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“The Beautiful Game”… minus headers?: Discussing USSF’s recent announcement to limit headers in youth soccer leagues

23 Nov, 15 | by Angy El-Khatib

In the United States, sports-related traumatic brain injuries (concussions and otherwise) have been a HOT topic. In 2013, approximately 4,500 former NFL players sued the league, claiming that the NFL failed to educate, manage, and protect its players from head injuries. Judges approved a settlement of $765 million that would fund concussion-related compensation, including medical exams and research for ex-players. This past year, Chris Borland, a 24 year-old, highly revered linebacker, decided to retire after playing only one year of professional football. His reasoning was that football was “not worth the risk” to his health.

The NFL is not the only sporting organization looking at concussions among its players; other organizations include the National Hockey League (NHL) and the National Collegiate Athletic Association (NCAA). Most recently, the U.S. Soccer Federation (USSF) announced that it has developed a set of guidelines for its youth leagues in which it recommends a ban on headers for players ages 10 and under and a limit on headers for players between 11 and 13 years of age. The USSF also developed a standard protocol in which medical professionals, as opposed to coaches or referees, make decisions about return-to-play for players who are suspected of sustaining a concussion.


The USSF developed these guidelines in response to a class-action lawsuit which targeted six of the largest youth soccer groups, including FIFA, U.S. Youth Soccer, and the American Youth Soccer Organization. The lawsuit claims that these organizations have “failed to adopt effective policies to evaluate and manage concussions.”

But will policy changes – “banning headers” – solve the concussion problem among youth soccer players?


A September 2015 study in JAMA by Comstock, et al. evaluated trends in soccer concussions among youth players. The study found that the most common concussion mechanism was contact with another player (player-player), not a ball – this is consistent with other literature.

The most common mechanism for all concussions was contact with another player, accounting for 68.8% of all concussions among boys and 51.3% among girls. The most common mechanism among heading-related concussions was also contact with another player, accounting for 78.1% of heading-related concussions among boys and 61.9% among girls.


Among soccer-specific activities, heading was responsible for 30.6% of concussions among boys and 25.3% of concussions among girls.

The study concludes that reducing athlete-athlete contact across all phases of play – not just headers – would be more likely to prevent concussions. It also mentions that, culturally, banning headers may not be a feasible prevention effort. After all, an integral part of the Beautiful Game is headers (Robin Van Persie during the 2014 FIFA World Cup, anyone?). The soccer community, anecdotally, seems exceptionally resistant to the prospect of banning headers. As injury researchers, we know that one of the most important aspects of a successful and effective public health intervention is cultural feasibility.

With this in mind, I don’t think it is likely the USSF’s announcement about banning or limiting headers will significantly affect the epidemiology of concussions in youth soccer.  At most, this sends a strong message to coaches and brings safety management to the forefront. (The new rule which requires a Health Care Professional, [shoutout to Athletic Trainers!] to be present to make decisions regarding concussions instead of coaches or referees could be positive, though!)

Either way, one has to commend USSF’s attempt at targeted prevention efforts to bring soccer to its high and honorable state:


Joga Bonito!



P.S. – you’re not allowed to make fun of me for calling it “soccer” instead of “football”! :)

Undergraduate research experience

9 Nov, 15 | by Bridie Scott-Parker

I read an interesting blog last week in which two undergraduate students shared their perspectives after completing a research placement, and it prompted me to reflect upon my own research training, and how much of what we researchers – while it sometimes feels as if it is innate – is actually learned skills and abilities (oft by trial and error) that need to be shared with our up-and-coming researchers. Today I want to share a recent experience with an undergraduate student from another Queensland university.

I was approached by Sehana last month regarding the potential to gain some experience in research during her summer semester studies. I invited her to accompany myself and my University of the Sunshine Coast (USC) Research Assistant Ms Jamie Caldwell as we collected data during week four of the the first wave of an 18-month longitudinal study. Today Sehana shares her story:

When speaking to the placement officer at USC regarding a work experience in research, Bridie Scott-Parker was the first name she mentioned.  She thought the placement would be perfect for me especially because of Bridie’s extensive knowledge in research and having recently being awarded the Tall Poppy Science award for her research contributions. 
From reading about her extensive research online, reading a couple of her published papers, and speaking to her about her work, I am now a full convert to “the dark side of research” – as she calls it.
Throughout my degree I have done numerous research assignments, doing certain sections of a report for various courses.  You are always given data, or parts of the report are completed for you and you do the rest.  I have never been involved in any research related activities out in the real world. 
We visited a school, collecting and distributing surveys and sleep diaries to adolescent school children.  From the beginning there were issues that as a novice researcher caught me off guard.  The students came in drips and drabs, many did not have their sleep diaries, others had multiple from previous weeks, some students did not attend at all. 
I stood there the entire time panicking with “missing data” running through my head, while Bridie and Jamie casually took it all in their stride.  It wasn’t until I reflected on it at the end that my theoretical learning and practical experience actually fit together.  And it was exactly that – experience – which they had and I didn’t that made the difference. 
I could see that Bridie and Jamie both had enough experience to know the little things such as bringing spare pens and surveys.  It was when I heard them speaking about participant codes for the research that I realised my degree may have taught me how to do ANOVAs and correlations, but experience like this, out in the real world, surrounded by real participants (and real missing data) is invaluable. 
The first day of any job is nerve wrecking, but I feel this experience has taken away much of the anxiety associated with being a graduate fresh in the research field.  I would highly recommend to anyone who is leaning towards a research career to spend time with real researchers, speak to them, help collect data and just see how it all works in the real world. 

Ms Sehana Naz

Howzat?! An Injury Prevention and Prediction App for Cricket?

8 Nov, 15 | by dbui

As the 1st test is underway between Australia and New Zealand at the Gabba, British Medical Journal Injury Prevention brings you an interview with Dr Naj Soomro, a physician with a passion for Technology and Sports Medicine in Cricket. I met Dr Soomro at the National Conference of Sports Medicine Australia last month where I was representing the University of New South Wales Sports Medicine Society, and his presentation was one of my personal highlights of the conference! He presented on a novel Injury Surveillance, Prevention and Prediction App, “Cricket Predict”.

Dr Soomro kindly agreed to answer a few questions for the blog!

Q1. Tell us about Cricket Predict; what is it and how did you come up with the concept?

I’ve been interested in prediction for a long time now. Today, we use technology and science to predict everything from the weather to cardiovascular risk. This carries into Sport as well: If you have a look at NFL, previous injury is used extensively in determining injury risk; Rugby players are similarly triaged using GPS data and the number of tackles per game. My aim was to develop a similar system for Cricket.

Cricket predict is a mobile app that harnesses technology in the surveillance of injuries, measures risk factors for injury and ultimately, aims to predict (and prevent!) injury. By tracking risk factors for injury in real-time, medical and coaching staff can receive alerts when an individual player’s risk profile is high – and interventions can be implemented. Further, whenever a player is injured, there is an electronic injury form which can be filled out through the app that goes onto a central online database, helping with identification of injuries.

Q2. Cricket predict utilises a number of different risk factors to help predict injury, what is the evidence for using these risk factors specifically?
The risk factors that are used in Cricket Predict are all validated in the literature. They include:
I. Cricket workload, such as number of balls bowled
II. Non-cricket workload e.g. Strength and conditioning sessions, cross-training
III. Psychological status – measured by a modified Profile of Mood States (POMS) questionnaire, usually 76 items but modified to 10 items to be cricket-specific and “player-friendly”.
IV. Sleep, a measure of fatigue and documented risk factor for injury, measured by an accelerometer and analysed by Activ Graph.
V. Previous injury profile
VI. Pre-season strength parameters, including Internal Rotation to External Rotation ratio (predicts injury in Throwing Athletes), Hamstring to Quadriceps ratio (predicts hamstring injury)

Cricket Predict’s algorithm incorporates all of these risk factors and displays to the user a graphical representation of the player’s injury risk. However, exactly how predictive these risk factors are in cricket players is yet to be studied and my research group is running a prospective validation study to do just that.
Q3. What are the implications of the findings of this study for readers?
There are 2 main implications of this research:

One of the biggest implications of my research is the integration of technology into Sports Medicine, which I see as the way forward. Its one of the reasons I developed this mobile app. Developing an electronic injury surveillance system makes data collection very easy, and numerous studies have demonstrated that electronic injury surveillance systems are superior to paper-based systems. Additionally, with the advent of wearable technology, large amounts of quantitative data can be incorporated.

Secondly, if the algorithm in Cricket Predict is validated, this research will revolutionise the way that Sportspeople play the game. Based on what we prove and validate, the coaches are going to change their coaching techniques, they will be able to select the best players for their teams, and develop policies for junior players as well.

Q4. Has this type of research been undertaken in other sports?
There is a recent article by Tim Gabbett which studied an injury prediction model in Australian Rugby League in which he was able to predict approximately 50-80% of soft-tissue non contact injuries over the course of 2 seasons. In the course of a tournament, an injury to a key player can change the balance of a team. Even if an algorithm can predict 10-20% of injuries, for an elite team that is very significant.

Q5. This research is heavily reliant on Technology, where do you see Technology and Medicine, or Technology and Injury Prevention going forward?
A lot of data that we get these days is subjective data from players, and I think the best way to quantify data and validate data is to get data electronically from the use of sensors. Sensor-based technology and imaging technology is going to go very far in terms of performance analysis and the usage of physical characteristics of players. I see the usage of wearable technology being really big in sports. What I mean by this is the use of accelerometers or gyroscopes to look at movement patterns, similar sensors to look at medical data such as the amount of perspiration, and the amount of stress hormones such as Cortisol that can be measured in saliva and also in sweat. We can also look at blood sugar levels, heart rate, oxygen saturations – all of these things can be measured using wearable technology which can send wireless information to the medical and coaching staff. One of the most important things coaches can get out of this is the amount of fatigue of their players. If we can use technology to quantify this fatigue, that is going to revolutionise sport.


If you’d like to keep this conversation going, or be involved with Cricket Predict in the future, please get in touch with Dr Najeeb Soomro via email or Twitter @CricDoctor. Specifically, if you are a cricket club, sports scientist or health professional interested in doing injury surveillance or helping to validate the app, Dr Soomro is happy to share the app with you! 
Let us know what you think @BMJ_IP too!

David Bui is a final year medical student at the University of New South Wales and outgoing President of the University of New South Wales Sports Medicine Society. He has an interest in Orthopaedics, Sports Medicine and Injury – in all forms! @David_Bui_

Water safety in Australia: The Royal Life Saving National Drowning Report 2015

6 Nov, 15 | by Sheree Bekker


Kudos to Royal Life Saving for releasing both an infographic and video along with their National Drowning Report 2015, making the content more accessible and easier to share. The video – linking data, story, and prevention measures – is an excellent example of a clear, simple way of disseminating research findings.

This important information, in these formats, speaks for itself – and in lieu of an in-depth post.

Two recent Injury Prevention articles on this topic for further reading:

Interventions associated with drowning prevention in children and adolescents: systematic literature review

Does teaching children to swim increase exposure to water or risk-taking when in the water? Emerging evidence from Bangladesh

On a cheeky note: unfortunately no infographics to summarise these – something I feel we as researchers/authors/bloggers should consider for key papers!

On a related note: Justin Scarr, the Chief Executive Officer, Royal Life Saving Society – Australia, and Convenor, Australian Water Safety Council will be a keynote speaker at the 12th Australasian Injury Prevention and Safety Promotion conference – hosted by the Australian Injury Prevention Network, and The George Institute for Global Health – in Sydney from 25-27 November 2015. There is still time to register today to hear him, or indeed for any of the other speakers on the program, present. More information here.


Botswana reflections: on learning the ABCs

15 Oct, 15 | by Sheree Bekker

I am currently in Botswana: a landlocked southern-African country of roughly two million people. I grew up here, and it is a place that I consider one of the most beautiful in the world (particularly the Okavango Delta – a bucket list destination for wildlife). The country and its people were beautifully portrayed in this music video from Nico and Vinz (take note Taylor Swift).

Although Botswana is amongst the most economically and politically stable countries in Africa, the need for public health improvements (as with other countries) remains a priority.

The top ten causes of death in Botswana, according to the Centers for Disease Control and Prevention (2010) are:

  1. HIV
  2. Cancer
  3. Stroke
  4. Tuberculosis
  5. Ischemic Heart Disease
  6. Diarrheal Disease
  7. Diabetes
  8. Road Injuries
  9. Lower Respiratory Infections
  10. Malaria

It is no surprise that HIV remains at number one on this list, in 2014 the prevalence of HIV in adults aged 15 to 49 was 25.2% – second in the world only to Swaziland.

The ubiquitous presence of the HIV epidemic can still be seen in the faded remains of the educational messaging that was painted on every available public wall in the 1990s and early 2000s.



Indeed, I so clearly remember that we learned our ABCs at school in Botswana, the letters themselves certainly, but almost more importantly the potentially life-saving versions too: A) Abstain, B) Be wise, C) Condomise. To this day, condoms are widely and freely available (useful, except when the HIV awareness ribbons are stapled to – through – the condoms themselves).

Botswana has generated what is often referred to as a ‘stunning achievement‘ in its multi-faceted response to the HIV epidemic. This success means that the government can now allocate resources to start to address other public health concerns.

Number eight on the above list, road injuries, is now seeing an uptick in prevention initiatives. A 2012 abstract published in Injury PreventionCharacteristics of casualty crashes in the Republic of Botswana: identifying evidence-based prevention opportunities showed that:

Fatality rates increased by 383% (per 10 000 vehicles) from 1975–1998, with recent estimates indicating a 50% higher fatality rate per population than the global average.

The Global Burden of Disease 2010 Study showed that alcohol use was the leading risk factor for disease burden in Botswana. A 30% tax on alcohol (reduced from the initial plan for a 70% tax) was subsequently introduced. A second 2012 abstract in Injury PreventionComparing fatal alcohol-related road traffic crashes in Botswana pre- and post-passage of a national alcohol levy showed:

A large percentage of fatal alcohol-related crashes (FARCs) occurred on weekends (49%), among males (78%), and among 25–34 year-olds (35%).

Comparing changes pre- and post-levy, we found that there was a statistically significant change in FARCs per 10 000 registered vehicles (rate pre-levy=10.4; 95% CI 9.1 to 11.8 vs rate post-levy=8.3; 95% CI 7.3 to 9.3; p=0.01). However, rates per 100 000 population remained stable pre- and post-levy (rate pre-levy: 6.9; 95% CI 6.0 to 7.7 vs rate post-levy: 7.5; 95% CI 6.6 to 8.4; p=0.29).

Alcohol is, obviously, only one element of the highly complex issue that is road safety in Botswana. Road safety issues that I notice here daily include: lack of seatbelt use, unrestrained children, unroadworthy vehicles, animals on roads, speeding, negligent driving, potholes, and overcrowded vehicles. It is encouraging to see work being done on the ground to improve safety (police spot licence checks for example), however it will take time and a multifaceted, focused, local strategy similar to that seen in the HIV response for any great strides to be made. Encouragingly, we know that research and policy have had positive impacts in similar countries around the world. Interestingly, Botswana’s current road safety initiatives do not seem to be as creative as the robots in the Democratic Republic of Congo.

Whilst there is much to achieve in Botswana on the issue of road safety, the success of the HIV campaign means that Botswana can be proud of its initiatives to prevent injury to and illness in its citizens and visitors alike.


*Please note that I am not a researcher in the area of HIV or road safety, and this blog is largely based on my personal observations and knowledge. I welcome comments and insights from people who are – either below, or on our Twitter or Facebook.

Ohio – “the epicenter of the heroin epidemic”

1 Oct, 15 | by Angy El-Khatib

Unintentional drug overdose deaths have increased in the last decade in the United States. In the state of Ohio (which is where I now work as a researcher!), unintentional drug overdose is the leading cause of injury-related death (ODH, 2014).  Since 1999, more than 13,000 Ohio residents lost their lives to unintentional drug overdoses.  Based on 2014 preliminary data from death certificates, unintentional drug overdoses caused the deaths of 2,482 Ohio residents – a 17.6% increase compared to 2013.

Number of Deaths and Death Rate per 100,000 from Unintentional Drug Overdose by Year, Ohio Residents, 1999-2014


Source: Ohio Department of Health, Office of Vital Statistics; Analysis Conducted by Injury Prevention Program

The rise in drug overdose deaths is thought to be attributed to the reemergence of an opioid called “fentanyl” – a synthetic opiate that is that is 30 to 50 times more potent than heroin; often times, fentanyl is mixed in with other commonly abused drugs, like heroin.

According to the National Forensic Laboratory Information Systems (NFLIS) – a U.S. Drug Enforcement Administration program that collects drug chemistry analysis results from cases analyzed by state, local, and federal laboratories – fentanyl drug seizures in the South, Northeast, and Midwest parts of the United States increased by 300% from the second half of 2013 to the first half of 2014.

Fentanyl-Related Drug Overdoses, Ohio, 2012-2014


Source: Ohio Department of Health, Office of Vital Statistics; Analysis Conducted by Injury Prevention Program

Six days ago, the Washington Post released an article calling Dayton, Ohio “the epicenter of the heroin epidemic.” This is likely due to several different drug trafficking groups having easy access two major highways: (1) I-70 is used to move their product east to west to Indianapolis, Indiana and Columbus, Ohio; while (2) I-75 is used to move drugs north to south from Toledo, Cleveland, and Cincinnati in Ohio.

Intersection of Interstate-70 and Interstate-75 in Ohio


With this in mind, and since 2011, the state of Ohio has been partnering and building on several initiatives to improve interdiction, raise awareness, reduce prescription abuse, and expand treatment options.

As a harm reduction strategy, Ohio Governor John Kasich signed HB 4  into law on July 16, 2015.  This allows pharmacists and pharmacy interns to dispense naloxone, an opiod overdose reversal medication, without a prescription but in accordance with a physician-approved protocol and while calling 911 for medical assistance. When administered through intramuscular injection, intranasal spray, or auto-injector, naloxone reverses the effects of an overdose by blocking receptors in the brain from the effects of opioids while restoring breathing.

Another harm reduction strategy used by opioid overdose prevention programs (OOPPs) are take-home naloxone kits. Recently published in the BMJ – Injury Prevention, researchers Kelly Gurka, Alexnadria Macmadu, and Herbert Linn, found that the acceptability and feasibility of a take-home naloxone program was high among participants.

Both harm reduction strategies empower drug users to protect themselves and others. Although objections exist over economic benefit and moral disarray, working on preventing overdose deaths rather than focusing exclusively on stopping opioid and opiate use may be more developmentally and culturally appropriate and may enable drug users to pursue effective treatment.


Can we utilise coaching science to improve injury prevention practices?

30 Sep, 15 | by Sheree Bekker


Basketball Team by BoB McElroy licenced under CC BY 2.0

This week I invited Dr Scott Talpey (follow him on Twitter @s_talps), a research fellow at the Australian Centre for Research into Injury in Sport and its Prevention, to share his insights on sports coaching science and injury prevention – given that a couple of previous Injury Prevention blog posts on similar topics have generated interesting conversation on social media. 

A coach has the potential to have a profound impact on an athlete’s development both on and off the field of play. Coaching is often referred to as both an art and a science, and there is a rapidly growing body of knowledge focused on the science underpinning the role of a coach. Two recent blog posts (A potential “home run” for little league elbow prevention and Injury prevention the new performance enhancing) by @David_Bui have highlighted the important role coaches can play in the prevention of sports injuries. Indeed coaches can be viewed as either a barrier or facilitator to successful uptake of sports safety practices as discussed in this paper by Finch et al., and are often the delivery agents of injury prevention research trials in team ball sports. With the growing intrigue surrounding how the coach can influence sports safety, is it time for sports injury prevention research to incorporate coaching science literature to improve implementation, similar to how Donaldson and Finch did with implementation science?

What is coaching science? Coaching science has been described as a blend of sport psychology, sport pedagogy, sport biomechanics and sports medicine (sports medicine is even included in the definition!). The overarching goal of coaching science is to better understand why coaches do what they do when interacting with the athletes they coach.

What does coaching science research focus on? Coaching science focuses on topics such as coaching behaviour, coaching decision making, coach education/development and coaching effectiveness.

How can we as sports injury prevention researchers use this information? If we want to facilitate sports safety through sports coaches, it makes sense to utilise research focused on improving coaching practice. Sports injury prevention research often claims that additional coach education is needed to improve the prevention of injuries. One such example of this is a recent publication focused on the challenges faced by coaches when trying to implement concussion guidelines. The authors stated, as a practical implication, that:

“education for coaches and sports trainers needs to be tailored to the football code, and the personnel if the concussion guidelines are to be implemented in a sustained and effective way”

Now, if we as sports injury researchers can link the practical implication from the previous article with results of the recent publication in the Journal of Sport Science by Stoszkowski and Collins that found coaches like to obtain information through a combination of formal, informal and self-directed sources that incorporate social interaction. Understanding of how coaches as a key component of the injury prevention process want to learn can help us tailor our interventions to improve coach buy in.

Coaches are often encouraged to have many “tools in their toolbox” to help them successfully fulfil their many responsibilities, we as researchers can use coaching science as a “tool in our injury prevention toolbox” to improve the translation of our evidence into practice.

~ Dr Scott Talpey

The door zone: looking out for cyclist’s safety

17 Sep, 15 | by Sheree Bekker


Bicycling related injuries are a complex problem. Take for example injuries related to “dooring” – in which a car driver or passenger opens a car door into the path of a cyclist, causing the cyclist to hit the door or veer into the path of oncoming traffic – which are becoming all-the-more common in our cities. Real video examples of this risk can be seen here and here.

Multiple factors contribute for the occurrence of “dooring” events, including those related to the behavior of road users, the infrastructure, traffic regulations, policies, and even recommendations based on bicycling safety research.

It has been suggested that the lack of awareness among car users can be in part explained by the limited efforts of city administrators to change the attitudes and social norms via increased penalties for “dooring” bikers and stronger campaigns promoting looking for bikers on the road.

In Injury Prevention Global News Highlights from 2014, Barry Pless wrote:

“A column in the New York Times, “Is it OK to kill cyclists?”, was prompted by the observation that “motorists in America generally receive no punishment for crashing into or killing cyclists, even when the ‘accident’ is transparently their fault.” In the Netherlands, the opposite is true: “if a motor vehicle hits a cyclist, … it is always assumed to have been the driver’s fault… ” because “the law treats pedestrians and cyclists as weaker participants in traffic…” The result is far fewer injuries to cyclists: 12 per billion km cycled in the Netherlands versus 58–109 in the USA.

Editor’s comment: Bicyclists need better protection. I am tired of complaints about how some cyclists behave. Their foolish behaviour mostly leads to harming themselves. In contrast, the far more dangerous car and truck drivers tend to be tolerated. Until there is equal condemnation for driver infractions, I suggest we cut bicyclists some slack. An example: recently, coroners reports were issued following three bicyclist deaths in Montreal. In the last year, 92 bicyclists were doored; 58 were taken to hospital and 2 died. The fine for dooring is US$30! Alongside a public awareness campaign reminding drivers that dooring is illegal, one coroner recommended charges of criminal negligence and a substantial increase in fines. “Motorists (must) accept that cyclists … are not obligated to restrict themselves to bike lanes.” It is time now for the balance in North America to swing in the direction of the Netherlands.” [emphasis ours] 

Another contributing factor to “dooring” is unsafe infrastructure. For example, even if bike lanes might be associated with overall risk reduction on average, they become a problem when built near to car parking spots, as open car doors usually block most of bike lane areas giving bikers no options to avoid crashes.

A 2014 commentary in Injury PreventionUnsuitability of the epidemiological approach to bicycle transportation injuries and traffic engineering problems, argued that problems such as the ‘door zone’ are also unwittingly created through the application of unsuitable methodologies in an attempt to solve complex problems:

“bicycle lanes have through systematic review received epidemiological approval. In cities around the world, these lanes, whether curbside of parked cars (therefore being cycle tracks) or roadside (ordinary bicycle lanes), typically run in the door zones. They are thus an obvious hazard. What is the common remedy offered, by epidemiologists and governments? Hypervigilance and luck, to be provoked by reducing turnover or putting the conflict on the passenger and curb side, large fines, stickers reminding drivers to watch out, advice to open the door with the opposite hand or for riders to look through vehicle windows for occupants’ heads, or even for occupants to open vehicle doors inch by inch”

It is true that bicycling safety is a complex problem. Indeed, complexity, by nature, increases the unpredictability of effects.  Likely, solutions to the “dooring” problem and others alike, would require embracing this complexity in scientific research and policy development, and also the work of of multidisciplinary teams, including engineers, road users, epidemiologists, sociologists, etc., that can study and rethink bicycling safety from different angles.

Two examples of strategies that are working to address this complexity are Vision Zero and Fatality Free Friday. Both bring together a diverse range of stakeholders – such as local traffic planners and engineers, police officers, policymakers, and public health professionals – to work towards safer mobility.

In the words of Leah Shahum, director of Vision Zero:

traditionally, traffic planners and engineers, police officers, policymakers, and public health professionals have not collaborated in meaningful, cross-disciplinary ways to meet shared goals (partly because they literally did not have shared goals for safe streets).  Vision Zero acknowledges that there are many factors that contribute to safe mobility infrastructure, enforcement, individual behavior/education, and policies — and all must be coordinated with a safety-first approach.”

Injury prevention, at its core, remains a complex endeavour and one in which the strengths of multidisciplinary teams and different fields of research must be harnessed for full effectiveness. 

~ Julian Santaella and Sheree Bekker

Dying en route to safety – the mortality rates of refugees to Europe

15 Sep, 15 | by Klara Johansson

Refugees are often barred from conventional modes of transport, and thus reduced to using unsafe means of travel. But people who are running away from horrible risks are willing to take quite extreme risks. Or as stated by the somalian-british poet Warsan Shire “you have to understand that no one puts their children in a boat unless the water is safer than the land” (from her poem Home, you can read it in fulltext here or hear the author read it herself here).

We’ve seen this over the last few years, when ever-increasing numbers of desperate people attempt to reach Europe, pushed by a number of converging factors (war in Syria, conflicts in Afghanistan and Nigeria, repressive regime in Eritrea – and overfull refugee camps, and instability in Libya, which has previously harboured many refugees). Europe is by no means the most common destination for refugees – millions are displaced within their own countries or harboured in neighbouring countries, often under very difficult conditions – but Europe is the most dangerous destination for clandestine migrants globally, according to the International Organization for Migration.

I’ve been looking for some comprehensive overview of mortality of the refugees entering Europe. There is a lot of data available online, but I couldn’t find any summary of mortality in relation to how many refugees are arriving. So I downloaded some of the available data and made some calculations and graphs, for my own understanding, and now sharing it with you. As always, please let me know if you find some factual errors or missing information (but complete zero-tolerance for haters and demagogues!)

The graph below shows the numbers of arriving migrants side to side with number of deaths (=dead and missing-at-sea), by year and split by which route they arrived. (See extra information about the data at the bottom of this post.) Deaths so far in 2015 are a little over 3,000, of which about 2,800 died on the Mediterranean and about 200 died on European ground. The IOM states that 95% of deaths on the Mediterranean occur along the Central Mediterranean route (going from North Africa to Italy), which we also see here (the red fields). Though the numbers of migrants are the highest in 2015, deaths are lower than in 2011, which is also a conclusion of the latest newsletter of the Migrant Files. This should mean that the overall mortality rate (per number of migrants) is going down. In the left graph, we also see that the safer, Eastern route has increased it’s share in 2015 (as far as I understand, partly from geopolitical reasons). So, have the mortality rates declined per route, or has the overall rate declined because the routes have shifted?

migrants and deaths, low qual smaller

I then computed mortality rates (graph below) based on the two different sources presented above. Combining different sources in this way is of course a risky business, in case they are based on different definitions or such. Or error sources could differ across time for the two sources. For instance, it’s possible that more migrants passed undetected in the earlier years, when Frontex had less resources – but of course, for the same reasons, more deaths could also have been undetected.

Bearing in mind that there are several possible sources of error for the graph below, I still think the graph shows a relevant story. Mortality is indeed down hugely compared to 2011, for all routes and especially for the Central Mediterranean route. Mortality on the Western Mediterranean route (from Morocco to Spain) has kept decreasing. But from 2012 onwards, mortality rates for the most dangerous route, the Central Mediterranean seem to remain roughly the same, despite the large rescue operations. This graph only goes up to July 2015, and the Migrant Files state that mortality rate during June-August has been the lowest since start of data collection, so it’s possible that the graph will change when all of 2015 is included.

The available data is a bit fuzzy still regarding the causes of death (many cases are unclear, so it’s hard to make an overview). For the deaths on the Mediterranean, drowning is one major cause of death of course, while others have suffocated below board or died from dehydration or exhaustion; also some deaths due to fall injuries after being pushed (accidentally or intentionally) and at least two cases of death during childbirth. For the deaths on land during 2015, suffocation seems to dominate (largely inside trucks during transport), followed by traffic related causes – including people hiding under trucks or similar to cross borders, and being crushed after losing their grip –  and exhaustion/dehydration and similar. For previous years, violence and suicide also play a significant role.

Data collection and research on vulnerable, hard-to-reach populations is extremely difficult. The data on deaths I used here have been painstakingly compiled from multiple sources by a group of obviously hardworking journalists; and the data on arrivals are based only on those who are registered. (See more details on data at the bottom of the post.) Both deaths and number of migrants are likely to be underestimated – and the incidence rate of non-fatal injuries remains unknown, along with other information that is vital both for humanitarian efforts and decision-making at the top political level. Maybe some organization could reach out to the refugees and crowdsource information about health, injuries and needs from those who know it best, using for instance a tool like Ushahidi? Refugees and aid workers along the routes have phones, all that would be needed is a central initiative to coordinate and validate the data. And the refugees crossing the mediterranean could maybe be tracked using cell phone data, like one research study did in Haiti, and which is now done at the Flowminder foundation.

For added understanding of the circumstances, turn to professor Hans Rosling:

…and for added understanding of the human side, I share a video from #helpiscoming. But you should have some tissue paper close at hand if you watch it.


About the sources:

Number of deaths are available from at least two sources, the Missing Migrants Project of the International Organization for Migration, and the Migrant Files (the latter is a project from a European consortium of journalists). The method of data compilation seems quite similar between the two sources (combining reports from rescuers, rescued, and media). In many cases of boats rescued at mid-sea, they only know the number of missing, and have no actual dead bodies, which mean that the numbers presented here represent “dead and missing”. The IOM numbers are marginally more conservative, but the difference is small. Since the IOM only has data for 2014 and 2015, I chose to use the data from the Migrant Files. The data is available as a spreadsheet from their site; I downloaded it, cleaned up the categorizations of routes, and summed it up by year, so you won’t find these exact numbers on their site.

I picked the data on arrivals from Frontex, the EU border authority. If you follow the link, data from 2015 are available in the map, and data and metadata for previous years are available per route if you click the arrows in the map. The arrivals along the Western Balkan route is a combination of people who already arrived via the Eastern Mediterranean route, and people arriving across land. So some of those who first came across the Eastern Mediterranean might be registered twice.

Back to basics: On social media and injury prevention

7 Sep, 15 | by Sheree Bekker


I recently attended the inaugral Mayo Clinic Social Media and Healthcare Summit, held in Brisbane, Australia. Billed to excite, educate and demonstrate the power of social media to healthcare providers – no matter where they work or what they do – this promised to be an innovative few days. I have already blogged about this Summit in my capacity as social media coordinator for the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) on my personal blog, which you can read here: #MayoInOz: Curate. Credible. Conversation.

Whilst social media can be perceived as seemingly-frivolous and as an add-on to the work that we do as researchers, I have chosen to do a separate blog post here – as I think that there was an aspect that would be of particular interest to the injury prevention community: that of our responsibility to share vital, potentially injury-preventing or life-saving information via social media. I have blogged on this platform in a light-hearted manner a few times now, and whilst my blog posts are always underpinned by rigorous research from this very journal, it is sometimes easy to forget the very real impact and real-life difference that a seemingly frivolous blog post or status update on social media can make.

This week marks world suicide prevention week. We will see important campaigns staged around the globe to open up this conversation. For example, in Australia, a simple campaign, R U OKAY Day, urges people to reach out to their friends, family, acquaintances, and wider networks to simply ask: ‘Are you okay?’. I have been personally touched by the genuine and heartfelt ways in which friends of mine reach out and ask ‘R U Okay?’ on their social media platforms. Of course, we know that it may not be within our capacity to help, but it is a way to reach out and hold space for others who may be struggling, and in turn to then provide them with the resources or support structures that they may need.

Perhaps this will not be news to most of you reading this, but I learned at the Summit that Google has a similarly simple way of reaching out: if you type the word ‘suicide’ into Google, your first result will be a helpful resource based on your IP address. In other words, you get relevant, credible information irrespective of who or where you are. Yes – suicide prevention is incredibly complex, and a simple initiative such as this one by no means provides all the answers – nevertheless, it remains important.



One of the more innovative forms of simple social media messaging shared at the Summit was the Twitter-Storm: a 10-minute en masse blast of credible information to counteract a trend of dubious information on a current topic. This was done with much success for #MeaslesTruth (read more: Did #MeaslesTruth Create a New Form of Twitter Communication?). 

A further important initiative shared at the Summit is the Healthcare Hashtag Project – in which experts are working to standardize hashtags used for common healthcare issues. It is fascinating, and an excellent way in which to curate credible information under a conversation linked to a hashtag on Twitter.

Could we harness simple initiatives such as these for injury prevention messages?

Social media, and the internet as a whole, can be a wonderful resource. It is our job as injury prevention advocates to use it to amplify our voices to spread our message. To not engage becomes ethically problematic, especially if you have the information and resources at your fingertips. As researchers, it is important to remember that we do not always need to disseminate purely our most up-to-date research results, or even the most innovative interventions; sometimes our work life’s work is bigger than that. Sometimes we need to advocate for the very heart that lies at our work: simple, credible information and resources that can make a difference in even one person’s life.

Food for thought.

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