Injury Prevention•

Behavioural and environmental risk factors for household injuries: semistructured interviews with health professionals and mothers in Iran

Abstract

Background Injuries are increasing global public health problems, causing disability and death among children. This has considerable financial, emotional and social effects on families and society. This study aimed to investigate the behavioural and environmental factors leading to unintentional home injuries and attempts to highlight the pivotal role of mothers’ behaviour and performance to provide a safe place for children at home.

Methods The current research is a qualitative study of a directed content analysis type. The data were gathered through semistructured interviews conducted in participants’ workplaces, namely universities, research centres and health centres. In some cases, telephone interviews were conducted within 3 months, from February 2021 to May 2021 in Tehran, Iran. The participants were selected through non-probability and purposive sampling. All the recorded interviews and notes were accurately evaluated, and data analysis was performed based on the content analysis. There were 29 interviews in total: 12 interviews with mothers, 9 with treatment and prevention specialists, and 8 with researchers.

Results A total of 66 factors, 6 subcategories and 2 main categories were extracted after analysing the interviews. The main categories included environmental and behavioural factors. The subcategories included house infrastructure, house equipment/furniture, children’s equipment/furniture, provision of precarious conditions, access to hazardous substances and appliances, and unsafe arrangement of furniture.

Conclusion Despite the existing obstacles such as the long-term implementation, financial difficulties and overcomplicated policy-making process, health interventions can make it possible for mothers of children under the age of seven to adopt preventive measures through appropriately designed instructions and optimal use of existing facilities.

What is already known on this topic

  • According to statistics reported by child health centres in Iran, on average, 20.2% of child mortality under the age of five is caused by unintentional injuries.

What this study adds

  • Environmental factors predisposing to child injuries include problems with house infrastructure such as no handrail on stairs.

  • Other environmental factors include unsafe furniture and toys.

  • The mothers in this study identified a wide variety of behavioural factors which can also predispose to child injuries.

How this study might affect research, practice, or policy

  • In line with the suggestions offered by the participants, regular inspections and making sure that the safety standards are implemented are significant factors in minimising house accidents and injuries.

  • Our findings can be the springboard for the dissemination of information to encourage policy-makers and lawmakers to pass stricter laws to implement safety standards for the required infrastructure. Passing laws and enforcing the policies and strategies can put into effect the preventive measures to reduce house injuries.

Introduction

The term ‘injury’ has been defined by WHO as exposure to energy of mechanical, radiant, thermal, electrical or chemical kind in amounts exceeding the threshold of physiological tolerance,1 being largely predictable and preventable on a global scale.2 Since immunity programmes and vaccinations eliminate the threat of infectious diseases such as poliomyelitis, diphtheria and measles, children’s health has dramatically changed over the last 50 years. However, one severe public health crisis threatening all children and coming with no vaccination is injury. Child injuries is of the most insidious public health threats1 classified in the category of intentional and unintentional injuries.3

The injuries arising from road accidents, falling, burning, poisoning and suicide are among the common causes of intentional and unintentional injuries4 in Eastern Mediterranean.5 The injuries incur huge costs6 in a way that 90% of injury-related financial burden falls on low-income or middle-income countries.7 In assessing risks, researchers pay particular attention to child protection services and precarious living conditions with the latter inflicting severe injuries to children.7 The WHO reported that 55 039 children under the age of five lost their lives due to injuries in Eastern Mediterranean Region, with nearly 336 271 children in all regions.8 Disease and disability are among the primary causes of death among children in Iran. In addition to physical and emotional costs, injuries can take a heavy toll on a country’s healthcare system.9 10 Based on child healthcare centres, an average 20.2% of deaths under the age of five are due to injuries.11

Studies show that home can be a significant place for injury. In the analysis of child injuries, this was proven right. This is because children, especially preschool children, spend most of their time at home.12–14 The WHO and the UNICEF set out child injuries as an important priority for the global public health and communities' development.15 Identification of preventive measures, dealing with the way humans interact with their surroundings, seems crucial in proper management of injuries.3 Different behavioural patterns can also increase the possibility of injuries.6 Therefore, effective interventions should be made to prevent injuries and accidents for this vulnerable subgroup. Basically, human behaviour is a complex phenomenon determined by individual, behavioural and environmental factors. Identifying individual and environmental determinants and designing appropriate programmes considering the explored factors are instances of such interventions.2

Most research has been done quantitatively and the prevalence has been investigated have been less studied. To discover these reasons, the best research method is to conduct a qualitative research. Therefore, this study attempts to represent a wide range of viewpoints from experts and families on behavioural and environmental determinants influencing home injuries among pre-schoolers. The findings of such studies can provide the valuable basis for effective preventive programmes and interventions.

Methods

Study design

The present study is a qualitative research of the type of guided content analysis, being one of the most effective methods for extracting the experiences and views of individuals and groups on a specific subject or phenomenon.16

Study setting and participants

In this study, we considered the views of professionals specialising in prevention, treatment and research (six health education experts, two epidemiologists, two paediatricians, five nurses, two healthcare experts) as well as mothers as subgroup. The participants were selected through non-probability and purposive sampling method with maximum variation (age, education level, people’s experiences, income level and job status).

The inclusion criterion for researchers was that their field of research was in line with children’saccidents and incidents, also for treatment and prevention specialists, paediatricians, healthcare workers with experience, and nurses who had experience working in the accident department or children ’s department. In the case of mothers, the entry criterion was to have at least 1 child under 7 years old. A total of 29 people, including 12 mothers, 9 treatment and prevention experts, and 8 experts in the field of research were interviewed. The time of the interview session and the place of the interview were set in the best and most convenient way for the participants.

Data collection

This study consisted of 29 participants. The data were collected through semistructured interviews from February 2021 to May 2021. The interviewer was an experienced researcher in conducting qualitative studies. Interviews were conducted at people’s workplaces, universities, research centres, health centres and in some cases, telephone interview was conducted in Tehran. Guide questions were prepared based on the environmental and behavioural determinants, whose content validity was checked by the research team, and in the interview session, it started with demographic questions (age, occupation, education, etc). Then, it continued with more comprehensive questions about domestic incidents (table 1). Each interview lasted 20–40 min. After the interviews were transcribed, they were sent to the participants and were approved. The research team confirmed data saturation by conducting 26 interviews. However, for further confirmation, three additional interviews were conducted, but no new data were found, so the interview process was stopped.

Table 1
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The guide to the interview questions addressed to mothers and experts

Data analysis

In this study, Granheim and Lundman method was used to analyse the research data.17

Step 1: data preparation, including verbatim transcription of interviews.

Step 2: deciding on the unit of analysis.

Step 3: classification.

Step 4: Coding test in text samples.

Step 5: Coding all the text.

Step 6: Coding stability.

Step 7: drawing conclusions from coded data.

Trustworthiness

Dependability, transferability, credibility and confirmability used to ensure the validity and reliability of the current study (Guba and Lincoln’s assessment method). The data were reviewed by two independent individuals for confirmation of dependability. For transferability, the research team provided a detailed description of the participants and the overall analysis. To ensure credibility, the researchers spent a lot of time conducting the interviews and analysing the data. Confirmability were maintained by returning the codes extracted from the interviews to the participants and receiving their views.18

Patient and public involvement

Patients or people were not involved in the design, conduct and reporting or the publication programs. The results will be available to all employees and participants through our usual channels of communication.

Results

Characteristic of participants

In this study, 29 participants’ views were examined: 12 mothers, 8 researchers and 9 treatment and prevention experts. The average age of mothers was 31±4.48, where 7 of them were housewives and 5 employees. The group of mothers were all highly educated. Also, there were nine experts in the field of clinical prevention and eight experts in the field of research. After analysing the interviews, 66 factors, 6 subcategories and 2 main categories were extracted. The main categories included environmental determinants or behavioural factors. The subcategories included house infrastructure, house equipment/furniture, children’s equipment/furniture, provision of precarious conditions, access to hazardous substances and appliances, and unsafe arrangement of furniture. Figure 1 shows the output results.

Figure 1
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Figure 1

Classification of environmental and behavioural factors for domestic injuries.

Environmental determinants

The environmental factors included house infrastructure, house equipment/furniture, and children’s equipment/furniture (tables 2–4).

Table 2
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Environmental factors (house infrastructure)
Table 3
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Environmental factors (house equipment/furniture)
Table 4
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Environmental factors (child’s equipment/furniture)

House infrastructure

Most of the participants believe that household injuries are more likely when children’s preferences and features are not considered in the architectural plan of the house.

“Accidents might have to do with the environment as it is not properly designed. The design in most buildings are not child-friendly. The designers had only adults in mind. Children can’t adjust themselves to living in such living spaces” (P#27, an epidemiologist).

House equipment/furniture

Most of the participants reported that lack of safe furniture or kitchen utensils can contribute to lots of accidents.

“Kitchens are not safe. It’s only mothers who should keep children away from them. Unsafe furniture, equipment, and home appliances can easily turn home—a haven of peace—into an unsafe place” (P#17, an epidemiologist).

Children’s equipment/furniture

Lack of meticulous attention to children’s toys and furniture in terms of safety can contribute to accidents and injuries.

“All safety standards must be met to make toys as safe as possible. For example, small batteries must not be used in toys. Or small parts and pieces must not be used in making toys” (P#22, a health educator expert).

Behavioural determinants

The behavioural factors included house provision of precarious conditions, access to hazardous substances and appliances, and unsafe arrangement of furniture (tables 5–7).

Table 5
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Behavioural factors (provision of precarious conditions)
Table 6
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Behavioural factors (access to hazardous substances and appliances)
Table 7
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Behavioural factors (unsafe arrangement of furniture)

Provision of precarious conditions

Most of the specialists and mothers attribute the accidents and injuries to measures and steps ignored, and consequently, the house turns into a minefield of accidents.

“At this age when parents are not around, children are in danger of accidents and injuries. However, when parents are around, they can directly or indirectly manage everything in a way that children’s self-confidence and independence are not undermined” (P#12, a mother).

Access to hazardous substances and appliances

The participants asserted that visibility and accessibility of hazardous substances and appliances could pave the way for a lot of preventable accidents and injuries.

“We witness lots of cases of poisoning, most of which are unintentional and medicine-related. Some families recklessly make it easy for children to reach medicine and cause such injuries” (P#20, a paediatrician).

Unsafe arrangement of furniture

The participants also contend that the arrangement of furniture can sometimes cause accidents as a result of a reckless disregard for safety.

“It’s possible to prevent some of the accidents, for example, the fall of some decorative objects from the wall. Once a kid kicked the ball and it hit the clock on the wall. The clock fell on the face of one of the kids and left him with cuts and bruises. Thank Goodness for that. Something worse could have happened” (P#2, a mother).

Discussion

This study aimed to investigate the behavioural and environmental factors leading to unintentional home injuries and attempts to highlight the pivotal role of mothers’ behaviour and performance to provide a safe place for children at home. All around the world, over 200 families mourn the death of their children due to injuries every day.19 This is a critical issue in desperate need of preventive measures.2 Children usually fall prey to adults’ recklessness and mistakes. At times, accidents happen as a result of parents’ lack of awareness, recklessness or ignorance.

In this study, we witnessed the extraction of some factors such as unsafe infrastructure, lack of safety in home appliances, children’s toys and unsafe behaviours undermining house safety and contributing to accidents.

Consistent with the findings of our study, a similar study identified four main themes: home injury and associated hazards, superficial changes inside the house, barriers and facilitators in improving the house quality and conditions. A wide range of strategies were introduced to change the house to make it a safer place for children such as house adjustments and installing safety equipment, removal of dangerous items or limiting children’s access to these sources of danger, and changing behaviour to guarantee house safety. The obstacles to implementing the mentioned strategies were lack of awareness regarding injury management, limited financial resources, surface topography, shoddily constructed houses and not assuming responsibility for injury prevention. The facilitators in improving the house quality and conditions included raising awareness, financial support, and family and society participation.20 In another study, most of the injuries were linked to child’s growth, economic factors and the physical features of the living space. Low-income families typically live in houses where more sources of dangers contributing to accidents exist, such as infrastructure restriction, absence of guards in kitchens, basins, sinks, fireplaces and paraffin stoves, unprotected balconies, and open water reservoirs.21 In another study, the findings showed that living in rented accommodations with limited possibility of renovations and changes constitutes the main obstacle to preventing accidents and injuries. In addition, responsible parents should teach appropriate safety measures to their children.22

One study pointed to the physical–environmental level as a contributing factor to home injuries such as jerry-built houses and absence of smoke detectors.22 Other scholars warned against some possible sources of danger such as easy access to unsafe electrical sockets, hanging electrical wires, non-standard and unsafe furniture, small stuff (eg, coins, buttons, bolts, cotton, paper and nylon containers), medicine, chemical substances, wet kitchen floors, sharp points (of knives, razor, glass and containers), and absence of guards in balconies.19 The house environment and socioeconomic factors are also found to contribute to injuries such as falling, burning and poisoning.2 Furthermore, unsafe buildings and cooking in similar conditions are of main risk factors.7 23 According to 1 study, only 1 in every 10 families kept hazardous substances in locked cabinets.24 Another report revealed that 97% of families left their prescribed medicine unattended,25 which is a tell-tale sign of total negligence. A Nepalese study demonstrated that 98% of families have not installed handrails, 80% do not use window guards, and half of the families have not installed a balcony guard.26 Unsafe living space, insufficient supervision and lack of safety education were also found to be primary determinants.2

Adults’ recklessness and mistakes typically take a heavy toll on children. In general, we can assert that houses are usually constructed for adults and are not children friendly, in a way that adjustment to such living spaces is an intractable problem for children. Since accidents can be traced to infrastructure and environment on the one hand, and most of them are irreversible due to families’ conditions and facilities on the other hand, it is likely to minimise the risk of injuries through behavioural factors. Mothers’ safety interventions in response to preventive measures apparently explain that if safety standards are not adhered to properly and promptly, mild to severe injuries are waiting for children.

One of the strengths of this research study was inviting therapists and specialists to collaborate with an eminent research team to determine the factors leading to injuries more precisely. This study attempted to interview mothers whose children had experienced house injuries. Employing two researchers to analyse and encode the data was another strong point of this study. Only Iranian participants were studied in this research project. Other factors might emerge in relation to house injuries in other countries and continents. In line with the suggestions offered by the participants, regular inspections and making sure that the safety standards are implemented are significant factors in minimising house accidents and injuries. Our findings can be the springboard for the dissemination of information to encourage policy-makers and lawmakers to pass stricter laws to implement safety standards for the required infrastructure. Passing laws and enforcing the policies and strategies can definitely put into effect the preventive measures to reduce house injuries.

Conclusion

Despite the existing obstacles such as long-term implementation, financial difficulties and overcomplicated policy-making process, health interventions can make it possible for mothers of children under the age of seven to adopt preventive measures through appropriately designed instructions and optimal use of existing facilities. Although this study identified a wide range of potential environmental and behavioural changes to reduce house injuries among children, the agents of such preventive interventions also need to get involved with the target communities so as to effectively identify the necessary changes related to the local culture.

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