Main points

• Every year, 12 per cent of the population, i.e. about 600 000 people seek medical attention for injuries.
• Every 12th hospitalisation is injury-related.
• Unintentional injuries cost many lives and are the main cause of death for Norwegians under 45 years.
• Deaths are primarily due to falls, poisoning (including overdoses) and traffic crashes.
• People from lower socioeconomic groups are more prone to injuries than people from higher socioeconomic groups.
• Compared to other countries, Norway has a high number of overdoses and hip fractures.
• Injuries can be prevented. Structural preventive measures have proven to be particularly effective.

About injuries

It is common to distinguish between unintentional and deliberate injuries (assault and self-harm).

In some cases, it is difficult to determine the cause of an injury. An unknown number of suicides are disguised as unintentional injuries, i.e. accidents. Some data sources do not distinguish between different causes of injury.

In this chapter the term injury is limited to physical injury, therefore psychological injury, property damage and injury to animals are excluded. Strain injuries and other injuries caused by chronic or prolonged exposure (e.g. from chemicals, radiation and noise) are also excluded.

Injuries in Norway: 12 per cent of the population treated for injuries each year

Injuries vary in severity and cover a wide range from trivial abrasions to more extensive damage that may result in hospitalisation, permanent disability or even death.

Injuries must normally exceed a certain severity in order to be registered. Statistics show that each year, over 12 per cent of the population (just over 600 000 people) is treated by a doctor for injuries (NIPH, 2014).

The majority of the recorded injuries are minor and are treated in a primary care setting, i.e. by a GP or out-of-hours emergency primary care facility. However, there are also a large number that are referred to hospitals or handled directly at the hospital.

Figure 1 provides an overview of injuries in Norway, by severity and different treatment levels in the health service. Besides unintentional injuries, the pyramid also includes injuries due to assault and deliberate self-harm. 

Figure 1. The total injury scenario per year in the period 2009-2011. The degree of severity increases towards the top of the pyramid. Sources: NIPH/Cause of Death Registry, Norwegian Patient Registry (NPR) and reimbursements filed to the Norwegian Health Economics Administration (KUHR). 

About 2 500 people die each year from injury, see top of the pyramid in Figure 1. These deaths make up about 6 per cent of all deaths in Norway. Approximately 2 000 are due to unintentional injuries, the remainder are mainly from suicide.

Every year, just under 300 000 people receive treatment in hospital (the two middle levels in Figure 1). Of these, 119 000 were also treated in a primary care setting, either for the same injury in the form of a referral or check-up, or for another injury. Approximately 95 per cent of these injuries are unintentional, while the others are mainly assault injuries (Norwegian Directorate of Health, 2016a).

Annually, about 440 000 patients receive treatment from their doctor or out-of-hours emergency primary care facility (the bottom two steps in Figure 1). The majority of these do not need specialist treatment.

Despite the fact that in recent decades we have seen a significant decrease in mortality due to unintentional injuries (see next section), they are still a major public health challenge. Injuries have a major impact on quality of life and health.

• A study of social security data for the period 1992-1997 estimated that every year, 1 200 people received a disability pension as a result of unintentional injuries (Lund, 2001). There have been no similar analyses since 1992-97.
• Figures from the Norwegian Patient Registry (Norwegian Directorate of Health, 2016b) show that every tenth hospitalisation is injury-related.

Costs

• In 2002, unintentional injuries at home, in school and during sport and leisure activities were estimated to cost Norwegian society 167 billion Norwegian kroner (ITE, 2007). At 2015 rates, this would be equivalent to over 200 billion kroner.
• A hip fracture is estimated to cost society an average of 500 000 kroner in the first year (Hektoen, 2014).

Trends over time

Deaths:

In recent decades, mortality due to unintentional injuries has declined significantly (NIPH, 2014). The decline can partly be attributed to a positive development with far fewer traffic and drowning fatalities.

Figure 2 shows the trend in mortality due to unintentional injuries from 1970 to 2016.

Figure 2. Deaths from unintentional injuries, by gender. Number of deaths per 100,000 inhabitants per year, from 1970 to 2016. 5-year moving average (dotted line) and annual rates. Age adjusted rates. Source: NIPH / Cause of Death Registry.

Figure 2 shows a sharp reduction in unintentional injury mortality for both men and women. 88 per 100 000 men died because of unintentional injury in 1970. In 2016, this number had fallen to 55 per 100 000 men, a decline of almost 40 per cent (NIPH, 2017).

The decline has been particularly evident among children, adolescents and young adults, but also among the elderly, unintentional injury mortality rates have dropped considerably. For the 65-79 year age group, unintentional injury mortality almost halved from the 1970s until today.

Figure 3 shows the sharp reduction in road traffic deaths since 1970. This decline is the result of systematic road safety efforts over many years.

Figure 3. Road traffic deaths per 100 000 inhabitants, age-standardised. The graph shows the period 1970-2016, men (blue line) and women, all ages combined. See also Figure 7. Data Source: NIPH / Cause of Death Registry. 

We see a similar positive trend for drownings, with 55 deaths in 2016, compared with 157 in 1970.

Non-fatal injuries:

Due to data limitations, it is difficult to give a similar description of trends in the incidence of non-fatal injuries. Norway does not have a national register with unambiguous injury data and a complete description can only be obtained by collecting information across data sources. Furthermore, most registers with information about injuries are characterised by underreporting and insufficient data quality (NIPH, 2014).

Population differences

Injury incidence is strongly associated with age and gender, see Figure 4-6.

Age differences: Elderly and young most vulnerable

Unintentional injury mortality increases with age and is particularly high for the elderly over 80 years. In this age group, the risk of dying as a result of an unintentional injury is over 10 times higher than in the younger age groups, see Figure 4. Falls and fractures are an important part of this picture.

Figure 4. Deaths from unintentional injuries, by gender and age group. Number of deaths per 100 000 inhabitants per year, average for 2010-2016. Source: NIPH / Cause of Death Registry.

Among younger people, the number of deaths from unintentional injuries is significantly lower than among the elderly, but when a young person dies, the cause is more often an unintentional injury (NIPH, 2014). While older people mainly die from disease, unintentional injuries are the most frequent cause of death in the under-45 age group, see Figure 5. Among men under 25 years, one in five deaths is from an unintentional injury. Traffic in particular claims many young lives.

 

 

Figure 5. Distribution of selected causes of death by age, as a percentage of all deaths, average for 2011-2016. Tumours are mainly cancerous. Source: NIPH / Cause of Death Registry.

Deaths from unintentional injuries in younger age groups mean many years of life lost. In 2013, the number of years of life lost due to unintentional injury (including road traffic injuries) is estimated to be 28 629, which represents about 5.2 per cent of all lost years of life in Norway (NIPH, 2016).

Figure 6 shows that as for deaths from unintentional injury, those injuries that result in hospital treatment often occur among the elderly. In addition, adolescents and young adults are a vulnerable group.

Figure 6. People treated in the specialist health service for injuries by age and gender. Number per 100 000 inhabitants per year in the period 2009-2011. Source: Norwegian Patient Registry (NPR).

Gender differences: Men die more often from unintentional injuries than women

More men than women die from unintentional injuries, across all age groups, see Figure 4. The gender difference is greatest among adults aged 20-64 years. Men die more often than women in traffic and by drowning and poisoning. Four out of five overdose deaths involve men (Simonsen, 2011). For deaths due to falls and fire, the gender differences are more even.

For non-fatal injuries, the frequency is also higher among men than women, especially in the 20-34 year age group. Figure 6 shows that men injure themselves more often than women until about 55 years of age but, with advancing age, injuries are more frequent among women. This difference can largely be attributed to a higher incidence of hip fractures and other fractures among older women. 

Risk factors

Injuries can happen anywhere. Every day, we are surrounded by hazards and situations that may cause unintentional injuries. Therefore, risk must be seen in the context of where we spend most time and the activities we engage in.

• The home is the most common location for injury, especially for the youngest children and the elderly. About 30 per cent of all unintentional injuries occur in the home (NIPH, 1989; Norwegian Directorate of Health, 2016a).
• Registration of all injuries treated in out-of-hours emergency primary care facilities or hospitals in four Norwegian cities showed that during the first seven years of life, about 10 per cent of children were injured in childcare or at the playground (Engeland, 1999).
• Adolescents and young adults are often injured during sport and exercise.
• For adults of working age, a significant proportion of injuries occur in the workplace. A study by the National institute of occupational health estimates that approximately 90 000 injuries occur annually (Gravseth, 2010). Craftsmen, farmers, fishermen and nurses are particularly prone to injuries.

Elderly are prone to falls

Fall injuries are ranked as the sixth major contributory factor to years lived with disability in Norway, larger than the health loss associated with cardiovascular disease (NIPH, 2016). The elderly are particularly affected by falls, often with fractures as an outcome. When hip fractures and forearm fractures occur, reduced bone mass (osteoporosis) is a common contributory factor. Outdoors, many falls are caused by slippery conditions and ungritted pavements, while loose wires, carpet edges, stairs and other potential obstacles increase the risk of falls indoors (NIPH, 1989).

Drivers are to blame in most road traffic crashes

Although the number of road traffic injuries has been greatly reduced in recent decades, there are still many deaths and serious injuries. There are often several factors in combination. The main contributory factors are related to drivers, especially inadequate driving skills, high speed, intoxication and fatigue. However, road quality and the driving environment, as well as technical and safety aspects of the vehicle contribute to many road traffic crashes.

Although the number of people killed or injured is greatest for car drivers, the risk of injury per kilometre travelled is highest for drivers of light motorcycles, followed by mopeds, heavy motorcycles and cyclists (ITE, 2015).

High risk for cyclists

The injury risk is higher for cyclists than for car drivers, passengers and pedestrians (ITE, 2015) but the number of cycling injuries is uncertain. Many incidents are not reported to the police or health services, especially where only one person was involved. In theory, the Norwegian Patient Registry should be able to identify cycling injuries through a separate injury module, but less than 50 per cent of the injuries treated in Norwegian hospitals are reported.

In 2014, Oslo Accident and Emergency Department conducted a study of all cycling injuries. The total number of unintentional injuries was approximately 2 000 (Directorate of Health, 2015).

Poor swimming skills - increased risk of drowning

Poor swimming skills are a risk factor for death by drowning (WHO, 2014). An investigation on behalf of the Norwegian Swimming Federation (Ipsos MMI, 2013) suggests that Norwegian children have poor swimming skills.  Only half of fifth graders can swim at least 200 metres, which is the minimum requirement for swimming ability.

This study also shows that immigrant children from non-European countries are significantly worse at swimming than ethnic Norwegian children and are more dependent on swimming lessons in school. Cultural and religious issues are suggested to be behind this difference (ITE, 2013).

Many injuries occur while intoxicated

The use of drugs, medicines, chemicals and other toxic substances contribute to many deaths. In 2016, poisoning caused 342 deaths in Norway (NIPH, 2017).

In addition, drugs are often a contributory factor in many non-fatal injuries. A study of injured patients at the emergency department at Oslo University Hospital showed that one in three patients was under the influence of one or more drugs at the time of injury (Bakke, 2016). Alcohol was the most common drug, present in 26 per cent of patients. The proportion of those who were intoxicated was particularly high among patients with assault injuries and injuries that occurred on licensed premises.

The same data also show that the proportion of injured patients with alcohol detected in their blood is highest in December, during peak Christmas season (Bogstrand, 2011).

Drugs are a major risk factor in traffic. In a study of blood samples, drugs were detected in four out of ten deceased drivers in the period 2001-2010 (Christophersen, 2014). Among drivers who had driven off the road or other incidents with only one involved party, the figure was 64 per cent.

Socioeconomic and geographic differences

There are significant socioeconomic differences in the incidence of injuries (NIPH, 2009; WHO, 2009). Injuries vary with the level of education. People with primary education are more prone to injuries than people with secondary education, while the lowest incidence is seen among people with university and college education.

Geographical differences are also observed in injuries but there is no clear north-south or east-west gradient for differences in mortality. These geographic differences must be interpreted with caution as they may reflect factors other than injury occurrence (e.g. distance to the nearest hospital, capacity in the health service and local referral practices).

International differences

International comparisons show that Norway is in the middle layer when ranking countries by mortality from unintentional injuries (NIPH, 2014). Norway scores relatively well for traffic deaths, but performs poorly for poisoning deaths. Overdose figures are particularly high in Norway, which may be due to several factors:

• In Norway there is a tradition of taking heroin, methadone and other narcotic drugs intravenously, while sniffing and smoking of such substances is more prevalent in other countries.
• Norway has frequent autopsies and good surveillance of overdose deaths. In other countries, surveillance is lacking and the deaths will not show in the statistics.

For the younger segment of the population, the trend in unintentional deaths has been less favourable in Norway than in other OECD countries in recent years. The reason for this development is unknown but may be related to the high number of poisoning deaths in Norway.

Road traffic crashes are a frequent cause of death worldwide. According to the World Health Organization (WHO, 2015):

• Road traffic crashes kill 1.25 million people each year.
• Half of those killed are pedestrians, cyclists and motorcyclists.
• Nine out of ten fatalities come from low and middle-income countries.
• In 2030, road traffic crashes will be the seventh leading cause of death worldwide if preventive interventions are not introduced.

In EU countries, 26 000 people died in road traffic crashes in 2015, while 135 000 were seriously injured (European Commission, 2016). Costs related to rehabilitation, treatment, damage to property etc. are estimated to be at least 100 billion Euros. The EU has set a target to halve the number of fatalities in road traffic from 2010 to 2020 (European Commission, 2010).

Norway is among the countries with the highest incidence of hip fractures (NIPH, 2016b).

Opportunities for prevention

Unintentional injuries are largely preventable, and there are many initiatives with demonstrable effect (Lund, 2004). However, some undesirable incidents are unavoidable, even if the underlying mechanisms are identified, for example after natural disasters or during play among children.

Structural measures, such as changes in legislation, product and environment have been shown to be particularly effective, see Figure 7 below for examples. Behaviour-modification measures (especially reward systems) can give good results. Attitude-changing measures (brochures, information campaigns and the like) are rarely effective alone.

Figure 7. Number of deaths per 100 000 in road traffic crashes, by gender, with selected interventions, 1970 - 2015. The sum of many initiatives over time has contributed to the decline. Compare this with Figure 3. Data source: Cause of Death Registry.

Car, cycle and road environment. Road traffic safety has progressed far. Many different measures have contributed to a sharp reduction in the extent and consequences of road traffic crashes (ITE, 2012), see Figure 7. Measures that have contributed to fewer deaths are:

• Better roads and safer cars
• Low speed limits and low blood alcohol limits
• Better driver training
• Use of seat belts and better safety for children in cars
• Improved trauma care

Politicians plan for more cycling, both because it will help reduce road traffic and provide better health through physical activity. Meanwhile, the injury risk is higher for cyclists than for drivers and pedestrians (ITE, 2015). Safer cycle paths are therefore a preventive measure. More cycling in itself may also have a preventive effect, since an increase in the number of cyclists reduces the risk for each cyclist (ITE, 2016). One important explanation for this "Safety in Numbers" effect is that cyclists become more visible to other road users.

Alcohol. Alcohol-related injuries are best prevented through measures aimed at the whole population, rather than at individuals with alcohol abuse problems. High prices, limited availability and regulation of drink-drinking are most effective in reducing alcohol consumption and alcohol-related problems (Babor, 2010).

The following preventive measures show potential for other types of unintentional injuries:

• Hip protectors, shock-absorbing floors and gritting slippery pavements can prevent fall injuries among the elderly (Norwegian Directorate of Health, 2013).
• Use of helmets and other safety equipment, balance exercises and strength training can prevent sports injuries.
• Smoke detectors, stove protection and regulation of water temperature can prevent burns and scalding at home (WHO, 2008).
• Swimming training and the correct use of flotation devices prevents drowning (WHO, 2014).  

Injury prevention is a field without an "owner" although many stakeholders have a responsibility. Cross-sector efforts are therefore necessary.

Injury prevention is part of environmental health protection and is regulated by the Public Health Act. Responsibility for environmental health protection lies with the municipality’s political and administrative leadership.

Through systematic and ongoing prevention efforts, municipalities can be certified as "safe communities", a concept developed by WHO. In 2016, there are a total of 26 such communities in Norway, while another 20 are working towards certification.

Registration of injuries is an important tool in local prevention efforts. Municipalities can use a registration system to get an overview of injuries, follow the trend of injuries over time and measure the impact of various interventions. In Norway, local injury registration has provided good results in Harstad (Ytterstad, 1996), Værøy (Tellnes, 2006) and Os in Østerdalen (Lund, 1997).