Remote and rural Australians generally experience poorer health than people living in major cities. Australians living in remote and rural areas also sustain injuries at higher rates than their counterparts living in major cities. In some parts of Australia, the injury rate is almost double for remote residents compared with city residents. Access to timely medical care can influence patient outcomes following an injury. The Royal Flying Doctor Service (RFDS) fixed-wing, long-distance aeromedical retrieval service may be tasked with transporting an injured patient for treatment when road transport is not appropriate due to remoteness. The RFDS has first-hand experience of the impacts of injuries in remote and rural areas. Evidence presented in this report shows that across almost every category of non-intentional and intentional injuries, incidence rates and associated death and morbidity are higher in remote and rural areas. Hospitalisations and deaths resulting from injuries increase with increasing remoteness. This disparity in injury prevalence is the focus of this report, giving voice to the needs of remote and rural Australians. Throughout the world, at least 14,000 people die from an injury every day. Five million lives are lost internationally each year. Deaths from injuries account for 9% of the world’s total deaths. The true incidence and prevalence is likely underreported, as not all people seek treatment for their injuries. In 2009—10, injuries across both metropolitan and country Australia were responsible for 10,668 or 7.6% of all deaths. The most common causes of injury deaths in Australia were falls, intentional self-harm, and transport accidents. The age-standardised death rate varied between males and females–the male rate was more than twice as high as the female rate overall. Injuries are by far the greatest cause of death for Australians in the first half of their lives. Throughout Australia, injuries are also a leading cause of hospitalisation and death in children aged 0—14 years–more children in Australia die from injuries (36%), than from cancer (19%) and diseases of the nervous system (11%) combined. Indigenous Australians are also more likely to die from, or be hospitalised for, an injury, compared to non-Indigenous Australians–injury deaths are nearly three times higher for Indigenous Australians compared to non-Indigenous Australians. Further, Indigenous Australians are twice as likely as non-Indigenous Australians to be hospitalised for an injury. In the decade from 2004, Indigenous hospitalisation rates for injuries increased by a third, compared with only a one-tenth increase for non-Indigenous Australians. Injuries comprised 27% (1,841,516) of all emergency department presentations in Australia in 2014—15. The most recent Independent Hospital Pricing Authority (IHPA) data established the average cost of an emergency department presentation was $578. The RFDS estimates the annual cost of emergency department presentations for injuries in 2014—15 was therefore a conservative $1,064,396,248–this cost could be reduced if more injuries were prevented. Injuries accounted for 6% of all public and private hospitalisations and resulted in 624,000 patient admissions in 2013—14. The main types of injuries people were hospitalised for were associated with transportation, poisoning, falls, burns, self-harm and assault. Recent data showed that the injury death rate for residents of remote Australia was 1.8 times the injury death rate of residents of major cities. For very remote residents, the injury death rate was 1.7 times the rate of major city residents. Injury hospitalisation rate Transport injury deaths accounted for the majority of unintentional injury deaths in remote and very remote areas, according to the most recently available data. Death rates for transport injuries amongst remote and very remote Australians were four times higher than for major city residents. Although more than two thirds of Australia’s population live in major cities, more than half of all road fatalities occurred on remote and rural roads. Indigenous Australians living in remote and very remote areas, in particular, experienced higher rates of road transport injury deaths and injury hospitalisations than both their Indigenous counterparts in major cities, and their non-Indigenous counterparts in remote and very remote areas of Australia. Remote and very remote Indigenous Australians were 2.5 times and 2.3 times more likely, respectively, to be killed in a road crash, compared to non-Indigenous Australians in remote and very remote areas. In 2014—15, a total of 271 people drowned in Australia. A disproportionate two thirds of these drowning incidents occurred in remote and rural areas. Drowning deaths in remote and very remote locations often occurred as a result of swimming and recreation, or accidents involving watercraft. Recent data on poisoning showed that death rates were 3.5 times higher in remote and 2.5 times higher in very remote areas compared to major cities. Injury deaths from self-harm in remote and very remote areas of Australia were 1.7 and 1.8 times (respectively) higher than in major cities. Suicide rates amongst men were 1.8 and 2.9 times higher in remote and very remote areas (respectively), compared to men in major cities. Injury deaths from assault were 3.8 times higher in remote areas and 4.2 times higher in very remote areas (respectively) compared to major cities. The injury fatality rate for workers in the agricultural industry in 2013—14 was nine times the rate across all industries. For children in country Australia, recent data demonstrated that the rate of drowning and thermal injury hospitalisations was highest for infants younger than 12 months, compared to other age groups. Rates of hospitalisation for unintentional poisoning by pharmaceuticals and other substances were highest amongst children aged 1—4 years. Rates of hospitalisation due to falls were highest for children aged 5—9 years. Falls were the leading cause of hospitalised injury for 10—14-year-olds, and transport injuries were also significant. Rates of hospitalisation due to self-harm and assault were more common amongst 10—14-year-olds than for younger children. The RFDS provided 292,174 patient care episodes in 2014—15. Transporting patients by air or road to access medical care accounted for 64,673 of these care episodes. One in five aeromedical retrievals carried out by the RFDS in 2014—15 were in response to an injury. Viewed in an Australia-wide context, this is comparable to the one in four emergency department presentations for an injury. This report publishes data arising from RFDS aeromedical patient transfers for the first time. The data demonstrates that diseases of the circulatory system (e.g. heart attacks) were the most common reason for an aeromedical retrieval, comprising 14,039 (24.5%) retrievals. Injuries were the second most common reason for an aeromedical retrieval, comprising 11,404 (19.9%) retrievals. Two thirds of injured remote and rural Australians requiring an RFDS aeromedical retrieval were males. Indigenous Australians accounted for more than one in four retrievals. Risks contributing to injuries in country Australia include environmental factors, injury health literacy, lifestyle factors, age, socio-economic status, supervision of children, individual behaviours, historical factors, and community cohesion. Each of these risks can be ameliorated through preventative actions, provided they are evidence-based and well designed. Doing so will save lives, prevent morbidity and disability, and ultimately save governments and taxpayers money, while improving the lives of remote and rural Australians. Australia requires a reinvigorated, innovative and contemporary approach to injury prevention, that is genuinely multi-sectoral, with targeted strategies for specific population groups most impacted, and for different injuries. This paper considers policy-relevant solutions to address the burden of injury in remote and rural Australia, and provides a platform for discussion between service delivery organisations, researchers, policy makers, the public, private and philanthropic sectors. Based on the evidence presented in this report, the RFDS recommends that: * The Council of Australian Governments (through the Australian Health Ministers Advisory Council) develop and commit to resourcing a new national injury prevention and safety promotion plan, that includes remote and rural Australians as a priority group, identifying particular risk factors and evidence-based prevention strategies; * As part of a new plan, targeted intervention strategies are developed for population groups most impacted by injuries, and particular causes of injury. This should include: — Indigenous Australians in remote and rural Australia; — Males aged 20—29 years; — Females over 80 years of age in remote and rural Australia; — Farm safety, with a particular focus on children on farms; — Road safety in remote and rural Australia; and — Drug use and alcohol consumption in remote and rural Australia; * The new plan sets measurable targets for all Governments to achieve over the life of the plan, including that there is no disparity in the rates of injury or injury-related deaths between remote and rural Australians and their major city counterparts, nor between Indigenous and non-Indigenous Australians; * The new plan focuses on, and provides investment for, better data linkage throughout the health system, with other sectors, and across state and territory boundaries, in order to improve understanding about the incidence and impact of injuries; causes of, and factors contributing to, injuries for different population groups; and reasons for disparities in the rate of injuries amongst specific communities, for example those in remote and rural areas, and Indigenous Australians; and * Governments continue to invest in essential health services for remote and rural Australia to provide high-quality responses and treatment to injured remote and rural Australians with equity of access to health care where few or no permanent services exist. In addition to the 10 principles contained in The national injury prevention and safety promotion plan: 2004—2014, the RFDS recommends that the following principles should guide future injury prevention initiatives, and are particularly important for remote and rural communities: * Initiatives are multi-sectoral, including the community, industry and (as relevant) all levels of government, and are community-led wherever possible; * Initiatives recognise and address the social determinants of health as risk factors for injury (including, but not limited to, income, employment, education and housing); * To be effectively targeted, initiatives take a ‘whole-of-life’, ‘whole-of-person’ perspective and take into account the multiple influences on an individual, including their family and community; * Initiatives are culturally appropriate, are acceptable to, and developed in consultation with, Indigenous Australians with a strong role to be played by the Indigenous community-controlled health sector; and * Wherever possible, initiatives are focused on community development and the empowerment of individuals in an effort to develop a culture of safety. 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