How Healthy Is Camp? Exploring Early Results From the Surveillance Study of Injuries and Illness

by Linda E. Erceg., R.N., M.S., P.H.N.; Barry A. Garst, Ph.D.; Gwynn M. Powell, Ph.D.; and R. Dawn Comstock, Ph.D.


ACA Mission Partner
Markel Insurance Company is providing the financial support needed to continue this project for five consecutive summers.

Healthy Camp Study
This article explores what was learned from the Healthy Camp Study during the first two years of the study (summers of 2006 and 2007). Although we'll have a more complete picture after the next three years of the study, we are already gaining important information about where camps might target prevention efforts. Before you read about these results, think about how your camp currently benefits from this exciting study. Have you participated in either or both of the past two summers? Did you know that participation is free and that you can still enroll for next summer? Did you know that you don't have to be ACA accredited or be affiliated in any particular way in order to participate? Did you know that participating camps receive a detailed injury-illness report that they can use as a risk-management tool?

Learn how to monitor and analyze your injury and illness data and the best strategies to keep your staff on the job and your campers in program and not in the health lodge. See your health statistics in comparison to national averages. Join hundreds of other camps and learn as a collective group. Find out how you can be a part of the Healthy Camp Study by contacting the ACA Research Team at 765-349-3511 or or visit Healthy Camp Study.

We all want camp to be as safe as possible. But how can we really determine if camp is safe in comparison to other places where youth spend their time? For several years, the American Camp Association (ACA) has recognized that in order to make good decisions about camp safety and quality, we need to collect useful, relevant information about the camp experience that can be translated into new knowledge and (most importantly) specific, practical strategies that camps can use. With this philosophy in mind, ACA embarked on an ambitious five-year surveillance study of U.S. camp injuries and illness sponsored by Markel Insurance. Although research indicated that youth are more likely to get injured playing football, soccer, and volleyball than in camp (Centers for Disease Control 2006), ACA believed that much more could be learned to improve our camp health and wellness efforts. Camps are committed to ongoing program improvement and few directors and administrators pass up the opportunity to improve camp safety by reducing the likelihood of camper and staff injuries and illness.

There are two important concepts to keep in mind as you read the results: impact and rate. First, the Healthy Camp Study looked at injuries and illness that had "impact." What does this mean? For resident camps, impact was described as an injury or illness that took a person (i.e., camper or staff member) away from their usual camp experience for at least four hours. For the day camp community, injuries and illnesses had to remove a person from their usual camp experience for at least one hour. By examining only the injuries and illness that met these criteria, the study examined only the most impactful incidents. This does not minimize skinned knees and mosquito bites, but rather, this keeps the focus on those injuries and illnesses that take campers and staff out of their camp experience. We all want the same thing — to keep our campers and staff in camp!

The second important concept pertains to the word "rate." Many readers are familiar with using percentile (percent) to get an idea of how pervasive something is. While some data in this study will be reported in percent, the core data is reported as a rate. Rate accounts for "exposure" (i.e., the length of time a person was at camp) in the results. Campers who spent a week at camp had less exposure than campers who stayed four or more weeks. The same held true for staff; the number of days a staff member worked determined how long that person was exposed to camp risks. An employee who worked only a week had a different exposure than a person who worked all summer. Using a rate meant the data was adjusted for this and was reported as "per 1,000 camp days." To make sense of this, imagine 1,000 of your campers and staff standing in front of you. Now imagine that you were told that your camp injury-illness rate per 1,000 camp days was 1.5. This means that given those 1,000 people, 1.5 of them would get so injured or ill on this day that it pulled them from their camp routine (met the definition for inclusion in this study). Let's explore some of the Healthy Camp Study findings.

Quick Look at the Overall Results

While it's interesting to look at results from individual camps, pooling data across camps allowed a fuller understanding of what is happening in camps across the nation. In 2006, 140 camps (88 resident and 52 day) participated in the Healthy Camp Study, and in 2007, 160 camps (110 resident and 50 day) were involved. Take a look at Table 1 to see the types of information that camp health care staff reported each week.

During the summers of 2006 and 2007, the injury and illness data remained relatively constant, which increases our ability to trust the results and highlights areas we should investigate. The broad understanding we gained can be summarized as:

  • The likelihood of campers or staff getting ill or injured is fairly low (about 1.5 people in resident camps and about 0.75 people in day camps per 1,000 camp days).
  • Campers and staff tend to get ill more often than injured in both day and resident camps.
  • Campers and staff experience injuries and illness differently.

Each of these results triggers questions best answered by looking more deeply into the data. Because resident and day camps experienced injuries and illness differently, we'll explore them separately. Want to know how day and resident camps' results differed?

Injuries and Illness in Resident Camps

The likelihood of a person becoming ill or injured enough to impact their camp experience is relatively low (about 1.47 incidents per 1,000 camp days). If something does occur, a person is more likely to become ill (1.00 per 1,000 camp days), than be injured (0.46 incidents per 1,000 camp days). The same trend is true when we compare campers and staff. One would expect campers to have many more impactful incidents than staff because of their higher growth and development rate. Yet, the data shows relatively similar rates. On average, campers sustained five adverse events for every four staff adverse events.

When an incident did occur, the majority of campers and staff received care for that injury or illness on-site at camp (54.9 percent in 2007). However, 43.4 percent of the incidents were significant enough that the person not only lost at least four hours from camp but also received treatment off-site (e.g., saw a physician in town). Assuming that most resident camps would prefer that campers and staff not lose camp time by going offsite for care, this suggests that resident camps can either improve the ability of health care professionals to provide care at camp and/ or reduce the severity of incidents so not as many need out-of-camp care. Although it was rare that an incident resulted in a camper or staff member not returning to camp (about 5 percent overall), overall down-time from injury-illness events was substantial. Fiftyfive percent of camper injury-illness events kept them away from their camp experience for four to twenty-four hours, and 58 percent of staff events kept them away from their job duties for four to twenty-four hours. Imagine how different camp would be if you weren't losing these staff hours!

Resident Camp Injuries
Sprains/strains (28.9 percent) topped the list of injuries most likely to take people away from camp for four or more hours, followed by wounds (15.4 percent); bruises/ contusions (15.0 percent); and fractures (15.0 percent). The context in which these injuries occurred included: while playing a sport or game (34.4 percent); during other recreational activity (15.7 percent); while walking (8.4 percent); and when running, jogging, or jumping (6.3 percent). Since these injuries occurred during some type of physical activity, it raises the question of supervision as well as use of protective equipment. In about 40 percent of these injuries the activity was one for which protective equipment was recommended yet it was not used about 15 percent of the time. When injury occurred, a staff/volunteer person was on-site and on duty only 23.5 percent of the time.

What are we doing at camp to increase the use of sports equipment that is appropriate for participants' age and development level? How can we ensure that proper supervision is provided during camp activities, particularly those requiring physical activity and movement? Camps were asked if staff were present at the area when the incident occurred, but the study did not assess the adequacy of staff supervision, which is something that is being considered starting in 2008.

Injuries tended to happen to male campers (58 percent of camper incidents) and female staff (55 percent of staff incidents) and were more likely to occur midweek (Wednesday and Thursday) with more injuries occurring between noon and 6:00 p.m. than at other times of day. About 10 percent of all injuries were associated with pre-existing chronic conditions.

A new piece of information regarding knife injuries by resident camp staff requires special attention as it was not reported in 2006. A significant number of knife injuries involved cutting a finger (81.8 percent) during food preparation (73 percent) and needing treatment off-site (63.6 percent). Since job-related injury impacts worker compensation rates and given that there are training programs that target this risk, it is an area that needs our attention. Are there better ways to train staff in proper cutting techniques? What type of training is available in the use of knives and other sharp objects? What protective equipment might reduce this type of injury?

Specifically with regards to injury, both campers and staff at resident camps were more likely to have an injury treated off-site (68 percent for campers, 75 percent for staff) than to remain at camp for treatment. Since the study group reported that most health center staff were professionals (licensed MDs and RNs), this may well reflect the need for professional equipment and skills — like stitches and X-ray — that are not available at most camp health centers. In addition, caring for staff injuries may be influenced by workers' compensation procedures and, as a result, make it more likely that staff were referred out-of-camp for treatment.

Resident Camp Illness
Illness has more impact on campers and staff than injury. Campers were injured at a rate of 0.48 per 1,000 camp days, but got ill — to the point of it interrupting the camp experience for at least four hours — at a rate of 1.06 per 1,000 camp days. A similar ratio was shared by staff: their illness rate (0.83) was about twice their injury rate (0.41). Illness among female staff (65 percent) was more common than male staff illness (35 percent). Male campers reported more illness (54 percent) than female campers (46 percent). These illnesses were related to a chronic medical condition 20.4 percent of the time for campers, and 18.8 percent of the time among staff. Almost one in five illnesses reflected a chronic health condition, meaning that camps may want to monitor the status of people with chronic health conditions closely.

Like injuries, illnesses were more likely to be reported during camp activities and during free time, but illness rates also increased during overnight experiences, something not seen in the injury data. As might be expected, illness was more likely to occur as the day wore on, which may be related to individuals' circadian cycles — the natural ebb and flow of physiology. Illnesses were also more likely to be treated at camp if one was a camper (75 percent) but had a 50:50 chance of referral for out-of-camp care if the individual was a staff member.

Illness symptoms tended to be upper respiratory events (27 percent for campers, 29 percent for staff ) followed by gastrointestinal events (20.1 percent for campers, 17.3 percent for staff) and unspecified virus/ fever events (10.2 percent for campers, 10.6 percent for staff ). This raises a question about the impact of communicable diseases within the resident camp population. Communicability was reported in 2007 in 42 percent of the camper illness events and 41 percent of the staff events; however, only half of these were communicable illnesses actually seen in other people, suggesting that communicable illness is certainly present but not always passed along within the resident camp community.

Injuries and Illness in Day Camps

For day camps, this section focuses on 2007 data, because after the summer of 2006 the definition of a reportable injury-illness event for the day camp population was modified. In 2006, injury-illness events took a camper or staff away from their expected camp experience for four hours or more; starting in 2007, it was changed to one hour. This change was made after careful consideration of the day camp community. In day camps, once one loses an hour of work or activity at a day camp, it's impactful, hence the change. As a result, data from Year 1 and Year 2 cannot be directly compared.

Overall, the likelihood of someone experiencing an impactful illness or injury during their day camp experience was low (0.70 per 1,000 camp days for campers and 0.92 for staff) (Table 2). While campers shared a comparable injury rate with their day camp staff (0.30 and 0.33 respectively), the two groups had different illness experiences (0.41 per 1000 camp days for campers and 0.60 for staff). Campers, on average, were more likely to present to health care staff with an injury as compared to an illness, which may be explained by day campers who are kept home by their parents when ill. This suggests that day camps that focus on injury reduction among campers may reduce the time and monetary impact of this experience for their campers (and parents).

In contrast with campers, day camp staff were twice as likely to become ill than injured. Female staff were more likely than male staff to become ill or injured. This tendency for female staff to become ill may reflect the demographic trend that more females than males work in day camp staff positions. Camps that focus on illness prevention among day camp staff may improve the operational burdens associated with reduced and/or limited staffing.

The camper groups, however, were fairly balanced between males and females regardless of injury or illness events. While most of the camper events (61.3 percent of illness and 66.4 percent of injuries) occurred while the camper was at camp, the data also suggests that away-from-camp day trips do contribute to the injuryillness burden among campers (around 38 percent). Since a camp's usual health care provider is often not on these day trips, the potential impact of away-from-camp injuries and illness may be greater than those experienced on-site.

Injury-illness events occurred most commonly during day camp activities rather than during free (unscheduled) time or meal breaks. However, overnight experiences accounted for almost 50 percent of staff illnesses. What happens on those overnights? In addition, injury-illness events tended to occur most often to campers on Monday, Tuesday, and Wednesday, but on Thursday and Friday for staff. Why this difference? Finally, events clustered around midday (10:00 a.m. – 3 p.m.), which may be more related to a day camp's hours of operation than anything else — with two exceptions: hunger and fatigue. Injury epidemiology indicates that as humans fatigue and/or get hungry, the chance of an incident increases (Williamson 2006). There is much more to learn here.

Most camper events were treated at camp whereas a significant percent of staff events, over 60 percent of injuries in particular, were treated off-site. In fact, day camp staff were seven times more likely than campers to seek off-site treatment for their injury-illness events. Given that many day camps do not have in-camp, licensed health care professionals, this may indicate that staff events were significant enough that they needed professional assessment, hence the need for out-of-camp referral, or this may indicate a difference in severity between camper and staff events.

With regard to illness, day campers and staff sought health care primarily because of gastrointestinal concerns (30.2 percent and 24.5 percent, respectively) and upper respiratory discomforts (19.9 percent and 40.8 percent, respectively). These results pose interesting situations, especially since both gastrointestinal concerns and upper respiratory discomforts are associated with communicable illness. Research data indicated that 32 percent of camper and 44 percent of staff illnesses were communicable in the day camp population. But the illness was seen in others (for both campers and staff) just under 50 percent of the time.

Here's an opportunity for intervention. If we improve infection control practices in day camps, then, a widening gap between communicable illness and its expression in others may result. Such an intervention may be as simple as appropriately covering one's mouth when coughing or sneezing and improved hand-washing. However, given the prevalence of communicable disease among day camp staff, it may also make sense to explore how they may be sharing pathogens in ways that campers are not!

The most prevalent reason for day campers seeking injury care was because of head/ face wounds (13.5 percent) and blows to the head (11.2 percent). Staff injuries were most often the result of musculo-skeletal events (27.2 percent). Close attention needs to be given to reducing head injury since younger children — the clientele of many day camps — have larger heads in proportion to their bodies and underdeveloped motor skills. In addition, injury to one's head has potential for life-time impact. Most camper injury incidents occurred on playing fields/gyms (43.5 percent) followed by "near water" (14.1 percent); this provides an indication of where to start to manage camper head injuries, given that in half of the applicable injury events, protective equipment was not being used.

Collecting Systematic Health Information

Considering the results you just read, and the opportunities for prevention recommended in the "How Camps Can Use This Information" box, how will you respond? Think of the statement, "What gets measured gets improved." When was the last time you systematically examined your health care logs? Have you incorporated health log information and analysis into your annual evaluation process? The simple act of tracking your own injury and illness patterns will likely draw your attention to trends and details you might have overlooked before, but the real power is in collaborating with other programs to learn more about the bigger picture. When we think about staff and participant safety, recognize the trends, and apply the knowledge to our own setting, we influence decisions about staff training, health care staffing patterns, and preventative interventions.

Understanding where and when preventable incidents occur allows us to highlight those areas during staff training. If we realize the conditions that are most likely to yield illness, we are more likely to have the appropriate number and type of staff available or on call. But, when we examine our policies or procedures and make modifications that reduce incidents, we are really living up to our calling as a profession. Knowledge and action can make a difference.

How Camps Can Use This Information

Centers for Disease Control. (2006). Sports-Related Injuries Among High School Athletes, United States, 2005-2006. Morbidity and Mortality Weekly Report, 55(38), September 29, 2006.
Williamson, J. (2006). Potential causes of accidents in outdoor pursuits: A matrix.
Proceedings of the 13th Annual Wilderness Risk Management Conference. Lander, WY: NOLS.

Linda Ebner Erceg, R.N., M.S., P.H.N., is executive director of the Association of Camp Nurses and associate director of Health & Risk Management for Concordia Language Villages, Bemidji, Minnesota.

Barry A. Garst, Ph.D., is the director of research application for the American Camp Association.

Gwynn M. Powell, Ph.D., is an associate professor in the Recreation and Leisure Studies Program in the Department of Counseling and Human Development Services at the University of Georgia.

R. Dawn Comstock, Ph.D., is an assistant professor at Ohio State University College of Medicine and Nationwide Children's Hospital Center for Injury Research and Policy. Her research focus is the epidemiology of injury among the physically active.

Originally published in the 2008 March/April issue of Camping Magazine.