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

伤害是世界各地儿童死亡的主要原因。在全球范围内，每年有近65万名15岁以下儿童因受伤和暴力而丧生。这种负担在低收入和中等收入国家（LMIC）和高收入国家（HIC）之间分布不均，中低收入国家因意外伤害造成的死亡率几乎是高收入国家的两倍。特别是，撒哈拉以南非洲是世界上5岁以下儿童死亡比例最高的地区。这些伤害中有70%以上是非交通意外或“意外”伤害。有证据表明，很大一部分儿童意外伤害发生在家中及其周围，人们通常认为儿童在家中受到很好的监督。儿童，特别是5岁以下儿童，在家中及其周围花费大量时间，这使他们暴露于各种伤害危险之中，例如没有安全烤架的楼梯和窗户，接触有毒物质和化学品，接触露天水域，使用地面炉灶。尽管过去二十年来全球儿童伤害死亡率总体下降，但现有数据表明，中低收入国家的下降速度要慢得多，中低收入国家与高收入国家之间的差距正在扩大。造成这种情况的部分原因是中低收入国家的风险较高、预防措施不足以及无法及时获得医疗服务。高收入国家对儿童家庭伤害的性质有充分的记录，但中低收入国家对家庭伤害的了解要少得多。我们对预防儿童在家中受伤的了解大多来自于在高收入国家进行的研究，在这些国家，预防措施已被证明是有效的，例如安全帽、烟雾报警器、楼梯门以及对父母/照顾者的教育。目前尚不清楚的是，这些措施在中低收入国家的效果如何。本研究旨在测试儿童安全工具包（通过共同设计开发，以反映不同的风险概况、文化适宜性和可用性/可负担性）与传统教育的有效性。该研究将在乌干达金贾进行，分为两个阶段：第一阶段（该发展赠款的重点，为期一年）将侧重于将儿童伤害问题置于背景下，并通过混合方法（审查医院数据、与父母/护理人员进行焦点小组讨论、对关键线人进行深入访谈、进行可负担性/可获得性调查以及进行市场调查，以确定购买安全设备的意愿）开发儿童安全工具包；第二阶段将通过集群随机对照试验（cRCT）来衡量行为变化和伤害减少。我们将评估两个村庄（组）的儿童伤害减少情况，其中一个村庄将拥有完整的儿童安全工具包，包括教育材料、讲习班和家长宣传活动，而另一个村庄只有教育，为期3年。第一阶段的一个关键组成部分将是支持科研人员、决策者和家长之间的合作研究，以便所有与5岁以下儿童健康有关的利益攸关方都有机会从构思到成果交流全程参与。共同设计方法将导致制定一项全面的干预措施，其中包括儿童安全包、教育材料、为父母举办的培训讲习班和以社区为基础的提高认识运动。从一开始就让社区参与进来，将通过分享意见和经验来提高知识和意识，并将优化第二阶段的设备使用。第一阶段的结果将确定实施干预的任何挑战，为计算cRCT的样本量和确定关键结果提供准确的数据。据我们所知，这将是第一次在非洲开展的儿童安全设备和教育方面的应急响应小组。

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.