean and «pensive to replace.Hninfw» god mobility.
In efforts to prevent Ms, institutional care staff sometimes
0
The patient should practice functional exercises, such as restrain residents, either chemically or physically (e.g.. by putwalking on aU types of surfaces and cHmbmg stairs, along with nag a table over their chair or simple giving them one from
practising the correct procedures for transferringfromchain which t is difficult torise).These measures actually reduce the
and toilets. (Sec Squirts 4 Bayliss, 1985, for information on patient's mobility and stability, which increases the likelihood
of Ming. Residents should be allowedfreedomto move about,
these procedures.)
under as much supervision as possible, rather than being ex- '
posed
to sdf-defeating polldes of ratraint.
charge home visits in order to assess the patient's abfflty to cope
Usted
below are the steps which can be taken to prevent falls
with the activities of daily living. The patient should be assisted m Institutions,
while fostering residents' autonomy and indem making arrangements for continuing care and community pendence.
support services, if needed, such as meals-on-wheels, home
0
hdp, nsshrancc with transportation, and the
Identify residents who are at high risk of falling, e.*. those
of
advanced age with multiple pathology on multiple medioReferrals to Other Parts of the Health <£ Sodal Core System
Because the causes and consequences of falls by older people ûons and those with intellectual Impairments. The Ugh risk
are so diverse, the services that may be required by elderiy fall profile may differ somewhat from institution to institution,
victims span practically the entire continuum of h«Wt ^
^ o Analyze staffing patterns to assure that adequate nursing
aafT are available to provide dose observation of high risk residal care.
dents and to respond promptly to call lights (Kaiçhihaler et aL
The following diagramfllusiratesthe many »paths« which an
lJW:Swaft&x*.19&). M
dderiy fall victim may take through these systems in Great Brisident's reach at all
times.
^^
tain.
o Monitor older residents dosely during thefirstfew weeks Of
Adapted from: M. Green, »CommunIry and Hospital Scrvi- residence and when they are moved to new units (Bogue, 1982:
ces«,: in MS. Kataria (Ed.), Fits, Faints, and Falls in Old Age.
Land é Sheofor, 1985). Resident or volunteer companion proLancaster: MTP Press
1985.
grams aad the presence of family members could be helpful during these periods.
Another illustration of the interplay between the h^mhu 2nd sodal care sectors in the prevention of fans is provided by die fol- o Monitor during acute aînesses, such as pneumonia, which
are Ugh risk times fbr Ming {Tmetti et ai, 1986; Morris A
lowing British case study, reported by Green (2985):
Isaacs, 1980).
0
o Monitor careftffly during the post-fen
p » a s theriskfor B. Steps To Be Taken by Older Persans and Thdr Families
another fan is thought to be hightUém
Older persons and their
wouldfrffnfffftfromfacr—
1
o Smirtfrw staff to recognize changes ht physical vigor and knowledge about both the T***?» and environmental fattftn
weight that may signal silent changes in health sous which are that can cause falls by the ddcriy. In feet, the prévention of
many types of faQs wffl depend rlfhrmHy upon the actions of
a preiude to falls (Brody et al, 1984b; Wells et aL 1989).
older people, themselves, who need to be provided with accuo MoBiim* the nKdkadoos taken by elderiyresidents.Make ef- rate Information on the precautions they can take to avoid falforts to reduce the usé of sedatives and tranquUhHs
ling.
lar (Bane-Szostafc, 1984: Swanzbedc. 1983; Wdtsetd. 1985).
9 Dress residents m their own clothing: do not pontic than to
walk about in long gowns and robes and illflwfag«Uppers. L Self-Care Measures to Prevent Falls
o Ensure a barrier-free environment Insofar as pHH* Se> • o Be aware that certain hicpsmmw awH certain drugs may pin^g
you at increased risk of faffing.
move carts promptly and leave hallways andnnered.
0
Seek good vision and podiatric care,
oraimîimtirenvironmental hazards, such as spills, mafflme*
o Wear glasses if they are prescribed.
firming wheelchairs, and the Oka. .
0
Wear proper shoes or sfippos which have:
- A secure fit. with eadosed hed If possible
& Examples ùf Fall Prevention Pro&uins in Health Cara Set• tread paftirni which are siqyresistazxt and durable so *hpt
tings
wore, areas do not develop
Programs to prevent faQs by the elderly can be
- low heels with a broad surface which
the floor:
in a variety of health care ««"fug»,
^ rmru Bwpw.
- avoid metal deals; '
IWH et ,1 M
* " ' i ^TrnMlffrrrfnTt rrnçriiniff. irhrrrr tnrm hrnrlmln. tuid - avoid l»»**!—• oifoy
long-tenn care facilities.
o Do not wear long robes and other bed clothing
At the Kitter Geriatrics Department of M l Sfaai MedioU
CnrtfT in Mew York, for example, a »FalIs
Immobility o Engage inregularphysical exerdse and cat a balanced diet.
Protteama H» W n jw+rfaf—4ftspy^wwflfofofryrtânlAmm
° Take steps In mid-life and beyond to prevent «^«gQjMif.^,
who are pat risk« of faffing, those whose fear of faffing has
made them increasingly ifldflllywfthrfrattm, a^d «ftrtygrfrfc gafro Resume regular daily activities as soon as possible after otpeand
impairments. A wmWrffcgtpHiwy »—w, condnets rfsndug à fen.
thorough evaluations of the dderly patimts* physical and psy- 0 Be alert to certain sensory changes that may result in
chological health status, thdr pattern of
use, and but critical losses In the abfllty to prevent falls.
pototial environmental obstacles, and then develops preven- 0 Take time to recover balance «hen w^ng from a chair or
tive programs tailored to individual needs. The evaluation in/» bed.
dnrtw an analysis of patients' walking rgr"*'Hî. " r t j video• I ^ w to bend andreachproperty; use appropriate strategies
tape and other sophisticated methods. {
In Britain, a progmui of in-home physiotherapy to prevent for getting in and out of can; cany butty packages cautiously;
recurrent faQs in highriskolder people was developed through -be alert to sudden movements by pets or toddlcra.
a department of geriaoic W^M™» It suggested that short, hi*
tensive exposure of tha patients and thdr relatives to a skald Z // a Fall Occurs
jtf»ys»o!hàapi8taggg8E&sthc probability of recurrent falls Both older people and thdr families wffl fed more confident
QÇbonyo et al, 1984).: >
if they know what to do fhgqld a faU occur.
• la tw6 IUiU Utaiii care fadHtias in the U-S-, p r o g i a m to prevent faQs among high risk patients (those aged 70 and older) o Be aware that any fell, even if no injury results, may be a
have resulted in substantial reductions in the nnznbff of faQ h> sign of underlyingfflnessand should be reported to one's physiexdems. {fife et al 1984; BainvUle. 198^. Thœ programs included patient and family éducation, environmental changes ° Ttf » summon hdp. Leaving a bdl on thefloor,e.g., under
(such as leaving beds in low positions, pladng can bdls within a chair, is a wise precaution since shouting can be tiring. Aneasy reach), and staff education through inservlce training. other simple safeguard is to place a telephone, along with emerEducation about faQ prevention can also be incorporated in ho- gency numbers, on a low stooL
spital discharge planning. At a community hospital in the U.S., There is also a widerangeof security alarm systems available
a one-hour home safety program, which included the dissemi- in many nations. (See section C below for a description of some
nation of a checklist on how to »fall proofo one's home, was of these devices.)
integrated into the discharge program (Gray^Vtckrey, 1984).
At a large rehabilitation-oriented musing home m the mid- o Learn how to get np after a fan. Researchers in France have
western U.S., a falls prevention program resulted in a 70 per- observed that many older people are unable to get up
cent reduction in the number of fraoures sustained by residents afto a fan and appear to have lost the reflex to turn onto their
stomachs m order to rise {Albareda and Vellas, 1985). Older
{Rane-Szostak, 1984). A major component of this program waspeople
often have great difficulty getting up unaided after a
a concerted effort to decrease the use of sedatives and tranqui- feQ, and it is wise to be aware of various methods for doing
lizers. The facUlty sent letters to aQ of the physidans serving soÔf course. If an injury is suspected, do not attempt to rise.
its residents, asking than to reduce the use of such'medication Several methods of getting up have been suggested (Sauira &
and to drmfnnTft Jong-acting sedatives infavorof night-time se- Baytiss, 1985):
dation as needed. Nurses were also presented with alternatives
Ron and Crawl - Roll onto one's stomach, get up on aQ
to sedative use, including changes in bedtime routines, evening fours, crawl to a nearby piece offtirniture,place
on it,
snacks, and mild analgesics to decrease pain. Hie researchers and bring one's foot forward, putting it flat on the floor. Stand
concluded that, while In-service education aboutfellprevention up and sit on the chair to recover.
In general could have contributed to the reduction in fiamirçs. Sideways - If painful knees prevent crawling,fellersmay be
the only consistent change over the stnefy period was the deable to shuffle on their bottom to a piece of furniture and then
creased nse of sedatives and tranquilizers.
puQ themselves onto the kseu and
up.
Using Stabs - When oawQng and knecBng are impossible,
f^*fflhtg to tbe sain or a low stool may be possible. Faners
can
move up gradually to a hnght that p*""*** i^Ti'fîg
o Try to keep warm ifyou cannot get up. Pull anything accessible, sneh as rugs, coats, and blankets, over you and under you
if possible.
stall way, or the bottom step o n be marked with paint or brig
tape. Nothing should be stared on suits. Carpeted
sbou
not have repeating patterns;
(b) Outdoor areas: Lawns, cuiiyways, gardens, drivewa
and walkways should befreeof holes, cracks, and other tri
ping hazards, and cleared of wet leaves, ice, and snow.
4, Examples Of Community-based Programs to tmp
A Nota to Families and Oth& Cams
Home Safety
Family members and other carers, who are often middle aged Programs to improve home safety in olds people's homes c
or elderiy; should know-props methods of lifting and how to be initiated under manyfliwpteffl,fa^fa^fflgh^fllth and soc
ovoid injury when trying to lift an older relative who has fallen. care systems, narfonnl or local safety councils, voluntary org
It may be preferable to summon help.
tiizations serving the elderiy, and self-help groups of ole
When an older relative aAveiieuccs a £a&, family members people themselves.
oftenreactwith guilt and anxiety and may become »ovcrproAfenprevention program developed by a department of
tectivea hi their efforts to preventfixturefalls. Be aw&ie that rintrig TiifdMnf in the United Kingdom llhuwws some of t
attempts to restrict an older 'relative's normal activities may difficulties that can be encountered in trying to convince ok
harm their physical «"id mental health. in particular,- families people to change their home environments. Heahh visite
should know that the vast majority offellsare'not a cause for (community nurses with tiaiuiug in
promotion) visit
institutionalization: Many simple steps can be taken to prevent tbe homes of a group of elderiy patients Identified as being
future falls without tmderminfag autonomy.
highriskof faffing. Although the older people walcsmed :
. commendations for f*bBT1gfi in nutrition and the proper use
3• Reduang Hone Hazards
. medications, they were resistant to rrrrTTTmw^rt^nt for or
Most falls by elderly people occur m the home. There is little ronmexxtal changes in their homes such as «frfftfrig furnftn:
doubt that the homes of many older people are hasardons. Ef- tacking down carpets, or improving Hgtirfwg Those envire
forts need to be made to give older people information about mental hazards identified by the health visitors were not pi
what they can do to make their h***»* safer and to encourage cerved as such by the older residents. The program organic
* them to accept the value of such changes. Olds- people also concluded that the sense of having one's home inspected by
need to be particularly alert to hazirds in environments other »oinsider* may have produced some of the resistance and tfc
than their own home.
the older people might have been more responsive to reeo:
The emphasis in the following sections is on how to make mandations made by a regular membs of their «^"g ter
the hose environment safer through sfanple, non-structural
Thesefindingssuggest that health and sodal care person!
changes, and some of the techniques that have been used to with whom the elderiy have ongoing contact in their hoir
focus attention on the need for these changes. Some of the most such as home helpers and home health nurses (as well as gene
important areas of home environments that should be
practitioners In nations where home visits by physicians are r.
for potential hazards are:
common) may be in the best position to recommend
(a) Floor surfaces: Carpet edges should be tacked down; in the home environment. More information on fall prev«
rugs should have non-skid backings. Use wail-to-waQ carpet tion, for example, could be induded In training programs f
where possible, especially in tbe Mf.h»* /Kn^ room, and both home helpers -and nurses.
bathroom where spiQs can occur. Replace worn carpeting beIn a comprehensive effort to evaluate a fans prevention pr
cause it can cause both a slip and trip hazard. Where there gram, a large «health maintenance organization» in the U.
are hardfiooxsthat cannot be carpeted, make sure that the sur- is now assessing safety ha&rds In the homes of over 1,000 p«
faces are waxed regularly with non-skid wax. Be sure to follow sons aged 65 and older. This project Is being conducted by ?
waxing directions closely so that the non-skid properties have Kaiser Permanent Center for Health Research, a large prepâ
a chance to emerge. Keep all floor surfaces
Dust, group practice located in the Pacific Northwest. Its completicaumbs, and other contaminants can be as haahious as Utptfd is apeoed in 1988. The project win test the efficacy and co:
spiQs;
effectiveness of a falls prevention program with thine maj<
(b) Lighting: There should be even and high (nonglare) levels components: (I) a home safety audit and improvement pr.
offllumfuatioQthroughout the house, especially on stairs and gram designed to identify and remove externalriskfactors; (
pathways between the bedroom and the bathroom; light swit- a health behavior change program in a group setting to
ches should be easily accessible and near every doorway;
oldo- people tojp^stand thdr risk-taking behavior and to s
(c) Bathroom; Non-ddd rubber mats should be used in change sodaisnpjwj^dû (5) iNjsian screening and treatme
showers or tubs; handrails or grab bars in the shower or tub programAHonthe&, et ai, 1985^) Both experimental and cor
and by the commode; toflet heights can be raised; seats can be trol groups juTTT lu fulIeviUdTSr14 months after the inicrvei
used in tub or shower;
tion programs end.
(d) Traffic lanes should befreeof obstacles end fUmiture. Both voluntary organizations and national safety cound
' Telephone or electrical extension cords should be rafkffrf to the can also play important roles in
information c
wall;
fan prevention to the elderiy. Many national Red Cross sodi
<e) Furniture should not have casters (wheels) or sharp ed- ties, for example, carry out programs to prevent falls. In G>
ges. Couches, chahs, and beds should not be too low, too high. neva, the French Red Cross has developed a crime prcvcntic
or too soft for easy egress;
program for the elderly which includes training in bow to fa
(f) Sturdy step stools should be used cautiously. Standing on properly if attacked. In the U.S., a widely used home safet
chairs is to be avoided. Frequently used items should be placed program for older people has been developed by the Nation;
in easily reachable areas on shelves;
Safety Council in cooperation with the American Assoeiatio
(g) Stairs should have «"t-i"*»» illumination and nou-sldd of Retired Persons (AARP). Tbe program, which includes a
treads. Securely-mounted hamii^fly that are easy to grip (pic- informative slide show, ofTers practical advice onfindingan
ferably round and 1W or 4 cm in diameter) should «tend the clfmmarmg hazards in the home as we& as on good safety ha
fim length of the stairs, preferably on both sides; the end of bits. The program is one of the most popular offerings c
the rail should be designed so that itrfgwoifthe bottom of the AARP's Program Department, which provides information ti
12
VAI V 6 n . i i M M . i u .
right
lOUid»
older people onawide range of heaith-retaedissws. Older vol- Most of the basic knowledge and technology needed to make
w e e n proaa the fka prevention program fn local comimim- environmental changes that wouldftfipprgvwt
by the elC» around the country, booting approximately 500 showing derly, as wen uotho age groups» are available, but not applir4
or the ptogrea x r year which reach an estimated 25UX» old» ('Maker A Harvey, 1985). Fer example,
that are ea:
Afflqrcam. The background material* Mud* * vniii^^to grasp are a wetL^stabfisbed design principle, bat they rani
ertffiide with details on how to ptibltefee the program m the farfromthe norm In public
fwyttfuHnwaf care fa*
community, lead grouprifommlousand role play activités, and aBtics. Buildings can be
with stairs and ramps that
initiate foDow-up activities sudi as exercise classes and home give visual and tactile dues about changes in elevation through
repair registries listing local retired craftsmen who can
proper placement of îdnriln and steps with well-delineated
simple home repairs to reduce safety hasards. In addition» an edges (Waller. 1978a). (For examples of good design principles
«tensive home safety »checklist« is distributed to participants for bathrooms, stairs, handrails, and ramps, sea Appendix O).
(see Appendix E) and follow-up mirffrtgs are encouraged to The diffiailxy in getting such changes implemented, how
dlvrntt any hazards found in the
and steps —fr»" to elimi- eqr t is HtoSttated bv the fact that arqbahfr nna half to three
nate them.
fourths or allflightsof stairs in the U.S. do not mm the rnrOlder people themselves can dffrign and implement their own tax standards of thb'Ughi Safety uxla. which is iha dfllyu^.
fan prévention programs. In Vïborg, Denmark, a group of se- "nffUyl gHyUrrf-^MtiUtmfl u m i^Jii.^
However,
niors meeting in a »study drele,* a popular form of Danish the U.S., where building codes varyfromone locale to anoth».
adult education, produced a 50 minute color slide program on Is probably not alone m confronting major problems In adopfell prevention that is being used by other senior dtiaen groups* ting more uniform standards aad other policies that would
(pregersen. 1986). The result suggests that, whilefellprevm- make the world a safer place for the dderiy. Special interest
tion is a serious matter, it need not be addressed in an ungear groups such as the construction Industry and developers, for
that would g"*»»™» older people's
tivcor somber fashion. Each of the color slides is accompanied example, may resist
by a humorous and instructive rhyme written by the seniors safety due to the perception that these would entail Ugh
cftiftw.
it seems important to encourage greater Trmithemselves. The title of the program is:
mer
representation
by older people on the bodies responsible
Better pin the carpet - dot
for public safety such as local building departments. It would
Or the surgeon is pinning you!
also be helpful to draw upon the knowledge gamed through the
Another home safety program that has met with considerablè World Health Organization's Global Program on Accident
success in some countries is the use of security algm systems. Prevention, as wen as the successful advocacy efforts by groups
These systons can help prevent the dangers posed by the along of disabled persons in a number of nations in how to promote
Ilea and give those who live alone an moeased sense of smi- needed changes in publie polldes. Despite many barrios, the
rity. In the U.S.,fellshave been found to be the most common issue of how to construct urban environments as wen as public
emergency toe which one widdy used alarm system is activated and private buildings in ways more responsive to the needs
(kmbe fitted to a neighbour's home; (2) systemsfittedto tele- the elderly win become increasingly important with the raj
phones which signal a central exnsgency station that
is ftgiwg of the world's population.
needed; and (3) portable transmitters that may be worn around •
the nedc or wrist and also alert a central station. Although thoe
devices have not been uniformly successful because some older
people cannot reach them or forget to use them, they axe being
used in increasing
in some nations such as Sweden. *
Large numbers of Swedish local councils, which are responsible
for social service, provide trinphone and portable transmitter
alarm systems at no cost to elderly aad handicapped posons
living in their own homes. A famuli y into thdr effectiveness found that the subsoibets overwhelmingly felt-the systems gave them an important sense of security and were often
an importantfectorin thdr dedsion to remain in their homes
rather than move to an institutional setting (Orkan; 1984). Falling was the second most frequently given reason for activating,
the alarms. (Becoming 01 was thefirst.)Recognizing that some
older people are resistant to highly technical devices, the Swedes have made alarms more acceptable by marketing them as
«security telephones,* emphasizing that they are just a simplified means of communication m situations where the use of the
telephone may be much more difficult.
•ways t
tripirove
•scan
«odal
orga»
older
t
ifge- Ïe
•>f the \It
older
titers
isited
.ngat
,-d rese of
enviituxct
•irontpernizets
by an
Ithat
tODb
«am.
onnd
'.omes
meral
-estin
MOM
nugg •
evenis for
•
• *
LpiT>>
U.S.
3periy the
epazd
letion
cost*
nàjor
pro*
•nablc
to n*
l con*
Tvenan on
SOden Ce»
soon
ofan
safety
douai
iation
es an
sand.
y hags of
onto
i IS»
' .k,
C. Steps To Be Takai by Architects, Planners, and Public
Safety Authorises
Making the world â safer place for older people should be high
among the objectives of all àrchxteas, planners, and publie
safety authorities. It is the dderiy who suffer mostfromsuch
environmental hazards as poor maintenance of walkways, poor
Street lighting, delayed snow clearing, litter, and brief cycles hi
traffie lights. Within publie buildings, they are atriskfor fenf
due to non-slip resistant floor surfaces, jostling crowds, poorly
designed and lighted stairwells, and glaring lights. Some falls
may also be due to fatigue, yet few public buildings ami stores
have chairs wfase the weary can rest.
Daafeb MaÛaJ B u t e »
13
nr. RESEARCH ISSUES
APPENDIX A
Although is recent yean growing research attention has been
devoted to felb among .the elderiy, neither their canses nor the A GLOSSARY ON FALLS
most effective methods of preventing diem are yet wdl under- By Profe&ar Bernard haaes
stood, Epidemiological research on faQs among tha elderly is
also at an embryonic IeveL AH epidemiologicalresearchon fen*Since falls are part of everyday experience, they are described
is hampered because faQs are not recorded as a disease entity hi everyday langnagn which lacksrigorand precision. This rehifflfdfcalfrdfr*»such as Index M^ffa™ or the International suits in the faulty transmission of information between patient
Classification of Disease Xth Revision. This problem should be and physicien and between researchers, with consequent lode
of darity. The following definitions are proposed in the hope
remedied.
that
they wQI bdp to improve communication among these
Ona major barrier to research on faQs hasfrfrothe lack of
a dear ^"Hnlrtftn of faQs* a torn winch covers many disparate groups.
events. (See the introduction of this report for a proposed defi- A Fan
nition). In addition, there is a need for a system for classifying How a fen Is defined 4ftpfndi upon tbe purpose for which the
different types of faQs in order to make researchfindingsmore definition is being used. A fen Is an event which results in a
comparable.
person coming to rest inadvertently on the ground. For certain
The methodological problems in icscmUi on faQs are many. purposes, such as research and prognosis, it would be
Community-based samples have largely rdled upon icuuspeu- to exdndéfromthe definition those
resultingfromMil of
tive data and,
result in the misreportmg and undsre» consdousness, onset of paralysis, an epileptic attaiek, or impact
porting of feQ events. (Prospective studies are costly unless with a moving vehicle.
based on unrepresentative samples.) Very, few community-baAn faQs comprise an
event* a continuing çg^y», and
sed studies have used representative population-based sampte,
a
final
phase.
TV
initiating
event
is a displacement of the body
Hmirfwg their genoalismbQity. Studies comparing the charactebeyond
its
support
base,
which
may
be Initiated by tbe subject
ristics of those who havefeBcnwith
samples of those
in the course of voluntary movement such asrisingfrom a diair
who have not faQen arerare.Neither is it dear whether age and or climbing stairs or which may be imposed, on the subject dus « would have independent effects upon tberiskof falling if ring quiet standing, such as being jostled or during movement,
health status and mobiSty were controlled. sr«m most studies such as pladng one's foot on a slippery surface. The continuing
have
cross-sectional
fittlf
is w^wn about thg gai»» y* fnfftiFft t<* m m ^ f^frifoplacfmfntin tbf tfmir avgflabfe
ovgf time in the
factors fôrfaOûMfr af»j r*»
This may be because of:
oi age cannot be assessed, ma problem of sdcctivc attrition,
1- Loss of consciousness.
Simmon in longitudinal smdls of olds people, nay be espe=
2. Loss of awareness.
dally pronounced in studies on fells.
Finally, some important issues related tofellsamong the el- 3. Overwhelming of the
4. Inaffidacy of the mechanism.
deriy remain uncharted irîreh territory, including the effectiveness of various feQ prevention strategies and tbe sodal/ In thefinalphase, the body may coma to rest on the ground
emotional predpitants and CTHÎ"""****' of fafa
or on a soft mrfare such as a chair or bed, or the subject may
of these limitations In our Imowledge base about be caught by a helper. The proposed definition excludes loss
of consdousness as one of the continuing eauses offensbecaufalls among the elderiy, there is a need to:
se the determhiation of the canse of lost consdousness is a sepa1. Develop a terminology of faQs. (For afirststep in this direc- ratefieldof study. It
ffellsin which the subject comœ
tion, see Appendix A).
to rest other than on the ground
the consequences of
2. Develop a more comprehensive and uniform system for data these differfrom.theeffects of faffing onto the ground.
collection which fulfills the requirements for epidemiological studies. The already ^ « ^ g systems for recording acd- Fatal FaBs
dents leading to injuries could be expanded by adding just a FaQs are not usually recorded formally as a cause of death. The
few more questions related to falls.
International Classification of Diseases provides a category for
3. Add questions on falls to other investigations of older the indusion of acddexrtal causes contributing to death, but
people, including both .longitudinal studies and other clin- this is seldom employed by physicians recording the
of
ical research programs.
deaths of Old people who have suffered faQs. As a result, there
4. Conduct longitudinal studies to identity risk factors for falls Is a lack of sound epidemiological information. TUs will con»
in both community and institutional settings.
timte until physicians and registering authorities can be con5. Evaluate fan prevention and faQrehabflhstion programs for vinced of the Importance of recordingfells,whether or not asdifferent subgroups of the older population, such as those sociated withfractureswhich have preceded the patient's deap
who are at high or lowriskof felting.
th. A difficulty may occur m detennining the exact association
6. Investigate the possible role of social and emotional factors between the fell and the death. When death follows shortly
in the etiology offells,about which very little is known.
after a fen which
a subdural baematoma or a fracture
7. Identify both the behavioral and psychological consequen- of the neck of the femur, the association Is dear. The associaces of falling, even if no injury has resulted, for mobility tion Should be equaQy dear when the patient has spent a long
and morale.
time lying on thefloorunable toriseafter a fan, and death fol8. Determine the behavior of administrators and other staff In lows a subsequent period of Inanition, or when in such dreaminstitutional carefedUtieswith respect to fells.
stances hypothermia, bronchial pneumonia, or a pressure sore
9. Most importantly, elucidate the physiological mrrhanmns has resulted. The association between fells and «th^M^t
of and impairments in gait and balance
the elderiy, death should also be stressed when a patient has become chairwhether or not they are related to falls. There is also a need bound pr bed bound after suffering a series offellsand losing
to investigate the biomechanics of the gait of elderiy people, the ability to walk independently.
the ergonomics of their footwear, the nature of floor surfaces, and thdr interaction.
Drop Attacks'
This term was Introduced to describefellswhich occur without
warning during normal walking without evident eanse and
14
Vol 34 Scppinflx N*. 4/April 1pf7.
* ralyas of the limbs. It is doubtful if much 2s
by >.PM»i..g
these « a separate entity, and the use ef the tern*
be chanisas. Its importance is as a measure of h ^ a n & t a ^
discontinuai
Giddy, Light-headed, Vertigo*
»FaBm*
Subjeas with balance disorders experience a variety of sympThis term isfrequentiyusedto describe people who have fallen toms which theyfinddifficult to put into precise words. These
repeatedly and may be considered likdy to fall agnwi- Its USage jnchîdf?
is undesirable, however, since it labels people and since there 1. A sense of relative movement between the body aad the eiu
are no specific groups of people who are not liable to fall.
viroument when both are at rest. The subject may experience this visually or through a proprioceptive sense, and he
may fed that the movonent is within or without himself.
Balance and »Loss of Balance*
The movement may be experienced as vertical (»floaring«)
Balance is best defined as »the abxEty to prevent Ms on dsor as rotatory (»spinning<0.
placement.« It is not a unitary funsio&,'but a strategy which
màkcsuseofasetofftingïnns. which in mm Twpiny a mnnW 2. A vrorinn of nmfanatrfia between vfami ami
of anatomical structures. Thesefarftt*£the visual, vestibular
tive or vestibular information.
and proprioceptive pathways and their central connections, to- 3. A senatioa that the upper or lower part of the body is diffégether with their efferent outflow to musde groups.
rait from the other. This may be
r u m l as "gh»' In common parlance, a single fall or a tendency to recurrent
handedness or a »watery« feding in the lap.
falls are both attributed to »Ioss of balances The term is inap. 4. A sense that a fan is
pxopriate in sdrrntiffc discourse since balance is neve lost. It Hie words»ftdizqr,*Alight-headed,« »gtddy,« and »vertigo«
is better to explain a single faQ or i ecuman. falls in tanas of tend to be used variously fbr these aad other similar sensations,
tonporary or permanent impairment of part or all of the strate* a n d » scarcely be avoided in disaminrrc with r I t is
gic system of
important, however, to attempt to
what the
is trying to convey by thdr use.
»Trippbtg and SBpptng*
These events, which occur during waiting,.represent displace- »Fa£nt*
ments impound on the fnfrfated movement. A trip is a retarda- In common parlance, the teem is often used to desofbe a sudtion of the swing phase; a slip, an accélération of the yereq* den feding of diTrinm or weakness. In sdentific usage, howphase of walking. More fhtty, a trip is an
m m ^ ever, it is restricted to the transient loss of consciousness as a
betwem the swinging foot and an obstacle such as irregularity result of a vaso-vugal attack.
of the ground surface caused, for eonnple, by a stone. Thîs retards or arrests the swinging foot and leads to secondary effects »Bladcout*
which are partly "«^Trnfrnl and partly corrective.
The use of this ward mthtt Ewgfafa language HfltMft?anum
A slip occurs on ground contact when the foot or part of the ber of distinct experiences; including:.
shoe (usually the heel) encounters an unexpectedly Iow„dyna- 1. A transient loss of consciousness.
nuc fricrinnal resistance as a'result of lubricants or a
2. A transient loss of memory
in ground surface, in angle of attack, or in stride length. Hie 3. A transient loss of vision, or more predsdy, a greying of
foot moves forward with resultant secondary m«*an<r»at
the visualfieldwith loss of its spodfic content. corrective movement of the rest of the body. Whether or not
Thee
symptoms have different physiological mechanisms.
a trip or slip causes a fan depends on the efficiency of the corClarification of the patient's use of this com should always be
rection.
1
ASfconMe*
Postural Dustiness
A nstumblea is the name given to a rapid sequence of corrective This Is a light-headed sensation which occurs when the position
movements of die supporting feet which follows an unetpected Is changed from sitting to standing. Postural ^^'TTTT should
displacement during walking. It consists of one or several steps be distinguished from postural Instability, m which excessive
and comes to an end whan the subject resumes the former walk- sway or smggering occurs on change of position from sitting
ing pattern or stands stSL If a stumble fails to achieve its pur* to standing, and from postural hypotension. In some cases
pose of stabilizing, the subject fans.
postural hypotension may be the mechanism of postural dlzzîaos or postural Instability, but often these are.independent
MStaggera
The word astaggera is used to describe an irregnlar step pattern
usually with a wide base, which may be:
APPENDIX B
1. Initiated by the s u b j e c t o f impairment of the baTable
1. Medications and substance affecting balancew)
lance mechanism, usually resultingfromcerebellar, vestibuHealth care professionals and older people themselves should
lar, or visual disorder.
2. A' correction following a displacement, particularly if the be particularly alert-to the potential dangers of interactions
among prescription drugs, non-presoription drugs, and alcodisplacement is in the lateral plane.
3. In response to an irregular movement of the supporting hol.
base, e.g., on the deck of a ship. Whether or not a « ^ g y 1. Medications Which Reduce Aiertnea
leads to a fall depends on the efficiency of the correcting me- 1.1. Narcotics 1.2. Hypnotics
chanism.
13. Sedatives
1.4. Tranquilizers
*$way*
1.5. Alcohol
This word is used to describe the inverted pendnlar movement
of the trunk which occurs during quiet « W K ^ ft originates *) Prepared Bernard heae»
-
)
IS
2. MedfattfonsffTtfcftiteratf Central Cottditerion
APPENDIX D
2.1. Narcotics
Z2. Hypnotia
2J. Sedatives
2.4. Tranquilizers
2J. Analgoicx
3. Medications Which Impair Cerebral Perfusion
3.1. Vasodilators
3-2. Antihypertensive
4. Medications Which Affect Postural Control
4.1. Diuretic.
a DfgîtaHs.
4 J . (Soma) betablockos.
4A (Some) antihypertensives
APPENDIX C
Table 3* Environmental factors predisposing to fallsV
1. Subject Walking*
1.1. Poot-Cround Contort
1.1.L Movonent of foot within shoe
1.1.2. Paiaftil contact of foot with shoe
1.13. tcm slip resistance of shoe surface
•1.1-4. irregular slip resistance of shoe surface
1.1.5. Uneven shoe surface
1.1.6. Low sDp resistance of ground surface
, 1.1.7. Irregular slip resistance of ground surface
1.1 .S. Uneven ground surface
1.1.9. o«wattijTiaii»< on ground surface (for example
dirt and lubricants such as grease and water)
1.1.10. Changes m level of ground surface
L O I . Movement of ground support surface
1.2- Body Contact,
1.2.1. Impact with static body
1^2. Impact with moving body
1JL3. Wind
2. Subjea Changing Posture
2.1» Transferring from chair or toûet
2.1. L. Movement of chair on rising
2.1.2. Qiair or seat too low
2.1.3. Chair or seat too high
2.1.4. Seat slopes back
2.1.5. Chair back slopes back
. 2~2. Risingfrombed.
2^.1. Movement of bed on rising
2^2. Bed tod low
2 i 3 . Bed too high
ZZA. Mattress too soft
2.2.5. Lack of arm support
2.3. TransferringfromBath,
2J.1. Lack of handrails.
23.2. Lack of slip resistant covering on bath surface
3. General Factors
3.1. Poor illumination
3.2. Optokinetic effects of floor and .wall decoration.
3.3. Limited space
PRpml by St/fUfi Ztttfet
16
EXAMPLES OF PERFORMANCÈ4HIENTED ASSESS
MEN1S OF BALANCE AND GAIT
Tahle 1. Pafbmenct-Oriented
a c/bdanes*).
amntf
Patient begins
wnd
s in c hard,tielghtêeksd
s
ekdr. Thafaûaw
manaeuvm are
• observed:
V RESKWSB
MAKOEDVEa M O T
Adatem
Afamnl
Stmdy,
Sitting balance
Holds onto chair ^ slides
to keep eprigttt down la ch^^r
A/tdns from Able toriseIn A
Uses anas (en MaMpto
single movonent^nr cr wa^bng auo^B
chair
Wfthffllf UBBg aid) to as teqnfaed or
pgi^ ep; andfor unable wftbœ
arms
toovs fûnMid luiman
arise
Immediate Steady without Steady, but uses Any sign of
standing
olding onto waOdng aid or ^nfiîn*"»*
h.r.w.. m m yih
OUIIUHM
iM
wla
lking aid or other objects for
« seconds) othq object forIDPPOR
wpport
Standing
balance
Steady, able toSteady, but
stand with feet
together withouttogether
holding objecs
fer fitppoft
Any sign of
rrgrnrflm of
•tara or bok
eete ebjeet
Balance withSteady without Steady with feer Any sign of
nnsteadjœss
eyes dosed
onto op^^
(with feet as any object with
seeds to hold
dose togsdur feet togethv
onto an Gbjcc
u possible)
•
No grabbing or Steps axe
Any sign of
balance (360*)staggeriags ao Htixwrfum^ nSddbâi i
(patte p*** eee holds eete ar
fttitft anyfoot completely object
obfeets; steps art
enfloorMon
oondnsoos (tasraising ottaer
is a flowing
foci)
>
Steady able to Neods to moveft-gfpfte fall
fort, but
to «tiiiiim. i
withsttnd
Bttsaoin
help wnimiiH
Standing wiA
balance
balance
feet asdoK
together as.,
poiprfhle,
Nudge OR
sternum
pushes with
pressure over
UB'UUB 3
times) refleea
»WWfy tO
withstand
*) Rfpnmed with penmoioo frem tin America Csistsc Sodtfy, »A
mnofrOrfggod At^tMiowi at MobBfcy Preblaai Is Bltfarfy^ by M
ttacnl ÇJomd qf American Geriatria Sodety. voL 34. #2.
19SS.)
**) Urmraiftyitfrfinfri*»jff**8* uobjtni faf nippon. aagaiag.
VcL 34 Sapptono* Ne. 4/ApriI
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Q&/0B/91
£
ss-
16:57
©514 932 1502
SIDA UdeHontreal
DeptSantaComRlKl
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MAN08WB
QOMPONBNnP)
Any dga of
Step Height (begin Swingfootcompletely wing foot is sot
flflrrd
head s least half abOhytotmn unsteadiness or obsaviog afterfirstdearsfloorbta by eoS
mmpiffrty raised off
to turn bead way aide and be1 side to aide t
o
symptoms when iew asps; observe mora than 1-2 inshesfloor (may hear
ode and look eUeto bod ntrtid neck, butnrnurrg head or v
one foot, than the
^'i Ti'imi) or ii raised
op white
head back to
eths; observe from
too high (< 1-2
st^Bi^^Qg with leek atod&aa: gtabtinst op
sida)
inches)**)
feet ai dose no staggiàhig» SJ^BpttttS Of
gabbBog, or Hghthadedoesa
&e>teeth(observe At leatt the length of Step length less than
tympi^Bi of unsteadiness, or
potable)
fistaace betwei
endit
od
eual'stootbetweenduu Iliad
vi
hghthrwrtrtafu.
of nance foot and the stance toe end swinngormal**)
uasuadmasa, or
.bed of swing toot;bed (step lcagth usually
pais
observeftomsides longer ba_t foot length
do set judgefinefew provides basis for
One kg
Able to stead QB
or last tew steps;
ose kg for S
observe eno side et a
seeeeds wkhoia
holding object
for sappon
Sep symmetry (oburvo Step length same Sotrep length varies
tbe middle pan of the nearly n » en boh
tfh
lfiiffim aides or
Qood
Ttiestoeoead, wmaotattaupi path sot thefirstor lasttidesfi»most sen
p
a
tient advances .
ask padttto without
fats deavesedor no ^"iiiffft Stew obsgvefromside; cycte
w
i
th seme foot with
lean bade as object or
observe douanes becweo:
or i
ROM")
every Aep
fer as possible,
bed of cech «whig foot
(compared with
and toe of i
without
of
feet)
age) or
objectif
HMnit XO
objed to
Step continuity ' Begins ratefaag bed of eae
Places estbe and
foot (too of!) as of ettœ)
her os floor
foot touchesfloor(bed bcgiuuliigtoot*or
Beaching up Able to bod Able to gat
Unable or
strike): no bneio or steps completely
(have patient down object ûbjcct needs ^BSO^^
stops fa equal ovo* mos
bt
etween steps; or
annum to without needing to steady sdf by
Steps cydas
step length varies
trif
remove q
to hold onto
trrer over cycles**)
object from a othar object for
^rr**^1^ for
AtA
deviation
shelf hish
support and
Foot follows dose to Foot devfata ftrm
(obssve from • straight Use es patieot side to side or
SBOUgh to without
h^Mrfns
bfthiflrf; observe oneadvances
towsaiene
foot over sevaal
stretching or nnstody
direetion***)
— Q u
BTMB; observe In
rdddon to I*** ^n
we»)
fleer (e.g.tiles)if
ossible; difficult to
Bending dawn
Able to bod Able to gee
Unable to bendp
(pattest is down and pick object and get downer uashla assess if patient uses
* walker)
« M f£
up the object
np snail
end is able to gel
object* sach asup easfly hi needs to pnll sdf dowm or taks TrvnkstabiBty Trunk does not sway; Any of preceding
(observe from
bade are notflexed:anfdeatures present***)
apeu,fiomihe itfngjq ettaspt Qp
dtfllS Of
behind:tideto aide arms are not abdsctcd in
floor)
vrithott neding ^^^ QQtO
BOÛO& of trunk may effort to maintain
(0 poll tdf np soBSbtagfervprfght
be 8 normal pit
•
with anns
pattern, need to
Sttttof tfpwfl
Able totitdown Needs to use Falls into chaid
rt
,fferentteie
in one
aznu to gdde
idf bUû cbfiir »r dutanas (lends
Wtfif stems (observe Fee should almost touch Feet apart with
net a moeth off fleeter)
from behind)
ai one passes
stepping***")
Neck turning
Abte to on
dng
or
«
.or
tt
i
e»
4
Taming while
No staggomg; turning Staggos; stops
Table 2. PetfomaneeOriaaed Assessment of Gait**).
continuous with walking; before fnitiadog
parieur stands with examina- at and of obstacbrflte hallway. Poand steps are eoutfnaous turn: or oèp* are
tient uses usual waiting aid. Examiner asks patient to wait downhailwhile twwfag
way at his/her wusuoipaa*» Examiner observes one component ofgait
ask pate to walk st s »mro npU thaa »•*-[- pace and observe
at a time (analogous to heart asm)» Far some components, the examiWfcecbe- aoy wafldag ate t» a*cd ccmnly (See tot for dhoadoo.)
ner wdks behind thepatient;for other components, theezamin&wa&s
maynrfloRi newotaffcder imrtrwtwkdctal
ratadbeaqrrelatedto thefindingor icfeet a compensatory i
•
.
C
o
r
o
t
h
e
r
,
m
o
r
e
t
e
nets prebtan.
0B9SVA330N
•**) Abnarmafey say be cmreocd by wofidog afd r?ftiab
tM
tyv
<ewitb
COMPOMANIS
MNL
RTRIMIMNI
m vftboor waUte aid if ponibta.
'***) hbjùtmal ffrriTng b a snaQy eompeestery ma&eovff eaxhar Uoa a l*
Initiation qfgat
Begias walking
Resitaces;
immediately without ATDPTLF HLBFLTUM
of gait not a i>ewth
mfrtnfhm ofgatiniggla,BGTIFLW
smooth motion
KOM*m»ori
**)faptoriwhhpcrBteepftcntheAmatemQqfagfeSoàetf, »A"perforBBWOIOTCD A T T B N of MoWHiy JWIHIWteSUSî by MBJT GJ .
Tfcetti Ifcumai ofAmerican Cerinria Soàstj, S4, «, pp. 11*»12S,
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APPENDIX E
TESTS OF BALANCE PERFORMANCE IN THE
ELDERLY; A REVIEW
By Robert O, Andres, PhJ).
Slip* aad falls represent a hazard to humans by threatsilng the
quality» and sometimes even the quantity, of life. Injuries due
to slips and falls occur across all age groups in publie and private sectors, ^ " ^ f n g the work environment,' hence impinging
on the quality of life. However, longevity, or quantity of life,
is adversely affected by sSps and M s in elderiy people to a
greater extent than in people below the age of 55. The classical
DeptSanteComRlRl
23019
control system is challenged by displacing the base of support
and 3) balance tests which induce body sway without display
the base of support. The characteristics, and some advantage
and disadvantages of these different approach» win be smn
marized next. For further details on — o W y , several reviev
papers can be consulted (Andres, 1979; Kapteyn et at, 1983)
i yfrrtfr nvtrtfy
Stoce the studies of Romberg (1853), several investigators hav.
observed the characteristic body sway of quietly sanding hu
mans. Since the postural control system has
sensory
motor, and rafter artmpftflyflfr Wom.tfrg -rmriwMgqrçfr ^ /^fl.
can stand absolutely stflL However, there are several ways u
have someone stand quietly. Many investigators require thev
subjects to ffffnj with eyes open or chyH upon tfmnmn1
(Black et al, 1982; Qaniehev, 1980; Aggashyan, 1972; Naya
at al, 1982; Andres, 1982). The position of the feet during qdei
stance can also be varied:frombeds together and too comfor
t&bly apart (Andres, 1982), to heetoo-toc (Black et al, 1982),
to uncontrolled foot position which is then related to the bod>
sway (,Scarries and At/ia, 1978). Of course the footwear can
rangefromhigh heels to no footwear, although most investigators spedfy bare feet or stocking feet in an attonpt to remove
variability (Kapteyn et al, 1983). Position of the aims during
quiet stance is another variable; different approadus
folding the arms gently across the chest (Andres, 1979), dasp-
envuumnsxt consdos threefr**™**capahQitis which could
limit job performance: strength,flexibility,and
More recent reswiuh has suggested a fourth human ^pafflfty
which needs to be included in the over all « ^ m n i t of Job
requirements: balance .control. Lack of adequate opabtfity m
any one of these four categories can pievaul a workerfromperforming his job Successfully and safely.
The same approach can be used when considering the interactions of elderiy people with their esviromnos. In this case,
the »job« can be definedas unrestricted mobility in puhEc and
home environments. Without doubt, human capacity to suc»
ceed in performing this «jobà safdy decreases with age (femie
et ai, 1982). There is evidence that balance may,be thefirstof
the four human capabilities to show a performance decrement
(Ovostaii et al, 1977). which could then result In deenmsos let, 1968), or the Jendrassikmanuevcr where the arms are hdd
In strength,flexibility»and endurance due to dense. Therefore» at chest levd with the hands clasped so the,subject can exert
isometrically with one arm pulling against the othff
an operational definition of
is nftdtd so
hafancr function can be studied by balance performance tests. (Black et at, 1982).
Definitions of balance from dictionaries do not provide
Acquisition of body sway data during quiet stance is accommuch hdp. For the human standing upright, the most relevant plished in several ways. The most common method uses à fort*
definition from a dictionary (Webster's 7th New rM
platform to record the forces exerted by the feet on the platDictionary) is »to move with a swaying or swinging motion form surface. The disadvantages of this technique have
(compensate). « This is appropriate in that no one can stand ab- discussed before (Thomas and Whitney, 1959; Scott andDzsnsolutely still; everyone sways to some extent due to the com- dolet, 1972; Cwfmkel, 1973; Valk<Fai 1973; Roberts and
ptedty of the postural control system. The term compensate» Stenhouse, 1975; and Andres, 2979). BaskaQy, the technique
Iwwcver. appears more permafa ta th+ nprfghf hiwftfm qpm- assumes that the body behaves as an inverted p^ndulmn (Le.
pnisatc Is »to provide with means of counter acting variation, onerigidHnk rotating around a frictionless pin joint, with an
to offset an error, defect» or undesired effecL« Human balance of the body wdght located at the whole body center of gravity).
functions to prevent faBs in complex, oftentimes tmprediaable, Derivations of ankle torques from this modd ««m— tbat'the
situations and» hence, is a compensatory
sway motion is slow enough to be analyzed by static mechanics
The purpose of this paper is to ««"«'T how
func- Woshner, 1970). An ectensive list of references about platform
tion In elderiy people can be studied with tests of balance per- stabnometry has recently been published by Kapteyn et ai
formance. Testing techniques will be reviewed, following which (1983).
those most suitable for elderly people wilt be otamlned with re- There are alternatives to force platforms for registering body
spea to the costs in hardware, software» and support personnd sway during static stance. Mon of these techniques can also be
so that a cfmtdnn can make an educated selection of whidi used for dynamic postural tests. These methods
video
technique is appropriate in a given situation.
techniques, accdcrometzy, potentiometry, and integrated deeBefore going farther, a distinction needs to be made between tromyograms (EMG'i). Video techniques include the use of diclinical and research tests of
performance. Rœsrch gital lise scan cameras (Andres and Anderson, 1980), TV systests Investigate the mechanisms of balance performance tems (Cheng et al, 1975: Kapteyn, 1973),films(Spaepen et al,
changes and, in general, require more complicated hardware* 1979), and the use of real-time optoelectronic devices.
software, and personnd support.CTnfcattests of balance performance are concerned with individual assessment and compa- Another method of acquiring data about body sway involves
rison with established norms; these tests range from simple (Le.the use of accelerometers. Thomas and Whitney (195?) placed
requiring no specialized equipment) to complex (entering the a linear accelerometer on their subject's waist; Tokita et al
realm of efinicul research). The protocols used for testing also (1972) placed two linear accderometers on a hdmet to measure
drtftrmlue whether the results win be useful clinically or for re- bead inclination. The drawbacks of accderometry are several:
search only. This paper wfil concentrate on hardware and soft- alignment and calibration of the actual devices is aitical and
ware considerations because these directly affect cost and avafl- time-consuming, and acceleration dam needs to be differentiaabifity. If the hardware and software are available, balance per- ted twice to derive sway position. This proems is inherently noiformance test protocols can be configured for either research sy.
The least, complicated instrumentation for
body
or rf^flj purposes.
sway is the dectxppotentiometer which uses a thread attached
Three different approaches have evolved to test
ba- to the body to measure sway of that level of the body in one
lance performance: 1) assessment of postural sway during un- plane. Valk-Fal (1973), Tokita et af, (1S72), Coats and Stoltz
disturbed (static) stance, 2)
tests where the postural (1969), and Nashner (1970) have an utilized this approach sue-
02/03/91
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&914 932 1302
SIDA UdeMontreal
DeptSanteComRlKl
0020
cessfoHy, The only drawback to this tectadqoo is Uw mgbt mechanical foarffng that takes place with the threads.
These previous approaches aQ tdy on body sway either directly or indirectly as the measure of balance performance.
However, thee are other ways to measure twiaww performance. Astronaute used to be tested on balance beams of decreasing width pre- and post-flight (Qraybtd and Fregty, 1966),
.1
they couldremainon the beam. Another method of acquiring
1980). Another
balance performance informationfromsubjects «HMffng qui- rfjiB ta» wwfly been promoted by Voffyon « T T Z
Ttt mvolv* opplj^teckw^tapu^ o f J g J K S
d a with integrated EMG'a. Several investigators have used this tawtf» backward dàplaoni» to p W a n f a g . « T E
approach Qtashner, 1976; CordoandNsahner, \S&;Anderson
toad ÎMWâUty I» inaxpenàve and a o n J a v a r f ^ J ^
and Wernsss, 1984).
1
tnoush
balance Derfornmn«>hvt>,— i.
—
*"o» analyds
— w wof the
wcBuiBBceperroRnancebythaeiavatieaAnalysis of these measures of balance performance during
ton is costly and complicated. Obviously, there are semai opquiet stance can get quite complex. Body sway traiectnim have tions
to consider when selecting a balance performance tot
been examined for sway path and speed (ffack et ai, 1970; the which win cshallage an dderiy person.
root-meaa-square CRMS) deviation of sway patterns (from
force perform or actual dfcr^ciTtirt data) hove bem derived
ÇBlacketal, 1982; Kapteyn et ai, 1983). Alternatively. the spec-CBnieai tests for die Oderfy
trtl composition offorceplatform or body sway dan, has been Selection of the appropriate haia*™» performance test foe elderived with signal processing techniques (Bensei and Dzsndo-deriy patients win entan budgetary considerations in addition
Ist, 1968: see Kapteyn et al, 1983 fbr several references).
to the degree of challenge suitable to the situation. A deseriptiott of the costs involved In performing several of the
tests previously referred to win be attempted first.
Displaced base of support balatee tests
«— • — • —
• • H.MMMMMAQ HlljlWMThe
- dwta Hnrm Wtion systems have a wide cost taaga.
sesto several balancing challenges. One type of challenge is
maintenance of upright stance when the base of support !s dis- a potcatiomets and a thread attached to the body location of
placed. Different types of dlsplacemait, and the requisite in- iatmot. The force platforms can range from $1,000 for a
strumentation have bem described m detail elsewhere (Andres, homemade one up to S15.000 for three-dimensional force and
torque measurement products. Video techniques are expensive,
1979; Andres end Anderson, 1980; and Wemess, 1982); only
ranging from 52,000 for vidéocassette recordings to about
a brief overview is presented here.
A moving platform which translates Enearly in the pi*™» of 57,000 for two-digital Une scan cameras up to 550,000 for a two
the floor under servo-control WHS developed at Krage Hearing camera optodectronic system and to SIOO.OOO for a four-car
Research Institute (Andres, 1979). This device was used to in-mera TV based system. Therapidlyincreasing «ww for the
duce anteroposterior (AP) sway. Other investigators have video techniques is due to the supporting electronics and softused AP linear translation, also ÇNashner, 1970; Cantchev. Duware necessary to hztofoce the data with a computer. Even the
nev, and Draganova, 1972). Another approach involves rot*,potentiometer technique needs to be computer interfaced by
ting the support base around the ankle joints Qfashntr. 1970; analog-to-dlgital conversion of the data; with the computer
May&andBhtm. 1978). A platform which moves in a pendnlar equipment currently available the minimal micro computer sysfeshian has also been desofted (Rdckeand Yqfin, 1979; £ike-tem capable of just acquiring the data would cost about
aider, 1983). Begble 0967) described a platform that was ta- SS ,000-310,000. The more complex video techniques require
hcnntly unstable, and whoHy mechanical A dxoptester is under minicomputers costing on the order of $50,000 to 5100,000.
development at the Orthopédie Biomechanics Laboratory at Obviously, only the large research oriented institutions can supThe University of Michigan which would subjer theriderto port the most expensive techniques: the dinidan in private
a quick, smaU (10 cm or less) drop. Several devices have
practice or small group practice only has limited resources to
devised which combine several types of base support motions use for balance testing. Data acquisition should recdve a large
(Nashner, 1970; Kashnar, 1976).
proportion of the cost of a balance test system.
Dataacquisitian during base of support motion is only diffe- The challenge presented to the postural control system can
rentfromtiiestatic case in that force platform information is cover a wide range of approaches: from a gentle push to the
not useful. The video and poteztiometric tedmiqua are most uppo body when someone Is standing quietly with eyes dosed
Oftoi applied for these balance performance tests. However, to a six degree of freedom moving platform. The cost of the
there are some different analysis methods for dîsplaœment in- 'first approach is zero, but it is difficult to control the push. The
duced sway. Transfer function and system identification tedi- moving platform system with six degrees offreedomIs hydrauniqnas have been used by several investigators (Werness, 1982;lic and probably costs m excess of 550,000. A moving platform
with one degree offreedomand servo-control electronics an
Meyer andBhmt, 1978; Cantchev and Popov, 1973). Integrated
be built for about 510,000. The other stimulus delivery systems
errors have also been assessed (Andres et al, 1983).
desoibed earlier vary in cost, but are generally less expensive
than multiple degree offreedomplatforms. An exception could
Balance challenges dieted by other techniques
be the moving visual scene apparat! which can get quite comThere are other methods to challenge the balance control sys- plex and expensive.
tan besides moving the base of support. Some alternatives are
Analysis costs include a computer of suffident capadty to
mentioned in this section.
do the number-CTTinching, computer dme, and software devdGalvanic stimulation of the labyrinthine system has induced opment. This suggests one of the hidden costs of performing
body sway in several dinlcal laboratories (Coats, 1972;Naskr these quantitative balance tests: the need for support personnd
iter and Wotfan. 1974; Blade et at, 1980; Hlavadu and Wio-rapable of hardware and software design and Interfacing, and
kilctjien. 1983). Mechanical vibration of muscles has brn for data analysis and system operation. These tnslcs are usually
shown to induce body sway ÇEklund andLofstedt, lSHQiHayoutside the expertise of the
who *watw*«<«ij a practice,
osU at at, 1981; Cregork at aL 1978; Pyykko at al. 1983). so the cost Is real.
How, then, can a dedrion be reached about what type of bataitffi performance test to osa? CHvm budget constraints, a
range of challenges Is the optimal ifrimrtnn. Elderly subjects
and patients should be exposed to these challengesfatan order
which begins at a siisimal task (eyes open, Quiet standing with
feet comfortably apart for example), and then gradually inoeases the dfgft* of
This progression eould then
contmnc through eyes dtwud ft^fli^ then through stimuli of
moeasmg degrees offreedomsuch as motions of the base of
suypoti and of the visual surround. The larger the range of
gftaiigng«y available et one location, the more instrumentation
required and the more ••i-'irH the analysa hmnnn
CoanAC,SiolttMS.Theweeriedbedy^wAyreipensatogahwdB«tf
mntation of the labyrinth: a preBmlnaiy smdy. Laryagemepe
85-103, 1969.
fVmwuitinesca D, Nasse TH, Padfid M, Sagawira T, Baron JB
(pj^QÎ^CQKBDdifistfflBS O&tfliBfll ^^Q^^Q^^fj^ jpiy ^fC
qusncy magnate pdsatiena. AposeL 20(0:213-214,1979.
CordoPJ.
wfth rapid arm movements. J. of Neurophysiology 47(2): 287
1982.
EQceader K. The movement of tbe centre of gravity in aeo w
crease of angnlar ^ "wItut on a pf^îff
Abstraâ
ProceedEags of the Vn I1ntL Symposfasu Vcsdbalar and VSmal C
trol OQ Posture and TR* ITF uttttr Equilibrium, Houston, TX.
Eklnd O, Iflfttrtr L.
nnaiyrii of
nfam^g
Eng. 5: 333-337, 1970.
Feade GR, Oryfe Q, Hofflday PJ, UswaDya A. The raladensh
postural sway in uudhn to thefaddcnceof faSs la gdtftfe
Jeets, Age and Agriag lis 11-16, 1982.
CONCLUSIONS
GN. Studies on postural activity in oan. AgctStoU 2
A brief review of quantitative methods used to analyze human Gaucher
35-40, 1980.
balance in uptight frtatwtr situations has been presented* No at- Oamehev G, Dunsv S, Dragaaova N. On the sponmaeeua and In
tanpt has been made to include non-quantitative techniques
body «dilations.
In Second International Symposium on Mocc
which may be useful in a situation where no hardware or software support is possible. More complet tasks such as gait re< Control, ed. by Oydikov, Tankov, and Shosarov, Zaml By
tmrfyBgffl?
quire
also, but the
of gait hasfrftwrevie- Bulgaria, pp. 179*194, 1972.— ImMim iff
tions
I
n
man.
AgrasoL
1
4
(
C
)
:
9
1
9
4
,
1
9
7
3
wed elsewhere, and requires extensive hardware and software Orsybid A, Fïe^y AR. A now Quantitative otasba .
test basoy.
capability anyway. The advantage of most of the tprhnfqm re- Otolaryngologic* 61:292-312, 1966.
viewed here is
elder
with the amity to stand Crcgoric M, Takeya T, Baron JB, Bcsrinctcu JC Influe&ce of
^ KÎIWIK». QQ^QI hi man* Agrcssol. 19
updght can be tested for ********* performance. These tests can don of neck
37-38, 1978.
be performed in a sequence which increments the degree of Curfinkd
VS.
affafntariim hnd
amsvol fat B H
challenge to the balance control system, so that (he safety and AgrassoL 14(Qt 14, 1973.
the confidence of the
can be
Some of die Hayashl R, Mbake A. Jlflwe H. Watanabe S. Posutral readju
costs of performing these tests of balance have been approri- to body sway kdnced by vibration in man. Exp. Brain Resea
217-225, 1981.
maied to assist décisions abort the allocation of Hmitcd funds Hlracka
F, Npûidktjiai CH. Pos&snl responm evoked by demn
in an
maimer.
performance
have been
cmrcst
of the hnman tabyrinthi lafloesa of pos
used.for over a century, but they arefinallygaining acceptance don. Abstract in VII T«*fi, Sympodmn: Vodbular and Vissai C
on Posture and Tixcnnotor EquOlbrinm, Honstoa, "DC, 1983in mora
settings
of the Increased powers of
Kapteyn, IS. Afterthoughl about the physics and mechanics of th
technology, and the decreased costs.
ttxnl sway. Agressé. 13(C): 27-35, 1973:
Repuya TS, Hies W, NKokflctHen CH. Kbdde L, Mhsea CH,
TMV
in plfTtfi^p fftfVgçBK*'? taring a part of po
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Odmladon. Abstract m VU IntL Sympodum: Vedbnlar and VIc
' Basel, PWH E. RVPRWTNI»». POWFF NR""dasfcy analysis of theControl on Posture and Locomotor EqalQbHom. Houston, 1
Standing sway of males. Pwsept. Fsyshophyslsi 4: 285-288, 196
18
9.
83.
Black, FO, O'Leary, DP, Wall, C, and J Furnttn: The vcsdbuloRdckeN,
-spmal Yajin K. TTie combined examination of theataileandd
cfMiity ten (VESST):
Tfmft«. Presented at the Americanndc equmhriuau A^cssoL 20(B): 109-110, 1979. .
Academy of Opehalmelogy and Otolaryngology CQaieal ResearcR
hoberts TDM, Stohouse G. Tbe nature of pesturd sway. Agr
Forem, Oo. 8. 1976.
17(A): IM4, 1976.
Black FO,
FB, Wall C. Human vestibulospinal responsesRombog
to
MH. A manual of the nervous diswei of pan. Syde
direct electrical eighth nerve stimulation. Acta OtoIaryngoL 90
S:
odety, London* p. 39. 1853.
86-92, 1980.
Soott DE, Dzanddet E. Quantification of sway In standing f
Blade FO, Wall C, nodutte HE, Khch R. Normal subject postuArg
ar
lassoL 13: 35-40, 1972.
sway doting the Romberg test. Am. J. of Otolaryngol. 3(5): 3S0o9n
-m
3f
1t
8i
, RW, Atha J. Anteroposterior aad lateral sway in youn
1982.
and women. ApoooL 19(A): 13-14, 1978.
Cheng IS, Koonrfmimnl SH, Fatehi MT.A simple computer-televisi
So
pnaepen XAJ, Peeraar J, Wlllees EJ. Comer of gravity and c
{ntBâlynww fwf gtrit walyrit. ItiUP Traw*. gg
EngRXg.pressuie hi stabSoautric studies: a comparison with f3m an
22(3): 259, 1973:
AgresseL 20(B): 117-118, 1979.
XtfMtmy PT.
jywiiwit, Hitriw^ mwwwt «*mi4W
Coats AC Sinusoidal galvanic body sway response. Aea Otolaryngol.
74(5): 15J-162, 1972.
la num. J. AnaL London 93: 524*541, 1959.
20
VoL S4 Supptfifttfiw No. 4/April 19S
TokîtaT, TyrcM Tt Matuoka T. A study on labyrinthine aaxt* with
spedd
irffWBHO ta proprioceptive «refisses.
Acts Otelama. 74s
104-112» ira.
W — was vwasryn*. w None
Hazard
Raring
Vaflc-FdT. Attly* of tha dynandeal behavior of tfas body whQs
Yts No
Lighting^
«standing aSSU AgressoL mQt 2J-25,1973.
Wanes SAS. A Parametric Analysis of Dyaaafe Possrel Remue. 20. Do you have Egte switches near eray doorway?
WuD, Thesis st The UUtanhy of Mfchfeaa, Ana Arbor. Mdrfnl 21. Oo yon bave eaongh good lighting to m***—
1982.
shadowy areas?
WdûonLL Whipple R, Amman P, Weinberg A. Stressing the pom. 22. Do yon have a lamp or Oght switch within easy
rel response: A quantitative methodfortesting
in pros,
reachfromyour bed}
.23. Do you have nigbt lights hi your bathroom and in
1989.
ZBaannd VI, BaBa J. The effect of directional optic afamg on body the hallway w^gfromyourmntun to the
btdaooB?
gravity centre projection hi iLmdlng ott* AêssoL 14(B)! 71*77
1971.
' 24. Are all stairways well lighted?
25. Do yon havefightswitches at both the topi and
bottoms of stairways?
APPENDIX F
i
Stairways
26. Do sea&dy fasmnod handrafli eoend the ftiH
H O M E SAFETY rira n mi»)
• Jttphof the stairs on eedi side of stairways?
Z7, Oo tans stand outfromtha walls so 709 can get
Usethis rtirrirHirt to Identify thefellhazards in your
* good grip?
After youfindthe hazards, dedde how you will
or
28. Aie raSs Hlttfnnfr shaped so you're akrted whan
reduce than.
you reaah the end of e oainny?
To dittf«nw your home'sfallhazard rating, allow one point 29. Aie aB subways in good "i*^»»**- with no
broken, sagging, or sloping steps?
for every »no« answer. A score of one to seven Is excellent* and
eight to 14 Is good. If your score is 15 or higher, you're m trou- 30. Are all stairway arparing aad nt*Mi
fasuaed aad In good eondhloa?
ble.
3L Ham yon replant any sbgldevd oeps with
graduallyrisingrases - or made sure
steps
are well lighted?
Hasard
Name
Rating
Housekeeping
y«
1. Do you dean ep spills as soon as they e a r ?
2. Do you keep floors asdsairways dean md free of
dntter?
3. Do you put away books,
sewfug
supplies, aad otho- obleca as seea as you're
through with thes « and neve- leave them an
floors or muwytf
4. Do you storefireqnattlyused items on shdves that
are within easy reaefa?
Floors
5* . Do you keep everyonefromwaOc&kg on freshly
washed floors before they're dry?
6. If you waxfloor*,do you apply two thin eeats and
buff each thoroughly - or dse use sdf.polbfcxng.
so
Ladders and Sup Stools
32. Do you have a sturdy step stool that you use to
reach Ugh cupboard and dosei shrives?
33. Are all ladders and step stools in good condition?
34. Do you always use a step stool or ladder tbaCs tall
enough for tha job?
35. Do yen alwaji set up your ladder ® step ^wi on
a firm, levd base that'sfreeof dune? '
36. Before you cQmb a ladds or step iffml. do yon
always make sure U'sfuSy open and thai the
stcpladder spreaden are
37^ When you use a ladder or step stool, do you faes
the steps and keep yow body betwaa the stdcraQs?
38. Do you ovoid standing on top of a step stool or
sc8mbma beyond the second stepfromthe top on
a stepladds?
7. Do aQ small rugs haveftwrMifbackings?
8. Have you cHmjnatcd_saaJI
hoftoai of staowBys?
at the tops or
9. Are «n carpet edges tacked down?
10. Are rugs aad orpets free of «tied edges, worn
spots» and rips?
11. Have you chosenragsand carpett with short,
dose pile?
12. Are rugs and carpets intaOed over good q&aUty,
medhmuhSck pods?
Bathroom
13. Oo you use a rubber mat or non-slip decals In the
nib or shower?
14. Do you have a grab bar securely anchor^ ewthe
tub or on the shower wall?
15. Do you have a nonsldd rug on bathroom floor?
16. Do you keep soap to an casy-toieach receptacle?
Outdoor artes
39. Are walks and driveways In your yard and other
areasfreeof breaks?
40. Are lawns and gardasfreeof holes?
41. Do you put away garden tools and hoses when
they're not in no?
42. Are outdoor
ersas keptfreeofrocks,loose boards,
and otho1 uiippmg hasards?
43. Dp you keep outdoor walkways, steps, aad
porchesfreeof wet loves and anew?
44. Do you sprinkle ky outdoor areas with de-icen as
. soon as possible afto- a snowfall or taadl
45. Do you have mats at doorwiays for people to wipe
their feet on?
46. Do yoù know the safest wey of walking when you
, «n't avoid walking on atiîpperysurface?
Traffic Lanes
17. Can you walk across every room fa vour home,
and from one room to anwhc, without detouting
18. Is tbe traffic lane from
your bedroom to the
bathroomfreeof obasdes?
19. Are telephone aad appliance oonfs kept awsy from
«ess where people walk?
Footwar
47. Do your shoes have soles and heela that provide
• . good traction?
48. Do you war house sBppos that fit well and dont
fall off?
49. Do you avoid walking la
feed
50. Do yon wear lowtaded oxfords, loafers, or good
quality sneakers whoi you work in your or yard?
"3 PramftFsUZag- Tba Uneepeeied Trip*. A Safety Piugiam far Ofckr Ad5L
ainDo
. you replace boots or galoshes whea their Botes
Presram Leads'! Gsdds. By tfao QAfedoualSafety CcnS in coopérationor heels are won too smooth to keep you from
with the American Actnriatfaui of Retired Pawns. 1992.
iHrptng on wet or Icy sueftcs?
Name
Haard
Raring
In adaptable bathroons, provide for the f*TH
fe
grab bars so that <
may add than later as drcum
Stance
require. Vfaterials
avoid an
ttgainlns steei« appearance should be considered.
Pmortai prtcautiônt
Ya Xq
52. Are yes always alert for unexpected hands, sndi
as ôut-of-piâfio toxmani
53. If young grandchildren visit, ate yes akrt fer
efaOdm playing on thefloorand toys Idtfaxyour
path?
,
54. If yen hive pets, are yea alst fbr soddn
Bovoasts una your path* and pets gemag
'
—
Privacy
Locam the bathroom so that a door left open win not provlddirect views into the bathroom from the entry, Qving/dfflin
room, or kitchen.
55. When you cany bdky packages, do yeu sake sore
Safety
they don't obstruct your vision?
• Provide bathrooms that are safe, convenient, andfreeof shar
56. Dû yea divide targe loads into seaUcr loads
cornas, projections and slippery surfaces. Locate bathroot
whenem possible?
.• i
fixtures and equipment so that exoemve bending»fàanlngian<
57. Wha yea
or
do you hold QBO a £hm
twisting wiQ not be necessary for their operation. Lay out tfc
seppoxt and avoid ihtovioj yonr hesd beck Of
taming it tee
fisrt
•
• .. bathroom so that users need not reach across counters m orde
58. Do yeu always use a laddff or step stool to teach
to " T s storage
or
outlets.T ^ ^ ^
high places and never sand os a chair?
.
outlets adjacent to the lavatory, but not above sinks or tub
59. De yeu always move da&bnatdy aad avoid
where
rnsltieg to answer the phone or dootbdtt
" _
_ electrical appliances might fan into smrnting water. Pre
60. De yea take time to so. yonr hflltmrn wha yen
tecs Outlets with ground*feuJt interrupt devices. Temperatun
^QQI tytog dowo id SQI^^ ^Bd
limit controls should be provided on domestic hot water in tk
from utticg to sniB<ffng?
i —, — bathroom to keep tempezatures at thefixturebelow 115 degree
61. Do yeu held one grab ban vben youchange
F. and prevent accidental scalding. •
toftibnr ihwnf^
•
62. Do
you keep yrtiffldf h good coédition with
Storage
moderate «xaeeâa, good dfet, adequate rest, sad
regnlsr nwftil checkups?
^^^
CS. If yeu wear gtoiww. is your pieuipUon
Provide bathroom storage for toiletries,
and toweL
up-to-datt?
— »
64. Do you know how to rednoe injury in a fall? — . , .
Handrails65. If youfivealone, do you bave daily contact with
a Mnd er
Provide handrails that are easy to grasp andfreeof sharp* ec
gas. Recommended
include a «tfafawmi ^ ^ radii
Actions What you plan to do to achieve a perfect rating!
of ft inch and diameter of IVi to IK inches. Mount handrai
Dcvdoped by the National Safety Coundlfn Cooperation with 33 to 36 inchesfromthe floor to the top of the rail. If mounte
the National Retired Teachers Association and the American to a wan. provide a 1H inch space between watt and handrai
Association of Retired Persons.
Recessed rails should be avoided and an handrails should r
tun to the wan..
Since many facilities for the elderiy also require guardrai
to protea wansfromwheelchairs, carts and other wheeled tra
APPENDS G
fic, architects have frequently attempted to provide a single rt
Examples of Design Principles for Aging*)
to serve as both handrail and gtxardrafi. Although such ec
ftfftowflir (privets)
nomy may seemreasonable,the architect should carefuDy coi
Water
elder whether the dualpurpcse rail serves either purpose we)
The water closet cm pnsoxt a design Hngrptna to the architect For sample, to be easfly grasped with a strong enough grip t
and specifier: A seat height high enough tofacilitatean older keep an elderiy person from falling, the handratt form mm
poson's getting on and off the toilet may cut off blood circula- inn mit thefingersof the
to gient»»p«« virtually the ft;
tion to the legs and prevent the user's «mîmiint of the best circumference of a railing. Integrated hand and guardrails mu
position for moving the bowels (a full squat). On the other be carefuDy designed to serve their handrailftmctinnpropel;
hand, a seat height that is too low may
movement of Rantps
r
the bowels but prevent the user from getting off tbe fixture. Through good design, ramps can be avoided in fadEties us<
.^Handicapped toilets* (also see ANSI AU7.1 or applicable by the elderiy. Eliminating ramps alleviates the hasards th
barrier-free design standards) are not recommended for general ramps pose to the many elderly who walk with an off-balane
use by older people.
shuffling gait, and removes the barrier that ramps p»**»» •.
Standard height water closets - 15 inches to the top of the those who lack the strength or stamina to negotiate an ««wis»
seat - are recommended for general use by the elderiy, with ap- Many ambulatory peoplefindwheelchairrampsuncomfartab
propriately placed grab ban that help in getting on and off the and even impossible to use, so stairs should be Induded to pr.
fixture. Toilet seat covers are recommended to facilitate use of vide an alternative to ramps for some level changes. In max
thefixtureas a seat for grooming activities.
facilities i however, wheelchairs are used by the majority of c
cupants, either full-time or occasionally. A*Tïïi,n*v*fltvig bo.
Grab Bars
ambulatory people and whedchair users may the ef ore requi
Crab bars should be included in bathrooms to provide soBd multiple paths wherever a level ehange Is required. Wheelchc
handholds for the user entering and exiting the tub or shower, users must also enjoy easy access to tables, counters, and bu
and getting on and off the toilet. The use of a grab bar as a ding controls*
towd bar or drying rack defeats its purpose; this common use If the use of a ramp is unavoidable, a
gradient >
cannot be prevented, but the provision of adequate and accessi- 1 to 20 is recommended; this is a more gradual slope
ti
ble towel bars and drying racks m addition to grab bars helps 1 to 12 maximum gradient allowed by ANSI A1I7.1 unda tin
fHiflinqfr» jt,
ted conditions. To aceommodate wheelchair uses as wen .
ambulatory individuals, provide levd
at the top ar
*) be tks&forAtta?: An Ardùlea's Guide bydtsAffloiGBZBsdtBteef Arehfeem Feuaditiaa. Wastingtoa, D.C.: A1A Press, 1986.
bottom of the tamp, and at every 40 feet of horizontal travt
22
VOL SASuppleaA Nci. 4/A*U Ife
tor
at*'
!
de
irp
rm
ad
tha
Jer
cal
rothe
ed.
Jhts
oils
ited
•aa,
re*aflj
rafrall
ccbios*
/dL
pto
oust
full
oust
sriy.
used
thai
ace,
it to
Une.
able
pro
way
too
both
[aire
•hfli'p
baflltof
i the
U as
aad
jveL
.1!
!i
ii
v
Providerampsat least six feet long andflvafeet widft, Cree of BIBLIOGRAPHY
door swims, and wwtfc wKwih, wwiwHp iwfcww
flfltl*fc
ralls on both sides of the ramp, sosuSng a ^^"tfni'JffT of nn * Abraxas M. »FaBs by the elderiy, »g*"»** and Wtlm.« Unpublished
p
a
p
e
r
,
J
u
n
e
;
1
9
8
4
.
•
foot beyond the ramp's terminals. {rffl'ffrfifT less than 1 to 20 Albsnde JL, VeQoa R. »Rettrietion d'activités après la
la vaare not required to be cossidoed as »rauzps,« and thus do not tanne ageeui Rapport a l*O.M&, Cntre International de ÛŒcntûrequire '««^«g* aad hamlndls.
Icgie Soûle, lier mars, 1985,
Ambulatory usas will also appreciate benches or other op» Alle&Wâriw RC, Isaacs B, Noyik USL. »Progaestie ftooa h fracto»
es of the wrist in patients aged 65 and overs Unpublished paper,
portnnfrim to rest and regain stamina and «trangA at «mir atwi r
January, 1986.
rump landings.
American Aeademy of Orthopaedic Surgeons. Tbe Frequency of Oco»
nmea. tmpag. ar,A r**9Àt M...».!..^^) rv^^nffatfrf V"*ted States, 1984.
Stdrs
Stabs and stepdowns pose potential hazards to people with vi- American Initiate of ArchhEas9badadm.Detiga for Agmg: An A>
sual impairments as well as to those who have difficulty wal- chhccta Gdde. Wastttgton, D. Os AIA Press, 1986.
dersen DJ, RasehkeMF, Hemkfc JE. WcreosS, Glbsea R. »Dyuaking. Different colors and surfaces should be used to differen- Anu
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r"^"ihrly hrfpftii **
fmimirttti. «friwmgh ptMr^ ' tha dderty.« la dales In Oeristrle m-i*,*w> VeL 1» Naabcr
with a hypnotic effect should be avoided. Toe guards (without TA. Radebsugh et. aL (Eds.) FtfleddphU: W.B. Saunders Compuny, 1985.
nosing) and side curbs are also essential safety aids, as are Ral
frr â»ttTheprgynflnhttlty offaP^gIn pfgygnjonfffP^f**fathe
handrails (see ANSI A117.1 or the applicable bamer*£ree deE
lderiy, 3JL Mdr Gray (Ed.). London: Churchill LMngscne. 1985.
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Baker SP, Harvey AK.»Fofl Injuries in tbe eldedy.« Indoles In
flw Twi
Perception difficulties
reduced f * a*nm^ die et
tele Medidne. YoL I, Number
Radabangh et aL (Eds.)
Cuuipauy, 1985.
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SP, 0*NaHl B, Kmpf RS. »FB11M (Chapttt 10). In The htfury
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own residences can be traced to a singleriserwhose height is
«Old Age,Mohan$.Kataria(Ed.).Lancaster:MTP PressLtd^
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fhlls,
problem is common in builders' houses with prefabricated Boxy
in an ddgjy histinuloaal populations Journal of Amoioa Geriasrafai. ^ « H should be designed with runs that are as straight
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among iwMinnttpwaifY^ women widi Alzheimer's Dhoase.* Journal >
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1984.
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of a strenuous cfimb or descent. This featnre can be parricnlatiy hipfiramnreooeavrenoe In whitefinales.*American Journal of Pub
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A
in the surface ten me of a
can be used to Evans JG, Prndham DA, Wbndkss L »A prospective stndy of fractu
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différences in nwniitf to ensure
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LT, OTallon WM. »Lîmb fracture In a dpflniM population. t-Prequescy and distribution.* Mayo
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ft»..
In Old Age. Mohan S. Kataria (Ed). Lancaster: MTP Pros Ltd ,
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23
i / : uo OS14 832 1302
SIDA UdeMontreaJ.
DeptSanteCooRlKl
® 021.5...
ddmtypopdrieaiL Inrfdafleandmorfatfty.cAgeimdAgeiagtd» Ovcsmn PW. lFpMrmiuhJiLi aad pathophydotecr offtBs^&
end FaQs h Old Aga, Mohan S. ^ ^ (M>
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n»
vffleNQ. »Eflfeet of an
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fmr*
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cam
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t
t
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The
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ration du Centre Imniimlcmal de Gereatolode Sodale.(WH
Orion M. ©Seenrtty alarms for the ddsiy - 4Tri.nM.flyOTtbreat?«
ICSGftuiihiH»on tbe epidemiology of Ms In tbe dderty.) I
In The Bdofcr and Their Environment: Research in Saedo. ifretport. Copenhagen: World
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Rdnlos (Ed.) StnrtfrnMm- Swedish COnnefl for Bofldba ReseaYong
reh. LC. aPbysfcdogical changes aad medical problems la old
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le.< Singapore EUea, VôL 8, No. 1 end 2, 1985.
24
VoL 34 Suppkesett Me. 4/April »
f ormation
en
Prévention
Texte
réseau
des
complémentaire
traumatismes
de
référence
«Planification
et programmation
selon
l'approche
de
la
prévention
des traumatismes
appliquéeà la
problématique
des chutes
chez les personnes
âgées»
(Mme Jennifer O'Louçhfln, DSC de l'Hôpital général dé
Montréal)
AUWUM< .1U1W illib -r-r-r
IA
I;
CfljLfM* cjqjC
RftkoJa^VoWon
««Si
IO8-3\
Falls in the Elderly
Laura J.
McVey
Stephanie A . Studenski
Falls arc of special interest in geriatrics as a predictor of générai hcilth status,
as an indicator of underlying illness or disability, and as a. problem with the
potential for severe consequences. Yet rhe geriatric falling syndrome continues to be a poorly understood phenomenon of widely varied etiology. Ar
present, there is a lack of consensus regarding the definition of the event
itself. From a biomechanics perspective, afoilis an unintentional and uncorrected displacement of the body beyond its base of support. Other clinical
définirions have been proposed which include "unexpected displacement**
(Isaacs, 1985, p. 513) and "inadvertent events in which the subject came to
rest unintentionally on the ground" (Wild, Nayak, & Isaacs, 1980, p. 271).
The discrepancy in terminology has undoubtedly contributed ro the variability noted in reported studies of fall frequency, causation, and outcomes.
The development of a standard typology of foils has been recommended,
but has yet to be formalised (Hadley, Radebaugh, & Suzman, 1985; Kellogg International Work Group, 1987). We advocate a classification system
that recognizes the interactive effects of the individual-and the environment
on the components of postural competence (sensory input, cenrral processing, and motor response) (Robinson k Conrad, 1986). This conceptual
framework will be used to discuss the etiology of foils, along with a
multidisciplinary approach to clinical evaluation and management.
EPIDEMIOLOGY OF FALLS
Efforts to determine the magnitude of the problem have been limited by the
quantity and quality of available epidemiological data sources. While most
information has been retrospectively compiled on those who experience a
foil-related injury requiring medical attention, comparable data characterize
1 0 8
UZ/UX/H1
UHtDO
t.w
Falls in the E L M ?
rly
meral health status,
I problem with die
ag syndrome confined etiology. At
lirion of the event
ntional and uneoriort. Other clinical
ted displacement"
he subject came to
ics, 1980, p. 271).
iuted to the variaind outcomes,
^commended,
zman, 1985; Kelossification system
1 the environment
t, central process• This conceptual
lis, along with a
lagement.
«n limited by the
trees. While most
who experience a
data characteriz-
aUliLLË. INUKi; AIL
uepraantecomKin.1
m uuo/ u* /
109
ing the aged population who do not fall, or who fail to seek treatment for
minor injuries, is lacking for inferential analysis. Similarly, data pertaining
to the amount of time a person is exposed to risk are rarely collected, and a
standardized method of recording fall frequency and outcomes has not been
devised (Hogue, 1982; Morse, Tylko, & Dixon, 1987).
Although incidence and prevalence rates are generally unavailable, it is
estimated that approximately one-third to one-half of those aged 65 years
and older suffer at least one fall a year, depending on the population studied.
Community-based studies have reported that about one-third of older
individuals living at home experienced a fall or indicated a susceptibility to
foiling during the preceding 12 months (Campbell, Reinker, Allan, &
Martinez, 1981; Droller, 1955; Exton-Smith, 1977; Perry, 1982b; Prudham k Evans, 1981; Sheldon, 1948). However, nonreporting by the elderly has long been recognized as a contributing factor to the underestimation of foils that occur in the home. Older individuals have been known to
fall repeatedly, but to report the event only when a serious injury has been
sustained (Lucht, 1971; Perry, 1982b; Sheldon, 1948). Their failure to
report a history of falls may be due in part to error in recall, but may also
reflect a belief that foils are an inevitable consequence of aging or represent
an attempt to deny declining functional ability (Gordon, Huang, & Gryfe,
1982; Wieman, 1986).
The occurrence of foils is generally higher among the institutionalized
elderly, who tend to be older and more dysfunctional. At least one-third
and as many as one-half of nursing home residents are reported to foil each
year (Fernie, Gryfe, Holliday, & Llewellyn, 1982; Gryfe, Amies, & Ash-"
ley, 1977), with more than 40% of patients experiencing repeated foils
(Berry, Fisher, 6c Lang, 1981; Gryfe et al., 1977). Falls also constitute the
most frequently occurring incident in the acute-care hospital (Morgan,
Mathison, Rice, & Gemmer, 1985).
The majority of studies involving all settings have observed a steadily
increasing number of foils among those aged 75 and older (Barbieri, 1983;
Droller, 1955; Exton-Smith, 1977; Fine, 1959; Gryfe et aCl977; Ludit,
1971; Margulec, Librach, & Schadel, 1970; Morgan et al, 1985; Morris &
Isaacs, 1980; Naylor & Rosen, 1970; Prudham & Evans, 1981; Sheldon,
I960; Waller, 1974; Wild, Nayack, & Isaacs, 1981). Some investigators,
however, have noted a decline in the frequency of foils among the very
elderly (Exton-Smith, 1977; Morris & Isaacs, 1980; Prudham & Evans,
1981; Sheldon, 1948). A decreasing incidence of foils in the eighth and
ninth decades may be attributed to the survivor population of extremely fit
elderly (Exton-Smith, 1977), or reflect an attrition of those at highest risk
through death or confinement to a more protective sating (Perry, 1982a).
Older women residing in the community and in long-term care facilities
also appear to be at higher risk of foiling than older men (Droller, 1955;
23
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Dept Sant eComRlKl
MODULE NORD MTL
Oetioric RAabtiitation
Exton-Smith, 1977; Gryfe er al., 1977; Kalchthaler, Bason & Quintos,
1978; Lucht, 1971; MacQueen, I960; Margulec et aL, 1970; Naylor k
Rosen, 1970; Prudham k Evans, 1981; Sheldon, 1948; Wild et al., 1981).
Even when an adjustment is made to account for the greater number of
females surviving to old age, women are consistently reported to experience
a higher annual prevalence rate of falls (Prudham, 1981). An analysis of
studies conducted in the hospital setting, however, has shown a disproportionate number of foils occurring among the male inpatient population
(Morgan et al., 1985; Parrish k Weil, 1958; Sehested k Severin-Nielsen,
1977). It has been suggested d u t hospitalized elderly women may be more
cautious when required to function in a reduced physical capacity, while
older men may be more intolerant of the enforced passivity of hospital
confinement, thus enhancing their risk of foiling (Fagin k Vita, 1965).
CONSEQUENCES OF FALLS
While many older people may foil repeatedly without notable harm, they
are at higher risk of foil-related morbidity compared with other age groups
(Hogue, 1982).The rates of treated foils for those living in the community
range from 3 to 220 per 1,000 elderiy individuals (Lucht, 1971; Naylor SE
Rosen, 1970; Perry, 1982b), of which 1 in 40 is expected to require
hospitalization (Exton-Smith, 1977). It is also estimated that 10% to 15%
of foils in the institutionalized aged population result in serious injuries
(Berry, 1981; Gryfe et al., 1977; O v e r a l l , Johnson, k Exton-Smith,
1978).
Soft tissue damage (e.g., lacerations and bruising) is commonly associated
with folk in the elderly and may compromise independent activity. A
relatively rare yet serious consequence of foils, particularly in those over age
70, is cranial injuries, including subdural hematomas (Kirkpatrick k Pearson, 1978; Kraus, 1984).
The most frequent sites of fracture in the elderly as à result of falling
involve the hip, femur, humerous, wrist, and ribs (Kane, Ouslander, k
Abrass, 1984). An estimated 172,000 hip fractures occur annually ro those
aged 65 and older (Baker, O'Neill, k Karpf, 1984), with the incidence
rising dramatically in advanced age (Baker er al., 1984; Cummings, Kelsey,
Nevitt, k Dowd, 1985). Thirty-two percent of women and 17% of men
who survive to the age of 90 years are expected to suffer a fractured hip as a
consequence of foiling ("NIH Consensus Conference," 1984).
The susceptibility to a foil-related fracture, particularly involving the hip,
is enhanced for older women with bone fragility and impaired protective
responses (Eddy, 1972; Iskrant, 1968; Margulec er aL, 1970; Melton k
Riggs, 1985). While both sexes exhibit osteoporotic changes with age, loss
0006/027
02/01/91
09:59
Geriatric Rehabilitation
ÎT. Bason & Quintos,
1970; Naylor &
. VfldetaL, 1981).
he greater number of
reported to experience
1981). An analysis of
is shown a disproporinpatient population
;d
Scverin-Nielsen,
women may be more
ysical capacity, while
passivity of hospital
gin & Vita, 1965),
LS
it notable harm, they
vith other age groups
ing in the community
jcht, 1971; Naylor &
expected to require
ted that 10% to 15%
ilt in serious injuries
on, & Exton-Smith,
c ^ m o n l y associated
ent activity. A
a* v m those over age
(Kirkpatrick & Pearas a result of falling
Kane, O us lander, &
imr annually to those
, with the incidence
; Cummings, Kelscy,
ten and 17% of men
ÎT a fractured hip as a
" 1984).
ly involving the hip,
impaired protective
il„ 1970; Melton &
langes with age, loss
FAX 15149323359
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MODULE NORD MTL
DeptSanteComRlKi
007/027
ZZ1
of bone mass occurs earlier and at a faster rate in women (Newton-John &
Morgan, 1968). A decline in the incidence of wrist fractures, with a concomitant increase in the rate of hip fractures, has also been noted among
women over age 70, suggesting an impairment in the protective response to
falling, such as extending a hand to minimize the impact (Benton fit Strouthidis, 1985; Garraway, Stauffcr, Kurland, & O'Fallon, 1979).
Fractures in the aged population due to falls often necessitate an intensive
and prolonged rehabilitative course, placing heavy demands on the health
care system. It is estimated that each hip fracture requires an average 3-week
hospitalization period (Baker, 1984) at a total annual cost of approximately
$7 billion (American Academy of Orthopedic Surgeons, 1984). In addition, those who require admission to the hospital for their injuries may be
susceptible to further disability as a result of immobility and the iatrogenic.
complications of therapy (Kane et al., 1984). Older patients who are
chairbound or bedfast are at risk of developing decubiti, contractures and
joint stiffness, respiratory infections, arterial and venous thrombosis, dehydration, and bladder and bowel dysfunction (Ham, Pattee, & Marcy,
1983).
Although most elderly individuals escape serious physical injury, the
social and psychological consequences of a fall can promote a loss of
confidence, social withdrawal, depression, and confusion (Ham et al.,
1983). Older people who have experienced one fall may fear falling again to
the extent that they intentionally curtail their activities, leading to deconditioning and weakness (Tinetti, Williams, St Mayewski, 1986). Finally,
family members may be more inclined to place their older relative prematurely in a more protective institutional setting following a fall-related
injury (Kane er al., 1984).
Along with the substantial morbidity, falls are the leading cause of
injury-related death among those aged 65 years and older (National Safety
Council, 1980). Although the elderly comprise only 11% of the totalJJ-S.
population, they account for 72% of total deaths due to falls (National
Safety Council, 1980). The high case-fatality rate is particularly evident
among those aged 85 and older, who suffer 30% of all fall-related fatalities
(Baker et al., 1984).
The mortality rate from fall injuries is higher among whites aged 75 and
older than nonwhites, presumably as a result of a greater prevalence of
osteoporosis and hip fractures (Engh, Boiler, Hardin, & Parson, 1968;
Trotter, Broman, & Peterson, 1960). Recent trends also indicate that,
although aged women continue to fall more often and incur more injuries
than elderly men, the death tate is highest among males aged 65 and older
(Lucht, 1971; Margulec et aL, 1970; Wild et al., 1981).
Estimates of fall-related mortality must be viewed with caution, however,
due to the difficulty in establishing a causal relationship between the event
A
112
Gtriatric
Réhabilitation
of a fall and subsequent death (Nickens, 1985). Falls are rarely specified on
death certificates as the direct or contributing cause of mortality. Furthermore, in many cases, falls are simply another indicator of terminal decline
(Brody, Kleban, & Moss, 1984; Gryfe et aL, 1977).
CAUSES OF FALLS
The substantial risk of morbidity and mortality associated with falls in the
aged population highlights the need to examine those factors that may
explain its etiological basis. Falls can be viewed as the outcome of an
unfavorable interaction between the individual and the environmental set^
ting. Some have distinguished extrinsic or environmental hazards that creatc
the "opportunity to fall" from intrinsic or host-related factors that cnhancc
the "liability to fall," in order TO define the causes and circumstances of falls.
However, most generally agree that liability and opportunity are too
closely associated to draw a clear distinction (Droller, 1955).
It is estimated that one-third to one-half of falls occurring at home are due
to slipping or tripping over environmental obstacles (Lucht, 1971; Prudhim & Evans, 1981; Sheldon, 1960). Examples of the potential hazards
found in femiliar surroundings include low-lying and poorly visible tables,'
trailing electrical wires, pets, steep and unlit stairs, loose carpeting, unsafe
walking aids, inclement weather, inconvenient bathroom or kitchen
arrangements, poorly maintained sidewalks, lack of streetlights, and inaccessible shops (Ham et al., 1983). These occasional or "accidental" falls are
thought to occur most often among those elderly individuals who are
younger, healthier, and more functionally independent (Campbell et al.,
1981; Waller, 1974). Falls occurring in the institutional setting as a result of
excessive environmental demand are often related to changes in position,
such as transferring to and from a bed or chair (Sehested & Severin-Nielsen,
1977; Fine, 1959; Rodstein, 1964; Swartzbeck fit Mffligan, 1982) or involve toileting activities (Ashley, Gryfe, & Amies, 1977;'Barbieri, 1983;
Morgan.et aL, 1985). Unstable and defective equipment (e.g., nonfunctioning brake locks on wheelchairs, misplaced furniture, wet or excessively
waxed floors, and the improper placement of food trays in the hallway)
have also been suggested as contributing factors to the incidence of fails
among the institutionalised elderly (Barbieri, 1983; Fagin & Vita, 1965;
Sehested fit Severin-Nielsen, 1977). Although environmental factors may
enhance the susceptibility to or risk of falling, they fail to provide a
complete explanation for the etiology of falls in the elderly (Nickens, 1985;
Overstall et al., 1978; Tinetti et al.t 1986).
It appears that the role of host-related factors is significantly more important in determining the vulnerability of the aged to falls, particularly with
MW k ' -• -
trie Èb&abtiitation
a'
specified on
y. Further: terminal decline
with falls in the
actors that may
outcome of an
vironmental setzards that create
o n that enhance
nstances of falls,
rtunity are too
5).
at home are due
M, 1971; Prud)tential hazards
y visible cables,
irpering, unsafe
>m or kitchen
ght5, and inacdental" falls are
duals who are
'
bell et al.,
. a result of
fes in position,
sveria-Nielsen,
it 1982) or inîarbieri, 1983;
.nonfunction- "
or excessively
i the hallway)
idence of falls
& Vita, 1965;
al factors may
to provide a
fickens, 1985;
' more importicularly with
FaOs m the ELUrly
113
advancing age and greater physical impairment (Âshley et al., 1977; Barbieri, 1983; Droller, 1955; Kalchthaler, et al., 1978; Margulec et al., 1970;
Morse et al., 1987; Parrish &. Weil, 1958; Perry, 1982b; Rodstrin, 1964;
Sehested, Severin-Nielsen, 1977; Shddon, i960; Swartzbeck & Milligaru
1982; Waller, 1974; Walshc ôt Rosen, 1979; Wild et al., 1981). Campbell
et al. (1981) have described a higher frequency of repeated or pattern falls
among those aged 80 years and older who suffer from multiple intrinsic
disorders. While die mechanisms by which certain diagnoses and impairments product a greater liability to fell arc not clear, it might be postulated
that deficits in the components of balance control are major intrinsic factors
causing falls in the aged population. Balance control is the maintenance of a
stable; erect position and isjdepsndent upon the system's ability to recover
rapidly from a postural displacement. To accomplish this task, the sensory
system must be able to detect body displacement, the central nervous
system must be able to integrate various data in order to program an
appropriate motor response, and the neuromuscular system must be able to
execute the motor commands. There are several age-related changes in the
visual, proprioceptive, vestibular, arid motor systems that may contribute to
abnormal balance control and predispose the elderly ro falling. Postural
stability can also be adversely affectcd by various pathological processes
and the deleterious effects of medications.
The major balance deficits afflicting the elderly include a physiological
decline in postural control, as measured by increased sway, and an increase
in the time needed to respond to postural perturbation. Sway amplitude has
been reported to be greater among elderly subjects (Femie et al., 1982;
Overstall, Exton-Smith, Imrns, & Johnson, 1977; Sheldon, 1963), with
women observed to have a higher average speed of postural sway than men
(Overstall et al., 1977). A significant increase in sway has been associated
with an enhanced predisposition to falling among the aged (Femie et al.,
1982; Overstall, Exton-Smith, et aL, 1977; Overstall, Johnson, & ExtonSmith, 1978; Sheldon, 1963). Increased sway may be related to proprioceptive deficits, although evidence of a décrémentai change in proprioception
with aging remains inconclusive. Kokmen, Bossemeyer, and Williams
(1978) reported no major decline in joint motion sense with advancing age,
although other investigators have described diminished joint morion sense
accompanying senescencc that is greater during low- rather than highfrequency movement (Laidlaw & Hamilton, 1937; Skinner, Barrack, &
Cook, 1984). It has been suggested that decreased ankle proprioception in
the elderly may be related to a greater risk of falling (Woollacott, Shumway-Cook, fit Nashner, 1982), due to error in limb orientation and proper
foot placement. Similarly, altered mechanoreceprion in cervical spondylosis
may lttsen the accuracy with which the position and movement of the head
is perceived. There are also consistent reports of an increased perceived
U4/UX/&X
iu:ui
tAA XDX4»0*000«
JIUULilX. :>UfUJ JIXX.
UepCdanCeiUHUlllU.
Geriatric Rehabilitation
v
Oratory threshold (PVT) with aging (Brocklehurst, Robertson, & JamesGroom, 1982; Kokmen et al., 1978; Perrett & Regii, 1970; Whanger k
Wang, 1974). Brocklehurst et al. (1982) reported that a higher P V T was
correlated with increased sway in the elderly, but was not associated with a
decreased joint position sense. Sabin ( 1982), in a review of die neurological
basis for senile gait disorders, suggested that an increased P V T and increased sway might be attributed to age-related peripheral neuropathy,
particularly involving the peroneal nerve,
Vision provides important spatial information in maintaining equilibrium
and may serve as the predominant means of assessing body position, as aging
and disease diminish the input of the kinesthetic and vestibular systems.
However, certain visual deficits occur in the process of norma] aging, including a reduction in acuity, peripheral fields, color and depth perception, dark
adaptanon, glare tolerance, gaze stability, and temporal visual processing
(Leibowhz k Shippert, 1985; Sekuler, 1980). These may diminish the
overall contribution of vision to postural stability. Several studies have
identified visual impairment as a contributing factor to the occurrence of foils
in the elderiy (Lucht, 1971; MacQueen, 1960; Perry, 1982b; Prudham k
Evans, 1981; Waller, 1974; Wild et aL, 1980). Tobis, Laxman, and Hoehlen
(1981) also reported that error in visual perception of verticality and horizoncality was significantly more prevalent in older foil victims, compared
. with nonfollers. Diseases such as cataracts, glaucoma, and macular degeneration may further impair vision and entrance the risk of foiling.
Although age-related changes in the vestibular system are not well documented, some elderly individuals have demonstrated decreased vestibular
reflexes (Kenshalo, 1979; Overstall et aL, 1977). These acceleration»! and
positional reflexes are normally active during a foil response and may be
necessary to resolve conflicts in visual and proprioceptive input, in order to
maintain balance control (Melville-Jones k Watt, 1971). Disorders causing
vestibular dysfunction, such as acute labyrinthitis and Meniere's disease,
may result in vertigo, a rotary sensation that typically follows a positional
change. While vertigo a n occasionally precipitate a foil, there is often
sufficient warning so that the necessary precautions may be taken to regain
postural stability.
Central sensorimotor processing deficits that accompany the aging process are manifested by a delayed response time to sensory stimulation
(Woollacon et aL, 1982). These deficits are attributed to biological changes
in many areas of the central nervous system (Brody, 1980; Corso, 1981;
Feldmah, 1976; Ordy k Brizzee, 1979; Stelmach k Worringham, 1985)
that interfere -with the integration of input from the visual, vestibular, and
proprioceptive systems. The ability to respond quickly to a postural perturbation is a determining factor in foiling (Do, Breniere, k Brenquier, 1982;
Stelmach k Worringham, 1985).
IttlUlli
U4/MJ./tf1
itttric
Rthab&tatipn
r
"ton, &james; Whanger &
a higher P V T was
3t associated with a
of the neurological
ised P V T and initierai neuropathy,
raining equilibrium
y position, as aging
vestibular systems,
final aging, indudJi perception, dark
visual processing
may diminish the
rcral studies have
occurrence of foils
982b; Prudham &
man, and Hoehlen
rticality and horirictims, compared
macular degenerating.
ire not well docuceased vestibular
tccelerarional and
uid may be
L „ ^ in order to
Disorders causing
Meniere's disease,
lows a positional
11, there is often
* taken to regain
y the aging prosory stimulation
iological changes
10; Corso, 1981;
rringham, 1985)
I, vesribular, and
. postural penurJrenquier, 1982;
xu:ui
r.iA
1OX49O4OUO0
Fells in the EUerly
uvulll
MJIW JiiJ-
isepcdanteiuiiuiiAi
IIS
Diseases affecting the central nervous system may impair optimal balance
control by causing syncope, dizziness, and gait disorders. Idiopathic and
symptomatic epilepsies have a recurringjncidence in senescence, in conjunction with cerebral tumors or cerebrovascular disease, and may cause a
transient loss of consciousness with a foil. The abnormal gait and balance
disturbance associated with normal pressure hydrocephalus, intra-cranial
lesions, and trauma-induced subdural hematoma may inmate afoil,although
the frequency of such disorders in elderlyfollersis relatively rare. A sudden
loss of stability may also result from the impaired mobility and decreased
postural reflexes accompanying parkinsonism i{Hawans & Tanner, 1984).
Other neurological conditions such as acute cerebrovascular accidents and
transient ischemic attacks can sufficiently impair mobility and perceptual
function to contribute to the likelihood of foiling (Prudham & Evans,
1981). Finally, mental and psychological" sratus'have been reported to affect
gait, postural stability, and the perception of environmental danger (Tinetti
et alM 1986). The cognitively impaired or depressed elderly may be more
prone to take unnecessary risks in their daily activities or to demonstrate a
tendency for inattention and carelessness (Feist, 1978; Isaacs, 1978; Mossey, 1985; Wild et al., 1981).
Syncope,: a sudden and unexpected loss of consciousness, may be the
result of cardiovascular disorders including arrhythmias, valvular disease^
and vasovagal responses. Although a causal relationship between changes in
heart rhythm andfoilsis difficult to establish, Gordon et al. (1982) noted an
association between occult cardiac arrhythmias and elderly patients with a
history of unexplained foils. Lipsitz (1985) also described an increased
prevalence of falls among those with multifocal paired premature ventricular contractions, although he also noted that syncopal attacks due to eating
and defecation were equally as common. Carotid sinus hypersensitivity
may also precipitate a loss of consciousness mediated by vagal stimulation
associated with head turning. Syncope may also be manifested in the event
of acute disturbances such as hypoglycemia, hypoxemia, and dehydration.
Orthostatic hypotension!, defined as a fall in systolic blood pressure of
more than 20 mm Hg, occurs in 15% to 30% of the aged population
residing at home (Caird, Andrews, & Kennedy, 1973). Alterations in
baroreceptor-mediated autoregulation of blood pressure have been reported
in normal elderly subjects (Collins, Exton-Smith, James, & Oliver, 1980).
While orthostatic hypotension is often associated with metabolic, neurological, and endocrine disorders and medications with a hypotensive action,
there is considerable debate regarding its direct role in the occurrence of foils
(Caird et al., 1973; Campbell et al., 1981). A relationship between reduction in blood pressure and the predisposition to foils has been reported
(Blumenthal & Davie, 1980; Davie, Blumenthal, & Robinson-Hawkins,
1981; Droller, 1955; Overstall et al., 1978), although a number of recent
loiuii/u*/
«eu VA*/ V * I
^WIU/
216
OHUUFÎC TTihnhf firnriiin
studies suggest that many experience asymptomatic orthostasis, or successfully avert a fall by sitting down when they become light-headed (Rubenstem, 1983). While a severe fluctuation in blood pressure with positional
change may cnhance the potential for falling, there appears to be a lack of
sufficient evidence to link it directly with the circumstances of a fall or the
symptoms of the faller (Wild et al., 1981).
Specific types of medications.may have a detrimental effect on the central
nervous system by reducing mental alertness, psychomotor functioning,
and postural reflexes. The relationship berween specific drug use and falls
remains ill defined, yet elderly individuals on multiple-medication regimens
may be at higher risk of falling (Granek et al., 1987; Kalchthaler et aL,
1978; Sobel fic McCarty, 1983; Well, Middleton, Lawrence, Lillard, fit
Safarik, 1985; Wild et al., 1981). A lack of correlation between hypnotic
and tranquilizer use among elderly fallen has been found by some investigators (Isaacs, 1978; Parrish fic Weil, 1958). Others have reported that
those older subjects who had experienced a fall were more likely to be
taking sedatives, hypnotics, and/or tranquilizers (Barbieri, 1983; Feist,
1978; Granek et al., 1987; Prudham fit Evans, 1981; Sobel fie McCart,
1983; Wild et al., 1980). Nocturnal falls resulting in femoral fractures have
been associated with barbiturate sedation (MacdonaldfieMacdonald, 1977),
and a link has been shown between tricyclic antidepressants and the incidence of falls (Davie et al., 1981). Similarly, medications that produce
hypovolemia and hypotension (e.g., diuretics and antihypertensives) may
predispose the elderly to a loss of postural control and falls (Barbieri, 1983;
Pnidham & Evans, 1981; Sobel fit McCart, 1983; WalsheficRosen, 1979).
Finally, alcohol use has been suggested as a contributing risk factor in falls
among the aged living in the community (Waller, 1978).
- Drop attacks-have been described (Sheldon, 1960) as unexpecred and
sudden falls unrelated to dizziness or a loss bf consciousness. While the
underlying pathophysiology of this syndrome has not been well defined, it
has frequendy been attributed to vertebrobasilar insufficiency or cervical
spondylosis (Caird ctal., 1973). In earlier studies, drop attacks were
thought to be a common cause of falls, with a rise in incidence among
women and those of advanced age (Brocklehurst, Exton-Smith,ficLemper*
Barber, 1978; Overstall et al., 1977; Sheldon, 1960). More recent data,
however, suggest that drop attacks probably cause fewer falls than previously indicated (Rodstein, 1964; RubensteinficRobbins, 1984; Sehested
fit Severin-Nielsen, 1977).
Age-related changes are also reported in> peripheral systems. Declines in
both the strength and speed of muscle contraction are commonly reported
with aging (Aniansson, Grimby, fic Rundgren, 1980; Kroll fit Qarkson,
1978; Larsson, Grimby, fit Karlsson, 1979) and have been associated with a
decrease in acetylcholine at the neuromuscular junction, diminished nerve
'•eria&ie p**rHfffflfiVrn
asis, or successleaded (Rubenwuic with positional
îpears to be a lack of
ances of a fall or the
1 effect on the central
omotor functioning,
îc drug use and Mis
medication regimens
;
; Kalchthaler et al.,
awrence, Lillard, &
n between hypnotic
nd by some investitive reported that
: more likely to be
xbieri, 1983; Feist,
; Sobel & McCart,
Moral fractures have
Macdonald, 1977),
usants and the inclinons that produce
hypertensives) may
alls (Barbieri, 1983;
he & Rosen, 1979).
g risk factor in falls
nexpected and
ousness. While the
>een weQ defined, it
ficiency or cervical
drop attacks were
a incidence among
-Smith, & Lempert
More recent data,
wer falls than preins, 1984; Sehested
/stems. Declines in
ommonly reported
Kroll & Clarkson,
n associated with a
, diminished nerve
117
Fallâ In die Elderly
conduction velocity, and a reduction in the number and size of motor units
(Frolkis, Maryaenko, & Zamostyan, 1976; Gutman & Hanzdkova, 1976).
Muscle fiber changes are also associated with the normal aging process.
Latsson et al. (1979) reported a greater atrophy in fast-twitch muscle fibers
chàn slow-twitch fibers, and related these findings to the deerease in both
force and speed of muscle contraction in the aged.. ^
Along with the decrease in musculac strength and tone, the changes in
gait that occur with advancing age predispose the elderly to an increased
risk of falls (Campbell et al., 1981; Morse et al., 1987; Perry, 1982b;
Prudham & Evans, 1981; Rubenstein, 1983; Wild, 1981). Older men tend
toward à small-stepped, wide-based gait, while elderly women characterisdcally develop a narrow-based and waddling gait. It is also estimated that
90% of older people experience some combination of corns, callouses,
overgrown nails, or bony deformities from improper footwear, which may
contribute to impaired mobility and falling (Brocklehurst, 1967). Movement deficits are also compounded by a decreased range of motion and
flexibility in the aged population that may be due to pathological joint
degeneration, immobility, and deeondirioning.
In summary, age- and disease-related alterations in balance control may,
individually or in combination, produce instability and falls. Many of the
mechanisms described in this section remain speculative and require further
investigation to be validated.
CLINICAL EVALUATION
The purpose of clinical evaluation of the elderly client is to identify an
isolated reversible cause where possible, to detect modifiable impairments,
and to determine the presence of fixed disabilities that may require supportive services. While there axe few dan to support the efficacy of any particular evaluation sequence, several basic concepts in geriatric medicine can aid
the practitioner in developing a rational approach to the problem. One such
concept emphasizes the nonspecific presentation of 'disease in the elderly
(Levine, 1984). Falls can be thought of as a geriatric syndrome, along with
failure ro thrive or confusion, that may be due to a variety of acute problems
such as infections, drug intoxications, or metabolic problems. The individual with multiple chronic diseases may be vulnerable to acute rKniral
deterioration when faced with a new condition or an exacerbation of an
existing one. Thus, any further impairment in a frail, marginally compensated older person may literally "rip the balance." An example might be the
onset or exacerbation of orthostasis, due to dehydration, blood loss, or drug
intoxication (Robbins fit Rubenstein, 1984). Disease may present in an
atypical fashion in the elderly (Levine, 1984). Falls are not commonly
N
Geriatric BdtabHitatum
recognized as potential presenting problems for such illnesses as Parkinson's
disease and normal pressure hydrocephalus. Loss of postural reflexes may
be the initial deficit in Parksinson's disease, often not accompanied by the
classic mad of resting tremor, cogwheel rigidity, and akinesia. Special
awareness of this syndrome is required for early detection and treatment
(Klawans & Tanner, 1984). Normal pressure hydrocephalus may likewise
present as a gait disorder with subtle or minimal evidence of dementia or
incontinence (Adams, 1984; Botez & Hauser, 1982; Fisher, 1982).
Each fill represents an end product of the interaction between individual
elders and their environment. Falls that occur repeatedly with little environmental stress most likely represent a pathological syndrome requiring medical attention (Nickens, 1985). The smaller the environmental "excuse" for
a fall, the greater should be the clinician's suspicion that new or worsening
intrinsic impairments are contributing to the problem and require evaluation. An outline of the factors to be looked at is given in Table 5.1.
Several models for evaluation exist (Kane et al., 1984; Kellogg International Work Group, 1987; Rubenstein & Robbins, 1984) and may be
used as bases for developing a diagnostic plan. Table 5.2 provides an
overview of the general components of a clinical evaluation of die elderly
feller. The history of a specific recent fall should be obtained from thc~
patient and a witness if possible. The circumstances involved will help
sort out the relative contribution of environmental threat. Evidence for
frank loss of consciousness should be pursued and, if obtained, a more
focused evaluation for causes of syncope may be appropriate (Lipsitz,
1983). Associated symptoms suggestive of cardiovascular, vestibular, or
neurological events may also help target further investigations. Other potentially useful historical data include rccent changes in functional or cognitive status, onset and course of the foiling syndrome, and recent changes in
drug regimen. A general data base of active medical problems, prescription
and over-the-counter drug use, social resources, and living situations is
always pertinent.
The physical examination may be expanded in order to pursue suspicions
obtained by history but should generally include positional viral signs,
screening for visual problems, a cardiac examination, and a neurological
examination specifically targeted toward detecting focal deficits. One might
also screen for specific findings associated with Parkinson's disease (rigidity, tremor, akinesia) and normal pressure hydrocephalus (giasp reflex of
the foot, tonic foot reflexes, and cognitive changes) (Adams, 1984; Botez &
Hauser, 1982). A mental status screen for cognitive deficits should be
routine.
Balance evaluation can start with simple maneuvers such as a Romberg
test and mobility screen. Each patient should be observed performing basic
mobility tasks such as rising from a chair, walking, and turning. More
02/Ul/aJ.
1 1 9
FoQftintteBUcrly
«
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T A B 1 £ 5.1 E W * ?
se
may
y the
pecial
cment
ewise
tria or
^ Falls in tha Elderly
__
I;
Sen»o*V
Vestibular dysfunction
Proprioceptive deficit
r^twl/cogûm*
Sedation
vidua!
virontnediiCM for
sening
évalua; Internay be
ides an
elderly
om the
ill help
:nce for
a more
Lipsitz,
jular, or
tl
51
anges in
scripaon
tarions is
uspidons
taT signs,
irological
)ne might
ise (rigid> reflex of
I; Botez &
should be
. Romberg
ming basic
ing. More
Acute confusion
Seizures
Orthostasis
Dementia
Effector
Parkinsons disease
kpê occupying brain lesion
Cerebellar disorder»
Guillain-Bané)
Peripheral motor neuropathy le.*, uw»
Muscle
Joine
Polymyositis
Contractures
f o o t deformities
Other.
Otbpattadca
Metabolic.
calcium, gfacosc
Infections
Anemia
Hypo*»0**
Dehydration
Qnig intoxications
Alcoholism
t Diagnostic
r f f i testing
s s must
û «be st d t- a e. d »^^ ^
-ll
^
H
owcv«,bûsethe
a**-—"
I'ÀA
120
ITTUI/ULL HUAI/ ITT.
Geriodic HAtirilitttrio»
TABLE 5.2 Elements of Clinical Evaluation of the Elderly Faller
Kinory
Describe most recent fell in detail (symptoms, circumstances, ability to get up
again)
Onset and course of falling syndrome
Evidence fbr syncope or seizures
Recent change in cognition or functional ability
Roeent change in méditations
Acdve medical problems
Medications (prescription and over-the-counter)
Living situation/support system
Physical examination
Positional vital signs
Visual screen (acuity,fieldcots)
Cardiac exam
Neurological examination (cranial nerves, reflexes, motor and sensory ^rrrij Romberg, cognitive screen)
Mobility'screen
mented by a chest x-ray, ÉKG, and blood gas. Further diagnostic testing
remains controversial. Holter monitoring may often detect arrhythmias
(Gordon et al., 1982; Jonas, Klein, & Dimant, 1977), but their association
with symptoms is often poor (Rai, 1982; Taylor & Stout, 1983). Similarly,
screening for seizures with an electroencephalogram often yields nonspecific results (Lipsitz, 1983). Computerized tomographic (CT) scanning of
the head should probably be reserved for patients with focal neurological
deficits or high suspicion for normal pressure hydrocephalus. Because osteoarthritis is almost universal in this population, plain films of the spine or
joints are not particularly helpful unless cord or root compression is suspected. In such cases, further examination with electromyogram, C T of the
spine, or myelogram may be appropriate.
Often more helpful than indiscriminate diagnostic testing is referral
for further evaluation by pertinent health professionals. An ophthalmology examination for modification of prescription eyewear or evaluation
for glaucoma or cataracts may be appropriate. A physical therapist may
examine strength, range of motion, gait, and balance in detail, supplementing the diagnostic data base and contributing ideas to management of
nonspecific syndromes. An evaluation of the home setting by home health
or public health personnel can hdp identify modifiable environmental
threats.
When the clinical evaluation has been completed, a specific, treatable
etiology has been found in only a minority of cases. In such cases, clinicians
Éehabdixatwn
y Palier
Foils m the EUeriy
121
must thai assemble a package of interventions based on the impairments and
disabilities identified, with the goal of modifying the balance between the
individual's capacities and environmental conditions.
i, ability to get tip
MANAGEMENT OF FALLS
Intervention is still possible in the many patients for whom a single curable
lesion has not been identified. While virtually all of the approaches described here have not been subjected to rigorous therapeutic trials and thus
remain unconfirmed, they are_often benign and merit consideration. Appropriate interventions should be developed based on areas of deficit identified in the evaluation, with the goal of improving individual capacity and
reducing environmental risk in die areas of sensory function,, cognirive
performance, and neuromusculoskeletal performance.
itsory exam, Rom»
iagttostic testing
ect arrhythmias
their association
983). Similarly,
i yields nonsper n scanning of
teurological
Because oss of the spine or
pression is sus•ram, C T of the
ting is referral
in ophthalmolr or evaluation
I therapist may
ul, supplementnanagement of
yy home health
environmental
xific, treatable
cases, clinicians
Sensory Function
Impairments of vision are common in the elderly and may often be amenable to modification. Corrective eyewear itself may be improved by an
updated prescription, simple cleaning, or replacement due to excessive
scratching. Bifocals may produce conflicting visual information, particularly with downward gaze, as in descending stairs. Replacement with
separate pairs of glasses for far and near distance may be appropriate. Visual
field cuts related to vascular accidents or glaucoma are often completely
undetectable to the patient. Specific compensatory training to increase
awareness of the affectedfieldcan be provided by physical and occupational
therapists.
Glaucoma should be evaluated and treated in conjunction with an ophthalmologist sensitive to the needs of the elderly. Isolated marginally increased intraocular pressure, without other findings, may be professionally
monitored rather than treated (Reich, 1984). Many of the medications used
to treat these conditions have significant toxic side effects and so must be
employed with caution. For example, drugs tha{ constrict the pupil have
detrimental effects on night vision, and many classes of these drugs can
exacerbate confusion. In cases where treatment is necessary to prevent
visual loss, careful attention to the appropriate choice of agents is necessary.
Cataracts can reduce visual acuity to a variable degree. Mild to moderate
loss may be improved by agents that dilate the pupil. Surgical removal is the
standard of care for cases with major visual loss; however, the absence of the
lens is itself a source of major visual problems. Cataract glasses produce a
25% magnification of visual images, making objects appear closer than they
really are. Images are also distorted; straight lines appear curved. An axinu-
222
Geriatric MmMlifnffrm
lar visual defect is produced that reduces peripheral vision, resulting in a
"jack-in-the-box" phenomenon as objects appear to jump in and out of
view (Reich, 1984). Alternative therapies include contact lenses, intraocular
lens implants, and refractive keratoplasty.
Vestibular conditions are often chronic and not -amenable to specific
therapy. Antihistamines may be of benefit in some cases^ but again are
potential sources of excess confusion and sedation. Meclizine has somewhat
less potential for such side effects and is the drug of choice for a short trial
designed to test benefit (Baloh, 1984).
In general, vestibular and propriocepdve problems are not amenable to
specific therapy. A variety of sensory stimulation and balance practice
approaches have been proposed and appear to be of benefit anecdotally
(Horak & Shiim way-Cook, 1985; Kottke, 1982a; O v e r a l l , 1980). Referral to a reputable therapist for evaluation and instruction may be appro• priate.
It is also important to plan for the appropriate environmental interval, rion$_to compensate for sensory impairment. Thé elderly typically neeà
increased lighting as well as the capacity to control light levels in their
environment. Providing a light stimulus that can be managed by the aging
eye, or adding additional color and contrast, may make the environment less
hazardous. For instance, the older person should be provided with adequate
lighting at all times, preferably nonflickering, indirect, and incandescent
light. Background light should not be brighter or more intense than the
central field. Diffuse lighting rather than light originating from one direction is best for performing most activities. Similarly, soft lighting should be
provided at nighr, especially in hallways and the bathroom. Adequate
illumination in stairways should be provided, and stairs should not be
between or at the edge of differing levels of lighting.
Glare from bright light sources diminishes the ability of the elderly to
distinguish objects in the environment. Sun or lightbulb glare should be
blocked by shades or screens, or lower-wattage bulbs should be installed
Glossy and polished surfaces should be avoided (e.g., floôrs, enamel walls,
glass-covered items, and chrome). Light-colored walls and ceilings should
have a matte as opposed to a high-gloss finish. The glare from waxed riled
floors and polished wood can be minimized by the use of a short-nap wallto-wall carpeting or cork flooring. Sunglasses are helpful for outside glare,
as are umbrellas and hats with brims (Prince, 1978).
Color can enhance the visibility of the environment, especially red,
yellow,, or orange, which are easier to distinguish than cool colors such as
blue and green. Problems with color discrimination and lack of contrast
make depth perception more difficult for the elderly, particularly while
descending stairs. T o minimize the risk of falling due to the visual distortion
caused by the stair surface, risers can be painted a visible shade and steps can
|
;
i
,
j
:
'
j
»
, resulting in a
in and out of
.1 iwwses, intraocular
menable ro specific
as es, but again are
•izine has somewhat
sice for a short trial
ire not amenable to
id balance practice
benefit, anecdotally
.-stall, 1980). Referion may be approonmental intervenerly typically need
ight levels in their
naged by the aging
be environment less
r
ided with adequate
:, and incandescent
re incense than the
ng from one direcr lighting should be
chroom. Adequate
should not be
I
y of the elderly to
ilb glare should be
:hould be installed.
. oors, enamel walls,
md ceilings should
e from waxed tiled
•fa short-nap wallil for outside glare,
nt, especially red,
:ool colors such as
id lack of contrast
particularly while
lie visual distortion
dude and steps can
123
Fails in the Elderiy
riqcric Rdiabiliustion
V
be color coded at the edges, to contrast with the remainder of the tread.
Nonskid treads or solid-color carpeting can be installed on each step, and
the first and last steps should be marked for easy identification. Handrails on
both sides of the stairway should extend past the last stair and be securely
fastened, to support the user's weight (Cooper, 1981). A more detailed
discussion of the optimal design of stairways is offered by the Kellogg
International Work Group (1987).
Finally, although some older people may be handicapped in their, ability
to utilize other senses to compensate for failing vision, others can be taught
to notice other sensory cues. Increasing the number and quality of sensory
stimuli enhances the elderly person's information about the world, increases
orientation ro surroundings, and may reduce the risk of falling and related
injury.
Cognitive Function
Persons with baseline irreversible cognitive dysfunction may achieve useful
improvements in performance if exacerbating factors are removed. This
requires attention to correctable metabolic abnormalities and judicious elimination of potentially harmful medications/Medications thought to be most
commonly associated with falls include long-acting hypnotic-anxiolyrics
(including benzodiazepines and barbiturates), tricyclic antidepressants, and
phenothiazmcs (Macdonald, 1985; Ray, Griffin, Shaffner, Baugh, & Melton, 1987). Alcohol use may also exacerbate disequilibrium and result in
falls (Macdonald, ~1985). Regular réévaluation designed to optimize mental
status is useful, even in .the impaired older person for whom marginal
deterioration can be the "straw that breaks the camel's back" in terms of
precipitating a falling syndrome.
Transient episodes of lightheadedness, or weakness are a frequent concomitant of unexplained falls. One potentially interesting contributing factor recently emphasized by Lipsitz (1985) is postprandial hypotension. If
falls are temporally related to eating, a trial of frequent small meals may be
considered.
The environment can also be modified to compensate for an individual's
cognitive impairment. An example of measures intended to maximize safety
include the installation of an emergency alarm system and the mobilization
of available social supports (e.g., family, friends, church volunteers, ere.) for
supervision. Likewise, an investigation of community resources (e.g., telephone reassurance program) to aid the older person at risk of falling is
recommended. There may come a time when the most optimal modifications to the environment may no longer be effective in preventing harm as a
result of falling. At that point, thought needs to be given to relocating the
person to a safer environment.
124
Geriatric Réhabilitation
Neuromusculoskeletal Performance
Deconditioning aad contracture formation are a final common pathway of
many age- and disease-related problems in the elderly. Quadriceps and
especially ankle dorsifiexor weakness are particularly detrimental to balance
performance (Whipple, Wolfson, k Amerman, 1987; Wolfson, Whipple,
Amerman, Kaplan, & Kleinberg, 1985) and may be amenable to strengthening through exercise. Flexion contractures at the hip and knee occur with
aging and are exacerbated by prolonged bedrest. Normal upright resting
stance requires minimal energy expenditure. The presence of contractures
in the lower extremities disturbs this equilibrium, generating high force
requirements from lower-extremity muscle groups (Kottke, 1982b). Simple measures to reduce the problem include lying prone and performing
active and passive range-of-motion exercises (Kottke, 1982).
Foot problems chat produce pain and deformity can be addressed with the
help of a podiatrist. Footwear can be optimized for comfort, stability, and
traction. Specifications for safe footwear for the elderly have been described
(Finlay, 1986). Leg-length discrepancies, particularly related to arthritis
and deformities at the hip and knee, may be modified by shoe risers.
Devices that assist in ambulation range from the simple cane through a
variety of cane modifications to walkers and wheelchairs. All require expert
evaluation for proper prescription and specific training for their optimal use.
Again, referral to a physiarrist or physical therapist may be helpful.
The role of general exercise programs in preventing or ameliorating
balance problems remains largely unsubstantiated, although some supportive evidence does exist (Stelmach k Worringham, 1985; Stones, 1987).
Certainly, a major reduction in physical activity after a fall is only likely to
create a depressed, withdrawn, and weaker individual. Thus, a graded
supervised functional activity program may be attempted with many frail
elderly (Squires k Bayliss, 1985).
Despite all efforts, some elderly will continue to falL Practical advice
about methods of getting up again may be reassuring and useful (Squires &
Bayliss, 1985). For example, the individual may be able to roll and crawl or
"shuffle on the bottom" to a sturdy piece of furniture or to a staircase,
which can be used for getting up. Practice in the home setting can be
supervised by home health personnel.
Recommended environmental modifications include measures such as
removing throw rugs and securing the edges of carpeting. Modern furniture
is often designed without thought to the frail elderly. Hospital beds may be
set too high and chair seats too low for safe transfers. A safe sitting height
should be slightly higher than the individual's knees (Finlay, Bayles, Rosen,
k Milling, 1983). Blocks can be set under a favorite easy chair to achieve
this end. Safety items such as grab bars situated near the tub and commode
rie Rehabilitation
_ .< pathway of
Quadriceps and
nental to balance
)lfson, Whipple,
ible to strengthknee occur with
. upright resting
Ï of contractures
iting high force
:e, 1982b). Simand performing
2
>*
.dressed with the
rr, stability, and
e been described
lated to arthritis
shoe risers.
: cane through a
il require expert
heir optimal use.
>e helpful,
or ameliorating
h some support; Stones, 1987).
>tdy likely to
JS, a graded
with many frail
Practical advice
iseful (Squires &
roll and crawl or
•r to a staircase,
: setting can be
easures such as
lodera furniture
ital beds may be
; fe sitting height
Bayles, Rosen,
chair to achieve
b and commode
125
Foils In th* Elderly
and nonslip bathtub fixtures should be installed. A visit to the elderly
individual's home to assess the safety of the environment can be performed
by a nurse or therapist trained in. this area. A structured home safety
checklist and recommendations for environmental design have been published (Kellogg International Work Group, 1987).
The safety of the institutionalized elderly patient begins with a thorough
orientation to the person's surroundings and requires an ongoing eva uaoon
of the individual's adjustment to the unfamiliarity of the setting. Volunteer
helpers or a patient buddy system might be effectively implemented to assist
new patients in adapting to the routine of the hospital or nursing home.
Additional recommendations for promoting safety in die institution include
the stabilization of movable furniture, instruction in the proper use ot
walking aids, clear walking surfaces with adequate friction, raised toilet
scats, horizontal as well as vertical handrails, and wheelchairs with seat
belts While the use of low beds with half siderails may be appropriate tor
patient safety, siderails are questionable deterrents if used « the only form
of fall prevention (Fagin 8c Vita, 1965; Panish & Weil, 1958; Walshe &
Rosen, 1979).
SUMMARY
The geriatric falling syndrome is highly prevalent among older individuals,
has diverse etiologies comprising problems of both normal aging and disease, and has serious conséquences. A structured approach recognizing the
interactive effects of individuals and their environments on components of
postural competence may allow for systematic evaluation and a comprehensive intervention and prevention strategy. Further investigation will be
required to clarify epidemiological and etiological issues and validate clinical
evaluation and treatment approaches.
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i
formation
en
Prévention
Texte
principal
réseau
des
de
traumatismes
référence
«Planification
et programmation
selon
l'approche
de
la
prévention
des traumatismes
appliquée
à la
problématique
des blessures
sportives
et
récréatives»
(/W. Guy Régnier, Régie de to sécurité
dans les sports
du
Québec)
[SUES:
Dans le cadre des sessions de formation en prévention des traumatismes
da ministère de la Santé et des Services sociaux, tenues à Montréal,
les 20 et 21 février 1991 et à Québec, les 20 et 21 mars 1991
Guy Régnier, Ri.D.
Division Etudes et nonnes
Service de la normalisation
Régie de la sécurité dans les sports du Québec
Tfimx DES MKEEEKES
i
>
AVANT-PROPOS
.
EnpoDUcncN
L'approche préventive
r» La distinction entre "accident" et "traumatisne"..
- L'utilisation du terme "accident"
- La grille de Hâddon
- 10 stratégies de Haddon
- Tog mûrr-q passives et les mesures actives
- Toc trois grandes approches de l'intervention ....
AVANT-PROPOS
Ce document présente l1 approche adaptée par le milieu de la santé publique pour
£ir6uMmr
les traumatismes en l'appliquant aux traumatisées reliés aux activités
sportives et récréatives*
L'objectif est de sensibiliser les participants à l'application possible des principes
directeurs de l'approche préventive à d'autres, secteurs que celui de la prévention
routière.
Pour mieux situer les participants peu familiers avec la problématique de la sécurité
dans les spurts, voici quelques éléments d'information sur l'ampleur du phénomène1: ~
i
les traumatismes récréatifs et sportifs ont engendré en 1987 des coûts soci
éconcmiques de 184 millions de dollars;
-
selon l'erxjuête de Santé-Quâbec menée en 1987 , 21% des accidents avec blessures
qui ont obligé les personnes à n ^ - t w leurs activités normales étaient associées
au loisir et au sport, comparativement à 40% au travail, 18% à la maison et 12%
sur la route;
-
selon un sondage provincial, on estime à 239 000 le nombre de participants ayant
subi une blessure
1.
i
sévère pour, nécessiter une consultation médicale;
Tirés de: Sicard, C. et Daigle B. (1990) Analyse des coûts socio-économiques
associés à la morbidité et à la mortalité • d'origine sportive et récréative au
en 1987. Rapport de recherche. Trois-Rivières: Régie de la sécurité d
les sports du Québec.
'
ii
-
selon les données tirées de la banque Med-Echo du ministère de la Santé et des
Services sociaux, 11%. de l'ensemble dès hospitalisations pour traumatismes sont
^^cyvrjgpq aux activités récréatives et sportives;
-
en nombre absolu, les activités responsables du plus grand nombre die blessures en
sport sont:
le hockey sur glace, le ski alpin, les sparts de balle, le tennis et
la bicyclette.
C'est pour s'attaquer à ce phéncroène que le gouvernement du Québec adoptait en 1979 la
Loi sur la sécurité dans les sparts du Québec qui créait la Régie de la sécurité dans
les sports du Québec (R.S.S.Q.) dont le mandat est de "veiller à ce que la sécurité et
l'intégrité dès personnes dans lès sports soient assurées".
la R.S.S.Q. a des fonctions d'information, d'éducation, de recherche et de conseil, en
plus d'avoir des pouvoirs réglementaires et quasi-judiciaires.
Ses actions touchent
les fédérations sportives, les participants, les encadreurs, les propriétaires de
certaines installations sportives (notamment le ski alpin) et le grand public.
/
L'APPKXHE DE IÀ SANTE HBEJQUE FOUR LA PREVENTION DES
TOMMAHSMES:
APPUCKEICN M K TOMMKHaffiS REX3ŒM3FS ET SPCKECFS
!
Eh 1986, la Régie se donnait un "Modèle d'analyse et d'intervention" pour mieux
situer ses activités présentes et futures en relation avec son mandat, sa mission, ses
pouvoirs et ses fonctions.
*
Le modèle, basé sur des principes empruntés au domaine de la prévention, postulait
que la meilleure façon pour la Régie de remplir son mandat était de s'attaquer aux
différents %facteurs de risques associés aux blessures sportives et récréatives.
fcûJait donc
Il
ces facteurs (parmi la liste de facteurs humains, mécaniques
et environnenentaux) ; tenter si possible de les éliminer; sinon, tenter de les
contrôler; et enfin, ne pas ai cxéer de nouveaux.
Depuis, le motifrl* a servi de support à de nombreuses interventions publiques de même
qu'à la rédaction de textes et chroniques présentant les champs d'intervention de la
Régie.
Le
cfe sécurité pour organisateurs d'événements sportifs et le Quito de
sécurité et de prévention en activité ftysique sont basés en partie sur les principes
développés dans le modèle de 1986.
en
1989
et
qui
partaient
sur
De même pour les trousses d'informations produites,
les blessures
et
les moyens
de
prévention
au
baseball/balle-molle, en planches à roulettes, en ski alpin, en bicyclette et en
natation/baignade.
Le modèle est également expliqué dans ses grandes lignes dans le
vidéo institutionnel de la Régie.
Bifin, sans que ce soit toujours volontaire, les
articles composant les règlements de sécurité des fédérations d'organismes sportifs
respectent également cette stratégie.
.2
r
L'approciie préventive
La version originale du modèle d'analyse et d'intervention de la Régie reposait sur
nos connaissances de l'époque du domaine de la prévention des traumatismes.
Grâce à
un rapprochement graduel avec le milieu de la santé par différents projets communs, la
Régie paît maintenant compléter' ce modèle en y ajoutant des concepts de prévention
cantenparains pour refléter plus adéquatement ce qui se fait actuellement dans le
domaine.
Ces concepts sont expliqués dans
les sections qui suivent
et leur
application au domaine de la sécurité dans les sports est mise en- évidence à l'aide
f
d'exemples.
la distinction entre "accident" et "traumatisme"
i
Ce sont les travaux de l'Américain William Haddon à la fin des années 60 qui ont
le plus contribué à l'avancement de la science de la prévention des traumatismes 1 ' 2 .
C'est lui, entre autres, qui a souligné la distinction importante à
faire entre le traunetisoe (ou la blessure) et la suite d'événements qui ont
abouti à
la blessure, généralement appelée i'"accident*.
distinction,
Haddon
faisait
remarquer
que
les
efforts
ai faisant, cette
de
traumatismes peuvent être dirigés vers deux cibles différentes:
réduction
des
1) l'on peut
essayer d'enpêcher que l1 "accident" à l'origine du traumatisme se produise et 2)
l'on peut tenter d'éliminer le traumatisme ou d'en réduire la sévérité, une fois
que l'accident s'est produit ou pendant qu'il se produit,
cette distinction a
permis aussi de mettre en évidence un trait commun à tous les traumatismes c'està-dire, le transfert d'énergie.
Chaque type de traumatisme résulte soit d'un
transfert
(collision),
d'énergie
mécanique
thermique
(brûlure),
chimique
(intoxication) ou électrique, soit d'une absence d'"énergie" sous forme d'oxygène
(noyade) "ou de chaleur
(hypothermie).
Ce concept est important et 'il sera
réutilisé plias loin lorsqu'il sera question de stratégies de prévention.
La
distinction
entre
"accident"
l'exemple du ski alpin.
et
"traumatisme"
paît
être
illustrée
avec
Qi ski alpin, l'on peut tenter d'éliminer ou de réduire
la gravité des blessures à la tête résultant de collisions avec un pylône soit en
s'assurant que le skieur ne viendra jamais en contact avec un tel obstacle
(éliminer 1*"accident") soit en faisant en sorte que si la collision se produit,
elle n'entraîne pas de blessure grave.
Dans le premier cas plusieurs stratégies sont possibles.
L'on peut par exemple,
sensibiliser les skieurs au- danger que représentent les pylônes dans les pisti
pour qu'ils soient plus prudents, aménager les pistes pour que les pylônes soient
le moins possible dans lè chemin emprunté par les skieurs, s'assurer que la neige
autour des pylônes soit bien entretenue pour ne pas entraîner de pertes de
contrôle, etc.
Four ce qui est de minimiser les dommages corporels subis par le skieur une fois
1 "'accident"
survenu,
deux
options sent possibles
: l'on, paît
modifier
la
structure du pylône pour le rendre plus absorbant ou l'on peut "modifier la
structure" du skieur lui-même, en exigeant qu'il porte un casque
'l
est
probable
alors que
les blessures résultant
éliminées, au moins réduites en gravité.
de
protecteur.
l'accident
seront
Il
sinon
4
"Cette distinction conceptuelle entre l'événement potentiellement
dangereux, lf"accident11 (...) et les blessures (...) a permis d'ouvrir
une perspective beaucoup plus large pour ce qui est de la prévention
des traumatismes, bien au-delà des anciennes orientations liimtfm
surtout à 11 identification des individus à risque et des tentatives de •
modification de leurs emportements"3.
Nous 1 discuterons un peu plus loin quelles sont ces nouvelles perspectives et
«
iM!i|i>Miif
elles
récréatifs.
s'appliquent
à
la
prévention
des
traumatismes,, sportifs
et
Pour l'instant, quelques précisions s'imposent sur l'utilisation du
mot "accident".
i
L'utilisation du terme "accident"
la définition la plus courante du mot "accident" est "un événement fortuit,
imprévisible".
Dans l'esprit des gens, un accident est inévitable.
C'est
pourquoi il peut paraître paradoxal de parler de "prévention des accidents".
Il
- est donc préférable de parler de "prévention des traumatismes" pour décrire
l'objectif, de
nos
activités
à
la
Régie.
L'expression
"prévention
des
traumatismes" (ou son équivalent "prévention des blessures") inclut à la fois les
interventions faites pour empêcher que l'événement potentiellement dangereux se
produise et les interventions faites. pour éliminer ou réduire la gravité des
traumatismes
une
fois
l'événement
survenu.
L'expression
"contrôle
des
traumatismes" est également utilisée dans le même sens que "prévention des
traumatismes".
Par ailleurs, l'expression "événement potentiellement dangereux"
sera utilisée dans ce texte pour référer à ce qu'on entend généralement par
"accident" afin de mieux faire le lien avec les concepts décrits plus haut.
5
La grille de Haddon
Dans le mdftlft de la Régie; nous avions reconnu que les facteurs à l'origine des
traumatismes peuvent être regroupés en trois grands grapes
humains,
typologie
les
facteurs mécaniques
et
les
facteurs
: les facteurs
environnementaux.
Cette
fait ressortir le fait que les traumatismes sont le résultat de
plusieurs farces de nature différente et qu'il faut en tenir compte dans le choix
de nos interventions.
N
^'
Haddon fait également cette observation mais en y ajoutant une deuxième dimension:
le temps.
Il suggère que des facteurs issus de ces mânes trois groupes peuvent
influencer avant l'événement, pmdant l'événement et après l'événement.
Le
résultat de cette conception est un tableau à deux dimensions présentant, d'u
côté, les groupes de facteurs et de l'autre, les trois phases de l'événement.
La grille de Haddon a m ignéo à la prévention des traumatismes chez les skieurs
alpins est présentée à la page suivante.
Notez que Haddon ajoute une quatrième
catégorie de facteurs en divisant la catégorie "facteurs environnementaux» eh
"environnenent physique" et "environnement socicr-écxjnamique et législatif".
la grille de Haddon est donc compose* de 12 "cases" au départ vides, qu'il faut
tenter de remplir pour chaque secteur d'activités.
C'est une grille d'analyse
- très utile qui farce l'imagination des intervenants à penser à toutes les
pnFwiMIi*-*»' d'intervention.
C'est un instrument qui ouvre de multiples avenues
pour les spécialistes de la prévention, quel que soit leur champ d'activité.
/
*
•I
y-
Grille selon la matrice de Haddon
Facteurs de risque
ENVIRONNEMENT
HUMAINS
TECHNIQUES
PHYSIQUE
Phases
temporelles
Avant
ENVIRONNEMENT
SOC IO- ECONOM l(JJE
ET LEGISLATIF ' '
;
. Eclairage
. Signalisation
. Conception
pistes
. Entretien
pistes
. Code de conctùte
obligatoire
. Fixations déclenchent
. Arrêt d'urgence
sur remontepentes
. Coussins sur
obstacles
. Normes pour
fixation is
i
. Freins ski .
. Accès salle d e
premiers soins
. Condition phy- . Entretien d'éryiipement
sique
Achat d'équipe. Apprentissage
ment adéquat
. • Alcool
. Attitudes, comportements
1
Pendant
Après
. Port du casque
. Condition physique
. Formation des
patrouilleurs,
i
. Règlement
preniers soins
6
la grille de Haddon est un concept qui fait présentement l'unanimité dans le
domaine de
la prévention
au Québec,
au Canada
et aux Etats-Unis.
Il est
intéressant de noter que la Régie en avait déjà adopté une partie dans son modèle
de 1986 avec la dimension des facteurs de risques.
Les 10 stratégies de Haddon
la grille de Haddon facilite la tâche des intervenants en leur offrant un cadre
d 1 analyse pour dresser une liste de tous les secteurs d'intervention possibles
i
pour un dcnaine particulier.
La grille ne sert pas à cimisir les meilleures
stratégies, mais uniquenent à explorer toutes les possibilités.
Pour préciser
davantage cette liste de stratégies possibles, Haddon2 et plus tard Waller4 ont
proposé un deuxième instaurent d'analyse basé surtout sur la dimension temporel
de la matrice (pré, per et postévénement).
Il s'agit de 10 stratégies qui visent
à T ^ h g y qu'un traumatisme ne se produise ou, s'il se produit, à en réduire la
gravité.
Les 10 stratégies reposent sur le concept expliqué plus haut que le lien
cammun entre tous les genres de traumatismes est le transfert d'énergie.
"Les 10 stratégies de contrôle concernent soit les facteurs humains,
soit les facteurs environnementaux (physiques et sociaux), soit les
agents agresseurs.
Ces stratégies donnent lieu à une imposante
batterie de mesures préventives qu'il faut considérer. Cela peut se
faire selon l'importance du problème, son effet sur la santé, la
connaissance que l'on a de ses déterminants ainsi que la faisabilité
et l'acceptabilité des interventions."3
Les pages qui
suivent présentent chacune des 10 stratégies avec un exemple
appliqué aux activités sportives et récréatives.
volume '"Die Injury Fact Book"5. . .
Certains exemples sont tirés du
7
PHASE AVANT L'EVENEMDfF
1.
la production ou l'aocuznilaticn initiale d'énergie.
Cela revient à
éliminer à la source les situations potentiellement dangereuses.
Par exemple,
empêcher la fabrication ou l'utilisation de certains équipements susceptibles de
causer
des
blessures.
Aux
Etats-ttois,
après
que
1 "'American
Acadeny
of
Pediatrics" eut recommandé, en 1977, que l'usage des trampolines dans les écoles
soit interdit, le nombre de blessures sérieuses au cou et à la tête a baissé de
60%.
Au Québec, l'exemple des tri-motos illustre également bien cette, stratégie.
i
En 1988, devant le nombre élevé de décès associés aux véhicules tout-terrain
(trinotos) et surtout devant leur instabilité inhérente qui en font des engins
intrinsèquement dangereux* les ministres des transports de toutes les provinces et
du fédéral ont obtenu de l'industrie qu'elle cesse volontairement la vente des
motos à trois roues.
2. Limiter ou réduire la quantité d'énergie aocunulée.
Par exenple, réduire là
hauteur de laquelle les enfants peuvent sauter ou tomber sur un terrain de jeu,
llflii+ov les vitesses maximales des motoneiges, ou 1 imiter la vitesse des skieurs
débutants en leur offrant del pistes à faible'inclinaison verticale.
•
L'exposition
/
au danger peut aussi être réduite en limitant la durée des activités lorsque c'est
possible (lors des entraînements par exemple) ou en regroupant, les participants
par rl
t * muii^ dans les sparts de acmbat.
Prévenir le dégageront ou le transfert de l'énergie accumulée.
Par exemple,
fabriquer des armes qui ne risquent pas de se déclencher par mégarde.
L'entretien
des pistes de ski alpin pour s'assurer qu'aucune roche ou plaque de terre ne nuise
au skieur, est un autre exemple.
i
HBVSE EBflMNT L'ÏVBIBfaiT
ttxUfier le
source.
ou la répartiticn spatiale du transfert d'énergie à pm-tir de sa
Parmi les exemples de cette stratégie, notons le relâchement contrôlé
d'un barrage sur un lac pour protéger les plaisanciers en aval, et l'utilisation
de ''•r-anyu-trxz. plus courts sur les souliers de football pour que le pied puisse
tourner facilement sans transmettre une force soudaine au genou.
Sg|Miw
dais le + T * * ou ****** l'espace la source d'énergie et le récepteur
potmtiel.
Provoquer des avalanches lorsque les pistes sont fermées est un
exemple de séparation temporelle qui réduit les chances qu'une avalanche se
produise lorsque des skieurs sont sur la piste.
exemple
de
la
séparation
spatiale
entre
la
Les pistes cyclables sont un bon
source
potentielle
de
danger
(l'automobile) et les ' éventuelles victimes* (les cyclistes);, l'installation d'une
clôture autour d'une piscine résidentielle également.
Placer les bancs et autres
objets mobiles loin des lignes de côté dans les sports de gymnase est un autre
exemple.
.
. >
Séparer avec une barrière matérielle la source d?énecgie du récepteur potentiel.
C'est probablement la stratégie de prévention la plus évidente et la plus utilisée
•9
dans les spares.
Ttous les équipements protecteurs sont des exemples de cette
stratégie.
7.
s
Modifier la
de rrrfrf^- ou la structure de hase qui entrerait en ocntact
avec l œ
personnes.
Cette stratégie permet une répartition de l'énergie plus
grande.
Alors qu'avec. la stratégie no 6 l'on modifie la "structure" de la
personne, avec celle-ci, l'on nodifie la structure de son environnement physique.
Des exemples évidents en sport incluent l'utilisation des nouveaux ancrages de txit
de hockey qui se décrochent plus facilement, les matériaux absorbants ajoutés aux
pylônes sur les pistes de ski et les balles de base-bail moins dures utilisées par
les enfants.
8. Renforcer
^
y
les récepteurs potentiels pouvant
d'énergie..
être affectés par un transfert
Cette stratégie comprend par exaiple le renforcement du système
mosculo-squelettique, reconnu canne une bonne façon de prévenir les blessures.
le
développaient et l'entretien des autres déterminants de la bonne forme physique
font aussi partie de cette stratégie.
N B S E AERES
9.
L'EVEHEMENT
Agir rapidŒHit pour OUULLHL1 lesrtimirHjesdéjà subis.
Les athlètes qui subissent
'une fracture de la colonne vertébrale par exemple, doivent être déplacés avec soin
pour réduire les probabilités de paralysie.
L'application du traitement ICE (Ice-
Ccmpression-Elevation) aux athlètes blessés est un autre exe mple bien connu de
cette stratégie.
La disponibilité de systèmes de communication et de services
10
d'urgence à proximité paît' aussi contribuer à réduire la sévérité des dommages
déjà subis.
,
-
stabiliser, traiter et réhabiliter la peiAtime blessée dès que possible.
la
chirurgie,
de
la
réhabilitation
physique
et
mentale
et
la
modification
l'environnement pour acccmrripr la personne handicapée aident à minimiser les
effets néfastes des blessures sérieuses.
Les mesures passives et les mesures actives
le choix des stratégies d'intervention doit tenir compte du degré d'effort requis
de l'individu pour assurer sa propre sécurité.
C'est ici que- la distinction entre
les mesures d'intervention passives et les mesures actives est importante à faire
Uhe mesure dite "passive" est automatique.
Elle ne requiert pas la participation
de la personne que l'on cherche à protéger.
d'intervention qui modifient
mesures passives.
En général, toutes les stratégies
l'environnanent physique de l'individu sent des
C'est comme si on le protégeait à son insu.
Placer un matelas
protecteur sur le mur derrière la ligne de fond d'un terrain de basket-ball un peu
à l'étroit dans le petit gymnase d'une école élémentaire est un bon exenple de
mesure passive.
-
-
.
!
\
Les mesures actives, au contraire, font appel aux individus pour assurer leur
propre protection.
Pour reprerctre l'exemple du terrain de baket-ball, une mesure
active serait d'avertir les élèves du danger que représente le mur.
11
Le concept passif-actif n'est pas une. dichotomie nais plutôt un continuum qui
s'étend entre ces deux pôles selon le degré de participation exigé de l'individu.
Ainsi, il existe des mesures qui demandent un effort de la part de l'individu mais
'
i
qui le protègent automatiquement par la suite.
protecteur à bicyclette.
Par exemple, mettre un casque
La premier effort est de se procurer un casque,
deuxième effort est de le porter.
le
Mais une fois que le cycliste a son casque sur
la tête, il est protégé tant qu'il le gardera en place.
L'on remarque tout de
suite que .cette mesure demandera un effort constant de la part de l'individu qui
"aura le choix" à chaque fois de se munir de la protection ou non.
L'introduction
d'une réglementation obligeant tous les cyclistes à porter un casque ferait
g n . ^
la
mesure
l'environnement
un
peu plus du
(réglementaire)
l'adoption d'un emportement.
de
côté
"passif"
l'individu
sur
serait
le
continuum
modifié
peur
puisque
forcer
La figure de la page suivante illustre le concept
du continuum passif-actif appliqué a la prévention des collisions contre les
obstacles en ski alpin.
la tendance actuelle chez les spécialistes de la prévention des traumatismes est
de favoriser les mesures passives, tt» des raisons justifiant cette tendance est
le fait que les rassurés passives protègent toute la population, quelque soit leur
*
âge et
leur statut soci(>-écanamique.
Par exemple,
les clôtures autour des
piscines résidentielles protègent tous les baigneurs, y ccnpris (et surtout) les
enfants
chez qui les consignes de prudence n'ont aucun effet.
De plus, les effets
concrets des mesures actives (campagnes de sensibilisation à tel ou tel danger par
exaiple) ont rarement été démontrés.
Le continuum des stratégies d'intervention
passives vs actives
Le cas des collisions contre les obstacles en ski alpin
Coussins sur
obstacles
Mesure
passive
Obligerle
port du casque
Suggérer le
. pondu casque
"Faites . ,
attention!
Mesure
active
100%
0%.
Participation de l'individu
r
12
Le
recours
exclusif
à
des
mesures
"dërespansabiliser" les individus?
passives
ne
risque-t-il
pas
de
trop
Certains prétendent que la papulation visée
par les mesures passives sera portée k ajuster son emportement pour prendre plus
de risques puisqu'elle percevra les situât inns comme moins dangereuses.
les
spgoîaiîgtes rétorquent que certains individus réagiront de cette façon, mais que
l ' œ a f c l e de la population visée par la mesure ne modifiera pas ses habitudes.
Le résultat net de la mesure d'intervention serait alors positif.
Par contre, .il
est clair que si nous réussissons à modifier les attitudes et les comportements
des individus, les mesures de prévention passives auront encore plus d'effet.
La
solution réside probablement dans la combinaison astucieuse des^deux afçroches en
insistant sur l'une ou l'autre selon les circonstances, d'autant plus que les
mesures passives" à 100% sont très rares.
Les trois
grandes approches de l'intervention
1
**
'
-
/
Les stratégies d'intervention en prévention des traumatismes peuvent aussi être
regroupées selon les trois graitfes catégories d'approche favorisée.
L'on peut
prévenir
en
renforçant
c'est l'approche réglementaire.
L'an peut
les
blessures
en
adoptant
l'application de lois existantes?
de
nouvelles
lois
ou
aussi prévenir les blessures en éduquant la population en général ou un groupe
cible et en tentant de modifier des ccrapartements spécifiques qui entraînent des
blessures; c'est l'approche éducation/ modification de <xnpartement.
paît prévenir
les blessures en modifiant
Enfin, l'on
la conception des produits ou des
installations utilisées par les individus; c'est l'approche ingénierie.
approches ne sont évidemment pas mutuellement exclusives.
j
ces
Encore ici, c'est
13
souvent
l'utilisation combinée de chacune d'elles qui entraîne les meilleurs
résultats.
.
j
0CNCX05XCN
les grands principes de p r é v e n t i o n utilisés en santé publique s'appliquent au domaine
de la prévention des traumatismes, quelles que soient leurs origines : la route, lé
travail, la maison, le sport.,.
Il est utile de recourir à ces principes pour guider
le choix de ses stratégies d''intervention.
discutés
doivent- aussi
interventions,
être
leur réalisme,
considérés,
leur
D'autres critères qui n'ont pas été
notannnent
l'efficacité
implication politique et
probable
des
leur rapport coût-
bénéfice.
t
Par
ailleurs,
possibles
la maîtrise de
de
interactions
différents
et
l'approche préventive
milieux
accélérera
touchés
d'autant
par
par
les
les solutions
le plus
traumatismes
à
'
d'intervenants
facilitera
ce problème
les
aux imltiples
manifestations:
Le document présentait
les principaux éléments de cette approche- préventive en
insistant sur leur application aux activités sportives et récréatives.
Ces éléments
sont:
1.
la distinction sitre la blessure (le traumatisme) et les événements qui l'ont
entraîné
(1'"accident").
interventions possibles'soit
Cette
pour
distinction
permet
de
mieux
dégager
les
prévenir 1 "'accident", soit pour éliminer ou
réduire la sévérité des blessures, une Jois 1'"accident" survenu;
\
14
L'utilisation de l'expression "prévention des traumatisnes- plutôt que "prévention
des accidents11, à cause de la connotation fataliste et fortuite accordée au mot
>
"accident" laissant croire que tenter de les prévenir est une tâche inutile;
la grille da Batten, qui sert de grille d'analyse peur étudier à fond c h a q u e
problématique et force, l'imagination des intervenants peur trouver des stratégies
de prévention originales;
Les
10
stratégies
traumatismes
Haifcn,
qui
complètent
la
grille
en
présentant
les
de simples transferts d'énergie et en proposant différentes
façons d'en limiter les effets sur le corps humain;
•i
le
"passif-actif", sur lequel peuvent être placées toutes les mesures de
prévention selon le degré de participation requis de la part des individus pour
que la mesure soit efficace;
Les trois granlles aaitujbes d'intervention, c'est-à-dire l'approche réglementaire,
l'approche éducation/nçdification de cxnportement et l'approche engineering.
/
/
15
REFHŒNCES
Haddon, W. (1963). A note concerning accident theory and research with special
reference to ^rw^r véhiculé accidents. Anals of Hev York Academy of Sciences,
107, 635-646.
Haddon, W. (1970) • On the escape of tigers: An eoologic note. American Journal
gf PnhUn Health, 60, 2229-2234.
Beaulne et coll. (sous presse) • la prévention des LTHIIIMI ISNPB au Québec:
Omprenlre pour agir. Ministère de la santé et des services sociaux.
Waller, J.A. (1987).
Injury: Conceptual shifts and preventive implications.
Anual Review of Malic Health, 8, 21-49.
Baker, S.P., O'Neill, B. & Karpf, R.S. (1984). The Injury Fact Bock, Lexington,
Mass.: Lexington Books.
• , .
The National Committee far Injury Prevention and Control (1989).
Injury
Prevention m^» ''«J the QriLLenge. Oxford: Oxford University Press, 303 p.
formation
en
Prévention
Texte
réseau
des
complémentaire
traumatismes
de
référence
«Planification
et programmation
selon
t'approche
de la
prévention
des traumatismes
appliquée
à la
problématique
des blessures
sportives
et
récréatives»
(/M. Guy Régnier, Régie de la sécurité
dans (es sports
du Québec)
Ion de hi Randonnée tien QOuvemcun hou
ciuouioQef (fi fyclnici ion de kw powjgc, en l
SfïiMi Iflixl en biu)ltcv9 69 Quèbtt.
Benoit Dalglc et Claude Slcartf
Une enquête menée en 1987 nous apprend
que 21 % des accidents avec blessures, obligeant les victimes à limiter leurs activités
normales, sont associés au loisir ou au sport,
comparativement à 40% au travail, 18% à la
maison et 12 % à la route. Par ailleurs,
239000 personnes auraient subi une blessure
au cours de la pratique d'une activité sportive et récréative en 1987. Coût de société?
Plus de 184 millions de dollars!
Décidément, les victimes du sport coûtent.
cher à la société. Cest la conclusion à
laquelle en sont arrivés deux chercheurs,
Benoît Daigle, de l'Université du Québec à
Trois-Rivièrcs et Claude Sicard, de la Régie de
la sécurité dans les sports du Québec
(R.S.S.Q.) dans une étude sur l'analyse des
coûts socio-économiques associés à la
morbidité et la mortalité d'origine sportive
et récréative au Québec. Cette recherche,
réalisée grâcç à l'initiative de la R.S.S.Q.,
fait l'objet de notre dossier du mois.
epuls quelques années, on observe un accroissertient |mpor*
tant de la pratique ^'activités
sportives et récréatives, au
Québec. Cela est égaleméntvral
D
11
pour l'ensemble des pays ln.dustrial!sés. On accorde à cette f^îjqve de
nombreuses considération} positives,
notamment en cequl côncemêlemain*
tien et l'amélioration de ta santé .phy-
1•
tfSlAU / NOVIMBA11990
*ique et mentale. De plus, cc secteur
d'activité amène de nombreuses retombées économiques. Far contre, il faut
aussi considérer que ta pratique de ces
activités comporte aussi certains risques de blessures. On a pu constater, au
cours des dernières années, un accroissement marqué du nombre dc publications en rapport avec les blessures
d'origine sportive et récréative. Au
Québec, des efforts importants ont été
déployés par différents Intervenants
du milieu dans le but de mieux cerner
cette problématique, de manière à comprendre les conséquences sociales et
économiques dc cette nouvelle réalité.
Depuis le début des années quatrevingt, la sodété attribue une plus g rende
importance aux ressources humaines;
on y voit un capital & maintenir et on
tente même de l'accroître. L'activité
physique est sans aucun doute un outil
pour accroître ce capital. Des études
ont démontré que la pratique d'activités sportives et récréatives permet
d'améliorer le bien-être de la population et ainsi réduire les coûts des soins
de santé et les arrêts de travail.
D'autre part, il faut reconnaître que
l a blessures reliées à la pratique de
l'activité physique requièrent des ressources importantes pour leur traitement. Étant donné que les ressources
sont rares, il devient Important de prendre en considération les notions de
coûts. C'est à ce moment que l'économie de la santé entre en jeu et prend
touteson importance. Afin de souligner
l'ampleur de ce secteur d'activité économique, mentionnons qu'en 1987-1988,
les dépenses publiques dans le domaine
de la santé et des services sociaux au
Québec s'élevaient à 8,9 milliards de
dollars. Elles représentaient 29,4 % de
l'ensemble des dépenses gouvernementales.
U est possible de prévenir une part
significative des blessures qui surviennent lors de la pratique d'activités
physiques et ainsi réduire les coûts qui
y sont associés. La prévention pourrait
donc aider & maximiser les bénéfices
tirés de la pratique de ces activités. La
question est de savoir combien de ressources nous devony allouer à cette
fonction prévèotiîwûr s'assurer de
sa remabilité.A(Ctiielf8nnwntJes critères
pour allouer
. reposent
sur des fart eùr^tMquç,.,gàlitlque et
économique, àependimi/ dans 'une
optique où l'on veut rationaliser les
interventions, l'analyse socio-économique est sans doute l'une des approches
que l'on doit privilégier.
Dans une perspective de prévention,
on peut utiliser l'analysedes coûts socioéconomiques à deux fins principales.
La première concerne l'identification
des priorités d'intervention. Ce genre
d'analyse permet d'évaluer les coûts
pour un ensemble de traumatismes
dont les causes sont souvent très dlfférentes.Àla lumière decetyped'analyse,
il est possible d'Identifier des priorités
d'intervention.
La deuxième concerne l'évaluation
de l'efficacité d'un programme de prévention. 11 ne suffit pas de mettre de
l'avant des mesures préventives, il faut
aussi en mesurer l'efficacité. Pourquoi,
parexemple, utiliserions-nous une certaine quantité dc ressources pour sauver
une vie alors qu'avec les mêmes res-
sources, on pourrait en sauver plusieurs
ou encore prévenir un nombre lmportant de traumatismes ? L'approche économique peutfournlrcertalnséléments
de réponse en ce sens.
Depuis plusieurs années, on utilise
des Indices économiques pour identifier des priorités d'intervention ou pour
évaluer des programmes de prévention dans des secteurs comme la sécurité routière ou la sécurité au travail.
Malheureusement, on retrouve peu
d'études sur les coûts socio-économiques associés aux blessures d'origine
sportive, malgré l'existence de cadres
conceptuels pour les évaluer. Cette situation est principalement at tri bu able
aii manque dc données épidémiologiques sur le sujet. Cependant, depuis
quelques années, des'études ont été
réalisées au Québec po\ir pailler â cette
lacune. 11 devenait possible alors de
IS
tttiftP miï'W- -t*
penser à la réalisation do'la présente
étude qui a pour but d'évaluer le coût
économique associé à l'ensemble do la
morbidité et de la mortalité d'origine
sportive et récréative au Québec.
BILAN DES BLESSURES
Actuellement, il n'existepasdesystème,
universel pour répertorier l'ensemble
des blessures d'origine sportive ou
récréative au Québec, Par contre, des
études réalisées depuis 1987, ainsi que
certaines données provenant de banques de données, nous permettent de
tracer un portrait assez précis de la
situation. Ainsi, l'enquête de Santé
Québec (1987) et le sondage qui a été
effectué par la Arme Créatec +, à la
demande de la Régie de la sécurité dans
les sports du Québec (ÏLS.S.Q.), nous
permettent de constater que 21 % des
accidents avec blessures, obligeant les
victimes & limiter leurs activités normales, sont associés au loisir ou au
sport, comparativement à 40% au travail, 18 % à la maison et 12 % à la route.
Selon le sondage Créatec 239000
personnes auraient subi une blessure
au cours de la pratique d'une activité
sportive et récréative en 1987. La figure 1.1 présente les principales activités
responsables des traumatismes; on y
retrouve le hockey, le ski alpin, les
sportsde balle, le tennis et la bicyclette.
Le nombre élevé d'accidents entraîne
évidemment des consultations nombreuses auprès des principaux services de santé où les professionnels sont
ÉVALUATION DES COÛTS
les plus souvent mis à contribution.
Bien que l'évaluation des coûts reliés
Le tableau 1.1 Indique l'ordre d'Imaux blessures d'origine sportive et
portance du nombre de consultations
récréative soit très complexe, 11 demeure
effectuées par les blessés à la suite
que cette démarche est fort valable et
d'accidents d'origine sportive et récréative. Ces données auront un impact - peut contribuer A une meilleure rentabilité des investissements en ce qui
.important sur l'ensemble des coûts
concerne la prévention des blessures.
engendrés par ces accidents.
Dans la littérature, on identifie généÀ partir de la banque de données
ralement deux grandes catégories de
Med-Echo» du ministère de la Santé et
des Services sociaux, 11 a été possible coûts ; économiques et sociaux. Le coût
économique représente l'ensemble de
de compiler le nombre d'hospitalisala production de biens et de services
tions en fonction de l'Sge et du sexe.
qui n'ont pu être produits à la suite
La figure 1.2 Indique que, de façon
d'un décès ou d'une incapacité parti 1
générale, les blessures qui nécessitent
le ou totale. À cela, 11 faut ajouter
une hospitalisation sont trois fols plus
coût des ressources utilisées pour diafréquentes chez les hommes que chez
les femmes, et que les traumatismes les gnostiquer ou traiter les blessures.
plus fréquents sont causés par des chutes
Généralement, on reconnaît deux
et des collisions lors d'une activité
types de coûts économiques. Le presportive (45,4%) et les accidents immier type identifie les coûts directs, et
pliquant un cycliste sans véhicule
fait référence aux frais encourus pour le
diagnostic, le traitement, la réhabillmoteur (22,7%).
ffgon v.i Htmmm
in fONcm tx tOTWI* n ou s&i
1988)
Koafan*cB<Mfl*fiM) 1.4
Nouât* bbwmUicnSird »
U
HOMME Q
FEMME
M
U
U
n
14
n-
ri04
ttSEUl/NOVUIKH
tatlon et les frais Judiciaires. Ceux-ci
comprennent les biens et services qui
on r été utilisés en relation avec cette
blessure. Le deuxième type a trait aux
coûts qui sont liés indirectement aux
blessures. U s'agit, entre autres, dc la
perte de production que peut entraîner
une blessure.
Les blessures ont aussi des conséquences sociales. On qualifie souvent
celles-ci de «coûts sociaux», lesquels
font référence, par exemple, à la détérioration psychosociale qui résulte
d'une blessure. Parmi les facteurs qui
peuvent être à l'origine de cette détérioration, on note les effets de la dépendance économique, de l'Isolation sociale, la perte d'Image de soi et la souffrance. Évidemment, ces coûts sont
très Importants, quoique difficilement
quantifiable? d'un point de vue économique.
La revue de la littérature nous a
permis de constater l'existence de quelques articles en rapport avec l'évaluation des coûts économiques liés aux
blessures d'origine sportive. La majorité de ces études prenaient exclusivement en considération les coûts reliés
aux soins médicaux. On a relevé une
seule étude effectuée au Canada ayant
trait Â ce sujet Celle-ci a été réalisée par
la firme Environics (1986) pour le
compte du gouvernement de l'Ontario.
Cette étude prend en considération à la
fols les coûts économiques directs et
indirects. Cependant, elle comporte
plusieurs limitations du fait que les
données de base proviennent seuleTableau 1.2
ment de deux sondages de taille plutôt
coin Komirn dis rufs.ms/ip/fh
faible. L'évaluation des coûts reliés aux
soins médicaux a été réalisée par le
BLESSURES
biais de données provenant d'un sonCouh dirent
dage effectué auprès de la population
Scivimmeduoux
d'athlètes seulement. Il n'apparaît pas
Seivice^ jxirufnudiinu*
évident que cette population choisie
IX'[n? n\esa I i c i e n i
soit représentative de l'ensemble de la
Coùls indirect?
Petit de |ji(nlu(tivi1e
population des sportifs.
Les coûts indirects ne sont pas liés
DË(ÊS
au traitement d'une blessure mais à
Coùti directs
leurs conséquences, lesquelles peuvent
linnspo»! por ombuloncc
être d'ordre social ou économique. Les
(ufttiomiion dos de(tr>
coûts reliés & la perte de production
Rct'icithc du (oip'>
sont souvent considérés comme étant
Imjucic du loionci
la principale composante des coûts éco( o ù h indirects
nomiques indirects. La notion de perte
Terlc- de productivité
est ici liée au fait qu'un décès prématuré ou une invalidité diminue la capacité de la société à produire des biens et satisfaire les fins de cette approche, de
services.
données qui permettent d'évaluer la
valeur de la vie humaine pour les QuéDans la littérature, on trouve deux
bécois.
approches conceptuelles bien difféL'approche du capital humain suprentes pour évaluer la valeur d'une
pose que la valeur de la vie est mesurée
vie, celle du consentement à payer
(• willingness to pay ») et celle du capi- par la valeur anticipée de production
d'un individu,, qui est reflétée par tes
tal humain.
compensations reçues. Généralement,
Uapprochedu consentement à payer
les revenus sont considérés comme
est basée sur le principe que ce sont
une
mesure appropriée de cette comles individus eux-mêmes qui évaluent
pensation.
Par contre, cette méthode
la valeur qu'ils donnent à un prolongeassocie
la
personne
à une machine à
ment de leur vie. Bien que cette approproduction.
SI
celle-ci
est détruite, la
che présente l'avantage d'englober les
perte
économique
est
égale
à son coût
conséquences économiques et sociade
remplacement
ou
à
la
valeur
présente
les liées aux accidents, elle présente
des
services
qu'elle
aurait
pu
rendre
si
d'autre part des problèmes d'applicaelle
n'avait
pas
été
détruite.
De
plus,
tion. Actuellement, U n'existe pas, pour
cette approche sous-évalue la valeur de
la vie des jeunes, du fait qu'ils ne font
pas partie de la population dite active
et n'accorde aucune valeur au travail
ménager et au travail bénévole.
COÛTS DES BLESSURES
D'ORIGINE SPORTIVE
La compilation des coûts économiques
des accidents reliés à des activités d'origine sportive et récréative, présentée
d-après, fut effectuée en tenant compte
de composantes-coûts rattachées â la
morbidité et à la mortalité à l'aide de
l'approche dite du « capital humain ».
Le tableau 1.2 permet dc prendre connaissance dc l'ensemble des divers élé: ments qui entreront dans la détermination des coûts directs et indirects
/occasionnés par les blessures, ainsi que
i.par les décès reliés à des activités sportives et récréatives: I* coût total est
ttsua/umuam
is
Tabbù* M
COÙIS ÊCONQMWS DES BUSSmS U DES DÉCÈS DtCOWNÎ DE UmJWEÙ'ÂOMtS SmîMS ET
Bletsoras
Services médkoyi
32653000$
Dépenses afférent»
13800000$.
•btettwes mineures
• Wwint graves
12600000$
1200000$
Décès
Cota tidktcH
Coûh èntH
nvc AU QUÉBEC EH I
CoÔfi direct»
Coirs krirtcfi
Transport por cmbuioftce 15000$ Perte di productivité
de la personne décédée 59*83000$
'soins de SMlftâl'iirgMD 11 543 000 S• blessées mineorei 71 500000S Coratatoilon das décès 9000$
•ttfMdesmtiàlûtti»
d'un hospHoitaflaft
14 603 000 S » blessure Qrovti 1 500 000$ Recherche do corps
90 000 S
• «1nsmédicaux àlutériror
d'un centre hospitalier
6 507 000$
•«loin
55 000$
•trompât
. 35000$
Sirvlmporemédkotfs
4460 000$
Enquêta du coroner 82 000$
•solmde physiothérapie 2500 000$
•wmditliroprafa
1 960 000$
Perte de productivité
TOTAltSOmoOOS
TOTAli 7 3 0 0 0 0 0 0 $
T O W s 196 0 0 0 $
TOTAL: $9 9 8 3 0 0 0 $
GRAND TOTAL: 184 0 9 2 0 0 0 $
évalué à 184,1 millions de dollars pour
l'année 1987.
Les coûts directs entraînés par les
blessures proviennent des services
médicaux et paramédicaux et de diverses dépenses afférentes. Ils représentent environ 2S % de l'ensemble des
coûts occasionnés par les traumatismes d'origine sportive et récréative.
Le tableau 1.3 Indique que les coûts
les plus élevés ont trait aux services
médicaux. En effet, selon la banque
rtjtrro f.J OiltiE DES IWMmm
Med-EchoduM.S.S.S., 11 y eut, en 19861987,5 478 cas d'hospitalisation d'une
durée moyenne de 5,9 Jours. Certes, les
blessures qui nécessitent une hospitalisation utilisent passablement de ressources. Le coût moyen des honoraires
professionnels à la suite d'une hospitalisation est de 653 $ comparativement
à 81 $ si elle n'en nécessite pas. On
constate à la figure 1.3 que les blessures qui ne nécessitent pasd'hospltallsation sont traitées sur une période de
OU SANS HOSmitSATM
moins de quatre mois dans 95% des
cas. Par contre, celles qui nécessitent
une hospitalisation sont traités à l'Intérieur de cette période dans seulen
60% des cas.
Parmi les dépenses dites afférein*»,
U y a celles occasionnées par des blessures mineures et des blessures graves.
Selon le sondage Créatec, les dépenses
diverses (fournitures médicales, médicaments, prothèses, orthèses, etc.) pour
les blessures mineures d'origine spor-
ffgerê f«4 mùiPmatQNllÂSUIT!ÛWOtCÈSSHQHiliG?RUSSIE
(W D'ESCOMPTE, 6fk ÎMÙENMOVCïMt 2%)
TU
1
4S0
40
40B
|
|
1WI
AVKHOSffîAlfUTIQN
A
UttHOSMUfiATH)»
1
1
t
Km it
J •
2»
»
1
HUM K
4
WO
0
•
it
'i
«fr
150
1
-
tooSO
«
A* 0
\
t»
-
>
H'-
•
...
<
ir
»
i
*
:L J
-29 ffl • «
|
50
. 1 T ^ H3EJ
W
70 10
MtdttMHM()oufi)
U
tSm/tmutm
live et récréative représentent un coût
de 12.6 millions dc dollars. Bien que 4e
nombre de cas de blessures graves
(lésion médullaire» soit faible, cellrs-c»
entraînent des déficiences fonctionnelles importantes. Ainsi, en plus des
services médicaux, ces blessures requièrent beaucoup de ressources pour le
transport, la formation, la surveillance
médicale, les services ménagers et la
modification de la maison.
Le sondage Créatec rapporte que les
personnes blessées lors de la pratique
d'une activité sportive et récréative ont
été dans l'incapacité d'accomplir leurs
tâches courantes (travail, études) pendant une durée moyenne de 10,3 {ours.
À l'aide des taux d'activité pour les
différentes catégories d'âge et de sexe,
on évalue à 1,3 million le nombre de
Jours perdus. £ii ce qui concerne les
personnes i la maison, avec au moins
un enfant, on estime qu'elles ont perdu
0,1 million de lours de travail pour
cause de blessures. En tenant compte
également des coûts occasionnés par
des invalidités sur des périodes prolongées, on évalue que le total de cette
perte représente près de 40% du coût
économique des accidents d'origine
sportive et récréative.
Les données du Bureau du coroner
du Québec indiquent qu'il y a eu, en
1987, 186 décès reliés À la pratique
d'une activités sportive et récréative.
Les coûts directs occasionnés par ces
décès sont plutôt faibles; ils ne représentent même pas un pour cent de
l'ensemble des coûts. l>jr contre, les
coûts Indirects reliés aux pertes dc production, associées À un décès prématuré, sont évalués A 60 millions de
dollars, soit environ 33 %du coût total.
Certes, le coût relié à la perte de
production varie énormément en fonction du sexe et de l'âge au moment
dii décès (voir figure 1.4). Le coût
moyen par décès est de 350 000 $ pour
les hommes et de 174 000 S pour les
femmes. La différence entre les coûts
estl més pour les hommes et les femmes
s'explique par le fait qu'on évalue la
perte de production & partir du salaire
moyen et du taux d'activité. Or, en
1987, le salaire moyen des femmes
représentait seulement 59% de celui
des hommes.
Le taux d'activité des femmes sur le
marché du travail est également moins
élevé que celui des hommes. En effet,
plusieurs femmes n'Intègrent pas le
marché du travail parce qu'elles
préfèrent élever leurs enfants i temps
plein. Or, ce travail a, sans contredit,
une valeur économique. La présente
étude reconnaît la contribution importante des femmes qui élèvent leurs
enfants et leur accorde un salaire
équivalent aux femmes qui sont sur le
marché du travail. Si cette correction
n'était pas apportée, le coût moyen de
la vie d'une femme serait de 43 000 S
inférieur i celui rapporté précédemment
Le total des coûts associés k la mortalité et à la morbidité d'origine spor-
tive et récréative est estimé à un peu
plus de 184 millions de dollars pour
l'année 1987. Cette évaluation est très
conservatrice et cela pour plusieurs
raisons. La première est reliée au fait
que les coûts furent estimés à partir de
rapproche du capital humain. Si cette
étude avait utilisé l'approche du consentement â payer, qui prend en considération les conséquences économiques et sociales liées â l'accident, le
coût total serait beaucoup plus élevé.
Faute de données, cette étude sousestlme aussi les coûts découlant de déficiences fonctionnelles A long terme ou
permanente. Outre les lésions médullaires et les traumatismes crâniens, qui
ont été reconnus, de nombreuses autres
blessures peuvent entraîner des déficiences fonctionnelles permanentes.
Enfin, cette étude ne prend pas en
considération les coûts des frais furldlques et ceux reliés â l'administration des programmes d'assurance, les
donnéesdlsponlbles ne permettant pas
d'évaluer ces coûts. Cette évaluation
serait certes très pertinente puisque l'on
assiste depuis quelques années à une
augmentation importante des primes
d'assurance-responsabillté civile. K
mnmm
BINET, G., « Êrudtde mortalité et de morbidité des
victimes d'accidents de loisir au-Québec », Minuté» du LoUir, de U Chasse et de la Pèche, Québec,
1982.
DA(GL£. B.. - Lê coût économique des accidents
d'automobîlo eu Québac». Université du Québec
*TroU-EM**1,1976.
ENVIRONiCS, i An Rumination of the Economic
Costs of Sports, Fitness and Recreation Related
_r * Wpl BENOiTOÛlGU, Ph. D.
"C^BÉHE l'IJ,,1n: ''' décennie SOrXi)(Wr-ill\. (1 Vilih ifNM- .Ml plol'Icnlr ditInjurie» In Ontario », Toronto, 1986.
roui <Vv >it i ni i i» 11 [»• «tes ruvi«l«-nt\ J'.inUMnohilf .'m V.MH-IMNGOLUN.
. i <•»•G
»•.. • Sondage sur iee blessures tubta
^ L L W M initi.itiw- MINI il».' l'intérêt tir |«Insii iITN ( lu i» linns «l'.tnlnNpaprrl,es Québécois lors de la pratique d'activités
B^^w-* JJK vin» «.'N «I f^.rliMulH «lu i ! i i 11 i s t «/ n ' l»'»li'-l.il il<N Tl.M»pNhpgntiq
îu
\e
.s et sportives au Québec», Montréal,
p..
A 1.1 Mille (!«.- I.I uVt'NNM II 1 (ill tli-biM «1rs ,minf \ «pi.il n'-vnif.t. « I
A'. (.(HTM uni <L»S I LI.MJ'itm'IHN 411 1 <• I|»N .1 IR.NI ,M » lun.IT V MGo
Mu
>vernement du Québec. « Rapport de l'enquête
kaA^Sw'^ f it 11K1111 N 11H' dil Québr».'. il ».' 111 IV | ' 11 » I INIR il', BI-fiSa
Ln
Ut
-é
.UQtunénbiec », Et /« tenté, (a M ?. Québec, 1988.
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;uée
HARTUNIAN,
N.S, SMART, CN, THOMPSON,
(l:>nre|»ieneurvhip (H> M>JU rapidement reconnues, !»• i«wi\ril «In paih'tiai
M* • The Incidcnceand Economtaof Ma|or Health
<|ucbeu>is lui décerne en l'^ '<: •• prix de l'annee • p.Mii\a KM m il m» ton eI
xm
cp
eapi-rments : A Comparative Analysis o( Cancer,
Motor Véhicule Injuries», Lexington. MA. 1981.
tionnelle à la promotion «.t*• I education Oc<mmiiu|ueH dr IVniirpMsc; privée au
()ii(hee.
PELLETIER, R., • Enquête su r les blessures du sport
en Ontario», Ottawa. Université d'Ottawa, 19B7.
ClAUDt SICAR0, M. Se.
RICK, P.PM MACKENZIE, LS. and associates, «Cost
Ail (Klml lit s iiiiiit i'v < |u;il rr-vi» iy,l, il leiiinnr «Ifs rhules
Injury In the United States : A Report to Con•
1 ,scieiire-. «If r.H'livitr ph\\si»|UE -L l'I IiïiVi-rsitc «lll l.hH'lui; :'r !ofroiNg
r
e
s
, San Francisco, C-A.. Institute (or Health
A.
M Itivii'u s. i! enltrpu'nil.pai•laMiili-.dv.êludi-sauMyt U >snp< iirui sands»
Axing, University of California and injury
B» " ^ «fl l'tioiveisiiéileNlonirf'aliiIhuk-.suNiJéualiser enhionu-cMnnjuePrevention Center, The Johns Hopkins Unlv«.
sity, 1989.
[i y i»iin;-ièU' l'iér.L'iiiciVM.ni un «.li.»ct'.'Mi.
lfjJK;s
II. ir;iv.!ille depuis inaimeriiioi i|ii.itre ans a la Itejjie de laSIC AR1 >, C «frutlvduscriptivcues blcsiuru* (ToriiSrlv'- Avl. .sécurité dans les sports du Québec untune ar.ent de re« ben lie.giIn
lc sportiveu requérant des soins d'urgence dans
^'intéresseplus !>}»éeiti'|ue.'in ul .1 la reeliercliecu rapport ave» lepidèinM»ltîe4U'sun centre hospitalier*. Kégiede ta sécurité dans
les sports du Québec • Hôpital Mauonneuv*
blessures d <»i i>;ine spe>m t\ »• rt n ». m mi iv. »•.
RAstmont, Trois* (Uvietet 19HR.
ÉtAO/IOVQUtf IWO
17
f ormation
en
Prévention
des
Texte
de
principal
réseau
traumatismes
référence
«Résumé de l'évaluation
de la première
année
du programme
: Mon «Vélo-casque»
c'est
sauté!»
(Mme Céline fariey,
DSC
Charles-Lemoyhe)
d'implantation
:^
d
é
'TêiiSiaà^
:: déprogramma
'':'*..:..:IÎ;• :
:
-dîfit^
i^î-:-..
:^:^^MÛHF"VÉILO-ÇASOUÊ^;
:
•.
•. =
L
Céfine Fartsy, DSC Chartes UMoyrts
ta problématique dea aooldents de la routa chez lee Jeunes lait raaaortlr qua les soeidente A
bicyclette sont responsables d'une mortalité at (Tuna morbidité Important*» chas laa Jaunaa da
S à 14 ana. Pour la Québec, 93 décèa reliée aux aooldanta do bicyclette ont été enregistrée par
la Bureau du coronar an 1986 at 1087 dont 46% ohm laa |aunaa de 6 à 14 ana; ce qui représanta 10% da l'eneembl» dos déoèa pour ea groupa d'Age. Hull fols aur dix la décès lait suite
A un traumatlama orAnion.
Pour laa OSC da la Montérégle, Il davanalt Important da penser à una Intervention vieant à
réduire laa traumatlamaa crâniens dana cette population. Suite à la revue dea différante types
d'Intervention, l'analyse dea efforta da notre communauté pour améliorer la aécurlté à bicyclette,
l'efficacité du caaque à réduire de 89% le rleque de bleaaurea * la téta, le faible taux d'utilisation
du casque dana la population A risque (2.4%) et l'Impact positif des programmée de promotion,
lee DSC ont développé le programma "Mon vélo-casque, c'est aautér (Brown, 1988).
"Mon vélo-casque* c ast aautél" eat un programme de promotion d'une durée de quatre ans
favorlssnt l'utilisation du casque de cycliste chez lee Jeunea da 4% Se et 6e annéee du prlmaira
aur le territoire de la Montérégle dana le but de réduire lee traumatisme» orAnlena reliée aux
accidente de bicyclette. Pour son application, lee DSC ont opté pour la participation de la
communauté au développement et A la réallaatlon d'activités de promotion du casque de cycliste
Intégréee aux programmée de sécurité é blcyolotte déjà existante.
Lea organlsmee qui participent su programme sont la 8oolété de l'aaourance automobile du
Québec, le Comité de prévention du crime, l'Association dea Intervenante en formation pereon*
nelle et sociale, la Fédération dea comltée de parenta de la Montérégle, lee Clube optimiste® daa
districts centre et eud et lee DSC de la Montérégle. Un comité organlaateur, formé de repréeontants dea organlamea oMiaut mentionnée, a permis la aenalblllaatlon des Intervenants et l'opératlonnaltsatlon dea aetlvltée de promotion dana leur milieu reepectlf.
Laa aotlvltéa de promotion ont été nombreuaea pour la première snnée d'Implantation et ont
touché différents niveaux d'Intervention.
Milieu acolslre:
•
-
actfvltéa en milieu eoolalre touchant 244 éooles (48 140 enfanta et leura parents):
diffusion de 60 000 dépliants d'information s'adreaaant aux parents;
diffusion do 1 700 afflehee;
concours orgsnlsé pour trouver le nom de Is msseotte (lapin de l'affiche):
thèmes A discuter en classe A partir du dépliant;
activités spécifiques avec remise de casquee en csdesu.
Communauté:
- sensibilisation do 120 Clubs optimist®», 40 servloee do la polies municipale et de la Sûreté
du Québeo et 26 iminlclpalltéa;
- activités de promotion utlllaant dee outlla (afflchee, dépliante): dee kiosques, dee rallyes
spéolflqueo eux porteurs, de casque, la location du coatume de la mascotte et le remise de
oaaquee en eadeeui
- sensibilisation dee comltéa organisateurs d'événements cyclistes de la région: Tour du
Saint-Bruno,
la Pédale
douce...;
- Mont
information
do l'opinion
publique
par les Journaux locaux et nationaux.
Détaillants de aoorts
Un total de 110 magaalns de sport ont été sensibilisés pour participer au programme de promotion du caeque de la façon suivants!
• en spposant l'affiche bien en vue;
- en s'sssurant de la dlaponlblllté de caaquea de petite taille et de taille moyenne;
- en plaçant un "hang tag" (Information pour lee parents) au guidon dee bicyclettes neuvee
pour enfanta;
- en offrant un aervlce d'aide à la clientèle par l'Intermédiaire dee vendeura (ajustement du
ossquo, etc.);
* en faleant dea eoldee de caaquea durant la campagne.
Prix du caaouei
Afin de diminuer le prix du casque, des coupona-rsbala de 5.00) aur la marque Avantl ont été
remle aux enfante lore d'actlvltée è bicyclette. Dee bona de commando au prix coûtant ont été
remle aux organlamee participante pour lee inciter è donner dee caaquea eux enfants.
Efrvlrynpgment polltlouo:
Lobbying suprès de la Société de l'aasurance automobile du Québec pour prlorlaer la promotion
du caeque de oyollate chez lee jeunee.
Lobbying auprèa do l'Association dee pédlstres du Québec et du Canada pour obtenir leur appui
su programme.
.
Les réaultata de la première année eont prometteurs puisqu'un sondage auprès dea Intervenants
montre que 71% dee orgsnlsmee répondants (21 services de police, 54 Clubs optlmfetee et 20
munlclpalltée) ont participé au programme et 94% dea détaillante répondants (79) ont accepté
de eupporter le programme. L'eneemble dee 244 écolee a reçu et diffuaé le matériel promotionnel. Environ 15% dee éeollere ont participé au conooura de la mascotte et 13% ont été exposés à dee actlvltée spécifiques. Environ 85% des détaillante qui ont répondu à la question sur
l'accroissement dee ventee ont vu leurs ventes au moins doubler.
La diffusion dee outils totalise 62 000 dépliants, 3 500 affiches et 13 000 "hang tag* à travers la
Montérégle.
Un minimum de 830 caaquea et 13 000 coupona-rsbais de 5.00$ ont été remis gratuitement aux
enfants lors d'activités de séourlté è bicyclette par lee différente Intervenants.
;
La grande majorité dea répondante ont été satisfaits de participer au programme et sont prêts à
s'Impliquer dsns Is deuxième phase du progrsmme.
-3Pour la deuxième ennée d'application du programme, lea activités mleea aur pied en 1990 aeront
reconduitee avec un enrlchlaaement dee actlvltéa en milieu ecoialre. Dee cohiere d'aettvitée
ainal qu'un vidéo eeront développée avec la participation du milieu ecoieire, de le Régie de la
séourlté dana lee eporte, dea DSC et de la Compagnie Vidéotron. Lee regroupements de marchanda seront sensibilisés afin d'augmenter la participation dee détaillante au programme.
Une étude d'obeervatlon du taux de port du caaque chez laa enfanta de 8 è 12 ana eet prévu* à
l'été 1991 alnal qu'une enquête auprèa do le population cible afin de déceler dee modlflcatlona
au niveau dee déterminante du comportement aouhalté, soit la port du caaque de cycliste è
chaque foie que l'enfant utlllae eon vélo.
La poeelblltté d'étendre le programme au niveau provincial eet préaentement * l'étude avec le
comité provincial des traumatismes de l'Assoolatlon dee Hôpitaux du Québec et la Société de
l'assurance sutomoblls du Québeo.
Un document plue élaboré eat disponible au DSC Chsrlee LeMoyne: Évaluation de la première
année d'implsntation du programme "Mon vélo-casque, c'est aautél". Céline Farley et Géraldine
Queanel, 1990.
DOCUMENTS ADDITIONNELS
1. Brown, B., Farley, C. Lïmportsnce de promouvoir l'utilisation du casque protecteur chez lee
Jeunes cyclistes Agée de huit à douze ens. Maladies chroniques au Canada, volume 10, no.6,
novembre 1989.
2. Otla, et al. Predictors of Intention toUse s Bicycle Protective Helmet Among Pre-adoleaoente.
Présenté pour publication. Publia Health Reporta. 1990.
3. Affiches, dépliante, "hang tag" (développée par la SAAQ A partir de l'étude 2) et "focue group"
en Montérégle.
1991/01/23 dl
formation
en
Prévention
réseau
des
Texte, complémentaire
«Évaluation
programme
traumatismes
de
référence
de la première
: Mon «Vélo-casque»
(Aime Céline farley,
QSC
année
d'implantation
c'est
sauté!»
Çharles-Lemoyne)
du
LBS TRAUMATISMES BET-Tlte AUX ACCIDENTS DE BICYCLETTE
PROBLÉMATIQUE»
NATURE DES TRAUMATISMES ET
MESURES D'INTERVENTION
Claude Dussault
Direction des politiques et prograsmes
Vice-présidence à la planification et
à là promotion de la sécurité routière
Mai 1987
Régie de l'assurance automobile du Québec
TABLE DES MATIERES
.
INTRODUCTION
^
/
CHAPITRE 1:
Page
'
1
•
PROBLEMATIQUE DES ACCIDENTS DE BICYCLETTE
1.1
Lfampleur et l'évolution du problème
1.2
Les circonstances des accidents de bicyclette avec un véhicule
3
4
moteur (AVM)
5
L.3
Les accidents de bicyclette sans un véhicule moteur (SVM)
1.4
Synthèse
CHAPITRE 2:
....
7
10
LA NATURE DES TRAUMATISMES
12
2.1
Le processus causal des traumatismes
13
2.2
La localisation des blessures
14
2.3
Synthèse
15
CHAPITRE 3:
LES MESURES D'INTERVENTION
17
3.1
La revue des mesures d 1 intervention
18
3.2
Le choix des mesures d'intervention
19
CONCLUSION
REFERENCES
;
31
33
ANNEXE I:
Nombre et évolution des.victimes cyclistes en comparaison à
l'ensemble des victimes de la route (1981-1985)
....
37
ANNEXE Ils ' Importance relative du nombre de victimes cyclistes par rapport à l'ensemble des victimes de la route (1981-1985)
39
ANNEXE III: Indice des fluctuations du nombre de victimes cyclistes selon
leur importance relative (1981-1985)
'
i
41
ANNEXE IVÏ
Taux de létalité et de morbidité des victimes cyclistes en
comparaison à l'ensemble des victimes de la route (1981-1985)
ANNEXE V:
Nombre et pourcentage des victimes cyclistes selon la gravité
par régions pour la période 1981-1985
/
i
43
INTRODUCTION
-.2 -
L'origine de la bicyclette remonte à 1790 alors que monsieur de Sivrac invente
le célérifère. Ce dernier devait subir de nombreuses transformations pour
aboutir vers 1900 à la forme de bicyclette qu'on connaît aujourd'hui. Depuis
le début du siècle, ce véhicule a connu une expansion phénoménale; on estime
aujourd'hui le nombre de bicyclettes au Québec aux environs de 3 millions. Si
bien qu'avec la crise de l'énergie et la montée du mouvement écologique, certains n'ont pas hésité à accorder à la bicyclette le titre de véhicule des
années f80.
Comme pour les autres modes de transport, l1accroissement du nombre de
bicyclettes fut accompagnée parallèlement d'une hausse du nombre de victimes
d'accidents. Depuis le début des années '80, une trentaine de cyclistes se
tuent sur la route et plus de 3 000 autres s'y blessent annuellement au
Québec.
Ce document vise à identifier des mesures d'intervention pour accroître la
sécurité des cyclistes à partir d'une analyse du phénomène des traumatismes
reliés aux accidents de bicyclette. Notre analyse se divise en deux chapitres.
D'une part, nous avons étudié les facteurs qui sont à l'origine des accidents
de bicyclette et d'autre part, nous avons décortiqué le processus par lequel
surviennent les blessures consécutives à ces accidents.
Ainsi, le premier chapitre présente une revue de la problématique des accidents
de bicyclette, c'est-à-dire tout ce qui réfère à la dimension qui précède
l'accident (Pré-Impact). Le deuxième chapitre cerne l'étiologie.des traumatismes en étudiant le transfert d'énergie, cause des blessures, lors de la collision (Impact). Enfin, le troisième, chapitre procède à une revue des mesures
d'intervention à laquelle nous joignons une analyse sommaire-de leur efficacité
respective.
CHAPITRE ;1
PROBLEMATIQUE DES ACCIDENTS DE BICYCLETTE
- 4 -.
1-1
L 1 ampleur et l'évolution du problème
De 1981 à 1985, il y a.eu 177 décès'et 16 933 blessés parmi les cyclistesdu Québec. Ventilées selon la gravité des blessures subies, toutes les
catégories de victimes cyclistes ont connu une augmentation au cours de
cette période à l'exception des-victimes, décédées dont le bilan est relativement constant (voir annexe I).
L'importance relative des cyclistes sur l'ensemble des victimes de la
route au cours de cette période fut de 2,8% sur les décès et de 6,2Z pour
les blessés (voir annexe II). A partir d'un indice ou la valeur "100"
équivaut à la moyenne de 1981 à 1985, on peut constater que l'importance
relative des victimes cyclistes s'est accrue de façon notable depuis 1983
après avoir connu une baisse sensible au début.des années '80 (voir annexe
III ) •
Quant à l'évolution de la gravite des blessures subies par les cyclistes,
Charron & al. (1982) avaient observé une baisse graduelle du taux de
létalité (nombre de décès par 100 victimes) de 1975 à 1982. Le calcul des
taux de létalité et de morbidité pour la période de 1981 à 1985 nous
indique cependant que le nombre de décès et le nombre de blessés graves
par 100 victimes sont remarquablement constants depuis. 1981 (voir annexe
IV).
De même, l'année 1986 révèle une baisse importante (-22Z) des décès chez
les cyclistes tout en maintenant une importance relative supérieure à la
moyenne des années '80. Il appert toutefois que les cyclistes blessés en
1986 constituent un. sommet jamais atteint tant en nombre brut (environ
4 400), qu'en importance relative (plus de 1Z) depuis que la Régie de
l'assurance automobile du Québec compile des statistiques sur les bilans
routiers annuels (RAAQ, 1986).
Ainsi, les victimes cyclistes semblent constituer une clientèle en expansion bien qu'elles n'accaparent qu'un pourcentage restreint du nombre
total de victimes de la route. Il est- difficile d'interpréter les fluctuations du nombre de victimes cyclistes compte tenu du manque d'information quant à l'exposition au risque mesurée par des variables tels le
nombre de bicyclet.tes en circulation, le kilométrage moyen parcouru, etc.
Il convient également de noter que la température estivale a une incidence
directe sur le nombre de cyclistes en circulation et par conséquent, sur
le nombre de victimes cyclistes.
Enfin,, il importe de souligner que l'ampleur des accidents de bicyclette
est largement plus répandue que ce qu'indiquent les bilans routiers annuels. D'une part, ces bilans ne tiennent compte que des accidents de
bicyclette avec un véhicule moteur (AVM); d'autre part, les bilans routiers annuels sous-estimeraient les accidents de bicyclette AVM dans une
proportion que Pless & al. (1983) évalue à 35Z. Ledoux (1984) attribue
cette situation au fait que de nombreux parents transporteraient directement à l'Hôpital leurs enfants victimes d'accidents de bicyclette sans
prévenir la police.
- 5 -.
1*2
Lea circonstance des accidenta de bicyclette avec tm véhicule moteur
(AVM)
Les études qui portent sur-les-circonstances des accidents de bicyclette
AVM sont de deux natures. La première catégorie est de type corrélationnelle et met en relation diverses variables indirectes (appelées facteurs
de risque) avec les statistiques- d'accidents. La seconde catégorie* est
de type causal et vise à déterminer les facteurs qui sont directement
responsables des accidents.
Les facteurs de risque:
Dans une étude sur la problématique des accidents de bicyclette au Québec,
Ledoux (1984) fait ressortir les principaux facteurs de risque suivants:
Le sexe
78% des cyclistes décédés ou blessés gravement sont de
sexe masculin.
L'âge "
83% des cyclistes décédés ont entre 5 et 24 ans.
45% des cyclistes décédés ont entre 10 et 17 ans.
Le mois
85% des accidents surviennent entre mai et septembre.
Le jour
78% des accidents surviennent un jour de la semaine (du
lundi au vendredi).
L'heure
40% des accidents surviennent entre 16 h 00 et 20 h 00.
30% des accidents surviennent entre 12 h 00 et 16 h 00.
L'environnement:
1
• 50^ des accidents
40% des accidents
85Z des accidents
ou moins.
80% des accidents
sation.
—V
surviennent en milieu résidentiel.
surviennent en milieu commercial.
surviennent dans une zone de 50 km/h
surviennent"à un endroit sans signali-
En résumé, ces statistiques montrent que les accidents de bicyclette se
produisent surtout en milieu urbain, durant la période estivale, en aprèsmidi et en début de soirée, et impliquent principalement des jeunes de
sexe masculin.
Les causes des accidents de bicyclette:
A l'origine du processus causal des accidents routiers, on rétrouve trois
facteurs: le comportement, le véhicule et l'environnement (Shinar, 1978).
Concernant la problématique spécifique des collisions "auto-vélo", il
appert toutefois que les facteurs véhicule et environnement ne tiennent
qu'un rôle mineur ou indirect (Ledoux, 1984). Ces' deux facteurs se présentent davantage comme des éléments qui haussent la probabilité d'un
accident (facteur de risque) tout en étant rarement la cause directe.
1 Ces pourcentages ne sont pas mutuellement exclusifs à l'exception du
milieu résidentiel versus le milieu commercial.
Ainsi» on peut relever que le facteur comportemental s'inscrit d'une
manière prépondérante parmi les causes des accidents impliquant un cycliste. De fait» Ledoux (1984) signale que les rapports d'accidents indiquent
que la conduite du véhicule est jugée "anormale" dans 61% des cas pour les
cyclistes et dans 26% des caà pour les automobilistes. D'ailleurs, cela
est confirmé par l'étude "de Cross & al. (1977) qui souligne que le comportement du cycliste serait fautif dans 60% des accidents.
De plus, cette étude7 (Cross & al., 1977) présente l'intérêt d'identifier
36' types d'accidents entre un cycliste et un véhicule moteur. A- partir
d'une synthèse effectuée par Labrecque (1983), nous présentons les 7 types
d'accidents les plus fréquents:
•
Problème de type 1 (6,7% des accidents mortels et 5,7% des autres):
Le cycliste (habituellement très jeune: 6-8 ans) sort précipitamment
d'une entrée privée et entre en collision avec un véhicule moteur qui
circule sur la voie perpendiculaire.
•
Problème de 'tvpe 5 (7.8% des accidents mortels et 10,1% des autres):
^ Le cycliste.(50% avaient moins de 12 ans) n'arrête pas à une intersection contrôlée par un panneau d'arrêt, et entre en collision avec une
automobile qui circuïe sur la voie perpendiculaire.
•
A
Problème de type 9 (1,2% des accidents mortels et 10,1% des autres):
L'automobiliste heurte un cycliste lorsque celui-ci s'engage dans une
intersection après avoir fait son arrêt. Habituellement, l'automobiliste n'a pas vu le - cycliste. Dans 66% des cas le cycliste roule à
sens contraire. Le soir* les cyclistes n'ont habituellement 'pas d'éclairage.
V" Problème de type 13 (21,6% des accidents mortels et 5,1% des autres):
Ce type de problème compte pour près du quart de tous les accidents
mortels. Dans 70% des cas, le cycliste et l'automobiliste circulent
dans la même direction, le soir. Le cycliste n'a pas d'éclairage
adéquat. L'automobiliste circule * entre 45 et 55 km/h sur ûne route
sans accotement et frappe le cycliste par l'arrière.'Les automobilistes sont sous l'influence de l'alcool dans le tiers des cas.
.
Problème de type 18 (8,4% des. accidents mortels et 8,4% des autres):
Le cycliste circule dans le même sens que l'automobiliste, à sa droite,
et décide, sans regarder ni indiquer son intention, de tourner brusquement à gauche directement devant 1!automobile.
.
Problème de tvpe 23 (aucun accident mortel et 7,6% des autres):
L'automobiliste fait un virage à gauche et n'accorde pas la priorité au
cycliste venant en sens inverse.
- 7 -.
Problème de type 26 (2,4Z des accidents mortels et 3,6% des autres):
Le cycliste circule, dans le mauvais sens et l'automobiliste le heurte
de front.
En dépit du fait que la responsabilité•du cycliste soit plus souvent mise
en cause, il demeure néanmoins pertinent de considérer le comportement de
l'automobiliste, ne serait-ce que pour le problème de type 13 qui est le
plus meurtrier et où la responsabilité de l'automobiliste semble plus
importante.
Une dernière constatation concernant les accidents de bicyclette réfère à
la visibilité des cyclistes. Dans plusieurs types d'accidents, la mauvaise visibilité des cyclistes semble être un facteur contributif, soit que
le cycliste circule dans un espace inapproprié (ex: sens inverse), que
l'automobiliste ne porte pas attention aux cyclistes dans son champ visuel, que l'éclairage soit mauvais, etc.
Sur l'ensemble de la typologie, on peut retenir sommairement les éléments
suivants:
1° Les intersections au • sens large (incluant lès entrées privées) sont
particulièrement problématiques pour les cyclistes."
2° Le cas où l'automobiliste happe le cycliste par l'arrière (type 13)
constitue un problème majeur qui nécessite une attention spécifique.
3° La circulation en sens inverse par les cyclistes est associée à un
certain pourcentage d'accidents, notamment parce qu'elle comporte des
rencontres vélo-auto inusitées.
1.3
accidents de bicyclette
véhicule moteur (SVM)
Les accidents de bicyclette SVM constituent un domaine d'études peu aise
de la problématique générale des accidents de bicyclette. Contrairement
aux accidents de bicyclette AVM, il n'existe pas de système de collecte de
données exhaustif qui permettrait d'établir le nombre global d'accidents
de bicyclette SVM. Ainsi, toutes les études portant sur cette catégorie
d'accidents de bicyclette sont faites à partir d'échantillonnages. On
peut, tout au plus, établir certaines comparaisons avec les accidents de
bicyclettes AVM à l'intérieur de ces échantillons. Globalement, on peut
dire que ce sujet est peu et mal documenté.
Parmi la littérature existante sur le sujet, on peut relever deux types
d'études: les enquêtes par questionnaire et les. études épidémiologiques
faites à partir des admissions à l'hôpital.
- 8 - .
Les enquêtes par questionnaire?
Dans son controversé ouvrage intitulé "Cycling transportation engineering", Forester (1977) établit les pourcentages suivants des diverses
catégories d'accidents. de bicyclette à partir d'une synthèse de trois
enquêtes par questionnaire:
Tous les accidents
Chutes 3
Avec Véhicule Moteur (AVM)
Autre bicyclette '
Chiens
Voitiires en stationnement
Défaillances de la bicyclette
Piétons
Autres
Accidents sérieux^
44%
18%
17%
8%
4%
3%
1%
5%
100%
38%
26%
13%
10%
2%
3%
1%
7%
100%
Ces données indiquent que les accidents de bicyclette SVM représenteraient
82% de tous les accidents et 74% des'accidents nécessitant une admission à
l'hôpital.
Les études épidémiologiques:
Les études épidémiologiques viennent confirmer partiellement les données
avancées par Forester (1977). Dans une étude sur 573 cyclistes blessés,
Friéde & al. (1985) ont relevé la répartition suivante entre les accidents
de bicyclette AVM et SVM:
.
Nb d'admissions
Nb de cyclistes blessés
Avec Véhicule Moteur
19
(42%)
(27%)
71
(12%)
(100%)
Sans Véhicule Moteur
26
(58%)
(5%)
502
(88%)
(100%)
573
(100%)
(100%)
Total
45
'
(100%)
(8%)
Les résultats de Friede & al. (1985) indiquent que les accidents de bicyclette SVM représenteraient 88% des accidents avec un cycliste blessé (%
similaire à Forester, 1977), mais- le pourcentage tombe à 58% par rappprt à
l'ensemble des accidents de bicyclette nécessitant une admission à
l'hôpital. Ces résultats sont corroborés par quelques autres études (Bass
& al., 1985; Ivan & al., 1983; etc.).
2
3
Nécessitant une admission à l'hôpital.
Chutes: accidents de bicyclette en solo.
-9 La majeure ..arfcie de la littérature traitant des accidents de bicyclette
SVM sei'blc montrer que cette catégorie d'accidents serait la plus fréquente en nombre total d'accidents et qu'elle, représenterait un nombre deblessures sérieuses au moins équivalent aux accidents de bicyclette AVM.
La faiblesse de ces études réside toutefois dans le fait que la gravité
des blessures subies n'est pas plus définie que "nécessitant ou non une
hospitalisation". Ainsi, on ne relève aucun décès dans ces études épidémiologiques que ce soit pour les accidents de bicyclette AVM ou SVM.
L'absence de décès parmi ces études n'est pas surprenante en soi puisque
les cyclistes qui décèdent sont relativement rares (30. à 40 par année au
Québec) et que les échantillons utilisés (généralement n < l 000) sont trop
petits pour les déceler.
Aucune étude sur les accidents de bicyclettes SVM, à notre connaissance,
n'a utilisé une échelle de cotation de la gravité des blessures du type
A.I.S. (Abbreviated Injury Scale, voir States. & al.,. 1980). Une hypothèse voudrait que les blessures de niveau 4, 5, 6 selon l'A.I.S. (sévère,
critique, mortelle) soient surtout l'apanage des accidents AVM. Pour
appuyer cette hypothèse, nous disposons d'une étude suédoise (Nilsson &
al., 1982) sur le nombre et la durée moyenne des séjours à l'hôpital suite
aux accidents de bicyclette AVM et SVM.
Avec Véhicule
Moteur
Sans Véhicule
Moteur
AVM/SVM
.
. 0,52
Nb d'admissions par
10 6 personnes/km (A)
0,81
1.56
Durée moyenne du
séjour (jours), (B)
15,0
. 6 , 2
2,42
Nb de jours par 106
personnes/km (A X B)
12,15
9,67
1,26
Ces résultats nous indiquent que .les victimes d'accidents de bicyclette
AVM nécessitent la moitié moins : d'admissions à l'hôpital, mais qu'elles
séjournent à l'hôpital 2.1/2 fois plus longtemps que les victimes d'accidents de bicyclette SVM. Globalement, les accidents de bicyclette AVM
accaparent 26% de plus de journées d'hospitalisation que les accidents de
bicyclette SVM. Ceci nous permet raisonnablement de confirmer que les
accidents de bicyclette AVM génèrent davantage de blessures graves que les
accidents de' bicyclette SVM, même s'ils sont beaucoup moins fréquents dans
l'ensemble.
Concernant l'ensemble de la problématique des.accidents de bicyclette sans
véhicule moteur, nous sommes portés à dégager trois conclusions:
1° Les accidents de bicyclette SVM sont les. plus fréquents parmi les deux
catégories d'accidents de bicyclette (probablement plus de.80%).
- 10 - .
2° Les accidents de bicyclette SVM sont beaucoup moins gravés que les
accidents de bicyclette AVMv
3° Compte tenu de leur fréquence élevée, les accidents de bicyclette SVM
occasionnent un nombre -de blessures graves qui doit être d'environ 75%
du nombre de blessures graves occasionnés par les accidents de bicyclette AVM.
Ainsi, on peut retenir que la- fréquence élevée des accidents de bicyclette
SVM n'est pas surprenante en soi et qu'elle peut probablement être reliée
au jeune âge des cyclistes, à l'apprentissage™"dë"ïa-bicyciette, à la
particularité de ce véhicule (équilibre sur-2 roues), etc. La plupart de
ces accidents (plus de 90%) sont sans conséquence. Cependant, il demeure
important de les considérer parce qu'étant donné leur grand nombre, ils
représentent une portion substantielle de l'ensemble des accidents de
bicyclette graves qu'on peut estimer aux environs de 40%.
Enfin, ' il convient de souligner que cette catégorie d'accidents"de bicyclette (SVM) laisse place, à investigation, notamment au niveau de la
gravité des blessures subies, de l'ampleur, de l'évolution, de la cause
des blessures, etc.
1.4
Synthèse
*
Les accidents de bicyclette se divisent en deux grandes catégories: Avec
Véhicule Moteur (AVM), Sans Véhicule Moteur (SVM). La première catégorie
(AVM) est relativement bien documentée (voir Ledoux, 1984 pour une revue)
tandis que la seconde catégorie (SVM) l'est beaucoup moins.
D 1 abord, il importe de souligner que 1'ampleur réelle des accidents de
' bicyclette est largement sous-évaluée. D ' une part ,* les bilans routiers
annuels sous-estimeraient les accidents de bicyclette AVM de 35% (Pless &
al., 1983). D'autre part, il faut multiplier au moins par 2 le nombre
d'accidents déclarés (ÂVM) si. on veut obtenir un estimé incluant les
accidents de bicyclette SVM. Ainsi, le Québec a du avoir plus de 10 000
victimes cyclistes en 1986 plutôt que les quelques 4 400 officiellement
rapportées. Il convient de préciser toutefois que la proportion de décès
et de blessés gravés parmi lés victimes d'accidents de bicyclette SVM est
beaucoup plus faible que parmi les victimes d'accidents de bicyclette
AVM.
La problématique des accidents de bicyclette AVM est relativement bien
cernée-et fait ressortir principalement le comportement du cycliste (2/3
des cas) comme cause des accidents (Cross & al., 1977; Ledoux» 1984). En
contrepartie, la problématique des accidents de bicyclette SVM laisse de
nombreux points d'interrogation et gagneraà être davantage étudiée.
- 11 - .
De l'ensemble de la problématique des accidents de bicyclette, on peut
essentiellement, retenir trois éléments:
1° L'ampleur du phénomène est largement sous-évaluée.
2° Le comportement dti cycliste semble être un facteur déterminant pour la
majeure partie dès accidents de bicyclette (AVM ou SVM).
3° Les accidents de bicyclette sans véhicule moteur (SVM) constituent un
problème majeur dont la problématique.est.encore mal définie.
CHAPITRE 2
LA NATURE DES TRAUMATISMES
- 13 - .
2.1
Le processus causal dae traaactisnas
Selon le modèle épidémiologique des blessures, l'agent étiologique est le.
transfert d'éiïàrgie (Barry, 1975; Lecours, 1982). En fait, c'est la force
de l'impact tel celui d'une personne en mouvement contre un objet qui
explique la gravité dos blessures subies (Teret & al., 1981).
Or, peu importe la cause de l'accident, le premier fait qu'on doit-considérer est que pratiquement tous les accidents de bicyclette entraînent une
chute. Cross & al. (1977) ont relevé que 60% des blessures sont consécutives. au contact du cycliste avec la chaussée. Forester (1977) avance
même que 90% des blessures sont la résultante de la chute.
Ainsi;, l'étiologie des traumatismes des cyclistes nous révèle que la cause
là plus fréquente de leurs blessures est le contact avec le sol. Cette
considération d'apparence simpliste est relativement importante; elle a
des implications fondamentales sur les moyens à privilégier pour contrer
le transfert d'énergie. Dans le cas d'une collision .automobile, c'est le
contact entre l'individu et 1'intérieur de son propre véhicule (sauf dans
les cas plus rares d'éjection ou de. pénétration de l'habitacle) qui cause
les blessures (T.C., 1976); le véhicule absorbe toujours une partie de
choc et les mécanismes comme la ceinture de sécurité ou le sac gonflable
peuvent prévenir le contact individu-intérieur de son véhicule. On peut
d'ores et déjà constater que les moyens de prévenir le transfert d'énergie
diffèrent radicalement dans le cas des cyclistes et des.automobilistes.
Dans le cas d'une collision cycliste, le véhicule (vélo) n'absorbe pratiquement aucune énergie de l'impact (O.C.D.E., 1978). La conséquence en
est que le cycliste est projeté-à la vitesse de son véhicule dans le cas
d'un accident SVM ou à la vitesse transmise par le véhicule qui le frappe
dans le cas d'un accident AVM. Heureusement pour le cycliste, la direction de la force d'impact est, règle générale, principalement parallèle au
sol; l'énergie se dissipe ainsi sur une plus grande surface (la longueur
de la glissade), ce quii laisse au corps humain une meilleure chance de
résister. En contrepartie, cela explique les brûlures de frottement qui
sont présentes dans un grand nombre d'accidents cyclistes.
La physique des collisions cyclistes nous permet également d'expliquer
pourquoi les accidents de bicyclette AVM sont généralement plus graves que
les accidents de bicyclette SVM. Lors d'un accident de bicyclette AVM,
l'énergie de contact est plus grande parce qu'elle provient d'un véhicule
moteur qui circule usuellement plus vite (énergie cinétique) que peut le
faire un cycliste par ses propres moyens. Dans le chapitre précédent, on
avait effectivement relevé que les.accidents de bicyclette AVM, quoique
moins fréquents que les SVM, occasionnent des traumatismes plus sérieux.
Cela est d'ailleurs confirmé par Cross & al. (1977) qui ont établit que la
gravité des blessures subies était fonction de la vitesse du véhicule.
Les travaux de Hugh De Haven sur la physique des chutes accidentelles nous
fournissent encore davantage de précisions sur le processus causal des
- 14 - .
traumatismes consécutifs aux'accidents de bicyclette. De Haven' (1942) a
établi que le risque de blessures 'consécutives au transfert d'énergie
provenant d'une chute pouvait être réduit de 3 façons:
1° Si la personne atterrissait sur une surface molle.
2° Si la surface de contact était grande.
3° Si un tiers objet absorbait une partie de l'énergie lors du contact
avec le sol.
La première façon ne nous est d ' aucun recours dans le . cas des accidents
cyclistes puisque la chaussée doit être dure pour permettre aux véhicules
d'y circuler. La seconde façon fournit certaines indications. D'abord,
la chaussée est une surface plane, ce (qui contribue à dissiper l'énergie
tel que- discuté précédemment. Mais la notion de surface de contact s'applique également au corps humain. Les parties du corps humain qui présentent une moins grander surf ace telle la tête sont plus assujetties à des
blessures que les parties plus grandes tel le dos. La vulnérabilité des
diverses parties du corps est-discutée à la section suivante. Enfin, la
troisième façon est ..celle qui présente le meilleur potentiel et réfère à
l'équipement protecteur dont le cycliste peut se pourvoir.
Globalement, l'analyse du processus causal des traumatismes nous permet de
cerner la phase "impact" de l'accident et guidera notre choix des moyens à
privilégier pour prévenir le transfert d'énergie lors de l'accident.
2.2
La localisation des blessures
L'étude du processus causal des traumatismes nous a permis d'établir que
la grande majorité des blessures sont la résultante de la chute. La
localisation des blessures,sera fonction de 2 facteurs:
1° La probabilité qu'une partie du corps.entre en contact avec le sol lors
de la chute2° La capacité de cette partie du corps à absorber l'énergie.
Etant donné que le cycliste est projeté généralement d'une manière parallèle au sol, la surface du corps constitue la partie la plus exposée. De
fait, plus de 75% des blessures des cyclistes se produisent sur la partie
externe du corps lors d'accidents de bicyclette AVM (Cross & al., 1977;
Pless & al., 1983). Ce pourcentage est fort probablement plus grand lors
des accidents de bicyclette SVM puisque ces accidents sont généralement,
moins graves. Toutefois, l'énergie de contact étant dissipée sur une
grande surface de la route et du corps, ces blessures sont moins graves.
Pless & al. (1983) évalue que 98%.de ces blessures sont mineures (M.A.I.S.
= 1).
Les parties du corps qui sont exposées à des blessures plus sérieuses sont
celles qui risquent d'entrer en contact avec le sol d'une manière plus
directe (i.e. moins en parallèle). Compte tenu que la chaussée est une
- 15 - .
surface plane, ce sont les extrémités du corps (tête, bras et jambes) qui
sont le plus exposées parce qu'elles sont en périphérie du corps. Cela va
en opposition à la probabilité de recevoir un projectile sur une partie du
corps qui sera exactement fonction de la surface de chaquepartie du
corps. De plus, le centre de gravité du cycliste se situe légèrement en
haut du bassin, les extrémités du corps sont donc sujettes à une plus
grande vélocité consécutive au j eu des forces centrifuges (0.C.D.E.,
1978).
Les données des études épidémiologiques confirment la vulnérabilité des
extrémités du corps pour les blessures qui sont plus sérieuses:
)
Externe
Tête et cou
Poitrine
Colonne
Abdomen
Extrémités supérieures
Extrémités inférieures
Total
Pless & al., 1983
(MAIS >2)
5,5%
32,7%
1,8%
1,8%
1,8%
20,0%
36,4%
100,0%
Friede & al.,
1985
6,5%
31,0%
0,5%
-1,1%
0,5%
56f4Z
60,4%
100,0%
Enfin, la capacité d'absorption de l'énergie du contact contribue à l'incidence des blessures parmi les extrémités du corps et ce, particulièrement au niveau de la tête. Cette capacité d'absorption est fonction de la
grandeur de la surface et de la structure interne de la partie du corps
touchée.
Ainsi, la tête apparaît comme étant doublement exposée.* D'une part, la'
probabilité de contact de la tête avec le sol est relativement plus élevée
que pour les autres parties du corps. D'autre part, elle présente une
capacité d'absorption plus limitée. Jumelée au fait qu'il s'agit' d'une
partie vitale du corps, cette'situation fait que les blessures à la tête
sont tributaires de 80% des décès chez les cyclistes (Baker & al., 1984;
Fife & al., 1983).
En contrepartie, l'autre partie vitale du corps (le tronc) est beaucoup
moins exposée à un contact violent avec le sol et présente une meilleure
capacité d'absorption. Cela se réflète d'ailleurs dans la faible incidence des traumatismes à ce niveau.
2.3
Synthèse
L'épidémiologie des traumatismes de la route montre que c'est le transfert
d'énergie qui est l'agent étiologique des traumatismes. Ce transfert
d'énergie est caractérisé par le "phénomène de la chute" où le contact
avec le sol entraîne la majorité des blessures lors des'accidents impliquant un cycliste.
- 16 -
La surface du corps est la partie la plus exposée aux blessures (75%),
quoique la quasi-totalité de ces blessures sont mineures. En contrepartie, les extrémités du corps (tête, bras et jambes) sont davantage exposées aux blessures graves. La vulnérabilité de la tête fait que 80% des
cyclistes succombent suite à des blessures à ce niveau.
Enfin, la physique du "phénomène de la chute" nous indique que le seul
moyen réaliste de prévenir le transfert d'énergie "cycliste-chaussée" lors
d'un accident de bicyclette est de pourvoir le cycliste d'un équipement
protecteur capable d'absorber l'énergie de contact.
CHAPITRE 3
T.IK MESURES D'INTERVENTION
- 18 - .
3.1
La revue des mesures d'intervention
Il existe une panoplie d'interventions susceptibles d'accroître la
sécurité des cyclistes. La présente revue ne prétend pas être exhaustive;
toutefois, elle vise minimalement à identifier des interventions pour les
principaux éléments que nous avons retenus quant aux causes des accidents
(chapitre 1) et des blessures (chapitre 2).
Afin de présenter une liste la plus complète possible tout en maintenant
une structure, noiis avons produit notre liste à partir des dix stratégies
de base de Haddon 4
(1980):
1<> Eliminer complètement la probabilité que le danger se produise:
1.
Cesser la production.de bicyclettes.-
2° Réduire le danger existant si celui-ci est impossible à éliminer complètement:
2.
Limiter
moteur.
mécaniquement
ia capacité
d'accélération
des
véhicules
3° Prévenir ou réduire la probabilité qu'un danger existant se produise:
3.
4.
5.
6.
7.
8.
—
9.
10.
Modifier les comportements (information, éducation, législation, .
renforcement);
Améliorer la visibilité des cyclistes (feux réflecteurs, vêtements
réfléchissants, etc.);
Améliorer la contrôlabilité des bicyclettes (freins, direction,
etc.);
Permettre aux ;yclistes d'utiliser le transport en commun ( situations les
particulières);
Eliminer
obstacles visuels aux intersections; .
Emettre l'obligation que les -chiens soient toujours tenus en
laisse..
•
Vérifier l'état mécanique, des bicyclettes (freins, pneus, etc.);
Pourvoir les automobiles d'un miroir du côté droit.
4° Modifier l'effet âe l'Impact afin de prévenir ou minimiser les traumatismes:
11. Porter un casque protecteur;
12. Porter des vêtements protecteurs (gancs, genouillères, etc.).
5° Séparer
protéget":
le temps ou dans l'espace "le danger" et "ce qu'on veut
13. Pourvoir les bicyclettes d'écarteurs de danger (fanion latéral);
14. Identifier des trajets routiers plus sécuritaires pour les cyclistes ;
4
Traduction libre.
- 19 -
15. Installer des feux de circulation pour cyclistes (feu jaune de
longue durée);
16. Installer des dos d'âne ("speed bumps") à la sortie des entrées
privées;
17. Installer des dos d'âne ("speed bumps") aux intersections "stop ;
18. Aménager les intersections en considérant la présence des cyclistes;
19. Créer des grilles horaires pour.les diverses catégories- de véhicu;
20.. les
Limiter
l'accès à certaines routes.
21. Pourvoir les routes d'accotements solides;
—
6° Séparer "le danger" et "ce qu'on veut protéger" en utilisant des barrières physiques:
22. Construire des pistes cyclables.
7° Modifier certaines surfaces et structures:
23. Améliorer la conception des automobiles pour éviter des blessures
aux cyclistes (objets contondants sur le capot, matériel mou à
1'avant);
24. Recouvrir de matériel mou les parties contondantes de la bicyclette;
25. Enlever des objets dangereux en-bordure des routes;
26. Eliminer les pièges à cyclistes (puisards, voies ferrées, etc.).
8° Rendre "ce qu'on doit protéger" plus résistant aux dommages:
27. Améliorer la capacité d'absorption de V. impact des bicyclettes.
9° Réduire les conséquences résultant d'un impact;
28. Améliorer les servicés post-impact.
10° Traiter et réadapter les personnes ayant subi des traumatismes:
29. Améliorer le traitement et la réadaptation des traumatisés.
3.2
Le
des f ^ u r M
d'Intervention
Il n'existe aucune revue dans la littérature de l'efficacité de l'ensemble
des mesures d'intervention pour accroître la sécurité des cyclistes.
Plusieurs de ces mesures ont été implantées de façons fragmentaire et dans
des contextes différents. De plus, la plupart des interventions sur" la
sécurité à bicyclette n'ont pas fait l'objet d'une évaluation rigoureuse;
d'ailleurs, un grand.nombre.de ces mesures sont difficilement évaluables.
L'intervenant intéressé à la sécurité des cyclistes peut toutefois référer
à l'analyse sommaire que nous avons faite de1 chacune des 29 .mesures
recencées.
t
)
ANALYSE S O M A IBS DBS MESURES D' HfTKBVBNTIQN
MESURES D'INTERVENTION
BAODQN
Sf
AVANTAGES
1.- Cesser la production de
bicyclettes.
1
. Solution d é f i n i t i v e
e t complète
2. Limiter mécaniquement la
capacité d'accélération
des véhicules moteur
lors de leur fabrication.
2
3
INCONVENIENTS
v
. Socialement inacceptable
. T r a n s f e r t de v i c t i m e s à
d ' a u t r e s c a t é g o r i e s de
' véhicules
En p l u s d ' ê t r e - l n a c c e p t a b l e e t i n a p p l i c a b l e , c e t t e s o l u t i o n , que c e r t a i n s sugg è r e n t pour les m o t o c y c l e t t e s , n ' a pas sa
raison d ' ê t r e puisque les c y c l i s t e s prés e n t e n t r e l a t i v e m e n t un bon b i l a n e n é g a r d
du nombre de b i c y c l e t t e s e n c i r c u l a t i o n .
. Réduction s u b s t a n - '
t l e l l e de la f r é q u e n c e e t da l a g r a v i t é des b l e s s u r e s
. R é s i s t a n c e de la p o p u l a tion à accepter cette
mesure
C r o s s & a l . ( 1 9 7 7 ) o n t c l a i r e m e n t é t a b l i lu
l i e n e n t r e la fréquence e t la g r a v i t é des
b l e s s u r e s p a r r a p p o r t à l a v i t e s s e du v é h i c u l e moteur.
Compte Lenu q u e l a m a j o r i t é d e s a c c i d e n t s d e b i c y c l e t t e AVM s e
p r o d u i s e n t à une I n t e r s e c t i o n , c e t t e mes u r e a u r a i t s û r e m e n t un impact p o s i t i f .
T o u t e f o i s , c e t t e mesure e n g e n d r e r a i t s û r e ment une r é s i s t a n c e au n i v e a u , d e l a p o p u t ion.
. A t t e i n t e d'une large
• p r o p o r t i o n de l a
population
. Impact d i f f i c i l e à é v a luer :
C r o s s & a l . ( 1 9 7 7 ) recommande l a d i f f u s i o n
d ' i n f o r m a t i o n comme une d e s t r o i s m e s u r e s
à privilégier.
U i m p o r t e c e p e n d a n t de
bien f o c o l l s e r la c i b l e à - a t t e i n d r o .
A i n s i , la d i f f u s i o n d ' i n f o r m a t i o n d e v r a i t
f a i r e l ' o b j e t d ' u n e programmation s p é c i fique.
»
3.
Modifier les comportements.
3 a . Information, (campagnes
publicitaires).
Ex:
. Code d e l a
routière
sécurité
REMARQUES
i
HADDON
MESURES D* INTERVENTION
SI
AVANTAGES
INCONVENIENTS
ï
. P a r t a g e île l a r o u t e
. Comportement s p é c i flque (circuler à
droite
lb.
education
En: . MEQ-RAAQ
. Test v é l o - c i t é
. " E f f e c t i v e Cycling*'
3c.
législation
Ex: . Code de l a
r o u t 1ère
Id.
sécurité
Application
Ex: . C o n t r ô l e p o l i c i e r
. PAS-vélo
REMARQUES
. Atteinte d'un large
é v e n t a i l de comportements
. E f f e t s à long' terme
.. Impact d i f f i c i l e à é v a luer
OCDE ( 1 9 7 9 ) c o n s i d è r e 1 ' é d u c a t i o n comme
une composante n é c e s s a i r e , m a i s nons u f f i s a n t e . On peut c o n s i d é r e r q u ' u n e
b a s e é d u c a t I v e f a c i l i t e r a 1 * i m p l a n t a i ion
de programmes s p é c i f i q u e s .
. Atteinte d'une large
p r o p o r t i o n de l a population
. Uniformisation des
convent i o n s
. Exigence de r e n f o r c e r
législations
Un Code de l a s é c u r i t é r o u t i è r e e s t . u n e
composante e s s e n t i e l l e au s y s t è m e r o u t i e r
et doit Inclure à part e n t i è r e les cyclistes.
T o u t e f o i s , la valeur . I n t r i n s è que d ' u n e l é g i s l a t i o n ne s e m a n i f e s t e r a
que d a n s la mesure où e l l e e s t r e n f o r c é e .
. Impact c o n c r e t s u r
p o p u l a t ion
la . E f f e t s à . c o u r t
terme
les
C r o s s & a 1 . ( 1977) recommande 1 1 Implant a t l o n de Programmes d ' A p p l i c a t i o n S é l u c t l v e ( P . A . S . ) qui p e r m e t t e n t de m a x i m i s e r
l ' i m p a c t de l ' I n t e r v e n t i o n p o l i c i è r e .
MESURES D' INTERVENTION
i
IIAODGN
Sf
AVANTAGES
INCONVENIENTS
REMARQUES
3
. Réduction du nombre
d ' a c c i d e n t s AVH
. Certains éléments risquent
d ' ê t r e peu p o p u l a i r e s
(vêtements)
. L i m i t é aux a c c i d e n t s AVM
l.a v i s i b i l i t é d e s c y c l i s t e s e s t a s s o c i e à
un g r a n d nombre d ' a c c i d e n t s AVH ( v o i r
S e c t i o n 1 . 2 ) . Ces mesures s o n t nomb r e u s e s , e f f i c a c e s e t peu c o û t e u s e s .
S, A M l l o r e r l a c o n l r â l a b l 1 l t é des b i c y c l e t t e s
(freins, direction,
etc.)
f
1
. Réduction d e s a c c i d e n t s de b i c y c l e t t e s
(AVM e t SVM)
. Potent i c i
!.e f a c t e u r ' ' v é h i c u l e " a une Importance l i m i t é e comme c a u s e d e s a c c i d e n t s chez l e s
cyclistes.
T o u t e f o i s , l e s mesures à app l i q u e r s o n t e f l i c a c e s e t peu c o û t e u s e s .
6 . Permettre aux c y c l i s t e s
d * u l l l l s e r l e transport
en coaaun dans c e r t a i n e s
situations portlcu1lères.
3
. Réduction d ' a c c i d e n t s . C o n t r a i n t e aux a u t r e s
u s a g e r s du t r a n s p o r t en
r e l i é s â d e s segments
commun
du r é s e a u r o u t i e r à
haut r i s q u e pour l e s . P o t e n t i e l 1 i m i t é
cyclistes
k. Améliorer la v i s i b i l i t é <
des c y c l i s t e s
Kx; . Feux r é f l e c t e u r s
. Vêlements r é f l é c h i s sants,
. Fan 1 o n s phospho rescents
. etc.
Umlrônl
- Rive «nul
limité
C e r t a i n e s s e c t i o n s du r é s e a u r o u t i e r sont
partIculiùrement risquées (parfois inter*
d i t e s ) pour l e s c y c l i s t e s .
C e t t e mesure
ne r é d u i r a i t qu 1 un p o u r c e n t age 1 irait é
d ' a c c i d e n t s , mais e l l e s ' a v è r e r e n t a b l e en
t>gard â l ' e f f o r t à c o n s e n t i r .
MESURES D*INTERVENTION
HADDON
Sf
REMARQUES
INCONVENIENTS
AVANTAGES
j
7. Eliminer les obstacles
visuels aux Intersections.
3
. D é d u c t i o n du nombre
d ' a c c i d e n t s AVH
. Coût
. Réduction des a c c i d e n t s de b i c y c l e t t e
SVM
. Potentiel
l.a g r a n d e m a j o r i t é d e s a c c i d e n t s AVM. s e
p r o d u i s e n t aux i n t e r s e c t i o n s .
L'amélior a t i o n de la v i s i b i l i t é c o n t r i b u e r a i t sûrement à l a r é d u c t i o n du nombre d ' a c c i dents..
I l a p p e r t t o u t e f o i s que la r e n t a b i l i t é de l ' i n t e r v e n t i o n dépendra de •
chaque c a s s p é c i f i q u e .
élevé
i
8. Emettre l'obligation que
les chiens soient toujours tenus en laisse.
3
limité
j
9.. Vérifier l'état mécanique des bicyclettes
(freins, pneus, etc.).
3
. Réduction des a c c i d e n t s de b i c y c l e t t e
(AVH et'SVM)
. Potentiel
limité
Selon F o r e s t e r (1977), les c h i e n s sont
r e s p o n s a b l e s d e IOZ d e s a c c i d e n t s d e b i c y c l e t t e SVM. Empêcher la l i b r e c i r c u l a t i o n des c h i e n s é l i m i n e r a i t complètement
ce type d ' a c c i d e n t s .
Le f a c t e u r " v é h i c u l e " a une i m p o r t . i n r e l i m i t é e comme c a u s e d e s a c c i d e n t s de b i c y clette.
A i n s i . 11 n e n o u s p a r a i t p a s p e r t i n e n t d ' i n s t a u r e r une v é r i f i c a t i o n a u t r e
que l o r s d e l ' é d u c a t i o n ( a u t o v é r i f i c a t i o n ) ou l o r s q u ' u n p o l i r I c i i n l r r CT'pl E un r y r l i s l i ' p o u r uni* I n l r . i r t l o o AU
C.S.H.
•I
HADDON
SI
AVANTACBS
INCONVENIENTS
limité
REMARQUES
10. P o u r v o i r l e s automob i l e s d ' u n m i r o i r du
côté d r o i t .
3
. Réduction îles a c c i d e n t s AVH
. Potentiel
C u l t e mesure r e l a t i veinent peu c o û t e u s e
p o u r r a i t r é d u i r e un c e r t a i n nombre
d ' a c c i d e n t s AVM aux i n t e r s e c t i o n s
(Ex: Type 24 C r o s s & a l . , 1977).
I I . P o r t e r un c a s q u e p r o tecteur.
4
. E f f i c a c i t é systémat ique
. R é d u c t i o n d e s bles^s u r e s s u i t e aux a c c i d e n t s AVM e t SVM
. Absence a c t u e l l e de normes
de f a b r i c a t i o n
. Coût
. Acceptabilité?
8ÛZ d e s c y c l i s t e s , qui d é c è d e n t , s u c combent s u i t e & d e s b l e s s u r e s à l a t è t e
(Baker & a l . , 1984; e t c ) . r
Compte t e n u de 1 ' e f f I c a c i t é de c e t t e mes u r e pour l e s m o t o c y c l i s t e s , on p e u t p r a tiquement a f f i r m e r q u ' i l s ' a g i t d e l a
mesure l a p l u s e f f i c a c e .
12.' P o r t e r d e s v ê t e m e n t s
protecteurs (gants,
genouillères, etc.)
4
. E f f i c a c i t é systémat Ique
. Réduction des bless u r e s s u i t e aux acc i d e n t s AVH.et SVH
. P o t e n t i e l l i m i t é aux b l e s sures mineures
. R é s i s t a n c e de l a p o p u l a t i o n à a c c e p t e r c e t t e mesure
P l u s . d e 75Z d e s b l e s s u r e s d e s c y c l i s t e s s e
s i L u e n t s u r l a s u r f a c e du c o r p s ,
l.e p o r t
de v ê t e m e n t s p r o t e c t e u r s r é d u i r a i t s u b s t a n t i e l l e m e n t ce t y p e . d e b l e s s u r e s (Cross
A a l . , 1977). Compte t e n u q u ' i l s ' a g i t
«le b l e s s u r e s m i n e u r e s e t l ' a c c e p t a b i l i t é
d o u t e u s e de c e t L e m e s u r e , l ' i n f o r m a t i o n
nous p a r a î t s u f f i s a n t e .
MESURES 0'INTERVENTION
HADDON
SI
AVANTAGES
INCONVENIENTS
13. Pourvoir les bicyclettes d'écarteurs de
danger (fanion latéral I
5
. Bon p o t e n t i e l
cacité
d ' e f f i - . Portée
14. Identifier des trajets
routiers sécuritaires
pour les cyclistes.
5
. Réduction des
d e n t s AVM
acci-
IS. Installer des feus de
circulation pour cyclistes. (feu jaune de
longue durée)
5
. Réduction des
d e n t s AVM aux
sections.
acciinter-
.
spécifique
Diffusion
Acceptabilité
. Coût
REMARQUES
Cross & a l . (1977) ont i d e n t i f i é l e t y p e
13 comme l a s o u r c e l a p l u s f r é q u e n t e d e
décès parni tous les types d ' a c c i d e n t s .
C e t t e mesure, quoique s p é c i f i q u e , se p r é s e n t e comme une d e s p l u s e f f i c a c e s .
C e t t e mesure c o n s i s t e à e n c o u r a g e r l e s
c y c l i s t e s . à u t i l i s e r l e s r o u l e s qui
s ' a v è r e n t l e s p l u s s é c u r i t a i r e s pour eux.
C e l a p e u t f a i r e l ' o b j e t d é programmes s p é c i f i q u e s de " c o r r i d o r s d e s é c u r i t é " p o u r
l e s e n f a n t s du p r i m a i r e . I.e p o t e n t i e l
d ' e f f i c a c i t é demeure d i f f i c i l e m e n t é v a luable.
C e t t e mesure c o n s i s L e à p r é v e n i r l e cyc l i s t e p l u s longuement a l ' a v a n c e du c h a n gement au f e u r o u g e . C e t t e m e s u r e p o u r r a i t
s ' a v é r e r p e r t i n e n t e pour l e s i n t e r s e c t i o n s
de r o u t e s à p l u s i e u r s v o i e s qui sont p l u s
longues à t r a v e r s e r .
)
I
MESURES DB INTERVENTION
HADDON
SI
INCONVENIENTS
AVANTACKS
16. I n s t a l l e r -des d o s d ' â n e
k la s o r t i e des e n t r é e s
*pr1vées
5
. Coût
. Réduction des a c c i d e n t s AVH â la s o r t i e . A c c e p t a b i l i t é
des e n t r é e s p r i v é e s
17. I n s t a l l e r d e s d o s d ' â n e
aux I n t e r s e c t i o n s
"stop"
5
. Réduction
d e n t s AVH
sect ions
. Réduction
t e s s e des
moteur
18. Aménager l e s I n t e r s e c t i o n s en c o n s i d é r a n t
la présence des cyclistes.
S
des a c c i aux i n t e r -
C r o s s h a l . ( 1 9 7 7 ) ont i d e n t i f i é que c e
type d ' a c c i d e n t (No.l) é t a i t responsable
de 62 d e s a c c i d e n t s AVH. Les dos d ' â n e
( " s p e e d biunps") s o n t s û r e m e n t - e f f I c a c e s ,
on p e u t t o u t e f o i s d o u t e r d e ' 1 ' a c c ë p t a b i l i t é e t de l a v o l o n t é de l a p o p u l a t i o n à
Implanter c e t t e mesure.'
. Coût
. Acceptabilité
La g r a n d e m a j o r i t é d è s a c c i d e n t s AVM s e
p r o d u i s e n t aux I n t e r s e c t i o n s .
Malgré
l ' e f f i c a c i t é de c e t t e m e s u r e . I l e x i s t e
d e s c o n t r a i n t e s au n i v e a u du coût e t d e
l'acceptabilité.
. Coût
Les normes a c t u e l l e s de c o n c e p t i o n d e s i n t e r s e c t i o n s t i e n n e n t r a r e m e n t compte d e
la c i r c u l a t i o n c y c l i s t e .
C e t t e mesure
p e u t s ' a v é r e r peu c o û t e u s e l o r s d e l a
construction i n i t i a l e d'une i n t e r s e c t i o n .
Le réaménagement d e s i n t e r s e c t i o n s e n
f o n c t i o n d e s c y c l i s t e s d e v r a i t s e f a i r e à*
p a r t I r de l ' é t u d e de chaque c a s i n d é p e n damment.
de la v i véhicules
. Réduction d e s a c c i d e n t s AVH aux i n t e r sections .
REMARQUES
19. C r é e r d e s g r i l l e s h o r a i r e s pour l e s d i v e r s e s c a t é g o r i e s de
véhicules.
HADDON
SI
5
INCONVENIENTS
AVANTAGES
. Réduction d e s a c c i d e n t s AVH
REMARQUES
. L i m i t a t i o n de l a l i b e r t é
d e c i r c u l a t i o n de c e r taines catégories d'usag e r s de l a r o u t e
C e t t e mesure p o u r r a i t c o n t r i b u e r à r é d u i r e
l e s c o n f l i t s e n t r e c e r t a i n e s c a t é g o r i e s de
véhicules.
p o t e n t i e l d e c e t t e mesure
est difficilement évaluable.
E n f i n , on
d o i t p r é v o i r une c e r t a i n e r é s i s t a n c e d e la
p a r t d e s u s a g e r s de l a r o u t e c o n c e r n é s .
. L i m i t a t i o n de l a l i b e r t é
de c i r c u l a t i o n d e cer-:
talnes catégories d'usag e r s de l a r o u t e
C e t t e m e s u r e , q u i e s t d é j à en v i g u e u r à
m a i n t s e n d r o i t s , p e u t ê t r e de 2 o r d r e s ;
I n t e r d i r e les c y c l i s t e s sur les voles rapides et i n t e r d i r e la c i r c u l a t i o n lourde
dans les q u a r t i e r s r é s i d e n t i e l s .
Son pot e n t i e l e s t également d i f f i c i l e a é v a l u e r
e t on d o i t p r é v o i r une c e r t a i n e r é s i s t a n c e
à c e t t e mesure.
. Coût
C e t t e mesure p r é s e n t e un bon p o t e n t i e l
d ' e f f i c a c i t é e t c e , p a r t i c u l i è r e m e n t en
m i l i e u r u r a l (Zegeer & a l . , 1981).
Le
coût c o n s t i t u e une l i m i t e s é r i e u s e à l ' i m p l a n t a t i o n de c e t t e mesure.
I l e s t à cons i d é r e r t o u t e f o i s que c e t t e mesure e s t r e l a t i v e m e n t peu c o û t e u s e l o r s de la c o n s t r u c t i o n d ' u n e n o u v e l l e r o u t e ou d ' u n r é a ménagement .
i
20. L i m i t e r l ' a c c è s à
certaines routes.
. Réduction d e s a c c i d e n t s AVH
5
\
21. Pourvoir l e s
d'accotements
»
routes
solides.
5
Réduction des a c c i d e n t s AVH e t SVM
MESURES. D'INTERVENTION
22. C o n s t r u i r e des p i s t e s
cyclables.
23. Améliorer l a c o n c e p t i o n
des automobiles pour
réduire les blessures
aux c y c l i s t e s .
HADDON
SI
6
AVANTAGES
INCONVENIENTS
REMARQUES
. Réduction substant i e l l e des a c c i d e n t s
AVM
. Coût
P l u s i e u r s o r g a n i s m e s (CENT, 1981; OCDE.
1978; e t c . ) c o n s i d è r e n t l e s p i s t e s c y c l a b l e s cornue l e m e i l l e u r moyen de r é d u i r e
l e s a c c i d e n t s AVM. Le s e u l o b s t a c l e à
c e t t e mesure e s t m a j e u r » 11 s ' a g i t du
coût.
7
. Réduction d e s b l e s s u r e s s u i t e aux a c c i d e n t s AVM
. Coût
C e t t e mesure p r é s e n t e un c e r t a i n p o t e n tiel.
I l a p p e r t t o u t e f o i s que c e t y p e dc
. m e s u r e e s t r e l a t i v e m e n t peu d é v e l o p p é .
Le
c o û t p e u t é g a l e m e n t s e p r é s e n t e r comme un
élément l i m i t a t i f .
7
. Potent f '
. Réduction dos b l e s s u r e s s u i t e nux «r«:ldont a AVM et SVM
Ex: . E l i m i n a t i o n d e s obj e t s contondants sur
le capot
. P o u r v o i r le devant
des automobiles de
m a t é r i e l mou a b s o r bant d ' é n e r g i e
ccouvrlr de m a t é r i e l
ou l e s p a r t i e s c o n ondanlcts d e 1s b l c y -
"mité
La s t r u c t u r e de la b i c y c l e t t e «»si une
s o u r c e llmllêi* ili» i||onaum*n .aux r y r l l s i r * .
T o i i l ( « f o h , In RM'Nwre à d é p l o y e r i»ni r i ' l a v«'RW»nf
cmïi «Mise »»t ef f I c a r e .
1
MESURES D' INTERVENTION
HADDON
SI
AVANTAGES
INCONVENIENTS
25. E n l e v e r l e s o b j e t s d a n g e r e u x en b o r d u r e d e s
routes.
7
. R é d u c t i o n dus b l e s s u r e s aux a c c i d e n t s
AVH e t SVH
. Potentiel
. Coût
26. Eliminer les pièges è
cyclistes.
7
. Réduction des a c c i d e n t s SVH
. Coût
8
. Réduct ion d e s b l e s . P o t e n t i e l davantage- t h é o s u r e s s u i t e aux a c c i r i q u e que p r a t i q u e
d e n t s AVH e t SVH
Ex: .
.
.
.
.
limité
Puisards
Voies f e r r é e s
J o i n t s d'expansion
P o n t s de m é t a l
Etc.
27. A m é l i o r e r l a c a p a c i t é
d ' a b s o r p t I o n des
bicyclettes.
REMARQUES
Dans l a p l u p a r t d e s a c c i d e n t s , l e c y c l i s t e
s e b l e s s e l u r s du c o n t a c t avec' l a c h a u s s é e
( C r o s s & a l . . F o r e s t e r , 1977).
Compte
t e n u du coût é l e v é e t du f a i b l e nombre de
b l e s s u r e s aux c y c l i s t e s en r a i s o n d e s obj e t s dangereux en b o r d u r e d e s r o u t e s ,
l ' e n l è v e m e n t de c e s o b j e t s ne semble p a s
J u s t i f i e r pour l a s é c u r i t é d e s c y c l i s t e s
en t e r m e s de r a p p o r t b é n é f i c e / c o û t .
Un g r a n d nombre d e s a c c i d e n t s SVH s o n t
a s s o c i é s à l a s t r u c t u r e du r é s e a u r o u tier.
Certaines modifications (ex: puis a r d s ) s o n t peu c o û t e u s e s e t e f f i c a c e s .
La r é a l i s a t i o n de c e s m o d i f i c a t i o n s r e l è v e
de l ' é t u d e de chaque c a s s p é c i f i q u e .
L ' é t u d e des c o l l i s i o n s " v é l o - a u t o " r é v è l e
que l a b i c y c l e t t e n ' a b s o r b e p r a t i q u e m e n t
aucune é n e r g i e ' d e l ' I m p a c t (OCDE, 1978).
Le dévoloppèment de c e t t e mesure semblé
a i n s i l i m i t é compte t e n u d e s p o s s i b i l i t é s
techniques.
28. Améliorer l e s
post-impact.
BADDON
SI
services
9
Ex: . A m é l i o r e r l a r a p i d i t é
et la q u a l i t é des
services d'urgence
. I n s t a l l e r des t é l é phones d ' u r g e n c e
. Créer des c e n t r e s de
traumatologie régionaux
29. Améliorer l e t r a i t e m e n t
e t la r é a d a p t a t i o n
des traumatisés.
10
Ex: . S ' a s s u r e r de l a q u a l i t é des soins o f ferts
. Prévoir la r é i n s e r t i o n s o c i a l e des,,
traumatisés
)
AVANTAGES
. Réduction
de d é c è s
. Réduction
pleur des
quences à
du nombre
INCONVENIENTS
REMARQUES
. Coût
C e l l e mesure s ' a p p l i q u e à l ' e n s e m b l e d e s
v i c t i m e s de l'a r o u t e .
Compte t e n u de >son
c o û t » son a p p l i c a t i o n n ' e s t J u s t i f i a b l e
qu'en considérant l'ensemble des v i c t i m e s
de l a r o u t e .
. R é d u c t i o n du c o û t s o - . Coût
c i a l des accidents
.-.Amélioration-dé la
q u a l i t é de v i e d e s
individus
Cette mesure-s'applique à l'ensemble des
v i c t i m e s de la r o u t e .
Compte t e n u de son
c o û t , son a p p l i c a t i o n n ' e s t ' j u s t i f i a b l e
q u ' e n c o n s i d é r a n t l'ensemble des v i c t i m e s
de l a r o u t e .
de l ' a m consélong terme
)
CONCLUSION
y
\
/
X.
Malgré la carence de recherches évaluatives,. l'étude de la problématique des
accidents et des traumatismes reliés aux accidents de -bicyclette nous fournit
suffisamment d'information pour accroître l'efficacité de nos interventions en
cette matière.
L'incidence grandissante dés. accidents de bicyclette (telle que décrite au
chapitre 1) nous amène à suggérer l'implantation de mesures d'intervention,
selon les divers champs de compétence respectif, si on veut contrer l'expansion
du-nombre,de victimes cyclistes.
,
•
Les mesures d'interventions recensées ne prétendent en rien être définitives,
le développement et la recherche devraient permettre d* identifier d'autres
mesures efficaces. Il appert; toutefois, en fonction des données actuelles, que
plusieurs deces mesures d':intervention semblent constituer des éléments
importants pour accroître la sécurité des cyclistes.
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\/ SHINAR, D. (1978). Psychology on the Road: The Human Factor in Traffic Safety. Wiley & sons. New-York, N.Y.
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v
r
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1
and Human Services. Atlanta, Ca.
TRANSPORTS CANADA (1976)'. La collision humaine. Ministère des approvisionnements et services. . Réf. no. T46-131, 1976 F. Ottawa, Ontario.
/WATTS
GR
(1979).* Bicvcle Safety devices: Effects on vehicle passing distances. Transport and Road Research Laboratory. TRRL Supplementary
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/ZEGEER, C.V. & al. (1981). .Effect of lane and shoulder widths on accident
reduction on rural" two-lane roads. Transportation Research Board. TRRJi
806, p. 33-43.
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IHJIII.IC U E A I / l ' l l S U R V E I L L A N C E IN T H E U N I T E D S T A T E S
. H T K I ' I I K N IV T H A C K K U ' ALM
In 1963, Alexander D. Langmuir defined
disease surveillance as "the continued
watchfulness over the distribution and
trends of incidence through the systematic
collection, consolidation and evaluation of
morbidity and mortality reports and other
relevant data" and the regular dissemination of data to "all who need to know" (1,
pp. 182-183). Langmuir was careful to distinguish surveillance both from direct responsibility for control activities and-fro m
epidemiologic research, although he recognized thé important interplay among epidemiologic studies, surveillance, and control activities. In 1968, the 21st World
. Health Assembly held technical discussions
on the National and Global Surveillance of
Communicable Disease and identified these
main features of surveillance: 1) the systematic collection of pertinent data; 2) the
orderly consolidation and evaluation of
these data; and 3) the prompt dissemination of the results to those who need to
know, particularly those who are in a position to take action (2).
Subsequently, the applications of-surveillance concepts have broadened to include a wider range of health data—risk
factors, disability, and health practices—as
well as disease. This is reflected in the 1986
Centers for Disease Control (CDC) definition of epidemiologic surveillance:
A b b r e v i a t i o n * A I D S , acquired Immunodeficiency
syndrome; C D C , Centers for Disease Control; N C H 8 .
N a t i o n a l C e n t e r for H e a l t h Statistics; N I O S H , N a tional I n s t i t u t e for Occupational Safety a n d Health;
W H O . W o r l d H e a l t h Organization.
1
C e n t e t for E n v i r o n m e n t a l H e a l t h s a d Injury Control, Centers for Disease C o n t r o l . A t l a n t a , G A 30333.
( R e p r i n t requests t o D r . Stepheo B. T h a c k e r . l
1
Epidemiology P r o g r a m Office, Centers for Disease
Control. Atlanta, G A .
T h e authors t h a n k Dre. P h i l i p S. Brachmao, M i chael B. Gregg, Alexander D . U n g r o u i r , a n d R. Gibson
Porrish for their contributions t o the manuscript.
H U T U I..
I1KHKRI.MAN'
Epidemiologic surveillance is t h e ongoing systematic collection, analysis, a n d i n u r p r e t a t k m
of health data essential to the planning, implementation, and evaluation of public health practice. closely inlegraled w i t h the timely dissemination o f these data to those who need to know.
T h e final link in the surveillance chain is the
application of these data t o prevention a n d control. A surveillance system includes a functional
coparily for data collection, analysis, a n d dis« m i n â t i o n linked to public health program» 13.
p. ii).
A critical word in this definition is "ongoing"; one-time surveys or sporadic studies do not constitute surveillance. An on-_
going system of data collection and collation is also not sufficient to constitute
public health surveillance, because to he
useful lite data must he integrated into the
conduct and evaluation of specific public
health programs, which may include epidemiologic research leading to prevention.
The purpose of this review ia to describe
the historical and current practice of public
health surveillance, to discuss new directions for surveillance both in terms of new
public health priorities and new methodological tools, and to assess the limitations
of surveillance.
"N '
HISTORICAL
OVERVIEW
Current concepts of public health surveillance have evolved from public health
activities developed to control and prevent
disease in the community. In the late Middle Ages, governments in Western Europe
assumed responsibility for both health protection and health care of t he population of
their towns and cities (4). A rudimentary
system of monitoring illness led to regulations against polluting streets and public
water, instructions for burial and food
handling, and the provision of some types
of care. In the 17th century, John Graunt
used the Bills of Mortality to monitor dis-
ease in London (5). In 1766, Johann Peter
Frank advocated a more comprehensive
form of public health surveillance with hia
system of police medicine in Germany,
which covered school health, injury prevention, maternal and child health, and public
water and sewage (4). In addition, the governmental measures to protect the public
health were delineated (4).
William Parr (1807-1883) is recognized
as the founder of the modern concepts of
surveillance (6). As Superintendent of the
Statistical Department of the Registrar
General's Office of England and Wales
from 1839 to 1879, Fair concentrated his
efforts on collecting vital statistics, on assembling and evaluating those data, and on
reporting them to both responsible health
authorities and to the general public.
In the United States, public health surveillance has focused primarily on infec-.
tious diseases. Basic elements of surveillance.were found in Rhode.Island in 1741
when the colony passed an act requiring
tavern keepers to report contagious disease
among their patrons. Two years later, the
colony passed a law requiring reporting of
smallpox, yellow fever, and cholera (7).
National disease monitoring activities
did nut begin until 1850 when mortality
statistics based on the decennial census of
that year were first published by the federal
government for the entire United States
(8). In 1878, Congress authorized the forerunner of the Public Health Service (PHS)
to collect morbidity reports for use with
quarantine measures against pestilential
diseases such as cholera, smallpox, plague,
and yellow fever (9). In 1893, an act provided for the collection of information each
week from state and municipal authorities
throughout the United States. By 1901, all
state and municipal laws required notification (i.e., reporting) of selected communicable disease to local authorities such as
smallpox, tuberculosis, and cholera ( 10). Id
1914, PHS personnel were appointed as
collaborating epidemiologists to serve in
state health departments to telegraph reports weekly to the Public Health Service.
165
It was not until 1925, however, following
markedly increased reporting associated
with the severe poliomyelitis epidemic in
1916 and the influenza pandemic of 19181919, that all states were participating in
national morbidity reporting (11). After a
1948 PHS study led to the revision of morbidity reporting procedures, the National
Office of Vital Statistics assumed the responsibility for morbidity reporting. In
1949, weekly morbidity statistics that had
appeared for several years in Public Health
Reports were published by the National
Office of Vital Statistics. In 1952, mortality
data were added to what is now known as
the Morbidity and Mortality Weekly Report
Since 1961, this publication has been the
responsibility of CDC.
.The Malaria Eradication Program was
undertaken by CDC and state health de»
partments in 1946 to address endemic malaria in the United States at a time when
World War II veterans were returning from
Africa and from the Mediterranean and
Pacific theaters and introducing Plasmodium uiuax to the population (1). Spraying
of dichlorodiphenyltrichloroethane (DDT)
had begun before surveillance was initiated.
By 1947, it was clear that earlier reports of
morbidity and mortality had been erroneous. Mississippi, South Carolina, and
Teias had the highest reported incidences
of malaria, but because there was no diagnostic verification, the reported occurrence
was exaggerated. A change in reporting requirements that included case reports with
diagnostic verification was illuminating. In
Mississippi, for example, the reported incidence of provisional cases dropped from
17,764 to 914 in the Tiret year, only a very
few of which could be confirmed. Such new
criteria revealed that malaria had disappeared as an endemic disease from the
South. The malaria experience was a major
factor emphasizing the necessity of » more
current and comprehensive system of surveillance.
The critical demonstration in the United
States of the importance of surveillance
was made following the Francis Field Trial
US PUBLIC H E A L T H
166
SURVEII.l.ANi:E
167
THACKER ANI) BRU K Kl .M A N
ment measures that included isolating patients at home and rapidly vaccinating perdons in surrounding houses. Key population
contacts for surveillance included not only
government officials and religious leoders
hut also school children, lea shop owners,
people in markets, nomads, ond refugees.
The Conference (now Council) of State
and Territorial Epidemiologists was authorized in 1951 by its parent body. The
Associotion of State and Territorial Health
Officials, to determine what diseases should
be reported by states to the Public Health
Service and to develop reporting procedures. The Council currently meets annually and, in collaboration with CDC. recommends to its constituent members appropriate changes in morbidity reporting
and surveillance, including what diseases
should be reported to CDC and published
in the Morbidity and Mortality Weekly Repart.
Until 1950. the term surveillancé was
restricted in public health practice to
watching contacts of serious communicable
diseases, such as smallpox, to detect early
symptoms so that prompt isolation could
lie instituted (16). Langmuir has been credited with broadening the application of surveillance to populations (I), and in 1968,
Surveillance was critical to the containthe 21st World Health Assembly focused
ment strategy for global eradication of
on national and global surveillance of comsmallpox, and the success of the program
municable diseases, applying the term to
demonstrated to the international commudiseases rather than to the monitoring of
nity the practical value of surveillance (14).
individuals with selected communicable
To facilitate early outbreak detection, surdiseases (2). Over the intervening years, a
veillance teams actively investigated rewide variety of health events, such as childported cases, sought nearby cases, and inihood leod poisoning, leukemia, congenital
tiated rapid containment measures. Surmalformations, abortions, injuries, and beveillance was intensified in areas in which
hovioral risk factors have been brought uncases were confirmed. When outbreaks deder surveillance. In 1976, recognition of the
creased, these teams continued to search
breadth of surveillance activities throughhigh-risk areas for case9 until independent
out the world was made evident by a special
assessment confirmed that transmission
issue of the International Journal of Epihad been interrupted. Routine reporting of
demiology devoted to papers specially comcases and the work of the surveillance
missioned to examine health surveillance
teams were further supplemented in some
settings by one-week, village-level, inten<16>. , .
sive case identification. These surveillance
In 1986, CDC, in collaboration with the
activities were clearly linked to containCouncil of State and Territorial Epide-
of poliomyelitis voccine in 1956 (12, 13).
Within two weeks of the announcement of
the results of the Field Trinl nnd initiation
of a nationwide vaccinal iorf program, sii
canes of paralytic |*>liomyelitis were reported through the notifiable disease reporting system to state and local health
departments; case investigations revealed
that these children had received vaccine
produced by a single manufacturer. The
Surgeon General requested the manufacturer to recall all outstanding lots of vaccine and directed that a national poliomyelitis surveillance program be established
at CDC. Intensive surveillance and appropriate epidemiologic.investigations by federal, state, and local health departments
found 141 vaccine-associated cases of paralytic disease, 80 of which were found in
family contacts. Daily surveillance reports
were distributed by CDC to all persons
involved in these investigations. This national common-source epidemic was ultimately related to a particular brand of vaccine that had been contaminated with live
virus. Had the surveillance program not
been in eiistence, many and perhaps all
vaccine manufacturers would have ceased
production.
broadened applications. The use of the
miologists. published its first Comprehenterm epidemiologic, however, also engensive Plan for Epidemiologic Surveillance
dered both confusion and controversy. In
(3). In this document, CDC explicitly delin1971, Langmuir noted that some epideeated its policies and goals in surveillance,
specified plans to establish and evaluate miologists tend to equate surveillance with
surveillance systems, and described rele- epidemiology in its broadest sense, including epidemiologic investigations and revant activities in research and training.
search (16, p. 12). He found this "both
Since the term surveillance was first apetymologically unsound and administraplied to a disease rather than to an individtively unwise," favoring a definition of surual in 1950, it has assumed major significance in disease control and prevention. Its veillance as "epidemiological intelligence."
Surveillance activities," however, bave
' specific connotations, however, have not
been universally understood. In 1963, frequently led to epidemiologic investigaLangmuir clearly limited surveillance to tions of etiology. After the initiation of the
the collection, analysis, and dissemination National Influenza Immunization Program
of data (1). The term did not encompass in October 1976, cases of Guillain-Barre
di.ect responsibility for control activities. syndrome were reported to CDC through a
In 1965. the Director General of the World nationwide surveillance system established
Health Organization (WHO) established to monitor illnesses occurring after influan Epidemiological Surveillance Unit in enza vaccination (19). Subsequent epidethe Division of Communicable Diseases at miologic studies demonstrated a relation of
WHO (17). The Division Director, Karel Guillain-Barré syndrome to the swine inRaska, defined surveillance much mow fluenza vaccine that was in use, which rebroadly than Longmuir and included in it sulted in the cessation of the vaccination
-the epidemiological study of disease as a program for the year (20). To test whether
dynamic process." In the case of malaria, the syndrome could result from use of other
he saw epidemiologic surveillance as en- influenza vaccines, a special surveillonce
compassing control and prevention activi- system was established in 1978 which used
ties. Indeed, the WHO definition of malaria 1,813 neurologists as reporters (21). The
surveillance included'not only case detec- data collected for that and several subsetion but olso taking of blood films, drug quent years showed no association between
treotment, epidemiologic investigation, and influenza vaccines and Guillain-Barré synfollow-up (18).
drome.
The 1968 World Health Assembly discussions reflected the broadened concept of
epidemiologic surveillance and addressed
the application of the concept to public
health problems other than communicable
diseases (2). ln addition, epidemiologic surveillance was said to imply "the responsibility of following up to see that effective
action has been taken" (2, p. 9).
The use of epidemiologic to describe surveillance first appeared in the mid-1960s
and was associated with the establishment
of the WHO unit of that name. This was
done both to distinguish this activity from
other forms of surveillance, such as for
militory intelligence, and to reflect its
In addition, public health surveillance
systems are often the source of cases for
case-control studies. For example, in response to concerns expressed, by Vietnam
veterans about the possibility of increased
risk for fathering children born with birth
defects, CDC conducted a case-control
study using as cases with serious structural
birth defects infants identified by the Metropolitan Atlanta Congenital Defects Program (22). This surveillance system attempted to ascertain all infants with defects diagnosed during the first year of life
.born to mothers who resided in the Atlanta
area. Cases and controls were selected from
infants born alive in the Atlanta area dur-
jgg
SURVEII.l.ANi:E
169
THACKRH AND HKHKKIAIAN
m e a n i n g of surveillance in the puhlic health
setting, having led in the past to the inappropriate incorporation of research into the
definition of surveillance ( 18). For this reason, in this paper, we will not adhere to the
current practice of using ihe term epidemiologic to modify surveillance. We propose that a more appropriate term is public
health surveillance, because its use retains
the original benefits of the term epidemiologic cited previously and removes some of
the confusion surrounding current practice.
Surveillance is more correctly an element
of public health, and persons encountering
the term should understand this.
ing Ihe years I96H through 198U. This Htudy
found lhat Vietnam veterans did not have
Dn inrmined rink of fathering children with
defects. Other examples of epidemiologic
research facilitated by case ascertninment
through surveillance include Ihe demonstration of the association of tampon use
with the development of toxic shock syndrome (23), the relation between salicylate
use and Reye's syndrome (24), the risk of.
breast cancer associated with long-term
oral contraceptive use (25),.and quantification of the risk of acquired immunodeficiency syndrome (AIDS) from certain sexual practices (26).
We believe that there are two issues to
be addressed in this discussion. First, what
are the boundaries of surveillance practice?
Second, is epidemiologic an appropriate
modifier of surveillance as it is used in
' public health practice? To address these
questions, we must firet examine the structure of public health practice. One can divide public health octivities into surveillance, epidemiologic and laboratory research,
service
(including
program
evaluation), and training. Surveillance data
should be used to identify areas needing
research and service which, in turn, help to
- define training needs. Unless data are provided to those who set policy and implement programs, their use is limited to archives and academic pureuits and are appropriately considered to be health
information rather than surveillance data.
Surveillance, however, does not encompass
research or service. These are related hut
independent public health activities and
may be based on surveillance. Hence, the
boundary of surveillance practice is drawn
before the actual conduct of research and
the implementation of delivery programs.
Data collection
Surveillance data ore collected from multiple sources. Physicians, laboratories, and
. other health care providers are required to
report all cases of those diseases or health
conditions specified by state law to be notifiable (or reportable); most of these conditions are of infectious origin. Typically, a
case report form is completed for each case
by the health care provider or laboratory
and mailed to the local or slate health
department. In some states, the authority
to change the list of notifiable diseases is
granted to the stale health authorities; in
other states, each change inust be newly
legislated. Penalties for failure to report a
notifiable condition moy include suspension of a physician's license (27), but in
practice such penalties are rarely enforced.
Physician reporting is influenced by.disease
severity, availability of puhlic health measures, public concern, eose of reporting, and
physician appreciation of public health
practice in the community. ,
Given this context, the use of the term
epidemiologic to modify surveillance is misleading. Epidemiology is a broad discipline
that incorporates research and training
that is distinct from a public health process
that we call surveillance (table 1). Because
of the much broader content of epidemiology, the use of epidemiologic confuses the
À disease traditionally is notifiable only
when there is a clear link between a case
report and a public heailh action. For many
of these diseases, case investigations are
performed by the state or local health department. Individual names and other personal identifiers are often required for purposes of contact identification or treat-
SURVEILLANCE PRACTICE
TABLS-1
Distinctions between public health surveillnnce and epidemiologic research
Public health i n c l i n e »
l l / i w u ) feu i nil inline
m l |<¥ti»n
PrtJilcm detection
I ' n i l i l t n i deacriptiuu
bfenllfy e v e * for epidemiologic studies
May be tof ally required
Monitor geographic aad temporal trend*
In d i w w o t u r n n N
freipiency ••( date r » l k r -
Ongoing
Method «.! data o>llm»>n
EMaMiahed *y»tems «
I liuially lime-limit r d
pmerAi»*
Many p e n o n * involved
Traditionally depervds on voluntary par-
Usually lAinimel
CUMDplelcima of data <
1er l t d
Oit en incomplete
Anal>*i« ••! dut a
Traditionally simple
Primarily to detect change ia incidence
Usually rumple te
I 'UMII* historical nunparioon groupa
Timely
Regular
Review in puldic heailh agency
Targeted tu public health and clinical au-
Identifie* a problem
T rigger* i n tarvenl « n Ruggrsla hypotheses
Commonly tued l o evaluate program*
KMiinaie* magnit tide o f a problem
ment. In addition, collecting names aids in
identifying duplicate reports. Because of
the need to identify individuals, however,
concerns about confidentiality affect notifiable disease reporting, and individual
identifiers are not usually collected at the
national level. These concerns have been
heightened by the epidemic of AIDS (28).
The Council of Stale and Territorial Epidemiologists determines which notifiable
diseases should be reported from the state
health department to CDC. In addition, the
quarantinable diseases—yellow fever, cholera, ond plague—are reportable by international regulation. To obtain information
(case reports) on specific topics such as
birth defects, influenza, low birth weight,
and nosocomial infections, CDC has collaborated with state and local health depart-
Special procedures tailored I» hypotheses or
question* of interest
Fewer per*«i» involved
Depend* on paid, superviwd employee*
Can I * ciwuiidrralilr and uaually detailed
Amount « i data collected
per r i M
|iiK*rmiiiMli"n u l data
l l y p m l i M n testing
l ' H i l e m de*cription
(ten he complet
Itypotheais testing «AMI m | u i r r * u a i b l i c a l
meihoda
('.onrurreni control*
.
Nut timely
Sporadic
E i t e r n a l review
Targeted to academic a» well as puhlic heailh
and clinical audience
I f c t t r i h a i a problem in drtail
Provide* dialogic infer mutton
T n J i hypKhene*.suggest* additional hypothec*
Lea* often used to evaluate programs
ments to establish specialized disease reporting systems. Other federal agencies are
involved in the collection of surveillance
data; for example, the Food and Drug Administration (FDA) conducts postmarketing surveillance of adverse reactions to
drugs (29), and the Consumer Product
Safety Commission conducts surveillance
of product-related injuries (30).
For many health events, national surveillance systems rely on data collection
efforts by the National Center for Health
Statistics (NCHS) of CDC, including the
National Health Interview Survey (31), the
National Hospital Discharge Survey (32),
and the National 1 lealt h and Nutrition Examination Survey (33) (table 2). Although
such surveys do not constitute public health
surveillance systems, data obtained in these
U S P U B L I C H E A L T H SUIIVKH.I.ANOB
THACKKH AND HKHKRI.MAN
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171
surveys can be used as part of surveillance
systems that are more clearly linked to
public health practice (table 3). Similarly,
hospital abstracting services, such as the
Commission of Professional and Hospital
Activities (34),-provide information on
more than 50 per cent of all acute-care
civilian hospitul discharges in the United
States. In oddilion, more than half of the
states have enacted legislation placing hospital discharge or claims data into the public domain (35). Again, such data collection
activities do not constitute surveillance systems, but may provide useful dala for surveilla nee.
There are relatively few national data
sets in the area of ambulatory care, and
these are used only rarely for surveillance
purposes (36-38). National dota on diagnosis and drug therapy from office-based
practices are available from the National
Ambulatory Medicol Care Survey of NCHS
(36) and the commercially available National Disease and Therapeutic Indei (37).
National influenza surveillance efforts
have been complemented by a convenience
sample of family practitioners that provides
CDC with demographic data and culture
specimens for all cases of influenza-like,
illness seen in their offices during influenza
season (38). Emergency room <iata are
found in the National Electronic Injury
Surveillance System maintained by the
Consulter Product Safety Commission (39)
and the Drug Abuse Warning Network supported by the National Institute on Drug
Abuse (40).
Registries are also useful sources of information (41). Unlike national surveys
conducted by NCHS. registries are designed to collect-information on a specific
topic and are usually limited in scope, t i k e
the NCHS surveys, registries are not surveillance systems, but data from registries
can be used for public, health surveillance.
CDC's Metropolitan Atlanta Congenital
Defects Program is an example of a registry
that has been developed into a system of
' public health surveillance (42). The best
US I H t H U C H E A L T H
172
THAPKfiR
ANn
SlIKVEll.LANl.K
173
ItKKKM.MAN
known and most widely used registries are
those for cancer. There are populationhosed cancer registries in 38 states; 11 of
there un* purl »{. the National Cancer Inslilute'R Surveillance, Epidemiology, and
End Remit!* Program (43).
to those who implement or influence public
health practice. Public health surveillance
data can be used to inform policymakers
and the public alwut the nature and extent
of health problems and to persuode these
audiences to address particular issues. In
this way, a health agency can develop a
Data collation and analysis
constituency to support public health prol a n on infectious diseases are collated grams and to justify the expenditure of
and unalyzed in local and stale health de- public funds.
pertinent* as well as at CDC. Descriptive
More than half of all stat* health departstatistics, including sex. age, 'race, and "enta and 40 per cent of county health
countv of occurrence, have been the most . departments publish surveillance data in a
useful' for analyzing infectious disease data routine bulletin or «^«letter for the local
with emphasis on total number of cases for medical and public hea th community (48).
a defined time period (e.g.. weekly for no- State-specific notifiable disease data ore
tifiable diseases). Additional analyses for presented weekly in tabu ar (ormal m
trends «ver time and summary statistics on C D C . Morbidity and MortaUty Weekly Redemographic information on cases may be port- Infectious chsease djta are also pubperformed, and rates of disease may be «shed annually in the CDC sSummary of
calculated. An exception to these limited Notifiable Ureases ^
m s.m.lar publicaanalyseu has been the application of regres- tions by state hea t h department. In 1982,
sion and time series analyses to mortality CDC began publishing the CDC Surveddata'for the surveillance of influenza (44- lance Summaries. which contams surveillance reports on specific health eventa lor
461
Public health surveillance of noninfec- which CDC has program, responsibilities,
tious conditions emphasizes population- S u r v e i l l a n c e data from other agencies may
'based rales of disease. Linkage of data be published m spec.al pub .cations e.g.,
sources has facilitated calculation of rates the FDA Drug Bulletin). State and local '
and improved reporting (e.g., birth-weight- health ^ ^ r t m e n t ^ p o r t B , federri pubhspecific death rates, linked by birth and. cations like the Morbidity and Mortality
death certificates) (47). Typically, health Weekly Report, and peer-reviewed public
deportment statistical staff calculate dis- health and clinical journals, however, are
ease rates by sex. race, and age. In addition, the most common forms of disseminat.ng
trends over time (by year for most chronic surveHlance data. The "Rainbow Sems of
conditions) are determined. In the past, NCHS publications reflecU data collected
only national and regional data have been and analyzed from viuUtatist.es and^naavailablc for estimates of morbidity related tional surveys (49) A hough NCHS cbta
t o m a n y n o n i n f e c t i o u s conditions, and few
seta are not specifically linked to p u b h c
small-area comparisons have been made, health programs, they are frequently used
As increasingly large morbidity data sets to establish policy and monitor the effect
are being used (e.g.. hospital discharge ab- of national intervention programs (50).
atracts), the number and variety of appli•
Application to rprogram
cations are increasing (35).
^
The concept of public health surveillance
Dissemination of data
has evolved from primarily an archival
An important purpose of data analysis function prior to 1950 to one in which there
and dissemination is to provide easily is timely analysis of lite data with an apunderstood information in tabular or p r o p r i é t é response. Because surveillance is
graphic formats (in contrast/to raw data) part of public health practice, it should be
174
T H A C K R H AND
used lu guide control and/or prevention
measures (or relevant research). No puhlic
heiilth surveillance system is complété
without lieing linked lo action. The uses of
surveillance include detecting new health
problems (e.g., antibiotic-resistant strains
of bacteria), detecting epidemics, documenting the spread of disease, providing
quantitative estimates of the magnitude of
morbidity and mortality, describing the
clinical course of disease, identifying potential factors involved in disease occurrence,
facilitating epidemiologic and laboratory
research, and assessing control and prevention activities (51).
Surveillance has been vital to developing
hypotheses and stimulating epidemiologic
research. Historically, acute infectious disease problems have almost always been defined by epidemiologists in terms of their
temporal and geographic patterns. The
need to define chronic as well as acute
diseases in terms of temporal and geographic trends is being increasingly recognized (52).
Public health surveillance efforts have
often been intensified when the means for
primary prevention of most or all cases is
at hand (e.g., vaccine for measles or smallpox) or when the disease is severe and
newly emerging, with major efforts being
made to develop control and prevention
measures (e.g., toxic shock syndrome). Additionally, public health surveillance has
served as the means for identifying persons
with a health problem who can participate
in epidemiologic studies for developing prevention strategies (53). Even before AIDS
was documented to have a viral etiology,
for example, measures to lower a person's
risk of disease were suggested by studies of
cases detected through public health surveillance (26).
Evaluation of surveillance programs
Established surveillance systems require
regular review and modification based on
explicit criteria of usefulness, cost, and
quality (51). Most published evaluations of
surveillance systems have been limited to
US P U B L I C H E A L T H
HKHKKI.MAN
infectious diseases (54-57), although there
have lieen some efforts to assess the appropriateness of various data sources for the
surveillance of oilier kinds of health problems (58-60).
A surveillance system is useful if it van
lie applied to a public health program to
control and prevent adverse health events
or to belter understand the process leading
to an adverse outcome. The simplest, way
to assess usefulness is to ask those involved
in public health practice by means of interviews or surveys (48, 61, 62). A more rigorous approach lo defining usefulness is
through the assessment of the impact of
surveillance data on policies and interventions (63), but there are no published studies of this kind. Decisions affecting public
health surveillance programs are more
often based on changes in more general
program directions than on detailed analysis of a particular system (e.g., directing
resources away from routine contact tracing for gonorrhea control to programs for
preventing AIDS).
The economic analysis of surveillance
systems has received little systematic attention apart from the accounting of direct
costs to health agencies. In a 1983 report
from Vermont, the authors reasoned that
costs were too high lo justify active, healthdepartment-initiated surveillance of selected acute infectious diseases unless unq u a l i f i e d subjective benefits, such as improved relations with practicing physicians,
were great (56). In a 1985 report from Kentucky, on the other hand, the benefits associated with health-department-initiated
surveillance of hepatitis A were found to
outweigh the costs (64).
x
CDC has proposed a systematic method
to evaluate surveillance systems on the basis of usefulness and cost as well as seven
attributes of quality: sensitivity, specificity
and predictive value positive, representativeness, timeliness, simplicity, flexibility,
and acceptability (51, 65). These attributes
of a surveillance system are interdependent, and the improvement of one may
improve or compromise another. Increasing
the sensitivity of a system to detect a
greater proportion of a given health event
in a population may also improve representativeness and usefulness of the system,,
yet may lead to greater cost, lower specificity, and more false positive events. This
melhod of evaluation is currently being
used to assess all surveillance systems at
CDC at least once every three years. Such
an approach for evaluating surveillance
systems should enable public health practitioners to efficiently assess their surveillance practices and thus improve the delivery of public health services.
NEW
PUBLIC
HEALTH
PRIORITIES
Chronic diseases
Better data are essential for progress in
chronic disease prevention ant) control,
particularly incidence data to establish
priorities and to evaluate programs (66).
These data should describe the burden and
the determinants of disease and help to
evaluate programs.
Three aspects of chronic diseases make
surveillance difficult. First, for some diseases (e.g., mesothelioma following asbestos exposure), the latency between a precipitating event or.exposure, and the eventual
chronic disease not only hinders linkage
between eiposure and outcome but also
complicates development and evaluation of
prevention programs. Second, the multifac. torial etiology of many chronic conditions
often prevents accurate linkage between
exposures, risk factors, or interventions
and outcomes. Third, because the public
health community is often interested in
arresting or reversing the progression of a
chronic condition, surveillance of various
stages of disease is important.
- There has been extensive experience in
data collection and analysis of chronic disease occurrence. Indeed, at the community
level, there have been many examples of
monitoring of heart disease, stroke, and
cancer, although these programs are typically not ongoing, are usually limited to
data collection and analysis, and are rarely
SURVEILI.ANCK
175
directly linked to public health prevention
programs. ,For example, since 1945,
population-based community studies on
the natural history of stroke hove been
conducted on data collected from medical
records and death certificates in Rochester,
Minnesota (67). Similar community studies
have been conducted on cardiovascular disease (68, 69). For cancer, the most successful approach to community-based surveillance has been the use of registries (43,70),
an approach that has also been used for
stroke (71) and hypertension (72).
For various chronic conditions, efforts
have been made to obtain comprehensive
data not only from medical records and
death certificates but also from special surveys (73, 74). Cancer has become a notifiable disease in at least 36 states in an effort
to broaden the scope of data collection for
that condition (T. Aldrich, Oakridge National Laboratories, personal communication, 1988).
A l the state and national levels, large
data sets are available for application to
the surveillance of chronic diseases (table
1). For example, national stroke mortality
(75) and cancer deaths (76) have been monitored using death certificate data available
from the NCHS. An alternative approach
to the use of such national data bases is the
pooling of information from state and local
sources to monitor nationul trends, as ha9
been done with nutrition data. Data on
height and weight obtained from publicly
supported health and nutrition programs .
demonstrated high prevalences of growth
stunting in Native American and Hispanic
children (77). This finding, together with
high weight-for-height in these populations, suggests thai the diet of Ihese children is adequate in quantity but inadequate
in quality of nulrient intake. If confirmed,
such findings call for nutritional programs
focused on high quality protein and increased essential vitamins rather than simply increased calories. Although pooling of
state data is less efficient than conducting
national samples, the close linkage at the
state level of data collection and analysis
176
T t l A C K R i t A N D i l Kit K M . M A N
to program intervention in an important hensive-iiiilionat data base on workplace
consideration. In addition, there have been hazards existed (86).
efforts to bring together national data from
Major efforts are currently under way to
viirintm wmrriK for chronic health pfob- |M>rform surveillance of occupai ionnl disleins, such as esophngeul cancer <7H) and euses luth at the national and stale levels.
alcohol abuse and alcoholism (79).
Although ptiRl efforts have focused on data
The Surveillance, Epidemiology, mid gathering and analysis, current efforts are
End Results Program of the National Can- motivated by attempts to collect data in a
cer Institute is an elaborate registry of in- . way that will lead directly to intervention.
cident cancers in 11 geographic areas in the NIOSH first developed a list of the "Ten
United States which provides detailed Leading Work-related Diseases and Injupopulation-based information on mortality ries" and is now identifying those occupadue to malignant neoplasms (43). It is the tions and industries at high risk for adverse
principal source of national estimates of health events (87).
site-specific cancer incidence and trends,
A Rurvey of states conducted by the Iowa
documenting increases in cancer of the lung Department of Health in 1985-1986
and bronchus and declines in the incidence showed thnl at least 30 (60 per cent) states
of gastric cancer (80). This program, which had either voluntary or mandatory reportcost8 about $5,800,000 annually, is partic- ing programs for selected occupational
ularly useful for national trend estimates health conditions (88). The states have not
and epidemiologic research. Its uses for lo- been uniform, however, concerning the
cal prevention and control activities, how- - conditions for which they require reporting,
ever, .have been limited. Less elaltorale although lead poisoning, silicosis, and Bastate cancer registries may be more closely besiosis ore frequently included on the relinked to state cancer control efforts (70).
portable discose list. Also, the reporting
criteria for these occupational health
None of these data collection activities
events are not uniform across states (e.g.,
constitute public health surveillance sysTexas requires reporting of blood lead levtems. The usefulness of existing data sets
els >40 mg/ml, whereas New York requires
for chronic disease surveillance has not
re|M>rtiug of all blood lead.levels >25 nig/
-•-been proven.-Such data mny.-nonetheless,
ml) (P. Honchar, CDC, personal commuprove useful for.puhlic health and are esnication, 1987).
sential, to assess the completeness and accuracy of existing chronic disease data and
Although many state health departments
their appropriateness for this purpose. To have reporting laws, few have maintained
date, there has lieen-a limited effort to a professional staff that could respond to
apply the principles of public health sur- the incoming reports. Fortunately, this gap
veillance to specific chronic conditions (81) in surveillance is being addressed. For exor to assess alternative approaches to col- ample, the Texas Department of Health
lecting chronic disease data for public performs cuse investigations routinely in
health surveillance (82-84).
response to reported cases of occupationally acquired lead poisoning'(P. Honchar,
Occupational safety and health
CDC, |>ersonnl communication, 1987). Case
In 1984, J. Donald Millar, the Director investigation includes I) assuring proper
clinical management of the affected person
of the National Institute for Occupational
and 21 offering an evaluation of the workSafety and Health (NIOSH), told Congress
site to detect factors |>otentinlly responsible
that federal surveillance of occupational
for the case. This evaluation is accomillness was "70 years behind that of com- panied by recommendations for preventing
municable disease surveillance" (85, p. 11). further cases. Screening for elevated blood
Before the enactment of the 1970 Occupa- lead levels in coworkers may he conducted.
tional Safety and Health Act, no compre-
AH another example, NIOSH is conducting
the Fatal Accident Circumstances and Epidemiology Project, which focuses upon selected elcctricnl-related and confined
space-related fatalities (89). The purpose
of I he program is to identify factors influencing the risk of fulol injuries in the workplace.
In addition to data gained from case reports, 30 stutes now include occupational
information on death certificates; only 18
states collected such information in 1981
(90). Fourteen health departments include
parents' occupations on the birth certificate. Reporting to health departments will
be expanded through the Sentinel Event
Notification System for Occupational
Risks, a NIOSH-sponsored health event
reporting system based'on reporting selected occupational disease and injury outcomes amenable to control and prevention
(E. Baker, CDC, personal communication,
1987). Other data-used by state health departments for surveillance include hospital
discharge data, workmen's compensation
data, and cancer registries (11 states report
occupational history on all cancer cases).
At the national level, questions on health
outcomes and health risks of relevance to
occupational health have been incorporated
into the National Health and Nutrition
Examination Survey and the National
Health Interview Survey.
Health effects of environmental
. exposures
unie
Puhlic health surveillance in environmental health includes both hazard (exposure) and health effects monitoring. An
example of an ongoing national system for
collecting data on potential exposures is the
Hazardous Materials. Information System
of the Department of Transportation,
which wus established in 1971 by a federal
law that seeks voluntary reporting of spills '
occurring during interstate commerce (91).
Comparisons of these reports with independently collected data from the state of
Washington, however, indicated that the
federal system missed over 80 per cent of
SUHVEII.LANCE
177
spills and had inadequate data on injury,
death, and cost (91 ). The state of California
compared data from the Hazardous' Material» Information System with similar information collected by the California Highway Patrol related to hazardous material
spills to determine number and nature of
incidents (59). Of 941 incidents involving
highway transport of hazardous materials
and related exposures and injuries, only 18
were reported in both systems. Despite such
limitations, the Hazardous Materials Information System could be integrated into a
system of public health surveillance because it offers useful data on place, cause,
and mode of spill.
The most extensive public health surveillance system developed for outcomes
related to an environmental hazard evolved
from 62 childhood .lead-poisoning prevention programs (92). Over a 10-year period
ending in 1981, 247,000 children with lead
toxicity were identified among nearly 4 million screened. The data were disseminated
at both the local and national levels and
were applied to program planning.and implementation. This routine reporting system was complemented with data from the
Second National Health Assessment and
Nutrition Examination Survey (92). These
data sources documented the decrease In
blood lead levels associated with the reduction of lead used in gasoline. When federal
funding was discontinued in 1981, the national program stopped, and most local activities were curtailed or eliminated.
More typically, public health surveillance
of specific environmental health outcomes
is established, often in the' form of registries, and then attempts are made to relate
these outcomes to particular exposures or
etiologies. Important examples are the systems established for the surveillance of congenital malformations. Widespread interest
in birth defects followed the epidemic of
limb reduction deformities which was associated with women taking thalidomide
during early pregnancy. This event, coupled
with epidemiologic patterns for several
malformations indicative of an environ-
US PUBLIC HEALTH
178
SUHVEIU.ANCE
179
THACKER AND HKHKEI.MAN
mental etiology, led to the establishment of
the Metropolitan Atlanta Congenital Defuels. Program and the nationwide Hirlh.
Dcferts Monitoring Program in I9(>7 and
1974, respectively (42). These two systems
are used to monitor trends in specific birth
defects or combinations of defects and to
stimulate epidemiologic
investigations
when increases are identified. The data .
have been used to demonstrate the lack of
teratogenicity of exposures of serious puhlic
concern such as spray adhesives (93), vinyl
chloride (34), airport noise (94), and military service in Vietnam (22). Similarly,
cancer registries have been used lo study
possible relations between specific cancers
and environmental exposures (43).
The first challenge in the public Health
surveillance of environmental hazards is to
determine which hazards warrant ongoing
programs of surveillance. The major constraint of the outcome approach is the limited knowledge of the health effects of specific toxins (i.e., natural) and toxicants (i.e.,
man-made), which inhibits our ability to
delect unexpected associations between
disease and exposure. Humans have released thousands of toxins and toxicants
into the environment, but both the health
impact and the exposure potential of most
of these substances are unknown or, at best,
established only in laboratory animals. The
Agency for Toxic Substances and Disease
Registry has been given the responsibility
of ranking the leading priority chemicals in terms of risk to human health (95). Yet,
even when this task hns been accomplished,
policies for establishing systems of public
health surveillance will need to be formulated by local, state, and federal agencies.
Once priorities are established, data must
be identified for both exposures and outcomes. Fortunately, many data sets (e.g.,
the Birth Defects Monitoring Program) olready exist for both and need only to be
integrated into public health programs (42).
It is simpler and less costly to use existing
data and dala systems than to establish
new ones. Additionally, historical data enable one to analyze long-term trends.
Puhlic health surveillance in a disaster
setting is critical lo the optimal allocation
of sriircc and often |M>orly organized resources. Surveillance systems were established, lor example, to monitor exposure to
radiation following the incident ot the nuclear reactor al Three Mile Island (96).
Surveillance systems were also developed
to monitor the health effectsof the volcanic
ash plume created by the eruption of the
Mount St. Helens volcano in 1980 (97) and
the health effects of exposure to toxic waste
at Ijdve Canal (98). Similar short-term, local environmental monitoring systems have
been established in response to chemical
spills (99). Although these are examples of
ad hoc surveillance established in an acute
situation, there are few examples of ongoing systems of public health surveillance
linked to puhlic health programs of control
and prevention. Occasionally, emergency
preparedness plans include surveillance,
such as during the 1984 Olympics when the
potential for terrorist activities was considered high (100). Currently, CDC is working
with the American Red Cross to organize
disaster surveillance and lo establish an
international activity in this area (P. Duclos, CDC, personal communication, 1987).
Finally, there have been efforts to combine environmental monitoring data with
health outcome information. After the severe heat wave of 1980, for example, CDC,
in collaboration with medical examiners,
state and local health departments, and the
National Weather Service, developed a system of surveillance of mortality related to
summer heat waves (101).
Injuries
The recognition of both intentional (e.g.,
homicide) and unintentional (e.g., falls) injuries as major public health problems has
led to the need for developing systems, of
public health surveillance (102-104). Because of the acute nature of injury events,
surveillance principles learned from experience with acute infectious diseases are
often readily adaptable lo injuries (105).
The current approach lo establishing public
heailh data bases for i n j u r y has been to
adapt data, such as medical examiner reports and vital statistics, to public health
needs (103, 105). This approach has been
used most widely at the slate level where
vital statistics, hospital discharge data,
emergency room data, and household surveys have been used to measure the extent
end nature of the unintentional injury
problem in particular populations, as well
as to assess Ihe impact of prevention programs (102, 106-108). Medical examiner
data have also been used in the surveillance
of injuries and associated risk factors such
as alcohol and drug use (109).
Fatal Accident Reporting System ( I I I ) and
the National Accident Sampling System
(U2> maintained by the National Highway
Traffic Safety Administration, the National Burn Registry initiated by the National Institute of Burn Medicine (113), the
National Fire Incident Reporting System
established by the Federal Emergency
Management Agency (114), the US Coast
Guard investigations of boating incidents
(115), and the National Spinal Cord Injury
Network (116). As with chronic diseases,
the usefulness of many of these data
sources for public health surveillance remains lo be assessed.
The challenge of surveillance of intentional injuries is even more complex. Data
are available from vital records and medical
examiners, but information on the circumstances of homicide and suicide is often
absent or limitéd in these data sets. Public
heailh surveillance of intentional injuries
will require the collaboration of the public
health community with a new array of ex. perts, especially in the fields of law enforcement and sociology ( 113). At the state and
local levels, data from criminal justice agencies, medical examiners and coroners, and
medical and sociol service agencies are
being explored for use in the surveillance
of intentional injury (117). Illinois instituted mandatory uniform crime reporting
in 1972; the state maintains the data on
computer and publishes a report each year
(118). Few data exist on morbidity related
to assault or child abuse, and only rarely
have epidemiologic studies been conducted
in this area ( 119). Efforts are under way to
assess the feasibility of alternative opproachea to the surveillance of domestic
Several national data sets are available violence (120).
for the surveillance of unintentional injuOn the basis of data from the national
ries (table 2). NCHS compiles and analyzes
mortality statistics, hospital discharge mortality files of NCHS and population
data, office-based physician utilization estimates of the US Bureau of the Census,
data, and data collected in an ongoing a 40 per cent increase in youth suicide was
heolth interview survey of the general pop- documented in the decade ending in 1980
ulation. Other sources for national data (121). This increase was found primarily in
include the National Electronic Injury Sur- white males 15-24 years of age. These surveillance System maintained by the Con- veillance data documented the dramatic
sumer Product Safety Commission (39), the change of suicide as a problem of the elderly
Approaches to injury surveillance vary at
the state and local levels. During one year,
the Statewide Childhood Injury Prevention
Program in Massachusetts detected 5,953
fatal and nonfatal injuries in 87,022 children and adolescents through a public
health surveillance system based on hospital and emergency room records from 23
hospitals in 14 communities (102). Using
Ihese data, program personnel focused prevention resources on the injury problems
of highest incidence in particular communities. In 1987, the Council of State and
Territorial Epidemiologists adopted a resolution to recommend that spinal cord injury be made reportable in all states (168).
North Dakota has already made notifiable
all injuries resulting in at least one day of
disability (J. Pearson, North Dakota State
Department of Heolth, presented at the
annual Council of State and Territorial Epidemiologists meeting, May 1987). Trauma
registries can also be adapted for surveillance (110).
1R0
THA<KKIt AN» HKIIKHIAIAN
to a problem of the young. Current efforts
in fiiiicide surveillance have demonstrated
I lu» ir,i|h.rliui«riim1 iliflMiillv of arriving nt
uniform definiliotiH. 11 problem ronipliriitcd
by I hi! interdisciplinary imlurc of (his widen vor. Uniform definitions of child and
8|>ouKe a I ruse, problems for which incidence
data are sparse, are also needed. Yet, as
such data buses are developed, surveillance
will play a crucial role in public health
programs aimed at controlling and preventing these and other injuries. Other national data sources, such as the Uniform
Crime Reports of the Federal Bureau of
Investigation and the annual National
Crime Survey of the US Department of
•Justice, have proven to be useful (121-125).
Personal health {tractive*
At a national level, the Health Interview
Survey conducted by NCHS has provided
the most information on personal hèalth
practices such as alcohol use and smoking.
The prevention-supplements to.the 1982
.. and .1985 surveys have provided more detailed information in this area (126). As the
role of personal health behavior in the developmeni of chronic diseases and injuries
has become more fully recognized, state• based programs to reduce the prevalences
of unhealthy behaviors have been established. In turn, interest in providing a systematic means of collecting populationbased prevalence data on a state-specific
basis resulted in the initiation of the Behavioral Risk Factor Surveys in 1981 (127).
National estimates can be obtained more
efficiently, but local programs benefit from
involvement in data collection as well as
from the ability to adapt the collection
process to their particular needs. As of
1987,35 state heolth departments are conducting ongoing surveys of behavioral risk
factors in persons aged 18 years or older.
Each state, uses a standardized questionnaire to determine the prevalence of a variety of personal health practices including
cigarette smoking, smokeless tobacco use,
alcohol consumption, eiercise, seat belt
use, dieting, and hypertension control
(127). The wimple for each survey, conducted by telephone, is selected generally.
with n multistage cluster design hnsed on
the Wiilt*berg method (I2K).
Interview surveys can obtain personal,
hi-nll h • relut «il informal ion wil h only minor
difference» in the prevalence of various
health conditions when conducted by telephone or in person (127). Telephone interviews have the advantages of lower cost
(almut one-third to one-half the cost of
personal interviews) and the ease of supervising interviewers. Although there are .
problems of hias related to omitting those
households without telephones, telephone
coverage exceeds 93 per cent in the United
States (127).
Results of the surveys are published by
both CDC nnd stale health departments
(129, 130). They are also distributed to the
press and to a variety of local and stale
organizations, including voluntary, health
agencies, hospitals, health maintenance organizations. and slate legislators. In 1986,
the 43 stales thot hud conducted these surveys reported that these data were frequently used by the health department to
prepare slate planning documents and to
establish state-level health objectives (62).
Sixty-five per cent of these states reported
using the datn to support-legislative initiatives, especially seat belt and anti-smoking
legislation (62). Limitations, however, exist
when these data are used; many states cited
a circumscribed authority to disseminate
the findings. In addition, because the surveys only recently have lieen initiated at
the stale level, not enough time has elapsed
to adequately analyze trends.
I'rvventiue health technolvfties
Health technology includes the drugs, devices, and medical and surgical procedures
used in health care, and the organizational
and supportive systems within which such
care is provided (131). The implementation
of new technologies is a prominent growth
industry in health. Dramatic examples,
such as carotid endaiterectomy, artificial
hearts, osteoporosis screening, and AIDS
181
US I'lUILIC HEALTH SUHVKll.l-ANI'K
testing, are very much in the public eye.
Concerns regarding premature diffusion or
misapplication of health technologies have
highlighted the need for routine surveillance of the application of the technologies,
particularly as these new technologies are
used in healthy or asymptomatic populations to prevent disease (132). Currently,
efforts are under way in several state health
departments to assess the effectiveness of
both cervical cancer and breast cancer
screening programs. Systems of public
health surveillance are an integral part of
these assessments.
There are, however, few examples of surveillance of health technologies despite this
widespread diffusion of new devices and
practices. Immunization against selected
infectious diseases is probably the most
effective and well-known technology used
in public health. More recently, public
health surveillance of selected medical
technologies has been developed by CDC in
response to concerns in the public health
community. For example, in response to
state health officials during a perceived crisis in 1982 concerning the use of insulin
.pumps, CDC established a short-term surveillance system to determine the frequency and aèvérity of complications associated with these devices (133). Using physician reporting, the investigators identified previously unrecognized adverse
events associated with pump use as well as
35 deaths among pump users. The data
were used to assist the American Diabetes
Association in developing a policy statement for clinicians that included new criteria for initiating pump use (134).
Public health surveillance of technology
use provides a mechanism for monitoring
the use of a pract ice or device and, together
with data on morbidity and mortality, provides an ongoing measure of its effectiveness and safety in the populations being
monitored. Surveillance will also indicate
whether an effective technology is being
applied to the population that is likely to
benefit from such technology. I t is not
known, for example, whether the women
undergoing mammography are those most
likely to benefit from screening.
The need for surveillance of technology
use is evident, but the process of gathering
the primary data is not established currently for most technologies other than
drugs—the latter being n responsibility of
the Food and Drug Administration. As illustrated by the surveillance of luluil sterilization, some hospital data sets can be
helpful in tracking inpatient procedures.
There is a lack of state and national surveillance information,, however, to track
diffusion of technologies in the outpatient
setting, where complex and expensive technologies are being used increasingly (135).
Although surveillance is usually, undertaken by public health agencies at the jocal,
state, and federal levels in collaboration
with the medical community, efforts to establish surveillance systems nL all levels
have faltered in recent years. In ils lead
federal rolé in health care technology, the
National Center for Health Services Research and Health Care Technology Assessment should be encouraged to develop
priority-setting criteria for bringing technologies under surveillance and subsequently for analyzing the impact of technologies in terms of their effect on morbidity,.mortality, disability, and cost.
NF.W TOOLS FOR PUBLIC
HEALTH
SURVEILLANCE
Computers
•The introduction of computer hordwarb
and software has provided public health
professionals with the capability to jierform
surveillance more efficiently on commun
conditions. Large data bases inuy be better
managed and analyzed, and in soine in*
stances may lie linked. In addition, the
microcomputer has empowered the public
health professional with an increased ability to organize, communicate, tabulate, and
analyze data. Use of the computer has increased the timeliness of both data collection and analysis and has decreased the
epidemiologist's reliance on programmers
182
T H A C K E H AND BRUKEI.MAN
nnd hinslfltisticians for data analysis and
interpretation.
The Public Health Foundation initiated
an electronic mail system in 198:1. Several
federal health agencies, including CDC, and
44 slate health departments are now online. In addition, three stales have enrolled
their local health departments and can
telecommunicate with them. In 1984, this
network was used in six states to pilot-test
the transfer of notifiable infectious disease
data weekly to CDC (136). By early 1988.
37 reporting areas were transferring individual case data on over 40 notifiable diseases to CDC each week. The ability to
transfer binary file will allow the telecommunication of graphics, which facilitates
review of aggregate data. Surveillance at
the state level has been hampered by a lack
of microcomputer software for managing
and analyzing large numbers of disease records. Currently, software developed for use
in epidemic investigations has been
adapted for surveillance and used in 20
states (A. Dean, CDC, personal communication, 1987). Use of such software in Georgia has enabled early detection of an epidemic of illness due to Sa/mone/Ia hauana,
facilitating efforts to identify the environmental source of the organism (137).
Programs at CDC for vaccinepreventable diseases, tuberculosis, AIDS,
and diabetes have also developed computer
networks with state health departments to
enhance their surveillance capabilities. In
addition, state health departments have initiated computer linkage with selected local
health departments for disease reporting
(138). In Wisconsin, for exemple, case data
from sexually transmitted diseases clinics
are telecommunicated to each other and to
local and state health departments, improving the efficiency of follow-up of patients
(A. Dean, CDC, personal communication,
1987).
' Use of microcomputers has also expanded surveillance activities to nontraditional reporting sources. Computers in
medical examiners' offices will aid in injury
surveillance (139); microcomputers in a na-.
tional sample of hospitals currently aid in
collecting information on nosocomial infections (140).
.Sfati*ficaf 'mvthods
The increased sophistication of statistical methods, the availability of computers,
and the development of statistical software
for analysis have broadened the potential
of statistical analysis in day-to-day public
health practice and. have led to the investigation of new methods of data analysis.
The usefulness of time series analysis (46),
of detecting clusters of adverse health
events in time and place (141-144), and of
mathematical models to forecast epidemics
based on surveillance data ( 145) remains to
be fully assessed.
Although detecting temporal and spatial
clusters of disease has always been a goal
of public health surveillance, formal statistical testing for clusters has rarely been
applied to routinely collected surveillance
data. The statistical problems associated
with determining whether an "outbreak"
has occurred were addressed in depth in the
1960s, and a variety of alternative analyses
were proposed. Two commonly used methods for space-time clustering, proposed by
Knox and Lancashire (143) and by Ederer
et al. (146), are based on the number of
"close" pairs of cases and the sum, over all
space divisions, of the maximum number
of cases in any time unit within a space
division. For. example, Ederer et al. employed a summary statistic to detect both
clusters of leukemia over time and outbreaks of polio and hepatitis.
The SCAN statistic, based on such summary statistics as those used by Mantel
( 144) and Ederer et al. (146), was proposed
by Naus (147) and has recently been applied to a cluster of trisomies in three New
York City hospitals (148). This statistic is
computed by plotting points over time, taking a "moving window* of a fixed length of
lime, and then finding the maximum num• ber of observations revealed through the
window as it scans or slides over the entire
time period. The statistic is based on the
SURVEII.l.ANi:E
183
(152) has clearly demonstrated the important role graphs can play in visual decoding
of large quantities of data. Although Tukey's methods have not yet been widely
applied to surveillance data, his pioneering
work together with the introduction of
computer graphics has laid the foundation
for graphic analysis of surveillance data
(153). Microcomputer graphics, in particular, have also made the results of data
analysis far more useful to private and public policymakers in their planning and management of health care resources (36). Although simple data still are incorporated
best into textual material or a tabular format, a graphic display can give the reader
an understanding of large and complex data
sets that cannot be conveyed easily in other
ways (154).
The interest in computer mapping in
public health is strong. A 1976 workshop
sponsored by NCHS featured several applications of automated cartography to epidemiology (155). ln the area of surveillance, mapping of disease rates by county,
sex, age, and race based on large computerized data seta first proved its usefulness
when tbe cancer atlases were developed by
the National Cancer Institute in the 1970s
(76). The Environmental Protection
Agency has also produced maps on cancer
(156). Injury maps have been used to convey visually the race- and sex-specific differences in rates of various injuries (157).
Although it has been common practice to
plot individual cases or rates of disease on
geopolitical maps, population-based maps
have been produced to account for population size. More recently, exploded population maps have been considered for use in
surveillance. These maps are developed by
the isomorphic reduction of geographic entities in relation to the entity with the
greatest population density, with or without an overlap of the geopolitical map (158).
Other mapping of surveillance data for proGraphic methods for data analysis and
grammatic use has included the developdisplay
ment of probabilistic contouring, with maps
Graphics have the potential to serve as demonstrating tbe estimated probability of
powerful tools for displaying data both for a health event or an exposure, a technique
analysis and for communication. Tukey
assumption that the size of the population
at risk remains fairly .constant and that the
condition shows no seasonal or cylical pattern over the time period-plotted. Other
analytic methods have been suggested for
using -environmental data to predict the '
occurrence of Rocky Mountain spotted fever, but such methods have not been used
routinely (142).
The Chandra Sekar-Deming method developed by demographers has been used to
estimate completeness of reporting by comparison of two independent surveillance
systems with individual identifiers so that
the data may be linked (149). This method
has recently been applied to AIDS data
reported through the notifiable disease system and through death certificate registration (150). It has also been applied to estimate the sensitivity of two systems for detecting vaccine-preventable diseases (151).
Surveillance systems are subject to both
selection and information biases. Notifiable disease reports, for example, are likely
to come from a nonrepresentative sample
of practicing physicians who may report
specific diseases because of personal interest. Privât* practitioners, for example, may
be less likely than physicians at public
health clinics to report certain conditions
(e.g.. sexually transmitted diseases). At the
same time, certain kinds of data are less
likely to be reported than others because of
ease of ascertainment (e.g., age or sex vs.
pathologic diagnoses). Analytic models are
required to measure the impact of bias on
surveillance data. Other important research issues on the statistics of surveillance include the -development of methods
to handle incomplete or missing data, the
use of multiple subset sampling, modeling
of timeliness, and the combination of data
from independently collected data sets.
H SUNVKIU-ANCK
us PUBLIC IICAI.1
THACKRK AND HKHKFJA1AN
184
thai has proven particulnrly useful in program planning (159).
I.IMITATIONS
IN
TIIK
P H M T I C K
(IF
SUMVF.II.I.ANCK
The variety of uses of public health surveillance is not widely appreciated. Por
some, the concept of surveillance is limited
to re|M»rting notifiable communicable diseases to state and local health departments.
Others think in terms of laboratory- or
hospital-based surveillance, particularly for
nosocomial infections. Another interpretation is seen in recent legislation establishing the Agency for Toxic Substances and
Disease Registry, which limited health surveillance to medical screening of individuals (16Ù).
Other perspectives limit Ihe potential
scope of puhlic heolth surveillance. The
most common is t hat surveillance is limited
to data collection and collation. It is important for el system of public health surveillance to include analysis and interpret al ion
of data, as well as dissemination of those
data tu the relevant persons. Finally, to be
' complete, a puhlic health surveillance system requires linkage to programs. When
this broad |>erspective is not understood,
the practice of surveillance and of epidemiology in puhlic health is constrained
short of its potential.
Inexperience with surveillance
methods
Except in slate and local health departments, relatively few persons have been
involved in a complete program of public
health surveillance. Most persons are involved with only one portion of a surveillance system (e.g., data collection) or with
only a limited array of health events (e.g.,
communicable diseases). The lack of familiarity with puhlic heailh surveillance is
even more pronounced in medical schools
and schools of public health, where it is
rarely discussed and is almost never the
subject of. careful analysis. Textbooks of
epidemiology and public health are similarly remiss in addressing the scope of public health surveillance, with few texts de-
voting even a chapter to the subject (161,
162). The only substantive training for surveillance in ihe United StAtes is as part of
the act mi I prnclii-e of public health. The
public health community is only now Iteginning to approach surveillance in a more
scientific manner, looking beyond case
counting and simple descriptive epidemiology. Sophisticated statistical tools such as
time series analysis (45) and the SCAN
statistic (148), for example, have been applied successfully to surveillance data. Expansion of public health into new fields
such as chronic disease demands more rigorous scientific scrutiny of surveillance
methods as well as different approaches to
public health epidemiology (52).. To date,
however..the communities of both health
care providers and teachers of medicine,
nursing, and public health remain uninformed about needs in public heellli survèillance. Their involvement, in the future,
could contribute significantly to the practice and development of public health surveillance.
Data gaps
Even in communicable disease reporting,
data are often incomplete, unrepresentative, and untimely. Depending on the severity and perceived importance of a disease, rates of reporting notifiable diseases
have been estimated to vary from 6 per cent
to 94) per cent (54, 163-165). Both measles
and AIDS programs, for which many resources have been targeted toward surveillance efforts, attain greater than 90 per cent
sensitivity (150, 166). In a study of Shigella
surveillance in Washington, DC, however,
investigators found that persons with disease were more likely to be reported if they
were treated by private physicians—a practice that leads to unrepresentative surveillance data (55). Efforts lo improve the quality of reporting have lieen shown to have
some effect—improving sensitivity at the
local level as much as ninefold for selected
acute infectious diseases—but the ultimate
impact of such improvements in surveillance remains to be assessed in terms of
improved health and reduced cost (56, 57,
64,167).
Surveillance in rapidly evolving areas of
public health, sui:h as injuries and chronic
diseases, often relies on existing data sets,
because of the usefulness of historical data ,
and the prohibitive costs of new systems
(167). Evaluation of the use of such data
sets for public health surveillance represents an important new challenge.
Policy
185
CONCLUSIONS
Public health surveillance provides a
quantitative basis for other distinct facets
of public health practice, including epidemiologic research and control and preveri;
tion services. Public health surveillance includes not only data collection and analysis
but also the application of these data to
control and prevention activities by disseminating information to practitioners of
public health and others who need lo know.
Although surveillance has been conducted
in some form for more than a century, its
uses and practices have, evolved most dramatically over the past 40 years. A significant change has lieen the extension of surveillance beyond infectious disease to include the spectrum o f . public health
problems in chronic disease, occupational
health; injury, the environment, personal
behaviors, and preventive health technologies. A second significant change has been
the effort to put public health surveillance
on a more quantitative basis.
Effective public health practice requires
the following: l ) an accurate assessment of
the public health; 2) definition of specific
public health priorities; 3) development and
implementation of research and control
programs to improve health; and 4) an evaluation of these programs (2). Public health
surveillance data con provide a quantitative
basis for policy decisions and allocation of
scarce resources. Furthermore, the infor' motion gained from surveillance programs
can significantly contribute to the continuous redefinition of public health priorities
Public health surveillance has been peras problems are resolved and other needs
emerge. In short, good surveillance data can ceived by most as an early warning system,
and should be used to guide public health a crude indication of the occurrence of unusual disease patterns. Because of a focus
practice.
Policy should be based on accurate data. on limeliness and simplicity, there has
The quality and limitations of both sur- often been less concern for data quality. In
veillance data1 and their interpretation recenl years, however, there has been an
must be recognized by those communicat- increased use of data obtained oulside of
puhlic health practice and a concomitant
ing the informatipn and by those establishincreased concern with the quality of suring policy. Ideally, policymakers, in reveillance data and methods used to collect
sponding to questions related to health poland Analyze these data (61). It is appropriicy, will know to turn to the surveillance ate, therefore, fur the epidemiologist to exprogram.
amine this tool carefully and to ascertain,
Similarly, public health surveillance how one can efficiently improve the collecshould not be seen as an end in itself, but tion, analysis, and dissemination of surrather as a tool for use in promoting health veillance data. In other words, application
and preventing and controlling disease and of a scientific approach lo this method
disability. Surveillance data should not be should improve its usefulness.
acquired at the cost of privacy, nor 6hould
Several current activities will have a sigthe quest for precise numbers or exquisite
- analyses lead to costs that outweigh the nificant impact on Ihe practice of public
benefits of such information to the public health surveillance. We need to identify
health. Again, the need for data must be data sets relevant to specific health probkept in perspective in relation to their in- lems in the most rapidly evolving areas of
puhlic health. In some cases, this will retended use.
?
US PUBLIC
HEALTH.SUHVELLXANOE
187
THACKF.H ANR IIRKKE I.MAN
186
quire creating new data seta such as theBehavioral Risk Factor Survey, which is
jointly rmidoflud by CIMÎ tuid ntulo health
depart men Us (f»2). More often, ongoing datn
collection efforts, such as the notifiable disease data systems maintained by state
health departments, and data surveys conducted by NCHS, will be adapted to surveillance needs. Statistical and graphic
techniques will improve utilization and understanding of available data. Computers
will play an increasingly large role, not only
in analysis but also in graphic display
methods and electronic data dissemination.
The critical challenge in public health
surveillance today, however, remains the
ensurance of its usefulness. For this purpose, therefore, we need regular, rigorous
evaluation of public health surveillance systems. Even more basic is the need to regard
surveillance as a scientific endeavor. To do
this properly, one must fully understand
the principles of surveillance and its role in
epidemiologic research and other aspects of
the overall mission of public health. What
is necessary now is to develop the epidemiologic methods relevant to public health
surveillance; to apply computer technology
for efficient data collection, analysis, and
graphic display; to apply surveillance principles to practice; and to routinely assess
the usefulness of surveillance systems.
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143 K n o x G , Lancashire R. Detection of m i n i m a l
epidemics. S t a t M e d I 9 8 2 ; I : I 8 6 T 9 .
144. M a n t e l N . Re: "Clustering of disease m population units: a o exact test and its asymptotic version." A m J Epidemiol ! 9 8 3 ; l 18:62ft-9.
146 Longini I M J r . Fine P E M . T h a c k e r S B . Predicting the global spread of new infectious agents.
A m J Epidemiol 1986;123:383-91.
146. Ederer F , Meyere M . M a n t e l N . A statistical
problem in space a n d time: do leukemia cases
come i n clusters? Biometrics 1964;20:626-38.
147. N a u s J. T b e distribution o f the eixe o f (he maai m u m cluster o f points on a line. J A m S t a t Assoc
1966;60:632-8.'148 W e l l e n s t e i n S. A test for detection of clustering
over time. A m J Epidemiol I 9 8 0 ; l l 1:367-72.
149. Chandra Sekar C . D e m i n g W E . O n a method for
estimating b i r t h a n d death rates a n d t h e extent
of registration. J A m S t a t Assoc I949;44:101-16.
160 H a r d y A M . Starcher E T . M o r g a n W M . et al.
Review of death certificates to assess completeness of A I D S case reporting. Public H e a l t h Rep
1987;102:386-90.
. „
151 Oreostein W . B a i t S W . B a r t K J . et aL Epidem i o k c y of rubella a n d its complications. In:
Grunberg E M . Louie C . Goldson S E . eds. Vaccinating against braio syndrome»: the campaign
against measks and rubella. N e w Y o r k : Oxford
University Press, 1986. (Monographe In Epidemiology a n d Biooutiolica. V o l 19).
152 T u k e y J W . Exploratory data analysis. Reading.
M A : Addiaoo-Wesley, 1977.
163 Cleveland W S . T b e elements o f graphing data.
M u r r a y H i l l , N J : Bell Telephone Laboratories.
1986.
.
.
164 T u f t e E R . T b e visual display of quantitative
information. Cheshire, C T : Graphics Press, 1910.
166. N a t i o n a l Center for H e a l t h Statistics. Proceedi n p of the 1976 workshop o n automated cartography a n d epidemiology. Hyattevilla, M D : N a tional Center for H e a l t h Statistics. 1979.
' ( D H R W publication no. ( P H 9 ) 7 9 - 1 2 5 4 > .
166 Riggao W B . U S Cancer mortality rates and
trends, 1980-1979. E n v i r o n m e n t a l Protection
Agency. V o l 4. Research T r i a n g l e Park, N C :
House of Facts Research Laboratory ( i n press).
157
B a k e r S P , W h i t f i e l d R A . O ' N e a l B . Geographic
variations in mortality from motor vehicle
crashes. N E n g l J M e d 1987;316:1384-7.
168 Olson J M . Noncontiguous area cartograms. Prof
Geographer l 9 7 8 ; 2 8 J 7 1 - 8 0 .
169. F l a t m a n G T . B r o w n K W . M u l l i n s J W . Probabilistic spatial contouring of tbe plume around a
lead smelter. Silver Springs. M D : Superfund "85
Hazardous Materials C o n t r o l Research Institute.
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«
160
H e a l t h surveillance program. Congressional Heco r d - H o u a e , H 1 0 8 6 7 ; Dec. 4 , 1 9 8 5 .
161 B r a c h m a n P S . Surveillance. In: Evans A S . Feldm a n H H , ed. Bacterial infactions of humans.
N e w Y o r k : Plenum Medical. 1982:49-61.
162. Bennett J V , B r a c h m a n P S . eds. HosptCal infections. Boston. M A : L i t t l e , B r o w n & Co, 1986.
163 Rosenberg M L Shigella surveillance to the
U n i t e d States. 1976. J Infect Dis 1977;136:4589.
164. T h a c k e r S B , Choi K , B r a c h m a n PS. T h e surveillance of infectious diseases. J A M A 1983;
249:1181-6.
.
'
166. D a v i s J P . Vergeront J M . T h e effect of publicity
o n the reporting <if toxic-shock syndrome in Wisconsin. J Infect Dis 1982;146:449-67.
166. H i n m a n A R , E d d i n » D L . K i r b y C D , e l al. Progress 1 in measles elimination. J A M A
1982;
247:1592-6.
. ,
.
167. Brachott D . Mosley J W . V i r a l hepatitis in Israel,
t h e effect of canvassing physicians on notifications a n d the apparent epidemiological pattern.
B u l l W H O 1972;46:457-64.
168. Centers for Disease C o n t r o l Acute traumatic
spinal cord injury surveillance—United States,
• 1987. M M W R 1 9 8 8 ^ 7 : 2 8 5 - 6 .
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The Basic Strategies
for
Hazards
of ail
Kinds.
Reducing
Damage
from
m
M
For
Reducing Damage From
HAZARDS OF ALL KINDS
x
by William Haddon, Jr., M.D.. M.P.H.
President. Insurance Institute fo? Highway Safety
Watergate 600, Washington. D.C. 20Q37
Abstract
This paper identifies and illustrates the generic strategies
that encompass all of the-tactics that may be used to reduce
damage: to people and other living things: to inanimate
objects: and to systems of all kinds, by any. and all,
environmental hazards. These strategies, which have many
illustrations in current events and in history, are a
generalized extension o f those previously identified as
available for reducing the results of abnormal energy
exchanges, e.g., earthquake and hurricane damage, motor
vehide crash injuries.* gunshot wounds, lacerations, and
burns. The choice o f "strategies to reduee undesirable
environmental-hazard damage has many practical and, even,
ethical implications. It is therefore useful to be able to
i d e n t i f y systematically the strategy options at least
theoretically available for use in given situations: and to
f u l l y r e e o g n i z e parallels among situations that are
s u b s t a n t i v e l y d i f f e r e n t . Consequently, the analysis
presented should help facilitate policy options and analysis,
and management in the wide range of fields in which
damace from environmental hazards is o f concern. It also
systematically identifies the general strategies for reducing
the damage o f war and other forms of violence.
Our position as a species substantially reflects our
ancestors' abilities to survive and adapt to the hazards of
their environments - environments in the broadest sense,
political, biographical, and physical. Nor are we unique in
this resoect. All self-sustaining living, organisms and animate
and inanimate systems - whether sea turtles or sequoias,
the desert biome or Western Democracy - have also
survived substantially through their suecess in not being
overcome by the hazards of their particular situations.
In view o f this, it is not surprising that much attention,
as is well known, has been given to identifying and
understanding the means o f influence o f the hazards thatshaped. and sometimes terminated, various past forms of
life and systems. The inquiries into the reasons for the
death o f the Minoan civilization, and for vthe extinction of
the dinosaurs, as well ss the work of Darwin on the origin
o f soecies. are among the many illustrations. There has also
long been much consideration of the impact of known
hazards on past systems and species: studies of the
influence o f the last' ice age on the ecology, plants and
animals o f North America and other continents, and of the
irr.pact o f European civilization on various primitive
societies, are exampies.
In recent years, however, in addition to work to identify
past haza'rds and their effects, there has also been a, widely
recognized, huge increase in attention focused on present
ana future environmental hazards, their natures, the::
effects, and what can be done about them, ine effects of
8
*
oil spills and o f the release o f radioactive matter are but
two o f the many subjects of this accelerating emphasis, one
which promises to continue, and increase, fa; i very long
time.
Moreover, the sheer diversity o f hazards has led to a
c o r r e s p o n d i n g l y wide diversity in the people and
i n s t i t u t i o n s t h a t deal with them. And this, quite
understandably, has been accompanied by a :ene?|l failure ,
t o i d e n t i f y , and use, common, systematic principles
applicable whether the hazard is à dangerous virus, a hostile regime, or a larcenous employee.
,
.. I n f a c t . i n v i e w o f the Iimitless diversity o f
environmental hazards, of the species and systems they car
damage, and o f the protective responses they elicit, ii
would be easy to conclude that no simple and useful
classification of all such responses is possible. Nonetheless,
the classification problem is by no means unique, and is the
common scientific one of distinguishing and logically
grouping a very diverse subject matter (in comparison,
consider thé classification of plants, animals, organic
molecules, or rocks) sufficiently to.make broadly useful
distinctions, while avoiding such specificity of description
that such grouping is made impossible because each item is
thereby defined as unique.
With this necessity for a sufficient, but intermediate,
level o f generalization in mind, it is this paper's purpose t o
identify," illustrate, and briefly discuss the ten basic
r r w r e y t a that encompass ail of the measures that can
reduce damage: to people and all other living organisms: to
inanimate objects: and to systems of all kinds, by any, and
all, environmental hazards. These basic strategies are the
product o f the successful extension of earlier work presented by invitation as a Keynote Address to the Human
Factors Society's 1972 Annual Meeting - which identified
the ten strategies that, in one mix or another, are at least
theoretically available for reducing the results of "the
transfer o f energy in such ways and amounts, and at such
rapid rates'* that damage occurs. ("The harmful interactions,
w i t h people and property of hurricanes, earthquakes,
projectiles, moving vehicles, ionizing radiation, lightning,
conflagrations, and the cuts and bruises of daily life
illustrate this class.")!*'-! The new analysis, ir. subsuming
and extending the old. is necessarily very similar to it.
However, by'generalizing it to apply to all kinds o f
environmental-hazard damage situations, it shouid be of u
to many more , kinds of professionals and executives,
many more fields. A t the same time, this approach i L
c o h e r e n t l y and systematically identifies the general
strategies for reducaig the damage o f war. as will be oriefiy
illustrated oeiow in connection with each of the strategies.
H A Z A R D PREVENTION
september/'octsber i 9 6 0
intersection are not suitable for it. Dumps containing
hazardous chemicals and radioactive wastes are examples of
locations hazardous to people over very long periods; the
places where vehicles are moving are locations transiently
hazardous. The hazards involved, in such places are not.
however, necessarily products only of human activity. In
fact, before our species had evolved to the point of creating
its own environmental hazards, there were plenty ot
- n a t u r a l " ones, such as volcanoes and the paths of tigers.
But human activity is daily increasing the numbers ot
specific locations (many of them permanent) with wruch
people - and other living things - can intersect only at
their peril. Extended to its limit, this concept leads to the
well-known fear that man-made hazards spread throughout
the biosphere may make the earth itself a location
inimicabie to human health and survival; then the human
position - and that o f other living things - would be uke
that of sea birds in a generalized oil spill.
VI. To separate the hazard and that which is to be
protected by interposition of a material "barrier."
Illustrative tactics: electrical and thermal insulation, shoes,
safety glasses, shin and machine guards, helmets, shields,
armor piate, torpedo nets, nets under acrobats and other
elevated workers, scuba gear, space suits and other means
that interpose breathable mixtures between people and
hostile respiratory environments; containment structures
around nuclear reactors; vehicle air bags; and surgeons'
gloves all illustrate this widely used protective-barrier
strategy. Examples also abound in the attempts of peoples
in all periods' to protect their communities from so-called
"natural" hazards and from warlike neighbors. The dykes
'hat protect and define the polders of the Netherlands are
examoles of the former; the Great Wall o f China and the
Magiriot Line of the latter. Natural barriers - especially
oceans, rivers, deserts,' and mountains - have also often
served similar ourposes. Note that some barriers, such as
ionizinst radiation shields and surgical 'masks and many
other fillers, are less than totally efficacious: they attenuate
but do not totally block the hazard from reaching that
which Is to be protected. In the same way, geographical
barriers have not alwavs stopped hazards, the crossing ot
the Alos by Hannibal (no slight hazard to Rome) and of the
Hellespont by Xerxes to wage war on the Greeks being
well-known examples.
.
Although it is also a form o f time-and-place-ot-release
separation", this sixth strategy, like, the fifth, is also
separately identified from the fourth because the tactics
involved comprise a very large category, usually dearly
discrete from the others.
VU, To modify relevant basic qualities of the hasard. A
tactic which illustrates this strategy is altering the molecular
structures o f pharmacologic agents to eliminate undesirable
side efTects. This strategy is also illustrated by the tactic of
changing - t o reduce the possibility of electrocution - the.
voltages, wave forms, and frequencies with which electrical
power is delivered. Another group of tactics has to do with
changing surfaces, subsurfaces, or basic structures of
phvsical objects w i t h which damaging contact can be made.
One example would be changing the dimensions, shapes,
and physical and chemical characteristics of inorganic
fibers such as asbestos, as a means of reducing the human
darnase thev produce; another, increasingly used. :s making
roadside oôles so that they "break away" on impact. A
more obvious example is eliminating, rounding, or sottentng
corners, edges, points, floors, and other surtaces with wruch
people can (and therefore sooner or later do) come m
contact.
. ,
.
Though these principles have long been recognized and
apolied in situations involving the movement and handling
of oackaws and oroducts, as along industrial conveyor belts
c a r r v i n g damageable cargo, they have been widely
overlooked in the'design of buildings, furniture, toys, 1001s
10
and other eauioment, piaygrounds. and workplaces, w i t h
manv injuries the unnecessary result. Use of this strategy is
also greatly needed in the design o f nurseries, hospitals, and
nursing homes.
.
This strategy also has a logical piace in reducing the
damaee of war and of other forms o f collective violence,
specifically in the choice of weapons and means of defense
which, by being altered in their basic characteristics so as to
be less hazardous, do less permanent damage to people.,
prooerty, and natural systems. Tactics illustrating this
include use o f antipersonnel weapons which produce
transient incapacitation but less permanent damage. The
substitution bv some countries o f rubber bullets and water
hoses for real bullets in control of riots is illustrative 01
such tactics.
V I I I . To make that to be protected more resistant to
damage from the hazard. Examples include: immunization
against pathogenic organisms (such as- polio viruses) or
antigens (various pollens and others); Vitamin C (ascoroic
acid), or diea containing i t , for sailors to prevent scurry;
increasing the salt intake o f workers under thermal stress:
psychological and physical conditioning for athletes arid
soioiers; the comoartmentalization o f ships to make them
less likely to sink^ whether in war or peace; the toughening
of structures to make'them more resistant to earthquakes,
s t o r m s , a n d f i r e ; m i k i n g m o t o r v e h i c l e s more
crash-resistant; giving soldiers antimalarial compounds; and
giving drags (if any can be developed) to increase the
resistance of civilian and military personnel t o ionizing
radiation.
IX. To begin to counter damage already aone by tne
environmental hazard. A typical response to a flood,
invasion, fire, or other situation in which damage from
some environmental hazard is continuing or may have just
occurred has two pans - an effort (by strategies already
enumerated) to reduce or stop damage which may still be
occurring or may yet occur, and an eftort to counter
damage already done. Examples o f the former include
playing water on oil tanks adjacent to others already afire
(Strategy HI), turning o f f « s and water mains after breaks
(Strategy I V ) . evacuating people from places at which
damage is occurring ( S t r a t e ^ V ) , sandbagging in floods
( S t r a t e g y V I ) , tranquilizing rampaging large animals
(Strategy V I I ) , and giving gamma globulin to those alreaay
exposed to various viruses (Strategy V I I I ) . Examples of
tactics illustrative o f Strategy IX, beginning t o counter
damage already done, include boarding up shattered
windows, rescuing shipwrecked people or miners after
exolosions. taking steos to recover stolen property (the
thieves are the hazard, their thefts interactions w i t h the
environment to be protected), and ( i n the case of personal
injury) such measures as stopping hemorrhage, clearing
airwavs, splinting bones, and reattaching severed limbs. In
the case o f those ravaged by war, the rushing o f food and
other aid. the quick helping o f those in concentration
camps and other prisons, and the provision ot emergencywater, electricity, police, and other services also illustrate
this crucial and very frequently employed strategy.
:
j
|
j
;
;
;
X. To stabilize, repair, end rehabilitate the object of the :
damage. In the case o f damage to people, tactics under this ?
strategy include cosmetic surgery following trauma and »
phvsical theraoy for amputees and others w i t h disabling
injuries (including many thousands paralyzed annually by
s p i n a l c o r d damage s u s t a i n e d i n m o t o r vehicle
c r a s h e s ) . ] * . - * ] Other examples indude repairing o<
repiaeng buildings damaaed by fires and .earthquakes,
.•«seeding burned lorests. and programs such as the Marshal.
Plan which the United States implemented after World War
I I to rehabilitate European economies.
Hazard R «ponte Through History
The use of these strategies :o reduce da mace
h a z a r d
trotn
p r s v s î t i q î *
septeraber/october 19S0
frequencies of specific kinds of damage together with their
costs and then setting priorities accordingly, this approach
forces a far fuller consideration of options and tactics
which, in one mix or another, can commonly be applied
more cheaply and with far more satisfactory results.
Moreover, a far different set of priorities often results.
There are many illustrations of the difference. Thus,
when 19th century New England mill owners balked at
continuing paying " t h e very high annual fire insurance
premium based on fire frequency and size of loss, and
instead concentrated on the ways they could reduce their
bottom-line losses, their premiums fell by ninety-eight
percent. 11-1 In the process, they had set up their own
successful insurance group, developed -slow burning"
construction, invented far better sprinkler systems and fire
doors than those previously proposed, promulgated tough
standards, and gotten them enforced by law in many
domestic and non-U.S. jurisdictions.
It is imperative that all concerned approach the.
management of environmental hazard problems as logically
and efficiently as possible. Tne approach outlined here is a
tool to aid in the accomplishment of that objective.Tnis
framework also shows that although the .specific tactics
must usually be different, the underlying strategies that
may be useful are the same for all areas o f ' concern,
i n c l u d i n g t h o s e fodused on protecting the natural
environment, on the one hand, and those involving people
and man-made pro perry, on'the other.
Aeferenecs1. H a d d o n . W.. Jr., Energy damage and
the
ten
countermeasure strategies. Human Factors. 1973.
/Jf4>. 355-366.
2. Kaddon, W.. Jr., Advances in the epidemiology ot
injuries as a basis for public policy. Presented at the
]0?th annual meeting of the American Public Health
Association, New York, November 6 / 1 9 7 9 . in press,
Public Health Reports, September/October 1980.
3. Insurance Institute for Highway Safety. Seams Report
11:20. Washington: Insurance Institute for Highway
Safety. 1976.
4. Smart. C.N. and Sanders, C J U The Costs of Motor
5.
6.
7.
8.
Vehicle Related Spinal Cord Injuries. Washington:
Insurance Institute for Highway Safety. 1976.
Herodotus. Book VI I, fifth century B.C.
Plutarch's Lives(Tnemistodesh first century B.C.
Thucydides, Tne History of the Peloponnesien War.
fifth century B.C.
_
,
Kirby. R.S.. Wiihington, S„ Darling. A 3 . , et a l
engineering in History, New York: McGraw-Hill. 1956.
9. Katzev, S.W. and Katzev, M.L. Resurrecting the oldest
known Creek ship. National Geographic, 1970, IS7(6),
8 4 M 3 7 ;
.
. U
r
u
10. Katzev, S.W. and Katzev. M i . Last harbor for the
oldest
ship. National Ceogmhic,
Insurers Highway Safety Alliance, the National Association
of Indepenoent Insurers Safety Association, and several
individual insurance companies, which togetner write most'
of the nation's automobile insurance.
Or. Haddon became President of the I IKS in Varcn
1969. Since 1972. he also has concurrently served as
President of the Highway Loss Oata Institute, a nonprofit
organization established at that time to gather, orocess. and
provide the oublie with insurance industry data concerning
human and economic losses resulting from highway crashes.
Prior to Mardi 1963; Or. Haddon was Oirector o< tne
National Highway Safety Sureau (the present National
Highway Traffic Safety Administration!. United States
Department of Transportation, a position he held from his
appointment by President Johnson in the fall of 1963. with
the approval of the Senate, until his resignation early m
1969. As its first head, Dr. Haddon built the agency and the
extensive range of programs called for by the Congress m
the two safety acts of 1966. This included the development
of the national standards for state and community highway
safety programs, as well as the initial standards for motor
vehicles and their eouipment.
A physician with degrees from the Massachusetts
Institute of Technology. Harvard Medical School, and the
Harvard School of Public Health. Or. Haddon is an
authority on ecology of environmental hazards and publie
and private measures to reduce the damage to peooie and
prooerty associated with them.
Prior to his serviee w i t h the federal government. Dr.
wi
N f w
Y o f k
S:ata
Haddon was for ten
*h
Oepartment of Public Health. Ouring this period he earned
a reputation \as a thorough researcher and advocate of
analytical metnods in dealing with highway losses.. He
e s t a b l i s h e d special credentials in investigating the
relationship of -alcohol to fatal highway crashes: and,
subsequently, during his federal service, was principal
author of the 1968 Alcohol'and
Highway Safety
Repon
submitted by the Oepartment of Transportation to the
Congress. He also was senior author of Accident
Research:
Methods
and Approaches
(Harper & Row. 196*). one of
the basie works in the field of loss reduction, and his other
identifie publications, predominantly dealing with public
health, have been extensive.
Or. Haddon has been the recipient of numerous awards,
including the American Trauma Society's 1977
S;one
Award,
the American Public Health Association's
Î9S9
Bronfman Prize tor Public Health Achievement and the
19$9 MODERN MEDICINE Distinguished
Achievement
Award. ".~in recognition of outstanding contributions to
the progress of medicine as exemplified by his trailblazing
s c i e n t i f i c research in eauses of traffic trauma and
administrative efforts to promote highway safety".
1974, 144{5),
618-625.
11. Haddon, WM Jr., Cars that don't protect you m a ç n s h .
Surim and Society Review, Winter 1978*79, 28.
28-35.
•
.
1 2 . McKeon. P J . , Fire Prevention, A Treatise and
Textbook on Making Life and Property Safe Agsmst
Fire. Chapter I . 1-8. 1912, The Chief Publishing
Company, New York City.
About the Author
Or. William Haddon. Jr.. is President of the Insurance
I n s t i t u t e for Highway Safety, Washington. D.C.. an
I n d e p e n d e n t , n o n p r o f i t , scientific and educational
organization dedicated to reducing tne losses - deaths,
injuries and orooerty damage - resulting from crashes on
the nation's highways. MHS is suooorted by the American
Insurance Hignway Safety Association, the American
12
H A Z A R D P?^VINT:CN
septaaber/cctober 19 SO
formation
en
Prévention
des
Texte
de
principal
réseau
traumatismes
référence
«La violence
conjugale»
(Mme Hélène Cadrin, DSC de
Rimouski)
La vioCence conjugale
'Département
it santé
communautaire
Centre fiospitaCkr régional <Ce %}mous£i
février
1991
La violence, conjugate
Définition de la violence conjugale
La définition la plus largement acceptée par les auteurs pour décrire la
violence conjugale est la suivante : «Femme battue (violence physique),
menacée de l'être ou objet de scènes qui. laissent présumer qu'elle le sera
(violence verbale) ou encore humiliée par des critiques, des railleries
lesquelles à long terme peuvent détruire la personnalité et l'assurance
(violence psychologique). Cette violence est exercée par le conjoint dans les
cadres du mariage, de l'union de fait ou encore après que la femme l'ait
quitté» (Shee, 1980, Regroupement provincial, 1987).
Cette définition permet de distinguer les différentes formes de violence dont
sont victimes les femmes : violence psychologiquè, verbale et physique. À ces
trois formes de violence s'ajoute la violence sexuelle (Regroupement
provincial, 1987).
Prévalence
En 1980, le Conseil consultatif canadien sur la situation de la femme (CSSSF)
estimait que 1 Canadienne sur 10 était victime de violence conjugale. Au
Québec, en 1985, le ministère de la Santé et des Services sociaux publiait des
résultats similaires : 1 femme de 15 ans et plus sur 8 serait victime de
violence. Dans le cadre de la consultation d'experts par la Commission
d f enquête sur les services de santé et les services sociaux (CESSSS), les
estimations obtenues établissent que 1 femme sur 7 est violentée (CESSSS,
1987). Sur le plan judiciaire, on assiste à une augmentation considérable des
dénonciations des infractions relatives à la violence conjugale qui sont
passées de 6559 en 1987, à 8096 en 1988 et à 9376 en 1989 (ministère de la
Sécurité publique, 1990).
3
Caractéristiques des femmes victimes de violence conjugale
t
Cette forme de violence se retrouve dans tous les milieux socio-économiques,
à travers tous les groupes d'âge et toutes les races. Le statut socio-économique
ne protège aucunement de la violence conjugale.
Par contre, le profil socio-économique,des femmes faisant appel à des
ressources telles les maisons d'hébergement est plus facilement identifiable
que celui , des femmes victimes de violence qui n'ont pas recours à ces
services. En grande majorité, ces femmes se caractérisent par des moyens
financiers réduits et par l'isolement dans lequel elles vivent. Elles sont
généralement jeunes, dépendantes économiquement, peu scolarisées et sont
peu nombreuses à occuper tin travail à l'extérieur du foyer (MacLeod, 1980,
1987; Regroupement des maisons d'hébergement, 1987; CESSSS, 1987).
Traumatismes
Blessures «dites majeures» aux f e m m e s et à leur enfant
TYPE
Enfant (%)
F e m m e (%)
4,3
2,2
0,0
0,0
2,2
0,0
91,3
5,6
17,8
3,7
3,7
0,9
1/9
66,4
Fracture
Coupure
Brûlure
Fracture et coupure
Fracture et brûlure •
Coupure et brûlure
Aucune
100,0(46)
100,0 (107)
Total
Source: S. Kérouac, M. E. Taggart, J. Lescop. Portrait de la santé de femmes violentées et de leurs
enfants. Université de Montréal, Septembre 1986, p. 47.
Blessures «dîtes mineures» faites aux f e m m e s et à leur enfant
TYPE
FRÉQUENCE
Rarement Jamais
Total
Plupart du
temps
Souvent
47,7
7,6
0,9
1U
5,7
0,9
25,2
11,4
11,3
15,9
75,2
86,8
100,0 (107)
100,0 (105)
100,0 (106)
25,5
33,3
2,2
14,9
0,0
0,0
40,4
66,7
4,3
19,1
0,0
93,5
100,0( 47)
100,0 ( 3)
100,0 ( 46)
Femme
Ecchymoses
Lacérations
Pertes de conscience
Enfant
Ecchymoses
Lacérations
Potes de conscience
enfants, Université de Montréal, Septembre 1986, p. 45.
\
Traumatisme
Cibles visées lors des scènes de violence".
<
TYPE
Plupart du
temps
Souvent
FRÉQUENCE
Rarement Jamais
Total
•
Femme
Bras
Visage
Tête.
Cou
Épaules
Jambes
D09
Fesses
Ventre
Seins
Parties génitales
/
26,4
41,1
28,0
24,3
14,2
1U
8,4
6,6
3,7
0,9
03
26,4
93
14,0
5,6
12,3
103
5,6
0,9
6,5
3,7
2,9
17,0
27,1
22,4
27,1
193
15,9
15,9
9,4
73
73
43
30,2
22,4
353
43,0
533
62,6
70,1
83,0
82,2
87,9
923
100,0 (106)
100,0(107)
100,0 (107)
100,0 (107)
100,0 (106)
100,0 (107)
100,0 (107)
100,0 (106)
100,0 (107)
100 3 (107)
100,0 (104)
25,0
19,1
203
10,4
83
6,3
- 4,2
4,2
0/)
0,0
22,9
17,0
83
10,4
6,3
16,7
83
83
10,4
183
253
14,6
16,7
83
10,4
83
4,2
2,1
4,2
333
383
563
623
77,1
66,7
79,2
833
873
953
100,0 (
100,0 (
100 3 (
1003 (
1003 (
1003 (
1003 (
1003 (
1003 (
100,0 (
Enfant
Fesses
Visage
Tête
Bras
Épaules
Jambes.
Cou
Dos
Ventre
Parties génitales
03
48)
47)
48)
48)
48)
48)
48)
48)
48)
48)
enfants. Université de Montréal, Septembre 1986, p. 51.
2
Hiecâercfie : "État de (a santé des femmes et des enfants
victimes de violence
Objectif général
V
L'objectif de l'étude «État de santé des femmes et des enfants victimes de
violence conjugale» est d'établir le portrait de santé des femmès et des enfants
ayant vécu dans un contexte de violence conjugale en dressant le profil social
de ces femmes.
Objectifs spécifiques et analyse
" Les données ont été analysées en vue de décrire :
—
—
—
les caractéristiques socio-économiques des femmes enquêtées;
les caractéristiques conjugales de ces femmes;
la violence subie par ces femmes et leurs enfants, etc.
Cette analyse a permis de comparer la situation des femmes, au moment de
leur séjour en maison d'hébergement, parallèlement à celle vécue au moins
un an après ce séjour.
Méthodologie
Les femmes recensées pour agir à titre de répondantés pour l'enquête Santé
des femmes sont des ex-hébergées ayant séjourné, au moment de l'étude,
depuis au moins un an dans l'une des quatre maisons d'hébergement des
villes suivantes? : Rimouski, Matane, Pabos et Ste-Anne-des-Monts. Ces
maisons sont situées sur le territoire des régions du Bas-St-Laurent et de la
Gasipésie.
Les résultats obtenus sont comparés avec les résultats de l'enquête Santé
Québec, les répondantes ayant été jumelées aux femmes de cette étude sur la
base de leur âge, statut civil, statut d'activité et scolarité. Au total,
3
3510 femmes de l'enquête Santé Québec (ESQ) ont été jumelées au
110 femmes de l'enquête Santé des femmes (ESFV) et leurs 120 enfants ont u
groupe de référence de 3754 enfants.
Variables
Les variables indépendantes retenues sont :
—
—
—
< —
—
la scolarité;
le statut d'activité;
le revenu;
le statut civil;
le type de violence (physique, psychologique; verbale et
sexuelle).
'
!
Les variables dépendantes sont :
—
—
—
—
la perception qu'ont les femmes de leur santé;
la prévalence de problèmes chroniques de santé;
la consommation de médicaments;
le recours aux services de santé.
Cueillette dès données
La cueillette des données s'est déroulée entre le 15 octobre 1989 et le 15 avril
1990. Parmi les femmes hébergées entre la date d'ouverture de chacune des
maisons d'hébergement et le 1er ,octobre 1988, soit 583 femmes, 153 ont pu
être localisées, ce qui représente un peu plus de 1 femme sur 4. Aucune
information n'a pu être obtenue pour près des deux tiers de ces femmes, alors
que différentes démarches ont permis de constater que le tiers de ces femmes
avaient quitté la région. Sur ce nombre,;41 ont refusé de participer à l'enquête
tandis què 110 acceptaient. Le calcul des intervalles de confiance a permis
d'identifier les différences significatives pour l'ensemble des résultats et le
seuil de confiance a été fixé à 0,95.
LOCALISATION DES MAISONS D'HÉBERGEMENT
DES M.R.C. DU BAS-ST-LAURENT ET DE
LA GASPÉSIE-ILES-DE-LA-MADELEINE
SIE
BA8-SAINT-LAURENT
uousw-
\
NEI6ETTE
M , T
»
N.
RIVtb*E-OlM.OUP
KAMOUI
fLC3-DE-LA-MADELEINE
MAISON D'HÉBERGEMENT
LIMITS 0C9 M.R.C.
LIMITE HlilOHALE
0
SO
40 KM
V
2
LES RÉSULTATS EN BREF
1
•S
Bien que l'on reconnaisse de plus en plus l'importance du phénomène de la
violence conjugale très peu de recherches ont porté sur ses conséquences. Les
résùltats des études réalisées jusqu'à maintenant permettent de croire que l'état
de santé physique et mentale des femmes violentées serait moins bon que celui
d'une population comparable. L'étude de Kérouac, Taggart et Lescop (1986),
menée auprès de femmes violentées au moment de leur séjour en maison
d'hébergement, réflète que l'état de santé des femmes violentées est peu
enviable notamment par la présence de problèmes de santé chroniques et de
malaises variés telle l'insomnie, la fatigue générale, etc. Cependant, les
conséquences à long terme de la violence conjugale sur l'état de santé
demeurent peu documentées. La recherche, «État de santé des femmes et des
enfants victimes de violence conjugale» a été entreprise afin de mieux cerner le
problème.
Caractéristiques de la population étudiée
—
La plupart des femmes de l'enquête vivent sous le seuil de la pauvreté.
En effet, 85 % d'entre elles subsistent avec un revenu annuel inférieur à
12000$.
—
Le profil socio-économique des femmes au moment de l'enquête reste
sensiblement le même que celui qu'elles présentaient lors de leur séjour
en maison d'hébergement (scolarité, revenu, occupation, etc.).
—
Là'"modification la plus importante est le changement de statut civil. En
effet, près de la moitié des femmes qui étaient mariées ou qui vivaient en
union libre vivent maintenant sans leur conjoint violent Toutefois,
malgré ce changement de statut civil, près de 70 % de ces femmes restent
économiquement dépendantes d'un conjoint.
'
3
Violence subie
La majorité des femmes interrogées, ont subi avant leur séjour en hébergement
plus d'une forme de violence. Plus de 90 % ont été victimes de violence
psychologique alors que 54,7% ont été violentées physiquement. Ces femmes
nous rapportent que leurs enfants ont été battus dans 25 % des cas et que 5 %
d'entre eux ont été agressés sexuellement
TABLEAU 1
Violence subie par les femmes
Fréquence (95)
1 forme de violence
2 formes de violence
3 formes de violence et +
Prévalence
Violence psychologique
Violence verbale
Violence physique
Violence sexuelle
N
%
15
21
59
15,8
22,1
62,1
87
81
52
26
91,6
85,3
54,7
27,4
Profil, support et intégration sociale
Le profil social des femmes ex-hébergées indique qu'elles jouissent, depuis leur
passage en maison d'hébergement, d'une bonne intégration sociale et que leur
support, à ce niveau, repose principalement sur leurs amis. Paradoxalement,
ces femmes se retrouvent souvent seules lors de leur temps libre ce qui
démontre que la présence d'amis serait insuffisante pour assurer un support
social satisfaisant.
\
.
TABLEAU 2
Indice d'intégration sociale, ESFV et ESQ
Indice d'intégration sociale
ESFV
ESQ
%
%
Faible
Modéré
Élevé
3,2
23,2
73,7
5,5
15,6
78,6
4
Problèmes de santé des femmes ex-hégergées
À quelques exceptions près, toutes les femmes ex-hébergées ont plus d'un
problème de santé ce qui les démarque nettement des autres femmes (enquête
Santé Québec, population comparable) pour l'ensemble des problèmes de santé.
Les principaux problèmes que ces femmes présentent sont au niveau de la
santé mentale. À ces problèmes s'ajoute une série de problèmes chroniques de
santé physique.
TABLEAU 3
Fréquence des problèmes de santé chez les femmes,
ESFVetESQ
Problèmes de santé
Au moins un problème
•
Un problème
Plus d'un problème
Aucun problème .
j
Nombre moyen de problèmes/femme
*
ESFV
%
ESQ
%
•98,2
•10,0
•88,2
•1.8
•70,7
•25,2
•45,5
•29,3
4,1
1.8
Les résultats précédés d'un "" sont significativement différents entre les
deux groupes.
/
5
TABLEAU 4
Taux de problèmes de santé par 100 femmes, ESFV et ESQ
Problèmes de santô
Troubles mentaux
Maux de tête
Arthrite et rhumatisme
Maux de dos
Troubles digestifs fonctionnels
Troubles de la vision
Allergies et affections cutanées
Hypertension
Asthme, bronchite, emphysème
Traumatismes
Allergies
Anémie
Troubles des organes génitaux féminins
Rhume des foins
Ulcères gastriques et duodénaux
Maladies cardiaques
Affections respiratoires aiguës
Autres troubles digestifs
Troubles de thyroïde
Grippe
Troubles de la dentition
Malaise et fatigue
Troubles de l'audition
Autres affections ostéo-articulaires
Autres
ESFV
•75,5
•45,5
•32,7
•32,7
•25,5
•23,6
•22,7
•14,5
•13,6
13,6
12,7
•11,8
9.1
•8,2
8,2
7.3
4,5
4,5
2,7
2.7
2,7
2,7
1,8
0.9
47,2
E33
•19,9
•20.3
•18,0
•15,1
. *7,7
•1,3
•11,6
•6.7
•5,0
7,2
9,1
•3,8
4,9
•5,5
2.2
4,7
7,2
2.9
3,7
4,0
0.8
4,7
1.3
5.2
14.9
Les résultats précédés d'un "** sont significativement différents entre les deux groupes.
TABLEAU 5
Prévalence des problèmes psychologiques qualifiés de
sévères chez les femmes, ESFV et ESQ
Problèmes psychologiques sévères
ESFV
%
S3
%
Déficience mentale
Dépression
Grande nervosité ou irritabilité
Confusion ou perte de mémoire
Vision et voix
0,9
•14,5
•41,8
#
5,5
2,7
0.0
•3.7
•6.7
•0,4
0.2
Total des femmes
•45,5
*9,4
6
Les femmes qui vivent présentement sans conjoint présentent globalement un
meilleur état de santé mentale que les autres femmes. Cette constatation est
encore plus marquée chez les enfants.
Problèmes de santé chez les enfants
.
(
r
Comme c'est le cas pour leur mère, les résultats concernant les enfants des
femmes ex-hébergées se démarquent nettement des résultats obtenus pour les
enfants de l'enquête Santé Québec, en ce qui a trait à l'état de leur santé. Plus
de la moitié de ces enfants présentent au moins un problème de santé,
principalement au niveau de la santé mentale. En effet, plus de 16 % de-ces
enfants affichent lin problème psychologique qualifié de sévère.
À ces problèmes s'ajoutent, tout, comme c'est le cas pour leur mère, des
problèmes chroniques de santé physique. De plus, ces enfants se distinguent
des autres enfants (enquête Santé Québec, population comparable) par le taux
élevé d'accidents avec blessures graves qui surviennent à la maison.
i
TABLEAU 6
Fréquence des problèmes de santé chez les enfants,
ESFVetESQ
Au moins un problème
*
Un problème
Plus d'un problème
Aucun problème
Nombre moyen de problèmes/enfant
'
Los résultats précédés d'un
deux groupes.
ESFV
%
533
%
"62,8
*45,7
*36,4
*26,4
*29,6
M 6,1
* 3 7,2
*54,3
1,2
0,7
sont significativement différents entre les
7
TABLEAU 7
Taux de problèmes de santô par 100 enfants, ESFV et ESQ
ESFV
ESQ
Troubles mentaux
*20,7
*4,5
Allergies et affections cutanées
13,2
8,0
Maux de tête
8,3
3.0
Asthme
7,4
5,4
Traumatismes
7,4
4,4
Afféctions respiratoires aiguës
6,6
' 6,3
Troubles de la dentition
5,8
1.9
Allergies
5,0
6.4
Arthrite et rhumatisme
4,1
1 .2
Grippe
3,3
6,1
Bronchite, emphysème
3,3
1.4
Troubles de la vision
2,5
1.0
Maladies cardiaques
2,5
0,2
Troubles des organes génitaux féminins
2.5
0,3
Anémie
1.7
0,9
Rhume des foins
1,7
3,1
Maux de dos
1.7
0.7
Troubles de l'audition
1.7
3,8
Autres troubles digestifs
>
0,8
0,3
Autres affections ostéo-articulaires
0,8
0,4
Autres
13.9
B.7
* Les résultats précédés d'un "" sont significativement différents entre les deux groupes.
i
TABLEAU 8 . Prévalence des problèmes psychologiques qualifiés de sévères
chez les enfants, ESFV et ESQ
Problèmes psychologiques sévères
ESFV
Déficience mentale
Dépression
Grande nervosité ou irritabilité
3,3
2,5
•11,6
0,3
0,0
•1,3
% d'enfants
•16,5
•1.6
ŒQ
* Les résultats précédés d'un '** sont significativement différents entre les deux groupes.
8
Consultation et consommation de médicaments chez les femmes
ex-hébergées
Les femmes ex-hébergées sont deux fois plus nombreuses que les femmes de
l'enquête Santé Québec à avoir, au cours des deux semaines précédant
l'enquête, consulté un professionnel de la santé. Elles se démarquent surtout
par l'importance des consultations auprès des travailleurs sociaux et des
psychologues (10,9 % comparativement à 0,8 %). Elles sont, par ailleurs, plus
nombreuses à consommer des médicaments principalement en ce qui à trait
aux tranquillisants qu'elles utilisent deux fois plus que les autres femmes
(enquête Santé Québec, population comparable).
TABLEAU 9
Fréquence des consultations au cours des deux
dernières semaines, femmes, ESFV et ESQ
Consultation
•
Au moins une consultation
•
Une consultation
•
Plus d'une consultation
Aucune consultation
%
•25,6
•20.1
*5f5
•74,4
0.6
0,4
Les résultats précédés d'un "" sont significativement différents entre
les deux groupes.
TABLEAU 10
Médicaments consommés au cours des deux derniers
jours, femmes, ESFV et ESQ
Médicaments
Au moins un médicament
Un médicament
•
Deux médicaments
•
Trois médicaments et +
Aucun médicament
Nombre moyen de médicaments/femme
*
eso
%
•46,3
•33,6
•12,7
•53.7
Nombre moyen de consultations/femme
•
ESFV
.
ESFV
%
EBQ
%
"74,5
0,9
30,0
•43,6
•25,5
•64,4
0,1
32,6
•31,7
•35,6
3,4
2,4
Les résultats précédés d'un "" sont significativement différents entre
les deux groupes.
9
Consultation et consommation de médicaments chez les enfants des
femmes ex-hébergées
Les enfants des femmes ex-hébergées sont également plus nombreux que les
enfants de l'enquête Santé Québec à avoir consulté un professionnel de la santé
(toujours au cours des deux semaines précédant l'enquête). Os se distinguent
eux aussi par le taux élevé de consultations effectuées auprès de travailleurs
sociaux et de psychologues. De plus, près de la moitié de ces enfants prennent
des médicaments.
TABLEAU 11
Fréquence des consultations au cours des deux dernières
semaines, enfants, ESFV et ESQ
Consultation
ESFV
%
SQ
%
Au moins uné consultation
•32,2
•18,9
21,5
•10,8
16,3
•2,6
•
•
Une consultation
Plus d'une consultation
#
Aucune consultation
Nombre moyen de cônsultations/enfant
*
Les résultats précédés d'un
deux groupes.
TABLEAU 12
67;8
•81,1
0,3
0,2
sont significativement différents entre les
Médicaments consommés au cours des deux derniers
Jours, enfants. ESFV et ESQ
Médicaments
ESFV
%
fflQ
%
Au moins un médicament
42,1
37,5
0,0
29,7
12,4
0,0
28.1
9,4
57,9
62,5
1.1
1.0
•
Un médicament
Deux médicaments
Trois médicaments et +
Aucun médicament
Nombre moyen de médicaments/enfant
10
Conclusion
1
L'état de santé des femmes violentées ex-herbergées et de leurs enfants semble
étroitement associé au contexte général de violence dans lequel ces personnes
vivent. Ces femmes et leurs enfants ont un portrait de santé peu enviable
quand on les compare à une population ayant les mêmes caractéristiques socioéconomiques.
Le fait de se soustraire à la violence présente la meilleure garantie d'une
amélioration de l'état de santé. En effet, les femmes qui ont quitté leur
conjoint et qui vivent seules présentent un meilleur état de santé que celles qui
habitent encore avec leur conjoint violent. Il en va de même pour la santé de
leurs enfants. Toutes les actions futures visant à réduire la violence et les
conséquences de cette violence devraient prendre en considération ces
résultats.
Source : Hélène Cadrin
(418) 724-8469
(418)724-8454
iDossier violence au "DSC de $(imous(çi
La violence conjugale n'est pas un phénomène récent. Ce n'est pourtant que
depuis la dernière décennie que l'on tente de comprendre et de mesurer ce
phénomène. Jusqu'à tout récemment, on considérait que cette forme de
violence faisait partie des rapports privés existant entre deux personnes
adultes et qu'elle n'avait aucune incidence sociale. La portée socio-sanitaire
de la violence conjugale commence à peine à être reconnue.
Dans le but de .participer à l'amélioration des connaissances sur cette
problématique, le Département de santé communautaire (DSC) de Rimouski
s'intéresse spécifiquement, depuis bientôt quatre ans, à . diverses aspects
relatifs à la violence. Cet intérêt se concrétise par un soutien aux organismes
communautaires intervenant en violence. Ainsi, le DSC a participé à la mise
en place et au fonctionnement des services du Centre d'aide et de lutte contre
les agressions à caractère sexuel inc. (CALACS), du Centre d'aide aux victimes
d'actes criminels inc. (CAVAC) ainsi que du groupe d'intervention pour
conjoint violent. Contre toutes agressions conjugales inc. (C-TA-C). Ces
organismes sont situés sur le territoire du DSC de. Rimouski.
Des projets de recherche ont également été réalisés ou sont en voie de l'être.
Les personnes âgées, abusées et exploitées par leur famille, les enfants agressés
sexuellement et les conséquences de la violence sur l'état de santé des femmes
et des enfants sont lés sujets qu'ont documentés, au cours des dernières
années, les chercheurs du DSC de Rimouski.
Finalement, le DSC dispense aux intervenants—tes des réseaux des affaires
sociales, de la justice, de l'éducation et des groupes communautaires de la
formation concernant les divers aspects de la violence faite aux femmes, aux
enfants, aux personnes âgées ainsi qu'aux victimes d'actes criminels.
r
4
Bibliographie
Commission d'enquête sur les services de santé et les services sociaux (1987),
Programme de consultation d'experts, Dossièr «Femmes», Québec, 222 p.
Conseil du statut de la femme (1978), Pour les Québécoises : égalité et
indépendance. Éditeur officiel du Québec, Québec, 335 p.
Kérouac S., Taggart M.E., Lescop J. (1986), Portrait de la santé des femmes
violentées et leurs enfants. Conseil québécois de la recherche sociale,
147 p.
Larouche, Ginette (1985), Guide d'intervention auprès des femmes
violentées, Montréal, Corporation des travailleurs sociaux du Québec,
93 p.
MacLeod, Linda (1980), La femme battue au Canada : un cercle vicieux,
Conseil consultatif canadien sur la situation de la femme, Ottawa, 72 p.
MacLeod, Linda (1987), Pour de vraies amours... Prévenir la violence
conjugale. Conseil canadien consultatif sur la situation de la femme,
Ottawa, 191p.
Ministère de la Santé et des Services sociaux (1985), Une politique d'aide aux
femmes violentées. Gouvernement du Québec, 59 p.
Ministère de la Sécurité publique (1990), «Violence conjugale», Statistiques
1989, Gouvernement du Québec
Regroupement provincial des maisons d'hébergement et de transition pour
les femmes victimes de violence conjugale. L'amour brisé
formation
en
Prévention
Texte
réseau
des
complémentaire
traumatismes
de
«La violence
conjugale».
(Mme Hélène Cadrin, DSC de
référence
Rimouski)
formation
en
Prévention
des
Texte
de
principal
réseau
traumatjsmes
référence
«Présentation
d'intervention
sur
la
blessures
par arme à feu»
(M. Antoine Chapdelainè,
DSC de l'Hôpital de
problématique
l'enfant-Jésus):
des
i
Contrôle
des armes
à feu
i
accessibilité acceptabilité
économique
disponibilité
commodité
d'utilisation
en agissant sur
la :
r
manufacture ou
importation
-
T
vente ou
transfer
>
possession
-
utilisation
-
-)
Antoine Chapdelaine, 1990 ©
A matrix for a Comprehensive Gun Control Plan for Canada In the 1990*3.
„ availability
affordability
acceptability accomodation
manufacture or
importation
Ban any semiautomatic gun that
can be converted
or reconverted to
an automatic gun
and the sale of its
ammunition
Exclude guns and
ammunition from
any Free Trade
Agreement and
heavily tax all
imported guns
and ammunition
Public information
on the relative
safety of different
firearms
and
ammunition for
sale in Canada
Prohibit
the
importation
of
restricted guns in
Canada except for
the military and
police forces and
rare exceptions
sale or transfer
Ban certain semi*
automatic guns
that can contain
more than three
(3) bullets in its
magazine
Increase the fee
for a FAC & RWC
to the reai cost of
a complete, and
mandatory criminal
& mental check
Lengthen the
time
before
granting a FAC or
RWC to provide
time for more
checking and limit
the length of time
of validity for
purchase
of
ammunition
Require a separate
FAC & RWC for
each firearm, with an
ID photo on each
certificate and serial
number of gun sold,
to be shown when
buying ammunition
in a store
possession
Require that all
guns be stocked
in a safe place &
separate from any
ammunition
except during the
hunting season
(shooting club,
police station)
if guns are kept at
home, require the
purchase of a gun
safety vault with
the purchase of a
new gun
Public information
to stress the fact
that, ownership of
a firearm is a
privilege, not a
right
Revoke the FAC or
RWC and confiscate
all guns belonging
to anyone convicted
for poaching or to
criminals that serve a
sentence of more
than a year
use of a gun
Current regulation
for use and transit
of restricted guns
Is adequate, the
same
should
apply for hunting
guns
Increase taxes on
ammunition and
prohibit the sale of
materials .for the
manufacture of
homemade
ammunition
Require training in
gun use with a
mandatory test
before issuance
of a FAC or RWC
Restrict the sale of
firearms that are
safer
to
use
correctly and harder
to use inadvertently
when loaded (e.g.,
trigger locks)
Gun control
on :
FAC: Firearm acquisition Certificate
RWC: Restricted Weapons Certificate
Développé par Antoine Chapdelaine, DSC-HEJ, 1990
Antoine Chapdelaine, 1990 ©
17
formation
en
Prévention
Texte
réseau
des
complémentaire
traumatismes
de
référence
«Présent
at Ion
d'intervention
sur
la
problématique
blessures
par arme à feu»
{M. Antoine Chapdelaine,
DSC de l'Hôpital de /'Enfant-Jésus)
.
des
Le contrôle des armes à feu:
une question de santé publique
Mémoire présenté
au Comité spécial
sur l'objet du projet de loi C-80
Association des hôpitaux
du Québec
AHQ
LE CO NTR Û L E DES A R M E S
À FEU :
UNE QUESTION DE SANTÉ PUBLIQUE
Mémoire soumis au comité parlementaire, spécial sur
l'obiet du projet de loi C-80 (Armes à feu)
P A R :
Antoine
Chépdelaine,
Département
Hôpital
M.D.,
M.P.H.,
F.R.C.P.(C),
médecin-conseil,
de santé, communautaire, santé publique et environnement,
de l'Enfant-Jésiis
à
Québec
et
membre
du
Comité
des
32
Départements de santé communautaire du Québec sur la prévention des
traumatismes.
Jean-Pierre Bélanger, M.A., président sortant de l'Association de Santé.
Publique du Québec.
Robert Maguire, M.D., M.P.H., C.S.P.Q., directeur, Département de santé
communautaire, Centre hospitalier régional de Rimouski et président du
Comité de l'Association des hôpitaux du Québec sur les traumatismes.
\
•
TABLE
DES
MATIÈRES
INTRODUCTION
Avantagés et risques
Les avantages
^
Les risques
L'accessibilité: une préoccupation pour la santé publique
Problèmes actuels et législation en vigueur
f
Le Projet de loi CTBQ
Suggestions à l'égard du Projet de loi C-80
s
Sujets de recherche proposés
Une Loi pour le contrôle global des armes à feu au Canada
RECOMMANDATION
RÉFÉRENCES
page... It
INTRODUCTION
Au Canada, en 1986, le suicide et l'homicide occupaient respectivement le
deuxième et le troisième rang des causes d'années potentielles de vies perdues
par blessures, venant juste après les traumatismes liés aux véhicules moteur?
(1). Environ le tiers de tous les cas de suicides et d'homicidee sont commis
avec des armes à feu.*
Au Canada, de 1892 à 1978, les efforts concernant le contrôle des armes à feu
ont été orientés sur la réglementation de l'Importation, de l'achat, de la
possession et de l'utilisation de ces armes (2). La législation sur le contrôle
des armes à feu. en vigueur actuellement a été adoptée en 1978. On étudie
présentement la possibilité de la modifier au moyen du Projet de loi C-80,
déposé aux Communes en juin 1990.
Une dizaine d'années après la loi de
1978, ce mémoire
présentera
les
avantages d'un contrôle des armes è feu par rapport aux risques associés à
leur accessibilité en relation avec le suicide, l'homicide, les accidents et le
voL Nous décrirons le système actuel de contrôle des armes à feu appliqué au
Canada, ainsi que le Projet C-80. Enfin, nous formulerons des suggestions
*
(Dans le présent texte, l'expression "arme à feu" désigne tous les genres
d'armes à feu.)
page...
It
à l'égard du Projet de loi C-80 et des recherches à venir, en vue de
promouvoir une politique de santé publique plus efficace conforme au désir
d'un contrôle plus serré des armes à feu manifesté par les canadiens en 1990.
AVANTAGES ET RISQUES
L'objectif visé par le contrôle des armes à feu est de réduire les risques au
minimum et de maximiser les avantages découlant d'une bonne utilisation (2).
Les avantages
*
^
Les avantages liés à la possession légale d'une arme à feu sont décrits dans la
littérature comme étant associés à:
1°
la pratique d'une activité de loisir comme la chasse, le tir à la cible et la
collection d'armes à feu (3).
En 1987, on comptait
1,7 million de
chasseurs au Canada. Ce nombre représentait 8,4% de la population âgée
de 16 ans et plus, c'est-à-dire l'âge légal pour la possession des armes dé
chasse (4).
Le tir et la collection d'armes à feu (en l'absence de
munitions mortelles) ne sont ni un sport de masse, ni une activité
particulièrement dangereuse, à condition que les armes à feu ne soient
page... It
pas chargées pendant leur entreposage et qu'elles soient gardées dans un
lieu sûr où elles ne peuvent être volées et utilisées dans des actes de
violence.
2°
Un sentiment
de vulnérabilité (3) moindre chez les personnes pour
lesquelles de telles armes sont jugées nécessaires à titre de protection
pour leur travail.
3°
Une' protection personnelle contre les voies de fait et les vols qualifiés
(3).
En fait, les armes à feu ne procurent que rarement une telle
protection. Une étude menée aux États-Unis a démontré qu'il est six fois
plus probable qu'une arme à feu. chargée, gardée dans un domicile, soit la
cause d'une mort accidentelle plutôt qu'elle permette de tuer un intrus
(5).
Les risques
/
,i
Les armes à feu présentent un risque mortel à la fols pour les particuliers et
pour la collectivité.
En effet, les armes à feu .utilisées pour la chasse
sportive, le tir à la cible, les collections ou à des fins de protection peuvent
également être utilisées pour des suicides, des homicides ainsi que dans des
cas d'accident, de vol et de braconnage (3). Au Canada, en 1987, les armes à
feu (et les explosifs) ont causé la mort de 1 432 personnes (6). Ces décès ont
été classés comme suit:
page— 5/
•
1 126 suicides (79% des décès par arme à feu)
•
193 homicides (13,5% des décès par arme à feu)
•
6Q morts accidentelles
•
39 morts "de nature indéterminée, accidentelle ou non"
\
•
14 morts découlant d'interventions policières
1)
Le suicide.
i
L'accessibilité des armes à feu facilite le suicide (3).
De
fait, le suicide constitue un problème Important au Canada. En 1989, on
estime qu'il y a èu 3 640 suicides réussis. Dans 78% des cas, il s'agissait
d'hommes; dans 22%, de femmes. Le suicide est la deuxième cause de
décès chez les sujets
masculins
dé 5 à' 30 ans, et la principale cause pour
•
i
les hommes âgés de 30 à 40 ans (7).
Chez les femmes, la tendance est
semblable quoique moins importante.
Au Québec, de 1975 à 1979, c'est l'arme à feu qui a été utilisée le plus
souvent dans les suicides (33%). En 1988, au bureau du coroner du Québec, on
à enregistré 1 123 cas de suicide, dont 293 (26%) par arme à feu, ce qui a
porté les armes à feu au second rang des moyens de suicide, après la
pendaison. En 1988, 875 (78%) suicidés étaient des hommes, parmi lesquels
156 (18%) avaient entre 15 et 24 ans (8). Le groupe des 15 à 24 ans est
particulièrement sensible au contrôle des armes à feu pour prévenir les
suicides.
r
p
Dans une étude concernant la réglemehtatloh des armes à feu et des taux de
suicide, on a comparé les endroits suivants: . King County (Washington, É.-U.)
page... It
et Vancouver (C.B.) (9). L'on a observé à King County un taux de suicide par
arme à feu six fols plus élevé que celui de Vancouver. Pour les 15 à 24 ans, le
taux de suicide par arme à feu était presque dix fols plus élevé à King
County. Qui plus est, les taux de suicide par d'autres moyens chez les 15 à 24
ans de Vancouver n'étalent pas plus élevés. Les auteurs ont conclu qu'en
limitant l'accès aux armes à feu, l'on pouvait réduire le taux de suicide chez
les personnes âgées de 15 à 24 ans (9) puisqu'elles n'utilisent pas d'autres
moyens de remplacement.
2)
Homicide. Au Canada, en comparaison avec les États-Unis (30), l'on peut
observer les effets bénéfiques des dispositions législatives de
1978
• régissant le contrûle des armes à feu. En 1976, 39% dès 668 homicides
recensés au Canada ont été commis avec une arme à feu;
en 1988,
seulement 29% des 575 homicides l'ont été. De même, en 1976, 39% des
vols commis ont été faits à main armée, cette proportion étant tombée à
25% en 1988 (10). Cette chute est une tendance observée depuis près de
20 ans et accélérée depuis la loi de 1978.
Dans une étude où l'on comparait la réglementation des armes à feu et le
nombre d'actes criminels, de voies de fait et d'homicides à Seattle et à
Vancouver
(C.B.)
(11),
les
auteurs
ont
conclu
que
malgré
des
taux
généralement similaires d'activités criminelles et de voles de fait dans ces
deux villes, le risque de décès par homicide est plus élevé à Seattle qu'à
Vancouver. Cette grande différence s'explique par le fait que le risque d'être
page... 10/
tuâ par balle est cinq fols plus élevé à Seattle qu'à Vancouver, car le contrôle
des armes à feu est plus restrictif au Canada qu'aux États-Unis.
Les armes que l'on peut se procurer légalement peuvent être utilisés à des fins
non prévues, comme par exemple dans une dispute de ménage. De fait, les
meurtres sont souvent le résultat de telles disputes.
Dans un moment de
colère, une personne peut poser des gestes désastreux si elle a accès à une
arme à feu, puisqu'il est si facile de blesser ou de tuer avec de telles armes.
Par contre, il faut faire un effort prolongé et délibéré pour infliger des
blessures sérieuses avec ses poings, ses pieds ou même avec un couteau. Les
attaques au couteau sont souvent beaucoup moins graves que celles qui
mettent en cause une arme à feu (3,12). Limiter l'accessibilité aux armes à
feu ne réduit peut-être pas le taux de violence, mais cela limite les risques de,
mort (3).
De 1978 à 1987, 33% des homicides commis au Canada ont été perpétrés avec
des armes à feu (6), 28% avec des Instruments tranchants et 21% résultaient
des suites de coups. Le reste regroupait les décès dus à la suffocation, à la
strangulation, à la noyade et aux incendies (6).
L'allégation de ceux qui
s'opposent à un contrôle accru des armes à feu, à savoir: "ce ne sont pas les
armes è feu qui tuent les gens, ce sont les gens" devrait être remplacée par
l'observation suivante: "sans arme à feu, les gens se blessent; avec des armes
à feu, ils se tuent" (3,12).
page... 10/
Accidents.
Une utilisation impropre des armes à feu peut avoir des
conséquences tragiques.
Les cas. de personnes blessées ou tuées parce
qu'elles ont été prises pour des intrus ne sont pas rares, tout comme les
cas d'enfants qui ont pris une arme à feu pour un jouet (3, 13-16). Au
Canada, parmi les 60 décès accidentels causés par les armes à feu en
1988, 20 (33%) ont été enregistrés chez des enfants âgés de 5 à 19 ans
(6). De même, parmi les 29 décès "de nature indéterminée" causés par
des armes à feu, recensés au Canada en 1988, deux concernaient des
fillettes âgées de moins de A ans et deux, des garçons âgés de moins de 14
ans (6).
Par comparaison, la Loi sur les produits dangereux (LCR
1968-1969, ch. 42, art. 1, par. 6(l)b)* Partie I de l'Annexe I, no. 39) a
judicieusement Interdit en 1989 des "Jouets1' pour adultes,.comme les.
fléchettes aux extrémités allongées. Cette action pertinente a banni du
monde canadien un produit de consommation qui n'avait pourtant été
. incriminé dans aucun décès, mais qui avait causé environ 60 blessures
répertoriées au Canada. Avec les armes à feu, c'est d'au moins 60 morts
accidentelles dont 11 s'agit et elles impliquent souvent des enfants.
VoL
Enfin,
l'accessibilité
des armes à
feu
au domicile
accroît
l'éventualité des vols d'armes (3). De 1974 à 1989, on a signalé à la GRC
52 986 pertes, disparitions ou vois d'armes à feu (29). Les armes à feu
volées peuvent être utilisés pour des crimes violents ou encore pour des
infractions comme le braconnage.
page... 10/
L'ACCESSIBILITÉ: Une préoccupation pour la santé publique
Les armes à feu et les munitions servant aux loisirs ou à des fins
»
professionnelles sont beaucoup trop faciles à utiliser de façon Impulsive ou par
erreur, quand on considère que de telles armes constituent un danger pour la
santé publique.
De fait, on registre plus souvent des cas d'homicide, de
suicide, d'accident et de vol d'armes à feu quand ces dernières sont
1
accessibles au grand public
(3). Plusieurs
auteurs (3, 4, 11-16) ont souligné
^
que l'accessibilité aux armes à feu va à rencontre de l'objectif d'optimisation
de la santé et de la sécurité du public.
PROBLÈMES ACTUELS ET LÉGISLATION EN VIGUEUR
Les dispositions législatives de 1978 régissant le contrôle des armes à feu au
Canada permettent à toute personne âgée de 16 ans ou plus' d'acheter des
armes de chasse ordinaires ou de carabines semi<-automatlques chez un
armurier après l'obtention, d'une autorisation d'acquisition d'armes à feu
(AAAF).
SI, après enquête, l'on découvre que le demandeur a un casier
judiciaire ou des antécédents médicaux de désordres psychiatriques qui l'on
poussé è des actes de violence ou à des menaces, l'autorisation peut alors être
refusée. L'autorisation d'acquisition d'armes à feu, qui coûte 10 $, permet à
son détenteur d'acheter autant d'armes à feu destinées aux loisirs (y compris
page... 10/
des armes semi-automatiques) qu'il le désire, pendant une période de cinq
ans.
Selon un enquêteur
( 10), la
GRC
a signalé
158 972
demandes
d'autorisation d'acquisition d'armes à feu et seulement 1454 ont été refusées.
En d'autres termes, moins de deux demandeurs sur 100 se voient refuser cette
autorisation au Québec.
Obtenir un permis de conduire est beaucoup plus
difficile... De fait, au Québec, 30 candidats sur 100 échouent à l'examen écrit
(10). De plus, le permis de conduire n'est valide que pour certaines catégories
de véhicule et doit être renouvelé tous les deux ans, ce qui n'est pas le cas
pour l'autorisation d'acquisition d'armes à feu.
Les dispositions législatives de 1978 régissant le contrôle des armes à feu
limitent, l'acquisition d'armes de poing ou d'autres armes non destinées à des
fins de loisirs ou de sports aux personnes âgées de 18 ans ou plus qui peuvent
prouver qu'elles ont besoin de ces armes pour protéger des vies, pour leur
travail ou leur occupation légitime, pour une collection d'armes à feu (le
terme "collectionneur" n'est pas défini dans la loi) ou pour le tir à la cible sous
les auspices d'un
club
de
tir
approuvé
(qui
est
également
sujet
à
interprétation). Selon Aubin (10), 923 12S armes à autorisation restreinte sont
actuellement en circulation au Canada et leur nombre s'accroît de 30 000 par
année.
Ces personnes peuvent
obtenir
un permis de port d'armes à
autorisation restreinte gratuitement. Dans certaines provinces canadiennes,
Tautoprotectlon" (non définie dans la loi) est' considérée comme, étant une
raison valable pour l'acquisition d'une arme de poing (V. Lamontagne, Sûreté
du Québec, district de Québec, communication personnelle (28)).
page... 10/
Les dispositions législatives de 1978 interdisent également la vente d'armes à
feu automatiques, sauf si l'acheteur est un collectionneur qui a enregistré ses
àrmee à feu avant 1978 (10). Certaines armes à feu semi-automatiques (par
exemple, UZI et AK-47), que l'on peut posséder légalement au Canada,
peuvent être converties très facilement en armes automatiques illégales (Y.
Lamontagne,
Sûreté
du
Québec,
district
de
Québec,
communication
personnelle (28)). Les armes de chasse que l'on peut facilement dissimuler et
que l'on a coupées ou modifiées de façon que la longueur du canon soit
y
inférieure à 18 pouces sont également prohibées (10). Toutefois, ces types
d'armes ont été utilisés dans 2% des homicides commis avec une arme à feu
entre 1978 et 1987 au Canada (6). Sauf à de rares occasions, il est illégal de
transporter des armes de manière dissimulée dans des endroits publics (17).
Malgré ses limites, la loi de 1978 a permis de réduire le taux de morts
violentes au Canada si l'on se compare à la situation qui prévaut aux
États-Unis. Aujourd'hui, une majorité de Canadiens considèrent les armes à
i
feu comme étant moins socialement acceptables. Au lendemain de la tragédie
à l'École polytechnique, un sondage a révélé que 72% des Canadiens désiraient
que les dispositions législatives canadiennes visant le contrôle des armes à feu
soient modifiées afin qu'il soit plus difficile de se procurer une arme à feu.
Parmi les Québécois, 87% étalent en faveur d'une telle mesure (18). Le Projet
de loi C-80 arrivera-t-11 à réduire davantage l'accessibilité des armes à feu?
page... 10/
LE PROJET DE LOI Ç-80
En juin 1990, l'Honorable Klm Campbell, ministre de la Justice et procureur
de la Couronnera présenté le Projet de loi C-80 en vuë d'amender la loi de
1978. Le Projet de loi a été adopté en première lecture aux Communes. La
seconde lecture et l'étude en Commission parlementaire devaient avoir lieu à
l'automne 1990. Le Projet de loi C-80 qui est maintenant référé à un comité
parlementaire pour étude proposait les amendements suivants (2,19):
armes permises: les personnes qui demandent une autorisation d'acquisition
d'armes à feu devront joindre à leur demande leur photographie ainsi que les
noms de deux répondants qui les connaissent depuis au moins, trois ans et
devront
attendre
28
jours avant
de recevoir
l'autorisation.
Tous les
demandeurs devront terminer un cours avec succès ou subir
préalablement à l'obtention de leur autorisation.
un test
Ce document, qui devrait
coûter plus de 10 $ permettrait à son détenteur d'acheter autant d'armes à
feu
destinées
aux
loisirs
ou
à
la
chasse,
y
compris
des
armes
semi-automatiques, qu'il le désire et ce, pendant une période de cinq ans.
Armes à autorisation restreinte: Aucune modification ne serait apportée aux
règles qui régissent l'obtention d'un permis de port d'arme à autorisation
V
restreinte.
L'on rendrait plus accessible le transport d'armes à feu 'à
'
l'Intérieur
d'une
môme
page... 13/
province.
Le
détenteur
d'une
autorisation
d'acquisition d'armes à feu serait en mesure de transporter ou de porter
l'arme & autorisation restreinte de quelqu'un d'autre. Il serait également plus
aisé de rendre à leur propriétaire légitime les armes à feu volées ou perdues.
Armes prohibées:
Les armes entièrement automatiques. transformées en
armes semi-automatiques seraient prohibées. Cependant, les détenteurs de
telles armes, avant l'adoption du Projet de loi C-80, bénéficieraient sans
condition de droits acquis dans le cadre des dispositions de la Loi de 1978. De
plus, en vertu d'un arrêté en Conseil, toute arme dont le magasin peut
contenir
plus
de
dix
cartouches
et
toutes
les
armes
de
chasse
semi-automatiques dont le magasin peut contenir plus de cinq cartouches
seraient prohibées.
La modification ou la fabrication d'une arme à feu
entièrement automatique constituerait un acte criminel.
L'Interdiction de
posséder des armes militaires et paramilitaires serait considérée après la
tenue de consultations dont l'objectif serait d'élaborer des critères propres à
chaque arme. Un conseil consultatif sur les armes à feu a été formé à cette
fin par la Ministre.
page*.. 14/
SUGGESTIONS À L'ÉGARD DU PROJET DE LQTC-80
Lea stratégies mises en oeuvre afin de réduire les risques pour la santé
associés aux armes à feu ne devraient pas perdre de vue que l'accessibilité est
au coeur du problème. En ce qui concerne la santé publique, il s'agit non pas
seulement de garder les armes à feu hors de la portée des personnes mal
intentionnées, ce qui était le but du Projet de loi C-80 (2), mais aussi de
limiter l'accessibilité aux armes à feu et aux munitions de façon générale.
Étant donnée que le taux de mortalité des personnes blessées par balles est
extrêmement
élevé
(15
fois supérieur au taux dé mortalité
résultant
d'attaques perpétrées à l'aide d'un couteau, selon une étude danoise (12),
Teiret (26) laisse entendre que les armes à feu et les munitions devraient être
>
régies par une législation particulière comportant quatre étapes précises:
»
a) à l'étape de la fabrication et de l'importation : il serait difficile d'adapter
le Projet de loi C-80 aux modifications technologiques, sans imposer un quota
i
.
à la fabrication et à l'Importation de toute nouvelle arme prohibée ou à
autorisation restreinte et sans exiger des tests avant sa commercialisation. À
l'heure actuelle, les nouvelles armes à feu sont commercialisées en moins de
temps qu'il n'en faut pour formuler
des critères
visant
l'interdiction
page ... 15/
d'importer une arme en particulier. L'objectif du Projet de loi C-80 n'a pas
prévu de réglementer la fabrication et l'importation de munitions et d'armes à
feu pour les rendre plus faciles à utiliser correctement et plus difficiles à
utiliser par accident (12). Par exemple, la loi pourrait obliger le propriétaire
d'une arme à feu destinée au tir à la cible à installer un système qui
bloquerait la détente, qui exigerait que l'utilisateur appuie deux fols sur la
?
détente pour obtenir un tir ou encore qu'il emploie des balles non mortelles.
b) à l'étape de la vente ou du transfert : le Projet de loi C-80 ne modifierait
pas la réglementation régissant l'obtention d'un permis de port d'arme à
autorisation restreinte (sans frais, sans photographie, sans limite quant au
nombre d'armes à feu, des termes comme "collectionneurs d'armes à feu" ou
"tir à la cible" resteraient sujets à Interprétation, etc). Le Projet de loi C-80
n'exigerait pas non plus que le détenteur d'armes'présente pour chacune de ses
armes, lorsqu'il achète des munitions, une autorisation d'acquisition d'armes à
feu et un permis de port d'arme à autorisation restreinte sur lesquelles
j
i.
•
figureraient sa photo et le numéro de série de l'arme vendue* Actuellement,
la Loi sur les explosifs et son règlement d'application précisent que toute
personne âgée de plus de 16 ans peut importer, pour des. fins d'utilisation
.
!
-
personnelle, 5 000 cartouches de sûreté, sauf des balles à pointe creuse pour
armes
de
poing
(strictement
réservées
aux
forces
policières.)
p^ge... 16/
La Loi sur les explosifs ajoute que des carburants peuvent être remisés sur des
propriétés privées à condition que la quantité n'excède pas 1Q kg;1 aucun
permis de possession n'est exigé pour cette catégorie d'entreposage.
Une solution envisagée serait d'exiger une autorisation d'acquisition d'armes à
feu ou un permis de port d'arme à autorisation restreinte applicable pour une
arme à feu pour un an.
Une telle autorisation et un tel permis, qui
constituerait
un
également
permettraient d'améliorer
certificat
d'acquisition
de
munitions,
le contrôle de toutes les armes à feu (pas
seulement des armes à autorisation restreinte) et, si la Loi sur les explosifs
était amendée, cela permettrait de réduire les quantités de munitions vendues
aux particuliers et d'en interdire la vente aux personnes âgées de moins de 21
ans.
c)
à l'étape de la possession d'armes par un particulier :
l'art. 27 de
l'actuelle Loi sur les explosifs et son règlement d'application précisent qu'une
personne peut conserver dans sa résidence privée ou dans, toute autre
propriété, à des fins d'utilisation personnelle, les quantités de munition de
chasse dont elle a raisonnablement besoin pour une arme de poing ou un fusil
de chasse ou pour une collection. . Néanmoins, l'Individu doit se prémunir
contre tout accident notamment en conservant les cartouches* hors de la
page... 10/
portée des enfants. Les cartouches devraient être remisées dans un endroit
autre que celui réservé aux armes correspondantes. Toutefois, le Projet de loi
C-80 ne régirait pas le remisage et la possession d'armes à feu pas plus que.
s
l'emplacement dans un endroit donné des armes à feu par rapport aux
munitions (par
exemple
dans une résidence privée ou un commerce).
Toutefois, en considérant les risques de suicides, d'homicides, d'accidents et
de vols (depuis 1974, l'on a enregistré à la GRC 53 000 armes à feu volées,
perdues ou. disparues), on devrait exiger que toutes les armes è feu et les
/
munitions soient remisées sous clef, séparément, sauf au moment de leur
utilisation. En fait, les armes à feu devraient être démontées pour les rendre
inutilisables et ces parties devraient être rangées à l'extérieur des résidences
privées, par exemple dans un club de tir où un poste de police.
Afin de prévenir les blessures infligées par le feu, un grand nombre de
juridictions canadiennes exigent que les résidences soient dotées de détecteurs
i •
de fumée vérifiés régulièrement par les pompiers. En vertu du Bill C-80, les
droits acquis sur les armes à feu pourraient être conditionnels à une Inspection
policière et à l'approbation des techniques d'entreposage du propriétaire. Ces
dernières devraient aussi être revérifiées avant que le propriétaire légitime ne
reprenne possession de ses armes volées ou perdues. De plus, étant donné que
80% des décès par
balles
sont
des suicides,
les
médecins
devraient
systématiquement tenter de savoir s'il y a des armes à feu chez leurs malades
dépressifs et demander à la famille qu'elle les retire, tout comme un docteur
prescrit des quantités non mortelles de médicaments à de tels malades.
page... 18/
d) & l'étape de l'utilisation d'une arme à feu : le Projet de loi C-80 n'exige
pas (mais le devrait) du demandeur une autorisation d'acquisition d'armes à
feu ou d'un permis de port d'arme à utilisation restreinte qu'il précise le motif
de l'utilisation de l'arme (soit la chasse, le tir à la cible, la collection, la
protection
de vies ou pour
remplir
ses fonctions).
Cette
restriction
permettrait de limiter la possibilité de posséder des armes à feu à la maison
puisqu'elles sont
rarement
efficaces
pour
se défendre
et
permettrait
également de prévenir l'achat de munitions mortelles qui ne sont, pas
nécessaires pour une collection d'armes à feu ou pour le tir à la cible. Le
Projet de loi C-80 définit judicieusement une "arme" comme étant "tout engin
utilisé, conçu ou qu'une personne entend utiliser pour tuer oli blesser quelqu'un
(...) ou c f l D C l l pour
menacer
ou
Intimider quelqu'un"
(c'est nous qui soulignons)
(19). Le Projet de loi C-80 pourrait bannir avec raison tout autre engin (y
compris les couteaux de. combat, les lance-pierres, les menottes, les fouets,
les poings américains qui sont en vente libre actuellement) dont l'utilisation
ne correspond à aucune définition légalement acceptable d'une arme.r'•
SUJETS DE RECHERCHE PROPOSÉS
L'adoption du Projet de loi C-80 serait une occasion unique d'améliorer la
base d'Information requise (21) pour:
\
•
enquêter sur la portée, les caractéristiques et les coûts liés au taux de
page.... 19/
mortalité et d'invalidité causés par les armes à feu et toutes les autres
armes qui peuvent causer de telles blessures;
enquêter sur le lien possible entre l'accessibilité des armes et les taux de
mortalité, de morbidité et de violence. Le Projet de loi C-80 devrait
constituer un moyen de recenser la distribution d'armesvà feu selon la
catégorie, partout au Canada. On pourrait dès lors quantifier les risques
de
blessures
associées
à
la
possession
d'une
arme
à
feu
et,
éventuellement, d'autres armes;
•
évaluer la portée du Projet de loi C-80 en regard de la réduction des
risques de blessures par balle au Canada.
Par exemple, l'on pourrait
évaluer à fond l'efficacité de la nouvelle réglementation selon laquelle un
demandeur
devra
suivre - un cours de sécurité
des armes
à feu
préalablement à l'obtention de son autorisation d'acquisition d'armes à
feu.
page.** 20/
Actuellement, nous ne savons que très peu de choses concernant le type
d'armes à feu utilisées dans les cas de suicide (qui constituent 79% des décès
par balles (6)) et dans les cas de blessures non mortelles, infligées avec des
armes à feu (qui ont exigé 1 300 hospitalisations au Canada en 1995-1986 (2).
Nous ne savons également que très peu de choses, sauf pour ce qui est de
certaines données mises è Jour dans une étude sur les Amérindiens (22),
concernant les chances de survie qu'ont les jeunes qui se sont infligés des
blessures par balles et sur la possibilité qu'Us refassent une tentative de
suicide. .
UNE LOI POUR UN CONTROLE GLOBAL DES ARMES.À FEU AU CANADA
L'ampleur du problème des décès et des traumatismes par armes à feu auquel
nous avons à faire face à chaque année ne semble pas avoir été réduit par .la
loi de 1977-78 (30). L'on peut d'une part expliquer cette situation par le fait
que, malgré cette loi, l'accessibilité aux armes à feu a de fait augmenté au
Canada depuis 1978 (30). Par contre, il semble que la loi de 19.77-78 sur le
contrôle des armes à feu dont le but était de garder ces armes hors de la
portée des personnes mal Intentionnées a réussi à réduire la proportion des
vols avec une arme à feu. Cependant, au Québec en 1989, deux fois plus de
vols (34%
des vols qualifiés)
étaient
commis avec des armes à feu
page.- 21/
qu'en Ontario (16% des vois qualifiés). La Loi C-51 de 1977-78 est parvenue à
stabiliser la mortalité par arme à feu depuis 1974. Le Canada a aussi des taux
de suicide, d'homicide et d'accident par arme à feu et un nombre d'armes par
100 000 de population relativement plus faible qu'aux États-Unis (30).
A
Il n'en demeure pas moins que la dangerosité est Inhérente à toutes les armes
à feu. En effet, toute arme à feu, qu'elle soit de collection ou pour le tir à la
cible ou la chasse, peut être mortelle si elle est facilement accessible à un
enfant ou à un adulte, surtout chez une personne en situation de crise
suicidaire, ou à la portée de la main d'une personne lors d'Une crise de
violence, comme ce fut trop souvent le cas au Québec en 1989 et 1990.
>
Le Projet de loi C-80 qui vise également à garder les armes à feu hors de la
»
portée des personnes mal intentionnées doit être révisé. Nous croyons que le
principal objectif que la loi doit légitimement poursuivre est la réduction de la
mortalité par armes à feu au pays d'ici l'an 2000, par exemple de 20%. Avec
cette
approche1 par objectif de
• santé publique, le législateur peut plus
facilement prescrire dans le libellé de la loi les mesures pour atteindre ce
but. Ensuite, les règlements d'application peuvent s'ajuster, s'il s'avère après
évaluation qu'ils ne sont pas suffisamment efficaces pour ce qui de réduire les
traumatlsmes et la mortalité par arme à feu. Une loi qui vise un objectif de
réduction de la mortalité par arme à feu
est nécessaire. Le tableau suivant
peut
aider le
législateur
à Identifier
101 devrait
avoir
le plus grand
Impact.les problèmes reliés aux armes à feu où là
page**. 22/
Différents
j IMPACT de la Loi j
Là où C-80 doit
de 1978 sur les
avoir un IMPACT
problèmes reliés i
>
*
(
aux armes a feu au
Canada
TOTAL des DECES
(1.432 décès en 1987)
par SUICIDE
(1.126 décès en 1987)
par HOMICIDE
(193 décès en 1987)
par accident
(60 décès en 1987)
indéterminé quant à
l'intention et légal
(53 décès en 19871
VOLS avec ARMES à
FEU
(6.449 vols en 1989)
VOLS et PERTES d'armes
à feu
(moyenne de 3,532 par an)
ACCESSIBILITE des
ARMES à FEU
(Un estimé conservateur
11,960.000 armes à feu &
923,000 armes restreintes presque toutes des armes de
poing - en 1988)
Réf.: Mundt, 1990
d'ici à l'an 2000
ARMES À FEU
(i.e.: variations de
tendances de 1974 à
1987 au Canada)
Relativement MOINS
qu'aux USA
(La legislation de 1978 a
RÉDUIRE le TOTAL
eu peu d'effet au CANADA
sur les suicides et les
des décès par aime à feu au
homicides, car
l'accessibilité des armes à
CANADA de 20 %
feu a augmenté au Canada
de 1978 à 1988)
Les interventions sur ia
durée de vie d'une
ARMEÀ FEU pour
atteindre le but de
réduire la mortalité par
arme à feu d'ici à l'an
2000
RÉDUIRE
{'ACCESSIBILITY aux
armes à feu et aux
munidonns au moment de
l'importation, le transfert, .
la vente, la possession.
- l'entreposage et enregistrer
TOUTES les armes à feu et
les munitions au Canada.
AUCUNE '
RÉDUIRE 80% des
Contrôler la vente, et la
(Le toux de suicide par
arme à feu de 4.2/100,000 décès reliés aux armes possession et l'entreposage
à feu
des armes à feu dans les
de population en 1970 est
fovere des Canadiens
le même en 1985)
AUCUNE
Contrôler la vente et la
(Le taux moyen
possession
d'homicides par amie à feu RÉDUIRE .13% des décès
reliés aux armes à feu
de 2.7 en 1974-1978 est de
2.6 en 1978-1988)
REDUCTION,
RÉDUIRE 4% des décès Contrôler la possession
(Le taux d'accidents par
dans les foyers des
arme à feu de 0.6 en 1974
Canadiens
est de 0.1 en 1986)
INCONNU
RÉDUIRE 3%'des décès
REDUCTION
(La proportion de vols avec Réduire ies différences
arme à feu a chuté de 38%
encre provinces 0a
en 1977 à 34% en 1981 à proportion au Québec est
25% en 1988)
le double de l'Ontario)
TOTAL pour la période de
RÉDUIRE
1974 & 1989 a 52,986
armes perdues ou volées)
AUGMENTE
(44.500 armes à feu par
RÉDUIRE
100,000 de population en
1976-à 46,000 par
f
100.000 de population en l ACCESSIBILITÉ de
1988. et 2.970 par 100,000
TOUTES les ARMES
de population d'armes
restreintes en 1976 à
À FEU
3,560/100,000 de
population en 1988)
Contrôler la possession et
l'utilisation
Contrôler importation, le
transfert et la vente
Contrôler la possession,
l'entreposage et enregistrer
toutes les armes au Canada
Contrôler l'importation, le
transfert, la vente, la
possession, l'entreposage et
l'utilisation
page***. 23/
CONCLUSION
'i
Au Canada, nous avons enregistré certains progrès dans la réduction du risque
de blessures liées aux véhicules moteurs, en améliorant la conception des
véhicules, en Imposant des limites de vitesse sur les autoroutes, én adaptant
des lois exigeant le port de la ceinture de sécurité et. en'Imposant une
surveillance policière accrue (23,23). La campagne "Pour une génération sans
fumée" de ,1a Direction générale de la promotion de la santé ~de Santé et
Blen-£tre social Canada pourrait servir d'exemple de programme national
dont l'objectif serait d'encourager une génération sans arme au Canada, d'Ici
l'an 2000. Il en est des armes comme de la fumée de tabac: il faut en réduire
l'accessibilité dans notre environnement, en particulier dans les foyers des
Canadiens* Le temps est venu de considérer les blessures par balles comme
une question de santé publique d'Importance au Canada et de concentrer nos
'
-.
.
efforts pour trouver dés moyens de les contrôler (25-27).
RECOMMANDATION.
Que . le comité spécial sur l'obfet du Projet de loi C-80 encourage le
gouvernement du Canada & amender la loi actuelle sur le contrôle des armes à
feu et sa réglementation, afin que toutes les armes & feu soient moins
accessibles au public, afin de réduire les risques de décès reliés aux armes à
feu par suicide, par homicide, par accident, ainsi que les vols.
page... 10/
Références
(1)
McÇann-G, Années potentielles de vie perdues, Canada, 1986. Maladies Chroniques du
Canada, 1988;9:104-6..
(2)
Tighter Gun Control Proposed, fact sheets. Safer and betterfirearmscontrol, proposals for
change. Ottawa, Canada Communications and Public Affairs Department, 1990; Pamphlet
catalogue.no J2-106/1990. (Canada Department of Justice).
y
(3)
.
CHristoffelK.K., Christoffel T. Handguns:risksversus benefits. Pediatrics 1986;77:781-2.
_
(4)
•
--S
Service canadien de la faune, l'importance de la faune pour les Canadiens. Environnement
Canada, 1987.
(5)
Kellermann AL., Reay D.T;: Protection or peril? An analysis offirearm-relateddeaths in the
home, N.Engl. J.-Med 1986;314:1557-60.
(6)
.
Statistique Canada. Causes de décès 1987, ,1988. Centre canadien de renseignements sur la
santé, Ottawa, Catalogue No 84-203.1987-19088. ,
(7)
Bisch L., Lee K-I. f Mark E., Principales causes de. décès au Canada en 1989, Maladies
Chroniques du Canada, 1989;10:22-4.
(8)
Bureau du coroner Rapport annuel 1988, Les Publications du Québec, Québec, 1989:73.
page... 10/
(9)
Sloan J.H., Rivara F.P., Reay. Dt, Ferris JA, Kellermann et AL: Fïreaim regulations and
rates of suicide: a comparison of two metropolitan areas, N. Engl. J. Med,, 1990;322:369-73.
(10) * Aubin Henry.: Wanted: The will for real gun reform. Tougher rules fail'to interest justice
minister. The Gazette. Montréal, January 15,1990._
(11) Sloan J.H., Kelleimann AL Reay DT. Handgun regulations, crime, assault, and homicide: a
tale of two cities, N. EngL J. Med„1988;319:1256-62é
(12) Baker S.P. Without guns, do people kill people?. Am. J. of Public Health, 1985:587-8.
<1
.
(13) Wintemute G J., Teret SP, Wright MA. Unintentional firearm deaths in California. J Trauma
1989;29:457-61.
(14) Wintemute G.J., Teret SP Kraus JF Wright MA. Bradfieid G. When children shoot children:
88 unintended deaths in California, JAMA, 1987;257:3107-9.
!
(15) Wintemute GJ., Teret S.P., kraus J;F.: Plastic handguns that resemble toy guns: new
't
technology creates a uniquely hazardous product. Pediatrics, 1988;81:457-61.
(16)
Rivera F.P.: Traumatic deaths of children in the United States: currently available
• prevention strategies, Pediatrics,1985;75:456-62.
(17)
Criminal Code of Canada, Criminal Law Amendment Act, 1977, "firearms and offensive
weapons'* and gun control scheme, R.S., c.C-34, s. 106.2, Pan m . Revised statutes of Canada,
1985 edition.
page... 26/
(18)
Time for really tough gun control: Tight restrictions would save lives and be popular. The
Gazette 1990;15:B-2.
(19)
Bill C-80: An Act to Amend the Criminal Code and the Customs Tariff in consequence
thereof.. House of Commons of Canada 2nd Session, 38-39 Eliz. II, 1989-90.
(20)
Explosives Act, R.S., c.E-15 and Explosives Act Regulations, C.R.C, 1978, c.599 s.
(21)
Mercy A.J., Houk V.N.: Firearm Injuries: A call for science, N. Engl. J. Med,
1988;319:1283-5.
(22)
Shuck L.W., Orgel M.G., Vogel A.V.: Self-inflicted gunshot wounds to the face: A
review of 18 cases, J Trauma 1980;20:370-7.
(23)
Haddon W Jr., Options for the prevention of motor vehicle crash injury. Israel J Medical
Sciences 1989; 16:45-65.
(24)
Insurance Institute for Highway Safety. Policy options for reducing the motor vehicle
crash injury cost burden, Washingon, DC 1981.
(25)
Robertson LS., Injuries, causes, control. Strategies and public policy, Lexington , Mass:
Lexington Books, 1983.
i
(26)
1984.
Baker SP, O'Neil B, Karpf RS. The injury fact book. Lexington, Mass: Lexington Books,
page..* 27/
v
(27)
*
Teret S.P., Wintemute G*J.: Handgun injuries: the epidemiologic evidence for assessing
legal responsibility. Hamline Law Review, 1983;6:341-50.
(28)
'
Lamontagne, Y.: Personal communication, Régistraire local d'armes à feu. Sûreté du
Québec, distria de Québec, August 7,1990.
(29)
Gendarmerie Royale du Canada: Rapport annuel sur les armes à feu présenté au Solliciteur
général du Canada par le Commissaire de la G.R.G, article 117 du Code criminel, 1989;
(30)
Mundt R.J.: Gun Control and Rates of Firearms Violence in Canada and the United States,
Canadian Journal of Criminology, January 1990, pp. 137-154.
formation
en
Prévention
Bibliographie
réseau
des
traumatismes
Textes
de références
de
base
1.
Les traumatismes au Québec : Comprendre pour prévenir.
Rédigé par un collectif d'auteurs. Publié sous la direction de Ginette
Beaulne, Québec, MSSS, document en voie de publication.
2.
Injury Control.
William Haddon and Susan Baker. Insurance Institute for Highway
Safety, March 1981, (chap. 8 in Preventive and Community Medicine).
. 3.
Active versus Passive Approach.
Leon S. Robertson.
Center for Health Studies, Yale University,
Communication présenté à Montréal, April 16, 1982.
4.
Injuiy Prevention and Control : Prospects for the 1990s*.
Stuart T. Brown, William F. Foege, Thomas R. Bender and Normand
Axnick. Annual Rev. Public Health, 1990. 11 : 251-66.
5.
Prévention.
^
Garen J. Wintemute in Trauma Care System. Ed. Richard H. Carles,
Robert W. Heilig jr. Aspen Publication inc. Rockville, Maryland, 1986.
6.
Injuries.
Volumes
recommandé
s
1.
Baker S. P., O'Neill B., Karpf R. S. «The Injury Fact Book» Lexington
Books, Massachusetts, 1984, 315 pages.
2.
Robertson Leon S. «Injuries», Causes, Control Strategies and Public
Policy, Lexington Books, 1983,219 pages.
3.
Waller Julian A. «Injury Control. A Guide to the Causes and Prevention
of Trauma», Lexington Books, Massachusetts, 1985, 643 pages.
4.
Injury Control. A review of the Status and Progress of the Injury Control,
Program at the Centers for Disease Control National Academy Press,
Washington, D. C., 1988, 77 pages.
5.
Injury in America, A continuing Public Health Problem National
Academy Press, Washington D. C v 1985,164 pages.
6.
Rice Dorothy P. and Ellen J. MacKenzie. «Cost of Injury in the United
States», Atlanta, 1989, 280 p.
Formation réseau
formation
en
Prévention
réseau
des
traumatismes
Inventaire des organismes
oeuvrant
en prévention des traumatisme s
février
et mars 1991
i
Liste des associations
oeuvrant en prévention des traumatismes
Nom de l'organisme :
Association canadienne des automobilistes (ÇAA - National)
Département pertinent :
Bureau des membres et des clubs
Adresse :
1775 Courtwood Crescent *
Ottawa (Ontario)
K2C 3J2
Numéro de téléphone :
(613)226-7631
Numéro de fax :
(613)225-7383
Personne-ressource :
Richard J. Goddins, vice-présidenty
Association canadienne de santé publique
Adresse:
1565 av. Carling, suite 400
Ottawa (Ontario)
K1Z 8R1
(613)725-3769
Numéro de fax :
(613)725-9826
Gérald H. Dafoe, directeur général
Association des hôpitaux du Québec
Centre de coordination de la santé communautaire
Comité provincial des traumatismes
Adresse:
505, bout, de Maisonneuve Ouest, bureau 400
Montréal (Québec)
H3A 3C2
(514)842-4861 .
Numéro de fax :
(514)873-3471
Louise Mercier, conseillère en communication
Association québécoise du transport et des routes
Direction de la sécurité dans les transports
Adresse :
6455, av. Christophe Colomb, bureau 300
Montréal (Québec)
H2S 2G5
(514)274-3573 •
Numéro de fax :
(514)274-9608
Claire Laberge-Nadeau, présidente
Guy Paré, directeur général
" .
Bruce Brown, directeur de la Sécurité dans les transports»
•
Association canadienne des automobilistes (CAA - Québec)
Services s'occupant de sécurité routière :
—Service des affaires publiques;
t—Service de l'éducation routière;
—Service de protection du consommateur.
Adresse:
444, rue Bouvier
Québec (Québec)
G1G6N6
1
(418)624-2424
Numéro de fax :
(418)624-3297
Jean-Claude Dufresne, vice-président exécutif
Service des affaires publiques
Yvon Lapointe, directeur
Service de l'éducation routière
Paula Landry, directrice
Service de protection du consommateur
Ligue de sécurité du Québec
Adresse:
6785, rue St-Jacques Ouest
Montréal (Québec)
H4B1V3
(514)482-9110
Numéro de fax :
(514)482-3398
Yves Mondoux, président - directeur général
Conseil canadien des administrateurs en transport motorisé
(CCATM/CCMTA)
Adresse:
2323, boul. St-Laurent
Ottawa (Ontario)
K1G4K6
(613) 526-0550
Numéro de fax :
(613). 521-6542
Audray H. Lavoie, directrice des programmes
Consommation et Corporation Canada
Bureau de la consommation
Direction de la sécurité des produits
Adresse:
Place du Portage, Tour 1
50, rue Victoria
Hull (Québec)
K1A 0C9
Ottawa-Hull : (819) 997-4774
Montréal : (514) 283-283-3105
Ottawa-Hull : John Buchanan, chef
Division de la politique, de la planification et de l'information
Montréal : Jean-Louis Caya, gestionnaire régional
Sécurité des produits-
Bureau du coroner
Adresse:
2590, bouL Laurier, bureau 420
Ste-Foy (Québec)
G1V4M6
(418)643-1845
Numéro de fax :
(418)643-6174
/
Dr Jean Grenier, coroner en chef
"
Office de la protection du consommateur (OPCQ)
Direction des communications
Présidence et secrétariat
Adresse: -
400, bouL Jean-Lessage, bureau 450
Québec (Québec)
G1K8W4
(418)643-1484
Numéro de fax :
(418)643-8686
Léon Samuel, directeur des communications
-
.
Ministère de la Santé et des Services sociaux
Direction de la santé publique
Adresse:
1075, ch. Ste-Foy
Québec (Québec)
G1S2M1
(418)643-6390
Numéro de fax :
(418)644-2009
Personne-ressource:
Marc Dionne, directeur
Service de la promotion de la santé
Desmond Dufour, agent de recherche
Service de la promotion de la santé
Ministère de la sécurité publique
Direction générale de la sécurité civile du Québec
Adresse:
1500, boul. Charest Ouest, 1er étage
Ste-Foy (Québec)
G1N2E5
(418)646-8523
Numéro de fax :
(418)643-1941
Jean-Jacques Paradis, sous-ministre associé
P 11,131
9150
MSSS - S e r v i c e de formation
Réseau
Sess ion de formation en R r é v e n t i o n
des traumatismes : r e c u e i l de
DATE
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P 11,131

Prévention des traumatismes

Transcription

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