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International Journal of Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nics20
Epidemiology of injuries in metropolitan Tehran, Iran: a household survey a
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Mahdi Zangi , Soheil Saadat , Shizar Nahidi , Leif Svanström & Reza Mohammadi a
Department of Public Health, Karolinska Institutet, Stockholm, Sweden
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Sina Trauma Research Center, Tehran, Islamic Republic of Iran
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Department of Public Health and Community Medicine, University of New South Wales, Sydney, Australia Published online: 22 Apr 2014.
Click for updates To cite this article: Mahdi Zangi, Soheil Saadat, Shizar Nahidi, Leif Svanström & Reza Mohammadi (2014): Epidemiology of injuries in metropolitan Tehran, Iran: a household survey, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.908220 To link to this article: http://dx.doi.org/10.1080/17457300.2014.908220
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International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.908220
Epidemiology of injuries in metropolitan Tehran, Iran: a household survey Mahdi Zangia*, Soheil Saadatb, Shizar Nahidic, Leif Svanstr€oma and Reza Mohammadia a
Department of Public Health, Karolinska Institutet, Stockholm, Sweden; bSina Trauma Research Center, Tehran, Islamic Republic of Iran; cDepartment of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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(Received 2 March 2012; final version received 5 February 2014) A household survey was conducted to determine the epidemiological characteristics of injuries among people living in Tehran, the mega capital of Iran. Using cluster random sampling in April 2007, survey was conducted seeking information about injuries occurred within families in past Persian year. All injury patterns and causes were classified according to ICD-10 and analysed using SPSS version 16. Out of 9173 household participants, 765 ones (8.3%) had injuries during the past Persian year, frequently open wounds and burns with a male to female ratio of 0.54 : 1. They occurred mostly due to ‘exposure to the inanimate mechanical forces’, followed by ‘contact with heat or hot substances’ and ‘falls’. The common locations were home, and then streets. Approximately 15% of injuries required medical attention and the incidence rate was 175.5 per 10,000 person–year with male to female ratio of 2.37 : 1. They were frequently fractures and open wounds and mostly associated with falls and transport accidents that had been transpired on streets or at workplace. This study evidences the high rate of injuries in Tehran city and prevention priorities should be given to traffic and home injuries. Keywords: injury; epidemiology; external causes; severity
Introduction Injury, often addressed to as preventable non-random event, continues to be significant public health problems and is a leading cause of death and disability in many populations regardless of their sex, age, income or geographical region (World Health Organization, 1999). In other words, injury is one of the leading causes of life-years lost (YLL) due to its subsequent premature mortality and/or disability (Disability Adjusted Life Years [DALYs]). Moreover, it also entails many more serious consequences for individuals, families and communities, so does a substantial burden on healthcare systems (Anand & Hanson, 1997; Murray & Lopez, 1997). Globally, more than five million people die every year from different types of injuries, and many more who survive live with an unfortunate lifelong disability. In many parts of the world, unintentional injuries are responsible for more than 10% of DALYs, whereas intentional ones have a broader range from 1.5% to more than 6% of DALYs depending on the geographic region. Nonetheless, there have been insufficient attempts by health managers, policy-makers and other related authorities concerning injury prevention. Specific efforts have yet to meet the demands and the subject has been often a neglected public health issue (Anand & Hanson, 1997; Baker, ONeill, & Karp, 1984; Murray & Lopez, 1996,1997). The major causes of the injury resulting in death or disability in the world are road traffic accidents, burns, *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
falls, drowning, poisonings and deliberate acts of violence against one. When it comes to epidemiology arena, people’s sex, age and income should be taken into account along with geographical region of population to enable estimating and comparing different types and external causes of injuries. According to a WHO report, the leading causes of injury-related death and burden of disease in children were significantly different from those of adults, so were those of female from male (World Health Organization, 1999). Additionally, the main cause of injuryrelated death and disability varies among high-, middleand low-income societies and the elderly, children and males are defined as the most vulnerable groups (Tercero, Anderssonc, Pea, Rochae, & Castroa, 2006; World Health Organization, 1999). The epidemiological pattern of injuries, and particularly road traffic accident, has changed over the past decades. Based on a WHO report from Iran, approximately 15% of all deaths were due to injuries with 27% of YLL. Most fatal injuries were unintentional injuries amongst which traffic injuries were the most common one. The main intentional fatal injuries, especially among youth, were associated with suicide attempts (Akbari, Naghavi, & Soori, 2006; Mehryar & Malekpour, 1994). In recent years, a number of epidemiological studies have been carried out to explore the external causes of injuries such as road traffic injuries and falls, in particular age and sex groups in Tehran (Ghodsi, Roudsari, Abdollahi, &
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Shadman, 2003; Roudsari, Sharzei, & Zargar, 2004; Sanaei-Zadeh, Vahabi, Nazparvar, & Amoei, 2002; Zargar, Modaghegh, & Rezaishiraz, 2001; Zargar, Roudsari, & Shadman, 2003). Unlike the high-income countries, reliable information-system-based data of injuries are not readily available in most of the middle- and low-income countries such as Iran. In that sense, household surveys outstand across different ways of ensuring the representativeness of data, as accurate information can be provided by when no registry system has been established for injuries in a particular society (Centers for Disease Control, 1992; Kroeger, 1983). This study was necessitated by an undeniable demand to describe the pattern and external causes of injury in Tehran city, the capital and the largest city of Iran. It aims to tip off the stakeholders, policy-makers and relevant health authorities about the epidemiology of injuries in Tehran, and to motivate them allocating more resources and efforts in safety promotion and injury prevention.
Material and methods Subjects Using cluster random sampling, a household survey was conducted one month after the commencement of new Persian year in April 2007. Postal address registry of the metropolitan Tehran was considered as sampling data pool from which around 100 residential addresses were randomly selected. Each selected address was considered as the ‘starting point’ of a distinct cluster from where the interviewers practically began their activity and moved counterclockwise to capture 25 residential locations until they attain the desired sample size in each area.
Protocol design Interviewers whom were assigned to facilitate the interviews with family members were young, educated (with proper communication skills in local language), familiar with working in health field, interested in and motivated to work. Two field supervisors were responsible for defining all the 25 households of every segment, control up to five interviewers, ensuring compliance of interviewers’ work with instruction, follow-up and answer to interviewers’ questions by phone, check accuracy and completion of filled questionnaires, repeat 5%–10% of surveys in every segment in the absence of interviewers, dealing with survey obstacles faced by interviewers with getting help from coordinator and giving everyday report of interviewers’ work including the number of segments, households and injuries to coordinator.
Before the start of survey, interviewers and supervisors were invited for a training session to describe importance of work, members of work team, survey programme and coordination of survey. After describing survey process and steps as well as reading map, questionnaire was explained and discussed question by question. Both interviewers and supervisors were trained in interview techniques and also possible limitation/difficulties and the way to deal with were discussed. Following that each interviewers conducted two interviews in a nearby field at the presence of supervisors and coordinator as a pilot study. A random number was drawn to determine which household should be selected in each direction. All eligible respondents (either or both of parents who were at home) in the selected households were interviewed. If an eligible respondent was not at home, neighbours had been asked to confirm the presence of a family there and then interviewer tried to set another appointment later in that day in coordination with the supervisors. When the eligible respondent in a household was interviewed (or appointments made to return later in the day), the interviewer and/or supervisor were selecting the next household by counting three houses to the right. If the streets met before the desired number of interviews, the interviewer was crossing the street and kept on proceeding forwards. But if the crossing was a highway, he was changing the direction to the right and continued. Interviewers interviewed using a closed-ended, precoded questionnaire through which the questions were written in lay locally spoken language (Persian). The questionnaire involved demographic characteristics of family members, type of injuries, severity of injuries, mechanism of injuries, external causes of injuries and settings in which injuries have been occurred from March 2006 to March 2007 (which was compatible to the Persian year 1385). If there was any injury occurred during the last three months among family members, interviewers had preferred asking in depth questions relating to injuries directly from the injured person provided that the person was an adult and eligible to answer. Each day interviewers reported the number of interviewed segment, household and injuries to their supervisors via SMS. Then, two supervisors entered the gathered brief data in prepared chart and sent it to coordinator via email. All the respondents were provided with detailed information regarding the aims and nature of the study beforehand their written consent was sought. This study was ethically approved by the review board of ‘Sina Trauma and Surgery Research Center’ affiliated to Tehran University of Medical Sciences. Instruments All the patterns and external causes of injury were classified according to International Classification of Diseases
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Table 1. Incidence of all injuries in age–sex groups of study population. Gender Male Study population
Injuries
Incidence rate (%)
Study population
Injuries
Incidence rate (%)
Weighted overall incidence rate (%)
0–5 6–10 11–20 21–30 31–40 41–50 51–60 61þ
187 292 862 1137 571 647 526 474
10 26 57 73 47 29 15 20
5.35 8.90 6.61 6.42 8.23 4.48 2.85 4.22
188 256 845 954 691 769 450 324
10 25 32 128 124 99 50 20
5.32 9.77 3.79 13.42 17.95 12.87 11.11 6.17
5.33 9.31 5.21 9.61 13.55 9.04 6.66 5.01
Total
4696
277
5.90
4477
488
10.90
8.34
Age (years)
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Female
and Related Health Problems, 10th revision (ICD-10). Injuries that required medical intervention were classified as moderate to severe, and so mild injuries were defined as the injuries that did not require medical care. The incidence rates of injuries in age–sex categories were determined. In the present study, the following external causes are considered as ‘burn injuries’; contact with heat and hot substances and exposure to smoke, fire and flames. Likewise, ‘transport accidents’ encompass pedestrian(s), motorcycle rider(s) or car occupant(s) injured in transport accident.
Data analysis The collected data were coded, and then entered into a password-protected computer using database or survey software. Data were analysed using SPSS 16 while the clustered structure of sampling was taken into account. After a descriptive analysis, the data was assessed and compared with regard to severity of injury (mild and moderate to severe) and different causes of injuries. Chisquare test was used frequently to compare injuries in terms of age, sex, severity of injuries, causes of injuries, anatomical location and places of occurrence. P-value of less than 0.05 was considered as the level of statistical significance.
Results The parents of a total of 2475 families with 9173 family members (4696 male and 4477 female) were interviewed during April 2007. Interviewees reported a total of 765 injuries (8.3%) within their families during the past Persian year. Injuries were more prevalent among middleaged people and females. Virtually, women experienced injuries twice than men (Table 1).
The most common types of injuries were open wounds (43.3%), burns (22.5%), superficial injuries (16.6%) and fractures (12.2%). Anatomically, more than 40% of the injuries occurred in wrist and hand area, then in external body surface (19.2%) and knee and lower leg (10.2%). More than 60% of the settings in which the injury had occurred was home, followed by streets, highways and other public roads (13.6%).
Comparing ‘mild injuries’ with ‘moderate to severe injuries’ Out of the 765 injured persons, 604 (84.8%) experienced mild injuries, whereas 116 (15.2%) subjects reported moderate to severe injuries. About 73% of the mild injuries happened among women, while 71.4% of moderately to severely injured subjects were men (P-value < 0.001). Though both classes of injuries mostly involved middleaged people, the percentage of moderate to severe injuries was obviously higher (P-value < 0.001). The two common types of mild injuries were open wounds (51.3%) and burns (27.5%). Correspondingly, two common types of moderate to severe injuries were fractures (57.1%) and open wounds (13%) (P-value < 0.001). The most common anatomical locations for mild injuries were wrist and hand (48.7%), and external body surfaces (23.5%), whereas those of moderate to severe injuries were knee and lower limb (23%), and then head (18%) (P-value < 0.001). While the most common place of mild injuries was home (77%), moderate to severe injuries most often occurred on streets, highways and other public roads (36.6%) (P-value < 0.001). Table 2 shows causes of two classes of injuries. The most frequent causes of mild injuries were orderly, exposure to inanimate mechanical forces (52.2%) and falls (14.2%). Roughly similarly, those of moderate to severe injuries were falls (38.5%), traffic accidents (36%) and
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Table 2. External causes of mild and moderate to severe injuries of study population. Injury severity Mild External cause
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Pedestrian injured in transport accident Motorcycle rider injured in transport accident Car occupant injured in transport accident Falls Exposure to inanimate mechanical forces Exposure to animate mechanical forces Exposure to electric current, radiation and extreme ambient air temperature and pressure Other accidental threats to breathing Exposure to smoke, fire and flames Contact with heat and hot substances Total
Moderate to severe
Frequency
Per cent
Frequency
Per cent
Overall per cent
12 18 6 86 395 1 0
2 13.4 8.7 30 65.4 .2 0
10 23 25 62 30 3 1
6.2 14.3 15.5 38.5 18.6 1.9 .6
2.9 5.4 4.1 19.4 45.1 .5 .1
0 7 79 604
0 1.2 13.1 100
1 3 3 116
.6 1.9 1.9 100
.1 1.3 21.2 100
exposure to inanimate mechanical forces (18.6%) (Pvalue < 0.001).
the most common type of injuries were open wound (87%) and superficial injuries (8.4%), which were mostly associated with wrist and hand injuries (85.8%). These injuries nearly always took place at home (84.9%) or workplaces (10.4%).
External causes of injuries Table 3 presents the classified characteristics of external causes of injuries. Literally, about half the total external causes of injuries were exposure to inanimate mechanical forces, followed by contact with heat and hot substances (21.2%), falls (19.4%) and transport accidents (12.3%).
Falls Approximately 56% of these injuries occurred in men. 67.6% of injured people were between 6 and 40 years of age. Superficial injuries (46.6%), fractures (28.4%) and open wound (12.2%) were the most common types. Anatomical locations where these injuries often involved were knee and lower leg regions (30.4%), then ankle and foot (19.6%). These injuries usually happened at home (25%) and sports area (23%).
Exposure to inanimate mechanical forces Male to female ratio was 0.32 : 1 and most of the injured people (84.6%) aged between 20 and 60. In this category,
Table 3. External causes of injuries in sex groups of study population. Gender Male External cause Pedestrian injured in transport accident Motorcycle rider injured in transport accident Car occupant injured in transport accident Falls Exposure to inanimate mechanical forces Exposure to animate mechanical forces Exposure to electric current, radiation and extreme ambient air temperature and pressure Other accidental threats to breathing Exposure to smoke, fire and flames Contact with heat and hot substances Total
Female
Frequency
Per cent
Frequency
Per cent
Overall per cent
16 37 24 83 83 4 0
5.8 13.4 8.7 30 30 1.4 0
6 4 7 65 262 0 1
1.2 .8 1.4 13.3 53.7 0 .2
2.9 5.4 4.1 19.4 45.1 .5 .1
0 8 22 277
0 2.9 7.9 100
1 2 140 488
.2 .4 28.7 100
.1 1.3 21.2 100
International Journal of Injury Control and Safety Promotion Transport accident Nearly 82% of traumatised subjects were male and a majority of them (63.8%) were between 20 and 40 years old, with fractures (44.7%), superficial injuries (30.9%) and open wound (12.8%) as the most frequent types of injuries. Empirically, accidents resulted in injuries of knee and lower leg (26.6%), and then head (25.5%).
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Burns Male to female ratio was 0.21 : 1 and virtually 80.8% of burns came about between the ages of 20 and 60. Anatomically, external body surface burns (85.5%), and multiple and/or unspecified body regions burns (14.5%) were the most remarkable locations. A noticeable portion of these injuries came off at respondents’ home (89.5%).
Home injuries Of the total of the 765 injury cases, 486 (63.5%) cases occurred at home. Middle-aged people (mostly between 21 and 60) were more inflicted and male to female ratio was 0.15 : 1. The most notable types of home injuries were open wounds (57.6%), burns (31.7%), superficial injuries (7%) and fractures (2.1%). Two anatomic regions were predominantly involved in home injuries: wrist and hand (56%), and external body surfaces (27%). Around 60% of all the external causes of home injuries were exposure to inanimate mechanical forces. Contact with heat and hot substances (31.3%) and falls (7.6%) stood as the second and the third causes. A more precise pattern came out when the severity of injury was also taken into account. Given the mild home injuries, exposure to inanimate mechanical forces (61.7%) and contact with heat and hot substances (32.7%) were more prominent. However, in moderate to severe home injuries, falls (57.1%) and exposure to inanimate mechanical forces (28.6%) were common (P-value < 0.001).
Discussion Our study of 9173 participants revealed that there were 765 cases (8.3%) of injury per annum, of whom 15.2% required medical attention. Male to female ratio was 0.54 : 1. The two most frequently reported injuries were open wounds and burns. ‘Wrist and hands’ was the most commonly affected anatomical region. A majority of injuries were transpired at homes, then on streets and on highways. The incidence rates of all types of injuries (regardless of whether or not they required medical attention) are roughly similar when the results are compared across different studies in the same geographical region (Fatmi
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et al., 2007; Ma, Guo, Xu, Zhang, & Jia, 2008; Meldon, Reilly, Drew, Mancuso, & Fallon, 2002; Rizvi, Luby, Azam, & Rabbani, 2006). However, the results are varying when the attention-required injuries are on the focus. This variation has primarily been related to certain contextual attributes (e.g. geographic region and level of urbanisation) or methodological components (e.g. sampling methods of household surveys versus hospital-based ones) (Maziak, Ward, & Rastam, 2006; Rizvi et al., 2006; Tercero et al., 2006). Though there has been globally a male domination in either classes of injuries (Bangdiwala et al., 1990; Fatmi et al., 2007; Ma et al., 2008; Meldon et al., 2002), both females and males of our study presented a high incidence rate of ‘mild’ and ‘moderate to severe injuries’, respectively. We postulated that the gender composition of our respondents might have justified the reported high incidence rate of injuries among women. Given that the majority of our respondents were mothers, it is no longer startling that they remembered and reported their own history of injuries more than those of other family members (Recall bias). In addition, it can be claimed that females culturally stay at home more than men, hence are further exposed to inanimate mechanical forces. However, this contrasts the ongoing cultural shift which is yielding quite a few women staying nowadays at home to do the household chores such as tailoring, cleaning and cooking. Researchers have reported different causes for various domains of injuries. However, when the general causes are discussed, most of the studies converge when they consistently quote falls (Bangdiwala et al., 1990; Coggan, Hooper, & Adams, 2002; Fatmi et al., 2007; Kobusingye, Guwatudde, & Lett, 2001; Meldon et al., 2002; Mock, Abantanga, Cummings, & Koepsell, 1999), road traffic accidents (http:www.globalhealth.harvard.edu) and exposure to inanimate mechanical forces (Rizvi et al., 2006) as the most common mechanisms of injuries. Virtually compatible to other international studies, exposure to inanimate mechanical forces, falls, road traffic accidents and contact with heat and hot substances turned out to be the most common causes of injuries in the present study (Adam et al., 2008; Bangdiwala et al., 1990; Coggan et al., 2002; Fatmi et al., 2007; Kobusingye et al., 2001; Ma et al., 2008; Maziak et al., 2006; Meldon et al., 2002; Mock et al., 1999; Rizvi et al., 2006; Tercero et al., 2006). Exposure to inanimate mechanical forces was the leading cause of injuries especially the mild ones in the present study. It commonly occurred due to struck by thrown or falling object, caught between objects, and contact with sharp glass, knife and other hand tools. Based on Coggan’s study (Coggan et al., 2002), these kinds of injuries mostly occurred in middle-aged people, similar to our findings and among males, different from our study in which females were more endangered. These injuries mostly took place at workplace and then home, while they
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mostly occurred at home and then workplace in Tehran. Due to the fact that in our study these injuries (especially mild ones) mostly occurred among housekeeper women, it is not unjustifiable that home was the frequent location of occurrence. Promotion of home interior design in terms of safety and usage of safely designed products with appropriate guideline are required to reduce the number of home injuries owing to inanimate mechanical forces. Once the severity of injuries was taken into account, falls and road traffic accidents were found to be the two most frequent causes for the treatment-required injuries in our study. They are also noted in the reports of national registry systems and several household- or hospital-based surveys (Adam et al., 2008; Bangdiwala et al., 1990; Kobusingye et al., 2001; Maziak et al., 2006; Mock et al., 1999). Falls, a neglected and surprisingly the most common cause of severe injuries in Tehran, can individually result in fractures, dislocation and strain among the youth of both genders. Environmental hazards such as uneven surfaces, unsafe ladders and stairs, and risky indoor playgrounds and sport fields seem to underpin the persistence of the risk of falling down. We found road traffic accidents the second leading cause of severe injuries in Tehran. A preceding WHO report in 2002 declared that traffic accident injuries were the third leading cause of death in Iran. A later study revealed that 44 per 100,000 people died in Iran in 2005 because of traffic accidents (http:www.globalhealth.harvard.edu). This was the highest rate achieved so far in the world. Risk factors and root causes of road traffic accidents in Tehran include road users attitude and behaviour; insufficient driver training; inadequate enforcement of traffic regulations; inadequate vehicle compatibility and occupant protection; underdevelopment of public transportation system and shortcoming in safety of road network. Despite the fact that numerous measures have been taken to tackle road traffic accident (RTA) in Tehran, the city seems to suffer from being deficient in designing and formulating a comprehensive policy work regarding RTA yet. There are heaps of studies (Adam et al., 2008; Bangdiwala et al., 1990; Coggan et al., 2002; Fatmi et al., 2007; Kobusingye et al., 2001; Maziak et al., 2006; Meldon et al., 2002) attesting that injuries traditionally tend to occur at home. However, in terms of ‘attention-required injuries’, our findings led away from those of other studies. For instance, despite Coggan and her colleagues (Coggan et al., 2002) who claimed that around 40% of all the falling injuries came about at home, we could pertain a significant number of fall injuries to sport fields and playgrounds. Putting forward the current findings and levelling it with those of domestic studies (http://en.wikipedia.org/wiki/Tehran; Moshiro, Heuch, Astrøm, Setel, & Kvale, 2005), we could eventually postulate that public roads and workplaces in Iran are the two most unsafe places wherein ‘moderate to severe injuries’ are likely to happen.
Similar to another accidental burn survey in Iran (Sadeghi-Bazargani, Arshi, Mohammadi, & Ekman, 2006), almost all burns occurred among middle-aged females at respondents’ home and fortunately mostly did not require inpatient treatment. There were quite a few people admitted at hospital due to burns with the same trend as other studies in terms of demographic characteristics (Estahbanati & Bouduhi, 2002; Groohi, Alaghehbandan, & Lari, 2002; Saadat, 2005). Gas stove, oven, valors and samovar should be taken into consideration as common appliances leading to females’ domestic burn. In other words, prevention programmes are supposed to focus on home environments and scalding burns rather than outside burns due to flames. According to Mohammadi, Ekman, Svanstrom, and Gooya (2005), who explored home injuries in Iran, the two most prevalent types of injuries that required medical treatment were burns and lacerations/cuts caused by contact with sharp instruments. In our study, falls and exposure to inanimate mechanical forces represent the most common causes of ‘moderate to severe home injuries’. These findings are compatible to those of Alptekin, Uskun, Kisioglu, and Ozturk (2008), who conducted a quasi-similar household-based survey in a selected city in central Turkey. The controversy of the findings seems to have laid in the contextual and demographic differences between studies. For instance, Mohammadi et al. (2005) recruited people residing in both rural and urban areas. Unlike a recent report regarding drowning in two provinces in the north (Anand & Hanson, 1997.Centers for Disease Control, 1992 per 100,000 population–year) and south (Alptekin et al., 2008; Kiakalayeh, Mohammadi, Ekman, Yousefzade Chabok, & Janson, 2008 per 100 000 population-year) of Iran, which are near Caspian Sea and Persian Gulf (Kiakalayeh et al., 2008; Sheykhazadi, & Dibaei, 2010), two main seas around the country, not any case of drowning was estimated in the present survey in Tehran as an urban area. Due to the presence of only a few numbers of rivers, canals, lakes and ponds, we expected less than the north or south of the country, while probably it had been underestimated (with no drowning) in our study as result of limitations in household surveys (Sethi et al., 2004). Strength and limitations Despite the high-income countries, most of the low- and middle-income countries (LMC), such as Iran, suffer from lack of available reliable information-based data. Among different approaches of collecting representative data in the context where no injury registry system is established, household surveys are shown that can collect accurate data from the community (Sethi et al., 2004). Moreover, community-based injury surveys have one overriding benefit over the hospital-based ones in that they can obtain
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data that do not literally reach the hospitals (e.g. injuries treated outside hospitals or those require no treatment) (Sethi et al., 2004). Researchers have made their best effort to ensure the accuracy of data and to minimise the shortcomings of this study including sample selection issues, small sample size, measurement errors, misclassification of cases and mistakes in data analysis. However, there are still some limitations attached to the current framework: (1) Self-reporting: As expected, respondents’ reluctance to disclose such information face-to-face undermined our estimation of intentional injuries (e.g. sexual harassment or domestic violence) (Karbakhsh, Zargar, Zarei, & Khaji, 2008). Besides the nature of the community-based study, cultural barriers in Iran seem to have further attenuated the estimation of intentional injuries in other domestic studies (Zargar et al., 2003). (2) Recall period: Despite the sufficiency of one-year period in recalling the ‘moderate to severe injuries’, mild injuries often tend to be dismissed within this period. Hence, shorter recall period could have enhanced the accuracy of our estimation of ‘mild injuries’ (Moshiro et al., 2005; Sethi et al., 2004). (3) Proxy respondent: As discussed earlier, relying on parents as proxy respondents could have potentially resulted in underestimation of injuries, especially the intentional injuries. In addition, memory decay to recall mild injuries of other members could have made this problem more overwhelming (Sethi et al., 2004). (4) Generalizability: Tehran is a city with a variety of the physical, environmental and sociocultural attributes that noticeably vary across its different districts. Although we tried to select a representative study population by adopting the most proper sampling method, needless to acknowledge that the results cannot be extended to rural areas (Sethi et al., 2004). Conclusions and future directions Our study demonstrates that injury is still a public health problem in the Tehran capital of Iran (83 persons per 1000 per year). Furthermore, the incidence of treatmentrequired injuries was 175.5 persons per 10,000 per year, most of which resulted from falling and transport accidents. Household surveys are the stepstone in injury prevention in LMC. Having that said, qualitative focus group discussions are recommended to explore specific injury prevention experiences of residents, and hence, to obtain in-depth information about injury patterns and causes.
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Subsequent interventional studies will then be required to evaluate whether certain educational/environmental injury prevention programmes would yield any improvement in the incidence and the severity of injuries. On the basis of our findings, prevention priorities should be given to traffic and home injuries in the urban areas. Comprehensive educational programmes along with sustainable environmental interventions, with a specific focus on home injuries, are demanded to deal with the two most common causes of injuries: cuts/bruises and burns. To prevent home and playgrounds falls, environmental changes would be effective. To promote an efficient road traffic accident prevention programme, collaborations between police, municipality and health departments are required.
References Adam, S.H., Eid, H.O., Barss, P., Lunsjo, K., Grivna, M., Torab, F.C., & Abu-Zidan, F.M. (2008). Epidemiology of geriatric trauma in United Arab Emirates. Archives Gerontology and Geriatrics, 47(3), 377–382. Akbari, M.E., Naghavi, M., & Soori, H. (2006). Epidemiology of deaths from injuries in the Islamic Republic of Iran. Eastern Mediterranean Health Journal, 12(3/4), 382–390. Alptekin, F., Uskun, E., Kisioglu, A.N., & Ozturk, M. (2008). Unintentional non-fatal home-related injuries in Central Anatolia, Turkey: Frequencies, characteristics, and outcomes. Injury, International Journal of the Care of the Injured, 39, 535–546. Anand, S., & Hanson, K. (1997). Disability-adjusted life years: A critical review. Journal of Health Economics, 16(6), 685–702. Baker, S.P., O’Neill, R., & Karp, R.S. (1984). The injury fact book. Lexington, MA: Lexington Books. Bangdiwala, S.I., Anzola-Perez, E., Romer, C.C., Schmidt, B., Valdez-Lazo, F., Toro, J., & D’Suze, C. (1990). The incidence of injuries in young people: I. Methodology and results of a collaborative study in Brazil, Chile, Cuba and Venezuela. International Journal of Epidemiology, 19, 115–124. Centers for Disease Control. (1992). Injury surveillance in developing countries. MMWR CDC Surveillance Summaries, 41, 15–20. Coggan, C., Hooper, R., & Adams, B. (2002). Self-reported injury rates in New Zealand. The New Zealand Medical Journal, 115(1161), U167. Estahbanati, H.K., & Bouduhi, N. (2002). Role of artificial neural networks in prediction of survival of burn patients – a new approach. Burns, 28(6), 579–586. Fatmi, Z., Kasi, A., Hadden, W.C., Razzak, J.A., Qureshi, H.I., Hyder, A.A., & Pappas, G. (2007). Incidence, patterns and severity of reported unintentional injuries in Pakistan among children under five years: Results of the National Health Survey of Pakistan 1990–94. Paediatric and Perinatal Epidemiology, 23, 229–238. Ghodsi, S.M., Roudsari, B.S., Abdollahi, M., & Shadman, M. (2003). Fall related injuries in the elderly in Tehran. Injury, 34(11), 809–814. Groohi, B., Alaghehbandan, R., & Lari, A.R. (2002). Analysis of 1089 burn patients in province of Kurdistan, Iran. Burns, 28 (6), 569–574. http://www.who.int/classifications/icd/adaptations/iceci/en/ index.html
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Karbakhsh, M., Zargar, M., Zarei, M.R., & Khaji, A. (2008). Childhood injuries in Tehran: A review of 1281 cases. Turkish Journal of Pediatrics, 50(4), 317–325. Kiakalayeh, A.D., Mohammadi, R., Ekman, D.S., Chabok, S.Y., & Janson, B. (2008). Unintentional drowning in northern Iran: A population-based study. Accident Analysis & Prevention, 40(6), 1977–1981. Kobusingye, O., Guwatudde, D., & Lett, R. (2001). Injury patterns in rural and urban Uganda. Injury Prevention, 7, 46–50. Kroeger, A. (1983). Health interview surveys in developing countries: A review of the methods and results. International Journal of Epidemiology, 12, 465–481. Ma, J., Guo, X., Xu, A., Zhang, J., & Jia, C. (2008). Epidemiological analysis of injury in Shandong Province, China. BMC Public Health, 8, 122–128. Maziak, W., Ward, K.D., & Rastam, S. (2006). Injuries in Aleppo, Syria; first population-based estimates and characterization of predominant types. BMC Public Health, 6, 63–70. Mehryar, H., & Malekpour, M. (1994). Changing pattern of mortality in Iran: A review of available evidence. Tehran: Institute for Research in Planning and Development. Meldon, S.W., Reilly, M., Drew, B.L., Mancuso, C., & Fallon, W. Jr. (2002). Trauma in the very elderly: A communitybased study of outcomes at trauma and nontrauma centers. Journal of Trauma, 52(1), 79–84. Mock, C.N., Abantanga, F., Cummings, P., & Koepsell, T.D. (1999). Incidence and outcome of injury in Ghana. Bulletin of the World Health Organization, 77(12), 955–964. Mohammadi, R., Ekman, R., Svanstrom, L., & Gooya, M.M. (2005). Unintentional home-related injuries in the Islamic Republic of Iran: Findings from the first year of a national programme. Public Health, 119, 919–924. Moshiro, C., Heuch, I., Astrøm, A.N., Setel, P., & Kvale, G. (2005). Effect of recall on estimation of non-fatal injury rates: A community based study in Tanzania. Injury Prevention, 11, 48–52. Murray, C., & Lopez, A.D. (1996). The global burden of disease (Vol. 1). Cambridge, MA: Harvard University Press. Murray, C.J.L., & Lopez, A.D. (1997). Global mortality, disability and the contribution of risk factors: Global burden of disease study. The Lancet, 349, 1436–1442.
Rizvi, N., Luby, S., Azam, S.I., & Rabbani, F. (2006). Distribution and circumstances of injuries in squatter settlements of Karachi, Pakistan. Accident Analysis and Prevention, 38, 526–531. Roudsari, B.S., Sharzei, K., & Zargar, M. (2004). Sex and age distribution in transport-related injuries in Tehran. Accident Analysis and Prevention, 36(3), 391–398. Saadat, M. (2005). Epidemiology and mortality of hospitalized burn patients in Kohkiluye va Boyerahmad province (Iran): 2002–2004. Burns, 31(3), 306–309. Sadeghi-Bazargani, H., Arshi, S., Mohammadi, R., & Ekman, R. (2006). Prevention oriented epidemiologic study of accidental burns in rural areas of Ardabil, Iran. Burns, 32(3), 366– 371. Sanaei-Zadeh, H., Vahabi, R., Nazparvar, B., & Amoei, M. (2002). An epidemiological study and determination of causes of traffic accident-related deaths in Tehran, Iran (during 2000–2001). Journal of Clinical Forensic Medicine, 9 (2), 74–77. Sethi, D., Habibula, S., McGee, K., Peden, M., Bennett, S., Hyder, A.A., & Klevens, J. (2004). Guidelines for conducting community surveys on injuries and violence. Geneva: World Health Organization. Sheykhazadi, A., & Dibaei, A. (2010). Characteristics of the drowned in Khuzestan, south west of Iran. Jundishapur Scientific Medical Journal, 9(1), 63–74. Tercero, F., Andersson, R., Pe~ na, R., Rocha, J., & Castro, N. (2006). The epidemiology of moderate and severe injuries in a Nicaraguan community: A household-based survey. Public Health, 120(2), 106–114. World Health Organization. (1999). Injury: A leading cause of the global burden of disease. Geneva: World Health Organization. Zargar, M., Modaghegh, M.H., & Rezaishiraz, H. (2001). Urban injuries in Tehran: Demography of trauma patients and evaluation of trauma care. Injury, 32(8), 613–617. Zargar, M., Roudsari, B.S., & Shadman, M. (2003). Pediatric transport-related injuries in Iran: The necessity of implementation of injury prevention protocols. Injury, 34(11), 820– 824.
International Journal of Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nics20
Epidemiology of injuries in metropolitan Tehran, Iran: a household survey a
b
c
a
Mahdi Zangi , Soheil Saadat , Shizar Nahidi , Leif Svanström & Reza Mohammadi a
Department of Public Health, Karolinska Institutet, Stockholm, Sweden
b
Sina Trauma Research Center, Tehran, Islamic Republic of Iran
a
c
Department of Public Health and Community Medicine, University of New South Wales, Sydney, Australia Published online: 22 Apr 2014.
Click for updates To cite this article: Mahdi Zangi, Soheil Saadat, Shizar Nahidi, Leif Svanström & Reza Mohammadi (2014): Epidemiology of injuries in metropolitan Tehran, Iran: a household survey, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.908220 To link to this article: http://dx.doi.org/10.1080/17457300.2014.908220
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International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.908220
Epidemiology of injuries in metropolitan Tehran, Iran: a household survey Mahdi Zangia*, Soheil Saadatb, Shizar Nahidic, Leif Svanstr€oma and Reza Mohammadia a
Department of Public Health, Karolinska Institutet, Stockholm, Sweden; bSina Trauma Research Center, Tehran, Islamic Republic of Iran; cDepartment of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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(Received 2 March 2012; final version received 5 February 2014) A household survey was conducted to determine the epidemiological characteristics of injuries among people living in Tehran, the mega capital of Iran. Using cluster random sampling in April 2007, survey was conducted seeking information about injuries occurred within families in past Persian year. All injury patterns and causes were classified according to ICD-10 and analysed using SPSS version 16. Out of 9173 household participants, 765 ones (8.3%) had injuries during the past Persian year, frequently open wounds and burns with a male to female ratio of 0.54 : 1. They occurred mostly due to ‘exposure to the inanimate mechanical forces’, followed by ‘contact with heat or hot substances’ and ‘falls’. The common locations were home, and then streets. Approximately 15% of injuries required medical attention and the incidence rate was 175.5 per 10,000 person–year with male to female ratio of 2.37 : 1. They were frequently fractures and open wounds and mostly associated with falls and transport accidents that had been transpired on streets or at workplace. This study evidences the high rate of injuries in Tehran city and prevention priorities should be given to traffic and home injuries. Keywords: injury; epidemiology; external causes; severity
Introduction Injury, often addressed to as preventable non-random event, continues to be significant public health problems and is a leading cause of death and disability in many populations regardless of their sex, age, income or geographical region (World Health Organization, 1999). In other words, injury is one of the leading causes of life-years lost (YLL) due to its subsequent premature mortality and/or disability (Disability Adjusted Life Years [DALYs]). Moreover, it also entails many more serious consequences for individuals, families and communities, so does a substantial burden on healthcare systems (Anand & Hanson, 1997; Murray & Lopez, 1997). Globally, more than five million people die every year from different types of injuries, and many more who survive live with an unfortunate lifelong disability. In many parts of the world, unintentional injuries are responsible for more than 10% of DALYs, whereas intentional ones have a broader range from 1.5% to more than 6% of DALYs depending on the geographic region. Nonetheless, there have been insufficient attempts by health managers, policy-makers and other related authorities concerning injury prevention. Specific efforts have yet to meet the demands and the subject has been often a neglected public health issue (Anand & Hanson, 1997; Baker, ONeill, & Karp, 1984; Murray & Lopez, 1996,1997). The major causes of the injury resulting in death or disability in the world are road traffic accidents, burns, *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
falls, drowning, poisonings and deliberate acts of violence against one. When it comes to epidemiology arena, people’s sex, age and income should be taken into account along with geographical region of population to enable estimating and comparing different types and external causes of injuries. According to a WHO report, the leading causes of injury-related death and burden of disease in children were significantly different from those of adults, so were those of female from male (World Health Organization, 1999). Additionally, the main cause of injuryrelated death and disability varies among high-, middleand low-income societies and the elderly, children and males are defined as the most vulnerable groups (Tercero, Anderssonc, Pea, Rochae, & Castroa, 2006; World Health Organization, 1999). The epidemiological pattern of injuries, and particularly road traffic accident, has changed over the past decades. Based on a WHO report from Iran, approximately 15% of all deaths were due to injuries with 27% of YLL. Most fatal injuries were unintentional injuries amongst which traffic injuries were the most common one. The main intentional fatal injuries, especially among youth, were associated with suicide attempts (Akbari, Naghavi, & Soori, 2006; Mehryar & Malekpour, 1994). In recent years, a number of epidemiological studies have been carried out to explore the external causes of injuries such as road traffic injuries and falls, in particular age and sex groups in Tehran (Ghodsi, Roudsari, Abdollahi, &
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Shadman, 2003; Roudsari, Sharzei, & Zargar, 2004; Sanaei-Zadeh, Vahabi, Nazparvar, & Amoei, 2002; Zargar, Modaghegh, & Rezaishiraz, 2001; Zargar, Roudsari, & Shadman, 2003). Unlike the high-income countries, reliable information-system-based data of injuries are not readily available in most of the middle- and low-income countries such as Iran. In that sense, household surveys outstand across different ways of ensuring the representativeness of data, as accurate information can be provided by when no registry system has been established for injuries in a particular society (Centers for Disease Control, 1992; Kroeger, 1983). This study was necessitated by an undeniable demand to describe the pattern and external causes of injury in Tehran city, the capital and the largest city of Iran. It aims to tip off the stakeholders, policy-makers and relevant health authorities about the epidemiology of injuries in Tehran, and to motivate them allocating more resources and efforts in safety promotion and injury prevention.
Material and methods Subjects Using cluster random sampling, a household survey was conducted one month after the commencement of new Persian year in April 2007. Postal address registry of the metropolitan Tehran was considered as sampling data pool from which around 100 residential addresses were randomly selected. Each selected address was considered as the ‘starting point’ of a distinct cluster from where the interviewers practically began their activity and moved counterclockwise to capture 25 residential locations until they attain the desired sample size in each area.
Protocol design Interviewers whom were assigned to facilitate the interviews with family members were young, educated (with proper communication skills in local language), familiar with working in health field, interested in and motivated to work. Two field supervisors were responsible for defining all the 25 households of every segment, control up to five interviewers, ensuring compliance of interviewers’ work with instruction, follow-up and answer to interviewers’ questions by phone, check accuracy and completion of filled questionnaires, repeat 5%–10% of surveys in every segment in the absence of interviewers, dealing with survey obstacles faced by interviewers with getting help from coordinator and giving everyday report of interviewers’ work including the number of segments, households and injuries to coordinator.
Before the start of survey, interviewers and supervisors were invited for a training session to describe importance of work, members of work team, survey programme and coordination of survey. After describing survey process and steps as well as reading map, questionnaire was explained and discussed question by question. Both interviewers and supervisors were trained in interview techniques and also possible limitation/difficulties and the way to deal with were discussed. Following that each interviewers conducted two interviews in a nearby field at the presence of supervisors and coordinator as a pilot study. A random number was drawn to determine which household should be selected in each direction. All eligible respondents (either or both of parents who were at home) in the selected households were interviewed. If an eligible respondent was not at home, neighbours had been asked to confirm the presence of a family there and then interviewer tried to set another appointment later in that day in coordination with the supervisors. When the eligible respondent in a household was interviewed (or appointments made to return later in the day), the interviewer and/or supervisor were selecting the next household by counting three houses to the right. If the streets met before the desired number of interviews, the interviewer was crossing the street and kept on proceeding forwards. But if the crossing was a highway, he was changing the direction to the right and continued. Interviewers interviewed using a closed-ended, precoded questionnaire through which the questions were written in lay locally spoken language (Persian). The questionnaire involved demographic characteristics of family members, type of injuries, severity of injuries, mechanism of injuries, external causes of injuries and settings in which injuries have been occurred from March 2006 to March 2007 (which was compatible to the Persian year 1385). If there was any injury occurred during the last three months among family members, interviewers had preferred asking in depth questions relating to injuries directly from the injured person provided that the person was an adult and eligible to answer. Each day interviewers reported the number of interviewed segment, household and injuries to their supervisors via SMS. Then, two supervisors entered the gathered brief data in prepared chart and sent it to coordinator via email. All the respondents were provided with detailed information regarding the aims and nature of the study beforehand their written consent was sought. This study was ethically approved by the review board of ‘Sina Trauma and Surgery Research Center’ affiliated to Tehran University of Medical Sciences. Instruments All the patterns and external causes of injury were classified according to International Classification of Diseases
International Journal of Injury Control and Safety Promotion
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Table 1. Incidence of all injuries in age–sex groups of study population. Gender Male Study population
Injuries
Incidence rate (%)
Study population
Injuries
Incidence rate (%)
Weighted overall incidence rate (%)
0–5 6–10 11–20 21–30 31–40 41–50 51–60 61þ
187 292 862 1137 571 647 526 474
10 26 57 73 47 29 15 20
5.35 8.90 6.61 6.42 8.23 4.48 2.85 4.22
188 256 845 954 691 769 450 324
10 25 32 128 124 99 50 20
5.32 9.77 3.79 13.42 17.95 12.87 11.11 6.17
5.33 9.31 5.21 9.61 13.55 9.04 6.66 5.01
Total
4696
277
5.90
4477
488
10.90
8.34
Age (years)
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Female
and Related Health Problems, 10th revision (ICD-10). Injuries that required medical intervention were classified as moderate to severe, and so mild injuries were defined as the injuries that did not require medical care. The incidence rates of injuries in age–sex categories were determined. In the present study, the following external causes are considered as ‘burn injuries’; contact with heat and hot substances and exposure to smoke, fire and flames. Likewise, ‘transport accidents’ encompass pedestrian(s), motorcycle rider(s) or car occupant(s) injured in transport accident.
Data analysis The collected data were coded, and then entered into a password-protected computer using database or survey software. Data were analysed using SPSS 16 while the clustered structure of sampling was taken into account. After a descriptive analysis, the data was assessed and compared with regard to severity of injury (mild and moderate to severe) and different causes of injuries. Chisquare test was used frequently to compare injuries in terms of age, sex, severity of injuries, causes of injuries, anatomical location and places of occurrence. P-value of less than 0.05 was considered as the level of statistical significance.
Results The parents of a total of 2475 families with 9173 family members (4696 male and 4477 female) were interviewed during April 2007. Interviewees reported a total of 765 injuries (8.3%) within their families during the past Persian year. Injuries were more prevalent among middleaged people and females. Virtually, women experienced injuries twice than men (Table 1).
The most common types of injuries were open wounds (43.3%), burns (22.5%), superficial injuries (16.6%) and fractures (12.2%). Anatomically, more than 40% of the injuries occurred in wrist and hand area, then in external body surface (19.2%) and knee and lower leg (10.2%). More than 60% of the settings in which the injury had occurred was home, followed by streets, highways and other public roads (13.6%).
Comparing ‘mild injuries’ with ‘moderate to severe injuries’ Out of the 765 injured persons, 604 (84.8%) experienced mild injuries, whereas 116 (15.2%) subjects reported moderate to severe injuries. About 73% of the mild injuries happened among women, while 71.4% of moderately to severely injured subjects were men (P-value < 0.001). Though both classes of injuries mostly involved middleaged people, the percentage of moderate to severe injuries was obviously higher (P-value < 0.001). The two common types of mild injuries were open wounds (51.3%) and burns (27.5%). Correspondingly, two common types of moderate to severe injuries were fractures (57.1%) and open wounds (13%) (P-value < 0.001). The most common anatomical locations for mild injuries were wrist and hand (48.7%), and external body surfaces (23.5%), whereas those of moderate to severe injuries were knee and lower limb (23%), and then head (18%) (P-value < 0.001). While the most common place of mild injuries was home (77%), moderate to severe injuries most often occurred on streets, highways and other public roads (36.6%) (P-value < 0.001). Table 2 shows causes of two classes of injuries. The most frequent causes of mild injuries were orderly, exposure to inanimate mechanical forces (52.2%) and falls (14.2%). Roughly similarly, those of moderate to severe injuries were falls (38.5%), traffic accidents (36%) and
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Table 2. External causes of mild and moderate to severe injuries of study population. Injury severity Mild External cause
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Pedestrian injured in transport accident Motorcycle rider injured in transport accident Car occupant injured in transport accident Falls Exposure to inanimate mechanical forces Exposure to animate mechanical forces Exposure to electric current, radiation and extreme ambient air temperature and pressure Other accidental threats to breathing Exposure to smoke, fire and flames Contact with heat and hot substances Total
Moderate to severe
Frequency
Per cent
Frequency
Per cent
Overall per cent
12 18 6 86 395 1 0
2 13.4 8.7 30 65.4 .2 0
10 23 25 62 30 3 1
6.2 14.3 15.5 38.5 18.6 1.9 .6
2.9 5.4 4.1 19.4 45.1 .5 .1
0 7 79 604
0 1.2 13.1 100
1 3 3 116
.6 1.9 1.9 100
.1 1.3 21.2 100
exposure to inanimate mechanical forces (18.6%) (Pvalue < 0.001).
the most common type of injuries were open wound (87%) and superficial injuries (8.4%), which were mostly associated with wrist and hand injuries (85.8%). These injuries nearly always took place at home (84.9%) or workplaces (10.4%).
External causes of injuries Table 3 presents the classified characteristics of external causes of injuries. Literally, about half the total external causes of injuries were exposure to inanimate mechanical forces, followed by contact with heat and hot substances (21.2%), falls (19.4%) and transport accidents (12.3%).
Falls Approximately 56% of these injuries occurred in men. 67.6% of injured people were between 6 and 40 years of age. Superficial injuries (46.6%), fractures (28.4%) and open wound (12.2%) were the most common types. Anatomical locations where these injuries often involved were knee and lower leg regions (30.4%), then ankle and foot (19.6%). These injuries usually happened at home (25%) and sports area (23%).
Exposure to inanimate mechanical forces Male to female ratio was 0.32 : 1 and most of the injured people (84.6%) aged between 20 and 60. In this category,
Table 3. External causes of injuries in sex groups of study population. Gender Male External cause Pedestrian injured in transport accident Motorcycle rider injured in transport accident Car occupant injured in transport accident Falls Exposure to inanimate mechanical forces Exposure to animate mechanical forces Exposure to electric current, radiation and extreme ambient air temperature and pressure Other accidental threats to breathing Exposure to smoke, fire and flames Contact with heat and hot substances Total
Female
Frequency
Per cent
Frequency
Per cent
Overall per cent
16 37 24 83 83 4 0
5.8 13.4 8.7 30 30 1.4 0
6 4 7 65 262 0 1
1.2 .8 1.4 13.3 53.7 0 .2
2.9 5.4 4.1 19.4 45.1 .5 .1
0 8 22 277
0 2.9 7.9 100
1 2 140 488
.2 .4 28.7 100
.1 1.3 21.2 100
International Journal of Injury Control and Safety Promotion Transport accident Nearly 82% of traumatised subjects were male and a majority of them (63.8%) were between 20 and 40 years old, with fractures (44.7%), superficial injuries (30.9%) and open wound (12.8%) as the most frequent types of injuries. Empirically, accidents resulted in injuries of knee and lower leg (26.6%), and then head (25.5%).
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Burns Male to female ratio was 0.21 : 1 and virtually 80.8% of burns came about between the ages of 20 and 60. Anatomically, external body surface burns (85.5%), and multiple and/or unspecified body regions burns (14.5%) were the most remarkable locations. A noticeable portion of these injuries came off at respondents’ home (89.5%).
Home injuries Of the total of the 765 injury cases, 486 (63.5%) cases occurred at home. Middle-aged people (mostly between 21 and 60) were more inflicted and male to female ratio was 0.15 : 1. The most notable types of home injuries were open wounds (57.6%), burns (31.7%), superficial injuries (7%) and fractures (2.1%). Two anatomic regions were predominantly involved in home injuries: wrist and hand (56%), and external body surfaces (27%). Around 60% of all the external causes of home injuries were exposure to inanimate mechanical forces. Contact with heat and hot substances (31.3%) and falls (7.6%) stood as the second and the third causes. A more precise pattern came out when the severity of injury was also taken into account. Given the mild home injuries, exposure to inanimate mechanical forces (61.7%) and contact with heat and hot substances (32.7%) were more prominent. However, in moderate to severe home injuries, falls (57.1%) and exposure to inanimate mechanical forces (28.6%) were common (P-value < 0.001).
Discussion Our study of 9173 participants revealed that there were 765 cases (8.3%) of injury per annum, of whom 15.2% required medical attention. Male to female ratio was 0.54 : 1. The two most frequently reported injuries were open wounds and burns. ‘Wrist and hands’ was the most commonly affected anatomical region. A majority of injuries were transpired at homes, then on streets and on highways. The incidence rates of all types of injuries (regardless of whether or not they required medical attention) are roughly similar when the results are compared across different studies in the same geographical region (Fatmi
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et al., 2007; Ma, Guo, Xu, Zhang, & Jia, 2008; Meldon, Reilly, Drew, Mancuso, & Fallon, 2002; Rizvi, Luby, Azam, & Rabbani, 2006). However, the results are varying when the attention-required injuries are on the focus. This variation has primarily been related to certain contextual attributes (e.g. geographic region and level of urbanisation) or methodological components (e.g. sampling methods of household surveys versus hospital-based ones) (Maziak, Ward, & Rastam, 2006; Rizvi et al., 2006; Tercero et al., 2006). Though there has been globally a male domination in either classes of injuries (Bangdiwala et al., 1990; Fatmi et al., 2007; Ma et al., 2008; Meldon et al., 2002), both females and males of our study presented a high incidence rate of ‘mild’ and ‘moderate to severe injuries’, respectively. We postulated that the gender composition of our respondents might have justified the reported high incidence rate of injuries among women. Given that the majority of our respondents were mothers, it is no longer startling that they remembered and reported their own history of injuries more than those of other family members (Recall bias). In addition, it can be claimed that females culturally stay at home more than men, hence are further exposed to inanimate mechanical forces. However, this contrasts the ongoing cultural shift which is yielding quite a few women staying nowadays at home to do the household chores such as tailoring, cleaning and cooking. Researchers have reported different causes for various domains of injuries. However, when the general causes are discussed, most of the studies converge when they consistently quote falls (Bangdiwala et al., 1990; Coggan, Hooper, & Adams, 2002; Fatmi et al., 2007; Kobusingye, Guwatudde, & Lett, 2001; Meldon et al., 2002; Mock, Abantanga, Cummings, & Koepsell, 1999), road traffic accidents (http:www.globalhealth.harvard.edu) and exposure to inanimate mechanical forces (Rizvi et al., 2006) as the most common mechanisms of injuries. Virtually compatible to other international studies, exposure to inanimate mechanical forces, falls, road traffic accidents and contact with heat and hot substances turned out to be the most common causes of injuries in the present study (Adam et al., 2008; Bangdiwala et al., 1990; Coggan et al., 2002; Fatmi et al., 2007; Kobusingye et al., 2001; Ma et al., 2008; Maziak et al., 2006; Meldon et al., 2002; Mock et al., 1999; Rizvi et al., 2006; Tercero et al., 2006). Exposure to inanimate mechanical forces was the leading cause of injuries especially the mild ones in the present study. It commonly occurred due to struck by thrown or falling object, caught between objects, and contact with sharp glass, knife and other hand tools. Based on Coggan’s study (Coggan et al., 2002), these kinds of injuries mostly occurred in middle-aged people, similar to our findings and among males, different from our study in which females were more endangered. These injuries mostly took place at workplace and then home, while they
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mostly occurred at home and then workplace in Tehran. Due to the fact that in our study these injuries (especially mild ones) mostly occurred among housekeeper women, it is not unjustifiable that home was the frequent location of occurrence. Promotion of home interior design in terms of safety and usage of safely designed products with appropriate guideline are required to reduce the number of home injuries owing to inanimate mechanical forces. Once the severity of injuries was taken into account, falls and road traffic accidents were found to be the two most frequent causes for the treatment-required injuries in our study. They are also noted in the reports of national registry systems and several household- or hospital-based surveys (Adam et al., 2008; Bangdiwala et al., 1990; Kobusingye et al., 2001; Maziak et al., 2006; Mock et al., 1999). Falls, a neglected and surprisingly the most common cause of severe injuries in Tehran, can individually result in fractures, dislocation and strain among the youth of both genders. Environmental hazards such as uneven surfaces, unsafe ladders and stairs, and risky indoor playgrounds and sport fields seem to underpin the persistence of the risk of falling down. We found road traffic accidents the second leading cause of severe injuries in Tehran. A preceding WHO report in 2002 declared that traffic accident injuries were the third leading cause of death in Iran. A later study revealed that 44 per 100,000 people died in Iran in 2005 because of traffic accidents (http:www.globalhealth.harvard.edu). This was the highest rate achieved so far in the world. Risk factors and root causes of road traffic accidents in Tehran include road users attitude and behaviour; insufficient driver training; inadequate enforcement of traffic regulations; inadequate vehicle compatibility and occupant protection; underdevelopment of public transportation system and shortcoming in safety of road network. Despite the fact that numerous measures have been taken to tackle road traffic accident (RTA) in Tehran, the city seems to suffer from being deficient in designing and formulating a comprehensive policy work regarding RTA yet. There are heaps of studies (Adam et al., 2008; Bangdiwala et al., 1990; Coggan et al., 2002; Fatmi et al., 2007; Kobusingye et al., 2001; Maziak et al., 2006; Meldon et al., 2002) attesting that injuries traditionally tend to occur at home. However, in terms of ‘attention-required injuries’, our findings led away from those of other studies. For instance, despite Coggan and her colleagues (Coggan et al., 2002) who claimed that around 40% of all the falling injuries came about at home, we could pertain a significant number of fall injuries to sport fields and playgrounds. Putting forward the current findings and levelling it with those of domestic studies (http://en.wikipedia.org/wiki/Tehran; Moshiro, Heuch, Astrøm, Setel, & Kvale, 2005), we could eventually postulate that public roads and workplaces in Iran are the two most unsafe places wherein ‘moderate to severe injuries’ are likely to happen.
Similar to another accidental burn survey in Iran (Sadeghi-Bazargani, Arshi, Mohammadi, & Ekman, 2006), almost all burns occurred among middle-aged females at respondents’ home and fortunately mostly did not require inpatient treatment. There were quite a few people admitted at hospital due to burns with the same trend as other studies in terms of demographic characteristics (Estahbanati & Bouduhi, 2002; Groohi, Alaghehbandan, & Lari, 2002; Saadat, 2005). Gas stove, oven, valors and samovar should be taken into consideration as common appliances leading to females’ domestic burn. In other words, prevention programmes are supposed to focus on home environments and scalding burns rather than outside burns due to flames. According to Mohammadi, Ekman, Svanstrom, and Gooya (2005), who explored home injuries in Iran, the two most prevalent types of injuries that required medical treatment were burns and lacerations/cuts caused by contact with sharp instruments. In our study, falls and exposure to inanimate mechanical forces represent the most common causes of ‘moderate to severe home injuries’. These findings are compatible to those of Alptekin, Uskun, Kisioglu, and Ozturk (2008), who conducted a quasi-similar household-based survey in a selected city in central Turkey. The controversy of the findings seems to have laid in the contextual and demographic differences between studies. For instance, Mohammadi et al. (2005) recruited people residing in both rural and urban areas. Unlike a recent report regarding drowning in two provinces in the north (Anand & Hanson, 1997.Centers for Disease Control, 1992 per 100,000 population–year) and south (Alptekin et al., 2008; Kiakalayeh, Mohammadi, Ekman, Yousefzade Chabok, & Janson, 2008 per 100 000 population-year) of Iran, which are near Caspian Sea and Persian Gulf (Kiakalayeh et al., 2008; Sheykhazadi, & Dibaei, 2010), two main seas around the country, not any case of drowning was estimated in the present survey in Tehran as an urban area. Due to the presence of only a few numbers of rivers, canals, lakes and ponds, we expected less than the north or south of the country, while probably it had been underestimated (with no drowning) in our study as result of limitations in household surveys (Sethi et al., 2004). Strength and limitations Despite the high-income countries, most of the low- and middle-income countries (LMC), such as Iran, suffer from lack of available reliable information-based data. Among different approaches of collecting representative data in the context where no injury registry system is established, household surveys are shown that can collect accurate data from the community (Sethi et al., 2004). Moreover, community-based injury surveys have one overriding benefit over the hospital-based ones in that they can obtain
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data that do not literally reach the hospitals (e.g. injuries treated outside hospitals or those require no treatment) (Sethi et al., 2004). Researchers have made their best effort to ensure the accuracy of data and to minimise the shortcomings of this study including sample selection issues, small sample size, measurement errors, misclassification of cases and mistakes in data analysis. However, there are still some limitations attached to the current framework: (1) Self-reporting: As expected, respondents’ reluctance to disclose such information face-to-face undermined our estimation of intentional injuries (e.g. sexual harassment or domestic violence) (Karbakhsh, Zargar, Zarei, & Khaji, 2008). Besides the nature of the community-based study, cultural barriers in Iran seem to have further attenuated the estimation of intentional injuries in other domestic studies (Zargar et al., 2003). (2) Recall period: Despite the sufficiency of one-year period in recalling the ‘moderate to severe injuries’, mild injuries often tend to be dismissed within this period. Hence, shorter recall period could have enhanced the accuracy of our estimation of ‘mild injuries’ (Moshiro et al., 2005; Sethi et al., 2004). (3) Proxy respondent: As discussed earlier, relying on parents as proxy respondents could have potentially resulted in underestimation of injuries, especially the intentional injuries. In addition, memory decay to recall mild injuries of other members could have made this problem more overwhelming (Sethi et al., 2004). (4) Generalizability: Tehran is a city with a variety of the physical, environmental and sociocultural attributes that noticeably vary across its different districts. Although we tried to select a representative study population by adopting the most proper sampling method, needless to acknowledge that the results cannot be extended to rural areas (Sethi et al., 2004). Conclusions and future directions Our study demonstrates that injury is still a public health problem in the Tehran capital of Iran (83 persons per 1000 per year). Furthermore, the incidence of treatmentrequired injuries was 175.5 persons per 10,000 per year, most of which resulted from falling and transport accidents. Household surveys are the stepstone in injury prevention in LMC. Having that said, qualitative focus group discussions are recommended to explore specific injury prevention experiences of residents, and hence, to obtain in-depth information about injury patterns and causes.
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Subsequent interventional studies will then be required to evaluate whether certain educational/environmental injury prevention programmes would yield any improvement in the incidence and the severity of injuries. On the basis of our findings, prevention priorities should be given to traffic and home injuries in the urban areas. Comprehensive educational programmes along with sustainable environmental interventions, with a specific focus on home injuries, are demanded to deal with the two most common causes of injuries: cuts/bruises and burns. To prevent home and playgrounds falls, environmental changes would be effective. To promote an efficient road traffic accident prevention programme, collaborations between police, municipality and health departments are required.
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