Epidemiological Profile of Unintentional Childhood Injuries in Urban Area of Mangaluru Taluk, Dakshina Kannada District, Karnataka State, India

used to collect the data. Results: Period prevalence of unintentional childhood injury was 18.6%. Fall was reported as most common cause of injury among children. Fall, sharp injuries, burn was associated with certain environmental risk factors. Children were at risk of road traffic injuries, burns, sharp injuries, and fall. Protective factors against injury were children belonging to lower and middle socio-economic status, child with 1 sibling. Conclusions: Period prevalence of unintentional childhood injury was 18.6%. Majority of them had fall as a cause of injury, with the risk factors for fall in the child’s environment.


INTRODUCTION
Worldwide injury & violence is the most important cause of death in children.Every year it causes death in approximately 950000 children and youngsters who are under the age group of 18, ninety percent of it is caused by unintentional injuries. 1It is estimated that 55% of global injury mortality burden, is seen in South East Asia and Western Pacific regions of World health organization(under the age group of 20). 2 World report on childhood injury prevention 2008 by WHO/UNICEF, Profile of child injuries in selected member states in the Asia-Pacific region 2010 by WHO addresses and summaries the childhood injury and prevention. 1,24][5][6] For each area of childhood injury there are proven ways to reduce both the likelihood and severity. 1,5For effective intervention and prevention there is a need to assess the burden, causes and consequences of unintentional injuries. 6,7This study was conducted to determine the magnitude and associated epidemiological factors of unintentional childhood injuries, which will help in developing preventive measures.

METHODOLOGY
The Medical school where the study was conducted provides preventive, promotive, curative and referral services to defined urban and rural areas within 30 km radius of the Institute as a part of the governing council regulations.Of the total 3 urban areas (Bunder, Kudroli and Bengre with the total population of 27,104), one urban area was selected by lottery method (Kudroli).Selected urban area had a total population of 6250 with 1148 households; population under 18 years was 2437.
Community based cross sectional study was conducted during October 2018 to September 2020.Study population being children aged 0-18 years residing in the study area.Source of data was Mother/Father.Inclusion criteria were children aged 0-18 years, whose mother/father consent for study.Exclusion criteria were Intentional injuries, Injuries due to violence, children with epilepsy, fatal injuries.
Based on pilot study with 25 children it was found that prevalence of unintentional injuries was 25%.With the non-response rate of 10%, 5% absolute precision and 95% confidence, design effect of 1.5; sample size was calculated to be 476(rounded to 500).Sample size was calculated using Open Epi. 8 Unintentional injury was defined as Injury among children (0-18 years) in the past one year, which resulted in seeking of medical care or absence of school or inability to do normal physical activity for a duration of minimum of one day. 9,10mpling method: Multistage simple random sampling method was used.Of the total 3 urban areas (total population of 27,104), one urban area was selected by lottery method (Stage 1).In order to collect data from 500 children a total of 250 households were selected by simple random sampling method (Stage 2). 11udy tool: Internal reliability of the questionnaire was checked.The reliability was found to be good with Cronbach's alpha score of >0.7.The questionnaire was given to 5 subject expert for content and consensual validity.The agreement was more than 95 %.Predesigned pretested validated structured questionnaire was developed on the basis of similar studies, 9,10,12 World injury report 2008, 1 Haddon matrix, 13 pilot study and based on local cultural & social practice.Study questionnaire consisted of three parts: that is Socio-demographic profile, Injury profile, Epidemiological factors.
Institutional ethical committee approval was obtained (IRB number -YUEC/2016/216).Written informed consent was obtained from respondents after explaining the purpose and the nature of the study.Assent was obtained from children under the age group of 7-18years Method of data collection: Information was collected by one-to-one interview method from mother, if mother was not available father was the next respondent, if both were not available second visit was done.If on second visit, parents were not available then that child was not included in the study.
This study included injuries caused by sharp objects, falls, poisoning, road traffic injuries, burns/fire, injuries caused by animals, drowning, electric shocks, suffocation. 1 Statistical analysis: Data was analyzed using IBM SPSS Statistics for Windows, Version 23.0.Armonk, NY: IBM Corp. Descriptive statistic was reported as median and inter-quartile range for continuous variables; frequency and proportion for categorical variable.Multivariable logistic regression was performed to predict the unintentional childhood injuries based on the socio-demographic independent variables namely age, gender, type of family, occupation of parents and socio-economic status (Table 3).Bivariate logistic regression has been used to study the effect of defined environmental factors with respective type of unintentional childhood injury.(Table 4)

RESULTS
Socio-demographic profile: Median age of study participant was 9 (12-5) years, with 37% of them in the age group of 11-15 years.More than half of study participants were male (54.6%).Socio-economic status of study participant was middle (45.6%) and lower middle class (36%) (Table 1).
Majority of children (83.9%) with childhood injuries had parental/caregiver's supervision at home.While half of the children (52.7%) had parental/ caregiver's supervision at playground.Among the activity at the time of injury, Sports activity was present in almost half of the participants [43(46.15%)]and was majorly present in males [29(31.1%))]than females [14 (15.05%)].
Epidemiological factors: Association between Socio-demographic profile and unintentional injury is presented in Table 3. Middle class [Adjusted odds ratio: 0.29 (0.10-0.89) (p 0.03)] and lower class [Adjusted odds ratio: 0.32 (0.10-0.98) (p 0.04)] of socioeconomic status were found to be protective factors against unintentional childhood injuries.Children with 1 sibling [Adjusted odds ratio: 0.53 (0.31-0.89) (p 0.01) was also found to be protective factors against unintentional childhood injuries.
On assessing Environmental factors for unintentional injuries such as Road traffic injuries, Fall, Burn, Sharp injury; it was found that significant number of children were having these risk factors (Table 4).Animal injuries was found only in 2 children and other type of injury such as drowning, suffocation and electric shock was not reported hence it was not analyzed further.
Environmental factors namely storage of flammable substance at home, no separation of cooking area from living area, stove within reach of child were found to be associated with Burns.Environmental factors such as unprotected roof/balcony/staircase, unsafe equipment/ deep ditches in playground were found to be associated with Fall.Sharp objects within child's reach were found to be associated with Sharp injury.All the above association was statistically significant.Factors such as Protective gears by parents/driver/children was found to be protective factors and Child unattended while walking on road was found to be a risk factor for fall, but the association was not statistically significant (Table 4).

DISCUSSION
Brief description on injury profile: The period prevalence of injury in the present study was 18.6%.5][16] Fall was most common cause of injury re-ported in the present study.6][17] Children engage themselves in sports, outdoor and indoor activities, most of their free time, which sometimes lead onto fall injury.Sports was the most common activity noted during injury among males than females, similar findings were also seen in a study conducted in China. 18 Majority of children (83.9%) with childhood injuries had parental/caregiver's supervision at home.Similar finding was reported in studies conducted in Manipal and Darjeeling. 5,6Though parents/caregivers' supervision is present for majority of injured children, it could be possible that parents are not aware of potential injuries and its prevention methods.

Epidemiological factors associated with injuries:
Children belonging to middle and low class of economic status and those children with one sibling had lesser possibility of getting injured.0][21] While another study found to have no association . 22Socio-economic status might influence the occurrence of injury, but it might also depend on how hazardous is child's immediate environment, whether there is adequate supervision by parents/caregiver, how risky is the child's behavior.
With regard to presence of one sibling, a study reported that injury was less common with children with one sibling. 6This was contrast to a study conducted in Manipal, where injury was more common among children with one sibling. 5And few other studies reported as the presence of more than 3 siblings were found to have more injuries. 20,21Presence of sibling might have outcome on both the sides that is occurrence of injury or not.But it can be influenced by the factors such as how the elder sibling, or in that case how children are being taught on hazards of injuries, its prevention etc. Additionally small family size with better attention by parents could be protective factors.
It was found that majority of children/parents/ driver, followed usage of protective gears while driving.Studies has shown that usage of protective gears have reduced the occurrence of road traffic injuries. 23,24most one third of the children had risk factors for burn such as storage of flammable substance at home, No separation of cooking area from living area, Stove within the reach of child at their immediate environment.These Environmental risk factors were found to be associated with Burns.A study reported that risk factors for burns were, access to active fire (19.3%), access to fuel containers (16.25%) unsafe system for warming water (86%). 17Burns/scalds was associated with unsafe kitchen and access to fuel. 17Risk factors for sharp injury were present in 15.7% of the participants.Sharp objects within child's reach were found to be associated with Sharp injury A study reported that access to Sharps was reported in 29.3% of study participants and was associated with Sharps injuries. 17 the present study risk factors for fall at home, such as unsafe balcony/ staircase/ roof and risk factors for fall at play ground such as unsafe equipment, deep ditches at playground were present, in a range of 14.6-22% of the participants.A study reported the risk factors for fall at home which were seen in majority of participants were unsafe staircase, unsafe balcony. 17Environmental risk factors such as flooring, roofing, safety environment, etc. determines occurrence of fall. 25The above said environmental risk factors were significantly associated with fall.However, a study reported that there was no significant association between unprotected stair cases with fall. 17Risk factors present in the environment of the child both at home and outside have its effect on occurrence of injury.Fall is an important and most common form of unintentional injury during childhood.

STRENGTHS AND LIMITATIONS
Strengths: Questionnaire used was recommended by World health organization, which was later modified based on local needs.Limitation: This was a cross sectional study design, thus association observed may not infer causality.This study includes the selfreporting design, which may lead to recall bias.

CONCLUSION
The period prevalence of unintentional injury in the present study was 18.6%.Fall was a most common cause of injury.Children were found to be at risk of road traffic injuries, burns, sharp injuries.Epidemiological factors included the environmental risk factors (for fall, sharp injuries and burns), Socioeconomic status and small family size norms.Injury prevention, risk reduction should be part of school curriculum and school health programme.Parents should be sensitized about the common type of injury, risk factors and its prevention.

Table 2 :
Profile of unintentional injury based on cause of injury among study participants

Table 3 :
Association between Socio-demographic factors and unintentional childhood injuries * Non-Nuclear family includes Joint family and Three generation family

Table 4 :
Environmental factors and their association with type of unintentional injuries among study participants