Dinesh Sethi

Guidelines for conducting community surveys on injuries and violence

Global mortality data indicate that in 2002 an estimated 5.2 million people died as a result of some form of injury. This number, however, does not reflect the numerous individuals who are non-fatally injured, many of whom suffer lifelong health consequences and disabilities. Combined data from high-income countries, such as Australia, the Netherlands, Sweden and the United States, indicate that in these countries for every person killed by injury, approximately 30 times as many people are hospitalized and roughly 300 times as many are treated in hospital emergency rooms and then discharged. When disability resulting from injury is also taken into consideration, injuries represent an even more significant public health problem. Developing countries account for approximately 90% of all injury fatalities world-wide. It is in these environments where the least has been done to prevent injuries. This is because of the lack of visibility of the problem, multisectorality and a lack of ownership and a failure to realize that injuries can be prevented through organized efforts of society. The present paper reports on the development of guidelines for conducting community surveys, which will contribute to increasing the visibility of the injury problem, especially in lowand middle-income countries, by providing a reliable methodology for their documentation. In many lowand middle-income countries vital statistics and routine health information may be lacking or, at best, patchy. Furthermore, in these settings demographic data may be incomplete or out of date, because it has been some years since a population census has been held. This situation may be compounded by the effects of wars, which lead to large population displacements, as has happened in countries of subSaharan Africa. Additionally, in post-conflict conditions the problem of injuries may be greater due to the ready availability of firearms and the loss of social cohesion in local and displaced populations. Routine health service information may be incomplete or inaccurate and reliance on it may lead to underestimates of the numbers of injured people seeking treatment in hospitals and other health facilities. As a result of a combination of these factors, estimates of the burden of injuries in lowand middle-income countries may be unreliable. Estimates for these countries are often based on projections from countries with more comprehensive injury data or on projections from population laboratories. Community-based, household surveys are one way of obtaining data on injury occurrence and deaths; in some settings such surveys also provide a means of collecting baseline population denominator data, necessary for the calculation of prevalence or incidence rates and that otherwise would not be available. In less resourced environments, a community survey to assess injuries can be a stand-alone method for the surveillance of injuries or a valuable adjunct to hospital-based injury surveillance systems. Adequate data about types of injuries, their causes and consequences are vital to understanding the scale and nature of the local injury problem and, subsequently, the implementation and evaluation of effective prevention programmes. Reliable information on injuries is also important to build up a picture of the extent of the national, regional and global problem. To address the need for improved injury surveillance, in 2001 the World Health Organization (WHO),

Reducing inequalities from injuries in Europe

Injuries cause 9% of deaths and 14% of ill health in the WHO European Region. This problem is neglected; injuries are often seen as part of everyday life. However, although western Europe has good safety levels, death and disability from injury are rising in eastern Europe. People in low-to-middle-income countries in the Region are 3.6 times more likely to die from injuries than those in high-income countries. Economic and political change have led to unemployment, income inequalities, increased traffic, reduced restrictions on alcohol, and loss of social support. Risks such as movement of vulnerable populations and transfer of lifestyles and products between countries also need attention. In many countries, the public-health response has been inadequate, yet the cost is devastating to individuals and health-service budgets. More than half a million lives could be saved annually in the Region if recent knowledge could be used to prevent injuries and thus redress social injustice in this area.

The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis

BACKGROUND A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. METHODS In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. FINDINGS Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I2 of >75%) between estimates for almost half of the outcomes. INTERPRETATION To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. FUNDING Public Health Wales.

Experience of domestic violence by women attending an inner city accident and emergency department.

Objectives: To identify the prevalence of domestic violence (DV) (defined as physical abuse perpetrated by intimate partners) in women attending an inner city accident and emergency department and to elicit women’s response about being asked routinely about domestic violence in this setting. Methods: 22 nursing shifts were purposefully sampled to be representative of day, night, and weekends. A questionnaire was administered to 198 consenting women who were not intoxicated, confused, or critically ill. Results: The prevalence of acute trauma in women attributable to DV was 1% (95%CI 0.14 to 3.6), the prevalence of lifetime physical abuse was 34.8% (95%CI 28.2 to 41.5), of past year physical abuse was 6.1% (95%CI 3.2 to 10.3), and of lifetime life threatening physical abuse was 10.6% (95%CI 6.3 to 14.9). Seventy six per cent of women felt comfortable about being asked about DV and 60.5% of women felt that they should always or usually be asked about DV in this setting. Conclusion: This cross sectional survey adds to the body of knowledge showing that the prevalence of DV in women attending an accident and emergency department is high. Most women were in favour of being asked, and disclosure was associated with discomfort in few women. This sensitive area of history taking and referral could be undertaken by health professionals using a supportive approach.

A unified framework for injury control: the public health approach and Haddon's Matrix combined

Injury specialists have not successfully convinced policy makers and the public that injuries can be controlled. That failure may be due in part to the lack of a unified understanding of injury control. The two most important models utilized in injury control are Haddons Matrix1 and the Public Health Approach (PHA). This paper argues that the PHA should be combined with the two axes of Haddons Matrix to result in a model that is coherent and comprehensive. Thus it is better than either one of the original models on their own. Haddons Matrix has two axes. The first includes elements of the epidemiological triad, host, vector, and environment and likens injury to disease. The second axis includes three time intervals, pre-event, event, and post-event. The importance of including time was that injury was conceptualized as predictable and preventable. The weakness of Haddons matrix is that it lacks a systematic plan of action. The Public Health Approach is a methodology for addressing injury, which consists of a hierarchy of four levels; surveillance, risk factor identification, intervention evaluation and program implementation. The use of the PHA with no specific orientation or means of application is its weakness. The PHA lacks a systematic point of application. Haddons Matrix lacks a systematic action plan. Therefore we propose the PHA as the systematic strategy for the more theoretical framework of Haddons matrix. By combining these concepts a coherent and comprehensive three-dimensional framework is defined. The unified model closes the potential gaps in the two original models and includes a systematic approach not previously achieved. This unified model is practical in defining individual studies and groups of studies. It can be used as an inventory, for a complete understanding of a particular injury. Diagrams of the model are presented to help teach the concepts of injury described in this unitary model. In conclusion, we can say that the inclusion of three injury concepts in one framework provides a rigorous and coherent construct for the understanding of injury and implementation of control activities. It can therefore be used to design more comprehensive programs for injury control and promote policies and funding commensurate with the magnitude of the injury problem.

Systematic review and quality assessment of economic evaluation studies of injury prevention

OBJECTIVE To review and assess the quality of economic evaluation studies on injury prevention measures. DESIGN Systematic review. DATA SOURCES Electronic databases searched included Medline (Pubmed), EMBASE, Web of Science, PsycINFO, and Safetylit. INCLUSION CRITERIA Empirical studies published in English in international peer-reviewed journals in the period 1998-2009. The subject of the study was economic evaluation of prevention of unintentional injury. Cost-effectiveness (CEA), cost-benefit (CBA) and cost utility (CUA) analyses were included. METHODS Methodological details, study designs, and analysis and interpretation of results of the included articles were reviewed and extracted into summary tables. Study quality was judged using the criteria recommended by the Panel on cost-effectiveness in health and medicine and the British Medical Journal (BMJ) checklist for economic evaluations. RESULTS Forty-eight studies met the inclusion criteria of our review. Interventions assessed most frequently were hip protectors and exercise programs for the elderly. A wide variety of methodological approaches was found, including differences in type of economic evaluation, perspective, time horizon, study design, cost categories, effect outcomes, and adjustments for timing and uncertainty used. The majority of studies performed a cost-effectiveness analysis from a societal perspective with a time horizon of one to five years, in which the effect was expressed in terms of injuries prevented and only direct health care costs were included. Most studies deviated from one or more of the Panel recommendations or BMJ guidelines; e.g. not adopting the societal perspective, not including all relevant costs, no incremental analysis. CONCLUSIONS This review has shown that approaches to economic evaluation of injury prevention vary widely and most studies do not fulfill methodological rigour. Improving quality and harmonization of economic evaluation studies in the field of injury prevention is needed. One way of achieving this would be to establish international guidelines on economic evaluation for injury prevention interventions, based on established economic evaluation checklists, to assist researchers in the design and reporting of economic evaluations.

Challenge of drowning prevention in low and middle income countries

Editor,—We read the editorial on “The challenge of drowning prevention” with great interest.1 There is no doubt that drowning is a major but under recognised cause of premature loss of life and disability. This has been borne out by the Global Burden of Disease Study which highlights the scale of the problem, by region and by age and sex characteristics.2 It is worth examining their findings further. At a worldwide level, Murray and Lopez estimated that drowning was responsible for about half a million deaths in 1990 and ranked 20th as a leading single cause of …

Growing inequalities in child injury deaths in Europe

In this short report, we describe and compare mortality data for injuries in children aged <15 years in the WHO European region as estimated by the WHO Global Health Estimates for 2000 and 2011. Child injury deaths have decreased overall. Mortality rate ratios between low- and middle-income countries (LMIC) and high-income countries in the region show an increase in relative inequalities for childhood deaths from unintentional injuries and a narrowing from intentional injury. This growing inequality in unintentional injury is a public health concern and calls for renewed efforts to reduce childhood injuries in LMIC the region.

Mortality due to injuries by place of occurrence in the European region: analysis of data quality in the WHO mortality database

Background and Objective: The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) has codes for the place of occurrence of external causes of mortality. The purpose of this study was to investigate the quality of data available in the World Health Organization (WHO) mortality database on the place of occurrence of fatal injuries in the European region. Methods: Data on external causes of mortality from countries in the European region according to the ICD-10 with four-character subdivision, between the years 1998 and 2003, were analysed. The quality of ICD-10 place of occurrence data was analysed for each country, based on the completeness, coverage and percentage of unspecified place of injury occurrence. Results: Only three countries in the European region (Hungary, Iceland and Lithuania) had high quality of data on place of occurrence of injuries, and six had medium-quality data. Conclusions: Few countries in the European region have injury mortality data of adequate quality by place of occurrence.

Developing a national policy for injury and violence prevention

As injuries can happen in any setting, to anyone and at any time, the preventive responses required need to be comprehensive. Accordingly, this requires the involvement of many stakeholders from different sectors and disciplines (Krug, Dahlberg, Mercy, Zwi & Lozano, 2002; Peden et al., 2004). The development and implementation of national policies are rational ways of obtaining commitment and coordinating the efforts, roles, responsibilities and resources of the many actors involved (Schopper, Lormand & Waxweiler, 2006). The lack of such coordination may lead to an incomplete or fragmented response and to duplication or divergence of efforts. A policy has essential elements that include a vision, with targets, actions, resources and actors required to successfully implement it over a defined time scale in a coordinated way. In addition to providing evidence on the burden and on what works for prevention, WHO’s world reports on violence and health and road traffic injury prevention promote the development of national prevention policies (Krug et al., 2002; Peden et al., 2004). This paper draws upon WHO’s Developing policies to prevent injuries and violence: guidelines for policy-makers and planners (Schopper et al., 2006).