Introduction

Globally, injuries account for one quarter of all deaths among people aged 15 to 49 years [1,2]. The public health implications of injuries are well documented in high income countries but have been raised as an important concern also in rural areas of low and middle income countries (LMIC) [3]. Causes of trauma-related death align with gender. Worldwide, injury accounts for approximately half of all mortality among young males aged 10 to 24 years [2]. Available data in LMIC suggest males are at greatest risk of all injury-related deaths, with violence and road traffic injuries (RTI) predominating [3]. Less frequent trauma-related deaths, such as suicide and burns, are also important causes of concern [3,4], and under-documentation of trauma associated with gender-related interpersonal violence has been raised as a public health priority [5].

By 2030, RTI are projected to be the fourth leading cause of death globally [6]. However, the pattern of trauma-related deaths is less well documented in LMIC making it difficult to understand needs or develop and strengthen public health interventions [7-9]. In South Africa, examination of deaths in a rural demographic surveillance site found that injury was responsible for 9% of deaths across all ages, with the predominating causes being homicide, RTI, and suicides [10]. Other types of traumatic injuries in impoverished communities involve living, working and travelling in less safe environments, with few preventative interventions, and minimal access to quality treatment and rehabilitation [11]. In Kenya, as in many other countries of sub-Saharan Africa (SSA), trauma is thought to be an important contributor to premature death in rural communities [12]. However, documentation of trauma deaths outside hospital settings is often limited. Better understanding of the scope and cause of trauma-related deaths in rural areas of SSA is possible through the use of verbal autopsy conducted in health and demographic surveillance systems (HDSS). In western Kenya, the Kenya Medical Research Institute (KEMRI)/US Centers for Disease Control and Prevention (CDC) HDSS provides such an opportunity [13]. This paper reports on deaths attributed to injuries, and poisonings, identified through verbal autopsy, and examines risk factors associated with these deaths.

Materials and Methods

Results

Of 11,147 adult deaths recorded between 2003 and 2008, 447 (4% overall, or 2% of female and 6% of male deaths) were attributed to trauma (Tables 1, 2). The proportion of trauma related deaths increased from 2.5% to 5.9% between 2003 and 2008 (test for linear trend 35.5; p < 0.001). Among males, trauma-related deaths were proportionately higher than other causes among adolescents and young adult deaths, with 16% of trauma deaths in persons aged 15-24 years, compared with 5% for all other causes of death (Table 1). In this age group 17% (50/292) of all deaths were trauma related. Among females, trauma-related deaths were proportionately higher than other causes among older aged adult deaths. Except among deaths occurring in the very elderly, trauma deaths were 2 to 4-fold higher among males with, for example, close to four out of every five trauma deaths in the 15 to 24 year old age group being male (Figure 1; Table 3). Overall, mortality rates illustrated a 2 to 5-fold higher burden of trauma-related deaths among males compared with females by age category across the years of study (Figure 2). On a population basis, rates of trauma-related deaths were highest in older persons aged 65 years and above, for both males and females, reflecting the relatively high contribution of trauma amongst the elderly (Figure 2).

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Figure 1. Trauma (panel A) and non-trauma (panel B) deaths among adults aged 15 years and above by age and gender, 2003 to 2008.

https://doi.org/10.1371/journal.pone.0079840.g001

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Figure 2. Trauma mortality rates among adults aged 15 years and above by age group and gender, 2003 to 2008.

A: Male; B: Female.

https://doi.org/10.1371/journal.pone.0079840.g002

Causes of trauma-related deaths

Thirty one percent (n=140) of trauma deaths were recorded as arising from intentional causes (assault and suicides), and the remainder were non-intentional. Intentional causes accounted for 37% (n=117) of male deaths and 18% (n=23) of female deaths (RR 2.04, 1.37-3.04, p<0.001). Intentional causes accounted for a similar proportion of deaths among the youngest three age groups (43%, 43% and 39% respectively). Compared to the reference age group of 15<25 years, people aged 65<80 years were less likely to die from intentional causes (RR 0.37, 0.21-0.64, p<0.001), as were people aged 80+ (RR 0.16, 0.06-0.43, p<0.001). When data were split by age group, males were significantly more likely than females to die from intentional causes for ages 15<25 (intentional = 50% of male deaths and 15% of female deaths, RR 3.25, 0.88-11.98, p=0.025) and ages 25<40 (intentional = 49% of male deaths and 21% of female deaths, RR 2.34, 1.04-5.27, p=0.015) but there was no significant difference between males and females in the proportion dying from intentional causes in the older three age groups.

The leading causes of trauma death among adult females were ‘other injuries/poisoning’ (i.e. unspecified cause of trauma; n=38) and falls (n=17); for males the leading causes were assault (n=79) and RTIs (n=47, Figure 3). The contribution to all trauma-related deaths by cause differed by age and gender (Figure 4). The youngest median age at death for both males and females were among those who drowned, while the oldest median age at death was for males and females who had died from a fall.

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Figure 3. Major causes of trauma deaths among adults aged 15 years and above by gender, 2003 to 2008.

https://doi.org/10.1371/journal.pone.0079840.g003

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Figure 4. Age at death by cause of trauma death and gender among adults aged 15 years and above, 2003 to 2008.

https://doi.org/10.1371/journal.pone.0079840.g004

Discussion

The burden of trauma is growing globally and there has been a call for improving surveillance methodologies to capture information for public health interventions [6]. In this paper we present unique data identifying deaths associated with trauma in a rural community of Eastern Africa. While trauma contributes a relatively small percentage of deaths in rural areas of Eastern and Southern Africa (here 2% of female deaths and 6% of male deaths), where a high burden of HIV, TB and malaria dominate, case histories show considerable suffering and lack of access to care, in particular hospital-based care for women.

Global estimates suggest injuries account for half of all male mortality in the ages 10 to 24 [2,3]. Here, the contribution of trauma to all deaths in young adult males aged 15 to 24 years is lower (17% of all male deaths in this age group), but still considerable. Separate analysis found trauma equalled HIV as the main contributor to deaths among young males in this area [15], and confirms the need to document such health threats in adolescents and young adults in SSA [19]. We noted physical injuries leading to death among elderly members of the community; on a population basis, trauma-related mortality rates were highest among persons 65 years and older of both genders. While this belies the larger number of trauma deaths numerically occurring in younger age groups, it indicates a need for interventions to reduce injury risk in this age group, for example, home assessment and reducing safety risks.

Deaths from intentional causes accounted for one third of all deaths; of these there were 91 deaths from assault and 49 from suicide. Deaths from intentional causes accounted for a greater proportion of male than female deaths and a greater proportion of deaths of people in the youngest three age groups than the oldest two. Indeed assault was the main cause of death from trauma among males, comprising 25% of all male trauma deaths and 36% of deaths among young males aged 15 to 24. Interpersonal violence contributed 5.2% of all deaths among males aged 15-49 years globally in 2010 [2], with 12% of deaths among young males (ages 10 to 24 years) estimated to be due to violence [3]. In South Africa, interpersonal violence was the second leading cause of healthy years of life lost and Norman and colleagues recommended that violence be considered a priority health problem as well as a human rights and social issue [20]. In 2008, the number of male deaths from assault occurring in the HDSS accounted for 34% of male deaths, likely related to post election violence, raising the need for protective interventions during election periods when civil unrest might be predicted.

Global Burden of Disease data highlight injuries as an important cause of death in females, as well as males, worldwide [2-4]. Among females, injury from assault is mainly associated with intimate partner violence (IPV), with 1.6% of deaths among females 15-45 years due to this cause worldwide in 2010 [2]. However, prevalence studies show endemic levels of IPV in many countries [22]. In the nationally representative Kenyan Demographic Health Survey, 25% of women reported having been violently abused in the 12 months prior to survey [23]. Highest rates (of 36%) were reported in Nyanza Province, where the HDSS is located. Reasons women gave for “deserved beatings” included burning food, arguing, going out without telling, child ‘neglect’, and refusing sex [23]. However, despite the reported pervasive violence, only 1% of adult female deaths in the HDSS were classified as assault. Under-ascertainment of deaths from IPV is suspected since documentation through VA depends upon the spouse or partner, as next of kin, to report on the events surrounding death. Further consideration should be given to how IPV can better be captured using the VA tool.

The 49 deaths in the current study from suicide accounted for 11% of all injury deaths. By comparison, in South Africa, 9% of all injury deaths were due to suicide [20]. Globally, suicide (self-harm) was identified as a leading cause of death for both males and females in 2010, contributing 5.7% and 4.8% of all deaths in this age group, respectively [2]. These data underscore the need to strengthen health care services in LMIC for mental health disorders, including depression, which is the leading global cause of years lived with disability [21].

Between 1990 and 2010, one million more deaths from injuries worldwide has been calculated (a 24% increase), and accounting for close to one in ten (9.6%) of all deaths [2]. This was largely due to a rise in unintentional injuries, for example a 46% rise in deaths from road traffic injuries, and an increase in deaths from falls [2]. In our study area, RTIs accounted for 58 (13.0%) of trauma-related deaths; 81.0% were among males, a third occurred in persons aged 25 to 39, and half of the deaths were among pedestrians, who tend to walk on roads rather than footpaths. The contribution of RTIs to mortality in Kenya is significant in terms of human suffering and financial cost, and the number of fatalities is increasing [24,25]. Pedestrians and passengers are most affected [25,26], and in rural areas, passengers in buses and public service commuter vans (matatus) account for the majority of fatalities [24,25]. Road safety is determined by both individual behaviour and structural issues [25,26], and both should be considered by the National Road Safety Council of Kenya in terms of formulating road safety policy. Such policies could include the development of footpaths to protect pedestrians, education about where to walk and the need for reflective clothing if walking at night, street lighting, proper road maintenance, speed enforcement and regulations that ensure that drivers are capable of driving safely and vehicles are road worthy [26]. That trauma deaths significantly occur outside of care, and at home, also suggest road accident victims do not reach services in time to receive life-saving treatment, and support is needed to develop ambulance services to reach persons critically injured.

We identified a significantly higher proportion of male trauma-related deaths among regular alcohol drinkers compared with non-regular drinkers. Alcohol consumption is a well-established risk factor for injury [27]. Alcohol consumption in this population is characterised by persons drinking until they get drunk [28], placing them at risk of injury. Nearly half of all male assault deaths and a third of all female assault deaths recorded were regular consumers of alcohol. Four out of every five male deaths from poisoning were also reported to be regular drinkers. Poisoning may arise from excessive ethanol consumption or from tainted brews. Separate systematic chemical analyses of locally used traditional homebrews in Kenya found that an average changaa (a traditional spirit) drink equalled 3.5 standard drinks in the UK (2 in the USA), and busaa (a traditional beer) equalled 2.3 (1.3 in the USA) [29]. The ethanol content of changaa varied from less than 20% to just over 50% [29]. Toxicity from contaminants in the brewing process, by error or to enhance alcohol content, cause additional and potentially large scale morbidity and mortality [30]. The Kenyan Alcoholic Drinks Control Act, introduced in 2010 to control illicit brewing [31], has yet to be examined to determine its full impact on trauma-related morbidity and mortality.

Our multivariate analysis illustrated the risk of death among the elderly, persons who died without receiving any form of care, and who died in the home. Our data also show how unintentional injuries from falls disproportionately affected the elderly and women. Each year, about a third of people aged 65 years and over experience a fall, although this varies by country [32]. Unintentional falls among the elderly result from environmental hazards and an increased susceptibility due to sight loss, memory impairment, poorer posture control and muscle strength and tone [33]. Lower educational level and lack of resources place the elderly at risk of injury, and limit their ability to seek care following injury. Regular alcohol consumption was reportedly higher among these female deaths; a survey among this population noted the frequency of alcohol consumption increased with age among females, potentially placing the elderly at risk of accidental injuries [28]. This community, as in many SSA countries, has been disrupted by deaths from HIV/AIDs in prime aged adults, frequently leaving elderly female widows in poverty and unsupported [34]. The VA documented deaths following broken limbs, back, neck and pelvis as a consequence to falls, and found few of the injured received care from hospital after their fall and prior to death. Coupled with the deaths from house fires, especially among older women, these results suggest the need for home assessments to develop safety strategies through Kenya’s community health worker programme.

Conclusions

Publications documenting deaths from trauma, especially in LMIC, are relatively scarce. However, an understanding of causes of largely preventable trauma deaths is needed to guide the design of public health interventions and policies [36]. We conclude that, while a small portion of deaths in rural areas with high HIV, TB and malaria prevalence, are ascribed to trauma they represent preventable mortality, and interventions to reduce these deaths are urgently needed. Trauma among young males is well documented, but surprisingly high in this rural population, matching the mortality from HIV [15]. Here we also show the vulnerability of older groups, especially older women, from trauma deaths such as falls. Data suggest the elderly subsequently die at home, without any resort to care. Policies and guidelines for targeting interventions to prevent trauma in different population groups are needed, as are improvements in systems and tools to record underlying causes of death associated with trauma. Methods are required to improve the quality of data, including the underlying causes of deaths; while targeted research could provide new insights, more logistical changes such as earlier follow-up, and a broader scoping of informants could contribute to strengthening systems. Potential under-reporting of deaths from intimate partner violence among women is a particular concern.

Acknowledgments

We are grateful to the communities living in the HDSS for their support and assistance. We thank the HDSS field and office staff for their hard work collecting and evaluating HDSS data. INDEPTH is acknowledged for its support in strengthening HDSS and VA methodologies. Dr John Vulule is thanked for his advice and support. The Director of KEMRI has approved this manuscript.