In rural Bangladesh, non-fatal child injury, either major or minor, added considerable morbidity burden to non-communicable childhood illness; however, child injuries were preventable, and addressing the risk factors could help to reduce the number of injury events. There remained unavailability of recent information on the patterns and associated risks, particularly considering child age groups. This study presented with age group related variability in patterns with as well as the sociodemographic and environmental risks to child injury with an aim to aiding information for preventive measures, though identification of true risk factors was beyond its scope.
In this study, the observed prevalence of both the major and the minor injury was lower than before (21, 23, 27, 28) and variability was noted among age groups. However, this could not be considered a true reduction in burden. Because, for capturing minor injuries a shorter recall period of ‘previous three months’ was used in this study, and the contextual environment and study population were different for major injury, which might be the reason for the observed differences. Besides, both the prevalence might have changed due to changing socio-economic, cultural, and educational backgrounds over the past ten years, still requiring intervention for further reduction. The highest affected age groups were different for major and minor injuries. Prevalence in infants could not be obtained as neither major nor minor injury was observed in them. This indicated a target group approach for preventive measures to be considered for these two categories of injury.
The prevalence of death as observed in this study was lower in figure compared to an earlier study (prevalence of injury deaths in the one-year period was 0.096%, 95% CI 0.037%-0.199%) (27) and the nationwide survey in 2016 (prevalence of injury deaths in the two-year period was 0.13%, 95% CI 0.12%-0.14%) (21). However, these studies were different from the present as per the inclusion of people of all ages and a longer recall period for that survey one. In fact, the observed prevalence indicated a higher frequency of injury-related child death from the previous considering contextual relevance, which demanded the intervention.
For both types of injury, fall was the most common pattern; cut, transport, and burn injuries were in queue accordingly. These patterns matched with previous nation-wide BHIS 2016 survey, which showed that falls, cuts, and burns were major patterns of injury in children aged < 18 years (21); besides, fall was found as the leading pattern in other studies also.(13–15, 20, 29–31) However, patterns varied widely while considering different age groups. For the major type, 1-4-year children were mostly injured by cuts and burns, 5–9 years and 10–14 years by falls, and 15–17 year by cuts and other injuries respectively. And for the minor type, though falls were the commonest pattern throughout all age groups, other patterns varied considerably among different age groups. Interestingly, in contrast to other studies, only one event of near-drowning was reported here. The probable reason might be that earlier studies focused on injury-mortality and drowning was the leading cause of ‘fatal’ injury (21, 22, 29, 32), whereas this study targeted non-fatal injuries. Hence, patterns of injury should be taken into account before the introduction of any injury intervention measures.
In this descriptive study, the variation in risk profile with injury type was also observed. However, sub-analysis was not conducted for children with major injuries as the total number of cases was only 22. Among different social characteristics, a major injury occurred significantly more in male children as similar to prior findings of male predominance in such injury(23). The probable explanation might be related to the restlessness and risk-taking nature of a male child when compared to a female one. Henceforth, any preventive measure and ways of implementation should have a special emphasis on male sex.
For environmental traits, using non-electric power sources exclusively or as complementary and dumping garbage nearby households showed a significant risk for the occurrence of major injury. In a resource-inadequate country like Bangladesh, not all households had access to electricity, let alone an uninterrupted flow; and people were used to using alternate sources (kerosene lamp-like kupi, solar, candles, and others), though there was not enough lighting produced. The dim light, along with the source(33) and careless handling, might be the reason for association with injury. As for dumping garbage, it was a common practice in rural Bangladesh to throw many household wastes nearby and dump garbage on the premises. Movement of children unaware of these might result in injuries, severe enough to cause a fracture or deep cut. However, as the environmental observational checklists were developed depending upon the Bangladesh Health and Injury Survey 2005 survey (qualitative section) considering environmental settings common to rural Bangladesh (22), relevant other studies were not available for comparison. And also, identifying the true risk factors was beyond the scope of a descriptive study; and thereby case-control study along with a qualitative part was recommended for further evaluation.
While analyzing social risks for minor injury, children whose mothers worked for ≥ 5 hours and children < 6 years who had at least some supervision during mothers’ work were significantly more at risk of being injured. This was especially observed for 1-4-year children when the analysis was done considering age groups. The probable explanation could be that mothers who worked for longer hours, kept their children under the supervision of others, and then lack of closer supervision resulted in injury to those children. In fact, the absence of closer supervision was a risk factor for the occurrence of child injury as observed in previous literature. (15, 18, 34, 35) Considering that children were having injuries in presence of supervisors, caregivers of children could be provided with training on supervision and caring applications to reduce the home-based risks.
For the 10-14-year age group, male children and children of uneducated mothers were found to be at risk of minor injury out of all features. The similarity of social risk groups was found in other literature, however, irrespective of injury categorization (4, 13, 15, 27) and age-groups. (4, 7, 13, 16, 17, 28, 36, 37) Henceforth, education should be promoted for all, and male predominance should be considered while designing an intervention.
Of different environmental characteristics, fireplaces in open space were found to be more significantly related to a minor injury, particularly for 5-9-year children. Making fireplaces in open space was usual in rural areas, especially in winter, for processing rice from the grain and for cooking at times of occasions. (22) Children being unaware of these fireplaces or its remnants usually got injured. Studies were found showing the relation of injuries with active fire, fireworks, or firecrackers. (20, 37, 38) Therefore, injury prevention programmes should also direct at creating awareness in rural people about child-care while using open fireplaces and proper management of remnants to avoid injury.
Varying degrees of an insignificant relationship was observed between minor type injury in different age groups of children and different known environmental risk factors. (4, 22) This might be due to the dissimilar analysis approach used in this study, where age groups were considered. However, an in-depth study was needed to find out the actual scenario.
The findings in this study were limited by focusing on an age-group related style in a cross-sectional study, which could not establish a significant relationship of injury even with known risks, which might produce a good result for a case-control study. Also, analysis of risk profile could not be done for major injuries in the same way as such events were smaller in number. The latter might be due to the methods of categorization of injury, where minor ones might include some actually severe injuries. Besides, as data were collected from only one Upazila (sub-district), the results were not generalizable to all children of Bangladesh.