Social determinants of health associated with childhood accidents at home : An integrative review

OBJECTIVE
to analyze the factors associated with childhood accidents at home according to the levels of the social determinants of health.


METHOD
integrative review of the literature, with research in databases CINAHL, LILACS and PubMed, with the following main descriptors: child; social determinants of health; accidentes, home. We included 31 studies that related the social determinants of health and childhood accidents, in English, Portuguese and Spanish.


RESULTS
the proximal determinants identified were: age and sex of children, and ethnicity. Among the intermediate determinants of health, parental behavior, related to the supervision of an adult, prevailed. Parental employment and socioeconomic status were identified as distal determinants.


CONCLUSION
the age and sex of the child, besides direct supervision, were the determinants most associated with accidents. The distal determinants should be better studied because their relation with the occurrence of domestic accidents has not been sufficiently clarified.


INTRODUCTION
Accidents at Home (AH) in childhood represent an important global health problem (1)(2) , because they are potentially serious but still underestimated (3) .It is verified that these injuries have contributed significantly to raise the infant morbidity and mortality rates, since in addition to being closely related to the stage of childhood itself, they also often reflect the lack of protective capacity of the family and the lack of knowledge of the numerous risk factors that permeate the daily life of children (4) .
Among the major types of AH with children, there is a high prevalence of falls, burns and intoxications.From these accidents, the World Health Organization estimated that, in 2004, roughly 830,000 children under 18 would die worldwide as a result of an unintentional injuries.However, recent community-based studies conducted by the United Nations Children's Fund (UNICEF) suggested that the number could be much higher (2) .
In Brazil, a study aimed at analyzing the profile of emergency care due to accidents and violence involving children under 10 in 2011 showed that of the 7,224 emergency services among children from zero to nine years old, 7,043 (97.5%) were victims of accidents and 181 (2.5%) of violence.Of the total number of children, 19.5% were one year old and 42.7% two to five years old.Most of the events happened at home (67.4%), and this place was statistically associated with accidents (5) .
This situation indicates the need to know the determinants and conditions for the occurrence of AH with children, which relate to a wide network of social and cultural factors of individuals and their families (6) , such as lack of knowledge of families, non-cultural preventive measures, habits that favor the occurrence of accidents, poor supervision of children, unsafe domestic environments with the presence of dangerous products and materials, indiscriminate delegation of tasks incompatible with the child's age, access to guns, lack of more effective laws and lack of communication (7) .
Considering these facts, the broader context of health, which allows a more in-depth analysis of the risks for the occurrence of AH with children, should consider the complexity of the determinants of health.They are the conditions in which people are born, grow, live, work and age, shaped by the distribution of financial resources and power, as well as general resources, at the local, national and global levels (8) .Therefore, this set of factors must be organized and analyzed from the perspective of the Social Determinants of Health (SDH), to characterize the individuals' particularities and reflect their insertion in a space-time, as conditioning factors of AH in childhood (9) .
Based on this understanding, further studies are necessary to determine the risk factors for the occurrence of unintentional injury deaths (10) , since the detailed knowledge of these factors, in a preventive approach, is essential to allow progress to control accidents (7) .In addition, previous reviews of the literature analyzed the risk factors for AH in childhood but did not list them from the perspective of SDH.Therefore, knowing the elements/factors that determine the life and health conditions of children victims of AH will provide more appropriate actions, which may intervene to transform certain SDHs that represent negative aspects to the health of this population in this context (9) .

OBJECTIVE
To analyze the factors associated with childhood accidents at home according to the levels of the social determinants of health.

METHOD
This is an integrative review of the literature.For its elaboration, the following steps were adopted: identification/formulation of the problem; literature search/collection of data; evaluation of data; analysis of the findings of the articles included in the review; and presentation and interpretation of results (11) .
In the first step, the available knowledge about the relationship between social determinants of health and the occurrence of AH in childhood was listed.Thus, this study was guided by the following research question: What are the social determinants of health associated with the occurrence of AH in childhood?For its elaboration, the PICo strategy was adopted, in which the P corresponds to Participants, I to the phenomenon of Interest and Co to the Context of the study (12) .Subsequently, the controlled and uncontrolled index (CUI) were selected from the Health Sciences Descriptors (DeCS), Medical Subject Headings (MeSH) and List of Headings from CINAHL Information Systems, which are presented in Chart 1.
The search in the literature occurred between May and July 2017, simultaneously, by three researchers in databases accessed through the Portal of Journals of the Coordination of Improvement of Higher Education Personnel (CAPES), in an area with Internet Protocol (IP).The bases searched were: Index to Nursing and Allied Health Literature (Cinahl), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Medline (International Literature in Health Sciences), via PubMed.
Chart 1 -Stratification of the research question following the PICo strategy (12)  As inclusion criteria, we adopted: primary studies that addressed the relation between the social determinants of health and the occurrence of AH in childhood; published in English, Portuguese or Spanish.Studies related to the other age range other than childhood, studies of traditional literature review or systematic or integrative review, studies that analyzed AH associated with other types of accidents (such as traffic accidents), those selected in the search for another database and studies that did not respond to the question of research.It is emphasized that the temporal cut-off for the selection of articles was not carried out, since a broad approach was sought.
The selection of the studies was initially performed by reading the titles and abstracts, based on the inclusion criteria, totaling 1,040 articles.150 publications were considered potentially eligible and selected for reading in full, of which 31 were included in the final sample of this integrative review, as shown in Figure 1, which followed the PRISMA guidelines (13) .
in the population, such as housing, food, education, income and employment (16) .Finally, AH was considered the unintentional and avoidable event, causing physical and emotional damage, occurring in the home environment (living/family living space), excluding social environments (traffic, school, sports and leisure outside the home) (17) .
To evaluate extracted data, the Brazilian Center for Evidence-Based Health Care was determined by the Collaborating Center of the Joanna Briggs Institute (JBI), Brazil, based at the University of São Paulo (USP).The Levels of Evidence according to the type of study, according to the JBI are: Level I -Evidence obtained from a systematic review containing only randomized controlled clinical trials; Level II -Evidence obtained from at least one randomized controlled trial; Level III. 1 -Evidence obtained from well-outlined controlled clinical trials, without randomization; Level III. 2 -Evidence obtained from well-outlined or case-control and cohort studies, analytical studies, preferably from more than one research center or group; Level III. 3 -Evidence obtained from multiple time series, with or without intervention and dramatic results in uncontrolled experiments; Level IV -Opinion of respected experts in their fields, based on clinical criteria and experience, descriptive studies or reports of expert committees (12) .
The analysis of data of the articles included in the review involved a complete and impartial interpretation of primary sources, together with an innovative synthesis of evidence (11) .The data obtained through the analysis of the objectives, results and conclusion of each study were grouped by similarity and organized into thematic categories, which had as their guiding principle the model proposed by Dahlgren and Whitehead.In this model, the SDH are arranged in different layers, from a layer closer to the individual determinants to a distal layer, in which the macrodeterminants (16) are located.Thus, the presentation, analysis and discussion of data were divided into theoretical categories, according to the SDH, into: Proximal Determinants, represented by the operational categories related to the individual, such as age, sex, hereditary and ethnic/racial factors; Intermediate Determinants, which comprise the operational categories of lifestyle and social and community networks; and Distal Determinants (education, work environment, source of income, basic sanitation, culture, housing and social and health services) and general socioeconomic, cultural and environmental conditions (9) .

RESULTS
The characterization of the studies included in the review is presented in Chart 2. The years of publication varied between 1983 and 2017, and most of them were published as of 2010 (19  articles).Considering the place of development of the studies, most (8 articles) were carried out in North American countries (six in the United States -USA, and two in Canada).Regarding the types of AH analyzed in the surveys, the majority involved "general AHs" (16 articles), classification attributed to studies that did not specify AH or that addressed three or more accidents in the analysis; followed by seven articles that analyzed SDH related to Poisoning/Intoxication.As to the design, all the studies presented a quantitative approach, predominating the level of evidence III.(20 articles) (12) .
A complete reading of the selected articles was conducted, and data extraction was done using an adapted data collection form (14) capable of ensuring that all relevant data were extracted.The data included: definition of objects, methodology, sample size, variables measurement, method of analysis and concepts employed.
Regarding the underlying concepts, it should be pointed out that childhood was considered according to the proposal of the Statute of the Child and Adolescent (Federal Law 8.069/90) that considers a child to be a person under 12 incomplete years (15) ; and that the definition of social determinants of health was established from the proposal of the National Commission on Social Determinants of Health, which specifies the social, economic, cultural, ethnic/racial, psychological and behavioral factors that influence the occurrence of health problems and their risk factors Chart 2 -Characterization of selected studies in chronological order according to authors, country, study design, number of participants, objectives, social determinants of health, main results and level of evidence, 2017

Objectives Social Determinants of Health/ Main results LV
Mahdi AH, Taha AS, Al Rifai MR (18)  The AH addressed were Poisoning/Intoxication.The age range of children was from six months to seven years old, predominantly male.Most mothers were unaware of the toxicity potential of the substances.In 18% of cases supervision was delegated to an older child (sibling); 38% of families lived in small apartments and 30% in isolated houses in poor neighborhoods.In 80% of cases the father of the child had primary education and the mother had no formal education.

Retrospective longitudinal study/ N= 2.036
To examine the independent contributions of demographic, behavioral and environmental antecedents of medically assisted pediatric domestic injuries.Proximal DSH: (child's sex; ethnicity/race).Distal DSH: (living conditions, housing, mother's education, social factors, economic factors, access to health services).
General AHs were addressed.Boys were more likely to suffer a home injury.White, non-Hispanic children were significantly more likely too.Uninsured children were more likely to live below the poverty level and in households characterized as disordered, factors associated with the occurrence of injuries.

United Kingdom 2003
Case-control prospective study/ N= 207 To investigate the physical, social and psychological environment of families with preschool children to identify the most significant risk factors for unintentional injuries.
General AHs were addressed.For the case group, the child's primary caregiver was single, the majority received some benefit from the government.The assessment of physical and mental well-being did not reveal differences in both groups.A larger proportion (19%) of the group of cases did not receive social support when compared to those controlled, who received more support from friends and neighbors.The families of cases had more children.

III 2
Ramos CLJ, Targa MBM, Stein AT (21) Brazil General AH were addressed.There was a higher frequency of boys and unfavorable socio-demographic conditions.The sanitary conditions were precarious, the houses had few rooms, which favored the crowding of people in small spaces.There was no statistically significant association between mother's occupation, income and the occurrence of AH.

Descriptive study with quantitative approach/ N= 87
To identify the presence of risk factors for the occurrence burns and electric shock, in the opinion of the mothers and the researcher, in children during early childhood, and to verify the association with the sociodemographic data of mothers.
The AHs addressed were Burns and Electric Shock.In general, mothers were between 21 and 40, with a family income between one and two minimum wages, whose main occupation was to be housewives.It was verified that the researcher had a higher percentage of identification of risk factors than mothers, since they identified 98.85% of risk factors, whereas mothers, 66.70%.The identification of risk factors was not influenced by income (p=0.943),age (p=0.973),occupation (p=0.887) and marital status (p=0.899).

III 3
To be continued The AH addressed were Poisoning/Intoxication.Boys and girls had the same age pattern for hospitalization rates for poisoning.Rates of hospitalization for unintended intoxication were significantly higher in children aged one to three than among children under one and four.

III 3
Belonwu RO, Adeleke SI (27) Nigeria General AH were addressed.The caregivers of the children at the time of the accident were mostly women between the ages of 25 and 34, and the age group with the highest incidence of accidents was between two and three.

Quasiexperimental case-control study/ N= 70
To investigate the difference between small children injured and those not injured, based on the child's behavioral attributes and caregiver supervision indexes.

Proximal DSH: (child's sex). Intermediate DSH: (behavioral factors; mother's supervision). Distal DSH: (housing).
General AH were addressed.The results revealed that there are no differences between groups of children regarding behavioral attributes.However, the control group received more supervision in general and during specific activities leading to injuries.

III 2
Ramos CL, Barros HM, Stein AT, Costa JS (30) Brazil 2010 Case-control study/ N (caso)= 25 N(controle)= 25 To investigate whether the lack of knowledge about toxic agents at home is a risk factor for unintentional poisoning in childhood.The AH addressed were Poisoning/Intoxication.The mean age of the children was 31.8 months.The distraction was 15 times more likely to occur among caregivers of children who underwent poisoning compared to the control group.Among the families interviewed, 64% in the case group and 60% in the control group belonged to the lower socioeconomic classes.

III 2 Chart 2
To be continued

Social determinants of health associated with childhood accidents at home: An integrative review
Ribeiro MGC, Paula ABR, Bezerra MAR, Rocha SS, Avelino FVSD, Gouveia MTO.

Objectives Social Determinants of Health/ Main results LV
Atak N, Karaoğlu L, Korkmaz Y, Usubütün S (31) Tunisia General AH were addressed.Most accidents took place at home, and 65.3% of them were due to falls; 65.1% took place in the presence of the mother.The frequency of accidents was higher in the age range from 4 to 5 years old and lower in the ≤1 year group.

Quasiexperimental case-control study/ N(cases)= 50 N(control)= 50
To investigate how information provided to mothers of low education can improve the precautions taken to prevent burn injuries involving young children; and to compare the results with a group of mothers who did not receive information.

Distal DSH: (mother's education).
AH by Burns/Scalding were addressed.The results showed that the intervention had a significant impact on improving the precautions mothers have taken to protect their children from burns and bruises at home.

III 2
Johnston BD, Quistberg DA, Shandro JR, Partridge RL, Song HR, Ebel BE (35) USA 2011 AH by TV devices were addressed.More than 65% of the children were between one and three.The injuries rate was higher in boys (66.7%) than in girls (33.3%).The most common mechanism of injuries (71.4%) among all age groups was device fall.Pulling the TV to one's direction (19%) was the second most frequent mechanism of injuries.

III 3 Chart 2
To be continued

Social determinants of health associated with childhood accidents at home: An integrative review
Ribeiro MGC, Paula ABR, Bezerra MAR, Rocha SS, Avelino FVSD, Gouveia MTO.

Objectives Social Determinants of Health/ Main results LV
Carlberg MM, Shapiro-Mendoza CK, Goodman M (38) USA The AH addressed were Accidental Suffocation and Strangulation.
The children with the highest ASBS mortality rates were boys and were born between 20 and 33 weeks of pregnancy.The majority of ASBS mortality (71%) occurred before the infant reached four months.The mothers of babies with the highest ASBS mortality rates were black, non-Hispanic, Native American/Alaska Native, smoked during pregnancy, were younger, had less than 12 years of education, and had not undergone prenatal care.

Transversal study/ N= 362
To portray the sociodemographic profile of families living in a low income community; and to identify the associated factors for the occurrence of unintentional injuries in children.
The study addressed general AH.According to the family type, the majority (62.7%) were nuclear (father, mother and children).As for demographic density by residence, 43.6% of households had four people and 42.0% of families had five to seven.Considering the family income, 71.0% survived with up to a minimum wage.In 79.3% of households, at least one person was employed.In relation to the caregiver, the mother was cited in 71.8% of the families.In 50.1% it has been reported that parents have delegated responsibilities to their children.

III 3
Shah M, Orton E, Tata LJ, Gomes C, Kendrick D (40) United Kingdom 2013 Case-control study/ N(cases)= 986 N(control)= 9240 To identify risk factors for scald injuries in children under 5.
The AH addressed were Burns/Scaldings.Multivariate analysis showed that boys were 34% more likely to suffer scald injuries.With regard to age, children aged 1-2 were at higher risk when compared to those younger than 1 year old.A high number of older siblings were also associated with a greater chance of scalding injuries.
High maternal age at delivery was associated with a decrease in the chance of scald injuries.Children living in households with single adults showed an increased chance of injuries.

III 2
Sheikh S, Chang A, Kieszak S, Law R, Bennett HKW, Ernst E et al (41) USA 2013 Transversal study with descriptive and analytical components/ N= 23.536 To characterize demographic, health, and potential risk factors associated with lamp oil poisoning reported by poison center attendants in the US, and discuss their implications for public health.

Intermediate SDH: (behavioral factors). Distal SDH: (cultural factors).
The AH addressed were Poisoning/Intoxication.Most intakes occurred in children who were two years old; they involved tiki torch fuel products located on a table or shelf, and occurred indoors.The amount of oil in the lamp ingested does not appear to be associated with its odor (p=0.19) or oil color (p=1.00).Most of the exhibits were managed on-site and resulted in "effectless" medical results.

III 3
Kamal NN (42) Egypt The study addressed general AH.Boys have slightly higher injuries rates than girls.It was also determined that 32.9% of children who suffered injuries at home had between 24-35 months.The low educational level of parents significantly increased the risk of injuries.It was significantly higher for the children of families with lower income (p<0.05).Daughters of young mothers with parents of lower education and low socioeconomic status have a considerably higher risk of injuries.

Transversal study/ N= 80
To examine the relation between the socioeconomic and sociodemographic factors of the family and the risk factors for the domestic injury.
AH were addressed in a general way.In both low-income and higher-income families, risk factors were found.However, poorer families with younger parents have less knowledge to identify risk factors for the occurrence of AH.AH were addressed in a general way.The risk of ADHD among parents was significantly higher in children hospitalized for AH compared to the control group.Having a father at high risk for ADHD increased two times the relative risk of children being exposed to injuries.

Transversal study with descriptive and analytical components/ N= 6534
To investigate the association between unintentional injuries in children and postpartum depression.
General AH were addressed.9.8% of the infants suffered unintentional injuries and 9.5% of the mothers had postpartum depression.After adjustment for covariates, postpartum depression was significantly associated positively with any unintentional injuries.III 3 Stewart J, Benford P, Wynn P, Watson MC, Coupland C, Deave T, et al (47) United

Category 1 -Proximal Social Determinants of Health
According to the level of comprehensiveness, individuals are based on the Dahlgren and Whitehead model, with individual characteristics of age, gender and genetic factors that, of course, influence their potential and health conditions (49) .In 22 analyzed articles the relation between Proximal SDHs and the occurrence of AH in childhood was investigated.The child's age was reported as capable of influencing the occurrence of AH in 16 analyzed articles, varying the prevalence among younger and older children depending on the type of AH.
In studies involving AH in general, in which no type specification was made, a statistically significant association was observed between the frequency of AH that caused injuries and age groups (25,28,31,43) .The age group with the highest frequency is the group between four and five years old (31,43) .It is found that, in general, accidents are less frequent among children under one.In the context of the AH caused by a specific cause, the poisonings or intoxications were also analyzed from the age of the child in seven surveys (18,21,(26)(27)30,32,41) . The same nalysis was performed in cases of accidental drowning/submersion injuries in childhood (33) and television falling on the child (37) .Following the same tendency of studies involving AH without specification, it is evident that the most prevalent age group in these occurrences varies from one to three years old (37) , and one to five years old (18,33) , with a variation of the mean age of 31.8 (30) to 36 months (32) .The peak occurrence is usually between one and two years old (26)(27)30) and then decreasing to four years old (26) .
In this age group, there are intense changes related to the growth and development of mobility, cognitive ability and receptive comprehension, which may contribute to the occurrence of AH (1) .In addition, factors related to the child, such as age or stage of development, affect adult behavior, particularly supervision, an intermediate SDH (28) .It is identified that younger children are more supervised than older ones (25) .Parents are less likely to be present when accidents occur between the ages of two and four, and at that age, children tend to play more with their siblings, contributing to the occurrence of AH injuries (28) .

Social determinants of health associated with childhood accidents at home: An integrative review
Ribeiro MGC, Paula ABR, Bezerra MAR, Rocha SS, Avelino FVSD, Gouveia MTO.
not safe for children, either because families do not have enough economic conditions to invest in preventive measures (35) or because parents are unaware of risk situations (23) .In this context, there is again an association between different SDHs: housing, economic factors and education.

Study limitations
It is highlighted as a limitation of the study the non-inclusion of multiprofessional databases.For this review, three databases (Cinahl, Lilacs and Medline) were selected, which established a limiting factor, since the manuscripts that were not indexed could not be selected to make up the sample.In addition, it is indicated as limitations the non-inclusion of studies of the type review and the impossibility to consider in the discussion the great variety of contexts of origin of the reviewed articles.

Contributions to the Nursing, Health or Public Policy fields
The results presented in the study provide further information about the etiology of AH with children.When identifying the social determinants of health associated with these injuries, it is perceived that their prevention is not only the responsibility of parents and/or family, but of the community and the environment in which they live.Thus, primary health care plays a fundamental role in the prevention of these injuries, since it is the gateway of the Unified Health System and has a greater possibility of identifying the demands of individuals and their community.Knowledge of the associated social determinants of health may guide the development of new educational programs and activities that may intervene, mainly, in changeable determinants.

CONCLUSION
The analysis of the articles evidenced the complexity and the multifactorial nature of the occurrence of AH in childhood.The presence of different SDH in the same context of occurrence of AH, whether belonging to the same category or coming from different categories, has been found to mutually reinforce the risks and hinder the implementation of preventive measures.
It has been observed that the Proximal and Intermediate SDH are those more statistically associated with the etiology of AH.The age and sex of the child, identified as Proximal SDH, are the ones that most influence the occurrence and the type of accident.Among the intermediate determinants, the lack of supervision by an adult facilitates the occurrence of injuries, mainly related to poisonings and burns.Despite a significant number of studies inserted in the review, it is necessary to expand investigations about psychological factors (Intermediate SDH) and social and economic factors (Distal SDH), since it was not possible to consistently identify the mechanism of action of these determinants in the occurrence of childhood AH.
The identification of the main SDH involved in unintentional injuries with children should be used to adopt protective measures, mainly directed to factors that are changeable, such as behavioral ones.It also reinforces the importance of investing in public policies that reduce social inequities and exposure to risks, considering the different contexts in which children are inserted.
AH by Falls from Windows were addressed.The falls mostly happened in the rooms of the child's house.Most were boys.The main risk factors were the type of window, external height, depth of the threshold and absence of screen protection.

Social determinants of health associated with childhood accidents at home: An integrative review
AH were addressed in a general way.The results showed that a greater number of household risks were significantly attributed to school-age children.Migrant children are more exposed to risks at home compared to local children.High family stress has been identified as a risk factor as it can lead to mental distraction of parents and disturb the child's emotional behavior.Ribeiro MGC, Paula ABR, Bezerra MAR, Rocha SS, Avelino FVSD, Gouveia MTO.