World J Surg DOI 10.1007/s00268-015-3061-1
ORIGINAL SCIENTIFIC REPORT
Pediatric First Aid Practices in Ghana: A Population-Based Survey Adam Gyedu1,2 • Charles Mock3,4 • Emmanuel Nakua5 Easmon Otupiri5 • Peter Donkor1,2 • Beth E. Ebel3,6,7
•
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Introduction Children in low- and middle-income countries (LMIC) often receive care outside the formal medical sector. Improving pre-hospital first aid has proven to be highly cost-effective in lowering trauma mortality. Few studies in LMIC have examined home first aid practices for injured children. Methods We conducted a representative population-based survey of 200 caregivers of children under 18 years of age, representing 6520 households. Caregivers were interviewed about their first aid practices and care-seeking behaviors when a child sustained an injury at home. Injuries of interest included burns, lacerations, fractures and choking. Reported practices were characterized as recommended, low-risk, and potentially harmful. Results For common injuries, 75–96 % of caregivers reported employing a recommended practice (e.g., running cool water over a burn injury). However, for these same injuries, 13–61 % of caregivers also identified potentially harmful management strategies (e.g., applying sand to a laceration). Choking had the highest proportion (96 %) of recommended first aid practice: (e.g., hitting the child’s back) and the lowest percent (13 %) of potentially harmful practices (e.g., attempting manual removal). Fractures had the lowest percent (75 %) of recommended practices (e.g., immediately bringing the child to a health facility). Burns had the highest percent (61 %) of potentially harmful practices (e.g., applying kerosene). Conclusions While most caregivers were aware of helpful first aid practices to administer for a child injury, many parents also described potentially harmful practices or delays in seeking medical attention. As parents are the de facto first responders to childhood injury, there are opportunities to strengthen pre-hospital care for children in LMICs.
This paper was presented in part at International Surgical Week (ISW) 2013, Helsinki, Finland. & Adam Gyedu [email protected] 1
Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Private Mailbag, University Post Office, Kumasi, Ghana
2
Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
3
Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
4
Departments of Surgery, Global Health and Epidemiology, University of Washington, Seattle, WA, USA
5
Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
6
Departments of Pediatrics, Health Services and Epidemiology, University of Washington, Seattle, WA, USA
7
Seattle Children’s Hospital, Seattle, WA, USA
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World J Surg
Introduction Injury is a major global health problem. Each year nearly 5 million people die from an injury, and 90 % of these deaths occur in low- and middle-income countries (LMICs). Millions more are left with temporary or permanent disabilities from injury. Injury is increasingly a cause of death and disability in children in LMICs [1, 2]. In 2010, unintentional injury was the cause of 37 deaths per 100,000 Ghanaian children under age 14; resulting in 3241 disability-adjusted life years (DALYs) per 100,000 and 80 per 100,000 years of life lost to disability (YLD) [3]. Reducing the burden of pediatric injury demands both injury prevention and improvements in trauma care. Most injury deaths occur outside health facilities. The proportion of out-of-hospital deaths is inversely proportional to country resource levels, with such proportions being especially high in African countries. In the African nation of Ghana, even in an urban environment, 80 % of all injury deaths occurred in the field, in comparison to lower percentages in higher income countries [4]. To address the problem of out-of-hospital deaths, it is important to note that most of the world’s people do not have access to formal emergency medical services (EMS) or ambulance services. Developing a formal EMS system may or may not be cost-effective, depending on the context, and incipient services typically have limited coverage. Establishing an effective EMS system can also take considerable time and organization to implement [5]. In Ghana, there is no formal pre-hospital care. The National Ambulance Service was created in 2004. However, it still mainly serves the urban population and is not yet developed enough to serve the majority of the population, especially those living in rural and semi-urban areas. In addition, it focuses mainly on inter-facility transfer, not scene of injury response. Hence, emergency management training efforts, which are complementary to a formal EMS system, need to be considered. These approaches typically build on existing care being provided by first responders, by the community, and by family members. Studies have identified successful models to train, equip, and optimize the performance of village volunteers, police, and commercial drivers for first aid of injured persons [6–8]. Requisite to strengthening non-EMS, community-based pre-hospital care initiatives is the understanding of current home-based care practices and perceptions of emergency care need. The initial care provided by family members impacts injury outcome, whether this is first aid rendered before an injured person is taken for medical care or whether this is the only care the injured person receives. Currently, there is almost no information on home-based care practices by
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families of injured children in LMICs. We undertook this study to better understand existing care that families in Ghana provide for injured children, in order to identify practices likely to be beneficial and practices which may be harmful. We were particularly interested to identify opportunities to strengthen pre-hospital care in LMICs.
Methods Study population The study was conducted in the Asawase sub-metropolis of Kumasi, Ghana and was nested in the existing multicountry, longitudinal Family Health and Wealth Study (FHWS), a community-based survey examining how family size affects health and wealth [9]. The FHWS has conducted two rounds of data collection in 2009 and 2011, and a third round to cover the same cohort is scheduled for December 2014. A comprehensive description of the study area and study population has been provided in a prior report [10]. For the FHWS, every household in each of the four Asawase communities was enumerated for the sampling frame. Two hundred households containing caregivers of children under 18 years of age were randomly sampled from each of four communities. For the current study, 50 households were randomly sampled from each community cluster of 200 households. From each household, one eligible caregiver was randomly selected for interview. For the purpose of the nested child injury study, only one round of data collection was done. Participants were given a bar of soap as compensation for participating in the study. Survey design We conducted a cross-sectional, population-based survey of 200 primary caregivers of children under 18 years of age, representing 6520 of such caregivers in the Asawase sub-metropolis of Kumasi, Ghana. Using a structured questionnaire, caregivers were interviewed about household injuries sustained by their children [10] as well as first aid practices and health care-seeking behaviors when a child sustained an injury at home. The survey considered all mechanisms of injury that led to all outcomes (not only fatal ones) and were adapted from UNICEF Innocenti working papers on child injury and mortality in Asia [11]. For caregiver first aid practices and health care-seeking behaviors, specific questions were adapted from the child injuries module component of the Integrated Management of Childhood Illness (IMCI) tool [12]. This tool considered injuries from burns, lacerations, fractures and choking, and
World J Surg Table 1 Categorization of caregiver-reported treatment practices of common household child injuries Recommended practice Burn injury
Low-risk practice
Potentially harmful practice
Applying cool water
Applying oil, egg albumin, petroleum jelly, kerosene or traditional medicine
Taking child to a health facility
Taking the child to a prayer camp Doing nothing
Choking on a small object
Hitting the child’s back
Attempting manual removal of the object
Taking child to a health facility.
Giving the child plenty of water in an attempt to ‘‘push it down’’
Laceration
Tying laceration with a piece of cloth
Doing nothing Applying cold liquid
Applying sand
Applying salt
Applying traditional medicine
Taking the child to a health facility Fractures
Immediately taking child to a health facility
Taking the child to a prayer camp Initially treat child within the household and then take them to a health facility
they were also among the most commonly reported household child injuries [10]. Multiple responses were permitted. Reported practices were grouped into three categories: recommended, low-risk, and potentially harmful, through discussion with study team members in consultation with a panel of consultants including a plastic surgeon, an ENT surgeon, and an orthopedic surgeon (Table 1). Informed consent was obtained from all respondents. The study was approved by the Institutional Review Boards of the Kwame Nkrumah University of Science and Technology and the University of Washington. Data analysis Analyses utilized survey-sampling weights, adjusted for clustering by community and household. Household-level weights (WH) were estimated for each of the four communities. This was based on households with children under 18 years of age. Household with caregiver weights was also estimated for each community (WHC) and it was by population density. The overall weight was obtained by multiplying the household weight by the household with caregiver weight (WTOT = WH 9 WHC). All analyses were done using survey weights in STATA version 11 (StataCorp, College Station, TX). Analyses were undertaken using descriptive statistics. Univariate logistic regression was used to examine the association between caregiver factors and first aid practice for common injuries. For this analysis, two sets of caregiver practices were considered: recommended practices only (i.e., caregivers who only indicated that they would use recommended practices for a given condition) and potentially harmful practices only (i.e., caregivers who only indicated that they would use potentially harmful practices for a given condition).
Treating child within the household only Taking the child to a bone healer
Variables of interest were caregiver educational achievement, caregiver employment, household socioeconomic status, caregiver experience with household child injury, the number of children under the care of the caregiver, and caregiver relationship to the child. Caregiver education level was dichotomized as ‘‘no formal education’’ and ‘‘some formal education’’. The latter included caregivers with any level of education.
Results Characteristics of the study sample are summarized in Table 2. There were 200 caregivers in the sample representing 6520 households in Asawase. Primary caregivers were most commonly female (88 %) and were the mother of the reference child (85 %). Most caregivers had some education and were engaged in non-salaried jobs. Nearly half had 3–4 children under 18 years of age under their care. Caregiver-reported treatment practices are summarized in Table 3. For common injuries, most caregivers (between 75 and 96 %, depending on the injury mechanism) would employ a recommended treatment practice (e.g., running cool water over a burn injury, tying a laceration with a piece of clean cloth, or taking an injured child to a health facility). However, many caregivers (13–61 %, depending on the injury mechanism) also identified potentially harmful management strategies. Potentially harmful management practices included applying petroleum jelly to a burn injury, treating a fracture at home without seeking medical help, attempting manual removal of an object during a choking episode, and applying traditional medicines to a cut or laceration.
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World J Surg Table 2 Caregiver characteristics Unweighted Percent Mean caregiver age in years (SD)
Weighted Frequency (n = 200)
34 (7.0)
Percent
95 % CI
34 (7.0)
Relationship with child Mother Father
86 11
172 22
85 12
80, 90 7.5, 16
Othera
3.0
6
3.1
0.5, 5.7
None
17
34
16
11, 21
Basic
66
132
66
59, 74
Senior high and above
17
34
18
13, 24
Caregiver education
Employment status Unemployed
22
43
20
14, 26
Hourly worker
67
133
68
62, 75
Salaried worker
12
24
12
7.1, 17
1–2
35
70
37
30, 45
3–4
51
101
48
41, 55
C5
15
29
15
10, 21
Lowest 1 2
20.3 19.8
40 39
21.2 21.2
15.4, 27.6 15.5, 27.5
3
21.8
43
21.3
15.5, 27.6
4
18.3
36
16.4
11.4, 22.0
Highest 5
19.8
39
18.5
13.2, 24.3
Missing
1.5
3
1.5
No. of children under care of caregiver
Socioeconomic status (wealth quintiles)
Had previous experience with household child injury
a
Yes
53
105
55
48, 62
No
47
95
45
38, 52
Grandmother, nanny, older sibling
Parent response to choking had the highest proportion of recommended first aid practice. Choking was the one type of injury that had the best overall practices. Nearly every parent (96 %) identified a recommended first aid practice in the event of a choking episode (e.g., hitting the child’s back and/or taking the child to a health facility). Parents were less likely to suggest a potentially harmful practice in the presence of a choking episode (13 %). When providing first aid for a fractured bone, only three out of every four parents said they would bring the child to a health facility (75 %). A number of parents reported potentially harmful practices, such as seeking fracture care from a traditional bone setter or caring for the child at home (18 %). First aid practices for burn care often included potentially harmful practices (61 %), ranging from applying
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petroleum jelly or raw eggs to the burn, to applying kerosene. Parental first aid for cuts/lacerations typically included potentially harmful practices (30 %) such as applying sand or traditional medicine. We examined the univariate association between caregiver characteristics and recommended first aid practices (Table 4), and then examined the association between caregiver characteristics and identification of potentially harmful first aid practices (Table 4). Given the few significant associations noted in univariate analysis, we did not explore multivariable analysis. Being a father was associated with increased odds of recommended practices for burn injury (OR = 3.1, 95 % CI 1.2, 7.9, compared with mother). For all other injuries, reported first aid practices did not differ between male and female respondents.
World J Surg Table 3 Caregiver-reported injury management for common household child injury Unweighted a
Percent (%)
Weighted Frequency (n = 200)
Percenta
95 % CI
Burn Recommended
87
174
87
82, 92
Low risk Potentially harmful
– 63
– 126
– 61
– 53, 67
Recommended only
35
69
37
30, 44
Potentially harmful only
11
21
10
6.7, 16
Cuts Recommended
84
167
80
74, 86
Low risk
44
87
43
36, 50
Potentially harmful
32
64
30
24, 37
Recommended only
34
68
33
27, 40
Potentially harmful only
3.0
6
4.0
2.0, 8.3
Fractures Recommended
78
155
75
69, 82
Low risk
23
45
18
13, 22
Potentially harmful
61
121
55
48, 61
Recommended only
33
66
39
33, 45
Potentially harmful only
16
32
18
13, 24
Choking Recommended
97
193
96
93, 99
–
–
–
–
Potentially harmful
20
39
13
10, 18
Recommended only
79
158
85
80, 88
Potentially harmful only
2.0
4
2.0
0.6, 5.3
Low risk
a
Multiple responses were permitted for each category. Hence, percents for ‘‘recommended’’, ‘‘low risk’’, and ‘‘potentially harmful’’ in each category can add to more than 100 %
Having any education was associated with increased odds of potentially harmful practices for fractures (OR = 14.1, 95 % CI 1.8, 108.7, compared with no education). Caregiver education was not otherwise significantly associated with first aid practices. Household caregivers with higher socioeconomic status were less likely to report use of potentially harmful first aid practices for laceration injury (OR = 0.6, 95 % CI 0.4, 0.9) compared to caregivers with a lower socioeconomic status. Caregivers who were not the child’s parent had higher odds of potentially harmful practices for choking injury (OR = 42.8, 95 % CI 3.2, 575.7, compared with the child’s mother). Otherwise, no caregiver characteristic was significantly associated with recommended or potentially harmful practice for any type of injury. Many caregivers (76 %) also noted that they would seek a neighbor’s help in providing first aid, suggesting that the presence of a few trained first responders in the community might considerably benefit all families.
Discussion Given the limited information on home-based care practices by families of injured children in LMICs, we undertook this study to better understand existing care that families in Ghana provide for injured children, including what practices are beneficial and which ones are potentially harmful. By doing so, we hoped to provide data that would be useful in strengthening pre-hospital care in LMICs. Our data suggest that for common injuries, the majority of caregivers would employ a recommended treatment practice. However, for these same injuries, many caregivers also reported potentially harmful management strategies. Only in cases of pediatric aspiration events did very few caretakers describe potentially harmful management practices such as attempting manual removal of the object, giving the child plenty of water in an attempt to ‘‘push it down’’, or doing nothing.
123
123
0.92 (0.43, 1.19)
0.77 (0.25, 2.41)
Hourly worker
Salaried worker
0.96 (0.52, 1.81)
Some experience
Some educationa
1.31 (0.53, 3.26)
0.90 (0.14, 5.93)
Father
Otherb
1.80 (0.90, 3.61)**
2.13 (0.82, 5.51)
1.05 (0.84, 1.31)
3–4
C5
Socioeconomic statusc 1.06 (0.85, 1.33)
1.86 (0.73, 4.73)
1.55 (0.78, 3.06)
1.00
1.36 (0.22, 8.24)
3.11 (1.22, 7.93)*
1.00
0.89 (0.39, 2.00)
1.00
1.03 (0.55, 1.94)
1.00
0.71 (0.24, 2.11)
0.63 (0.30, 1.32)
1.00
c
b
a
0.96 (0.78, 1.17)
0.38 (0.13, 1.10)**
0.80 (0.41, 0.55)
1.00
3.08 (0.55, 16.73)
1.33 (0.55, 3.22)
1.00
1.67 (0.70, 4.02)
1.00
0.64 (0.35, 1.20)
1.00
0.71 (0.21, 2.38)
1.20 (0.56, 2.59)
1.00
Socioeconomic status (wealth quintiles) has been considered as a continuous variable
Grandmother, nanny, older sibling
Any level of education
*p\ 0.05; **p 0.05–0.10
- Insufficient numbers; - - convergence not achieved
1.00
1–2
Number of children under care
1.00
Mother
Relationship to child
1.00
0.93 (0.41, 2.12)
None
Education status
1.00
None
Previous experience with household child injury
1.00
Unemployed
Employment status
0.84 (0.64, 1.10)
0.52 (0.17, 1.60)
0.61 (0.27, 1.41)
1.00
0.32 (0.06, 1.88)
-
1.00
1.57 (0.64, 3.83)
1.00
1.11 (0.55, 2.24)
1.00
1.90 (0.59, 6.10)
1.88 (0.79, 4.43)
1.00
Choking
0.58 (0.36, 0.94)*
-
0.15 (0.02, 1.35)**
1.00
-
-
1.00
0.39 (0.67, 2.30)
1.00
0.16 (0.02, 1.45)
1.00
3.34 (0.27, 40.86)
0.87 (0.08, 8.92)
1.00
0.89 (0.64, 1.24)
0.97 (0.21, 4.45)
1.29 (0.44, 3.73)
1.00
-
0.34 (0.04, 2.78)
1.00
1.63 (0.36, 7.44)
1.00
0.56 (0.21, 1.46)
1.00
0.76 (0.06, 9.23)
2.81 (0.47, 10.08)
1.00
Burn
Laceration
Fracture
Laceration
Burn
For only potentially harmful practices
For only recommended practices
Table 4 Caregiver factors associated with engaging in first aid practices for common injury types: univariate analysis
0.75 (0.56, 1.01)**
0.42 (0.11, 1.65)
0.47 (0.20, 1.13)**
1.00
-
2.74 (0.99, 7.59)
1.00
14.10 (1.82, 108.79)*
1.00
1.57 (0.69, 3.58)
1.00
1.17 (0.26, 5.32)
1.19 (0.41, 3.47)
1.00
Fracture
0.58 (0.35, 0.94)
--
--
1.00
42.81 (3.18, 575.68)*
-
1.00
0.15 (0.01, 1.69)
1.00
1.02 (0.09, 11.47)
1.00
-
0.23 (0.02, 2.60)
1.00
Choking
World J Surg
World J Surg
There was little relationship between caregiver characteristics and the odds of a recommended or potentially harmful practice. Interestingly, education was associated with potentially harmful practices for fractures compared with lack of education. The reason for this unexpected observation was not known, and this paradoxical finding may be spurious, or may reflect the relatively homogenous population in these semi-urban communities. There is a heavy reliance on traditional medicine for health care among Ghanaians [13]. Traditional medical practitioners are culturally accepted and play important psychosocial and perhaps also medical roles in conducting treatments not provided by allopathic medicine, due to the deficits in allopathic practitioners and/or distrust of conventional medicine or other factors [14]. Household child injuries are common in semi-urban Ghana—for instance, lacerations occur in 119 per 1000 children per year, burns 31, falls 316, assault 27, motor vehicle injuries 12 and suffocation 11 [10]. Considerable effort has been dedicated to understand and improve home-based care for common childhood illnesses such as malaria, diarrhea, and respiratory tract infection, with remarkable improvements in LMIC mortality rates from dehydration and infectious disease [15–17]. These public health accomplishments contrast with the relatively limited knowledge of the home-based care practices for child injuries in LMICs. An assessment of the baseline knowledge of first aid for commercial drivers in Ghana, in preparation for development of training programs, revealed that only 13 % had ever had any type of first aid training [8, 18]. Provision of first aid for an injured child in the home is particularly important since one-third of injured people in Kumasi never receive formal care at a clinic or hospital and thus only receive whatever care is provided by relatives or in the community [19]. The percentage of families who do not seek care for an injured child was even higher (49 %) in rural Ghana [20]. Those individuals who did not receive formal health care initially for injuries such as a fractured bone may experience considerable delays and associated morbidity and disability when formal care is eventually sought [19, 20]. Our results underscore the need for community-based education and communication campaigns aimed at enhancing behavior change in health care seeking for household child injury among parents and caregivers. Patronage of traditional bonesetter services is particularly widespread in Ghana, as in other sub-Saharan African countries [21]. These bonesetters may also represent a good target audience for providing first aid training. Our relatively small study has a number of limitations. First, these data were gathered by self-report and we could not independently validate the accuracy of information reported by caregivers. Second, caregivers may have
provided socially desirable responses. Third, study households were relatively similar in terms of socioeconomic levels and education, and the relative lack of variation in these important variables may have limited our ability to examine associations between caregiver factors and first aid practices. Fourth, only 22 of the 200 caregivers were males, which we believe reflects the proportion in the study population. However, this low number does decrease our statistical power to draw conclusions about the role of gender in caregiving practices. However our findings may also reflect the relative scarcity of training and instruction on first aid response. Despite these limitations, the study offers the advantages of being community based, with random selection, using a structured questionnaire with trained researchers and a fairly large sample size. Hence, the data allow us to draw some conclusions regarding the nature of home-based care practices for injured children in the study environment.
Conclusions Apart from when a child is choking, only a minority of caregivers in semi-urban Kumasi would consistently manage an injured child according to recommended practices. Many caregivers engage in first aid injury management practices that are recommended. However, many would also manage the injury in other ways that may be potentially harmful to the child. There are opportunities to provide basic first aid training to interested parents, particularly if these efforts include strategies for community dissemination of best practices. This study provides data useful for efforts to understand, and ultimately strengthen pre-hospital care in LMICs, especially regarding development of programs for first aid training at the household and community levels. Examples of injury prevention and first aid interventions which are effective in the context of low-resource economies are badly needed. Careful epidemiologic surveillance will continue to be important so that the impact of these efforts can be measured and sustained [22, 23]. Better understanding of preventable and treatable child household injury is particularly important in LMICs, so that creative interventions can be developed and evaluated. Acknowledgments We wish to express our sincere thanks to all caregivers who participated in the study. Conflict of interest The authors have no conflicts of interest or financial ties to disclose. Funding This study was funded, in part, by a Grant (D43TW007267) from the Fogarty International Center, US National
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World J Surg Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References 1. Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet 380(9859):2095–2128 2. Peden M, McGee K, Krug E (2002) Injury: a leading cause of the global burden of disease, 2000. World Health Organization, Geneva 3. IHME. Data visualizations. Seattle (2013) http://vizhub.health data.org/gbd-cause-patterns/. Accessed 16 Dec 2014 4. Mock CN, Jurkovich GJ, nii-Amon-Kotei D et al (1998) Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 44(5):804–812 5. Sasser S, Varghese M, Kellermann A et al (2005) Prehospital trauma care systems. World Health Organ, Geneva 6. Husum H, Gilbert M, Wisborg T et al (2003) Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 54(6):1188–1196 7. Jayaraman S, Mabweijano JR, Lipnick MS et al (2009) Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program. World J Surg 33(12):2512–2521. doi:10.1007/s00268-009-0180-6 8. Tiska MA, Adu-Ampofo M, Boakye G et al (2004) A model of prehospital trauma training for lay persons devised in Africa. Emerg Med J 21(2):237–239 9. Johns Hopkins School of Public Health (2013) Family health and wealth study, Insights on wealth measurement and change. http:// www.jhsph.edu/departments/population-family-and-reproductivehealth/_docs/seminar-2013-02-20-fhws-presentation.pdf. Accessed 17 May 2014 10. Gyedu A, Nakua EK, Otupiri E et al (2014) Incidence, characteristics and risk factors for household and neighbourhood injury among young children in semiurban Ghana: a population-based household survey. Inj Prev
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11. Linnan M, Giersing M, Cox R et al (2007) Child mortality and injury in Asia: an overview. Florence: UNICEF Innocenti Research Centre. Contract No.: 2007-04 12. Wansi E, Mtango D, Maganga E et al (2000) Community IMCI baseline survey in Malawi. UNICEF. http://www.medcol.mw/ commhealth/publications/UNICEF%20Malawi%20HCPS.pdf. Accessed 28 Oct 2014 13. Falkenberg T, Sawyer J, Zhang X et al (2002) WHO traditional medicine strategy 2002–2005. WHO, Geneva 14. O’Brien KS, Soliman AS, Annan K et al (2012) Traditional herbalists and cancer management in Kumasi, Ghana. J Cancer Education 27(3):573–579 15. Ellis AA, Winch P, Daou Z et al (2007) Home management of childhood diarrhoea in southern Mali—implications for the introduction of zinc treatment. Soc Sci Med 64(3):701–712 16. Othero DM, Orago AS, Groenewegen T et al (2008) Home management of diarrhea among underfives in a rural community in Kenya: household perceptions and practices. East Afr J Public Health 5(3):142–146 17. Ukwaja KN, Talabi AA, Aina OB (2012) Pre-hospital care seeking behaviour for childhood acute respiratory infections in south-western Nigeria. Int Health 4(4):289–294 18. Mock CN, Tiska M, Adu-Ampofo M et al (2002) Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma 53(1):90–97 19. Spangenberg K, Mock C (2006) Utilization of health services by the injured residents in Kumasi, Ghana. Int J Inj Contr Saf Promot 13(3):194–196 20. Mock C, Ofosu A, Gish O (2001) Utilization of district health services by injured persons in a rural area of Ghana. Int J Health Plann Manage 16(1):19–32 21. Aries MJH, Joosten H, Wegdam HHJ et al (2007) Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences. Trop Med Int Health 12(4):564–574 22. Rahman A, Miah AH, Mashreky SR et al (2010) Initial community response to a childhood drowning prevention programme in a rural setting in Bangladesh. Inj Prev 16(1):21–25 23. Rahman F, Bose S, Linnan M et al (2012) Cost-effectiveness of an injury and drowning prevention program in Bangladesh. Pediatrics 130(6):e1621–e1628
ORIGINAL SCIENTIFIC REPORT
Pediatric First Aid Practices in Ghana: A Population-Based Survey Adam Gyedu1,2 • Charles Mock3,4 • Emmanuel Nakua5 Easmon Otupiri5 • Peter Donkor1,2 • Beth E. Ebel3,6,7
•
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Introduction Children in low- and middle-income countries (LMIC) often receive care outside the formal medical sector. Improving pre-hospital first aid has proven to be highly cost-effective in lowering trauma mortality. Few studies in LMIC have examined home first aid practices for injured children. Methods We conducted a representative population-based survey of 200 caregivers of children under 18 years of age, representing 6520 households. Caregivers were interviewed about their first aid practices and care-seeking behaviors when a child sustained an injury at home. Injuries of interest included burns, lacerations, fractures and choking. Reported practices were characterized as recommended, low-risk, and potentially harmful. Results For common injuries, 75–96 % of caregivers reported employing a recommended practice (e.g., running cool water over a burn injury). However, for these same injuries, 13–61 % of caregivers also identified potentially harmful management strategies (e.g., applying sand to a laceration). Choking had the highest proportion (96 %) of recommended first aid practice: (e.g., hitting the child’s back) and the lowest percent (13 %) of potentially harmful practices (e.g., attempting manual removal). Fractures had the lowest percent (75 %) of recommended practices (e.g., immediately bringing the child to a health facility). Burns had the highest percent (61 %) of potentially harmful practices (e.g., applying kerosene). Conclusions While most caregivers were aware of helpful first aid practices to administer for a child injury, many parents also described potentially harmful practices or delays in seeking medical attention. As parents are the de facto first responders to childhood injury, there are opportunities to strengthen pre-hospital care for children in LMICs.
This paper was presented in part at International Surgical Week (ISW) 2013, Helsinki, Finland. & Adam Gyedu [email protected] 1
Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Private Mailbag, University Post Office, Kumasi, Ghana
2
Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
3
Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
4
Departments of Surgery, Global Health and Epidemiology, University of Washington, Seattle, WA, USA
5
Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
6
Departments of Pediatrics, Health Services and Epidemiology, University of Washington, Seattle, WA, USA
7
Seattle Children’s Hospital, Seattle, WA, USA
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World J Surg
Introduction Injury is a major global health problem. Each year nearly 5 million people die from an injury, and 90 % of these deaths occur in low- and middle-income countries (LMICs). Millions more are left with temporary or permanent disabilities from injury. Injury is increasingly a cause of death and disability in children in LMICs [1, 2]. In 2010, unintentional injury was the cause of 37 deaths per 100,000 Ghanaian children under age 14; resulting in 3241 disability-adjusted life years (DALYs) per 100,000 and 80 per 100,000 years of life lost to disability (YLD) [3]. Reducing the burden of pediatric injury demands both injury prevention and improvements in trauma care. Most injury deaths occur outside health facilities. The proportion of out-of-hospital deaths is inversely proportional to country resource levels, with such proportions being especially high in African countries. In the African nation of Ghana, even in an urban environment, 80 % of all injury deaths occurred in the field, in comparison to lower percentages in higher income countries [4]. To address the problem of out-of-hospital deaths, it is important to note that most of the world’s people do not have access to formal emergency medical services (EMS) or ambulance services. Developing a formal EMS system may or may not be cost-effective, depending on the context, and incipient services typically have limited coverage. Establishing an effective EMS system can also take considerable time and organization to implement [5]. In Ghana, there is no formal pre-hospital care. The National Ambulance Service was created in 2004. However, it still mainly serves the urban population and is not yet developed enough to serve the majority of the population, especially those living in rural and semi-urban areas. In addition, it focuses mainly on inter-facility transfer, not scene of injury response. Hence, emergency management training efforts, which are complementary to a formal EMS system, need to be considered. These approaches typically build on existing care being provided by first responders, by the community, and by family members. Studies have identified successful models to train, equip, and optimize the performance of village volunteers, police, and commercial drivers for first aid of injured persons [6–8]. Requisite to strengthening non-EMS, community-based pre-hospital care initiatives is the understanding of current home-based care practices and perceptions of emergency care need. The initial care provided by family members impacts injury outcome, whether this is first aid rendered before an injured person is taken for medical care or whether this is the only care the injured person receives. Currently, there is almost no information on home-based care practices by
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families of injured children in LMICs. We undertook this study to better understand existing care that families in Ghana provide for injured children, in order to identify practices likely to be beneficial and practices which may be harmful. We were particularly interested to identify opportunities to strengthen pre-hospital care in LMICs.
Methods Study population The study was conducted in the Asawase sub-metropolis of Kumasi, Ghana and was nested in the existing multicountry, longitudinal Family Health and Wealth Study (FHWS), a community-based survey examining how family size affects health and wealth [9]. The FHWS has conducted two rounds of data collection in 2009 and 2011, and a third round to cover the same cohort is scheduled for December 2014. A comprehensive description of the study area and study population has been provided in a prior report [10]. For the FHWS, every household in each of the four Asawase communities was enumerated for the sampling frame. Two hundred households containing caregivers of children under 18 years of age were randomly sampled from each of four communities. For the current study, 50 households were randomly sampled from each community cluster of 200 households. From each household, one eligible caregiver was randomly selected for interview. For the purpose of the nested child injury study, only one round of data collection was done. Participants were given a bar of soap as compensation for participating in the study. Survey design We conducted a cross-sectional, population-based survey of 200 primary caregivers of children under 18 years of age, representing 6520 of such caregivers in the Asawase sub-metropolis of Kumasi, Ghana. Using a structured questionnaire, caregivers were interviewed about household injuries sustained by their children [10] as well as first aid practices and health care-seeking behaviors when a child sustained an injury at home. The survey considered all mechanisms of injury that led to all outcomes (not only fatal ones) and were adapted from UNICEF Innocenti working papers on child injury and mortality in Asia [11]. For caregiver first aid practices and health care-seeking behaviors, specific questions were adapted from the child injuries module component of the Integrated Management of Childhood Illness (IMCI) tool [12]. This tool considered injuries from burns, lacerations, fractures and choking, and
World J Surg Table 1 Categorization of caregiver-reported treatment practices of common household child injuries Recommended practice Burn injury
Low-risk practice
Potentially harmful practice
Applying cool water
Applying oil, egg albumin, petroleum jelly, kerosene or traditional medicine
Taking child to a health facility
Taking the child to a prayer camp Doing nothing
Choking on a small object
Hitting the child’s back
Attempting manual removal of the object
Taking child to a health facility.
Giving the child plenty of water in an attempt to ‘‘push it down’’
Laceration
Tying laceration with a piece of cloth
Doing nothing Applying cold liquid
Applying sand
Applying salt
Applying traditional medicine
Taking the child to a health facility Fractures
Immediately taking child to a health facility
Taking the child to a prayer camp Initially treat child within the household and then take them to a health facility
they were also among the most commonly reported household child injuries [10]. Multiple responses were permitted. Reported practices were grouped into three categories: recommended, low-risk, and potentially harmful, through discussion with study team members in consultation with a panel of consultants including a plastic surgeon, an ENT surgeon, and an orthopedic surgeon (Table 1). Informed consent was obtained from all respondents. The study was approved by the Institutional Review Boards of the Kwame Nkrumah University of Science and Technology and the University of Washington. Data analysis Analyses utilized survey-sampling weights, adjusted for clustering by community and household. Household-level weights (WH) were estimated for each of the four communities. This was based on households with children under 18 years of age. Household with caregiver weights was also estimated for each community (WHC) and it was by population density. The overall weight was obtained by multiplying the household weight by the household with caregiver weight (WTOT = WH 9 WHC). All analyses were done using survey weights in STATA version 11 (StataCorp, College Station, TX). Analyses were undertaken using descriptive statistics. Univariate logistic regression was used to examine the association between caregiver factors and first aid practice for common injuries. For this analysis, two sets of caregiver practices were considered: recommended practices only (i.e., caregivers who only indicated that they would use recommended practices for a given condition) and potentially harmful practices only (i.e., caregivers who only indicated that they would use potentially harmful practices for a given condition).
Treating child within the household only Taking the child to a bone healer
Variables of interest were caregiver educational achievement, caregiver employment, household socioeconomic status, caregiver experience with household child injury, the number of children under the care of the caregiver, and caregiver relationship to the child. Caregiver education level was dichotomized as ‘‘no formal education’’ and ‘‘some formal education’’. The latter included caregivers with any level of education.
Results Characteristics of the study sample are summarized in Table 2. There were 200 caregivers in the sample representing 6520 households in Asawase. Primary caregivers were most commonly female (88 %) and were the mother of the reference child (85 %). Most caregivers had some education and were engaged in non-salaried jobs. Nearly half had 3–4 children under 18 years of age under their care. Caregiver-reported treatment practices are summarized in Table 3. For common injuries, most caregivers (between 75 and 96 %, depending on the injury mechanism) would employ a recommended treatment practice (e.g., running cool water over a burn injury, tying a laceration with a piece of clean cloth, or taking an injured child to a health facility). However, many caregivers (13–61 %, depending on the injury mechanism) also identified potentially harmful management strategies. Potentially harmful management practices included applying petroleum jelly to a burn injury, treating a fracture at home without seeking medical help, attempting manual removal of an object during a choking episode, and applying traditional medicines to a cut or laceration.
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World J Surg Table 2 Caregiver characteristics Unweighted Percent Mean caregiver age in years (SD)
Weighted Frequency (n = 200)
34 (7.0)
Percent
95 % CI
34 (7.0)
Relationship with child Mother Father
86 11
172 22
85 12
80, 90 7.5, 16
Othera
3.0
6
3.1
0.5, 5.7
None
17
34
16
11, 21
Basic
66
132
66
59, 74
Senior high and above
17
34
18
13, 24
Caregiver education
Employment status Unemployed
22
43
20
14, 26
Hourly worker
67
133
68
62, 75
Salaried worker
12
24
12
7.1, 17
1–2
35
70
37
30, 45
3–4
51
101
48
41, 55
C5
15
29
15
10, 21
Lowest 1 2
20.3 19.8
40 39
21.2 21.2
15.4, 27.6 15.5, 27.5
3
21.8
43
21.3
15.5, 27.6
4
18.3
36
16.4
11.4, 22.0
Highest 5
19.8
39
18.5
13.2, 24.3
Missing
1.5
3
1.5
No. of children under care of caregiver
Socioeconomic status (wealth quintiles)
Had previous experience with household child injury
a
Yes
53
105
55
48, 62
No
47
95
45
38, 52
Grandmother, nanny, older sibling
Parent response to choking had the highest proportion of recommended first aid practice. Choking was the one type of injury that had the best overall practices. Nearly every parent (96 %) identified a recommended first aid practice in the event of a choking episode (e.g., hitting the child’s back and/or taking the child to a health facility). Parents were less likely to suggest a potentially harmful practice in the presence of a choking episode (13 %). When providing first aid for a fractured bone, only three out of every four parents said they would bring the child to a health facility (75 %). A number of parents reported potentially harmful practices, such as seeking fracture care from a traditional bone setter or caring for the child at home (18 %). First aid practices for burn care often included potentially harmful practices (61 %), ranging from applying
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petroleum jelly or raw eggs to the burn, to applying kerosene. Parental first aid for cuts/lacerations typically included potentially harmful practices (30 %) such as applying sand or traditional medicine. We examined the univariate association between caregiver characteristics and recommended first aid practices (Table 4), and then examined the association between caregiver characteristics and identification of potentially harmful first aid practices (Table 4). Given the few significant associations noted in univariate analysis, we did not explore multivariable analysis. Being a father was associated with increased odds of recommended practices for burn injury (OR = 3.1, 95 % CI 1.2, 7.9, compared with mother). For all other injuries, reported first aid practices did not differ between male and female respondents.
World J Surg Table 3 Caregiver-reported injury management for common household child injury Unweighted a
Percent (%)
Weighted Frequency (n = 200)
Percenta
95 % CI
Burn Recommended
87
174
87
82, 92
Low risk Potentially harmful
– 63
– 126
– 61
– 53, 67
Recommended only
35
69
37
30, 44
Potentially harmful only
11
21
10
6.7, 16
Cuts Recommended
84
167
80
74, 86
Low risk
44
87
43
36, 50
Potentially harmful
32
64
30
24, 37
Recommended only
34
68
33
27, 40
Potentially harmful only
3.0
6
4.0
2.0, 8.3
Fractures Recommended
78
155
75
69, 82
Low risk
23
45
18
13, 22
Potentially harmful
61
121
55
48, 61
Recommended only
33
66
39
33, 45
Potentially harmful only
16
32
18
13, 24
Choking Recommended
97
193
96
93, 99
–
–
–
–
Potentially harmful
20
39
13
10, 18
Recommended only
79
158
85
80, 88
Potentially harmful only
2.0
4
2.0
0.6, 5.3
Low risk
a
Multiple responses were permitted for each category. Hence, percents for ‘‘recommended’’, ‘‘low risk’’, and ‘‘potentially harmful’’ in each category can add to more than 100 %
Having any education was associated with increased odds of potentially harmful practices for fractures (OR = 14.1, 95 % CI 1.8, 108.7, compared with no education). Caregiver education was not otherwise significantly associated with first aid practices. Household caregivers with higher socioeconomic status were less likely to report use of potentially harmful first aid practices for laceration injury (OR = 0.6, 95 % CI 0.4, 0.9) compared to caregivers with a lower socioeconomic status. Caregivers who were not the child’s parent had higher odds of potentially harmful practices for choking injury (OR = 42.8, 95 % CI 3.2, 575.7, compared with the child’s mother). Otherwise, no caregiver characteristic was significantly associated with recommended or potentially harmful practice for any type of injury. Many caregivers (76 %) also noted that they would seek a neighbor’s help in providing first aid, suggesting that the presence of a few trained first responders in the community might considerably benefit all families.
Discussion Given the limited information on home-based care practices by families of injured children in LMICs, we undertook this study to better understand existing care that families in Ghana provide for injured children, including what practices are beneficial and which ones are potentially harmful. By doing so, we hoped to provide data that would be useful in strengthening pre-hospital care in LMICs. Our data suggest that for common injuries, the majority of caregivers would employ a recommended treatment practice. However, for these same injuries, many caregivers also reported potentially harmful management strategies. Only in cases of pediatric aspiration events did very few caretakers describe potentially harmful management practices such as attempting manual removal of the object, giving the child plenty of water in an attempt to ‘‘push it down’’, or doing nothing.
123
123
0.92 (0.43, 1.19)
0.77 (0.25, 2.41)
Hourly worker
Salaried worker
0.96 (0.52, 1.81)
Some experience
Some educationa
1.31 (0.53, 3.26)
0.90 (0.14, 5.93)
Father
Otherb
1.80 (0.90, 3.61)**
2.13 (0.82, 5.51)
1.05 (0.84, 1.31)
3–4
C5
Socioeconomic statusc 1.06 (0.85, 1.33)
1.86 (0.73, 4.73)
1.55 (0.78, 3.06)
1.00
1.36 (0.22, 8.24)
3.11 (1.22, 7.93)*
1.00
0.89 (0.39, 2.00)
1.00
1.03 (0.55, 1.94)
1.00
0.71 (0.24, 2.11)
0.63 (0.30, 1.32)
1.00
c
b
a
0.96 (0.78, 1.17)
0.38 (0.13, 1.10)**
0.80 (0.41, 0.55)
1.00
3.08 (0.55, 16.73)
1.33 (0.55, 3.22)
1.00
1.67 (0.70, 4.02)
1.00
0.64 (0.35, 1.20)
1.00
0.71 (0.21, 2.38)
1.20 (0.56, 2.59)
1.00
Socioeconomic status (wealth quintiles) has been considered as a continuous variable
Grandmother, nanny, older sibling
Any level of education
*p\ 0.05; **p 0.05–0.10
- Insufficient numbers; - - convergence not achieved
1.00
1–2
Number of children under care
1.00
Mother
Relationship to child
1.00
0.93 (0.41, 2.12)
None
Education status
1.00
None
Previous experience with household child injury
1.00
Unemployed
Employment status
0.84 (0.64, 1.10)
0.52 (0.17, 1.60)
0.61 (0.27, 1.41)
1.00
0.32 (0.06, 1.88)
-
1.00
1.57 (0.64, 3.83)
1.00
1.11 (0.55, 2.24)
1.00
1.90 (0.59, 6.10)
1.88 (0.79, 4.43)
1.00
Choking
0.58 (0.36, 0.94)*
-
0.15 (0.02, 1.35)**
1.00
-
-
1.00
0.39 (0.67, 2.30)
1.00
0.16 (0.02, 1.45)
1.00
3.34 (0.27, 40.86)
0.87 (0.08, 8.92)
1.00
0.89 (0.64, 1.24)
0.97 (0.21, 4.45)
1.29 (0.44, 3.73)
1.00
-
0.34 (0.04, 2.78)
1.00
1.63 (0.36, 7.44)
1.00
0.56 (0.21, 1.46)
1.00
0.76 (0.06, 9.23)
2.81 (0.47, 10.08)
1.00
Burn
Laceration
Fracture
Laceration
Burn
For only potentially harmful practices
For only recommended practices
Table 4 Caregiver factors associated with engaging in first aid practices for common injury types: univariate analysis
0.75 (0.56, 1.01)**
0.42 (0.11, 1.65)
0.47 (0.20, 1.13)**
1.00
-
2.74 (0.99, 7.59)
1.00
14.10 (1.82, 108.79)*
1.00
1.57 (0.69, 3.58)
1.00
1.17 (0.26, 5.32)
1.19 (0.41, 3.47)
1.00
Fracture
0.58 (0.35, 0.94)
--
--
1.00
42.81 (3.18, 575.68)*
-
1.00
0.15 (0.01, 1.69)
1.00
1.02 (0.09, 11.47)
1.00
-
0.23 (0.02, 2.60)
1.00
Choking
World J Surg
World J Surg
There was little relationship between caregiver characteristics and the odds of a recommended or potentially harmful practice. Interestingly, education was associated with potentially harmful practices for fractures compared with lack of education. The reason for this unexpected observation was not known, and this paradoxical finding may be spurious, or may reflect the relatively homogenous population in these semi-urban communities. There is a heavy reliance on traditional medicine for health care among Ghanaians [13]. Traditional medical practitioners are culturally accepted and play important psychosocial and perhaps also medical roles in conducting treatments not provided by allopathic medicine, due to the deficits in allopathic practitioners and/or distrust of conventional medicine or other factors [14]. Household child injuries are common in semi-urban Ghana—for instance, lacerations occur in 119 per 1000 children per year, burns 31, falls 316, assault 27, motor vehicle injuries 12 and suffocation 11 [10]. Considerable effort has been dedicated to understand and improve home-based care for common childhood illnesses such as malaria, diarrhea, and respiratory tract infection, with remarkable improvements in LMIC mortality rates from dehydration and infectious disease [15–17]. These public health accomplishments contrast with the relatively limited knowledge of the home-based care practices for child injuries in LMICs. An assessment of the baseline knowledge of first aid for commercial drivers in Ghana, in preparation for development of training programs, revealed that only 13 % had ever had any type of first aid training [8, 18]. Provision of first aid for an injured child in the home is particularly important since one-third of injured people in Kumasi never receive formal care at a clinic or hospital and thus only receive whatever care is provided by relatives or in the community [19]. The percentage of families who do not seek care for an injured child was even higher (49 %) in rural Ghana [20]. Those individuals who did not receive formal health care initially for injuries such as a fractured bone may experience considerable delays and associated morbidity and disability when formal care is eventually sought [19, 20]. Our results underscore the need for community-based education and communication campaigns aimed at enhancing behavior change in health care seeking for household child injury among parents and caregivers. Patronage of traditional bonesetter services is particularly widespread in Ghana, as in other sub-Saharan African countries [21]. These bonesetters may also represent a good target audience for providing first aid training. Our relatively small study has a number of limitations. First, these data were gathered by self-report and we could not independently validate the accuracy of information reported by caregivers. Second, caregivers may have
provided socially desirable responses. Third, study households were relatively similar in terms of socioeconomic levels and education, and the relative lack of variation in these important variables may have limited our ability to examine associations between caregiver factors and first aid practices. Fourth, only 22 of the 200 caregivers were males, which we believe reflects the proportion in the study population. However, this low number does decrease our statistical power to draw conclusions about the role of gender in caregiving practices. However our findings may also reflect the relative scarcity of training and instruction on first aid response. Despite these limitations, the study offers the advantages of being community based, with random selection, using a structured questionnaire with trained researchers and a fairly large sample size. Hence, the data allow us to draw some conclusions regarding the nature of home-based care practices for injured children in the study environment.
Conclusions Apart from when a child is choking, only a minority of caregivers in semi-urban Kumasi would consistently manage an injured child according to recommended practices. Many caregivers engage in first aid injury management practices that are recommended. However, many would also manage the injury in other ways that may be potentially harmful to the child. There are opportunities to provide basic first aid training to interested parents, particularly if these efforts include strategies for community dissemination of best practices. This study provides data useful for efforts to understand, and ultimately strengthen pre-hospital care in LMICs, especially regarding development of programs for first aid training at the household and community levels. Examples of injury prevention and first aid interventions which are effective in the context of low-resource economies are badly needed. Careful epidemiologic surveillance will continue to be important so that the impact of these efforts can be measured and sustained [22, 23]. Better understanding of preventable and treatable child household injury is particularly important in LMICs, so that creative interventions can be developed and evaluated. Acknowledgments We wish to express our sincere thanks to all caregivers who participated in the study. Conflict of interest The authors have no conflicts of interest or financial ties to disclose. Funding This study was funded, in part, by a Grant (D43TW007267) from the Fogarty International Center, US National
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World J Surg Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References 1. Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet 380(9859):2095–2128 2. Peden M, McGee K, Krug E (2002) Injury: a leading cause of the global burden of disease, 2000. World Health Organization, Geneva 3. IHME. Data visualizations. Seattle (2013) http://vizhub.health data.org/gbd-cause-patterns/. Accessed 16 Dec 2014 4. Mock CN, Jurkovich GJ, nii-Amon-Kotei D et al (1998) Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 44(5):804–812 5. Sasser S, Varghese M, Kellermann A et al (2005) Prehospital trauma care systems. World Health Organ, Geneva 6. Husum H, Gilbert M, Wisborg T et al (2003) Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 54(6):1188–1196 7. Jayaraman S, Mabweijano JR, Lipnick MS et al (2009) Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program. World J Surg 33(12):2512–2521. doi:10.1007/s00268-009-0180-6 8. Tiska MA, Adu-Ampofo M, Boakye G et al (2004) A model of prehospital trauma training for lay persons devised in Africa. Emerg Med J 21(2):237–239 9. Johns Hopkins School of Public Health (2013) Family health and wealth study, Insights on wealth measurement and change. http:// www.jhsph.edu/departments/population-family-and-reproductivehealth/_docs/seminar-2013-02-20-fhws-presentation.pdf. Accessed 17 May 2014 10. Gyedu A, Nakua EK, Otupiri E et al (2014) Incidence, characteristics and risk factors for household and neighbourhood injury among young children in semiurban Ghana: a population-based household survey. Inj Prev
123
11. Linnan M, Giersing M, Cox R et al (2007) Child mortality and injury in Asia: an overview. Florence: UNICEF Innocenti Research Centre. Contract No.: 2007-04 12. Wansi E, Mtango D, Maganga E et al (2000) Community IMCI baseline survey in Malawi. UNICEF. http://www.medcol.mw/ commhealth/publications/UNICEF%20Malawi%20HCPS.pdf. Accessed 28 Oct 2014 13. Falkenberg T, Sawyer J, Zhang X et al (2002) WHO traditional medicine strategy 2002–2005. WHO, Geneva 14. O’Brien KS, Soliman AS, Annan K et al (2012) Traditional herbalists and cancer management in Kumasi, Ghana. J Cancer Education 27(3):573–579 15. Ellis AA, Winch P, Daou Z et al (2007) Home management of childhood diarrhoea in southern Mali—implications for the introduction of zinc treatment. Soc Sci Med 64(3):701–712 16. Othero DM, Orago AS, Groenewegen T et al (2008) Home management of diarrhea among underfives in a rural community in Kenya: household perceptions and practices. East Afr J Public Health 5(3):142–146 17. Ukwaja KN, Talabi AA, Aina OB (2012) Pre-hospital care seeking behaviour for childhood acute respiratory infections in south-western Nigeria. Int Health 4(4):289–294 18. Mock CN, Tiska M, Adu-Ampofo M et al (2002) Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma 53(1):90–97 19. Spangenberg K, Mock C (2006) Utilization of health services by the injured residents in Kumasi, Ghana. Int J Inj Contr Saf Promot 13(3):194–196 20. Mock C, Ofosu A, Gish O (2001) Utilization of district health services by injured persons in a rural area of Ghana. Int J Health Plann Manage 16(1):19–32 21. Aries MJH, Joosten H, Wegdam HHJ et al (2007) Fracture treatment by bonesetters in central Ghana: patients explain their choices and experiences. Trop Med Int Health 12(4):564–574 22. Rahman A, Miah AH, Mashreky SR et al (2010) Initial community response to a childhood drowning prevention programme in a rural setting in Bangladesh. Inj Prev 16(1):21–25 23. Rahman F, Bose S, Linnan M et al (2012) Cost-effectiveness of an injury and drowning prevention program in Bangladesh. Pediatrics 130(6):e1621–e1628
