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Bebbington E, Kakola M, Majgi SM, Krishna M, Poole R, Robinson C. Exploring misclassification of injury intent: A burn register study. Burns 2024; 50:1735-1745. [PMID: 38862344 DOI: 10.1016/j.burns.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 03/30/2024] [Accepted: 05/02/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Burn registers are an important source of surveillance data on injury intent. These data are considered essential to inform prevention activities. In South Asia, intentional burn injuries are thought to disproportionately affect women. Assessment of injury intent is difficult because it is influenced by personal, family, social, and legal sensitivities. This can introduce misclassification into data, and bias analyses. We conducted a descriptive, hypothesis generating study to explore misclassification of injury intent using data from a newly digitised single centre burn register in south India. METHODS Data from 1st February 2016 to 28th February 2022 were analysed. All patients in the data set were included in the study (n = 1930). Demographic and clinical characteristics for patients are described for each classification of injury intent. All data cleaning and analyses were completed using RStudio. RESULTS Injury intent data were missing for 12.6% of cases. It was the most commonly missing variable in the data set. "Accidental" injuries had a similar distribution over time, age, and total body surface area (TBSA) for males and females. "Homicidal" injuries were more common in females. Injuries reported as "Suicidal" affected men and women equally. A decrease in reporting of "Suicidal" injuries in females corresponded to an increase in high TBSA injuries classified as 'Other' or with missing data. Overwriting of injury intent was present in 1.5% of cases. The overwritten group had a greater proportion of females (62.1% vs. 48.5%) and higher median TBSA (77.5% vs. 27.5%) compared to the group where intent was not overwritten. CONCLUSION Our findings indicate that some subgroups, such as females with high TBSA burns, appear to be more likely to be misclassified and should be the focus of future research. They also highlight that quality of surveillance data could be improved by recording of clinical impression, change in patient reported intent, and use of a common data element for intent to standardise data collection. We also recommend that injury intent is recorded as a unique variable and should not be mixed with other elements of injury causation (e.g. mechanism). Although this is a single centre study, the methods will be of interest to those who utilise routinely collected data and wish to reduce misclassification of this important variable.
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Affiliation(s)
- Emily Bebbington
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, LL13 7YP, UK.
| | - Mohan Kakola
- Department of Plastic Surgery and Burns, Mysore Medical College and Research Institute, KR hospital, Irwin Road, Mysuru, Karnataka 570001, India
| | - Sumanth Mallikarjuna Majgi
- Department of Community Medicine, Mysore Medical College and Research Institute, Mysuru, Karnataka 570001, India
| | - Murali Krishna
- Institute of Public Health 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka 560070, India
| | - Rob Poole
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, LL13 7YP, UK
| | - Catherine Robinson
- Social Care and Society, School of Health Sciences, Faculty of Biology, Medicine and Health, Jean McFarlane Building, Oxford Road, Manchester M13 9PY
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Dasari M, David SD, Miller E, Puyana JC, Roy N. Comparative analysis of gender differences in outcomes after trauma in India and the USA: case for standardised coding of injury mechanisms in trauma registries. BMJ Glob Health 2017; 2:e000322. [PMID: 29225936 PMCID: PMC5717963 DOI: 10.1136/bmjgh-2017-000322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 11/05/2022] Open
Abstract
Introduction While females generally have better outcomes than males after traumatic injury, higher mortality has been shown to occur in females after intentional trauma in lower-income countries. However, gender differences in trauma outcomes in different countries have not been previously compared. We conducted a two-country comparative analysis to characterise gender differences in mortality for different mechanisms of injury. Methods Two urban trauma databases were analysed from India and the USA for fall, motor vehicle collision (MVC) and assault patients between 2013 and 2015. Coarsened exact matching was used to match the two groups based on gender, age, injury severity score, Glasgow Coma Score and type of injury (blunt vs penetrating). The primary outcome of mortality was studied by using logistic regression to calculate the odds of death in the four country/gender subgroups. Results A total of 10 089 and 14 144 patients were included from the Indian and US databases, respectively. After matching on covariates, 7505 and 9448 patients were included in the logistic regression. Indian males had the highest odds of death compared with US males, US females and Indian females for falls, MVC and assaults. Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying for MVC and 40 times the odds of dying after assaults when compared with US females. Conclusion The high odds of death for Indian females compared with US females suggests that there are other injury and systemic factors that contribute to this discrepancy in mortality odds. This same mortality pattern and implication is seen for Indian males compared with all subgroups. Standardised coding of injury mechanism in trauma registries, in addition to intentionality of injury, can help further characterise discrepancies in outcomes by gender and country, to guide targeted injury prevention and care.
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Affiliation(s)
- Mohini Dasari
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Siddarth D David
- School of Habitat Studies, Tata Institute of Social Sciences, Deonar, India
| | - Elizabeth Miller
- Division of Young Adult and Adolescent Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nobhojit Roy
- Department of Public Health Sciences, School of Habitat Studies, Tata Institute of Social Sciences Karolinska Institutet, Stockholm, Sweden
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Bhate-Deosthali P, Lingam L. Gendered pattern of burn injuries in India: a neglected health issue. REPRODUCTIVE HEALTH MATTERS 2016; 24:96-103. [PMID: 27578343 DOI: 10.1016/j.rhm.2016.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022] Open
Abstract
There are an estimated 7 million burn injuries in India annually, of which 700,000 require hospital admission and 140,000 are fatal. According to the National Burns Programme, 91,000 of these deaths are women; a figure higher than that for maternal mortality. Women of child bearing age are on average three times more likely than men to die of burn injuries. This paper reviews the existing literature on burn injuries in India and raises pertinent issues about prevalence, causes and gaps in recognising the gendered factors leading to a high number of women dying due to burns. The work of various women's groups and health researchers with burns victims raises several questions about the categorisation of burn deaths as accident, suicide and homicide and the failure of the health system to recognise underlying violence. Despite compelling evidence, the health system has not recognised this as a priority. Considering the substantial cost of burns care, prevention is the key which requires health systems to recognise the linkages between burn injuries and domestic violence. Health systems need to integrate awareness programmes about domestic violence and train health professionals to identify signs and symptoms of violence. This would contribute to early identification of abuse so that survivors are able to access support services at an early stage.
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Affiliation(s)
- Padma Bhate-Deosthali
- Coordinator, CEHAT, Mumbai, India; PhD Scholar, Tata Institute of Social Sciences, Hyderabad, India.
| | - Lakshmi Lingam
- Professor, Tata Institute of Social Sciences, Hyderabad, India
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Gender is inevitable: Gender-based violence is avoidable. Burns 2016; 42:1155-1156. [PMID: 27126811 DOI: 10.1016/j.burns.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 11/24/2022]
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Spiwak R, Logsetty S, Afifi TO, Sareen J. Severe partner perpetrated burn: Examining a nationally representative sample of women in India. Burns 2015; 41:1847-1854. [DOI: 10.1016/j.burns.2015.08.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/21/2015] [Accepted: 08/26/2015] [Indexed: 10/22/2022]
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Sabri B, Sanchez MV, Campbell JC. Motives and Characteristics of Domestic Violence Homicides and Suicides Among Women in India. Health Care Women Int 2014; 36:851-66. [DOI: 10.1080/07399332.2014.971954] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Daruwalla N, Belur J, Kumar M, Tiwari V, Sarabahi S, Tilley N, Osrin D. A qualitative study of the background and in-hospital medicolegal response to female burn injuries in India. BMC WOMENS HEALTH 2014; 14:142. [PMID: 25433681 PMCID: PMC4260258 DOI: 10.1186/s12905-014-0142-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/28/2014] [Indexed: 11/23/2022]
Abstract
Background Most burns happen in low- and middle-income countries. In India, deaths related to burns are more common in women than in men and occur against a complex background in which the cause – accidental or non-accidental, suicidal or homicidal – is often unclear. Our study aimed to understand the antecedents to burns and the problem of ascribing cause, the sequence of medicolegal events after a woman was admitted to hospital, and potential opportunities for improvement. Methods We conducted semi-structured interviews with 33 women admitted to two major burns units, their families, and 26 key informant doctors, nurses, and police officers. We used framework analysis to examine the context in which burns occurred and the sequence of medicolegal action after admission to hospital. Results Interviewees described accidents, attempted suicide, and attempted homicide. Distinguishing between these was difficult because the underlying combination of poverty and cultural precedent was common to all and action was contingent on potentially conflicting narratives. Space constraint, problems with cooking equipment, and inflammable clothing increased the risk of accidental burns, but coexisted with household conflict, gender-based violence, and alcohol use. Most burns were initially ascribed to accidents. Clinicians adhered to medicolegal procedures, the police carried out their investigative requirements relatively rapidly, but both groups felt vulnerable in the face of the legal process. Women’s understandable reticence to describe burns as non-accidental, the contested nature of statements, their perceived history of changeability, the limited quality and validity of forensic evidence, and the requirement for resilience on the part of clients underlay a general pessimism. Conclusions The similarities between accident and intention cluster so tightly as to make them challenging to distinguish, especially given women’s understandable reticence to describe burns as non-accidental. The contested status of forensic evidence and a reliance on testimony means that only a minority of cases lead to conviction. The emphasis should be on improving documentation, communication between service providers, and public understanding of the risks of burns.
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Belur J, Tilley N, Osrin D, Daruwalla N, Kumar M, Tiwari V. Police investigations: discretion denied yet undeniably exercised. POLICING & SOCIETY 2014; 25:439-462. [PMID: 26376482 PMCID: PMC4338498 DOI: 10.1080/10439463.2013.878343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Police investigations involve determining whether a crime has been committed, and if so what type of crime, who has committed it and whether there is the evidence to charge the perpetrators. Drawing on fieldwork in Delhi and Mumbai, this paper explores how police investigations unfolded in the specific context of women's deaths by burning in India. In particular, it focuses on the use of discretion despite its denial by those exercising it. In India, there are distinctive statutes relating to women's suspicious deaths, reflecting the widespread expectation that the bride's family will pay a dowry to the groom's family and the tensions to which this may on occasion give rise in the early years of a marriage. Often, there are conflicting claims influencing how the woman's death is classified. These in turn affect police investigation. The nature and direction of police discretion in investigating women's deaths by burning reflect in part the unique nature of the legislation and the particular sensitivities in relation to these types of death. They also highlight processes that are liable to be at work in any crime investigation. It was found that police officers exercised unacknowledged discretion at seven specific points in the investigative process, with potentially significant consequences for the achievement of just outcomes: first response, recording the victim's 'dying declaration', inquest, registering of the 'First Information Report', collecting evidence, arrest and framing of the charges.
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Affiliation(s)
- J. Belur
- Department of Security and Crime Science, University College London, London, UK
| | - N. Tilley
- Department of Security and Crime Science, University College London, London, UK
| | - D. Osrin
- Institute of Child Health, University College London, London, UK
| | - N. Daruwalla
- Society for Nutrition, Education and Health Action, Urban Health Centre, Mumbai, India
| | - M. Kumar
- Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - V. Tiwari
- Department of Burns, Plastic and Maxillofacial Surgery, VM Medical College and Safdarjung Hospital, New Delhi, India
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Natarajan M. Differences between intentional and non-intentional burns in India: implications for prevention. Burns 2014; 40:1033-9. [PMID: 24433938 DOI: 10.1016/j.burns.2013.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 10/03/2013] [Accepted: 12/05/2013] [Indexed: 11/16/2022]
Abstract
Non-intentional and deliberate burns in India and other developing countries present particular challenges of prevention and treatment. This exploratory study sought improved understanding of burns in order to inform treatment and prevention. It gathered data in 2011/2012 on burns from the hospital registry (N=768) of a government hospital in India and from interviews with women patients (N=60) admitted to the burns ward. Analysis indicated that: (1) the conditions that facilitate intentional and non-intentional burns are similar, but intentional burns involve additional contributory factors; (2) a high proportion of patients subjected to burns are young women in domestic situations; and (3) a higher proportion of their TBSA was burned, with consequent higher mortality than for men. It was concluded that: (1) Haddon's matrix and the situational crime prevention framework of criminology assist in understanding the etiology of intentional burns and in identifying preventive measures; (2) social service and criminal justice agencies have important roles in dealing with victims of intentional burns during and after treatment; (3) full account should be taken of gender-related physical, psychological and family factors in planning treatment; and (4) maintaining careful records of burns cases is vital for estimating the prevalence and incidence of intentional injuries.
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Affiliation(s)
- Mangai Natarajan
- John Jay College of Criminal Justice, The City University of New York, Department of Criminal Justice, 524 West 59th Street, New York, NY 10019, United States.
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Burden, characteristics, and outcome of injury among females: observations from Bengaluru, India. Womens Health Issues 2011; 21:320-6. [PMID: 21570866 DOI: 10.1016/j.whi.2010.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 12/22/2010] [Accepted: 12/22/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE With injuries becoming a leading cause of mortality, morbidity, disability, and socioeconomic losses in India and other low- and middle-income countries, its impact on the female population is significant, affecting their multiple roles and functions. The objectives of the present study were to identify the burden, causes, characteristics, and outcomes of injury among females in Bengaluru city. METHODS Information on fatal and nonfatal injuries was collected from the Bangalore city police and the emergency rooms of 22 partner hospitals, respectively, under the Bengaluru Injury Surveillance Program in 2007 and 2008. Data were collected in an uniform manner by trained personnel using standardized methods. FINDINGS Females across all age groups accounted for 26% of fatal and 23% of nonfatal injuries and the highest numbers were among those 16 to 45 years old. Burns and hanging were the leading causes of death; road crashes and poisonings were the major causes of nonfatal injuries. Nearly half of the fatal and one third of the nonfatal injuries were suicides. Pedestrians and two-wheeler riders/pillions were mainly involved in road crashes. Very few received first aid at the injury site and the commonest modes of transportation were a private vehicle or taxi and the local three-wheeler vehicle. More than half of the injured were admitted in the hospitals for medical or surgical management. CONCLUSION Injuries are a major, preventable public health problem. There is a need to strengthen injury prevention and control programs, as well as increased research to understand risk factors and injury mechanisms.
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Dissanaike S, Rahimi M. Epidemiology of burn injuries: highlighting cultural and socio-demographic aspects. Int Rev Psychiatry 2009; 21:505-11. [PMID: 19919203 DOI: 10.3109/09540260903340865] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Burns are devastating injuries that disproportionately affect people in developing countries, including children. In addition to a high mortality rate, survivors are burdened with life-long physical and emotional scars. The etiology and nature of burn injuries varies significantly by country, and this chapter explores the predominant causes and patterns of burn injury in both the developing and industrialized worlds. Gender differences play a significant role in the risk of burn injuries, across a spectrum with a predominance of women injured in fires from cooking and heating fuels in the developing world and industrial accidents primarily affecting men in developed nations. Children are particularly vulnerable to burn injuries, accounting for almost 50% of all burn patients in some studies. A majority of pediatric burns are scald injuries usually affecting very young children below the age of 5 years, and we discuss the behavioral patterns underlying this finding. Finally, the elderly form a rapidly increasing proportion of the population in many countries, and are often burdened with comorbidities that are likely to pose significant challenges in burn care.
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Affiliation(s)
- Sharmila Dissanaike
- Division of Trauma and Burn Care, Department of Surgery, and Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA.
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