Abstract
Purpose
Little research has been done in China to study injury in individuals with disability. We investigated impact of type and severity of disability on injury among children with disability in Hubei Province of China.
Methods
A sample of 1201 children with disability were matched with 1201 healthy children on gender, age, and neighborhood. Disability type and severity were determined using the Chinese national standards. Caregivers were interviewed face-to-face about nonfatal unintentional injuries suffered by the child in the past 12 months prior to the interview. Univariate Chi-square test and logistic regression models were used to investigate association between disability type/severity and nonfatal unintentional injuries.
Results
Injury rate among children with disability was significantly higher than that among children without disability (10.2% vs. 4.4%; P <.001). Children with multiple disabilities had the highest risk of injury after controlling for confounding variables (OR=4.54; 95% CI=2.82, 7.30; P<.001). The magnitude of the association between disability and injury varied by type and severity of disability.
Conclusions
The magnitude of the association between the presence or absence of disability in children and their risk of injury was large and significant, regardless of the type or severity of the children's disabilities.
Keywords: Unintentional injury, Children, Disability, China
Introduction
Globally, an estimated 200 million - or 10% of the world's children - live with disability [1,2]. Disability in childhood brings lifelong physical and psychological challenges to the child and the family and could cause huge economic burdens to the society [3]. Children with disability appear to need more extensive health care services, but experience personal and environmental barriers that prevent full involvement in active life activities [4, 5]. Data from the Second National Disability Survey suggest that almost 83 million people, or nearly 6.3% of the population, have different types of disability in China [6]. Of those with disabilities, about 3.87 million are 0–14 years children [7,8]. It’s estimated that about 199,000 new cases of disability in children under 6 years old are diagnosed each year in China [8]. In response to the increasing number of children with disability, China has initiated special public health programs targeted at children with disability in recent years [9,10].
In comparison with children without disability, increasing evidence suggests that children with disability are at higher risk for secondary conditions [11–14], including unintentional injuries [15–21]. Children with disability may have a reduced ability to handle environmental hazards because of physical limitations, impairments in mental processing, or in their ability to adjust to their environment [16,17,22]. Previous publications that reported an increased risk of injury in children with disability came from high income countries [15,17–22]. In our recent publication about medically attended injuries among Chinese children with disability, we found that injury risk in children with disability is significantly higher than in children without disability [23]. We compared the patterns of injuries between children with and without disability and investigated the association between home environmental hazards and risk of nonfatal injuries. However, we did not examine impact of disability types and severity on injury risk in the previous publication.
We hypothesize that injury risk differs between children with different types or severity of disability. In this article, we report injury prevalence of children with single vs. multiple disabilities, injury prevalence by severity of disability, and odds ratios (OR) of injury. We also evaluated the recommended disability screening tool, the UNICEF Ten Questions (TQ) for childhood disability [24–29], in a subsample of Chinese children. Findings from our study add to the world literature on an important public health issue in children with disability.
Methods
Study setting
Hubei province, located in central China, has 102 counties and a total of 60 million population. The China Disabled Persons’ Federation (CDPF) is the official agency for individuals with disability in China. A registry database is maintained by the CDPF’s county level office to monitor the number of persons with disability in that county and to track medical and rehabilitation services provided by the government. Individuals with disability who want to apply for government funded services need to be evaluated by a certified physician using the standards of China Classification and Grading Criteria of Disability [30,31]. Individuals who meet the criteria will be issued an official certificate that lists the type and severity of the disability he/she has. With help from the Hubei Disabled Persons’ Federation, five counties were randomly selected for our study.
Data source and study population
We obtained the registry database of persons with all types and severity of disability in the selected five counties. No random sampling was conducted, and all children, aged 1–14 years, registered in the database were eligible for this study. In our survey, a child must have had the disabling condition(s) for at least 12 months prior to the interview to be eligible to participate. This allowed us to ensure that the disabling conditions pre-dated any injury that occurred in the past year. For every child with disability, we matched a healthy child who had the same gender and age and lived in the same neighborhood. If the parent or legal guardian agreed to participate in our study, a thirty minute interview was conducted face-to-face with the parent or guardian. The face-to-face interviews were carried out from May to August 2011 by Master degree and PhD students from Tongji Medical College whose training and field study supervision were overseen by the principal investigator at the Tongji Medical College. The questionnaire was developed together with researchers at the Center for Injury Research and Policy, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine. The questionnaire was tested before the formal survey. A pilot testing was conducted in 81 children in one of the selected five counties. Both children with disability and their healthy counterparts were interviewed using the same questionnaire except that questions about type and severity of disability, which were asked only in children with disability. During the survey, quality of finished questionnaires was checked by a field data collection manager each day and incomplete questionnaires were returned to the interviewer, who obtained the missing information from parents or guardians the next day.
The protocol of this study was approved by the Institutional Review Board of School of Public Health of Tongji Medical College.
Study measurements
Disability
Disability was categorized using the following six groups that are defined by the China Classification and Grading Criteria of Disability: vision disability, hearing disability, speech disability, physical disabilities, mental retardation, and mental health disorders [30–31]. In addition, individuals were also categorized as having either a single disability or multiple disabilities. In our study, a person who had multiple disabilities was classified into one of the six categories of disability mentioned above according to the most severe type of disability he/she had, which was consistent with the type of the disability listed in his/her official certificate issued by CDPF. Severity of disability was also classified into one of four levels of disability based on the China Classification and Grading Criteria of Disability: level 1 is the most severe disability level and level 4 is the mildest degree of disability [30–31]. The type and severity of disability were obtained from checking every child’s official certificate during the face-to-face interview to the parents or guardians, and recorded in the questionnaire by the interviewer.
Injury
Parents or guardians of children were asked to report nonfatal unintentional injuries suffered by the child in 12 months prior to the interview date. An injury was defined as an event that caused the injured child to seek medical care at a hospital or a community clinic. Detailed information was collected about the most recent injury episode, including the external cause of injury, body parts injured, location of injury, activity at time of injury, and medical treatment after injury. We selected the primary cause as the leading cause of injury. For example, if a child was struck by an object or a person first, and then fell, struck by a person or an object was considered the leading cause of injury.
Sociodemographic variables
We also collected sociodemographic variables that are usually considered as risk factors for injury: gender and age of the child, parent’s education level, family income, single-parent family status, time of being supervised by an adult per day, and total number of family members. Family members could include the child, the child’s parents, siblings, grandparents, and a father’s sister or brother who was not married. The time of being supervised by an adult refers to the average time per day that the child is within the range of his/her primary care giver’s supervision. Family income was self-reported as total monthly household income in Chinese currency Renminbi (RMB). One RMB was approximately equal to U.S. $ 0.157 at the time of the survey. All sociodemographic variables were categorical except for the age and number of family members when collected in the questionnaire.
The Ten Questions
In addition to sociodemographic information and health status questions, our questionnaire also included a Chinese language version of the UNICEF Ten Questions (TQ) about limitations in daily activities. The TQ contains ten questions, and is an appropriate and useful instrument for detecting disabilities for all children aged 2–9 years and in all cultures [24–29]. The ten questions were tested previously and found that the sensitivity, specificity and negative predictive value of it were perfect or near perfect for the severe and moderate disabilities [26–29]. To be consistent with previous studies around the world that used the TQ, only children aged 2– 9 years were needed to investigate the questions in the TQ.
Data analysis
Statistical analyses were performed using SAS statistical software. We first compared the rates of injury in children with no disability, single disability, and multiple disabilities by gender and age, parent’s education, number of family members, time of being supervised by an adult, single-parent family status, and family income per month. We used the Chi-square test to determine whether the association between disability status and injury rate was statistically significant for matched pairs of children with same sociodemographic status. We also investigated the association between severity of disability and injury rate by these sociodemographic variables.
We calculated odds ratios (ORs) and the 95% confidence intervals (CIs) using logistic regression analyses. Multivariable logistic regression models allowed us to assess injury risk in children who had each of six disability types, multiple disabilities, and severity of disability compared with children without disability, controlling for potential confounding effect of above-mentioned sociodemographic variables.
Results
The disability registry database in the selected five counties had 1379 1- to 14-year-old children with disability. A total of 2402 children completed the survey, including 1201 children with disability and 1201 healthy controls. The overall final response rate was 87.1% in this study. There were 807 boys and 394 girls in both groups of children with and without disability. Age of the interviewed children ranged from 1 to 14 years, with a median age of 6 years and interquartile range of 4 to 10 years.
When disability status based on the China Classification and Grading Criteria of Disability was compared with disability status defined by the TQ for 2–9 years old children, the Kappa coefficient for agreement was 0.913 (95%CI= 0.894–0.932). There was a high degree of consistency between the TQ and the Chinese criteria for identifying children with disability.
Table 1 presents rate of medically attended injuries occurred during the 12 months prior to interview for children with no disability, single disability and multiple disabilities, stratified by sociodemographic characteristics. Rate of injuries among children with single disability or multiple disabilities was significantly higher than that among children without disability (9.6% and 11.2% vs. 4.4%, P <.001). For the majority of sociodemographic factors, children with disability had a significantly higher rate of injury than children without disability. However, injury rate did not differ significantly between children with and without disability for the following groups (P >.05): children aged 1–4 years and 11–14 years; children in single parent households; children whose parents’ highest education was middle shool or less; children with less than 30% of time per day supervised by an adult; and children whose family income per month was less than 1000 RMB.
Table 1.
Rate of medically attended injuries among children with different disability status by selected sociodemographic characteristics in Hubei Province, The People's Republic of China, 2011
| Characteristics | Children without disability | Children with single disability | Children with multiple disabilities | P -valuea | |||
|---|---|---|---|---|---|---|---|
| N | Injured n (%) | N | Injured n (%) | N | Injured n (%) | ||
| Total | 1201 | 53(4.4) | 738 | 71(9.6) | 463 | 52(11.2) | <.001 |
| Gender | |||||||
| Boy | 807 | 36(4.5) | 493 | 53(10.8)** | 314 | 34(10.8)** | <.001 |
| Girl | 394 | 17(4.3) | 245 | 18(7.3) | 149 | 18(12.1)** | .005 |
| Age (years) | |||||||
| 1–4 | 359 | 19(5.3) | 214 | 15(7.0) | 145 | 14(9.7) | .202 |
| 5–10 | 598 | 21(3.5) | 379 | 43(11.3)** | 219 | 27(12.3)** | <.001 |
| 11–14 | 244 | 13(5.3) | 145 | 13(9.0) | 99 | 11(11.1) | .141 |
| Parent’s educationb | |||||||
| Middle school or less | 148 | 6(4.1) | 183 | 15(8.2) | 116 | 9(7.8) | .284 |
| High school | 748 | 30(4.0) | 462 | 48(10.4)** | 316 | 35(11.1)** | <.001 |
| Undergraduate degree or higher | 305 | 17(5.4) | 93 | 8(8.6) | 31 | 8(25.8)** | .003 |
| Number of family members | |||||||
| 1–3 | 353 | 22(6.2) | 162 | 20(12.3)* | 71 | 8(11.3) | .048 |
| 4–5 | 620 | 28(4.5) | 401 | 43(10.7)** | 260 | 36(13.8)** | <.001 |
| 6 or more | 228 | 3(1.3) | 175 | 8(4.6) | 132 | 8(6.1)** | .032 |
| Single-parent family | |||||||
| Yes | 48 | 3(6.3) | 46 | 4(8.7) | 42 | 2(4.8) | .755 |
| No | 1153 | 50(4.3) | 692 | 67(9.7)** | 421 | 50(11.9)** | <.001 |
| Daily adult supervision (% of day) | |||||||
| <30% | 256 | 15(5.9) | 64 | 7(10.9) | 17 | 3(17.6) | .142 |
| 30–59% | 332 | 15(4.5) | 129 | 18(14)** | 34 | 6(17.6)** | .001 |
| 60–89% | 444 | 19(4.3) | 280 | 23(8.2)* | 138 | 19(13.8)** | <.001 |
| >90% | 169 | 4(2.4) | 265 | 23(8.7)* | 274 | 24(8.8)* | .021 |
| Family income per month | |||||||
| Less than 1000 RMB | 65 | 5(7.7) | 112 | 10(8.9) | 74 | 6(8.1) | .955 |
| 1000–3000 RMB | 413 | 14(3.4) | 340 | 40(11.8)** | 223 | 25(11.2)** | <.001 |
| 3001–5000 RMB | 513 | 22(4.3) | 237 | 18(7.6) | 152 | 17(11.2)** | .006 |
| 5000 or higher | 210 | 12(5.7) | 49 | 3(6.1) | 14 | 4(28.6)** | .037 |
P- values were derived from Chi-square analysis between disability status and injury prevalence, by selected sociodemographic characteristics.
Parent’s education was defined as the highest level of education achieved by either the child’s mother or father.
Children with single disability or multiple disabilities compared with children without disabilities, respectively;
:P<0.01;
:P<0.05.
Table 2 shows rate of medically attended injuries by different severity levels of disability. When compared with children without disability, severity of disability and injury risk were significantly associated for boy, for children aged 1–4 or 5–10, for children whose parents’ highest education was high school, for children whose family members were 4–5, for children not came from single parent households, for children whose percent of daily supervision by adult was less than 30%, 30~59% or 60~89%, and for children whose family income per month was 1000–3000 RMB or 3001 –5000 RMB.
Table 2.
Rate of medically attended injuries among children with different severity of disability by selected sociodemographic characteristics in Hubei Province, The People's Republic of China, 2011
| Characteristics | Level 1 disability | Level 2 disability | Level 3 disability | Level 4 disability | P -valuea | ||||
|---|---|---|---|---|---|---|---|---|---|
| N | Injured n (%) | N | Injured n (%) | N | Injured n (%) | N | Injured n (%) | ||
| Total | 308 | 25(8.1) | 278 | 32(11.5) | 269 | 28(10.4) | 243 | 25(10.3) | <.001 |
| Gender | |||||||||
| Boy | 202 | 15(7.4) | 189 | 24(12.7)** | 182 | 19(10.4)** | 146 | 18(12.3)** | <.001 |
| Girl | 106 | 10(9.4) | 89 | 8(9.0) | 87 | 9(10.3) | 97 | 7(7.2) | .153 |
| Age (years) | |||||||||
| 1–4 | 94 | 3(3.2) | 72 | 9(12.5)* | 67 | 5(7.5) | 80 | 9(11.3) | .05 |
| 5–10 | 151 | 15(9.9)** | 140 | 19(13.6)** | 130 | 13(10.0)** | 120 | 13(10.8)** | <.001 |
| 11–14 | 63 | 7(11.1) | 66 | 4(6.1) | 72 | 10(13.9)* | 43 | 3(7.0) | .125 |
| Parent’s education | |||||||||
| Middle school or less | 97 | 10(10.3) | 76 | 6(7.9) | 67 | 7(10.4) | 59 | 1(1.7) | .087 |
| High school | 200 | 15(7.5)* | 187 | 23(12.3)** | 183 | 19(10.4)** | 176 | 24(13.6)** | <.001 |
| Undergraduate degree or higher | 11 | 0(0.0) | 15 | 3(20.0)* | 19 | 2(10.5) | 8 | 0(0.0) | .307 |
| Number of family members | |||||||||
| 1–3 | 39 | 3(7.7) | 43 | 4(9.3) | 53 | 6(11.3) | 38 | 8(21.1)** | .064 |
| 4–5 | 171 | 16(9.4)* | 159 | 24(15.1)** | 150 | 18(12.0)** | 142 | 15(10.6)** | <.001 |
| 6 or more | 98 | 6(6.1)* | 76 | 4(5.3) | 66 | 4(6.1)* | 63 | 2(3.2) | .057 |
| Single-parent family | |||||||||
| Yes | 33 | 3(9.1) | 22 | 0(0.0) | 16 | 1(6.3) | 15 | 2(13.3) | .476 |
| No | 275 | 22(8.0)* | 256 | 32(12.5)** | 253 | 27(10.7)** | 228 | 23(10.1)** | <.001 |
| Daily adult supervision (% of day) | |||||||||
| <30% | 8 | 1(12.5) | 11 | 4(36.4)** | 24 | 2(8.3) | 38 | 3(7.9) | .017 |
| 30–59% | 17 | 2(11.8) | 32 | 5(15.6)* | 60 | 10(16.7)** | 53 | 7(13.2)* | .001 |
| 60–89% | 98 | 13(13.3)** | 99 | 11(11.1)* | 99 | 7(7.1) | 92 | 9(9.8)* | .006 |
| >90% | 185 | 9(4.9) | 136 | 12(8.8) | 86 | 9(10.5) | 60 | 6(10.0)* | .299 |
| Family income per month | |||||||||
| Less than 1000 RMB | 46 | 6(13) | 56 | 3(5.4) | 41 | 5(12.2) | 39 | 2(5.1) | .512 |
| 1000–3000 RMB | 154 | 13(8.4)* | 127 | 15(11.8)** | 139 | 19(13.7)** | 113 | 12(10.6)** | .002 |
| 3001–5000 RMB | 104 | 5(4.8) | 84 | 13(15.5)** | 78 | 4(5.1) | 82 | 9(11.0)* | .003 |
| 5000 or higher | 4 | 1(25.0) | 11 | 1(9.1) | 11 | 0(0.0) | 9 | 2(22.2) | .121 |
P- values were derived from Chi-square analysis of association between severity levels of disability and injury prevalence.
Children with 4 levels of disability compared with children without disabilities, respectively;
: P <0.01;
: P <0.05.
Table 3 presents odds ratio of injury from univariate logistic regression models. In comparison with children who had 6 or more family members, odds ratio of injury was much higher for children who had 1–3 family members (OR=2.53, 95% CI=0.93, 4.36) or 4–5 family members (OR=2.48, 95% CI=1.50, 4.08). Odds ratios did not differ significantly among children with other sociodemographic characteristics.
Table 3.
Univariate logistic regression results of medically attended injuries among children by sociodemographic characteristics in Hubei Province, The People's Republic of China, 2011
| Variables | Sample N | Injured n (%) | Univariate model OR 95% CI |
|---|---|---|---|
| Daily adult supervision (% of day) | |||
| <30% | 337 | 25(7.4) | 0.97(0.59, 1.59) |
| 30–59% | 495 | 39(7.9) | 0.95(0.59, 1.54) |
| 60–89% | 862 | 61(7.1) | 1.07(0.63, 1.80) |
| >90% | 708 | 51(7.2) | 1 |
| Gender | |||
| Boy | 1614 | 123(7.6) | 1.14(0.82, 1.60) |
| Girl | 788 | 53(6.7) | 1 |
| Age | |||
| 1–4 | 718 | 48(6.7) | 0.87(0.56, 1.36) |
| 5–10 | 1196 | 91(7.6) | 1.01(0.68, 1.49) |
| 11–14 | 488 | 37(7.6) | 1 |
| Number of family members | |||
| 1–3 | 586 | 50(8.5) | 2.53(0.93, 4.36) |
| 4–5 | 1281 | 107(8.4) | 2.48(1.50, 4.08)* |
| 6 or more | 535 | 19(3.6) | 1 |
| Parent’s education | |||
| Middle school or less | 447 | 30(6.7) | 0.86(0.72, 1.44) |
| High school | 1526 | 113(7.4) | 0.96(0.64, 1.44) |
| Undergraduate degree or higher | 429 | 33(7.7) | 1 |
| Family income per month | |||
| Less than 1000 RMB | 251 | 21(8.4) | 1.22(0.64, 2.33) |
| 1000–3000 RMB | 976 | 79(8.1) | 1.18(0.70, 1.98) |
| 3001 –5000 RMB | 902 | 57(6.3) | 0.90 (0.53, 1.54) |
| 5000 or higher | 273 | 19(7.0) | 1 |
| Single-parent family | |||
| Yes | 136 | 9(6.6) | 0.89 (0.45,1.78) |
| No | 2266 | 167(7.4) | 1 |
Table 4 presents odds ratios of injury from multivariable logistic regression models. The reference group for all logistic models was children without disability. The multivariable OR of injury among children with any disability was significantly higher than that among children without a disability (OR=3.40; 95% CI=2.32, 4.98; P <.001). Our results indicated that children with multiple disabilities had the highest risk of injury (OR=4.54; 95% CI=2.82, 7.30; P <.001). The 95% CI for OR included unit 1 for children with only vision or hearing disability. For other types of disability, odd ratios of injury were statistically higher than those among the children without disability.
Table 4.
Multivariable logistic regression results of type and severity of disability on nonfatal injuries among children with disability, in Hubei Province, The People's Republic of China, 2011
| Sample n | Injured n (%) | Univariate model OR 95% CIa |
Multivariable model OR 95% CIb |
|
|---|---|---|---|---|
| No disability (reference) | 1201 | 53(4.4) | 1.00 | 1.00 |
| Any disability Type of disability | 1201 | 123(10.2) | 2.47(1.77, 3.45) | 3.40 (2.32, 4.98) |
| Any single disability | 738 | 71(9.6) | 2.31(1.60,3.33) | 3.05 (2.03, 4.56) |
| Vision | 79 | 6(7.6) | 1.78(0.74,4.28) | 2.00(0.81,4.91) |
| Hearing | 53 | 5(9.4) | 2.26(0.86,5.90) | 2.32(0.88,6.14) |
| Speech | 138 | 16(11.6) | 2.84(1.58,5.12) | 2.83(1.54,5.20) |
| Other physical disabilities | 250 | 21(8.4) | 1.99(1.18,3.36) | 2.12(1.22,3.68) |
| Mental retardation | 139 | 14(10.1) | 2.43(1.31,4.50) | 2.36(1.26,4.43) |
| Mental health disorder | 79 | 9(11.4) | 2.78(1.32,5.88) | 2.66(1.25,5.67) |
| Multiple disabilities | 463 | 52(11.2) | 2.74(1.84,4.08) | 4.54(2.82,7.30) |
| Severity level of disability | ||||
| Level 1 (Most severe) | 308 | 25(8.1) | 1.91(1.17,3.13) | 3.39(1.90,6.04) |
| Level 2 | 278 | 32(11.5) | 2.82(1.78,4.46) | 4.37(2.58,7.40) |
| Level 3 | 269 | 28(10.4) | 2.52(1.56,4.06) | 3.26(1.94,5.46) |
| Level 4 | 243 | 25(10.3) | 2.48(1.51,4.08) | 3.14(1.84,5.34) |
| Total | 1098 | 110 (10.0) | 2.41(1.72,3.38) | 3.47(2.32,5.80) |
OR=odds ratio; CI=confidence interval.
ORs were calculated for each type and severity level of disability versus no disability using univariate logistic regression.
ORs were calculated for each type and severity level of disability versus no disability using multivariable logistic regression and controlling for gender, age, parent’s education, family income per month, number of family members, daily adult car supervision, and single-parent family status.
Discussion
Emerging evidence from recent studies indicates that individuals with disability face a significant higher risk of injuries than those without disability [15–22]. Data about injury risk in individuals with disability in China are very limited [23]. Results reported here demonstrated a clear association between disability status (type and severity) and injury risk in this sample of Chinese pediatric population.
Our findings are consistent with studies conducted in developed countries using parent reported or care-giver reported data on pre-existing disabilities and medically attended injuries. Analysis of the U.S. National Health Interview Survey data found that children with disability were at a significant higher risk of injuries than children without disability [19]. A study from Canada reported a 30% increases in the risk of injury in children with disabilities compared with their healthy peers [20]. Ramirez et al. reported that children with disabilities had over twice the school injury rate of children without disability [32]. A similar association was reported among children with intellectual disability in Australia [22]. Our results also confirm the previous work that reported injury risk difference by disability types [18–20,33]. Although previous studies reported a dose-response association between disability severity and injury risk in adults with disabilities [34,35],we did not find a clear dose-response relationship in our study.
Children with a vision or a hearing disability did not have statistically significant injury OR, but children with other single types of disability did have significantly increased injury ORs compared with children without disability. Our findings are not consistent with the previous research examining injury ORs by specific types of disability in children with disability. One such study found that only children with emotional or behavioral problems had a significantly higher injury OR when compared with children without a disability [19]. In another study, Ramirez et al. reported that children with mental retardation had lower rates of injury compared with children who have physical impairments [32]. Children with multiple disabilities were at the greatest risk of injury after adjusting for sociodemographic factors. This finding supports the finding reported by Ramirez et al [36]. To date, injury risk in children with multiple disabilities has not been thoroughly studied. Prior research studies have sometimes excluded children with multiple disabilities to avoid the complexity in data analysis and in interpreting the results [19,37]. Therefore, further study is needed to investigate the increased injury risk among children with multiple disabilities.
Our study used the latest China Classification and Grading Criteria of Disability to define disability type and severity. Although the international standard, International Classification Functioning, Disability and Health (ICF), has been published [38], the 2011 revised Chinese standards took into account Chinese culture, history of Chinese previous standards, and practical operation of these standards in the field. This disability identification and classification system provides terminology, definition, and code of disability classification to regulate case identification in the field. According to the China Classification and Grading Criteria of Disability, disability is defined as “problems in body function or structure, individual activity limitations, and participation restrictions.” To some extent, the Chinese criteria are consistent with the main concepts of ICF. Because of the poor economics, weak social security system and some other sociocultural factors, low income and developing countries tend to adopt a measure focused on a narrow definition of impairments and report a lower disability prevalence rate than high income countries [39–41]. Although ICF has more domains that can provide more comprehensive information about the disability, simple operational case identification and classification standards for surveys need to be developed in China.
Our literature search and review identified a dozen publications on injury risk in individuals with disability from the high income countries but none from China. Our study provided some preliminary findings about unintentional injuries suffered by children with disability in China. As the first of this kind of research in individuals with disability in China, our study has several limitations. First, in comparison with studies conducted in the U.S. and Canada [18–20], the sample size of our survey was relatively small so that some of injury risk estimates in Table 2 was not stable. Second, our study was based on retrospective reporting from parents or guardians and is thus subject to recall bias. Our results would be biased if respondents for children with disability reported injuries differently than respondents for children without disability. Further research is needed to identify how disability status and severity of disability influence recall bias in injury reporting by parents or guardians. Finally, operational survey questions based on ICF that could be implemented in large population surveys have not yet been developed so we used the Chinese national standards to define disability. The advantage of using the disability type and severity information in the official certificate in our survey was the standardized classification confirmed by medical professionals. In future studies in China, researchers are encouraged to develop and use disability measurements based on the international ICF.
In conclusion, children with disability in China appear to have a significantly increased risk for nonfatal unintentional injuries than children without disability. However, little research and prevention efforts have been conducted to address this important issue in China. Thus, we call for more attentions from researchers and public health professionals to this public health problem and encourage efforts along the line of this research area in China.
Acknowledgements
We would like to thank Sizhe Wang, Daogen Yin, MPH, and Mei Yang, MPH, for their assistance in data collection, entry and processing. We also thank Lijuan Tang from Hubei Disabled Persons’ Federation for coordinating our survey in the field.
Source of Funding:
The data collection of this study was funded by a research grant from the Hubei Disabled Persons’ Federation. Efforts by Drs Stallones and Xiang in this study was supported by the USA-China Agricultural Injury Research Training Project, funded by the National Institutes of Health Fogarty International Center (PIs: L Stallones and H Xiang; Grant #: 1D43TW007257-01A2). The findings and conclusions are those of the authors and do not necessarily reflect views of the funding agencies.
ABBREVIATIONS
- OR
Odds ratios
- CI
Confidence interval
- UNICEF
The United Nations Children’s Fund
- TQ
Ten Questions
- CDPF
China Disabled Persons’ Federation
- ICF
International Classification of Functioning, Disability, and Health
Footnotes
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Conflicts of Interest
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References
- 1.Halfon N, Houtrow A, Larson K, Newacheck PW. The changing landscape of disability in childhood. Future Child. 2012;22(1):13–42. doi: 10.1353/foc.2012.0004. [DOI] [PubMed] [Google Scholar]
- 2.United Nations Children’s Fund. Early child development Unit. [accessed 21.5.11];Programming experiences in early child development. 2011 http://www.unicef.org/earlychildhood/files/programming%20experiences%20in%20early%20childhood.pdf. [Google Scholar]
- 3.Halfon N, Hochstein M. Life course health development: an integrated framework for developing health, policy, and research. Milbank Q. 2002;80(3):433–479. doi: 10.1111/1468-0009.00019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Nageswaran S, Silver EJ, Stein RE. Association of functional limitation with health care needs and experiences of children with special health care needs. Pediatrics. 2008;121(5):994–1001. doi: 10.1542/peds.2007-1795. [DOI] [PubMed] [Google Scholar]
- 5.McDougall J, King G, de Wit DJ, Miller LT, Hong S, Offord DR, LaPorta J, Meyer K. Chronic physical health conditions and disability among Canadian school-aged children: a national profile. Disabil Rehabil. 2004;26(1):35–45. doi: 10.1080/09638280410001645076. [DOI] [PubMed] [Google Scholar]
- 6.China Disabled Person's Federation. [accessed 17.3.11];2011 http://www.cdpf.org.cn/sytj/content/2008-04/07/content_30316033.htm. [Google Scholar]
- 7.National Bureau of Statistics of China and China Disabled Person's Federation. [accessed 14.3.11];Major data communiqué (no.1) of the Second National Disability Survey. 2011 http://www.cdpf.org.cn/sytj/content/2008-04/07/content_30316033.htm. [Google Scholar]
- 8.National Bureau of Statistics of China and China Disabled Person's Federation. [accessed 14.3.11];Major data communiqué (no.2) of the Second National Disability Survey. 2011 http://www.cdpf.org.cn/sytj/content/2007-11/21/content_30316035.htm. [Google Scholar]
- 9.China Disabled Person's Federation. [accessed 2.5.12];2012 http://www.cdpf.org.cn/kangf/content/2011-04/02/content_30316057.htm. [Google Scholar]
- 10.Disabled Person's Federation of Hubei Pronvince. [accessed 2.5.12];2012 http://www.hbdpf.org.cn/news_show.asp?id=293. [Google Scholar]
- 11.Simeonsson RJ, Bailey DB, Scandlin D, Huntington GS, Roth M. Disability, health, secondary conditions and quality of life: emerging issues in public health. In: Simeonsson RJ, McDevitt LN, editors. Issues in Disability and Health: The Role of Secondary Conditions and Quality of Life. Chapel Hill: University of North Carolina Press; 1999. pp. 51–72. [Google Scholar]
- 12.Lollar DJ. Public health and disability: emerging opportunities. Public Health Rep. 2002;117(2):131–136. doi: 10.1093/phr/117.2.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Wilber N, Mitra M, Walker DK, Allen D, Meyers AR, Tupper P. Disability as a public health issue: findings and reflections from the Massachusetts survey of secondary conditions. Milbank Q. 2002;80(2):393–421. doi: 10.1111/1468-0009.00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Kinne S, Patrick DL, Doyle DL. Prevalence of secondary conditions among people with disabilities. Am J Public Health. 2004;94(3):443–445. doi: 10.2105/ajph.94.3.443. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Sherrard J, Tonge BJ, Ozanne-Smith J. Injury in young people with intellectual disability: descriptive epidemiology. Inj Prev. 2001;7(1):56–61. doi: 10.1136/ip.7.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Petridou E, Kedikoglou S, Andrie E, Farmakakis T, Tsiga A, Angelopoulos M, Dessypris N, Trichopoulos D. Injuries among disabled children: a study from Greece. Inj Prev. 2003;9(3):226–230. doi: 10.1136/ip.9.3.226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Rowe R, Maughan B, Goodman R. Childhood psychiatric disorder and unintentional injury: findings from a national cohort study. J Pediatr Psychol. 2004;29(2):119–130. doi: 10.1093/jpepsy/jsh015. [DOI] [PubMed] [Google Scholar]
- 18.Xiang H, Stallones L, Chen G, Hostetler SG, Kelleher K. Nonfatal injuries among US children with disabling conditions. Am J Public Health. 2005;95(11):1970–1975. doi: 10.2105/AJPH.2004.057505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Sinclair SA, Xiang H. Injuries among US children with different types of disabilities. Am J Public Health. 2008;98(8):1510–1516. doi: 10.2105/AJPH.2006.097097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Raman SR, Boyce W, Pickett W. Injury among 1107 Canadian students with self-identified disabilities. Disabil Rehabil. 2007;29(22):1727–1735. doi: 10.1080/09638280601129231. [DOI] [PubMed] [Google Scholar]
- 21.Leland NL, Garrard J, Smith DK. Comparison of injuries to children with and without disabilities in a day-care center. J Dev Behav Pediatr. 1994;15(6):402–408. [PubMed] [Google Scholar]
- 22.Sherrard J, Tonge BJ, Ozanne-Smith J. Injury risk in young people with intellectual disability. J Intellect Disabil Res. 2002;46(Pt 1):6–16. doi: 10.1046/j.1365-2788.2002.00346.x. [DOI] [PubMed] [Google Scholar]
- 23.Zhu HP, Xia X, Xiang HY, Yu CH, Du YK. Disability, home physical environment and non-fatal injuries among young children in China. PLoS One. 2012;7(5):e37766. doi: 10.1371/journal.pone.0037766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gottlieb CA, Maenner MJ, Cappa C, Durkin MS. Child disability screening, nutrition, and early learning in 18 countries with low and middle incomes: data from the third round of UNICEF's Multiple Indicator Cluster Survey (2005–06) Lancet. 2009;374(9704):1831–1839. doi: 10.1016/S0140-6736(09)61871-7. [DOI] [PubMed] [Google Scholar]
- 25.World Health Organization. Geneva, Switzerland: 2011. World Report on Disability. [PubMed] [Google Scholar]
- 26.Thorburn M, Desai P, Paul T, Malcolm L, Durkin MS, Davidson LL. Identification of childhood disability in Jamaica: the ten question screen. Int J Rehabil Res. 1992;15(2):115–127. doi: 10.1097/00004356-199206000-00003. [DOI] [PubMed] [Google Scholar]
- 27.Maulik PK, Darmstadt GL. Childhood disability in low- and middle-income countries: overview of screening, prevention, services, legislation, and epidemiology. Pediatrics. 2007;120(Supplement 1):S1–S55. doi: 10.1542/peds.2007-0043B. [DOI] [PubMed] [Google Scholar]
- 28.Zaman S, Khan NZ, Islam S, Banu S, Dixit S, Shrout P, et al. Validity of the ‘Ten Questions’ for screening serious childhood disability: results from urban Bangladesh. Int J Epidemiol. 1990;19(3):613–620. doi: 10.1093/ije/19.3.613. [DOI] [PubMed] [Google Scholar]
- 29.Durkin MS, Wang W, Shrout P, Zaman S, Hasan ZM, Desai P, Davidson LL. Evaluation a Ten Questions screen for childhood disability: reliability and internal structure in different cultures. J Clin Epidemiol. 1995;48(5):657–666. doi: 10.1016/0895-4356(94)00163-k. [DOI] [PubMed] [Google Scholar]
- 30.Classification and Grading Criteria of Disability. [accessed 5.5.11];2011 http://www.standards.cn/bzsearch/bzdetail.asp?cnstdid=GB/T 26341-2010. [Google Scholar]
- 31.Standardization Administration of the People’s Republic of China. [accessed 5.5.11];2011 http://www.sac.gov.cn/bgs/xwxc/201104/t20110428_92145.htm.
- 32.Ramirez M, Fillmore E, Chen A, Peek-Asa C. A comparison of school injuries between children with and without disabilities. Acad Pediatr. 2010;10(5):317–322. doi: 10.1016/j.acap.2010.06.003. [DOI] [PubMed] [Google Scholar]
- 33.Mann JR, Zhou L, McKee M, McDermott S. Children with hearing loss and increased risk of injury. Ann Fam Med. 2007;5(6):528–533. doi: 10.1370/afm.740. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Xiang H, Leff M, Stallones L. Non-fatal injuries among adults with activity limitations and participation restrictions. Inj Prev. 2005;11:157–162. doi: 10.1136/ip.2004.006429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Brophy M, Zhang X, Xiang H. Injuries among US adults with disabilities. Epidemiology. 2008;19(3):465–471. doi: 10.1097/EDE.0b013e31816932ba. [DOI] [PubMed] [Google Scholar]
- 36.Ramirez M, Peek-Asa C, Kraus JF. Disability and risk of school related injury. Inj Prev. 2004;10(1):21–26. doi: 10.1136/ip.2003.002865. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Brehaut JC, Miller A, Raina P, McGrail KM. Childhood behavior disorders and injuries among children and youth: a population-based study. Pediatrics. 2003;111(2):262–269. doi: 10.1542/peds.111.2.262. [DOI] [PubMed] [Google Scholar]
- 38.World Health Organization. Geneva: Switzerland: 2001. International Classification of Functioning, Disability and Health. [Google Scholar]
- 39.Mont D. Measuring health and disability. Lancet. 2007;369(9573):1658–1663. doi: 10.1016/S0140-6736(07)60752-1. [DOI] [PubMed] [Google Scholar]
- 40.Barbotte E, Guillemin F, Chau N. Prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature. Bull World Health Organ. 2001;79(11):1047–1055. [PMC free article] [PubMed] [Google Scholar]
- 41.Me A, Mbogoni M. Review of practices in less developed countries on the collection of disability data. In: Barnatt SN, Altman BM, editors. International Views on Disability Measures: Moving toward Comparative Measurement. Oxford: Elsevier; 2006. pp. 63–87. [Google Scholar]