Violence –related injuries in a rapidly developing Middle Eastern country: A Retrospective Study from a Level 1Trauma Center

doi:10.21203/rs.3.rs-15549/v1

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Violence –related injuries in a rapidly developing Middle Eastern country: A Retrospective Study from a Level 1Trauma Center

https://doi.org/10.21203/rs.3.rs-15549/v1

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Background Violence is a global public health problem leading to injuries, long-term physical, sexual or mental health problems and mortality. The burden of violence-related injuries remains understudied in the Arabian Gulf region. The present study aimed to describe the epidemiology of violence-related injuries in Qatar.

Methods A retrospective analysis of trauma registry data from a level 1 trauma center was conducted by including all patients presented to the hospital following violence-related injuries in the duration between June 2010 and June 2017.

Results The incidence rate of violence-related injuries was 4.6 per 100,000 population per year; significantly higher rate in males (5.5/100,000 males/year vs. 1.8/100,000 females/year) and in younger population, specifically in 25-34 years age-group (41%). South Asians (55%) were the principal victims. Interpersonal violence (IPV: 71%) was the major contributor. Three quarters of the pediatric injuries were caused by IPV and mortality was 8% which in fact was higher than the overall mortality. In-hospital mortality was 6.4%. Higher case fatality rate was reported in females (16% vs.5%, p=0.001).

Conclusions Although the rate of violence-related injuries in Qatar was low, its disproportionate burden in the South Asians and young population warrants an evidence-based public health approach in violence prevention that addressing the risk factors. In addition, its burden in the pediatric population is also alarming.

Health Economics & Outcomes Research

Health Policy

violence

trauma

mental health

mortality

Qatar

Violence-related injuries refer to injuries resulting from intentional use of physical force or power against oneself or others. The World Health Organization (WHO) defined violence broadly by incorporating self-directed violence; interpersonal violence (IPV) and collective violence leading to injury or has a high probability of contributing to injury, death, psychological harm, mal-development or deprivation [1]. Each year, over 1.6 million deaths worldwide are attributed to violence, and many are getting injured and/or suffering long-term physical, sexual or mental health problems [1].

The young age (15–44 years) and male gender (14% vs. 7%) are the prime victims of violence [2]. IPV remains as a major contributor to the violence-related mortality with a rate of 8.8 per 100,000 population [1]. Nearly 28 million deaths out of 50 million global deaths in 2013 were related to IPV whereas self-directed violence accounted for 1.7 million deaths [3]. IPV includes family and intimate partner violence (child, partner or elder) and community violence (stranger or acquaintance). Family violence taking place at home refers to domestic violence (DV) and its lifetime prevalence estimated in women was 28–54% [4, 5]. Prevalence of sexual abuse in children was reported as 3–40% [6, 7].

The burden of violence-related injuries in Western countries is well documented but it remains understudied in the Middle Eastern region, especially in the Arabian Gulf region. Addressing these gaps in knowledge is crucial to inform the decision makers which ultimately contribute to develop evidence based strategies and ultimately strengthen the capacity of health system to prevent injuries and violence. The present study was first of its kind from Qatar, as per our knowledge, aimed at the epidemiology of violence-related injuries based on hospital database.

A retrospective analysis of data obtained from the Qatar National Trauma Registry at Hamad Trauma Center (HTC) was conducted. The study received ethical approval from Institutional Review Board (IRB) of Hamad Medical Corporation (#MRC-01-18-189). The HTC is the one and only level 1 trauma center in Qatar which sees and treats moderate to severely injured patients all over the country including referrals from other hospitals. Each year, Trauma Code (Level I, II or III Trauma Criteria) is activated for nearly 2500 patients and almost 1800 are admitted in the HTC. This study included all patients presented to the level 1 HTC following violence-related (IPV and self-inflicted) injuries in the duration between June 2010 and June 2017.

Data extracted included age, gender, nationality, mechanism of injury, injured regions, injury severity score (ISS), major procedures and outcome. The patients were grouped by nationality as following; South Asians (India, Nepal, Pakistan, Bangladesh and Sri Lanka); Southeast Asians (Indonesia and Philippines) and Northeast Asians (China, Japan, North Korea, and South Korea). The Gulf Cooperation Council (GCC) and Middle East countries include; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, Iran, Iraq, Jordan, Palestine, Lebanon, Syria & Yemen. African, European and American countries were also included. The population data were obtained from website of the Ministry of Development, Planning and Statistics [8].

The patients in this study were identified using the Classification of External Cause of Injury and Poisoning (E-Codes) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The E-codes for suicide and self-inflicted injury (E950-E959) included: injuries in suicide and attempted suicide, self-inflicted injuries specified as intentional. The codes for homicide and injury purposely inflicted by other persons (E960-E969) included: injuries inflicted by another person with intent to injure or kill, by any means. The codes for legal intervention (E970-E978) included: injuries inflicted by police or other law enforcing agents. Each patient record was given a unique study number, and patient anonymity was maintained throughout the study.

Case fatality rate (CFR) was calculated by dividing the number of deaths from violence-related injuries in the study duration by the number of patients presented with violence-related trauma during that time. The resulting ratio was then multiplied by 100 to yield a percentage. This manuscript adheres to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines (Suppl table) [9].

Statistical Analysis:

Statistical data analysis was performed using Statistical Package for the Social Sciences (IBM® SPSS version 18 (IBM Inc., Armonk, USA). Data were summarized in form of proportions and frequent tables for categorical variables. Continuous variables were summarized using means, median, mode and standard deviation. P-values were computed for categorical variables using Chi-square test and Fisher exact test depending on the size of the data set. Independent student t-test was used for continuous variables. A two-tailed p-value of less than 0.05 was considered to constitute a statistically significant difference.

The study identified 658 patients (595 males & 63 females) who sustained violence-related injuries in seven years duration in Qatar. This accounts for the incidence rate of violence-related traumatic injuries as 4.6 per 100,000 population per year. This rate was higher among the males (5.5 per 100,000 males per year) when compared to females (1.8 per 100,000 females per year). Females represented less than 10% in the study population. The total population in Qatar increased nearly 60% in the study duration. Population growth in this duration was comparable in both genders. Although the number of injured patients increased from 86 to 116 in 2010 and 2017 respectively, corresponding incidence rate showed a decreasing trend by 15% from 5.3 to 4.5 per 100,000 population (Table 1 & Fig. 1).

The mean age of patients was 31 years ranging from < 2 years to 77 years. Approximately 7% were pediatric population under 18 years. The majority of victims lie in the 25–34 age-group (41%). The elderly population aged over 60 years represented around 1% of the patients (Fig. 2).

The majority of injuries were IPV-related (71%) followed by self-inflicted injuries (22%). More than half (55%) of IPV-related injuries was reported in patients from South Asia. Nearly 11% were reported in Qatari nationals. The type of trauma was almost equally distributed between blunt (50.3%) and penetrating (49.2%), while burn cases were only 0.5%. Blood alcohol screening revealed 23% were having a blood alcohol concentration (BAC) above zero; with mean BAC level of 37 ± 17 mmol/L. The mean GCS upon arrival to trauma room was 13.0. Head, abdomen, chest, face and neck injuries were reported in 27%, 24.5%, 21%, 13% and 7.3%, respectively (Table 2).

The mean ISS was 10 ± 9, mean head AIS (3 ± 1), chest AIS (3 ± 1) and abdomen AIS (2 ± 1). Twenty eight percent of patients required ICU admission. Intubation was required in 24% of cases followed by exploratory laparotomy (19%) and chest tube insertion (13%). Twenty percent of patients were referred for psychiatric evaluation. The median hospital length of stay was 4 days, while the ICU length of stay was 3 days. Overall mortality was 6.4% (Table 2). Significantly higher CFR was seen in females than males (16% vs.5%, p = 0.001).

The present study described the epidemiology and outcomes of violence-related traumatic injuries in Qatar. Although the number of victims increased over the years, the incidence rate was decreasing, as there was 60% population growth in the study duration. The incidence rate estimated based on the present study was 4.6 per 100,000 population per year. Significantly high rate was found in males and in younger population, specifically in 25–34 years age-group. Notably, pediatric (< 18y) population represented 7% of the victims. In agreement with the population distribution by nationality in Qatar, South Asians were the principal victims in our study.

IPV was the major contributor in the large majority of victims followed by self-inflicted injuries. More than one out of five patients was proven to be under alcohol abuse and had a mean BAC level corresponding to the central nervous system depression level. Head and chest injuries were the most common severe injuries. The ISS data showed that polytrauma was not much frequent in our study population. Two out of seven patients required ICU admission. In-hospital mortality was 6.4%. Interestingly, a higher CFR was found in females than males; most probably linked to the differential mechanism of injury. Females were more likely to die from suicide-related injuries as per the present data; however the sample size of females were inadequate to establish the additional risk of suicide-related mortality in females.

As per our knowledge, this is a pioneer trauma registry-based study conducted on violence-related trauma in the Qatar. Only one study was found in this subject area from the Arabian Gulf region which was based on hospital data from the United Arab Emirates (UAE) [10]. Although the study by Osman et al was specific for IPV, their findings can be compared to ours, since the large majority of our study population was IPV victims. Osman et al estimated that the IPV –related hospitalization rate was 6.7 per 100,000 population which in fact was higher than overall violence-related trauma in Qatar (Fig. 1) [10]. The major strength of our study was its external validity since the data were obtained from the national trauma registry and therefore our findings were generalizable to the Qatar population.

A prior study conducted in Jordan in accidents and emergency departments revealed that the violence was the most common reason of injury (71%) and males (87%) were the main victims [11]. Although there is a paucity of information on violence-related injuries in the Arabian Gulf region, there are some studies which addressed the violence-related trauma by focusing either on mechanism of injury, age group or gender. These studies utilized survey techniques, more often, however provided some insights into the injury rates and associated exposures. Peyton et al conducted a study among middle school students in Oman based on a nationally representative study sample and found that nearly half of the injuries reported were attributed to physical fights [12]. Interestingly, 7% of our study sample were below the age of 18 years, with a mean age of 12 years. More than three quarters of injuries in pediatric population were due to IPV. Mortality rate among the pediatric population was nearly 8% which in fact was higher than the overall mortality.

The UAE study findings on violence-related trauma by age and gender were comparable to our findings. The mean age in the UAE and our study was 30 and 31 years respectively. Similarly, male predominance (85%) among the victims was also evident in the UAE study. Male predominance in our study was over 90%. Overall in-hospital mortality rate was 6.4% in our study. On the other hand, there were no deaths in the UAE study. Higher in-hospital mortality rate reported in our study can be related to the severity of injuries. Nearly 28% of patients required ICU admission whereas the UAE based study revealed that less than 3% were admitted to ICU, and no deaths were reported [9].

The main limitation of the study was the retrospective design of the study; however it provided valuable information about the epidemiology and pattern of violence-related injuries in Qatar. Although the frequency of hospital visits following violence-related injuries by nationality data was available, the nationality-wise population data by year was unavailable and therefore the disproportionate burden of injuries were not estimated based on the rate. In addition, several other important socio-economic data was unavailable, however, the available data address the main objectives of the study.

The rate of violence-related injuries in Qatar was low. The burden of violence-related injuries in South Asians and young population was high. In addition, its burden in the pediatric population is alarming because more than three quarters of the injuries in the pediatric population was caused by IPV and mortality was high. Further studies on risk factors leading to violence are required to develop an evidence-based public health approach in violence prevention.

Ethical approval and consent to participate: This is a retrospective study that was conducted without any direct contact with participants. It obtained ethical approval from Research Ethics Committee, at Medical Research Center, Hamad Medical Corporation (HMC), Doha (#MRC-01-18-189) with a waiver of consent.

Consent for publication: It obtained ethical approval from Research Ethics Committee, at Medical Research Center, Hamad Medical Corporation (HMC), Doha (#MRC-01-18-189) with a waiver of consent.

Availability of data and material: not applicable

Competing interests: none

Funding: none

Author contribution: all authors have contributed substantially in the study design, data interpretation, writing and critical reviewing of the manuscript

Acknowledgment: We thank the trauma registry team for their cooperation

World Health Organization.World report on violence and health: Summary. WHO: Geneva; 2002. Available at: http://www.who.int/violence_injury_prevention/violence/world_report/en/summary_en.pdf
Krug EG et al., eds. World report on violence and health. Geneva, World Health Organization, 2002. Available at: http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf
Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016 Feb;22(1):3-18.
Eisenstat S, Bancroft L. Domestic violence. N Eng J Med. 1999; 341:886–92.
Abbott J, Johnson R, Koziol-McLain J, Lowenstein S. Domestic violence against women: incidence and prevalence in an emergency department population. JAMA. 1995; 273:1763–7.
MacMillan H, Fleming J, Trocme N, et al. Prevalence of child physical and sexual abuse in the community: results from the. Ontario Health Supplement JAMA. 1997;279:131–5.
Ernst C, Angst J, Foldenyi M. Sexual abuse in childhood. Frequency and relevance for adult morbidity: data of a longitudinal epidemiological study. Eur Arch Psychiatry Clin Neurosci. 1993;242:293–300
Ministry of Development Planning and Statistics, Qatar (MDPS) available at: https://www.mdps.gov.qa/en/statistics1/Pages/default.aspx
von Elm E, Altman DG, Egger M, Pocock SJ, Gotz sche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008; 61(4):344-49.
Osman OT, Abbas AK, Eid HO, Salem MO, Abu-Zidan FM. Interpersonal violence in the United Arab Emirates. Int J Inj Contr Saf Promot. 2014; 21(3):260-5.
Alzghoul MM, Shakhatreh MK, Al-Sheyab N. Unintentional Injuries and Violence among Adults in Northern Jordan: A Hospital-Based Retrospective Study. Int J Environ Res Public Health. 2017 Mar 24;14(4).
Peyton RP, Ranasinghe S, Jacobsen KH. Injuries, Violence, and Bullying Among Middle School Students in Oman. Oman Med J. 2017;32(2):98-105.

Table 1. Number and rate of violence-related injuries by gender in Qatar (2010-2017)
	Number of admissions at the trauma center			General population in Qatar (Mid-year)
Duration	Males	Females	Total	Males	Females	Overall
2010-2011	80	6	86	1228635	408808	1637443
2011-2012	82	7	89	1271194	436562	1707756
2012-2013	75	9	84	1364063	472613	1836676
2013-2014	87	12	99	1530101	515138	2045239
2014-2015	80	12	92	1686228	549203	2235431
2015-2016	83	9	92	2423175	1853001	570174
2016-2017	108	8	116	2597453	1974699	622754
Total number/ Rate	595	63	658	4.6	5.5	1.8

Table 2. Characteristics of patients presented to trauma center following violence-related injuries (n=658)

Age; mean ±SD

30.8± 11.1

Males; n (%)

595 (90.4)

Type of trauma; n (%)

Blunt
Penetrating
Burn

331 (50.3)

324 (49.2)

3 (0.5)

Violence type; n (%)

Interpersonal
Self-directed
Notdocumented

468 (71.1)

142 (21.6)

48 (7.3)

GCS; mean ±SD Scene

ED
After 1 hour

13.63 ± 3.0

13.29 ± 3.9

*BAC Positives; n (%)

BAC; mean ±SD

143 (23.4)

36.9 ± 17.0

Injury at body sites; n (%)

Head
Face
Neck
Chest
Abdomen
Spine
Arm
Pelvis
Leg
External

177 (26.9)

86 (13.1)

48 (7.3)

137 (20.8)

161 (24.5)

53 (8.1)

59 (9.0)

39 (5.9)

57 (8.7)

433 (65.8)

AIS; mean ±SD [Median (range)]

Head
Face
Neck
Chest
Abdomen
Spine
Arm
Pelvis
Leg
External

3.4 ± 0.9

1.8 ± 0.4

2.4 ± 1.2

2.7 ±0.9

2.3 ±0.8

2.3 ± 0.9

1.9 ± 0.6

2.2 ± 0.7

2.2 ± 0.5

1.1 ± 0.5

ISS; median (range)

9 (1-75)

Management; n (%)

Intubation
Exploratory Laparotomy
Thoracotomy
Chest tube insertion
Crniotomy/Craniectomy
ORIF

158 (24.0)

122 (18.5)

12 (1.8)

82 (12.5)

23 (3.5)

39 (5.9)

Psychiatric referrals; n (%)
ICU LOS; median (range)
Hospital LOS; median (range)

133 (20.2)

3 (1-142)

4 (1-142)

Outcomes; n (%)

Alive
Mortality

616 (93.6)

42 (6.4)

SD: Standard deviation; GCS: Glasgow Coma Score; ED: Emergency Department; BAC: Blood alcohol concentration in mm/L; ISS: Injury Severity Score; ORIF:Open reduction internal fixation; ICU: Intensive Care Unit; LOS: Length of Stay;

* among age ≥18 years

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Editorial decision: Major revision
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Violence –related injuries in a rapidly developing Middle Eastern country: A Retrospective Study from a Level 1Trauma Center

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