Saving of children's lives from drowning project in Bangladesh

Distribution and determinants of unintentional injuries among older adults population in Tamil Nadu, India: a community-based injury prediction model

BACKGROUND

Unintentional injuries among older adults represent a significant public health challenge, particularly in low-resource settings. This study aimed to estimate the prevalence of unintentional injuries among older adults in Tamil Nadu, identify associated risk factors and develop a prediction model for unintentional injuries.

METHODS

A cross-sectional study was conducted among older adults in Tamil Nadu, India, and used probability proportional to size sampling. Data were collected via a semistructured questionnaire. The receiver-operating characteristic curve was created to show the probability of the occurrence of unintentional injuries among older adults.

RESULTS

Among 995 older adults, 13.9% reported having unintentional injuries. Among those injured, about 49% of all injuries were due to falls. The best cut-off point for predicted probability was found to be 0.88 for a sensitivity of 81% and a specificity of 61%, from receiver-operating characteristic curve. The regression analysis showed that fear of falling (4.5 times higher risk), being tribal (3.15 times higher risk), female gender (1.98 times higher risk) and alcohol consumption (1.95 times higher risk) significantly increased chance of unintentional injury.

CONCLUSIONS

The study highlighted the critical need to prioritise the prevention of unintentional injuries among older adults, particularly focusing on high-risk populations such as those from low socioeconomic and tribal communities. The use of receiver-operating characteristic curve in this study provides a robust and reliable method for predicting unintentional injuries in older adults in India, offering actionable insights for healthcare professionals and public health planners, if validated in future studies.

Socioeconomic, demographic and environmental factors of child drownings in Northern Bangladesh

BACKGROUND

Drowning is the leading cause of death among children aged 0-17 years in rural Bangladesh, resulting in over 14 438 deaths annually-an average of 43 deaths per day. This study aims to identify socioeconomic, demographic and environmental factors linked to child drowning deaths in Northern Bangladesh-a region of high poverty, which is behind in overall socioeconomic indicators compared with other regions in the country.

METHODS

We conducted a cross-sectional survey through purposive sampling to identify child fatal and non-fatal drownings among a total of 18 004 households, comprising 71 185 people, in 2 unions in Northern Bangladesh. Interviews were conducted between January and March 2024 with the households that experienced child drownings in the region. We employed a mixed-methods approach to data collection, using quantitative analysis to examine socioeconomic, demographic and environmental factors, alongside qualitative analysis to explore situational factors associated with drownings in the region.

RESULTS

Through household visits, a total of 117 households were identified that faced child drowning incidents, comprising 84 fatal (71.8 %) and 33 non-fatal (28.2 %) drownings between 2018 and 2023. The households that faced drownings were comparatively of lower income groups, had lower rates of education and were mostly engaged in agriculture and other domestic work. In 2023, the number of drowning incidents was 34. Out of 117 drownings, 95% occurred between 9:00 and 15:00 hours, and more than 82% occurred between June and October. Out of 117 drowning incidents, approximately 97% of children did not know how to swim prior to the incident. Out of 117 respondents, 73.5% stated that they did not teach their child how to swim. Of those who taught their child to swim, the average age for learning to swim was 8.33 years. Out of 84 child drowning deaths, 75% were male and 25% were female, and the average age was 3.9 years. Out of the 84 fatal drowning deaths, 72.6% occurred in ponds.

CONCLUSION

Identification of socioeconomic, demographic and environmental factors associated with child drownings will help to develop feasible prevention strategies and interventions in the region.

Caregivers’ Compliance and Perception of Daycare Centers—A Community-Based Childhood Drowning Prevention Intervention Implemented in Rural Bangladesh

Drowning was one of the most prevalent causes of death worldwide for children under five in 2020. Drowning was the second leading cause of death for children under five in Bangladesh, while 58% of all deaths in the 1–5 years old age group resulted from drowning. Adult supervision helps prevent child drowning in rural areas where water bodies are easily accessible and located very close to homes. This paper aims to assess caregivers’ compliance and perception of community daycare centers in rural Bangladesh, piloted as a child drowning prevention intervention. In this longitudinal study, each child enrolled in the daycare intervention was visited and data on compliance and satisfaction with the daycare were collected. Descriptive statistics on daycare attendance, patterns of supervision, and caregivers’ perceptions about daycare were reported. When inquired about daycare attendance (n = 226,552), a total of 77.4% of children (n = 175,321) were found to attend daycare. The distance from homes and an adult’s unavailability to take the child to daycare were the most common reasons for not attending or discontinuing enrollment. The majority of children (76.4%) were supervised by their mothers during daycare closures. A total of 67.7% of respondents perceived daycare to be a safe place, where children also developed cognitive (51.7%) and social skills (50.6%). There were no incidences of drowning among children while attending daycare. Rural families were found to be compliant with the daycare and professed it to be a safe place protecting children from drowning and other injuries, while allowing them to focus on household chores or income-generating activities. These findings indicate a potential for the expansion of this intervention in rural Bangladesh and similar settings.

Compliance to playpen usages to enhance parental supervision of under-five children in rural community of Bangladesh

Introduction

In Bangladesh, injury is one of the leading causes of death and morbidity in children. All children under 5 years of age are at high risk for drowning though the risks are highest when children first learn to walk and crawl while they do not understand the danger of water. The Centre for Injury Prevention and Research, Bangladesh (CIPRB) in collaboration with Johns Hopkins International Injury Research Unit (JH-IIRU) has been implementing two drowning prevention interventions, providing playpens and community day care centres (anchal), or both in three rural sub-districts of Bangladesh under Saving of Lives from Drowning (SoLiD) project in Bangladesh. In CIPRB intervention areas, wooden playpens were distributed among the children nine months to three years at household (HH) level.

Objective

The aim of this study was to explore and understand the acceptability and perceptions of parents towards playpen and its relevance for drowning and injury related mortality and morbidity prevention.

Methods

Anchal mothers (‘anchal maa’ in Bangla) distributed 30,553 playpens and collected compliance information at the HH level using a structured questionnaire. 1600 trained anchal maas collected data via face to face interviews from May 2014 to November 2015. Playpen compliance visits were conducted periodically on the second and seventh days and every two months after delivering the playpen. Data were entered using standard data entry formats and analyzed using SPSS software version 23.

Results

Parents reported that playpen is a safe place and protects children from drowning and other injuries. During compliance data collection, anchal maa founds that 71.8% of all children were using playpen and 93.7% (of 71.8%) children were playing inside the playpen while mothers were busy with their household chores like cooking, washing dishes and clothes, taking care of their poultry and domestic animals etc. 95.7% parents reported playpen is being used for keeping the child safe. On an average, the children were placed two to six times per day in a playpen. 99.1% of the children who reported using a playpen did not get any injuries (falls, cuts and bruises) while using the playpen. Satisfaction level with the playpen intervention among mothers was 90.5%. Some respondents suggested improving the playpen utilization by providing toys, adding wheels for ease of mobility, and increasing the height.

Conclusion

The playpens were found to be well accepted and utilized for the children, especially when mothers were busy with their household chores.

Cost-effectiveness analysis of a large-scale crèche intervention to prevent child drowning in rural Bangladesh

Background

Drowning is the leading cause of death among children 12–59 months old in rural Bangladesh. This study evaluated the cost-effectiveness of a large-scale crèche (daycare) intervention in preventing child drowning.

Methods

The cost of the crèches intervention was evaluated using an ingredients-based approach and monthly expenditure data collected prospectively throughout the study period from two agencies implementing the intervention in different study areas. The estimate of the effectiveness of the crèches intervention was based on a previous study. The study evaluated the cost-effectiveness from both a program and societal perspective.

Results

From the program perspective the annual operating cost of a crèche was $416.35 (95% CI: $221 to $576), the annual cost per child was $16 (95% CI: $8 to $23), and the incremental-cost-effectiveness ratio (ICER) per life saved with the crèches was $17,008 (95% CI: $8817 to $24,619). From the societal perspective (including parents time valued) the ICER per life saved was − $166,833 (95% CI: − $197,421 to − $141,341)—meaning crèches generated net economic benefits per child enrolled. Based on the ICER per disability-adjusted-life years averted from the societal perspective (excluding parents time), $1978, the crèche intervention was cost-effective even when the societal economic benefits were ignored.

Conclusions

Based on the evidence, the crèche intervention has great potential for generating net societal economic gains by reducing child drowning at a program cost that is reasonable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00351-9.

Determining child drowning mortality in the Sundarbans, India: applying the community knowledge approach

BACKGROUND

The Sundarbans in India is a rural, forested region where children are exposed to a high risk of drowning due to its waterlogged geography. Current data collection systems capture few drowning deaths in this region.

METHODS

A community-based survey was conducted in the Sundarbans to determine the drowning mortality rate for children aged 1 to 4 years and 5 to 9 years. A community knowledge approach was used. Meetings were held with community residents and key informants to identify drowning deaths in the population. Identified deaths were verified by the child's household through a structured survey, inquiring on the circumstances around the drowning death.

RESULTS

The drowning mortality rate for children aged 1 to 4 years was 243.8 per 100 000 children and for 5 to 9 years was 38.8 per 100 000 children. 58.0% of deaths were among children aged 1 to 2 years. No differences in rates between boys and girls were found. Most children drowned in ponds within 50 metres of their homes. Children were usually unaccompanied with their primary caretaker engaged in household work. A minority of children were treated by formal health providers.

CONCLUSIONS

Drowning is a major cause of death among children in the Sundarbans, particularly those aged 1 to 4 years. Interventions keeping children in safe spaces away from water are urgently required. The results illustrate how routine data collection systems grossly underestimate drowning deaths, emphasising the importance of community-based surveys in capturing these deaths in rural low- and middle-income country contexts. The community knowledge approach provides a low-resource, validated methodology for this purpose.

Day care as a strategy for drowning prevention in children under 6 years of age in low- and middle-income countries

BACKGROUND

Drowning is responsible for an estimated 320,000 deaths a year, and over 90% of drowning mortality occurs in low- to middle-income countries (LMICs), with peak drowning rates among children aged 1 to 4 years. In this age group, mortality due to drowning is particularly common in rural settings and about 75% of drowning accidents happen in natural bodies of water close to the home. Providing adequate child supervision can protect children from drowning, and organized formal day care programs could offer a way to achieve this.

OBJECTIVES

Primary objective • To assess the effects of day care programs for children under 6 years of age on drowning-related mortality or morbidity, or on total drowning accidents (fatal and non-fatal), in LMICs, compared to no day care programs or other drowning prevention interventions Secondary objectives • To assess the effects of day care programs in LMICs for children under 6 years of age on unsafe water exposure • To assess safety within these programs (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) • To assess the incidence of unintentional injury within these programs • To describe the cost-effectiveness of such programs, in relation to averted drowning-related mortality or morbidity SEARCH METHODS: On November 23, 2019, and for an update on August 18, 2020, we searched MEDLINE (PubMed), Embase, CENTRAL, ERIC, and CINAHL, as well as two trial registries. On December 16, 2019, and for an update on February 9, 2021, we searched 12 other resources, including websites of organizations that develop programs targeted to children.

SELECTION CRITERIA

We included randomized, quasi-randomized, and non-randomized controlled studies (with explicitly listed specific study design features) that implemented formal day care programs as a single program or combined with additional out-of-day care components (such as educational activities aimed at preventing injury or drowning or early childhood development activities) for children of preschool age (below 6 years of age) in LMICs for comparison with no such programs or with other drowning prevention interventions. Studies had to report at least one outcome related to drowning or injury prevention for the children enrolled.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection and data extraction, as well as risk of bias and GRADE assessment.

MAIN RESULTS

Two non-randomized observational studies, conducted in rural Bangladesh, involving a total of 252,631 participants, met the inclusion criteria for this review. One of these studies compared a formal day care program combined with parent education, playpens provided to parents, and community-based activities as additional out-of-day care components versus no such program. Overall we assessed this study to be at moderate risk of bias (moderate risk of bias due to confounding, low risk of bias for other domains). This study showed that implementation of a formal day care program combined with parent education, provision of playpens to parents, and community-based activities, in a rural area with a high drowning incidence, likely reduces the risk of death from drowning over the study period of 4 years and 8 months compared to no day care program (hazard ratio 0.18, 95% confidence interval [CI] 0.06 to 0.58; 1 study, 136,577 participants; moderate-certainty evidence). Drowning morbidity (non-fatal drowning resulting in complications), total drowning (fatal and non-fatal), unsafe water exposure, and program safety (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) were not reported, nor was the incidence of other unintentional injuries. Cost-effectiveness was reported as 812 USD (95% CI 589 to 1777) per disability-adjusted life-year averted as a consequence of drowning (moderate-certainty evidence). The second study compared day care programs with or without playpens provided to parents as an additional component versus only playpens provided to parents as an alternative drowning prevention intervention. Overall we assessed the study to be at critical risk of bias because we judged bias due to confounding to be at critical risk. As the certainty of evidence was very low, we are uncertain about the effects on drowning mortality rate of implementing a day care program compared to providing playpens (rate ratio 0.25, 95% CI 0.15 to 0.41; 1 study; 76,575 participants; very low-certainty evidence). Likewise, we are uncertain about the effects of a day care program with playpens provided as an additional component versus playpens provided alone (rate ratio 0.06, 95% CI 0.02 to 0.12; 1 study, 45,460 participants; very low-certainty evidence). The other outcomes of interest - drowning morbidity, total drowning, unsafe water exposure, program safety, incidence of other unintentional injuries, and cost-effectiveness - were not reported.

AUTHORS' CONCLUSIONS

This review provides evidence suggesting that a day care program with additional out-of-day care components such as community-based education, parent education, and playpens provided to parents likely reduces the drowning mortality risk in regions with a high burden of drowning compared to no intervention.

Exploring the Use and Appeal of Playpens to Protect Infants from Exposure to Animals, Animal Feces, and Dirt in Rural Ethiopia

The persistence and pervasiveness of growth stunting in low- and middle-income countries spur reexamination of disease transmission pathways related to water, sanitation, and hygiene. Animal feces constitute a more important reservoir of enteric pathogens in homes in low-income countries than previously recognized, and exploratory object mouthing and direct ingestion of soil and animal feces represent underexplored exposure pathways. The effectiveness, adoption, constraints, and scale-up potential of measures for reducing infant and young children's exposure to fecal pathogens are recently beginning to be systematically explored. This mixed methods study tested the feasibility and appeal of using playpens to establish a hygienic "safe zone" for infants in rural Ethiopia. We conducted home trials of three playpen designs, including two models made from locally available materials through user-centered design. After using playpens for several weeks, caregivers reported extensive benefits, ranging from perceived safety to developmental and hygiene benefits for infants and relief from physical stress and worry for caregivers. We observed many playpens contaminated with Escherichia coli after weeks of use, though at concentrations below those of the common room floor on which infants might otherwise have played. Caregivers reported daily playpen use, but for intervals likely insufficient to protect infants from pathogen exposure affecting growth. We determine that playpens alone cannot plausibly protect infants from environmental contamination, but our results support further exploration of the potential benefits and commercial viability of scaling up use of playpens in rural, agricultural households as part of a comprehensive approach to child development and women's empowerment.

Large-scale evaluation of interventions designed to reduce childhood Drownings in rural Bangladesh: a before and after cohort study

Background

This paper estimates the impact on childhood drowning rates of community-based introduction of crèches or playpens or both in rural Bangladesh for children aged 0–47 months.

Methods

A baseline census of the whole population of 270,387 households in 51 unions, 451 villages from 7 rural sub-districts in Bangladesh was conducted in 2013. The baseline census determined retrospective, age-specific, and cumulative drowning incidence rates (IR) experienced in the target households in the 12 months prior to the intervention. Beginning in late 2013, creches for drowning prevention were established across the study area. Acceptance into creches was provided and written assent to attend a creche was obtained for all children aged 9–47 months in all participating unions. Playpens were provided to 45,460 of these children, of which 5981 children received only the playpens. All children were followed-up until their 48-month birthday or administrative censoring (fixed timepoint to stop observing the drowning deaths), after a two-year implementation period (2014–2016). Drowning IR were estimated for children and compared to corresponding baseline rates from 2012. Age-specific drowning IR under different “as treated” categories (playpen-only, creche-only, and playpen-plus-creche) were compared to the baseline rates experienced by the categorized households prior to intervention.

Results

A total of 3205 creches (average of 7 creches per village) were established, and 116,054 children aged 9–47 months were exposed to the intervention packages. Aggregated drowning IRs between age 0 and 47 were estimated per 100,000 population per year at 86.73 (95% CI: 69.67–107.97) and 43.03 (95% CI: 35.55–52.10) in the baseline and post implementation period, respectively. Risk ratios were 0.40 (95% CI: 0.28–0.57) overall, and 0.34 (95% CI: 0.13–0.90), 0.09 (95% CI: 0.02–0.36), and 0.04 (95% CI: 0.002–0.60) in children under the creche-only, aged, 1, 2, and 3 years old respectively. Inexplicably, drowning rates were statistically significantly higher post-intervention in children 0-11 months. There was no mortality reduction with playpen use (alone or in combination), and this group may actually have had a higher risk of drowning.

Conclusions

Creches are effective for preventing childhood drowning in rural Bangladesh for children above age 1-year, and should be considered for further scale-up.

Animal-related injuries and fatalities: evidence from a large-scale population-based cross-sectional survey in rural Bangladesh

OBJECTIVE

This study determines the magnitude and pattern of animal-related injury mortalities and morbidities in rural Bangladesh.

DESIGN AND SETTING

A cross-sectional survey was conducted in 51 Unions of 7 subdistricts of Bangladesh from June 2013 to September 2013.

PARTICIPANTS

A total of approximately 1.17 million individuals across all age and gender profiles were included in the survey. The participants had to be residents of the seven subdistricts and have provided consent to participate in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Animal-related injury characteristics and demographic information was collected in the study. Frequency, proportion and 95% CIs of variables such as type of animal, type of animal attack, activity of the person prior to attack and the seasonality of the injury were reported. Data was then statistically analysed for associations between injury and sociodemographic characteristics.

RESULTS

The incidence rate of fatal and non-fatal animal-related injuries across all ages were 0.7 (95% CI 0.4 to 1.4) and 1635.3 (95% CI 1612.0 to 1658.0) per 100 000 populations, respectively. Non-fatal animal-related injury rates were highest among adults 18 years and older (1820.6 per 100 000 population (1777.2 to 1865.1)), and in males across all age groups. The most common animal injury was wasp/hornet/bee sting (49%), followed by cow/buffalo (25%), dog bite (9%) and snake bites (9%).

CONCLUSIONS

Animal-related injuries are an important public health issue in rural Bangladesh. The incidence of animal-related morbidities was found high in the study area. Males, school-going and productive age groups were at high risk. Immediate attention should be given to prevent these events.

Burden of Lesser-Known Unintentional Non-Fatal Injuries in Rural Bangladesh: Findings from a Large-Scale Population-Based Study

Around 90% of all fatal and non-fatal unintentional injuries occur in low- and middle-income countries (LMICs). The magnitude of unintentional injuries is unclear due to limited research and data. This paper describes the burden of lesser-known injuries (LKIs-cut injuries, unintentional poisoning, machine injuries, electrocution, injury by blunt objects, and suffocation) in rural Bangladesh, using data from the Saving of Lives from Drowning (SoLiD) project in Bangladesh. Descriptive statistics were used to report counts and rates of injuries by socio-demographic factors, injury characteristics, and circumstantial details. The annual morbidity rate of LKIs was 6878 injuries per 100,000 persons, involving 3.4% (40,520) of the population. Cut injury (44,131.2/100,000 per year) and injury by blunt objects (19768.6/100,000 per year) attributed in large numbers to the overall burden of LKIs. Males (66.1%) suffered more injuries than females. More than half (52.9%) occurred among people aged 25 to 64 years. Those involved in agriculture suffered the most injuries, mainly cut injuries (9234.1/100,000 per year) and machine-related injuries (582.9/100,000 per year). Most injuries occurred in the home setting. Increased awareness about packaging, storage, and the proper handling of appliances can help lower the frequency of LKIs. Safe architecture and awareness about home injuries is required to reduce injuries occurring in the home environment.

Epidemiological characteristics and influencing factors of fatal drowning in children under 5 years old in Hunan Province, China: case-control study

BACKGROUND

Drowning is still the primary cause of death in children under 5 years old, however, little is known about the drowning of Hunan province children. This study identifies the previously unpublished incidence and characteristics of fatal drowning in children of Hunan Province, and provide a basis for formulating strategies for children's survival, development and protection.

METHODS

Data were collected through sampling with the multistage stratified cluster. The case group included all fatal frowning children under 5 years old in 13 districts between October 2015 and September 2016. The control group was matched 1:1.The epidemic features and influencing factors of fatal drowning were analyzed retrospectively according to descriptive analysis, conditional univariate and multivariate logistic regression analysis.

RESULTS

For children aged 0-4 years, the fatal drowning was 16.1/100000 in Hunan Province. Drowning rates were higher for boys than girls. The proportion of rural areas is much higher than that of urban areas. The 1-2 years age-group was the highest of all age groups. Fatal drowning mainly occurred in summer. The three leading drowning locations were pond, ditch and well. Playing close to the water were the leading activities that preceded fatal drowning. Multivariate logistic regression analysis showed that: children with primary caregiver education in high school and above (OR = 0.05) have a lower risk of fatal drowning; children with full-time care (OR = 0.17) have a lower risk; children who received unintentional drowning safety education (OR = 0.23) have a lower risk of fatal drowning. Children who were always swimming or playing near the water in the past 6 months (OR = 3.13) have a higher risk of fatal drowning.

CONCLUSION

The fatal drowning among children under 5 years is the result of the interaction of multiple factors. A significant number of child deaths could have been prevented if parents and other close relatives had been more concerned about the safety of their children. We should develop health education plans for villagers to warn them of the dangers of drowning and preventive measures.

The association between water, sanitation and hygiene (WASH) conditions and drowning in Bangladesh

The present study investigated associations between water, sanitation and hygiene (WASH) factors and fatal and non-fatal drowning events in Bangladesh. Here, we report findings from a large household survey (89,700) conducted in Barisal Division of Bangladesh. Univariate analyses showed that the use of surface water rather than piped water was associated with an increased risk of both fatal and non-fatal drowning events. Additionally, increased risk of non-fatal drowning events was associated with shared toilet facilities, lack of toilet facilities and non-cemented flooring such as bamboo and wood. The WASH measures reduce the need to access exposure to open water, thus reducing drowning events.

A Community-Designed Play-Yard Intervention to Prevent Microbial Ingestion: A Baby Water, Sanitation, and Hygiene Pilot Study in Rural Zambia

Malnourished children in low-income contexts usually suffer from environmental enteric dysfunction, which is damage to the intestines caused by chronic exposure to bacterial pathogens from feces hypothesized to contribute to stunting. Many intervention studies are piloting "Baby water, sanitation, and hygiene (WASH)" to help rural farming families reduce infant and young children's (IYC's) exposure to human and free-range livestock feces. One proposed Baby WASH intervention is a play-yard, which consists of a baby-proofed structure (i.e., playpen) that caregivers can place IYC into while doing chores around the household yard. This article describes the pilot development and assessment of a community-built Baby WASH play-yard and a plastic play-yard intervention with 21 caregivers of 6- to 24-month-old IYC in rural Zambia. A modified Trials of Improved Practices approach was used to conduct three visits in each household: an introductory visit during which play-yard use was explained, a second visit consisting of a semi-structured interview and a session of behavioral counseling, and a final visit which included a 2-hour observation of play-yard use. The second and final visits also included 24-hour recalls, and all three visits included spot observations of play-yard use. Reports from caregivers suggest that the community-built play-yard protected IYC from ingesting soil and livestock feces. Barriers to intervention use included caregivers' WASH beliefs and practices, community reactions, and play-yard maintenance. More work is needed to examine the role of women's time use in their home environment, community reactions to the intervention, and the biological efficacy to reduce microbial ingestion.

Risk profile for drowning deaths in children in the Indian state of Bihar: results from a population-based study

BACKGROUND

We report on incidence of drowning deaths and related contextual factors in children from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy (VA).

METHODS

Interviews were conducted for deaths in 1-14 years population that occurred from January 2012 to March 2014 in 109 689 households (87.1% participation) in 1017 clusters representative of the state. The Population Health Metrics Research Consortium shortened VA questionnaire was used for interview and cause of death was assigned using the SmartVA automated algorithm. The annualised unintentional drowning death incidence, activity prior to drowning, the body of water where drowning death had occurred and contextual information are reported.

FINDINGS

The survey covered 224 077 children aged 1-14 years. Drowning deaths accounted for 7.2%, 12.5% and 5.8% of all deaths in 1-4, 5-9 and 10-14 years age groups, respectively. The adjusted incidence of drowning deaths was 14.3 (95% CI 14.0 to 14.7) per 100 000 children, with it being higher in urban (16.1, 95% CI 14.8 to 17.3) areas. Nearly half of the children drowned in a river (5.9, 95% CI 5.6 to 6.1) followed by in a pond (2.8, 95% CI 2.6 to 2.9). Drowning death incidence was the highest while playing (5.1, 95% CI 4.9 to 5.4) and bathing (4.0, 95% CI 3.8 to 4.2) with the former accounting for more deaths in 1-4 years age group. Sixty per cent of children were already dead when found. None of these deaths were reported to the civil registration system to obtain death certificate.

INTERPRETATION

The findings from this large representative sample of children document the magnitude of and variations in unintentional drowning deaths in Bihar. Urgent targeted drowning interventions are needed to address the risk in children. Gross under-reporting of drowning deaths in children in India needs attention.

Fatal and non-fatal injury outcomes: results from a purposively sampled census of seven rural subdistricts in Bangladesh

BACKGROUND

90% of the global burden of injuries is borne by low-income and middle-income countries (LMICs). However, details of the injury burden in LMICs are less clear because of the scarcity of data and population-based studies. The Saving of Lives from Drowning project, implemented in rural Bangladesh, did a census on 1·2 million people to fill this gap. This Article describes the epidemiology of fatal and non-fatal injuries from the study.

METHODS

In this study, we used data from the baseline census conducted as part of the Saving of Lives from Drowning (SoLiD) project. The census was implemented in 51 unions from seven purposively sampled rural subdistricts of Bangladesh between June and November, 2013. Sociodemographic, injury mortality, and morbidity information were collected for the whole population in the study area. We analysed the data for descriptive measures of fatal and non-fatal injury outcomes. Age and gender distribution, socioeconomic characteristics, and injury characteristics such as external cause, intent, location, and body part affected were reported for all injury outcomes.

FINDINGS

The census covered a population of 1 169 593 from 270 387 households and 451 villages. The overall injury mortality rate was 38 deaths per 100 000 population per year, and 104 703 people sustained major non-fatal injuries over a 6-month recall period. Drowning was the leading external cause of injury death for all ages, and falls caused the most number of non-fatal injuries. Fatal injury rates were highest in children aged 1-4 years. Non-fatal injury rates were also highest in children aged 1-4 years and those aged 65 years and older. Males had more fatal and non-fatal injuries than females across all external causes except for burns. Suicide was the leading cause of injury deaths in individuals aged 15-24 years, and more than 50% of the suicides occurred in females. The home environment was the most common location for most injuries.

INTERPRETATION

The burden of fatal and non-fatal injuries in rural Bangladesh is substantial, accounting for 44 050 deaths and 21 million people suffering major events annually. Targeted approaches addressing drowning in children (especially those aged 1-4 years), falls among the elderly, and suicide among young female adults are urgently needed to reduce injury deaths and morbidity in Bangladesh.

FUNDING

Bloomberg Philanthropies.

A systematic approach to injury policy assessment: introducing the assessment of child injury prevention policies (A-CHIPP)

Introduction

This study presents a systematic approach—assessment of child injury prevention policies (A-CHIPP)—to assess and track policies on effective child injury interventions at the national level. Results from an initial pilot test of the approach in selected countries are presented.

Method

A literature review was conducted to identify conceptual models for injury policy assessment, and domains and indicators were proposed for assessing national injury policies for children aged 1–9 years. The indicators focused on current evidence-supported interventions targeting the leading external causes of child injury mortality globally, and were organised into a self-administered A-CHIPP questionnaire comprising 22 questions. The questionnaire was modified based on reviews by experts in child injury prevention. For an initial test of the approach, 13 countries from all six WHO regions were selected to examine the accuracy, usefulness and ease of understanding of the A-CHIPP questionnaire.

Results

Data on the A-CHIPP questionnaire were received from nine countries. Drowning and road traffic injuries were reported as the leading causes of child injury deaths in seven of these countries. Most of the countries lacked national policies on interventions that address child injuries; supportive factors such as finance and leadership for injury prevention were also lacking. All countries rated the questionnaire highly on its relevance for assessment of injury prevention policies.

Conclusion

The A-CHIPP questionnaire is useful for national assessment of child injury policies, and such an assessment could draw attention of stakeholders to policy gaps and progress in child injury prevention in all countries.

Developmental Assessments during Injury Research: Is Enrollment of Very Young Children in Crèches Associated with Better Scores?

The Developmental Study is part of a larger intervention on “saving of lives from drowning (SoLiD)” where children were enrolled either into crèches (daycare centers) or playpens to prevent drowning in rural Bangladesh. Sampling ~1000 children between the ages of 9–17 months, we compared problem-solving, communication, motor and personal-social outcomes assessed by the Ages and Stages Questionnaire in the two interventions. After controlling for variables such as home stimulation in multivariate regressions, children in crèches performed about a quarter of a standard deviation better in total scores (p < 0.10) and 0.45 standard deviations higher in fine motor skills (p < 0.05). Moreover, once the sample was stratified by length of exposure to the intervention, then children in crèches performed significantly better in a number of domains: those enrolled the longest (about 5 months) have higher fine motor (1.47, p < 0.01), gross motor (0.40, p < 0.05) and personal-social skills (0.95, p < 0.01) than children in playpens. In addition, children in crèches with the longer exposure (about 5 months) have significantly higher personal-social and problem-solving scores than those in crèches with minimum exposure. Enrollment in crèches of very young children may be positively associated with psychosocial scores after accounting for important confounding variables.

The Burden of Suicide in Rural Bangladesh: Magnitude and Risk Factors

The aim of the paper is to quantify the burden and risk factors of fatal and non-fatal suicidal behaviors in rural Bangladesh. A census was carried out in seven sub-districts encompassing 1.16 million people. Face-to-face interviews were conducted at the household level. Descriptive analyses were done to quantify the burden and Poisson regression was run to determine on risk factors. The estimated rates of fatal and non-fatal suicide were 3.29 and 9.86 per 100,000 person years (PY) observed, respectively. The risk of suicide was significantly higher by 6.31 times among 15-17 and 4.04 times among 18-24 olds compared to 25-64 years old. Married adolescents were 22 times more likely to commit suicide compared to never-married people. Compared to Chandpur/Comilla district, the risk of suicide was significantly higher in Narshingdi. Students had significantly lower risk of non-fatal suicidal behavior compared to skilled laborers. The risk of non-fatal suicidal behavior was lower in Sherpur compared to Chandpur/Comilla. Among adolescents, unskilled laborers were 16 times more likely to attempt suicide than students. The common methods for fatal and non-fatal suicidal behaviors were hanging and poisoning. Suicide is a major public health problem in Bangladesh that needs to be addressed with targeted interventions.

Epidemiology of Fall Injury in Rural Bangladesh

Globally, falls are the second leading cause of unintentional injury deaths, with 80% occurring in low-and middle-income countries. The overall objective of this study is to describe the burden and risk factors of falls in rural Bangladesh. In 2013, a large household survey covering a population of 1,169,593 was conducted in seven rural sub-districts of Bangladesh to assess the burden of all injuries, including falls. The recall periods for non-fatal and fatal injuries were six and 12 months, respectively. Descriptive, bivariate and multiple logistic regression analyses were conducted. The rates of non-fatal and fatal falls were 36.3 per 1000 and 5 per 100,000 population, respectively. The rates of both fatal and non-fatal falls were highest among the elderly. The risk of non-fatal falls was higher at extremes of age. Lower limb and waist injuries were frequent following a fall. Head injuries were frequent among infants (35%), while lower limb and waist injuries were frequent among the elderly (>65 years old). Injuries to all body parts (except the waist) were most frequent among men. More than half of all non-fatal falls occurred in a home environment. The injury patterns and risk factors of non-fatal falls differ by sociodemographic factors.

Impact of First Aid on Treatment Outcomes for Non-Fatal Injuries in Rural Bangladesh: Findings from an Injury and Demographic Census

Non-fatal injuries have a significant impact on disability, productivity, and economic cost, and first-aid can play an important role in improving non-fatal injury outcomes. Data collected from a census conducted as part of a drowning prevention project in Bangladesh was used to quantify the impact of first-aid provided by trained and untrained providers on non-fatal injuries. The census covered approximately 1.2 million people from 7 sub-districts of Bangladesh. Around 10% individuals reported an injury event in the six-month recall period. The most common injuries were falls (39%) and cuts injuries (23.4%). Overall, 81.7% of those with non-fatal injuries received first aid from a provider of whom 79.9% were non-medically trained. Individuals who received first-aid from a medically trained provider had more severe injuries and were 1.28 times more likely to show improvement or recover compared to those who received first-aid from an untrained provider. In Bangladesh, first-aid for non-fatal injuries are primarily provided by untrained providers. Given the large number of untrained providers and the known benefits of first aid to overcome morbidities associated with non-fatal injuries, public health interventions should be designed and implemented to train and improve skills of untrained providers.

Caregiver Supervision Practices and Risk of Childhood Unintentional Injury Mortality in Bangladesh

Unintentional injury-related mortality rate, including drowning among children under five, is disproportionately higher in low- and middle-income countries. The evidence links lapse of supervision with childhood unintentional injury deaths. We determined the relationship between caregiver supervision and unintentional injury mortality among children under five in rural Bangladesh. We conducted a nested, matched, case-control study within the cohort of a large-scale drowning prevention project in Bangladesh, “SOLID—Saving of Children’s Lives from Drowning”. From the baseline survey of the project, 126 cases (children under five with unintentional injury deaths) and 378 controls (alive children under five) were selected at case-control ratio of 1:3 and individually matched on neighborhood. The association between adult caregiver supervision and fatal injuries among children under five was determined in a multivariable conditional logistic regression analysis, and reported as adjusted matched odds ratio (MOR) with 95% confidence intervals (CIs). Children under five experiencing death due to unintentional injuries, including drowning, had 3.3 times increased odds of being unsupervised as compared with alive children (MOR = 3.3, 95% CI: 1.6–7.0), while adjusting for children’s sex, age, socioeconomic index, and adult caregivers’ age, education, occupation, and marital status. These findings are concerning and call for concerted, multi-sectoral efforts to design community-level prevention strategies. Public awareness and promotion of appropriate adult supervision strategies are needed.

Care-Seeking Patterns and Direct Economic Burden of Injuries in Bangladesh

This study provides a comprehensive review of the care-seeking patterns and direct economic burden of injuries from the victims’ perspective in rural Bangladesh using a 2013 household survey covering 1.17 million people. Descriptive statistics and bivariate analyses were used to derive rates and test the association between variables. An analytic model was used to estimate total injury out-of-pocket (OOP) payments and a multivariate probit regression model assessed the relationship between financial distress and injury type. Results show non-fatal injuries occur to 1 in 5 people in our sample per year. With average household size of 4.5 in Bangladesh--every household has an injury every year. Most non-fatally injured patients sought healthcare from drug sellers. Less than half of fatal injuries sought healthcare and half of those with care were hospitalized. Average OOP payments varied significantly (range: $8–$830) by injury type and outcome (fatal vs. non-fatal). Total injury OOP expenditure was $355,795 and $5000 for non-fatal and fatal injuries, respectively, per 100,000 people. The majority of household heads with injuries reported financial distress. This study can inform injury prevention advocates on disparities in healthcare usage, OOP costs and financial distress. Reallocation of resources to the most at risk populations can accelerate reduction of preventable injuries and prevent injury related catastrophic payments and impoverishment.

Epidemiology of Burns in Rural Bangladesh: An Update

Each year, approximately 265,000 deaths occur due to burns on a global scale. In Bangladesh, around 173,000 children under 18 sustain a burn injury. Since most epidemiological studies on burn injuries in low and middle-income countries are based on small-scale surveys or hospital records, this study aims to derive burn mortality and morbidity measures and risk factors at a population level in Bangladesh. A household survey was conducted in seven rural sub-districts of Bangladesh in 2013 to assess injury outcomes. Burn injuries were one of the external causes of injury. Epidemiological characteristics and risk factors were described using descriptive as well as univariate and multivariate logistic regression analyses. The overall mortality and morbidity rates were 2 deaths and 528 injuries per 100,000 populations. Females had a higher burn rate. More than 50% of injuries were seen in adults 25 to 64 years of age. Most injuries occurred in the kitchen while preparing food. 88% of all burns occurred due to flame. Children 1 to 4 years of age were four times more likely to sustain burn injuries as compared to infants. Age-targeted interventions, awareness of first aid protocols, and improvement of acute care management would be potential leads to curb death and disability due to burn injuries.

Our Shrinking Globe: Implications for Child Unintentional Injuries

Unintentional injuries are a leading cause of deaths for children of all ages. Globally, they accounted for 15.4% of 2.6 million deaths recorded among children aged 1 to 14 years in 2013. The 12 highest burden countries in the world by absolute death count and mortality are low- and middle-income countries (LMIC) except for Russia and Equatorial Guinea. These countries accounted for 58% of the 406,442 unintentional injury deaths among 1 to 14 year olds in 2013. Globalization drives inequalities in the distribution of economic gains, risks, and opportunities for preventing child unintentional injuries between high-income countries and LMIC.