WH&Y authors: Professor Rebecca Ivers

WEBINAR: Unintentional injury in the adolescent years – what’s happening and who is paying attention?
PRESENTER: Professor Rebecca Ivers
DATE: 28 October  2021




Kate Steinbeck: [00:00:04] Hello, everyone, and welcome to the October webinar series for WH&Y Wellbeing, Health and Youth. I'm Kate Steinbeck and I'll be chairing this session. Before I introduce you to our fabulous speaker, I'd first like to acknowledge all the universities that have been involved in our Centre of Research Excellence from which this webinar grows. I would also like to acknowledge the traditional owners of the country throughout Australia wherever you are and recognise their continuing connection to land, waters and cultures, and we pay our respects to their elders past, present and emerging. 

Kate Steinbeck: [00:00:51] I also want to welcome you as WH&Y members of the Community of Practice, I encourage anyone who has not signed up to be part of us to do that, as we are developing a very active and interactive community of practice around adolescent health, and this is led in partnership with Western Sydney University collaborators and with the wonderful WH&Y Commission of young people trained in research. 

Kate Steinbeck: [00:01:29] A few things. Your microphone is muted as long as we're presenting and your video is also switched off. I want to remind you that if you have something to say or a question to ask, please use the 'chat' on the right-hand side. And if you want to comment on anything in the chat, you can go down to the little plus sign where you can type in your message. I'll be running the question and answer session after our fabulous guest has presented. 

Kate Steinbeck: [00:012:06]  I now welcome Professor Rebecca Ivers. Rebecca and I have worked together for quite a while on adolescent research. Rebecca is an NHMRC senior research fellow and head of the School of Population Health at the University of New South Wales and also an honorary professorial fellow at The George Institute for Global Health. Rebecca leads a vast global research program focusing on the prevention and management of injury, and clearly that's what she's going to be talking to you about today. And remind you that unintentional injury is one of the major causes of morbidity and mortality in adolescents. Rebecca, welcome.

Rebecca Ivers: [00:02:56] Thanks very much, Kate, and it's lovely to be here. And I too would like to acknowledge that we're all meeting on unceded lands of Aboriginal people across the country, and I'm here coming to you today from Gadigal country.

Rebecca Ivers: [00:03:09] So, it's great to be here and to talk to you all about injury. Some of this is going to be a bit of an injury 101 - just to remind you all about injury, the burden of injury.

Rebecca Ivers: [00:03:21] First of all, what I want to do is just talk to you a little bit about myself. Who am I? What's my standpoint? I'm a non-Aboriginal woman. I grew up in Sydney. Firstly trained, believe it or not, as an optometrist, and my first career was actually as an optometrist working in the Northern Territory, where I got a pretty quick induction into inequities in health systems, working around eye care in remote parts of the Northern Territory. And I had the great privilege of working with wonderful Aboriginal people in the Northern Territory, in remote community-controlled health services and the Northern Territory Aboriginal Eye Health Committee. I guess I pretty quickly developed an understanding about the inequities and the inadequacies of our health system. So I decided to go and retrain in public health and do my Master's in public health at the University of Sydney. And if you're wondering how you get from optometry to injury, my PhD was on the relationship between poor-vision falls and hip fractures in old people, and I went onwards.

Rebecca Ivers: [00:04:28] So that's my story. As Kate said, I'm now at UNSW, head of the School of Population Health, and working across a whole range of projects on unintentional injury. My program of research really looks at injury across the life course - children and adolescents and aging. I also work on projects around cultural safety in health care. But much of my work has got a focus on where the gain will be greatest. And looking at marginalised and under-served populations, because that is generally where the burden is. And that's where our impact can be greatest. We're talking about changing lives and improving health, which really is always the focus of my work, and I'm sure all of yours as well. Big cohort studies and trials and co-design processes and implementation science really underpins most of the work that we do. I think we have a lot of challenges in the work that we do and the challenges in conducting research in poorly resourced settings. But often the gains are going to be greatest.

Rebecca Ivers: [00:05:41]. I'm also involved in three NHMRC Centres of Research Excellence in Adolescent Health. With the CRE that's associated with this seminar series, REACH [Centre of Research Excellence in Child and Adolescent Health] with a focus on capacity development. And CRE with George Patton and Susan Sawyer another group of wonderful investigators on global investment in adolescent health. So I'm very privileged to have the opportunity to work with so many and such diverse groups of people, always learning, always hearing different ways of doing things, and learning and understanding about my own biases and privileges and trying to move forwards in a way that is appropriate. 

Rebecca Ivers: [00:06:33] I'm going to talk a little bit today about one of the studies I'm involved in, Drive our Young Drivers Study. I worked with Kate on the ARCHER  Study [Rural Adolescent Cohort Study of Health, Hormones, Environments, and Education and Relationships] the Next Generation Study, which is is another NHMRC, in fact they are all NHMRC studies. It's an Aboriginal cohort study led by Sandra Eades, and then another with Jen Marino and Rachel Skinner, which is looking at risky behaviour in the RAINE cohort study. And I'm also involved in a few other studies in adolescent health: a cluster randomised controlled trial of the PAX Good Behaviour Game in New South Wales schools led by Michelle Tye of the Black Dog Institute, and we in fact have a PhD student funded by the WH&Y CRE working on that, and again, that's a really great piece of implementation science research in action. Also, I'm working with a group of people at Walgett Aboriginal Medical Services Geronimo Playgroup, and this is a program which is a co-design and feasibility of a child injury-prevention program for Aboriginal children in Walgett. Another NHMRC-funded project, which has ended, but we're still pumping papers out, is Burns in Aboriginal and Torres Strait Islander Children. And for that one, I'm really proud to say that we've actually had many publications, and four PhD students have been working on this study, three of them have already been confirmed, one has just submitted, and three of those four PhD four students are Aboriginal women and a really talented bunch of Aboriginal women I've ever had been privileged to work with. So, that's been a fantastic experience. And then also work on Driver Licensing Support programs in Aboriginal people, and I'll talk a little bit about that project today.

Rebecca Ivers: [00:08:19] So we come back to injury 101. What is an injury? Just to remind you, it's damage to a person caused by an acute transfer of energy or a sudden absence of heat or oxygen, which takes the body beyond its bounds of resilience. There are various types of injury, but of course, injury is not just a physical harm, there are also psychological, spiritual, emotional and cultural aspects of harm that we ought to consider. Prevention doesn't only need to focus on reduced hospital bed days or lives lost, the mortality or the disability-adjusted life, but also the safety and emotional wellbeing of individuals. And that should always be our focus. We grade injuries, we classify injuries into unintentional and intentional, unintentional being road traffic injuries, falls, poisoning, drowning, burns and so on, and then intentional, self inflicted, self harm, interpersonal violence, war related and other. When we look at injury, and again, remembering injury is a little bit different from most other health conditions, when you think about prevention, you really do need to understand the context of the injury. We have special ICD codes (International Classification of Diseases) to code injuries: by intent, whether intentional, unintentional, by type, so obviously fractures, open wounds, burns, traumatic head injuries, organ injury and so on. But we also actually need to classify injuries by how they occurred, by external cause or whether it was a cutting or piercing, a drowning, a fall, a fire, fire flame or a hot object or transportation injuries, and also by what people were doing at the time of injury. Because if we hope to prevent injury, we really do need to understand a little bit more about the context. 

Rebecca Ivers: [00:10:09] Coming back to adolescence, why is it important? Well, we all know that you're here because you understand about adolescence, it's a critical period. It sets the scene for patterns of growth, development and behaviour that will influence health and wellbeing for the rest of life. And of course, the population of people aged 10 to 24 is currently the biggest ever, 1.8 billion in 2016. So, what happens when we're thinking about injury during the adolescent years? Well, of course, we know people are growing independent, shifting roles and you begin independent travel. Young people are more likely to be pedestrians, out on their own, catching public transport, cycling, riding motorbikes and cars. And then we have that whole issue of inexperienced drivers. There are changes in cognitive function and development, this is the time for identity formation, discovery and testing boundaries. And this can involve risk-taking, rule breaking and peer pressure, which combined with access to driving and motorcycles, independent behaviours that can lead to increased risk of injury. Also, engagement with alcohol and other drugs, and distractions while driving. It's no surprise therefore that we see injury rates rise during adolescence. 

Rebecca Ivers: [00:11:24] Coming back to the burden of injury, just thinking about what the global burden is, it's a big deal. Injury in 2017 was eight percent of all deaths and 10 percent of the global burden of disease, 4.5 million injury deaths every year, and 521 million cases of non-fatal injury, which was an increase from 1990. Globally, the major causes of injury deaths are road injury, self harm, falls and interpersonal violence. And really, from the time that we can move or we can crawl, injury death rates are twice as high in men than in women, and that's pretty consistent across all injuries at all stages. As soon as you can start crawling, males are overrepresented. The only differences, where we see women are overrepresented, are burns, particularly in South India in young women, and that's related to homicide, some self-harm, but there's a lot of violence related injury. And there are some unintentional cooking injuries and also intentional injury and also falls in older people. Women again can be overrepresented. 

Rebecca Ivers: [00:12:34] When it comes to the global burden of injury, though, years of life lost are responsible for the majority of the injury-to-survivability-adjusted life years, and that's because a lot of the injuries are young people who lose a lot of years of life if they're killed, and the greatest contributors are road injury, falls, self-harm, interpersonal violence and drowning. We have seen over the last 30 years, age standardised rates of the years of life lived with disability and years of life lost from injuries decline, while the incident stays about the same. We also see for many causes of injury that it decreases with increasing socio-demographic index. If you have a look here, you can see years of life lost on the left, years of life lived with disability on the right. You can see here this is other transport injuries and road injuries, the red one, you can see that as the social demographic index goes up, the incidence of road injury goes down and that's pretty much what we see. You can see for falls, that's not the case. And again, that's because falls are predominantly injuries that occur in high-income settings or in wealthy populations, older people falling, for example. 

Rebecca Ivers: [00:13:52] When we look at how injury patterns change over time, this is an example from the US from 2017. You can see that it shifts from children, all the way through to 20, 24, and you can see the rise in unintentional injuries over time as young people get older, and you can also see suicide changing as well. This is another example you can see across the life course, and again, this is US data where you see very high rates of poisoning, that is poisoning, and opioid deaths and unintentional drug deaths are included in that. But here you'll see motor vehicle deaths, you can see as people become more independent, road deaths go up really dramatically in those early years, drop a bit and then rise a bit and then drop down again to older age. And this one here is falls, which you can see is predominantly in older sage. 

Rebecca Ivers: [00:14:51] Just to cut across the world again, the injury death rate for children zero to 19, and this cuts across WHO regions, you can see road injuries up the top here, self-harm and interpersonal violence and other unintentional injuries. And you can see this is a European region, this big red bit here is due to self harm and interpersonal violence, a lot of that is around conflict that's been in that region in the Middle East. Similarly in Latin America, where you see that big red blob in the middle. But it does show this overwhelming burden of unintentional injuries, road injury and other unintentional injuries down the bottom in blue across the whole globe. And again, this is causes of death for children between five and 14, for the world, you can see the leading causes of death are road accidents, drowning, and then you see homicide, suicide and fire down here as well. So really, right up there at the top [road accidents] is the leading cause of death and disability for children and young people globally. A major, major issue. 

Rebecca Ivers: [00:16:04] This again highlights the inequities, the overrepresentation of males here on the left compared to women on the right. And you can see with the global drowning burden, you can see very, very young ages, it's very high, but it's still very high all the way across the adolescent years. But you see that overrepresentation of males compared to females and again, drownings, very much so in the countries of SouthEast Asia. 

Rebecca Ivers: [00:16:31] Coming back to Australia, what do we know about injury? In Australia from 2007 to 2019, 73 per percent of all deaths for young people aged 15 to 24 and unintentional deaths in injury accounted for 32 per cent of all deaths, and 43 per cent of all the injuries. So, unintentional injury is a big problem. And I know intentional injury is also a problem for adolescents in Australia, but I'm really going to concentrate on unintentional injury here. The most common causes were transport, driving cars, motorbikes, pedestrians, poisoning and again that includes drug deaths, and drowning. Again, you might be surprised to see that drownings are so high. You've got to remember that these are deaths. So these are injuries that have got high lethality and that cause death. And what we saw again in the trends is that unintentional injury deaths declined, but hospitalised cases were stable. We're getting better at preventing deaths, but we're still seeing a large burden of people ending up in hospital, and that's something that we really need to keep tackling. 

Rebecca Ivers: [00:17:41] Again, this is just showing you the overrepresentation of males compared to females from the younger to older ages during adolescence. And you can see there is a huge discrepancy between males and females across these years -  it's very much a gendered issue. And I'm sorry, I don't have much data for gender diverse populations, and I will come to this later. Much of our data is coded very much using males and females, and we have severe inadequacies with our data collection so that we're unable to look at gender diverse populations in our routinely collected data sets because of a lack of data collection in those data sets. When we look at leading causes of unintentional deaths, again, it’s traffic crashes, poisoning and accidental drowning.  Again, that really big burden of land transport deaths here as well. Just to highlight where the biggest burden is, 60 percent, compared to 20 percent for poisoning, and drowning eight percent. So, traffic crashes are a huge burden. 

Rebecca Ivers: [00:18:51] We have seen over time, though, that motor-vehicle injury deaths among young people have been going down and that really was the case in line with the rest of the community. Road traffic deaths have been coming down in Australia, but then they've all pretty much plateaued. And for young people, that's the same as you can see here, you can see males overrepresented here and you can see that overpresentation hasn't shifted, so we still see that compared to the rest of the population, road deaths in young people are really a substantial issue, even though they have come down. We do still need to look at what we can do to prevent deaths on the road with young people. 

Rebecca Ivers: [00:19:34] When we come to look at hospitalised injury for young people, again, similarly, 14 percent of all hospitalisations, that was the top reason for hospitalisation for men and for women. Males 2.3 times as likely to be hospitalised for unintentional injuries as women and the top injuries again, land transport crashes, that's road crashes, inanimate mechanical injuries, and these are pretty much workplace injuries. I know we use the most dreadful terminology, but these are if you are on a construction site, you get hit by some machinery, that's the kind of injury. Now this is a big deal. Workplace injuries, 21 percent. And then the third one is falls, these could be sporting falls due to collision with or pushing falls, through to roller skates, skateboard falls due to slipping or tripping, and that's 19 per cent. So again, these are the high causes of hospitalisation for unintentional injury. You can see here that we do have inequity in these injury rates., both for the deaths on the left hand side and the hospitalised injury cases, you can see that all young people here in orange, you can see people born in Australia have got higher rates than people born overseas for deaths, and that's basically because when people come to Australia they don't engage and it takes them a while to actually come to terms with the behaviours that other Australians engage in. I'll talk to you a little bit about some results from the Drive Study on that. But you can see here the injury death rates go up by remoteness. So compared to major cities, much higher death rates in rural and remote places and socio-economic status much higher for lower than higher areas. And for major cities again for hospitalisation, it is a lot higher. 

Rebecca Ivers: [00:21:22] So the difference by gender? There's a great question that is really hard to explain. And I think it probably is a whole lot of gender normative behaviour, there's probably developmental things, whether there's other rationales for that, we don't really know, but it's a really good question and that's something that we do need to pay more attention to. At the moment, though, what we do need to understand is that it is very gendered behaviour. 

Rebecca Ivers: [00:21:52] Let's come back to sport injury, though. And again, this is a big burden as well in Australia. At 31 percent of unintentional hospitalised cases, it's got the highest injury rate for all ages and again, a three times higher rate for males than females. And it's higher for young males than older males. Younger males tend to get injured more than older males, and I guess that's something to do with risk taking behaviour and pushing the boundaries and peer pressure. Interestingly, for both males and females, the most common cause is actually football codes. And again, it says something about the way in which we play sport and I guess the rules around football codes. But what's also interesting is that motorcycling, basketball, cycling, and skateboarding, I guess not surprisingly, considering the kind of danger involved in many of those activities, I guess basketball's probably knee injuries. But I think it's worth noting that motorcycling for young males was the second most common hospitalised sport injury and cycling was the third. It  alway surprises people, but again, motorcycling does have a high risk attached to it, and especially for young people because you've got young people whose risk behaviour may not yet be moderated by age, potentially riding a vehicle which has got very high power and they may not be wearing appropriate protective clothing, which may or may not protect you in any case, if you're traveling fast enough. We often see this very high burden from motorcycling, both in high- and low-income countries. So there's a question about motorcycle injuries counted as sport, it's actually pretty tricky the coding. We actually classify sport differently, so the codes are pulled from a range of different codes, and motorcycle injuries are actually counted as road-traffic injuries. 

Rebecca Ivers: [00:23:49] Some of the other people that we need to be thinking about are young Aboriginal and Torres Strait Islander people. Now, what we do know, and again this comes from the Aboriginal and Torres Strait Islander Adolescent and Youth Health and Wellbeing Report that was done by AIHW in 2018, which I had the privilege of being on the Advisory Committee for. We know many young Aboriginal people are in excellent health, have falling mortality rates and are closely connected to culture. We also know, though, that young Aboriginal and Torres Strait Islander people face additional barriers to making a successful transition to adulthood because of the impact of intergenerational trauma and the racism and the socio-economic disadvantage that they may suffer, that is part of their lives. We do see leading contributors to the disease burden around suicide and self-inflicted injuries, anxiety disorders, alcohol use disorders, and road traffic crashes and injury is responsible for most deaths of young Aboriginal people, including suicide, land transport crashes and assaults. So again, a population that requires absolutely special targeted programs and policies and a voice, a strong voice in what actually happens and how injuries are addressed and how it's treated. 

Rebecca Ivers: [00:25:09] Another group about which we know much less are the gender-diverse populations, and as I said earlier, we don't have good data collections, I think we saw that recently in the Census, and many young gender-diverse people live very healthy and fulfilled lives, but a disproportionate number experience poorer mental health outcomes and have higher risk of suicidal behaviours than their peers. And of course, we see challenges with stigmatisation, prejudice and access to appropriate health care. There's actually very little evidence on unintentional injury, the bigger issues seem to be in intentional injury and violence and mental health. But as I said, we have challenges in the data collections and this is a bit of an unknown area. 

Rebecca Ivers: [00:25:53] When we come back to talking about prevention of injury, what's really important? We understand a lot about injury risk factors and the social determinants. We know that injuries are higher in low- and middle-income countries than in high-income countries. We know that even within high-income countries, there is a bi-directional relationship between injury and poverty. If you're poor and you live in a worse environment, you're going to have higher rates of injuries. We know the environment is a contributor, the conditions of the roads you drive on, your laws and the enforcement, the housing that you live in, child labour and poor working conditions. All of those things contribute to higher injury rates in resource-poor settings than within high-income countries. And as I've said, within gender, injury rates are higher in males.

Rebecca Ivers: [00:26:36] When we start talking about prevention, it's critically important that we focus on all of these social determinants and risk factors to make sure that we're actually addressing the right things. Injury is not equitably distributed, and we see that across the US, New Zealand and the UK, where we see persistent socio-economic inequalities. The two areas where we don't see that same bi-directional relationship are in fact sporting injury, and you see a higher preponderance of sporting injuries in higher income, and again, I think with young people and likely because people who are more well off are probably more inclined to actually enroll children in sporting activities, and also in falls in older people, that socio-economic divide disappears. 

Rebecca Ivers: [00:27:21] Now, I'm going to talk a little bit about some of the work that we've done and just highlighting this in driving related injuries in young people. The Drive Study was an NHMRC funded cohort study. My first post-doctoral project, actually, my supervisor, Robyn Norton, got funded for this project. We enrolled over 20,000 young people in this cohort study looking at young drivers. They completed a baseline survey and gave consent to linkage to crash events, hospitalisation and death data. And in fact, it was an incredible challenge because it was the first CHeReL (Centre for Health Record Linkage) data linkage unit project, and we used mainly online consent.  I think 90 percent of people completed this online and gave online consent for later data linkage. And we linked the data after two years and 13 years to police-reported crash, offence, hospitalisation and death data. 

Rebecca Ivers: [00:28:18] So what did we see after two years? We enrolled people 17 to 24 years old on their red P plates, so they've just got their driver's license within the last 12 months, and we asked lots of questions about things like risky driving, risk perception, supervised driving experience, mental health, drug and alcohol use. We used AUDIT-C and  Kessler 10, we used the Beck Suicide Inventory Stem question, which is about self-harm in the last 12 months. What we found was that if people reported high scores on risky driving scales, two years later they had a 50 percent increased risk of crash, and that's adjusting for all the other usual confounders that you'd expect. People who reported self-harm behaviours in the previous 12 months, had an increased risk of crash. If you lived in regional, remote areas, you're more likely to have serious crashes, single vehicle versus multiple vehicle, and you're more likely to have injury versus non injury crashes. And of course, we also saw that drivers of lower socioe-conomic status had higher risk of crash related hospitalisation. 

Rebecca Ivers: [00:29:19] We also saw that there were some factors associated with decreased risk of crash. Asian born young drivers had a 50 per cent reduction, so the longer they've lived in Australia, the more the crash rate came back to what the Australian norm was. But when people first come to Australia, young Asian people, if you were born in Hong Kong and came to Australia and got your driver's license, you actually had a lower risk of crash than the Australian born. We also found that people who had done a particular type of resilience-based school education program, which was RISK up on the Northern Rivers, had a 44 percent reduced risk of crash compared to a one-day, driver-focused program, which was really prevalent across the rest of the state. We did find that drivers living in rural or remote areas had a 50 percent reduced risk of crash, but that was actually just risk of crash, they were more likely to have been involved in serious crashes, it was just more that if you live in an urban area, you've got a higher risk of crashing because you've got more cars to crash into you. But crashes tend to be more trivial and not as serious as they are if you were in a country area. And we also found that if you had a supervisor who had offenses, so when you were learning to drive if your supervisory driver had driving offenses, you were more likely to crash. And again, you share characteristics with your parents as well, so that's really not surprising. For those of you who've got young people or if you're going for a drivers test, I can also tell you that the driving test worked pretty well. If you fail your driving test a number of times you've actually got a high risk of a crash. The tests that we use are actually pretty good at screening out drivers who aren't very good or need a bit more experience. 

Rebecca Ivers: [00:31:05] When we did the 13-year linkage, it really confirmed a lot of those - if you're from a low SES area baseline, you still have an increased risk of crash and drivers with offenses at baseline have an increased risk of crash. If you are driving badly and/or being picked up by the police at baseline, increased risk of crash. And we also saw a sustained impact of risky driving behaviour, so if you said to us in 2003 and 2004 that you engaged in a range of different risky driving behaviours like hooning or driving fast, habitual speeding, you actually had a sustained crash risk 13 years later. That's sort of suggesting that there is a group of people that aren't growing out of these risk-taking behaviours, and that there are other factors at play. And we again also saw that the resilience-based program participants were still less likely to have any crash. 

Rebecca Ivers: [00:32:00] So what's a hypothesised mechanism? When you think about socio-economic status and injury, if you're poor, if you're from a low income area, you're driving on poor quality roads, poor quality infrastructure, your parental influence may be different, you may have less access to emergency services and emergency health care, you're more likely to live in outer regional areas when you're driving, it's really not surprising that you've got different susceptibility, different differential exposure, and then you've got a higher risk of injury. But it's really important that when we target our programs that we make sure we take all of these things into account when we're talking about prevention. 

Rebecca Ivers: [00:32:44] When we look at prevention for injury, the traditional injury-prevention models are the three Es: education and behaviour change; legislation and enforcement; engineering and technology. Engineering technology - better roads, better cars. Legislation and enforcement - speeding laws, drink-driving laws, graduated driver licensing laws and enforcement. All accompanied by appropriate education - social marketing and behaviour change. That's been pretty much the standard for injury prevention for many, many years, and it has been very effective. If you start thinking about all the different types of injury that these things apply to, consumer product safety, hot water mixes to prevent scolds in the household, all the different road traffic injury laws that we have, you can see that it's worked pretty well. But injury is a multi-sectional problem that requires a multi-sectional approach to prevention. If you think about it again, it's different from any other other health problem. When we address injury, we need to actually have collaboration, working across health. Health often actually treats the outcomes of injury, but doesn't necessarily have a big role to play in prevention. But we do work with sectors in education, in transportation, in housing, sporting clubs, the environment, people who design the urban environment and do urban planning, and workplaces and workplace regulation and so on. And of course, community members and NGOs, and indeed a lot of injury prevention, some done by government, but a lot is done by NGOs, you think of all the NGOs that you can think of, Royal Life Saving, Kids Safe and there's a whole lot of other NGOs out there who are actually designing and implementing injury-prevention campaigns in the community. 

Rebecca Ivers: [00:34:29] This is also a classic approach that we use for injury prevention, the Haddon's Matrix, and it really just identifies ways in which you can prevent injury, cutting across the phase. This is one for road traffic injuries. Pre-crash, you think of all the different things that you might do before the crash, during the crash, and post crash, and the factors that you need to include, the human, vehicles and equipment and the environment. And you can see that there's a range of different things cutting across crash prevention, injury prevention during the crash, which might be the use of the seatbelts, and life-saving interventions which are more about hospital care. Now that's all very well, but that doesn't take into account the social environment, and what we do understand in injury is that because there's such a wide range of risk factors, both structural and individual and complex interactions between all of those things, we need upstream systems-based approaches that address these issues across the disease groups and strengthen the health systems. And they're much more likely to be effective, especially in remote or resource-poor settings where you might have limitations in preventative programs and health services. So it's really important that we take all these things into account. 

Rebecca Ivers: [00:35:40] And this is another version of the Haddon's Matrix, which is a little bit more up to date. You can see that we still cut across the pre-event, event, and post-event, and the different agents, so whether it's the vehicle, the physical environment, the social environment. You can see here all these other decision criteria come in around equity, stigmatisation, preferences, feasibility, cost and effectiveness, and we need to take all of these things into account when we're designing injury-prevention approaches. It's more of a systems thinking approach compared to this reductionist approach on the left hand side. If you're thinking about road traffic injury, you might think about that for drug-affected drivers, which again is an increasing problem, a reductionist approach just says alright well they're a problem we have to get them off the road, so we'll have enforcement, pick up drivers under the influence and that will reduce crashes and fatalities. Whereas the reality is we know there needs to be a much more sophisticated approach on the right-hand side here and involving much more. I would actually even take it up to the next level and actually look at social determinants feeding into that around drug use and also access to transport for people. 

Rebecca Ivers: [00:36:51] So what I'm going to do now just before we finish is talk a little bit about driving change. This is some research that we did in partnership with multiple Aboriginal communities across New South Wales looking at driver licensing in young Aboriginal people. I guess it was participatory action research where we co-designed a program and implemented it, and now in fact, it's led to statewide funding of similar programs across New South Wales, really successful in terms of impact. We did some pilot work in Bourke at the Aboriginal Medical Service and did a study with people attending Aboriginal medical services across a range of different locations in New South Wales, and that was to look at road safety. 

Rebecca Ivers: [00:37:21] There were real gaps in understanding about road safety and injury in Aboriginal people, because our crash data doesn't collect indigenous status well. What happened, though, when we did that, is that people said, well, actually, the bigger issue is in fact not so much road safety, but it's actually licensing. Licensing rates are really low. We found really strong links between licensing, employment and education in that study. If you had a driver's license, you had four times the odds of being in employment or having a degree qualification compared to those who didn't have a license. And there were really similar findings from other studies across the country, including some of the work that we did for the Northern Territory Government. And this comes from work that Yvonne Helps, James Harrison, Allana Bush and Ilona Kickbusch had done in South Australia many years ago, showing that a driver's license is much more around road safety. We can see that young people really want their driver's license for independence and for Aboriginal people, even more important, particularly if you're living in rural and remote places without good access to public transport, it's about autonomy, mobility and access. Unfortunately for young people, it also comes with an increased risk of fatal crash and injury. 

Rebecca Ivers: [00:39:01]We heard many stories from young people and older people about barriers to driver licensing, finance, identification documents, poor access to drivers and appropriate vehicles for learners, so many young people had parents who weren't drivers or didn't have a car who might have had difficulty with literacy or numeracy in getting through the learner knowledge system. And then also issues with fines and excessive contact with the justice system, which meant they were barred from getting a driver's license and, of course, a lack of culturally responsive service provision. The program was put together, with funding from AstraZeneca and from several grants from Transport New South Wales and also from New South Wales Health. But it was set up as a case-management approach with a young Aboriginal person or an Aboriginal person with strong links to the local community sitting in a local community organisation that was accessible, not necessarily a health service, often a Lands Council or a youth service and supported by the local community or key stakeholders and basically case-managed people through the driver licensing system. They had access to cars, they could provide people with supervised driving practice, and coordinate activities like removing debt, case managing people through getting a license, getting your I.D. documents. Throughout the program, lots of people got a license. Nearly 224 got a full license and lots of financial assistance and lots of supervising driving and lots of community members engaged in the process. And what we found, again, was that they were again more likely to find employment or have a change of employment 12 months later. And the number of people in those communities increased in those places. But more importantly, the program is now funded across the state and has led to similar programs in other states and a real focus on local ownership. This was a program that was very much led by the young Aboriginal people and Aboriginal people in the communities in which it was run. And here's some pictures from it. 

Rebecca Ivers: [00:41:10] We also had a really engaged steering committee for the study with a number of politicians and the police,  they had meetings quarterly around the projects, as well as the Aboriginal community organisations. When the project finished and we had results, it was very easy to turn it into policy because they'd been engaged along the whole way, which was really important and obviously really well regarded by the community. And in fact, I was talking to one of the community organisations this week, who had just been refunded to deliver the program for another couple of years, and they're still saying that in their regional town, young people are still getting their license and it's just been an incredibly successful program. So fantastic. But again, this is a kind of holistic program that will address injury and injury rates, but also address social determinants and cut across a whole lot of the other issues that young people are facing in community settings. And I am a big fan of having these, I call them horizontal programs, not just siloed programs, it's very easy for injury to come back and go, I'm just going to do a road safety program or a poisoning program. If you actually want to see sustained change, we need programs that are going to cut across a range of different health conditions and factors.

Rebecca Ivers: [00:42:26] So Injury is a national priority, hard to believe, it's been a national priority for a long time and we've had national injury plans, but they've never actually had action plans assigned to them. And there are various state related action plans and programs, but we really have struggled for a long time to get national action and coordinated action, and we really would love to see a CDC-style (Centre for Disease Control) organisation that develops and implements plans nationally. 

Rebecca Ivers: [00:42:254 ]We've just been involved in putting together the next National Injury Prevention Strategy. Kate Hunter at the George Institute led that, I was on the advisory committee. Again, it hasn't quite been launched and we definitely need an action plan that's funded alongside it, and that's always going to be the challenge with these kinds of things. But what this strategy aims to do is to look at self harm, but also road related injury, workplace injuries, sports injuries, but also really importantly, prioritise the availability of access to culturally appropriate programs and services for young people. These are the strategy aims for young people, and you can see again the kind of things reducing road traffic injuries, so strengthening graduated driver licensing systems, which really are the cornerstone of our approaches to reducing young driver injuries, but also again supporting driver licensing programs like Driving Change, and people experiencing socio-economic disadvantage and those living in rural and remote areas. Workplace injuries, sport injuries, and culturally sensitive services. A lot of really great recommendations, I think what we know is that this is going to take time and money and a lot of commitment from government. I think we're going to need to do a lot of advocacy going forward to make sure that these are in fact funded. 

Rebecca Ivers: [00:44:14] There are a lot of gaps identified in the strategy. We don't know much about effective interventions to reduce poisoning, overdose and drowning among young people, including Aboriginal and Torres Strait Islander people. And I would just like to give a shout out to Amy Pedon, one of the lecturers in our school in Population Health who has just received an investigator grant to look at drowning in adolescents. We do need more evidence of workplace injury, burden and causes, including with young Aboriginal people. The cost of acquired brain and spinal cord injuries, and programs around legislative environmental measures to reduce violence. Road trauma associated with other drugs, and violence against women and girls. A lot of work to do. And I hope some of you are enthusiastic about getting involved in some of this. And of course, I would love to see some of you get engaged and work with us on some of these because it really is an exciting area to work in because it's multi-disciplinary and multi-sectoral. It is always challenging because a lot of the interventions are legislative, we are always working with government and we are always working with community because without that, you can't actually get change. In many ways, injury researchers have been doing co-design and policy reformed responses from the beginning because without that, we can't do anything. I would encourage you to think about where injury sits within the work that you do, because injury in adolescence is such an important area and it's so under-funded and so under-addressed in terms of research. 

Rebecca Ivers: [00:45:48] So just coming back to the future, I think recognising the role social determinants play is key to addressing adolescent injury, understanding the interplay of all those factors. And I think often we'll find that addressing social determinants is actually going to reduce injuries without us having a specific targeted injury program. We do want targeted local programs to address injury, they're important, but as we know, self-determination and local ownership is key to delivery of successful programs. But what's most important are policy interventions, system level interventions that tackle the social determinants of health. That's critical. 

Rebecca Ivers: [00:46:24] So that's all I've got, I think we can go over the questions now. Hopefully, if you're interested, come back to me at some other time. Very happy to talk to people if anyone's interested in engaging in injury. And I will hand over to Kate now and we might capture some questions. Thanks very much. It's been lovely to speak to you all. Great to have the opportunity.

Kate Steinbeck: [00:46:47] Rebecca, thank you for a fantastic presentation. We have some pretty heavy questions, and I'm going to start with one from Rachel who asked: "What's the reason for the difference by gender? Is it social influence, gender normative behaviour, biological or developmental? And is there research exploring this." I'd love you to perhaps expand on that.

Rebecca Ivers: [00:47:43] Kate, it's such a tricky question, as you know, I don't actually have an easy answer to that. I think we often question whether there's a biological underpinning of that. I think, you know, from the ARCHER study it hasn't given us any great sort of answers about whether there really are any differences there. I mean, I think it's likely to be gender normative behaviour and us basically having expectations of the way in which people behave, and that leads to risk-taking behaviour, peer pressure and so on. I don't really have anything that's a more sophisticated answer than that, but it's so consistent across the globe, across every type of injury. I mean, there really is quite a stark difference between male and female.

Kate Steinbeck: [00:48:32] Next question comes from Daniel: “Have there been any changes in injury trends by gender. And I assume that sports injuries are likely to increase with increase in female sports participation. Go the Matildas. And I'm wondering if there may be any other areas where this might occur, e.g. motorcycle injuries." So again, on that issue of gender. 

Rebecca Ivers: [00:49:04] Again, good question. And I think as we see increased exposure, we're going to see increased injuries. But the issue is that again, we still see more injuries for males than females because of the way in which they engage in those. For example, if you look at road traffic injuries, I mean, as many young women as men might drive, but men tend to have more crashes. We have actually shown, and this is interesting, with young women in the Drive Study, there were more hospitalised injuries for women than men. And one of the reasons why we think that is, is that cars are designed for male bodies not female bodies. So, not that young women are crashing more, it's just that when they are in a crash, they're more likely to be injured because of the geometry of the car, which is better suited for a man than a woman, and that's to do with the way in which we design cars. It's a kind of nuanced issue. We do see injuries will increase with increased female sports participation, absolutely. But again, even if you look at the football codes, you might ask questions, with the same level of exposure, men are more likely to be injured because they play football in a different way. Are they rougher? Are they engaging in more heavy duty tackles than women? Is there a gender difference in the way  in which people actually play sport? And that's not clear at this point in time. So I think you've got to differentiate between increased exposure, which will lead to increased injury, but we're still seeing increases in males compared to females even with similar exposure. 

Kate Steinbeck: [00:50:35] Thanks, Rebecca, that's food for thought. Coming to Jennifer's question next. Her question is: "You describe some associations between not, and having, a driver licensing program, and economic and educational outcomes. Is there a lot of understanding around directions of these associations because you certainly were quite careful to say bi-directional?" 

Rebecca Ivers: [00:51:12] Look, driver licensing and employment and education are not necessarily going in one direction. When we first did the cross-sectional studies, we could see that people who had a driver's license also reported that they were more likely to be educated and to have a job. But who knows? Is it because people have a job that they're more likely to get a driver's license if they can overcome the barriers to licensing? Or is that the other way around? What we did see with the prospective data from Driving Change is that when people got their driver's license through the program, they were more likely to have a job or a change in job 12 months later. We could see some changes, and that's work that we continue to explore because I think it's important. At the end of the day though, we know that those two things go together, particularly if you're unskilled. A driver's license is as good as a qualification because it gives you a certificate to drive, it gives you opportunities to go and work for councils, jobs where you can drive a truck, and other things where you might not actually need other qualifications. If you've got low levels of literacy, and it's an issue for people of low income across the country, that's why supportive programs to help people get through driver licensing is really important. Or we make sure that there's alternative ways for people to get around. As much as I put my hand on my heart and say I'd love everyone to ride their bikes and catch public transport around everywhere because it's better for the environment, driving is actually essential for many people in the country, particularly people in outer regional areas and big cities and in country areas. We're not quite there yet, we do need to make sure that licensing is accessible. I'm someone that has actually done a lot of advocacy, though, to strengthen graduated driver licensing programs and make it tougher for young people to get a license. And the reason why is that those systems do work, it creates safer drivers and reduces the death rate in young drivers. And we know that that's devastating. You only need to have heard about a couple of those devastating young crashes that we see so often where you have two or three people killed in a car to understand the trauma that's involved. Road traffic injury is a huge issue for young people, and graduated driver licensing systems are a really excellent policy response to that. But they do mean that for some people It's much harder to get a driver's license, so we need to make sure that rather than dumbing down the graduated driver licensing system to make it easy for people, what we need to do is provide supporting programs for everyone to be able to get through the system and to be able to drive safely. 

Kate Steinbeck: [00:53:55] Great answer. Thanks, Rebecca. And this is from Annabel: “In regard to your point about data collection in LGBTQI and in particular gender diverse young people, and unintentional injury, have there been any changes made to current or ongoing studies in an attempt to provide a better understanding of this?" 

Rebecca Ivers: [00:54:28] Now, that's a question, and I think that's something that we should all be feeling responsible for and uncomfortable about, because I think there'd be many of us here in this seminar that haven't taken enough action to actually change that. And I think it's something that we all need to have in mind, to make sure that we are asking the right questions in our datasets. There's a couple of things. One, is when we're actually doing studies, making sure that we are collecting data in the most appropriate way with the most appropriate questions and that we are working with an informed group of people to make sure that our questionnaires are designed appropriately. But also doing advocacy at government level to make sure that our routinely collected datasets are asking the right questions. We do all have a responsibility to do that. And I can say myself It's nothing that I've done to date, I'm aware that it's something that we should be asking questions about. In the same way, changing the way in which I work with Aboriginal and Torres Strait Islander communities has changed over time as I've become more reflective about the way that I work as a researcher and my role as a supportive person in terms of building capacity and training the next generation of Aboriginal and Torres Strait Islander researchers. Likewise, for gender diverse people, we do need to make sure that we are building and growing research leaders and asking the right questions and collecting the right sort of data. And I think that's really critically important. And we all need to be reflective in the way in which we are doing research and understand that things have to change and we've got a responsibility to contribute to that. 

Kate Steinbeck: [00:56:15] That's a great message for everyone. We've still got a couple more questions before we run out of time. And this one is from Nicola who said: "Thanks, Rebecca, great presentation. How long do you follow participants with data linkage?" 

Rebecca Ivers: [00:56:34] Oh, well, look, that's the million dollar question, really, isn't it? It just depends on what the consent was at the beginning and what participants consented to. If you're doing data linkage with routinely collected data, that's up to the ethics committee, because you're not actually asking for participants’ consent. For something like the Drive Study, we had open-ended consent, but we are reliant on the ethics committee approving that every time we relink to make sure that it's still ethical. 

Kate Steinbeck: [00:57:11] We've come back to women in sport and from Rachel saying: "Women are more prone to injury due to physical differences and hence the reason to restrict women from involvement in more strenuous or aggressive sports. And is this still considered to be the case?" 

Rebecca Ivers: [00:57:35] I mean, what a question. I'm not a sports injury person, so I'm not going to do anything more than speculate here. I'll put my hand on my heart and say this is not my field. I would say that that's probably a retrograde kind of approach. I know that, for example, young women are more prone to knee injuries, but there are some really great prevention programs in place to make sure that they're not injured, but certainly wouldn't be restricting women from involvement in more strenuous and aggressive sports. I'm sure, there's other people out there with more expertise that would be  my response to that question.

Kate Steinbeck: [00:58:18] Yes, sounds discriminatory to me. From Ashan: "The nuances or differential differences between terms such as self harm and injury, is this addressed in the injury strategic plan?" And I think that's a great question about the sort of intentional/unintentional aspects of injury. 

Rebecca Ivers: [00:58:50] I talked about that a little bit, it's a tricky area, but at the end of the day, we need some pretty broad brush ways to define injury when we're looking at prevention.There's a lot of injury that cuts across both, and we're trying to do some untangling of that because It's not actually that clear-cut. We use definitions on intent, but actually often you might say many unintentional road injuries may be self harm, you think about the relationship in adolescents in particular, they're tied up between mental health, drug and alcohol use, risky behaviours, and then you have to make some kind of decision about whether it's intentional and unintentional. So again, when we looked at the Drive Study, we actually looked at the self harm data and we asked people was it true self harm? And there was a lot of road-related self harm in that some people were saying yes, so we had to go through it and code it. Is this true harm or is this just something that's not real self harm?  I think road-related self harm might have been driving at high speed down the wrong way on the highway. Now again, you could have expected that that's going to have a high likelihood of death or severe injury: that's intentional self-harm versus road traffic injury. But it's actually a tricky thing for road authorities because they like to try and get as many road deaths off their books as they can, so often tjey are quick to code things as intentional injury as opposed to unintentional injury. But for adolescents in particular, it's fluid, and I think we have to understand that. I think we do need to move away from siloed programs and look at programs that address the social determinants and if you look at adolescent injury, cutting across a whole range of different factors is what's going to be important. 

Kate Steinbeck: [01:00:45] I think that's an excellent note to end on, and we've run out of time for this webinar. Rebecca, thank you for a fantastic presentation. Lots of food for thought and we hope to have you back again sometime to hear about some of your other studies as well. But thank you again for coming and talking to us this afternoon. 
Rebecca Ivers: [01:01:08] My pleasure. Thanks, everyone for attending. 

About The Authors


Rebecca Ivers is Head, School of Public Health and Community Medicine, University of New South Wales...