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Prevalence of Head Injury Among Trauma Patients at Debre Tabor Comprehensive Specialized Hospital, North Central Ethiopia

Authors Tesfaw A , Eshetu M, Teshome F , Fenta E , Gelaw M , Mihret G , Atiklt G , Yosef T 

Received 22 May 2021

Accepted for publication 6 August 2021

Published 22 August 2021 Volume 2021:14 Pages 47—54

DOI https://doi.org/10.2147/OAS.S321404

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Luigi Bonavina



Aragaw Tesfaw,1 Mekdim Eshetu,2 Fentaw Teshome,1 Efrem Fenta,3 Moges Gelaw,3 Gashaw Mihret,2 Getaneh Atiklt,1 Tewodros Yosef4

1Department of Public Health, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia; 2School of Medicine, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia; 3Department of Anaesthesia, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia; 4School of Public Health, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia

Correspondence: Aragaw Tesfaw
Department of Public Health, College of Health Science, Debre Tabor University, P.O. Box: 272, Debre Tabor, Ethiopia
Tel +251 921743820
Email [email protected]

Background: Head injury is one of the most common reasons for patient admission and death in surgical units of Ethiopian hospitals, but little is known about the problem in North-central Ethiopia. Therefore, this study aimed to assess the magnitude and associated factors of head injury at Debre Tabor Teaching and Referral Hospital in south Gondar zone, North-central Ethiopia.
Methods: A cross-sectional study was conducted on 370 trauma patients at Debre Tabor Teaching and Referral Hospital from November 1 to December 30, 2019, using a systematic random sampling technique. The data were collected through a face-to-face interview. The data were analyzed using SPSS version 23. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with head injury. P-value < 0.05 was used to declare statistical significance.
Results: The mean (±SD) age of patients was 41.4 (± 11.6) years. The prevalence of head injury was 39.7%, 95% CI (34.9– 44.9%). Two hundred sixty-five (72%) were male and 259 (70%) of all trauma patients were from rural residents. The study also found that younger age (20– 24 years) [AOR=1.2; 95% CI (1.29– 8.86)], being male [(AOR=2.02; 95% CI (1.31– 6.24)], alcohol use [(AOR=6.31; 95% CI (2.03– 16.08)], and rural residence [(AOR= 1.40; 95% CI (1.13– 6.94)] were the factors associated with head injury.
Conclusion: Like other studies done in Ethiopia, head injury is a major problem in the study area. The study also revealed that socio-demographic and behavioral factors are mainly associated with head injury. Therefore, appropriate prevention strategies should be devised and implemented against the contributing factors both at the individual and community level to minimize the risk of head injury.

Keywords: head injury, prevalence, trauma, Ethiopia

Introduction

The World Health Organization (WHO) global burden of injury estimate ranked injury among the top ten leading causes of death, and men in Africa have the highest injury-related mortality rates in the world.1 Among African nations, the rate of injury mortality in the year 2004 was the highest in Nigeria and the lowest in Egypt. Ethiopia was ranked as the third leading country.2

Head Injury is one of the major public health problems and the leading cause of mortality and morbidity across all age groups, particularly the young and productive part of the world’s population.2,3 It is classified as mild, moderate, and severe using the Glasgow Coma Scale (GCS). The problem happens with a greater burden in low- and middle-income countries and it is magnified by the high prevalence of risk factors and poor health care delivery systems.2–4

Worldwide, the incidence of traumatic brain injury (TBI) is rising.5,6 It is estimated that 1–2% of people living in high-income countries live with a TBI disability and the incidence is high in some countries in Africa.7 The mortality rate of TBI in Africa was reported to be 81/100,000 per year, with greater than 10% of all case fatality rates in South Africa.6

In Ethiopia, like other developing countries, head injury is a common public health problem.8 According to previous studies done in Ethiopia, the prevalence of head injury in patients presenting to the surgical emergency department ranged from 24.9% to 49.4%.9–11 The main causes and risk factors for head injury are diverse and may include road traffic accidents (RTA), falls, and interpersonal violence/assault.6,8,10–13

According to several studies, the higher prevalence of head injury was seen in adolescents, young adults, and the elderly,6,10,12 males,6,9–11,14 daily laborer, unemployed and illiterate.11 Studies also mentioned behavioral factors as contributors to head injury. A study conducted in southern Ethiopia revealed that 31% of the head injury patients had a history of alcohol consumption before 6 hours of the trauma.10

Head injury is a devastating trauma that results in loss of life or affects patients’ quality of life even after treatment.15 Managing the problem requires resource preparedness and professional skills. Therefore, understanding the magnitude and associated factors of head injury will reduce occurrences and improve patient outcomes through effective interventions.

Even though the hospital reports in the country indicate a high burden of the problem, evidence-based information about head injuries remains scant. Hence, we aimed to determine the magnitude and associated factors of head injury among trauma patients at Debre Tabor Teaching and Referral Hospital, which serves the majority of the rural and urban population in the south Gondar zone, North-central Ethiopia.

Methods

Study Design and Setting

A hospital-based cross-sectional study was conducted from November 1–December 30, 2019, at Debre Tabor Teaching and Referral Hospital (DTTRH), which is found 665 km from Addis Ababa (the capital city of Ethiopia). The hospital is the largest in the South Gondar zone, which was established in 1953 and serves more than 2.5 million population in its catchment area. It has more than 33 specialists in various areas of medical specialization and 230 other health professionals constituting the health care team with a total capacity of 160 inpatient beds in five major departments. The surgical department is one of the main departments, which provides major and minor operations, outpatient and inpatient services, a surgical referral clinic, and surgical emergency service. In general, the hospital provides diagnostic and treatment services for trauma patients.

Source and Study Population

All trauma patients presented to the emergency department of DTTRH were the source population, while all trauma patients presented to a surgical emergency department in the study period from November–December 2019 were the study population. All trauma patients who visited the emergency department in the study period with an age greater than 18 years were included in the study.

Sample Size Determination and Sampling Techniques

The required sample size was determined using the single population proportion formula by taking the prevalence of head injury (40.5%) among trauma patients from a study done at the surgical department of Gondar University Referral Hospital, Northwest Ethiopia,11 with a 95% level of confidence and 5% margin of error, non-response rate of 10% and calculated using Epi info 7.2. The final sample size was 406. A reference population of 7200 patients presented to the surgical emergency department of DTTRH in the last six months of the year 2019 (May–October/2019) was used and then by taking the proportion in the two-month period, which becomes 2400. A systematic random sampling technique was used to get the participants (2400 were divided by 406 to obtain the constant for the sampling interval, which was 6). Then, taking every six patients from a random start was studied until the total sample size (406 trauma patients) was obtained.

Study Variables

The dependent variable was a head injury. The independent variables were sociodemographic characteristics (age, sex, marital status, religion, educational status, and place of residence), behavioral characteristics (smoking, alcohol, psychoactive substances/khat, and traditional medicine), and clinical characteristics (mechanisms of injury and history of comorbidities).

Operational Definitions

Head injury is any physical damage/structural change to the scalp or skull due to any type of external force to the head.16,17

Traumatic brain injury (TBI) is an alteration in brain function, which is manifested as confusion, altered levels of consciousness, coma, seizures, etc.18

Trauma is any serious injury to the body resulting from violence or an accident.19

GCS: Glasgow coma scale was used to assess the neurological status of the patient.18

Mild head injury is an injury to the head when GCS is between 13 and 15.18

Moderate head injury is an injury to the head when GCS between 9 and 12.18

Severe head injury is an injury to the head when GCS ≤ 8.18

Psychoactive substances: ingredients that alter mood, cognition, and behavior.20

Data Collection Tools and Procedures

The data were collected using a structured questionnaire, which was developed after a review of similar kinds of literature. The data was collected using a face-to-face interview with each trauma patient. The interview included information on socio-demographic characteristics, clinical characteristics, and behavioral factors. Two intern medical doctor students (who were working in the emergency department) were trained and collected the data. To ensure the reliability of the information, the respondents were interviewed using their local (Amharic) language. To ensure the quality of the data, every questionnaire was reviewed for completeness, accuracy, and clarity daily during the data collection period by trained data collectors.

Data Processing and Analysis

The data were checked for completeness, coded and entered into Epi-info version 7.2, and analyzed using SPSS version 23. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with head injury. First, a bivariate logistic regression analysis was done to determine the association between the dependent and each independent variable. Independent variables in the bivariate logistic regression model with a p-value of less than 0.25 were included in the multivariable logistic regression analysis. Finally, variables in multivariable logistic regression with a p-value <0.05 were considered as significantly associated with the outcome variable. An adjusted odds ratio (AOR) with a 95% confidence interval was used to measure the strength of association. Multi-collinearity between independent variables in the model was checked, and the variance inflation factor was found acceptable. The Hosmer-Lemeshow goodness-of-fit test indicated (P = 0.267) that the model was good enough to fit the data well.

Results

Socio-Demographic Characteristics

Out of 406 selected trauma patients, 370 patients have participated in this study with a response rate of 91.1%. Two hundred sixty-five (72%) were male patients. The mean (±SD) age of patients was 41.4 (± 11.6) years. About (207, 55.9%) of the trauma patients were married and only (50, 13.5%) completed college and above. Most of the patients (329, 88.9%) were orthodox religious followers, and more than two-thirds (259, 70%) were from rural residences (Table 1).

Table 1 Socio-Demographic Characteristics of Trauma Patients at DTTRH in North-Central Ethiopia

Behavioral Characteristics

For the behavioral characteristics of the respondents (9, 2.4%) individuals have been found to have a history of cigarette smoking. There were (192, 51.9%), trauma victims with a history of alcohol consumption 30 minutes before the incident, (113, 58.9%) of them were within the age range of 25–44 years. Beer was the most consumed beverage (107, 55.7%) followed by tela (local beverage) (39, 20.3%). There were (112, 30.3%) respondents who have been found to have consumption of psychoactive substances (khat) (Table 2).

Table 2 Behavioral Characteristics of Trauma Patients at DTTRH in North-Central Ethiopia

Clinical Characteristics

Nearly two-thirds (64.9%) of trauma patients stayed for the one hour until they arrived at their first health care contact and only (3, 0.8%) patients were delayed for more than 24 hours without seeking health care. Based on the patient’s level of consciousness, the study has found that most of all trauma patients (274, 74.1%) have been found to have a normal level of consciousness and (56, 15.1%) have minimal injury. One hundred forty-four (38.9%) of the patients who arrived at SED have been managed as an outpatient (Table 3).

Table 3 Clinical Characteristics of Trauma Patients at DTTRH in North-Central Ethiopia

Mechanism of Injury

Regarding the mechanism of injury in all trauma patients, the majority of injury cases (152, 41.1%) were due to assault (interpersonal conflict), followed by (145, 39.2%) and (73, 19.7%) of injury cases were due to road traffic accident (RTA) and fall-down accident, respectively. The prevalence of head injury in trauma patients visiting the emergency department of DTTRH was 39.7%, 95% CI (34.9–44.9%). The study also showed that out of all patients with a head injury (124, 33.5%) sustained a blunt head injury.

Factors Associated with Head Injury

In the bivariate analysis, the age of respondents, residence, sex, alcohol consumption, history of any comorbidities, mechanism of injury, and type of alcohol consumed were identified to be significantly associated with head injury. However, age, alcohol consumption, sex, and residence were remained significantly associated with head injury in the multiple logistic regression analysis. Patients whose age group was 20–24 years were 1.2 times more likely to be diagnosed with head injury [AOR=1.2; 95% CI (1.29–8.86)] than patients above 65 years. Male trauma patients [AOR=2.02; 95% CI (1.31–6.24)] were approximately two times more likely to have a head injury than females. Trauma patients who were from a rural residence [AOR=1.40; 95% CI (1.13–6.94)] were 1.4 times more likely to have a head injury than those from urban residences. Patients who drank alcohol before the injury were approximately six times more likely to develop head injury than those who did not have alcoholic exposure before the incident [AOR=6.31; 95% CI (2.03–16.08)] (Table 4).

Table 4 Determinant Factors of Head Injury Among Trauma Patients of DTTRH in North-Central Ethiopia

Discussion

This study aimed to assess the magnitude and factors associated with head injury among trauma patients in north-central Ethiopia. The magnitude of head injury in trauma patients visiting the surgical emergency department of DTTRH was 39.7%, 95% CI (34.9–44.9%). This finding was in line with 40.5% at Gondar University Referral Hospital, Ethiopia11 and 42.3% in Singapore.21 It was lower than 49.4% in Gedeo Zone, Southern Ethiopia.10 However, it was higher than 5.4% in Nigeria22 and 12.4% on the island of Viti Levu, Fiji (Island).23 The observed variation compared to previous studies might be due to the difference in socio-economic status, social relationship, and lifestyle factors. Besides, the variation may be explained by the difference in sample size, the operational definitions used across studies, and the methodology of the research as a whole.

Concerning the cause of injury, this study revealed that the majority of injuries were mostly related to interpersonal violence (152, 41.1%), followed by RTA (145, 39.2%), and falling accidents (73, 19.7%). This finding was also mentioned in the study conducted at Jimma University Hospital, Southwest Ethiopia, which revealed that interpersonal fights accounted for 38.5% and road traffic accidents for 36.5% of head injury cases3 and a study from Gondar university Referral Hospital (Northwest Ethiopia) also revealed similar findings.11 However, this finding was not supported by a study done in Australia, which revealed that the majority of the injuries occurred due to sport and recreational activities.24 The possible reason for this variation may be due to the difference in socio-cultural and behavioral characteristics of the study participants.

The odds of sustaining head injury among those who are aged 20–24 were 1.2 times more likely when compared with those aged above 65 years. This is consistent with previous reports from WHO,25 Qatar,26 Addis Ababa,9 Jimma,12 and Tikur Anbessa27 in Ethiopian studies. Might be because of their high level of involvement in interpersonal violence and their working-age exposure to different factors related to their activities because of their age as interpersonal violence is also the most common mechanism of injury. Young people are usually sustaining more RTA than other age groups as they travel more for work. This magnifies the possible economic impact of head injury as the productive age group of the society is primarily affected. In contrast, those individuals above the age of 65 spend their time in a more stable environment and are relatively protected from violence and injury when compared with other age groups.

This study also found that the sex of respondents was significantly associated with head injury. Being male was approximately 2 times more likely to sustain head injury than females. This finding was supported by previous studies conducted among head injury patients in an Ethiopia emergency center and reported that the majority of the trauma patients were male27 and in Nigeria.22 The finding may be explained by the higher rates of traveling, emotional, and risk-taking behavior among males.

Alcohol consumption was also shown to be another important variable significantly associated with head injury. Those patients who consumed alcohol were approximately 6 times more likely to be present with a head injury. This finding was supported by a report from WHO that showed up to 45% of injured patients reported consumption of alcohol before their injury28 and another study reported that drunkenness behavior (social risk-taking) was positively associated with the occurrence of injuries.29

This study found that residency was a factor associated with head injury. Patients from rural residences were 1.4 times more likely to have a head injury than patients from urban residences. This finding was supported by studies conducted elsewhere.30,31 This might be explained as people from rural areas have low awareness about road traffic accidents and most of them consume local alcohol drink (Areki) and are usually exposed to assault and/or interpersonal violence.

Limitations

This study had some limitations. First, the study was done in a single institution (DTTRH), which makes it difficult to generalize to the greater population in Ethiopia. This study did not collect data related to the mental health history of the patient like epilepsy and other antisocial disorders. Besides, the cross-sectional nature of the study may not show a cause-and-effect relationship.

Conclusion

Like other studies done in Ethiopia, head injury is a major problem in the study area. The study also revealed that socio-demographic and behavioral factors are mainly associated with head injury. Therefore, appropriate prevention strategies should be devised and implemented against the contributing factors both at the individual and community level to minimize the risk of head injury.

Abbreviations

DTTRH, Debre Tabor Teaching and Referral Hospital; ED, Emergency Department; GCS, Glasgow Coma Scale; RTA, Road Traffic Accident; TBI, Traumatic Brain Injury; WHO, World Health Organization.

Data Sharing Statement

The data sets used in this study are available from the corresponding authors on reasonable request.

Ethical Approval and Consent to Participate

An ethical approval letter was obtained from Debre Tabor University ethical review Committee. An official letter of co-operation was written to Debre Tabor Teaching and Referral Hospital to obtain their co-operation in facilitating the study. Written consent was obtained from each participant for a patient with good GCS scores and family for a patient with low GCS scores before data collection. Confidentiality of information was assured by excluding names and identification in the questionnaire. All participants were informed about the purpose of the study, and that it was conducted in accordance with the Declaration of Helsinki.

Acknowledgments

The authors would like to acknowledge Debre Tabor University, College of Health Science for approving the ethical review process. The authors are also keen to express gratitude to data collectors, hospital staff, supervisors, and study participants.

Author Contributions

All authors made a significant contribution to the work reported, in the conception, study design, execution, acquisition of data, analysis and interpretation, drafting, revising or critically reviewing the article; and they gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

No funding was obtained for this particular study.

Disclosure

The authors declare no conflicts of interest for this work.

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