Author: AKM Fazlur Rahman; Aminur Rahman; Saidur Rahman Mashreky; Michael Linnan
Bangladesh Health and Injury Survey (BHIS), 2005 documented that injury is a major child health problem in Bangladesh. Due to lack of relevant information this particular child health issue was not a priority issue. In the developed world there is abundant evidence that injuries are preventable. However, there was no evidence that the prevention measures of the developed could be effective in low income countries including Bangladesh. As there are marked socio-cultural, economic and environmental differences it is obvious that the interventions of the developed world may not be effective in a low income country setting. Therefore, with the demonstration of injury as a leading killer of children in Bangladesh, there was a need to develop and test child injury interventions that were appropriate for the socio-cultural and economic environment of Bangladesh. CIPRB and its partners – UNICEF-Bangladesh and TASC designed, implemented and evaluated a community based comprehensive child injury prevention model ―Prevention of Child Injuries through Social-intervention and Education (PRECISE)‖ to learn how this can be achieved.
The main objective of the PRECISE was to identify the effective interventions which can be replicated and scaled up to the rest of the country. The experience from this project can benefit other countries with similar levels of development and similar burdens of child injury.
The PRECISE was a quasi-experimental community trial to evaluate the effectiveness of intervention modalities and approaches for various packages. Both quantitative and qualitative methods were utilized in the study.
Study settings and population
The study was implemented in two different settings, rural and urban. For rural areas four upazilas, namely Raiganj, Sherpur, Manohardi and Raipura, were identified which are representative of rural Bangladesh, and almost all types of child injury mortality and morbidity were prevalent in those areas. The first three upazilas were chosen as intervention areas and the rest served as a control. In each upazila approximately 40,000 households comprising of about 200,000 population was covered. In urban setting Mirpur (DCC zone 8, Ward 2 & 5) was considered as intervention area and for control area Mohammadpur (DCC zone 6, Ward 46,47 & a part of 48) was selected. Similar to each rural area, in each urban area the same sample size was taken.
Duration of the study
The study was conducted between September 2005 and December 2008.
Intervention package development
The intervention measures were designed considering the causes or risk factors and location of various injuries. The guiding principles in designing the intervention were low cost, utilizing available resources and involving community from design stage to final implementation. The main components of the intervention package were home safety, school safety and community safety programs. These components were developed through series of workshops and consultation with the relevant stakeholders. The home safety program was designed to create safe homes through changing the hazard environment in and around the home and the risk behaviours of the household members by a trained person. To heighten knowledge and awareness of students and teachers on injury prevention and to reduce risk of injuries at school environment, school safety program was designed. Grade specific injury text books were developed and distributed to the children for teaching-learning sessions of the selected schools. The major programs of the community safety component include Anchal (community crèche), water safety program, behaviour change communication, emergency injury care and prevention of injuries during disaster.
Project implementation strategy
In the rural settings the home safety program was implemented in three different ways. In Raiganj (high intensity area) community injury prevention promoters (CIPPs), paid volunteers, implemented the program. In Sherpur (medium intensity area) and Manohardi (low intensity area) the program was implemented by the government community health workers. The only difference is that the community health workers of Sherpur received some additional financial support, which the workers of Manohardi did not get. All other programs and activities were implemented in the same way in all the intervention areas.
Evaluation of the project
To evaluate the efficacy and effectiveness of the intervention the following measures were taken:
1. Base line survey on injury mortality, morbidity and KAP of mothers/caretakers in all intervention and control areas
2. An inbuilt Injury Surveillance System (ISS) was also developed in the intervention areas
3. End line survey on injury mortality, morbidity and KAP of mothers and caretakers in the control area
4. Baseline and end line assessment of the knowledge of school children.
Base line, ISS and end line survey data were collected by trained data collectors using structured checklists by face to face interview with the adult household occupants. To gather qualitative data trained qualitative interviewers were deployed. For analysing quantitative data a software was developed and the trained data enterers entered the data. For injury mortality and hospitalizations rates were calculated per 100,000 children. Qualitative data were analysed manually.
1. Knowledge and practice of injury prevention increased among the mothers of children
2. There was 28.0 percent reduction of injury deaths in children 0-17 years in the intervention areas.
3. Drowning the single largest killer of children 1-4 years declined about 44.0 percent.
4. The injury hospitalization rate reduced about 29.0 percent in 0-17 years old children.
5. A significant proportion of students‘ knowledge on injury prevention was increased through school safety program.
6. Anchal (community crèche) was found effective in preventing injury mortality and morbidity among young children.
7. SwimSafe program appeared effective in prevention of drowning in children four and over.
The overarching conclusion is that child injury prevention works in rural Bangladesh. For the first time, there is evidence that injury, a leading cause of child death and serious morbidity in an LMIC such as Bangladesh can be prevented with the same reductions seen in the classical child survival interventions such as immunizations, breast feeding and micro-nutrient supplementation. The reductions are largest in the home environment or in adjunct environments such as a crèche. These environments are directly under the control of parents or their adjuncts and because of this, are most easily changed. These are where children with the highest injury rates, the under-fives, spend the largest amount of their time.
Once children are old enough to spend time outside the household environment, injury prevention is more difficult to achieve. This is due to the lack of control over the risk environment where the children spend much of their time outside the home. Drowning is an exception to this as the intervention of survival swimming is not aimed at changing the risk environment, but providing skills to the child that prevents them from drowning when they are exposed to water hazards without supervision. Given the cost-benefit advantage for protection of children in the home and ancillary environments as seen in PRECISE as well as the protection observed from survival swimming it is apparent that the interventions that targeted these need to be further explored. It is likely that further refinements would pay dividends in learning how to scale these.
Continue the activities in the PRECISE project to allow examination of the effects over a longer time period. This provides the opportunity to gain necessary knowledge required to scale up the effective interventions as the basis of a national child injury reduction program. The continuation of the Safe Home program should be done through formal combination with the Anchal program where the Anchal mother is the core implementer. This leads to the need to scale up Anchals to cover much larger proportions of the community in order to provide the benefits to all at-risk children. The ongoing research examining the contributions of the social autopsy, BCC, IPT and other interventions should guide the inclusion of these efforts in future activities. The SwimSafe program should be expanded as rapidly as possible. This will require an exploration of ways to increase throughput. It will also address ways to increase the scope of the intervention through the addition of resuscitation as a skill taught as early as children are shown to be able to perform it.
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