Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention.

Burn prevention requires adequate knowledge of the epidemiological characteristics and associated risk factors. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs), such as the United States, due to sustained research on the descriptive epidemiology and risk factors, the same cannot be said of developing or low- and middle-income countries (LMICs). To move from data to action and assist preventive efforts in LMICs, a review of the available literature was conducted to assess the current status of burn preventive efforts. A MEDLINE search (1974-2003) was conducted on empirical studies published in English on the descriptive epidemiology, risk factors, treatment, and prevention of burns in LMICs. Review of the 117 identified studies revealed basically the same descriptive epidemiological characteristics but slightly different risk factors of burns including the presence of pre-existing impairments in children, lapses in child supervision, storage of flammable substances in the home, low maternal education, and overcrowding as well as several treatment modalities and preventive efforts including immediate application of cool water to a burned area. Continuous evaluation of promising interventions and those with unknown efficacy that have been attempted in LMICs, along with testing interventions that have proven effective in HICs in these LIMC settings, is needed to spearhead the move from data to action in preventing burns in LMICs.

An epidemiological study of injury in mines: implications for safety promotion.

The role of various factors in coal mine-related injuries was investigated using a case-control design. The study setting was two neighbouring underground coal mines in India. Cases comprised mine workers (n = 150) who had sustained a prior mine-related injury from a population of 1000 underground workers. Controls were selected from those mineworkers with no history of a prior mine-related injury using frequency matching (n = 150) from the same source population. Data were collected from the cases and controls using a structured survey questionnaire. Based on the responses of the participants, each factor was grouped into three categories. High-low plots and Chi-square tests were conducted to explore the differences between the cases and controls. Bivariate logistic regression was run to estimate the crude odds of injuries, while multivariate logistic regression estimated the adjusted odds of injuries to the workers for the various variable categories. High-low plots and the Chi-square test clearly revealed that the cases and controls significantly differed in their responses for the variables studied. Accident-involved workers take more risks, are negatively affected, job dissatisfied, feel more production pressure, job stress, work hazards and are less job involved and are more dissatisfied with safety environment and social climate of the mines compared to the controls. The multivariate odds of injuries to high risk taking, negatively affected and job dissatisfied workers are 1.21, 9.34 and 2.00 times more compared to their lowest counterparts. Similarly, workers satisfied with the overall safety practice and safety equipment availability and maintenance are 1.5 and 3.12 times less likely to be injured than the workers with little or no satisfaction with the above factors. It is therefore concluded that negative affectivity and job dissatisfaction are the two major personal level factors that contribute more towards accident/injury in the mines studied. Identification and elimination/reduction of negative attitudes are of utmost importance.

Parental knowledge of school backpack weight and contents.

Parental knowledge of their students' backpack weight and contents was assessed by identifying 188 students who carried backpacks weighing at least 10% of their body weights through a survey of 745 students in three elementary schools. Most parents (96%) had never checked their child's backpack weight; 34% had never checked the backpack contents.

Open-access appointment scheduling in family practice: comparison of a demand prediction grid with actual appointments.

BACKGROUND: Inadequate access to their primary care physician remains a major reason for patient dissatisfaction in ambulatory care. The concept of open-access appointment scheduling has been found to accommodate patients' urgent health care needs while providing continuous, routine care. We describe the development of a demand prediction grid for future appointments, compare it with one developed by Kaiser Permanente, and compare the predictions with actual appointments made and held in our clinic. METHODS: Using adjusted 1999 appointments based on historical data for the Scott & White Killeen Clinic (> 75,000 annual appointments; 13 family physicians), we computed appointment predictions for calendar year 2000 by day of the week and by month of the year. We then compared our predictions with those of Kaiser and actual appointments for the first half of 2000. RESULTS: Our data and the Kaiser data agreed on the day of week, but they were different for the summer and winter months. Overall, actual appointments made and held at our clinic for January through June 2000 were within 6% of the predictions. Appointments for January and February were 18% and 4% more than the predictions, respectively, while appointments for March were 3% less than the predictions. Appointments for April through June were 3% to 7% more than the predictions. Few daily variations were observed between actual appointments and predictions. CONCLUSIONS: We conclude that the Kaiser data might be tempered by a different climate, underscoring the need for each practice to develop its own demand prediction grid. That our actual appointments were 6% more than predicted overall but fluctuated month by month reemphasizes the need for continuous monitoring of the adjustment factor for prediction.

E-mail communications in family practice: what do patients expect?

OBJECTIVE: Many health care providers and patients are exploring the feasibility of using E-mail to address a variety of medical issues. The researchers wanted to determine the proportion of their patient population with E-mail access, determine patients' willingness to use this technology to expedite communication with health care providers, and assess their expectations of response times. STUDY DESIGN: A cross-sectional, in-person prevalence survey. POPULATION: Patients (n=950) with scheduled appointments to see a primary care provider in 6 of 18 family practice clinics in a large health care delivery system in central Texas. OUTCOMES MEASURED: The proportion of patients with E-mail access, their willingness to use it, and their expectations regarding the timeliness of responses to their E-mail queries about selected clinical services. RESULTS: Overall, 54.3% of the patients reported having E-mail access, with significant variation among the 6 clinics (33%-75%). Reported areas of strongest desire for using E-mail were to request prescription refills (90%), for non-urgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Patients' expectations regarding the timeliness of responses to their E-mail queries varied by clinical service. For laboratory results, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26%. CONCLUSIONS: Most patients attending family practice clinics in central Texas have E-mail access and indicate they would use it to request prescription refills, for non-urgent consultations, and to obtain routine laboratory results or test reports. Regardless of sex or race, patients have high expectations that these tasks can be completed within a relatively short time.

Back-up antibiotic prescriptions for common respiratory symptoms. Patient satisfaction and fill rates.

BACKGROUND: In recent years much has been written about the overuse of antibiotics, especially for common respiratory illnesses. One approach to this issue is the use of a back-up prescription, only to be filled if a patient's condition deteriorates or fails to improve. The purpose of our study was to determine patient satisfaction, prescription fill rates, and correlates of these outcomes among patients receiving back-up antibiotic prescriptions. METHODS: In our observational study we obtained survey data from 28 physicians and 2 physician extenders in 3 family practice clinics and their patients presenting with complaints of common respiratory symptoms. We computed patient satisfaction and fill rates of back-up antibiotic prescriptions. Agreement between the perceived need of patients for antibiotics before the office visit and the subjective rating of their physicians of the clinical necessity to prescribe antibiotics for these patients was assessed using the kappa statistic. Finally, we determined correlates of satisfaction and the rate of filling back-up prescriptions. RESULTS: Of the 947 patients enrolled in the study, 46.6% received no antibiotic prescriptions, 30.2% received back-up antibiotic prescriptions, and 23.2% were given immediate-fill prescriptions for an antibiotic. Patients' self-reported satisfaction and fill rates for back-up antibiotic prescriptions were 96.1% and 50.2%, respectively. CONCLUSIONS: Our findings indicate that patients were very satisfied with a back-up antibiotic prescription. The fact that half of the patients chose not to fill these prescriptions suggests a potential health care cost savings.

Child maltreatment related injuries: incidence, hospital charges, and correlates of hospitalization.

OBJECTIVE: This study was undertaken to determine the incidence, hospital charges, and correlates associated with inpatient treatment of child maltreatment related injuries. METHODS: The data were based on the 1995 Pennsylvania Hospital Discharge Data which included all Pennsylvania acute care hospitals that reported child maltreatment discharges. Per capita hospital discharge rates were computed for children discharged with child maltreatment related injuries according to selected variables. Odds ratios for child maltreatment related injury hospitalizations were also computed. RESULTS: A total of 348 maltreated injured children ages 0-19 years were discharged from Pennsylvania hospitals in 1995, representing an incidence rate of 10.8 per 100,000 persons. The total hospital charges for child maltreatment related injury discharges amounted to over $5.4 million, of which Medicaid alone paid for 45%. Compared to a random sample of non-maltreated injured children (n = 1052), maltreated injured children were found to be significantly younger, more likely to be females, and more likely to be Black. Child maltreatment related injury hospitalizations were more likely to be urgent and via physician referral or transfer from other health care facility. Maltreated injured children were three times as likely to die as other children. CONCLUSIONS: These findings indicate that injury from child maltreatment is a major cause of hospitalization of young children 5 years and younger and represents a significant cost to publicly financed health care. While hospital discharge data can be used for population-based surveillance of child maltreatment related trauma, there is need for improvement in the surveillance of these injuries.

Epidemiology of transport-related injuries in Ghana.

To better elucidate the incidence, characteristics, and consequences of transport-related injuries in a less developed country in Africa, we undertook an epidemiologic survey in Ghana. A total of 21,105 persons were surveyed, in both an urban area (Kumasi, n = 11,663) and a rural area (Brong-Ahafo, n = 9442). In the preceding year, a total of 656 injuries were reported in the urban area and 928 injuries reported in the rural area. Transport-related mechanisms accounted for 16% of all injuries in the urban and 10% of all injuries in the rural area. The annual incidence of transport-related injuries was almost identical in the two settings, 997/100,000 persons in the urban area and 941/100,000 in the rural area. In both settings, transport-related injuries were more severe than other types of injuries in terms of mortality, length of disability, and economic consequences. In the urban area, the most common transport-related mechanisms were either to passengers involved in crashes of mini-buses or taxis (29%) or to pedestrians struck by these vehicles (21%). In the rural area, the most common transport-related mechanisms were bicycle crashes. The second most common rural mechanisms were motor vehicle crashes, which were the most severe and which involved commercial (83%) rather than private vehicles. Prevention strategies need to be different from those in developed countries and should target commercial drivers more than private road users.

Child death reviews: a gold mine for injury prevention and control.

OBJECTIVES: The purpose of this study was to demonstrate how child death review teams can be used to prevent future deaths through retrospective, multiagency case analysis and recommendations for educational programs and policy change. METHODS: A listing of all deaths to persons ages 21 years and younger in Philadelphia that occurred in 1995 was compiled by the Philadelphia Interdisciplinary Youth Fatality Review Team (PIYFRT), a multiagency, multidisciplinary, community based group created in 1993 with the mission to prevent future deaths through review, analysis, and initiation of corrective actions. Data were collected on demographic variables, as well as the circumstantial variables on injuries such as weapon type, alcohol and drug use, and contact with the criminal justice system, among others. Each case was reviewed thoroughly to determine whether or not the death was preventable. Selected injury related death cases were analyzed further by demographic and circumstantial variables. RESULTS: In 1995, 607 children ages 21 years and younger died in Philadelphia from natural causes (61.6%), unintentional injuries (16.3%), homicide (18.6%), suicide (2.3%), and undetermined causes (1.2%). More than a third (37.2%) of all deaths were considered preventable. Of the injury deaths (n=224), 95% were judged to be preventable. Preventable fire/burn injury deaths (n=29) were associated with lack of a smoke detector, nonsupervision of children, and faulty home appliances. Violent deaths were associated with substance abuse, gang involvement, chronic truancy, academic failure, and access to weapons. CONCLUSIONS: Relevant policies for these preventable or intervenable deaths are discussed such as use of non-battery powered smoke detectors.

Correlates of injury to women with partners enrolled in batterer treatment programs.

OBJECTIVES: This study examined correlates of injury in a cohort of women who were partners of men enrolled in batterer treatment programs. METHODS: Cross-sectional data of 670 pairs of battered women and their partners were analyzed. Prevalence rates of women's self-reports of injury due to their partners' abusive behavior were computed and compared by couples' demographic and behavioral characteristics. RESULTS: Men's use of severe tactics of abuse was the characteristic most significantly associated with injury (odds ratio = 15.47; 95% confidence interval = 9.02, 26.55). CONCLUSIONS: Our findings underscore the need to obtain information on the specific tactics used by couples to settle their disputes during universal screening by practitioners.

The mechanisms, intensity of treatment, and outcomes of hospitalized burns: issues for prevention.

The mechanisms, intensity of treatment, and outcomes of fire and burn injuries that result in hospitalizations were investigated to assist in ongoing prevention efforts. All hospital discharge records with a fire or burn diagnosis were extracted from the 1994 Pennsylvania statewide hospital discharge data. Cases were categorized into 4 specific burn mechanisms: conflagrations, controlled fires, clothing ignition, and hot substances and scalds. A total of 3173 cases were reported for a rate of 26.3 per 100,000 people. Hot substances and scalds were the most common mechanism (58%) of fire and burn hospitalizations. While most injuries resulting from clothing ignition, conflagrations, and hot substances and scalds were reported as unintentional, 25% of the cases resulting from controlled fires were reported as self-inflicted. The mean hospital charge per hospitalization day (which reflected the intensity of burn treatment) was 2783 but varied significantly by mechanism (P < .001): $4102 for cases resulting from conflagrations; $3402 for cases resulting from clothing ignition; and $2187 for cases resulting from hot substances and scalds. The overall in-hospital case fatality rate was 2.4%. Prevention strategies for these injuries are outlined for injury control professionals.

Getting together for injury control.

The proceedings of a round table session on injury control in Africa, held as part of the Third International Conference on Injury Prevention and Control, are outlined in the present article. The prospects for collaborative efforts in this field seem reasonable, but increased support from governments and the international donor community is essential if the immense burden of injury is to be significantly diminished.

Injury control in Africa: getting governments to do more.

Despite increasing recognition of injury as a major public health problem worldwide, it has received limited attention and resources. This lack of attention is most notable in low-income countries. As part of efforts to develop coordinated injury control activities in Africa, a round table session was held at the Third International Conference on Injury Prevention and Control in Melbourne, Australia. The aims of the forum were to provide injury control researchers from Africa the opportunity to come together and reflect on issues of injury control in Africa, to deliberate on strategies of getting African governments to show more interest in injury control, and to solicit more assistance from the international donor community Participants from Ghana, Kenya, South Africa and Zimbabwe presented the magnitude of the injury burden in their respective countries, reflected on current research efforts and highlighted the preventive efforts being undertaken. The forum made many recommendations including several regarding specific actions required of African governments, individual researchers and donor agencies.

Violence against children and adolescents. International perspectives.

Selected topics of violence against children and adolescents that occur in countries outside of the United States are discussed. Focus is given to middle-income and low-income countries and emphasis is placed on the epidemiology of this pressing public health problem, particularly on conditions that are peculiar to children and adolescents in international settings, such as female genital mutilations, wars, displacements, and land mines. The discussion of child maltreatment is presented in the context of child rearing and discipline in different cultures. Recommendations for action and violence prevention are offered in the light of vast cultural differences.

PIP: This article reviews the literature on various aspects of violence against children and adolescents in middle- and low-income countries to reveal the epidemiology and public health consequences and offer recommendations. The first section of the article, on the maltreatment of children, considers how child rearing, discipline, and punishment practices differ in different cultures and then focuses on 1) child maltreatment by intentional injuries such as culturally sanctioned burning and cutting and 2) infanticide. The chapter continues with a look at studies of the epidemiology of child sexual abuse and at the practice of female genital mutilation. The next topics examined are child and adolescent homicide and assault and adolescent suicide, all of which are shown to be on the increase. Finally, the effects of wars, displacement, and ethnic cleansing as well as of land mines and other unexploded lethal weapons are reviewed. It is concluded that health practitioners should oppose all forms of violence and should apply a public health, population-level approach to efforts to prevent and control violence. Health practitioners should espouse the view that the safety of each child and adolescent is the responsibility of all.

Victimization from physical violence in Pennsylvania: prevalence and health care use.

OBJECTIVES: To determine the prevalence of interpersonal physical violence (IPV) among Pennsylvania adults, to identify the personal characteristics of the victims, and to determine their health care use for resulting injuries. METHODS: Population-based data describing physical violence were obtained through a statewide telephone survey of 3,620 Pennsylvania adults selected from households by random-digit dialing in 1994. The prevalence and 95% confidence interval (95% CI) of victimization from IPV along with ED or other medical care facility use for IPV-related injuries were computed by several personal characteristics. Logistic regression was used to compare victims of IPV and their levels of health care use. RESULTS: The prevalence of reported victimization from IPV was 5.6% (95% CI = 4.9, 6.3). Significantly more victimization was reported by males, persons aged 18-29 years, those employed, and unmarried persons. The proportion of victims who reported to have gone to an ED or other medical care facility for IPV-related injury treatment was 12.9%. Significantly more persons with annual household incomes < $20,000 reported health care use for injuries resulting from IPV than did those with incomes of > or = $20,000 (OR = 3.98; 95% CI = 1.27, 12.48). Health care use for injuries was not found to be related to gender, age, race, employment, or marital status. CONCLUSIONS: This population-based study of health care use for IPV-related injuries found that victims of physical violence in Pennsylvania were not only young and unmarried men, but also employed. Health care use for resulting injuries was greater among persons with lower incomes.