https://orcid.org/0000-0002-4630-6799
Figures
Abstract
Background
Home injuries are an important cause of morbidity and mortality in high-income countries. In Sub-Saharan Africa, including Cameroon, many people live in unplanned settlements with poorly constructed houses, predisposing them to home injuries. However, little is known about the epidemiology and care-seeking behaviors of the domestically injured. In this study, our objective was to determine the epidemiology and care-seeking behaviors of home injuries in the Southwest Region of Cameroon.
Methods
A sub-analyses of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months was conducted. Sampling was done using three-stage cluster sampling technique. Differences between groups were evaluated using Chi-squared and Adjusted Wald tests.
Results
Of 8065 participants, 157 suffered home injuries giving an incidence of 19.6 (16.8–23.0 95% CI) cases per 1000-person years. Home injuries comprised 31.2% of all 503 injuries and affected more females (60.8%) and younger individuals (mean age (SE) 25.1 years (2.0)) than non-home injuries. The most common activity and mechanism of home injury was leisure/play (51%) and falls (37.9%) respectively. Amongst those with home injuries, 37.6% did not seek care from any care provider (versus 25.0% of non-home injuries, p = 0.004) and were more likely to seek treatment within the family or at home (p = 0.008) or at church (p = 0.010). Those with home injuries experienced a median of 14 disability days and 22.9% of families faced difficulties affording basic expenses (p = 0.001).
Conclusion
Home injuries comprise about a third of the Southwest Region of Cameroon’s burden of injury and likely have a profound socioeconomic impact. Though these injuries cause severe disabilities, a large proportion of victims do not seek care from providers. Prevention efforts should address the design of homes and victims of home injury should be encouraged to utilize formal care services.
Citation: Cole EOB, Christie SA, Oke R, Motwani G, Dickson D, Chendjou W, et al. (2022) Too serious to ignore: The epidemiologic and economic burden of home injuries in the Southwest Region of Cameroon—A community-based study. PLoS ONE 17(9): e0274686. https://doi.org/10.1371/journal.pone.0274686
Editor: Denis Bourgeois, University Lyon 1 Faculty of Dental Medicine, FRANCE
Received: October 19, 2021; Accepted: September 1, 2022; Published: September 22, 2022
Copyright: © 2022 Cole et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: SAC was supported by the Association for Academic Surgery (AAS) Global Surgery Research Fellowship Award. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Injury is one of the leading causes of death and disability worldwide, with more than 90% of global deaths from injury occurring in low- and middle-income countries (LMICs) [1]. In 2012, about 10% of the mortality burden in Sub-Saharan Africa (SSA) was attributable to injuries [2]. The Global Burden of Disease study also found that unintentional injuries comprised the eighth leading cause of death in both SSA and Cameroon in 2016, resulting in estimated mortality rates of 26 per 100,000 population and 32 per 100,000 population, respectively [3].
Home injuries, defined as injuries occurring within the home and its premises, are a serious public health problem and an important cause of morbidity and mortality. Several studies carried out in the United States and Europe report a high incidence of home-related injury consultations, hospitalizations, and death [4–10]. In Europe every year, an estimated 32 million require admission and almost 110,000 die due to home injury [5]. In New Zealand alone, one study estimated that unintentional home injuries impose an annual social cost of about USD 9 billion annually [11, 12].
Some people in SSA, including in countries like Cameroon, are known to live in unplanned settlements with poorly constructed houses, further predisposing them to home injuries which have the potential to result in significant disability, loss of productivity, and death [11, 13–17]. Research from 1998 in South Africa demonstrated that more than three-quarters of all injuries were unintentional, most of which were sustained at home [18]. Despite the suspected high incidence, associated disability, and economic consequences, very little additional research has been carried out on home injuries in SSA, and to the best of our knowledge, none in Cameroon. Accurate information regarding the epidemiology of home injuries is critical to informing prevention strategies tailored to this specific health issue.
In a prior hospital-based study in Cameroon, in-home injuries comprised 20% of all injuries, second only to roads in terms of injury location [19]. Research carried out in several LMICs suggests that there is a low rate of utilization of formal care services [20–23]. Hospital-based data therefore may not accurately reflect the underlying burden of injury in the population, both underestimating the magnitude and introducing selection bias regarding the types of injuries reported. Additionally, little is known regarding the reasons injured individuals may or may not choose to seek formal care, further limiting our interpretation of hospital data.
To estimate the magnitude and burden of home injury, we conducted as part of a larger community-based study on injury in the Southwest Region of Cameroon, a sub-analysis to determine the epidemiology and outcomes of home injuries. We also sought to describe therapeutic itineraries of individuals injured in the home and assess factors influencing care-seeking decisions after sustaining a home injury. Additionally, we compared the epidemiology and care-seeking behavior of individuals injured at home to those injured in other locations and individuals with no injuries.
Methods
Study design, setting and population
This study was carried out as a sub-analysis of a cross-sectional community-based study between January and March 2017 in the Southwest Region of Cameroon, which has both urban and rural communities and is primarily Anglophone. The community-based study was powered to identify the incidence of injury that had occurred in the preceding one-year period and was carried out on a representative population, including people of all age groups and sexes. The one-year recall period was selected based on Mock et al.’s work, in order to prioritize information on the more severe, but less frequent injuries [24].
The study population consisted of all individuals residing in the SWR. Eligible households were those who consented to participate and had been living, eating, and sleeping for at least 6 months. Households without a member older than 18 years present after two attempts, those who did not understand the consent, or individuals not permanently residing in the SWR were excluded from the study.
Sampling strategy
Study participants were selected using a three-staged cluster sampling framework. Details about the sampling strategy and sample size calculation are described elsewhere [25]. Briefly, the first and second sampling levels were the health districts and health areas, respectively, which were selected with probability of selection proportionate to population size. For the third level (households) a location point was randomly determined in the selected community and household sampling began with the settlement nearest to the starting point, then continued until the target value was reached (200 households per health area). The targeted sample size for the community-based survey was calculated using the World Health Organization’s (WHO) guidelines for community-based cluster surveys [25, 26]. A minimum sample size of 4,680 individuals was calculated for the larger study which was deliberately exceeded during data collection by approximately 50% at each site to account for multiple sub-analyses of relatively rare events.
Survey administration and data collection
Nine Cameroonian students served as trained research assistants and administered a standard oral informed consent script and a pre-tested structured questionnaire (S1 Appendix) adapted for Cameroon from the WHO’s Guidelines for conducting community surveys on injuries and violence to an adult family representative selected from each household [26]. Basic information was collected from the representative on demographics of all family members, and on injury mechanism, outcome, and care-seeking behavior for family members who sustained home injuries within the study period. To maximize participation with survey results, participants were advised that they could abstain from providing an answer for any question which was important given the inclusion of questions on culturally uncomfortable subjects like payment remuneration and substance abuse. Participants did not receive any renumeration for their participation in the study. For the purposes of the survey, “injury” included any sudden bodily insult directly resulting in death or loss of routine daily activity by any family member for at least one day or bodily insult requiring treatment [27]. Home injury was defined as injury occurring at home or its immediate premises. Further details about questionnaire administration have been previously described [25].
Data management and analysis
All data were periodically entered into University of California, San Francisco REDCap database [28]. The data was adjusted for clustering methodology using svy commands as appropriate and performed all analyses on Stata Version 14 [29]. Descriptive analyses were performed using frequencies, proportions, mean and standard errors (SEs) for continuous, normally distributed variables and medians with interquartile ranges (IQR) for nonparametric variables. Differences between groups were evaluated using Pearson’s Chi-squared and Fisher’s exact tests (as applicable) for categorical variables and Adjusted Wald tests for quantitative variables. Statistical significance was set at p ≤0.05. Data missingness varied by question but remained less than 10% for all questions in the sample. We excluded for this sub-analysis those without injury location which is the main variable for this sub-study.
Ethical considerations
Ethical approval including the consent procedure for participants was obtained from the Institutional Review Boards of the University of California, San Francisco (IRB# 15–18424) and the University of Douala (No IEC-UD/694/10/2016/A). A family representative selected from each household was administered a standard oral informed consent script.
Results
A total of 1,551 households were approached for consent with 151 (9.7%) found to be ineligible and 113 (7.3%) households refused consent. Thus, 8065 participants were included in the community-based study from 1,287 households that provided consent. Overall, 503 injuries were reported, of which 157 (31.2% of all injuries) were home injuries, yielding an incidence of 19.6 home injury cases per 1000 person-years (95% CI 16.8–23.0 cases per 1000-person years). A total of 10 injuries did not report on location of injury and were excluded from analysis.
Socio-demographic characteristics
The majority of home injury victims were significantly females (60.8% p = 0.003) and lived in rural settings (58.4%) (Table 1). The mean age (SE) of the domestically injured was 25.1(2.0) years and a range of 3 months to 95 years. Those who sustained home injuries were younger when compared with those who sustained non-home injuries (mean age (SE), 29.0 (1.1) years), however they were older than the no-injury (mean age (SE), 23.9 (0.3) years) cohort (p = 0.56). When compared with those who sustained non-home injuries and no injury, a significantly larger proportion of those with home injuries used charcoal (p = 0.039) and liquid petroleum gasoline (LPG, p = 0.006) as cooking fuels. A greater proportion of the domestically injured owned agricultural land, and obtained a tertiary education when compared to the other groups, although these did not reach statistical significance.
Injury characteristics
The top two activities resulting in home injury were leisure or playing (51.0%) and working around the home (22.6%) (Table 2). Other activities (n = 34) at the time of injury are household chores (32.4%) and cooking (17.6%). The commonest mechanisms of home injury were falls (37.9%) followed by contact with sharp objects (28.1%). In those who sustained home injuries, lacerations were the most frequently cited injury type (59.2%). A greater proportion of individuals experiencing home injuries (14.6%) reported the type of injury being a burn as compared with individuals experiencing non-home injuries (4.5%; p = <0.001). The majority of home injuries were to the lower and upper extremities (49% and 33.8%, respectively).
Care-seeking and barriers to care
Overall, whereas 75.0% of those with non-home injuries sought care from a formal or informal care provider, 62.4% of those with home injuries sought care from some provider (p = 0.004). As expected, home injuries had a higher proportion of first responders providing help to the injured being family members (61.0%) compared to non-home injuries (21.1%) (p = <0.001). Those who sustained home injuries were more likely to seek treatment within the family/home (36.3% versus 24.0%, p = 0.008) or at church (2.6% versus 0%, p = 0.010). Conversely, those with non-home injuries were more likely to seek care from a traditional healer/bonesetter (14.0% versus 7.6%, p = 0.043). (Table 3).
Similar to the non-home injuries, those with home injuries thought that the biggest problem with formal care use is that it is too expensive (27.0% versus 29.3%, p = 0.6). Amongst those who did not seek formal care first, a higher proportion of those with home injuries thought formal care was too expensive compared with non-home injuries victims (7.6% versus 3.9%, p = 0.075) or simply preferred not to seek formal care first (16.6% versus 12.8%, p = 0.262). (Table 4).
Outcomes
Of the 157 home injury events, 103 (65.6%) reported at least a form of disability with the top two reported disabilities being difficulties with standing/walking by 36.4% and activities of daily living (dressing, eating or going to the bathroom) by 33.8%. A total of 240 disabilities were reported with 47.1% being considered as severe (Fig 1). Interestingly, amongst those with non-home injuries, a slightly lower percentage of disabilities (43.5%) were considered by injury victims to be severe. Also, 7.1% of home injury victims completely lost their jobs or stopped going to school as a result of disabilities they sustained from their injuries (p = 0.012) while 22.9% of households were unable to afford basic necessities (food, rent) after injury (p = 0.001) (Fig 2).
*Disabilities include any difficulty speaking or communicating; dressing, eating, going to the bathroom; leaving the home, shopping, traveling; engaging with friends/family; going to school; seeing or hearing; standing or walking; picking things up or using their hands; weakness, shortness of breath, fatigue; understanding or remembering things; depression or shame; Individuals could report multiple disabilities **Pearson’s Chi square.
*pvalue: Pearson’s Chi squared test.
The median number of disability days reported was 14 (IQR 3–30) days and the median cost of treating home injuries was 5000 (IQR 1000–15000) Central African francs (CFA). In as much as 40.4% of home injury cases, injury victims were unable to independently carry out their daily activities (p = 0.000), hence a family member had to shift their usual activities in order to care for the victim, resulting in that family member being absent from work for a median of seven days (IQR 6–18 days).
Discussion
Through our community-based study, which provides a rare opportunity to understand home injuries at the population-level, we found that the incidence of home injury in the Southwest Region of Cameroon was 19.6 per 1000 person-years, comprising about a third of the overall burden of injury in this region. Though those who suffered home injuries reported experiencing severe disabilities more often than those who were injured outside of the home, they were less likely to seek care (formal or informal). When they did seek care, they were more likely to seek care within their family/home or their church than those injured outside the home. Interestingly, compared with those who experienced non-home injuries, those with home injuries may have been of a higher socioeconomic status (SES) based on their use of LPG [30, 31]. Most home injuries were lacerations or burns to the extremities and occurred because of falls during leisure/play or while working around the home. Finally, home injuries had significant consequences: a median disability of two weeks for the injured, with one-fifth of families facing difficulties affording basic needs.
The incidence of home injury we found was similar to that obtained by a study conducted in a semi-urban community in India (17 per 1000 person-years) [32] but much lower than that obtained from a study done in the rural area of Punjab, Northwestern India (106 per 1000 person-years) [33]. The study conducted in the rural area of India might have found a higher incidence of home injury because it seems to have employed a broader definition of home injury, based on the authors’ finding that a little more than 70% of home injuries were trivial or minor. Also, the study in rural India used a descriptive prospective epidemiological design which is less prone to recall bias than the retrospective design used in our study. Females were more affected by home injuries in our study similar to those obtained in studies done in several populations in India [32–35]. We also identified similar age groups (15 to 45years) most affected by home injuries as studies in India [33, 35]. However, our findings were different from those in a study done in Bangladesh [36], which found that males suffered more home injuries, and from other studies done in India [37, 38], which found that children under five years and adults over 65 years were the most affected age groups. The authors of the study in Bangladesh note that their finding is surprising, given that females in Bangladesh likely spend more time around the home, predisposing them to home injury. Females are also more likely to be involved in household chores and cooking which may explain their higher predisposition to home injuries. Younger and older individuals in the Indian studies might be more affected by home injury possibly because these groups spend more time at home, and also are more likely to suffer from falls. Specific interventions such as kitchen safety education can thus be directed to these groups to reduce the burden of home injuries.
Studies conducted in other countries have also found that falls are the main mechanism of home injuries [32–34, 37, 39]. We speculate that falls were common in our study because of the stony and hilly attributes of most home premises, which serve as playgrounds and work surfaces, and because of the poor floor designs (such as uneven, rough, and uncemented floors) that we observed in many participants’ homes. Further, we observed that several of the participants’ homes were poorly illuminated and were in areas where the supply of electricity is unreliable. As such, implementing preventive measures such as proper home design (including proper floors and incorporation of windows and bright lighting) may help reduce the rate of falls and therefore home injuries. Studies done in India [32–34, 37], Ghana [40], and Bangladesh [36] had similar findings and recommendations. A randomized controlled trial conducted in New Zealand amongst low-income individuals suggested that low-cost home modifications can be a means to reduce injury in the general population [39].
Victims of home injury were less likely to seek care from some care provider—despite classifying almost half of all disabilities they self-reported as severe. Although about a third of home injury victims reported the biggest barriers to formal care use as cost, the most prevalent reason they gave for not seeking formal care first was that they considered their injury not to be serious enough. Also, as reported earlier, home injury victims may have been of a higher SES due to their use of LPG which has been found to correlate with a higher SES [30, 31] than non-home injury victims, implying that, even though perceived cost of treatment was considered a substantial barrier to formal care, perception of injury severity at the time of injury might have had a bigger influence on the use of formal care. Furthermore, participants’ perception of injury as “not serious” maybe relative to expense of evaluation and treatment. Our study’s findings regarding the care-seeking behaviors of those injured domestically were similar to those reported in studies done in India [38], Bangladesh [36], and Hong Kong [41]. Subsidization of the cost of formal care treatment and implementation of a national insurance policy by the government may encourage the use of formal care facilities by the population. Our study shows that the direct economic consequences of home injury in the Southwest Region of Cameroon are serious, making salient the need for formal care subsidization and population sensitization on the impact of home injuries. Moreover, a study done in Tamil Nadu, extreme south of India found that the mean number of days of work lost for caretakers was 1.65 [42]; the median in our study was seven days. Up to 75% of home injury victims in India used formal care services, had a quicker recovery, and a lower number of post-injury disability days; in our study, only 58% of home injury victims used formal care. It is possible that access to formal care may play a role in mitigating the disability and caretaker task-shifting consequences of injury. Reducing the burden of home injuries in Cameroon may require preventing these injuries from happening in the first place, while also improving access to formal care services. Since the majority of home injury victims in our study had family members as first responders to their injury, providing appropriate first aid education/training to families during health campaigns may be an important measure in reducing disability severity, thus economic burden.
Limitations
This study is, to the best of our knowledge, the first one at the population level that sought to understand the epidemiology and outcomes of home injury as well as care-seeking behaviors after home injury in Cameroon. However, the methods we used have some inherent limitations. In particular, we administered the survey to a single household representative who was responsible for remembering and reporting the injury events of all household members for one year. It is possible that representatives did not accurately report all injury events because, for instance, they might have been unable to recall all injury events and the relevant details, especially for minor injury events. Finally, our estimates of disability severity were necessarily based on respondents’ perception, as injuries occurred in the past, which is subject to recall bias.
Conclusions
Home injuries comprise a significant proportion of all injuries in the Southwest Region of Cameroon. Despite being associated with increased disability compared to injuries outside of the home, as well as significant economic consequences, people who sustained home injuries are less likely to seek care. Improved safety and design of homes may improve injury prevention in this setting. To curtail the burden of disabilities and economic consequences of home injuries, efforts should be made to improve financial access to formal care services.
Supporting information
S1 Appendix. Community based household survey questionnaire.
https://doi.org/10.1371/journal.pone.0274686.s001
(PDF)
S1 Dataset. The person-level data set used for Table 1 socio-demographic results.
https://doi.org/10.1371/journal.pone.0274686.s002
(DTA)
S2 Dataset. The injury data set used for injury characteristics and all other presented results.
https://doi.org/10.1371/journal.pone.0274686.s003
(DTA)
References
- 1. Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG. Injuries: the neglected burden in developing countries. Bull World Health Organ 2009; 87:246–a. pmid:19551225
- 2.
Jasen Van Vuurem P. Fact sheet: the leading causes of death in Africa in 2012. Africa Check Organization; 2014.
- 3.
GBD Compare Data Visualization. Institute for Health Metrics and Evaluation, University of Washington, Seattle. 2016. https://vizhub.healthdata.org/gbd-compare/heatmap Accessed 23 Mar 2018.
- 4.
Miller T, Kolosh KP, Fearn KT, Porretta KT. The National Safety Council: injury facts. https://archive.org/details/injuryfacts201300nati/page/2/mode/2up Accessed on 5 Jun 2015.
- 5.
Angermann A, Bauer R, Nossek G, Zimmermann N. Injuries in the European Union: statistics summary 2003–2005. Austrian Road Safety Board; 2007.
- 6. Keall MD, Ormandy D, Baker MG. Injuries associated with housing conditions in Europe: a burden of disease study based on 2004 injury data. Environmental Health. 2011 Dec; 10(1):1–0.
- 7.
Bonnefoy XR, Annesi-Maesano I, Aznar LM, Braubach M, Croxford B, Davidson M, et al. Review of evidence on housing and health: background document, Fourth Ministerial Conference on Environment and Health Budapest, Hungary.2004. Jun 23–25 WHO-EURO.
- 8.
EuroSafe. Injuries in the European Union, Report on injury statistics 2008–2010. Amsterdam: European Association for Injury Prevention and Safety Promotion (Eurosafe). 2013.
- 9. Majori S, Ricci G, Capretta F, Rocca G, Baldovin T, Buonocore F. Epidemiology of domestic injuries. A survey in an emergency in an emergency department in North-East Italy. J PREV MED HYG 2009; 50:164–9.
- 10. Paget LM, Thélot B. Home and leisure injuries in Mainland France based on the health care and insurance survey, 2012. Bull Epidémiol Hebd 2017; 32: 660–7.
- 11. Chenal J. Capitalizing on urbanization: the importance of planning, infrastructure and finance for Africa’s growing cities. Forest Africa 2016; 1: 59–71.
- 12. Keall MD, Guria J, Howden-Chapman P, Baker MG. Estimation of the social costs of home injury: a comparison with estimates for road injury. Accident Analysis & Prevention. 2011 May 1;43(3):998–1002. pmid:21376893
- 13.
The World Bank. Growing African Cities facing challenge and opportunity. The World Bank Organization; 2015.
- 14. Hove M, Ngwerume ET, Muchemwa C. The urban crisis in Sub-Saharan Africa: a threat to human security and sustainable development. International Journal of Security and Development 2013; 2 (1): 7.
- 15.
Arimah BC. Slums as expression of social exclusion: explaining the prevalence of slum in African countries. United Nations Human Settlements Programme; 2016.
- 16.
Rabat KR. Towards African cities without slums. Africa Renewal; 2012.
- 17.
Yango J. The World Bank: AFTU1 and 2. The World Bank Organization; 2002.
- 18. Jordaan ER, Atkins S, Van Niekerk A, Seedat M. The development of an instrument measuring unintentional injuries in young children in low-income settings to serve as an evaluation tool for a childhood home injury prevention program. Journal of safety research. 2005 Jan 1;36(3):269–80. pmid:16038934
- 19. Juillard CJ, Stevens KA, Monono ME, Mballa GA, Ngamby MK, McGreevy J, et al. Analysis of prospective trauma registry data in Francophone Africa: a pilot study from Cameroon. World journal of surgery. 2014 Oct;38(10):2534–42. pmid:24791906
- 20.
The World Bank. Improving health, nutrition and population outcome in Sub-Saharan Africa. The International Bank for Reconstruction and Development/The World Bank; 2005.
- 21. O’Donnell O. Access to health care in developing countries: breaking down demand site barriers. Cad Saude Publica 2007; 3: 2820–34.
- 22.
Abraham O. Factors influencing care-seeking behaviour among patients in Ethiopian primary health care units. Yale University School of Public Health; 2016.
- 23. Peters DH, Walker DG, Bloom G, Brieger WR, Hafizur RM. Poverty and access to health care in developing countries. Annals of the New York Academy of Sciences 2008; 1136 (1):161–71. pmid:17954679
- 24. Mock C, Acheampong F, Adjei S, Koepsell T. The effect of recall on estimation of incidence rates for injury in Ghana. International journal of epidemiology. 1999 Aug 1;28(4):750–5. pmid:10480706
- 25. Christie SA, Dickson D, Mbeboh SN, Embolo FN, Chendjou W, Wepngong E, et al. Association of health care use and economic outcomes after injury in Cameroon. JAMA network open. 2020 May 1;3(5):e205171-. pmid:32427321
- 26.
Sethi D, Habibula S, McGee KS, Peden M, Bennett S, Hyder AA, et al, World Health Organization; 2004. Guidelines for conducting community surveys on injuries and violence. https://apps.who.int/iris/bitstream/handle/10665/42975/9241546484.pdf;jsessionid=7024DEA9154C8083CC73F750180FBDE8?sequence=1
- 27. Mock CN, Maier RV. Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma. Journal of Trauma and Acute Care Surgery. 1997 Mar 1;42(3):504–13.
- 28. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. pmid:18929686
- 29.
StataCorp. Stata Statistical Software: Release 14. StataCorp LP; 2015.
- 30. Eyler L, Hubbard A, Juillard C. Optimization and validation of the EconomicClusters model for facilitating global health disparities research: examples from Cameroon and Ghana. PLoS One. 2019 May 23;14(5):e0217197. pmid:31120921
- 31. Eyler L, Hubbard A, Juillard C. Assessment of economic status in trauma registries: a new algorithm for generating population-specific clustering-based models of economic status for time-constrained low-resource settings. International journal of medical informatics. 2016 Oct 1;94:49–58. pmid:27573311
- 32. Bhanderi DJ, Choudhary SK. A study of occurrence of domestic accidents in a Semi-urban community. Indian J Community Med 2008; 33(2):104–6.
- 33. Aggarwal R, Singh G, Aditya K. Pattern of domestic injuries in a rural area of India. The Internet Journal of Health 2009; 11:2.
- 34. Masthi NR, Kishore SG, Gangaboriah . Prevalence of domestic accidents in the rural field practice area of a medical college in Bangalore, Karnataka. Indian J Public Health 2012; 56(3): 235–7. pmid:23229218
- 35. Kommula VM, Kusneniwar GN. A study of domestic accidents in the rural area of south India. Int.J.Curr.Microbiol.App.Sci 2015; 4(4): 764–7.
- 36. Shawon SR, Hossain FB, Rahman M, Ima SZ. Domestic accidents in a rural community of Bangladesh. A cross-sectional study on their incidence and characteristics. Developing Countries Study. 2012; 2(7):14–9.
- 37. Radhakrishnan S, Nayeem A. Prevalence and factors influencing domestic accidents in a rural area in Salem District. Int J Med Sci Public Health 2016; 5:1688–92.
- 38. Divya BV, Jayasree TM, Felix AJW. A community based cross sectional study on types of domestic accidents and their treatment seeking behavior. Int J Community Med Public Health 2016; 3(9): 2414–20.
- 39. Keall MD, Pierse N, Howden-Chapman P, Cunningham C, Cunningham M, Guria J, et al. Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: a cluster-randomised controlled trial. The Lancet. 2015 Jan 17;385(9964):231–8. pmid:25255696
- 40. Gyedu A, Nakua EK, Otupiri E, Mock C, Donkor P, Ebel B. Incidence, characteristics and risk factors for household and neighborhood injury among young children in semi-urban Ghana: a population based household survey. Inj Prev J 2015; 21: e71–9.
- 41. Chan EY, Kim JH, Ng Q, Griffiths S, Lau JT. A descriptive study of non-fatal, unintentional home-based injury in urban Settings: evidence from Hong Kong. Asia Pac J Public Health 2008;20: 39–48. pmid:19533860
- 42. Kumarasamy H, Prabhakar VR. Prevalence and pattern of domestic injuries in rural area of Tamil Nadu. Int J Health Allied Sci 2016; 5: 215–9.