Preventing childhood injuries in Uganda - development of a child safety kit; preparation for a cluster randomised controlled trial

Injuries are a leading cause of death among children around the world. Globally, nearly 650,000 children under the age of 15 lose their lives every year to injuries and violence. This burden is unequally distributed between low- and middle-income countries (LMIC) and high-income countries (HIC) with the mortality rate from unintentional injuries in LMICs being nearly double that of HICs. In particular, Sub-Saharan Africa has the highest proportion of under 5 deaths in the world.

More than 70% of these injuries are non-transport unintentional or "accidental" injuries. Evidence shows that a large proportion of childhood unintentional injuries take place in and around the home, where children are generally believed to be well supervised. Children, especially those under 5 years, spend a significant amount of their time in and around the home which exposes them to various injury hazards e.g. stairs and windows without safety grills, access to poisonous substances and chemicals, areas of open water, access to ground level stoves.

Despite an overall global reduction in child injury mortality rates over the past two decades, available data indicates that the rate of decline has been much slower in LMICs and the gap between LMICs and HICs is widening. This is due in part to higher risks, inadequate preventive measures and a lack of access to timely medical care in LMICs. The nature of household injuries among children has been well documented in HICs but much less is known in LMICs. Much of what is known about preventing child injuries in the home stems from research conducted in HICs where preventive measures have been shown to be effective e.g. safety caps, smoke alarms, stair gates coupled with education of parents/carers. What is not known is how effective these measures would be in LMICs.

This study aims to test the effectiveness of a child safety kit (developed through co-design to reflect differing risk profiles, cultural appropriateness and availability/affordability) against traditional education. The study will be carried out in Jinja, Uganda and will involve two phases: Phase 1 (the focus of this development grant, conducted over 1 year) will focus on contextualizing the child injury problem and developing the child safety kit through mixed methods (a review of hospital data, focus groups with parents/carers, in-depth interviews with key informants, an affordability/availability survey and a market survey to ascertain willingness to pay for safety equipment); and Phase 2 which will measure behaviour change and reductions in injuries through a cluster Randomised Control Trial (cRCT). We will assess the reduction in child injuries in two villages (clusters) - one which will have the full child safety kit of equipment plus educational material, workshops and awareness campaign for parents versus the other cluster with only education - over 3 years.

A key component of Phase 1 will be to support collaborative research between scientific researchers, policy makers and parents such that all stakeholders involved in the health of under 5's have the opportunity to be full participants from conceptualisation to communication of results. The co-design approach will result in the development of a holistic intervention to include the child safety kit, educational material, training workshops for parents and a community-based awareness campaign. Engaging the community from the beginning will result in improved knowledge and awareness through the sharing of opinions and experience and will optimise equipment usage during Phase 2.

The results of Phase 1 will identify any challenges to implementing the intervention, provide accurate data on which to calculate sample sizes for the cRCT and determine the key outcomes. To our knowledge, this will be the first cRCT on child safety equipment and education conducted in Africa.

Globally, nearly 650,000 children lose their lives to injuries every year. Injuries that occur in the home to children under the age of 5 years (burns, falls, drowning, poisoning) can be prevented through the provision of appropriate safety equipment e.g. barriers, childproof containers, smoke alarms, etc coupled with parental education. A number of studies conducted in high-income countries have shown significant reductions in child injuries following this approach.
This proposal aims to reduce unintentional injuries in the home among under 5's in Jinja, Uganda through the provision of a child safety kit and parental education. It will be conducted in two phases: Phase 1 is formative and will be guided by a community-based participatory approach utilizing mixed methods (in-depth interviews, focus group discussions, market surveys) to contextualize the child injury problem and develop a child safety kit and educational material/training; Phase 2 will measure behaviour change and reductions in injuries through a cluster Randomised Control Trial. The specific objectives are:
1. To describe the under 5 child injury context in Jinja, Uganda
2. To explore practices and behaviours that put under 5's at risk of injury in the home environment
3. To develop an appropriate child safety kit including supporting educational material for a low-income setting
4. To test the impact of implementing a child safety kit versus traditional education
5. To explore opportunities for scale-up to other low-income countries.
To our knowledge this will be the first cRCT on child safety equipment and education conducted in Africa. The results will thus have significant implications for other lower income countries both in terms of research methodology and effectiveness information. Phase 1 will inform the development of an appropriate/affordable child safety kit and accurate incidence rates on which to base the sample size for the cRCT.

Injuries are the leading cause of death among children and result in thousands of non-fatal injuries every year. However, there are many known interventions which, if implemented, could save lives. For babies and children, the development of a tailor-made intervention, which this research proposes, will not only result in lives saved and reductions in injuries and disabilities, but also reductions in pain, suffering and loss of potential earnings. If the project reduces these outcomes in Uganda there is no reason why it could not be applied to children in other countries in the region and perhaps other LMICs.

Unintentional injuries and their sequelae have significant social and economic impacts on families, carers and communities. Oftentimes a family member needs to be taken out of school or work in order to care for severely injured or disabled baby or child resulting in decreased earning power or even additional out of pocket costs for hospital visits and long-term rehabilitation. Reducing the incidence of unintentional injuries would therefore have huge social and economic impact on these groups.

A core feature of the study design is the community-based participatory approach which will engage parents from initial conception through to dissemination of results enabling them to participate in knowledge exchange, research and ultimately the impact of this project. A key component will be focused on strengthening relationships with end-users and forming partnerships with local groups to ensure the timely success of the project.
A recent study looking at costs of unintentional injuries in urban slums in Kampala, Uganda estimated that the average household out-of-pocket expenses of treating an unintentional injury was USD24.1. Significant indirect productivity losses were also found with injuries resulting in the loss of an average of 25 school days per injury victim. Understanding which interventions work among the child population will save both households and the government money if it results in reductions in deaths, hospitalizations and the need for rehabilitation.

The information generated through this project will support decision-making by policy makers. The new knowledge of what works among this vulnerable population of babies and children under 5 could be integrated into current child and adolescent policies which traditionally ignore these types of non-traditional health issues. The educational material developed for parents will also benefit nongovernmental organizations and civil society working in the area and either delivering primary prevention activities or advocating for policy change. Raising awareness and facilitating uptake of the child safety kit will be enhanced through training workshops for end-users and a culturally appropriate awareness campaign targeting parents and caregivers. These impact activities will be co-designed in order to effectively shape communications and knowledge exchange interactions between the research team and all partners.

Journalists are an important stakeholder in getting the message across to the community through outputs such as blogs, websites, and articles in the popular press, on TV and radio. They will be provided with the tools to report responsibly and promote primary prevention practices. They will work together with the researchers and end-users who will be involved with the project.

This project will foster a new group of injury experts in Uganda who are passionate about the issue and who produce outputs for academic consumption, talk at public forum both locally and internationally, appear on radio and TV and use other social media to get the prevention message across. An early-career researcher and a local statistician and health economist will be supported through this grant and capacity developed to implement mixed method studies, conduct complex statistical analysis and write articles supported by the senior investigator team.