Predictors and burden of injury mortality

in the Thai Cohort Study 2005-2015.

Callum Lowe
Bachelor of Philosophy - Science
3rd year undergraduate
 Injury mortality – a global health problem

Global injury mortality

Low- and middle-income countries

High-income countries

Adapted from Figure 1, WHO Injuries and Violence: The facts, 2014.

Injury deaths in 2013 – 4.8 million (~9% global mortality)

• HIV/AIDS + TB + Malaria – 3.25 million

Injuries warranting health care – 973 million

Burden of injury decrease in high-income countries over past decade but increase in
low-income countries.
• Increase in low-income countries: often attributed to rapid infrastructural and economic development
outpacing law enforcement, safety measures, and poor data collection leading to ineffective strategies for
prevention of injuries.
Chandran A, Hyder AA, Peek-Asa C. “The global burden of unintentional injuries and an agenda for progress”. Epidemiol Rev 2010;32:110–20
Global Health Data Exchange. “Global burden of disease Results Tool” (2017). Accessed online: http://ghdx.healthdata.org/gbd-results-tool.
Accessed during August – November 2019.
Haagsma JA, Graetz N, Bolliger I et.al. “The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the
Global Burden of Disease study 2013.” Injury Prevention. 2016. 22(1): 3-18.
 Injury plays a large role in pre-mature mortality

Global causes of death, 2012

Rank 5 – 14 15 - 29 30 - 49 50 – 69 70+
1 Diarrhoeal
diseases
Road traffic
injuries
HIV/AIDS
Ischemic heart
disease
Ischemic heart
disease
Injury
2 plays Lower
respiratory Suicide
Ischemic heart
Stroke Stroke

a large role
disease
infections

3 Chronic Chronic

in pre- HIV/AIDS HIV/AIDS

Road traffic
injuries
obstructive
pulmonary
disease
obstructive
pulmonary
disease

4 mature Road traffic

Homicide Stroke
Trachea,
bronchus, lung
Lower
respiratory
injuries
cancers infections

5 mortality Drowning
Maternal
Suicide
Diabetes
Trachea,
bronchus, lung
conditions Mellitus
cancers

6 Meningitis
Lower
respiratory Tuberculosis
Cirrhosis of the Diabetes
liver mellitus
infections

7 Protein-energy Diarrhoeal Cirrhosis of the

Lower
respiratory
Hypertensive
malnutrition diseases liver heart disease
infections

8 Endocrine,
Adapted from 2012 data sourced from WHO Report on Injuries and Violence, 2014.
Alzheimer’s
blood, immune Drowning Homicide Tuberculosis
 Injuries in Thailand
• Highest rate of transport accidents globally (36.2 per 100 000
population) (WHO, 2015).
• Alcohol-related assaults and ageing-related falls are part of injury death
burden.
• Young males consistently reported as the highest risk group.
WHO. Global status report on road safety 2015. Geneva: World Health Organisation, 2015.
WHO. Thailand’s Report on Situation of Severe Injuries 2005-2010. Geneva: World Health Organisation, 2012.

Shortcomings in the study of injury deaths

• Has a more efficient national mortality registration system but
cause of death data is often unreliable.
• Causes of death are poorly assigned.
– Lack of training in using the WHO International Classification of Disease
(ICD).
• Majority of studies on risk factors are cross-sectional.
– Depression  Injury
– Alcohol  Injury
– Often only risk factors in the 24hrs prior to injury studied.
Porapakkham Y, Rao C, Pattaraarchachai J, et al. “Estimated causes of death in Thailand, 2005: implications for health policy.” Popul Health Metr 2010;
Tiesman HM, Peek-Asa C, Whitten P et.al. “Depressive symptoms as a risk factor for unintentional injury: a cohort study in a rural county.” Injury
prevention. 2006; 12(3): 172-77.
 Thai Cohort Study (TCS)
Longitudinal cohort study of 87 151 Thai adult Open University students.
Responded to a 20-page mail-out health questionnaire in 2005
• Socio-geo-demographic characteristics, occupation and work hours, health service use, disease,
injury, social/psychological factors, alcohol/smoking and other health-risk factors and local
environment)
Follow up surveys sent in 2009 and 2013.

Use for mortality data:

1. Participants provided their Thai Citizen ID number.
2. Ministry of Interior provide list of deaths in the cohort.
3. Ministry of Public Health add WHO ICD Code.
4. 1 402 deaths from 2005-2016.

5
 Questions we aim to answer in the TCS

1. How great is the burden

of injury mortality?
Questions
we aim to
answer in
2. What
the TCS are risk factors for
all injury mortality in the
TCS?
 Methods

Research question Methods

How great is the burden of injury mortality
in the TCS?
• Calculate top causes of death
for each age group.
• Age standardized calculation
for injury death rate in cohort
and overall Thai Population.
• Plotting distribution of injury
deaths by injury cause.

What are the risk factors for all-cause • Chi-square test for
injury mortality in the TCS? significance.
• Binary logistic regression –
Odds ratio for injury death.
Outcome = Injury
death
Control = Alive by
endpoint
 Questions we aim to answer in the TCS

1. How great is the burden

of injury mortality?
Questions
we aim to
answer in
the TCS
 Injury deaths in the cohort

Burden of injury deaths Leading causes of death, TCS 2005-2015

Injury Non-injury Rank 15-29 30-49 50+
N = 363 N = 869 1 Symptoms and ill- Symptoms and ill-

Injury deaths
All other external causes
defined conditions defined conditions

29.5% 70.5%
2 All other external

in the cohort Transport accidents

causes
Liver cancer

3 Symptoms and ill-defined

conditions
Transport accidents
Other malignant
neoplasms

Age standardized injury 4 Assault

Other infectious and
Other infectious
and parasitic
parasitic diseases
mortality rate (per 100 000 diseases

population) 2005 - 2015 5 Other malignant neoplasms

Other malignant Transport
neoplasms accidents
Thai
TCS Populati 6 Pneumonia
Trachea, bronchus
and lung cancer
Ischaemic heart
diseases

on
7 Other genitourinary
diseases
Cerberovascular
disease
Trachea, bronchus
and lung cancer
All data 407.5 740.1
20-74 8 Other infectious and
parasitic diseases
Breast cancer Pneumonia

age 658.5 941.7

9 HIV
Cancer of colon,

group Assault / HIV / Liver

rectum or anus

10 Accidental drowning
cancer Cerebrovascular
disease / All other
external causes
 Results – Injuries by underlying cause

Distribution of injury mortality by injury cause, Thai Cohort Study

All other external causes

Exposure to smoke, fire and flames

*
Falls

Accidental drowning

Intentional self-harm

Assault Re-distributed data Raw cohort data

Transport Accident
0 25 50 75 100 125 150 175 200 225

Number of deaths

*A minimum of 84.7% of “All other external causes” were of unknown injury-

causes after analyzing the WHO ICD death code assigned.
 Questions we aim to answer in the TCS

Questions
we aim to
answer in
2. What
the TCS are risk factors for
all injury mortality in the
TCS?
 Description of variables with significant association with
injury mortality

• Age – midpoint (2010), categorical as not linear predictor.

• Sex

• Highest education level at baseline – not include STOU studies at baseline.

• Residence at baseline (countryside/urban).

• Regency (North, North-east, Central, Bangkok, South)

• Income (Thai Baht per month, categorical)

• Work for income

• Smoking at baseline (Current, quit, never).

• Alcohol consumption at baseline (Regular, occasional, never).

• Doctor diagnosed anxiety/depression.

• Prior injuries (none or at least one, 12 months prior to baseline).

• Drink-driving (3+ glasses of alcohol then driven past 12 months at baseline)

Predictors of injury mortality

13
14
 Injury mortality Binary Logistic Regression

Age – sex Fully adjusted Age – sex Fully adjusted

Crude Crude
Variabl adjusted model adjusted model
Variable
e 95% 95% 95% 95%
OR OR OR OR OR OR
C.I C.I C.I C.I
Age Educatio
n

15-29 Reference Junior Reference

High
School

30-44 0.92 0.76* 0.69- 0.79 0.60- High 0.73 0.84 0.53- 0.98 0.52-
0.97 1.06 School 1.35 1.83
45-59 1.00 0.71* 0.51- 0.87 0.58- Dip./Cert. 0.61* 0.840 0.51- 1.11 0.59-
0.99 1.31 1.37 2.12
60+ 3.28*** 1.96* 1.12- 2.16 0.86- Universit 0.38** 0.50** 0.30- 0.67 0.35-
3.79 5.44 y 0.83 1.31
Sex Alcohol
consumpti
on

Male 4.14*** 4.25*** 3.32- 3.55*** 2.57- Never Reference

5.45 4.89
Female Reference Occasion 1.47* 0.93 0.69- 0.80 0.57-
ally 1.25 1.13
Drink- Regularly 2.87*** 1.27 0.81- 0.85 0.50-
driving
2.00 1.46
Yes 2.16*** 1.40** 1.12- 1.37* 1.02- Injury
history
1.75 1.85
 Age – sex Fully adjusted Age – sex Fully adjusted
Crude Crude
Variabl adjusted model Variabl adjusted model
e 95% 95% e 95% 95%
OR OR OR OR OR OR
C.I C.I C.I C.I
Smoking Home
(baseline
)

Never Reference Countrys 1.36** 1.31* 1.06- 1.23 0.96-

ide 1.61 1.58
Quit 1.87*** 1.10 0.82- 0.85 0.60- Urban Reference
1.47 1.20
Current 3.76*** 2.07*** 1.57- 1.55** 1.12- Residen
2.74 2.17 cy

Anxiety/ Central/E Reference

Depressi ast
on

Yes 1.83* 1.90** 1.23- 1.78* 1.07- Bangkok 0.82 0.87 0.60- 1.02 0.68-
2.93 2.96 1.24 1.53
No Reference North 1.26 1.16 0.85- 1.18 0.83-
1.59 1.66
North- 1.33 1.16 0.87- 1.02 0.73-
east 1.56 1.44
South 1.73*** 1.69* 1.24- 1.52* 1.07-
2.31 2.16
 Risk factors for injury mortality (I)

Male sex
Single strongest predictor of injury mortality.
• Significance of p<0.0001 stays in fully adjusted model.

Reflects nature of males to take more risks and less

precaution.
Unambiguous amongst all studies and regions with the
exception of elderly categories where sex difference
Risk factors
diminishes.
Haagsma JA, Graetz N, Bolliger I et.al. “The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the

for injury
• Not observed in cohort due to insufficient numbers.
Global Burden of Disease study 2013.” Injury Prevention. 2016. 22(1): 3-18.

Drink-driving

Significant in fully adjusted model supports the fact that

drink-driving is a biological cause, thus a risk factor
amongst all socio-demographic groups.
• Unambiguous association reported by all literature
used.
 Risk factors for injury mortality (II)

Historical alcohol consumption – not a significant predictor

• Literature – alcohol as a risk factor typically reported in cross

sectional studies – Blood Alcohol Concentration at time of injury
(tested at the hospital).

• However a cross-sectional study of non-fatal injury risk in the U.S

general populationa , another study of older U.S adults finding
Risk factors
increasing alcohol consumption habits to increase risk of fatal
for injury
injury. b
• Two ways historical alcohol consumption could increase injury
mortality risk:
Cherpitel CJ, Tam T, Midanik L et.al. “Alcohol and non-fatal injury in the U.S. general population: A risk function analysis.” Accident Analysis and Prevention. 27(5): 651-61.
Sorock GS, Chen L, 1.Gonzalgo
Direct biological
S and Baker SP. “Alcohol-drinking effects
history and fatalof injuryalcohol
in older adults.” Alcohol. 2006. 40(3): 193-99.

2. Health-related behaviours associated with alcohol-

drinking.
• Possible not yet present in a younger cohort.

Smoking
• Independent risk factor in the cohort whilst often reported to be
confounded by alcohol consumption.
• AGAinternational meta-analysis ofratescohort studies cohort study.” found
Ann Intern Med,this
Leistikow BN, Martin DC, Jacobs J, et al. “Smoking as a risk factor for accident death: a meta-analysis of cohort studies.” Accid Anal Prev 2000;32:397–405.
I Kawachi, Colditz, MJ Stampfer et.al. “Smoking cessation in relation to total mortality in women: A prospective 119 (1993), pp. 992-1000

association with mean RR = 1.51 for fatal injury (smokers vs non

 Risk factors for injury mortality (III)

Injury history

• Logical deduction
• Strengthens use of TCS (injuries were self-reported).
• Persistent risky behavior – may be due to lack of effective
interventions.
• Could be attributed to law enforcement.
Risk factors
for injury
Anxiety/Depression
• Most report this association as Injury  Depression.
• Similar result observed in a study of U.S adults (Tiesman,
2009).
• Risk ratio for injury (non-fatal) given depressive symptoms = 1.43 (1.09-
1.81)
• Stigma (Burnard, 2006) may lead to underestimation of
adjusted odds ratio.
• Cause may be an increased willingness to take risks, poor
judgement,
Tiesman HM, less
Peek-Asa C, Whitten P et.al. care
“Depressive foras asafety,
symptoms but also
risk factor for unintentional potentially
injury: a cohort study in a rural county.” Injury prevention.

confounded
2006 12(3).
BURNARD, P. , NAIYAPATANA, W. and (drugLLOYD, G.use etc.).
(2006), Views of mental illness and mental health care in Thailand: a report of an ethnographic study.
Journal of Psychiatric and Mental Health Nursing, 13: 742-749
 Age – Risk vs incidence of injury

Distribution of mortality outcomes by age in the TCS

cohort, 2005 – 2015

Age – risk vs Age

Endpoint

burden Alive Death - injury Death - other

15 – 29 23 844 (99.2%) 104 (0.4%) 100 (0.4%)

• “Majority of severe injury cases
were 15-29 years of age (34.2%).”
(WHO, 2012)
30 – 44 49 277 (98.8%) 197 (0.4%) 403 (0.8%)
• Cohort – 104 deaths are 15-29
years age, out of 363 this is 28.7%
45 – 59 11 909 (97.3%) 52 (0.4%) 284 (2.3%)

60 + 700 (88.4%) 10 (1.3%) 82 (10.4%)

 Southern/Southern-border region

• Ongoing political and religious violence since the

early 2000’s “South Thailand Insurgency”.
• Not advised for non-essential travel by most
governments.

Southern-border region in the TCS

Defined by reporting residential postcode 90xxx-96xxx

– Pattani, Yala and Narathiwat
5 308 southern-border residents in cohort (6%)

Gov.Uk (2019). Map of Thailand. Accesed on 03/03/2019: https://www.gov.uk/foreign-travel-

advice/Thailand.

Jitpiromsri S and McCargo D. “The Southern Thai Conflic Six Years On: Insurgency, Not Just Crime.” Contemporary Southeast Asia. 2010. 32(2): 156-83.
 Distribution of injury mortality by southern
border residency status
P e r c e n t a g e o f t o t a l in ju r y d e a t h s ( % )

N = 17

p = 0.21

50
45 Southern border residents
40 All other residents p = 0.10

35 p <
30 N = 23
0.0001
25
20
15
10 p = 0.24
5 p = 0.13 p = 0.63
p = 0.36
0
Transport Assault Intentional Accidental Falls Exposure to All other
accidents self-harm drowning smoke, fire external
and flames causes

p value obtained from Chi-Square test of proportions between southern-border residents and all other residents for
each injury death type.

*If rate of assaults in southern-border residents is same as the rest of the cohort, southern region
OR becomes 1.1.
 Southern border region

Difficult to compare TCS regional distribution of injury

deaths to global estimates as they are country-wide;
individual provinces combined.

• Thailand’s Injury Surveillance data collection:

– 2005-2010 most of the southern provinces had increasing number of
injuries.
– All other regions overall had a decrease.

• Assault likely higher proportion due to political situation.

WHO. Thailand’s Report on Situation of Severe Injuries 2005-2010. Geneva: World Health Organisation, 2012.
 Limitations

Older demographic underrepresented in the

cohort study.
• Lower burden of non-injury deaths  higher % injury deaths.
• Underrepresentation of old-age related injury death causes
such as falls.

Self-reported survey

Limitations
• Possible underrepresentation of risk factors (or just not 100%
reliable).
Underrepresentation of low socio-economic
status.

Lack sufficient number of deaths for injury cause-

specific regression.

Ageing cohort
 Conclusions

• Approximately 30% of cohort deaths over 2005 to 2015 were injuries.

• Majority of injuries were transport accidents.
1. How great is the burden of • Injury major cause of pre-mature mortality in the cohort.
injury mortality in the TCS? • Burden of injuries estimated to be 43% higher in the Thai population.

2. What are risk factors for

general injury mortality in the
• Being male is the strongest predictor of injury mortality.
TCS?
• Drink-driving, smoking, anxiety/depression and history of injuries significant
independent risk factors for injury mortality.
• Assault deaths disproportionately high in the southern border region –
possibly reflective of political situation.