Injury is a threat to health in every country in theworld (The Melbourne Declaration, 1996). Atleast 3.5 million people die from injuries around
Fazlur Rahman, MBBS, MPhil (PSM), is Assistant Pro-fessor at the Department of Epidemiology and Biostatistics,Institute of Child and Mother Health, Dhaka, Bangladesh; andGuest Researcher and PhD student at the Department of Pub-lic Health Sciences, Unit of Social Medicine, Karolinska In-stitute in Sweden.
Ragnar Andersson, M.Eng., PhD, is Injury Program Di-rector and Head of the Safety Promotion Unit at the Stock-
holm County Council and the Department of Public HealthSciences, Unit of Social Medicine at the Karolinska Institute.
Leif Svanström, MD, PhD, is Professor and Chairman ofthe Department of Public Health Sciences, Unit of SocialMedicine, and Chairman of the WHO Collaborating Centeron Community Safety Promotion at the Karolinska Institute inSweden.
the world each year, including more than 2 mil-lion in developing countries (World Health Orga-nization [WHO], 1993). Globally, about half ofall deaths in the age group 10 to 24 years are dueto injuries, intentional and unintentional (Freid-man, 1985). For all ages, injury is responsible for7% of world mortality and accounts for 10% to30% of all hospital admissions (Manciaux &
214 Journal of Safety Research
Romer, 1986; The Melbourne Declaration,1996). In addition, in many developing countries,injuries are rapidly becoming one of the leadingcauses of death and disability (Smith & Barss,1991). In India, the number of annual injurydeaths has been estimated to range from 130,000to 650,000, and 15% of all hospital beds are oc-cupied by injury victims (Mohan, 1984). A moredisastrous picture is found in Thailand. In 1983,nearly 2 million injured people were treated inhospitals, with 31,000 deaths, and 31% of hospi-tal beds outside Bangkok were occupied by in-jury patients (WHO, 1987). In Africa, it has beenestimated that about 100 deaths per 100,000 pop-ulation occur due to injuries each year (Nord-berg, 1994). The picture of injury in Latin Amer-ica is almost the same. Injuries are the leadingcause of death and morbidity in the middle of theage spectrum (from 5 to 35 years), and the inci-dence of specific injuries such as motor vehicleand occupational injuries is much higher in somedeveloping countries (The Melbourne Declara-tion, 1996). Injuries will assume an even higherproportion of total deaths and disability in devel-oping countries in the future (WHO, 1996). Eco-nomic development, safe water supply, and vac-cination programs reduce deaths from diarrhealdiseases, viral diseases, acute respiratory infec-tion, and nutritional deficiencies. Even if their in-cidence rate does not change, injuries will emergeas a leading cause of death (Baker, O’Neill, &Ginsberg, 1992). In addition to the decline ofcompeting illness, major factors leading to in-creased injuries include urbanization, industrial-ization, and motorization of developing coun-tries. Besides all of these, poverty has a profoundinfluence on all types of injury, and the great ma-jority of people in developing countries live inextreme poverty (Berger & Mohan, 1996).
Injuries in Bangladesh
Injuries are causing great concern to the commu-nity in Bangladesh. According to the official sta-tistics, there were at least 2,320 fatalities and4,510 injuries in 4,010 reported road trafficcrashes in 1992 (Bangladesh Bureau of Statistics,1994). In addition to road traffic accidents, vio-lence, homicide, suicide, drowning, and other typesof injuries have been increasing in Bangladesh,and ultimately the frequency of casualty inci-dence will increase enormously over the courseof time (Hossain, Kamal, Chakraborty, & Ziaud-
din, 1991). A study by Fauvean et al. (1989) foundthat 19.3% of deaths of women aged 15 to 24years were caused by injuries in the rural area ofBangladesh. From a hospital-based study, it hasalso been found that about half (49.8%) of allsurgical beds of a district hospital were occupiedby injury patients (Aditya, 1989). Another reportfrom the orthopedic hospital of Bangladeshshows that 56.3% of all emergency patients wereroad traffic accident victims, followed by fall vic-tims (29.5%; Haque, 1995). Road accident fatali-ties expressed in deaths per 10,000 vehicles aremuch higher in Bangladesh, where there were16.9 deaths per 10,000 vehicles, compared with,for example, Norway’s 2 deaths per 10,000 vehi-cles (Lundebye, 1995) and the United States’s2.3 deaths per 10,000 vehicles (Bureau of theCensus, 1994).
Injury Information in Developing Countries
Valid data on injuries are necessary to assess thenature and extent of injuries in a population, toidentify groups that are most at risk for specificinjuries, and to establish priorities for interven-tion and for the allocation of appropriate re-sources for the injury control program (Berger &Mohan, 1996). In developed countries, epidemio-logical studies have begun to identify the causesand means of prevention of injuries (Smith &Falk, 1987; National Committee for Injury Pre-vention and Control, 1989), but unfortunately,much less is known about the incidence and thecause of injury in developing countries, or aboutthe groups at high risk for injury in those coun-tries. Smith and Barss (1991) reviewed a numberof studies about the injury data from developingcountries and found only two countries from Asiaand two from Africa that reported injury data tothe WHO over the 10-year period ending in1987. So, valid, up-to-date and prevention-ori-ented data on the incidence of injury are lackingin developing countries.
In Bangladesh, injury information is not avail-able in any organized form. The severity of dataconstraints is particularly highlighted in the re-cent International Seminar on Road Safety (Tho-mas, 1995) held in Dhaka. Widespread under-reporting of injuries prevents the real magnitudeof the injury problem from being known. Hospitalsurveys indicate that the number of road accidentcasualties may be several times greater than thatreported to the police (Hoque, 1995).
Winter 1998/Volume 29/Number 4 215
Due to the lack of valid data, the objective ofthis study is to assess injury morbidity and mor-tality in a local community of Bangladesh.
MATERIALS AND METHODS
Study Area and Study Population
The study was undertaken in the Sherpur SaderThana of Bangladesh. This region contains bothurban and rural areas, is situated in the northernpart of the country, about 200 kilometers fromthe capital, Dhaka, and has a total population of381,419 (Bangladesh Population Census, 1991).All individuals living in the area during the studyperiod comprised the study population. From atotal of 180 rural villages and 42 municipalityblocks in the area, nine rural villages and twomunicipality blocks were selected by randomsampling for data collection. Heads of all house-holds in the selected areas were interviewed.When the head of the household was not avail-able, the next responsible person was taken as in-terviewee. Cases were included in the studywhen an injury occurred within 15 days preced-ing the date of interview. Data regarding injurydeaths were collected for the past five years.
Questionnaires
Three structured and standardized questionnaireswere used for data collection. The questionnaireswere developed in the Karolinska Institute, De-partment of Public Health and Sciences. Ques-tionnaire 1 was a screening form used to identifywhether there had been any eligible cases ordeaths in the households. If so, Questionnaire 2was used for each case; for each death, Question-naire 3 was completed. Age and sex characteris-tics of all household members were also enteredonto Questionnaire 1. Questionnaire 2 coveredsociodemographic characteristics of the head ofthe household, the site at which the injury oc-curred, and a description of the injury. Question-naire 3 was used to collect information about in-jury deaths, including treatment prior to deathand the postmortem history.
Data Collection
For data collection, five data collectors were se-lected from the existing field-level health staffs.Data collection was adapted to their usual activi-
ties. One supervisor was selected from the doc-tors of the hospital. Five days of extensive train-ing was conducted, including both conceptualand practical matters. A field test of the question-naires was also aimed at testing the data collec-tors’ performance. A manual for the data collec-tors was developed.
Quality Control
From the development of data collection instru-ment to the analysis of data, a quality control sys-tem was followed that included the selection ofefficient data collectors and their training, exten-sive supervision, and consultation with orthope-dic surgeons. Four percent of the questionnairesfilled out were repeated by the first author tomeasure reliability. For the deaths and severemorbidity cases, the information collected wasreliable, but for the minor injuries, 12.5% weremisclassified.
Definitions
Injury.
Injuries are caused by acute exposure to phys-ical agents such as mechanical energy, heat, elec-tricity, chemicals, and ionizing radiation interact-ing with the body in amounts or at rates thatexceed the threshold of human tolerance. Insome cases (e.g., drowning and frostbite), inju-ries result from sudden lack of essential agentssuch as oxygen or heat (Baker et al., 1992). Aninjury was included in the study when it was seri-ous enough to warrant medical treatment or to al-ter “normal” activity for one or more days.
Severity of injury.
The Abbreviated Injury Scale (AIS; Commit-tee on Injury Scaling, 1985) was used in thestudy. Descriptions of the injuries were writteninto the questionnaire by the interviewers in locallanguages and then the researcher consulted anorthopedic surgeon to determine the severity ofinjury.
Mortality.
Injury deaths were registered when the deathoccurred within 30 days of injury. Mortality in-formation was collected for the past five years.The verbal autopsy method (Kakrani, Pratinidhi,& Gupte, 1996; Nykanen, Tamaona, Cullinan,Van Oosterzee, & Ashorn, 1995; Snow et al.,1992) was used for diagnosis of injury.
216 Journal of Safety Research
Analysis.
Data were analyzed using Epi Info (Center forDisease Control, 1995). Deriving incidence ratesrequires the annual number of cases of injury.For each age and sex category, the number ofcases was divided by the sampling days (15days) on which those cases had been found, andthe quotient multiplied by 365 (Brown & Nell,1991). The demographic data of the 1991 censuswas used to calculate the 95% confidence inter-val for each estimated annual incidence rate.
RESULTS
A total of 3,258 households with a population of14,922 were surveyed. In these households, 18injury deaths were documented in 5 years, and191 injury cases were diagnosed during the 15days prior to interview. A total of 1,450 morbid-ity cases occurred during the 15-day period, andthe total number of deaths recorded was 617 in 5years. The estimated total mortality rate is 8.2%,and the morbidity rate is 262 per 100 person-years. Injuries accounted for 13% of the totalmorbidity, and proportional mortality for injurieswas 2.9%.
Population Characteristics
The majority (51.5%) of the population were young(0–19 years), and the mean age was 23.2
6
17.4years. There were 104 males for every 100 females.The average household size was 4.6
6
1.8.
Injury Morbidity
The crude morbidity from injury was estimatedat 311 per 1,000 population per year. Males had a
greater injury rate than females, sustaining 73.8%of all injuries. The overall ratio of male to femaleinjury rates was 2.82:1. The age- and sex-specificestimated injury incidence rate is shown in Table1. Children and the elderly experienced higherinjury rates than others, and male children in theage group 5–14 years had the highest incidencerates. Females in the 15-to-34-year age grouphad the lowest incidence rate of injuries. Fallsand cutting injuries (62% of all injuries) tendedto be the most frequently observed types of inju-ries among the victims in this survey (Figure 1).The home and workplace were the sites of mostof the injuries (Figure 2), and the majority (70%)of nonfatal injuries posed a minor threat to life,27% posed a moderate threat, and 3% posed a se-rious to critical threat.
Causes of Injury by Age
For all ages combined, falls were the most com-mon causes of injury, followed by cutting andcrushing injuries and being struck by other ob-jects. Among children 0–14 years old and theelderly, falls were the main cause of injury, but inolder children and the middle-aged group, cut-ting and crushing injuries were more salient (Ta-ble 2). Cutting fingers was more common whenperforming agricultural work. It is important tonote that burns were the most common cause ofinjury in younger children (0–4 years). The ma-jority (55.7%) of the falls caused moderate inju-ries, but more severe or serious injuries were at-tributed to hits by contact with other objects. Nosevere or serious burn cases were identified, andonly 10% of the burn cases were moderate in se-verity (Figure 3). Most of the injuries in the agegroup 0–14 years and in the older age groups oc-curred in the home and leisure area. Workplaces
Table 1.
Estimated Injury Incidence Rate in Sherpur Sader Thana of Bangladesh during 1996, by Age andSex, and CI
No. of Injury Cases Incidence Rate per 1,000 Person-Years (95% CI)
were the common site of injury among the olderchildren and middle-aged group (Figure 4).
Injury Deaths
Only 18 deaths from injuries were registered thatoccurred five years before the interview. It hasbeen estimated that the overall number of deathsfrom injury was 24 per 100,000 population peryear. Annual injury death rates were 37 per100,000 among men, and 11 per 100,000 amongwomen. Age-specific estimates of injury deathsper 100,000 person-years are shown in Table 3.Drowning and homicides were recorded as the mostcommon causes of fatal injury (Table 4).
DISCUSSION
Methodology
Methodological problems in the epidemiologicalstudy of injuries are numerous (Cummings,Koepsell, & Mueller, 1995; Tursz, 1986). Injuryresearch is usually limited to the “tip of the ice-berg,” that is, those injured persons who die orreceive medical care (Cummings et al., 1995).There are very few population-based epidemio-logical studies on injuries in developing coun-tries. Several hospital-based studies attempted todescribe the injury epidemiology in both devel-
oped and developing countries (Smith & Barss,1991). Hospital-based data for injury epidemiol-ogy may be acceptable for developed countries,since most of the injury cases seek medical carein hospitals, but in developing countries, injuredpeople are much less likely to go to the hospital(Berger & Mohan, 1996; Smith & Barss, 1991).Studying severe cases, such as hospital admis-sions and fatalities, does not provide an accurateview of the magnitude of the problem or of theetiological factors responsible for the vast num-ber of nonfatal injuries (Tiret, Garros, Maurette,Nicaud, Hatton, & Erny, 1989). As mentionedabove, mild injuries are usually studied by re-viewing medical or emergency room records in adefined group of hospitals or trauma centers for agiven period (Gallagher, Finison, Guyer, & Goode-nough, 1984; Gustaffsson, 1977; and Tiret et al.,1989). Although this approach is not subject torecall bias, it usually suffers from incomplete de-tails of the circumstances surrounding the injury.Further, the study population is not usually welldefined, because it is often not possible to iden-tify the catchment area of a particular hospital,and the hospital-based approach does not readilypermit comparisons of people with or withoutinjuries (Klauber, Barrett-Conner, Hofstetter, &Micik, 1986). Injuries that often result in imme-diate death, such as drowning, pesticide poison-ing, and homicide, will be underrepresented inhospital data (Berger & Mohan, 1996). On the
FIGURE 1 External causes of injury in Sherpur of Bangladesh.
FIGURE 2 Places of injury occurrence in Sherpur of Bangladesh.
218 Journal of Safety Research
other hand, a household survey would providepopulation-based injury incidence data and de-sired information on circumstances in a represen-tative sample (Bangdiwala et al., 1990). However,there is substantial potential for bias in householdsurveys due to unreliable memory, embarrass-ment regarding certain types of injury, and differ-ences among people in perception of seriousness.In a household survey, the sample size wouldhave to be huge to include a significant numberof deaths or serious injuries. Nevertheless, todescribe the injury epidemiology in a particularcommunity in developing countries, a householdsurvey is more representative than a hospital-basedstudy.
Validity of Data
Limitations.
Although a quality control system was fol-lowed from the planning phase to analysis of thefindings, including an initial training period fordata collectors, frequent problem solving meet-ings, the use of a manual, selected duplicate cod-ing by researchers, and manual scanning of allcompleted forms, the study does contain a num-ber of possible biases. First, the sample size wasnot large enough to include a significant numberof injury deaths and serious injuries. This ismainly due to time and logistical constraints,which is a common feature of population-based
Table 2.
External Causes of Injury in Sherpur Sader Thana of Bangladesh during 1996, by Age
FIGURE 3 External cause and severity of injury ( Minor; Moderate; Serious and severe).
Winter 1998/Volume 29/Number 4 219
surveys. Second, inclusion of some injury casesmay lead to overrepresentation due to inter-viewer bias, where special attention is paid tofinding injury cases. During pretesting of thequestionnaire, it was found that the illiterate vil-lagers did not consider a simple injury an illness,although they may have altered their normal ac-tivity because of it. So interviewers were advisedto inquire about injury cases in every householdby describing various types of injury. In this pro-cess, injury may be overrepresented compared toother types of morbidity. No doubt, almost all in-jury cases were included in the study, since veryfew did not meet the very flexible inclusion criteria.There was also some chance of overreporting dueto recall bias. The problem of recall bias has beenconsidered for a range of reported events (Alam,Henry, & Rahman, 1989; Hutty, Barros, Victoria,Beria, & Vaughan, 1990; Ross & Vaughan, 1986).However, Ross, Hutty, Dollimore, and Binka(1994) have suggested a two-week recall periodfor morbidity studies, and in this study, the recalltime used for considering injury cases was 15
days, which is acceptable. For the inclusion ofinjury deaths, information on all deaths was col-lected for the previous five years, which wassubjected to serious recall bias. But, in a Ban-gladeshi community, any deaths considered as amajor event in the village were well remembered(Fauvean et al., 1989). Again there is a generaltendency to conceal the real cause of death whenit is the result of complications from an inducedabortion or from violence. The deaths from in-duced abortion were not included as injurydeaths in this study. For maintaining the timeframe, when any injury case or death was re-ported, the interviewers were asked to find outthe exact date of occurrence by relating it to thetime of local events. Thirdly, the determinationof the mechanism and severity of injuries maynot be strictly maintained. The interviewers wereasked to record the details of the injuries in thelocal language on the questionnaire and from this
FIGURE 4 Age and place of injury ( Traffic area; Home/leisure; Work place; Others).
Table 3.
Age-Specific Injury Death Rate in SherpurSader Thana of Bangladesh during 1996
Age Group NInjury Deaths per
100,000 Person-Years
0–14 10 3015
1
8 19Total 18 24
Table 4.
Causes of Injury Deaths in Sherpur SaderThana of Bangladesh during 1996
description the researcher and an orthopedic sur-geon coded the mechanism and severity of injuryaccording to Nomesko (Swedish National Boardof Health and Welfare, 1989) classification andAIS (Committee on Injury Scaling, 1985), re-spectively. Thus, dependency on the descriptionof the interviewers may cause some error in thedetermination of the mechanism and severity ofinjury. The better method still seems to be tocode the injury mechanism and severity by thephysician after collection of data, rather than bythe interviewers (nonphysicians) during face-to-face household surveys on injuries.
Population statistics.
The age structure of the population in thisstudy is almost consistent with the figure fromthe 1991 national census (Bangladesh PopulationCensus, 1991), and the sex ratio of 104 found inthis study is also the same as the 1991 census.The fact that almost the same crude death rateper 1,000 population was found in this study asin the Bangladesh Health and Demographic Sur-vey (Bangladesh Bureau of Statistics, 1995) alsovalidates the data of this study.
Comparison of the Findings
There are very few population-based studies oninjuries in developing countries. However, it isworthwhile to mention the works of Bangdiwalain four Latin American countries in 1990(Bangdiwala et al., 1990); Gordon, Gualati, andWyon’s (1962) study in a local community in In-dia; studies conducted in Ghana by Mock et al.(1993, 1995, 1997); and a recent population-based cohort study conducted by Sathiyasekaran(1996) in India. There is also a number of studieson specific injuries in developing countries. Ad-amo et al. (1995) conducted a study on burns inAngola; van Geldermalsen (1993) worked inLesotho on assault injury; Gedlu (1994) studiedaccidental injury among children in Ethiopia; andCourtright, Haile, and Kohls (1993) conducted astudy on burns in Ethiopia. Wu and Malison(1990) studied motor vehicle injuries in Taiwan.
It is very difficult to compare the study resultswith other studies, since other studies often lacka defined risk population and their research isbased on hospital records; also, there is a widevariation in the socioeconomic status of the vari-ous study populations. In addition, different defi-
nitions of injury were used in various studies,which makes it difficult to compare rates be-tween countries (Smith & Barss, 1991). Never-theless, many findings are more or less similar tothose reported by previous studies concerning theexternal causes of injuries and the pattern of inci-dence by age and sex. Gordon, Gualati, andWyon (1962) found an incidence of injury of 116per 1,000 inhabitants per year in four villages inIndia in 1959, which is much smaller than thefinding of this study; this study estimated an inci-dence of injury of 311 per 1,000 population peryear, which is comparable to the rate of 328 per1,000 population in the United States (Robertson,1992). The community component of anotherstudy in Chile found injury incidence rates of303 per 1,000 population per year (Bangdiwalaet al., 1990). In the Northeastern Ohio TraumaStudy, Barancik and Chatterjee (1981) found aninjury incidence rate of 197 per 1,000 populationin 1977, and Gallagher et al. (1984) found an an-nual incidence rate of injury among Massachu-setts children and adolescents of 223.9 per 1,000inhabitants.
The study results confirmed the pattern of causeof injuries seen in studies in developed countries(Fife, Barancik, & Chatterjee, 1984; Gallagher etal., 1984; Langley & Silva, 1985; and Tiret et al.,1989) and suspected to apply to developing coun-tries as well. For example, falls are the mostcommon cause of injury in younger age groups,boys experience higher rate of injuries (Barancik& Chatterjee, 1981; Lindqvist, 1989; Schelp &Svanström, 1986), and the majority of the inju-ries took place at home (Gordon et al., 1962;Schelp & Svanström, 1986). Injury at the work-place that involved mainly cutting or crushingwas found more frequently in this study, whichmay be due to the fact that rural people of Bang-ladesh work in agriculture with unprotected con-ventional equipment. Interestingly, the very lowincidence of traffic injury in the study populationsupports the fact that rural people have very littleaccess to motorized vehicles.
This study had a limited ability to depict theinjury problem of the entire country. The only fo-cus was on injuries at the local level. In addition,it is beyond the scope of this study to specify de-tailed injury prevention or control strategies. In-stead, further investigations are planned on thisissue. Despite its limitations with regard to repre-sentativeness and an in-depth investigation, thisstudy constituted the first attempt to map out theinjury situation at the local level in Bangladesh.
Winter 1998/Volume 29/Number 4 221
CONCLUSION
Although the sample size was small, the study re-veals that injury is an important public healthproblem that accounts for an estimated 13% ofthe total morbidity and 2.9% of the total mortal-ity. Members of younger age groups are the mostcommon victims of injury, which is also a verystriking feature, since injury may cause disabilityfor life. This study is an attempt to highlight theextent of ill health due to injury in a developingcountry’s population. A more standardized ap-proach to collection and presentation of injurydata would make a growing body of epidemio-logical research considerably more useful in set-ting priorities for more detailed research and pol-icy recommendations.
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