Child supervision practices for drowning prevention in rural Bangladesh: a pilot study of supervision tools

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.

Incidence of childhood injuries and modifiable household risk factors in rural Ghana: a multistage, cluster-randomised, population-based, household survey

OBJECTIVE

We aimed to describe the incidence of childhood household injuries and prevalence of modifiable household risk factors in rural Ghana to inform prevention initiatives.

SETTING

357 randomly selected households in rural Ghana.

PARTICIPANTS

Caregivers of children aged <5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Childhood injuries that occurred within 6 months and 200 metres of the home that resulted in missed school/work, hospitalisation and/or death. Sampling weights were applied, injuries were described and multilevel regression was used to identify risk factors.

RESULTS

Caregivers from 357 households had a mean age of 35 years (SD 12.8) and often supervised ≥2 children (51%). Households typically used biomass fuels (84%) on a cookstove outside the home (79%). Cookstoves were commonly <1 metre of the ground (95%). Weighted incidence of childhood injury was 542 per 1000 child-years. Falls (37%), lacerations (24%), burns (12%) and violence (12%) were common mechanisms. There were differences in mechanism across age groups (p<0.01), but no gender differences (p=0.25). Presence of older children in the home (OR 0.15, 95% CI 0.09 to 0.24; adjusted OR (aOR) 0.26, 95% CI 0.13 to 0.54) and cooking outside the home (OR 0.28, 95% CI 0.19 to 0.42; aOR 0.25, 95% CI 0.13 to 0.49) were protective against injury, but other common modifiable risk factors (eg, stove height, fuel type, secured cabinets) were not.

CONCLUSIONS

Childhood injuries occurred frequently in rural Ghana. Several common modifiable household risk factors were not associated with an increase in household injuries. Presence of older children was a protective factor, suggesting that efforts to improve supervision of younger children might be effective prevention strategies.

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.

Implementing a crèche-based community drowning programme in rural Bangladesh: a process evaluation

Background

Living and environmental conditions in rural Bangladesh expose children to drowning. The Anchal programme protects children through crèche-based supervision in an enclosed space run by locally recruited carers. It is unclear under what conditions the programme best operates to maximise protection. We conducted a process evaluation of Anchal to determine enabling factors and challenges to implementation.

Methods

Quantitative programme data were analysed to calculate metrics including child participation and fidelity of implementation to defined processes. Qualitative data collection with programme participants and implementers provided insights into barriers and enablers of implementation. Analysis was guided by the UK Medical Research Council’s process evaluation framework.

Results

Anchal operated 400 centres with an average of 22.2 children enrolled, as per target. However, daily attendance averaged lower than the 80% target. Children aged 1–2 years old, who are most at risk of drowning, were least likely to enrol and attend regularly due to low engagement with activities and parental concerns for safety. Greater distances and lower educational attainment in some regions reduced attendance and increased carer attrition.

Conclusions

The Anchal programme met most programme delivery targets. However, programme success could be improved through increasing supervision, providing communication training for implementing staff, designing programmes for children aged 1–2 years old, encouraging community ownership and providing child pick-up services. These contextual solutions can be adapted to similar programmes operating through grassroots-level engagement and recruitment of community health workers, to maximise their effectiveness and sustainability.

Prevention of childhood unintentional injuries in low- and middle-income countries: A systematic review

Injuries are a leading cause of death and disability among children. Numerous injury prevention strategies have been successful in high-income countries, but the majority of unintentional injuries happen to children living in low- and middle-income countries (LMICs). This project aims to delineate the childhood injury prevention initiatives in LMICs. For inclusion, peer-reviewed articles needed to address unintentional injury, include children <18, assess a prevention-related intervention, contain a control group, and be published after 1988. Two pairs of reviewers evaluated articles independently to determine study eligibility. 74 articles were included. 30 studies addressed road traffic injuries, 11 drowning, 8 burns, 3 falls, 8 poisonings, and 21 an unspecified injury type. The findings show positive effects on injury outcome measures following educational interventions, the need for longer follow-up periods after the intervention, the need for effectiveness trials for behavior change, and the need for an increase in injury prevention services in LMICs. This is the first systematic review to summarize the prevention initiatives for all types of childhood unintentional injuries in LMICs. Increased attention and funding are required to go beyond educational initiatives with self-reported measures and little follow-up time to robust interventions that will reduce the global burden of unintentional injuries among children.

Environmental change interventions to prevent unintentional home injuries among children in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Unintentional home injury is an important cause of death and disability among children, especially those living in low- and middle-income countries (LMICs). This systematic review aimed to synthesize evidence about the effectiveness of environmental interventions to prevent unintentional child injury and/or reduce injury hazards in the home in LMICs.

METHODS

Seven electronic databases were searched for randomized controlled trials (RCTs) and controlled before and after (CBA) studies published up to 1 April 2018. Potentially eligible citations were screened by title and abstract and full texts of studies obtained. Synthesis was reported narratively, and where possible, meta-analysis was conducted.

RESULTS

Four studies met the inclusion criteria: One CBA study reported changes in injury incidence, and three RCTs reported changes in frequency of home hazards. In one study, child resistant containers were found effective in reducing the incidence of paraffin ingestion by 47% during and by 50% postintervention. A meta-analysis of two trials found that home inspection, safety education and safety devices reduced postintervention mean scores for poisoning hazards [mean difference (MD) -0.77; 95% CI [-1.36, -0.19]] and burn-related unsafe practices (MD -0.37; 95% CI [-0.66, -0.09]) but not for falls or electrical and paraffin burn hazards. A single trial found that home inspection and safety education reduced the postintervention mean scores for fall hazards (MD -0.5; 95% CI [-0.66, -0.33]) but not for ingestion hazards.

CONCLUSION

There is limited evidence that environmental change interventions reduce child injuries but evidence that they reduce some home hazards. More evidence is needed to determine if altering the physical home environment by removing potential hazards reduces injuries in LMICs.

Microbiological contamination of young children's hands in rural Bangladesh: Associations with child age and observed hand cleanliness as proxy

Background

Hands are a route of transmission for fecal-oral pathogens. This analysis aimed to assess associations between hand E. coli contamination and child age and determine if observed hand cleanliness can serve as a proxy for E. coli contamination on young children’s hands.

Methods

Trained field workers collected hand rinse samples from children aged 1–14 months in 584 households in rural Bangladesh and assessed the visual cleanliness of child hands (fingernails, finger pads and palms). Samples were analyzed using the IDEXX most probable number (MPN) methodto enumerate E. coli. We assessed if child age (immobile children aged 1–4 months vs. mobile children aged 5–14 months) is associated with log₁₀E. coli counts on hands using generalized estimating equations (GEE). We estimated the log₁₀ difference in hand E. coli counts associated with the cleanliness of different hand parts using a multivariable GEE model.We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for dirty fingernails, fingerpads, palms and overall hands (the three observed parts combined) against binary E. coli presence on hands.

Results

E. coli was detected on 43% of child hands. Children in the mobile age range had 0.17 log₁₀ MPN higher E. coli on hands than those in the immobile age range (Δlog₁₀ = 0.17, 95% CI = 0.02, 0.32, p = 0.03). Children with visible dirt particles on finger pads had 0.46 log₁₀ MPN higher E. coli on hands than those with clean finger pads (Δlog₁₀ = 0.46, 95% CI = 0.05, 0.87, p = 0.03). Dirty fingernails indicated binary E. coli presence with 81% sensitivity and 26% specificity while dirty fingerpads and palms indicated E. coli presence with 29% sensitivity and 75–77% specificity. The PPV was 45–48% and NPV 59–65% for all three types of observations.

Conclusion

Hand contamination with E. coli was prevalent among young children in rural Bangladesh, with higher levels of contamination among mobile children. Studies should assess if strategies to remove animal feces from the courtyard, provide designated hygienic play spaces for children and deliver targeted messaging to mothers to wipe or wash children’s hands after contact with animals and animal feces reduce child hand contamination. Visible hand cleanliness was a poor predictor of E. coli presence on young children’s hands so other low-cost field measurements are needed to accurately detect fecal contamination on hands.

Complexity in Implementing Community Drowning Reduction Programs in Southern Bangladesh: A Process Evaluation Protocol

Living and geographical conditions in Bangladesh expose children to a high risk of drowning. Two programs operating in the Barishal Division of Bangladesh aim to reduce drowning risk through the provision of crèches (Anchal) and swim and rescue classes (SwimSafe). Anchal provides a safe environment with early childhood education to children aged 1⁻5 years old, while SwimSafe teaches children aged 6⁻10 years old basic swimming and rescue skills. Despite evidence for their effectiveness, it is unclear under which conditions these programs best operate. This protocol describes a project that seeks to conduct a process evaluation and gender analysis to identify implementation inefficiencies and contextual considerations for improved sustainability of the programs. A mixed- method approach using both qualitative and quantitative data will be used. Quantitative program data will be analysed to measure program utilisation, delivery and reach, while qualitative data will be collected via key informant in-depth interviews (IDIs), focus group discussions (FGDs) and observations. The process evaluation of the Anchal and SwimSafe programs provides an opportunity for implementers to identify practical strategies to improve program delivery and improve contextual adaptability of these programs. Furthermore, the findings may provide guidance to other implementers aiming to deliver community-based programs in rural lower-middle income contexts.

Epidemiology of Drowning in Bangladesh: An Update

Over one-quarter of deaths among 1-4 year-olds in Bangladesh were due to drowning in 2003, and the proportion increased to 42% in 2011. This study describes the current burden and risk factors for drowning across all demographics in rural Bangladesh. A household survey was carried out in 51 union parishads of rural Bangladesh between June and November 2013, covering 1.17 million individuals. Information on fatal and nonfatal drowning events was collected by face-to-face interviews using a structured questionnaire. Fatal and non-fatal drowning rates were 15.8/100,000/year and 318.4/100,000/6 months, respectively, for all age groups. The highest rates of fatal (121.5/100,000/year) and non-fatal (3057.7/100,000/6 months) drowning were observed among children 1 to 4 years of age. These children had higher rates of fatal (13 times) and non-fatal drowning (16 times) compared with infants. Males had slightly higher rates of both fatal and non-fatal drowning. Individuals with no education had 3 times higher rates of non-fatal drowning compared with those with high school or higher education. Non-fatal drowning rates increased significantly with decrease in socio-economic status (SES) quintiles, from the highest to the lowest. Drowning is a major public health issue in Bangladesh, and is now a major threat to child survival.

Global childhood unintentional injury study: multisite surveillance data

OBJECTIVES

We aimed to analyze the epidemiology of childhood unintentional injuries presenting to hospitals in 5 select sites in low- and middle-income countries (LMICs) (Bangladesh, Colombia, Egypt, Malaysia, and Pakistan).

METHODS

We collected standardized data from children ages 0 to 12 years at participating emergency departments (EDs) in 2007. Statistical analyses were conducted to compare the characteristics of these injuries and to explore the determinants of injury outcomes.

RESULTS

Among 2686 injured children, falls (50.4%) and road traffic injuries (16.4%) were the most common, affecting boys more often (64.7%). Home injuries were more common among younger children (average 5.41 vs 7.06 years) and girls (38.2% vs 31.7%). Following an ED visit, 24% of injured children were admitted to the hospital, and 6 died. Injury outcomes were associated with risk factors, such as age and sex, to varying extents.

CONCLUSIONS

Standardized ED surveillance revealed unintentional injuries are a threat to child health. The majority of events took place inside the home, challenging traditional concepts of children's safety and underscoring the need for intensified context-appropriate injury prevention.

Supervision to prevent childhood unintentional injury: developmental knowledge and self-efficacy count

Caregiver developmental knowledge was tested as a moderator of the association between caregiver-perceived self-efficacy and perceived supervision to prevent childhood unintentional injury. Caregivers (N = 123; 95 mothers and 28 fathers) of children (M = 3.5 ± 1.2 years, 49.6% female, 80.8% Caucasian) were recruited from pediatric primary care offices and local message boards. All caregivers completed self-report questionnaires on perceived self-efficacy, developmental knowledge, and perceived supervision to prevent injury. Separate hierarchical linear regression models were conducted to test moderation for mothers and fathers. The interaction effect of perceived self-efficacy and developmental knowledge significantly predicted maternal-perceived supervision, R (2) change = .06, F(1, 86) = 6.76, p < .01. No significant findings were detected for fathers. Models of studying injury prevention that consider complex cognitive-behavioral interactions and their potential modifiable role in the development of injury-prevention practices may elucidate upon the attitude-practice gap currently identified in the literature.

Unintentional injuries: magnitude, prevention, and control

The World Health Organization estimates injuries accounted for more than 5 million deaths in 2004, significantly impacting the global burden of disease. Nearly 3.9 million of these deaths were due to unintentional injury, a cause also responsible for more than 138 million disability-adjusted life years (DALYs) lost in the same year. More than 90% of the DALYs lost occur in low- and middle-income countries (LMICs), highlighting the disproportionate burden that injuries place on developing countries. This article examines the health and social impact of injury, injury data availability, and injury prevention interventions. By proposing initiatives to minimize the magnitude of death and disability due to unintentional injuries, particularly in LMICs, this review serves as a call to action for further investment in injury surveillance, prevention interventions, and health systems strengthening.

Global health: injuries and violence

Injury and violence rank among the leading causes of death worldwide, with more than 5 million deaths annually, representing a significant portion of the global burden of disease. This article examines how injury and violence relate to global health using recent global burden of disease data and selected key studies and databases, and further explores risk factors and intervention initiatives that address unintentional and intentional injuries. The article serves as a call to action to enhance understanding of the growing burden of injury and violence, especially in low-income and middle-income countries, where more than 90% of injuries occur.

Current trends and update on injury prevention

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.