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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 4  |  Page : 352-355  

Unintentional childhood injuries and their association with activity and location at the time of injury - A case–Crossover study in Delhi


1 Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Assistant Professor, International Institute of Health Management Research, New Delhi, India
3 Director Professor and Former Head, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
4 Medical Officer, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission28-Feb-2021
Date of Decision12-Apr-2021
Date of Acceptance18-Aug-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Rupsa Banerjee
International Institute of Health Management Research, Plot No 3, Sector 18A, Dwarka, Phase II, New Delhi - 110075
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_55_21

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   Abstract 


Background: Childhood injury has been identified as a grave public health problem globally as well as in India. Most studies have reported injuries to have occurred while the child was at home, though injuries while on road, school, or playground also commonly occurred. Objective: The objective of the study is to find the association between unintentional childhood injury and the activity and location of the child at the time of injury. Methods: The present study is part of a larger study for preventing childhood injuries, conducted from August 2017 to January 2019 in Delhi, and reports the activity and location of the children at the time of injury. A total of 173 injuries that occurred during the total study duration were included in the analysis. Data regarding activity and location of the subjects were collected and analyzed by case-crossover study design, during “case/hazard period” and two “control/reference periods.” Results: Majority of the injuries occurred while the subjects were at home and engaged in activities other than normal activity. When various locations and activities were combined, unmatched odds ratios (ORs) were raised for activity other than normal activity (statistically significant) and for location other than at home. Similar results were obtained for matched Mantel–Haenszel OR, with activity other than normal being significantly more risk for injury (P = 0.000). Conclusion: Majority of unintentional injuries occurred in children and adolescents, while the subjects were away from home and engaged in any activity other than normal daily activities. This indicates the importance of teaching safety behavior to children so that they can prevent being injured wherever they go and whatever activity they perform.

Keywords: Activity, case–crossover, location, unintentional childhood injuries


How to cite this article:
Banerjee B, Banerjee R, Ingle G K, Mishra P. Unintentional childhood injuries and their association with activity and location at the time of injury - A case–Crossover study in Delhi. Indian J Public Health 2021;65:352-5

How to cite this URL:
Banerjee B, Banerjee R, Ingle G K, Mishra P. Unintentional childhood injuries and their association with activity and location at the time of injury - A case–Crossover study in Delhi. Indian J Public Health [serial online] 2021 [cited 2022 Jan 17];65:352-5. Available from: https://www.ijph.in/text.asp?2021/65/4/352/333982




   Introduction Top


Childhood injury has been identified as a grave public health problem globally as well as in India and has been recognized as a major threat to child survival and health.[1] Injuries can occur while the child is at home, in playgrounds and parks, at school, or on road. Of all locations, most studies have reported injuries to have occurred while the child was at home,[2],[3],[4],[5],[6],[7],[8] with falls as the most common cause of injuries,[5],[7],[8],[9],[10],[11],[12] implying that safety measures implemented at home are likely to have great impact on the burden of childhood injuries. However, road traffic accident too was reported to be the common cause of injuries and many injuries also occurred while the children were in school or playground.[2],[3],[6],[11],[12] This reveals the importance of teaching safety behavior to the children so that they can prevent being injured wherever they go and whatever activity they perform.

The present study analyzed the association between unintentional childhood injury and the activity and location of the child at the time of injury, through a case–crossover study design.


   Materials and Methods Top


The present study is part of a larger intervention study which was conducted to study the effect of child-to-child approach in preventing childhood injuries, conducted in two villages of Northwest Delhi, during the period August 2017 to January 2019. Ethical clearance was taken from Institutional Ethics Committee of Maulana Azad Medical College with Approval Letter Number: F.1/IEC/MAMC/(56)/2/2017/No 74; dated May 17, 2017. The original study was registered under the Clinical Trial Registry – India. Written informed consent was taken from heads of the families, subjects aged 18–19 years, and mothers/guardians of the minor subjects with assent from children aged 7–17 years, as applicable for all the subjects interviewed. The study was conducted following all ethical guidelines of the Indian Council of Medical Research.

A total of 397 children and adolescents aged 0–19 years were included in the research, according to the WHO sample size formula,[13] for the variables and outcomes proposed to be measured in the original study. Data were collected over a period of 16 months on the occurrence of unintentional injuries among the study subjects. Each family recruited in the study was visited once every week during the study period, and details regarding injury events, if any, which occurred in the previous week were enquired into. One injury event was considered as one child injured at one point in time, even if it resulted in multiple injuries.

A case–crossover study design was used in this study, and it reported the activity and location of the children at the time the injury occurred. All injury events (n = 173) that occurred among all the study subjects during the total study duration were included in the analysis.

Data included in the present study were collected by interview of either subjects or their mothers/guardians. Information was collected regarding location and activity of the child during three time periods before injury, one of which was the case/hazard period and the other two were control/reference periods. “Case/hazard period” was considered as time immediately before injury. “Control/reference period 1” was the same time of the day, 1 day earlier. “Control/reference period 2” was same time on same day of the week, 1 week earlier [Figure 1]. Location of the child was categorized as home, place of education, place of employment, playground, or road. Activity included work-related activity which was work at the place of employment; travel-related activity that included travel on main road or streets in the neighborhood, while walking or on any vehicle; normal activity included sitting, walking, climbing stairs, bathing, crawling of baby; other activities included housework, dancing, playing at home, school playground, or neighborhood playground that is outside the boundaries of home.
Figure 1: Timeline of case–crossover study.

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Data were entered into MS Excel and analyzed using IBM SPSS Statistics for Windows Version 25.0, released 2017, Armonk, NY. Descriptive data were presented in frequencies and percentages. Unmatched odds ratio (OR) and Mantel–Haenszel OR (ORMH) were calculated for assessing magnitude of risk for grouped and paired observations, respectively. McNemar test of significance was used to test for difference between paired observations.


   Results Top


Most of the study subjects (41.62%) belonged to the age group of 10–14 years followed by 10–19 years (30.64%). Majority of the injuries occurred in males (68.79%). [Table 1] is constructed with activity and location of the study subjects for all the injury events that occurred throughout the total duration of the study, in all three time periods under consideration. Majority of the injuries occurred while the subjects were engaged in other activity as defined earlier. Work-related injuries were very few, as very few subjects were employed. Considered according to individual location of the subject during injury, majority of the injuries were observed to have occurred while the subjects were at home. However, by presenting the results as binomial variables “at home” and “other than at home,” it was observed that majority of the injuries had occurred while doing any activity other than normal activity and majority of the injury events had occurred while the subject was at any place other than home.
Table 1: Activity and location of injured children during case/hazard period and control/reference periods

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Hence, risk of being injured while engaged in any activity other than normal activity and located at any place other than at home was estimated by calculating unmatched OR [Table 2]. The odds of injury occurrence while engaged in activity other than normal were significantly higher than while engaged in normal activity. The odds of injury occurrence outside home were also greater than injury within the house, but this was not statistically significant. However, since information given on these aspects depended on recall, the data for control period 2, i.e., 1 week before injury, might have been compromised in some cases. Hence, only control/reference period 1 was considered in the next table for calculating matched OR.
Table 2: Risk of injury according to activity and location of injured children

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In [Table 3], the risk was estimated for case/hazard period against control/reference period 1. Since unmatched OR may mask the effect due to the presence of confounders, the risk of being injured was estimated by calculating ORMH by matched pair interval analysis, for any activity other than normal activity and location at any place other than at home, at the time of occurrence of injury.
Table 3: Matched pair interval analysis for risk of injury according to activity and location of injured children

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ORMH is seen to be raised for both activity and location during the injury and are higher than their unmatched counterparts, indicating possible presence of confounders, which were controlled here [Table 3]. The ORMH was tested for significance by McNemar, by which risk for activity other than normal activity was seen to be significantly raised. The difference in location was, however, not significant.


   Discussion Top


Across the world, the leading causes of child death from unintentional injuries were identified as road traffic injury, drowning, fire-related burns, falls, and poisoning. In some regions of the world, drowning has been reported to be responsible for about half of total child injury deaths.[14] Road traffic injuries and falls, which are two of the leading causes of injury deaths, are predicted to rise in rank compared to other causes of death, becoming the 7th and 17th leading causes of death by 2030, respectively.[15] Hence, the greatest need of the hour is to implement context-specific preventive measures that include safe behavior, safe environment, safety products, safety management, and raising awareness among the community regarding this enormous problem.

Categorized according to location, injuries occurred while at home, in playgrounds and parks, at school, or on road. Home injuries have been reported to be more common than injuries occurring while the child was outside the home.[3] Of all locations, most studies have reported injuries to have occurred while the child was at home followed by road, school, playground/sports/athletic area, farm, etc.[2],[3],[4],[5],[6],[7],[8] One study reported physical injuries mostly occurred in streets (53%) followed by home (33%).[16] Statistically significant association between home injuries and environmental risk factors have been reported, such as falls and slippery floor, injury with sharps and access to sharps, burns/scalds with unsafe kitchen, and access to fuel.[7] All these observations imply the need of implementing safety measures at home for prevention of unintentional injuries in children.

In the present study, a case–crossover study design was employed to assess the risk of specific activity and/or location in causing increased injuries. Majority of the injuries were observed to have occurred while the subject was at home engaged in activity such as housework, dancing, and playing, followed by injuries while traveling on road. On estimating risk of activity and location, unmatched OR was significantly raised, being more than 2 times higher risk of injury while engaged in any activity other than normal daily activity. Injury occurring while the child was outside the home also showed greater risk than while at home, though not statistically significant. When matched ORMH was done, activity other than normal bore significantly higher risk than normal activity, but risk was not significantly different according to location.

Our study is unique as there are very few studies using case–crossover design, especially for all types of injuries in children and adolescents. However, the study has some limitations. The data have been obtained by interview of subjects, and hence, it has the possibility of bias as may happen with all interview-based research. Though data were based on recall by the subjects, recall failure is unlikely to have occurred as the recall period was extremely short that is 1 day and 1 week.


   Conclusion Top


Present study shows that majority of unintentional injuries occur in children and adolescents while the subjects are away from home and engaged in any activity other than normal daily activities. This reflects the importance of teaching safety behavior to children and adolescents as the first safety measure to prevent unintentional injuries since it may not always be possible to ensure environmental modification in locations outside the home.

Acknowledgment

We acknowledge St. John's Ambulance Services of Indian Red Cross Society, Delhi Traffic Police, and HeroMotoCorp, Hero Honda, for conducting trainings.

Financial support and sponsorship

The study was supported by Indian Council of Medical Research, New Delhi; IRIS number: 2013-1263.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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WHO and UNICEF. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Rahman AK, et al., editors. World Report on Child Injury Prevention. Geneva: World Health Organization WHO and UNICEF; 2008.  Back to cited text no. 1
    
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Kundal VK, Debnath PR, Sen A. Epidemiology of pediatric trauma and its pattern in urban India: A tertiary care hospital-based experience. J Indian Assoc Pediatr Surg 2017;22:33-7.  Back to cited text no. 11
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Sheriff A, Rahim A, Lailabi MP, Gopi J. Unintentional injuries among children admitted in a tertiary care hospital in North Kerala. Indian J Public Health 2011;55:125-7.  Back to cited text no. 12
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Child Injury Prevention. Sixty-Fourth World Health Assembly WHA64.27, Agenda Item 13.14; 24 May 2011. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_R27-en.pdf?ua=1. [Last accessed on 2019 Mar 28].  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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