Background

Globally, injury is a leading cause of morbidity and mortality that disparately affects low- and middle-income countries (LMICs) [1]. With an injury mortality rate of 32.2 per 100,000 population, Africa bears the highest burden of injury mortality [2]. Cameroon has an injury mortality rate (102 people per 100,000 population) that is over three times that of its continent [3]. In many parts of Sub-Saharan Africa, like The Gambia (48%) and South Africa (25%), traumatic injuries are the most common reason for surgical admissions among youth [4, 5].

Pediatric injury is a major preventable public health problem that has not received the attention that it merits. Every year, about 830,000 children globally die due to unintentional injury with over 95% of these deaths occurring in LMICs [6]. Among adolescents aged 10–19 years, unintentional injury is the leading cause of death [6]. African children (age < 18 years) are significantly predisposed to and affected by injury. Challenging environments, increasing traffic, lack of safe play spaces, and the absence of child care options combined with greater vulnerability for injury put children and adolescents at increased risk of injury [7]. Inaccessible and unaffordable emergency health services for children in such resource-limited settings also contribute to the high injury morbidity and mortality [7].

There are costs associated with pediatric injury. Such costs include but may not be limited to financial costs (e.g., the cost of healthcare, transportation), health costs (e.g., the resultant change in health status, morbidity and mortality), and the opportunity costs resulting from the injury. In a resource-limited country such as Cameroon where almost half of the population lives below the poverty line, an understanding of the cost of injury is vital to patients and other stakeholders. In addition to quantifying the cost of pediatric injury, there is a need to explore the impact of these costs on households, patients, and their access to care. Despite its importance, cost of injury in Cameroon is poorly understood.

Information on the epidemiology and patterns of injury among children in Cameroon is necessary to make evidence-based decisions and policies. There is a need to identify the risks and determinants of injury specific to the pediatric populations in resource-poor settings, such as Cameroon. Despite the high burden of injury, little is known about patterns of injury, injury-related health care utilization, and the cost of injury especially as it relates to children and adolescents in Cameroon [8]. Such findings will enhance effective injury prevention, treatment, and policy formulation in these contexts.

This paper aims to identify the: (1) demographic and clinical patterns of injury among the pediatric population in Cameroon; (2) determinants and predictors of pediatric injury and surgery in Cameroon; and (3) costs of pediatric trauma care. These findings will inform injury prevention efforts and targeted resource allocation as well as improve understanding of health care costs and utilization associated with child injury [9,10,11,12,13,14,15]. Further, it will inform political prioritization and policy formulation with respect to pediatric injury in Cameroon.

Methods

The Central Hospital of Yaoundé (CHY) is a teaching and referral hospital that handles the highest trauma volume in Yaoundé, Cameroon’s capital city [16]. CHY has about 650 beds and an emergency department (ED) that is staffed 24 h by house officers, nurses, a surgeon, and select subspecialties available for consultation [17]. The facility serves 1.5–2 million people in Cameroon [18].

Study instrument and data collection

We prospectively designed a trauma registry and implemented it at CHY. The data collection methodology for this trauma registry has been previously described elsewhere [17, 19, 20]. The trauma registry data collection instrument design was informed by the World Health Organization (WHO) Guidelines for Injury Surveillance and other instruments used in similar low-income settings [17, 21,22,23,24]. The registry was comprised of demographic (e.g., age, sex, residence, socioeconomic status), transportation (mode of transport, therapeutic itinerary), clinical (e.g., nature of injury, injury mechanism, context and severity, vital signs, diagnosis, clinical management, disposition at discharge from the ED, etc.), and cost (e.g. cost of care) variables.

Trained research assistants collected non-clinical data from the patients and doctors gathered the clinical data. Injury severity was assessed using the Kampala Trauma Score (KTS) and the estimated injury severity score (eISS). Because of the challenges in calculating a traditional injury severity score in resource-poor settings, eISS methodology has been applied here, having been previously described and validated in high-income settings [25, 26]. All patients presenting to CHY’s ED with traumatic injuries, as defined by WHO, were eligible for inclusion in the trauma registry [21]. Each patient included in the trauma registry was approached for consent to be included in this study.

Data were recorded using a paper trauma registry form and subsequently entered into Microsoft Excel [27]. The data were analyzed using Stata version 13.1 [28]. Missing values were excluded from analyses. Results were expressed using tables and charts.

This study received ethical approval from the National Ethics Committee in Cameroon and the Institutional Review Board of Johns Hopkins Bloomberg School of Public Health in the United States.

Data analysis

We analyzed the trauma registry data that was collected from April 15 to October 15, 2009 with a focus on the pediatric subpopulation. While there is no consensus age range defining childhood or adolescence in the literature, for the purpose of this study, patients aged less than 20 years were included in the pediatric subset analysis. We selected this age range as it is consistent with both the WHO definition and close to the age of majority in Cameroon, which is 21 years [6, 29, 30]. The age of majority is defined as the threshold of adulthood as recognized or declared in law [31].

First, we generated descriptive statistics on demographic (e.g., age, gender, residence, student status, socioeconomic status, etc.) and clinical (e.g., injury mechanism, injury context, and injury severity) characteristics of the study subjects. Using the Chi-square and Fisher’s exact tests of independence we evaluated potential differences in demographic and clinical characteristics between children in their first decade (age < 10 years) and with adolescents in their second decade of life (ages 10–19 years).

We created a socioeconomic index using the principal component analysis approach. Based on the Cameroon Demographic and Health Survey (DHS), principal components analysis was conducted to generate a socioeconomic index and a corresponding wealth score for each patient relative to the broader urban Cameroonian community [32, 33]. We classified patients into wealth quintiles, based on their wealth score, and this was used as an index of socioeconomic status (SES). The wealth quintiles were also used to build a logistic regression model to assess relationships between wealth and likelihood of pediatric patients to receive surgery. Costs associated with pediatric care were collected in Central African francs (CFA) and converted to US dollars (USD) at the 2009 exchange rate of 472.19 CFA to 1 USD [34]. Mean and median costs were calculated and presented in 2009 USD.

Results

Ninety-one percent of all eligible trauma patients consented to be included in this study. Pediatric patients accounted for 544 (19.1%) of all injured patients that presented to the CHY ED over the 6-month study period. The majority of these children were between the ages of 15 and 19 years (42.0%) (Table 1). Two-thirds (67.6%) of the pediatric trauma patients were male, while 71.1% were students. Ninety percent of patients resided in urban Yaoundé. Most patients (34.7%) belonged to the wealthiest quintile and the smallest proportion (3.6%) of patients belonged to the poorest wealth quintile (Table 2).

Table 1 Demographics and injury characteristics (n = 543)
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Table 2 Comparing demographic and injury characteristics between the two decades of childhood, n (%)
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The majority (69.4%) of pediatric patients arrived to CHY by taxi or bus, while 22.1% of patients arrived by private car (Fig. 1). Only 1.5% of patients arrived to the hospital by ambulance and 1.7% by police car. A preponderance (71.1%) of the severely injured and profoundly injured patients was transported via either taxi or bus. The median cost of care for pediatric patients was USD12.71 [IQR 12.71, 23.30].

Fig. 1
figure 1

Mode of transport to the hospital

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Over half (53.4%) of the pediatric injuries were due to road traffic injuries (RTI) and half of these RTI victims were pedestrians. RTIs mostly injured the limbs and pelvis (37.3%) and head, neck, and face (32.4%) regions. The limbs and pelvis were the most commonly injured body parts in patients with RTIs (37.3%, n = 284), falls (54.8%, n = 73), burns (57.1%, n = 28), and penetrating trauma (66.2%, n = 65) (Table 3). Burns were commonest among children aged 1–4 years (p < 0.001) (Fig. 2). Compared to those in their second decade of life, children in their first decade of life were more often injured at home (p < 0.001) by falls (p < 0.001) (Table 2). Patients aged 10–19 years sustained injuries during travel and on paved roads or highways significantly more often than younger patients (p < 0.001). Based on eISS, burn patients had the highest proportion (26%) of severe or profound injuries (Table 4). No other mechanism of injury comprised up to half of that proportion of severe or profound injuries than that due to burns.

Table 3 Distribution of body area injured by injury mechanism (n = 524)
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Fig. 2
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Mechanism of injury by age

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Table 4 Mechanism of injury and transportation by injury severity (eISS)
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Various determinants of surgical care utilization were identified. Children presenting with an eISS ≥ 9 (32.4%) were more likely to receive surgery (Table 5). Of the injured children, 18% received major surgical procedures while 21% received minor surgical interventions. Relative to the poorest wealth quintile, other wealth quintiles were less likely to undergo surgery (Table 5). The likelihood of receiving surgery for injuries resulting from falls was nearly three times as much as for RTIs, after controlling for age, sex, injury severity, anatomical region most affected, injury setting, and SES quintile. Multivariate logistic regression models identified injury severity (adjusted odds ratio (AOR) = 1.12), sustaining abdominal injuries (AOR = 4.40), being injured by a fall (AOR = 3.14), on an unpaved or dirt road (AOR = 4.24), a sports site (AOR = 11.36), and school (AOR = 783.86) to be significant predictors of receiving surgery (Table 6).

Table 5 Predictors of receiving surgery among pediatric trauma patients (n = 513)
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Table 6 Adjusted odds ratios for likelihood of receiving surgery (n = 503)
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Discussion

The findings of this study demonstrate that pediatric patients comprise a considerable proportion of injured patients that seek care at CHY. Findings also show specific patterns of child injury based on age, gender, and injury mechanism and setting. Most pediatric trauma patients presenting to CHY were male, students, and in the latter half of their second decade of life. This agrees with the findings of other studies in Sub-Saharan Africa that present similar findings with regards to gender, but more often report a majority of patients from younger age groups [4, 9, 35]. A considerable proportion of pediatric injuries resulted from RTIs, which is also consistent with findings in similar settings [5].

Pediatric patients are more likely to be injured on paved roads. Factors contributing to the higher prevalence of RTI include poorly maintained transport systems and infrastructure coupled with low visibility of children and adolescents walking along roads. Improved road design and lighting, dedicated pedestrian walkways, provision of reflective vests for children, speed reduction strategies, and separation of traffic mix may be viable methods to prevent injury and to reduce the associated incidence, morbidity, and mortality [6]. In addition to road injuries, falls and burns were also leading causes of injuries among this population. Burns and falls are typically commoner and more severe among children [36, 37]. This may suggest that childcare and adequate supervision could play an important role in child injury prevention [38]. Burn injury prevention efforts are also crucial for children as they are not only more likely to suffer burns than adults but are also more likely to suffer severe or profound injuries.

The findings of this study indicate the need for improved prehospital care and accessible transportation to the hospital. As the majority of pediatric trauma patients arrived to the ED via taxis or public buses without receiving any formal prehospital care, the risks of further injury and increasing morbidity and mortality are higher. About 71% of patients who were severely or profoundly injured were transported by taxi or bus. This makes the need for prehospital care more pertinent. The lack of formal prehospital care providers and training programs in resource limited countries such as Cameroon presents a significant challenge. Studies suggest the use of laypersons as first responders in other parts of Africa including Cameroon [39,40,41,42]. The WHO encourages lay provider education programs as an essential step in the development of emergency medical systems in resource-poor settings [43]. In this setting, taxi and bus drivers could be integrated into prehospital care systems through appropriate education programs [44]. Engaging commercial drivers can promote accessible transportation to health facilities and emergency care as well as maximize existing resources to stabilize trauma patients and potentially decrease mortality and severity of trauma patients.

The cost of care for pediatric injury is alarmingly high considering that around 40% of people in Cameroon lived at or below the national poverty line (USD1.25 per day) as of 2007 [45]. The poorest wealth quintile was under-represented in the patient pediatric population yet they were four times more likely to receive surgical care. This could imply that only the most severe of the poor, whom need surgery, travel to CHY to seek surgical care. The significant cost of treatment may explain why only the wealthiest groups of the population are represented in this hospital-based study, as these groups are more likely to be able to afford necessary treatment; however, other barriers to accessing care for members of the lower SES quintiles merit exploration. Greater representation of wealthier patients to the ED suggests inequities in access to trauma care for children and the need for research into feasible and sustainable financing and insurance schemes targeted at this population.

There is a need for innovative healthcare financing models to tackle injury prevention and care. Students comprised 71% of the study population, which is approximately the same proportion (70%) of students seen in the DHS cohort of the same period, indicating that the study sample may be representative of the larger population with respect to educational status [46]. This information can be leveraged to design a solution that is context-appropriate. For instance, a school health program can be created to train staff and students to administer prehospital care. A school-based pediatric insurance scheme is a way to potentially finance pediatric trauma care. Funds from the insurance scheme can be used mitigate ED costs and can help prevent the delay(s) in instituting care that occurs due to the lack of funds. An insurance scheme like this could engage first responders, families, and providers to formalize transport and referral systems to minimize delays in care and maximize timely attention to the acutely injured child, potentially leading to reductions in morbidity and mortality. Finally, schools and the educational system can be leveraged as an avenue for advocacy, injury prevention education, and prehospital care.

Limitations to this study include the selection bias inherent in hospital-based data collection and restricting the sample of pediatric trauma patients to those arriving to CHY for treatment. Patients who succumbed to their injuries at the scene or during transport may not have been brought to the hospital. Additionally, those who chose to seek care elsewhere, either at formal healthcare facilities or traditional practitioners, are similarly not represented in this patient population. As a result, it is possible that this study may understate the true burden of pediatric injury in Yaoundé due to lower utilization of formal care in this context. In addition, as this study is based in Cameroon’s capital city, it may not be reflective of the patterns of pediatric injury and care-seeking choices in rural areas of Cameroon. Finally, it is possible that the eISS method used in this study may understate injury severity.

Conclusions

Injury is a child health problem that requires adequate attention and funding. Improved data collection infrastructure and evidence-based resource allocation for surgical services can aid in addressing pediatric injury, which is a major public health problem. This study highlights some benefits of improved data infrastructure and management, often in the form of registry systems, for policy formulation and the development of targeted interventions to improve public health. The burden and cost of injury as shown in this study draws attention to the need for universal health coverage (UHC) and highlights the important role of strengthening surgical care systems to achieve UHC as emphasized by the World Health Assembly Resolution 68.15 [47].

Future research could explore strategies to strengthen prehospital care in Cameroon, such as education of commercial drivers as first responders, which has been done in similar settings. Efforts aimed at prevention of pedestrian injury in school-aged children and burns in children below five years of age are also warranted. Data describing patterns of trauma and utilization among the poorest wealth quartiles of pediatric patients remain limited and should be explored to improve access to emergency trauma care and surgical services for the most vulnerable of patients. Considering the high proportion of students represented in this patient population, future research should explore school-based interventions focused on injury prevention, road safety, prehospital care, as well as school-based pediatric insurance systems.