Disparities in fatal and non-fatal injuries between Irish travellers and the Irish general population are similar to those of other indigenous minorities: a cross-sectional population-based comparative study.

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by  Abdalla, Safa

Open Access Research
Disparities in fatal and non-fatal
injuries between Irish travellers and the
Irish general population are similar to
those of other indigenous minorities: a
cross-sectional population-based
comparative study
Safa Abdalla, Cecily C Kelleher, Brigid Quirke, Leslie Daly, on behalf of the
All-Ireland traveller Health Study team
Tocite:AbdallaS, ABSTRACT
ARTICLE SUMMARY
KelleherCC,QuirkeB,etal. Objectives:Toassessrecentdisparitiesinfataland
Disparitiesinfatalandnon-
non-fatalinjurybetweentravellersandthegeneral Article focus
fatalinjuriesbetweenIrish
travellersandtheIrish populationinIreland. ▪ Assessingrecentdisparitiesinfatalandnon-fatal
generalpopulationaresimilar Design:Across-sectionalpopulation-based injury between Irish travellers, a disadvantaged
tothoseofotherindigenous comparativestudy. indigenous minority in Ireland, and the Irish
minorities:across-sectional Setting:RepublicofIreland. general population, using national population
population-basedcomparative Participants:Populationcensusandretrospective and mortality data from the All-Ireland traveller
study.BMJOpen2013;3: mortalitydatawerecollectedfrom7042travellerfamilies, Health study, routine population-based statistical
e002296.doi:10.1136/
travellersbeingthoseidentifiedbythemselvesandothers reportsandpopulationsurveys.
bmjopen-2012-002296
asmembersofthetravellercommunity.Retrospective
Key messages
injuryincidencewasestimatedfromasurveyofa
▸ Prepublicationhistoryand randomsampleoftravellersinprivatehouseholds,aged ▪ Irish travellers continue to bear a disproportion-
additionalmaterialforthis 15yearsorover(702menand961women). ately higher mortalityburden of unintentional and
paperareavailableonline.To intentionalinjurythantheIrishgeneralpopulation
Comparablegeneralpopulationdatawereobtainedfrom
viewthesefilespleasevisit inthe21stcentury,withhighercasefatalityratios.
officialstatisticalreports,whileretrospectiveincidence
thejournalonline ▪ Despite lower traveller rates of non-fatal injury
wasestimatedfromthe
(http://dx.doi.org/10.1136/ overall,elderlytravellershadhigherratesofnon-
SurveyofLifestyle,AttitudeandNutrition2002,a
bmjopen-2012-002296).
fatalinjurythanthegeneralpopulation.
randomsampleof5992adultsinprivatehouseholds
▪ Injury prevention efforts and further research
Received1November2012 aged18yearsorover.
should address the problems of alcohol, suicide
Revised19December2012 Outcomemeasures:PotentialYearsofLifeLost
andelderlyinjuryamongtravellers.
Accepted7January2013 (PYLL),StandardisedMortalityRatios(SMR),
StandardisedIncidenceRatios(SIR)andCaseFatality Strengths and limitations of this study
Thisfinalarticleisavailable
Ratios(CFR). ▪ Strengths include the use of census and survey
foruseunderthetermsof
theCreativeCommons Results:Injuryaccountedfor36%ofPYLLamong data for Irish travellers from a national study
AttributionNon-Commercial travellers,comparedwith13%inthegeneralpopulation. with a high household response rate in a gener-
2.0Licence;see travellersweremorelikelytodieofunintentionalinjurythan ally hard-to-reach population. Also, part of the
http://bmjopen.bmj.com thegeneralpopulation(SMR=454(95%CI279to690)in analysisaccountsforanunderestimationofnon-
menand460(95%CI177to905)inwomen),witha fatalinjuryincidenceduetoincompleterecall.
similarpatternforintentionalinjury(SMR=637(95%CI ▪ Limitations include under-reporting of injury
367to993)inmenand464(95%CI107to1204in events for reasons other than incomplete recall,
women).Theyhadalowerincidenceofunintentionalinjury different methodologies for intent ascertainment
butthoseaged65yearsoroverwereabouttwiceaslikely between fatal and non-fatal injury in the data
SchoolofPublicHealth,
toreportaninjury.Travellershadahigherincidenceof sources used, lack of ascertainment of injury risk
PhysiotherapyandPopulation
intentionalinjuries(SIR=181(95%CI116to269)inmen differentials among survey non-respondents and
Science,UniversityCollege
and268(95%CI187to373)inwomen).InjuryCFRwere theuseof2002generalpopulationsurveydatato
Dublin,Dublin,Republicof
Ireland consistentlyhigheramongtravellers. comparewith2007–2008travellersurveydata.
Conclusions:Irishtravellerscontinuetobeara
Correspondenceto disproportionateburdenofinjury,whichcallsforscalingup furtherresearchshouldfocusonsuicide,alcoholmisuse
DrSafaAbdalla; injurypreventioneffortsinthisgroup.Preventionand andelderlyinjuryamongIrishtravellers.
[email protected]
AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296 1
Disparities in injury between Irish travellers and the general population
INTRODUCTION Outcome measures
Injuries are one of the leading causes of mortality and Potential Years of Life Lost (PYLL) were used to
morbidity worldwide, accounting for 5.8 million deaths measure the burden of premature mortality due to
(10% of world deaths). They are the leading cause of injury. PYLL are the number of years lost due to death
death among youth aged 15–29years.1 Disadvantaged occurring earlier than an arbitrarily determined refer-
indigenous minorities are known to bear a greater ence age. Overall and gender-specific disparities
burden of injuries than the general population in between travellers and the general population were
their countries.2–9 Most of this information comes expressed as directly age-standardised PYLL rate ratios.
from the classical parts of the world such as Australia, Standardised Mortality Ratios (SMR) were used to
New Zealand and Canada, where the dire health and express overall and gender-specific disparities in unin-
social conditions of their indigenous minorities have tentional and intentional injury mortalityas intent disag-
long been recognised and systems set up and operated gregation of PYLL was not possible with the data
to capture reliable information on their trends. In available. We expressed disparities in non-fatal injuries
Europe too, Sami men in Sweden, Sami men and as Standardised Incidence Ratios (SIR). We also calcu-
women in Finland,10–12 Roma women in Serbia13 and lated overall and gender-specific injury Case Fatality
Roma men and women in Bulgaria,14 all had higher Ratios (CFR) foreachgroup.
injury mortality than the corresponding general popula-
tion inthose countries. Data
Irish travellers are an indigenous minority in Europe Traveller mortalityand population data
who have been part of Irish society for centuries, with We used traveller data from the AITHS. The method-
a distinct culture, language and value system, based on ology of the study was published in a series of technical
a nomadic tradition. They are similar to many other reports.20 21 Ethical approval for AITHS in the Republic
indigenous minorities in their experience of assimila- of Ireland was obtained from the University College
tive social policies and of disadvantage and social Dublin Human Research Ethics Committee, and all par-
exclusion due to discrimination, unemployment and ticipants provided a written informed consent. The def-
lower education achievement,15–17 although cultural inition of atraveller in AITHS was a person identified by
and contextual differences remain. Injuries are the him or herself and others as a member of the traveller
leading cause of death among young people in community, in keeping with the definition of the travel-
Ireland,18 and while a wealth of information on injur- ler community in the Equal Status Act in Ireland.22 The
ies in the general population continues to be gener- study included a census of Irish travellers conducted
ated by a range of national routine mortality and over 6weeks starting from mid-October 2008, with a
morbidity data sources, the lack of ethnic or cultural response rate of 78% of traveller families in the
group identification in such sources hinders their use Republic of Ireland. All families completed the census
to investigate the patterns of injuries among travellers. section. In addition, mothers completed a child health
Such epidemiological information is critical for status interview if there was a child aged 5, 9 or 14years
informing targeted injury prevention policies and in the family. Otherwise, an adult aged 15years or
detecting areas that warrant action and further over was selected at random from available adults to
research. Yet, apart from a 20-year-old record, from a complete either a health status or a health service
national study, of higher injury mortality than the utilisation interview. In this way, all eligible households
general population,19 very little is known about the completed the census survey and, if eligible, one
current burden of injuries among Irish travellers. further subinterview.
Recently, the All-Ireland traveller Health Study The mortality substudy of AITHS provided the
(AITHS) provided census and survey data that allowed number of deaths, including injury deaths, over the year
such investigation. We thus aimed to use these data to preceding the census. Travellers’ deaths were reported
assess recent disparities in fatal and non-fatal injury mainly by census respondents, with additional reports by
between travellers and the general population in Public Health Nurses working with traveller families.
Ireland. Following duplicate elimination, a final list of traveller
deaths was successfully matched with the official data-
base of death records maintained by the General
METHODS Registrar Office (GRO) for 104 (63%) of a total of 166
Study design identified deaths, with the identification of 22 further
This is a comparative study based on cross-sectional
deaths not reported by the other sources, but with dwell-
population-based data.
ing or occupation characteristics that were typical of tra-
vellers. Ninety-three per cent of the reported ages for
Studysettings andparticipants those successfully matched with the official database
The study included Irish travellers in the Republic of were within a 5-year range of the ages in the official
Ireland together with the general population of the death record. The GRO death records were matched
Republic of Ireland as acomparisongroup. next with the Central Statistics Office (CSO) database of
2 AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296
Disparities in injury between Irish travellers and the general population
International Classification of Disease (ICD)-10 coded Analysis
causes of death to obtain the traveller death codes for PotentialYears of LifeLost
comparability with the general population. Deaths PYLL were calculated with 100years as the reference
coded to mental and behavioural disorder (F00-F99) age. The average age at death was taken as 0.1years for
were included with those coded to external causes infants and 2.6years for the 1–4years’ group. For the
(V01-Y89), in keeping with the current CSO practice of remaining groups, it was age at the beginning of the age
reporting the former as unintentional injuries. Among group added to half the age group width, assuming a
the successfully matched deaths, 22 of 26 deaths coded uniform distribution of deaths across the age group. For
to external causes (V01-Y89) were also reported as injury the open-ended group, it wastwice the mean survival for
deaths by traveller respondents. The latter reported a that age according to Silcocket al.27
total of 23 injury deaths. We thus considered uncon- Age-specificPYLLratesandthedirectage-standardised
firmed injury deaths to be of acceptable validity and PYLL rate for travellers were computed, with the general
included them in the total injury death count. We used population as the reference. Age-standardised PYLL
traveller population counts from AITHS census for rate rate ratios were calculated as the ratio of the traveller’s
calculations. estimate to the general population estimate, with 95%
CIs computed using the method described by
Kuroishietal.28
Traveller non-fatalinjury data
Theadulthealthstatussurvey(asamplesizeof1663;702
Standardised Mortality Ratios
menand 961women)providedretrospectivedataonthe
Using indirect standardisation, we calculated SMR by
occurrence of any injury serious enough to limit daily gender and intent, as the small age-specific number of
activity among travellers over the 2years preceding the
traveller deaths prohibited intent disaggregation of PYLL.
survey,andintentofthemostrecentinjury(table1).
SMRs were the ratio of the observed number of traveller
injury deaths to that expected if the traveller population
experienced the age-specific injury death rates of the
General population mortalityand population data
general population. The intent breakdown of observed
General population injury deaths by age, gender and
numbers was obtained by applying the distribution by
intent were obtained from the 2008 CSO report of pro-
intent of ICD-10 coded deaths (unintentional: V01-X59,
spectively registered deaths coded to external causes
F00-F99, intentional: X60-Y09) to the total number
(V01-Y89) and to mental and behavioural disorder
(F00-F99).23 Population counts from census 2006 were of deaths in each gender group, and redistributing the
used for ratecalculations.24 injuries of unspecified intent proportionately over unin-
tentional and intentional injuries where applicable. The
exact 95% Poisson confidence limits were calculated for
General population non-fatalinjury data SMRs using the χ² distribution as proposed by Ulm.29
Statistical significance was indicated by 95% CIs that did
The publicly available national Survey of Lifestyle,
notinclude100.
Attitude and Nutrition (SLAN) 2002 of adults aged
18years or over with a sample size of 5992 provided
comparable retrospective data on non-fatal injury,25 Standardised Incidence Ratios
using the same survey items as the travellers’ adult SIRs were calculated by gender and intent overall and
health status survey (table 1). The survey was originally for those aged 15–64years and those aged 65years and
powered to detect differences in key lifestyle factors by over, separately. SIR was the ratio of the observed
socioeconomic status, with allowances for non-response number of traveller non-fatal injuries to that expected if
and likelihood of ineligibility. A national postal sample travellers experienced the age-specific retrospective inci-
was generated randomly and proportionately distributed dence of non-fatal injury of the general population.
by population size of the former Irish health boards and Ninety-five per cent CIs for SIRs were calculated in the
theirurban–ruraldistributions.26 samewayasthose for SMRs.
Table1 InjuryitemsusedintheAll-IrelandtravellersHealthStudy(AITHS)adulthealthsurveyin2008andtheSurveyof
Lifestyle,AttitudeandNutrition(SLAN)in2002
Concept Surveyitem
Occurrenceofinjury ‘Inthelasttwoyearshaveyouhadoneormoreinjuriesseriousenoughtointerferewithyourdaily
activities?’
Yes[]No[]Don’tknow[]Refused[]
Intentofinjury ‘Wasyourmostrecentinjurymainly…’
Accidental[]Non-accidental[]Don’tknow[]Refused[]
AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296 3
Disparities in injury between Irish travellers and the general population
Theonlinesupplementaryappendixtabledetailsthefor- rates, which were then applied to the traveller popula-
mulasusedinthecalculationoftheestimatesandtheirCIs. tion aged 15years and over in 2008 and the general
population aged 15years and over in 2006, respectively.
Survey data were analysed using BM-SPSS (V.18). All
Case Fatality Ratios
other calculations were conducted in Excel 2007
We estimated injury CFR as the ratio of injury deaths to
spreadsheets.
the total number of fatal and non-fatal injuries over
1year. The number of non-fatal injuries was obtained by
correcting the 2-year-recall non-fatal injury rate for RESULTS
underestimation due to failure to recall injuries far back Comparing the burden of injury deaths between travel-
in the recall period, and then annualising it by dividing lers and the general population (table 2), a total of 188
by two. Recall correction factors were based on recall traveller deaths occurred over 1year, 27% of which were
patterns observed in the 2003 World Health Surveys con- due to injury (33% in men and 18% in women), com-
ducted by the WHO. The recall analysis was performed pared with 8% in the general population (10% in men
for the Global Burden of Disease-2010 Study (Bhalla K, and 6% in women). The median age at death from
personal communication, Harvard School of Public injuries was 35years in men and 32years in women,
Health, 2012. Publication reporting results is forthcom- much lower than that in the general population
ing). Using recall patterns for medically attended and (47years in men and 78years in women). Injuries
non-medically attended injuries separately, correction accounted for 36% of PYLL among travellers (41% in
factors based on four recall periods, 1, 3, 6 and men and 25% in women), compared with 13% in the
12months preceding the surveys were estimated. general population (17% inmenand 8% in women).
Logarithmic models were fitted to the change in annual- Unintentional deaths represented a larger proportion
ising factors with recall time (R2=0.89 for medically of injury deaths in travellers and the general population,
attended injuries, 0.98 for non-medically attended injur- but the proportion of intentional injuries was higher in
ies), and were used to predict the correction factor for travellersthanthegeneralpopulation(figure1).Inboth
2-year recall; 2 for medically attended injuries and 3.8 travellers and the general population, the majority of
for non-medically attended injuries. Using the predicted deaths of the intentional category were suicides and
factor for medically attended injuries to correct the intentional self-harm (12 of13 traveller deaths identified
annualised rate of emergency department attended atGRO,and424of463(92%)ofthegeneralpopulation
injuries from the SLAN 2002 data yielded an estimate deaths).Oftheunintentionalcategory,morethanhalfof
(6%) that was reassuringly not substantially different thetravellerdeaths(12of17)wereaccidentalpoisoning,
from the independently derived overall rate of emer- halfofthemduetoalcohol,whileonly24%(229of974)
gency department attended injuries in those aged ofthe generalpopulation unintentionaldeathsweredue
15years and over (8%), based on national extrapola- toaccidentalpoisoning.
tions of the results of a pilot injury surveillance project Table 3 displays the disparities in fatal and non-fatal
in 2005,30 and converted from episode-based rate to a injuries between Irish travellers and the Irish general
person-based rate using injury data from the SLAN 2007 population in terms of age-standardised PYLL rate
survey. We applied the same factorsto unintentional and ratios, SMRs and SIRs for those aged 15years and over,
intentional injuries, as the available data did not allow by gender and intent. Both PYLL rate ratios and SMRs
the development of intent-specific factors. We used the indicated higher injury mortalityamong travellers (PYLL
same factors to correct traveller and general population rate ratio of 490 (95% CI 368 to 652 and SMR of 496
Table2 InjurydeathsandburdenofprematuremortalityduetoinjuryamongIrishtravellersandthegeneralpopulation,
RepublicofIreland2008*
Men Women Total
General General General
Travellers population Travellers population Travellers population
Totaldeaths 124 14413 64 13779 188 28192
Medianageatdeath(IQR) 50(36) 75(20) 61(40) 81(19) 54(38) 78(20)
Proportionofdeathsduetoinjury 33% 10% 18% 6% 27% 8%
Medianageatdeathfrominjuryinyears 35(18) 47(40) 32(33) 78(38) 34(20) 56(47)
(IQR)†
TotalPYLL(100)inyears† 6124 422056 2816 310168 8940 732224
PYLL(100)duetoinjury(%oftotal)† 2520(41%) 71943(17%) 710(25%) 25702(8%) 3230(36%) 97645(13%)
*Asthemortalitystudyincludedtravellerdeathsthatoccurred1yearbeforethecensusinterviewsthatstartedinmid-October2008,someof
thedeathswouldhaveoccurredinOctober–December2007.
†Excludingfourmaledeathsandtwofemaledeathswithmissingagedata.
PYLL(100):PotentialYearsofLifeLostwithareferenceageof100years.
4 AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296
Disparities in injury between Irish travellers and the general population
Figure1 Distributionoffatalandnon-fatalinjuriesbyintentforIrishtravellersandthegeneralpopulation,RepublicofIreland.
Thefiguredisplaysverticalbarchartsofthedistributionoffatalandnon-fatalinjuriesbyintentamongIrishtravellersandthe
generalpopulation.Thex-axisrepresentsthecategoriesofIrishtravellerswith34injurydeathsinAll-IrelandtravellerHealth
Study(AITHS)mortalitystudyand193non-fatalinjuriesamongthoseaged15yearsoroverinAITHSadulthealthstatussurvey
samplein2008,andthegeneralpopulationwith2277injurydeathsin2008and 908non-fatalinjuriesamongthoseaged
18yearsoroverinSLAN2002sample.They-axisrepresentsthepercentageofunintentional,intentionalandunspecifiedintent
injuriesoutofthetotalforeachcategory.Unintentionaldeathsrepresentedalargerproportionofinjurydeathsintravellersand
thegeneralpopulation,buttheproportionofintentionalinjurieswashigherintravellersthanthegeneralpopulation,withasimilar
patternfornon-fatalinjury.
(95% CI 368 to 654)). At the intent level, men and women), but those over the age of 65 were about twice
women were more than four times more likely to die of as likely to report an injury as the general population.
unintentional injurythan their generalpopulation coun- All these differences were statistically significant.
terparts. Traveller men were more than six times more The same pattern was apparent for unintentional injur-
likely to die of intentional injuries, and traveller women ies, although the differences in those aged 65years and
were more than four times more likely to die of inten- over werenotstatisticallysignificant.Travellershadastat-
tional injuries. Travellers had a lower incidence of unin- istically significantly higher incidence of intentional
tentional injury than the general population (SIR of 42 injuries (SIR of 181 (95% CI 116 to 269) in men and
(95% CI 32 to 55) in men and 46 (95% CI 34 to 61) in 268 (95% CI 187 to373) inwomen).
Table3 Disparitiesininjurydeathsandnon-fatalinjuriesbetweenIrishtravellersandthegeneralpopulationintheRepublic
ofIreland
Men Women Total
Fatalinjury
Age-standardisedPYLLrateratio*(95%CI) 541(392to748) 429(219to841) 490(368to652)
OverallinjurySMR†(95%CI) 523(372to715) 462(230to826) 496(368to654)
UnintentionalinjurySMR(95%CI) 454(279to690) 460(177to905) 446(292to634)
IntentionalinjurySMR(95%CI) 637(367to993) 464(107to1,204) 583(362to885)
Non-fatalinjury
OverallinjurySIR‡15+(95%CI) 57(46to71) 73(59to90) 65(56to75)
15–64 53(42to66) 67(53to83) 59(50to69)
65+ 237(108to450) 191(102to327) 208(130to314)
UnintentionalinjurySIR15+(95%CI) 42(32to55) 46(34to61) 44(36to53)
15–64 39(29to51) 42(31to57) 40(33to49)
65+ 176(64to383) 115(46to238) 137(73to235)
IntentionalinjurySIR15+(95%CI) 181(116to269) 268(187to373) 224(171to289)
15–64 170(107to258) 258(176to364) 213(160to278)
65+ 607(73to2192) 471(97to1375) 517(168to1206)
*RatioofPotentialYearsofLifeLost(PYLL)forIrishtravellerstothatofthegeneralpopulationintheRepublicofIrelandin2008.
†StandardisedMortalityRatioofIrishtravellersusing2008age-specificdeathrateofthegeneralpopulationintheRepublicofIrelandas
standard.
‡StandardisedIncidenceRatioofIrishtravellersusing2002age-specificincidencerateofthegeneralpopulationintheRepublicofIrelandas
standard.
AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296 5
Disparities in injury between Irish travellers and the general population
The overall injury CFR was 25/1000 in traveller men findings, we note their limitations. Injury events are
and 8/1000 in traveller women, compared with 4/1000 subject to under-reporting in mortality and morbidity
in general population men and 3/1000 in general popu- surveys for other reasons apart from incomplete recall,
lation women (table 4).The CFR was consistently higher and intentional injuries in particular might have been
in travellers than the general population, a gap that was, under-reported. There is no reason to suspect differen-
in its relative form, more marked for unintentional (15/ tial under-reporting ofnon-fatalinjuries,and in this case
1000 among travellers compared with 3/1000 among conclusions about differentials between travellers and
the general population) than intentional injuries (20/ the general population in non-fatal injury would be
1000 among travellers compared with 8/1000 among unaffected. As multiple sources were used to identify
the general population) and for men than women. traveller deaths, it is also unlikely that under-reporting
of retrospectively identified traveller deaths is a major
issue, and even if this was the case, travellers would have
DISCUSSION
an even higher injury mortality than that observed here.
Summaryof main findings
Another limitation is that the intent for injury deaths
Our analysis revealed stark inequalities in the burden of
was mainly medicolegally determined, while the intent
injury affecting one of Europe’s indigenous minorities,
for non-fatal injuries was self-reported, which could have
with ahigher proportion of injurydeaths and PYLL, and
caused some mismatch in the numerator and denomin-
death at younger ages in comparison to the general ator of the intent-specific CFR. There are no pointers to
population, contributing to the shape of their popula- potential differential misclassification of intent between
tion pyramid (see online supplementary appendix
travellers and the general population. It is also unlikely
figure). After two decades, Irish travellers are still at that differential misclassification of non-fatal injury
higher risk of dying of an injury than the general popu-
intent had a role in generating the considerably lower
lation, more so for intentional than unintentional injur-
unintentional injury rate among travellers, as it cannot
ies. Although they fared better in terms of non-fatal
similarly explain the reversal of this pattern in older tra-
injuries, this was not the case in older travellers and nor vellers. The non-fatal differential findings are generalis-
was it the case for all types of injuries. Intentional injur-
able insofar as the non-respondents to the surveys were
ies occurred at a higher rate among travellers than the
not different from respondents with respect to injury
general population in both the young and the old, and
risk, which could not be ascertained here. Finally, we
travellers had a higher CFR from both intentional and
used 2002 general population survey data to compare
unintentional injuries. with 2007–2008 traveller survey data, as it was the only
comparable dataset available. A change in general popu-
Strengths and limitations lation injury rates since 2002 could partly explain the
The strength of this study is that it used census and disparities, but probably negligibly, as the general popu-
survey data for Irish travellers from a national study with lation rate previously declined minimally between 1998
a high household response rate in a generally and 2002 in men (23% in 1998 and 21% in 2002) with
hard-to-reach population. Also, part of the analysis no obvious trend in women (14% in 1998 and 2002),26
accounted for underestimation of non-fatal injury inci- predicting a similarly minimal decline from 2002
dence due to recall bias. However, before discussing the onwards for men.
Table4 Injurydeaths,non-fatalinjurycasesandcasefatalityratios(CFR)forIrishtravellersandthegeneralpopulation
aged15+intheRepublicofIreland
Injurydeaths15+ Non-fatalInjuryincidence15+ CFR/1000injured
Traveller Generalpopulation Traveller Generalpopulation Traveller Generalpopulation
Men
Allinjuries 38 1402 1474 384778 25 4
Unintentional 21 998 1054 351398 20 3
Intentional 17 404 420 33380 39 12
Women
Allinjuries 10 832 1319 276035 8 3
Unintentional 7 729 766 242816 9 3
Intentional 3 103 554 33219 5 3
Total
Allinjuries 48 2234 2793 660813 17 3
Unintentional 28 1727 1819 594214 15 3
Intentional 20 507 974 66599 20 8
Sometotalsdonotaddupduetorounding.
6 AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296
Disparities in injury between Irish travellers and the general population
Discussion of findings problem among travellers. Non-fatal intentional self-
The findings largely echo what is known about the harm could also be more common among travellers,
burden of injury in other disadvantaged indigenous accounting for the higher rates of intentional injury
minorities. The lower rate of reported unintentional together with interpersonal violence. Fatal and non-fatal
non-fatal injury among young travellers, however, is not self-harm and assault also occur at a higher rate among
inkeepingwiththehigherunintentionalnon-fatalinjury other disadvantaged indigenous minorities.5 8 It is quite
among the indigenous people of Australia, who had 1.5– likely that behind these findings lie complex pathways
1.8 times the hospitalisation rates of the non-indigenous translating distress from adverse social circumstances
populationfortransportandotherunintentionalinjuries into physical harm. Excessive alcohol consumption
among those aged less than 74years compared with the could havea role in these pathways, being closely related
general population.8 It is likely that the higher travellers’ to suicide and interpersonal violence,34–36 and alongside
CFRresultedfromthedistributionofinjurycausesbeing other substance misuse, it was found to be associated
skewed towards more fatal causes than in the general with suicide in other disadvantaged groups.37–41 Despite
population, namely alcohol poisoning, which featured the lack of exact estimates, illicit drug use too seems to
strongly as a cause of unintentional injury deaths. be a substantial and increasing problem among
Although travellers report a lower frequency of alcohol travellers.20 42
consumption than the general population, they have
higher proportions of excessive alcohol consumption
Conclusionandimplications
than a socioeconomically comparable group of the
Irish travellers continue to bear a disproportionate
general population.20 The problem of excessive alcohol burden of injury in patterns that seem to fit well with
consumptionamongtravellerscouldinfactbeunderesti-
the circumstances of social exclusion and deprivation
mated in a cross-sectional survey of survivors. It is also
that affect most of them, and the expected negative
possible that while alcohol poisoning was classified as an
impact of such circumstances on mental and physical
injury in mortality data, non-fatal alcohol intoxication
health. Injury prevention efforts targeting Irish travellers
was not conceptualised by survey respondents as an
should thus be scaled up, utilising evidence-based effect-
injury. The higher mortality could also partly be due to
ive interventions within a social determinants frame-
differences in care seeking behaviour oraccessto appro-
work. While the experience of other countries with
priatemedicalcaresuchasalcoholdependenceservices.
similarly affected culturally distinct minorities in Europe
Another reason why young travellers had lower unin- and elsewhere may offer useful guidance, the specificity
tentional injuries rate overall could be fewer opportun- of Irish travellers’ circumstances, which is quite likely
ities forengagement in activities such as education, work reflected in some of the findings, should be taken into
related activities and sports that would put them at risk
consideration when planning such efforts. In the case of
of transport and other unintentional injury. Factors
Irish travellers, a focus on preventing suicide, alcohol
implicated in the higher unintentional transport injury
misuse and elderly injury should materialise in existing
mortality and morbidity among indigenous minorities in
and futurepolicies, action and research.
Australia, Canada and Scandinavia, namely remoteness
and the use of off-road vehicles,3 5 12 are unlikely to Acknowledgements TheauthorswishtothanktheIrishtravellers,traveller
affect travellers. Although ‘going on the road’ is a defin- peerresearchers,studycoordinators,PublicHealthNurses,theGeneral
RegistrarOffice,CentralStatisticsOfficeandtheAITHSTechnicalSteering
ing feature of traveller culture, nearly 80% of traveller
Group.TheauthorsalsowishtothankDrKaviBhallaforprovidingWorld
families have not travelled for more than 3days in a HealthSurveyrecallpatterns.
year, and only a small proportion of travellers (less than
Collaborators TheAITHSstudyteammemberswereMsFranCronin,
20%) live in accommodation conditions perceived by DrAnneDrummond,DrPatriciaFitzpatrick,DrKateFrazier,DrNoorAman
them as unsafe or associated with environmental Hamid,MsClaireKelly,MsJeanKilroe,MrJuzerLotya,DrCatherine
hazards, such as proximity to a main road.20 A higher McGorrian,DrRonnieGMoore,MsSineadMurnane,MsRoisinNic
Carthaigh,MsDeirdreO’Mahony,MsBridO’Shea,ProfAnthonyStaines,
unintentional injury rate among older travellers would
MrDavidStaines,DrMaryRoseSweeney,DrJillTurner,MsAileenWardand
not be surprising on the other hand, as older travellers
DrJaneWhelan.
report higher proportions of poor health and chronic
illnesses.31 Those would compound ageing-related Contributors SAparticipatedinthecollectionofthetravellerdata,designed
andimplementedtheanalysisstrategyanddraftedthemanuscript.CCKisthe
factors such as gait problems, which increase the risk of
PrincipalInvestigatoroftheAllIrelandtravellerHealthStudy.Shedesigned
falls, the commonest cause of elderly injury.31 32 This andsupervisedtheimplementationofthetravellerstudiesonwhichthis
was also reflected in the finding of a higher hospitalisa- paperisbasedandcontributedtothewritingandrevisionofthemanuscript.
tion rate for head injury among Australian indigenous BQsupervisedthefieldactivities,participatedinthetravellerdatacollection
andmanagementandreviewedthemanuscript.LDdesignedandsupervised
people aged 60years orover,where80% ofinjuries were
theimplementationofthetravellerstudies,supervisedtheanalysisand
due to falls.7
reviewedthemanuscript.Allauthorsapprovedthefinalmanuscript.
Suicide has recently overtaken road traffic injury as
Funding ThisworkisbasedontheAll-IrelandtravellerHealthStudy,
the main cause of injury death in Ireland,33 and the
commissionedandfundedbytheDepartmentofHealthandChildren(DoHC)
finding that it caused the majority of travellers’ inten- andtheHealthServiceExecutiveintheRepublicofIrelandandthe
tional injuries indicates that this is an even greater DepartmentofSocialServicesandPersonalSafetyofNorthernIreland
AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296 7
Disparities in injury between Irish travellers and the general population
(DSSPSNI)(grantno.V0350).Theviewsexpressedinthisstudyarethe 18. CSO.Annualstatisticalreport2007.Dublin:CentralStatisticsOffice,
authors’ownanddonotnecessarilyreflecttheviewsandopinionsofthe 2010.
DepartmentofHealthandChildrenortheDepartmentofHealth,Social 19. BarryJ,HerityB,SolanJ.Thetravellershealthstatusstudy.Dublin:
TheHealthResearchBoard,1987.
ServicesandPublicSafety.
20. AITHS.Technicalreport1:healthsurveyfindings.Dublin:
Competinginterests None. DepartmentofHealthandChildren,2010.
21. AbdallaS,QuirkeB,FitzpatrickP,etal.TheAll-Irelandtraveller
Ethicsapproval UniversityCollegeDublinHumanResearchEthics HealthStudy:demographyandvitalstatisticspartAoftechnical
Committee. report2.Dublin:DepartmentofHealthandChildren,2010.
22. GovernmentofIreland.Equalstatusact.Dublin,2000.
Provenanceandpeerreview Notcommissioned;externallypeerreviewed. 23. CSO.Vitalstatistics:fourthquarterandyearlysummary2008.
Dublin:CentralStatisticsOffice,2008.
Datasharingstatement Noadditionaldataareavailable. 24. CSO.Census2006:principaldemographicresults.Dublin:Central
StatisticsOffice,2007.
25. ©HealthPromotionUnitandUCD.SLAN2002microdata.Dublin:
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8 AbdallaS,KelleherCC,QuirkeB,etal.BMJOpen2013;3:e002296.doi:10.1136/bmjopen-2012-002296