|Ahead of print publication
A Mixed-Method Study on Recurrent Unintentional Injuries in Children and Adolescents in a Rural Area of Delhi
Bratati Banerjee, Priyanka Yadav
Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Submission||05-Jan-2021|
|Date of Decision||15-Feb-2021|
|Date of Acceptance||16-Feb-2021|
|Date of Web Publication||09-Jun-2021|
Department of Community Medicine, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110002
Source of Support: None, Conflict of Interest: None
Introduction: Unintentional injuries are largely preventable causes of death and disability in children. Understanding the extent of the problem and its contributing factors will help us in addressing them and thus prevent their occurrence to a great extent. Methodology: It is a mixed-method study, which is a part of a funded research project on unintentional childhood injuries, conducted in two villages of Delhi, on 397 children and adolescents. Quantitative data for occurrence of injuries was collected over 16 months during the period 1st September 2017-31st December 2018. Outcome variables included incidence of unintentional childhood injuries, knowledge of subjects regarding injuries and their prevention, family practices for injury prevention and treatment seeking behavior as reported by subjects, safety score regarding domestic and peridomestic environment, and danger signs within the house. Subjects with three or more incidents of unintentional injuries during the entire period of data collection were considered to have recurrent injuries and were classified as belonging to high-risk group. The qualitative part of the study included in-depth interview of subjects who suffered from recurrent injuries and their guardians in their families. Total 13 children were identified as high-risk group, of which three were below 10 years of age and hence were not interviewed. Purpose of interview was to assess the perception of each adolescent subject and his/her guardian in the family, regarding possible reasons for occurrence of recurrent injuries and the ways in which injuries can be prevented in these subjects. Results: Recurrent injuries occurred in 3.28% of total population, significantly more in male subjects. Mean age of the recurrently injured subjects and mean age of their guardians were lower than the corresponding uninjured group. Rate ratio and rate difference indicated greater vulnerability of the high-risk group of subjects. KAP scores of mothers and practice of families were significantly lower in the high-risk group than the other group. The main reasons for injury occurrence mentioned by both subjects and their guardians were that children are careless, naughty, fight with other children, and since parents do not stay at home there is no one to monitor them. Work-related injuries were also stated. Other than preventing the reasons for recurrent injuries stated by both the groups, some more measures were suggested. These were to keep the community clean as one major injury had occurred due to unclean surroundings, take help from close neighbors, particularly by working mothers of nuclear families, and elder siblings to take care of their younger siblings. Conclusion: Deeper understanding of the factors associated with unintentional injuries in specific cases provides a scope for targeted interventions. Educational programs and training of the people in the community and counseling members of the concerned families, will significantly help in prevention of injuries.
Keywords: Childhood injuries, qualitative research, recurrent injuries, unintentional injuries
|How to cite this URL:|
Banerjee B, Yadav P. A Mixed-Method Study on Recurrent Unintentional Injuries in Children and Adolescents in a Rural Area of Delhi. MAMC J Med Sci [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=318088
| Introduction|| |
Child injury has been recognized as a major threat to child survival and health. However, this still remains a neglected public health problem. Injuries constitute a large proportion of global burden of childhood death, particularly for older children in whom it accounts for almost half of the deaths. About 90% of these deaths are categorized as “unintentional.” Many more children suffer from the consequences of nonfatal injuries and subsequent life-long disabilities., Road injuries are the leading causes of death among adolescents globally, with a stagnant or increasing trend in most developing countries.
The burden of childhood injuries and its consequences in India are not clearly known and widely varying figures have been given in different studies. Research done in various parts of the country has reported percentage of children below 18 years of age suffering from injuries, to vary from 7.1% to 58.9%.,,,,,
Unintentional injuries are largely preventable causes of death and disability in children. Understanding the contributing factors will help in addressing these and thus preventing their occurrence to a great extent. It is therefore important to know the reasons behind occurrence of injuries and vulnerability of some children to repeatedly become injured, which has still remained unexplored. In this background, the objective of this study is to estimate the incidence of recurrent unintentional injuries in children and adolescents in a rural area of Delhi and to study the factors associated with its occurrence.
| Methodology|| |
This study, using a mixed-method approach, is a part of a funded research project on unintentional childhood injuries, conducted in two villages of Delhi, India.
Study population included all the children and adolescents, that is, age group 0 to 19 years, belonging to the selected families. Total 397 children and adolescents, belonging to 116 families, were included in the study. Quantitative data for occurrence of injuries was collected by longitudinal survey over 16 months during the period 1st September 2017-31st December 2018, using a pretested semi-structured schedule. Subjects with three or more incidents of unintentional injuries during the entire period of data collection were considered to have recurrent injuries and were classified as belonging to high-risk group.
The eldest adolescent in each of the selected families were interviewed by making weekly visits, to collect data about occurrence of injuries in themselves and their younger siblings, in the past week, along with their details. The schedule also included knowledge regarding injuries, of various groups of population which were the adolescents and mothers of the subjects included in the study. Subjects were also asked about safe family practices for injury prevention and treatment seeking behavior of the families. Environmental condition was observed from the perspective of peridomestic and domestic environment and danger points within their homes.
This part of the study included children and adolescents who suffered from recurrent injuries, defined for the purpose of this study as three or more injuries occurring within the study period, and his/her adult woman guardian in the family. A total of 13 children were identified as high-risk group within the study population, of which three children below 10 years of age in the high-risk group were not interviewed. In-depth interviews were conducted using a Topic Outline Guide maintaining full auditory and visual privacy, individually for 13 guardians and 9 adolescents. Purpose of interview was to assess the perception of each adolescent subject and his/her guardian in the family, regarding possible reasons for occurrence of recurrent injuries and the ways in which injuries can be prevented in these subjects. All the guardians interviewed were mothers of the high-risk children except in one case where the guardian was the sister-in-law.
| Data analysis|| |
Outcome variables included incidence of unintentional childhood injuries, knowledge of subjects regarding injuries and their prevention, family practices for injury prevention and treatment seeking behavior as reported by subjects, safety score regarding domestic and peridomestic environment, and danger signs within the house. Maximum attainable scores were as follows: Subject Knowledge score 29, Family Practice score 60, and Environmental Safety score 93. Higher scores implied better knowledge of subject, better practice of families, and safer environmental conditions of the household. All these variables of the high-risk group were compared with those of the other subjects who were not recurrently injured and with those of the total study population.
Data were entered in MS-Excel and were analyzed using IBM SPSS Statistics version 25.0, released 2017, IBM Corp, Armonk, NY. Mean and standard deviations of all quantitative variables were calculated. All differences were tested statistically using t test for mean, z test of proportion, and Welch test for safety scores. Statistical significance was considered at a P-value < 0.05.
For the qualitative part of the study, the textual data obtained was coded and then consolidated into thematic areas. Total seven codes were identified in two thematic areas for reasons for recurrent injury in the children, which included factors related to children and factors related to families. For measures that can be taken for prevention of injuries in children and adolescents, total eight codes in three thematic areas were identified, which included measures related to children, measures related to families, and external support. The data were finally compiled for the responses of all subjects in a group and presented as (+) or (−) sign. If more than half of the interviewees in the group mentioned a particular code it was scored as two plus (++), if less than half the group mentioned the reason it was scored as one plus (+), and if no one in the group mentioned a particular reason it was given a negative (−) score.
| Results|| |
Recurrent injuries occurred in 13 subjects (3.28% of the total population) of whom three were girls and 10 were boys. There were four subjects in age group 0 to 9 years of which three were aged 5 to 9 years, one was aged 2.5 years, and the rest nine subjects were adolescents. Thus, proportion of children and adolescents recurrently injured, out of the total study population, were 3.74% and 3.10%, respectively.
Mean age of the recurrently injured or high-risk group was 11.19 years that was slightly lower than the other subjects. Mean age of mothers of these children was also lower than the mean age of mothers of other subjects. However, the differences in mean age were not significant. Recurrent injuries were significantly more (P < 0.05) in male subjects (5.10%) than in female subjects (1.49%) [Table 1].
Incidence of injury events was 2.72 per 100 person-months in the total study population. In the high-risk group that comprised of 13 subjects, incidence was 23.08 per 100 person-months. This was significantly higher than the incidence of the group calculated excluding these high-risk subjects, which were 2.04 per 100 person-months [Table 2].
In [Table 3], safety scores included knowledge and practice (KAP) score of the nine high-risk adolescent subjects and their 11 guardians, practice of their families regarding prevention and immediate management of injuries as reported by the subjects, and environmental score of the families to which these subjects belonged. Scores of the high-risk group has been compared with that of the total group as well as scores of the group that was not at high risk. KAP scores of mothers and practice of families showed statistically significant difference between the high-risk group and the other group, being unfavorable for the high-risk group.
[Table 4] depicts the observations from the qualitative study. According to perception of the guardians, the most important reason for occurrence of recurrent injuries was that the children are very careless. They also said that the children are naughty and since the parents do not stay at home there is no one to monitor them. They said that work-related injuries also occur. The most important reason stated by the adolescents was that they fight with other children which results in injuries. Other reasons stated were being careless and work-related injuries. They also mentioned that the parents do not stay at home and do not pay attention to them, as a result of which they get repeated injuries. None of the adolescents said that they are naughty and do not listen to elders.
The subjects and their guardians were asked to suggest measures that can be taken to reduce injuries. Other than preventing the reasons for recurrent injuries stated earlier by both the groups, some more measures were suggested. One of these was to keep the community clean as one major injury had occurred due to unclean surroundings. Another suggestion made by the guardians was to take help from close neighbors, particularly by working mothers of nuclear families. Many participants of both groups suggested that elder siblings can take care of their younger siblings as well as be careful themselves [Table 4].
| Discussion|| |
In the present study, total 13 subjects (3.28%), three girls and 10 boys, suffered from recurrent injuries, defined as three or more injury events during the study period. These subjects have been named here as high-risk group, as they were at higher risk of being injured. A study conducted in Australia with 2692 participants from the Environments for Healthy Living: Griffith Birth Cohort Study 2006–11, reported the number of injury episodes per child ranged from 0 to 9 events, with 29.8% of the injured population presenting more than once for injury. Our study has found lower proportion of children suffering from recurrent injuries.
The Australian study identified two factors to be significantly associated with recurrent episodes of injury in children aged <3 years. Children born to mothers aged <25 years were almost fourfold more likely to have recurrent episodes of injury compared with children of mothers aged ≥35 years. The second significant factor was the child’s age. As the age at first injury increased, odds of experiencing recurrent episodes of injury decreased. No differences were found in sociodemographic characteristics of children aged 3 to 7 years with single compared to recurrent episodes of injury.
Recurrent injury has been observed to be associated with several social factors. A study from Los Angeles reported children whose mothers were unemployed and whose homes needed repair were at higher injury risk than other children. Other predictors of a higher injury risk were children’s behavioral characteristics as well as their being older than 2.5 years. Another study from Denver showed that risk factors for more than one injury included maternal substance abuse, maternal age under 18 years, a primary caregiver who was single or mentally ill, and a history of family violence.
A study conducted in the urban slums of southern India concluded that children with working mothers and those living in overcrowded families are more likely to suffer from unintentional injuries. In another community-based survey conducted in Ujjain, India, it was found that boys were at a higher risk for sustaining unintentional injuries as opposed to girls, and children in the age group of 6 to 10 years were more likely to get injuries than the rest.
In our study, the incidence of injuries in the high-risk group was significantly higher than that of the other subjects. Mean age of children of the high-risk group as well as their mothers was lower than that of the other subjects. However, these differences were not significant. There was no significant difference between scores for knowledge of adolescents or environmental condition among the high-risk and other subjects. Statistically significant difference was observed in knowledge of guardians and family practice regarding prevention of injuries. Another significant difference that was observed was that incidence of injuries occurred more in male than female children. This indicates presence of some factors in male children that make them susceptible to being repeatedly injured. These factors could be identified through the qualitative study that revealed that children being naughty and absence of parents, as two most important reasons for recurrent injuries.
The incidence of unintentional injuries in children and adolescents continue to be a major public health issue in low-income countries. In accordance with previous studies, the rates of injuries are higher in males than in females, in our study as well. Based on the in-depth interviews of the high-risk subjects, the higher rates in males can be attributed to their aggressive and naughty behavior and to their carelessness. Contrary to the Australian study, our study shows that the adolescents are more prone to unintentional injuries than children.
While certain risk factors for injuries are similar to those in previous studies, some other risk factors pertaining to the rural settings were found through the in-depth interview, for instance the poor infrastructure of community and mismanagement of unclean surroundings due to stray cattle resulting in fall in one child. While most of the injuries occurred outside of the home, in case of a 4-year-old child of high-risk group, poor structure of the house was responsible for all cases of injuries that were reported in the child. The injuries were reported to have reduced significantly in this child since he started attending school, 3 months prior to interview of the mother for qualitative analysis. Two families of high-risk subjects who had the highest incidence of unintentional injuries reported that both the parents worked till late evening and were not able to spend much time with their children.
The detailed understanding of these factors has revealed the necessity of making appropriate and relevant interventions for the reduction of unintentional injuries, which include parental attention and care, and structural changes in houses. Furthermore, the role of community has been found to be very important both in terms of personal support as well as maintaining cleanliness. The importance of health education and its effectiveness in injury prevention has also been stressed.
| Conclusion|| |
Unintentional injuries are preventable. Deeper understanding of the factors associated with unintentional injuries in specific cases provides a scope for targeted interventions. Educational programs and training of the people in the community and counseling members of the concerned families, will significantly help in the reduction of injuries.
Financial support and sponsorship
This study was supported by Indian Council of Medical Research, New Delhi.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]