Developing a systematic approach for Population-based Injury Severity Assessment (PISA): a million-person survey in rural Bangladesh.

INTRODUCTION: There is currently no defined method for assessing injury severity using population-based data, which limits our understanding of the burden of non-fatal injuries and community-based approaches for primary prevention of injuries. This study describes a systematic approach, Population-based Injury Severity Assessment (PISA) index, for assessing injury severity at the population level. METHODS: Based on the WHO International Classification of Functionality conceptual model on health and disability, eight indicators for assessing injury severity were defined. The eight indicators assessed anatomical, physiological, postinjury immobility, hospitalisation, surgical treatment, disability, duration of assisted living and days lost from work or school. Using a large population-based survey conducted in 2013 including 1.16 million individuals from seven subdistricts of rural Bangladesh, information on the eight indicators were derived for all non-fatal injury events, and these were summarised into a single injury severity index using a principal component analysis (PCA). Principal component loadings derived from the PCA were used to predict the severity (low, moderate, high) of non-fatal injuries, and were applied to the fatal injury data to assess the criterion validity of the index. The determinants of non-fatal injury severity were determined using ordered logistic regression. RESULTS: There were 119 703 non-fatal injuries and 14% were classified as high severity based on the PISA index. The PISA index accurately predicted 82% of all fatal injuries as highly severe. Non-fatal injuries of high severity were frequent with unintentional poisoning (57%) and violence (35%). Injuries of high severity were commoner among males (OR 1.16, 95% CI 1.12 to 1.21), adults 65 years and older (OR 1.30, 95% CI 1.23 to 1.36), lower socioeconomic status and intentional injuries. Education was associated with reduced odds of high severe injuries. CONCLUSION: The PISA index provides a valid and systematic approach for assessing injury severity at the population level, and is relevant for improving the characterisation of the burden and epidemiology of injuries in non-health facility-based settings. Additional testing of the PISA index is needed to further establish its validity and reliability.

Shifting disease burden in low and middle-income countries: a 14-year survival analysis of childhood mortality in Bangladesh.

BACKGROUND: The objective of this study is to compare all-cause mortality and drowning-specific mortality rates and survival times among birth cohorts of children from rural Bangladesh over a 14-year period. METHOD: Seven birth cohorts of children aged 12-59 months were created using data from the Matlab Health and Demographic Surveillance System in Bangladesh. Each cohort represents children born within a 2-year interval between 1 July 1995 and 30 June 2009, who were then evaluated over a 2-year snapshot. All-cause and drowning-specific mortality rates were compared for each cohort using the oldest cohort (cohort 1) as reference. A Cox proportional model was used to estimate hazard rate ratios (HRR) comparing the cohorts, and adjusted for key independent variables. Kaplan-Meier survivor function was estimated for each birth cohort and compared with cohort 1 using log-rank test. RESULTS: The adjusted HRR for all-cause mortality showed that children in cohorts 4, 5, 6 and 7 had significantly lower hazard rate compared with cohort 1 with a dose-response relationship, the adjusted HRRs were 0.51 (95% CI 0.31, 0.84), 0.53 (95% CI 0.32, 0.87), 0.44 (95% CI 0.26, 0.76) and 0.42 (95% CI 0.24, 0.74), respectively. For drowning, none of the adjusted HRR was statistically significant. Mother's primary education and being married were protective of risk of death from all causes. CONCLUSION: Whereas child mortality rates from all causes declined remarkably between 1998 and 2012 in rural Bangladesh, drowning-specific mortality rates remained unchanged. This shifting burden of disease underscores the epidemiological transition in the childhood causes of death in Bangladesh and the need for urgent action to review child health interventions.