INTRODUCTION

The relationship between accidents in the home and those that occur during leisure time, on the one hand, and permanent injuries, on the other, is one that has attracted virtually no research interest. Unlike the analysis of the impact of other types of accident, such as traffic accidents or accidents at work (see, among many others, Mohanty et al. (2022)Mohanty, Panda, Gandupalli, Arya, and Lenka (2022)), those occurring at home or while performing leisure, cultural and sports activities have been largely ignored, due to the lack of rigorous databases that might support detailed analyses. However, two trends highlight the increasing need to advance in the study of home and leisure accidents (HLAs): on the one hand, population aging will probably cause an increase of accidents at home, given the high correlation between advanced ages and falls in the home; and, on the other, people’s changing habits with regards to their participation in sports and leisure activities, with higher than ever accident rates being recorded among youngsters due to participation in sport activities, and among the older population when other types of leisure and cultural activity are included in the analysis. ¹ The increase in the number of people left vulnerable to risks of home and leisure accidents and their associated physical and socioeconomic consequences motivate our analysis.

In this study, we define HLAs as any unintended event that causes physical and/or psychological injuries to a person while inside their home or in any of the outbuildings of that property, or while participating in a recreational, leisure, sport or educational activity. As such, suicides, incidents of self-harm, traffic accidents, work accidents and acts of violence are excluded from the definition.

According to the most recent data, about 24.6 million people suffered HLAs in the European Union (EU) between 2012 and 2014 (Eurosafe, 2016). Recently, in November 2022, the Swiss Council for Accident Prevention BFU ² reported that more accidents occur at home and in leisure time, excluding sports, than on the roads and in sports combined. According to BFU projections, the trend is increasing, and people over the age of 85 are especially prone to serious injuries occurred in private homes (81% of cases corresponding to falls). These results are in line with earlier reports published by the World Health Organization (WHO, 2009), indicating that 63% of all unintentional injuries occur at home, in sports or during leisure time. Indeed, the rate of fatalities resulting from injuries incurred during HLAs in the EU is projected to be double that of traffic accidents, and more than ten times that of workplace accidents (EuroSafe, 2006). In Norway,Lund and Bjerkedal (2001) found that 20% of all accidents resulted from domestic and leisure activities, with the ratio between disability pensions and mortality resulting from home accidents standing at 1:2.7 in the 15-64 age group. As for prevention,Keall et al. (2015) show that home modifications aimed at preventing domestic injuries help reduce specific bodily damages by 39%, and injuries attributed to falls that require medical attention by 26%.

Studies examining the relationship between HLAs and permanent injuries and disability are rare. In a study of severe domestic injuries as a cause of disability in Turkey,Kiliç et al. (2017) show that the risks of HLAs causing injury and subsequent disability are, respectively, four and six times higher in children under the age of five than in the rest of the age groups.Chammem, Domi, Vecchia, Gilbert, and Schott (2021) indicate that the occurrence of a harsh event affecting elderly people, such as a domestic accident, usually motivates a significant change in their lifestyle or living environment. Studies of the relationship between home accidents and the elderly are more frequent than for younger population (Spanish Ministry of Health, Social Services and Equality, 2011; ) (Heywood & Turner, 2007; Vicente & García, 2013). Here, we define disability as the difficulty performing the basic activities of daily living (ADLs) (that is, of mobility, eating, maintaining continence, etc.) as well as the so-called instrumental and functional activities (that is, answering the phone, managing personal finances, etc.). These disabilities are considered permanent when they affect an individual for more than a year and are deemed irreversible (their sequelae affecting the individual for the rest of their life).

Several studies have analyzed the effects of HLAs in terms of hospital visits/admissions, and medical and administrative expenses (Alves et al., 2020; ) (Hopkin & Simpson, 1996; Veisten, Nossum, & Akhtar, 2009), as well as during the COVID-19 pandemic (Alves, Rodrigues, Neto, Mexia, & Matias-Dias, 2021). Others have analyzed their social impact on early mortality, reduction in productivity and the social costs attributable to disability (Veisten & Nossum, 2007). In Spain, a report entitled “Injury Prevention Program: Detection of Domestic and Leisure Accidents 2011” (DADO 2011), carried out by the Ministry of Health, Social Services and Equality in the framework of an initiative launched by the European Parliament and the EU Council in 1999, is probably the most pertinent source of information for studying the profile of HLAs. Data for the report were obtained about the sociodemographic characteristics of the victims, the nature of the accidents and the injuries incurred in a total of 7,751 domestic and leisure accidents. ³ HLA injuries are among the most frequently occurring injuries in Spain but among the least studied, with 5 out of every 100 Spaniards suffering an HLA each year, according to the DADO report (2011).

In a similar way,Mateos et al. (2012) study the sociodemographic characteristics of victims (age, sex, time, place, type and cause of accident) in a representative sample of 2,889 HLAs registered in 88 primary healthcare centers in Castile and León, ⁴ and report that the most frequent accidents are falls occurring in the home on weekdays. DVicente and García (2013) arrived at similar conclusions using a sample of 1,067 individuals aged over 65 who reside in their family homes. Falls are found to be the most frequent type of accident being recorded in 36% of the households analyzed.

Now we propose conducting a similar analysis to that carried out by Alemany, Ayuso, and Guillen (2013) for the impact of road traffic injuries, albeit that our objective here is to determine the impact of injuries resulting from HLAs on long-term care (LTC) prevalence rates in Spain. All information here about disabilities, aging and the population’s health status has been obtained from the Survey of Disability, Personal Autonomy and Long Term Care situations EDAD 2020, conducted by the Spanish National Institute of Statistics. Since 2007, Spanish Law 39/2006 of 14 December has promoted the provision of personal care for dependent people and offers long-term care to citizens who cannot perform the basic ADLs without the help of a third party. Note that from responses obtained in the EDAD2020 survey we cannot exactly know whether or not people have an official LTC level as stablished by the Spanish law, but we can estimate it based on the answers that the respondents do offer about whether or not they suffer from the disabilities that are taken into account in the official assessment of the level of LTC in Spain, and their severity, information that does appear in the survey. The authors use the formula that the regulated LTC scale itself establishes in order to estimate the LTC score assigned to each individual. In line with what the LTC Law itself indicates, if the estimated score for the individual is less than 25, it is estimated that the respondent has a LTC level equal to zero and is not entitled to public LTC coverage. If the estimated score is between 25 and 50 points, the respondent has a LTC level equal to one (I), or moderate level, with public coverage. If the score is between 50 and 75 points, the estimated LTC level is two (II) or severe; and if it is greater than 75, the estimated LTC level is maximum or level III. Logically, these last two with public coverage.

Here, we analyze: (a) chronic impairment attributable to HLAs; (b) estimated LTC prevalence rates attributable to HLAs among people aged 6 years and older; (c) estimated LTC prevalence severity levels attributable to HLAs; (d) estimated 2020 LTC annual cost associated with HLAs, according prevalence rates for each severity level and expected hours of care by third parties; and its volume as a fraction of the Spanish GDP. Finally, we compare distributions of impairment, age and LTC prevalence severity levels for people presenting disabilities attributable to both HLAs and other causes. In so doing, we select the least restrictive definition and consider a victim of an HLA needing long term care when they present at least one limitation (sight, hearing, communication, etc.) attributable to HLA causes.⁵

DATA AND METHODS

The Survey of Disability, Personal Autonomy and Long Term Care situations EDAD 2020 is a macro-survey aimed at all people aged 2 and over who reside in family homes throughout the Spanish territory. This survey is not conducted with regular periodicity. 68,000 households are interviewed after a stratified two-stage sampling is performed. A multichannel interviewing method is implemented (web questionnaire, personal interview and computer-assisted telephone interview). The concept of disability is identified when an individual answer positively to the whether they suffer "significant limitations to the performance of activities of daily living that have lasted or are expected to last more than one year, and that have their origin in an impairment”. Once the presence of a person with a disability at home has been recognised, an additional extensive questionnaire for that person is conducted individually. Table 1 presents the set of activities of daily living (ADLs) considered in the analysis and corresponds directly to the protocol for evaluation of the degree of LTC published in the Spanish LTC assessment scale (RD 174/2011 and Resolution of July 13, 2012). As mandated by law, the evaluation aims to identify whether or not there are limitations to perform each ADL, and the corresponding level of difficulty.

In this study, we consider those individuals that explicitly stated that at least one of their functional or sensory limitations are attributable to HLAs. We then use the Spanish LTC valuation score, which we call the LTC index, to quantify the LTC severity level of the disabled individuals and their LTC needs. The LTC index considers the 21 disabilities presented in Table 2, which are directly related to the ten categories of functional/sensory limitations defined in Table 1.

The LTC index of person $i$ , $S_i,$ is calculated using the following formula,

where $D_{ij}$ is a dichotomous variable with a value of 1 if individual i suffers disability j and 0 otherwise ( $i=1,\dots ,N;j=1,\dots ,21$ ) and $N$ is the sample size; $C_{ij}$ is a categorical variable for which the Law establishes a value of 0.9 if the need for support $j$ for individual i is moderate, 0.95 if it is severe, 1 if it is full, and 0 if no support is required; and, variable $P_{ij}$ includes the scoring factors provided in Table 1 for disability $j$ .

The LTC index ranges between 0 and 100. When the score is under 25, the individual suffers some impairment but the severity is considered low and the evaluation concludes that the individual does not require third-person help (level 0); if the score is between 25 and 50, the individual is considered to have moderate LTC (level 1) and requires help at least once a day; if the score is between 50 and 75, the LTC level is considered severe (level 2) and the individual requires help more than once a day, albeit not permanently; finally, if the score is over 75, the individual has full LTC (level 3) and requires permanent help.

Here, we calculate national LTC prevalence rates estimates by incorporating the population aged 6 years or older (Ine, 2021) from the EDAD 2020 sample weights and the 2020 Spanish Census estimates. The analysis has been conducted using R. First, we estimate the LTC prevalence rates attributable to HLAs by using formula (1). Note that we refer to HLA-long term care when an impairment is attributable to disabilities that were caused by a home or leisure accident. Then, we estimate the costs associated to dependent individuals in terms of third-person help as a consequence of their HLA, and compare these costs and those attributable to other causes. We consider the same LTC-need scenarios used in previous studies as provided by geriatricians and social workers (Ayuso & Guillen, 2011) to undertake these calculations.

The average costs (per hour or per year) for formal LTC services provided in Spain are presented in Table 3, and the care needs at each LTC severity level are presented in Table 4. According previous research (Alemany et al., 2013; Artís, Ayuso, Guillen, & Monteverde, 2007), an individual with a moderate level of LTC needs can be expected to require home help for three hours each day; individuals with a severe level of LTC needs require support in a day care center and home help for one hour each day; and those with full disability require supervision in a nursing home because their needs are permanent. Because the same caregiver can visit several patients, severe dependents will incur a lower average expected cost than moderate dependents. According to the Resolution passed on 13 July 2012 by the Spanish Secretary of State for Social Services and Equality, public coverage extends to a maximum of 20 hours per month for those with moderate dependence; between 21 and 45 hours per month for those with severe dependence; and between 46 and 70 hours per month for those with full dependence. Copayment costs can be high.

RESULTS

Based on the estimated Spanish population aged 6+ according to EDAD 2020 the prevalence of disabilities considering all causes is 9.35%. The prevalence of disabilities caused by HLAs is 0.42%, which is higher than the prevalence of disabilities attributed to traffic accidents, which is estimated at 0.20%. In absolute terms, in Spain we estimate that there are more than 4 million people with disabilities aged 6 or older. We estimate that 193,799 individuals ⁵ present a disability attributable to HLAs and 91,679 individuals have a disability caused by a traffic accident.

In Table 5 we present estimated impairment prevalence rates for every 100 disabled individuals when considering i) all possible causes, ii) only accidents in the home, and iii) only leisure accidents, for each of the 21 impairments included in the LTC index. Figure 1 presents a comparison and shows that mobility and physical effort impairments among victims of HLAs is significantly high. ⁶ Of those disabled as a result of HLAs, 71.50% (home) and 58.92% (leisure), respectively, have major difficulties walking, moving or travelling outside their home unaided (type 14 in Table 2). Similarly, 57.37% and 47.13%, respectively, have difficulties maintaining the body in the same position, changing their body posture or walking and moving in their house without help or supervision (type 13 in Table 2).

Similarly, they also have problems when trying to perform their own self-care: 47.66% (home) and 32.60% (leisure), respectively, have major difficulties cleaning or drying parts of body or performing other basic body care activities without help or supervision (type 17 in Table 2); and 42.27% and 30.24%, respectively, have difficulties dressing, undressing, feeding themselves, going to the bathroom or taking medicine unaided (type 18 in Table 2).

In some cases, estimated impairment prevalence rates are higher among victims of home accidents than among those that have suffered leisure accidents. This is the case of undertaking daily housework activities (type 20 in Table 2): 58.27% for disabilities due to home accidents (vs. 36.46% for those caused by leisure accidents); organizing and buying food, clothes or other house items without help or supervision (type 19 in Table 2): 56.44% (vs. 39.57%, respectively); lifting or carrying an object using hands and arms without help or supervision (type 15 in Table 2): 31.75% (vs. 28.54%); seeing the letter of a newspaper when wearing glasses or contact lenses (type 2 in Table 2): 13.44% (vs. 10.91%); and being blind (type 1 in Table 2): 3.03% (vs. 2.01%). In contrast, major difficulties manipulating and moving objects using arms, hands and fingers without help or supervision (type 16 in Table 2): 20.58% (vs. 17.75%) are more marked among those that have suffered leisure accidents than for those who suffered a home accident.

Estimated impairment prevalence rates for Spanish population over 6 years old with disability due to any cause and separately as a result of home and leisure accidents (EDAD 2020)

Table 6 shows the estimated number of people with disabilities caused by HLAs vs. the rest of causes by age interval in Spain, according to EDAD 2020 (total Spanish population by age interval is also shown). Table 7 and Figure 2 present the estimated rates of prevalence of disabilities as a result of HLAs vs. all other causes, by age interval. As is evident (Table 6), the number of people with disabilities among younger adults (especially up to the age of 44) attributable to leisure accidents is higher than that attributable to home accidents, a pattern that is also reflected in the estimated prevalence rates (Table 7). Indeed, up to approximately the age of 54, the prevalence of leisure accidents is higher than that of domestic accidents. However, after that age, the prevalence rates for home accidents begin to increase exponentially, at rates that are even higher than those attributable to the rest of causes. These results confirm previous research findings that identify domestic accidents as one of the leading causes of disability in the elderly (BFU, 2022; De Vicente and Garcia, 2013). Rates of leisure accidents also increase with age but their incidence in the older population is notably lower than that of accidents in the home.

When we use formula (1) and compute the LTC index for a person $i$ , $S_i,$ according to EDAD 2020, we obtain the Spanish LTC prevalence rates attributable to HLAs and the rest of causes by level of severity (levels 0, 1, 2, and 3), as has been explained at section 2. Our results (Table 8 and Figure 3) highlight the marked impact of home and leisure accidents on the LTC severity levels, with higher rates than those reported for the rest of causes (with the sole exception of the rate for level 2 attributable to leisure accidents – last column Table 8). However, notable differences are detected by age interval. Thus, while the incidence of home accidents on LTC care needs is very low up to the age of 35, leisure accidents have a marked incidence on the prevalence of full severity level (level 3) up to the age of 24. For the 25-34 age group, 42.72% of people with LTC needs attributable to leisure accidents present a moderate severity level (level 1) and 26.39% a severe level (level 2), figures that are significantly higher than those attributable to the rest of causes in this age group (12.34 and 5.48%, respectively). Given these LTC levels in young people attributable to leisure accidents, and specifically the need for long-term assistance, the impact on LTC costs, as we discuss in the next section, is likely to be high.

The LTC severity level for victims of home accidents after the age of 55 is predominantly moderate to severe (levels 1 and 2, respectively). For example, in the 55-64 age group, the prevalence of moderate and severe LTC needs is 36.84 and 13.49%, respectively vs. 17.57 and 6.27%, respectively, for the rest of causes (excluding leisure accidents). The LTC needs becomes more evident in the population over the age of 65; indeed, between 75 and 84 y.o., almost 78% people with LTC needs as a result of a domestic accident are at level 1 or higher vs. c. 47% of those with LTC needs as a result of other causes (excluding leisure accidents).

These percentages increase to 93 and 63% respectively from the age of 85. Moreover, we detect a marked rise in those presenting full severity level (level 3) in later life, increasing from 21.59% in the 65-74 age group to 52.11% for victims of domestic accidents aged over 85.

In short, what our result show is the notable incidence of leisure accidents on the LTC needs of Spain’s young and adult population, and the rising incidence of home accidents on that of Spain’s older population.

Based on the estimated prevalence of the LTC levels presented by Spain’s disabled population over 6 years old, and according long term care needs at each severity level as presented in table 4, in Table 9 we present the estimated total annual costs related to third parties help -we name them LTC costs-in 2020 (the year the survey was conducted) for individuals with disabilities attributable to HLAs and those with impairments attributable to the rest of causes. In the case of home accidents (upper panel), these costs rise to c. 1,547 million euros in 2020; in the case of leisure accidents they rise to c. 647 million euros. These totals represent 0.138% and 0.058% of Spanish GDP for 2020, respectively. ⁷ The impact in terms of cost for domestic accidents is, as expected, greater than that of leisure accidents, given the higher number of people that need help from third parties attributable to the former. This impact is also greater than that attributable to the rest of causes, including most notably disabilities caused by road traffic injuries (the LTC cost of traffic accidents is estimated at 869 million euros in 2020, 44% lower than the costs attributable to domestic accidents).

The highest percentage of home accidents was suffered by those over the age of 55, with LTC costs as a percentage of total costs representing 5.28% in the 55-64 age group, 3.23% in the 65-74 age group, 5.95% in the 75-84 age interval and reaching 7.03% for those aged over 85. In contrast, LTC costs for victims of leisure accidents are higher for the young and adult populations, representing 3.26% of total costs for those in the 18-24 age group, 3.88% of total costs for those in the 25-34 age group and 5.60% for those in the 35-44 age interval. Above the age of 65, LTC costs attributable to leisure activities are notably lower (less than 3% in all age groups).

Results, when analyzed according to the severity level, are also revealing. Individuals aged 18-24 with level 3 following a leisure accident represent 6.36% of annual LTC costs, a figure that is 9.50% in the case of those in the 45-54 age group. These percentages correspond approximately to 12.92 million euros for the former and 59.53 million for the latter. Level 3 in the 75-84 age group with a disability attributable to home accidents represent 6.72% of annual LTC costs, and 8.04% in those aged 85+ (that is, 194.41 and 405.56 million euros, respectively).

Despite the obvious impact of full severity level (level 3) on total LTC costs, the costs associated with the lower severity level in 2020 should not be ignored. For example, level 1 in the 25-34 age group with a disability attributable to leisure accidents account for 6.02% (c. 13.96 million) of annual estimated LTC costs, while level 1 in the 75-84 age group, victims of home accidents, represent 5.54% of annual costs (200.72 million euros).

Total estimated LTC costs attributable to leisure accidents represent 647 million euros in 2020, while total estimated LTC costs attributable to home accidents represent 1,547 million euros in 2020.

DISCUSSION

Different studies have focused on assessing the social and economic impacts that long-term care can have, both from the point of view of formal and informal care provision ( ; Klimaviciute and Pestieau, 2023 and so on) (Alcañiz, Alemany, Bolancé, & Guillen, 2016; Comas-Herrera et al., 2003; Guralnik, Alecxih, Branch, & Wiener, 2002; Pozo & Escribano, 2012). However, studies on the incidence of HLAs and their impact on LTC needs are practically non-existent in the literature. Indeed, disability and long term care have typically been analyzed globally, sometimes in the context of mortality ( ; Kogure et al., 2021, and so on) (Artís et al., 2007) with few studies focusing on specific causes of disability (Mayhew & Smith, 2021) or regional disparities (Pons-Novell & Guillen, 2022). To the best of our knowledge, some authors have analyzed factors, other than aging and health, in the context of road traffic injuries (Alemany et al., 2013; Shults, Jones, Kresnow, Langlois, & Guerrero, 2004; Zimmerman, Mzige, Kibatala, Museru, & Guerrero, 2012), but analyses of other causes, including HLAs, are much less frequent.

Changes in lifestyle such as increasing sports activities, greater propensity to travel, and increased cultural activities may be associated with an increase in the accident rate linked to these causes, which may increase the likelihood of LTC needs if preventive policies are not designed to address this impact. In addition, the elderly is more prone to domestic accidents, what in contexts of greater longevity may contribute to an increase in LTC needs (Chammem et al., 2021).

According to the EDAD 2020 survey, the estimated disability prevalence rates in Spain for people aged 6+ are 9.35% when including all causes, and 0.42% when considering only HLAs. Although the percentage of HLAs in total disability cases is lower, victims of HLAs still constitute a significant group of individuals with lifelong LTC needs.

Our results confirm that the incidence of HLAs in Spain is greater than that attributable to traffic accidents, and therefore, public entities should attach more importance to accidents of this type, as is the case with traffic accidents where road safety campaigns are frequent. Providing more information to the public, including both the younger and the elderly population, about the potential consequences of HLAs could reduce their physical and economic consequences. Moreover, greater awareness of the associated LTC needs may lead individuals to seek additional coverage for this type of risk, such as through insurance (He, Qian, Chan, & Chou, 2023; Mayhew & Smith, 2021; Shang, Wang, Qin, & Zhao, 2023; Xia, Chai, Zhang, & Sun, 2022).

For victims of domestic and leisure accidents, the greatest functional limitations are related to mobility and the realization of physical effort. The impact of home accidents on the LTC prevalence rates is higher in those aged over 55, while leisure accidents have a more marked effect on the young and adult populations (up to the age of 54). Indeed, the incidence of leisure accidents in preventing young and adult people from forming part of the labor market should not be ignored. However, we should not underestimate the increasing incidence of leisure accidents among older individuals, reflecting what is probably a change in lifestyle (travelling more, greater participation in cultural activities, etc.). The LTC prevalence attributable to domestic accidents present an exponential behavior with age, a pattern that is not observed for leisure accidents.

Various studies have analyzed the economic impact of HLAs in terms of administrative costs and hospitalization rates (Alves et al., 2020; ) (Hopkin & Simpson, 1996; Veisten & Nossum, 2007; Veisten et al., 2009; Walter, 2010) but, to the best of our knowledge, we are unaware of any studies that have attempted to quantify the costs of LTC (i.e. assistance from a third party) when the cause of disability is either a domestic or leisure accident. Previous studies demonstrate that the adoption of preventive measures in the homes of the elderly (replacement of bathtubs for showers, etc.), or the provision of technical aids (elevators and rotating discs in armchairs, adjustable beds, etc.) can help increase autonomy, reducing the probability of accidents and LTC needs (Alemany et al., 2013; Heywood & Turner, 2007; Keall et al., 2015; Meseri, Demiral, Sönmez, Kaynak, & Ergör, 2017). The rapidly rising numbers of people that will reach advanced ages, as a consequence of increasing longevity, means we cannot underestimate the relevance of HLAs, given the impact they are likely to have on the budget for the LTC coverage, both at the public and individual level. However, one of the limitations of our work would be given by the aggregation we carry out in relation to the care needs for the different LTC levels, as they appear in the table 4. We have followed the criterion used in previous studies (Alemany et al., 2013) but asPozo and Escribano (2013) point out, the level of heterogeneity in terms of benefits received based on the LTC law in Spain could be high. The analysis of dispersion in the estimates is proposed as a future line of research. To do this, it will be necessary to have more detailed information on the personalized help offered by law to people who suffer long term care needs from HLA causes, or to make estimates based on the personalized help for any cause, using processes similar to those carried out by other authors (Pozo & Escribano, 2013).

One of the main reflections obtained from the research carried out is the tendency to work together leisure accidents and household accidents in the existing literature. From our point of view, it is to be expected that both causes will begin to be worked on independently, as a greater number of people in older age ranges become available, and that both causes will end up representing a greater weight in the set of causes that lead to long-term care.

ACKNOWLEDGEMENTS

The authors are grateful to the Spanish Ministry of Science and Innovation for funding received under grant PID2019-105986GB-C21, and AGAUR 2021 SGR 00299.