Article Text
Abstract
Background Child injury is not seen as a new issue in medical science and public health; however, for years it has been either generally brushed aside or been conspicuously absent from the world health agenda. This study aims at investigating the factors leading to house injuries and attempts to highlight mothers’ pivotal role to provide a safe place for children at home.
Methods A qualitative research method was used. There were 29 interviews in total: 12 interviews with mothers, 9 with cure and prevention specialists and 8 with researchers. The data were gathered through semistructured interviews conducted in participants’ workplaces namely universities, research centres, health centres and in some cases through telephone in 3 months from February 2021 to May 2021 in Tehran, Iran. The participants were selected through non-probability and purposive sampling. All of the recorded interviews and notes were accurately evaluated and data analysis was performed based on the content analysis.
Results In this study, 29 participants’ views were examined: 12 mothers (41.37%), 8 researchers (27.5%) and 9 treatment and prevention experts (31%). After the analysis of the interviews, 96 codes, 14 subcategories and 3 main categories were extracted. The main categories included the predisposing factors, reinforcing factors and enabling factors. The subcategories included perceived sensitivity, perceived susceptibility, health control centre, perceived benefits, observational or peripheral learning, social support, family support, abstract norms, valuing children’s health, background factors, skills, rules and regulations, child’s character traits and self-efficacy to overcome barriers.
Conclusion House injuries among children are a complicated and multifaceted issue that requires a comprehensive investigation to determine the contributing factors.
- multiple injury
- education
- health education
- public health
Data availability statement
Data are available upon reasonable request.
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Introduction
Child injury is not seen as a new issue in medical science and public health; however, for years it has been either generally brushed aside or been conspicuously absent from the world health agenda. As a result, the WHO, UNICEF and many other organisations have resolved to put child injury high on their list of priorities to develop public health and healthy societies.1 Injury can be classified as intentional and unintentional. The latter happens when there is no intent to cause an injury.2 3 As a result of recent developments in research and preventive measures, the global sufferings due to injury-related diseases have been on the decline.4 5 However, five million deaths with 12% child mortality are still annually reported to be directly linked to injury.6 Over 900 000 children under the age of 18 years die of unintentional injury every year.6 According to UNICEF report in 2018, injury accounted for the 30% of fatalities in the 0–19 years age group.7 In the same year, WHO reported that 55 039 children under the age of 5 years in eastern Mediterranean region lost their lives due to injury, with nearly 336 271 children in all regions.8 Unintentional injuries have recently been a major threat to children’s health.9 WHO sees the reduction of injuries a high priority10 and introduces it as a critical issue in global public health. Such injuries not only impose a big burden on healthcare system2 but emotionally and socially they can also have an adverse effect on children, family and society as a whole. Children living in poor countries usually bear the brunt of the injuries.11 Children in the eastern Mediterranean region suffer the most with regard to unintentional injuries in a way that 12% of injury-related deaths happen to low-income and middle-income countries and to people under the age of 20 years.12 The injuries explain the main reason for medical expenses, disabilities, loss of efficiency and premature death.3 What increases the risks of ever-increasing injury in low-income and middle-income countries is a delay in attempts to respond to unintentional injury, which is generally the result of a faltering health infrastructure.13 14 Over 90% of global deaths and injury-related disability-adjusted life years (the number of years lost due to ill health, disability or early death) are witnessed in low-income and middle-income countries, which is three to four times higher than that of rich countries.15 According to statistics reported by child health centres in Iran, on average 20.2% of child mortality under the age of 5 years is caused by unintentional injuries.16
Margaret Chan, the former Director-General of the WHO, and Ann Veneman, the UNICEF’s former Executive Director, asserted that unintentional injures pose a serious risk to children’s survival within the first 5 years. These injuries and the resulting disabilities, which prove preventable,1 can contribute to long-term effects on all aspects of the child’s life such as their communication, learning and playing,17 or at worst to death or severe disability.18 19
House injuries reflect people’s personality and lifestyle and with every new technological or cultural change, a new category of injury appears.19 The pattern of injury among children and teenagers represents the basic profile of the particular risk. However, there is not much awareness raising to minimise house injuries in a culturally appropriate manner.20 Therefore, in order to have a better understanding of health and safety behaviour, we need to take heed of people’s reaction to injuries and assess the factors influencing their behaviour.21 Studies show that the home can be a significant place for injury. In the analysis of child’s injuries, the home is an important place for injuries, because children, especially preschool children, spend most of their time at home.22 23 The WHO and the UNICEF set out child injuries as an important priority for the global public health and communities' development.1 Thus, it is necessary to design and implement health education and promotion interventions to reduce children’s home injuries. The theoretical frameworks and models set our general perspective on a topic and clarify people’s views on what activities should be done, which provide a framework to address health problems, design, implementation and evaluation of programmes, and experts—especially health education and health promotion professionals—need to have a deep understanding from the educational and ecological determinants of the subject for planning. The PRECEDE–PROCEED1 model is the result of over 40 years of research by Dr Lawrence Green and his teammates.24 This model investigates and analyses the contributing factors to change of behaviour in enhancing health over time.25 26 The PRECEDE–PROCEED model involves two common components and eight stages and directs planning and developing health interventions by taking into account epidemiology, health education, behavioural science and health management.27 This model can be broadly divided into planning (PRECEDE, phases I–IV) and evaluation (phases V–VIII).28 The PRECEDE component specifically focuses on identifying health problems and investigating the predisposing factors as well as the frameworks to account for health behaviour. This component consists of social evaluation, epidemiological evaluation, genetics, behaviour and environment, educational and ecological evaluation to identify the predisposing, reinforcing and enabling factors, official evaluation and policy making.27 The PROCEED component is specified by four stages in implementation, intervention evaluation and the effect of intervention on determining factors of behaviour.25 26
During the prolonged lockdowns due to COVID-19, parents and health advocates can play a key role in helping children to restore a healthy and socially active life.29 In fact, many international reports have pointed out that parents, health experts and other key agents can effectively prevent a great number of house injuries.30 Some studies have mentioned that factors such as technology, cultural structure and people’s perception affect the occurrence of events, which can be effective in the current research and programme design; on the other hand, the evidence in this subject is limited and have no necessary comprehensiveness. Therefore, in order to have a better understanding of health and safety behaviour and how people perceive the risks of injury and what factors affect their behaviours, the basis of the research started with a qualitative study and using a comprehensive planning model, Since the PRECEDE–PROCEED model is a comprehensive framework for evaluating the quality of life and health and is also identified as an effective approach toward improving health and quality of life,25 this study aims at investigating the factors leading to house injuries and attempts to highlight mothers’ pivotal role to provide a safe place for children at home. It is hoped that such measures can prevent or minimise house injuries and a culture for children’s health and welfare is established.
Methods
Study design
The qualitative research is an effective method to extract participants’ experiences and viewpoints with respect to a particular topic or area.31 The current research is a qualitative study of a directed content analysis type.
Participants
This study aimed at understanding the views of two professional groups specialising in prevention, treatment and research (health education experts, epidemiologists, paediatricians, nurses, healthcare experts) and mothers. Their views helped to identify the educational and ecological factors with respect to house injuries among children. The participants were selected through non-probability and purposive sampling method with maximum variation (education level, income level, age, people’s experiences and job status).
There were participation criteria for the researchers: those with research interest in child injury, only paediatricians as cure and prevention specialists, experienced healthcare experts, experienced nurses having served in injuries’ and children’s wards and mothers with a child younger than 7 years. There were 29 interviews in total: 12 interviews with mothers, 9 with cure and prevention specialists and 8 with researchers. The participants were informed about the purpose and the questions of the study. Then, the time and the place of the interview were chosen at their convenience.
Data collection
There were 29 participants. The data were gathered through semistructured interviews conducted in participants’ workplaces namely universities, research centres, health centres and in some cases through telephone in 3 months from February 2021 to May 2021 in Tehran, Iran. All interviews were conducted by the researcher. The guiding questions were based on the fourth phase of the PRECEDE–PROCEED model, that is, educational and ecological assessment with its content validity determined by the research team. The interview began with demographic questions (age, education, occupation, etc) and proceeded to more comprehensive questions regarding house injuries (table 1). The interviews lasted between 20 and 40 min. The interview transcripts were sent to the participants for approval. Data saturation was reached with the 26 interviews. In the interviews saturation in the data was general.
Three more interviews were conducted just in case. However, no additional new information was obtained and the data collection process came to an end.
Data analysis
Content analysis method was employed to inductively analyse the interviews through the software MAXQDA. The interviews were recorded, transcribed and analysed. The interview transcriptions were encoded by two independent researchers. Data analysis was conducted simultaneously and continuously during the data collection process. In sum, the coding process includes extracting open codes from the participants’ sentences (after having read the interviews thoroughly) and reviewing the codes several times. On the basis of similarity and consistency, codes representing one similar issue were classified under the same category. The main themes were integrated into their similar subcategory. This process was examined and summarised several times by the research team.
Guba and Lincoln’s assessment method was used to ensure the validity and reliability of this study and four criteria were assessed: credibility, confirmability, transferability and dependability. Long-term conflict engagement (immersion) and peer review were considered to achieve credibility.32 The description of the participants and the research environment were used for increased transmissibility. To approve conformability, we recorded all of the research activities over time. The data were reviewed by two independent individuals for confirmation of dependability.32
Results
Characteristic of participants
In this study, 29 participants’ views were examined: 12 mothers (41.37%), 8 researchers (27.5%) and 9 treatment and prevention experts (31%). The average age of mothers was 31 years, when 58.3% of them were housewives and 41.6% were employees (table 2). After the analysis of the interviews, 96 codes, 14 subcategories and 3 main categories were extracted. The main categories included the predisposing factors, reinforcing factors and enabling factors. The subcategories included perceived sensitivity, perceived susceptibility, health control centre, perceived benefits, observational or peripheral learning, social support, family support, abstract norms, valuing children’s health, background factors, skills, rules and regulations, child’s character traits and self-efficacy to overcome barriers. Figure 1 shows the output results.
Classes of ecological educational factors
Predisposing factors
The predisposing factors are those that encourage the occurrence of a particular behaviour. According to experts and mothers, these include perceived sensitivity, perceived susceptibility, health control centre, perceived benefits and observational or peripheral learning (table 3).
Perceived sensitivity
Some of the participants mentioned mothers’ understanding of and attitudes toward house injuries and how vulnerable children can be.
Sometimes it goes back to mothers’ attitudes. In general, they don’t see their own children prone to danger. We conclude that most of the times, mothers don’t think that such things might happen to their own children. (P=15, a health education expert)
Perceived susceptibility
The participants believed that the sense of susceptibility to injuries and the possibility of children’s death are crucial factors in observing safety issues.
Our mistakes might have dire consequences for our children. injuries might not happen, but when it happens, the injury might be irreversible, causing lifetime challenges. (P=23, a paediatrician)
Health control centre
It refers to the extent that an individual’s health is controlled by internal or external factors such as luck or destiny.
Sometimes it has to do with the family’s attitude. I mean they don’t care about injuries or safety issues. They think if something is going to happen, it will. (P=26, a nurse)
Perceived benefits
In this subcategory, the participants refer to mothers’ understanding of the benefits they will have from adopting safety measures.
Taking safety measures can often contribute to the family both emotionally and economically because injuries affect the child emotionally, harm the family economically, and put a lot of psychological pressure on mothers. (P=21, an epidemiologist)
Observational/peripheral learning
Some of the participants said that seeing others wearing seat belts or witnessing bus injuries could encourage passengers to wear seat belts on buses.
When I see what has happened to a child, I become more aware of my actions and try to take better care of my child for a while. (P=10, a mother)
Reinforcing factors
Reinforcing factors that follow an action or the result of an action include the subcategories such as social support, family support, social norms and valuing children’s health (table 4).
Social support
According to most participants, accessing social and emotional support, provision of equipment and information access are some of the most important factors to prevent house injuries.
I remember that in the1980s there were some great movie clips and animations about potential dangers such as using a meat mincer or children literally playing with fire at home. Although these programmes were designed to target children, somehow parents were influenced as well, in a way that they made parents sensitive to and aware of such dangers and risks. (P=1, a mother)
Family support
Participation and encouragement by all family members were considered indispensable in keeping up with preventive measures to avoid house injuries.
If the father and other family members assume some responsibility at home, the mother will have more free time to take care of her children and as a result prevent many injuries. (P=28, a health expert)
Abstract norms
Some of the participants assert that a mother needs to believe that her family members approve of her safety measures and in turn that mother is highly likely to take others’ views into serious consideration.
Sometimes some views towards childrearing such as ‘don’t spoil your child’ or ‘let him experience everything’ might make mothers discouraged. Sometimes older people might cause trouble by giving improper food to the child, leading to choking or other complications. At times, there is a need for caretakers, young and old, to take part in sessions to prevent injuries. (P=20, a paediatrician)
Valuing children’s health
The participants pointed out mother’s preference to ensure child’s safety and giving priority to the safety of household appliances over their beauty and attraction.
Most mothers are concerned about cleanliness and putting away everything. However, most of them keep the detergents and washing liquids on the accessible shelves in the cabinet. In fact, they care more about tidiness than safety. They don’t realize that when there is a child at home, only necessary items should be visible and accessible. (P=8, a mother)
Enabling factors
The enabling factors include subcategories such as background factors, skills, rules and regulations, child’s character traits and self-efficacy to overcome barriers (table 5).
Background factors
Factors such as age, sex, mother’s education, mother’s skill, training and socioeconomic condition play a significant role.
When there are more children in a family and more chores to do, mothers can’t have full control over children’s playing. (P=27, a health educator expert)
Skill
Some of the respondents stated that behavioural skills are an important factor in implementing safety measures at home.
Living environments are very risky, which definitely requires sufficient and appropriate skills to perform safety measures before accidents, such as the skill of replacing safe tools or the skill of managing accident-prone cases, or at the time of an injury such as first aid. (P=1, an epidemiologist)
Rules and regulations
What some of the participants mentioned in relation to the significant role of rules and regulations is as follows: regulating civil engineering; manufacturing house appliances and the role of import and business in the ministry of health, department of education, social welfare system, municipality and many such organisations which can directly or indirectly impact injuries.
There are no child’s safety measures in relation to the completion of the building. However, in the end, the crux of the matter is whether you have observed all the safety standards. If not, no certificate of completion of the building is granted. The certificate implies that this house is safe for all the members of the family. If it is not granted, it means the house is incomplete. (P=19, an epidemiologist)
Child’s character traits
The respondents pointed out some of the dominant personality traits contributing to injuries such as stubbornness, curiosity, naughtiness and small physique.
In my opinion, some children are more curious, and some are more active and prone to house injuries. It’s all about childhood curiosity and the desire to know more about the environment. (P=2, a mother)
Self-efficacy to overcome barriers
Despite some challenges, the participants consider mother’s self-efficacy as very critical to implement safety issues.
Children are surrounded by many incidents inducing injuries. However, our behaviour and reactions can mitigate the extent of injuries. This way children will be at least less in danger. (P=18, a nurse).
Discussion
Research studies have shown that although fewer children die of infectious and chronic diseases these days, more mortalities have been globally reported as a result of injuries.33 Therefore, prevention of injury should be an integral part of public health.34 This study demonstrated that three categories of factors contribute to house injuries. The first category includes the predisposing factors which cause a behaviour prior to or during its occurrence.35 In other words, they encourage a particular type of behaviour.36 The factors extracted included parents’ lack of sensitivity, understanding the dire consequences of house injuries, understanding the benefits of following safety standards, understanding the controllability of events and the effect of watching others taking safety measures.
The second category—the reinforcing factors—includes the rewards and punishments, which accompany or are predicted by the result of an action or behaviour. These factors can stimulate a particular type of behaviour.35 According to the results of this study, these factors include social support, family support to implement safety measures, complying with significant members of the family with respect to following preventive measures and parents prioritising children’s safety over anything else. The third category deals with the enabling factors, which facilitate and improve reactions, skills or the essential resources needed for a particular action to take place.35 The typical examples cited are demographic and cognitive factors, parents’ skills in recognising ways to minimise dangers, certain rules and regulations, child’s personality traits and many other factors that are compatible with the results of this study. One study showed the inevitably of house injuries; however, safety matters did not receive due care and attention.21 Another research study demonstrated prevention of child injury as a result of the inevitability of threats, not parents’ power of prediction.37 In fact, if the adverse effects and the resulting complications of injuries on child’s present and future life were fully understood by parents and caregivers, lots of such injuries could be prevented. In addition, some evidence was found to exist on the effect of perceived susceptibility on the adoption of safety measures.38
One research study in Bangladesh blames destiny for a child’s drowning and regards it as inevitable.39 In another study, understanding the potential threats as one way to prevent disasters was considered effective, although the nature of injuries was believed to be influenced by one’s destiny.40 The results of another study linked the child’s injuries to coincidence, bad luck, witchcraft and tragic fate.41 The evidence suggests that the main factors influencing injury prevention are sociocultural setting such as belief in destiny in a particular community or state policies such as lack of safety standards in homes.30 Not knowing how to prevent injuries and believing in the inevitability or unpreventability of injuries are two critical issues in a community, which can be tackled through educating children and adults. We might not be able to keep danger at bay completely; however, we can take measures to turn real dangers to potential ones. A Nepalese study recommends educating parents and children regarding safety.41 At times, education and awareness raising consistent with children’s age can change people’s attitude and their perceived susceptibility, leading to the adoption of preventive measures. In addition, children’s training should be designed in a simple, cautious and careful manner. Despite their cognitive development, children cannot understand and evaluate the environmental condition in its totality. Therefore, they might not act promptly and properly in the face of dangers.
Another important factor is observational or peripheral learning that can not only form new sets of behaviour but it can also affect the frequency of occurrence of former learnt behaviour. Peripheral learning can even reinforce forbidden behaviour.32 Thus, it is expected that observing other parents taking safety measures can influence mother’s behaviour. The perceived benefits include those that one gains in return for following safety measures which can play a key role in behaviour change.32 According to one study, communicating with one’s spouse, not trusting neighbours or not entrusting one’s child to strangers and viewing politicians with scepticism were cited to be the contributory factors in house injuries.40 Following these steps seems to be helpful: holding regular family meetings and discussing safety matters at home, planning to remove the source of dangers, reducing the level of exposure to danger and division of labour and responsibilities.
In England, a group of health experts found out that lack of regulation in fire department services has resulted in budget deficiency, for example, to instal smoke detectors in houses. They regarded bad and unfair laws as an impediment to implementing injury-prevention programmes.42
The results of a study indicate that the government’s policies and practices as well as safety programmes are the main predictors of house injuries.21 Research findings point out that reviewing policies and considering unequal health services can significantly reduce unintentional injuries among children.40 One research study examined a multitude of factors such as holes and conflicts in laws, lack of control over resources, supplying and installing safety equipment, constant use and support, maintenance and inspection, family’s lack of access to proper information about laws and policies and the adverse effects of tenancy and living in crowded areas.40 Inspecting and checking houses as well as training courses on safety equipment can reduce the possibility of poisoning and falling.11 In another research project, policy-makers asserted that they are not directly involved in the prevention of unintentional child injuries; however, they take other measures that can indirectly alleviate the problem such as developing the required infrastructure, supervision and inspection and leadership and operational activities.9 Disregarding the alarms installed on equipment is introduced as another cause of house injuries.43 The participants of another study cite financial difficulties as an obstacle to preventing house injuries.44 Parents living in rented houses report that they do not have adequate facilities to provide safe places for their families.40 Promotion of safety measures for mothers requires amendments to the existing laws, passing new laws and providing funds for families.
The results of one study reveals that the root cause of house injuries lies in culture, socioeconomic condition of families as well as state policies and geography. Parents who attempt to minimise and prevent house injuries are influenced by many factors mainly related to lack of awareness and economic difficulties.30 It seems that families who live in poverty usually underestimate the potential dangers and receive less training and preparation. Families should accept safety as a representation of culture and its development should be a primary concern for individuals, families and societies.
The demographic features of a family were seen to be related to an increase in the possibility of unintentional injuries among children. Low education, female breadwinners, more children and a feeling of fatigue were reported to be some of the hurdles parents face, which make adoption of safety measures ever more challenging.37 Among children, boys suffer more threats and injuries.45 This might be due to the fact that boys are highly exposed to danger compared with girls. Psychological factors also play a part. For instance, behavioural disorders, lack of impulsivity control and antisocial behaviour as external behaviour are closely linked to an increase in injuries. In addition, anxiety and depression as internal behaviour might disturb concentration for a child and pose increasing threat of injury as a result.46 Due to lack of discernment of threats and lapse of attention and concentration in stressful moments, children are obviously in danger of more injuries. The findings of this study provide a comprehensive view of the determinants occurrence of home injuries in Iran and suggest the necessity of interventions in mothers ’attitudes, skills and perceptions, ongoing education, more attention to environmental issues and careful consideration needs to be given to safety legislation and regulation throughout the country.
Strengths and limitations
One of the strengths of this research study was inviting therapists and cure and treatment specialists to collaborate with an eminent research team so as 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.
Conclusion
House injuries among children are a complicated and multifaceted issue that requires a comprehensive investigation to determine the contributing factors. These factors interact with individual, social, structural and political facets and proper interventionist strategies need to be presented to prevent house injuries. This study highlights a multitude of barriers and facilitators, which hinder or enable mothers to prevent child injuries in Iran. The results of this study can positively influence decision-making and the programmes designed to prevent and minimise house injuries among children in Iran.
What is already known on the subject
Studies in the area of injuries among Iranian children have mostly focused on their frequency and epistemological pattern, with a few interventionist studies.
Qualitative studies have classified the factors in a limited fashion.
What this study adds
The extracted factors in this study include a wide variety of factors in three main categories: predisposing factors, reinforcing factors and enabling factors.
This qualitative study is known to be the first of its kind to employ the views of two research areas—therapists as well as researchers—in light of mothers’ perspectives on house injuries.
The results of this study provide valuable insights into the reasons for the observance of preventive measures to reduce injuries among children.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study is part of a Ph.D. dissertation on Health Education and Promotion approved by the Ethical Committee of Shahid Beheshti Medical University (IR.SBMU.PHNS.REC.1399.068). By highlighting the purpose of the study prior to the interview, the interviewer made an effort to establish a good relationship with the participants. The participants were reassured about the confidentiality of their names and the reason for their inclusion in the study.
Acknowledgments
The research team appreciates all the participants—specialists and families. The authors are also deeply thankful to the reviewers whose comments and suggestions will definitely make a remarkable improvement to the quality of this research paper.
References
Footnotes
Contributors All authors conceived and designed the study and read and approved the final manuscript. EL-M: interviews. EL-M and MG: data analysis, were responsible for the initial drafting and editing of the manuscript and approved the manuscript for submission. MG, SR and AR: revised the manuscript. MG is guarantor for this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
↵PRECEDE, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation - PROCEED, an acronym for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development.