Sex differences in interpersonal violence in Malawi: analysis of a hospital-based trauma registry

Associations between social determinants of health and interpersonal violence-related injury in Cameroon: a cross-sectional study

Introduction

Risk factors for interpersonal violence-related injury (IPVRI) in low-income and middle-income countries (LMICs) remain poorly defined. We describe associations between IPVRI and select social determinants of health (SDH) in Cameroon.

Methods

We conducted a cross-sectional analysis of prospective trauma registry data collected from injured patients >15 years old between October 2017 and January 2020 at four Cameroonian hospitals. Our primary outcome was IPVRI, compared with unintentional injury. Explanatory SDH variables included education level, employment status, household socioeconomic status (SES) and alcohol use. The EconomicClusters model grouped patients into household SES clusters: rural, urban poor, urban middle-class (MC) homeowners, urban MC tenants and urban wealthy. Results were stratified by sex. Categorical variables were compared via Pearson’s χ² statistic. Associations with IPVRI were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI).

Results

Among 7605 patients, 5488 (72.2%) were men. Unemployment was associated with increased odds of IPVRI for men (aOR 2.44 (95% CI 1.95 to 3.06), p<0.001) and women (aOR 2.53 (95% CI 1.35 to 4.72), p=0.004), as was alcohol use (men: aOR 2.33 (95% CI 1.91 to 2.83), p<0.001; women: aOR 3.71 (95% CI 2.41 to 5.72), p<0.001). Male patients from rural (aOR 1.45 (95% CI 1.04 to 2.03), p=0.028) or urban poor (aOR 2.08 (95% CI 1.27 to 3.41), p=0.004) compared with urban wealthy households had increased odds of IPVRI, as did female patients with primary-level/no formal (aOR 1.78 (95% CI 1.10 to 2.87), p=0.019) or secondary-level (aOR 1.54 (95% CI 1.03 to 2.32), p=0.037) compared with tertiary-level education.

Conclusion

Lower educational attainment, unemployment, lower household SES and alcohol use are risk factors for IPVRI in Cameroon. Future research should explore LMIC-appropriate interventions to address SDH risk factors for IPVRI.

Characteristic and outcomes of human and animal bites in Malawi

INTRODUCTION

Bites are an important contributor to traumatic injury worldwide. In low- and middle-income countries, data regarding bite injuries outside of rabies is limited. Therefore, we sought to describe the injury characteristics and outcomes of bites in Lilongwe, Malawi, and determine risk factors for animals and human bites.

METHODS

We performed a retrospective analysis of the Kamuzu Central Hospital trauma registry from 2008-2018. We performed Bivariate analyses comparing bite to non-bite trauma and human to animal bites. Multivariable Poisson regression modeling then estimated risk factors for bites.

RESULTS

A total of 124,394 patients were captured by the registry, of which 3,680 (3%) had a bite injury mechanism. Human bites accounted for 14.5% of bite injuries, and animals represented the remaining 85.5%. In rare cases, animal bite victims had serious complications, such as amputation (n = 6, 0.2%), orthopedic procedures (n = 5, 0.2%), and death (n = 7, 0.2%). Risk factors for an animal bite included being on a farm, field, or lake and being at home, whereas risk factors for a human bite included alcohol use and being at home.

CONCLUSION

Animal bite injuries in Malawi can confer a risk of serious complications, such as amputation and, in rare cases, death. Alcohol-associated, in-home interpersonal violence is a significant risk factor for human bite injuries. Further studies are needed to identify risk factors for complications and mortality.

In-home interpersonal violence: Sex based prevalence and outcomes

Introduction

There is a shortage of data on intimate partner and interpersonal violence in sub-Saharan Africa. We, therefore, sought to characterize patterns of sex-based risk of in-home interpersonal violence in Malawi.

Methods

We performed a retrospective analysis of the Kamuzu Central Hospital Trauma Registry data from 2009 to 2017 on adult patients presenting the emergency room following assault. Data variables collected include basic demographics, injury characteristics, and outcomes. We performed a bivariate analysis for covariates based on sex and Poisson regression analysis to estimate the risk of domestic violence and sex-based mortality.

Results

The in-home assault interpersonal violence was 37.1% (n = 10,854) of the total assault cohort and 37.4% (n = 4056) were female. Women were more likely to be assaulted at home (n = 4065, 69.6%)compared to men. The overall prevalence of in-home interpersonal violence over eight years was 9.09%, with the prevalence in men and women being 7.85 and 12.38%, respectively. Women injured following in-home interpersonal violence assaults were less severely injured. Women were more likely to be injured following slaps, punches, or kicks (n = 950, 41.2%) and men were more likely to be injured by an object, 41.0% with a blunt object (n = 1658) and 37.9% by a knife or another sharp object (n = 1532). For patients experiencing in-home interpersonal violence, overall mortality is 1.8% and 0.5% for men and women, respectively (p < 0.001). After controlling for covariates, the relative risk for In-home interpersonal violence was 2.25 (p < 0.001) times higher for women. Still, men had a 3.3 times risk of mortality following in-home interpersonal violence (p < 0.001).

Conclusion

Interpersonal violence is a global problem. In Malawi, women are more likely to be victims of in-home interpersonal violence. However, men are more likely to die following in-home interpersonal violence. Prevalence of in-home interpersonal violence is likely an underestimation.

•

In-home interpersonal violence is a global phenomenon

•

There is a higher incidence on women than in men at 12.38 and 7.85 %, respectively

•

We show a higher mortality following in home interpersonal violence in men.

•

The prevalence of in home interpersonal violence is likely underestimated.

The Inter-Relationship Between Employment Status and Interpersonal Violence in Malawi: A Trauma Center Experience

INTRODUCTION

As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa's unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability.

METHODS

We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008-2018. All adult patients (>14 years) injured by interpersonal violence (IPV) were included. Age was categorized as 15-24 (youth), 25-45, and >45 years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV.

RESULTS

During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28 years, IQR 23-34) were younger than those unintentionally injured (30 years, IQR 23-39, p < 0.001). More patients injured following IPV were unemployed (n = 7,178, 23.6% vs. n = 10,148, 17.9%, p < 0.001), injured at night (n = 19,346, 63.7% vs. n = 10,148, 17.9%, p < 0.001), and reported alcohol use (n = 4.973, 16.4% vs n = 2,461, 4.4%, p < 0.001). Being unemployed (RR 1.25, 95% CI 1.22-1.27), youth compared to age >45 years (RR 1.72, 1.66-1.79), and those injured at night (RR 2.18, 95% CI 2.14-2.23) had increased the risk of being victims of IPV.

CONCLUSION

In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states.

Characteristics of interpersonal violence in adult victims at the Adult Emergency Trauma Centre (AETC) of Queen Elizabeth Central Hospital

Introduction

Globally, the burden of interpersonal violence and its significant impact on mortality, morbidity and disability makes it a major public health problem which necessitates intervention. This article examines characteristics of victims of interpersonal violence and violent events in Malawi. The focus is on a population that has been traditionally neglected in literature.

Methods

Queen Elizabeth Central Hospital (QECH) maintains a trauma registry with data that is prospectively collected. Patients offered trauma care after interpersonal violence from May 2013 to May 2015 were evaluated.

Results

There were 1431 patients with violent events recorded at the Adult Emergency Trauma Centre (AETC) with a male predominance of 79.5%. The dominant age group was young adults between 25–29 years old (22%). Most attacks occurred during cold and dry season (46.9%) and most common location was on the road (37.2%). Alcohol use by victims was recorded in 10.5% of cases. Soft tissue injuries were the most common injuries sustained (74.1%). Most patients were treated as outpatients (80.9%). There were two deaths. At multivariate analysis, women had a lower risk of interpersonal violence as compared to men, (OR 0.82 [0.69–0.98]). Victims' use of alcohol was associated with increased risk of assault (OR 1.63 [1.27–2.10]). As compared to other places, odds of being assaulted were higher at home (OR 1.62 [1.27–2.06]) but lower at work (OR 0.68 [0.52–0.89) and on the road (OR 0.82 [0.65–1.03]). Odds of being assaulted were higher in the cold and dry season as compared to hot and dry season, (OR 1.26 [1.08–1.47]).

Conclusion

Young males were most involved in interpersonal violence. Location of injury and seasonal variation were significant factors associated with interpersonal violence and most commonly sustained injuries were soft tissue injuries. These findings will help in identifying targeted interventions for interpersonal violence in Malawi and other low-and-middle-income countries (LMICs).

Risk Factors for Injuries From Physical Violence in African Women in the Gambia

BACKGROUND

Physical violence against women is a major public health problem in African countries; however, no studies have focused on factors associated with violent injuries to women in Africa.

OBJECTIVES

A matched case-control study was conducted to investigate risk factors for injuries from physical violence against African women in The Gambia.

METHODS

Over a 12-month study period, study participants were recruited from emergency departments of eight government-managed health care facilities. Cases were female patients aged ≥ 15 years who had been violently injured. Matched by the health facility, date of injury, sex, and age, a control patient for each case was selected from those injured due to nonviolent mechanisms.

RESULTS

In total, 194 case-control pairs were recruited. Results of a conditional logistic regression showed that being a Fula (odds ratio [OR] 2.45; 95% confidence interval [CI] 1.06-5.66), living in an extended family compound (OR 3.07; 95% CI 1.22-7.72), having six or more female siblings (OR 3.10; 95% CI 1.38-6.97), having been raised by grandparents (OR 3.34; 95% CI 1.06-10.51), and having been verbally (OR 3.04; 95% CI 1.56-5.96) or physically abused (OR 3.36; 95% CI 1.34-8.39) in the past 12 months were significantly associated with injury from physical violence.

CONCLUSION

Most risk factors identified for violent injury among African women are unique to the studied geography. Violence prevention programs, if designed based on these identified risk factors, may be more effective for this population.

Prevalence, pattern, magnitude and associated factors of trauma in the Emergency Department at Health Institutes in Ethiopia: A systematic review

BACKGROUND

Trauma is one of the important public health problems that causes significant economic and social crisis with more than 10% of all disease cases are associated with it. We aimed to identify and describe the prevalence, patterns, magnitude and associated factors of trauma in the Emergency Department at Health Institute in Ethiopia.

METHODS

In this systematic review, we searched for peer-reviewed and grey literature publications reporting the prevalence, pattern, magnitude and associated factors of trauma between 2000 and 2019. The documents which recruited are directly related to trauma and emergency department. In this regard, we searched databases of PubMed, Elsevier, Science directed, MEDLINE, and Google scholar by using Google as searching engine. Furthermore, publication with secondary data and not in English was excluded.

FINDINGS

A total of 9,768 injured participants were included in the studies, of which 71.2% (6950) were males. Among the injured participants, 53.4% of cases were living in Addis Ababa followed by Gondar and Jimma with 20.3% and 11.3% cases, respectively. Severe road traffic accident, occupational injury, and surgical patients were among the major risk factors of trauma. The mortality rate of the trauma case fatality was reached about 4%. The majority of the studies (37.5%) analyzed the pattern and magnitude of trauma among patients seen at emergency outpatient department of health institutes in Ethiopia. The largest percentage of studies (62.5%) relied on systematic random sampling. Thirty eight percent of the reviewed studies were utilized retrospective approaches to address the research questions. An completed the registry forms and/or Kampla Trauma Score (KTS), which accounted for 37.5% of articles on prevalence, pattern, magnitude and associated factors of trauma in the emergency was the most commonly used strategy. The majority (75%) of the reviewed studies were used both descriptive statistics and bivarate and multivariate logistic regression for data analysis. The majority 6950 (71%) of the participants who have been included in those reviewed articles were male and 2818 (29%) were female by gender. Meanwhile, the majority 5 (62.5%) of reviewed studies had included < 1000 injured persons.

CONCLUSION

The degree and types of injuries in different hospitals in Ethiopia was considerably high and its casualty is also under predictable. Therefore, a variety of actions including policy decision should be implemented in order to minimize the incidence of trauma at department of emergency care center in the country.

Risk Factors for Recurrent Injuries from Physical Violence Among African Men in The Gambia

While men are known to be at high risk of recurrent injuries from physical violence, the risk factors in African men have not been investigated. We conducted a matched case-control study to identify factors associated with recurrent injuries from physical violence in The Gambia. Eligible participants were injured male patients aged ≥ 15 years. Over the 12-month study period, 257 cases with recurrent injuries from physical violence, and 257 control patients each from two control groups (violence controls and nonviolence controls) were recruited from eight emergency rooms located in six districts of the Greater Banjul Metropolitan Area, The Gambia. The two control groups matched cases at the same health facility, date of injury, and age, in which violence controls (VCs) experienced only one violence-related injury in the past 12 months and nonviolence controls (NCs) experienced no violence-related injuries. Results of the multivariable conditional logistic regression showed that for both the VC and NC groups, a polygamous family (OR_VC, 3.62; OR_NC, 2.79), > 8 family members (OR_VC, 5.60; OR_NC, 4.81), being brought up by a family relative (OR_VC, 5.17; OR_NC, 2.11), having smoked cigarettes in the past week (OR_VC, 3.53; OR_NC, 4.03), and perceiving no family support (OR_VC, 1.12; OR_NC, 1.19) were significantly associated with the occurrence of recurrent violent injuries. Furthermore, compared to the NCs, three additional factors of > 2 male siblings (OR_NC, 1.84), low household income (OR_NC, 3.11), and alcohol consumption in the past week (OR_NC, 4.66) were significantly associated with the occurrence of recurrent violent injuries. These findings may fill in a knowledge gap that will be beneficial for developing effective intervention programs to reduce recurrent injuries from physical violence among African men.

Establishment of trauma registry at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi and mapping of high risk geographic areas for trauma

BACKGROUND

Less attention is directed toward gaining a better understanding of the burden and prevention of injuries, in low and middle income countries (LMICs). We report the establishment of a trauma registry at the Adult Emergency and Trauma Centre (AETC) at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi and identify high risk geographic areas.

METHODS

We devised a paper based two-page trauma registry form. Ten data clerks and all AETC clinicians were trained to complete demographic and clinical details respectively. Descriptive data, regression and hotspot analyses were done using STATA 15 statistical package and ArcGIS (16) software respectively.

RESULTS

There were 3,747 patients from May 2013 to May 2015. The most common mechanisms of injury were assault (38.2%), and road traffic injuries (31.6%). The majority had soft tissue injury (53.1%), while 23.8% had no diagnosis indicated. Fractures (OR 19.94 [15.34-25.93]), head injury and internal organ injury (OR 29.5 [16.29-53.4]), and use of ambulance (OR 1.57 [1.06-2.33]) were found to be predictive of increased odds of being admitted to hospital while assault (OR 0.69 [0.52-0.91]) was found to be associated with less odds of being admitted to hospital. Hot spot analysis showed that at 99% confidence interval, Ndirande, Mbayani and Limbe were the top hot spots for injury occurrence.

CONCLUSION

We have described the process of establishing an integrated and potentially sustainable trauma registry. Significant data were captured to provide details on the epidemiology of trauma and insight on how care could be improved at AETC and surrounding health facilities. This approach may be relevant in similar poor resource settings.

Child Protection and Social Inequality: Understanding Child Prostitution in Malawi

This article draws on empirical research to develop understandings of child prostitution, previously theorised on the basis of children’s rights, feminist, and structure/agency debates, largely ignoring children’s own understandings of their involvement in prostitution. Conducted in Malawi, which is one of the economically poorest countries in the world, the study goes to the heart of questions of inequality and child protection. Within a participatory research framework, nineteen girls and young women used visual methods to generate images representing their experiences of prostitution. Individual and group discussions were used to illuminate the meanings and significance of their images. With the exception of the youngest, participants understood their initial involvement in prostitution as a means of survival in the face of poverty and/or parental death, or escape from violent relationships, experiences that were subsequently mirrored by exploitation and violence within prostitution. Using the lens of the capability approach, we capture the complexity of child prostitution, demonstrating the ambiguous agency of participants in the face of deeply embedded patriarchal cultural norms that constrained their choices and limited their freedom to pursue valued lives. We end by reflecting critically on the theoretical and methodological contributions of the study, making policy and practice recommendations and identifying opportunities for further research.

Interpersonal violence, circumstances of aggressions and patterns of maxillofacial injuries in the metropolitan area of Campina Grande, State of Paraíba, Brazil (2008-2011)

The aim of this study was to determine the circumstances of aggressions and patterns of maxillofacial injuries among victims of interpersonal violence. This was a cross-sectional and exploratory study conducted from the analysis of 7,132 medical-legal and social records of interpersonal violence victims seen in a Forensic Medicine and Dentistry Center. Descriptive and multivariate statistics were performed using Multiple Correspondence Analysis. Three groups with different victimization profiles were identified. The first group was mainly composed of men of different age groups, victims of community violence that resulted in facial bones or dentoalveolar fracture. The second group was mainly composed of adolescents (10-19 years) of both sexes, victims of interpersonal violence and without specific pattern of injuries. The third group was composed of adult women (≥ 20 years) victims of domestic violence that resulted in injuries of soft tissues of face or other body regions. The results suggest that sociodemographic and circumstantial characteristics are important factors in victimization by maxillofacial injuries and interpersonal violence.

Perceptions of the mental health impact of intimate partner violence and health service responses in Malawi

BACKGROUND AND OBJECTIVES

This study explores the perceptions of a wide range of stakeholders in Malawi towards the mental health impact of intimate partner violence (IPV) and the capacity of health services for addressing these.

DESIGN

In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in three areas of Blantyre district, and in two additional districts. A total of 10 FGDs, 1 small group, and 14 IDIs with health care providers; 18 FGDs and 1 small group with male and female, urban and rural community members; 7 IDIs with female survivors; and 26 key informant interviews and 1 small group with government ministry staff, donors, gender-based violence service providers, religious institutions, and police were conducted. A thematic framework analysis method was applied to emerging themes.

RESULTS

The significant mental health impact of IPV was mentioned by all participants and formal care seeking was thought to be impeded by social pressures to resolve conflict, and fear of judgemental attitudes. Providers felt inadequately prepared to handle the psychosocial and mental health consequences of IPV; this was complicated by staff shortages, a lack of clarity on the mandate of the health sector, as well as confusion over the definition and need for 'counselling'. Referral options to other sectors for mental health support were perceived as limited but the restructuring of the Ministry of Health to cover violence prevention, mental health, and alcohol and drug misuse under a single unit provides an opportunity.

CONCLUSION

Despite widespread recognition of the burden of IPV-associated mental health problems in Malawi, there is limited capacity to support affected individuals at community or health sector level. Participants highlighted potential entry points to health services as well as local and national opportunities for interventions that are culturally appropriate and are built on local structures and resilience.