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Unintentional non-fatal home-related injuries in Central Anatolia, Turkey: Frequencies, characteristics, and outcomes
Injury, Int. J. Care Injured (2008) 39, 535—546
www.elsevier.com/locate/injury
Unintentional non-fatal home-related injuries in Central Anatolia, Turkey: Frequencies, characteristics, and outcomes Fadimana Alptekin a, Ersin Uskun b,*, Ahmet Nesimi Kisioglu b, Mustafa Ozturk b a
Gulagac Health Center, Provincial Health Directorate, Aksaray 68000, Turkey Department of Public Health, Faculty of Medicine, Suleyman Demirel University, East Campus Cunur Isparta 32260, Turkey
b
Accepted 26 February 2007
KEYWORDS Unintentional; Non-fatal; Home injury; Frequency; Characteristics; Outcome; Causes of injury
Summary Injuries constitute a major public health problem worldwide. Homes are an important setting for non-fatal unintentional injuries. The aim of this study is to determine the frequency, the characteristics, and the outcome of unintentional nonfatal injuries in the household, and to describe the related risk factors through a community-based survey. The study was conducted using a household-based survey design. Eight hundred inhabitants were sampled from the entire population in the city centre by a stratified sampling method in 2004. All unintentional non-fatal home-related injuries occurring in the previous year were registered and examined, making special note of the mechanism of the injuries, the time and place of the incidents and their outcomes. The frequency of unintentional non-fatal home-related injuries requiring some form of medical attention was established as 10.8%. Falls were the most common injuries among all the study groups. Injury rates were highest among the oldest (aged 65) and youngest (aged <15) age groups, females, adults having incomes under s 500, individuals living alone, or the unemployed. Contact with hot objects/substances or hot liquid/gas was the leading mechanism in children 4 years of age or younger, falls ranking second. Falls are a significant problem particularly among older adults. Multiple analysis revealed that participants with low incomes, living alone and single or divorced had a high risk for injury at home. The findings related to disability highlighted a need to focus attention on the prevention of residential falls among
* Corresponding author at: Iskender mah 121 cadde, Buyuk Bucakli Apt. No. 40 Daire 5, 32040 Isparta, Turkey. Tel.: +90 2462113633; fax: +90 2462371165. E-mail address: [email protected] (E. Uskun). 0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.042
536
F. Alptekin et al. the elderly, and the burns and falls among young children. Preventive measures should be prioritised to risk groups such as individuals with low incomes and those living alone. # 2007 Elsevier Ltd. All rights reserved.
Introduction Injuries, which are major causes of mortality46 and morbidity,47,59 constitute a significant public health problem worldwide, in addition to a cost burden.32,33,50,57,61 Dimensions and nature of this problem are difficult to establish due to lack of valid and representative data.56 In some countries of low and mid-socio-economic status, the leading injuryrelated causes of death are those occurring in the household.40 Mortality is a very important indicator of the magnitude of a health problem. However, the number of non-fatal outcomes must also be recorded in order to accurately characterise the burden of injury.40 The panorama of the injury occurring in the household has been well described in countries with high-income.45—47,60 Every year, many unintentional home injuries45 and deaths60 related to these injuries are reported in the developed countries. In addition, the annual society-related cost of non-fatal unintentional home injuries was relatively high in these countries.60,66 Falls are the most common mechanisms of nonfatal unintentional injuries,47 and the leading cause of both home-related injury deaths and non-fatal injuries.18 Approximately 45% of all injuries in the household environment resulting in medical attention are caused by falls.47 Risk factors in home-related injuries vary. The rates of non-fatal unintentional home-related injuries are high among the elderly (over 65 years old) and youngsters (0—14 years old).47 Falls are very common in older people.4,38,48,52 Burns are primarily a problem in young children, the most frequent scenario being a scald injury.34 Although men have similar rates of non-fatal injury when compared to women,47 the death rate in unintentional homerelated injuries is higher in males than in females.13,46 Countries with mid-level income have not recognised injuries as a major public health problem as very few have actually studied the magnitude of the problem.3,35 There are very few population-based studies on injuries in developing countries.42 In the developed countries, epidemiological studies have begun to identify the causes and means of prevention of injuries, but unfortunately, much less is known about the incidence and the cause of injuries in developing countries, or about groups at high risk
for injuries in those countries.44 There have also been a number of studies either on specific injuries or among different age groups in Turkey. Dallar et al.10 and Tarim et al.54 conducted two different studies on paediatric burns; Asirdizer et al.5 worked on infant and adolescent deaths due to home acci˘lu et al.27 estabdents; Evci et al.15 and, Keskinog lished the impact of the main characteristics of the elderly on home accidents; Goren et al.20 and Ozdemir et al.39 conducted two different studies on foreign body asphyxiation in children. All of these studies were hospital-based. As seen, there are very few population-based studies on home-related injuries in Turkey. There is no common definition of the mechanisms of the injuries and no constructive information on the accidents occurring in households in Turkey. For this purpose, population-based studies and the assessment of mechanisms of home-related injuries are especially required in developing countries such as Turkey. The aims of this study are to determine the incidence and outcome of unintentional non-fatal injuries at home, and to describe the related risk factors through a community-based survey.
Materials and methods Housing and individual characteristics of the study region This study was conducted in the centre of Aksaray, in Central Anatolia, Turkey, using growth indicators (such as the housing characteristics, education, health status and the economic indicators) similar with rest of Turkey.53 The housing and individual characteristics of Turkey have been described by the Turkish Demographic and Health Survey.24 Females outnumber males in Turkey (51 and 49%, respectively). The population pyramid has a wide base, with a large portion (29%) of the population being under 15 years of age. This pattern is typical in countries that have had relatively high fertility in the recent past. There is an educational gap between males and females in Turkey. Overall, about 77% of males at least completed primary school, compared with 61% of females. The median number of school years for men was 4.8 which was
Unintentional non-fatal injuries at home about 0.5 year higher than the median for women (4.3 years). There were, on the average, four individuals per household in Turkey. More than four in ten households had fewer than four members, while another quarter of the households had five members, and one third of the households had six or more members.
Recruitment into the study and participants A cross-sectional study, by a stratified sampling method, was carried out in 2004 with 800 inhabitants sampled from the entire population in the city centre of Aksaray. The sampling size was calculated (estimated value43: 0.20; minimum difference: 0.05; a: 0.05; b = 0.05; power: 80% and confidence interval: 95%) using the GraphPad Software, Instat (GraphPad Instat, 1990—1993, V2.02). The sample size (n: 753) was adapted to 800 in order to calculate the stratified sampling method. There is a national health registration system in the health centres all over the country whose data are collected by the Provincial Health Directorate. The size of the entire population of the study area
Figure 1
537 was reported as 103,726 according to the data of the Provincial Health Directorate.41 Initially, using the data of the Provincial Health Directorate, nine health centres in the city were categorised into three strata according to low, middle, and high socio-economic properties, and the size of each group was calculated according to the number of their residents within the entire population using the data of the Provincial Health Directorate. One health centre from each stratum was selected using random sampling method. Consequently, each stratum was represented by one health centre. The numbers of residents in three strata were taken into consideration in order to calculate the number of samples from each health centre. In each of the three strata, 30% (n = 240) of the 800 people studied were randomly selected from the ‘low’ category, 39% (n = 312) from the ‘middle’ category, and 31% (n = 248) from the ‘high’ category (Fig. 1). In the national health registration system, the health centre worker made the record of every household and individual on separate cards, so, every individual had a registration card, which included socio-demographic information such as age, sex, educational level. A table of random numbers was used to
Total field under survey, sample and sampling methods.
538 identify specific household from the household health registration cards. An adequate number of houses was chosen with this random sampling method by using the information in the household health registration cards, until the intended number of persons at each level was reached. For every house, an equivalent (same area, and same number of house members) a backup house was determined by the random method, in case, the house members would not agree to contribute to the study. Since there was no individual who did not agree to contribute, no data were gathered from the backup houses. In the research, 800 persons were contacted in 180 houses. The number of persons in a house was (S.D.) 4.4 (1.3) in average (min: 1—max: 9).
Procedure and assessment In the study group, every individual was personally visited. All of the individuals who were invited agreed to participate. Structured interviews with participants were used. The participants under the age of 15 were interviewed in the presence of their mothers. A questionnaire created by the authors was applied in order to inquire about the socio-demographic properties of participants and unintentional non-fatal home-related injuries occurring in the previous year. The questionnaire was read out for each participant so as to overcome the problem of illiteracy of some participants. In cases where the participant was injured in the previous year, the mechanism of injury (external cause of injury), the time and place of the incident and the outcomes (‘cured’, ‘under treatment with no long-term consequences’ and ‘disabled’) were recorded.
F. Alptekin et al. that took place in the home environment, which was defined as the ‘person’s usual residence’ and its corresponding ‘parts of the building’ sub-module under the ‘place of occurrence’’ section of the ICECI.25
Ethics This study was conducted according to the ethical standards set by the Declaration of Helsinki62 that promote respect for all human beings and protect their health and rights. After informing the participants about the purpose of the trial (investigation, research, study) and about where and how the obtained data would be used, written consents were obtained. All participants in the research survey gave their consent for the release of information for public use.
Statistical analysis All data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS 9.0 Inc., California, 1999) with a two-tailed p-value of 0.05 used as the threshold for significance, and Instat (Graph Pad Software, Instat, 1990—1993, V2.02) was used to calculate the sample size. The results were expressed as the mean and standard deviation for quantitative variables, and as the frequencies for categorical findings. We calculated an odds ratio (OR) for each variable in order to determine the effects of the socio-demographic properties of the study groups on injury matters, and all variables (economic status, gender, occupation, education and marital status) regressed against the injury frequency in the logistic regression analysis.
Definition of unintentional home-related injuries in this study
Results This study included only the cases with unintentional, non-fatal home-related injuries. All serious unintentional, non-fatal home-related injuries recalled and reported by the participants during the last 1-year period were included, and only those needing medical attention were considered serious. None of the participants reported more than one injury in 1 year. Injuries were classified as unintentional and non-fatal in correlation with the mechanism of injury according to the International Classification for External Causes of Injuries (ICECI).25 An unintentional non-fatal home-related injury was defined as ‘‘an unforeseen incident, where there was no intent by a person to cause harm or injury, but which resulted in injury, and any episode of unintentional injury
Sample characteristics The mean age of the study group was 26 years (range: 2 months 97 years). As a result of the effects of the past demographic trends, Turkey now has a young age structure: 32% of the population is below age 15, while 4% is age 65 or older.58 The demographic profile of the sample was similar when compared to that of the whole country. Thirty-three percent of the sample population was under the age of 15 and only 2.5% were over the age of 65. Four hundred and ten participants (51.3%) were men, while 396 (49.5%) participants stated that they were single. Of all participants, 30.6% indicated they were unemployed, and 69.0% stated they were in
Unintentional non-fatal injuries at home
539
Table 1 Socio-demographic variables in the 800 participants in the study and distribution of injury frequency according to socio-demographic variables n (%)
Participant injured (n (%))
OR (95% CI)
AORa (95% CI)
Age groups 0—4 5—9 10—14 15—24 25—44 45—64 65
73 82 64 186 258 117 20
17 14 10 15 17 8 5
4.3 (2.1—9.0) *** 2.9 (1.4—6.2) ** 2.6 (1.1—6.1) * 1.2 (0.6—2.6) Reference 1.0 (0.4—2.5) 4.7 (1.5—14.6) **
2.6 (0.5—12.3) 1.6 (0.3—7.8) 1.6 (0.3—8.0) 1.0 (0.3—2.1) Reference 0.8 (0.3—2.1) 1.7 (0.4—7.0)
Gender Male Female
410 (51.3) 390 (48.8)
36 (8.8) 50 (12.8)
Reference 1.5 (1.0—2.4) *
Reference 1.5 (0.9—2.5)
Education 8 years and low 8 years over
438 (54.8) 362 (45.3)
65 (14.8) 21 (5.8)
2.8 (1.7—4.7) *** Reference
1.6 (0.7—3.4) Reference
Marital status Married Single Widows/widowers or divorced
381 (47.6) 396 (49.5) 23 (2.9)
24 (6.3) 55 (13.9) 7 (30.4)
Reference 2.4 (1.5—4.0) *** 6.5 (2.4—17.3) ***
Reference 1.5 (0.4—5.6) 4.9 (1.5—16.8) *
Occupation Unemployed Employed
574 (71.8) 226 (28.2)
73 (12.7) 13 (5.8)
2.4 (1.3—4.4) ** Reference
1.1 (0.5—2.5) Reference
Economic status Income <500 s/(person month) Income 500 s/(person month)
552 (69.0) 248 (31.0)
69 (12.5) 17 (6.9)
1.9 (1.1—3.4) * Reference
1.9 (1.1—3.4) * Reference
Total
800 (100.0)
86 (10.8)
(9.1) (10.3) (8.0) (23.3) (32.3) (14.5) (2.5)
(23.3) (17.1) (15.6) (8.1) (6.6) (6.8) (25.0)
*p < 0.05, **p < 0.01, ***p < 0.001. a Economic status, age groups, gender, education, marital status and occupation were included in the adjustment.
a low economic status and that their income were under 500 s per month (Table 1).
Frequency of unintentional non-fatal home-related injuries In the survey area, the incidence of unintentional non-fatal home-related injuries was established as 10.8%. Women had a higher rate of unintentional home injuries when compared to men. The highest rate of non-fatal unintentional home injury was determined among adults having an income of under 500 s/(person month), among those aged under 14 or over 65, among those who were single, divorced or unemployed (Table 1).
Risk factors for injury Univariate analysis revealed many risk factors for injuries. The frequency of injuries correlated with age, gender, education, socio-economic and marital status, and occupation. The variables related to economic status, age groups, gender, education,
marital status and occupation were included in the adjustment. Multivariate analysis including all significant risk factors revealed economic and marital status as two independent risk factors for injuries. The frequency of home injuries was 4.9 times higher in widow/widower or divorced people ( p < 0.05); 1.9 times higher in people with an income of under 500 s/(person month) ( p < 0.05) (Table 1).
Characteristics of unintentional non-fatal home-related injuries Mechanism of injury Falls were the primary cause of injury (38.4%), followed by cut/piercing (22.1%) and contact with hot objects or liquid/gas (20.9%) (Table 2). Stratified by age groups (0—4, 5—9, 10—14, 15—24, 25—44, 45—64, 65), contact with hot objects/substances or hot liquid/gas was the leading mechanism of injury in children 4 years of age or younger, and falling was the second. Falls were the leading mechanism in children aged 5—9 years or in adults aged over 45 (Fig. 2).
540
Table 2 Descriptions of unintentional non-fatal home-related injuries; numbers and frequencies according to age groups and gender Age groups (n (%)a) 0—4
1. Place of occurrence Living room Kitchen Bathroom, toilet Bedroom Balcony Corridor
26 23 19 8 6 4
(30.2) (26.7) (22.1) (9.3) (7.0) (4.7)
10 3 1 2 — 1
(58.8) (17.6) (5.9) (11.8)
2. Time of incident Morning (04:00—07:59 h) Before-noon (8:00—11:59 h) Noon (12:00—15:59 h) Afternoon (16:00—19:59 h) Evening (20:00—19:59 h) Night (20:00—03:59 h)
21 8 19 3 28 7
(24.4) (9.3) (22.1) (3.5) (32.6) (8.1)
7 2 2 — 5 1
(41.1) (11.8) (11.8)
3. Mechanism of injury (cause) 3.1. Blunt force Falling, stumbling, jumping, pushed Cut/piercing
33 (38.4) 19 (22.1)
6 (35.2) 1 (5.9)
3.2. Thermal mechanism (contact with) Hot object/substance or hot liquid/gas Fire or flame
18 (20.9) 2 (2.3)
7 (41.2) 1 (5.9)
3.3. Exposure to chemical substance Poisoning with medicines or chemicals Carbon monoxide poisoning
8 (9.3) 3 (3.5)
3.4. Other specified mechanism of injury Electric shock 4. Outcome Cured Under treatment with no long-term results Disabled a
Column percentage.
(5.9)
(29.4) (5.9)
5—9 5 3 2 — 2 2
(35.7) (21.4) (14.3)
2 2 4 — 5 1
(14.3) (14.3) (28.6)
(14.3) (14.3)
(35.7) (7.1)
10 (71.5) 3 (21.4)
Gender (n (%)a) 10—14 3 5 — 1 1 —
(30.0) (50.0)
3 1 3 — 3 —
(30.0) (10.0) (30.0)
(10.0) (10.0)
(30.0)
15—24
25—44
45—64
65
Male
Female
3 4 5 2 1 —
(20.0) (26.7) (33.3) (13.3) (6.7)
2 4 6 3 2 —
(11.8) (23.5) (35.3) (17.6) (11.8)
3 (37.5) 3 (37.5) 2 (25.0) — — —
— 1 (20.0) 3 (60.0) — — 1 (20.0)
14 7 8 2 4 1
(38.9) (19.4) (22.2) (5.6) (11.1) (2.8)
12 16 11 6 2 3
(24.0) (32.0) (22.0) (12.0) (4.0) (6.0)
4 1 3 2 4 1
(26.7) (6.6) (20.0) (13.3) (26.7) (6.7)
4 1 6 1 3 2
(23.5) (5.9) (35.3) (5.9) (17.6) (11.8)
1 1 1 — 4 1
—
(50.0) (12.5)
— — 4 (80.0) 1 (20.0)
11 4 7 1 8 5
(30.6) (11.1) (19.4) (2.8) (22.2) (13.9)
10 4 12 2 20 2
(20.0) (8.0) (24.0) (4.0) (40.0) (4.0)
(12.5) (12.5) (12.5)
3 (30.0) 4 (40.0)
3 (20.0) 5 (33.3)
3 (17.6) 3 (17.6)
4 (50.0) 3 (37.5)
4 (80.0) —
17 (47.1) 9 (25.0)
16 (32.0) 10 (20.0)
— —
1 (10.0) —
3 (20.0) —
6 (35.3) —
1 (12.5) —
— 1 (20.0)
6 (16.7) 1 (2.8)
12 (24.0) 1 (2.0)
1 (5.9) —
1 (7.1) —
2 (20.0) —
2 (13.3) 1 (6.7)
2 (11.8) 2 (11.8)
— —
— —
2 (5.6) 1 (2.8)
6 (12.0) 2 (4.0)
3 (3.5)
1 (5.9)
—
—
1 (6.7)
1 (5.9)
—
—
—
3 (6.0)
70 (81.4) 7 (8.1) 9 (10.5)
17 (100.0) — —
13 (86.7) 2 (13.3) —
13 (76.4) 2 (11.8) 2 (11.8)
7 (87.5) — 1 (12.5)
1 (20.0) — 4 (80.0)
12 (85.7) 2 (14.3) —
7 (70.0) 1 (10.0) 2 (20.0)
31 (86.1) 4 (11.1) 1 (2.8)
39 (78.0) 3 (6.0) 8 (16.0)
F. Alptekin et al.
Total (n = 86) (n (%)a)
Unintentional non-fatal injuries at home
Figure 2
541
Distribution of unintentional non-fatal home-related injury mechanisms by age groups.
Place of occurrence Thirty percent of the injuries occurred in the living room. The kitchen was the second most common place for injuries (26.7%), and the bathroom or the toilet was the third (22.1%) (Table 2). Falling was the most common injury and 75.0% of all falls occurred in the bathroom or toilet among the people 65 years of age or older. Contact with a hot object or liquid was the most common injury under 5 years and 71.4% of these children were injured with a hot object or liquid in the living room. All electrical injuries occurred in the living room and all carbon monoxide poisoning occurred in the bathroom or toilet (Table 3). Time of incident Injuries occurred in the morning (24.4%) and evening (32.6%) more frequently than the other times of the day (Table 2). Outcomes Most of the injured participants were cured (70/86) after their first visit to one of the health facilities (health centres or hospital emergency wards) (81.4%). In seven cases (7/86) (8.1%), however, there was a need for further treatment. In nine cases (9/86) (10.5%), there was a permanent disability (Table 2). Leading causes of disability were falls (18.2%), burns (11.1%) and cuts (5.3%). Other mechanisms of injury did not give rise to disability. In all disabled participants over aged 65 (n = 4), the cause of the disability was a fall.
Discussion This study was able to expand our understanding of the frequencies and underlying mechanisms of injury occurring in the home environment. The annual incidence of non-fatal, unintentional home-related injury was 10.8% and the disability rate was 1.1%. The World Health Organization (WHO)65 study on dwelling health found the incidence for home accidents to be 25%. There are several other studies on home injuries
from Turkey but they generally focus on the elderly and the injuries caused by accidents in the elderly.14,15,27 Although they do not allow direct comparison with our injury frequencies, they help us to comment on our outcomes from different perspectives. Young children (especially those under 5 years of age), older adults (especially over 65 years) and females experience the highest rates of home injury.11 We obtained the highest rates among these risk groups in univariate analysis but not in multivariate analyses. Children younger than 5 years are unique in terms of rapid growth and developmental changes, which influence the risks for a number of specific causes of injury.1 Children had the highest rates of contact with hot materials and falling. Burns were the leading cause, and falls were the second leading cause of injury in children aged 0—4 in the current study. Falls were the leading cause of injury in the group aged 5—9. Rahman et al.42 stated that burns were the most common cause of injury in younger children (0—4 years). Sikron et al.51 found that burns caused 9% of all home injuries, increasing to 18% among children (0—4 years). In their community-based study, Matanhire et al.31 found that falls (68.8%), burns (16.3%) and scalds (4.7%) featured as prevalent types of injuries in 0—5 years olds. Agran et al.1 reported that the leading cause of injury in 0—4 ages was a fall, with poisoning as the second. In Gulliver et al.’s study,23 the most frequently recorded causes of hospitalisation were found to be falls, scalds, poisonings and cut/piercing incidents among children under 5 years of age. In this study, over two thirds of hot object contacts among 0—4 ages occurred in the living room. People in a low socio-economic status generally heat their houses by a wood-burning stove in Turkey. Stoves are generally installed in the living room. Children whose houses were heated by a wood-burning stove may have injury risks such as contact with hot stove in the living room. In addition, heating by a woodburning stove may cause carbon monoxide poisoning since people sleep in the living room heated by the
542
Table 3 Distribution of mechanisms of unintentional non-fatal home-related injuries according to the age groups and the place of occurrence Mechanism of injury
Age groups a
Place of occurrence (n (%)b) Living room
Falling, stumbling, jumping, pushed
0—4 5—9 10—14 15—24 25—44 45—64 65
Total Cut/piercing
0—4 5—9 10—14 15—24 25—44 45—64
Total Hot object/substance or hot liquid/gas
0—4 10—14 15—24 25—44 45—64
Total Fire or flame
0—4 65
Total Poisoning with medicines or chemicals
0—4 5—9 10—14 15—24 25—44
Total Carbon monoxide poisoning
15—24 25—44
Total
Total a b
Age groups with no injury were not presented. Row percentage.
0—4 15—24 25—44
Total (n) Bathroom, toilet
Bedroom
Balcony
Corridor
3 (50.0) 3 (30.0) 1 (33.3) 1 (33.3) 1 (33.3) 2 (50.0) —
— 1 (10.0) 1 (33.3) — — — —
1 (16.7) 2 (20.0) — 2 (66.7) 1 (33.3) 2 (50.0) 3 (75.0)
1 (16.7) — — — — — —
— 2 (20.0) 1 (33.3) — 1 (33.3) — —
1 (16.7) 2 (20.0) — — — — 1 (25.0)
6 10 3 3 3 4 4
11 (33.3)
2 (6.1)
11 (33.3)
1 (3.0)
4 (12.1)
4 (12.1)
33
— — — — — —
— — — — — —
— — — 1 (20.0) 1 (33.3) —
— — — — — —
1 3 4 5 3 3
—
—
2 (10.5)
—
19
2 (33.3)
1 (33.3) 1 (16.7)
1 1 2 3
— — — — —
— — — — —
7 1 3 6 1
6 (33.3)
3 (16.7)
2 (11.1)
7 (38.9)
—
—
18
1 (100.0)
— 1 (100.0)
— —
— —
— —
— —
1 1
1 (50.0)
1 (50.0)
—
—
—
—
2
— 1 (100.0) 1 (50.0) 1 (50.0) —
1 (100.0) — 1 (50.0) — —
— — — 1 (50.0) 2 (100.0)
— — — — —
— — — — —
— — — — —
1 1 2 2 2
3 (37.5)
2 (25.0)
3 (37.5)
—
—
—
8
— —
— —
1 (100.0) 2 (100.0)
— —
— —
— —
1 2
—
—
3 (100.0)
—
—
—
3
1 (100.0) 1 (100.0) 1 (100.0)
— — —
— — —
— — —
— — —
— — —
1 1 1
3 (100.0)
—
—
—
—
—
3
— 1 (33.3) 1 (25.0) — — —
1 2 3 4 2 3
(100.0) (66.7) (75.0) (80.0) (66.7) (100.0)
2 (10.5)
15 (78.9)
5 (71.4)
1 (14.3)
(14.3) (100.0) (66.7) (50.0)
1 (100.0)
F. Alptekin et al.
Electric blankets
Kitchen
Unintentional non-fatal injuries at home stove in the winter. Carbon monoxide poisoning is decreasing in developed countries owing to appropriate measures and technological facilities. However, it is still a major cause of home accidents in developing or underdeveloped countries.19,63 We did not observe any case of carbon monoxide poisoning in the living room. All carbon monoxide poisonings occurred in the bathroom. Gas geysers should only be installed in areas that are well ventilated and should not be installed in the bathroom since lack of proper ventilation in the bathroom will result in accumulation of fumes, which can lead to suffocation/asphyxiation.22 However, people in Turkey still sometimes install the gas geyser in their bathroom and they may eventually be poisoned. The most common mechanism of injuries was falls (38.4%) in all study groups and WHO (27.9%) also pointed out the similar incidents.7 We determined that the most common injury type among those over 65 was falling and many previous studies reported detailed findings on this issue.12,21,26,48,49 Older adults probably experience home injury more frequently because they spend more time in the home environment, compared with other age groups who spend a significant duration of time at work.46 In addition, the loss of muscle strength and flexibility, and impaired balance and reaction time may also lead to injuries in the elderly.36,64 When older adults sustain an injury, most become disabled. In the current study, falls, burns and cuts were the leading causes of unintentional home injury-related disability. Approximately half of the disabilities occurring after injury was seen in those over 65, and almost all of them were in females. Many falls and fractures (also disability) would be prevented8,36 if subjects at high risk for falls would be identified through implementation of a multifactorial and individualised approach.17 Given the rapid increase in the numbers of elderly adults, it is imperative to invest now to find ways in preventing injuries and to plan for social and environmental changes that would reduce injuries among the elderly.6 Despite reports in the literature stating that females sometimes have similar11,47 rates of nonfatal injury rates to males, males show a higher rate of unintentional home injury-related death.2,13,46 In the current study, females experienced higher rates of home-related injury than males in univariate analysis. However, multivariate analysis did not determine a gender difference for injury risk at home. Males and females have different roles in life in Turkey. Females are concerned with the care of children and their houses and the preparation and cooking of food. This means that females spend
543 more time and have more responsibility at home. Although 82% of female participants in our study did not work outside the home and spent all their daytime at home, they were not more frequently injured than males. We deduced that injuries occurred mostly in the morning or in the evening, as seen in the literature.37,44 People may hurry in the morning to be on time for their job, and they may be extremely tired at the end of the day’s work in the evening, consequently causing them to be careless, at which time the injury occurs. In the current study, approximately one third of all the injuries occurred in the living room. Children under five were injured frequently in the living room, but the elderly were injured frequently in the bathrooms/toilets. The most frequent injury type, falling, occurred either in the living rooms or the bathrooms/toilets. These findings were consistent with those in the literature9,30 and emphasised the fact that people use both the living rooms and the bathrooms/toilets as the major recreation areas. In this study, we did not aim to determine home environment safety level or any risk factors related to home environment. On the other hand, our results show that most of the injuries occurred in particular areas at home and the most dangerous areas for injuries were the living rooms and bathrooms/toilets. As elderly and children under five spent most of their time in their houses, indoor safety conditions constituted an important factor in the occurrence of home accidents. In particular, the living rooms and bathrooms as the major recreation areas should be reconstructed for both children and the elderly according to safety criteria.
Limitations Reporting of injuries was often dependent on the severity of the injury and whether medical care was sought.16 A combination of methods, both selfreporting and reports from different authorities, was suggested to estimate the true incidence of injuries in the population.55 A national database of unintentional home injuries does not exist in Turkey. The present study was a community-based survey and data were gathered by findings of a household survey. A household survey would provide population-based injury incidence data and desired information on circumstances in a representative sample.42 The goal of the study was to determine the true incidence and data were collected by interviews based on self-expression. There is substantial potential for bias in household surveys due to unreliable memory and embarrassment regarding certain types of injuries. In addition, this study did not
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include any hospital or emergency department survey data. In the future, surveillance and prospective studies should be proposed in the community in order to estimate the true population incidence of injuries and risk factors.
appropriate education, as well as legal regulations for manufacturers of household articles may significantly reduce the number of injuries and disabilities related to household injuries.
Suggestions
Acknowledgements
Treatment after injuries is always more expensive than the prevention. The causes of injuries can be roughly grouped into two, insecure conditions/ environment and insecure behaviour. Main predictors for all kinds of unintentional home injuries are associated with not only individual characteristics but also housing conditions.28,65 Injuries can be prevented by changing the environment, individual behaviour, products, social norms, legislation, and governmental and institutional policy.29 Injuries encountered at home can also be avoided. Strengthening individuals’ knowledge and skills, promoting community education, changing organisational practices, and insisting on related policy-making and legislation may help promotion of effective prevention effort. The systematic national injury surveillance system should undergo development in Turkey and collection of morbidity data should include the development of consistent definitions for home injuries. In addition, to prevent domestic accidents, unsafe housing conditions should be identified and changes in the houses can be made. For the unsafe behaviour, education for individuals can be provided. Due to the presence of a large number of people affected by injuries in the home environment, special attention should be paid towards preventive strategies without delay.47 Major prevention priorities should be devoted to risk groups such as individuals with a low socio-economic status.
We thank the participants for their cooperation and the regional health insurance association for supplying the National Health Registration System data of the study region. All cost of this research was covered by the authors. There was no external financial support.
Conclusion The findings in this study are very helpful in understanding unintentional injuries at home as a major problem, since they are of high incidence and cause a high rate of injury-related disabilities. Participants who were under five or over 65 years of age, with low economic status, with an education less than 8 years, females, single people, widows/ widowers and divorced people were more frequently injured. Multiple analysis showed that the individual who had low economic status or were divorced had a high risk of injury at home. Findings related to disability highlighted a need to focus attention on the prevention of residential falls among elderly adults, and burns/falls among younger children. Determination of risk factors,
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545 36. Myers AH, Young Y, Langlois JA. Prevention of falls in the elderly. Bone 1996;18:87—101. 37. Navascues RJA, Soleto MJ, Cerda Berrocal J. Epidemiologic study of injuries in childhood: the fist pediatric travma registry. Ann Esp Pediatr 1997;369—72. 38. Northridge ME, Nevitt MC, Kelsey JL, et al. Home hazards and falls in elderly: the role of health and functional status. Am J Public Health 1995;85:509—14. 39. Ozdemir C, Uzun I, Sam B. Childhood foreign body aspiration in Istanbul, Turkey. Forensic Sci Int 2005;153(2—3):136—41. 40. Peden M, McGee K, Krug E, editors. Injury: a leading cause of the global burden of disease, 2000. Geneva: World Health Organization; 2002. 41. Provincial Health Directorate of Aksaray, Statistical Department. Results of household definition health card analyses. Aksaray, Turkey; 2004. 42. Rahman F, Andersson R, Svanstro ¨m L. Health impact of injuries: a population-based epidemiological investigation in a local community of Bangladesh. J Safety Res 1998;29 (4):213—22. 43. Republic of Turkey Ministry of Health Research Planning and Coordination Council. Health statistics 1964—1994. Ankara; 1996. 44. Roche LM, Cody PR. Occupational injury visits to run Emergency Department-opportunity for prevention. Acad Emerg Med 1998;354. 45. Runyan CW, Casteel C, editors. The state of home safety in America. Facts about unintentional injuries in the home. 2nd ed., Home Safety Council; 2004. 46. Runyan CW, Casteel C, Perkis D, et al. Unintentional Injuries in the Home in the United States. Part I. Mortality. Am J Prev Med 2005;28(1):73—9. 47. Runyan CW, Perkis D, Marshall SW, et al. Unintentional Injuries in the Home in the United States. Part II. Morbidity. Am J Prev Med 2005;28(1):81—7. 48. Sattin RW, Lambert Huber DA, DeVito CA, et al. The incidence of fall injury events among elderly in a defined population. Am J Epidemiol 1990;131:1028—37. 49. Scott VJ, Gallagher EM. Mortality and morbidity related to injuries from falls in British Columbia. Can J Public Health 1999;90:343—7. 50. Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health 2003;57:740—4. 51. Sikron F, Giveon A, Aharonson-Daniel L, et al. My home is my castle! Or is it? Hospitalizations following home injury in Israel, 1997—2001. Isr Med Assoc J 2004;6(6):332—5. 52. Sorock GS. Falls among the elderly: epidemiology and prevention. Am J Prev Med 1988;4:282—8. 53. T.R. Prime Ministery State Planning Organization. Regional development and development performance for Aksaray. Retrieved December 4, 2005 from http://www.dpt.gov.tr/ bgyu/ipg/icanadolu/aksarayper.pdf. 54. Tarim A, Nursal TZ, Yildirim S, et al. Epidemiology of pediatric burn injuries in southern Turkey. J Burn Care Rehabil 2005;26(4):327—30. 55. Tercero F, Andersson R, Pena R, et al. Can valid and prevention-oriented information on injury occurrence be obtained from existing data sources in developing countries? An example from Nicaragua. Int J Consumer Product Safety 1998;5: 99—105. 56. Tercero F, Andersson R, Pena R, et al. The epidemiology of moderate and severe injuries in a Nicaraguan community: a household-based survey. Public Health 2005 [Epub ahead of print]. 57. Thanh NX, Hang HM, Chuc NT, et al. The economic burden of unintentional injuries: a community-based cost analysis in
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www.elsevier.com/locate/injury
Unintentional non-fatal home-related injuries in Central Anatolia, Turkey: Frequencies, characteristics, and outcomes Fadimana Alptekin a, Ersin Uskun b,*, Ahmet Nesimi Kisioglu b, Mustafa Ozturk b a
Gulagac Health Center, Provincial Health Directorate, Aksaray 68000, Turkey Department of Public Health, Faculty of Medicine, Suleyman Demirel University, East Campus Cunur Isparta 32260, Turkey
b
Accepted 26 February 2007
KEYWORDS Unintentional; Non-fatal; Home injury; Frequency; Characteristics; Outcome; Causes of injury
Summary Injuries constitute a major public health problem worldwide. Homes are an important setting for non-fatal unintentional injuries. The aim of this study is to determine the frequency, the characteristics, and the outcome of unintentional nonfatal injuries in the household, and to describe the related risk factors through a community-based survey. The study was conducted using a household-based survey design. Eight hundred inhabitants were sampled from the entire population in the city centre by a stratified sampling method in 2004. All unintentional non-fatal home-related injuries occurring in the previous year were registered and examined, making special note of the mechanism of the injuries, the time and place of the incidents and their outcomes. The frequency of unintentional non-fatal home-related injuries requiring some form of medical attention was established as 10.8%. Falls were the most common injuries among all the study groups. Injury rates were highest among the oldest (aged 65) and youngest (aged <15) age groups, females, adults having incomes under s 500, individuals living alone, or the unemployed. Contact with hot objects/substances or hot liquid/gas was the leading mechanism in children 4 years of age or younger, falls ranking second. Falls are a significant problem particularly among older adults. Multiple analysis revealed that participants with low incomes, living alone and single or divorced had a high risk for injury at home. The findings related to disability highlighted a need to focus attention on the prevention of residential falls among
* Corresponding author at: Iskender mah 121 cadde, Buyuk Bucakli Apt. No. 40 Daire 5, 32040 Isparta, Turkey. Tel.: +90 2462113633; fax: +90 2462371165. E-mail address: [email protected] (E. Uskun). 0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.02.042
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F. Alptekin et al. the elderly, and the burns and falls among young children. Preventive measures should be prioritised to risk groups such as individuals with low incomes and those living alone. # 2007 Elsevier Ltd. All rights reserved.
Introduction Injuries, which are major causes of mortality46 and morbidity,47,59 constitute a significant public health problem worldwide, in addition to a cost burden.32,33,50,57,61 Dimensions and nature of this problem are difficult to establish due to lack of valid and representative data.56 In some countries of low and mid-socio-economic status, the leading injuryrelated causes of death are those occurring in the household.40 Mortality is a very important indicator of the magnitude of a health problem. However, the number of non-fatal outcomes must also be recorded in order to accurately characterise the burden of injury.40 The panorama of the injury occurring in the household has been well described in countries with high-income.45—47,60 Every year, many unintentional home injuries45 and deaths60 related to these injuries are reported in the developed countries. In addition, the annual society-related cost of non-fatal unintentional home injuries was relatively high in these countries.60,66 Falls are the most common mechanisms of nonfatal unintentional injuries,47 and the leading cause of both home-related injury deaths and non-fatal injuries.18 Approximately 45% of all injuries in the household environment resulting in medical attention are caused by falls.47 Risk factors in home-related injuries vary. The rates of non-fatal unintentional home-related injuries are high among the elderly (over 65 years old) and youngsters (0—14 years old).47 Falls are very common in older people.4,38,48,52 Burns are primarily a problem in young children, the most frequent scenario being a scald injury.34 Although men have similar rates of non-fatal injury when compared to women,47 the death rate in unintentional homerelated injuries is higher in males than in females.13,46 Countries with mid-level income have not recognised injuries as a major public health problem as very few have actually studied the magnitude of the problem.3,35 There are very few population-based studies on injuries in developing countries.42 In the developed countries, epidemiological studies have begun to identify the causes and means of prevention of injuries, but unfortunately, much less is known about the incidence and the cause of injuries in developing countries, or about groups at high risk
for injuries in those countries.44 There have also been a number of studies either on specific injuries or among different age groups in Turkey. Dallar et al.10 and Tarim et al.54 conducted two different studies on paediatric burns; Asirdizer et al.5 worked on infant and adolescent deaths due to home acci˘lu et al.27 estabdents; Evci et al.15 and, Keskinog lished the impact of the main characteristics of the elderly on home accidents; Goren et al.20 and Ozdemir et al.39 conducted two different studies on foreign body asphyxiation in children. All of these studies were hospital-based. As seen, there are very few population-based studies on home-related injuries in Turkey. There is no common definition of the mechanisms of the injuries and no constructive information on the accidents occurring in households in Turkey. For this purpose, population-based studies and the assessment of mechanisms of home-related injuries are especially required in developing countries such as Turkey. The aims of this study are to determine the incidence and outcome of unintentional non-fatal injuries at home, and to describe the related risk factors through a community-based survey.
Materials and methods Housing and individual characteristics of the study region This study was conducted in the centre of Aksaray, in Central Anatolia, Turkey, using growth indicators (such as the housing characteristics, education, health status and the economic indicators) similar with rest of Turkey.53 The housing and individual characteristics of Turkey have been described by the Turkish Demographic and Health Survey.24 Females outnumber males in Turkey (51 and 49%, respectively). The population pyramid has a wide base, with a large portion (29%) of the population being under 15 years of age. This pattern is typical in countries that have had relatively high fertility in the recent past. There is an educational gap between males and females in Turkey. Overall, about 77% of males at least completed primary school, compared with 61% of females. The median number of school years for men was 4.8 which was
Unintentional non-fatal injuries at home about 0.5 year higher than the median for women (4.3 years). There were, on the average, four individuals per household in Turkey. More than four in ten households had fewer than four members, while another quarter of the households had five members, and one third of the households had six or more members.
Recruitment into the study and participants A cross-sectional study, by a stratified sampling method, was carried out in 2004 with 800 inhabitants sampled from the entire population in the city centre of Aksaray. The sampling size was calculated (estimated value43: 0.20; minimum difference: 0.05; a: 0.05; b = 0.05; power: 80% and confidence interval: 95%) using the GraphPad Software, Instat (GraphPad Instat, 1990—1993, V2.02). The sample size (n: 753) was adapted to 800 in order to calculate the stratified sampling method. There is a national health registration system in the health centres all over the country whose data are collected by the Provincial Health Directorate. The size of the entire population of the study area
Figure 1
537 was reported as 103,726 according to the data of the Provincial Health Directorate.41 Initially, using the data of the Provincial Health Directorate, nine health centres in the city were categorised into three strata according to low, middle, and high socio-economic properties, and the size of each group was calculated according to the number of their residents within the entire population using the data of the Provincial Health Directorate. One health centre from each stratum was selected using random sampling method. Consequently, each stratum was represented by one health centre. The numbers of residents in three strata were taken into consideration in order to calculate the number of samples from each health centre. In each of the three strata, 30% (n = 240) of the 800 people studied were randomly selected from the ‘low’ category, 39% (n = 312) from the ‘middle’ category, and 31% (n = 248) from the ‘high’ category (Fig. 1). In the national health registration system, the health centre worker made the record of every household and individual on separate cards, so, every individual had a registration card, which included socio-demographic information such as age, sex, educational level. A table of random numbers was used to
Total field under survey, sample and sampling methods.
538 identify specific household from the household health registration cards. An adequate number of houses was chosen with this random sampling method by using the information in the household health registration cards, until the intended number of persons at each level was reached. For every house, an equivalent (same area, and same number of house members) a backup house was determined by the random method, in case, the house members would not agree to contribute to the study. Since there was no individual who did not agree to contribute, no data were gathered from the backup houses. In the research, 800 persons were contacted in 180 houses. The number of persons in a house was (S.D.) 4.4 (1.3) in average (min: 1—max: 9).
Procedure and assessment In the study group, every individual was personally visited. All of the individuals who were invited agreed to participate. Structured interviews with participants were used. The participants under the age of 15 were interviewed in the presence of their mothers. A questionnaire created by the authors was applied in order to inquire about the socio-demographic properties of participants and unintentional non-fatal home-related injuries occurring in the previous year. The questionnaire was read out for each participant so as to overcome the problem of illiteracy of some participants. In cases where the participant was injured in the previous year, the mechanism of injury (external cause of injury), the time and place of the incident and the outcomes (‘cured’, ‘under treatment with no long-term consequences’ and ‘disabled’) were recorded.
F. Alptekin et al. that took place in the home environment, which was defined as the ‘person’s usual residence’ and its corresponding ‘parts of the building’ sub-module under the ‘place of occurrence’’ section of the ICECI.25
Ethics This study was conducted according to the ethical standards set by the Declaration of Helsinki62 that promote respect for all human beings and protect their health and rights. After informing the participants about the purpose of the trial (investigation, research, study) and about where and how the obtained data would be used, written consents were obtained. All participants in the research survey gave their consent for the release of information for public use.
Statistical analysis All data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS 9.0 Inc., California, 1999) with a two-tailed p-value of 0.05 used as the threshold for significance, and Instat (Graph Pad Software, Instat, 1990—1993, V2.02) was used to calculate the sample size. The results were expressed as the mean and standard deviation for quantitative variables, and as the frequencies for categorical findings. We calculated an odds ratio (OR) for each variable in order to determine the effects of the socio-demographic properties of the study groups on injury matters, and all variables (economic status, gender, occupation, education and marital status) regressed against the injury frequency in the logistic regression analysis.
Definition of unintentional home-related injuries in this study
Results This study included only the cases with unintentional, non-fatal home-related injuries. All serious unintentional, non-fatal home-related injuries recalled and reported by the participants during the last 1-year period were included, and only those needing medical attention were considered serious. None of the participants reported more than one injury in 1 year. Injuries were classified as unintentional and non-fatal in correlation with the mechanism of injury according to the International Classification for External Causes of Injuries (ICECI).25 An unintentional non-fatal home-related injury was defined as ‘‘an unforeseen incident, where there was no intent by a person to cause harm or injury, but which resulted in injury, and any episode of unintentional injury
Sample characteristics The mean age of the study group was 26 years (range: 2 months 97 years). As a result of the effects of the past demographic trends, Turkey now has a young age structure: 32% of the population is below age 15, while 4% is age 65 or older.58 The demographic profile of the sample was similar when compared to that of the whole country. Thirty-three percent of the sample population was under the age of 15 and only 2.5% were over the age of 65. Four hundred and ten participants (51.3%) were men, while 396 (49.5%) participants stated that they were single. Of all participants, 30.6% indicated they were unemployed, and 69.0% stated they were in
Unintentional non-fatal injuries at home
539
Table 1 Socio-demographic variables in the 800 participants in the study and distribution of injury frequency according to socio-demographic variables n (%)
Participant injured (n (%))
OR (95% CI)
AORa (95% CI)
Age groups 0—4 5—9 10—14 15—24 25—44 45—64 65
73 82 64 186 258 117 20
17 14 10 15 17 8 5
4.3 (2.1—9.0) *** 2.9 (1.4—6.2) ** 2.6 (1.1—6.1) * 1.2 (0.6—2.6) Reference 1.0 (0.4—2.5) 4.7 (1.5—14.6) **
2.6 (0.5—12.3) 1.6 (0.3—7.8) 1.6 (0.3—8.0) 1.0 (0.3—2.1) Reference 0.8 (0.3—2.1) 1.7 (0.4—7.0)
Gender Male Female
410 (51.3) 390 (48.8)
36 (8.8) 50 (12.8)
Reference 1.5 (1.0—2.4) *
Reference 1.5 (0.9—2.5)
Education 8 years and low 8 years over
438 (54.8) 362 (45.3)
65 (14.8) 21 (5.8)
2.8 (1.7—4.7) *** Reference
1.6 (0.7—3.4) Reference
Marital status Married Single Widows/widowers or divorced
381 (47.6) 396 (49.5) 23 (2.9)
24 (6.3) 55 (13.9) 7 (30.4)
Reference 2.4 (1.5—4.0) *** 6.5 (2.4—17.3) ***
Reference 1.5 (0.4—5.6) 4.9 (1.5—16.8) *
Occupation Unemployed Employed
574 (71.8) 226 (28.2)
73 (12.7) 13 (5.8)
2.4 (1.3—4.4) ** Reference
1.1 (0.5—2.5) Reference
Economic status Income <500 s/(person month) Income 500 s/(person month)
552 (69.0) 248 (31.0)
69 (12.5) 17 (6.9)
1.9 (1.1—3.4) * Reference
1.9 (1.1—3.4) * Reference
Total
800 (100.0)
86 (10.8)
(9.1) (10.3) (8.0) (23.3) (32.3) (14.5) (2.5)
(23.3) (17.1) (15.6) (8.1) (6.6) (6.8) (25.0)
*p < 0.05, **p < 0.01, ***p < 0.001. a Economic status, age groups, gender, education, marital status and occupation were included in the adjustment.
a low economic status and that their income were under 500 s per month (Table 1).
Frequency of unintentional non-fatal home-related injuries In the survey area, the incidence of unintentional non-fatal home-related injuries was established as 10.8%. Women had a higher rate of unintentional home injuries when compared to men. The highest rate of non-fatal unintentional home injury was determined among adults having an income of under 500 s/(person month), among those aged under 14 or over 65, among those who were single, divorced or unemployed (Table 1).
Risk factors for injury Univariate analysis revealed many risk factors for injuries. The frequency of injuries correlated with age, gender, education, socio-economic and marital status, and occupation. The variables related to economic status, age groups, gender, education,
marital status and occupation were included in the adjustment. Multivariate analysis including all significant risk factors revealed economic and marital status as two independent risk factors for injuries. The frequency of home injuries was 4.9 times higher in widow/widower or divorced people ( p < 0.05); 1.9 times higher in people with an income of under 500 s/(person month) ( p < 0.05) (Table 1).
Characteristics of unintentional non-fatal home-related injuries Mechanism of injury Falls were the primary cause of injury (38.4%), followed by cut/piercing (22.1%) and contact with hot objects or liquid/gas (20.9%) (Table 2). Stratified by age groups (0—4, 5—9, 10—14, 15—24, 25—44, 45—64, 65), contact with hot objects/substances or hot liquid/gas was the leading mechanism of injury in children 4 years of age or younger, and falling was the second. Falls were the leading mechanism in children aged 5—9 years or in adults aged over 45 (Fig. 2).
540
Table 2 Descriptions of unintentional non-fatal home-related injuries; numbers and frequencies according to age groups and gender Age groups (n (%)a) 0—4
1. Place of occurrence Living room Kitchen Bathroom, toilet Bedroom Balcony Corridor
26 23 19 8 6 4
(30.2) (26.7) (22.1) (9.3) (7.0) (4.7)
10 3 1 2 — 1
(58.8) (17.6) (5.9) (11.8)
2. Time of incident Morning (04:00—07:59 h) Before-noon (8:00—11:59 h) Noon (12:00—15:59 h) Afternoon (16:00—19:59 h) Evening (20:00—19:59 h) Night (20:00—03:59 h)
21 8 19 3 28 7
(24.4) (9.3) (22.1) (3.5) (32.6) (8.1)
7 2 2 — 5 1
(41.1) (11.8) (11.8)
3. Mechanism of injury (cause) 3.1. Blunt force Falling, stumbling, jumping, pushed Cut/piercing
33 (38.4) 19 (22.1)
6 (35.2) 1 (5.9)
3.2. Thermal mechanism (contact with) Hot object/substance or hot liquid/gas Fire or flame
18 (20.9) 2 (2.3)
7 (41.2) 1 (5.9)
3.3. Exposure to chemical substance Poisoning with medicines or chemicals Carbon monoxide poisoning
8 (9.3) 3 (3.5)
3.4. Other specified mechanism of injury Electric shock 4. Outcome Cured Under treatment with no long-term results Disabled a
Column percentage.
(5.9)
(29.4) (5.9)
5—9 5 3 2 — 2 2
(35.7) (21.4) (14.3)
2 2 4 — 5 1
(14.3) (14.3) (28.6)
(14.3) (14.3)
(35.7) (7.1)
10 (71.5) 3 (21.4)
Gender (n (%)a) 10—14 3 5 — 1 1 —
(30.0) (50.0)
3 1 3 — 3 —
(30.0) (10.0) (30.0)
(10.0) (10.0)
(30.0)
15—24
25—44
45—64
65
Male
Female
3 4 5 2 1 —
(20.0) (26.7) (33.3) (13.3) (6.7)
2 4 6 3 2 —
(11.8) (23.5) (35.3) (17.6) (11.8)
3 (37.5) 3 (37.5) 2 (25.0) — — —
— 1 (20.0) 3 (60.0) — — 1 (20.0)
14 7 8 2 4 1
(38.9) (19.4) (22.2) (5.6) (11.1) (2.8)
12 16 11 6 2 3
(24.0) (32.0) (22.0) (12.0) (4.0) (6.0)
4 1 3 2 4 1
(26.7) (6.6) (20.0) (13.3) (26.7) (6.7)
4 1 6 1 3 2
(23.5) (5.9) (35.3) (5.9) (17.6) (11.8)
1 1 1 — 4 1
—
(50.0) (12.5)
— — 4 (80.0) 1 (20.0)
11 4 7 1 8 5
(30.6) (11.1) (19.4) (2.8) (22.2) (13.9)
10 4 12 2 20 2
(20.0) (8.0) (24.0) (4.0) (40.0) (4.0)
(12.5) (12.5) (12.5)
3 (30.0) 4 (40.0)
3 (20.0) 5 (33.3)
3 (17.6) 3 (17.6)
4 (50.0) 3 (37.5)
4 (80.0) —
17 (47.1) 9 (25.0)
16 (32.0) 10 (20.0)
— —
1 (10.0) —
3 (20.0) —
6 (35.3) —
1 (12.5) —
— 1 (20.0)
6 (16.7) 1 (2.8)
12 (24.0) 1 (2.0)
1 (5.9) —
1 (7.1) —
2 (20.0) —
2 (13.3) 1 (6.7)
2 (11.8) 2 (11.8)
— —
— —
2 (5.6) 1 (2.8)
6 (12.0) 2 (4.0)
3 (3.5)
1 (5.9)
—
—
1 (6.7)
1 (5.9)
—
—
—
3 (6.0)
70 (81.4) 7 (8.1) 9 (10.5)
17 (100.0) — —
13 (86.7) 2 (13.3) —
13 (76.4) 2 (11.8) 2 (11.8)
7 (87.5) — 1 (12.5)
1 (20.0) — 4 (80.0)
12 (85.7) 2 (14.3) —
7 (70.0) 1 (10.0) 2 (20.0)
31 (86.1) 4 (11.1) 1 (2.8)
39 (78.0) 3 (6.0) 8 (16.0)
F. Alptekin et al.
Total (n = 86) (n (%)a)
Unintentional non-fatal injuries at home
Figure 2
541
Distribution of unintentional non-fatal home-related injury mechanisms by age groups.
Place of occurrence Thirty percent of the injuries occurred in the living room. The kitchen was the second most common place for injuries (26.7%), and the bathroom or the toilet was the third (22.1%) (Table 2). Falling was the most common injury and 75.0% of all falls occurred in the bathroom or toilet among the people 65 years of age or older. Contact with a hot object or liquid was the most common injury under 5 years and 71.4% of these children were injured with a hot object or liquid in the living room. All electrical injuries occurred in the living room and all carbon monoxide poisoning occurred in the bathroom or toilet (Table 3). Time of incident Injuries occurred in the morning (24.4%) and evening (32.6%) more frequently than the other times of the day (Table 2). Outcomes Most of the injured participants were cured (70/86) after their first visit to one of the health facilities (health centres or hospital emergency wards) (81.4%). In seven cases (7/86) (8.1%), however, there was a need for further treatment. In nine cases (9/86) (10.5%), there was a permanent disability (Table 2). Leading causes of disability were falls (18.2%), burns (11.1%) and cuts (5.3%). Other mechanisms of injury did not give rise to disability. In all disabled participants over aged 65 (n = 4), the cause of the disability was a fall.
Discussion This study was able to expand our understanding of the frequencies and underlying mechanisms of injury occurring in the home environment. The annual incidence of non-fatal, unintentional home-related injury was 10.8% and the disability rate was 1.1%. The World Health Organization (WHO)65 study on dwelling health found the incidence for home accidents to be 25%. There are several other studies on home injuries
from Turkey but they generally focus on the elderly and the injuries caused by accidents in the elderly.14,15,27 Although they do not allow direct comparison with our injury frequencies, they help us to comment on our outcomes from different perspectives. Young children (especially those under 5 years of age), older adults (especially over 65 years) and females experience the highest rates of home injury.11 We obtained the highest rates among these risk groups in univariate analysis but not in multivariate analyses. Children younger than 5 years are unique in terms of rapid growth and developmental changes, which influence the risks for a number of specific causes of injury.1 Children had the highest rates of contact with hot materials and falling. Burns were the leading cause, and falls were the second leading cause of injury in children aged 0—4 in the current study. Falls were the leading cause of injury in the group aged 5—9. Rahman et al.42 stated that burns were the most common cause of injury in younger children (0—4 years). Sikron et al.51 found that burns caused 9% of all home injuries, increasing to 18% among children (0—4 years). In their community-based study, Matanhire et al.31 found that falls (68.8%), burns (16.3%) and scalds (4.7%) featured as prevalent types of injuries in 0—5 years olds. Agran et al.1 reported that the leading cause of injury in 0—4 ages was a fall, with poisoning as the second. In Gulliver et al.’s study,23 the most frequently recorded causes of hospitalisation were found to be falls, scalds, poisonings and cut/piercing incidents among children under 5 years of age. In this study, over two thirds of hot object contacts among 0—4 ages occurred in the living room. People in a low socio-economic status generally heat their houses by a wood-burning stove in Turkey. Stoves are generally installed in the living room. Children whose houses were heated by a wood-burning stove may have injury risks such as contact with hot stove in the living room. In addition, heating by a woodburning stove may cause carbon monoxide poisoning since people sleep in the living room heated by the
542
Table 3 Distribution of mechanisms of unintentional non-fatal home-related injuries according to the age groups and the place of occurrence Mechanism of injury
Age groups a
Place of occurrence (n (%)b) Living room
Falling, stumbling, jumping, pushed
0—4 5—9 10—14 15—24 25—44 45—64 65
Total Cut/piercing
0—4 5—9 10—14 15—24 25—44 45—64
Total Hot object/substance or hot liquid/gas
0—4 10—14 15—24 25—44 45—64
Total Fire or flame
0—4 65
Total Poisoning with medicines or chemicals
0—4 5—9 10—14 15—24 25—44
Total Carbon monoxide poisoning
15—24 25—44
Total
Total a b
Age groups with no injury were not presented. Row percentage.
0—4 15—24 25—44
Total (n) Bathroom, toilet
Bedroom
Balcony
Corridor
3 (50.0) 3 (30.0) 1 (33.3) 1 (33.3) 1 (33.3) 2 (50.0) —
— 1 (10.0) 1 (33.3) — — — —
1 (16.7) 2 (20.0) — 2 (66.7) 1 (33.3) 2 (50.0) 3 (75.0)
1 (16.7) — — — — — —
— 2 (20.0) 1 (33.3) — 1 (33.3) — —
1 (16.7) 2 (20.0) — — — — 1 (25.0)
6 10 3 3 3 4 4
11 (33.3)
2 (6.1)
11 (33.3)
1 (3.0)
4 (12.1)
4 (12.1)
33
— — — — — —
— — — — — —
— — — 1 (20.0) 1 (33.3) —
— — — — — —
1 3 4 5 3 3
—
—
2 (10.5)
—
19
2 (33.3)
1 (33.3) 1 (16.7)
1 1 2 3
— — — — —
— — — — —
7 1 3 6 1
6 (33.3)
3 (16.7)
2 (11.1)
7 (38.9)
—
—
18
1 (100.0)
— 1 (100.0)
— —
— —
— —
— —
1 1
1 (50.0)
1 (50.0)
—
—
—
—
2
— 1 (100.0) 1 (50.0) 1 (50.0) —
1 (100.0) — 1 (50.0) — —
— — — 1 (50.0) 2 (100.0)
— — — — —
— — — — —
— — — — —
1 1 2 2 2
3 (37.5)
2 (25.0)
3 (37.5)
—
—
—
8
— —
— —
1 (100.0) 2 (100.0)
— —
— —
— —
1 2
—
—
3 (100.0)
—
—
—
3
1 (100.0) 1 (100.0) 1 (100.0)
— — —
— — —
— — —
— — —
— — —
1 1 1
3 (100.0)
—
—
—
—
—
3
— 1 (33.3) 1 (25.0) — — —
1 2 3 4 2 3
(100.0) (66.7) (75.0) (80.0) (66.7) (100.0)
2 (10.5)
15 (78.9)
5 (71.4)
1 (14.3)
(14.3) (100.0) (66.7) (50.0)
1 (100.0)
F. Alptekin et al.
Electric blankets
Kitchen
Unintentional non-fatal injuries at home stove in the winter. Carbon monoxide poisoning is decreasing in developed countries owing to appropriate measures and technological facilities. However, it is still a major cause of home accidents in developing or underdeveloped countries.19,63 We did not observe any case of carbon monoxide poisoning in the living room. All carbon monoxide poisonings occurred in the bathroom. Gas geysers should only be installed in areas that are well ventilated and should not be installed in the bathroom since lack of proper ventilation in the bathroom will result in accumulation of fumes, which can lead to suffocation/asphyxiation.22 However, people in Turkey still sometimes install the gas geyser in their bathroom and they may eventually be poisoned. The most common mechanism of injuries was falls (38.4%) in all study groups and WHO (27.9%) also pointed out the similar incidents.7 We determined that the most common injury type among those over 65 was falling and many previous studies reported detailed findings on this issue.12,21,26,48,49 Older adults probably experience home injury more frequently because they spend more time in the home environment, compared with other age groups who spend a significant duration of time at work.46 In addition, the loss of muscle strength and flexibility, and impaired balance and reaction time may also lead to injuries in the elderly.36,64 When older adults sustain an injury, most become disabled. In the current study, falls, burns and cuts were the leading causes of unintentional home injury-related disability. Approximately half of the disabilities occurring after injury was seen in those over 65, and almost all of them were in females. Many falls and fractures (also disability) would be prevented8,36 if subjects at high risk for falls would be identified through implementation of a multifactorial and individualised approach.17 Given the rapid increase in the numbers of elderly adults, it is imperative to invest now to find ways in preventing injuries and to plan for social and environmental changes that would reduce injuries among the elderly.6 Despite reports in the literature stating that females sometimes have similar11,47 rates of nonfatal injury rates to males, males show a higher rate of unintentional home injury-related death.2,13,46 In the current study, females experienced higher rates of home-related injury than males in univariate analysis. However, multivariate analysis did not determine a gender difference for injury risk at home. Males and females have different roles in life in Turkey. Females are concerned with the care of children and their houses and the preparation and cooking of food. This means that females spend
543 more time and have more responsibility at home. Although 82% of female participants in our study did not work outside the home and spent all their daytime at home, they were not more frequently injured than males. We deduced that injuries occurred mostly in the morning or in the evening, as seen in the literature.37,44 People may hurry in the morning to be on time for their job, and they may be extremely tired at the end of the day’s work in the evening, consequently causing them to be careless, at which time the injury occurs. In the current study, approximately one third of all the injuries occurred in the living room. Children under five were injured frequently in the living room, but the elderly were injured frequently in the bathrooms/toilets. The most frequent injury type, falling, occurred either in the living rooms or the bathrooms/toilets. These findings were consistent with those in the literature9,30 and emphasised the fact that people use both the living rooms and the bathrooms/toilets as the major recreation areas. In this study, we did not aim to determine home environment safety level or any risk factors related to home environment. On the other hand, our results show that most of the injuries occurred in particular areas at home and the most dangerous areas for injuries were the living rooms and bathrooms/toilets. As elderly and children under five spent most of their time in their houses, indoor safety conditions constituted an important factor in the occurrence of home accidents. In particular, the living rooms and bathrooms as the major recreation areas should be reconstructed for both children and the elderly according to safety criteria.
Limitations Reporting of injuries was often dependent on the severity of the injury and whether medical care was sought.16 A combination of methods, both selfreporting and reports from different authorities, was suggested to estimate the true incidence of injuries in the population.55 A national database of unintentional home injuries does not exist in Turkey. The present study was a community-based survey and data were gathered by findings of a household survey. A household survey would provide population-based injury incidence data and desired information on circumstances in a representative sample.42 The goal of the study was to determine the true incidence and data were collected by interviews based on self-expression. There is substantial potential for bias in household surveys due to unreliable memory and embarrassment regarding certain types of injuries. In addition, this study did not
544
F. Alptekin et al.
include any hospital or emergency department survey data. In the future, surveillance and prospective studies should be proposed in the community in order to estimate the true population incidence of injuries and risk factors.
appropriate education, as well as legal regulations for manufacturers of household articles may significantly reduce the number of injuries and disabilities related to household injuries.
Suggestions
Acknowledgements
Treatment after injuries is always more expensive than the prevention. The causes of injuries can be roughly grouped into two, insecure conditions/ environment and insecure behaviour. Main predictors for all kinds of unintentional home injuries are associated with not only individual characteristics but also housing conditions.28,65 Injuries can be prevented by changing the environment, individual behaviour, products, social norms, legislation, and governmental and institutional policy.29 Injuries encountered at home can also be avoided. Strengthening individuals’ knowledge and skills, promoting community education, changing organisational practices, and insisting on related policy-making and legislation may help promotion of effective prevention effort. The systematic national injury surveillance system should undergo development in Turkey and collection of morbidity data should include the development of consistent definitions for home injuries. In addition, to prevent domestic accidents, unsafe housing conditions should be identified and changes in the houses can be made. For the unsafe behaviour, education for individuals can be provided. Due to the presence of a large number of people affected by injuries in the home environment, special attention should be paid towards preventive strategies without delay.47 Major prevention priorities should be devoted to risk groups such as individuals with a low socio-economic status.
We thank the participants for their cooperation and the regional health insurance association for supplying the National Health Registration System data of the study region. All cost of this research was covered by the authors. There was no external financial support.
Conclusion The findings in this study are very helpful in understanding unintentional injuries at home as a major problem, since they are of high incidence and cause a high rate of injury-related disabilities. Participants who were under five or over 65 years of age, with low economic status, with an education less than 8 years, females, single people, widows/ widowers and divorced people were more frequently injured. Multiple analysis showed that the individual who had low economic status or were divorced had a high risk of injury at home. Findings related to disability highlighted a need to focus attention on the prevention of residential falls among elderly adults, and burns/falls among younger children. Determination of risk factors,
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