Fall Injuries Prevention among Rural Population, with Contribution of Rural Health Workers

 
Fall Injuries Prevention among Rural Population, with Contribution of Rural Health Workers
 
Mohammadreza Shokouhi ^1,2*
 
1 Department of Emergency & Disasters Health, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
² Deputy of Treatment, Hamadan University of Medical Sciences, Hamadan, Iran
 

he fall injury is an important public health problem associated with morbidity, individual and collective cost of the health care (1, 2). Furthermore, Falls are significant health concerns for adults with intellectual disability of all ages resulting  injuries (3). One-third of people older 65 years, experience at least one fall annually (4). Injuries caused by falls such as broken bones or head injury, may result in disability, premature death, or a lower quality of life (5, 6). Falls account for 1% of the total loss of healthy in 2002 (WHO)(1).  In low and middle-income countries, it is ranked as number one in Disability-Adjusted Life Years(DALYs) lost in the age group 5 to 14 years; however, it is negligible as a cause of death in these countries(1).
In middle-income countries there is limited knowledge about fall epidemiology in the general and in the rural areas, in particular. However,  different studies show that falls are common among the elderly (5, 7). Considering health transition and increasing life expectancy in such countries it is indicated that fall injuries need more attention.
Fall injuries are preventable just as other injuries (8). Preventive measures could be possible through environmental modifications (in and outdoors), product design and individual behaviour, although the modification of high risk behaviour, as an important factor, could be more difficult to achieve(1).
In Iran, in general and in rural areas, studies about the epidemiology of fall injuries and their prevention are  not common(6) and increasing knowledge in this field to develop any context relevant prevention program is essential both in urban and rural areas. Currently, approximately one-third of the total population lives in rural areas (9) where people benefit from a well-established health network, consisting of village-based
local "health houses". These houses are run by well-trained community health workers (known as Behvarzes) who are also local residents.
The control and prevention of all kinds of injuries affecting people from rural areas has been put at the agenda of the Ministry of Health and Medical Education of Iran for some time. A number of injury studies have been conducted in recent years in Toyserkan County (10-15) which is the setting of this study. The previous studies showed that falls are the second most frequent cause of severe injuries after road traffic injuries; furthermore, they are more common among adults rather than children under 15 years (13, 15). The data gathered in those prior studies will be revisited in order to better characterize those falls and highlight various manners in which they could be prevented.
Rural Health Services in Iran: The Islamic Republic of Iran  is a middle-income country located in Middle East (area of 1,648,000 square kilometres). In 2008, Iran had a population of 73 million and the life expectancy at birth was 69 for males and 73 for female (year 2006). Iran has 30 provinces, 336 counties, 1012 cities and approximately 64 000 villages. In 2006 one-third of people was living in rural areas(9).
Rural areas in Iran have a well-established primary health network.The most peripheral and basic unit of service delivery is the health house which covers an average of 1500 people. Health houses are run by the community health worker known as “Behvarz”.
Material and Methods
Study setting: The study setting was the rural areas of Toyserkan (Twiserkan) county, located in Hamadan province,west of Iran. Toyserkan  is about 100Km south of Hamedan city which is the capital city of the province. The total population of the Toyserkan County was about 110 000 inhabitants of which about 58% lived in rural areas at the time of this study. Rural people in Toyserkan County have access to primary health care services, free of charge, as other rural areas of the country. There were 17 health centres and 62 health houses in the county and 113 Behvarzes whose participations were sought.
Design and procedure: In the context of the broader research project on injuries in study setting, one study has been initiated in order to assess the epidemiology of injuries among rural communities and also to capture how injury is controlled and prevented by rural health workers, given the role that they are expected to play for local health and safety promotion. In this study Behvarzes were asked to report any severe injury (leading to hospitalization more than 6 hours or death occurring in their community over a six-month follow-up period. This study focuses on results obtained from falls, as the second most common cause reported after road traffic injuries(14).
This study was a six-month prospective injury data collection, using logbooks for registering data during follow up period as a special assignment for all Behvarzes of the county. They were asked to register all injuries (including fall-related ones) regarded as severe, i.e. leading to hospitalization over six hours or death. Prior to the study, all Behvarzes were trained. They were also invited to answer the questionnaire at the end of the six month period.
Follow-up and logbook: During the follow up period, data were gathered only for severe injuries in the population. A common and familiar definition was used – similar to that proposed by the WHO – and no unnecessary extra burden was put on Behvarzes.
At the end of the period, all logbooks were collected and checked by the supervisor/contact person. Thereafter, to make sure, the logbooks were re-checked by one of research team members and the probable questions were answered if necessary.
Self-administered questionnaire sessions: At the end of the period and after gathering logbooks all Behvarzes were invited through the letter sent by director of district health centre to participate in a session in main district health center. They were asked to fill in a questionnaire, included essay type questions. In this questionnaire they were asked to give their suggestions/opinion about control and prevention of injuries among rural community. Behvarzes also were asked to identify the barriers of controlling and preventing fall injuries. A total of 87 Behvarzes (76% of all those in the district) answered to the questionnaire.
Data treatment
Fall injuries registered: A total of 23 fall injuries were reported and coded using the WHO guidelines for injury community surveys and surveillance(16), the circumstances of the reported falls and the main attributes of injured persons are summarized. In addition, the estimated annual incidence rate of severe falls was compiled both globally and by age and sex of victims. For this estimation the number of falls was multiplied by two (for an annual duration) as the period was six months.
Ethical considerations: The data for this study were part of a broader study on different mechanisms of injuries. also It was also part of a PhD project approved by Iranian National Ethics Committee in Medical Research, Ministry of Health and Medical Education of Iran.
Results
Fall injuries registered: A total of 23 people were reported by Behvarzes, who were severely injured during the 6 month period with the annual estimated incidence rate of 8/10 000 (95% CI: 6-11). Two deaths were reported. Table 1 shows the estimated annual incidence rates of severe fall injuriesdevided by age and sex of victims. The rate was significantly higher among males than females (12/10 000 vs. 3/10 000 person-years) and it was much higher among people over 65 years (24/10 000 person-years).

Table 1: Estimated severe fall injury incidence rate per 10 000 person-years (95% CI) by sex and age group.

 
 

Table 2: Circumstances of injury event, registered in the logbooks, in six month follow-up period.

Table 3: Suggestions on what can be done for fall-injury control and prevention, made by Behvarzes in relation to each specific injury in registered in follow-up period (n=23).

 
Table 4: Suggestions for what can be done for fall-injury control and prevention in general,
made by Behvarzes after follow-up period (n=87).

*Number in the parenthesis is the number of Behvarzes who mentioned the related code.
 

 
Table 5: Barriers to control and prevention of fall injury, suggested both during and after follow-up period.

*First written number in parenthesis is related to the “follow-up logbooks” and second one is related to the “questionnaires”, for each mentioned code.
“−”: No suggestion