Country level economic disparities in child injury mortality

Social and economic factors associated with child unintentional injury mortality in high-income countries

INTRODUCTION

Recognising the connection between country-level social determinants of health, and child unintentional injury mortality can contribute to better resource allocation for child safety. This cross-sectional country-level study aims to investigate such a link where the role of income inequality (Gini Index) is examined alongside education expenditure, current health expenditure and gross national income (GNI) per capita.

METHODS

A total of 49 high-income countries were studied, using the WHO Global Health Estimates 2016, the World Bank's World Development Indicators for education and GNI per capita, and the standardised world income inequality database to compile estimates of child unintentional injury mortality rates and selected socioeconomic characteristics.

RESULTS

A wide range of childhood mortality rates from unintentional injury was observed (1.3-10.0 deaths per 100 000 children). Such risk is strongly associated with income inequality (0.50), GNI per capita (-0.35) and education expenditure (-0.01) (mediated by income inequality). No association was found to current health expenditure. The results explain 52% of the variance in child unintentional injury mortality.

CONCLUSIONS

In countries with higher overall economic activity and lower-income inequality, child mortality from unintentional injuries is lower. Allocation of education expenditure is one contributor to reducing income inequality; other factors need further exploration.

Academic Pediatric Surgery Capacity Building in Vietnam Through PASS, a Pediatric Acute Surgical Support Course

Neonatal and pediatric surgical emergencies in Low and Low Middle Income countries remain a significant challenge in combatting the burden and inequities of global health. IPSAC-Vietnam is a small Non-Governmental Organization that has been engaged in a 12-year multi-pronged partnership with several children’s hospitals in Vietnam VN to enhance pediatric surgery capacity. We describe the health care, medical training and emergency system in VN as the background for IPSAC activities and development of Pediatric Acute Surgical Support (PASS) course. The course goal is to prepare health care personnel in the immediate management of neonatal/pediatric life-threatening surgical conditions and road injuries at their first point of entry into Vietnam hospitals. PASS is a horizontal outreach initiative that adopts an interprofessional, multidisciplinary, team-training, train-the-trainers, and outcome-based training approach. PASS can be used as a tool for sustainable horizontal capacity-building by champion leaders at the teaching children’s hospitals and medical universities in developing countries, to strengthen training for pediatric surgical emergencies, to integrate pediatric and pediatric surgical care and to advocate for a comprehensive approach to emergency care of the critically ill child.

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Background

Maternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions.

Methods

We conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease - 10^th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words "maternal mortality", "maternal death", "pregnancy-related death", "reproductive age mortality" and "causes" as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates.

Results

We identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes.

Conclusions

Limitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

Inclusion of Children's Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children's Surgery

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Injuries among children and adolescents in a rapidly growing urban African metropolis: a cross-sectional survey of 1,968 households in Dar es Salaam, Tanzania

Objectives

To assess the patterns and incidence of child and adolescent injury and explore associations with household deprivation and child characteristics in a low-income urban setting.

Study Design

Cross-sectional household survey in Dar es Salaam, Tanzania.

Methods

Data collection took place during July 2009. Injuries requiring medical attention were recorded with a one month period of recall. A total of 1,968 households representing 3,927 children and adolescents were visited by health workers. Gender-, age-, and type-specific injury incidence was compiled. Odds ratios were calculated to measure associations with child injury, perceived deprivation, household characteristics and child characteristics.

Results

One household in five reported injuries. The estimated incidence was 3.2 per 10,000 child-years. The most common identifiable injuries were falls (41%), cuts (22%) and burns (16%). Male and younger children aged 1-4 years were at higher risk (respectively OR = 1.36; p = 0.004; OR = 1.47; p ≤ 0.001).

Conclusions

In Dar e Salaam injuries are common. Future investigations should take into account both subjective and objective measurements of relative household deprivation and a clear criteria for the assessment of injury severity in community-based survey contexts.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017

BACKGROUND

The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates.

METHODS

Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate.

RESULTS

For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced.

CONCLUSIONS

The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

Status of injuries as a public health burden among children and adolescents in China: A systematic review and meta-analysis

INTRODUCTION

Injuries among children and adolescents remain a major public health problem in China. In the present study, we undertook a systematic review and meta-analysis of the published literature of epidemiological studies investigating injuries among children and adolescents in China and aimed to describe the status of injury among children and adolescents (aged 0-19 years) in China nationwide. A random-effects meta-analysis model was used to calculate the pooled prevalence of injury with 95% confidence intervals (CIs) across studies. The potential heterogeneity moderators were identified by subgroup and sensitivity analysis. A total of 775,615 children and adolescents were included in this study. Overall, the pooled injury prevalence among children and adolescents aged 0 to 19 years was 23.0% (95% CI 20.0%-27.0%) in studies using 1996 version of injury definition, and 13.0% (95% CI 10.0%-17.0%) in studies using 2004 version of injury definition. Relevant heterogeneity moderators have been identified by subgroup analysis. Sensitivity analysis yielded consistent results.

CONCLUSION

Our study shows a moderately high injury prevalence among children and adolescents aged 0 to 19 years in China, more prevention policies and programs should be urgently developed to decrease the occurrence of child and adolescent injury.

Mothers' perception of childhood injuries, child supervision and care practices for children 0-5 years in a peri-urban area in Central Uganda; implications for prevention of childhood injuries

Background

Injuries are a major concern in childhood. They are especially associated with high morbidity, disability and death in low-income countries. This study aimed at describing mothers' perceptions, child supervision and care practices for children 0-5 years old and how these influence prevention of childhood injuries among children in peri-urban areas of Wakiso district, Uganda.

Methods

In this qualitative study, 10 in-depth interviews and 4 focus group discussions were held with mothers of children aged 0-5 years living in peri-urban areas of Wakiso district, Uganda. The interviews were audio recorded in the local language (Luganda). The audios were transcribed verbatim and later translated into English. We conducted thematic analysis for transcripts from the focus group discussions and in-depth interviews.

Results

Most respondents considered injuries as inevitable events among children, although, they acknowledged the impact of injuries on children's health. Close child supervision was highlighted as key in preventing injuries. Hostile situations that place children at increased risk of injuries in this setting include: lack of adult supervision, harsh punishments and lack of safe play areas.

Conclusion

Our study highlights the different aspects of child care in low resource settings which put children at an increased risk of injuries. Injury prevention programs for children living in low resource settings should thus be aimed towards improving caregivers' perceptions towards injuries, child supervision, care practices and the children play environment.

Child Supervision and Burn Outcome among Admitted Patients at Major Trauma Hospitals in the Gambia

Burn-related injuries are a significant burden in children, particularly in low- and middle-income countries (LMICs), where more than 90% of burn-related pediatric deaths occur. Lack of adult supervision of children is a major risk for pediatric burn injuries. The goal of this paper was to examine the general characteristics of burns and identify burn injury outcomes among adult-supervised children compared to those who were not supervised. The study examined burn injury and clinical characteristics among all burn patients admitted to two trauma hospitals in The Gambia, West Africa. At intake in the emergency room, the treating physician or nurse determined the need for admission based on body surface area burned (BSAB), depth of burn, and other clinical considerations such as co-occurring injuries and co-morbidities. During the study period of 1 April 2014 through 31 October 2016, 105 burn patients were admitted and data were collected by the treating physician for all of them. Information about supervision was only asked for children aged five years or less. More than half (51%) of the burn patients were children under 18 years, and 22% were under 5 years. Among children under five, most (86.4%) were supervised by an adult at the time of burn event. Of the 19 supervised children, 16 (84.2%) had body area surface burned (BSAB) of less than 20%. Two of the three children without adult supervision at the time of burn event had BSAB ≥ 20%. Overall, 59% of the patients had 20% + BSAB. Females (aOR = 1.25; 95% CI = 0.43–3.62), those burned in rural towns and villages (aOR = 2.29; 95% CI = 0.69–7.57), or burned by fire or flames (aOR = 1.47; 95% CI = 0.51–4.23) had increased odds of having a BSAB ≥ 20%, although these differences were not statistically significant. Children 0–5 years or 5–18 years (aOR = 0.04, 95% CI = 0.01–0.17; aOR = 0.07, 95% CI = 0.02–0.23, respectively) were less likely to have BSAB ≥ 20% than adults. Those burned in a rural location (aOR = 9.23, 95% CI = 2.30–37.12) or by fire or flames (aOR = 6.09, 95% CI = 1.55–23.97) were more likely to die. Children 0–5 years or 5–18 years (aOR = 0.2, 95% CI = 0.03–1.18; aOR = 0.38; 95% CI = 0.11–1.570, respectively) were less likely to die. Children constitute a significant proportion of admitted burn patients, and most of them were supervised at the time of the burn event. Supervised children (compared to unsupervised children) had less severe burns. Programs that focus on burn prevention at all levels including child supervision could increase awareness and reduce burns or their severity. Programs need to be designed and evaluated with focus on the child development stage and the leading causes of burns by age group.

Associations between national viral hepatitis policies/programmes and country-level socioeconomic factors: a sub-analysis of data from the 2013 WHO viral hepatitis policy report

Background

As more countries worldwide develop national viral hepatitis strategies, it is important to ask whether context-specific factors affect their decision-making. This study aimed to determine whether country-level socioeconomic factors are associated with viral hepatitis programmes and policy responses across WHO Member States (MS).

Methods

WHO MS focal points completed a questionnaire on national viral hepatitis policies. This secondary analysis of data reported in the 2013 Global Policy Report on the Prevention and Control of Viral Hepatitis in WHO Member States used logistic regression to examine associations between four survey questions and four socioeconomic factors: country income level, Human Development Index (HDI), health expenditure and physician density.

Results

This analysis included 119 MS. MS were more likely to have routine viral hepatitis surveillance and to have a national strategy and/or policy/guidelines for preventing infection in healthcare settings if they were in the higher binary categories for income level, HDI, health expenditure and physician density. In multivariable analyses, the only significant finding was a positive association between having routine surveillance and being in the higher binary HDI category (adjusted odds ratio 26; 95% confidence interval 2.0–340).

Conclusion

Countries with differing socioeconomic status indicators did not appear to differ greatly regarding the existence of key national policies and programmes. A more nuanced understanding of the multifaceted interactions of socioeconomic factors, health policy, service delivery and health outcomes is needed to support country-level efforts to eliminate viral hepatitis.

The global burden of child burn injuries in light of country level economic development and income inequality

Child burn mortality differs widely between regions and is closely related to material deprivation, but reports on their global distribution are few. Investigating their country level distribution in light of economic level and income inequality will help assess the potential for macro-level improvements. We extracted data for child burn mortality from the Global Burden of Disease study 2013 and combined data into 1–14 years to calculate rates at country, region and income levels. We also compiled potential lives saved. Then we examined the relationship between country level gross domestic product per capita from the World Bank and income inequality (Gini Index) from the Standardized World Income Inequality Database and child burn mortality using Spearman coefficient correlations. Worldwide, the burden of child burn deaths is 2.5 per 100,000 across 103 countries with the largest burden in Sub-Saharan Africa (4.5 per 100,000). Thirty-four thousand lives could be saved yearly if all countries in the world had the same rates as the best performing group of high-income countries; the majority in low-income countries. There was a negative graded association between economic level and child burns for all countries aggregated and at regional level, but no consistent pattern existed for income inequality at regional level. The burden of child burn mortality varies by region and income level with prevention efforts needed most urgently in middle-income countries and Sub-Saharan Africa. Investment in safe living conditions and access to medical care are paramount to achieving further reductions in the global burden of preventable child burn deaths.

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Burden of child burn deaths is 2.5/100,000, largest burden in Sub-Saharan-Africa.

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34,000 lives could be saved yearly from burns if all countries had similar rates.

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Globally child burns decrease as economic wealth increases.

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Prevention efforts needed urgently in middle-income countries, Sub-Saharan-Africa.

Disparities in Under-Five Child Injury Mortality between Developing and Developed Countries: 1990-2013

OBJECTIVE

Using estimates from the 2013 Global Burden of Disease (GBD) study, we update evidence on disparities in under-five child injury mortality between developing and developed countries from 1990 to 2013.

METHODS

Mortality rates were accessed through the online visualization tool by the GBD study 2013 group. We calculated percent change in child injury mortality rates between 1990 and 2013. Data analysis was conducted separately for <1 year and 1-4 years to specify age differences in rate changes.

RESULTS

Between 1990 and 2013, over 3-fold mortality gaps were observed between developing countries and developed countries for both age groups in the study time period. Similar decreases in injury rates were observed for developed and developing countries (<1 year: -50% vs. -50% respectively; 1-4 years: -56% vs. -58%). Differences in injury mortality changes during 1990-2013 between developing and developed nations varied with injury cause. There were greater reductions in mortality from transport injury, falls, poisoning, adverse effects of medical treatment, exposure to forces of nature, and collective violence and legal intervention in developed countries, whereas there were larger decreases in mortality from drowning, exposure to mechanical forces, and animal contact in developing countries. Country-specific analysis showed large variations across countries for both injury mortality and changes in injury mortality between 1990 and 2013.

CONCLUSIONS

Sustained higher child injury mortality during 1990-2013 for developing countries merits the attention of the global injury prevention community. Countries that have high injury mortality can benefit from the success of other countries.

Our Shrinking Globe: Implications for Child Unintentional Injuries

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