**1. Introduction**

Though rarely reported, physical trauma remains one of the major causes of mortality and disability in the rural and semi-urban regions of the low and middle income countries (LIMCs). Unlike in the high income countries, where most occupational injuries happen in

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the formal sector and transportation, trauma in LMICs particularly rural regions occurs in informal occupations that are seldom monitored by occupational health laws and regulations. For example, a majority of the working class in the developing rural regions are informally self-employed in agricultural and entrepreneurship activities that are not governed by any occupational health and safety regulations. It can fairly be perceived that there are more factors for physical trauma in LMICs, as compared with developed regions, and so prevention is multifarious.

The author of this chapter is a senior physiotherapist and assistant lecturer at the Kilimanjaro Christian Medical Centre and University College in the North-East of Tanzania. Being born here, he has witnessed serious traumatic incidents resulting from very diverse risky activities and environment of rural and poverty-stricken regions within and around the Kilimanjaro region. While taking his Masters Studies for 2 years in Cape Town—South Africa, he had a chance to supervise undergraduate students in their clinical placement in Groote Schuur and Tygerberg hospitals in the Western Cape. He noted that in the Western Cape, the leading causes of trauma were far different from those dominating Tanzanian rural and townships. Furthermore, he wrote his Master's thesis (and now PhD) on occurrence and life after spinal cord injury in the rural settings of Tanzania. In both of his endeavors, he further noted that spinal cord injuries in rural settings of the LMICs result from various causes unique to these areas. In this chapter, he takes what he has learnt over the years as a clinician and a researcher and supports this with various studies from other settings with relatively similar characteristics. The literature search to support each subtopic of this chapter was carried out in PubMed, reference lists of various studies, and Google Scholar. Commonly used terms during the search were Trauma, injury, Rural, developing countries, low and middle income

Physical Trauma and Its Consequences in Rural and Semi-Urban Regions of Low and Middle…

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**2. Causes of trauma in the rural and semi-urban regions of LMICs**

Road traffic accidents are reported to be the leading cause of trauma and death globally due to the resulting fatal injuries, worse in most parts of LMICs. A novel cohort study carried out in sub-Saharan Africa reported that most of serious injuries in rural and semi-urban regions were due to road traffic accidents [4]. In rural areas of Bangladesh, for each 1 million people, 8890 gets injured of whom 60 dies annually due to road traffic accidents alone. It was also found out that of those who sustain RTAs as pedestrians, one-third died [5]. Still, like in many other trauma epidemiologic studies in LMICs, those who died before arriving to the hospital were lost to the count. For this reason, the reported figures do not reflect the true magnitude

There are unique environmental, economic, and sociocultural factors that make RTAs prevalent in these regions of the LMICs. First, the number of vehicles does not match the available road space; hence, there is a congestion of pedestrians, cyclists, trees, and two motorcyclists. Most African rural and semi-urban regions have witnessed an influx of three- and twowheeled motorized vehicles as means of public transport, while the number of roads and structures remains more or less the same. Following the increase of motorized vehicles in limited road space in the LMICs, especially in the rural regions, the incidence of RTAs in the recent years has been escalated. A recent population-based study in one of the Tanzanian rural areas indicated that most road traffic injuries (RTIs) were due to motorcycle accidents, affecting males in their twenties [6]. Furthermore, most roads in LMICs have neither traffic

countries, and etiology.

**2.1. Road traffic accidents**

of the problem.

Causes of physical trauma in the rural and semi-urban regions are as diverse as the diversity in geographical, cultural, and socioeconomic features of these areas. For this reason, even within the same country, strategies to prevent and manage physical trauma ought to consider these variations. Furthermore, rural traumatic causes of physical injuries are significantly different from those dominating big cities even though they may be in the same country. For example, activities that involve climbing trees (from which one may fall) or working in the farmyard, hence a risk of being bitten by venomous insects or animals, are rare in big towns and cities of the high income countries but common in rural LMICs. Furthermore, individuals living in these regions continuously face danger of being attacked by either a domestic or wild animals which may charge and cause injuries. In one study in Ethiopia, both hospitalized and nonhospitalized persons who had suffered a dog bite were enrolled, and it was shown that more than 655 persons had suffered such injuries in a period of 1 year only [1]. Regardless of the population size, it is obvious that this is a high incidence rate and reflects poor legislation governing domestic animal keeping in most LMICs. Legislations for keeping domestic animal which are either ill-stipulated or lightly implemented add a risk of animal-related trauma to individuals living in LMICs. Furthermore, environmental and socioeconomic activities that add to the risk of trauma to the inhabitants of the rural areas are living in unsafe buildings, cooking in open fires, frequent head loading, working with sharp cutting objects, and working up or under trees. Head loading is the act of carrying heavy load on the head as means of transferring objects over a considerable distance. Head loading is a very common act among LMICs rural inhabitants in their crucial attempt to collect water, firewood, cattle feed, and crops to the homes or market place. In one of the centers for rehabilitation for persons who are paralyzed in Bangladesh, it was shown that for 3 years at least 84 persons had suffered cervical spinal cord injury as a result of falling while carrying heavy load on the head [2].

Trauma is costly in terms of evacuation, transportation, and management, and it is even worse when the individual has to remain permanently disabled. In the LMICs, this cost is normally borne by the individual and or immediate family as most countries have weak social support for a disabled person. Bearing in mind that rural and semi-urban regions of LMICs are residences for the poorest, this cost is unbearable in most cases. This unmet cost could explain the reported unavailability and unaffordability of transport services for trauma victims in these regions [3]. Delays and mismanagement of a traumatized person due to lack of appropriate equipment adds to the risk of secondary injury and death. Poorly managed and or rehabilitated victim of any physical trauma is at higher risk of health complications, dependency and in the worst case scenario, death.

The author of this chapter is a senior physiotherapist and assistant lecturer at the Kilimanjaro Christian Medical Centre and University College in the North-East of Tanzania. Being born here, he has witnessed serious traumatic incidents resulting from very diverse risky activities and environment of rural and poverty-stricken regions within and around the Kilimanjaro region. While taking his Masters Studies for 2 years in Cape Town—South Africa, he had a chance to supervise undergraduate students in their clinical placement in Groote Schuur and Tygerberg hospitals in the Western Cape. He noted that in the Western Cape, the leading causes of trauma were far different from those dominating Tanzanian rural and townships. Furthermore, he wrote his Master's thesis (and now PhD) on occurrence and life after spinal cord injury in the rural settings of Tanzania. In both of his endeavors, he further noted that spinal cord injuries in rural settings of the LMICs result from various causes unique to these areas. In this chapter, he takes what he has learnt over the years as a clinician and a researcher and supports this with various studies from other settings with relatively similar characteristics. The literature search to support each subtopic of this chapter was carried out in PubMed, reference lists of various studies, and Google Scholar. Commonly used terms during the search were Trauma, injury, Rural, developing countries, low and middle income countries, and etiology.
