Injuries in Khartoum State, Sudan. Magnitude, consequences and healthcare utilization: a community-based survey

Background: Injuries contribute significantly to the global burden of disease accounting for 5.1 million deaths annually. Fatal injuries are the tip of the iceberg and many more who survive an injury suffer the consequences with varying durations of disability. Fatal and non-fatal injuries are of increasing public health concern globally, particularly in low and middle income countries where they contribute to 90% of the global burden of injuries. Injuries mostly affect the productive age group, which results in huge socioeconomic impacts for poor populations which are caught in a poverty trap. As for Sudan the present data sources are Sudan Household Health Survey Round 2, hospital-based data, mortuary data, and police data. The scope of these data sources on injuries is limited; a household survey is needed to address the gaps. This thesis draws information from a household survey on the magnitude of injuries, consequences and healthcare use. Methods: The studies presented in this thesis are from a retrospective community-based survey which was conducted in 50 clusters in Khartoum State during October and November 2010. The community-based survey was conducted using a household sample size of 1000. A two stage cluster design with probability of inclusion proportional to size was used to select clusters. The latest sampling frame from CBS considered the state to be 80% urban and 20% rural. In the first stage of sampling, the state was stratified according to urban and rural strata. In the second stage a probability proportionate to size method was applied. Households were selected in each cluster using systematic random sampling. Trained data collectors collected data using structured questionnaires for face to face interviews. Details about non-fatal injuries which occurred 12 months preceding the interview were recorded. Information on fatal injuries which occurred 5 years preceding the interview was taken. Data was cleaned and analysed using SPSS 18 and STATA 13. The incidence per 1000 person years at risk was calculated for non-fatal injuries. Poisson regression analysis was used to model injury determinants in urban and rural areas separately. Multivariate negative binomial regression using generalized linear model was applied for hospitalization and disability days. Logistic regression analysis was performed with the dependent variable being use of formal healthcare among injured individuals and with potential confounding variables included in the model. Results: The total number of individuals included in the analysis was 5,661 residing in 973 households. The household response rate in both the urban and rural clusters was 97%. The overall injury incidence rate was 82.0/1000 person-years-at-risk (95% CI: 74.5, 90.0). Stratifying the incidence by sex showed a significant difference between males and females. The total incidence for males was 110.6/1000 person years at risk (95% CI: 98.4, 124.0), while the total incidence for females was 69.2/1000 person years at risk (95% CI: 59.6, 79.9). The leading causes of non-fatal injuries were falls followed by mechanical forces (such as cuts, stabs, struck by object, etc.) and road traffic crashes. Low socioeconomic status was a risk factor for injuries in urban areas. Males had a significantly higher risk of being injured in both urban and rural areas. There were 28 deaths due to injuries out of a total of 129 reported deaths over 5 years. The number of disability days differed significantly between mechanisms of injury. Road traffic crashes and falls caused the longest duration of disability. Males had a higher probability than females of losing a job due to an injury. A total of 26 individuals' accessed formal healthcare and about a quarter of the injured persons were admitted to hospital. Injured persons from road traffic crashes and males were most likely to utilize formal health services. The lowest socioeconomic strata were less likely to utilize formal healthcare. Conclusion: The studies from this thesis give ample evidence on injury specific events, the consequences for individuals and families, and on patterns of health care use in Khartoum State. They have explored who is at risk of an injury, and which population groups and causes of injury are more likely to be associated with a longer duration of hospitalization or disability. This study has investigated injured persons' use of formal healthcare. Injuries occurred mainly in the home and street environments. Most injured people reported being injured during work activity. The most vulnerable population groups for injuries were found to be low socioeconomic categories and males, bearing the largest burden and most serious consequences. There is an urgent need to consider injuries in Khartoum as a public health concern, with special emphasis put on primary, secondary and tertiary prevention