Bangladesh Health and Injury Survey (BHIS)

Bangladesh Health and Injury SurveyReport on Children

Report authors

Aminur RahmanAKM Fazlur RahmanShumona ShafinazMichael Linnan

Directorate General of Health Services,Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh

Institute of Child and Mother Health

United Nations Children's Fund

The Alliance for Safe Children

Dhaka, Bangladesh, January 2005

Bangladesh Health and Injury SurveyReport on Children

Published: January 2005

ISBN 92-806-3855-6

This report has been prepared under the guidance of

Dr. Md. Abdur Rahman Khan, Director General of Health Services, DGHS.

Prof. Dr. Abdul Hannan, Executive Director, Institute of Child & Mother Health.

Dr. Iyorlumun Uhaa, Chief, Health & Nutrition Section, UNICEF Bangladesh.

Copyright

Directorate General of Health Services (DGHS), Ministry of Health & Family Welfare (MOH&FW),

Government of the People's Republic of Bangladesh

Institute of Child & Mother Health (ICMH), Matuail, Dhaka 1362, Bangladesh

Tel: (880 2) 7512820-3, Fax: (880 2) 7512672, www.icmh.org.bd

United Nations Children's Fund (UNICEF), Bangladesh Country Office, BSL Office Complex, 1 Minto Road, Dhaka 1000,

Bangladesh, Tel: (880 2) 9336701-10, Fax: (880 2) 9335641-2, www.unicef.org/bangladesh

The Alliance for Safe Children (TASC), 4/1 Sukhumvit Soi 1 Klongtoey Nua, Vadhana District Bangkok 10110, Thailand,

Tel: (66 2) 6554811, Fax: (66 2) 6554814, www.tascfoundation.org

The authors are alone responsible for the views expressed in this publication. Any part of Bangladesh Health and Injury Survey:

Report on Children may be freely reproduced with appropriate acknowledgement.

Foreword

Today, the biggest killer of Bangladeshi children between age 1 and 18 is injury. The greatest killer in this group is

drowning, which is the most common single cause of death in children in both the 1-4 age and the 5-9 age groups.

This is a dramatic change from the situation of even two decades ago, and this has largely been due to the success

in preventing and treating common childhood diseases, such as diarrhoea, acute respiratory tract infections, and

vaccine-preventable diseases. As deaths due to infectious diseases continue to decline, other factors are emerging

as the leading causes of death.

Injuries and accidents, in particular drowning, were first detected as a growing cause of death among young children

by ICDDR,B's Demographic Surveillance System (DSS) in Matlab. However, this epidemiological trend was not

recognized as a national phenomenon since regular health information systems have difficulties in reporting injury

cases and nationally representative data obtained at the community level were not available.

Responding to this need for data, the Directorate General of Health Services (DGHIS), the Institute of Child and

Mother Health (ICMH) under the Ministry of Health and Family Welfare (MOH&FW) in collaboration with UNICEF and

The Alliance for Safe Children (TASC) conducted the national Bangladesh Health and Injury Survey (BHIS) in 2003.

The BHIS is the largest injury survey ever conducted at the community level in a developing country. While the

sample size alone gives this survey unique status, (some 171,366 households representing over 800,000 persons),

the case-control, environmental and behavioral risk survey and qualitative survey modules included in the BHIS have

provided researchers with information on the factors contributing to the high prevalence of specific types of injuries

such as drowning, burns, poisonings, and selected intentional injuries. These insights, along with the power of the

data in the survey, provide direction for creating interventions to prevent future child injury.

The survey has established conclusively that an epidemiological transition has occurred in Bangladesh, and that

injury is now one of the major killers of children. Drowning, in particular, was found to be the single largest killer

amongst all causes of injury in children.

Much of the world's research in child survival has been conducted in Bangladesh, and many of the important

interventions have been developed and tested here. The Expanded Programme on Immunisation (EPI), Oral

Rehydration Therapy (ORT) and Vitamin A supplementation are some of the best examples of evidence-based

interventions to improve child survival developed in Bangladesh. This Report provides key policy makers and decision-

makers in Bangladesh with the basis for pioneering injury interventions for child survival which can be applied locally

and possibly replicated in other developing countries.

It is encouraging to note that injury is already one of the priority areas for action in the Sector Investment Plan (SIP)

of Health, Nutrition and Population Sector Programme (HNPSP). We hope this report will be a valuable resource for

designing and implementing various safety promotion programmes. The government of Bangladesh, UNICEF and

TASC are committed to work together to fulfill the rights of Bangladeshi children to survival, development, and

protection.

We would like to thank the researchers from ICMH, UNICEF and TASC for their hard work in developing this new

national evidence-base for injuries and accidents in Bangladeshi children. We further pledge our continued

cooperation and support of the interventions that will now be possible, based on the data presented in this report.

Table of Contents

Page

Executive Summary 7

Chapter 1 Background 9

Chapter 2 Methodology 13

Chapter 3 Mortality Overview 23

Chapter 4 Morbidity Overview 33

Chapter 5 Drowning and Near-drowning 47

Chapter 6 Transport Injury 57

Chapter 7 Burn Injury 65

Chapter 8 Fall Injury 73

Chapter 9 Cut Injury 81

Chapter 10 Falling Objects 87

Chapter 11 Poisoning 91

Chapter 12 Animal Injury 97

Chapter 13 Electrocution 103

Chapter 14 Machine Injury 107

Chapter 15 Suffocation 113

Chapter 16 Intentional Injury 117

Chapter 17 Injury Orphanhood 125

Chapter 18 Behavioural Research 131

Chapter 19 Conclusions and Recommendations 155

References

Appendices

A. Glossary

B. Tables

C. Population characteristics

D. Contributors

07Executive Summary

The Bangladesh Health and Injury Survey (BHIS) is the largest injury survey everconducted at the community level in a developing country, with a sample size of 171,366households and a total surveyed population of 819,429. The survey, conducted betweenJanuary and December of 2003, included all age groups; 43 percent (351,651) of thesurveyed population were children. Children are defined in this Report as infants andchildren of all ages, up to their 18th birthday (0-17 years old).

The BHIS characterises injuries in all age groups, looking at moderate, major, serious,severe, and fatal injuries in detail to better determine the risk factors and some of thesocial and economic costs related to these injuries. As children represent almost half (47percent) of the population of Bangladesh, the epidemiology of both fatal and non-fatalinjury in the 0-17 age group is of enormous importance to the country.

The survey documented an overall child injury rate of 1,592/100,000 children per year.This means that almost two in every 100 children were injured significantly enough torequire medical care, or lost at least three days of school or work in the year before thesurvey. There were over 30,000 children fatally injured in the year before the survey, thatis, roughly 83 children per day, or three children per hour.

The BHIS addresses all causes of death and helps characterise the causes within eachage group. Communicable and non-communicable disease is still considered a majorconcern for children, especially infants. However, a newly identified threat is significantlychallenging the placement of this concern. Injury, as documented by this survey, nowaccounts for 38 percent of all classifiable deaths in children aged 1-17. Not surprisingly,the proportion of injury-related mortality increases as children get older with injuriescausing 2 percent of infant deaths, 29 percent of 1-4 year old deaths, 48 percent of 5-9year old deaths, 52 percent of 10-14 year old deaths, and 64 percent of 15-17 year olddeaths. The survey supports the observation that injury is a stage of life issue, and thatall children must be considered at risk, not just the under-fives.

The data concerning non-fatal injury is equally staggering, documenting almost a million(955,000) injuries to children in the year prior to the survey. This is more than 2,600 perday, 109 each hour, or roughly 2 per minute. Injury leads to over 13,000 permanentdisabilities a year among the children of Bangladesh.

This Report clearly documents a previously unrecognised epidemic of child injury.

In addition to the quantitative survey providing hard data documenting the extent of theproblem, the survey also included a qualitative study to capture the cultural andbehavioural factors related to the perception of risk, prevention and practices related toinjuries. Taken together they provide a road map for future action designed to promote anagenda of safety for children of all ages in Bangladesh.

Executive Summary

08 Bangladesh Health and Injury Survey: Report on Children

The principal findings and recommendations from the BHIS are:

1. There is a previously unrecognised epidemic of child injury in Bangladesh, which shouldbe responded to now.

2. In addition to being a leading killer of children after infancy (ages 1-17), injury is also aleading cause of morbidity and one of the major causes of permanent disability.

3. Drowning is the single largest cause of death of children over age one.

4. Drowning, road traffic accidents, burns, falls, suffocation, and intentional injuries are allimportant contributors to child injury, but they affect children at different stages in theirlives.

5. Given the complexity of the problem, an effective response will require the broadintegration of injury prevention, response, and rehabilitation interventions into childsurvival programmes in Bangladesh.

6. Bangladesh has made great progress in addressing the issue of communicable diseasewhich affects infants and children under-five. However, all children, from infancy upthrough to their 17th year, must be considered at risk of injury and targeted forprevention-based interventions.

7. Focusing programmatic efforts on the under-five mortality rate is important but to do soexclusively is short sighted, especially if the gains made in one age group are lost inanother as children mature. The BHIS provides policy and decision-makers with asignificant tool for moving the issue of child safety in its entirety, rapidly ahead inBangladesh.

8. It is child lives that are at stake and the goals that governments and internationalorganisations have set to improve those lives cannot be met unless child injury isaddressed as part of the package.

Chapter 1

Background

The Bangladesh Health and Injury Survey (BHIS) attempts to quantify theburden of injury and to describe the nature of injury for the Bangladeshipeople.

11Chapter 1: Background

Background

Global burden of injury

Injury is a leading cause of death and disability inthe world. According to World Health Organization(WHO), every year more than 5.8 million peopledie from injuries, with a rate of 97 per 100,000population. Of this, 3.8 million (128.6 per100,000 population) are male and 1.9 million(66.7 per 100,000 population) are female1. Aquarter of the deaths are due to road trafficaccidents, 16 percent are suicides and 10 percentare homicides. Among all age groups, injury is thefifth leading cause of death in the world andaccounts for 10 to 30 percent of all hospitaladmissions2. More than one-quarter of injurydeaths occured in South East Asia3. The burdenof injury in developing countries is not new,however, the recognition of it is.

Historically, child injury was largely associatedwith industrialised countries. However, aUNICEF/Innocenti Research Centre studypublished in 2001 showed that over 98 percent ofall child deaths from injury occurred in developingcountries, where most of the world's children live.The study found that the rate of child death frominjury in low and middle-income countries wasfive times higher than high-income countries4,5.The major causes of injury are drowning,transport accident, burn, fall, poisoning andintentional injuries.

In low and middle-income countries, children growup exposed to much higher levels ofenvironmental hazard in cultures that do not havean awareness of safety and risk avoidance, andwhere social situations make close adultsupervision difficult. This is compounded by alack of preventive services and access toemergency medical care, except for a smallminority of urban dwellers. A final significantcontributor is the general lack of knowledge andskills in basic first aid.

Child injury in Bangladesh

Child mortality and morbidity

In Bangladesh, births and deaths are seldomrecorded, making basic health indices such as

causes and rates of death difficult to know withany real degree of certainty. However, basic dataavailable from the Bangladesh Bureau ofStatistics6 and the Bangladesh Demographic andHealth Survey7 shows a steady decline in theInfant Mortality Rate (IMR) and the Under-FiveMortality Rate (U5MR). Figure 1.1 shows childsurvival in Bangladesh has improved significantlyover the last two decades. In particular, under-fivemortality has fallen by half, from 146 to 76deaths per 1,000 live births during the lastdecade.

Although there are few studies where causes ofdeaths are directly comparable, most public healthexperts have noted a gradual shift in the cause ofchild death in Bangladesh from largely infectiousdisease to largely non-communicable disease andinjury8. Recent evidence from the DemographicSurveillance System of the International Centrefor Diarrhoeal Disease Research, Bangladesh(ICDDR,B) shows a growing proportion of childdeaths due to injuries. In 1983, nine percent of alldeaths among 1-4 years children were due todrowning, by 2000 this had risen to 53 percent9.This shift indicates a sharp reduction in childmortality from infectious diseases, with accidentsand injuries now the major concern for childhealth in Bangladesh. It has been estimated thateach year about 25,000 children die of injuries;and half of these children are under five


age10. However, most of the child healthprogrammes in Bangladesh are focused onprevention of infectious and nutritional causes ofchild death. Injuries and chronic diseases have yetto be addressed.

Rationale of Bangladesh Health and InjurySurvey (BHIS)

During last few years, a number of small-scalechild injury research projects have been carriedout by various institutions. These institutionsinclude the Accident Research Centre atBangladesh University of Engineering andTechnology (BUET), the Centre for Health andPopulation Research (ICDDR,B), the Institute ofChild and Mother Health (ICMH) and theBangladesh Safe Community Foundation. Studiesconducted by these institutions suggest that anepidemiological transition has taken place inBangladesh and injury is now one of the majorcauses of mortality and morbidity11,12,13.

The official statistics on injuries are difficult tointerpret as there is wide variation among themany figures. For example, there are at least threedifferent estimates of the U5MR in Bangladesh.While there is general agreement that an averageof these rates is a good estimate of the U5MR,there is very little data on actual causes of deathat the community level which is truly nationallyrepresentative. It is generally reported that theleading causes of death in children under fiveyears of age include acute respiratory infection(ARI), diarrhoea, malnutrition and injury as well asnon-communicable diseases. Children older thanfour years of age (5 to 17 years) are usually notincluded in child health statistics, and it is in thesechild age groups that injury usually predominates.The epidemiology of fatal and non-fatal injury inthe entire child age group (0 to 17 years) is ofenormous importance as children representalmost half the population (47 percent) ofBangladesh6.

The Bangladesh Health and Injury Survey (BHIS)was conducted to characterise the epidemiologyof injuries using a large, nationally representative,community-based sample. It looked at theincidence of moderate, major, serious, severe andfatal injury in detail in all age groups anddetermined the epidemiology, risk factors and

some social and economic costs related toinjuries. Using the data from that Survey, thisreport focuses on children (0 to 17 years). Furtherreports will be prepared, investigating the impactof injury on mothers, fathers and significantcaregivers of children; reports for all ages will bepublished separately as well.

Objectives

The BHIS attempts to describe the nature of injuryin Bangladesh and to quantify the burden of injuryfor Bangladeshi people so that comparisons canbe made across various population groups; andmost importantly, so that intervention and controlprogrammes can be developed. The objectives ofthe study were to:

determine the cause of death andserious morbidity of children and theirparents

estimate the incidence and proportionalmortality and morbidity due to injury

describe the pattern and characteristicsof injury

explore risk factors for childhooddrowning

gain an understanding of thebehavioural, attitudinal and otherfactors related to risks, hazards andcare-seeking behaviours related to injury

identify the environmental risk andhazards for injury in and aroundhouseholds

provide information to design affordableand effective interventions forprevention of child injuries inBangladesh.

Chapter 2

Methodology

The BHIS is the largest injury survey ever conducted at the communitylevel in a developing country: 171,366 households were included,representing 819,429 infants, children and adults.

15Chapter 2: Methodology

Introduction

This collaborative injury study pooled theresources and expertise of ICMH, DirectorateGeneral of Health Services (DGHS), UNICEFBangladesh, The Alliance for Safe Children (TASC)and the Centers for Disease Control andPrevention (CDC-USA). The study was composedof four components. The first component was across-sectional national survey looking at theincidence of injury. The second component was acase-control study to determine the risk factors ofdrowning. The third component was a behaviouralstudy examining knowledge, attitude andpractices related to injury; and the fourthcomponent was a risk survey to examine theprevalence of certain risk factors for child injury inthe home environment. Detailedmethodology of each component iselaborated in the followingsections. The methodology andtools used in the BHIS werefinalised through consultativemeetings involving experts fromdifferent organisations under theguidance of the DGHS.

Cross-sectional nationalsurvey

A cross-sectional survey wasconducted to estimate incidenceand proportional morbidity andmortality of injury in children. Thefield activities for data collectionwere conducted between Januaryand December 2003.

Sampling

Twelve out of 64 districts wererandomly selected for thesurvey.

A separate survey of DhakaMetropolitan City was includedto show the injury picture of alarge metropolitan mega-city

environment. This sample was included in thenational data for the overall analysis.

Multi-stage cluster sampling was used toselect 171,366 households; 88,380 from ruralareas, 45,183 from district towns (urbanareas) and 37,803 households from DhakaMetropolitan City.

In each district, one upazila (rural sub-district)was randomly chosen. In each upazila, twounions (lowest administrative units composedof approximately 20,000 people) wereselected randomly. A total of 24 unions wereselected for the study. All households in theunion were included in the survey.

The district headquarters of the 12 selecteddistricts and Dhaka Metropolitan City

Methodology

BANGLADESHSurvey Areas

constituted the urban areas. In the urbanareas, mohallas served as clusters andsystematic sampling was done to achieve therequired number of households.

A household member was defined as amember living in the same house, includingdomestic helpers, long-term guests, etc. andsharing meals and information. All householdresidents in the selected urban and rural areasof Bangladesh constituted the samplepopulation. There were a total of 467,778adults and 351,651 children. The populationcharacteristics are detailed in Appendix C.

Data collectors

There were 48 data collectors and six supervisors.The data collectors were university graduateswith previous experience in community research.They were given extensive hands-on-training withstandardised role-playing scenarios, interviewingtechniques in real situations, and record keeping.The supervisors were university graduates whohad participated in many previous ICMHcommunity research projects.

Research instruments

Data collectors administered a set of instrumentsat each household. The instruments were adaptedfrom those used in the Vietnam Multi-CentreInjury Survey14 and were pre-tested and revisedseveral times prior to the actual survey. Five setsof forms or questionnaires were used for thissurvey:

1. Screening Form: to collect age, sex,mortality and morbidity information ofhousehold members and injury hazardspresent at household level.

2. Verbal Autopsy Form: to determine thecause of death, with a form for eachage group.

3. Verbal Diagnosis Form: to determine thecause of morbidity, with a form foreach age group.

4. Injury Form: to collect information oncharacteristics of injuries. Separateforms were used for each mechanismof injury.

5. Questionnaire for the control group inthe case-control drowning study.

Validation activities for instruments,interviews and results

The screening forms included information tocompute various indirect measures of infant andchild mortality (preceding birth estimates, siblingsurvivorship, etc.) to serve as internal validationpoints for the major child mortality indices.Additionally, the mortality data was structured toallow construction of life tables for comparisonwith the most recent life tables generated by thenational census.

The verbal autopsy modules were based on theVMIS module, which was adapted from the WHOstandard for verbal autopsies. Major revisionsinvolved asking specific questions about eachtype of injury, and extending the age groups toinclude children from five years to 17 years aswell as a module for adults aged 18 years andover (the WHO standard forms are for childrenunder five years of age). All the modules, for allage groups, were tested and validated in the fieldpractice area of the ICMH before use in thenational survey. After the verbal autopsy formswere entered, the cause of death was determinedby two independent panels of paediatricians in ablinded, two-stage procedure that requiredconsensus on the final cause of death.

As part of the field activities, supervisors re-interviewed 5 percent of all households. This wasone of the tasks associated with supervising thedata collectors. Additionally, 316 verbal autopsieswere audio-recorded by supervisors which werelater compared with written verbal autopsy datacollected by researchers. This assisted in thevalidation of data. The data collectors also tookphotographs of serious and severe injurymorbidities and places where the injury occurred.

Respondents

Mothers were preferred as the main respondent.When a mother was unavailable, the mostknowledgeable member of the household presentat the time of interview was the respondent.Where possible, it was the head of household,with as many members of the household presentas possible to corroborate or add detail to therespondents’ answers. The respondents wereasked if there had been any deaths in thehousehold in the last year and in the yearpreceding that. Respondents were then asked



about illness for each member of the household inthe last six months. If there were any deaths orillness, the interviewer asked the child's primarycaretaker be present to assist with answers to thequestions. If a household was unattended at thetime of the first visit, a repeat visit was madebefore excluding the household.

Adjustment of data for cross-sectional survey

The stratified, multi-stage sampling schemegenerated a national sample that requiredweighting to allow for proper representation.Weighting factors were calculated for DhakaMetropolitan City (DMC) and for districts otherthan DMC. Weighting factors for DMC werecalculated for slum, non-slum and peri-urbanpopulations. For other districts, weighting factorswere calculated for rural and urban populations ineach district. For the national estimation, theproportional size of the population of DMC andother districts was taken into consideration incalculating final weighting factors.

Recall bias

To ensure a sufficient number of deaths wererepresented in the survey, the recall period wastwo years in the national survey and three yearsin Dhaka. (The national sample of 130,000households was sufficiently large to allow a twoyear recall period. The sample size in Dhaka wasonly 40,000 households, requiring a longer recallperiod). An analysis of deaths by year of recallshowed that most fatal events were recalled inthe first year of the recall period with a rapid falloff in each year after that (Fig. 2.1 & 2.2). This isconsistent with significant recall bias. Due to this,

final analysis was conducted using deaths fromthe most recent year to obtain the most accuratefatality rates. However, many of the sub-classification variables (for example, injury type byage or sex) had a zero frequency as a result. Insuch cases, where an annualised two or three-year period incidence rate was not zero, this isincluded and noted. The net effect of using anannualised period incidence rate is tounderestimate the rate for that particular variable.

Case-control study

A case-control study was done to determine therisk factors of drowning. A total of 141 childdrownings were identified in the two yearspreceding the survey. When a child drowning wasfound during the interview process, controls wereselected and interviews conducted by the sameinterviewer who found the case.

Cases: Drowning deaths in the last two years.

Controls: For each child drowning, at least twoliving children, age and sex matched from thesame locality.

Qualitative study

The objective of the study was to gain an in-depthunderstanding of the occurrence of injuries,including the current situation and protectionpractices for prevention of injuries with a view todeveloping intervention programmes.

Focus Group Discussions (FGD) were conductedamong mothers, fathers, adolescent boys andgirls and local elites from urban and rural areas in

Narsingdi District. The Narsingdi District wasselected because of its high injury rates, identifiedby the BHIS quantitative survey. A total of 52FGDs were carried out on six leading causes ofinjury (drowning, transport injury, burn, poisoning,fall and animal bite) involving more than 500participants. Six teams, each consisting of anorganiser, a moderator and two note takers whowere university graduates in social science andwell experienced in FGD conduction wereemployed. A week-long training programme wasorganised including classroom exercises and fieldpractice. ICMH principal investigators and socialand behavioural scientists from PIACT-Bangladeshfacilitated the training. Draft FGD guidelines werepiloted and then finalised based on the field tests.The discussion sessions were carried out duringAugust and September 2003. Groups of 10 to 12persons from the target group population weregathered for the sessions. The sessions beganwith participants requested to recall a real eventleading to injury that they may have observed orheard about. Once the storytelling was over andthe participants were comfortable in taking part infurther discussions, the facilitator explained theprescribed points of discussion and aided theparticipants to take part in the discussionspontaneously. Professional team membersincluding representatives from ICMH, UNICEF and

PIACT-Bangladesh monitored the FGD sessions.Manual note taking and audio cassettes wereused to record the dialogues throughout thesessions. Field teams prepared final notes on eachFGD and then it was transcribed. The primarydocumentation, field notes and transcriptionswere prepared through a consensual process,resulting in the final report.

Environmental and behaviouralrisk surveyA cross-sectional survey was conducted amongthe subset of the main survey population todetermine the prevalence of swimming skills inrural and urban (other than DMC) populations, toassess the level of these skills, to identify thepersons involved in swimming training, to identifythe place of swimming training and to determinethe age at which children attain swimming skills.The survey also aimed to identify the hazards ofaccidental poisoning, to assess the risk of cutsand injury from sharp objects in households, toassess the risk of drowning in and aroundhouseholds, to assess risk of burns or fires inhouseholds and to identify other injury hazards.

A total of 2,598 households from three districtswere selected by cluster sampling from the 12districts of the national injury survey. One ruraland one urban area were selected from each


district. From each rural area, 600 households(comprising of about 3,000 people) and fromeach urban area 250 households (comprising ofabout 1,250 people) were interviewed. A villagewas considered as a cluster in rural area and amohalla was considered as a cluster in urban area.

Trained interviewers used a structured, pre-testedquestionnaire to collect the following information:

Swimming skills - age, sex, swimmingability, when and where learnt andtaught by whom.

Poisoning - poison type, container type,container closure, container label, placekept.

Sharp objects/tools - presence, type andwhere/how stored.

Drowning - potential place of drowning(inside and outside house).

Burn - type of stove for cooking, waterboiler type, hot water container,electricity.

Electrocution - type of wiring (earthenor not, fused or not, extension corduse).

Hanging hazard - curtains, ropes, cords,stair rails.

Bites - presence of household pets anddomestic animals; snakes seen nearby.

Suffocation - Place of infant sleepingand sleep position.

A seperate report on environmental andbehavioural risk survey will be published later.

Data management and analysis

Data collected in this survey was entered into adata entry programme developed by theinvestigators using Epi-Info 6. Data was doubleentered by two different groups and then mergedfor validation of data entry. After cleaning, thedata was exported to SPSS 12.1 for analysis.

Ethical issues

Informed consent was obtained from allrespondents before collecting data. Respondents

were assured that the data would only be used forresearch purposes and all answers wereconfidential. Consent was also obtained forphotographs and audio recordings. Ethicalclearance for this study was obtained from EthicalReview Committee of ICMH.

Discussion

Deaths are best studied where they occur, whichis in the community. Data gathered at clinics,hospitals and other levels higher than thecommunity are subject to many sources of bias.Many of the biases are so large that they can leadto data that misrepresents the picture of mortalitywithin the community.

To understand these biases and their importance,it is useful to consider how deaths occurring inthe community are reported by the healthinformation system:

1. To report a death at a clinic or hospital, thedeath must be seen there. Deaths that occurimmediately, such as drowning are not seen atclinics or hospitals because parents bury thedrowned child (death certificates are rare ornon-existent in most areas and a dead child isalmost never taken to a hospital). This createsa survivorship bias, where deaths from causesthat kill quickly are under-reported; and thequicker they kill, the less likely they are to bereported. Injury is most affected by this asmany severe injuries such as drowning,electrocution, falls from heights, etc. areimmediately fatal.

2. If a death occurs at the hospital, the causereported is usually the final cause of death,and not the underlying cause of death. Forexample, the final cause of death in an elderlyperson who dies while hospitalised from a hipfracture suffered in a fall is usually aninfectious complication (pneumonia), but theunderlying cause is actually the fall, which isan injury. Injury and non-communicable causesare most affected by this source of bias, whichis a misclassification bias.

3. There are several dozen diseases legallyrequired to be reported by a health facility.These diseases are predominantly infectiousand the requirement for reporting creates asystematic reporting bias favouring infectiousdiseases over non-communicable and injurycauses.


4. While many facilities report diligently, a largenumber do not, and the completeness andaccuracy of reporting varies substantially.Thus, information on the cause of death isoften unreliable.

These differing types of bias and lack ofcompleteness are often summarily referred to as'facility bias'. They make it difficult, if notimpossible, to obtain accurate and preciseinformation on injuries in developing countries.Therefore, to obtain the actual pattern ofmorbidity and mortality at the community level,the BHIS survey was conducted at the householdlevel in the community.

Within household surveys, there are a number ofpotential sources for bias and they generally fall intwo groups: those due to finding the death(enumeration errors); and those due to labellingthe death (classification errors).

Enumeration errors

The goal of the survey was to include every deathfrom the area surveyed. However, this isimpossible to achieve, as at any point in timemany normal residents of an area are not presentand are unable to give information on deathswithin their household. Many residents are part ofthe migratory population who work or areseeking work outside their districts; many arevisiting family members in other communities orare travelling for business or other reasons. Theirdeaths or their knowledge of deaths of otherscannot be determined, and these are lost to thesurvey. Additionally, there are people who do notwant to be counted, visited or interviewed byresearchers for a variety of reasons, especially,where there is a legal issue, such as an assault orhomicide. These are also lost to the survey. Thereare also lost deaths due to other reasons: if aperson normally not resident in an area is killed inthat area, they do not get listed in the survey(their household is elsewhere and not beingvisited). If a head of household dies, that deathand any others in the household are lost, becausethe household often disbands with the remainingdependents joining families elsewhere.

The net effect of these is to undercount deaths,and this is a factor common to all householdmortality surveys in the community, including thecensus. A general rule of thumb in large

household surveys is that even with the mostrigorous canvassing it is impossible to find morethan 95 percent of total deaths. The significanceof the undercounted deaths depends on theamount of undercounting of total deaths, as wellas any systematic biases operating to undercountparticular types or causes of deaths. Great effortwas taken to capture all deaths (and othersignificant non-fatal health events), but inevitably,some deaths were not counted.

There are differing approaches taken to deal withundercounting. The first, which is often used inlarge surveys such as the census, is to use asecond small survey to ascertain the rate of newdeaths found compared to the initial rate, andthen to use this to adjust the initial rates.Depending on how rigorous the initial canvas ofdeaths was, as well as the re-canvas, adjustmentsby this method commonly increase rates by 10 to20 percent compared with the unadjusted rates.The second approach is to use existing 'goldstandards' such as the crude mortality rate, infantmortality rate and child mortality rate from thecensus, and adjust the survey ratesproportionately accordingly to their differencefrom the gold standard. A third approach is toreport the rates "as-is" and show the comparisonof the survey rates and the gold standards, as wellas showing the results of internal validationmeasures built into the survey. Users of the surveydata are expected to make any adjustmentsnecessary for their specific circumstances.

The BHIS rates reported are not adjusted forundercounting; they are "as-is". Users shouldcompare the agreement of the 2003 BHISdemographic rates with the 2001 census rates(which refer to the count from 2000) adjustedaccording to their expectations for the three-yeartime difference. Additionally, two other validationexercises are in progress: a life table analysis isbeing conducted that will allow age-specificcomparison of all-cause mortality with the censusrates; an indirectly derived index of early childmortality rates (IECM) from preceding births andsibling survivorship methods are also beingprepared. For this initial report, a series ofmortality indices were computed from the samplepopulation and compared with the census data(IMR, CMR, CDR, ASMR, etc). There was a highdegree of concordance as seen in the following table.



Classification errors

The classification process was standardised.When each household was visited a screeningform was used to collect information on thehousehold, including information about thenumber of household members, age, sex, numberof deaths in the household in the last two or threeyears (depending on the study area), and thenumber of sick (ill or injured) persons in thehousehold in the last six months. If any deathsor morbidities were identified, a standard verbalautopsy or verbal diagnosis form was completedto determine the cause of death or morbidity. Thisprovided a systematic process of death andmorbidity classification that allowed a translationof the layman's description to a medicaldiagnosis. When injury deaths/morbidities weredetected, injury mortality/injury morbidityquestionnaire(s) were used to gather detailedinjury related information. Most injury morbidityand mortality was relatively easy to identify asthey were often reported as such by respondents(drowning, traffic crash, electrocution, poisoning,etc.); however, classifying communicable andnon-communicable diseases was a biggerchallenge. To classify these, two panels of medicaldoctors (paediatricians) were involved, eachcomposed of three members. Each panel began byindependently identifying the underlying cause ofdeath (rather than the final cause of death). Eachpanel then blindly classified these separately andthen classifications of the two panels werematched. For discordant cases, the groups met,discussed and reached a consensus. In a numberof cases, (10 to 15 percent), there wasinsufficient knowledge of the death by the

respondent to allow adequate classification. Itwas coded as "cause unable to be determined".Characteristics of deaths coded as "cause unableto be determined" were compared with thosewith a known cause to ascertain whether therewas a systematic source of classification biasintroduced by the classification system.

Issues of sample size

To appreciate the issue of sample size, it is usefulto consider the current situation in Bangladesh.The 2001 census found a crude death rate of5.4/1,000 population. In an average household offive persons about one death can be expected tooccur in every 200 households each year. Thetwo groups with the highest mortality rates areelderly persons and neonates. To find a singledeath in a child older than infancy severalthousand households have to be visited. To find alarge enough number for statistically reliable ratesto be measured, the total number of householdssurveyed has to be quite large. Despite theenormous sample size, given the relative rarity offatal events, the confidence intervals around therate estimates can be wide. This must berecognised when the rates are beings interpreted.

Related to sample size is the issue of the power ofthe survey. In order to calculate a rate ofoccurrence for an injury event, at least one of theinjury events being measured must occur. As thesize of the group in which the injury event occursgets smaller as they are stratified during analysis(e.g. moving from all injury deaths in Bangladeshto a subset of fatal injuries in rural areas, then tofatal injury in males in rural areas, then to fatalinjury in male infants in rural areas) the numbers


of the events in the last, smallest group may notbe sufficient to occur even once. In this case, therate cannot be determined, as it is below thepower of the survey to measure. It is important torecognise that the rate is not zero (i.e., it does notoccur); but that it did not occur at a sufficientlyhigh level to be measured.

The sample size for the study was 171,366

households with 819,429 residents - 434,598rural and 384,831 urban. There were 1,452 childdeaths and 19,304 morbidities in the year prior tothe survey. This enormous sample size wasrequired in order to provide sufficient power tocapture the rare fatal child injury events. To ourknowledge, this is the largest survey of injury atthe household level in a developing country todate.

Chapter 3

Mortality Overview

Over 30,000 children die from injury each year in Bangladesh. This is 83children each day, over half (46) die from drowning.

25Chapter 3: Mortality Overview

Introduction

In the survey a total number of 1,452 deathsamong children 0-17 years were identified in thepreceding one year. The causes of these deathswere initially classified into four broad categories:infection; non-communicable disease (NCD);injury; and 'information insufficient forclassification'. The specific causes of the deathsthat were classifiable were determined, and thetop ten leading causes are presented in thischapter. The unclassifiable portion ranged from 11percent to 26 percent in different age groups.(Detailed information available in table 3.3 ofappendix C).

Child injury is a stage of life issue. Injury ratesdramatically change with the changing stages ofa child's life.

Table 3.1 shows that infectious and NCD deathsgreatly outnumber injury deaths during infancy,with over 27 infectious deaths and over 28 NCDdeaths for each injury death. This is due to theinfant's physical dependence on the mother orcaretaker, which provides protection from mostinjuries. However, the situation changesdramatically when the infant begins to walk atage one. The young child is now independent andhas greatly increased unsupervised exposure toenvironmental hazards. After age one, over thenext 17 years of childhood, there are almost equalnumbers of children killed from injury as infectiouscauses (1:1.2) and over twice as many childrenkilled from injury as non-communicable causes(2.5:1).

As infancy is relatively injury free, it is moreappropriate to report injury rates for infancyseparately. In this report, injury rates are reported

separately for infants and children 1- 17 years, orthe childhood age groups (1-4 years, 5-9 years,10-14 years, and 15-17 years).

Proportional mortality by category

Injury accounted for 38 percent of all classifiabledeaths in children aged 1-17. Injury caused 2percent of infant deaths, 29 percent of 1-4 yearold deaths, 48 percent of 5-9 year old deaths, 52percent of 10-14 year old deaths and 64 percentof 15-17 year old deaths (Fig.3.1). In infants,death due to non-communicable diseases washigher than infectious diseases, as almost two-thirds of these deaths occurred in the neonatalperiod, and most of the neonatal deaths were theresult of birth-related causes, which were codedas non-communicable diseases.

Leading causes of child deathsThe tables that follow show the leading causes ofchild deaths by age of child. The causes of death,where there was a large number of deathsassociated with them, within each of the threemain categories (infection, non-communicable,and injury) were ranked by frequency to determinethe leading causes of death. Within the threecategories of death, specific causes of death thathad only one or two deaths associated with themwere not ranked as single cause, but as 'other'.Where there were more than 10 causes, only the

Mortality Overview


top 10 are listed; where there were fewer than 10,all are listed.

As mortality in infants generally occurred in theneonatal period, neonatal causes (low birthweight, preterm, etc.) predominate. Injury was nota large cause of infant deaths, with falls being thetenth leading cause (Fig.3.2).

Drowning was the leading cause of death inchildren aged 1-4, followed by pneumonia. Thedrowning rate was 86.3/100,000 and itaccounted for 26 percent of mortalities in the agegroup. Malnutrition, diarrhoea, meningitis,septicaemia, transport injuries and dengue wereamong the top ten causes of mortality in childrenaged 1-4 years (Fig.3.3).

There was a direct relationship between age andinjury. As age increased, so did the proportion ofchildren dying of injury, which was 48 percent inchildren aged 5-9 years. Drowning was theleading cause of death, responsible for 29 percentof deaths. The rate of drowning in this age group

was 26.2/100,000. Transport injuries, animalbites and electrocution were also leading killersfor children aged 5-9 years (Fig. 3.4).

Transport injury, falls, drowning and animal biteswere four of the five leading causes of death inthe 10-14 year age group, and accounted foralmost 44 percent of all deaths (Fig. 3.5).


Injury was responsible for five of the ten leadingcauses of death among children aged 15-17 years(Fig. 3.6). In this age group, suicide was theleading cause of death (38 percent), with animalbites, transport injury, drowning and violenceamong the other leading causes.

In children aged 1-17 years, drowning was theleading cause of death, responsible for almostone-quarter of deaths, followed by pneumonia,malnutrition, diarrhoea and meningitis (Fig. 3.7).

Fig. 3.8 shows there were differences in ratesbetween males and females in many of theleading causes of deaths in the 1-17 age group,but none of these differences were statisticallysignificant.

Age specific causes of injury mortality

Injury mortality rates by age are presented in thefollowing figures.

As seen in Fig. 3.9 suffocation was the majorcause of fatal injury (30.9/100,000) in infants.The fatal injury rates from falls, drowning andburns were 24.7, 18.5 and 6.2/100,000respectively.


Drowning was the leading cause (86.3/100,000)of injury death in 1-4 year old children. Itaccounted for more than 90 percent of fatalinjuries in this age group (Fig. 3.10).

As seen in Fig. 3.11 drowning was the majorcause of injury mortality (26.2/100,000) in the5-9 year age group and accounted for about 60percent of fatal injuries. Transport injuries beganto appear as a significant cause in this age group.

On reaching the 10-14 age group transportinjuries become the leading cause of fatal injury(7.8/100,000) among children, followed by falls,drowning, and animal bites with rates 3.9, 2.9and 2.9/100,000 respectively. Intentional injury(homicide) appeared for the first time as a leadingcause of injury death (Fig. 3.12).

Fig. 3.13 shows intentional injury (suicide, mostoften by poisoning) was the leading cause of fatal


injury among 15-17 years children at the rate of23.5/100,000. Even though animal bites andtransport injury were significant as other causesof fatal injury, suicide was responsible for overhalf (57 percent) of fatal injury deaths in this agegroup.

For the child age group 1-17 years, drowning wasthe leading cause of injury death. The other fiveleading causes of fatal injuries were transportinjuries, animal bites, suicides, falls andelectrocutions (Fig. 3.14).

There were differences in rates between malesand females for many of the causes of deathsfrom injury in the 1-17 age group (Fig.3.15), butnone of these differences were statisticallysignificant.

The numbers in table 3.2 represent the totalnumber of child deaths (infants and children 1-17)

resulting from injury in 2002, the year precedingthe BHIS. The numbers were computed byapplying the age-specific fatal injury rates foundin the BHIS to the actual numbers of infants andchildren in Bangladesh in each age groupaccording to the SVRS (adjusted for 2002). Thenumbers in a projection such as this aresusceptible to all the errors inherent in the BHISrates as well as those in the SVRS rates. Theyshould be interpreted with appropriate cautionand in light of the confidence intervals for theBHIS. They are offered as one measure of theimportance of the child injury issue in Bangladesh.

Discussion

The epidemiology of child deaths from injury isboth simple and complex. It is simple in that as asingle factor, injury is the leading cause of childdeath after infancy. It is complex however, in thatin each stage of the child's life after infancy, thepattern of injury death changes.

First and foremost, it is clear that injury is theresult of the interaction of the child with it'senvironment. During infancy, interactions with theenvironment, and the potential hazards in thatenvironment are controlled by the mother or otherprimary caregiver. This is usually an adult, and asa result, injury rates are very low. Exceptions tothis occur when the adult is actually the cause ofthe injury (overlayment and suffocation of theinfant) or is not actively supervising the infant


(falls, burns and drowning). In the later stages ofthe child's life, the child itself determines theinteraction, and the injuries resulting from thatinteraction are influenced by the child's growthand development stage, as well as its ability tolearn from experience. Early in toddler-hood, thechild is small in stature, has limited co-ordinationand strength, is confined mainly to the home andis unaware of the hazards presented by water, fire,animals and heights. Thus, while drowningpredominates, burns, falls and animal bites arealso leading causes of injury death, and almost allfatal events occur in and immediately outside thehome. Later, in middle childhood when the child issocially active and ranging further with friendsand schoolmates, drowning remains high, butfurther away, and in larger bodies of water. Roadtraffic accidents (RTA) become a significant causeof death as the child is frequently exposed totraffic as a pedestrian or bicyclist. As the childenters the adolescent years, the characteristics ofadolescence including the pressures and demandsfrom approaching adulthood such as earlymarriage and employment, intentional injurybecomes a leading cause of death.

Therefore, a focus on one type of injury or oneage group will not be an effective approach tochild injury reduction. Child injury reduction willrequire interventions across the different stages ofa child's life and which address the differing typesof injury; both unintentional and intentional.

Secondly, the BHIS demonstrates convincinglythat an epidemiological transition has occurred inBangladesh, largely as a result of enormousefforts in health development that have literallytransformed the pattern of mortality in thecountry over the last three decades. It is anamazing achievement, accomplished primarilythrough the focus on young children and theirmothers. As a result, after infancy, the singleleading cause of death in children is nowdrowning; in any child age group, injury is eitherthe leading killer or a leading killer; and in the lateadolescent years, intentional injury is the leadingcause of child death. In order to continue thedownward pressure on child death rates, injurywill have to be targeted as single-mindedly andeffectively as the previous leading causes of childdeath: infectious diseases.

Thirdly, most early childhood mortality is nowcompressed into the infant age group, and withinthis group, most death occurs in the first monthof life. Most of the mortality previously occuringfrom infectious causes in early childhood is nowoccuring later in childhood from injury. Thisshifting and splitting of the bulk of mortality froma single span of years beginning at birth andending by age five, into mulitple areas thatencompass later stages in childhood mandates amid-course correction to continue to effectivelytarget mortality in the child age group.


Figure 3.16 shows the vast majority of mortalityin the under-five age group occurs in infancy andwithin this period, most occurs in the neonatalperiod-the first month of life. This distributionstrongly indicates the need to continue the focuson infant mortality reduction as a priority. Withinthis period, the real target now becomes neonatalmortality, and the focus on finding affordable andsustainable ways to provide perinatal services thatinclude emergency obstetric care to all pregnantwomen in Bangladesh. Eighty percent of

pregnancies in Bangladesh are in rural areas andthese pregnancies are the main contributors toneonatal mortality. Reducing the rate of neonatalmortality will be a monumental challenge,requiring major changes in the current healthinfrastructure. Developing effective, affordableand sustainable interventions will require a greatdeal of operational research and programmaticeffort.

Figure 3.16 also shows that while injury is anissue in infant mortality, it is greatlyovershadowed by neonatal causes, non-communicable disease and infections. Whereinjury occurs, it is mainly in the postneonatalperiod, and involves suffocation and falls in theearly post-neonatal period and drowning in thelate postneonatal period. However, injury is aleading cause of child deaths in the rest of theunder-five age group, from age 1-4. Within thisgroup, drowning is the single largest cause ofdeath, accounting for over a quarter of all deaths.To reach the Millennium Development Goal (MDG)of U5MR reduction, drowning mortality in the 1-4age group will need to be targeted, as well asneonatal mortality.


Figure 3.17 shows that further significantreductions in child mortality in the middle andadolescent age groups will only be possible

through directly targeting injury as the leadingcause of child mortality in these age groups.Accidental causes predominate in the 5-9 agegroups, and intentional causes predominate in the15-17 age group; there is a mix in the 10-14 agegroup. Thus, effectively addressing injury inchildhood from the age of five years and up willrequire interventions in both unintentional andintentional injury.

The success of the child survival effort inBangladesh has fundamentally changed thepattern of mortality in Bangladesh. To continuethe encouraging decline in child mortality willrequire integration of child injury prevention intothe current programme mix and a broadening ofits focus from child survival to child protection.How to best accomplish this should be a majornew focus of operational research.

Chapter 4

Morbidity Overview

Almost 1 million children are injured each year, seriously enough to bedisabled, hospitalized or miss three or more days of school or work.This is over 2,600 children each day.

35Chapter 4: Morbidity Overiew

Morbidity Overview

Introduction

Mortality is relatively easy to study, as there areonly two outcomes - alive and dead. In contrast,for morbidity, there are many possible outcomeswith different levels of severity. At one end of thespectrum is what might be called "minor" injury,or injury that does not require medical attention.This type of injury does not result in lost schoolor work, and does not incur social or economiccosts, for example, a scraped knee. At the otherend of the spectrum is the highest degree ofseverity, short of death, where injury causespermanent disability; for example, a broken neckwith full paralysis of the body (quadriplegia).Severity levels in between are not standardisedand have many operational definitions. Thedefinitions used in the BHIS are:

Moderate: Sought medical care but notadmitted to hospital; or had at least athree-day work loss or absence fromschool or inability to do normal dailyactivities, but had no permanent disability.Three days was set as the minimumnumber following extensive discussionswith social scientists and epidemiologistsfamiliar with Bangladeshi cultural norms.

Major: Hospitalised for a period of lessthan 10 days but no permanent disability.

Serious: Hospitalised for 10 days or more,but no permanent disability.

Severe: Permanently disabled (loss ofvision, hearing, handling, ambulation, ormentation) regardless of whetherhospitalisation occurred.

BHIS did not include injury (or illness) that did notincur a cost. To be included, an injury had to resultin seeking care, or missing school or work orinability to do normal daily activities. Thisrequirement for inclusion in the survey was toenable the BHIS to examine the economic andsocial costs of injury.

Most of the costs of injury are incurred as a resultof non-fatal injury. Fatal injury often occursquickly, and in Bangladesh most deaths frominjury occur outside the hospital, with little directeconomic costs for medical care. Non-fatalinjuries, which result in hospitalisation have highereconomic costs for medical care. Categorisingnon-fatal injury by different severity levels allowscomparisons of types of injuries at comparablelevels of severity. This allows for thedetermination of factors such as social andeconomic burden of injury in a meaningful way.For example, comparing all children injured fromfalls with all children injured by machines isdifficult as there are great differences indistribution of severity. Most children (over 90percent) injured from falls did not requirehospitalisation, and less than 2 percent hadpermanent disability. However, about 15 percentof children injured by machines were hospitalisedand over 6 percent were permanently disabled.The nature of the injury and the physical forcesinvolved in the two events differ, and the amountof trauma and severity of injury differs. By usingthe same level of severity of injury, it is possibleto more directly compare injury from falls withinjury from machines to determine the relativeeconomic and social burden of each type of injury.

Finally, it must be noted that like fatal injury, non-fatal child injury is a stage of life issue as well.Non-fatal injury rates dramatically change withthe changing stages of a child's life.

Table 4.1 shows that infectious and NCDmorbidities greatly outnumber injury morbiditiesduring infancy, with almost 14 times as manyinfectious morbidities and one and a half timesmore NCD morbidities than injury morbidities.


This is because the infant is physically dependenton the mother or caretaker and is protected frommost injuries. However, the situation changesdramatically when the infant begins to walk atage one. The young child is then independent andhas greatly increased unsupervised exposure toenvironmental hazards. From this point on, overthe next 17 years of childhood, there are 49 timesas many children injured than in infancy. (On aper-year basis, this is about three times as many).As infancy is relatively free of injury, it is moreappropriate to report infancy injury ratesseparately rather than combined with childhood(1-17 years). In this report, injury rates arereported separately for infants and children aged1-17 years, or the childhood age groups (1-4years, 5-9 years, 10-14 years, and 15-17 years).

Proportional morbidity by category

A total of 19,304 morbidities were identifiedamong all children (0-17) in the year precedingthe survey. About a third of total morbidities weredue to injury. About 5 percent of morbidities didnot have enough information reported to beclassifiable by cause.

Fig. 4.1 shows only 6 percent of infant morbiditywas caused by injury. Proportional morbidity dueto injury was much higher in the older age groups,with 26, 40, 37 and 38 percent among 1-4, 5-9,10-14, and 15-17 year old children respectively.

Leading causes of childhood illness

For the infant age group, acute respiratory tractinfection (ARI)/pneumonia was the leading cause

of morbidity. Injury occurred at lower rates thanother causes and was predominantly falls andburns (Fig. 4.2).

ARI/pneumonia and diarrhoeal diseases were thefirst and second leading causes of morbidity


among children aged 1-4 years. Burns, fallsand near-drowning were among the top tencauses of morbidity among children in this agegroup (Fig. 4.3).

There was a direct relationship between age andinjury as a cause of illness. As age increased, sodid the proportion of children injured. Falls werethe leading cause of morbidity in children aged 5-9 years (Fig. 4.4).

Injury accounted for the second, fourth, seventhand ninth leading causes of morbidity in the agegroup 10-14 years (Fig. 4.5). As seen in Fig. 4.6the pattern of morbidity in the late adolescent agegroup (15-17 years) was very similar to that ofthe early adolescent age group (10-14 years).


The higher morbidity rates in the early and middlechild age groups (1-4 and 5-9) skewed thedistribution of morbidity by cause in all childrentowards that of the lower age groups (Fig. 4.7).

There were sex differences in rates in the leadingcauses of illness. The male predominance in ARI,diarrhoea, fever, falls, cuts and transport injurywas statistically significant. The rest were not(Fig. 4.8).

Age specific causes of injury morbidity

The injury morbidity rate was 1,636/100,000 forchildren aged 1-17. The stage of life issue as itrelates to injury morbidity can clearly be seen inFig. 4.9. Infants had the lowest injury rates.Injuries dramatically increased to a peak in earlychildhood (1-4 years) and then decreased in theolder age groups.

Fig. 4.10 shows there was a strong malepredominance in injury morbidity rates in all agegroups. The differences were statisticallysignificant in all age groups except infancy.


Injury severity

The largest proportion in each age group wasmoderate, followed by major, then serious andsevere (Fig. 4.11).

The same pattern by sex was seen when infantswere separated out from the other age groups. Itwas statistically significant in all severity levelsexcept severe (Fig.4.12).

External causes of non-fatal injury

While injury rates were very low in infants, fallsand burns predominated (Fig. 4.13).

Burns, falls and near-drowning were the leadingcauses of non-fatal injury in toddlers (Fig. 4.14).


Transport injury became more prominent inchildren aged 5-9 years (Fig.4.15).

Fig. 4.16 shows cut injury and transport injurywere increasingly important as a cause ofmorbidity in the early adolescent age group (10-14 years).

Falls continued as the leading cause, withtransport injury also continuing to increase inimportance, now the second leading cause inchildren 15-17 years (Fig. 4.17).

Overall, the leading causes of morbidity frominjury were falls, burns, cuts, transport injury,followed by lower rates of other injury causes(Fig. 4.18).

The male predominance is statistically significantin all injuries in children 1-17 except poisoning(Fig. 4.19).

Permanent disability from injury

Permanent disability is the highest level of severityfor non-fatal injury in the BHIS. This level ofclassification was chosen due to the enormoussocial, medical and other economic costs incurredover the rest of a child's life when they become


permanently disabled. There are many othercauses of permanent disability besides injury(birth trauma, congenital defects, andcomplications of many infectious and non-communicable diseases) but injury is one of theleading causes, if not the leading cause, in thechildhood age groups. The infant age group doesnot appear in the following set of figures becausenot enough cases of permanent disability werefound to enable a meaningful distribution. This islikely to be due to the rate of occurrence in infantsbeing below the power of the survey to measure.It is unlikely that there was no permanentdisability due to injury in infants.

Falls from heights and severe burns were the mostcommon causes of permanent disability inchildren aged 1-4 years (Fig. 4.20).

Cuts resulting in major nerve damage andamputations along with burns were the leadingcauses of permanent disability in the age group 5-9 years. Violence was a significant cause as well(Fig. 4.21).


As seen in Fig. 4.22 burns and falls stand out asthe two leading causes of permanent disability inchildren aged 10-14 years.

Transport injury and falls tied for the leading causeof permanent disability in 15-17 age group(Fig. 4.23).

Falls, burns, cuts and transport injury stand out asleading causes of permanent disability in theoverall child age group (Fig. 4.24).

Fig. 4.25 shows with the exception of infancy,permanent disability rates were almost double inmales compared to females. The sex differencesin each age group were statistically significant.The lack of permanent disability in male infantsand females in the 15-17 age group was mostlikely due to insufficient power, rather than a lackof occurrence. For the females 15-17, the ratewas probably too low for the BHIS to measure, asthe leading cause of permanent disability in thisage group was likely to be RTA, and females inthis age group have very low RTA rates, due tovery low exposures compared to males (seeChapter 6 for details).

Fig. 4.26 shows the full spectrum of severity fornon-fatal injury. Severe injury, causing permanent


disability, is really the "tip of the ice-berg" inrelation to the rest of non-fatal injury. For eachpermanently disabled child, there were two otherchildren hospitalised for at least 10 days, or whohad major surgery as a result of the injury. Therewere four other children hospitalised between oneand nine days, and 64 children who requiredmedical care, or missed three days of school orwork.

The numbers in tables 4.2 and 4.3 represent thetotal estimated number of child morbidities and

permanent disabilities (infants and children aged1-17) resulting from injury in 2002, the yearbefore the BHIS was conducted. The numberswere computed by applying the age-specific non-fatal injury rates found in the BHIS to the actualnumbers of infants and children in each age groupaccording to the SVRS (adjusted for 2002). Thenumbers in a projection such as this aresusceptible to all the errors inherent in the BHISrates as well as those in the SVRS rates. Theyshould be interpreted with appropriate cautionand in light of the confidence intervals for theBHIS. They are offered as one measure of theimportance of the child injury issue in Bangladesh.

Discussion

The same statement made about fatal child injuryis appropriate for non-fatal child injury; it is simpleand complex at the same time. Simple, in that it isa leading cause of morbidity, and complex forseveral reasons:

There is only one outcome for a fatal injury,and the social, economic and other costs offatal injury are relatively straightforward. Incontrast, non-fatal injury, with its multipleoutcomes spans a range of outcomes that varyfrom minor nuisance, to permanent disabilitywith all of its life-altering consequences andextraordinary social and economic burdens.

It may be overly simplistic, but it can be saidthat the costs of fatal injury are fixed andrelatively finite as compared to the real costsof serious injury morbidity, which has higherdirect and indirect economic costs and greatersocial burdens.

The social burdens of many types of non-fatalinjury (particularly intentional) far outstrip theeconomic costs associated with fatal injury.

Fatal injury can only happen once; in contrast,non-fatal injury can happen (and usually does)multiple times over the various stages ofdevelopment of the child.

The BHIS did not look at what might be called"minor" injury. The lowest level of severity thatwas permitted for inclusion in the survey requireddirect medical care or loss of school, work ornormal daily activities. Given the very high rates


of non-fatal injuries of all kinds, in all age groups,in both sexes, and in both urban as well as ruralareas which satisfied these criteria, it is clear thatinjury in infants, children and parents inBangladesh imposes a burden on daily life that isharsh, relentless and often brutal.

There are clear gender and other equity issuesapparent in the BHIS results which will, by theirnature, mean that successful interventions willneed to be undertaken with a trans-generationalapproach. Schools and other social institutionsthat are currently employed in other equity issueapproaches will be fundamentally important indecreasing both the rates of the specific injuriesas well as the equity gap.

The health sector will be a necessary and centralpartner in injury prevention in children, as they areoften the gatekeepers to mothers, havingprogrammatic contact with them at key accesspoints in a child's life, first at the fetus stage, thenat the neonate stage, and later during thedangerous transition from infancy to childhoodwith its increased risk of injury. Many of theprevention efforts for child injury will necessarilybe focused on mothers and other caretakers anddecision-makers. However, in contrast with manyof the child survival programmes, the child itselfwill be a major focus for much of the preventionand response programmes. Other gatekeepers toolder children will be key in injury prevention. One

key sectoral gatekeeping partner for UNICEF andGovernment of Bangladesh injury programmes willbe teachers and the education sector. InBangladesh this is writ broadly, with partners ingovernment, in NGOs in the madrassas and otherreligious schools and in the private sector. All willbe key partners in injury prevention for children.

Injury cannot be prevented in its entirety, and anycomprehensive approach must include injuryresponse and rehabilitation programmes. Theresults of the BHIS show that a strategy of simplyincreasing the numbers of clinical facilities andhealth personnel will not solve the real issue ofinjury response-appropriate and effective first-response care to injured children (and parents andother adults). Even if there was a functioningsystem of emergency medical care in rural areaswhere 80 percent of the population lives, it is ahollow victory to transport to hospital a child RTAvictim who has an intact spinal cord immediatelyafter the crash, but then was rendered aquadriplegic because the only available firstresponders-the child's friends and adults aroundthem-did not have the basic first aid knowledge toprevent that outcome. It will be decades beforethere is a functional emergency response systemthat covers all of rural Bangladesh, where traumaand other injury rates are several times that ofurban areas. The only practical way to providewidespread first aid knowledge and first-response


skills to children that are effective in a publichealth sense, is to teach them these basic lifeskills as a component of the school system.UNICEF has a programme called "Facts For Life"(FFL) and endorses a "Life Skills Approach" inmany of the programmes for over-five children.TASC has advocated for the adoption of "SkillsFor Life" (SFL) as a companion to FFL and clearly,non-fatal (and fatal) injury rates will not fall untilthere is widespread acquisition of first aid andbasic trauma response skills as necessarycomponents of an SFL programme. GivenBangladesh's centralised educational trainingsystem, it would be possible over several years tocreate an entire national legion of children as firstresponders. They would have the ability to swimand the skills for rescue when their friends are atrisk of drowning; to splint a fracture and prevent

the potential for amputation later; to stop severebleeding and prevent shock and rapid death; toknow to "drop and roll" to put out clothing fires;to perform abdominal thrusts when their friendsare choking; and so on. Currently, when injured,the usual responses either do not help or worsenthe degree and severity of the injury incurred.

The figures 4.27 & 4.28 clearly show that injuryis an issue in each stage of the child's life, andthat it's toll increases as the child becomes older.The distribution of injury, throughout the stages oflife of the child mandates that it be addressed ineach stage. Arguments to the contrary, or aboutwhether to focus on the over-fives as well as theunder-fives, whether to deal with intentionalinjury or only unintentional injury, or whether anintegration of injury prevention into a protectionapproach threatens resources for the continuedsuccess of child survival need to be evidence-


based. The BHIS provides clear and compellingevidence that injury is a key health issue forchildren. Each year almost a million children(955,000) are injured seriously enough to requirecare or miss school or work, and over 13,000children are permanently disabled. This is a dailytoll of over 2,600 children injured and 36

permanently disabled. This is over a hundredchildren each hour-a staggering figure in pain andsuffering that is preventable. Many of thepotential interventions and prevention approachesare discussed in the following chapters on thespecific types of injury.

Chapter 5

Drowning and Near-drowning

Drowning is the leading cause of injury for children.

Almost 17,000 children die from drowning each year. This is over 46each day.

Over 68,000 children become victims of near drowning each year and narrowly escape death.

49Chapter 5: Drowning and Near-drowning

Introduction

Drowning may seem like a simple event to define,however, classifying it as an injury is not simple.For example, drowning when swimming forpleasure can easily be classified as drowning.However, if the swimming was to escape a naturaldisaster, for example a flash flood or the sinkingof a ship, it could also be classified as a death dueto a natural disaster or as a transportation fatalitywhich are two entirely different classifications.

There is an issue of whether drowning is alwaysfatal, or can be survived. Many people think ofdrowning as an always fatal event that cannot besurvived. Others think of near-drowning as anoutcome that is never fatal. For the purposes ofinterpreting the data obtained from this survey, itis important to recognise the definitions used inthe survey.

In the BHIS study, the definition used fordrowning was: death resulting from suffocationwithin 24 hours of submersion in water; victimsof near-drowning survive for at least 24 hours.Thus, drowning is always a fatal event and near-drowning may or may not be. If the drowningoccurred due to direct exposure to water NOTinvolving water transport, it was a drowning. If itoccurred as a result of a water transport mishap,

then it was a water transport death. Drowningduring a flood was considered to be drowning, butdrowning related to a ship sinking was considereda transport fatality.

Magnitude of drowning

The fatal drowning rate among children 1-17years 28.6/100,000; males 32.4/100,000 andfemales 24.8/100,000.

Drowning peaked in the 1-4 age group and thenrapidly declined as age increased (Fig. 5.1).



There was no statistically significant difference inrates between males and females in any agegroup (Fig. 5.2).

Fig. 5.3 shows that among children, one-year oldshad the highest rates, with rates falling rapidly forthe older children. The rapid decline in drowningrates after the first year is likely related todevelopment. As a child develops in the secondand third years of life, they acquire co-ordinatedmotor skills and physical stature. A child who isalmost one metre tall is able to stand in shallowditches and ponds and not drown. They also havethe physical strength to pull themselves out of aditch or shallow pond. Most drowning occurswithin the window of hazard formed between thefirst steps in infancy and the end of the third year.The reciprocal relationship between swimmingability and drowning that is clearly evident afterthis window closes is convincing evidence thatswimming skills are the public health "magic

bullet" for drowning of children after age four.There are two key issues clear in this relationship:1) that children in a country like Bangladesh withno pools, no certified life guards and no otherinfrastructure assumed to be necessary forteaching swimming on a large scale can acquireswimming skills, in the context of their normalenvironments, 2) that it is a cultural norm, at leastin rural areas, that children learn to swim veryearly, as most rural mothers are aware of the veryhigh drowning hazards for their children, and seeswimming as a necessary life skill.

Magnitude of near-drowning

The age pattern of near-drowning was identical tothat of drowning, only the rates of near-drowningwere several times higher (118/100,000 near-drowning; 28.6/100,000 drowning) amongchildren 1-17 years (Fig. 5.4).


Most near-drowning (94 percent) was moderate inseverity and did not result in hospitalisation. Sixpercent of near-drownings were major whichresulted in hospitalisation. All of thosehospitalised were in the younger child age groups(1-4 and 5-9) as shown in Fig. 5.5.

Factors associated with drowning

Significantly different drowning rates wereobserved among different age groups of rural andurban children in Bangladesh. The differences aremost likely due to the differences in urban andrural environments regarding water sources.Urban areas have few, and rural areas have many.Children aged 1-4 years old in rural areas had thehighest drowning rate (136.9/100,000). The agegroups 10-14 and 15-17 do not appear as therewere too few drownings in these age groups toenable a meaningful comparison between urbanand rural distributions (Fig. 5.6).

As shown in Fig. 5.7 natural bodies of water suchas ponds, ditches, lakes and rivers were commonplaces of drowning. Ponds were the mostcommon place of childhood drowning inBangladesh. More than 80 percent of drowningoccurred in natural water bodies as opposed toman-made containers (tubs, buckets and drums).Infants drowned in ponds and ditches near theirresidence, and not in lakes or rivers at furtherdistances from their residence. Toddlers (1-4years) mainly drowned in ponds and ditchesoutside the home, and in buckets, tubs and drumsinside and in the house yard.

More than three quarters of drownings took placein bodies of water less than 20 metres from thehouse. Infants drowned in bodies of water veryclose to the house, within 10 metres (Fig. 5.8).

Fig. 5.9 shows water bodies where drowningoccurred were used for bathing and washing (33


percent), collecting cooking and drinking water(13 percent) and raising fish (20 percent). Aboutone-third of the water bodies where drowningoccurred, were not used for household work.

Studies in Matlab reveal a seasonal pattern ofdrowning which shows a clear increase in childdrowning in the rainy season peaking in thesummer (July) with the winter relatively free ofdrownings15. The BHIS has almost a similarpattern of seasonality except a sudden decreasein July and increase in December in the year priorto the survey due to reasons which are not clear(Fig. 5.10).

Almost all (97 percent) drownings occurred duringthe daylight between 0600 hours and 1800 hours(Fig. 5.11).

Fig. 5.12 shows almost half (42 percent) of thedrowned children were either working or playingnear the water reservoirs before drowning.


As shown in Fig. 5.13 most of the drownedchildren could not swim. Almost half (46 percent)were under four years of age and too young toknow how to swim. Among those five years orolder, an age where they could have learnt toswim; only 7 percent of drowned children couldswim. Swimming skills appear to be highlyprotective for drowning prevention.

In about two-thirds of instances (64 percent)when children drowned, they were alone, oraccompanied by someone who was not capableof rescuing them (Fig. 5.14).

For those two-thirds of child drownings where thechild was accompanied, almost half wereaccompanied by children too young to rescuethem. Almost one-third (29 percent) of drowningchildren were accompanied by a child under-fiveand a fifth (19 percent) were accompanied by achild less than 10 years old (Fig. 5.15).

At the time of the child drowning more than two-thirds (67 percent) of mothers or caregivers wereinvolved in household activities; 16 percent wereworking outside and 7 percent were sleeping ortalking with others (Fig. 5.16).


Risk factors for childhood drowning

Case-control study

A case-control study was conducted as aseparate component of the BHIS to identify thedemographic, environmental and caring factorsassociated with childhood drowning. The oddsratios with 95 percent confidence intervals wereestimated for various associated factors fordrowning and shown in tables 5.1 & 5.2.

Having a mother who was illiterate (OR 1.7) orhaving five or more children in the family (OR1.95) were significantly associated withchildhood drowning, as well as caring factors

such as the main attendant of the child not beingthe mother (OR 74.5), and the accompanyingperson of child when drowned not being themother (25.4). Lack of swimming ability (forchildren five and over) was associated withchildhood drowning (OR 4.5).

Discussion

Drowning is the leading cause of death in childrenaged one year and over in Bangladesh. Based onthe rate reported in the BHIS, in the yearpreceding the survey, almost 17,000 childrendrowned or about 46 per day. There was aboutfour times this number (over 68,000) of near-drownings. This was about 188 child near-drownings per day. Drowning rates in Bangladeshare 10 to 20 times the rates of child drowning indeveloped countries16,17,18.

There are a number of findings in the survey thatare important to consider. First, drowning ispredominantly an issue in infants and toddlersaged 1-4, who account for almost half of alldrownings. The rates increase as infants begin towalk, and peak during the first year. The onset inlate infancy is likely to be the result of mothersbeing unaware that the child is about to begin towalk, and leaving the child unsupervised thinkingthey can only crawl. Among children 1-4 yearsold, one-year olds have peak rates, with ratesfalling rapidly as the child gets older. The rapiddecline in drowning rates after the first year is


development related, with most drowningoccurring within the window of hazard formedbetween the first steps in infancy and the end ofthe third year when the child's physical andmental development has rendered them lesssusceptible to drowning in the shallowdepressions and ditches that are frequently filledwith water during the rainy season.

Second, there is a distinct temporal period fordrowning, which peaks during the heavy rains andmonsoon/cyclone season, and has a nadir in thedry, winter months. Fig. 5.17 shows the usualseasonality of drowning in Bangladesh asdetermined by the Matlab research site, between1983 and 1995. There was a clear increase inchild drownings in the rainy season which peakedin the summer (July) and the winter was relativelyfree of drownings with the lowest month January.However, the BHIS has almost a similar pattern ofseasonality except a decrease in July and increasein December in the year prior to the survey due toreasons which are not clear.

Third, the place of drowning for infants andtoddlers was almost entirely within 10 metres ofthe house, in ditches, ponds, tubs and drums.They drowned immediately outside the house,while unsupervised by the mother, and eitheralone or accompanied by a peer or an oldersibling.

Fourth, drowning occurs in the daylight hours, andwhen mothers are often engaged in housework orother chores.

Fifth, it occurs when there are large families, andthe mother is busy with other chores and the

responsibility of the infant or toddler falls to oneof the older siblings, still a child themselves.

Families with illiterate mothers who have manychildren can be targeted as high-risk as thefindings of the case-control study are very clear.Illiteracy in the mother is a possible marker fortraditional roles, rather than a factor in itself.These mothers lack education, not intelligence,and when given facts regarding risks for their veryyoung children, can use that for the benefit oftheir children. Similarly, having more than fivechildren is also a likely marker for this traditionalrole, and one that necessitates assigningsupervision responsibility onto an older sibling ofthe infant or toddler. Unfortunately, the oldersibling is him/herself not yet capable ofsupervising an infant or toddler with the criticalattention necessary. Informing these mothers thatan older sibling must be well developed beforethey are capable of performing child supervision,and working with the mothers to discussalternatives for adult or adolescent supervision ofthe youngest children should allow them to findways to increase supervision, and to reduce thedrowning hazards (fencing around the pond, etc).

It is clear that for children over five years of ageswimming is a necessary life skill for survival in acountry such as Bangladesh. The good news isthat most children over five in rural areas doacquire this life-saving skill, and as a result,drowning rates dramatically decrease. Thereciprocal relationship between swimming abilityand drowning that is clearly evident is convincingevidence that development of swimming skills isthe public health "cure" for the epidemic ofdrowning in children after age four.

There are two key issues in this relationship: 1)children in a country like Bangladesh with nopools, no certified swimming instructors or lifeguards and no other infrastructure assumed to benecessary for teaching swimming on a large scalecan acquire swimming skills, in the context oftheir normal environments. 2) it is a cultural norm,at least in rural areas, where children learn toswim very early. Most rural mothers are aware ofthe very high drowning hazards for their children,and see swimming as a necessary life skill.

There are some obvious interventions that areappropriate and affordable in the context ofBangladesh. Health workers can identify

56

households with four or more children; inform themother of the risks to her younger children andthe need to provide adult supervision to theyoungest children; and survey the home for watersources nearby and devise ways to decreaseaccess to these (fences, door gates, etc).

For all mothers, health workers can use the ninemonth EPI visit for measles immunisations tocounsel the mother on the need to increasesupervision of the infant in the next severalmonths as they begin to walk. A hazard checklistfor drowning hazards could be given to mothers atthis visit (suitable for both literate and illiteratemothers) allowing them to critically appraise theirhomes for drowning hazards to their youngestchildren. It could also encourage them to teachtheir children to swim at an early age. Finally,given the fact that homes are the most hazardousplaces for children for injury of all causes, not justdrowning, the EPI-centred drowning hazardreduction could include other injury hazards toyoung children (burns, falls, poisons, etc). Thatwould provide continuing reductions in injuryhazards to the children as they grow up in thehome.

Bangladesh has an opportunity to integratedrowning prevention (and other injury prevention)programmes into the existing child survival anddevelopment programmes. The existing EPIprogramme provides one direct contact tomothers of children at nine months who areentering the window of drowning risk. Given thatdrowning is the single largest contributor tounder-five deaths in the post-infant period, (over a

quarter of all deaths are between the years 1-4)fully integrating a drowning hazard reductionprogramme into the existing EPI programmewould rapidly reduce the U5MR and helpBangladesh achieve its MDG goal in this criticalarea. Fully integrating a home-hazard basedintervention programme (Child Safe Home) fordrowning plus other leading injury causes of earlychild death and disability (burns, poisons, animalbites, etc) with EPI, ARI, CDD and ECDprogrammes would provide a commensuratelygreater decrease in U5MR.

Using programmes and communications channelsto encourage all mothers and fathers, urban aswell as rural, to ensure their children learn toswim as early as possible, will provide childrenwith a critically needed life skill in Bangladesh.Any programme that leads to swimming skills inyoung children will decrease drowning later inchildhood, and as drowning is the leading singlecause of child deaths from one to 17 years,responsible for nearly one quarter of deaths (23percent) this will certainly decrease overall childmortality. Joint UNICEF/TASC research currentlyunderway to define norms, safe methods andhazards in inter-generational swimming skillstransmission will be helpful in this regard. Usingthis knowledge, it will be possible to develop anappropriate, effective, and sustainable earlychildhood swimming programme with nationalcoverage to meet the goal of having all childrenlearn to swim as a needed life skill in a countrysuch as Bangladesh.

Bangladesh Health and Injury Survey: Report on Children

Chapter 6

Transport Injury

Road traffic accidents kill over 3,400 children each year.

This is about 9 children each day.

59Chapter 6: Transport Injury

Introduction

Bangladesh is a country often described as a deltaformed by the three major rivers and theirtributaries that intersect the country. Boats,barges, ships and rafts are major sources oftransport for most members of the populace. Insome regions, boats, launches and steamers arethe main means of transportation, especially inthe southern part of the country. Natural disasterslike floods and cyclones cause frequent boat andlaunch capsizings and a considerable number oflives are lost every year.

For road traffic accidents, the accident situation isworsening in Bangladesh. Data constraints andwidespread under reporting of accidents preventsthe real magnitude of the road accident problemfrom being known, but the available data indicatesthat road accidents and fatalities are increasing inBangladesh. Factors responsible for this increaseinclude rapid urbanisation, large scale shifts oftraffic previously carried by rail and boat to roads,poor socio-economic conditions, lack ofenforcement of traffic safety regulations, andpoor engineering factors. In 1982, the accidentfatality rate was 125.7 per 10,000 vehicles. Thisrose to 170 in 1992. This rate was the highest inAsia, and almost 100 times more than Norwayand Sweden19,20. One study from the onlyorthopaedic hospital in Bangladesh reported thatover half (56 percent) of total emergency patientswere the victims of road traffic accidents. About80 percent of road fatalities occurred on ruralsections of the main highways. In urban areas,pedestrians represent up to 70 percent of roadfatalities19. The estimated total annual cost ofroad traffic crashes is approximately US$ 750million13.

Transport injury types

Despite the importance of water transport inBangladesh, most transport related deaths aredue to road transport. Ferries and other shipsfrequently sink in Bangladesh due to overcrowdingand other unsafe practices, and drowning deathsbecause of this often reach several hundred per

year. However, while the sinking of ships causelarge losses of life, they are sporadic by nature.Road trauma occurs around the clock, day in andday out. All transport deaths found in BHIS wererelated to RTA.

In children aged 1-4 years and 5-9 years old, therate of fatal RTA was higher among females thanmales. In children aged 10-14 years, fatal RTA wasabout three times higher among males(11.6/100,000) than females (3.9/100,000). Thelack of fatal RTA in females aged 15-17 years oldis likely due to the power of the survey beinginsufficient to determine the rate in this group. Itis probably less than the rate in 10-14 year oldfemales, but not zero (Fig. 6.1 & 6.2).

Transport Injury


Non-fatal transport injury rate is highest in 15-17years. Rates increased for males as age increased,but decreased for females. This most likelyreflects the different gender roles for males andfemales in Bangladesh, with fewer femalesspending time outside the house (and at risk ofRTA) than males in the ages 10+ when genderroles become strong factors (Fig. 6.3 & 6.4).

Significantly different non-fatal transport injuryrates were observed in all age groups of rural andurban children in Bangladesh except in infants andchildren 1-4 years (Fig. 6.5).


More than 40 percent (8 out of 19) of fatal RTAoccurred among pedestrians. Heavy motorvehicles caused 32 percent of the fatal injury(Fig. 6.6).

More than 40 percent of the road users in fatalRTA were passengers and an equal proportionwere pedestrians (Fig. 6.7).

Heavy motor vehicles including buses and truckswere involved as counterparts in about one-thirdof the fatal RTA. Motor cycles, cars, jeeps etc.,which were labelled as light motor vehicles, werethe counterpart in 21 percent of RTA. In 32percent of cases there was no counterpart (Fig. 6.8).

Among all children, non-motorised vehicles werethe main (39 percent) transport involved in non-fatal injuries. Next in proportion were pedestrians(36.3 percent). The highest proportion (52percent) of non-fatal injuries occurred amongchildren aged 5-9 years, who were pedestrians(Fig. 6.9).


Consequences of Road TransportAccidents Hospitalisation and severity

The pattern of severity can be seen in this figure.Most (79 percent) RTA injuries were moderate inseverity (did not require hospitalisation). Onepercent, 8 percent and 12 percent of the injurieswere severe, serious and major in naturerespectively. Levels of severity increased in theolder age groups, with children in the 10-14 agegroup having the largest proportion of severityrequiring hospitalisation (Fig. 6.10).

Discussion

RTA was the second leading cause of fatal injuryand the sixth leading cause of death in children1-17 years. The rates were high enough to beseen at all levels of severity, from fatal topermanent disability and lengthy hospitalisationas well as simply seeking care or missing school.At the rates found in the BHIS, over 3,400children were killed by RTA in the year prior to thesurvey, most of them as pedestrians. That is overnine children each day. Due to the high levels oftrauma incurred, it was the fourth leading causeof permanent disability from injury, responsible forover 1,360 children being permanently disabled oralmost four children each day. It was the eighthleading cause of morbidity in children, causingover 110,000 child injuries, or over 300 per day.

There is a clear male predominance in most agegroups for both fatal and non-fatal RTA injury. Thisis because of the gender roles that predominate inBangladeshi culture, and which leads to differentexposure rates for males and females to thevarious RTA hazards. As a generalisation, femalesspend much more time at home and do not gooutside the home with the same frequency asmales. This places them at lower risk of RTA andthis is seen in the rates. One of the most visibleareas is in the age groups where the different


gender roles become the social norm. In the10-17 age groups, the female rates for fatal andnon-fatal RTA are less than a quarter of the males.It is also particularly visible in comparing risks forthe two sexes regarding specific types of RTA. Inearly childhood the rates are closer to parity, asmale and female toddlers both play or walk nearroads at about equal rates, and are struck aspedestrians at almost the same rates. However, inmiddle childhood, when children begin to ridebicycles as a major means of transport, there is astark difference in fatality rates between malesand females, in large part because in Bangladesh,females rarely, if ever, ride bicycles.

Child RTA prevention poses many challenges.Developed countries have made great progress inmaking the transportation infrastructure muchsafer, with controlled access to highways andother engineering approaches that result inseparation of traffic streams, less harmful barriers,greatly decreased injury hazards within vehicles,and in massive investments in enforcement andeducation. Clearly, these work, and work well. Butjust as clearly, these are not options in the here-and-now in a country such as Bangladesh. The

road infra-structure is flooded annually and isconstantly being washed out; just keeping itpassable is a major challenge. Enforcementrequires a massive investment in traffic police tobe anywhere near a ratio of police to drivers thatis effective and this creates an unsustainableburden in benefits and other retirement issuesthat would be necessary to support the expandedcivil service. The same issues make it financiallyimpossible to move forward with sufficient healthsector investment to provide emergency medicalservices of the level that have contributed somuch to the developed world's record of rapidreduction in traffic-related fatalities. Finally, mostchild RTA injury occured as pedestrians, sodeveloped country technologies such as seatbelts, air-bags, child seats and helmets, have noeffect on these injuries.

The current approach to RTA prevention in thedeveloping world with its focus on trying to adoptthe strategies and technologies that have been soeffective in the developed world face majorconstraints beyond finance and personnel. Thereare barriers related to culture and level ofdevelopment that will need to be lowered


significantly in order to establish an effectivenational RTA programme. For example, basicliteracy is required for driver training andunderstanding of signs and road hazards; andcreation of new behavioural norms for roaddiscipline will be required. Ultimately, asdevelopment progresses they will have an impact,but this will be a process likely to be decadeslong. In the space of one decade, over fiftythousand Bangladeshi children will be killed orpermanently disabled by RTA; several hundredthousand will be hospitalised and an additionalhundred thousand children will lose their parentsdue to RTA. It is clear that Bangladesh need toembrace a more immediate, more sustainable andmore feasible approach to this epidemic of RTAinjury. A well designed primary and secondaryschool curricula with knowledge and skillsappropriate for each level of child developmentwould have a significant impact on the toll that

RTA imposes today. Young children are mainlykilled or injured as pedestrians, and they could begiven the knowledge and the skills to more safelyshare the existing road system. Schoolsthemselves are points where children convergewithin the transportation system and much couldbe done to make them safer places for comingand going to school. Traffic calming measures andcontrolled pedestrian access to schools caneasily be incorporated into a Safe Schoolsprogramme. Given that there is a centralisedtraining system for the schools in Bangladeshthrough the teachers training colleges, it ispossible to quickly implement a skills-basedprogramme taught by teachers that would have arapid and sustainable impact on the child RTAepidemic, and over time, through inter-generational knowledge transfer and growth andwith legions of students trained, would providethe basis for a national impact.

A schools-based system would also be anopportunity to provide skills for response as wellas prevention. The current reality is that there isno effective emergency response to children (andadults) injured through RTA. Many childrenneedlessly die or are permanently disabled as aresult. Child pedestrians are most likely to beaccompanied by their peers when struck, and iftheir peers were trained in basic trauma responseskills through a school-based programme, it islikely that more children would survive with fewerpermanent disabilities. Given the factors of timeand the group effect, the students trained wouldform a base for an effective national first responsesystem, for all injury, not only for RTA.

Chapter 7

Burn Injury

Burns injure over 170,000 children each year, and permanently disableover 3,400 children.

67Chapter 7: Burn Injury

Introduction

In developing countries, burns are importantcauses of injury mortality and morbidity, oftenranking as a significant source of mortality aftertraffic injuries, drowning and falls. House fires andclothing fires are the most severe and lethalevents, but are less frequent than scalds andother mild to moderate burns. Scald injuries areparticularly severe as they often lead topermanent disability from the extensive scarringover large body areas, or blindness from cornealscarring.

Most burn injuries in developing countries,particularly among children and women, occur inhomes21. Most homes are heated by burning woodor coal in open fires, and cooking is done on thesame, open fire. Since most homes are single-room dwellings in rural areas, there is alwaysclose proximity of children and fire or scaldingliquids. This is the case in Bangladesh as well,where almost all rural homes (which make up 80percent of all homes) have open fires or kerosenestoves for cooking and heating. Rural homes areoften single room homes, or with rooms separatedby reed curtains, and with a separate area setaside for cooking, with no way to effectivelyexclude children from the cooking area. Childrencommonly help the mothers in cooking and thusare also exposed to many sources of fire and hotliquids. Additionally, most rural homes areengaged in rice farming, and the newly harvestedrice is boiled to loosen the husks in large, pressurecookers commonly made from discarded oildrums. Children are commonly exposed to theseas they help in the threshing and processing ofthe rice, and the home-made rice boilerscommonly leak and occasionally explode,showering everyone nearby with scalding,superheated water.

Burn injury pattern

There were only two fatalities for children due toburns in the survey sample, one in a male infant,and one in a male toddler in the age group 1-4.

These numbers are too small to use formeaningful fatal burn patterns across the childage group. Despite the low fatality numbers, thehigh incidence rates mean that fatal burns are stilla major problem for Bangladeshi children. About340 children are fatally burnt each year inBangladesh, with almost one children dying eachday from burns. Fatal burn injury was0.6/100,000/year among all children. The ratesfor the infant and 1-4 age group are listed intables 3.12 and 3.13. The rest of the data citedrelates to non-fatal burn injury in children.

As shown in Fig 7.1 the highest non-fatal burnrate (782.1/100,000) was among children 1-4years old. Burn injury rates were highest in thesetoddlers, in direct consequence of the highexposure rates for them to many burn and scaldhazards in the typical Bangladeshi home, and theirlack of stability in walking as well as their lack ofknowledge about the hazards of stoves, lamps,cooking surfaces or hot liquids. The risks decreaserapidly as the child gets older, acquires dexterityand acquires knowledge through experience aboutthe risks of hot objects and liquids.

The following Fig. 7.2 shows that there is a malepredominance through infancy, early and middlechildhood until the age of 10, when gender rolesplace females at higher risk due to cooking andother roles with higher fire exposure rates. Non-fatal burn injury was higher among females in the

Burn Injury


older age groups, with 114.3 and 110.9 per100,000 female children of 10-14, and 15-17year old compared to 58.2 and 54.0 per 100,000male children of the same age groups (Fig. 7.2).

Burn injury had a rural predominance in all agegroups (Fig. 7.3).

Fire, hot liquid and hot objects were the majorcauses of burns and scalds in children. Theproportions were similar across the age spectrumof infants and children (Fig.7.4).

Fig. 7.5 shows 90 percent of burns occurred athome (inside and immediately outside).

Three-quarters of burn injuries occurred insidehomes; more than half of them occurred in thekitchen or kitchen area (Fig. 7.6).

Consequence of burn injury For children 1-17, most of the burns (93 percent)were moderate in severity. However, in each agegroup there were more serious burns, and in allage groups there were burns serious enough tocause lengthy hospitalisation and/or permanentdisability (Fig. 7.7).


As shown in Fig.7.8 children burnt or scaldedseriously enough to require hospitalisation, thesource of the burn or scald was about the samein all age groups; one-third open flame, one-thirdhot object and one-third hot liquid.

Infants were permanently disabled by scalds,toddlers aged 1-4 by hot objects (mainly walkingor falling into hot ashes left in open fires), andchildren 5-9 by open flames. Older children werepermanently disabled by all three major sources ofthermal injury. There were no 15-17 year oldspermanently disabled by burns (Fig. 7.9).

Discussion

Burns were the fifth leading cause of child injuryin Bangladesh, and the survey shows there wereover 340 children burnt to death in the year priorto the survey, or about one per day. Almost173,000 children were burned significantlyenough to require medical attention or sufferserious consequences, including permanentdisability. This was about 474 children each day.Burns were the second leading cause ofpermanent disability from injury in children, withover 3,400 permanently disabled, almost nine perday. Even in cases of non-permanent disability, itwas a significant cause of loss of school days, as


well as hospitalisation and medical expense. Thereis also the very real social burden incurred throughburn injury: the scarring and disfigurementassociated with burns of young children havemajor effects on their lives as adults, especiallywhen it occurs to young girls.

Bangladeshi culture has several unique factorsthat increase burn risks for children. First, rice isa staple of the daily diet, and it is boiled, ratherthan steamed as is most common in East Asia.(Boiling rice requires much larger volumes ofwater than steaming it and the steaming processleaves no left-over rice water to set aside to cool).Large quantities of rice are boiled every day inmost homes, resulting in large pots of scaldingliquid being set aside after the rice is boiled. Thus,in the typical rural home in Bangladesh with onlyone room and a portion of it set is aside forcooking, large pots of scalding rice water on thefloor or on a table presents a serious scald hazardto children.

Second, Bangladeshi people prefer the use ofround-bottomed pots called hari or patil that haveflared tops and no handles for cooking rice and

boiling liquids. As seen in the photographs, theselarge pots have no fixed tops and with no handleand rounded bottoms, present serious risks fortipping over, spilling or burning while handling,especially when used by children.

Third, tea and coffee is an important part ofBangladeshi culture and it is prepared fresh whenserved, and this involves boiling water in theround-bottomed hari preferred in Bangladesh,rather than using closed thermoses to store hotwater as is common in East Asia. Burns andscalds are frequent for those preparing tea andcoffee as well as creating a scald hazard forchildren when the unused water is set aside tocool.

The high rate of fatal burns in children aged 1 - 4and the very high rates of non-fatal burns thatrequire hospitalisation in infants as well aschildren show this is a major public health andsafety issue for Bangladeshi children. One of themost common burn injuries in infants and youngchildren is scalding which causes severemorbidity, but is not usually fatal. From a publichealth perspective, scalding is one of the largestchild health problems due to the enormous burden


in direct medical costs as well as later, the highsocial costs from the disfigurement andpermanent disability. Another similar injury isburns from fire ash, as very young childrencommonly walk or fall into the open fire pit wherethe hot ashes envelope the extremity and part ofthe trunk. These cause extensive burns andscarring, often resulting in severe burns andpermanent disability. These injuries arepreventable.

In Bangladesh, most homes in urban areas dohave separate rooms for kitchens, and thus youngchildren can be kept isolated from cooking stoves,which often have the round-bottomed pots filledwith hot or boiling water. Most kitchens typicallyhave a raised platform at a height of one-metre forstoves and pots, pans and thermos jugs. Thisheight is a dangerous height as it is just at arm'slength for toddlers and very young children. Whenleft unsupervised and when pots are simmering,very young children can pull the contents of thepans directly on to themselves. This results insevere injury as large areas of the body arescalded when this happens. Since the toddler is

looking up when pulling the pot down, severefacial burns accompanied by blindness oftenoccurs. Relocation of the cooking surface to adifferent place, using pots and pans with flatbottoms and handles and turning the handles sothey do not extend over the floor, or best,isolation of the cooking area from the place wherethe toddler is active are all potentially appropriate,cheap and effective prevention measures. It ismore difficult in the rural environment to keepchildren separate from cooking stoves and fires,as most houses are one room dwellings or do nothave solid walls with closable doors betweenrooms. In these circumstances it is important totrain mothers to place stoves and pots containinghot water (from boiling rice, for example) in areasthat are difficult for children to reach, to placebarriers around open fire pits and to dispose of hotashes in ways that prevent children from beingburnt. Mothers should also be encouraged to usecontainers with handles, and keep toddlers awayfrom the food preparation area.

Given the high burn rates for children inBangladeshi households, a Safe Home programme


that helps mothers to identify the obvious burnhazards for their children and modify the child'shousehold environment to reduce the burnhazards would have an enormous payback inreduced permanent disability rates and the socialburden that burns create. The fact that most ofthe serious or severe burns in infants and youngchildren result from scalds, or ashes associatedwith cooking provides evidence that focusing onthe kitchen or cooking area for hazard reduction

would likely result in decreased permanentdisability for children.

As infants are victims of scalding, the mosteffective way to implement the programme wouldbe as a combined effort with poisons, falls andother causes of infant injury. Implemented as apart of an ante-natal care, it is an effective way tointegrate infant and child injury prevention in SafeMotherhood programmes.

Chapter 8

Fall Injury

Falls are the leading cause of non-fatal injury with over 770 childreninjured each day.

Falls are one of the major causes of permanent disability in children,disabling 10 children each day.

75Chapter 8: Fall Injury

Introduction

Falls are generally the most frequent non-fatalinjury in childhood in developed countries and inother developing countries where they have beenstudied. They were also known to be verycommon in Bangladesh. Several studies inBangladesh have shown that falls comprised one-third of total childhood injuries and that falls fromtrees and tree-related injuries are the main causeof hospital admission due to trauma amongchildren11,22. Major categories of falls inBangladesh are fall from trees, cliffs, buildings,through windows or from roofs, from furnitureand jumping or diving into water.

Fall injury pattern

The fatal fall injury rate was 2.8/100,000 forchildren of all ages.

Fig. 8.1 shows rates were highest in infants, andthe high fatality rates in this age group were mostlikely due to the vulnerability of infants to braininjury due to soft skulls with bones not yet fusedtogether. Falls from even low heights can result infatal brain injury. Infants sleeping in the same bedwith their parents often fall off the bed whilecrawling around, even as their parents sleep.

The fatal fall injury was significantly higher infemale infants than in male infants. It is not clearwhether this gender difference was due to chanceor other reasons. The lack of incidence in bothsexes in early and middle childhood, and theabsence of falls in the 15-17 group were mostlikely due to insufficient power of the BHIS to findthese rates rather than there being no falls inthese age groups (Fig. 8.2).

Non-fatal falls were very common in all agegroups, as can be seen from the high rates,including infancy. The highest rates were in theearly and mid-childhood when children are mostactive and still developing motor skills and co-ordination (Fig. 8.3).

Fall Injury


Non-fatal falls were significantly higher in malesthan in females in all age groups. Thispredominance in males was seen in all other agegroups for non-fatal falls. The highest non-fatalfall injuries (726.5/100,000/year) were amongmale children 5-9 years old (Fig. 8.4).

Non-fatal fall injury rates were higher in rural areasthan in urban areas. However, significantdifferences were observed in infants, 5-9 yearsand 10-14 years age groups (Fig. 8.5).

Level of Fall

About half the falls were from the same level andabout half were from different levels. Theproportion of falls from these two levels wasalmost the same in different age groups ofchildren (Fig. 8.6).


Not surprisingly, the higher the fall, the higher thelevel of severity of the injury incurred from the fall.Almost a third of falls leading to permanentdisability (severe) were from heights of more than10 metres (Fig. 8.7).

Stumbling was the major cause (41 percent) ofthe same level fall among children. Slipping ortripping was the next common cause (31 percent)of the same level fall (Fig. 8.8).

Sports areas were the most common place (34percent) for same level non-fatal fall injuries. Mostof these falls occurred while children wereengaged in sports and games (Fig. 8.9).

Fig. 8.10 shows accidental falls were thepredominant cause of different level non-fatal fallinjuries.


About one-third of different level falls occurredfrom trees. Over half (55 percent) of falls ininfants ocurred from furnitures, mainly beds(Fig. 8.11).

The highest proportion (44 percent) of fallshappened from a height of 1-5 metres. However,about one-quarter of falls occurred from heightsof more than 5 metres (Fig. 8.12).

Consequences of fall injuries

Hospitalisation and severity

Most of the falls were moderate in severity. About2 percent of falls resulted in permanent disability.Infants tended to have a higher proportion of fallsrequiring hospitalisation (over 20 percent) thanother age groups (Fig. 8.13).


Discussion

In Bangladesh, as in most developing anddeveloped countries elsewhere, falls were theleading cause of child injury, and in the year priorto the survey, there were over 280,000 childreninjured in falls, or about 770 per day. Falls killedover 1,700 children (almost five per day); andwere the leading cause of permanent disabilitydue to injury in children, responsible for over3,750 children being permanently disabled in theyear prior to the survey, over 10 children per day.

The places that children fell from in Bangladeshwere not dramatically different than in developedcountries. However, the severity of the resultinginjury was generally higher. Over a third of fallsoccurred while children were engaged in sportsand play. These happened without the usualprotective gear that children in developedcountries wear; the sports and recreational areasare often bare earth, or hard macadam coveredroad surfaces.

Children engaged in sports and play in developedcountries often have adult supervision whileplaying, and access to emergency medicalservices, or at least have peers who areknowledgeable about basic first aid and themeasures needed to be taken to prevent furtherinjury or disability where the falls have resulted inbroken bones or potential spinal cord injury. Thisis not the case in Bangladesh, and children whosuffered serious injury from falls, whether athome or outside the house were almost alwaysunsupervised by the mother, and either alone oraccompanied by a peer or an older sibling.

Bangladeshi homes are hazardous places forchildren, and this is especially true for falls. Eveninfants had relatively high rates of falls, withsubsequent serious injury (22 percent of infantfalls resulted in hospitalisation). Infants areespecially vulnerable to brain trauma, given theirsoft, incomplete skulls, and many serious fallinjuries occurred when infants fell from the bed


while the parent was sleeping, or while placed onraised surfaces and left unsupervised.

For older children, homes have many fall hazardsin them as well; stairs and roofs often lackrailings, the stair cases usually have non-standardpitches (heights and depths of treads), electricalextension cords often snake across the floor, etc.The floors in urban areas are often bare tiles orconcrete and in rural areas hard packed earth. Theimmediate area outside the house often containsvery tempting places for young children who loveto climb; many homes have water towers, roofsare usually easily accessed by young children, andtrees are "child magnets".

A Safe Home programme is clearly needed inorder to render homes less dangerous for children.Given the frequency and severity of infant falls,educational efforts aimed at expectant mothers aspart of the usual antenatal care programme wouldlikely reduce these. A checklist given to parents ofyoung children that focused on hazard

identification and risk reduction for fall hazards inthe typical home would be one way to reducethese.

The most common first responder for a child otherthan an infant, who has suffered a serious injuryas a result of falling, will almost always be a peeror older sibling. Currently, they lack even a basicknowledge of how to properly respond, and oftenincrease the severity of the fall injury, sometimescausing permanent disability and even death. ASafe School programme that incorporated basicfirst aid and first response skills in the curriculathat was appropriate for the different age groupswould be one effective way of addressing thisissue. It would also provide a greatly needed first-response capability for children at the communitylevel, and if implemented as a nationalprogramme, would likely have a substantial andbeneficial impact for all post-event injuries,whatever the cause.

Chapter 9

Cut Injury

About 350 children are victims of cut injury and 5 of them becomepermanently disabled each day.

83Chapter 9: Cut Injury

Introduction

Cut injury primarily relates to the mechanism ofinjury. It is classified as such because inBangladesh, there is an almost universal exposureof children to sharp cutting objects in everyenvironment they find themselves in. Indeveloping countries and predominantly in ruralBangladesh, children are surrounded by sharpobjects in their daily lives. Sharp objects areubiquitous regardless of age or sex, such asknives and other cutting implements used indomestic chores; farm tools used in cultivation ofcrops or animal husbandry, and tools used inhome handicrafts such as weaving.

Non-fatal cut injury

The universality of exposure is clearly seen in thehigh rates that were almost uniform in all agegroups after infancy in the figure above. Even inthe infant age group, cut injury was a relativelycommon occurrence at 18.5/100,000 infants(Fig. 9.1).

The cut injury rate among all children was204.7/100,000. The highest cut injury rate(246.0/100,000) was in children aged 5-9 years old.The cut injury rate was highest (325.7/100,000)among male children in the 10-14 year age group(Fig. 9.2).

Cut Injury


While cut injury was significantly higher in ruralareas, it is noteworthy that cut injury rates in allchild age groups were high in urban areas and hadthe same pattern as rural areas. However, urbaninfants do not seem to have the same hazardousexposure to sharp objects that their rural peers do(Fig. 9.3).

As shown in Fig. 9.4 most (40 percent) non-fatalcut injuries were caused by knives or knife-likecutting instruments. The second most commoncause was rubbish on the ground (glass, brickchips, snail shell etc) followed by agricultural tools(hoes, sickles, etc).

Overall, for children aged 1-17, 94 percent cutinjuries were moderate. Five percent requiredhospitalisation, and 1 percent caused permanentdisability. Children in the 5-9 and 10-14 year agegroups had the highest permanent disability rates(Fig. 9.5).

Discussion

At the rates found in the BHIS, in the year prior tothe survey over 120,000 children suffered cutinjuries, or over 330 per day. Over 1,700 childrenwere permanently disabled each day (almost fiveper day) from cut injuries. It is a major publichealth problem for children in Bangladesh, both inurban and rural areas, but appears to be especiallyserious in rural areas. Clearly, a Safe Homeprogramme is needed to reduce the risk of sharpobject exposure for young children.

85Chapter 9: Cut Injury

The rural nature of Bangladesh means mostchildren are reared in homes engaged inagriculture, and this means frequent exposure tosharp tools and cutting machines, often in thehouse, as well as in the fields. Children are at riskfrom sharp objects and tools stored in the homesand yards, as well as in using them to help withchores. This increased risk of cut injury in childrenin rural areas is a common theme in developingcountries elsewhere, as children usually supply alarge amount of the family labour in the fields.However, Bangladesh culture has a unique issuethat increases cut risks for very young children.This is the almost universal use of a special kindof knife that is especially hazardous to children.This is called a boti. The boti, as seen in thefollowing photograph resembles a small sicklewith a set of feet to kept it steady and the bladepositioned pointing up. It is hazardous in that theblade is keep steady, and the object being cut ispressed into the blade, usually using both handsand the hands are moved into the blade in orderto cut the object. In contrast, the usual (andsafer) way of cutting is to keep the object being

cut stationary, and holding the blade in the handsand slicing the object to be cut in a motion awayfrom the hands and body. This type of cuttinginstrument, a boti, is often quite large, and usuallythe person using it sits on it or uses a foot to keepit steady. This also increases the hazard in usingit, and the size makes it unlikely to be kept in adrawer or elsewhere out of reach of children.Thus, it is often present on the floors whereinfants and young children are playing nearby, andmakes a tempting object of play. Constructedwith feet so that it is always facing up with theblade exposed, it is extremely hazardous totoddlers and anyone who walks or falls nearby.

Given the almost universal use of boti byBangladeshi women and men for cooking andcutting chores, it will be difficult to get mosthomes to abandon its use in favour of safercutting instruments. However, parents can beeducated to place it in a cabinet or on a shelf in abox to keep it away from young children. Even inthe setting of the poorest one room home, beingplaced on its side in a box and left in a corner willdecrease the hazard it presents to young children.


Other, less hazardous cutting instruments wouldbe rendered less risky to children if they wereplaced in boxes, drawers, or simply stored onhigh shelves out of reach of children. A SafeHome programme that incorporates a systematicapproach to identifying the predominant cuthazards for children in and around the home, andthen provides knowledge for parents on how to

render these hazards less risky would likely paygreat dividends in lower cut rates, especially forinfants and very young children. For maximumeffectiveness, it should be implemented as part ofa broader Safe Home programme focused onreducing the other hazards for the children withinthe house.

Chapter 10

Falling Objects

86 children are injured by falling objects each day. and 2 are permanentlydisabled.

89Chapter 10: Falling Objects

Introduction

Being struck by falling objects is a frequent causeof injury in developing countries. In contrast todeveloped countries, which have building codes,standards, and populations who have beeneducated into a culture of safety, children indeveloping countries are often exposed to allmanners of falling objects. This is the case inBangladesh, where the lack of building codes andsafe construction practices, and the lack ofsecure storage areas with lockable doors inhomes, schools and other buildings, all contributeto the hazardous environment for children.Additionally, children engaged in organised andinformal sports in developed countries usuallyhave safety equipment like helmets, face masks,etc., that protect them from being struck byobjects while playing games with bats, balls and other objects that can be dangerous. Suchprotections are virtually non-existent in most rural communities, and are infrequent in urbanareas as well.

Non-fatal injury caused by falling objects

The rate of non-fatal injury caused by fallingobjects was 55.4/100,000 in children aged1-17. The highest rate (127.3/100,000) wasobserved among the 15-17 year male children(Fig. 10.1 & 10.2).

Falling object injury was relatively constant inpattern across all age groups, and higher in ruralchildren than in urban children (Fig. 10.3).

Falling Objects


Many of the falling objects were the same amongthe different age groups. Sporting paraphernalialike bats and balls were common across all agegroups, as were tree branches and constructionmaterials. Bicycles and rickshaws figured in fallingobjects rather than RTA for these episodes ofinjury as they were leaning against a wall or othersupport and fell, striking the child (Fig. 10.4).

Fig. 10.5 shows that the majority (85 percent)of injuries caused by falling objects weremoderate in nature in children aged 1-17 years.

However, 5 percent were major (requiringhospitalisation of less than 10 days) andanother 7 percent required hospitalisation formore than 10 days. Three percent of childrenwere injured severely enough to have permanentdisability.

Discussion

Falling objects were not a large cause of fatalinjury in children, but they were a significantcause of permanent disability, hospitalisation andmissed school and work. At the rates found in theBHIS, there were over 850 children permanentlydisabled in the year prior to the survey (over twoper day) and over 31,500 children were injured byfalling objects (86 per day).

The nature of the falling objects injury amongchildren in Bangladesh says a great deal about thedaily life and exposures of children in a developingcountry like Bangladesh. The range of objects thatcaused the injury included bicycles and rickshaws,farm tools, household objects as well as trees andbranches. To cause injury serious enough torequire hospitalisation, or result in permanentdisability, the objects and the physical forcesinvolved must have been large.

While a Safe Home, Safe School and SafeCommunity programme could decrease theserates to a degree, it will require a sustained effortover years to create the necessary culture ofsafety in children and their parents that ultimatelywill make a major difference in this. Creating thatculture of safety will be a large part of the overallactivity, and best accomplished through the twomost powerful forces of socialisation in anyculture: the schools and peer pressure. Effectiveuse of these two powerful mediators of behaviourwill require a well-thought out communicationprogrammes and a set of targeted communicationand behaviour change strategies.

Chapter 11

Poisoning

Almost 6,000 children are accidentally poisoned each year, almost 16per day.

93Chapter 11: Poisoning

Introduction

Children are exposed to all manner of poisons inBangladesh. Most children live in rural homes, andsince most rural households engage in farming,children have high exposure rates to agriculturalchemicals such as insecticides and rodenticides.In urban settings, poisons are also commonlyfound, as well as cleaners and solvents. Mosthomes do not have special storage areas for drugsand poisons such as medicine cabinets which arecommon in developed countries, and poisonousliquids are commonly stored in used beveragecontainers.

Bangladesh does not have policies that requireuse of child-proof containers for poisonoussubstances, nor restrictions on selling or storageof particularly deadly agricultural chemicals suchas organophosphate insecticides. Whether sold atsomewhat lower concentrations for householduse as insecticides, or in concentrated form tofarmers as pesticides, these highly poisonouschemicals figure prominently in child poisoning inBangladesh.

This chapter focuses only on accidental poisoningas all the fatal poisoning found by BHIS surveywas intentional and has been included in chapter 16.

Non-fatal poisoning

As shown in Fig. 11.1 the non-fatal poisoning ratein children aged 0-17 years was 9.7/100,000.

The highest rate (24.7/100,000) was in infantsfollowed by among children aged 1-4 years(21.6/100,000). The rates decreased in the olderage groups. This pattern is consistent with unsafestorage of poisons in places in the householdwhere infants and very young children canbecome accidentally poisoned while exploringtheir environments.

The sex pattern of poisoning is difficult tointerpret due to sample power issues (rare eventsand small groups) as well as the uncertaintyintroduced by the association of poisoning andsuicide attempts. The female predominance ofaccidental poisoning in the adolescent age groupsmay reflect this (Fig. 11.2).

Poisoning


The rural predominance in infants is most likelydue to the almost universal exposure of infants toagricultural chemicals often stored in the home,which is often only one room. This set ofcircumstances leads to high poisoning rates ininfants as seen in the Fig. 11.3 above. It is unclearif the rural predominance in the early and lateadolescent groups (10-14; 15-17) is due to thehigher rates of attempted suicide in rural areas,with poisoning the common method.

As seen in Fig.11.4 one-third of non-fatalaccidental poisonings were caused by insecticidesfollowed by pesticides and detergent (19 percentin each category). Pesticides are used inagriculture, and insecticides are used in domesticsettings. Pesticides are frequently moreconcentrated and are more lethal as a result. Theoccurrence of pesticides as the major agent inpoisoning in the 15-17 age group providescompelling evidence that a number of the

95Chapter 11: Poisoning

poisonings claimed to be accidental are morelikely attempted suicides.

The majority (60 percent) of non-fatal poisoningrequired hospitalisation for less than 10 days.More than one-tenth of the cases requiredhospitalisation for more than 10 days (Fig. 11.5).

Discussion

Clearly, homes in Bangladesh contain manyhazardous substances for children, and these areoften stored in a dangerous manner. As a result,according to the rates found in the BHIS, in theyear prior to the survey, there were over 5,800children poisoned or over 16 children each day.The lack of fatal poisonings found by the surveyis almost certainly due to the lack of power of thesurvey to find these relatively rare events. Thesurvey documented storage of poisons inhouseholds that were hazardous to children, withthe toxic chemicals ranging from bleach anddisinfectants to rat poisons and insecticides.

In Bangladesh, infants are especially vulnerable toaccidental poisoning, as in this stage of life, theinfant explores the world orally, by tasting andsucking on anything in it’s immediateenvironment. As the picture of the infants on thecover page shows, these infants have clearlysucked and licked their hands, which were heavilycontaminated with blue aniline dye, which itselfcan be toxic. Throughout rural Bangladesh, infantsare routinely placed on surfaces that have hadfarm chemicals such as pesticide prepared foruse, and parents are not aware of the hazard thisentails for poisoning their children.

Turning a hazardous home into a home safe fromchild poisonings can be done without newtechnology and quite cheaply and simply.Teaching parents to keep poisons like insecticidesand rat poisons on high shelves will keep themout of the reach of crawling infants. Ensuringparents use locked cabinets or boxes to storedrugs prevents drug overdoses, and teachingparents not to store household chemicals likebleach in empty beverage bottles prevents childpoisoning from these chemicals.

Interventions such as these are cheap andeffective, but to have an impact over a broadpopulation, they must be part of an organised andbroad Safe Home intervention. The earlier in thechild's life this starts, the more likely it is toprevent them from becoming a victim ofpoisoning. Thus, to be most effective in infants,which have high rates of poisoning with almostthree per day (980 per year), any interventionshould be implemented as part of an antenatalcare programme. In the last several months of theANC programme, mothers and fathers could be

educated regarding the risks to their infant frompoisoning (as well as falls, cuts and other high-frequency infant injury issues) and given achecklist that allows them to "child-proof" theirhome in ways appropriate for their home'sconditions and construction.

The other issue that is worthy of comment is thatof the intention regarding many of thesepoisonings. Given the agents involved, and thefemale predominance in the late adolescent age

groups, it is very likely that these events that arelabelled as accidental are in reality unsuccessfulsuicide attempts. While there are many barriers toeffective interventions for these, it is noteworthythat other countries with similar issues (China andIndia) have found in pilot programmes thatinterventions to decrease ready access to highlylethal pesticides through controlled distributionsystems have successfully demonstrated thatimpulsive suicide attempts can be reduced.


Chapter 12

Animal Injury

Almost 2,600 children die from bites of animals each year. About halffrom dogs and half from snakes.

99Chapter 12: Animal Injury

Introduction

Animal injury is a very common cause of childinjury in developing countries like Bangladesh.Most children live in rural areas, in householdsengaged in farming. This leads to the constantexposure of children to animals, both in thepractice of assisting in farming activities, as wellas pets and stray non-farm animals such as dogs.Animal injury can result from butting, impaling,being bitten or being stepped on, and the severityof these can range from minor to death. Dog bitesthat would not otherwise be serious often lead todeath from rabies, as it is endemic in Bangladesh,and both hyper-immunglobulin and vaccine arecostly and not available in many rural areas.

Fatal animal bite

The exposure rates of children to animals werehigh enough in all age groups to lead to significantinjury rates in every age group. Rates werehighest in middle childhood and late adolescence.The peak rate was 7.8/100,000 in 15-17 year oldchildren (Fig. 12.1).

Males tended to have higher animal injury ratesthan females, especially in the adolescent agegroups. The male predominance in these agegroups is most likely due to the differing genderroles, with females working mainly inside thehouse (Fig. 12.2).

The fatal bites were all due to dogs and snakes,with an equal proportion of each, and all occurredin rural areas. This rural predominance wasprobably a combination of higher exposure ratesto snakes and rabid dogs in rural areas, as well asless availability of anti-venom and rabies vaccinein rural areas.

As seen in Fig. 12.3 more than three-quarters(79%) of the bites were caused by unprovokedanimals.

Non-fatal injury caused by animalIn general, the age distribution for non-fatalanimal injury was similar to fatal animal injury,except it decreased in late adolescence, in

Animal Injury


contrast to fatal animal injury which peaked inthat age group (Fig. 12.4).

Among all children the non-fatal animal bite ratewas 98.4/100,000. The highest rate(120.1/100,000) of injury caused by animal biteoccurred in children aged 10-14 years (Fig.12.5).

There was a different pattern for animal injury inurban areas as compared to rural areas. In urbanareas it peaked in young children and decreasedas they grew older. This pattern is consistent withhigh bite rates in toddlers who do not know howto play safely with dogs and other pets, and thenas the children grow older, the increasingknowledge and experience of the danger of animalbites leads to decreasing rates. In rural areas, therates peak later in the child's life due to the everincreasing exposure of children to animals as theyhelp with work on the farm (Fig. 12.6).

Fig. 12.7 shows almost all (98 percent) non-fatalbites did not require hospitalisation. About 1percent required hospitalisation for one to ninedays, and another 1 percent was hospitalised forover 10 days. These were mainly the result ofmauling by packs of stray dogs.

A large majority (87 percent) of non-fatal injuriescaused by animals were the result of bites. The

101Chapter 12: Animal Injury

majority of animal bites were from dogs. Infantswere bitten exclusively by pet dogs, probablybecause they were mainly exposed to the familypet, as they were not walking and did not gooutside alone and encounter strays. After infancy,dog bites were almost equally split between petdogs and stray dogs across all age groups. Snakebites were a significant problem in most child agegroups, and the lack of them in the 5-9 age groupis likely due to the numbers being below thepower of the survey, rather than there being nosnake bites in this age group. Injury caused bycows were a significant problem in the youngerchild age groups as well (Fig. 12.8).

There is an almost equal chance of non-fatalanimal injury for provoked and unprovoked cases(Fig. 12.9).

Discussion

Animal bites are a very serious cause of injury forchildren in Bangladesh. At the rates found in theBHIS, almost 2,600 children died from animalinjury in 2003, mostly from bites, and of these,about half were bitten by venomous snakes, andthe other half by rabid dogs. This is about sevenchildren a day; a very high toll for a fatal injurythat can be prevented with proper treatment.There were an additional 59,000 children whowere non-fatally bitten, or over 160 per day.Together, this is almost 62,000 children injured orkilled by animal injury, the vast majority of whichwere from dog and snake bites.

Given these staggering numbers, it is clear this isa problem that cannot be ignored. Behaviouralstudies carried out showed many unsafe beliefsthat almost certainly contribute to a largeproportion of the deaths resulting from the bites.The most common behaviour following a snake ordog bite was to seek help from a traditionalhealer. The varieties of advice given were almostall universally incorrect and contributed heavily to

the failure of the child to receive appropriatemedical care. Undoubtedly there are economicissues complicating the picture, as anti-venomand rabies vaccine are costly, and not alwaysavailable in rural areas. However, children andparents should be made aware of the need to seekproper medical care for children bitten by snakesand dogs.

This will likely be a fruitful area to address as partof a school based curricula for child safety.Knowing how to play with animals safely, how toavoid being bitten, how to seek proper care whenbitten, are all a necessary part of a 'Skills for Life'programme for children. Given the frequency ofanimal injury for Bangladeshi children, an animalinjury component of a Safe Home and SafeSchool programme that imparts these skills forchildren will be a central focus.

There is great potential for using the schools as aprevention measure against snake bites. Thesnake bites often occur following floods.Bangladesh has a very predictable seasonalpattern of weather that creates flooding. Much ofBangladesh is very close to sea level and thecombination of this low level and the heavy rainsand cyclonic storms means that as much as 20-30 percent of the country is flooded on an annualbasis. As water rise and children and their parentsconverge on the high ground, so do snakes. Snakeenvenomation is a common cause of child deathin flooding, and in the recent flood of 2004, manyof the child deaths resulted from snake bites.

Children bitten while trapped on high ground inclose proximity to snakes are unable to seekmedical care and anti-venom. Thus, floods andsnakes are a fatal combination for children.

Given the predictability of this annual flooding,and the near certainty that many regions of thecountry will be flooded at least every five years,consideration should be given to creating anational network of safe havens from floods usingthe local schools. Constructed to last decades,and often build on high ground to withstandfloods, these can serve as safe havens wheresnakes can be excluded and kept away fromchildren. As safe havens they could be stockedwith stores of anti-venom, emergency medicalkits, emergency relief supplies such as plasticsheets and water purification equipment, highenergy biscuits and other disaster relief foods.Used as part of a national natural disasterpreparedness network, they could be an effectivemeans of decreasing the large numbers of snakebites associated with floods. They would alsoserve to decrease drownings, and the laterdiarrhoeal disease deaths associated with floods.

A Safe School programme conducted in a school-based disaster preparedness network wouldprovide the opportunity to incorporate disasterpreparedness skills in a 'Skills for Life'programme. Such a programme could use schoolchildren to ensure that their homes have adequatepreparations for flooding.


Chapter 13

Electrocution

More than 800 children die from electrocution each year, over 2 per day.

Introduction

Injury from electrocution occurs as a result ofman-made electricity or from lightning. Man-madeelectricity is usually distributed from the powergrid, but in developing countries, electricity isoften used for fishing, to stun the fish. In thiscase, it is usually generated from a poweredgenerator taken to the fishing site. A generatorproducing high amperage current, and usedaround water presents a very real electrocutionrisk for children. An unusual source ofelectrocution is naturally occurring bio-generatedelectricity from fishes and eels. This is a relativelyrare source of electrocution in Bangladesh;however, it is one that children are especiallyvulnerable to, due to their much lower body massand increased susceptibility to fatal cardiacarrhythmia when electrocuted.

Fatal electrocution

During the survey, only five deaths were founddue to electrocution among children and all ofthem were males in rural areas. Four were causedby exposed electric wires inside the house, andone from an exposed electric wire outside thehouse. The highest fatal electrocution rate(3.7/100,000) was found in children aged 5-9years. Because of the relative few numbers offatal electrocutions, occurring in only two age

groups, the overall rates for child electrocutionneed to be interpreted with caution (Fig. 13.1).

Non-fatal electrocution

The non-fatal electrocution rate among childrenaged 1-17 years was 81.4/100,000. The highestrate (126.3/100,000) was observed among malechildren aged 5-9 years (Fig. 13.2 & 13.3).

Morbidity severity was generally low, in childreninjured due to electrocution, 3 percent requiredhospitalisation for less than 10 days. The vastmajority had either, three days work or school loss

Electrocution

105Chapter 13: Electrocution

and/or required medical care that did not result inhospitalisation.

Electrocution injury had a rural predominance inall age groups, with rural rates typically four orfive times higher than urban rates (Fig. 13.4).

Most of the electrocutions occurred throughlightning strikes and other electrocutions occurreddue to man-made electricity (Fig. 13.5).

Discussion

Electrocution is not often given much attention asa cause of child death and morbidity in developingcountries. However, it is a significant cause inBangladesh. According to the rates given by theBHIS, there were over two children fatallyelectrocuted each day, and over 125 more injuredby electrocution. In total, there were over 47,000children killed or injured by electrocution.

Most of the non-fatal electrocutions outside thehome occurred through lightning strikes,especially in rural areas. Bangladesh is uniquelyexposed to severe storms and weather associatedwith lightning and in rural areas, virtually nohomes have lightning rods. There are almost notall buildings or other structures to attractlightning strikes. People working in the fields areoften the tallest feature on the landscape otherthan the occasional tree. They often are workingwith metal implements that are swung in use, likesickles and hoes. Most adults or children have noknowledge of ways to protect themselves whencaught outside, and often take refuge under treesor continue working, swinging the metal farmtool. It is likely that a large number of these fataland non-fatal electrocutions from lightning strikescould be avoided through providing knowledgeand protection skills. Once again, this would bemost easily and effectively addressed through aknowledge and skills-based programme as part ofa Safe School programme.

Most of the other electrocutions occurred withinhomes, and were the result of hazardousexposures to electricity, in almost all casesthrough electrical systems that lacked groundingand the use of old, frayed extension cords orelectric appliances around water sources.Providing grounded electrical systems is wellbeyond the scope of an affordable and sustainable"first response" intervention. However, providingknowledge about the hazards of an ungroundedelectrical system, or safe use of electricalappliances or how to minimise overload risks withextension cords is well within the scope of anelectricity safety module in a Safe Homesprogramme and a Safe School programme.


Chapter 14

Machine Injury

Over 17,000 children are injured by machines each year, almost 50 per day,

109Chapter 14: Machine Injury

Introduction

Machine injury primarily relates to the mechanismof injury, and has been classified this way afterlengthy discussion among the research team andpolicy-makers who will use the data. In developedcountries, much of what is classified here asmachine injury would come under theoccupational injury category as most contact withpowered machinery occurs in the workplace andusually does not involve children. Bangladesh is apredominantly rural country, and at presenteconomic levels of development, children oftenwork to support their families. For this reason,contact with powered machinery is ubiquitous. Itoccurs in rural areas where children work onfarms or in processing food from the farm beforeshipping. Even very young children provideassistance in farming and crop production. Mostrural dwellings consist of only one room, and it iscommon for machinery to be stored in closeproximity to children. In urban areas, childrenoften work in shops and light assembly factoriesusing powered tools and other machines. Becauseof the almost universal exposure to machines,regardless of age and place of residence, it wasdeemed appropriate to have a classification thatreflected this reality.

Machine injury

The occurrence of machine injury in all age groupsunderscores the universality of exposure of

children to machines. As seen in Fig. 14.1 the riskof injury was highest in the age groups that wereusing the machines on a frequent basis, such asoccurs with occupational activity. The non-fatalmachine injury rate in all children was29.6/100,000. The rate was highest(56.7/100,000) in children aged 15-17 years,followed by in children aged 10-14 years(38.8/100,000).

There was a marked sex difference in all agegroups. Males had much higher rates thanfemales and the difference increased dramaticallyin the older age groups. The rates among femalesstayed at relatively constant levels throughout theage groups. The pattern in females most likelyrepresents a "background" exposure rate and thedramatic upsurge in males in adolescence is mostlikely due to gender differences with males havingvery high exposure rates as they begin to workwith machines in an occupational setting (Fig. 14.2).

Machine Injury


The same "background" effect can be seen inurban children, where in almost all ages there is arelatively constant exposure level to machines.Rural children have much higher rates of machineinjury (Fig.14.3), primarily due to machines beingused in planting and processing crops. In bothgroups, rates begin to increase sharply duringadolescence. Younger children have lowerexposure rates and thus lower injury ratesbecause they are helping with chores on a part-time basis, and either going to school or playing.But older children are no longer at school and arehelping in a full-time capacity and withsubsequently higher injury rates.

As seen in Fig. 14.4 fourteen percent of thechildren injured by machines were hospitalisedand a total of 6 percent had permanent disability.In the adolescent age groups where the rateswere the highest, severity levels were high as well.

Shallow machines (self-propelled, wheel-mounted, diesel engines that serve as pumps, andpower-takeoffs for farming chores) were the mostcommon source of injury across all age groups.These, along with rice-mills, tractors andthreshing machines are mainly found in ruralareas. In contrast, machine tools, printing presses,sewing machines, and construction machines aremainly urban. Saws and welding machines arecommonly found in both areas. Threshing andshallow machines were almost entirelyresponsible for injuries in 1-4 year old children,and mainly in rural areas. At the other end of theage spectrum, in the older child age groups (10-17) machine tools and sewing machines werefrequent causes of injury in adolescents, and weremainly found in urban areas, where children wereusually injured in occupational settings (Fig.14.5).

Rice threshing machines are particularlydangerous for young children. All of thepermanent disability caused by machine injurywas caused by these machines. There is a greatrisk of children feeding the rice stalks into thethreshing machines to have their hands and armspulled into the machine, and consequently suffera traumatic amputation. At the rates found by theBHIS, over a thousand children sufferedpermanent disability from threshing machines inthe year prior to the survey. This was more thanthree children each day.

The majority (41 percent) of the children wereinjured at home. Occupational injury beganoccurring in the 5-9 age group and 15 percent ofthe machine injury in this age group occurred infactories and workshops; 18 percent of the

111Chapter 14: Machine Injury

machine injury in the 10-14 age group occurred infactories and workshops; and over half (52percent) of the machine injury in 15-17 year oldsoccurred in factories and workshops. One-quarterof all machine injuries in children aged 1-17 tookplace at factories and workshops (Fig. 14.6).

Discussion

At the rates found in the BHIS, over 19,000children were injured in 2002 by machines. Thiswas almost 50 children a day injured, three of

them injured severely enough to be permanentlydisabled, and more than one killed each day.

It is clear that children in Bangladesh are at greatrisk of injury from machines, regardless ofwhether they live in urban areas or in rural ones.Just as clearly, rural areas are the most dangerousin this regard, and rural homes have very highexposure rates for children to farming machinerythat is particularly dangerous. These machines aredesigned to cut, rip, thresh and tear, and almostuniversally lack even the most basic operatorsafety guards. Even those that do are designedwith the assumption that they will be used byadults, who are aware of the potential hazardsinvolved in their use. However, it is the norm forthem to be used by children as young as primaryschool age.

The highly traumatic nature of machine injury,especially in cut injury and crush injury leads tovery high permanent disability rates. Given theubiquity of exposure, and the economiccircumstances, it poses a considerable challengeto reduce these risks for children. Basicbehavioural research is needed to understand theprocess of machine exposure and use in children,this is an area that would greatly benefit from


behavioural study regarding the norms andknowledge, attitude and practices involved. A firmunderstanding of these will be a necessarycomponent of any intervention aiming tosuccessfully lower risks for children in ruralBangladesh from machine exposure. Children'suse and exposure to machines is deeply ingrainedin the culture of both urban and rural Bangladesh.Simply telling parents about the risks involved isnot likely to reduce children's use and injury rates.While there are many potential areas forengineering improvements to the machinesthemselves, or for behavioural changes to reducethe exposure rates for children, to be effective inchanging this deep-rooted cultural norm forchildren working with and around dangerousmachinery, the interventions will have to beunderpinned by a good understanding of thecontext of use and hazard exposure.

Given the likelihood that it will be difficult torapidly reduce the exposure rates for children tothese very hazardous machines, it is important toprovide children with a set of first response skillsthat will reduce the ensuing severity of injurywhen it occurs. Hand and foot amputations fromtilling machines or arterial lacerations fromthreshing machines require very rapid applicationof tourniquets to stop the massive bleeding, anddelay is often fatal. Currently, children are injuredin settings where they and their peers or adultsworking around them have no knowledge of howto do this. This is an area where a skills-basedtrauma response module as part of a first aid andsafety curricula in a Safe Schools programmewould be an enormous asset for Bangladeshichildren.

Chapter 15

Suffocation

Almost 1,200 infants suffocate each year; 3 infants each night.

115Chapter 15: Suffocation

IntroductionSuffocation is a significant cause of death ininfants, primarily due to the common practice ofmothers and fathers sleeping with the infant inthe same bed, often between them. Young infantsare unable to sit up or roll over until about thesixth month of infancy, when motor developmenthas progressed. Before this, they are relativelydefenceless and unable to react if anythingobstructs their breathing, whether bed clothes,covers or an unaware, sleeping adult who hasrolled over on the infant, or placed an arm overthe infants face. After the sixth month, the childcan defend him/herself by kicking and thrashing,which often clears the obstructing bed cover orwakes the intruding adult. Thus, infantsuffocations usually occur in the first half ofinfancy.

In developed countries there is a distinction madebetween adult overlayment deaths and sudden-infant death syndrome (SIDS, cot or crib death).But a SIDS diagnosis usually is made based onautopsy findings and forensic information whichis unavailable in a survey such as the BHIS. Infantdeaths were recalled retrospectively bylaypersons, and the response "accidentallysmothered the baby while sleeping" was mostcommonly used. Undoubtedly, some of the infantdeaths occurring are SIDS deaths, but it is likelyto be a small percentage.

In older children, suffocation is associated withinhaling foreign objects, being trapped in airtightspaces, or in cave-ins when digging wells or deepditches. It is not unusual for children to suffocatefrom carbon monoxide, especially in the coldermonths when one-room homes are being heatedby poorly ventilated heaters. Finally, children areoften exposed to the risk of suffocation inoccupational settings in cleaning out containerswhich had chemicals stored in them, such asrailroad tank cars, silos or bilges. Children arepreferentially used as they are small and able toget into tight places that larger adults could not.

Fatal suffocation

Fig. 15.1 shows death due to suffocationoccurred mostly in infancy at a rate of24.7/100,000. However, deaths (1.9/100,000)were also found among children aged 5-9 years.The lack of suffocation deaths in the other agegroups is most likely due to the power of thesurvey being unable to measure the rate as aresult of very small numbers. Suffocationundoubtedly occurs in the other child age groupsas well.

The rates were about the same for males andfemales (Fig. 15.2).

Suffocation


As seen in Fig. 15.3 the main cause of infantsuffocation was adult overlayment. A quarter wascaused by bedcovers.

The causes of suffocation in the 5-9 age groupwere equally split between gas and foreignbodies.

The cultural preference for keeping infants andvery young children in the same bed with themother and father can clearly be seen here. It wasalmost universal that infants and children in thefirst years of life sleep with their parents in thesame bed (Fig.15.4).

Bangladeshi mothers show a strong preference forplacing infants to sleep face up. However, fourpercent of mothers place infants to sleep facedown (Fig. 15.5). This position has been shownto be associated with higher rates of infantsuffocation and SIDS, and the supine and sidepositions are safer for the infant.

Discussion

Suffocation is a major problem for infants. At therate found in the BHIS, almost 1,200 infantssuffocated in the year prior to the survery. This isabout three infants each night. This is due to theuniversal practice of keeping the infant in thesame bed as the mother and father. There aremany benefits from bed-sharing in developingcountries like Bangladesh, such as increasedbreast feeding rates. The benefits to the childfrom the increased likelihood of breast feeding aresignificant. However, bed-sharing is also ademonstrably hazardous practice to the infant,and the risk to the infant should be minimised.The risks are not only for suffocation, but for fallsas well, which is a significant cause of injuryresulting in hospitalisation and deaths. Reducingthe risk of suffocation and falls and maintainingthe cultural tradition of infants and parentssharing a bed is possible. Safe bed-sharingdevices can provide protection for an infant, whileallowing the infant to sleep next to the mother orfather. TASC is currently developing one calledSleepSafe, and devices like this can beincorporated into a comprehensive programmethat targets infant suffocation and falls. Aprogramme that focused on expectant mothersduring antenatal care to educate them to the needto share the bed safely with the infant, as well asto place the infant to sleep in the supine positionor on its side would also reduce the rate ofsuffocation and falls.

Chapter 16

Intentional Injury

Everyday in Bangladesh at least 1 child dies and 66 children are injuredby violence.

Six children commit suicide each day.

119Chapter 16: Intentional Injury

Introduction

Injuries are categorised according to whether ornot they were deliberately inflicted and by whom.Commonly used categories are: unintentional (i.e.accidental), and intentional (i.e. deliberate).Intentional injuries result from most of the samemechanisms of unintentional injury (drowning,poisoning, cut injury, etc.), but can be further sub-classified as to assault, homicide or suicide.Determining intentional injury rates is difficult dueto the sensitive nature of the information that isbeing sought. In many cases, there are cultural,personal and legal disincentives to admitting aninjury was intentional. Additionally, the techniqueof survey has an impact on the willingness ofrespondents to admit intentionality. In a door-to-door household survey, where there is no realprivacy for the interview and little time toestablish good rapport between the interviewerand the respondent, it is especially difficult toobtain valid information. Finally, in the case of theBHIS, the respondents for the questionnaire werenot always the most knowledgeable regarding theintentionality of the injury. For these reasons, it isvery likely that the intentional injury rates found inthe BHIS are substantial underestimates.

Intentional Injury

The proportion of unintentional injury (59.7percent) was higher among boys and theproportion of suicide (54 percent) was higheramong girls (Fig.16.1).

In all children the proportion of unintentionalinjury (66 percent) and violence (87 percent) washigher among boys and the proportion of suicidalattempt (75 percent) was higher among girls (Fig. 16.2).

As seen in Fig. 16.3 the vast majority of injurywas unintentional in nature. The proportion ofintentional injury increased with increasing age ofthe child.

Intentional Injury

The nature of the intentional injury depended onage. In the age group 10-14, it was a mixture ofviolence and sucide but in the older age group, itwas predominantly suicide (Fig. 16.4).

Fatal Violence

All fatal violence in the survey occurred in theadolescent age groups. Due to the small numbers,rates by gender were not appropriate (Fig. 16.5).

Non-fatal ViolenceNon-fatal violence was much more common, andconsequently was seen in all age groups ofchildren. The rates were relative stable among theyounger age children, and almost double in lateadolescence (15-17). Among children 1-17 yearsold, the non-fatal violence rate was 42/100,000(Fig. 16.6).

As seen in Fig. 16.7 there was a clear differencein rates and patterns between males and females.The rates in males were relatively similar in theearly and middle child age groups. Post-puberty, inlate adolescence, the rates basically doubled formales. In contrast, in females, the rates werelowest in young girls aged 1-4 and then basicallyincreased by doubling in each age group afterthat. In all age groups, males had rates 3-10 timeshigher than females. The highest non-fatalviolence rate (123.4/100,000) was observed in15-17 year old males.

Rural violence rates were significantly higher thanurban violence rates in all age groups. In eachlocation, both rural and urban, the rates wererelatively similar in the younger age groups andthen almost doubled in the post-pubertaladolescents aged 15-17 (Fig. 16.8).


The level of severity for intentional injury washigher than unintentional injury. Almost a quarter(23 percent) of the injured children requiredhospitalisation. Moreover, 2 percent of thechildren had permanent disability caused byviolence (Fig. 16.9).

In male children 10-14 years old, almost half (43percent) of the perpetrators were friends oracquaintances of the child and mainly males.Friends or acquaintances were perpetrators inmore than three-quarters (83 percent) of theviolence directed at females and were mainlymales (Fig. 16.10).

Female children aged 15-17 were assaulted aboutequally by spouses, neighbours and friends (one-third for each), and all of whom were known tothe females. Males, in contrast were very rarelyassaulted by their spouse, and about three-quarters of the time knew those assaulting them,and about a quarter of the time were assaulted bystrangers (Fig. 16.11).


Suicide

Suicide was an adolescent phenomenon. Therewere no suicides in children younger than 14years old. Suicides began at 14 years anddoubling each year after that. It was alsopredominantly a rural phenomenon; 8 percent ofreported suicides were urban and 92 percent wererural (Fig. 16.12).

Over the 14-17 age group, females had higherrates of suicide than males. It is unclear if this isa real phenomenon in the lower age groups, asmales and female suicide rates were similar in 15and 16 year olds. There was a clearpreponderance of females in the 17 year agegroup, but it is difficult to interpret whether thisis a real gender difference in 17 year olds, giventhe similar rates for both genders in the 15 and 16year old children (Fig. 16.13).

Fig. 16.14 shows the majority of the suicidestook place at the residence of the children.

More than three-quarters (77 percent) of thesuicides were due to poisoning (Fig. 16.15).


More than two-thirds (67 percent) of theadolescents used pesticides for suicide (Fig. 16.16).

Discussion

As noted at the beginning of this chapter,obtaining valid rates for intentional injury in asurvey such as the BHIS is exceedingly difficult,due to the nature of intentional injury, as well asthe interview process. It is most probable that therates found by the BHIS for both violence andsuicide are underestimates, and probably verylarge underestimates. Nonetheless, at the ratesfound by the BHIS, the numbers are large. In theyear before the survey, over a thousand childrenwere murdered or permanently disabled as aresult of assault; this was three children each day.Over 24,000 children were injured seriouslyenough to seek medical care, or stay away fromschool or work for three days because of assault.This was 66 children each day.

The numbers for suicide were as striking, and allthe more so in light of the numbers being entirely

within a very small and narrow age range forchildren; from 14 to 17 years old. At the ratesfound by the BHIS, in the year prior to the study,over 2,200 children committed suicide; or over sixchildren each day; nearly four a day were females.

Intentional injury, whether self-directed ordirected at other children is a very difficult issueto address. There are social and culturalcomponents that will make any interventionprogramme less effective and more costly toimplement as compared to unintentional injury.However, given the scale and scope of the issue,especially in the late adolescent female group, itwill have to be addressed.

Current efforts to mainstream girls and to elevatethe status of women in general are likely to resultin decreased rates of intentional injury in women,but it will take an inter-generational change andthe establishment of new cultural norms. Thereare likely effective and culturally appropriateinterventions that would help stem this dreadfulloss of children as they stand on the cusp ofadulthood. Many of the suicides are impulsive innature, characteristic of this stage of life, and


operational research into providing supportnetworks appropriate for urban and ruralBangladesh would be a positive and affirmingapproach to this most difficult issue in injuryprevention. Hotlines have been shown to providesignificant support mechanisms to helpadolescents cope with emotional upsets in otherdeveloping countries. This is certainly onepotential option for urban adolescents.

Rural culture and the lack of confidentiality in thevillage environment pose significant obstacles.However, there are the beginnings of anexperience base in countries such as India and

China on methods to provide support and developcoping skills for rural adolescents (and urban aswell). At the very least, Bangladesh should beginto assess these, and consider how they might beimplemented in the context of Bangladesh. Aspreviously noted in the section on poisonings,interventions that reduce access to extremelylethal chemicals such as pesticides through acontrolled access distribution system arebeginning to establish a credible decrease insuicide attempts. These might be combined withother interventions in a pilot programme to gainexperience in this new area.


Chapter 17

Injury Orphanhood

Injury is the leading cause of children losing a mother, father or both inBangladesh.

About 7,900 fathers and 4,300 mothers die from injury each year.

ntroduction

It is easy to understand the toll of injury onchildren with a visit to any hospital. Most of thechildren in the emergency room and admitted tothe surgical casualty wards will be the victims ofinjury. However, less appreciated, but just asimportant is the toll that injury exerts on childrenindirectly when it robs them of a parent. Theleading cause of death of parents during the child-raising years is injury. Loss of a father, mother, ormost tragically, both, has a devastating impact ona child's future health and social well being.

To put injury orphanhood into perspective, it ishelpful to compare the magnitude of the differentcauses of death for women in the maternal agegroups. Injury is the leading cause of death formarried women of reproductive age (Fig. 17.1).

The most critical time to lose a mother in the lifeof a child is in infancy. It has the most severeimpact, as it usually leads to loss of continuedbreastfeeding, lower immunisation rates andpoorer nutritional status of the infant as it entersthe early childhood years, so important for growthand development. Over 600 married women aged18-19 years die from injury annually. This meansthat about two infants each day lose theirmothers because of injury. Suicide was theleading cause of infants losing their mothers (Fig. 17.2).

Almost 4,300 mothers died from injury, leavingabout 22,000 fathers, infants and children inhouseholds without the primary caregiver. Theleading cause of injury death for mothers wassuicide, followed by RTA, and then violence (Fig. 17.3).

127Chapter 17: Injury Orphanhood

Injury Orphanhood

The figure 17.4 shows the rates of fatal injuryfrom suicide, violence and RTA in women in theearly and mid reproductive years. About 1200,800 and 600 women aged 18-29 years died fromsuicide, violence and RTA respectively in the yearprior to the BHIS survey.

More than one third (38 percent) fathers ofchildren 0-17 years died due to injury (Fig.17.5).

Fig. 17.6 shows almost 7,900 fathers died frominjury, leaving about 30,000 mothers, infantsand children (0-17) in households that lost the


primary economic earner. The leading cause ofinjury death in fathers of children was RTA,followed by violence and suicide.

Discussion

The leading cause of death in parents during thechild-raising years is injury. Loss of a father,mother, or most tragically, both, has a devastatingimpact on a child's future health and social wellbeing. While this report has focused mainly on

child injury, it also must make clear thatimplementing measures to make homes andcommunities in Bangladesh safe for children alsohelp to make them safer for the parents ofchildren. Clearly there is a need to reduce the tollof injury on children both directly as well asindirectly. It is equally clear from the causes ofdeath or disability in the fathers and mothers ofBangladeshi children that a focus on accidental orunintentional injury only will not be enough. Inboth fathers and mothers, intentional injury-thatis, homicide and suicide-is a leading killer. Giventhat intentional injury is a leading killer in theparental age groups, any significant reduction inmortality in these groups will require addressingthis issue.

Injury robs children of their parents in largenumbers of both genders. In that regard it is anequal opportunity killer and disabler. However,the impact of the loss of the primary caregiver orthe primary economic earner is dramaticallydifferent depending on the socio-economic statusof the family involved. Families that are well-offhave options unavailable to poorer families. Poorfamilies often cease to exist as a nuclear familywhen the father is killed or disabled. The mother

129Chapter 17: Injury Orphanhood

and children are taken into relatives families (atbest) or forced into a lifestyle of transient andimpermanent households. Infants and youngchildren's health outcomes are markedly poorerwhen they lose their mother, and are no longerbreastfed or cared for. For older children, loss of amother or father often results in them droppingout of school and taking over the lost earnings orcare-giving role for the family. In either case,whether in early or later childhood, their physical

health and continued development are placed incertain jeopardy. In most cases, their lifetrajectories are irrevocably truncated andBangladesh incurs a major social cost. Childrenare a particularly vulnerable group in regards toinjury; suffering an inequitable burden from injuryregardless of being directly injured themselves, orindirectly through the loss of their parents. It is amajor health and social equity issue.


Chapter 18

Behavioural Research

Injury prevention can use very simple technologies developed frombehavioural research. This child has a bell tied to his waist so that hiswanderings can be audible to his mother.

The objective of this study was to get an in-depth understanding on the

occurrence of injuries including the current situation and protection

practices with a view to developing programmes for prevention of injuries.

Focus Group Discussions (FGD) were conducted among mothers, fathers,

adolescents and local elites in both urban and rural areas of Narsingdi

district. Separate discussion sessions were organised on six leading causes

of fatal and non-fatal injuries among children, such as drowning, transport

injury, burns, poisoning, falls and animal bites. The adolescent groups were

further divided into boys and girls groups for discussions on burns and

poisoning as these were expected to include gender sensitive issues.

The facilitator requested the group members to state a real event of the

selected type of injury that they had observed or heard about. Once the

storytelling was over and participants were comfortable for taking part in

further discussions, the facilitator gradually explained the prescribed points

of discussion and aided the participants to take part in the discussion

spontaneously. The discussions and recommendations of different target

groups are summarised and presented in the following sections.

133Chapter 18: Behavioural Research



Life stories

A seven year old boy fell from a Shako (bamboo bridge) into the canaland no one was there to rescue him. In the evening, the grandfatherof the drowned child pulled out the dead body using a fishing net.

A two-year old child was drowning in a neighbouring pond. A four-yearold child witnessed the incident, and rushed to the house and informedthe mother of the drowning child. The mother then rescued the child.

A young child was sinking in a ditch but nobody noticed him. A passer-by saw and rescued him.

An announcement was made over a community loud speaker to alertpeople that a child was missing. The relatives of the child searchedevery pond in and around the house. At last the grandmother found thedrowned child's dead body in a pond by probing a bamboo stick intothe water.

One child went out to a riverside to play and fell into the water. Hiscompanions rushed back home to inform the mother of the child. Atthe mother's hue and cry the local youths jumped into the river torescue the child. After half an hour's search the dead body of thedrowned child was found.


"Drowningoccurs whenyoung childrengo to take bathaccompaniedby their elderbrothers andsisters or peerswho are notmature enoughto look afterthe children."

Attitudes towards the event

In general, participants expressed great sympathy for drowned children andplaced responsibility on the lack of awareness and supervision of familyand neighbours. Their comments included:

Drowning is more painful than normal death. Normal death can beacceptable.

It is harrowing that my son is no more today. Nobody wants that Godwould dispense such type of accident on anyone.

We think that these types of accidents should be given importance sothat no more families suffer. We should always take care of the safetyof children so that they do not fall into water.

Such accidents are nothing but unnatural or premature death. Wecherish a hope that our children will be well groomed and educated.

An accident is an accident. Nonetheless, the condition of our countryis such that we do not think of our responsibilities after a drowningcase. We should avoid this sort of accident by adopting precautions. Weshould emphasise the importance of taking good care of children andshould ensure that we are giving as much care as they need. Otherwise,our negligence will be the cause of deaths.

Common places of occurrence

The participants knowledge of places of drowning was consistent with theresults of the quantitative data. The participants said that most drowningoccurs outside the house, including ponds, ditches, canals, rivers and openwater bodies. Only a few respondents mentioned that a small child maydrown inside the house, in a water reservoir, dug well, open drain, bigbucket, bowl or a trough containing water for cows.

Causes

The participants noted the limitations of mothers caring practices (manystated that the mothers preoccupation with household work, which leftchildren unattended, was a cause of drowning). Absence or inadequacy ofswimming skills was also stated as a cause of drowning. Most of theparticipants stated that the risk of drowning was greater for children withno swimming skills when they were in the proximity of water bodies likeponds, rivers or canals. Other causes of childhood drowning includedchildren's play activities, the natural curiosity of children, and theattraction of water to children, especially for young children.

Vulnerable groups and other risks

While the quantitative data shows that the highest risk of drowning is inthe youngest children (peak age one year), the majority of the participantsfelt that children in the age group 5-10 years ran the highest risk ofdrowning. They observed that the children of this age group werevulnerable to drowning as they were more courageous, and dared to go to

water sources such as ponds, rivers, canals, etc. to learn to swim or to playin the water. According to participants, girls are less vulnerable than boys.

Many participants believed that most child drownings occurred at noonwhen mothers and other family members were busy with their householdduties. Further, drownings were considered more frequent in the Banglamonth of 'Kartik' (mid-October to mid-November) as they go out for fishingduring this period.

First aid practices and health seeking behaviour

Following are the first aid responses mentioned by both rural and urbanparticipants:

The body of the rescued child is kept over the head of a person whothen starts running and spins the child around.

The body of the rescued child is laid straight on the ground and thewhole body is rubbed and covered by ashes and/or salt so that theash/salt would absorb the water and keep the body warm.

The stomach of the child is pressed repeatedly to bring out water fromthe stomach.

The rescued child's mouth is cleaned by hand.

The rescuer's mouth is put on the child's mouth to suck out water fromthe stomach.

Rotten food (commonly rotten banana leaf), uncooked eggs or 'kochurdoga' (arum stem) are forced into the child's mouth to induce vomitingwhich would clear out water from the stomach.

A few of the participants in one rural area believed that 'kabiraj'(indigenous herbal medicine practitioners) knew how to treat near-drowning patients and favoured taking near-or drowned child to the kabirajand then to a doctor. Other participants stated, "We will take the drownedchild to a good doctor". They unanimously said that a drowned childshould be taken to a qualified medical doctor/health centre for treatment.

Existing preventive practices

There were almost no preventive practices in communities. Discussionsrevealed that people knew some preventive measures but they rarelypractise any. Only a few believed that accidents were inevitable and pre-decided by God, and that it was not possible for the human beings to revert'God's will'.

Suggested preventive measures to be implemented

These measures generally involved looking after children, preventingchildren from going near water, and teaching children how to swim underadult supervision. Specific suggestions were tying bells to children andplacing obstructions around bodies of water. Keeping the main door ormain gate closed was suggested by participants in urban areas.


"Children of 5-6 years whodo not knowhow to swimdie bydrowning,when theywant to learnswimming bythemselves."


Roles of the community and community-level institutions identified by theparticipants are as follows:

Ditches and drains should be filled up and vigilance is needed to protectchildren from drowning.

Community organisations can identify the risks of drowning, organisemeetings and take necessary initiatives to minimise the risks.

The Imams of the mosques and teachers of schools and madrasas(religious schools) and community leaders should tell children not to gonear water.

The community could take the initiative and erect fences around pondsand water bodies to prevent children from drowning. This suggestionraised much discussion and debate regarding the material to be used forfencing, cost sharing, and maintenance etc.

The participants suggested that government could play an important roleby making the environment safer through hazard reduction (cement coversto be placed on drains and manholes in urban areas, filling in unwantedwater bodies or fencing around major ponds). Moreover, governmentshould take measures to drain out accumulated water during rainy season.All children should be required to learn to swim as a necessary life skill andswimming competitions could be arranged for children to promoteswimming practices. The Government could organise campaigns or use themass media to raise awareness among the community."Mothers

should alwaysbe carefulregardingchildren'swhereabouts.When motherswill be busy,they shouldassign aresponsiblemember of thefamily to takecare of the child."

Burn Injury

Life stories

Almost every one of the groups had either observed or heard about anincidence of burn in their home or in their community.

A three-year old boy fell into a heap of ashes near the house of aneighbour that had a dormant fire inside. The uncle of the child sawand rescued him immediately.

A one-year old baby was burnt while trying to reach an idle pot of firewhich fell on it. The mother rescued the baby.

A five-year old girl was asked by her mother to light a 'kupi' (anindigenous lamp) from the cooking stove. Her dress caught fire and shewas seriously burnt.

Twin brothers, Jewel and Jony fell into a large furnace where paddy(rice) parboiling was done. The grandmother saw this and called herson and daughter-in-law. They came and rescued the boys from thefurnace, but they had severe burn injuries.

One of the participants said that her three children, aged 4, 7 and 9years, were burnt to death when another young child from theneighbouring house set fire to a stack of straw inside which thechildren were playing. They could not get out and couldn't be rescuedby their parents or neighbours despite their frantic efforts.


Generally, participants considered burns as a very serious issue for childrenas the following comments attest:

The incidence is quite common. It may take place any time of the dayor night and anywhere, in our own houses or in other people's, in placeswhere usually dormant fire is kept.

It is a painful and horrifying incident and children are mostly thevictims. These small innocent children suffer from painful burn injury fora long time. Often their faces, hands or limbs get maimed. The childrenmay die also.

In most cases, the parents or elderly household members keep theunused fire around in places without much care. As a result, children,who do not have much awareness about what may happen to them,unknowingly get into fires and get burns. This is awful.


Most participants' knowledge of places where burns occurred wasconsistent with the data from the quantitative research. Commonly citedplaces were:

Kitchens, where ashes are piled up with dormant fire in it.

In the large furnaces where parboiling of paddy is done.

In the fire used to fight against cold in winter.

In the cattle-house fire.

Inside rooms where there is bad wiring or electric short circuits.

Fire from gas burners and other hot objects in the kitchen.

Causes

According to the participants, the main reason for accidental burn injury isindifference of parents, especially mothers and other caretakers. Commoncomments were:

The whole family environment is such that the children are treated asif they are old enough to take care of themselves. So they are allowedto move independently.

Household members are indifferent about their children. They forgetthat the children need special care.

There was a special mention of intentional burn injury with acid, withadolescent girls being assaulted with acid as well as mention ofoccupational burns in factories (cracker and welding factories).


The participants identified the highest risk age group as beginning in youngchildhood and increasing with age, and also noted the sex difference ofolder children, specifically mentioning the association of burn injury withcooking and kitchen activities in females. Burn occurs more in winter aspeople sit beside the fire to warm up their bodies and children like to playwith fire.


“The incidenceof burn is oneof the mostgruesomeaccidents thattake place inour day-to-daylife. It is verypainful andcontinues for along timedepending onthe seriousnessof the burn.”



In general, the following measures were stated, with almost no differencesbetween urban and rural participants:

Using raw egg, rotten part of banana tree on the burn wound (forcooling).

Soaking the wound with water continuously.

Pasting the area of wound with mud.

Applying coconut oil, lime water, raw potato mash, toothpaste, onion,ice or ice-cream on the wound.

Applying kerosene oil to avoid water boil and pain.

Giving Kabiraji medicine.

Applying heat on the burn wound (as a measure to destroy poison withapplication of poison).

Applying sesame oil on the burn wound to avoid scarring from wound.

Using juice of Kapila leaves on the wound.

Applying domestically prepared medicine by boiling milk, sesame oiland wax together.

Applying herbal medicines made out of leaves of herbal plants.

There were very few mentions of the following measures like:

Applying antiseptic powder.

Giving medicine from medicine shop.

Applying burn ointment.

In acid burn cases plain cold water is applied as soon as the incidenceshappen.

Regarding use of emergency facilities a hierarchy of responses wasmentioned: 1) Kabiraj, rural practitioners and use of herbal medicines werethe first choice, 2) if the victim was not cured, then he was taken to aqualified doctor, private clinic or others if needed, and 3) in the case of anelectric shock or acid burn, the victim is taken directly to the hospital.


Preventive practices are rare in communities though people can identify thepreventive measures to be undertaken.


These generally involved looking after the children, preventing access tofire and hot objects, and repairing hazards such as faulty electric lines.

Participants identified the following roles of the community andcommunity-level institutions:

They should be motivated to select places for dumping ashes far fromhomes so as to keep children away from the dumping ground.

Furnaces for parboiling rice or boiling date juice should be made farfrom dwellings so that children do not become victims of burn injuriesby touching or getting into hot pans or caldrons.

“Childrenshould not beassigned to doany activitythat mightcause themburn injuries.”

Awareness raising campaigns can be organised using slogans urgingcommunities to turn off gas burners or other kitchen stoves when theyare not being used.

Strong resistance must be encouraged against acid throwing.

The suggested initiatives to be taken by government are

Government should stop buying and selling of acids and crackers andshould execute strong laws against use, application and throwing ofvarious types of explosives, such as firecrackers, acid etc.

Government electricity service providers should check electric lines atregular intervals and faulty lines should be mended at once.

Government agencies should be engaged in awareness raising activitiesthrough various media.

A Fire Service Station should be established in every union.

Health workers can check whether there are any risky places for burninjury.


Transport Injury

Life stories

A ten-year old girl was travelling with her parents by bus. While shepeeped out of the window to see something, another bus comingfrom the opposite direction brushed past the standing bus. The girl'shead was torn off her body and fell on the road. There was no scopeto provide first aid. The police came and sent the body to the morgue.

An adolescent girl described how her younger sister aged eight years,was crushed under the wheels of a car. The younger sister waspicking up pebbles from the roadside when two cars trying to overtakeeach other came by and one of them knocked her down. People tookher to the hospital where the doctors declared her dead.

A rural elite participant described an accident which caused the deathof his own son. A lot of people had gathered in his house on theoccasion of a wedding. All the children rushed to the bus stand to seethe groom. Among the children was his eight-year old son who wascrushed by a speeding car. He died on the spot.

A boy aged between 11 and 12 years was trying to hurriedly cross arailway line. He thought that he could make it. But he was knockeddown by the train engine. He was taken to Narsingdi hospital fromwhere he was referred to Dhaka. He died on the way.

An urban adolescent described an accident that he heard from hismother. His uncle and other members of the family were travelling bybus to attend a wedding. They got down at a place to change the buswhile the uncle went to the other side of the road to buy cigarettes.His son Imran, aged five or six years, followed him and was knockeddown by a bus and was crushed under its wheels. He wasimmediately taken to the local hospital but died soon after.



Generally transport accidents were seen as road traffic accidents. Theywere regarded as very common events that were tragic in nature, as thefollowing comments suggest:

In our society such accidents happen quite often. People feel very sadwhen they see or hear this happening. Such accidents can destabilisea family socially and economically.

It is extremely sorrowful when a near and dear one becomes a victimof an accident. If somebody is killed in an accident, he is gone; but ifsomebody is crippled by an accident it is more heart-rending.

Such accidents leave an adverse effect on the mind. However, thesealso lead to increase in awareness of the people and members of thefamily.

Such accidents are unfortunate and cause anguish in us because thechild killed in the accident could have lived much longer.


Participants noted highways, roads, small lanes, rivers, play fields,railroads, level crossings and bus stations. Mothers of under-five childrenin rural areas also mentioned canals and water bodies as places ofoccurrence of accidents.

Causes

The most frequently mentioned causes of accidents were:

Carelessness of the rickshaw pullers and drivers of mechanisedvehicles.

Playing of children on the roads.

Defects in roads, dense fog and slippery roads.

Boarding and exiting buses while in motion.

Taking passengers beyond the capacity of river craft.

Head on collision of two river crafts.

Mechanical problem or defect of buses and trucks.

Peeping out or thrusting hands out of the bus windows.

Derailment of trains/collision of two trains or collision of train with othervehicles.

Inclement weather causing boats, launches and steamers to haveaccidents.

Learning to ride bicycles, going to and from schools and markets.


Participants identified older children as at the highest risk of transportaccidents (especially road transport). They also noted the genderdifference with males more at risk than females.


Most participants listed actions that should be taken after road trafficaccidents (not included drowning). Most suggested that cuts should first

be treated with Savlon (antiseptic cream). In the case of fractured bones,bones should be tied firmly to a hard substance and the injured personshould be taken to the doctor as quickly as possible. It was commonlynoted that in a major accident when administering first aid is difficult, theinjured person should be taken immediately to a doctor. Other suggestions,common to most of the groups, were:

Shaking of arms and legs.

Pouring water on the head.

Pouring water on the affected part of the body.

Treating the injury with the sap of black arum stalk or grass.

Applying a paste of lime, bamboo ash and oil to prevent bleeding.

Applying Savlon cream to stop major bleeding.

Applying garlic mixed along with lime on the wound.

Pouring ice-cold water on cut injury to lessen pain.

Most of the participants said that the patient is taken to a doctor or ahospital when the condition does not improve. Mothers in rural areas saidthat accident victims are also taken to NGO clinics. However, in the caseof major accidents they are always taken to government hospitals. It isworth noting that none of the participants mentioned taking a transportaccident victim to an indigenous medical practitioner or a faith healer.


Preventive practices such as urban mothers accompany their youngchildren do exist. Parents also tell their children to be careful while they areon the roads, but they do not teach children safe road behaviour.


Everybody, especially parents should be aware of potential hazards.

Traffic islands should be erected in front of schools.

Roads should be repaired and provisions made for zebra crossings.

Vehicles should not be allowed to take extra passengers.

Parents should teach their school-going children how to cross the road.

Signboards should be erected in front of schools so that drivers becomecareful.

Children should be taught techniques for self-defence and prevention ofaccidents.

Children should be taught not to get down from moving vehicles or getonto the roof or bumper of a vehicle.

The children should be restrained from going near railway tracks.

Motorcycle riders and passengers should wear helmets.

Roads should be paved or made even by removing raised areas and pitholes.

Speed breakers should be erected in front of schools and markets.


“Overloading ofroad and watertransportvehicles andtaking inpassengers andgoods inexcess of avehicle'scapacity needsto be strictlycontrolled.Nobody shouldbe allowed totravel on theroof of thebus.”


Vehicles with mechanical problems should not be allowed on the road.

Speeding vehicles should not be allowed and drivers should not beallowed to drive under the influence of liquor.

In general, participants identified clear responsibilities for government,particularly in law enforcement. However, there was little awareness of therole of the community in preventing transport accidents. The specificsuggestions were:

Traffic laws should be strictly enforced.

Only trained drivers should be given a license to drive. Vehicles alsoshould have a road worthy license.

Each vehicle should have proper lights and the law in this respectshould be enforced.

The Union Parishad Chairperson and Members should be informed ofthe occurrence of any accident so that they may give assistance in legalmatters subsequently.

Proper signs should be displayed in case of low draught or char (islands)areas on riverine routes.

Government should repair damaged or defective roads and bridges toensure traffic safety.

Government should increase community awareness of accidentprevention.

Traffic police should be posted in front of schools and market places.

Traffic police force in greater numbers should be recruited, trained anddeployed.

“Theseincidentsshould begivenimportance. A healthy childplaying orroaming aroundus, whosuddenly takespoison and diesis verypathetic. Wedon't giveenoughimportance toit as we arevery busy.”

Poisoning

Life stories

Ten life stories were documented from participant's experiences. Amongthese, three children took poisonous substances accidentally and therests were suicides. The suicide victims were mostly adolescents andyoung adults, both males and females.

Farzana, a six-year old girl, accidentally took a mosquito coil and herpeers immediately informed the family. She was saved as she wasimmediately taken to the hospital. Similarly Mary, a two-year old urbangirl drank Harpic (a toilet cleaner) and was about to die. Another boyof seven years drank insecticides brought to kill ants.

Bilkis, an eighteen-year old girl, took endrin (one type of pesticide) tocommit suicide when her father scolded her for not going to in-lawshouse. Bilkis's mother and other relatives forcefully gave her raw eggand cow-dung into her mouth to induce vomiting. Then her familycalled in a village doctor for medical care.


Generally, attitudes related to poisoning differed according to whether itwas intentional (suicide) or unintentional (accidental). Suicide was usuallydescribed as tragic, but sinful. Accidental poisoning was seen as tragicand sad. The following illustrate many of the comments in the FGDs:

Sudden death due to poisoning is a terrible and a sorrowful event. It isour responsibility to give proper attention so that no such incidencesoccur.

It is a tragic event; the mother should take care of the child. There isevery possibility of dying by poisoning. Children are the future of thenation, they should be given the opportunity to develop, but they areinnocents and don't realise the consequences of poisoning.

Suicide by poisoning is a tragedy. It is also a great sin according to ourreligious point of view.

Poisoning is an abnormal accident and one's life can be spoiled unlessproper treatment is given. There is no opportunity for proper treatmentof poisoning victims in rural areas, and as a result, the victims are tosent to the upazila health complex. Due to delayed treatment thepatient sometimes dies.

Place of occurrence

Village mothers noted that most poisoning cases took place at thechildren's own home, at the home of neighbours or around their home. Thevillage elites further added that most of the incidents take place in poorand/or illiterate families where poisonous objects are kept under the cotand young children can easily access them. Participants mentioned thatfathers, when returning from the field after spraying insecticidessometimes leave insecticides in the courtyard.

Causes

Comments specific to suicide were as follows:

Adolescents take poison out of anger

Wives take poison if they are tormented by their husbands or in-laws

Misunderstanding in love affairs

Girls take poison out of shame or fear if rumours of a relationship withboys spread in the community

Adolescents want to stay independent and any restrictions on this mayprompt them to take poison

Unemployment and frustrations regarding employment are also causesof suicides.


Participants of all FGDs identified different ages at risk of poisoning fromdifferent causes, both intentional and accidental:


“Young childreneat whateverthey find andthis habitcontinues up tothe age of three years.”


Infants and young children may mistakenly take endrine andinsecticides considering these as medicine or other edible substances.

The infants sometimes mistakenly drink kerosene.

Children are fond of bright objects. Soap is bright and attractive, so theyfeel tempted to eat it.

As soon as infants start crawling they may pick up and take poisonoussubstances.

An overdose of sleeping pills, finis (ant-killer), harpic (toilet cleaner),and kerosene, were commonly mentioned poisons for suicide inadolescents.


The first response to poisoning was to induce vomiting. The methods andthe agents commonly used for the purpose were:

Forcibly feeding victims sour things like tamarind, uncooked eggs andcow dung.

Pushing the inside stem of banana stalks and human excreta into themouth of the victim.

Inserting a hand into the victim's mouth to cause vomiting.

Forcing rotten food and vegetables, parts of dead animals, mustard oiland kerosene.

There were a few possibly helpful measures mentioned such as forcingthe victim to drink a large quantity of water, olives, local berries (boroi)and juice of neem leaves, however this relied on a co-operative andconscious victim and also placed them at risk of aspiration of theemetic substance.

Usually those who provide first aid do so from their own experiences. TheFGDs revealed that there was no trained person in the community toprovide first aid to the poison victims. If the locally available first aidfacilities were not sufficient, the patients were transferred to the upazilahealth complex, district hospital, rooms of renowned doctors, privateclinics and nearby pharmacies, where experienced service providers wereavailable. Comparatively serious patients were referred or sent to morerenowned doctors or tertiary hospitals. None of the participants suggestedsending a poison victim to a traditional healer (kabiraj, ojha, peer, fakir,etc.) for treatment.

Existing preventive practices and suggested practices to be implemented

Almost all participants of FGDs proposed that poison should be keptcarefully out of reach of the children. Different categories of participantsused different words to explain the phrase out of reach. Fathers said itmeant "to keep poison up", elites said "to keep poison in hidden place",mothers said poisons should be kept "under lock and key". However, someparticipants noted that in rural homes, especially poor ones, there were noshelves, drawers or cabinets.

“Young childrenare curious totry theirmothers'medicine.”

In the case of suicide, the following preventive measures were often cited:

Campaign for education for all, especially female education.

Ensure quality education and discouraging copying in examination.

Creating job opportunities.

Prevent violence against women, girls and disadvantaged members ofthe community, combating child trafficking, early marriage of girls, etc.

Safe use of drugs, insecticides, manure, etc.

Incentives for attainment of child rights.

Discouraging divorce (broken family), second marriages, domesticviolence, quarrels with parents, neighbours and relatives, etc.

Generally, participants identified individual parents and caregivers as beingresponsible for prevention. They specifically noted the following:

Taking care and supervision of children: There is no alternative to themother. She takes affectionate care of children. Mothers stay at homemost of the time. Even working mothers stay at home for longer thanworking fathers. However, most of mothers remain busy with householdwork. In urban areas a good number of mothers were found to engagethemselves with many outside activities. Therefore, it is not easy forthem to take continuous care of the children. Further, the mother maytake the child safety casually and with less seriousness if she is notaware of the risks and consequences of the poisoning. Appointing anadult female supervisor or caretaker for the child was stronglyrecommended in urban areas.

Counsel and guide children: Parents and elder members of the family,community members and relatives should counsel and guide children sothat they do not commit suicide. Elder members of the community havedefinite roles, but school teachers can play more significant roles in thisregard. Currently elders are not well aware of the degree of harmbrought about due to poisoning. Some may be aware but may not beserious about it. They may make sporadic efforts without any follow-ups. There is a lack of appropriate programmes to assist elders to playtheir due roles.

Putting poisonous substances out of reach of young children: It needslittle effort by parents and others. This practice, if sustained for a longtime, would be a good habit for elder members of the family. But it isimperative to note that some parents have no idea where they shouldkeep poisonous substances. Also in poor households there is littlefacility of storage, such as drawers, shelves, almirahs, etc., forsafekeeping of poisonous substances.

Participants identified the role of government in the drafting andenforcement of laws that regulate the safe distribution and storage ofmedicines, pesticides and insecticides in particular.


Puttingpoisonoussubstances outof reach ofyoung children:It needs littleeffort byparents andothers.



Many participants think the lack of parents' awareness about the situationand children's movement to be an important reason for this kind of injury.Some participants specifically mentioned in this regard, "Parents, otherelderly household members and also neighbours are not appropriatelyaware and conscious. As a result, children move about indiscriminatelywithout their knowledge and as a result are often bitten by snakes, dogsand other animals or insects".


Almost all the participants stated that an animal or insect bite can takeplace anytime, any day or in any season. The most common placesmentioned by the rural participants included, on roads, in fields, in forests,in water, on date trees or palm trees, in rats' holes, in the corner of theroom, in the haystack, in logged water in the jungles and bushes. On theother hand, urban people mentioned that bites occurred on the branch oftrees, in the bushes, corners of rooms or kitchens, cracks of old walls,holes inside trees, in stacks of old bricks where insects and animals maketheir homes.

Causes

The overwhelming theme of comments on the causes was indifference andlack of awareness on the part of the victims. Some representativecomments are:

It appears that they forget their children when they are away. They donot even think of taking care of their children for their safety, not

“All age groupsvulnerable due to the ubiquity of biting animals and insects.”

Animal Injury

Life stories

It was a summer afternoon when Ziaur, a 5 year old boy was standingin front of the kitchen with a coconut in his hand. Suddenly a dogcame and bit near his naval. Bleeding started from the wound and hewas rapidly taken to a local doctor and then to the sadar hospital. Hereceived 14 injections and gradually recovered.

Nasima was walking with her grandfather in rainy season when asnake bit at her leg. Her grandfather immediately put three ties abovethe wound. He then cleaned the wound with savlon. She was nottaken to any doctor as the grandfather saw the snake and ascertainedby colour that it was a non-poisonous type of snake. Still she wasgiven to eat chili as it was believed that chili would work as antidoteof snake poison.

A 7 year old girl was passing by a pond side where three or four dogswere quarreling. One of the dogs bit her hand and took off a piece offlesh resulting deep wound. People heard the girl crying loudly. Theparents could not take her for any treatment due to extreme poverty.Gradually her condition became worse and then she was taken to aKabiraj (traditional healer). But she died within two months.

because they do not want them to be safe but because they are ignorantand lack awareness about the consequences.

Another form of carelessness and ignorance is reflected in the dumpingof garbage indiscriminately inside and outside the households. The elderpeople of the households are not aware that this dumping may causeharm to their children.

In many houses dogs, cats etc. are reared as pets. These pets often gomad as they are not given vaccines regularly.


Two of the more common responses are listed below:

The adults are vulnerable as they work outside home, catching fish,crop cultivation etc, in bushes or beside dumps of garbage and marshyland.Young children usually are victims of animal bites more frequently asthey do not have fear of anything and get closer to certain animals,especially the dogs. Often they set their feet on the body of the dogsor pull by their tails. The dogs get annoyed and bite.


The common first aid responses after animal bites are as follows:

In case of dog bites

An enchanted plate is administered to see if the dog was mad. If theplate sticks to the back of the person, then the dog is to be consideredmad. In that case, the victim should be taken to the doctor immediatelyfor injections. If it is not mad, the victim is treated at home warm waterand Savlon.

Enchanted molasses or bananas are given to the victim of a dog bite toeat in the morning so that the victim does not have dog's puppies inthe womb.

Leaves of trees are smashed and applied to the place of wound.

Enchanted caustic soda, turmeric or molasses are used.

The victim is taken to a Kabiraj who gives tablets.

Hujur (religious leader) gives enchanted salt to eat.

The victim is given pepper to eat. If the victim says it is hot, then it isto be understood that there is no venom in the body. If there is venomin the body, the opposite happens.

If the hair is tied, then it has to be untied.

Flower of brinjel is given to the victim to eat. The flower is mixed withblood of the bite wound and applied at the place of wound.

Ginger and salt mixed with oil are given to the victim to eat and thevictim is not allowed to eat any type of animal protein like, meat, fishor egg.

In case of snake bites

People should ensure three tightly bound knots, two on the upper sideand one knot below the wound with the help of jute or cord.



The victim is kept sitting outside the room because according to elderpeople the knots of the house and those used for snake bite becomeconnected together leading to jeopardy.

An "Ojhaa" (traditional healer) brings out the venom from the victim.

An organ of a chicken or frog is cut to expose blood oozing and pressedat the wound. If the chicken or the frog dies, it is to be considered thatthe snake is dangerous. Victims of snake bite in some areas are notallowed to call 'mother' aloud, because it is said that if the victim callsmother the venom will spread all over the body leading to a fatalincidence. Instead, the victim is motivated to call his/her father. As aresult, the snake becomes afraid.

Some participants stated there is medical treatment for bites of apoisonous snake.

In case of other animal/insect bites

Applying lime on the wound of bee-bite or other insects' bite andbringing out the sting by rubbing a knife and lime on the place ofwound.

Giving Kabiraji medicine.

Often a pain relieving injection or paracetamol is also given.

If a cat or a rat bites, usually, enchanted salt or molasses is given bythe Hujur.

The wound is washed clean and lime is applied.

Following a bee-bite, lime and molasses is rubbed together on thewound with the help of hair.

Lime is applied at the wound if rat or bee bites.

Salt and ointment are applied on the wound, if it is a leech bite.

The wound is washed well with soap and cleaned with Savlon.

If a cat bites, the wound is cleaned with soap soon after the incidence.Then homeopathic medicine or roasted salt is administered.

Emergency measures are used depending on the intensity or seriousnessof the biting:

The victims are taken usually to rural practitioners, locally known asOjhaa, Boddi, Hujur etc., and to homeopaths and drug sellers.

The victims are taken to a qualified doctor (University or districthospital, NGO clinic, private practitioner, etc.) only when they are notcured by the rural practitioners. But the injections prescribed by thedoctors are expensive and poor people can not afford them.

Suggested preventive measures

The children should be kept away from domestic animals.

Vigilant eyes should be kept on younger members of the family,

“The victims are taken to aqualified doctor onlywhen they are not curedby the ruralpractitioners.”


especially children. They should not be allowed to go to jungles andbushes and marshy areas.

Insecticides should be sprayed in the jungles and bushes to killpoisonous insects.

Common dumping grounds in neighbourhoods should be kept clean sothat snakes, rats or any other insects cannot stay safely and become athreat to people in the neighbourhood. They should be motivated tocreate the dumping ground away from dwellings at a safer distance.

Ditches or marshes in the neighbourhood should be managed properlyand kept clean so that they do not turn into breeding grounds formosquitoes, snakes or leeches. This will definitely reduce the bitingincidences in the neighbourhood.

Government should play the following roles, as identified by theparticipants:

Government should strictly execute existing laws for killing mad dogsand appropriate measures should be taken if there is any need to reviewlaws.

Government should also take appropriate measures locally to seal upholes and stop water logging.

Government can pass necessary orders to the relevant local authoritiesfor keeping the environment clean and health friendly.

Fall Injury

Life stories

An adolescent participant of FGD described that she fell from a mangotree 2-3 years back and her leg was broken. Her mother cleaned thewound with savlon and applied the juice of banana tree. Then shepulled the broken part to straighten it. Later the girl was taken to avillage doctor. She recovered from the injury but still suffers fromoccasional pains.

A 5 year old girl fell on a slippery courtyard and her wrist was brokenand dislocated. She started crying and returned home. Her motherpulled the hand to fix it up. She wrapped the area with cloth andstarted pouring water on the cloth. She was later taken to a Kabiraj(traditional healer) and after three days to a village doctor. Butunfortunately she still faces difficulties in using her hand.

A 12 year old boy was playing in the school playground with his peers.During playing he jumped on one of his friends and fell on the ground.As a result there was a fracture in his leg and he became unconscious.His playmates started shouting for help and the nearby people rushedto the place and carried him to his house. His parents poured water onhis head for about half an hour and then he was taken to a privateclinic. He was under treatment for one and a half month and graduallyrecovered from the injury.



The following statements express their concerns and feelings about suchincidences:

Falls are a very common phenomenon. When it results in a fractured orbroken bone, it is very painful and takes a long time to be healeddepending on the nature of the fracture.

The incidence can damage a person for life if proper treatment is notgiven. Children can suffer from serious injuries after falls and these mayhamper their education and working abilities in the long run.

The guardians often fail to understand the importance of giving propertreatment to children after a fall. After the incidence, we massage theirwounds and rub oil on those. This often leads to a continuing injury anda costlier medical treatment.

Injuries from falls could damage children's brains, resulting in paralysisor permanent disability and even death. These injuries might lead totetanus.

One participant said that a child could develop pneumonia or breathingproblems as a result of a fall and another participant said that a fallmight weaken the heart of a child.

Common Places of Occurrences

Falls can occur anywhere; in and around the house, at school, in aplayground, in a workplace or outside their own community. Falls occurwhen, mostly boys, indulged themselves in climbing trees or in dangerousgames.

Causes

The following are the most commonly mentioned causes of falls:

The earthen roads in rural areas become slippery in the rainy seasonand cause a number of fall incidences involving both children andadults.

Serious injuries also occur from falling on slippery concrete slabs placedaround a tube-well.

Children fall from their beds and cots or slip from the lap of anotherchild. Young children often fall when they learn to walk.

Other causes given included plucking fruits from high branches of trees(especially in the rainy season when the branches are wet and slippery);taking part in risky games (football, cricket, kabadi or high-diving); bicycleor rickshaw accidents; slipping from high roofs, embankments, walls,poles, stairs; jumping from a running vehicle; slipping by stepping onbanana skins; being tripped by other children; chasing a dog or a cat;presence of the evil spirits during noon etc.


Most of the participants thought that boys (aged 8-12 years) were morelikely to be a victim of a fall than girls. They felt that boys were

Children agedunder three years must notbe leftunwatched,sitting on a high bedor cot.


adventurous and restless by nature and take part in tree-climbing and riskygames more frequently. A few participants said that afternoon is the mostlikely time for falls to occur as this is the time when most of the childrenplay outside. Falls occur more in rainy season.

First Aid practice and health seeking behaviour

The urban participants had a better understanding of first aid than theirrural counterparts. It was also apparent that health care awareness wasbetter in urban participants than in rural participants. Rural participantslargely depend on indigenous treatments, but in general, both rural andurban participants seemed to have faith in the power of secret spells andsacred pendants in healing fractured or broken bones.

Rural Areas

After a fall, participants said that they tried to find out whether thechild had a fractured bone or had a sprain. If it was a sprain, theyrubbed oil and garlic on it. If bones were dislocated, they tried to putthe bones back in place. The child was taken to the doctor only whenthe case seems to be very serious.

In the case of bleeding wounds, herb paste, grass paste, kerosene orlime is rubbed on the wounds to stop the bleeding. According to theparticipants, paste of 'Manpata' and bamboo ashes can stop bleedingimmediately.

Some participants said that there were people who knew secret spellsand could use those to heal injuries, fractures and broken bones. Theytook their children to these 'learned men' for treatment.

A few participants said that there were Kabiraj and quacks whospecialised in the treatment of broken bones, and many people tooktheir children to these Kabiraj and quacks after a fall. Some victimswere cured, while some were not. There were even some victims whoreceived the wrong treatment and became disabled forever.

Some participants said that they applied disinfectant onto the woundsfirst and then took the child to a doctor.

Urban Areas

Most participants said that they clean up the wounds with water and aclean piece of cloth and applied a disinfectant. If the wound was severe,they took the child to a doctor after covering the wound tightly with aclean piece of cloth, so that it did not get infected.

In the case of broken bones, they put ice or a wet cloth on the injuredpart and tied a bamboo stick to keep it from moving until a doctorattended the child. They said that they did not massage the injuredorgan as it might worsen the situation.

In case of sprains, they put ice and wet clothes. A few participants saidthat sprained organs should be massaged with mustard oil and salt.

Some participants stated that if a child hurt its head, someone has tostrike the child on its back as part of the treatment.

Some participants were aware of the fact that a child with a broken orfractured bone has to be taken to an orthopaedic specialist.


As in rural areas, the applying molasses, extracts of grass or bamboo-ashes, lime, extracts of marigold and herbs to the wound is common. Someparticipants believed that "tabij" (sacred pendants) and "harbhangar tel"(oil for healing broken bones) should be tried first or the child shouldremain under the supervision of a Kabiraj with qualified doctors consultedlater if the injury lingers or becomes complicated. A few participantsstrongly opined that the medicines given by the Kabiraj and the oilproduced by a company named Manda is effective for healing broken andfractured bones.

Existing Preventive Practices

Some of the participants opined that such accidents can be prevented bytaking some pragmatic, precautionary measures, while others felt thatprevention was not possible at all as the prime vulnerable group was oftenbeyond complete control. They did not have a very systematic pattern ofideas about prevention of accidents. Others still believed that even ifaccidents could not be totally prevented, the magnitude and the associatedrisks could be substantially reduced. However, the present level ofknowledge in the community about accident prevent is not of optimumlevel. One participant reported that he nailed spikes on the trees so thatchildren do not climb them. Another participant said, "I regularly clean theconcrete slab below my tube-well so that it does not get slippery". Therewas a distinct gap between people's knowledge and prevalent practices.


The suggestions for prevention are common in rural and urban areas andinclude the following:

All members of the family should remain careful. The children mostlydo not understand the risk of injury and breaking bones from a fall. Iffamily members remain alert and vigilant this kind of accident can beaverted.

Parents must advise their children not to climb high trees and to avoidslippery roads and surfaces while walking, running or cycling.

Guardians must make sure that their children are holding the hoods ofa rickshaw while travelling, so that they do not fall out of a rickshaw ifit jerks or collides with another rickshaw.

Parents must not ask children to climb the trees to collect firewood orto pluck fruits. They themselves can do these jobs or can ask thechildren to do those from the ground with the help of long woodensticks.

Parents must ensure that the shoes worn by their children are notslippery.

Parents must make sure that the roofs of their houses have protectiverailings.

Everyone in the neighbourhood must make sure that his or her yard isnot slippery and in the rainy season, bricks, sawdust or sands are putover the slippery surfaces.

Governmentmust buildprotectiverailings aroundthe roofs ofschools,colleges ormadrasas. Therailings must atleast be threefeet high.


Everyone in the neighbourhood has to make sure that banana skins aretaken away from the roads.

The participants identified the following roles for the community:

The community has to take steps to level the uneven plains and roadsin their locality.

Members of the community must come forward to help the victim orthe family of the victim after the accident.

The participants suggested some ways in which government can helpprevent death from fall:

Government must maintain the roads so that the roads do not getuneven or slippery and cause accidents.

Government can telecast programmes through national media to makechildren and their parents aware of the dangers of falls and thepreventive measures.

Government can build more children's parks or playgrounds in both ruraland urban areas where children can play safely.

Discussion

The qualitative portion of the research revealed, that in general, there wasa disconnect between the predominant beliefs and the knowledge of thecommunity regarding injury causes and risk groups. In some cases, suchas drowning, the misperceptions that young children were not at riskplayed a role in the very high drowning rates found in the survey for youngchildren. Mothers and other caregivers who do not recognise the risk ofdrowning in late infancy and early childhood cannot take preventivemeasures. The generalised lack of accurate factual information concerningthe risk of serious and fatal injury for children indicates the need for broadand comprehensive communications activities to correct misperceptionsand educate people about the causes and child groups at risk.

A similar situation exists with injury that has already occurred and thuscannot be prevented. Once injury has occurred the main focus must be onappropriate first response and then definitive treatment with the goal Asimilar situation exists with injury that has already occurred and thuscannot be prevented. Once injury has occurred the main focus must be onappropriate first response and then definitive treatment with the goal ofminimising the seriousness of injury and preventing permanent disability ordeath. There was the same wide gap in correct knowledge and appropriatepractice between what first aid or first response actions should be takenand what actions were actually taken. With the exception of injury due toroad transport, generally most of the actions reported as commonly takenwere largely ineffective. In the cases of drowning, poisoning, burns, andanimal bites, most of the commonly mentioned responses are actuallyharmful and either increase the severity of the injury incurred or increasethe risk that permanent disability or death will result.


Given that the Government does not have the resources for out of hospitalemergency medical response at the community level, the real burden ofresponse to injury must, by necessity, be placed on the community and theinhabitants of the community. This means that teaching first aid andappropriate first response activities should be a major focus of any injuryprevention and control programme. Given the very high rates of serious andfatal injury for children, it is clear that first aid should become a basic,necessary life skill for all children, and should be a focus of injuryprevention activities in any community-based intervention.

The overall conclusion that is clearly evident from the qualitative portion ofthe research is that as a general rule, in all groups surveyed, there was alack of awareness regarding the level of risks for child injury, as well as ageneral lack of knowledge of appropriate measures to be taken once injuryhas occurred. It was also clear that most of the respondents saw externalforces and factors beyond their individual control as being both the causeof injury as well as the factors important in preventing it. This "locus ofcontrol" issue will need to be addressed in any injury preventionprogramme. The reality of any successful community based injury controlprogramme is that it is based on the sum of the knowledge, attitudes andpractices in the individuals in that community. Thus community safety isdependent on individual awareness and adoption of behaviours andpractices that contribute to safety. This is directly analogous to the "herdeffect" noted with community rates of communicable disease. It is alsodirectly analogous at the level of the individual family, as the risk of injuryfor any child is largely determined by the risk awareness and safetybehaviours of that child's parents and caregivers. To protect children frominjury, it is necessary to broadly focus on their parents and caretakers, andthis mandates broad-based, comprehensive awareness and behaviouralchange communication activities.

Chapter 19

Conclusions & Recommendations

The time to act for the children of Bangladesh is NOW.

Conclusion One

There is an epidemic of child injury andthe response to it needs to begin now.

One definition of an epidemic commonly used byepidemiologists is the occurrence of an adversehealth event in more than 1 percent of thepopulation. Using this definition, the overallconclusion of the survey has to be that there is anepidemic of child injury occurring in Bangladesh.The survey documented an overall child injury rateof 1,592/100,000 children. This means thatalmost two in every hundred children inBangladesh were injured significantly enough torequire medical care, or lose three days of schoolor work in the year prior to the survey.

This epidemic has been unrecognised until now,which explains why there are few, if anyprogrammes which attempt to prevent childhoodinjury, or prevent permanent disability once theinjury has occurred. The BHIS provides thisrecognition, as well as much of the informationnecessary to develop the interventions that are soclearly needed. While there is a need for furtherresearch in some areas, a great deal can be donewith what is known now. We know that drowningis a leading cause of child mortality, andincreasing responsible supervision of toddlers, andteaching older children to swim will reducedrowning rates considerably. We know that homesin Bangladesh are full of risks of burns, scalds,poisons, cuts, falls and other major causes ofinjury, and that they can be made safer. We knowthat schools and the walk or ride to and fromthem can be very hazardous to children, and wecan ensure that the schools are safer as well asthe journey to and from them. It is important tostart now. Each day's delay means paying adreadful toll in children's lives and futures.

Conclusion Two

Injury is the leading killer of childrenafter infancy.

There were over 30,000 children fatally injured inthe year before the survey. This is about 83children each day, or about three per hour.

Drowning was the single leading cause ofdeath of children after infancy (1-17).

Almost one third of all child deaths in the 1-4age group were caused by injury.

Over half of the deaths in the children over five(5-17) were caused by injury.

Injury is also the leading killer of the parents ofBangladeshi children.

About two infants each day lose their mothersbecause of injury with suicide the leadingcause.

About 11 children lose their mothers each daydue to injury with suicide, RTA and violence theleading causes.

About 21 children lose their fathers each dayto injury with RTA, violence and suicide as theleading causes.

Conclusion Three

Injury is a leading cause of morbidity,and the impact of serious and severemorbidity exceeds that of fatal injury.

There were almost a million (955,000) childreninjured in the year prior to the survey. This isabout 2,600 per day, 108 children each hour, andalmost two children each minute.

Injury is one of the leading cause of disabilityfor children in Bangladesh with over 13,000permanently disabled each year, or 36 childrenper day.

157Chapter 19: Conclusions & Recommendations

Conclusions & Recommendations

Permanent disability is only the "tip of theiceberg" for non-fatal injury.

For each permanent disability, two children arehospitalised for more than 10 days, fourchildren are hospitalised for one to nine days,and 64 children seek care or miss three days ofwork or school.

The direct, indirect and social costs of non-fatalinjury far outstrip that of fatal injury.

Conclusion Four

It is a simple issue but a complexproblem.

These simple facts stand out very clearly.However, the epidemic of child injury is a complexone. Different age groups had different patterns ofinjury, and the patterns depended on the stage oflife of the child, and the environment around thechild.

The data speaks for itself. One doesn't have to bea trained epidemiologist to see that falls,drowning and suffocation are the major issues ininfancy; that drowning is the overwhelming issuein early childhood; that middle childhood and earlyadolescence have a more complex set of injuryissues; and that suicide is the overwhelming issuein late adolescence.

The BHIS data have a very clear message. Giventhe complexity of the problem, and it's magnitude

in all age groups and stages of the child's life, theoverall programmatic response will require acomprehensive programme to make Bangladesh'shomes, schools and local communities safer forchildren.

Conclusion Five

All children count, and they mustbe counted.

Within injury of all causes, there are some that arealmost entirely age-related. Suffocation is mainlyan issue of infancy, and suicide is wholly an issueof adolescence. The numbers are equallyimportant regardless of the cause and the age ofthe child. All children count, and deaths of allchildren must be counted and used to benchmarkthe pace of progress in reducing child mortality. Itis time that deaths of all children, from infants to17 year olds, are counted, and a child mortalityrate that includes the older children becomes abasic, standard benchmark for child survivalprogrammes.

The development community has maintained alaser-like focus on the under-five age group and inlarge part helped achieve the epidemiologicaltransition as a direct result of it. We now need torecognise that this success has meant a greatdeal of preventable child mortality is nowoccurring in the over-fives, where 40 percent ofthe child deaths after infancy are now occurring.

The BHIS shows that injury is an issue in eachstage of the child's life, and that its toll increases


as the child becomes older. The distribution ofinjury, throughout the stages of life of the childmandates that it be addressed in each stage. Anydiscussions regarding this must be framed withthe preface that deaths which occur in childrenover-five are equally important under the UnitedNations Conventions on the Rights of the Child.

Conclusion Six

The problem is of equal urgency withother programmatic priorities.

Bangladesh, like most other developing countries,has a gross imbalance between the number ofmajor health issues needing to be addressed, andthe amount of the resources available. Hence, it isimportant that the resources be allocated asefficiently as possible. One of only ways to ensurethis is to base the decisions for resourceallocation on data that accurately portrays thereality of the health situation. The BHIS showsconclusively that using facility-based data, ormodels derived from other countries or regionsmisrepresents the reality of health in children andtheir parents in Bangladesh. Policy makers willneed to carefully review the BHIS data andcompare it to the data currently used in resourceallocation decisions. It is clear that Bangladeshhas made enormous progress over the last severaldecades and the current leading causes of childdeath are very different from what they used to be.

It is helpful to use HIV/AIDS as a recently-emerging priority issue as a comparative

benchmark for the importance of injury in childrenand their parents.

This figure uses HIV/AIDS as a benchmark forcomparison of the public health priority of injury.In the graph, the 2002 rates of HIV/AIDS fromThailand, which is acknowledged as one of themajor hotspots for HIV/AIDS in Asia, are appliedto the Bangladesh population. The yellow barsshow what the numbers of deaths from AIDSwould be if Bangladesh had a "Thai-like" epidemic(all available information shows that HIV is not yeta significant problem in Bangladesh). The red barsrepresent the current injury death rates asdetermined by the BHIS. HIV/AIDS has beenidentified as a major priority for the Governmentand its development partners, and currently anestimated 35 million USD are being programmedfor HIV/AIDS prevention. It is clear from the graphthat injury deaths in almost all age groups areorders of magnitude larger than those fromHIV/AIDS. HIV/AIDS is a particularly cogentbenchmark, as injury and HIV share manycommonalities:

They both have no vaccines or 'magic bullets'for prevention and require multi-sectoralresponses.

They both require education and behaviouralchange as a main prevention strategy.

They both require 'harm reduction' approachesfor most effective prevention.

They both require environmental risk reductionand individual protection strategies for besteffect.

Given the dramatic differences in the numbers ofdeaths currently attributable to each of them, it isclear that injury also needs to be reflected infunding, planning for programme implementation,and development of a broad consortia of partnersfor a national intervention strategy.

Conclusion Seven

The MDGs will not be met withoutaddressing injury.

The Millennium Development Goals guide policy


decisions as we cross the midpoint of the timeperiod they refer to, and begin to focus on 2015.To achieve them, it will take more thanrededication and working harder on what hasbeen done in Bangladesh over the last twentyyears. It will require doing what has not beendone before; preventing injury in under-fives,specially among 1-4 years would reduce theU5MR substantially. This would ensure thatBangladesh meets the two-thirds reduction that isspecified by 2015.

It will be necessary to maintain the same single-mindedness in ensuring that all pregnant womenhave antenatal care and a clean delivery; that theirinfants are breastfed and fully-immunized; andthat their daughters go to schools just like theirsons. However, injury prevention needs to beintegrated into the programmatic infrastructure ofchild survival, so that the neonate who wasprotected from tetanus is also protected fromsuffocation; the infant who is protected frommeasles is protected from drowning, and the childwho was breastfed to get a good start in lifecontinues along that path, and is not killed lateras a pedestrian walking to school.

In May 2002, the United Nations Special Sessionon Children recognised that to meet the MDGs,working harder on the current focus was

necessary, as was working smarter with a newmandate. Hence, the passage of the Plan ofAction with a specific tasking to, "Reduce childinjuries due to accidents or other causes throughthe development and implementation ofappropriate preventive measures," was adopted.

Recommendation

The central finding of the BHIS is that anepidemiological transition has occurred inBangladesh. From this survey it is clear that insome child age groups injury is the single leadingcause of death and disability, and a significantcause of death and disability in all age groups. Inorder to continue the downward pressure on childdeath and morbidity rates, injury will have to betargeted as determinedly and effectively as theprevious leading causes of child death. It is timeto begin developing injury prevention, control andrehabilitation interventions as integral parts ofBangladesh's development efforts. In the newmillennium, for which the MDGs were crafted,child health programmes cannot be considered tobe complete without injury prevention, withcontrol and rehabilitation being major, integralparts. The time to act for the children ofBangladesh is now.


References1 Krug E (ed). Injury: a leading cause of global burden of disease. 1999, Geneva, World Health Organization.

2 Berger L.R. and D. Mohan. Injury Control: A Global View. 1996, New York, Oxford University Press.

3 Injuries in South East Asia: priorities for policy and action, SEA/INJURIES/AI. 2002, World HealthOrganization Regional Office for South East Asia.

4 UNICEF. A league table of child deaths by injury in rich nations. 2001, Florence: Unicef Innocenti ResearchCenter.

5 Petridou E. Childhood injuries in the European Union: can epidemiology contribute to their control. ActaPaediatr. 2000; 89 (10):1244-9.

6 Bangladesh Bureau of Statistics. The statistical year book 2001, Dhaka.

7 Bangladesh Demographic and Health Survey Reference Data (1985, 1989, 1995). Measure/DHS ORCMacro International.

8 Baqi AH, Black RE, Arefeen SE, Hill K, Mitra SN, Sabbir A. Causes of Childhood deaths in Bangladesh:results of a verbal autopsy study. Bulletin of the World Health Organisation. 1998; 76(2): 161-71.

9 Health and Demographic Surveillance System, Matlab: Registration of Health and Demographic Events,2000; Volume 33, ICDDR,B, Centre for Health and Population Research.

10 Rahman F, Rahman A, Barua PC. Magnitude of injury problem and its determinants. 2000, Dhaka, Instituteof Child and Mother Health.

11 Rahman F, Rangnar A, and Svanstršm L. Health Impact of Injuries: A population based epidemiologicalinvestigation in a local community of Bangladesh. Journal of Safety Research. 1998; 29 (4):213-222.

12 Rahman F, Ali Y, Rangnar A and Svanstršm L. Epidemiology of injury: results from a computerized injuryregistration for injury surveillance at a district level hospital in Bangladesh-implications for prevention inlow income countries. International Journal for Injury Control and Safety Promotion. 2002; 8(1): 29-36.

13 Aeron-Thomas A and Rahman F. Bangladesh Crash Costing Study. 2003, Institute of Child and MotherHealth, Dhaka and TRL, Crowthorne.

14 Linnan MJ, Pham CV, Le LC, Le PN, Le AV (eds). Report to UNICEF on the Vietnam Multi Center InjurySurvey, 2003, Hanoi, Hanoi School of Public Health.

15 Ahmed MK, Rahman M, van Ginneken J. Epidemiology of child deaths due to drowning in Matlab,Bangladesh. International Journal of Epidemiology. 1999; 28 (2): 306-11.

16 Morgenstern H, Bingham T, Reza A. Effects of pool-fencing ordinances and other factors on childhooddrownings in Los Angles county, 1990-19995. American Journal of Public Health. 2000; 90 (4): 595-601.

17 Mackie IJ. Patterns of drowning in Australia, 1992-1997. Medical Journal of Australia. 1999; 171: 587-90.

18 Quan L and Cummings P. Characteristics of drowning by different age groups. Injury Prevention. 2003; 9:163-168.

19 Hoque M. M. Understanding Road accident Problems and Their Remedies, Road Safety Training Course2003.

20 Lundebye M.S. Road Safety in Developing Countries: An Overview, International Seminar on Road Safety.1995, Dhaka.

21 Bangdiwala S.I. The incidence of injuries in young people: 1 methodology and results of a collaborativestudy in Brazil, Chile, Cuba and Venezuela. International Journal of Epidemiology. 1990; 19(1): 115-24.

22 Rahman F, Rangnar A, and Svanstršm L. Medical help seeking behaviour of injury. Public Health. 1998;112: 31-35.


Appendices

A. Glossary B. Tables C. Population characteristics D. Contributors

GlossaryInjury: Physical damage due to the transfer of energy. Injury occurs when the amount of energy transferexceeds the host organism's threshold tolerance. The type of energy can be mechanical, thermal,chemical, electrical, radiation or the absence of essentials such as oxygen (asphyxiation, drowning) orheat (hypothermia). Mechanical energy is the most frequent cause of injury.

Unintentional Injuries: Unintentional injuries include only those injuries that occur without intent of harm.Such injuries are frequently called accidents or accidental in common usage.

Intentional Injuries: Intentional or violent injuries are injuries purposively inflicted by an aggressor or selfinflicted by the victim.

Injury severity:

Moderate: Sought medical care but not admitted to hospital; or had at least a three-day work lossor absence from school; and no permanent disability.

Major: Hospitalised for less than 10 days; but no permanent disability.

Serious: Hospitalised for 10 days or more; but no permanent disability.

Severe: Permanently disabled (loss of vision, hearing, handling, ambulation, or mentation).

Accident: An unexpected, unplanned occurrence which may involve injury.

Infection: The entry and development or multiplication of an infectious agent in the body.

Non-Communicable Diseases: Diseases not capable of being directly or indirectly transmitted from personto person.

Epidemic: The unusual occurrence in a community or region of disease, specific health-related behaviouror health-related events clearly in excess of expected occurrence.

Infant Mortality Rate: The ratio of infant (under one year of age) deaths registered in a given year to thetotal number of live births registered in the same year, usually expressed as a rate per 1000 live births.

Neonatal Mortality Rate: The ratio of neonatal (under 28 days of age) deaths registered in a given yearto the total number of live births registered in the same year, usually expressed as a rate per 1000 livebirths.

Post-neonatal Mortality Rate: The ratio of post-neonatal (from 29 days to under one year of age) deathsregistered in a given year to the total number of live births registered in the same year, usually expressedas a rate per 1000 live births.

Child Death Rate: The number of deaths of children aged one to four years (before completion of the 5thbirthday) per 1000 children of same age group.

Under-Five Mortality: Number of deaths under the age of five years per 1000 live births.

Crude Death Rate: Number of deaths per 1000 population per year in given community.

Violence: Use of physical force with the intent of causing injury or death.

Drowning: Death due to asphyxia (lack of oxygen reaching the body tissues) caused by immersion influid, usually water.

Near-drowning: Near-drowning is the term for survival after suffocation caused by submersion in wateror another fluid. Some experts exclude cases of temporary survival that end in death within 24 hoursfrom this definition; these they prefer to classify as drowning, or fatal near-drowning.

Suicide: The termination of an individual's life resulting directly or indirectly from an act of the victimthemselves which they know will produce this fatal result.

Attempted Suicide: The term "attempted suicide", in its broadest sense, refers to actions taken by anindividual with the intention of self-destruction but which are not fatal.

Upazila: Sub district.

Union: Lowest administrative unit at rural area. Several unions constitute one upazila.

Ward: Lowest administrative unit at urban area. Each ward consists of several mohallas.

165Appendix A

Appendix A

List of Tables Page

Mortality Overview

Table 3.1 Ratio of deaths by category in Bangladesh 25Table 3.2 Estimated numbers of child deaths from injury in Bangladesh 29Table 3.3 Child mortality rates (per 100,000) and proportional mortality by cause and age 168Table 3.4 Leading causes of deaths in infants, rates (per 100,000) and propotions 168Table 3.5 Leading causes of deaths in children 1-4, rates (per 100,000) and proportions 169Table 3.6 Leading causes of deaths in children under five, rates (per 100,000) and proportions 169Table 3.7 Leading causes of deaths in children 5-9, rates (per 100,000) and proportions 170Table 3.8 Leading causes of deaths in children 10-14 years, rates (per 100,000) and proportions 170Table 3.9 Leading causes of deaths in children 15-17, rates (per 100,000) and proportions 171Table 3.10 Leading causes of deaths in children under 18, rates (per 100,000) and proportions 171Table 3. 11 Leading causes of death rates (per 100,000) in children 1-17 by sex 172Table 3. 12 Type-specific injury mortality rates (per 100,000) and propotions, infants 172Table 3. 13 Type-specific injury mortality rates (per 100,000) and propotions, children 1-4 172Table 3. 14 Type-specific injury mortality rates (per 100,000) and propotions, children 5-9 173Table 3. 15 Type-specific injury mortality rates (per 100,000) and propotions, children 10-14 173Table 3. 16 Type-specific injury mortality rates (per 100,000) and propotions, children 15-17 173Table 3.17 Type-specific injury rates (per 100,000), children 1-17 174

Morbidity Overview

Table 4.1 Ratio of morbidities by category in Bangladesh 35Table 4.2 Estimated number of permanently disabled infants and children due to injury 43Table 4.3 Estimated number of infants and children injured 43Table 4.4 Cause-specific morbidity rates(per 100,000) and proportions, all children 174Table 4.5 Leading causes of illness in infants, rates (per 100,000) and proportions 175Table 4.6 Leading causes of illness in children 1-4, rates (per 100,000) and proportions 175Table 4.7 Leading causes of illness in children 5-9, rates (per 100,000) and proportions 176Table 4.8 Leading causes of illness in children 10-14, rates (per 100,000) and proportions 176Table 4.9 Leading causes of illness in children 15-17, rates (per 100,000) and proportions 177Table 4.10 Leading causes of illness in children 1-17, rates (per 100,000) 177Table 4.11 Age and sex-specific injury morbidity rates (per 100,000) 178Table 4.12 Injury severity rates (per 100,000) and proportions by age 178Table 4.13 Injury severity rates (per 100,000), children 1-17 by sex 178Table 4.14 Specific non-fatal injury rates (per 100,000) and proportions, infants 179Table 4.15 Specific non-fatal injury rates (per 100,000) and proportions, children 1-4 179Table 4.16 Specific non-fatal injury rates (per 100,000) and proportions, children 5-9 180Table 4.17 Specific non-fatal injury rates (per 100,000) and proportions, children 10-14 180Table 4.18 Specific non-fatal injury rates (per 100,000) and proportions, children 15-17 181Table 4.19 Specific non-fatal injury rates (per 100,000), children 1-17 181Table 4.20 Permanent disability due to injury in children 1-4, rates (per 100,000) and proportions 182Table 4.21 Permanent disability due to injury in children 5-9, rates (per 100,000) and proportions 182Table 4.22 Permanent disability due to injury in children 10-14, rates (per 100,000) and proportions 182Table 4.23 Permanent disability due to injury in children 15-17, rates (per 100,000) and proportions 183Table 4.24 Permanent disability due to injury in children 1-17, rates (per 100,000) and proportions 183Table 4.25 Permanent disability rates (per 100,000) due to injury in children by age and sex 183

Drowning and Near-drowningTable 5.1 Association between socio-demographic factors and childhood drowning 49


Appendix B

List of Tables Page

Table 5.2 Association between environmental & caring factors and childhood drowning 54Table 5.3 Drowning rates (per 100,000) by age and sex 184Table 5.4 Drowning rates (per 100,000) and proportions by year of age 184Table. 5.5 Near drowning rates (per 100,000) and proportions by age 185Table 5.6 Drowning rates (per 100,000) among children, Urban and Rural 185

Transport InjuriesTable 6.1 Fatal RTA rates (per 100,000) by age and sex 186Table 6.2 Non-fatal RTA rates (per 100,000) by age and sex 186Table 6.3 Non-fatal RTA rates (per 100,000) by age and place of residence 186

Burn InjuryTable 7.1 Non- fatal burn injury rates (per 100,000) by age and sex 187Table 7.2 Non- fatal burn injury rates (per 100,000) by age and place of residence 187

Fall InjuryTable 8.1. Fatal fall injury rates (per 100,000) by age and sex 187Table 8.2. Nonfatal fall injury rates (per 100,000) by age and sex 188Table 8.3 Non-fatal fall injury rates (per 100,000) by age and place of residence 188Cut InjuryTable 9.1 Non-fatal cut injury rates (per 100,000) by age and sex 189Table 9.2 Non-fatal cut injury rates (per 100,000) by age and place of residence 189

Falling ObjectsTable 10.1 Non-fatal injury rates (per 100,000) caused by falling objects by age and sex 190Table 10.2 Non-fatal injury rates (per 100,000) caused by falling objects by age and place of residence 190

PoisoningTable 11.1 Non-fatal poisoning rates (per 100,000) by age and sex 190Table 11.2 Non-fatal poisoning rates (per 100,000) by age and place of residence 191

Animal InjuryTable 12.1 Fatal animal bite rates (per 100,000) by age and sex 191Table 12.2 Non-fatal injury rates (per 100,000) caused by animal by age and sex 191Table 12.3 Non-fatal injury rates (per100,000) caused by animal by age and place of residence 192

ElectrocutionTable 13.1 Non-fatal electrocution rates (per 100,000) by age and sex 192Table 13.2 Non-fatal electrocution rates (per 100,000) by age and place of residence 192

Machine InjuryTable 14.1 Non-fatal machine injury rates (per 100,000) by age and sex 193Table 14.2 Non-fatal machine injury rates (per 100,000) by age and place of residence 193

SuffocationTable 15.1 Suffocation fatality rates (per 100,000) by age and sex 193

Intentional InjuryTable 16.1 Intentionality of fatal injury rates (per 100,000) by age 194Table 16.2 Intentional fatal injury rates (per 100,000) by age 194Table 16.3 Fatal violence rates (per 100,000) by age 194Table 16.4 Non-fatal violence rates (per 100,000) by age and sex 194Table 16.5 Non-fatal violence rates (per 100,000) by age and place of residence 195Table 16.6 Suicide rates (per 100,000) by age and sex 195

Injury OrphanhoodTable 17.1 Leading causes of death rates (per 100,000) for mothers of children 0-17 195

167Appendix B


169Appendix B


171Appendix B


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175Appendix B


177Appendix B


179Appendix B


181Appendix B


183Appendix B


185Appendix B


187Appendix B


189Appendix B


191Appendix B


193Appendix B


195Appendix B


197Appendix c

Contributors

Research Team

Principal Investigators

AKM Fazlur Rahman, Associate Professor, Department of Epidemiology and Biostatistics, ICMH, Dhaka.

Aminur Rahman, Assistant Professor, Department of Epidemiology and Biostatistics, ICMH, Dhaka.

Co-investigators

Pravat Chandra Barua, Professor, Department of Community Medicine, Chittagong Medical College,Chittagong.

ARM Luthful Kabir, Professor, Department of Paediatrics, ICMH, Dhaka.

Research Associates

SM Saidur Rahman Mashreky, Assistant Professor, Centre for Medical Education, Dhaka.

Salim Mahmud Chowdhury, PhD Student, Karolinska Institutet, Stockholm, Sweden.

MS Giashuddin, Statistician, Department of Epidemiology and Biostatistics, ICMH, Dhaka.

Technical Advisors

Michael Linnan, Technical Director, TASC, Bangkok, Thailand.

Monjur Hossain, Project Officer, Health and Nutrition, UNICEF Bangladesh.

Shumona Shafinaz, Assistant Project Officer, Health and Nutrition, UNICEF Bangladesh.

Reviewers

Dr. A K M Shamsuddin, Director, Administraion, DGHS.

Dr. Mohd. Mahbubur Rahman, Director PHC & Line Director ESD, DGHS.

Dr. Md. Moazzam Hossain, Director, MIS, DGHS.

Dr. Alia Akhter Begum, Director, Homeo and Traditional Medicine, DGHS.

Dr. Md. Abdur Rashid, Director, Hospital & Clinics, DGHS.

Dr. Kaniz Fatema, Director, Planning and Research, DGHS.

Dr. Md. Mazharul Hoque, Professor, Civil Engineering, BUET and Director, ARC.

Prof. M Kabir, Professor, Department of Statistics, Jahangirnagar University, Dhaka.

Prof. Shafique Uddin Ahamed, Professor and Head of Neurosurgery Department, Dhaka Medical College.

Md. Nowsher Alam, Project Director, SVRS, Bangladesh Bureau of Statistics.

Mr. Muhammad Shuaib, Associate Professor, Institute of Statistical Research and Training, Dhaka University.

Dr. Zahidur Rahman, Assistant Professor, National Institute of Preventive & Social Medicine (NIPSOM).

Dr. Z M Zahurul Islam, Assistant Director, DGHS.

Dr. Md. Mossarof Hossain, Assistant Director, DGHS.


Appendix D

Dr. A T M Mustafa Kamal, Assistant Director, DGHS.

Dr. Md. Jahir Uddin, Assistant Director, DGHS.

Dr. Md. Siddiqur Rahman, Deputy Programme Manager, DGHS.

Dr. Taufiqur Rahman, Research Officer, DGHS.

Dr. Syed Azam Mohammad, Medical Officer, Planning, DGHS.

Dr. Md. Faruque Hossain, Medical Officer, DGHS.

Mr. Md. Didarul Alam, Assistant Programmer, ARC.

Dr. Salamat Khandker, Medical Officer, World Health Organization.

Dr. Shams El Arifeen, Head, Child Health Programme, ICDDR,B.

Dr. Lauren Blum, Social Scientist, ICDDR,B.

Dr. Rosella Morelli, Senior Project Coordinator, UNICEF Bangladesh.

Mr. James Jennings, Chief, Education, UNICEF Bangladesh.

Dr. Harriet Torlesse, Project Officer, Nutrition, UNICEF Bangladesh.

Dr. SM Asib Nasim, Project Officer, Health, UNICEF Bangladesh.

Dr. Nawshad Ahmed, Project Officer, Planning, Monitoring and Evaluation, UNICEF Bangladesh.

Ms. Birgitte Van Delft, Project Officer, Protection, UNICEF Bangladesh.

Mr. Jose Paulo Arujo, Project Officer, Protection, UNICEF Bangladesh.

Ms. A Laleh Ebrahimian, Project Officer, Protection, UNICEF Bangladesh.

Paediatricians of ICMH who analyzed the Verbal Autopsy and Verbal Diagnosis

Prof. ARM Luthful Kabir, Prof. Soofia Khatoon, Dr. Shafi Uddin Ahmed (Associate Professor), Dr. SMShahnawaz Bin Tabib (Associate Professor), Dr. Selim Ahmed (Assistant Professor), Dr. M QuamrulHassan (Assistant Professor), Dr. Md Al-Amin Mridha (Registrar), Dr. Wahida Khanam (Registrar), Dr.Nasima Akter (Registrar), Dr. Zahid Arefin (Registrar), Dr. M A Mannan (Registrar), Dr. Shahin Akter(Assistant Registrar).

Field Staff

Research Manager: Md. Sekander Ali

Supervisors: Md. Muklesur Rahman, Md. Salim Mia, Mahbubul Haque, Atiqul Haque Badal, Abu Hanif,Anwarul Haque, Abdul Motalib, Sharifur Rahman

Data Collectors: Borhan Uddin, Michale Barua, Nizam Uddin, Shekhar Kumar Shah Subra, KamalHossain, Md. Ashraf, Aminul Islam Babu, Ziaur Rahman, Alamgir Hossain, Mahfuz Ali, Rubel Quaium,Tozammel Haque, Shamim Mia, Mizanur Rahman, Jannatul Islam Ferdous, Omar Sharif, Golam Rahman,Md. Amin Ullah, Khan Ilias Ahamed, Yasir Arafat, Md. Maksudur Rahman, Nurullah, Huzzat Ullah, TopanChandra Misra, Md. Mahbubur Rahman, Anuj Kumar Barua, Ishak Ali khan, Abu Baker Siddique, Md.Kamruzzaman, Abdus Salam, Safait Hossain, Abdul Halim, Humayun Kabir, Taslima Akter, RezwanaNasrin, Maksuda Akter, Shahen Sultana, Shelly Sultana, Rumia Begum Ruma, Gulshan Ara Parvin Lima,Sharmin Sultana Laboni, Rabeya Khatun, Shahi Nazmun Nahar Neela, Sanjida Akter Khanom Polin, Salma

199Appendix D

Siddiq Ratna, Hamida Khanom, Shefali Akter Shefu, Habibunnahar, Marzia Khatun Nupur, Shaila AfrinMimi, Selina Akter, Shahela Khadaker, Rabina Parvin, Shirin Akter Swapna.


Conducted in collaboration with PIACT, Bangladesh

Photography

Shefali Akter Shetu, Abul Kashem, Hamida Akter Bristi, Iqbal Hossain, Pintu Sikder, Foysal AhmedDadon, Rabeya Sarkar Rima, Zohirul Shekh Falan, Rafanoor Akter Moly, Shopna Akter, Zakir Hossain/Outof Focus/DRIK/UNICEF.

Akash, Azizur Rahim Peu, Shehzad Noorani, Shafiqul Alam Kiron, Shumona Shafinaz/Unicef

Graphic Design

Dhrupadiemail: [email protected]


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Bangladesh Health and Injury Survey (BHIS)

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