This study showed that Native children in Alberta, Canada, have a fivefold increased risk of death from injury compared with non-Native children in the province. An increased mortality risk (Native vs. non-Native) was noted across all categories of injury intent and mechanism, in particular, pedestrian injury, accidental poisoning, homicide by piercing objects, and suicide by hanging. Last, injury mortality rates declined over the study period for both Native and non-Native children, with no difference in the rate of decline between the two groups.
This study had several strengths. First, the study was population-based, with Provincial Vital Statistics data used to provide information on injury deaths for both Native and non-Native children. Vital Statistics coders were unaware of Native status at the time of coding. Therefore, differential misclassification of cause of injury death by status was considered unlikely. Other investigators have reported high sensitivity (>90#x0025;) and specificity (>98% for ICD 9 E-codes derived from death certificates, for broad groupings such as motor vehicle crashes, homicide, and suicide.20
Multivariable Poisson regression analysis was used to take into account the effects of potential confounding variables (age and gender).
The main limitation of the study related to the use of administrative databases. Important factors, such as living on or off reserve, socioeconomic status, involvement of alcohol, hazard exposure, supervision, preexisting medical conditions, time and type of transport to medical care, and type of medical care given were not captured in Vital Statistics records. In addition, there is a delay in data entry into the Alberta First Nations Mortality Database and, as such, the time period examined is not current.
The results of this study confirm and extend the findings of previous studies.3–10
In particular, several studies in other jurisdictions in Canada prior to 1982 revealed that injury mortality rates for Native children were two to six times higher than for non-Natives.3–5
A recent CDC report examined injury mortality rates among American Indian and Alaska Native children for the period from 1989 to 1998.12
Native rates were compared with those for the general pediatric population in the United States. The all-cause injury mortality rate for American Indian and Alaska Native children was two times higher than for the general population. The relative risk was thought to be underestimated given the likelihood of significant misclassification of ethnicity on state death certificates.
The reasons for the excess injury mortality in Native children (compared with non-Native children) are numerous and complex. Based on national data, Canadian Natives have a lower socioeconomic status compared with the general population, as reflected in higher unemployment, lower mean family income, greater reliance on social assistance, less education, and higher-density living arrangements. The inverse correlation between socioeconomic status and injury risk in children is well established.21,22
Beyond socioeconomic deprivation, Native populations in Canada are also thought to experience cultural alienation,23
which is related to oppressive experiences such as loss of identity, restricted economic opportunity, suppression of beliefs and spirituality, discrimination, and racism. Such major social stressors may contribute to the increased rates of unintentional injury, suicide, and homicide in Native populations.24–26
Other investigators have reported increased injury morbidity and mortality associated with alcohol and drug abuse among Natives compared with non-Natives.26–29
It has been estimated that more than 75% of suicides and homicides among American Indians involve alcohol.30
Canadian Natives acknowledge that substance abuse is a serious problem in the Native adolescent population.25
An excess of deaths associated with off-road recreational vehicles in Native children has also been reported.31
These vehicles are often an important means of transportation on the reserve, and their use by children is often poorly regulated. Other authors have speculated that poorly maintained roads and vehicles contribute to the greater risk of motor vehicle deaths in Native communities.26,32
The remoteness of Native communities may also make timely access to medical facilities difficult.3,33
Last, awareness of (or compliance with) injury prevention strategies may be less common in Native populations compared with non-Natives.34,35
The relative risk for intent unknown deaths was noticeably higher than the relative risk for other intent categories. While the reasons for this statistic are unknown, others have reported that deaths in which intent is considered unknown have characteristics similar to homicide deaths.36
If that were the case in this study, the effect of such misclassification of homicide deaths as intent unknown deaths would be to bias the homicide relative risk (Native vs. non-Native) toward the null.
Almost 20 years ago, in response to the high injury rates in the Native population in the United States, Indian Health Services (IHS) developed an injury prevention initiative now referred to as the IHS Injury Prevention Program.36
This program provides expertise and support to communities or tribes interested in implementing injury prevention strategies in their jurisdiction. There is evidence that this program has reduced injury morbidity and mortality in some communities.37–40
Similar initiatives are underway in Canada. At the federal level, the Medical Services Branch within Health Canada is responsible for providing health services to the Native population. Delivery of health services is organized around a network of regional offices and health centers across the country, and priority setting at the local level is encouraged. Injury mortality data are already being collected at the local and national level. Therefore, the basic framework for implementing injury prevention initiatives in the Native population already exists. A major current impediment, however, is the lack of a central national agency dedicated to the coordination of injury control, such as the National Center for Injury Prevention and Control in the United States. Such an agency could assist local efforts in data collection, training, priority setting, implementation, and evaluation of injury prevention interventions.
The present study does not examine injury morbidity in Native children. A related study from the same geographic area examined the incidence of severe injury, both fatal and nonfatal, in Native adults. Again, Natives were found to be at increased relative risk for such injury than the general population (RR53.7, 95% CI 3.0 to 4.6).41
It would thus seem that Natives in this geographic area are at a similarly greater risk for both injury morbidity and mortality.