Sex Differences in Civilian Injury in Baghdad From 2003 to 2014: Results of a Randomized Household Cluster Survey.

OBJECTIVE: To examine sex differences in injury mechanisms, injury-related death, injury-related disability, and associated financial consequences in Baghdad since the 2003 invasion of Iraq to inform prevention initiatives, health policy, and relief planning. BACKGROUND: Reliable estimates of injury burden among civilians during conflict are lacking, particularly among vulnerable subpopulations, such as women. METHODS: A 2-stage, cluster randomized, community-based household survey was conducted in May 2014 to determine the civilian burden of injury in Baghdad since 2003. Households were surveyed regarding injury mechanisms, healthcare required, disability, deaths, connection to conflict, and resultant financial hardship. RESULTS: We surveyed 900 households (5148 individuals), reporting 553 injuries, 162 (29%) of which were injuries among women. The mean age of injury was higher among women compared with men (34 ±â€Š21.3 vs 27 ±â€Š16.5 years; P < 0.001). More women than men were injured while in the home [104 (64%) vs 82 (21%); P < 0.001]. Fewer women than men died from injuries [11 (6.8%) vs 77 (20%); P < 0.001]; however, women were more likely than men to live with reduced function [101 (63%) vs 192 (49%); P = 0.005]. Of intentional injuries, women had higher rates of injury by shell fragments (41% vs 26%); more men were injured by gunshots [76 (41%) vs 6 (17.6%); P = .011). CONCLUSIONS: Women experienced fewer injuries than men in postinvasion Baghdad, but were more likely to suffer disability after injury. Efforts to improve conditions for injured women should focus on mitigating financial and provisional hardships, providing counseling services, and ensuring access to rehabilitation services.

Road traffic injuries in Baghdad from 2003 to 2014: results of a randomised household cluster survey.

INTRODUCTION: Around 50 million people are killed or left disabled on the world's roads each year; most are in middle-income cities. In addition to this background risk, Baghdad has been plagued by decades of insecurity that undermine injury prevention strategies. This study aimed to determine death and disability and household consequences of road traffic injuries (RTIs) in postinvasion Baghdad. METHODS: A two-stage, cluster-randomised, community-based household survey was performed in May 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about household member death, households were interviewed regarding crash specifics, healthcare required, disability, relatedness to conflict and resultant financial hardship. RESULTS: Nine hundred households, totalling 5148 individuals, were interviewed. There were 86 RTIs (16% of all reported injuries) that resulted in 8 deaths (9% of RTIs). Serious RTIs increased in the decade postinvasion and were estimated to be 26 341 in 2013 (350 per 100 000 persons). 53% of RTIs involved pedestrians, motorcyclists or bicyclists. 51% of families directly affected by a RTI reported a significant decline in household income or suffered food insecurity. CONCLUSIONS: RTIs were extremely common and have increased in Baghdad. Young adults, pedestrians, motorcyclists and bicyclists were the most frequently injured or killed by RTCs. There is a large burden of road injury, and the families of road injury victims suffered considerably from lost wages, often resulting in household food insecurity. Ongoing conflict may worsen RTI risk and undermine efforts to reduce road traffic death and disability.

Mortality in Iraq associated with the 2003-2011 war and occupation: findings from a national cluster sample survey by the university collaborative Iraq Mortality Study.

BACKGROUND: Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011. METHODS AND FINDINGS: We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study. CONCLUSIONS: Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war. Please see later in the article for the Editors' Summary.

Mothers' knowledge of domestic accident prevention involving children in Baghdad City.

BACKGROUND: Accidental injuries are the most common cause of death in children over the age of one. Every year, millions of children are permanently disabled or disfigured because of accidents. OBJECTIVE: To assess the level of knowledge of women with respect to children's domestic accidents, and to determine its association with some demographic factors. METHOD: This cross-sectional study was conducted in both sides of Baghdad City during the period from April through to August 2013. The targeted population were women attending the primary health care centers (PHCCs). A random sample of 20 PHCCs was taken through a stratified random sampling technique by dividing Baghdad City into its two main parts Karkh and Russafa. Ten centers were then chosen from each sector by a simple random sampling technique. A well-structured questionnaire was developed that constituted of questions on four main types of accidents involving children (poisoning by chemicals and detergents, electric shock, injuries from sharp instruments in the kitchen, and burns). RESULTS: The total number of women enrolled in this study was 1032 aged from 15-50 years. The results revealed that only 9.2% of the mothers acquired a good level of knowledge in prevention of injuries from chemicals and detergents, and more than 90% were found to have poor knowledge. The same was found regarding knowledge about preventing electrical accidents caused by power sockets and electrical appliances where only 10.2% of the mothers were found to have a good level of knowledge. The results were not much better regarding accidents caused by fire, only 11.6% of the mothers scored well. With respect to dealing with accidents caused by sharp instruments in the kitchen, only 6.3% of the mothers obtained a score that indicated a good level of knowledge. Older mothers were statistically found to have a better level of knowledge than younger mothers. Higher educated mothers' were statistically associated with a lower level of knowledge in accident prevention. Mothers with more children and those whose children had previously been involved in an accident were found to have a better level of knowledge. CONCLUSION: It can be concluded from this study that women in Baghdad are poorly educated about how to protect their children against domestic accidents.

COVID-19 in Baghdad, Iraq: adaptive and emotional findings in a household cluster survey.

Purpose: The objective of this study was to assess the impact of COVID-19 infection on households in Baghdad, Iraq. Methods: A cross-sectional household survey was conducted in early 2022; 41 clusters were selected proportional to population size from the districts of the Baghdad governorate. Households were randomly selected for inclusion. The head of household or senior female member present was interviewed to obtain a listing of COVID-19 infections, deaths, and vaccinations among members of the household and to understand if social and economic changes occurred during the pandemic. All analyses incorporated the complex survey design and sample weights for clustering. Findings: The findings revealed that there were 1,464 cases of COVID-19 (37.1%) and 34 reported fatalities among the 927 households enrolled in this study. One or more COVID-19 immunizations were received by 50.9% of household members. Preventive measures against COVID-19 were widely reported to be being practiced but were not more commonly reported in households having reported a clinical case of infection. While some households where infections had occurred stated that their household expenses were increased, overall, infections were not associated with significantly increased household costs. In households where COVID-19 had occurred, senior members reported a substantial increase in emotional and psychological problems compared with uninfected households. Implications: COVID-19 deaths were rare, though infections were common, suggesting an effect of vaccination and other efforts. The household economic implications were minimal in houses with and without COVID-19-infected members. COVID-19 had mental health consequences on affected and unaffected populations alike. It is conceivable that the fear and uncertainty generated by the pandemic had an effect on senior household members which was out of keeping with the other effects in the households sampled. This suggests that there may be a persisting need for mental health services for a protracted period to manage the consequences of mental health needs arising from the pandemic.

Pediatric injury during conflict and prolonged insecurity in Iraq from 2003-2014.

BACKGROUND: Injury disproportionately affects low- and middle-income countries, and in Iraq, this risk has been compounded by conflict and insecurity since the Coalition invasion in 2003. Children in such settings are particularly vulnerable; yet, the epidemiology of pediatric injury during conflict has not been previously described. This study aimed to characterize the pattern and outcomes of pediatric injury in Baghdad, Iraq from 2003-2014. METHODS: We conducted a cluster-randomized, cross-sectional, community-based survey in Baghdad in 2014 to determine the epidemiology and impact of injuries since 2003. This study details the injury patterns and outcomes among children (ie, <18 years of age) as well as care sought and provided. RESULTS: A total of 900 households, which represented 5,148 persons, were surveyed. There were 152 pediatric injuries from 2003-2014 (28% of all injuries). The incidence of childhood injury during the study period was 6.5 per 1,000 life years. The most common cause of injury was fall (52 injuries; 34% of pediatric injuries) followed by road traffic crash (32; 22%). Fifteen percent of pediatric injuries were directly related to conflict (22 injuries). There were 10 reported deaths (7% of pediatric injuries). CONCLUSION: Although falls and road traffic crashes were the most common causes of childhood injury, conflict was directly responsible for 1 in 6 injuries. The number of pediatric injuries that resulted in death far exceeded that of low- and middle-income countries unaffected by conflict. These findings reflect the importance of pediatric injury prevention, protection of vulnerable populations, and essential trauma care during conflict.

Fall injuries in Baghdad from 2003 to 2014: Results of a randomised household cluster survey.

INTRODUCTION: Falls incur nearly 35 million disability-adjusted life-years annually; 75% of which occur in low- and middle-income countries. The epidemiology of civilian injuries during conflict is relatively unknown, yet important for planning prevention initiatives, health policy and humanitarian assistance. This study aimed to determine the death and disability and household consequences of fall injuries in post-invasion Baghdad. METHODS: A two-stage, cluster randomised, community-based household survey was performed in May of 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about household member death, households were interviewed regarding injury specifics, healthcare required, disability, relatedness to conflict and resultant financial hardship. RESULTS: Nine hundred households totaling 5148 individuals were interviewed. There were 138 fall injuries (25% of all injuries reported); fall was the most common mechanism of civilian injury in Baghdad. The rate of serious fall injuries increased from 78 to 466 per 100,000 persons in 2003 and 2013, respectively. Fall was the most common mechanism among the injured elderly (i.e. ≥65 years; 15/24 elderly unintentional injuries; 63%). However, 46 fall injuries were children aged <15 years (49% of unintentional injuries) and 77 were respondents aged 15-64 years (36%). Respondents who spent significant time within the home (i.e. unemployed, retired, homemaker) had three times greater odds of having suffered a fall injury than student referents (aOR 3.34; 95%CI 1.30-8.60). Almost 80% of fall injured were left with life-limiting disability. Affected households often borrowed substantial sums of money (34 households; 30% of affected households) and/or suffered food insecurity after a family member's fall (52; 46%). CONCLUSION: Falls were the most common cause of civilian injury in Baghdad. In part due to the effect of prolonged insecurity on a fragile health system, many injuries resulted in life-limiting disabilities. In turn, households shouldered much of the burden after fall injury due to loss of income and/or medical expenditure, often resulting in food insecurity. Given ongoing conflict, civilian injury control initiatives, trauma care strengthening efforts and support for households of the injured is urgently needed.

Burns in Baghdad from 2003 to 2014: Results of a randomized household cluster survey.

PURPOSE: Civilians living amid conflict are at high-risk of burns. However, the epidemiology of burns among this vulnerable group is poorly understood, yet vital for health policy and relief planning. To address this gap, we aimed to determine the death and disability, healthcare needs and household financial consequences of burns in post-invasion Baghdad. METHODS: A two-stage, cluster randomized, community-based household survey was performed in May 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about cause of household member death, households were interviewed regarding burn specifics, healthcare required, disability, relationship to conflict and resultant financial hardship. RESULTS: Nine-hundred households, totaling 5148 individuals, were interviewed. There were 55 burns, which were 10% of all injuries reported. There were an estimated 2340 serious burns (39 per 100,000 persons) in Baghdad in 2003. The frequency of serious burns generally increased post-invasion to 8780 burns in 2013 (117 per 100,000 persons). Eight burns (15%) were the direct result of conflict. Individuals aged over 45 years had more than twice the odds of burn than children aged less than 13 years (aOR 2.42; 95%CI 1.08-5.44). Nineteen burns (35%) involved ≥ 20% body surface area. Death (16% of burns), disability (40%), household financial hardship (48%) and food insecurity (50%) were common after burn. CONCLUSION: Civilian burn in Baghdad is epidemic, increasing in frequency and associated with household financial hardship. Challenges of healthcare provision during prolonged conflict were evidenced by a high mortality rate and likelihood of disability after burn. Ongoing conflict will directly and indirectly generates more burns, which mandates planning for burn prevention and care within local capacity development initiatives, as well as humanitarian assistance.

Injuries, Death, and Disability Associated with 11 Years of Conflict in Baghdad, Iraq: A Randomized Household Cluster Survey.

BACKGROUND: The objective of this study was to characterize injuries, deaths, and disabilities arising during 11 years of conflict in Baghdad. METHODS: Using satellite imagery and administrative population estimated size for Baghdad, 30 clusters were selected, proportionate to population size estimates. Interviews were conducted during April and May 2014 in 900 households containing 5148 persons. Details about injuries and disabilities occurring from 2003 through May 2014 and resultant disabilities were recorded. FINDINGS: There were 553 injuries reported by Baghdad residents, 225 of which were intentional, and 328 unintentional. For intentional injuries, the fatality rate was 39.1% and the disability rate 56.0%. Gunshots where the major cause of injury through 2006 when blasts/explosions became the most common cause and remained so through 2014. Among unintentional injuries, the fatality rate was 7.3% and the disability rate 77.1%. The major cause of unintentional injuries was falls (131) which have increased dramatically since 2008, followed by traffic related injuries (81), which have steadily increased. The proportion of injuries ending in disabilities remained fairly constant through the survey period. INTERPRETATION: Intentional injuries added substantially to the burden of unintentional injuries for the population. For Baghdad, the phases of the Iraqi conflict are reflected in the patterns of injuries and consequent deaths reported. The scale of injuries during conflict is most certainly under-reported. Difficulties recalling injuries in a survey covering 11 years is a limitation, but it is likely that minor injuries were under-reported more than severe injuries. The in- and out-migration of Baghdad populations likely had effects on the events reported which we could not measure or estimate. Damage to the health infrastructure and the flight of health workers may have contributed to mortality and morbidity. Civilian injuries as well as mortality should be measured during conflicts, though not currently done.