Socio economic profiles of the injured children up to the age of five years and management approaches in a village of Bangladesh

Sayeed Mahmud1   ,  Abu Zafar Mahmudul Haq2  
1Associate Professor & Head, Department of Community Medicine, Chittagong Medical College,
 Chittagong, Bangladesh
           2Associate Professor, Department of Business Administration, City University, Dhaka, Bangladesh
injured children

Abstract
This study was a descriptive type of cross sectional study with a sample size of 162. The selected samples were children up to the age of five years. Sample and selected sites of the study were done purposively. Data were collected with the help of pre structured questionnaires through direct interviews. Interviews were conducted among the mothers, fathers, grandparents or any other superiors of the selected children. Techniques of analyses were frequency and percentage. Many outcomes and suggestions were derived from the study.
Keywords
Bangladesh, children up to 5 years, injury, village
  1. Introduction
Childhood injury is a growing global public health problem that requires urgent attention. Injury and violence are major killers of children throughout the world, responsible for 9,50,000 deaths in children each year. (WHO 2004).
Child development and behavior is highly associated with particular injuries. For example, poising is linked to grasping and drinking behavior of children aged 1-3 years while falls are related to the stage of learning to walk between 9-18 months (UNICEF 2008).
The burden of injury is greater on children of low income families as those children are less likely to get benefit from the protective measures whereas others may receive. Rate of death due to injury is 3-4 times higher in low income and middle income countries than in high income countries (WHO 2004).
In Bangladesh the number of injury related child death each year 30,200 and number of permanent disabilities in children caused by injury each year 13,134 (UNICEF 2008). Those children who survive injuries are burdened with disability and free an uncertain future. These children are likely to become trapped in poverty as they are often devoid of adequate treatment, education, protection and lack of physical capacity to cope with the unexpected and challenging environment (ibid).
Management approach following injury and health seeking behavior has great impact on morbidity and mortality rate of the children due to injury. Lack of supervision and required skill are main reasons behind childhood injuries. Parents and care giver often pre occupied or unable to take proper care of children due to poverty. This aggravated by low awareness of risks, hazards and children’s vulnerability. Lack of knowledge about first aid and different social and cultural belief about the treatment procedure later on gives rise to complication following injury.
Several studies have been done from the various dimensions. Study of Agran et al (2003) showed poising injury started to rise at the age of  9 month, continuing up to 21-23 months and then declined. Burns from hot liquids were substantially higher among those aged 12-18 months. The small structure of children increases their risk in road environment. They are less visible than adults and if hit by a vehicle, they are more likely than an adult to sustain a head or neck injury (Wilson 1991). It is also found that small children have difficulty injury over vehicles, judging the speed of oncoming vehicles and discerning the distance of vehicles from the sound of its engine (WHO 2007).
Unless injury prevention is included in different programs such as breastfeeding, growth monitoring, immunization and older rehydration therapy as these children grow up and are subjected to injuries, the impact of the large investments in immunization, nutrition and maternal and child health care may be lost (Linnan et al 2007).
It is reported that burden of injuries in five Asian countries including Bangladesh and finds that injuries cause over a third (36.6%) of deaths of children aged 1-4 years while the number of deaths in more among young age groups, the proportion of injury deaths increases with age in all the countries surveyed (ibid).
Another study (Rahman et al 2005) mentioned that twenty nine percent injury causing mortality is between 1-4 year old deaths. Drowning was the leading cause (80.3/100000) of injury death in 1-4 year old children. Almost 17000 children drown each year, roughly 46 per day. Drowning rates in Bangladesh are 10-20 times higher than the rates of child drowning in developed countries. It is accounted for more than 90% fatal injuries in this age group. In children aged 1-4 years and 5-9 years old, the rate of fatal RTA was higher among females than males. In children aged 10-14 years, fatal RTA was higher among males (11.6/100000) than females (3.9/100000). The highest non fatal burn rate (782.1/100000) was among children 1-4 years old. The fatal injury was significantly higher in female infants than in male infants.
Study of Puspa et al. (2015)  aimed to describe the epidemiology of unintentional injuries in children, explore risk factors and estimate the burden faced by families and the community in the Makwanpur district. It conducted a household survey in Makwanpur, covering 3441 households. Injuries that occurred during the 12 months before the survey and required treatment or caused the child to be unable to take part in usual activities for three or more days were included. The study identified 193 cases of non-fatal unintentional child injuries from 181 households and estimated an annual rate of non-fatal injuries of 24.6/1000 children; rates for boys were double (32.7/1000) that for girls (16.8/1000). The rates were higher among the children of age groups 1–4 years and 5–9 years. Falls were the most common cause of non-fatal child injuries followed by burns in preschool children and road traffic injuries were the most likely cause in adolescence. Mean period of disability following injury was 25 days. The rates and the mechanisms of injury vary by age and gender. Falls and burns are currently the most common mechanisms of injury amongst young children around rural homes.
Accordong to Borse et al. (2008), childhood injury report for children less than one year old age, two thirds of injury deaths were due to suffocation in USA. Drowning was the leading cause injury death for those 1-4 years of age, falls accounted for over 50% of non fatal injuries. Rate for fires or burns and drowning were the highest for children 4 years and younger.
Unintentional injuries are the leading cause of death among Florida residents ages 1-44. Florida’s age adjusted injuries death rates were higher than in the national average. It is reported that a staggering 200.4 percent for unintentional drowning among children ages 1-4 (Florida’s need for injury prevention, 2013).
It also reported that motors vehicle crashes are a leading cause of unintentional injury death and hospitalization among children ages 0-14(Washington state child occupant safety policy and systems strategies, 2012-2016)
Results from two school based health surveys of 6-17 year old children in Sweden examined correlations between ADHD and ASD and injury risk in Sweden children. It found evidence of increased risks in children with ADHD but those with ASD (Carld B et al. 2016).
Another study was to identify the risk factors for pediatric injury within a rural Roma community in Cluj county, Romania. The main hazards identified in the community were burn risks due to unprotected and accessible metal stoves, CO intoxications due to inadequate heating systems, fire and electric shocks due to lose electric wires, cuts and puncture wounds due to unsupervised tools and metal garbage, bite wounds from stray dogs, as well as road traffic injuries (LUMINITA-Rural risk assessment: child injury in a Roma community 2009-2010).
  1. Objective and Methodology
The objective of the study was to examine the socio economic profiles of the injured children up to the age of five years and management approaches which are followed by their respective guardians. Selection of the children (162) and Gorduara village of Hathazari sub district in the Chittagong district of Bangladesh were done purposively. Data were collected with the help of pre structured questionnaires through interviews. Interviews were conducted upon the respective guardians of the selected children such as mother or father or grandparents. Analysis was done through percentage and frequency. The survey period was 2013-2014.
  1. Results and Discussion
From the study it has been found that most of the respondents (50%) were between 26-35 years age group and 43.21% were between 15-25 years age group. It also found that some respondents (4.32%) were between 36-45 years age group and some were in the 46-55 years age group.
Among the total respondents’, 91.97% were housewives, 3.08% were service holders, 1.85% were small traders and 3.10% were tailors. In relation to marital status of the respondents, 98.77% were married and 1.23% was widows.
Regarding gender of the respondents, most of them (93.21%) were females and rest (6.79%) were males. From the study it was found, most of the respondents (40.13%) were educated up to secondary level, 35.8% were SSC pass, 8.64% were primary pass, 8.02% were HSC pass, 1.23% were able to put signature only and 3.71% were illiterate. Among the respondents, some (2.47%) were graduate respondents also. So it can be said, that educational status of the respondents was satisfactory (Table 1).
The study revealed that most of the respondents (46.91%) were belong to nuclear, 43.21% were from joint family and 9.88% respondents were belong to extended family. In relation to number of family members (Table 2), most of the families were consisted of 5-7 members which was 40-74%, families consisting of 2-4 and 8-10 members were 32.1% and 21.60% respectively, only 5.55% families had more than 10 members. It implies that, most of the respondents were conscious enough to keep their family small. From the study, it was found that most of the respondents (90.13%) were mother of the children and 5.55% respondents were father of the children while rest of the respondents were aunt and grandparents of the children also.
Regarding the socio-economic status of the respondents, the study reveals that 57.4% of the respondents’ were from upper middle class family, 29.63% belong to lower middle class family while 9.87% were from upper class family. Only a small portion (3.09%) was of lower class family. In this study, it is found that most of the families of Gorduara village had semi brick made houses and well sanitary system.
In relation to age of children, most of the children (26.98%) were in between 2-3 years age group and 21.16% were in between 1-2 years age group. It is found that 12.7%, 19.58% and 19.58% children were in between 0-1, 3-4 and 4-5 years respectively (Table 3). Regarding the gender of the children, male and female were 53.97% and 46.03% respectively.
From the study, it revealed that 51.85% children faced injury before the survey year and most of the injury occurred (60.2%) about 1-12 months back, 25.51% injury occurred 1-7 days back and 14.29% gives history of concurrencies of injury 1-4 weeks back (Table 4).
In relation to type of injury, it was found that most of the children (48.98%) were injured due to falls. Uneven brick or muddy floor at different levels lead to many falls. The second most leading type of injury was due to hit by others whereas 6.12% were injured by drowning and 4.08% faced thermal injury. Trapping of foreign particles in the nasal cavity had been found in 3.06% children and 2.04% children swelled unusual substances (Table 5).
The study revealed that 55.1% injury occurred inside house and 44.96% happened outside yard, playground and school street. Various patterns of injury were disclosed by the study. In most of the cases after affect of the injury was swelling (20.41%), followed by bleeding (20.4%), 18.37% of laceration, 16.33% had bruise and 7.14% complains of fracture. Some (4.08%) mentioned about discoloration also. The respondents mentioned about some other effects also which were 6.12% (Table 6).
It is found that 71.43% of the injured children were provided with first aid treatment. It is really satisfactory and praiseworthy in such a village. It implies the consciousness of the respondents regarding their children. Among 71.43% children (Table 7), who received first aid treatment, majority of the children (88.57%) got first aid treatment at home. Some (9.29%) were instantly treated at the place of incidence.
It was found that, 51.02% of the injured children were not given any further treatment and 48.98% of the injured children were lucky enough to get further treatment.
It is appreciating that most of the children (79.17%) were given modern medical treatment, 6.25% went to kabiraj and 14.58% mentioned about other medication. It reflects the belief of villagers on modern medical science (Table 8).
In majority of cases (52.62%) the children received medical treatment from private chambers which reflects their consciousness, 28.95% went to sub district health complex and 7.89% got treatment from union health complex.  Some children received (2.63%) treatment from community clinic, 5.27% mentioned about district hospital and 2.63% went to private hospitals (Table 9). It is encouraging that 73.68% of the injured children, who had received medical treatment, went to follow up care. But 26.32% were not interested to go for further check up.
In majority of cases (95.92%), there was no complication following injury. Only a few children (4.08%) faced complications like diarrhea, fever, pain, swelling around the injured area.
It was found that most of the cases (60.49%) mother was the decision maker about the treatment procedure of the children. In some cases (30.25%), decision was taken by father. Grandparents were also took decision in 7.41% cases and 1.85% cases decision was taken by others. It is found that most of the respondents (95.68%) did not have any hesitation in hospitalization, taking drugs or injections. It must say that it is a milestone for the village people. Only 4.32% had hesitation; reasons were due to expenses (57.14%) and other (57.14%) and other belief (42.86%).
Majority of the respondents (50.62%) usually preferred to go to sub district health complex in case of accidental injury, 20.37% mentioned about private chamber, 11.73% went to union health center and 10.49% told about community clinic. Some (6.79%) went to private hospital also (Table 10). For most of the respondents (65.43%), nearest health service center was community clinic. Some of the respondents (22.23%) mentioned that doctors private chamber was nearer to them and 10.49% told about institutional health nearer to them(Table 11).
In most of the cases (77.16%), there was first aid arrangement at home. It implies the changing pattern in management approach at the village that they are becoming more conscious day by day. Regarding usual child care provider, most of the respondents (95.68%) mentioned that the children were mainly looked after by mother herself. In 2.47% cases, grandparents played role bringing up the children (Table 12).
In 94.44% cases, sharp cutting weapons like scissors, knife, blade, and axe, were kept away from children. But 5.56% were not aware of keeping these things out of reach of the children.
In relation to EPI schedule, 96.91% had knowledge about it while 63.58% had completed EPI schedule and it is ongoing 31.48% and it did not participate 4.94%. The study revealed that BMI of most of the children (61.9%) were below average. 31.75% children were in between 18.5- 24.9 which was normal and 6.35% children had BMI between 25-29.9% which is more than normal range.
  1. Recommendations
  1. Child health programs can no longer be considered complete without injury prevention efforts at the core.
  2. All children of fewer than five must be considered at risk of injury and targeted for prevention based intervention.
  3. Better information can be achieved if survey is performed with enough time and vast aspect.
  4. Parents should be guided properly so that they may be aware of child injury and prevention.
  5. Parents should be introduced properly with appropriate treatment procedure of child injury. Frequent health related programs can be launched in this regard.
  1. Conclusion
It has been noted that a gradual shift in the cause of child death in Bangladesh from largely infectious disease to largely non communicable diseases and injury. Half of this affected population is under five years of age. According to the study, 51.85% of children had injury history during the previous year of survey and 48.15% of children had no history of injury during the same period of duration. Among the injury patterns the highest incidence was fall which was 48.98%.
Child health is public health as well social penance in Bangladesh. It is a significant cause of morbidity. Although most of the injuries can be prevented if proper preventive strategy is adopted farm all concerned. This involves proper identifications of risk group and risk factors as well as the context in which the injury occurs and the mechanism by which injury takes place.
References
  1. Agran, P.F.(2003). Rates of pediatric injuries by 3 month intervals for children 0-3 years of age. Pediatics.111: 683-692.
  2. Borse,N. N and Gilchrist,J. (2008). Patterns of unintentional injuries among 0-19 years olds in the U.S.A. CDC childhood injury report, 2000-2006.
  3. Carld B., Linda B., Staffan J.,Carotina J. (2016). Injury risk in schoolchildren with attention –deficit/hyperactivity or autism spectrum disorder: results from two school based health surveys of 6-17 year old children in Sweden. Journal of safety Research.58:49-56. September. doi:10.1016/j.jsr.2016.06.004.
  4. Fazlur,R. and Aminur,R.(2005). Bangladesh health and injury survey report on children. January 9.
  5. Florida’s need for injury prevention (2013) in http://www.floridahealth.gov/programs-and -services/prevention/inju...(Accessed August 8, 2016).
  6. ICDDRB (2000). Health and demographic suirvillance system, MATLAB. Registration of health and demographic events. Vol.33.
  7. LUMINITA-Rural risk assessment: child inmjury in a Roma Community 2009-2010 in http://publichealth.ro/index.php/luminita-rural-risk-assessment-child-injury-in-a-roma-community-2009-2010/. (Accessed, August 8, 2016).
  8. Linnan,M., Morten,G. and Rose,C.(2007). Child mortality and injury in Asia: policy and program implications. Innocenti working paper. No. 4. Florence. UNICEF Innocenti Research center.
  9. Linnan,M, Morten, G and Rose,C. (2007). Child mortality and inmjuryin Asia: an overview, Innocenti working paper. No.1. Florenece. UNICEF Innocenti Research Center.
  10. Puspa, R.P, Elizabeth,T., Mathew,E.,Dharma M, Paul P., and Julie M. (2015). Epidemiology of unintentional child injuries in the Makwanpur district of Nepal: a household survey. International Journal of Environmental Research and Public Health. 12:15118-15128; doi 10, 3390/ijerph 121214967.
  11. UNICEF. (2008). World report on child injury prevention.
  12. WHO. (2004). Global burden of disease. Health statistics and informatics in the information, evidence and research cluster.
  13. WHO. (2007). Youth and safety. Geneva, Switzerland.
  14. Wilson,M. (1991). Saving children: a guide to injury prevention. NY. Oxford University Press.
  15. Washington State child occupant safety policy and systems strategies 2012-2016 in www.doh.wa.gov/portals/1/documents/pubs/971005.pdf. Accessed, August 7, 2016.
Appendix
Table 1 Educational status of respondents
Educational StatusFrequency
Illiterate6(3.71%)
Eligible for signing2(1.23%)
Primary14(8.64%)
Secondary45(40.13%)
S.S.C58 (35.80%)
H.S.C13(8.02%)
Graduate and above4(2.47%)
Total162(100%)
Table 2 Number of family members
Groups of family membersFrequency
2--452(32.10%)
5-766(40.74%)
8-1035(21.60%)
10 and above9(5.56%)
Total162(100%)
Table 3 Age of children
Age groupsFrequency
0-121(12.7%)
1-235(21.16%)
2-344(26.98%)
3-431(19.58%)
4-531(19.58%)
Total162(100%)
Table 4 Time of injury prior to survey period
TimeFrequency
1-<7 days25(25.51%)
1-<4 weeks14(14.29%)
1-12 months59(60.20%)
Total98(100%)
Table 5 Injury type
Type of injuryFrequency
Falls48(48.98%)
Thermal injury4(4.08%)
Drownong6(6.12%)
RTA0(0.0%)
Injury by any instrument15(15.31%)
Electrocution0(0.0%)
Trapping of foreign particle in the nasal cavity3(3.06%)
Swallowing of unusual substances2(2.04%)
Injury due to hit by others9(9.18%)
Injury by animals1(1.02%)
Any accidental poisoning0(0.0%)
Others10(10.21%)
Total98(100%)
Table 6 Pattern of injury
Name of injuryFrequency
Bruise16(16.33%)
Abortion/Laceration18(18.37%)
Fracture7(7.14%)
Discoloration4(4.08%)
Bleeding20(20.41%)
Swelling23(23.47%)
Burn4(4.08%)
Suffocation0(0.0%)
Poisoning0(0.0%)
Others6(6.12%)
Total98(100%)
Table 7 Place of first aid provision
NameFrequency
Home62(88.57%)
Place of incidence3(4.24%)
Others5(7.14%)
Total70(100%)
Table 8 Medication type
NameFrequency
Medical38(79.17%)
Kabiraj3(6.25%)
Herbal/Ayurveda0(0.0%)
Homepathy0(0.0%)
Others7(14.58%)
Total48(100%)
Table 9  Place of medication immediately after incidence
NameFrequency
Community clinic1(2.63%)
Upazilla health complex11(28.95%)
Private chamber20(52.63%)
Union health center3(7.89%)
Private hospital1(2.63%)
District hospital2(5.27%)
Total38(100)
Table 10 Preference of treatment site
NameFrequency
Community clinic17(10.49%)
Upazila health complex82(56.62%)
Private chamber33(20.37%)
Union health center19(11.73%)
Private hospital11(6.74%)
District0(0.0%)
Total162(100%)
Table 11 Nearest health service center
NameFrequency
Community clinic106(65.43%)
Institutional health center17(10.45%)
Private chamber of doctor36(22.23%)
Traditional health center0(0.0%)
Private hospital3(1.85%)
Government hospital0(0.0%)
Others0(0.0%)
Total162(100%)
Table 12 Usual child care provider
NameFrequency
Mothers’ herself155(95.68%)
Siblings0(0.0%)
Grandparents4(2.47%)
Others3(1.85%)
Total162(100%)
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