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The incidence and economic burden of injuries in Jiangxi, China
p u b l i c h e a l t h x x x ( 2 0 1 6 ) 1 e8
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Original Research
The incidence and economic burden of injuries in Jiangxi, China X. Fang a,*, G. Zeng b, H.W. Linnan c, R. Jing d, X. Zhu e, P. Corso f, P. Liu a, M. Linnan g a
International Center for Applied Economics and Policy, College of Economics and Management, China Agricultural University, Beijing, China b Chinese Field Epidemiology Training Program, Beijing, China c Maternal and Child Health Consultant, Bangkok, Thailand d School of Public Health, Eastern South University, Nanjing, China e United Nations Children's Fund, Beijing, China f College of Public Health, University of Georgia, Athens, GA, USA g The Alliance for Safe Children (TASC), Bangkok, Thailand
article info
abstract
Article history:
Objectives: This study estimated the incidence, direct medical and non-medical costs, and
Received 27 June 2015
productivity losses due to morbidity and mortality across multiple strata for injuries that
Received in revised form
occurred in Jiangxi, China.
17 February 2016
Study design: Cross-sectional study.
Accepted 28 March 2016
Methods: Data came from the Jiangxi injury survey, a provincially-representative, popula-
Available online xxx
tion-based sample of 100,010 households. The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and
Keywords:
direct non-medical costs. Indirect costs refer to the productivity losses due to injury-
Injuries
related morbidity and mortality.
Economic burden
Results: In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. Overall,
China
fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of all injuries, while fall, RTC, drowning, and self-harm injuries accounted for 80% of fatal injuries. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days.
* Corresponding author. International Center for Applied Economics and Policy, College of Economics and Management, China Agricultural University, No. 17, Qinghuadong Road, Haidian District, Beijing, 100083, China. Tel.: þ86 10 62738705. E-mail address: [email protected] (X. Fang). http://dx.doi.org/10.1016/j.puhe.2016.03.024 0033-3506/© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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Conclusions: The unequivocal evidence of the substantial health and financial burden of injuries indicates to Chinese policy makers that more research and efforts are needed to find efficacious and cost-effective interventions targeting injury. © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Injuries pose a large and growing health risk to children and adults in many countries.1e5 In China, the overall injury death rate remained relatively stable between 1995 and 2008, with the injury death rate decreasing from 60 per 100,000 per year in 1995 to 52 in 2003, and then increasing to 55 in 2008.6 Injuries are the leading cause of death among children and adults aged 1e44 years and the fifth leading cause of death for all ages.7 Injuries affect the health and welfare of all Chinese people through premature death, disability, medical costs, missed school work, and lost productivity. Estimating the economic burden of injuries is important for raising awareness of the magnitude of injury and its costs for the population. Although injuries are one of the leading causes of mortality and morbidity in China, few studies have systematically assessed the economic burden of injuries. The only study we found used the mortality data from the 1999 National Health Statistics Report and the morbidity data from the 1998 Second National Health Service Survey to estimate the total costs of injuries.8 While study by Zhou et al.8 includes both direct and indirect costs, there are a number of limitations to this study. First, the study used only premature mortality to estimate the losses due to different types of injury because morbidity data by type of injury were not available. Second, the study did not include the economic costs caused by disability due to the lack of detailed disability data by injury. Therefore, the economic burden is seriously underestimated. The objectives of this study were to present estimates of the incidence, medical costs, direct non-medical costs, and value of lost productivity due to morbidity and mortality across multiple strata for injuries that occurred in Jiangxi, China, in the year 2005.
Methods In this study, the injury experience from a provinciallyrepresentative, population-based sample of 100,010 households is used to estimate the incidence and economic burden of injuries in Jiangxi, China in 2005.
Sources of data Data came from the Jiangxi injury survey (JIS), which was conducted using a multistage, stratified, cluster sample selected from the current Jiangxi Public Security Bureau roster using probability-proportional-to-size (PPS) sampling methods. Jiangxi is one of China's inland provinces, a
predominantly rural province with a total population of about 43 million. It is located in the southeastern part of the country, on the southern bank of the Yangtze River. The fieldwork for the JIS was conducted by the Provincial Health Bureau and Jiangxi Center for Disease Control and Prevention during SeptembereDecember, 2005. Funding for JIS was provided by United Nations Children's Fund (UNICEF) and technical assistance for the survey was provided by Chinese Field Epidemiology Training Program (CFETP), Centers for Disease Control and Prevention (CDC), and The Alliance for Safe Children (TASC). Following the TASC/UNICEF regional survey protocol, 100,010 households were interviewed in 250 townships/street committees among 98 counties across the entire Jiangxi province. The total number of respondents included in this study was 319,543 including 98,335 children under 18 years of age, making this one of the largest community based injury surveys ever conducted in a developing country. Informed consent was obtained from all respondents as the first step in the interview process. The respondent was chosen as the most knowledgeable adult member of the household among those present at the time of the interview. Where possible, the head of household plus as many household members as possible were present to corroborate answers or add detail. For a child death or serious morbidity, the respondent was the child's caretaker, usually the mother. Details about the design and methods of the JIS can be found elsewhere.9 The survey questionnaire consisted of separate modules on demographics, socio-economic information, household risk factors, and structured questions regarding injury mortality for 3 years prior to the survey and morbidity events during the 12 months preceding the JIS survey for all household residents. However, only mortality events from injury occurring the year preceding the survey were included in this study for the incidence and economic burden estimation of injuries for the year 2005. In addition, a set of questions was developed to collect information on costs and the treatment outcomes when injury occurred. For each injury event, respondents were asked how much they spent on medical treatments, transportation to and from the hospital (or clinic), the costs of hiring somebody to provide care for the injured individual, and how many days of work, household work, and school work lost by both the injured individual and family members or friends who provided nursing care for the injured.
Measures of injury incidence All members of a household were given a comprehensive list of types of injury and asked whether any deaths from those caused had occurred in the preceding three years, and
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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whether there had been any non-fatal occurrences in the previous year. The list of injuries included both unintentional injuries (drowning, road traffic crashes, falls, burns, cuts, poisons, suffocation, electrocution, injury from blunt object, falling objects and animals) and intentional injuries (suicide and assault). The minimum criteria for inclusion in the survey was any injury that caused a household member to seek medical care, or caused them to miss one day or more of school or work. For those who were unemployed or of preschool age, the minimal criteria for inclusion was being unable to perform activities of daily life (ADL) such as eating, bathing, and moving at least for one day. Following Corso et al.'s work10 on estimating injury costs in the USA, injury incidence counts and rates in this study are presented for three mutually exclusive categories that reflect severity of injury: non-hospitalised injury, injuries resulting in hospitalisation or permanent disability (hospitalised/permanent disability injury), and fatal injury. The measure of nonhospitalised injury was defined by reporting that the respondent had experienced a non-fatal injury during the preceding year that resulted in at least one day missed work or school, or a doctor's visit, or at least one day loss of ADL, but not caused hospitalisation or permanent disability. The measure of hospitalised/permanent disability injury was defined by reporting that the respondent had experienced a non-fatal injury during the preceding year that resulted in hospitalisation or permanent disability. Permanent disability was defined as the loss of a physical sense (sight, hearing, etc.), loss of mobility (loss of use of arm, hand, leg or foot) or loss of ability to speak.9 The measure of fatal injury refers to any injury that resulted in death during the preceding year, regardless of whether care was sought or the person was hospitalised. To compute incidence counts at the Jiangxi population level, we used population counts from the China Statistical Yearbook 2005, with an estimate of 42.84 million residents in Jiangxi by the end of year 2004.
Measures of injury costs The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and direct non-medical costs. Medical costs are the direct costs incurred to secure medical treatments, such as the costs of tests, drugs, hospitalisation, and visits to a clinician. Direct non-medical costs include the costs of transportation to and from the hospital (or clinic), and the costs of hiring somebody to provide care for an injured individual. Indirect costs refer to the productivity losses associated with missed work and/or school days due to morbidity, and lost economic productivity due to premature death from injury. School loss days refer to the number of school days missed for the individual, including both the days missed because the individual him/herself was injured and the days missed because the individual was asked to provide nursing care for the injured family members. The adverse effects of school loss are likely to go far beyond the loss of educational investment expenditures as a result of lost school days, as school absenteeism increases failure rates, repetition of school years, and drop-out rates which may, in turn, adversely affect the country's future productivity. However, the overall impact of school loss on human
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capital development remains largely unexplored and unquantified.11 Thus, the indirect costs associated with school loss due to injury were not quantified in this analysis. The quantified indirect costs due to injury only include the productivity losses associated with missed work days due to morbidity and lost economic productivity due to premature death. For non-fatal injuries, productivity losses were divided into short-term and long-term productivity losses. Short-term productivity losses represent lost earnings and household services due to short-term disability in the acute recovery phase. It includes the value of work or household work lost by both the injured individual, and family members or friends who provide nursing care for the injured. The average daily wage across all sectors in Jiangxi was used to place a monetary value on temporary work loss, and average daily wage in the hotel and restaurant sector and in-home care services was used to value temporary housework loss. All the wage data came from the China Statistical Yearbook 2005. Long-term productivity losses for non-fatal injuries represent the economic productivity lost due to permanent or longterm disability, for the subset of injuries that cause lasting impairments that restrict work choices or preclude return to work. According to a national survey of the disabled conducted in 1987,12 among the disabled caused by injury, 31.8% totally lost the ability to work and 51.8% partially lost the ability to work. Since this appears to be the only survey ever done for the Chinese disabled, we assumed the percentage of disabled (due to injury) suffering total or partial loss of work ability did not differ over time. Furthermore, we assumed for those partially losing the ability to work, their productivity is half that of non-disabled workers. Based on the above assumptions, the average productivity of permanently disabled persons was about 42% that of non-disabled persons. In other words, the permanently disabled persons due to an injury on average would lose 58% (31.8% þ 51.8%*0.5 z 58%) of their future productivity, compared to non-disabled persons. To compute productivity loss due to permanent disability, we multiplied the present value of age-specific lifetime earnings by a factor of work disability, 0.58. For someone of a given age who sustained a fatal injury, the net present value of future wage earnings was used to approximate productivity losses.13 We assumed that productive ages are from age 15 to 64. We summed the products of the probability of surviving to each subsequent year of age until age 6414 and the expected earnings for someone in that age. Data for average annual earnings in Jiangxi for year 2005 came from the published documents on the website of National Bureau of Statistics. Earnings at future ages were adjusted upward to account for a 2.6% productivity growth rate for the years before the year 2020 and a 1% for the post-2020 years,13,15 and then discounted to present value using a 3% discount rate. All costs in the study were estimated using the Chinese currency, renminbi (RMB). One USA dollar was equivalent to approximately 8.1 RMB in the year 2005.
Results In 2005, the population of Jiangxi province in China suffered more than two million injuries that resulted in at least one day of
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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missed work or school, or a doctor's visit, or at least 1 day loss of ADL. There were approximately 68 injuries per 1000 males and 45 injuries per 1000 females. Nearly 42,000 (or 1.7%) injuries were fatal. The total lifetime costs of injuries due to morbidity and mortality occurring in Jiangxi in 2005 were approximately 17.4 billion RMB ($2.1 billion): 2.6 billion RMB ($319 million) in medical costs, 97 million RMB ($12 million) in non-medical direct costs, and 14.7 billion RMB ($1.8 billion) in productivity losses. In addition to the total lifetime costs, injuries caused approximately two million lost school days in Jiangxi in the year 2005. Table 1 and Table 2 present incidence counts and rates (per 100,000), and total lifetime costs of injuries by age category. Table 1 lists that in general, injuries affected young and old alike (between 51 and 69 injuries per 1000), with the exception of persons age 15 to 24 who had the lowest injury rate of 35 injuries per 1000. The overall rate of injuries was about 50% higher among males than among females. The age pattern of injuries among males differed from that among females. Males younger than age 65 were more likely to suffer an injury than same-age females, while females older than age 65 were more likely to suffer an injury than same-age males. For males, the highest rate of injury, 76 per 1000 males, occurred among ages 5e14 and 45e64, which were about 80% and 30% higher than they were for same-age females respectively. In contrast, the highest rate of injury occurred among females older than age 75 (79 injuries per 1000), which was about 40% higher than the same-age males. The pattern for each of the three different severity levels of injury (fatal, hospitalised/ permanent disability, and non-hospitalised) by age category and sex was similar to the overall pattern.
The total costs resulting from injuries in Jiangxi in 2005 exceeded 17 billion RMB ($2.1 billion), with 85% of the total resulting from lost productivity (Table 2). Persons age 15 to 44, who represented 40% of the Jiangxi population, accounted for only 33% of injuries but 47% of total costs. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct medical & non-medical costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct medical & non-medical costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days. Overall, injury costs were 2.6 times higher for males (12.6 billion RMB, or $1.6 billion) than for females (4.8 billion RMB, or $588 million). Males who represented 51% of the Jiangxi population, accounted for 61% of all injuries and 73% of total costs. The main reason for the disproportionately large percentage of injury-attributable costs for males was due to not only the higher incidence of injuries in males compared to females, but also the different patterns of injury distribution by age for males and females: males were more likely than females to suffer an injury prior to or during their peak earning years. Table 3 and Table 4 show incidence counts and rates (per 100,000) and total lifetime costs of injuries by type and sex. Overall, fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of injuries, and sharp object
Table 1 e Incidence counts and rates (per 100,000) of injuries by age category and sex, Jiangxi 2005. H/PDa
Fatal Incidence
Rate (95% CI)
Incidence
Non-hospitalised
Rate (95% CI)
Incidence
Rate (95% CI)
Total Incidence
Rate (95% CI)
Total 0e4 5e14 15e24 25e44 45e64 65e74 75þ
41,695 4156 3352 1743 8178 9385 6837 8044
97 113 44 42 64 89 253 608
(87e109) (77e161) (29e65) (22e72) (49e82) (69e112) (189e333) (464e782)
374,180 23,059 47,862 27,752 122,403 109,264 26,545 17,295
873 629 629 668 953 1036 983 1307
(841e906) (539e730) (566e698) (581e766) (892e1016) (967e1109) (851e1129) (1092e1551)
2,025,074 183,001 412,254 117,040 522,859 587,345 136,480 66,095
4727 4991 5419 2819 4070 5570 5053 4995
(4654e4801) (4736e5256) (5234e5609) (2638e3010) (3946e4197) (5411e5732) (4755e5365) (4573e5443)
2,440,949 210,216 463,468 146,535 653,440 705,994 169,862 91,434
5697 5733 6092 3529 5087 6695 6289 6910
(5618e5779) (5461e6015) (5897e6292) (3327e3741) (4949e5228) (6521e6872) (5958e6633) (6417e7428)
Male 0e4 5e14 15e24 25e44 45e64 65e74 75þ
26,143 2815 2548 1341 6167 6167 4424 2681
121 129 61 64 103 118 328 452
(104e139) (80e198) (37e95) (31e118) (75e137) (86e157) (226e461) (276e697)
252,715 16,088 34,991 20,646 90,629 69,715 13,943 6703
1168 740 834 992 1507 1333 1034 1129
(1116e1222) (614e884) (736e941) (842e1161) (1396e1624) (1222e1452) (846e1252) (839e1486)
1,200,699 123,609 281,406 77,356 309,157 323,637 60,866 24,668
5549 5682 6708 3718 5140 6188 4516 4155
(5438e5662) (5331e6050) (6433e6991) (3426e4028) (4938e5349) (5951e6432) (4118e4940) (3587e4785)
1,479,557 142,512 318,945 99,343 405,953 399,519 79,233 34,052
6838 6551 7603 4774 6750 7639 5878 5736
(6716e6962) (6175e6943) (7311e7902) (4445e5122) (6519e6986) (7378e7908) (5426e6356) (5069e6462)
Female 0e4 5e14 15e24 25e44 45e64 65e74 75þ
15,552 1341 804 402 2011 3218 2413 5363
74 90 24 19 29 61 178 735
(61e88) (43e165) (9e51) (4e57) (16e49) (39e90) (106e282) (526e1000)
121,465 6971 12,871 7106 31,774 39,550 12,602 10,591
573 467 377 343 465 744 931 1452
(536e611) (349e613) (306e460) (257e449) (408e528) (662e834) (753e1139) (1151e1806)
824,375 59,391 130,849 39,684 213,702 263,709 75,613 41,427
3888 3983 3835 1916 3128 4961 5589 5678
(3793e3984) (3627e4363) (3602e4078) (1706e2145) (2979e3283) (4749e5179) (5148e6055) (5078e6326)
961,392 67,703 144,524 47,192 247,487 306,477 90,628 57,381
4535 4540 4236 2278 3622 5766 6698 7865
(4432e4638) (4161e4944) (3991e4490) (2049e2527) (3463e3789) (5538e6000) (6218e7024) (7163e8612)
a
H/PD refers to injuries resulting in hospitalisation or permanent disability.
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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Table 2 e Lifetime costs of injuries by age category and sex, Jiangxi 2005 (cost unit: million RMB; school day unit: 1000 days). Fatal
H/PD
Non-hospitalised
Total
Direct costs
Prod. losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
Lifetime costs
School losses
Total 0e4 5e14 15e24 25e44 45e64 65e74 75þ
116.7 5.2 2.8 12.0 24.6 43.1 19.6 9.5
6813 1482 1351 697 2322 940 12 8
1953 58 143 221 776 562 133 61
6899 243 1482 805 2809 1439 74 47
1058 30 715 292 11 7 2 1
614 34 96 34 173 200 50 27
994 19 32 25 278 437 124 79
1008 85 755 156 6 2 3 0
2684 98 242 267 973 805 202 97
14,705 1744 2865 1527 5409 2815 210 134
17,389 1842 3107 1795 6382 3620 412 231
2065 115 1470 448 17 9 5 1
Male 0e4 5e14 15e24 25e44 45e64 65e74 75þ
92.9 4.0 1.6 10.5 21.9 33.8 16.5 4.6
4958 1006 1022 539 1740 641 8 3
1412 44 99 166 615 382 81 25
5284 210 1095 638 2321 971 36 13
767 24 497 231 9 4 2 0
371 23 67 23 115 111 21 11
512 12 21 17 172 227 38 24
732 57 552 117 4 1 2 0
1875 71 167 199 752 527 118 40
10,753 1227 2138 1194 4233 1839 82 40
12,629 1299 2305 1393 4985 2367 200 81
1499 81 1049 348 13 5 3 0
Female 0e4 5e14 15e24 25e44 45e64 65e74 75þ
23.8 1.2 1.2 1.5 2.7 9.3 3.1 4.8
1855 477 329 158 583 299 4 5
542 14 44 56 161 180 52 35
1615 33 387 168 487 468 38 34
291 7 218 61 2 2 0 1
243 11 29 11 58 89 29 16
483 7 11 8 105 210 86 55
276 28 204 39 2 2 1 0
809 26 75 68 222 277 84 56
3952 517 728 334 1175 976 128 94
4761 543 802 402 1397 1253 212 151
567 35 422 100 4 4 1 1
Note: Direct costs include medicals costs and direct non-medical costs. Prod. Losses refer to productivity losses. One US dollar was equivalent to approximately 8.1 RMB in the year 2005.
injuries accounted for an additional 10% of injuries. Although self-harm and drowning injuries were comparatively rare, these injuries were far more likely to be fatal than those caused by other mechanisms. For example, while only 1.8% of fall injuries and 2.3% of RTC injuries were fatal, more than 60% of self-harm and drowning injuries were fatal. Combined, fall, RTC, drowning, and self-harm injuries, accounted for 79% of fatal injuries among males and 81% of fatal injuries among females. The rate of injuries among males was higher than among females for every type but self-harm: females were roughly 40% more likely than males to suffer a self-harm-related injury, and two times as likely as males to suffer a fatal injury due to self-harm. In contrast, males were roughly six times as likely as females to suffer an electrical injury and over two times as likely as females to suffer a RTC, assault, falling object, or blunt object injury. Combined, RTC injuries and fall injuries accounted for more than 50% of the total costs of injuries. Although injury from drowning accounted for less than 0.5% of all injuries, more than 60% of those injuries were fatal; as a result, drowning accounted for approximately 12% of the total costs of injuries and had the highest average cost per case e 202,853 RMB ($25,044) per overall drowning injury. Similarly, although self-harm, asphyxia, and electricity injuries were comparatively rare, these injuries were far more likely to be fatal or severe than those caused by other types and therefore the average cost per case was disproportionately high: self-harm,
asphyxia, and electricity injuries accounted for 0.3%, 0.5% and 0.3% of the incidence of injuries but 3%, 3.6% and 1.5% of the total costs respectively. For both males and females, RTC injuries caused the greatest burden from the productivity losses. Regarding direct medical & non-medical costs, RTC injuries caused the greatest burden for males, while fall injuries caused the greatest burden for females. For both sexes, fall injuries caused the greatest number of lost school days.
Discussion This study presents an important estimate of the economic burden of injuries occurring in Jiangxi province, China in the year 2005. In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. On average, each injury generated 7124 RMB ($880) in direct and indirect costs and, an additional loss of 0.85 school days. The total lifetime cost of injuries e 17.4 billion RMB ($2.1 billion), accounted for about 4.3% of Jiangxi's 2005 gross domestic product (GDP) and was 407 RMB ($50) for every resident in Jiangxi in the year 2005. The findings provide an important perspective on the extent to which injuries are draining Jiangxi province's vital resources and human capital. When the burden of injuries was defined by lifetime costs, RTC injuries posed the greatest burden to Jiangxi province, 5 billion RMB, which was 33% greater than the lifetime costs of the next highest type (fall injuries, 3.8 billion RMB). However,
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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Table 3 e Incidence counts and rates (per 100,000) of injuries by type and sex, Jiangxi 2005. Injury type
Fatal
H/PD
Incidence Rate (95% CI) Incidence
Non-hospitalised
Rate (95% CI)
Total Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
41,695 5095 9921 1341 12,066 1207 0 134 6167 670 0 938 402 2413 1341
97 12 23 3 28 3 0 0 14 2 0 2 1 6 3
(87e109) (8e16) (18e29) (2e6) (23e35) (1e5) (0e1) (0e2) (11e19) (0e4) (0e1) (0e5) (0e3) (3e9) (2e6)
374,180 2279 124,414 16,356 118,917 12,870 21,451 12,066 670 22,121 17,563 1475 16,624 2547 4827
873 5 290 38 278 30 50 28 2 52 41 3 39 6 11
Male Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
26,143 1609 7374 938 7240 1073 0 0 4424 670 0 670 268 1609 268
121 8 34 4 33 5 0 0 21 3 0 3 1 8 1
(104e139) (4e13) (26e44) (2e9) (25e44) (2e10) (0e2) (0e2) (14e29) (1e7) (0e2) (1e7) (0e4) (4e13) (0e4)
252,715 1341 90,227 13,004 67,033 11,127 15,552 8044 268 14,881 14,881 1207 10,993 1073 3084
1168 6 417 60 310 51 72 37 1 69 69 6 51 5 14
Female Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
15,552 3486 2547 403 4826 134 0 134 1743 0 0 268 134 804 1073
74 16 12 2 23 1 0 1 8 0 0 1 1 4 5
(61e88) (11e24) (7e19) (0e6) (16e32) (0e4) (0e2) (0e4) (4e14) (0e2) (0e2) (0e5) (0e4) (1e8) (2e10)
121,465 938 34,187 3352 51,884 1743 5899 4022 402 7240 2682 268 5631 1474 1743
573 4 161 16 245 8 28 19 2 34 13 1 27 7 8
Incidence
Rate (95% CI)
Total Incidence
Rate (95% CI)
(841e906) (3e9) (272e310) (32e46) (260e296) (24e37) (43e58) (23e35) (0e4) (44e60) (34e49) (2e6) (32e46) (4e9) (8e16)
2,025,074 536 296,957 36,064 538,277 34,455 227,377 83,389 3084 77,222 98,807 5094 497,387 7508 118,917
4727 1 693 84 1256 80 531 195 7 180 231 12 1161 18 278
(4654e4801) (0e3) (665e723) (74e95) (1218e1296) (71e91) (506e557) (180e211) (5e11) (166e196) (214e248) (8e16) (1124e1199) (13e23) (260e296)
2,440,949 7910 431,292 53,761 669,260 48,532 248,828 95,589 9921 100,013 116,370 7507 514,413 12,468 125,085
5697 18 1006 125 1562 113 581 223 23 234 272 17 1201 30 292
(5618e5779) (14e24) (972e1042) (114e138) (1520e1606) (102e126) (555e608) (207e240) (18e29) (217e251) (254e290) (13e23) (1163e1239) (23e36) (274e311)
(1116e1222) (3e11) (386e450) (49e73) (283e338) (41e64) (59e86) (28e48) (0e4) (57e83) (57e83) (3e11) (40e63) (2e10) (9e21)
1,200,699 268 204,585 24,400 269,876 25,339 135,541 47,057 1877 50,543 71,726 4424 291,326 3620 70,117
5549 1 946 113 1247 117 626 217 9 234 331 20 1346 17 324
(5438e5662) (0e4) (899e994) (97e130) (1194e1303) (101e135) (589e666) (195e241) (5e15) (211e258) (304e361) (14e29) (1291e1404) (11e24) (297e353)
1,479,557 3218 302,186 38,342 344,149 37,539 151,093 55,101 6569 66,094 86,607 6301 302,587 6302 73,469
6838 15 1397 177 1590 173 698 254 31 306 400 29 1398 30 339
(6716e6962) (10e22) (1340e1455) (157e199) (1530e1653) (154e195) (658e740) (231e280) (22e40) (279e334) (370e432) (21e39) (1342e1457) (21e39) (312e369)
824,375 268 92,372 11,664 268,401 9116 91,836 36,332 1207 26,679 27,081 670 206,061 3888 48,800
3888 1 436 55 1266 43 433 171 6 126 128 3 972 18 230
(3793e3984) (0e5) (404e469) (44e68) (1211e1322) (33e55) (401e467) (152e193) (3e11) (109e145) (111e147) (1e7) (924e1021) (12e26) (207e255)
961,392 4692 129,106 15,419 325,111 10,993 97,735 40,488 3352 33,919 29,763 1206 211,826 6166 51,616
4535 21 609 73 1534 52 461 191 16 160 141 5 1000 29 243
(4432e4638) (15e31) (571e648) (60e87) (1473e1595) (41e64) (428e496) (170e214) (10e23) (141e181) (123e160) (3e11) (951e1049) (21e39) (220e269)
(536e611) (2e9) (142e182) (10e23) (221e270) (4e14) (20e37) (13e27) (0e6) (26e45) (8e20) (0e5) (19e36) (3e12) (4e14)
RTC injuries are preventable, and there is an established set of interventions that have been demonstrated in high-income countries to significantly reduce incidence and impact of RTC injuries.16 These include the enforcement of legislation to control speed and alcohol consumption, mandating the use of seatbelts and crash helmets, the safer design and use of roads and vehicles, and many other proven science-based interventions. Although solutions for China may differ from those of high-income countries, basic intervention principles apply. The substantial burden of RTC injuries to society calls for attention of the Chinese government to make use of existing science-based solutions to develop effective and costeffective intervention programs to reduce RTC injuries.
When the appropriate level of resources to dedicate towards preventing one type of injury or another is concerned, there are issues more than lifetime costs to be considered. For example, drowning injuries accounted for 0.5% of the incidence of injuries but 12% of the total costs. Similarly, self-harm, asphyxia, and electricity injuries accounted for 0.3%, 0.5% and 0.3% of the incidence of injuries but 3%, 3.6% and 1.5% of the total costs respectively. If one was to allocate injury prevention dollars based on incidence alone, the amount allocated towards reducing these types of injuries might be less than the amount based on both incidence and total costs. Special attention might also be focused on preventing childhood injuries since injuries occurring to children not only pose a great economic burden (in
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Table 4 e Lifetime costs of injuries by type and sex, Jiangxi 2005 (cost unit: million RMB; school day unit: 1000 days). Fatal
Total Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others Male Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others Female Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
H/PD
Non-hospitalised
Total
Direct costs
Prod. losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
Lifetime costs
School losses
116.7 4.7 53.5 5.6 39.5 1.4 0 0.05 1.7 0.3 0 0.1 1.5 4.4 3.9 92.9 1.6 46.5 4.8 32.2 1.2 0 0 1.1 0.3 0 0.05 0.6 3.8 0.8 23.8 3.1 7.0 0.9 7.3 0.2 0 0.05 0.6 0 0 0.02 0.9 0.6 3.1
6812 470 1907 392 718 272 0 7 2010 133 0 205 58 587 54 4958 100 1485 288 560 262 0 0 1556 133 0 110 58 396 11 1854 370 422 104 158 10 0 7 454 0 0 95 0 191 43
1953 5 858 98 579 81 64 57 1 29 100 32 25 13 14 1412 4 640 83 358 67 52 33 0.4 22 84 31 16 10 11 542 2 218 14 221 14 12 24 0.2 7 16 1 8 3 3
6899 47 1958 339 1818 321 1296 154 0.1 11 786 19 100 14 35 5284 46 1442 293 1332 265 987 83 0.05 6 731 19 44 14 23 1615 1 517 46 486 56 309 71 0.03 5 55 1 56 1 11
1058 2 445 32 404 18 24 62 0 1 34 4 25 6 2 767 2 318 26 278 6 23 46 0 1 32 4 23 6 2 291 0 126 6 125 12 1 16 0 0 2 0 2 0 0
614 1 128 16 228 10 29 21 0.2 9 25 2 116 1 28 371 0.1 90 10 121 8 21 13 0.1 6 19 2 65 1 15 243 0.5 38 6 107 2 8 8 0.1 3 6 0.1 52 0.3 13
994 0 192 24 457 22 72 31 0.1 13 42 6 71 1 64 512 0.1 132 13 164 18 49 16 0.05 8 30 4 39 0.3 35 483 0.2 60 10 293 4 23 15 0.04 5 11 1 31 0.3 29
1008 16 169 39 446 5 45 51 1 1 48 0.3 154 2 31 732 0 110 36 345 4 40 37 1 0.1 36 0.3 105 1 17 276 16 59 3 101 1 5 14 0 1 12 0 49 1 14
2684 10 1039 119 846 93 93 78 3 38 125 34 142 18 46 1875 5 776 98 511 76 73 46 2 28 103 34 82 15 27 809 5 263 21 335 16 20 31 1 10 22 1 61 4 19
14,705 518 4057 755 2994 616 1368 192 2010 157 828 230 228 602 153 10,753 147 3058 594 2056 545 1036 99 1556 147 761 133 141 410 70 3952 371 999 161 937 70 331 93 454 10 66 97 87 192 83
17,389 528 5096 874 3839 708 1460 270 2013 195 952 264 371 620 199 12,629 152 3835 692 2567 622 1109 145 1557 175 864 167 223 424 97 4761 376 1262 182 1272 87 351 124 455 20 89 98 148 196 102
2065 18 614 71 850 23 69 113 1 2 82 4 179 8 33 1499 2 428 62 624 10 63 82 1 2 67 4 128 7 19 567 16 185 9 226 13 6 30 0 1 15 0 51 1 14
terms of direct costs and productivity losses) to the society, but also cause a large number of lost school days which adversely affect human capital development in children and eventually the country's future productivity. Finally, it is useful to recognise that some types of injury are more easily prevented and at lower cost than others. Recent work in Bangladesh has shown childhood drowning to be highly preventable at low cost (Precise Program, Bangladesh).17 The rate of injuries among males is higher than that among females for every type but self-harm. Females were two times as likely as males to suffer a fatal injury due to self-harm. The present findings are consistent with other research that found China is one of the very few countries that report higher rates of completed suicide in women than in men.18,19 To address
this issue and related challenges, such as the complex social issues involved in suicide, more research and efforts are needed to understand and target the unique nature of suicide among residents of China. This analysis has several limitations. First, the prevalence of assault and self-harm is likely underestimated. Intentional injury experts note that household surveys such as the Jiangxi Injury Survey provide little privacy and do not foster the rapport needed for obtaining good response rates for questions relating to intentional injury. Second, the costs included in this analysis focus exclusively on direct medical & non-medical costs and productivity losses, and do not include the rehabilitation costs for the disabled (due to the unavailability of data), the future or current productivity
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losses due to lost school days, the costs for pain and suffering, or other non-monetary costs that result from injuries (such as reductions in functional capacity and quality of life). While some of these non-monetary outcomes are difficult to quantify in monetary terms, excluding them means that these total cost estimates are substantially underestimated. Third, the probabilities of total and partial disability were computed from a national survey of the disabled conducted in 1987. We further assumed that for those partially losing the ability to work, their productivity was half that of non-disabled workers. Although these assumptions were made because of data unavailability, caution should be taken in interpreting the long-term productivity losses for non-fatal injuries, and that future research is needed to validate these results with a more updated and complete assessment of disability. Fourth, this study relies on retrospective self-reports to measure the incidence and costs of injuries. Retrospective measures may introduce biases which may limit the validity and reliability of these reports. As such, participants may not remember clearly all their utilisation of health care or numbers of days missed from work or school, or they may choose not to tell the truth. In turn, this raises the issue of the extent to which errors in the retrospective self-reported variables may have influenced the study results. Despite these limitations, the estimates reported above should be viewed as the best available estimates of injury incidence and costs in China to date. As new data become available, future studies will improve upon the methodology and results. The burden of injuries, which are substantial in terms of lives lost, pain and suffering and economic consequences, should indicate to policy makers that more research and efforts are needed to find efficacious, effective, and costeffective interventions targeting both intentional and unintentional injuries.
Author statements Acknowledgements Funding for the Jiangxi Injury Survey was provided by UNICEF China. The project was a collaboration between UNICEF China, The Alliance for Safe Children, the National Working Committee for Women and Children, and the Jiangxi Provincial Health Bureau and Center for Disease Control. Technical assistance was provided by The Alliance for Safe Children (TASC), Chinese Field Epidemiology Training Program and East Asia and Pacific Regional Office, United Nations Children's Fund. Jiangxi Provincial Health Bureau, Jiangxi Center for Disease Control conducted the field work and participated in the data analysis and report writing. Special thanks go to the field workers of Jiangxi County and Prefecture Centers for Disease Control for their participation and dedication on data collection. All protocols and survey instruments were submitted to an UNICEF ethical review board for approval prior to the commencement of fieldwork.
Ethical approval None sought.
Funding None declared.
Competing interests The authors report no conflicts of interest.
references
1. Joshi R, Cardona M, Iyengar S, Sukumar A, Raju CR, Raju KR, et al. Chronic diseases now a leading cause of death in rural India-mortality data from the Andhra Pradesh Rural Health Initiative. Int J Epidemiol 2006;35:1522e9. 2. Murray CJ, Lopez A. The global burden of disease, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996. 3. Peden M, Oyegbite K, Ozanne-Smith J, Hyder A, Branche C, Rahman A, et al., editors. World report on child injury prevention. Geneva: World Health Organization/UNICEF; 2008. 4. Rivara F, Mueller B. The epidemiology and causes of childhood injuries. J Soc Issues 1987;43:13e31. 5. World Bank. World development report 1993: investing in health. New York: Oxford University Press; 1993; pp. 26e7, 213e25. 6. Wang SY. Epidemiological features and research progress of injury in China. Chin J Epidemiol 2011;32(7):637e42. 7. Ministry of Health, People's Republic of China. China health statistics yearbook 2010. Beijing: Ministry of Health; 2000. 8. Zhou Y, Baker TD, Rao K, Li G. Productivity losses from injury in China. Inj Prev 2003;9:124e7. 9. Jiangxi Center for Disease Control and Prevention, Chinese Field Epidemiology Training Program (CFETP), The Alliance for Safe Children (TASC), UNICEF China. Technical report on child injury: Jiangxi injury survey. Beijing: UNICEF China; 2007. 10. Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev 2006;12:212e8. 11. Sachs J, Malaney P. The economic and social burden of malaria. Nature 2002;415:680e5. 12. Office of National Sampling Survey of the Handicapped, People's Republic of China. China Data of 1987 sampling survey of the handicapped. Beijing: China Disabled Persons' Federation; 1989. 13. Haddix A, Teutsch S, Corso P. Prevention effectiveness: a guide to decision analysis and economic evaluation. New York, NY: Oxford University Press; 2003. 14. Yu HQ, Liu Y, Zeng HL, Yuan ZK. Jiangxi Province life tables, 2000 (Jiangxi Sheng 2000 Nian Jian Lue Shou Min Biao Fen Xi). Acta Acad Med Jiangxi 2002;42:143e5. 15. Young A. Gold into base metals: productivity growth in the People's Republic of China during the reform period. J Political Econ 2003;111:1220e61. 16. World Health Organization (WHO). World report on road traffic injury prevention: summary. Geneva: WHO. Available from: http://www.who.int/world-health-day/2004/infomaterials/ world_report/en/summary_en_rev.pdf; 2004. 17. Rahman F, Bose S, Linnan M, Rahman A, Mashreky S, Haaland B, Finkelstein E. Cost-effectiveness of an injury and drowning prevention program in Bangladesh. Pediatrics 2012;130. e1621e8. 18. Phillips MR, Li X, Zhang Y. Suicide rates in China, 1995-99. Lancet 2002;359:835e40. 19. Zhao XH, Lester D. The gender difference in Chinese suicide rates. Arch Suicide Res 1997;3:81e9.
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Original Research
The incidence and economic burden of injuries in Jiangxi, China X. Fang a,*, G. Zeng b, H.W. Linnan c, R. Jing d, X. Zhu e, P. Corso f, P. Liu a, M. Linnan g a
International Center for Applied Economics and Policy, College of Economics and Management, China Agricultural University, Beijing, China b Chinese Field Epidemiology Training Program, Beijing, China c Maternal and Child Health Consultant, Bangkok, Thailand d School of Public Health, Eastern South University, Nanjing, China e United Nations Children's Fund, Beijing, China f College of Public Health, University of Georgia, Athens, GA, USA g The Alliance for Safe Children (TASC), Bangkok, Thailand
article info
abstract
Article history:
Objectives: This study estimated the incidence, direct medical and non-medical costs, and
Received 27 June 2015
productivity losses due to morbidity and mortality across multiple strata for injuries that
Received in revised form
occurred in Jiangxi, China.
17 February 2016
Study design: Cross-sectional study.
Accepted 28 March 2016
Methods: Data came from the Jiangxi injury survey, a provincially-representative, popula-
Available online xxx
tion-based sample of 100,010 households. The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and
Keywords:
direct non-medical costs. Indirect costs refer to the productivity losses due to injury-
Injuries
related morbidity and mortality.
Economic burden
Results: In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. Overall,
China
fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of all injuries, while fall, RTC, drowning, and self-harm injuries accounted for 80% of fatal injuries. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days.
* Corresponding author. International Center for Applied Economics and Policy, College of Economics and Management, China Agricultural University, No. 17, Qinghuadong Road, Haidian District, Beijing, 100083, China. Tel.: þ86 10 62738705. E-mail address: [email protected] (X. Fang). http://dx.doi.org/10.1016/j.puhe.2016.03.024 0033-3506/© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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Conclusions: The unequivocal evidence of the substantial health and financial burden of injuries indicates to Chinese policy makers that more research and efforts are needed to find efficacious and cost-effective interventions targeting injury. © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Injuries pose a large and growing health risk to children and adults in many countries.1e5 In China, the overall injury death rate remained relatively stable between 1995 and 2008, with the injury death rate decreasing from 60 per 100,000 per year in 1995 to 52 in 2003, and then increasing to 55 in 2008.6 Injuries are the leading cause of death among children and adults aged 1e44 years and the fifth leading cause of death for all ages.7 Injuries affect the health and welfare of all Chinese people through premature death, disability, medical costs, missed school work, and lost productivity. Estimating the economic burden of injuries is important for raising awareness of the magnitude of injury and its costs for the population. Although injuries are one of the leading causes of mortality and morbidity in China, few studies have systematically assessed the economic burden of injuries. The only study we found used the mortality data from the 1999 National Health Statistics Report and the morbidity data from the 1998 Second National Health Service Survey to estimate the total costs of injuries.8 While study by Zhou et al.8 includes both direct and indirect costs, there are a number of limitations to this study. First, the study used only premature mortality to estimate the losses due to different types of injury because morbidity data by type of injury were not available. Second, the study did not include the economic costs caused by disability due to the lack of detailed disability data by injury. Therefore, the economic burden is seriously underestimated. The objectives of this study were to present estimates of the incidence, medical costs, direct non-medical costs, and value of lost productivity due to morbidity and mortality across multiple strata for injuries that occurred in Jiangxi, China, in the year 2005.
Methods In this study, the injury experience from a provinciallyrepresentative, population-based sample of 100,010 households is used to estimate the incidence and economic burden of injuries in Jiangxi, China in 2005.
Sources of data Data came from the Jiangxi injury survey (JIS), which was conducted using a multistage, stratified, cluster sample selected from the current Jiangxi Public Security Bureau roster using probability-proportional-to-size (PPS) sampling methods. Jiangxi is one of China's inland provinces, a
predominantly rural province with a total population of about 43 million. It is located in the southeastern part of the country, on the southern bank of the Yangtze River. The fieldwork for the JIS was conducted by the Provincial Health Bureau and Jiangxi Center for Disease Control and Prevention during SeptembereDecember, 2005. Funding for JIS was provided by United Nations Children's Fund (UNICEF) and technical assistance for the survey was provided by Chinese Field Epidemiology Training Program (CFETP), Centers for Disease Control and Prevention (CDC), and The Alliance for Safe Children (TASC). Following the TASC/UNICEF regional survey protocol, 100,010 households were interviewed in 250 townships/street committees among 98 counties across the entire Jiangxi province. The total number of respondents included in this study was 319,543 including 98,335 children under 18 years of age, making this one of the largest community based injury surveys ever conducted in a developing country. Informed consent was obtained from all respondents as the first step in the interview process. The respondent was chosen as the most knowledgeable adult member of the household among those present at the time of the interview. Where possible, the head of household plus as many household members as possible were present to corroborate answers or add detail. For a child death or serious morbidity, the respondent was the child's caretaker, usually the mother. Details about the design and methods of the JIS can be found elsewhere.9 The survey questionnaire consisted of separate modules on demographics, socio-economic information, household risk factors, and structured questions regarding injury mortality for 3 years prior to the survey and morbidity events during the 12 months preceding the JIS survey for all household residents. However, only mortality events from injury occurring the year preceding the survey were included in this study for the incidence and economic burden estimation of injuries for the year 2005. In addition, a set of questions was developed to collect information on costs and the treatment outcomes when injury occurred. For each injury event, respondents were asked how much they spent on medical treatments, transportation to and from the hospital (or clinic), the costs of hiring somebody to provide care for the injured individual, and how many days of work, household work, and school work lost by both the injured individual and family members or friends who provided nursing care for the injured.
Measures of injury incidence All members of a household were given a comprehensive list of types of injury and asked whether any deaths from those caused had occurred in the preceding three years, and
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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whether there had been any non-fatal occurrences in the previous year. The list of injuries included both unintentional injuries (drowning, road traffic crashes, falls, burns, cuts, poisons, suffocation, electrocution, injury from blunt object, falling objects and animals) and intentional injuries (suicide and assault). The minimum criteria for inclusion in the survey was any injury that caused a household member to seek medical care, or caused them to miss one day or more of school or work. For those who were unemployed or of preschool age, the minimal criteria for inclusion was being unable to perform activities of daily life (ADL) such as eating, bathing, and moving at least for one day. Following Corso et al.'s work10 on estimating injury costs in the USA, injury incidence counts and rates in this study are presented for three mutually exclusive categories that reflect severity of injury: non-hospitalised injury, injuries resulting in hospitalisation or permanent disability (hospitalised/permanent disability injury), and fatal injury. The measure of nonhospitalised injury was defined by reporting that the respondent had experienced a non-fatal injury during the preceding year that resulted in at least one day missed work or school, or a doctor's visit, or at least one day loss of ADL, but not caused hospitalisation or permanent disability. The measure of hospitalised/permanent disability injury was defined by reporting that the respondent had experienced a non-fatal injury during the preceding year that resulted in hospitalisation or permanent disability. Permanent disability was defined as the loss of a physical sense (sight, hearing, etc.), loss of mobility (loss of use of arm, hand, leg or foot) or loss of ability to speak.9 The measure of fatal injury refers to any injury that resulted in death during the preceding year, regardless of whether care was sought or the person was hospitalised. To compute incidence counts at the Jiangxi population level, we used population counts from the China Statistical Yearbook 2005, with an estimate of 42.84 million residents in Jiangxi by the end of year 2004.
Measures of injury costs The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and direct non-medical costs. Medical costs are the direct costs incurred to secure medical treatments, such as the costs of tests, drugs, hospitalisation, and visits to a clinician. Direct non-medical costs include the costs of transportation to and from the hospital (or clinic), and the costs of hiring somebody to provide care for an injured individual. Indirect costs refer to the productivity losses associated with missed work and/or school days due to morbidity, and lost economic productivity due to premature death from injury. School loss days refer to the number of school days missed for the individual, including both the days missed because the individual him/herself was injured and the days missed because the individual was asked to provide nursing care for the injured family members. The adverse effects of school loss are likely to go far beyond the loss of educational investment expenditures as a result of lost school days, as school absenteeism increases failure rates, repetition of school years, and drop-out rates which may, in turn, adversely affect the country's future productivity. However, the overall impact of school loss on human
3
capital development remains largely unexplored and unquantified.11 Thus, the indirect costs associated with school loss due to injury were not quantified in this analysis. The quantified indirect costs due to injury only include the productivity losses associated with missed work days due to morbidity and lost economic productivity due to premature death. For non-fatal injuries, productivity losses were divided into short-term and long-term productivity losses. Short-term productivity losses represent lost earnings and household services due to short-term disability in the acute recovery phase. It includes the value of work or household work lost by both the injured individual, and family members or friends who provide nursing care for the injured. The average daily wage across all sectors in Jiangxi was used to place a monetary value on temporary work loss, and average daily wage in the hotel and restaurant sector and in-home care services was used to value temporary housework loss. All the wage data came from the China Statistical Yearbook 2005. Long-term productivity losses for non-fatal injuries represent the economic productivity lost due to permanent or longterm disability, for the subset of injuries that cause lasting impairments that restrict work choices or preclude return to work. According to a national survey of the disabled conducted in 1987,12 among the disabled caused by injury, 31.8% totally lost the ability to work and 51.8% partially lost the ability to work. Since this appears to be the only survey ever done for the Chinese disabled, we assumed the percentage of disabled (due to injury) suffering total or partial loss of work ability did not differ over time. Furthermore, we assumed for those partially losing the ability to work, their productivity is half that of non-disabled workers. Based on the above assumptions, the average productivity of permanently disabled persons was about 42% that of non-disabled persons. In other words, the permanently disabled persons due to an injury on average would lose 58% (31.8% þ 51.8%*0.5 z 58%) of their future productivity, compared to non-disabled persons. To compute productivity loss due to permanent disability, we multiplied the present value of age-specific lifetime earnings by a factor of work disability, 0.58. For someone of a given age who sustained a fatal injury, the net present value of future wage earnings was used to approximate productivity losses.13 We assumed that productive ages are from age 15 to 64. We summed the products of the probability of surviving to each subsequent year of age until age 6414 and the expected earnings for someone in that age. Data for average annual earnings in Jiangxi for year 2005 came from the published documents on the website of National Bureau of Statistics. Earnings at future ages were adjusted upward to account for a 2.6% productivity growth rate for the years before the year 2020 and a 1% for the post-2020 years,13,15 and then discounted to present value using a 3% discount rate. All costs in the study were estimated using the Chinese currency, renminbi (RMB). One USA dollar was equivalent to approximately 8.1 RMB in the year 2005.
Results In 2005, the population of Jiangxi province in China suffered more than two million injuries that resulted in at least one day of
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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missed work or school, or a doctor's visit, or at least 1 day loss of ADL. There were approximately 68 injuries per 1000 males and 45 injuries per 1000 females. Nearly 42,000 (or 1.7%) injuries were fatal. The total lifetime costs of injuries due to morbidity and mortality occurring in Jiangxi in 2005 were approximately 17.4 billion RMB ($2.1 billion): 2.6 billion RMB ($319 million) in medical costs, 97 million RMB ($12 million) in non-medical direct costs, and 14.7 billion RMB ($1.8 billion) in productivity losses. In addition to the total lifetime costs, injuries caused approximately two million lost school days in Jiangxi in the year 2005. Table 1 and Table 2 present incidence counts and rates (per 100,000), and total lifetime costs of injuries by age category. Table 1 lists that in general, injuries affected young and old alike (between 51 and 69 injuries per 1000), with the exception of persons age 15 to 24 who had the lowest injury rate of 35 injuries per 1000. The overall rate of injuries was about 50% higher among males than among females. The age pattern of injuries among males differed from that among females. Males younger than age 65 were more likely to suffer an injury than same-age females, while females older than age 65 were more likely to suffer an injury than same-age males. For males, the highest rate of injury, 76 per 1000 males, occurred among ages 5e14 and 45e64, which were about 80% and 30% higher than they were for same-age females respectively. In contrast, the highest rate of injury occurred among females older than age 75 (79 injuries per 1000), which was about 40% higher than the same-age males. The pattern for each of the three different severity levels of injury (fatal, hospitalised/ permanent disability, and non-hospitalised) by age category and sex was similar to the overall pattern.
The total costs resulting from injuries in Jiangxi in 2005 exceeded 17 billion RMB ($2.1 billion), with 85% of the total resulting from lost productivity (Table 2). Persons age 15 to 44, who represented 40% of the Jiangxi population, accounted for only 33% of injuries but 47% of total costs. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct medical & non-medical costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct medical & non-medical costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days. Overall, injury costs were 2.6 times higher for males (12.6 billion RMB, or $1.6 billion) than for females (4.8 billion RMB, or $588 million). Males who represented 51% of the Jiangxi population, accounted for 61% of all injuries and 73% of total costs. The main reason for the disproportionately large percentage of injury-attributable costs for males was due to not only the higher incidence of injuries in males compared to females, but also the different patterns of injury distribution by age for males and females: males were more likely than females to suffer an injury prior to or during their peak earning years. Table 3 and Table 4 show incidence counts and rates (per 100,000) and total lifetime costs of injuries by type and sex. Overall, fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of injuries, and sharp object
Table 1 e Incidence counts and rates (per 100,000) of injuries by age category and sex, Jiangxi 2005. H/PDa
Fatal Incidence
Rate (95% CI)
Incidence
Non-hospitalised
Rate (95% CI)
Incidence
Rate (95% CI)
Total Incidence
Rate (95% CI)
Total 0e4 5e14 15e24 25e44 45e64 65e74 75þ
41,695 4156 3352 1743 8178 9385 6837 8044
97 113 44 42 64 89 253 608
(87e109) (77e161) (29e65) (22e72) (49e82) (69e112) (189e333) (464e782)
374,180 23,059 47,862 27,752 122,403 109,264 26,545 17,295
873 629 629 668 953 1036 983 1307
(841e906) (539e730) (566e698) (581e766) (892e1016) (967e1109) (851e1129) (1092e1551)
2,025,074 183,001 412,254 117,040 522,859 587,345 136,480 66,095
4727 4991 5419 2819 4070 5570 5053 4995
(4654e4801) (4736e5256) (5234e5609) (2638e3010) (3946e4197) (5411e5732) (4755e5365) (4573e5443)
2,440,949 210,216 463,468 146,535 653,440 705,994 169,862 91,434
5697 5733 6092 3529 5087 6695 6289 6910
(5618e5779) (5461e6015) (5897e6292) (3327e3741) (4949e5228) (6521e6872) (5958e6633) (6417e7428)
Male 0e4 5e14 15e24 25e44 45e64 65e74 75þ
26,143 2815 2548 1341 6167 6167 4424 2681
121 129 61 64 103 118 328 452
(104e139) (80e198) (37e95) (31e118) (75e137) (86e157) (226e461) (276e697)
252,715 16,088 34,991 20,646 90,629 69,715 13,943 6703
1168 740 834 992 1507 1333 1034 1129
(1116e1222) (614e884) (736e941) (842e1161) (1396e1624) (1222e1452) (846e1252) (839e1486)
1,200,699 123,609 281,406 77,356 309,157 323,637 60,866 24,668
5549 5682 6708 3718 5140 6188 4516 4155
(5438e5662) (5331e6050) (6433e6991) (3426e4028) (4938e5349) (5951e6432) (4118e4940) (3587e4785)
1,479,557 142,512 318,945 99,343 405,953 399,519 79,233 34,052
6838 6551 7603 4774 6750 7639 5878 5736
(6716e6962) (6175e6943) (7311e7902) (4445e5122) (6519e6986) (7378e7908) (5426e6356) (5069e6462)
Female 0e4 5e14 15e24 25e44 45e64 65e74 75þ
15,552 1341 804 402 2011 3218 2413 5363
74 90 24 19 29 61 178 735
(61e88) (43e165) (9e51) (4e57) (16e49) (39e90) (106e282) (526e1000)
121,465 6971 12,871 7106 31,774 39,550 12,602 10,591
573 467 377 343 465 744 931 1452
(536e611) (349e613) (306e460) (257e449) (408e528) (662e834) (753e1139) (1151e1806)
824,375 59,391 130,849 39,684 213,702 263,709 75,613 41,427
3888 3983 3835 1916 3128 4961 5589 5678
(3793e3984) (3627e4363) (3602e4078) (1706e2145) (2979e3283) (4749e5179) (5148e6055) (5078e6326)
961,392 67,703 144,524 47,192 247,487 306,477 90,628 57,381
4535 4540 4236 2278 3622 5766 6698 7865
(4432e4638) (4161e4944) (3991e4490) (2049e2527) (3463e3789) (5538e6000) (6218e7024) (7163e8612)
a
H/PD refers to injuries resulting in hospitalisation or permanent disability.
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Table 2 e Lifetime costs of injuries by age category and sex, Jiangxi 2005 (cost unit: million RMB; school day unit: 1000 days). Fatal
H/PD
Non-hospitalised
Total
Direct costs
Prod. losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
Lifetime costs
School losses
Total 0e4 5e14 15e24 25e44 45e64 65e74 75þ
116.7 5.2 2.8 12.0 24.6 43.1 19.6 9.5
6813 1482 1351 697 2322 940 12 8
1953 58 143 221 776 562 133 61
6899 243 1482 805 2809 1439 74 47
1058 30 715 292 11 7 2 1
614 34 96 34 173 200 50 27
994 19 32 25 278 437 124 79
1008 85 755 156 6 2 3 0
2684 98 242 267 973 805 202 97
14,705 1744 2865 1527 5409 2815 210 134
17,389 1842 3107 1795 6382 3620 412 231
2065 115 1470 448 17 9 5 1
Male 0e4 5e14 15e24 25e44 45e64 65e74 75þ
92.9 4.0 1.6 10.5 21.9 33.8 16.5 4.6
4958 1006 1022 539 1740 641 8 3
1412 44 99 166 615 382 81 25
5284 210 1095 638 2321 971 36 13
767 24 497 231 9 4 2 0
371 23 67 23 115 111 21 11
512 12 21 17 172 227 38 24
732 57 552 117 4 1 2 0
1875 71 167 199 752 527 118 40
10,753 1227 2138 1194 4233 1839 82 40
12,629 1299 2305 1393 4985 2367 200 81
1499 81 1049 348 13 5 3 0
Female 0e4 5e14 15e24 25e44 45e64 65e74 75þ
23.8 1.2 1.2 1.5 2.7 9.3 3.1 4.8
1855 477 329 158 583 299 4 5
542 14 44 56 161 180 52 35
1615 33 387 168 487 468 38 34
291 7 218 61 2 2 0 1
243 11 29 11 58 89 29 16
483 7 11 8 105 210 86 55
276 28 204 39 2 2 1 0
809 26 75 68 222 277 84 56
3952 517 728 334 1175 976 128 94
4761 543 802 402 1397 1253 212 151
567 35 422 100 4 4 1 1
Note: Direct costs include medicals costs and direct non-medical costs. Prod. Losses refer to productivity losses. One US dollar was equivalent to approximately 8.1 RMB in the year 2005.
injuries accounted for an additional 10% of injuries. Although self-harm and drowning injuries were comparatively rare, these injuries were far more likely to be fatal than those caused by other mechanisms. For example, while only 1.8% of fall injuries and 2.3% of RTC injuries were fatal, more than 60% of self-harm and drowning injuries were fatal. Combined, fall, RTC, drowning, and self-harm injuries, accounted for 79% of fatal injuries among males and 81% of fatal injuries among females. The rate of injuries among males was higher than among females for every type but self-harm: females were roughly 40% more likely than males to suffer a self-harm-related injury, and two times as likely as males to suffer a fatal injury due to self-harm. In contrast, males were roughly six times as likely as females to suffer an electrical injury and over two times as likely as females to suffer a RTC, assault, falling object, or blunt object injury. Combined, RTC injuries and fall injuries accounted for more than 50% of the total costs of injuries. Although injury from drowning accounted for less than 0.5% of all injuries, more than 60% of those injuries were fatal; as a result, drowning accounted for approximately 12% of the total costs of injuries and had the highest average cost per case e 202,853 RMB ($25,044) per overall drowning injury. Similarly, although self-harm, asphyxia, and electricity injuries were comparatively rare, these injuries were far more likely to be fatal or severe than those caused by other types and therefore the average cost per case was disproportionately high: self-harm,
asphyxia, and electricity injuries accounted for 0.3%, 0.5% and 0.3% of the incidence of injuries but 3%, 3.6% and 1.5% of the total costs respectively. For both males and females, RTC injuries caused the greatest burden from the productivity losses. Regarding direct medical & non-medical costs, RTC injuries caused the greatest burden for males, while fall injuries caused the greatest burden for females. For both sexes, fall injuries caused the greatest number of lost school days.
Discussion This study presents an important estimate of the economic burden of injuries occurring in Jiangxi province, China in the year 2005. In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. On average, each injury generated 7124 RMB ($880) in direct and indirect costs and, an additional loss of 0.85 school days. The total lifetime cost of injuries e 17.4 billion RMB ($2.1 billion), accounted for about 4.3% of Jiangxi's 2005 gross domestic product (GDP) and was 407 RMB ($50) for every resident in Jiangxi in the year 2005. The findings provide an important perspective on the extent to which injuries are draining Jiangxi province's vital resources and human capital. When the burden of injuries was defined by lifetime costs, RTC injuries posed the greatest burden to Jiangxi province, 5 billion RMB, which was 33% greater than the lifetime costs of the next highest type (fall injuries, 3.8 billion RMB). However,
Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024
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Table 3 e Incidence counts and rates (per 100,000) of injuries by type and sex, Jiangxi 2005. Injury type
Fatal
H/PD
Incidence Rate (95% CI) Incidence
Non-hospitalised
Rate (95% CI)
Total Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
41,695 5095 9921 1341 12,066 1207 0 134 6167 670 0 938 402 2413 1341
97 12 23 3 28 3 0 0 14 2 0 2 1 6 3
(87e109) (8e16) (18e29) (2e6) (23e35) (1e5) (0e1) (0e2) (11e19) (0e4) (0e1) (0e5) (0e3) (3e9) (2e6)
374,180 2279 124,414 16,356 118,917 12,870 21,451 12,066 670 22,121 17,563 1475 16,624 2547 4827
873 5 290 38 278 30 50 28 2 52 41 3 39 6 11
Male Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
26,143 1609 7374 938 7240 1073 0 0 4424 670 0 670 268 1609 268
121 8 34 4 33 5 0 0 21 3 0 3 1 8 1
(104e139) (4e13) (26e44) (2e9) (25e44) (2e10) (0e2) (0e2) (14e29) (1e7) (0e2) (1e7) (0e4) (4e13) (0e4)
252,715 1341 90,227 13,004 67,033 11,127 15,552 8044 268 14,881 14,881 1207 10,993 1073 3084
1168 6 417 60 310 51 72 37 1 69 69 6 51 5 14
Female Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
15,552 3486 2547 403 4826 134 0 134 1743 0 0 268 134 804 1073
74 16 12 2 23 1 0 1 8 0 0 1 1 4 5
(61e88) (11e24) (7e19) (0e6) (16e32) (0e4) (0e2) (0e4) (4e14) (0e2) (0e2) (0e5) (0e4) (1e8) (2e10)
121,465 938 34,187 3352 51,884 1743 5899 4022 402 7240 2682 268 5631 1474 1743
573 4 161 16 245 8 28 19 2 34 13 1 27 7 8
Incidence
Rate (95% CI)
Total Incidence
Rate (95% CI)
(841e906) (3e9) (272e310) (32e46) (260e296) (24e37) (43e58) (23e35) (0e4) (44e60) (34e49) (2e6) (32e46) (4e9) (8e16)
2,025,074 536 296,957 36,064 538,277 34,455 227,377 83,389 3084 77,222 98,807 5094 497,387 7508 118,917
4727 1 693 84 1256 80 531 195 7 180 231 12 1161 18 278
(4654e4801) (0e3) (665e723) (74e95) (1218e1296) (71e91) (506e557) (180e211) (5e11) (166e196) (214e248) (8e16) (1124e1199) (13e23) (260e296)
2,440,949 7910 431,292 53,761 669,260 48,532 248,828 95,589 9921 100,013 116,370 7507 514,413 12,468 125,085
5697 18 1006 125 1562 113 581 223 23 234 272 17 1201 30 292
(5618e5779) (14e24) (972e1042) (114e138) (1520e1606) (102e126) (555e608) (207e240) (18e29) (217e251) (254e290) (13e23) (1163e1239) (23e36) (274e311)
(1116e1222) (3e11) (386e450) (49e73) (283e338) (41e64) (59e86) (28e48) (0e4) (57e83) (57e83) (3e11) (40e63) (2e10) (9e21)
1,200,699 268 204,585 24,400 269,876 25,339 135,541 47,057 1877 50,543 71,726 4424 291,326 3620 70,117
5549 1 946 113 1247 117 626 217 9 234 331 20 1346 17 324
(5438e5662) (0e4) (899e994) (97e130) (1194e1303) (101e135) (589e666) (195e241) (5e15) (211e258) (304e361) (14e29) (1291e1404) (11e24) (297e353)
1,479,557 3218 302,186 38,342 344,149 37,539 151,093 55,101 6569 66,094 86,607 6301 302,587 6302 73,469
6838 15 1397 177 1590 173 698 254 31 306 400 29 1398 30 339
(6716e6962) (10e22) (1340e1455) (157e199) (1530e1653) (154e195) (658e740) (231e280) (22e40) (279e334) (370e432) (21e39) (1342e1457) (21e39) (312e369)
824,375 268 92,372 11,664 268,401 9116 91,836 36,332 1207 26,679 27,081 670 206,061 3888 48,800
3888 1 436 55 1266 43 433 171 6 126 128 3 972 18 230
(3793e3984) (0e5) (404e469) (44e68) (1211e1322) (33e55) (401e467) (152e193) (3e11) (109e145) (111e147) (1e7) (924e1021) (12e26) (207e255)
961,392 4692 129,106 15,419 325,111 10,993 97,735 40,488 3352 33,919 29,763 1206 211,826 6166 51,616
4535 21 609 73 1534 52 461 191 16 160 141 5 1000 29 243
(4432e4638) (15e31) (571e648) (60e87) (1473e1595) (41e64) (428e496) (170e214) (10e23) (141e181) (123e160) (3e11) (951e1049) (21e39) (220e269)
(536e611) (2e9) (142e182) (10e23) (221e270) (4e14) (20e37) (13e27) (0e6) (26e45) (8e20) (0e5) (19e36) (3e12) (4e14)
RTC injuries are preventable, and there is an established set of interventions that have been demonstrated in high-income countries to significantly reduce incidence and impact of RTC injuries.16 These include the enforcement of legislation to control speed and alcohol consumption, mandating the use of seatbelts and crash helmets, the safer design and use of roads and vehicles, and many other proven science-based interventions. Although solutions for China may differ from those of high-income countries, basic intervention principles apply. The substantial burden of RTC injuries to society calls for attention of the Chinese government to make use of existing science-based solutions to develop effective and costeffective intervention programs to reduce RTC injuries.
When the appropriate level of resources to dedicate towards preventing one type of injury or another is concerned, there are issues more than lifetime costs to be considered. For example, drowning injuries accounted for 0.5% of the incidence of injuries but 12% of the total costs. Similarly, self-harm, asphyxia, and electricity injuries accounted for 0.3%, 0.5% and 0.3% of the incidence of injuries but 3%, 3.6% and 1.5% of the total costs respectively. If one was to allocate injury prevention dollars based on incidence alone, the amount allocated towards reducing these types of injuries might be less than the amount based on both incidence and total costs. Special attention might also be focused on preventing childhood injuries since injuries occurring to children not only pose a great economic burden (in
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Table 4 e Lifetime costs of injuries by type and sex, Jiangxi 2005 (cost unit: million RMB; school day unit: 1000 days). Fatal
Total Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others Male Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others Female Self-harm RTC Assault Fall Falling object Sharp objects Burn Drowning Poison Blunt object Electricity Animal bite Asphyxia Others
H/PD
Non-hospitalised
Total
Direct costs
Prod. losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
School losses
Direct costs
Prod. losses
Lifetime costs
School losses
116.7 4.7 53.5 5.6 39.5 1.4 0 0.05 1.7 0.3 0 0.1 1.5 4.4 3.9 92.9 1.6 46.5 4.8 32.2 1.2 0 0 1.1 0.3 0 0.05 0.6 3.8 0.8 23.8 3.1 7.0 0.9 7.3 0.2 0 0.05 0.6 0 0 0.02 0.9 0.6 3.1
6812 470 1907 392 718 272 0 7 2010 133 0 205 58 587 54 4958 100 1485 288 560 262 0 0 1556 133 0 110 58 396 11 1854 370 422 104 158 10 0 7 454 0 0 95 0 191 43
1953 5 858 98 579 81 64 57 1 29 100 32 25 13 14 1412 4 640 83 358 67 52 33 0.4 22 84 31 16 10 11 542 2 218 14 221 14 12 24 0.2 7 16 1 8 3 3
6899 47 1958 339 1818 321 1296 154 0.1 11 786 19 100 14 35 5284 46 1442 293 1332 265 987 83 0.05 6 731 19 44 14 23 1615 1 517 46 486 56 309 71 0.03 5 55 1 56 1 11
1058 2 445 32 404 18 24 62 0 1 34 4 25 6 2 767 2 318 26 278 6 23 46 0 1 32 4 23 6 2 291 0 126 6 125 12 1 16 0 0 2 0 2 0 0
614 1 128 16 228 10 29 21 0.2 9 25 2 116 1 28 371 0.1 90 10 121 8 21 13 0.1 6 19 2 65 1 15 243 0.5 38 6 107 2 8 8 0.1 3 6 0.1 52 0.3 13
994 0 192 24 457 22 72 31 0.1 13 42 6 71 1 64 512 0.1 132 13 164 18 49 16 0.05 8 30 4 39 0.3 35 483 0.2 60 10 293 4 23 15 0.04 5 11 1 31 0.3 29
1008 16 169 39 446 5 45 51 1 1 48 0.3 154 2 31 732 0 110 36 345 4 40 37 1 0.1 36 0.3 105 1 17 276 16 59 3 101 1 5 14 0 1 12 0 49 1 14
2684 10 1039 119 846 93 93 78 3 38 125 34 142 18 46 1875 5 776 98 511 76 73 46 2 28 103 34 82 15 27 809 5 263 21 335 16 20 31 1 10 22 1 61 4 19
14,705 518 4057 755 2994 616 1368 192 2010 157 828 230 228 602 153 10,753 147 3058 594 2056 545 1036 99 1556 147 761 133 141 410 70 3952 371 999 161 937 70 331 93 454 10 66 97 87 192 83
17,389 528 5096 874 3839 708 1460 270 2013 195 952 264 371 620 199 12,629 152 3835 692 2567 622 1109 145 1557 175 864 167 223 424 97 4761 376 1262 182 1272 87 351 124 455 20 89 98 148 196 102
2065 18 614 71 850 23 69 113 1 2 82 4 179 8 33 1499 2 428 62 624 10 63 82 1 2 67 4 128 7 19 567 16 185 9 226 13 6 30 0 1 15 0 51 1 14
terms of direct costs and productivity losses) to the society, but also cause a large number of lost school days which adversely affect human capital development in children and eventually the country's future productivity. Finally, it is useful to recognise that some types of injury are more easily prevented and at lower cost than others. Recent work in Bangladesh has shown childhood drowning to be highly preventable at low cost (Precise Program, Bangladesh).17 The rate of injuries among males is higher than that among females for every type but self-harm. Females were two times as likely as males to suffer a fatal injury due to self-harm. The present findings are consistent with other research that found China is one of the very few countries that report higher rates of completed suicide in women than in men.18,19 To address
this issue and related challenges, such as the complex social issues involved in suicide, more research and efforts are needed to understand and target the unique nature of suicide among residents of China. This analysis has several limitations. First, the prevalence of assault and self-harm is likely underestimated. Intentional injury experts note that household surveys such as the Jiangxi Injury Survey provide little privacy and do not foster the rapport needed for obtaining good response rates for questions relating to intentional injury. Second, the costs included in this analysis focus exclusively on direct medical & non-medical costs and productivity losses, and do not include the rehabilitation costs for the disabled (due to the unavailability of data), the future or current productivity
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losses due to lost school days, the costs for pain and suffering, or other non-monetary costs that result from injuries (such as reductions in functional capacity and quality of life). While some of these non-monetary outcomes are difficult to quantify in monetary terms, excluding them means that these total cost estimates are substantially underestimated. Third, the probabilities of total and partial disability were computed from a national survey of the disabled conducted in 1987. We further assumed that for those partially losing the ability to work, their productivity was half that of non-disabled workers. Although these assumptions were made because of data unavailability, caution should be taken in interpreting the long-term productivity losses for non-fatal injuries, and that future research is needed to validate these results with a more updated and complete assessment of disability. Fourth, this study relies on retrospective self-reports to measure the incidence and costs of injuries. Retrospective measures may introduce biases which may limit the validity and reliability of these reports. As such, participants may not remember clearly all their utilisation of health care or numbers of days missed from work or school, or they may choose not to tell the truth. In turn, this raises the issue of the extent to which errors in the retrospective self-reported variables may have influenced the study results. Despite these limitations, the estimates reported above should be viewed as the best available estimates of injury incidence and costs in China to date. As new data become available, future studies will improve upon the methodology and results. The burden of injuries, which are substantial in terms of lives lost, pain and suffering and economic consequences, should indicate to policy makers that more research and efforts are needed to find efficacious, effective, and costeffective interventions targeting both intentional and unintentional injuries.
Author statements Acknowledgements Funding for the Jiangxi Injury Survey was provided by UNICEF China. The project was a collaboration between UNICEF China, The Alliance for Safe Children, the National Working Committee for Women and Children, and the Jiangxi Provincial Health Bureau and Center for Disease Control. Technical assistance was provided by The Alliance for Safe Children (TASC), Chinese Field Epidemiology Training Program and East Asia and Pacific Regional Office, United Nations Children's Fund. Jiangxi Provincial Health Bureau, Jiangxi Center for Disease Control conducted the field work and participated in the data analysis and report writing. Special thanks go to the field workers of Jiangxi County and Prefecture Centers for Disease Control for their participation and dedication on data collection. All protocols and survey instruments were submitted to an UNICEF ethical review board for approval prior to the commencement of fieldwork.
Ethical approval None sought.
Funding None declared.
Competing interests The authors report no conflicts of interest.
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Please cite this article in press as: Fang X, et al., The incidence and economic burden of injuries in Jiangxi, China, Public Health (2016), http://dx.doi.org/10.1016/j.puhe.2016.03.024