**3. Common causes of trauma to children in the LMICs**

Armed conflicts not only cause physical trauma, but also increases mortality rate. For example, while it is estimated that the crude mortality rate globally and in sub-Sahara region are 1.2 and 1.4, respectively, that of DR Congo during the unrest of 2006/2007 was 2.2 deaths in every thousand people. The mortality increase is not only on adult population for there are reports showing indicating an increase in death rate to post-neonatal in war born regions [37]. Furthermore, armed conflicts create poor living conditions and economic insufficiency. Although many people die as a result of direct trauma during the conflicts, many more are likely to die due to the resulting socioeconomic and environmental constraints such as disease outbreaks and hunger. Armed conflicts are so traumatic that they cannot be forgotten easily. For this reason, even those who survive the war, whether injured or not, still suffer depression.

Other causes of trauma are less common when compared to road traffic accidents and falls but are of a relatively high incidence in the low and middle than in the high income countries. These other causes include; burns, assaults (either by human or animals), being fallen over by heavy load such as injuries due to a collapse of a wall, tree, or landslide. These causes make a big distinct epidemiological difference between LMICs and high income countries. Burns are among the most common cause of severe injuries, mortality, and disability which affects

Assault incidents are frequently reported in these regions and in some studies in South Africa, Uganda, and Latin America are rated as the leading cause of trauma ahead of RTA and falls [4, 38, 39]. Assault incidents in these regions are associated with alcohol consumption, interpersonal, and ethnic conflicts [40, 41]. Poverty as a result of high levels of unemployment among youths in these regions is also associated with violent crimes and attempt to earn a living by illegal means which includes forceful robbery. Incidents of alcohol consumption and violent behavior within lower and middle income countries can further be described. First, availability of local brews in so many alcohol outlets (bars) within the communities offers an opportunity people to access it easily. Local brews are cheap and are socially shared so that even those who cannot afford can still get a drink from a friend. Second, there are social events such as weddings, after burial and thanksgiving in the rural and semi-urban communities in which people can get local brews for free during such occasions. All these features increase accessibility to alcohol for the rural and semi-urban regions of LMICs. As a result, incidences of violence and assaults related to alcohol use increases simultaneously with the increase in traumatic incidents. Venomous snakes, insects, and other animals that can bite and cause serious injuries are also common especially to rural areas of the LMICs. For example, in Bangladesh, rural areas snake bite had incidence of about 624/100,000 person years, the majority of who works in the farms [42]. In one study from India, most deaths from envenomation were due to scorpion stings and affected mostly the children in rural regions [43]. The incidents of snake bites are so common, and the World Health Organization has issued a guideline for management of such injuries [44]. Despite the issuing of the guideline by the WHO, the challenge that remains is making it accessible to the rural dwellers of the LMICs. Even when the guideline is accessed, read, and understood by the people, they may need to be enabled to attain the tools and

**2.4. Other causes of trauma**

72 Current Issues in Global Health

children than adults.

equipment to respond to such incidents accordingly.

Children in rural LMICs incurs trauma frequently from various causes. Although children are also affected by RTAs and falls common causes of trauma in this group for rural and semi-urban regions is burns. Most of the burn injuries to children in these regions happens in the kitchen during cooking but may occur in other activities [45–47]. The use of open fires for cooking in areas is unsafe to children and elderly and ignorance on fire dangers are some of the contributing factors to burn accidents. In Uganda, it was found that burn is the leading cause of injury to children and in one hospital in Iran up to 47% of the burn cases were children less than 16 years of age [48]. Elsewhere in Bangladesh, a population-based study indicated that to every 100,000 children, 528 sustain burn injury of whom two may die while others recover with substantial impairments [45]. However, some studies reported that youth sustain burn injuries even more than children do. For example, in Nepal, it was found that young persons at the age between 24 and 25 had higher incidents of burn injuries than children [46]. A situational analysis of acute burn management in 32 low- and middle income countries indicated that most of the health facilities particularly in the rural and semi-urban regions were not equipped for burn management [49]. This being the case, it is reasonable to expect children who sustain burn injuries in these regions to have higher risk of disability and mortality as compared to those in higher income countries, where healthcare is more prepared for such incidents.

Apart from burn injuries, children in the rural and semi-urban regions of LMICs are faced by risks of other forms of physical trauma just like adults. As most of the rural areas of LMICs are characterized by trees and scarce play grounds, children not only tend to climb trees as part of their plays but also in search of edible seeds and fruits. In Bangladesh and India falling from height is one of the leading causes of trauma to children predominantly males dwelling in the rural and semi-urban regions [50, 51]. There are also accounts of children falling from poorly constructed balconies and windows of which the majority dies and the remaining suffering serious injuries with potential for a long-term disability [27]. In India it was reported that fall from height is the second cause of pediatric head injury next to RTAs [51–53]. Incidents of RTAs involving children and teenagers in LMICs are markedly high as compared to the high income countries [54]. This increased risk of being involved in RTAs can be explained by the fact that a majority of children and teenagers walks to school (pedestrians) or plays near roads where they are exposed to accident and other forms of road-related trauma. Crosswalks are few and where available, they are either not used by children due to ignorance or abused by the drivers or motorized vehicle. This problem could be reduced significantly if community members could volunteer in one accord to guide children in safely using the roads especially when going or coming from school. There is a saying in Kiswaili that "Mtoto wa mwenzio ni mtoto wako" meaning that your fellow's child is yours. If such a saying is used in this setting, it means every person will view the child on the road as his or hers, hence ensuring safety to every child.

It is common in these regions for children to join their parents in different socioeconomic and cultural activities such as feeding cattle and farm works in what can be regarded as "learning by doing." While assisting or performing these tasks by themselves, children frequently sustains physical trauma due to mismatch between the forces demanded by the task against their physical abilities. Furthermore, children may not perceive risks of falling and getting injured as adults do. These two facts may account for injuries sustained by children when working in the rural and semi-urban regions. A study from one of the rural areas of Nigeria reports that most children with ocular injuries sustained were injured while working in the farms or playing [55]. Furthermore, children are comparatively vulnerable to physical trauma during dangerous incidents that may happen in their residences. These dangerous incidents are such as a fall of a poorly constructed house, throwing of wreckages during strong winds, earthquakes, and heavy rains. Youths and young adults may manage to escape in such disastrous incidents, while a majority of children fail to do so hence sustaining physical trauma.

elementary school teachers and school environment will be equipped to deliver such education and skills. There are other opportunities in LMICs to train laypersons on this regard. For example, women cell groups, village community banking (VICOBA) meetings, and faith based gatherings such as churches and mosques. However, as civilian services are hardly standardized and rarely sustainable, LMIC governments should be encouraged to plan for paramedic services which will ensure that a seriously injured person is handled by a well

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

http://dx.doi.org/10.5772/intechopen.79545

75

Rural and semi-urban regions of the LMICs are predominantly inhabited by the poorest of the world population. In general terms, poverty instigates risky activities and poor environmental and occupational safety standards leading to trauma and the resulting disability is also associated to future poverty, hence a vicious cycle [59]. For this reason, any financial-demanding preventive, curative, or rehabilitative strategies against trauma and its consequences are severely limited. Although there is scarcity of reports on trauma-related health costs from LMICs, it is generally apprehended that such cost is unbearably high to this population [59, 60]. Consequently, persons who sustains trauma in these regions either dies (before or immediately on arriving to the health facility) due to a lack of emergency and life support services or remains with irreversible disability. It is "lucky" for a seriously injured person from these regions to survive without any residual significant impairment. Inadequacy in evacuation, transportation, and timely management of trauma casualties are factors prehospital mortal-

**5. Consequences of trauma to rural and semi-urban regions** 

ity, secondary injury, and disability which could otherwise have been avoided.

health system individual and immediate family.

The cost associated with trauma-related disability in these regions is rarely researched, but it is an irrefutable fact that they are common and costly in these regions. Reporting in the bulletin of the World Health Organization, Gosselin and colleagues refers to injuries as a neglected burden in LMICs [60]. It is indeed forgotten as very few projects on trauma are carried out and or published from these regions. When matched against country-specific gross domestic product (GDP) trauma in the rural and semi-urban regions of the LMICs are astronomically costly. It is estimated that most countries in the LMICs spend between 1.1 and 2.9 of their Gross Domestic Product (GDP) to trauma due to RTAs alone [61, 62]. In Thailand, it was estimated that for 10 years, more than 5 billion dollars had been used due to RTAs-related trauma [63]. Trauma also induces a significant straining on the already resource-constrained

In these regions, there are hardly any published estimates of social costs due to trauma including those resulting from other causes such as falls, burn, and assaults. However, it is known that most developing countries lack basic social security system from which a person who incurs trauma can be supported to attain healthcare and rehabilitation services accordingly. This means that the whole treatment cost for someone with significant trauma is left to the individual and immediate family. It follows that if the injured person and immediate family

trained personnel from incident scene.

**of the LMICs**
