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Abstract
Objective This article characterises the burden of childhood injuries and provides examples of evidence–based injury prevention strategies developed using a citywide injury surveillance system in Pasto, Colombia.
Methods Fatal (2003-2007) and non-fatal (2006-2007) childhood injury data were analysed by age, sex, cause, intent, place of occurrence, and disposition.
Results Boys accounted for 71.5% of fatal and 64.9% of non-fatal injuries. The overall fatality rate for all injuries was 170.8 per 100,000 and the non-fatal injury rate was 4,053 per 100,000. Unintentional injuries were the leading causes of fatal injuries for all age groups, except for those 15-19 years whose top four leading causes were violence-related. Among non-fatal injuries, falls was the leading mechanism in the group 0-14 years. Interpersonal violence with a sharp object was the most important cause for boys aged 15-19 years. Home was the most frequent place of occurrence for both fatal and non-fatal injuries for young children 0-4 years old. Home, school and public places became an important place for injuries for boys in the age group 5-15 years. The highest case-fatality rate was for self-inflicted injuries (8.9%).
Conclusions Although some interventions have been implemented in Pasto to reduce injuries, it is necessary to further explore risk factors to better focus prevention strategies and their evaluation. We discuss three evidence-based strategies developed to prevent firework-related injuries during festival, self-inflicted injuries, and road traffic-related injuries, designed and implemented based on the injury surveillance data.
- Childhood injuries
- injury surveillance
- fatal and non-fatal injuries
- prevention
- Latin America
- child
- developing nations
- government
- surveillance
- violence
Statistics from Altmetric.com
- Childhood injuries
- injury surveillance
- fatal and non-fatal injuries
- prevention
- Latin America
- child
- developing nations
- government
- surveillance
- violence
Introduction
Road traffic related injuries, drowning, burns, falls and poisoning are the most common mechanisms of childhood injuries in the world.1 According to the World Health Organization, nearly 9 million children under 18 years of age die each year due to an injury. Unfortunately, 95% of this burden exists in low and middle income countries.2 One common problem in these countries is the lack of injury surveillance data to inform appropriate injury prevention interventions. In addition, there is little information about the causes and risk factors for childhood injuries, particularly in countries such as Colombia.
In Pasto, the capital of Nariño State in Colombia, a city with 383 846 inhabitants, in 2003 the local government established an injury surveillance system to supply data to inform prevention strategies. The results have provided local authorities information that has been used to devise injury control strategies in the city.
Political process and motivations that led to creation of the system—In 2002, the local government was interested in establishing an injury surveillance system and sent a delegation to visit other cities in Colombia where surveillance systems were in place to learn more about the methods used and system requirements. Following these visits, they began collaboration with experts from the CISALVA Institute3 and the Georgetown University Colombia Program. These two institutions were involved in the development of Observatories in other municipalities in Colombia. Together they came up with the idea to establish an Observatory of Crime in Pasto, which could be used as a tool to strengthen the local government. In 2003, the Observatory was created officially through a decree of the municipal council. Subsequently, the institutions that could potentially provide data (forensic medicine, police, transportation office, district attorney) and the resources needed for the project were identified. The local government demonstrated its commitment to the programme by financing personnel costs. The Georgetown University Program contributed the first equipment and training costs. Since then, fatal injury data are collected through monthly meetings with staff from the different data source institutions, and the city has a standardised fatal injury dataset to inform and monitor prevention activities.
In 2005, with the contribution of CISALVA Institute, the Observatory expanded to include non-fatal injuries, child maltreatment, and domestic violence. Information from all 16 public and private emergency departments (ED) existing in Pasto city is combined into a single dataset.
The funding of the system—The Observatory is now financially supported by the mayor's office through the secretaries of health, government, and transportation. The funds cover personnel, equipment, office space, and materials. The total annual budget is approximately 80 million Colombian pesos (US$40000).
Reporting requirements of the system—The Observatory office collects and analyses the data on a regular basis and publishes a quarterly bulletin including mortality and morbidity data. Printed and electronic copies of these bulletins are sent to the mayor's office, other local authorities, stakeholders, participating institutions, and hospital personnel involved in the surveillance system. These reports are analysed in the Epidemiological Surveillance Committee in the Health Secretary, and in the Security Council in the mayor's office.
The quality and stability of both the fatal and non-fatal datasets is maintained through several factors:
There is a general coordinator of the observatory since it was established, who is an epidemiologist from the Municipality Health Office. This person is in charge of interpreting the results for decision making and maintaining the topic of injury prevention on the local government agenda.
A nurse periodically visits the health institutions to provide training to new personnel and assure quality control of data. Information collected in the ED is sent to the Observatory where data are aggregated into one single dataset. After that, data are cleaned and prepared for analysis and production of periodical reports.
A psychologist leads a monthly meeting with participants from all data sources for the fatal surveillance system, which guarantees the quality of data and maintains the motivation of participants. Cases are compared and discussed in this meeting based on the information from each participating institution.
A system engineer is in charge of dataset management and receives the data sent from health institutions, reviews the quality of data, and prepares the reports.
Although information about fatal and non-fatal injuries by age group is periodically reported by this system,4 a detailed analysis of the characteristics, risk groups, and causes of childhood injuries has not been published. The first objective of this paper is to characterise the burden of fatal and non-fatal injuries for both violence related and unintentional injuries among children aged 0–19 years. The second objective is to provide examples of evidence based strategies designed and implemented by the mayor's office and other stakeholders to reduce the burden of injuries in Pasto.
Methods
We included all recorded fatal injuries from 2003 to 2007, and non-fatal injuries from 2006 to 2007 among children aged 0–19 years residing in Pasto city. Variables included in the analysis were age, sex, cause of injury, intent, place of occurrence, and disposition of the injured person (ie, treated and discharged, hospitalised). Injuries were categorised by intent into violence related and unintentional injuries. We further classified the violence related fatal injuries into either homicides or suicides, and the violence related non-fatal injuries into interpersonal or self inflicted injury cases. Similarly, unintentional injuries were categorised into road traffic related and other unintentional injuries (ie, falls, burns, drowning, and poisoning). We used SAS (version 9.1)5 to analyse the data.
The 2005 midyear population was used to compute the fatal injury rates; combined census population6 (2006 and 2007) was used to calculate non-fatal injury rates. Rates were not calculated if the number of observations was below 20.7 We included 2 years (2006 and 2007) of fatal and non-fatal injury data to calculate case fatality rates by dividing the number of fatal injuries by the number of fatal plus non-fatal injuries and multiplying by 100.
Results
Burden of childhood injuries
Fatal and non-fatal Injuries by intent, sex and age group
During 2003 to 2007, there were 246 fatal injuries among children aged 0–19 years (table 1). Overall, 51.6% (127/246) were violence related deaths: 28.9% (71/246) homicides, and 22.7% (56/246) suicides. A total of 48.4% (119/246) were due to unintentional injury related deaths: 17.5% (43/246) road traffic related, and 30.9% (76/246) other unintentional injuries. Boys accounted for 71.5% (176/246) of all fatal injuries. Children aged 15–19 years contributed the highest proportion of violence related and unintentional injury deaths, 56.3% (99/176) among boys and 47.1% (33/70) among girls. The proportion of violence related deaths was highest among boys and girls aged 15–19 years, 85% (108/127). Children aged 0–4 years accounted for the highest percentage, 45.3% (54/119), of unintentional injury deaths, with the majority of these, 87% (47/76), falling into the other unintentional injury category.
Numbers, percentages, and rates of fatal injuries among children aged 0–19 years by intent, sex, and age group in Pasto (2003–2007)
Death rates differed by sex, cause, and intent. Overall, the death rate for all injuries was 170.8 per 100 000, 243.4 for boys and 97.6 for girls. The highest death rate (52.8 per 100 000) was found for other unintentional injuries (eg, burns, drowning, poisoning, and falls), followed by homicide (49.3 per 100 000). Among boys, the highest rate was found for homicide (84.3 per 100 000 children), followed by other unintentional injuries (70.5 per 100 000). However, among girls, the highest rate was found for suicide (39.0 per 100 000), followed by other unintentional injuries (34.9 per 100 000). Overall, the male to female rate ratio for all injuries was 2.5. The male to female rate ratios were highest for homicides (6.0) and road traffic related injuries (5.1), and equal for suicide (1.0).
During 2006 and 2007, there were 12 015 non-fatal injuries among children aged 0–19 years (11 894 cases with information on sex, age group, and intent) (table 2). Overall, 75.8% (9012/11 894) of all non-fatal injuries were due to unintentional causes, 11.8% (1405/9012) were road traffic related, and 64% (7607/9012) were other unintentional injuries. Boys accounted for 64.9% (7728/11 894) of all non-fatal injuries. The pattern by age group was evenly distributed with about one quarter of the non-fatal injuries occurring among each of the four age groups. Boys aged 15–19 years represented 56.8% (1039/1828) of interpersonal violence (IPV) cases, and 87.8% (65/83) of self inflicted non-fatal injuries. A similar situation was observed for girls aged 15–19 years, with 34.8% (290/833) of interpersonal violence injuries, and 77.9% (102/138) of self inflicted injuries. Those aged 0–4 years had the highest proportion of unintentional injuries, 29.7% (2677/9012), with the highest percentage of these falling into the other unintentional category, 41.7% (1489/4893) for boys, and 35.2% (956/2714) for girls.
Non-fatal injuries among children aged 0–19 years by intent, sex, age group, and disposition in Pasto (2006–2007)
Non-fatal injury rates also differed by sex, cause, and intent. Overall, the non-fatal injury rate was 4053 per 100 000 (5244 for boys and 2853 for girls) (table 2). Among the four causes of injury, the highest rate was found for other (non-traffic-related) unintentional injuries (2583 per 100 000), followed by the rate for interpersonal violence (903.5 per 100 000). Among both boys and girls, the highest non-fatal injury rates were found for the other unintentional injury category (boys 3309 per 100 000; girls 1851 per 100 000), followed by interpersonal violence (boys 1236 per 100 000; girls 568 per 100 000). The highest non-fatal injury rates were found in the other unintentional injury category among boys (6068 per 100 000) and girls (2952 per 100 000) aged 0–4 years old. Boys 15–19 years had the second highest rate (2790 per 100 000), due to interpersonal violence related injuries.
Leading causes of fatal and non-fatal injuries by age group
The leading causes of fatal injury differed by age group (table 3). For children aged 0–4 years the leading cause was unintentional suffocation. For children aged 5–9 years and those aged 10–14 years the primary cause was road traffic, and homicide was the principal cause for those aged 15–19 years. The leading cause of non-fatal injury was falls for those younger than 15 years, and interpersonal violence for those aged 15–19 years. Drowning was in third place for children aged 0–4 (10%).
Five leading causes and mechanisms of fatal (2003–2007), and non-fatal injuries (2006–2007) among children aged 0–19 years by age group in Pasto
Case fatality rate by intent and sex
We used the case fatality rate as an indication of the lethality of the mechanism (or cause) of the injury. Overall, the case fatality rate (CFR) for children 0–19 years was 0.7 and was highest for self inflicted injuries (8.9) (table 4). The overall CFR was higher for boys (0.9) than girls (0.5). The CFR for self inflicted injuries was higher for boys compared to girls (CFR 12.6 vs 6.3).
Case fatality rate by intent and sex in Pasto (fatal and non-fatal injury data for 2006 and 2007)
Fatal and non-fatal childhood injuries by age group and place of occurrence
Figure 1 shows the distribution of fatal and non-fatal injuries by age group and place of occurrence. Among children aged 0–4 years, 78% of fatal injuries and 70% of non-fatal injuries took place at home. Among children aged 5–9 years and 10–14 years, fatal injuries happened most frequently in several locations (home, on the street, and field or playground); most of the non-fatal injuries occurred at home, public places, and at school. In contrast, for those aged 15–19 years, 40% of fatal injuries and 58% of non-fatal injuries occurred on the street or in a public place.
Fatal and non-fatal injuries among children 0–19 years by age group and place of occurrence.
Disposition by intent
Hospital admission is an indirect measure of severity used here in the absence of information such as the injury severity score (ISS). Analysis of disposition data showed that of all non-fatal injuries, 76.4% cases were treated and released and 11.5% were admitted to a hospital. The proportion of non-fatal injuries requiring hospital admission differed by type of injury. Of all self inflicted injuries, 45% required hospital admission, followed by 22.1% of road traffic related injuries.
Interventions to address the leading causes of injury
In Pasto, the mayor's office and other stakeholders have used the surveillance data to design and implement injury prevention interventions. We discuss three evidence based strategies developed to address: (1) firework related injuries during the festival season; (2) self inflicted injuries, and (3) road traffic related injuries.
Interventions to address firework related non-fatal injuries
In Pasto city, there is a traditional festival in the first days of the year, which includes firework activities. In December 2004/5, a pilot test of the injury surveillance system collected data for firework injuries attended in EDs during the festival season. This information was used as a baseline for this strategy. The mayor's office, in collaboration with fire departments, hospitals, and other stakeholders, designed strategies to reduce burn related injuries during the festival season in December 2005 and January 2006, and in the following year. The strategies included media campaigns, fireworks ban, neighbourhood fireworks, community sentencing for parents, and promotion of alternative products. A public awareness campaign was planned to communicate the dangers of fireworks, especially related to burn injuries among children. Another part of the plan was to ban the manufacturing and sale of fireworks. The municipality created authorised areas for community fireworks in neighbourhoods with assigned emergency staff (police, medical staff, and fire department) to attend burn cases immediately. A mandatory community service sentencing law was established for parents whose child sustained a firework related burn injury. The intention of this law was to improve child supervision during the festival season. At the same time, public authorities promoted activities to substitute the local production of fireworks to other products like handicrafts and items to be used at the carnival. Figure 2 shows firework related injuries for the months of December and January, for the period 2004 to 2006. Although a formal evaluation has not been done, data have shown a reduction of 80% of burn cases with the largest decrease among children aged 5–14 years.8
Number of firework related burn injuries during the period of carnival and parades in Pasto, 2004–2006.
Interventions to address non-fatal self inflicted injuries
The surveillance data indicated self inflicted injuries were a public health problem in the city, especially for youth aged 10–19 years (table 2). Data from 2005 were used to identify and target higher risk communities. In 2006, the local government formed an expert group to study and design prevention programmes for self inflicted injuries. The analysis of data from the surveillance system was used to identify high risk neighbourhoods and to develop, target and monitor cultural, sports and educational programmes. Two communities were identified as high risk. Health personnel were trained to follow a special protocol for patients who attempted suicide and to provide psychological support to their families. Preliminary results from 2006 to 2007 showed a 41% reduction in the number of suicide attempts among youth aged 10–19 years9
Interventions to address road traffic injuries
In 2006, the Transportation Office in Pasto used road traffic injury data to design intervention strategies to reduce road crashes. Two main strategies were: (1) checkpoints for drunk drivers in risky areas of the city, based on the findings of alcohol consumption in a high percentage of injured patients—an analysis of alcohol and injury visits showed that 20% of them had consumed alcohol10; and (2) road safety education for pre-school, elementary and high school students, based on the fact that road traffic injuries are among the five leading causes of injuries and deaths among children in Pasto. Analysis of initial data shows traffic related fatal injuries has been reduced by 37% from 18.4 per 100 000 population in 2004 to 11.6 per 100 000 population in 2007.9
Discussion
This study was possible because the mayor's office in Pasto supported and implemented the injury surveillance system in the city. The successful creation of one standardised injury data system gathering information from multiple sources (eg, police, hospital) is uncommon in many parts of the world. In many low and middle income countries, this type of system and the research it facilitates are still not possible due to a lack of infrastructure and the necessary resources for injury surveillance activities.
The findings of this study revealed two important target groups for injury prevention efforts among children in Pasto: children aged 0–4 years were most affected by unintentional injuries (suffocation and falls); and children aged 15–19 years were most affected by interpersonal violence and self directed violence, including homicides and suicide. These two groups have been found to be at high risk for injury in many countries.1 11
Among children aged 0–4 years most of the fatal suffocation injuries happened at home. A detailed risk analysis of suffocation related child deaths is needed to understand common risk factors and to design interventions to reduce these preventable deaths. Parenting programmes aimed at improving parenting skills and strengthening child supervision have the potential to prevent such injuries.12 Among those aged 0–4 years, falls are a common cause of non-fatal injury, occurring primarily at home. School and public places pose a great threat for non-fatal injuries in children aged 5–9 and 10–14 years old. Efforts aimed at removing hazards in the home and making schools and parks safer (eg, with respect to equipment and surfaces) could also prevent many of these early childhood injuries.12 Drowning is the most common cause of deaths among children under the age of 18 years in South and East Asia13; however, this has not been shown in Latin American countries. We found 10% of deaths among children aged 0–4 years due to drowning. In addition, there was 10% and 15%, respectively, of other unintentional fatal injuries in these groups (0–4 and 5–9), that need further study to define what type of mechanisms are included in this category.
The second target group for prevention is those aged 15–19 years old, particularly boys affected by interpersonal violence. Fatal and non-fatal assaults involving youth contribute greatly to the global burden of premature death, injury, and disability.14 The proportion of homicide among those aged 0–19 years (83%) in Pasto is high relative to other countries15–17 However, two other cities in Colombia have even higher proportions of homicide deaths among this same age group (Cali 92%, Cartagena 96%).18 19 Understanding the risk factors for becoming victims or perpetrators of violence in Pasto is essential for developing effective policies and programmes to prevent violence.
The CFR indicated that for every 100 non-fatal self inflicted injuries, there are nine deaths, which is more than 10 times higher than the average CFR for all injury causes (0.7). Poisoning was a common method for non-fatal attempts for a self inflicted injury, which has been reported in other places,20 21 while hanging was a common method among those who died from a self inflicted injury. Adolescence is a difficult transition period in the lives of many young people, and there are many factors that can trigger a suicide attempt (eg, ending of a relationship, difficulties experienced in school or with peers or finding employment, experiencing a traumatic event).22 Although some interventions have been implemented in Pasto to prevent these types of injuries, it is necessary to further explore risk factors to better focus prevention strategies and their evaluation. In addition, it is important to know the type of poisoning substance used in the attempt to assess whether it is possible to limit its distribution or access to minors.
Road traffic injuries were one of the leading causes of fatal injuries across all age groups, especially for children aged 5–14 years. The strategies, such as checkpoints and education, currently applied to prevent this type of injury in Pasto have been found effective; this indicates these interventions must be maintained. However, road traffic injuries remain high in Pasto. In order to get an injury reduction, the local government needs to adopt, promote, and increase the use of other preventive measures such as child safety seats and seat belts.23 Attention should also be given to reducing drinking and driving, as well as other risk taking behaviours among teenagers such as non-use of seat belts, or helmets for motorcyclists and cyclists.
This study has some limitations to consider when interpreting the results. The years analysed for fatal and non-fatal injuries were different, making a direct comparison of fatal to non-fatal injuries difficult. The information on International Classification of Diseases (ICD) codes was also incomplete for non-fatal injuries which limited the data available on cause of injury, and 12% of non-fatal IPV cases among youth 0–4 years, and 7% of non-fatal IPV cases among 5–9 years, had unknown mechanisms. The number of cases caused by an unknown mechanism are an indication of the necessity to improve the process in the ED at the hospitals. Also indicated is a need for periodic training of the personnel in charge of data collection, especially new personnel.
Although information from the injury surveillance system did not collect detailed information about the circumstances surrounding the injury incident, the data have provided valuable information to design several successful prevention strategies in Pasto.
However, a formal evaluation should be carried out to confirm these results. The participation of the research centres of the local universities could contribute to the design and implementation of a formal evaluation of the interventions implemented in Pasto.
This city-wide injury surveillance system is an example of what can be accomplished when strong political will and cooperation from all sectors of the community combine to produce reliable and useful data that can then guide the development of evidence based strategies specific to local needs. Such efforts would be useful in other low and middle income countries to help reduce the heavy burden injury imposes on their communities. This method has demonstrated that if the will of the local authorities is present, even small infrastructure with limited personnel can effectively prevent injuries using data collected in an injury surveillance system. One of the first steps in establishing a similar system should be the involvement of the decision makers and local authorities, who must be willing to use the data to orient their decisions.
What is already known on this subject
Road traffic related injuries, drowning, burns, falls, and poisoning are the most common mechanisms of childhood injuries in the world.
Ninety-five per cent of the burden generated by injuries occur in low and middle income countries.
One common problem in these countries is the lack of injury surveillance data to inform appropriate injury prevention interventions.
What this study adds
We describe the citywide injury surveillance system developed as a result of strong political will and cooperation from all sectors of the community. This surveillance system produced reliable and useful data that were used to guide the development of evidence based strategies specific to local needs. Such efforts would be useful in other low and middle income countries to help reduce the heavy burden injury imposes on their communities.
Findings indicate two important target groups for injury prevention efforts among children in Pasto: children aged 0–4 years were most affected by unintentional injuries (suffocation and falls); and children aged 15–19 years were most affected by interpersonal violence and self directed violence, including homicide and suicide.
We confirm that poisoning was a common method for non-fatal attempts for a self inflicted injury, while hanging was a common method among those who died from a self inflicted injury.
Acknowledgments
We wish to thank the health personnel participating in the data collection in the public and private health facilities in Pasto, and institutions participating as a source of data for the injury mortality system: Police, Forensic Medicine, District Attorney, Comisaria de Familia, Bienestar Familiar, Secretarias de Salud, Gobierno y de Transporte. We also wish to thank the stakeholders using data from the injury surveillance system to inform prevention activities: Dr Silvia Paz Benavides, Health Secretariat, Dr Maria del Socorro Basante, Transportation Secretariat, Dr Jose Luis Guerra, Government Secretariat, and Dr Eduardo Jose Alvarado Santander, City's Mayor.
Footnotes
Disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.