Risk factors for childhood burns: a case-control study of Ghanaian children

STUDY OBJECTIVE

To study risk factors for childhood burns in order to identify possible preventive strategies.

DESIGN

Case-control design with pair matching of controls to cases in relation to age, sex, and area of residence. The cases and controls were identified by a community based, multisite survey. The effects of host and socioenvironmental variables reported by mothers were investigated in a multivariate analysis using conditional logistic regression.

SETTING

A developing country setting the Ashanti Region in Ghana.

PARTICIPANTS

These comprised 610 cases aged 0-5 years who had been burned (as evidenced by a visible scar) and 610 controls with no burn history.

MAIN RESULTS

The presence of a pre-existing impairment in a child was the strongest risk factor in this population (OR = 6.71; 95% CI 2.78, 16.16). Other significant risk factor included: sibling death from a burn (OR = 4.41; 95% CI 1.16, 16.68); history of burn in a sibling (OR = 1.79; 95% CI 1.24, 2.58); and storage of a flammable substance in the home (OR = 1.51; 95% CI 1.03; 2.21). Maternal education had a protective effect against childhood burns, although this effect was not strong (OR = 0.76; 95% CI 0.55, 1.05).

CONCLUSIONS

Community programmes to ensure adequate child supervision and general child wellbeing, particularly for those with impairments, as well as parental education about burns are recommended, to reduce childhood burns in this region of Ghana. The public should bed advised against storing flammable substances in the home.

Determinants of modern health care use by families after a childhood burn in Ghana

OBJECTIVES

This study examined determinants of modern health care use by families after their child aged 0-5 years sustained a burn injury in the Ashanti Region of Ghana.

METHODS

A community based survey of children aged 0-5 years was conducted in 50 enumeration areas in the region. Mothers of all children with scars as evidence of a burn were selected for a follow up interview using a standard questionnaire two to three months later. Determinants of health care use were investigated through a multivariate logistic regression using interview responses from mothers of 617 children for whom report on some treatment was given.

RESULTS

Overall, 48% of the burned children were taken to a modern health facility for treatment. Of those taken to a modern health facility, 68% were sent within 24 hours of the burn event. Factors with large adjusted odds ratios for modern health care use included wound infection, burns covering 6% or more of the body surface, and third degree burns. Compared with scalds, children with contact and flame burns were less likely to be taken to a health facility, as were burns to rural children, and those given first aid treatment at home.

CONCLUSIONS

It is concluded that families, particularly rural residents, should be educated about appropriate health care seeking practices after a burn.

Childhood burns in Ghana: epidemiological characteristics and home-based treatment

The objectives of this research were to study the epidemiological characteristics and home-based treatment of childhood burns in the Ashanti Region of Ghana. Children aged 0-5 years with a burn history were identified through a community-based, multisite survey. A standard questionnaire was administered to mothers of 630 of these children to elicit information on their sociodemographic characteristics and the circumstances of the burn event. Ninety-two per cent of the burns occurred in the home, particularly in the kitchen (51 per cent) and the house yard (36 per cent), with most of them happening in the late morning and around the evening meal. The main causes of the burns were scalds (45 per cent), contact with a hot object (34 per cent) and flame (20 per cent). 'Cool' water was applied to the burned area in 30 per cent of cases. Otherwise, treatment with a traditional preparation was the most popular first-aid choice. Since a considerable proportion of burns happened between meals when children 'play with fire' in the house yard, the provision of alternative play activities and community play areas may reduce the incidence of burns to these children. Secondly, we recommend that education on first-aid management of burns be intensified, with special emphasis on alternatives to the use of traditional preparations.

Do provider practices conform to the new pediatric immunization standards?

OBJECTIVE

Standards for pediatric immunization practices were issued by the Centers for Disease Control and Prevention, Atlanta, Ga, in May 1992. This article provides baseline data on immunization practices related to eight of the standards.

DESIGN

Survey of pediatric providers before publication of the standards.

SETTING

Baltimore, Md.

PARTICIPANTS

Forty of the 41 health centers, clinics, and private practices serving children in designated high-risk census tracts participated in the survey. One hundred seventy-three of the 251 eligible physicians and nurse practitioners at the sites responded.

MAIN OUTCOME MEASURES

Conformity with the eight standards was measured as a percentage of either sites or physicians and nurse practitioners across the sites.

RESULTS

Conformity with the standards varied, ranging from nearly universal conformity with the need to educate parents and guardians about immunizations (standard 5) to less than 3% for simultaneous administration of all vaccine doses when a child is first eligible (standard 8). For most of the standards, considerable variability was found between and within public and private sites.

CONCLUSIONS

Providers often followed practices that did not conform to the new standards (prior to issuance). Some of the standards are ambiguous and require clarification before they can be fully applied. The impact of the standards on immunization rates and pediatric primary health care has yet to be tested empirically.

Immunization coverage and its relationship to preventive health care visits among inner-city children in Baltimore

OBJECTIVE

To provide empirical data on immunization coverage and the receipt of preventive health care to inform policy makers' efforts to improve childhood immunization.

DESIGN AND METHODS

We surveyed a random sample drawn from a birth cohort of 557 2-year-old children living in the inner-city of Baltimore. Complete information on all their preventive health care visits and immunization status was obtained from medical record audits of their health care providers.

MAIN OUTCOME MEASURES

Age-appropriate immunizations and preventive health care visits.

RESULTS

By 3 months of age, nearly 80% made an age-appropriate preventive health visit, but by 7 months of age, less than 40% had a preventive visit that was age-appropriate. In the second year of life, 75% made a preventive health visit between their 12- and 17-month birthdays. The corresponding age-appropriate immunization levels were 71% for DTP1, 39% for DTP3, and 53% for measles-mumps-rubella vaccine. Infants who received their DTP1 on-time were twice as likely to be up-to-date by 24 months of age.

CONCLUSIONS

Our analyses focus attention on the performance of the primary health care system, especially during the first 6 months of life. Many young infants are underimmunized despite having age-appropriate preventive visits, health insurance coverage through Medicaid, and providers who receive free vaccine from public agencies. Measles vaccination coverage could be improved by initiating measles-mumps-rubella vaccine vaccination, routinely, at 12 months among high risk populations.

Differences in gestational age-specific birthweight among Chinese, Japanese and white Americans

This study investigated racial differences in gestational age-specific birthweight in a sample of 21,288 Chinese, 11,882 Japanese and 65,818 White resident singleton livebirths, obtained from the National Center for Health Statistics 1983 and 1984 linked birth/infant death cohort files. The gestational age-specific birthweight distributions of Chinese and Japanese were similar, but differed from those of Whites both in the mean level and in the variance. The mean birth-weights of Chinese and Japanese as compared to that of White infants were 4-5% lower among preterm births, and 5-6% lower among term births, after adjustment was made for gestational age, demographic variables, use of antenatal care and infant gender. The racial differences in gestational age-specific birthweight were even greater at the 90th percentile but smaller at the 10th percentile. These racial differences should be considered in both clinical evaluation of newborns and in epidemiological studies. Significant interactions were found between race and such maternal variables as education, marital status, birthplace, and month during which antenatal care began. It suggests that recognition of racial differences in risk factors and exposure-response relationships may be valuable in specifying interventions for intrauterine growth retardation among different racial groups.

Needs assessment for reducing infant mortality in Baltimore City: the Healthy Start Program

Needs assessments are essential for policy formulation and the appropriate design of intervention programs. Recent nationwide data show that among large metropolitan areas of the United States, Baltimore has one of the highest infant mortality rates and ranks in the worst top 10 for blacks and the top 5 for whites for most indicators of poor pregnancy outcome. In this paper, we present the methods and results of a needs assessment that used multiple sources of routinely collected data and was conducted for the purpose of identifying intervention factors contributing to infant mortality in Baltimore City. This needs assessment was used by the Baltimore City Health Department to successfully secure funding for the federal Healthy Start Infant Mortality Prevention Initiative. We present the results of the analyses, along with some of the proposed interventions that resulted from the needs assessment. We also discuss the limitations of this type of needs assessment as well as suggestions for future needs assessments for the design of interventions to improve perinatal health.

Differences in cause-specific infant mortality among Chinese, Japanese, and white Americans

Although black-white differences in infant mortality have received much attention, information is limited about mortality differentials among Asian Americans. This study investigated racial differences in infant mortality in a sample of 21,288 Chinese, 11,882 Japanese, and 65,818 white resident singleton livebirths obtained from the National Center for Health Statistics 1983 and 1984 linked birth/infant death files. The crude infant mortality rates were 8.03, 6.56, and 8.46 per 1,000 livebirths for Chinese, Japanese, and white births, respectively. Cause-specific mortality varied considerably among the three racial groups. While the Japanese had lower rates of infant deaths and deaths from perinatal conditions for firstborn infants, they had higher rates of sudden infant death syndrome, as did Chinese females. The results of a logistic regression analysis indicate that the racial differences in total and cause-specific mortality persist when adjustment is made for demographic factors, use of prenatal care, infant sex, and birth weight. The effect of these latter variables on infant mortality varied by causes of death. The relations between infant mortality and variables such as marital status, maternal education, and birth interval appear indirect, operating partially through birth weight. While birth weight was the single strongest determinant of infant mortality, its relative importance varied by cause of death. The study findings suggest that policy decisions surrounding racial differences in infant mortality should not only be considered in light of specific races, but also with regard to cause-specific mortality. Moreover, additional research is needed to understand the cultural, biological, and behavioral factors that give rise to the racial differences.

The cost of medical care for injuries to children

STUDY OBJECTIVES

To estimate the mean cost of initial medical treatment for a variety of injury types and injury causes and project the national cost of initial medical care for injuries to children.

DESIGN

We combined injury incidence data from the Massachusetts Statewide Childhood Injury Prevention Project (SCIPP) with a claims data set (1987 charges) from the Health Data Institute, Lexington, Massachusetts.

SETTING AND STUDY POPULATION

SCIPP incidence data were obtained from hospital emergency department and inpatient facilities for a population of 87,000 Massachusetts children 0 to 19 years old between 1979 and 1982. Health Data Institute charge data for children were derived from insurance claims for 3% of all privately insured patients throughout the United States.

RESULTS

The estimated mean cost of initial hospitalization for injury was $5,094, while ED care was $171. Projected annual cost for initial medical care of injury to children for the nation was $5.1 billion, which was about equally divided between cases seen in EDs and those requiring inpatient care. Although there was little difference in mean cost between the genders, mean cost increased with age. Because of both a higher injury incidence and a greater mean cost per injury, the projected initial cost of injuries to teenagers 15 to 19 years old was much higher than that of younger children.

CONCLUSION

Expenditures for medical care of injured children, particularly adolescents, are great. The prevention of childhood injuries should become a higher priority in the United States. To improve the quality of national estimates of the incidence and cost of injury, a national surveillance system for nonfatal injuries should be developed. Such a system should include information on the major causes of injury and their costs.

Childhood injuries in the United States. Mortality, Morbidity, and cost

National estimates of the mortality, morbidity, and cost of childhood injuries are presented by specific causes. Motor vehicle-related injuries, homicide, and suicide are the leading causes of childhood injury deaths. Falls and sports-related injuries are the leading causes of hospitalizations and emergency department visits. We estimate that unintentional childhood injuries cost the nation $7.5 billion in 1982. The highest direct costs per year for unintentional injuries are attributable to falls, sports, and motor vehicle occupant injuries, while the highest indirect costs are related to motor vehicle occupant injuries, pedestrian injuries, and drowning. Injury accounts for 78% of the total fatalities among late adolescents (age 15 to 19 years), the pediatric age group at highest risk for injury mortality. A stronger federal and state commitment is needed to prevent childhood injury.

Injury surveillance using hospital discharge abstracts coded by external cause of injury (E code)

Current knowledge of the patterns of injury in the United States derive principally from mortality statistics that constitute less than 0.1% of all injuries reaching medical attention. There presently exists no national system for the surveillance of nonfatal injuries. To illustrate the usefulness and feasibility of conducting injury surveillance using E-coded hospital discharge data, we examined the surveillance data from the Massachusetts Statewide Childhood Injury Prevention Program. By using E-coded hospital discharge data, we increased the number of cases available for analysis by 40-fold over deaths, and we were able to describe the epidemiologic characteristics of the important causes of nonfatal childhood injuries. We therefore propose the development of a national injury surveillance system based on the Uniform Hospital Discharge Data Set coded by both the nature of the injury (N Code) and external cause (E Code).

Intentional injuries among children and adolescents in Massachusetts

We estimated age-specific and sex-specific incidence rates of intentional injuries (assaults or suicide attempts) occurring between 1979 and 1982 in a population of 87,022 Massachusetts children and adolescents under 20 years of age in 14 communities with populations of 100,000 or less. The average annual incidence of intentional injuries treated at a hospital was estimated to be 76.2 per 10,000 person-years. Overall, 1 in 130 children was treated each year for an intentional injury. More than 85 percent of the injuries resulted from assaults, such as fights, rape, and child battering; 11.4 percent were self-inflicted. Intentional injuries were most common among adolescents. Each year, 1 in 42 teenage boys was treated for an assault-related injury, and 1 in 303 teenage girls was seen for a suicide attempt. Repeated episodes of intentional injury were identified in 4.3 percent of the children. In this population, intentional injuries accounted for 3.4 percent of all injuries but 9.8 percent of hospital admissions and 15.7 percent of deaths from injury. The rate of intentional injury was directly correlated with both the degree of urbanization and the poverty level of the community of residence. We conclude that intentional injuries are relatively common in this population and that attempts to prevent them must be directed to the children who are at greatest risk.

Prevention of childhood injuries: evaluation of the Statewide Childhood Injury Prevention Program (SCIPP)

We evaluated the effectiveness of a community-based injury prevention program designed to reduce the incidence of burns, falls in the home, motor vehicle occupant injuries, and poisonings and suffocations among children ages 0-5 years. Between September 1980 and June 1982, we implemented five injury prevention projects concurrently in nine Massachusetts cities and town; five sites, matched on selected demographic characteristics, were control communities. An estimated 42 percent of households with children ages 0-5 years were exposed to one or more of the interventions over the two-year period in the nine communities. Participation in safety programs increased three-fold in the intervention communities and two-fold in the control communities. Safety knowledge and practices increased in both intervention and control communities. Households that reported participatory exposure to the interventions had higher safety knowledge and behavior scores than those that received other community exposure or no exposure to intervention activities. We found a distinct reduction in motor vehicle occupant injuries among children ages 0-5 years in the intervention compared with control communities, associated with participatory exposure of about 55 percent of households with children ages 0-5 years. We have no evidence that the coordinated intervention programs reduced the other target injuries--although exposure to prevention messages was associated with safety behaviors for burns and poisonings.

Are preterm black infants larger than preterm white infants, or are they more misclassified?

In birth certificate data for Massachusetts resident births from 1978 to 1982, 12-27% of births purportedly under 31 weeks of gestation were probably misclassified, i.e. had birthweight greater than or equal to 2500 g. Correcting for maldistribution of births removed 34% and 23%, respectively, of black and white births with reported gestational ages less than 36 weeks but with implausible weights. Percentages of unknown and incomplete reports of last menstrual period were also significantly higher for blacks. After adjustment, preterm black infants weighed less than whites at each gestational age. The proportion of infants less than 2500 g born at term (greater than or equal to 37 weeks gestation) was higher (although not significantly) among blacks. These findings are consistent with hypotheses that low socioeconomic status negatively affects the rate of intrauterine growth.

Classification and analysis of fetal deaths in Massachusetts

Fetal deaths, in contrast to infant deaths, have been subject to epidemiologic analysis infrequently. We characterized 574 Massachusetts resident fetal deaths from 1982 and assessed the accuracy of cause-of-death information available from vital records compared with that from corresponding fetal autopsies. The fetal death rate exceeded the neonatal mortality rate. Fetal mortality was higher among black, unmarried, and older mothers. Fetuses of multiple-gestation pregnancies had an unusually high risk of fetal death. Autopsy reports were obtained for 61% of fetal deaths. The underlying cause of death from the fetal death record differed from that on the autopsy report in 55% of cases. Systematic collection of population-based autopsy data is a useful approach for improving the quality and accuracy of mortality statistics on fetal deaths. Many stillbirths remain unexplained, however, and research is needed to identify pathological markers that might reduce the heterogeneity within the fetal deaths currently ascribed to unknown causes.

The postponement of neonatal deaths into the postneonatal period: evidence from Massachusetts

Part of the slow decline in the postneonatal mortality rate and the rapid decline in the neonatal mortality rate during the 1970s may have been due to a postponement of some neonatal deaths into the postneonatal period. The authors hypothesized that any such postponement should be accompanied by a lack of decline, or even an increase, in late neonatal and postneonatal mortality rates among low birth weight babies and babies dying of conditions originating in the perinatal period. To examine this theory, the authors used vital records data to compare infant mortality rates in Massachusetts during 1970-1972 with rates during 1978-1980. Log-linear hazard models were used to calculate death rates, while controlling for changes in maternal age, race, education, and prior reproductive history. The authors found that babies of birth weight under 1,500 g had no decline in late neonatal mortality rates and babies of birth weight under 2,500 g had no decline in postneonatal mortality rates. Babies of birth weight 500-999 g had an increased postneonatal mortality rate (rate ratio = 2.4; 95% confidence limits = 1.0-5.4). These unimproved or increased death rates were due in part to conditions originating in the perinatal period. The authors conclude that, although infant mortality rates have declined, this postponement was real, and that efforts to monitor infant mortality will benefit from its routine quantification.

An epidemiological assessment of immunization programme participation in the Philippines

Because a large proportion of preschool children failed to present for free diphtheria-pertussis-tetanus (DPT) immunizations in a poor, rural area of the Philippines, we undertook an epidemiological analysis of their characteristics. The parents of 159 children were interviewed to determine the demographic, attitudinal, knowledge, and administrative correlates of immunization status. Logistic regression was used to model immunization status. Children were less likely to be immunized if they had a high score on an Adversity Index (composed of measures of the weather, the number of visits the team made, the distance, the appropriateness of the time of day, and miscellaneous problems), if they received health care from a native mother and child health specialist, if a parent was not on the town council, and if pain was an important deterrent. By contrast, many demographic and attitudinal measures that have traditionally been thought to predict health behaviour were not useful discriminators. Recommendations are made for immunization programme management. The general use of this method for programme planning is elaborated.

Pedestrian injuries to children and youth

Prevention of pedestrian injuries constitutes a most difficult problem, involving not only driver and pedestrian behavior, but also the design of streets, highways, and automobiles. The epidemiology of these injuries is assessed, using the host-agent-environment model, and approaches to prevention are presented, from child behavior modification to engineering.