Chronic Diseases and Injuries in Canada

Volume 33 · Number 3 · June 2013

Injuries related to consumer products in Canada–a systematic literature review

S. A. Huchcroft, PhD (1); C. R. McGowan, PhD (2); F. Mo, PhD (3)

This article has been peer reviewed.

Author references:

  1. Epidemiology Consultant, Calgary, Alberta, Canada
  2. Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
  3. Science Integration Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario, Canada

Correspondence: Catherine R. McGowan, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom; Tel.: (011 44) 20 7927 2888; Email: Catherine.McGowan@lshtm.ac.uk

Abstract

Objectives: To conduct a systematic literature review of injury related to certain consumer products.

Methods: Forty-six empirical research reports along with 32 surveillance reports from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were examined to determine the approximate number of injuries associated with a given product per year and any trends in frequency. Percentages of injuries that: (1) resulted in hospitalization, (2) appeared to result from the product itself and (3) were associated with risky or inappropriate use and/or non-use of a helmet were also extracted from the reports.

Results: Outdoor play and sports equipment appear to be associated with the greatest numbers of injuries. A relatively high proportion of injuries appear to result from inappropriate or risky use of a product and/or inadequate safety precautions.

Conclusion: This review identified the following areas of concern regarding consumer products and injuries: lack of helmet use by people using in-line skates, sleds, snowboards, downhill skis and personal-powered watercraft; operation of all-terrain vehicles (ATVs) and snowmobiles by alcohol-impaired people; operation of snowmobiles at excessive speeds; poor design of playground equipment; and unsafe storage and use of matches.

Introduction

Consumer product safety has been identified as an injury prevention priority in Canada.Endnote 1 Data from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP)Endnote 2,Note * indicate that almost half of injuries in children and youth (aged 19 years and less) are related to consumer products.Endnote 3

At least four broad categories of factors influence injury associated with consumer products:

  1. The quality of the product and its potential to cause injury by defects or characteristics such as sharp edges, faulty workmanship, poor assembly and product failure;
  2. Factors related to how the product is used, for example, with too much force or speed, for an inappropriate purpose, or carelessly;
  3. The element of chance whereby a sound product is used appropriately but an accident that possibly could not have been predicted or prevented occurs; and
  4. Non-use of protective gear that could prevent or reduce the severity of injury in some instances.

This paper presents the results from a systematic review of the literature on the topic of injury related to consumer products in Canada. It examines, by product, what proportion of injuries may have resulted from a fault in the product itself or from inappropriate or risky use; what proportion of injured people were not using a helmet (where appropriate) when injured; the frequency and severity of injury by product; and any reported frequency trends.

Methods

Definitions of consumer product and injury

According to the Canada Consumer Product Safety Act (CCPSA), a consumer product is

''a product, including its components, parts or accessories, that may reasonably be expected to be obtained by an individual to be used for non-commercial purposes, including for domestic, recreational and sports purposes, and includes its packaging.''Endnote 4, section 2

Excluded from this definition are firearms, ammunition and explosives, cross-bows, food and drugs, pest control products, feeds, fertilizers, plants, seeds, controlled substances, aeronautical products, animals, tobacco and tobacco products, boats and vehicles within the meaning of section 2 of the Motor Vehicle Safety Act (MVSA) (i.e. ''any vehicle that is capable of being driven or drawn on roads by any means other than muscular power exclusively….'').Endnote 5, section 2 However, even though they technically fall under the MVSA, off-road recreational powered vehicles, such as all-terrain vehicles (ATVs), snowmobiles and powered scooters, have been included in this review. Injuries in team sports that use equipment, such as soccer, hockey or baseball, were excluded from this review because they are fairly discrete categories that merit separate reviews, as were injuries resulting from poisonings. Finally, we did include playground equipment because, although not strictly domestic, Health Canada includes it among consumer products.Endnote 6

The definition of injury was problematic in that the CCPSA does not define it. However, in the context of this review, injury implies International Classification of Diseases, 10th Revision (ICD-10)Endnote 7 External Cause of Injury codes for unintentional injuries V01–X59, Y85–Y86, excluding motor vehicle traffic injuries occurring on a public highway or street where the injured person is an occupant, poisonings, complications of medical and surgical care, self-inflicted injuries and injuries due to assault, undetermined intent and legal intervention/war. It includes injuries to the head, neck, thorax, abdomen, lower back, lumbar spine, pelvis, shoulder and upper arm, elbow and forearm, wrist and hand, hip and thigh, knee and lower leg, ankle and foot (ICD-10 site codes S00–S99), and multiple body regions, unspecified parts of trunk, limb or body region, effects of foreign body entering through natural orifice, burns and corrosions (ICD-10 codes T00–T32). Because the majority of articles did not define injury, nor cite ICD codes, this systematic literature review relies on the definition of injury as described by the authors of the included material. All injuries were attended by a medical professional, most often in a hospital emergency department.

Systematic literature review search strategy

We searched seven databases covering: allied health, clinical medicine, nursing and health policy (CINAHL Plus, EMBASE, ); general science (Web of Science); public health (Global Health); social science (Social Policy & Practice), and applied life sciences (CAB Abstracts). The search took place in February 2011 and included literature published over the last 20 years.

The search terms were: Canad* + (injur* or accident*) + (consumer* or product*). As a convenient crosscheck for the thoroughness of this search, we examined the much larger number of results from an earlier search for a separate project on risk factors related to injury, conducted in July 2010. The risk factor search terms were Canad* + (injur* or accident*) + (risk factor or inciden* or caus* or hospital* or mortality or disabilit* or fall*). This larger search did not identify any additional research on consumer-product-related injury.

We also considered various additional sources including books, book chapters, electronic articles and reports. Three important sources published by the Public Health Agency of Canada (PHAC) were Child and Youth Injury in Review, 2009 Edition -- Spotlight on Consumer Product Safety;Endnote 3 CHIRPP Injury Reports/ Briefs/Data Samplers;Endnote 8 and Inventory of Injury Data Sources and Surveillance Activities.Endnote 9 Reference lists were examined for pertinent articles missed by the search strategy. Articles were retrieved in both official languages.

Inclusion and exclusion criteria

We included reports of empirical research in Canada that examined injury associated with a consumer product and provided some numerical estimate of importance but excluded commentaries and editorials. Review articles were used as a source of additional references that may have been missed in the initial search, but were not included with the empirical material.

Indices for identifying risk management priorities

After examining all the research retrieved, we selected six indices to assist in identifying priorities for injury reduction. These were (1) approximate annual number of injuries (estimated by dividing the number of injuries reported by the time period covered); (2) relative severity of the injury expressed in terms of percentage of injured people admitted to hospital; (3) reported trends; (4) proportion of injuries caused by the product itself (e.g. defects); (5) proportion of injuries caused by inappropriate or risky use (CHIRPP records circumstances surrounding the injury, e.g. excessive speed or jumping off the top bunk); and (6) the proportion of injured people who were not using a helmet at the time of the injury (where helmet use is considered appropriate, and where recorded). We highlighted for consideration as priorities those consumer products associated with about 500 or more injuries annually, 20% or more of injured people admitted to hospital, an increasing trend, 5% or more of injuries attributable to the product itself, 50% or more of injured people using the product inappropriately or recklessly, and 50% or more of injured people who were not using a helmet. Cut points on the indices were chosen arbitrarily to identify between five and ten consumer products each. Consumer products for which injuries were either the most numerous or more serious and which met at least one of the four remaining criteria were selected for consideration as priorities for risk management.

Results

The database search located 703 records after removal of duplicates. Of these, 46 reports met our inclusion criteria of original quantitative empirical research (Table 1). Within the resource and time constraints for this project, full articles were obtained for 37 of these. We used information in the abstract for the remaining nine reports. Abstract-only articles were retained in order to avoid any bias associated with using only references for which the whole article could be obtained and also to enable further attempts to locate the full article. In addition, 32 online reports from CHIRPP were retrieved from the Internet using the same search terms and augmented the data retrieved from the literature database search.

TABLE 1
Selected characteristics of injuries associated with consumer products
Product, years, age group studied and reference Approximate number of injuries per yearTable 1 - Footnote a, n Percentage of injured people admitted to hospital, % Age group most affected Most common type/site of injury (percentage of all injuries from that product) Trend

Abbreviations: ATV, all-terrain vehicle; BC, British Columbia; CHIRRP, Canadian Hospitals Injury Reporting and Prevention Program; NB, New Brunswick; NS, Nova Scotia; PEI, Prince Edward Island.

Note: Highlighted items are associated with 500 or more injuries per year, have hospitalization rates of 20% or higher, and injuries are increasing.


aData from CHIRRP.
bArticle about trampolines includes comparison with other recreation-related equipment.
Stroller
1990–October 2002, ages 0–23 monthsEndnote 27 140 4.1 0–5 mo Head, face (78%)
Infant swing
1990–September 1995, ages < 18 monthsEndnote 28 9 6.0 3–5 mo Head (87%)
Car seat
1994–2000, ages < 12 months, KingstonEndnote 29 3–5 mo Head (40%)
Baby walker
1990–early 2003, ages 5–14 monthsEndnote 3,Endnote 30 158 8.1 7–10 mo Head, face (89%)
1994–2000, ages < 12 months, KingstonEndnote 29 6–8 mo Head (50%)
November 1990–January 1991, NB, PEI, NSEndnote 31 5–10 mo
Bath seat
1990–2005, ages < 24 monthsEndnote 3 <1 50 6–9 mo
Baby gate
1990–October 2002, ages 0–5 yearsEndnote 32 75 3.6 9–11 mo Head, face, neck (75%)
Playpen
1990–October 2002, ages 0–5 yearsEndnote 33 29 4.9 9–11 mo Head, face, neck (45%)
Gas fireplace
1990–2002, TorontoEndnote 34 30.0 Median 14 mo Hand(s) (92%)
Bassinet, cradle crib
1990–January 1996, ages < 5 yearsEndnote 35 155 5.4 < 2 y Head, neck (66%)
Magnet
1993–2007, ages 13 years and underEndnote 3 22 2.7 2–4 y Ingestion (54.3%)
1993–2003, ages
≤ 13 yearsEndnote 36
16–17 3.9 0–4 y Foreign body (82.8%)
Television
1990–2007, ages 0–19 yearsEndnote 3 195 < 4.1 Median 2.8 y
1990–2002, Halifax, childrenEndnote 37 2–4 y Head and neck (47%)
Motorized ride-on toy
1990–2003, ages 1–9 yearsEndnote 38 2–3 9.1 2–4 y Head and face (45.4%)
Blind or drapery cord
1990–2003Endnote 3 1–2 52.9 3–5 y
Bunk bed top bunk
2002–2006, all agesEndnote 3 187 10.8 3–5 y Upper extremity (39%)
1999–2001, all agesEndnote 39 238 9.4 4–5 y
Playground equipment
2000, ages 0–14 yearsEndnote 40 4225 7.6 5–9 y Fracture (43%)
1995–2002, Toronto, fracturesEndnote 41 29.0 5–9 y Upper extremity (85% of fractures)
Summers 1991 and 1995, MontrealEndnote 42 5–9 y
1995–1996, Toronto, severe injuriesEndnote 43 21.4 Mean 6.5 y Fracture (47.6%) Upper extremity (47.6%)
1995, ages 1–16, KingstonEndnote 44 Mean 8.3 y Extremities (55.6%)
Fracture (35.6%)
Wheeled shoes
2000–2006, all agesEndnote 45 19 2.9 5–14 y Upper extremity (61.8%)
1990–2007, all agesEndnote 46 12 2.9 Median 9.8 y
June 2005–June 2007, Calgary childrenEndnote 47 0.0 6–14 y Upper extremity (76.7%)
Trampoline
1999–2003, all agesEndnote 3,Endnote 48,Table 1 - Footnote b 541 12.4 5–14 y
median 10.1 y
Lower (39.8) and upper (39.4)
limb fracture
January 1996–October 1997, Winnipeg, children, orthopedic injuryEndnote 49 2–15 y
Unpowered scooter
1990–May 2001, all agesEndnote 50 27 4.6 8–13 y Upper extremity (33.9%)
1990–2007, all agesEndnote 46 236 7.3 Median 10.1 y
1999–2003, ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 273 6.2
June 2005–June 2007, Calgary childrenEndnote 47 6–9 y Upper extremity (54.3%)
Swimming pool (drowning or near drowning)
1990–2003, ages 0–14 yearsEndnote 51 46 57.1 < 4 y
(entrapments) 1990–2003, all agesEndnote 52 2–3 5.7 10–14 y Foot (57%)
Fireworks, fire crackers and sparklers
June 1998–March 2004, all agesEndnote 53 16–17 7.4 10–14 y Upper extremities (46%)
In-line skates
1998, all agesEndnote 54 962 7.8 10–14 y Fracture (47.6%)
1999–2003, ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 763 7.5
1990–2007, all agesEndnote 46 657 6.9 Median 11.9 y
June 2005–June 2007, Calgary childrenEndnote 47 10–14 y Upper extremity (55.1%)
Bicycle
2006, ages ≥ 1 yearEndnote 55 3993 11.0 11–15 y Upper extremity (44.0%)
1990–2007, all agesEndnote 46 4726 10.7 Median 11.0 y
1999–2003, ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 3189 10.2
1994, ages 0–19, Kingston and areaEndnote 25 5–14 y
1994–1998, childrenEndnote 26 2342
1986–1991, Ontario fatalitiesEndnote 56 15–44 y
mean 26 y
Head (75%)
June 2005–June 2009, Calgary childrenEndnote 47 5.4 10–14 y Upper extremity (49.1%)
1993–2002, Halifax, children ≤ 15 yearsEndnote 57 9.6 6–13 y Shoulder/arm (48.2%)
Go-cart
2000–2002, ages ≥ 5 yearsEndnote 58 45 6.0 10–14 y Head, face, neck (32.1%)  
Upper extremity (32.1%)
1990–2007, all agesEndnote 59 40 8.2 Median 11.9 y
Powered scooter
1998–2005, ages ≥ 7 yearsEndnote 60 5 15.0 10–19 y Upper extremity (57.5%)
1990–2007, all agesEndnote 59 3–4 15.3 Median 12.3 y
Sled
2000–2002, ages ≥ 5 yearsEndnote 61 855 9.2 5–14 y Fracture (37.7%)
Winter 2001–2002Endnote 62 1027 10.5 5–14 y Upper (32.3%) and lower (28.0%) extremity and head, face, neck (29.8%)
1999–2003 ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 759 9.4
April 1997–March 1999, EdmontonEndnote 63 11.0 Median
12 y
Lower (32%) and upper (30%) extremity
1 December, 1992–24 March, 1993, SudburyEndnote 64 7.0 Mean 16 y Extremity (49%)
Ice skates
2000–2002, ages ≥ 5 yearsEndnote 61 866 4.0 5–14 y Fracture (32.4%)
1999–2003, ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 760 3.2
Skateboard
1990–2007, all agesEndnote 46 755 6.7 Median 13.5 y
1999–2003, ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 1001 7.3
June 2005–June 2007, Calgary childrenEndnote 47 10–14 y Upper extremity (53.7%)
Snowboard
2000–2002, ages ≥ 5 yearsEndnote 61 1471 11.3 10–14 y Fracture (57.7%)
April 2000–March 2001Endnote 65 1177 17.2 Upper limb fracture (51.3%)
1999–2003 ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 1262 12.0
Snowshoes
2000–2002, ages ≥ 5 yearsEndnote 61 4 0.0 10–14 y Fracture (38.5%)
Snowblades
2000–2002, ages ≥ 5 yearsEndnote 61 35 10.6 10–14 y Fracture (54.8%)
Dirt bike
1993–2002, Halifax, children ≤ 15 yearsEndnote 57 158 ≈20.0 10–15 y Shoulder/arm (50.6%)
1990–2007, all agesEndnote 59 25.7 Median 14.4 y
Matches
1993–2003, ages ≤ 15 yearsEndnote 66 3–4 25.6 13–15 y Head, face and neck (39%)
ATVs
1990–2007, all agesEndnote 59 272 33.6 Median
15 y
1999–2001, all agesEndnote 67 298 38.4 20–29 y Lower (30.4%) and upper (30.2%) extremity
September 1 1998–August 31 2003, London, childrenEndnote 68 19.5 8–17 y mean 13.7 y Fracture (76%)
1990–1997, Alberta, ages 0–17Endnote 69 Median
13 y
Head (44.7%)
June 1990–December 2002, Halifax children < 16 years, hospital admissionsEndnote 70 13–15 y mean 12 y Orthopedic (71.7%)
2002, ages > 15 years, major traumaEndnote 71 16–34 y Head injury (24%)
2001–2004, Montreal pediatric hospital admissionsEndnote 72 3–17 y median
13 y
Brain injury (54%)
1993–2002, Halifax, children ≤ 15 yearsEndnote 57 30.8 14–15 y Lower extremity (42.3%)
Downhill/alpine skis
2000–2002, ages ≥ 5 yearsEndnote 61 899 12.6 10–14 y Fracture (41.8%)
October 1999–September 2000Endnote 65 865 16.0 Fracture (41.0%)
1999–2003 ages ≥ 1 yearEndnote 48,Table 1 - Footnote b 699 12.9
1991–1992 ski season, Blackcomb, BCEndnote 73 7–17 y Head or face (26.5% of males), knee (30% of females)
Water tube
1990–2008, all agesEndnote 74 18 8.7 15–19 y
Water skis
1990–2008, all agesEndnote 74 35 9.0 15+ y
Lawnmower
1990–2006, all agesEndnote 75 69 23.0 20+ y Lacerations (32%)
Jet ski/personal-powered watercraft
1990–1997, all agesEndnote 76 11 28.4 20+ y Head or neck (33.7%)
1990–2007, all agesEndnote 59 16 18.8 Median
20 y
Cross-country skis
2000–2002, ages ≥ 5 yearsEndnote 61 34 12.8 20+ y Fracture (34.3%)
Annual average in the database as of December 2003Endnote 65 37 8.5 Fracture (27.1%)
Snowmobile
1990–2007, all agesEndnote 59 215 32.4 Median 22.6 y
2000–2002, ages ≥ 5 yearsEndnote 61 223 39.0 20+ y Fracture (39.3%)
1985/86–1989/90, Ontario fatalitiesEndnote 23 Mean
29.9 y
January 1998–December 1997, Winnipeg, hospital admissionsEndnote 77 19–25 y mean 29.1 y Musculoskeletal (57%)
Wheelchair
Nova Scotia, all agesEndnote 78 1.8 21–40 y, mean 44.1 y Head and neck (50%)

Table 1 summarizes the results of the systematic literature review by consumer product in terms of estimated annual numbers of injuries, percentage of injured admitted to hospital, most common type/ site of injury and any reported trend. The results are ordered approximately by age group most affected, from youngest to oldest.

From the literature reviewed, in which injuries to children and teenagers predominate, outdoor play and sports equipment appear to be associated with the greatest numbers of injuries. Playground equipment (e.g. swings, monkey bars, slides, teeter-totters) and bicycles are related to more than 3000 injuries per year each. Downhill winter activities using sleds, snowboards and skis are the next most common at about 1000 injuries per year each. Other consumer products that are involved with between 500 and 1000 injuries per year are skateboards, in-line skates, ice skates and trampolines.

Consumer products used around the home play a more important role in terms of injury severity than absolute numbers. Injury severity is defined here in terms of the proportion of the injured who are admitted to hospital. Although hospitalization rates can serve as a proxy for severity of injury across consumer products, the fact that CHIRPP data do not include information on people who died without being taken to hospital likely underestimates the severity of some types of consumer product-related injury. Over half of children injured by a blind or drapery cord or in a swimming pool are admitted to hospital, as are 25% to 30% of children burned by gas fireplaces or matches and over 20% of people injured by a lawnmower. Beyond the home, consumer products most likely to be related to serious injury are powered recreational equipment such as ATVs and snowmobiles (over 30% of injured admitted to hospital), personal-powered watercraft and dirt bikes (over 20% admitted to hospital).

Consumer products for which the numbers of injuries may be on the rise include infant bath seats, trampolines, wheeled shoes, powered scooters, ATVs, dirt bikes, snowboards, water tubes and magnets.

Tables 2 through 4 show the circumstances related to the injury. Because most of the research describing injury circumstances is based on CHIRPP data, consumer products used by children and youth predominate. From the available data, it appears that injuries related to product characteristics are relatively rare (Table 2). Baby swings appear to be the product most often at fault with 12.0% of injuries attributable to the product itself, followed by wheeled shoes (7.6%), powered scooters (7.5%), playground equipment (6.6%), cribs, cradles or bassinets (5.7%), playpens (3.8%), baby gates (3.4%), motorized ride-on toys (3.0%), bunk beds (1.4%) and unpowered scooters (1.0%).

TABLE 2
Proportions of injuries caused by product characteristics
Product Percentage of injuries caused by product failure, % Percentage of injuries caused by body entrapment, % Total percentage of injuries attributable to product characteristics, %
aRough edge.
bIncludes 0.3% caused by child eating the wood or being injured by splinters.
Baby swing 12.0Endnote 28 12.0
Wheeled shoes 7.6Endnote 45 7.6
Powered scooter 7.5Endnote 60 7.5
Playground equipment 2.2Endnote 44,Table 2 - Footnote a 4.4Endnote 44 6.6
Crib, cradle, bassinet 1.3Endnote 35,Table 2 - Footnote b 4.4Endnote 35 5.7
Playpen 2.2Endnote 33 1.6Endnote 33 3.8
Baby gate 1.2Endnote 32 2.2Endnote 32 3.4
Motorized ride-on toy 3.0Endnote 38 3.0
Bunk bed 1.2Endnote 39 0.2Endnote 3 1.4
Unpowered scooter 1.0Endnote 50 1.0
In-line skates 0.5Endnote 54 0.5
Bicycle 0.3Endnote 55 0.3
Trampoline 0.1Endnote 79 0.1
TABLE 3
Proportions of injuries caused by inappropriate or risky use of a product
Product Types of risky or inappropriate use Percentage of injuries caused by risky or inappropriate use, %
aDeaths.
bMajor trauma.
Magnet Ingestion, insertion in nose or ear 93.9Endnote 3
Snowmobile Impaired 69.0Endnote 23,Table 3 - Footnote a; 70.0–88.0Endnote 77
Excessive speed 82.0Endnote 77
Matches Playing with or ingesting 71.8Endnote 66
Bath seat Leaving child alone in seat 60.0Endnote 3
All-terrain vehicle Impaired ≤ 56.0Endnote 71,Table 3 - Footnote b
Baby gate Left open or unsecured 43.4Endnote 32
Bunk bed (top bunk) Playing, jumping and standing, being pushed 40.5Endnote 3
Baby walker Lack of a barrier at the top of stairs 24.7Endnote 30
Bicycle Impaired or inappropriate use 1.8Endnote 55; 7.0Endnote 56

TABLE 4
Non-use of helmets among injured people by product
Consumer product % of injuries where a helmet was not used
aFatalities.
bMajor trauma.
cPediatric hospital admissions.
Sled 99.0%Endnote 64; 93%Endnote 63
Wheeled shoes 95.4Endnote 47; 87.3Endnote 46
Jet ski/personal-powered watercraft 90.9Endnote 59
Skis and snowboard 79.1%Endnote 80
Skateboard 73.7Endnote 47; 67.9Endnote 46
Unpowered scooter 72.4Endnote 50; 66.3Endnote 47; 57.6Endnote 46
In-line skates 56.8Endnote 47; 50.5Endnote 54; 49.6Endnote 46
Snowmobile 43.1Endnote 59
Go-cart 39.6Endnote 58; 17.8Endnote 59
Powered scooter 38.9Endnote 59
Bicycle 37.3Endnote 55; 29.8Endnote 46; 15.4Endnote 47; 96.0Endnote 56,Table 4 - Footnote a
All-terrain vehicle 29.0Endnote 59; 28.2Endnote 67; 35.0Endnote 68,Table 4 - Footnote b; 84Endnote 71,Table 4 - Footnote b; 84Endnote 72,Table 4 - Footnote c; 31.7Endnote 70,Table 4 - Footnote c
Dirt bike 12.7Endnote 59

A relatively high proportion of injuries result from inappropriate or risky use of a product (Table 3). For magnets, almost all of the injuries (93.9%) appear to be the result of risky or inappropriate use (e.g. ingestion or insertion in the nose). About three-quarters of injuries from snowmobile accidents can be attributed to alcohol impairment or excessive speed. Alcohol impairment is implicated in just over half of ATV-related injuries. Over 70% of injuries from matches result from inappropriate use (e.g. playing with or ingestion). Leaving a child alone in a bath seat is likely the single most common reason for a related injury, accounting for 60.0% of injuries from bath seats. Other injury causes are leaving a baby gate open or not secured (43.4% of injuries), playing, jumping, standing or being pushed from a top bed bunk (40.5%), and lack of a barrier at the top of stairs when a baby is in a walker (24.7%).

The only type of protective gear for which data were available across some products was helmet use. Almost everyone (over 90%) injured while sledding, using wheeled shoes or a personal-powered watercraft were not wearing a helmet (Table 4). Approximately one-half to three-quarters of people injured while downhill skiing, snowboarding, or using an unpowered scooter or in-line skates were not using a helmet. A considerable proportion of those injured while using powered recreational equipment were also not wearing a helmet. For bicycles and ATVs, helmet non-use percentages were available by severity of injury. Almost everyone who was killed in a bicycle-related accident was not wearing a helmet, and for ATV-related injuries, non-use of a helmet occurred in a greater proportion of cases requiring hospital admission or where there was major trauma.

None of the 41 products included in Table 1 was identified by all priority indices, but 26 products were identified by at least one (Table 5). Assuming that priorities are likely to focus on products where injuries are either the most common or the most serious, this table identifies 18 products that fall into one or the other category. The 9 products associated with the most injuries differ from the 9 that result in a higher proportion of hospital admissions. Further selection of products based on at least one other index reduces the prioritized products to 11, that is, 6 that result in a high number of injuries and 5 that appear to result in more serious injuries requiring hospitalization.

TABLE 5
Combined priority indices from Tables 1 to 4
Consumer Product > 500 injuries per year ≥ 20% of injured people hospitalized Increasing trend ≥ 5% caused by product characteristics ≥ 50% caused by inappropriate or risky use ≥ 50% of injured not using a helmetTable 5 - Footnote a

Note: Highlighted products are those that are most numerous or serious and have values that exceed the cut-point on at least one other priority index.

aWhere helmet use is considered appropriate and where reported.
Infant swing
Infant bath seat
Gas fireplace
Crib, cradle, bassinet
Magnet
Blind or drapery cord
Playground equipment
Wheeled shoes
Trampoline
Unpowered scooter
Swimming pool
In-line skates
Bicycle
Powered scooter
Sled
Ice skates
Skateboard
Snowboard
Dirt bike
Matches
All-terrain vehicle
Downhill skis
Water tube
Lawnmower
Personal-powered watercraft
Snowmobile

Table 6 highlights consumer products and areas of concern. Of the 6 products associated with a high number of injuries, 4—in-line skates, sleds, snowboards and downhill skis—are associated with a relatively low proportion of helmet use.

TABLE 6
Consumer products and areas of concern
Issue Consumer Product
Helmet non-use In-line skates
Sleds
Snowboards
Downhill skis
Personal-powered watercraft
Use while impaired All-terrain vehicles
Snowmobiles
Excessive speed Snowmobiles
Product design Playground equipment (includes surface material)
Inappropriate storage and use Matches

Discussion

Systematic literature reviews are prone to both reporting bias (the tendency for statistically significant results to be reported over results that show no association) and publication bias (the greater likelihood that reports showing statistical significance will be published). This review has attempted to deal with these sources of bias by including both published and unpublished information and articles for which only the abstract was located. A further source of bias can arise from the choice of search terms. Despite every attempt to make this review as comprehensive as possible within the resource constraints, we acknowledge that searching for each individual consumer product (sometimes with different names such as jet ski or personal-powered watercraft) would have been a more exhaustive approach than using the generic term ''consumer product,'' which some publications may not have used as a keyword.

''Grey literature'' (i.e. literature not included in the databases searched) was partially addressed by including online publications (all of which used CHIRPP data); however, the fact that we did not search for government publications in each of the Canadian provinces means that we may have missed some relevant material.Endnote 10-14 We assumed that the national reports using CHIRPP data would have included the data used in provincial reports.

The topic of injury associated with consumer products does not lend itself well to the classical systematic literature review for at least two reasons. First, epidemiological studies often take years to design, carry out, write up and publish in scientific journals; therefore, published epidemiological reports likely will not represent those products where incident reports result in early recalls. Second, a literature review that spans several years may not be relevant to today's hazards, in that dangerous products may already have been recalled and are no longer available and new products and designs have appeared. For example, missing in the results of this search are potentially harmful effects of personal electronic devices. An example is hearing loss associated with MP3 players.Endnote 15

Since the bulk of CHIRPP data comes from hospitals in cities, and most are pediatric hospitals, injuries suffered by older teenagers and adults seen at general hospitals and by First Nations, Métis, Inuit and other people who live in rural and remote areas are under-represented in the CHIRPP database. In addition, not all provinces and territories have hospitals participating in CHIRPP (e.g. Saskatchewan, New Brunswick, Prince Edward Island, Yukon, Northwest Territories, Nunavut). Fatal injuries are also under-represented because CHIRPP does not capture information about people who died before they could be taken to hospital.Endnote 2 Studies that have assessed the representativeness of CHIRPP data indicate other biases. Sensitivity ranged from 30% to 91% across some hospitals;Endnote 16 injuries among older children were more likely to be missed in some hospitalsEndnote 17,Endnote 18 but not others;Endnote 16 and more serious injuries (e.g. those admitted to hospital) were less likely to be missed in some hospitalsEndnote 17,Endnote 18 and more likely to be missed in others.Endnote 16 However, the data collected have been found to be both reliable and valid.Endnote 19

Future efforts to look at consumer products and injuries in Canada may wish to focus on the following:

Population attributable risk

One possible approach would involve using the approximate number of injuries per year along with the prevalence of modifiable risk factors (e.g. non-use of helmets) to estimate the population attributable risk reduction of specific interventions. Such an estimate of the potential public health benefit could be used as the basis for setting priorities. However, this approach would likely require a meta-analysis based on a subset of articles with data suitable for pooling and/or the use of raw data from the CHIRPP database.

Exposure-based risk estimates

Although this review identifies those types of products associated with the greatest numbers of injuries, the absolute number of injuries is a function of both the availability of a given product and the risk of injury related to the product. To illustrate, does the fact that there are three to four times as many injuries associated with bicycles as with in-line skates indicate that cycling is riskier, that there are more bicycles than in-line skates or that people spend more time cycling than using in-line skates? Likely, it is a combination of all three factors. With a few exceptions, the studies cited here have not provided estimates of risk of injury relative to exposure to a product, which is necessary to identify particularly hazardous products and their associated activities. The difficulty in providing comparative estimates of risk lies in finding suitable denominators. In the future, for at least some types of consumer products, calculations of injury rates in relation to exposure may be possible. Methods similar to those used by othersEndnote 20-23 could be used to relate CHIRPP data to survey data, such as the physical activity of youth and adults collected in the Canadian Health Measures Survey,Endnote 24 to estimate risk in relation to exposure. Another approach would be to combine injury data with sales data to give an estimate of risk based on the availability of certain consumer products.

Population-based injury rates

The studies cited here involved different age groups, in different locations and over different time periods, making comparisons of injury rates across products difficult. The CHIRPP database permits the calculation of injury rates in relation to the total number of injuries in the database (overall or for a particular age stratum); however, these rates only approximate population rates, in that people in the CHIRPP database likely do not represent the entire population from which they are drawn. CHIRPP data could be related to Census data to estimate the validity of the former method for estimating population rates (crude and adjusted) and to allow comparisons across products and with other studies where population rates have been used.Endnote 25,Endnote 26

Age-specific rates

Although this review was able to identify the age groups most affected by injury related to specific consumer products, it could not identify the products most likely to be associated with injury for specific age groups throughout the lifespan. The CHIRPP dataset could be used to provide this information, which would assist priority-setting and injury reduction strategies in relation to specific age groups.

Conclusions

Despite its acknowledged limitations, this systematic literature review has provided a broad look at the problem of injury related to specific consumer products in Canada in terms of injury frequency, severity, possible trends, and likely causes. The most numerous injuries appear to involve playground equipment and bicycles; the most serious injuries occur around the home or while using powered recreational equipment; injuries related to several consumer products may be increasing; and the most frequent causes of injury appear to be behavioural (i.e. inappropriate or risky use and insufficient safety precautions, such as helmet use), rather than the fault of the product itself. The analysis presented here identified the following areas of concern regarding consumer products and injuries: (1) lack of helmet use by people using in-line skates, sleds, snowboards, downhill skis and personal-powered watercraft; (2) the operation of ATVs and snowmobiles by people who are impaired by alcohol; (3) the operation of snowmobiles at excessive speeds; (4) poor design of playground equipment; and (5) non-secure storage and use of matches.

Acknowledgements

The authors wish to thank Jane Falconer, Information Services Librarian at the London School of Hygiene & Tropical Medicine, UK, for her invaluable contribution to the design of the literature search strategy.

References



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