Circumstances and factors associated with accidental deaths among children, adolescents and young adults in Cuiabá, Brazil

Circunstâncias e fatores associados às mortes por causas acidentais entre crianças, adolescentes e jovens em Cuiabá, Brasil

Christine Baccarat de Godoy Martins Maria Helena Prado de Mello-Jorge About the authors

Abstracts

CONTEXT AND OBJECTIVE

Analysis on accidents from the perspective of population segments shows there is higher incidence among children, adolescents and young adults. Since the characteristics and circunstances of the event are closely related to educational, economic, social and cultural issues, identifying them may contribute towards minimizing the causes, which are often fatal. The aim here was to identify the environmental, chemical, biological and cultural factors associated with deaths due to accidents among children, adolescents and young adults in Cuiabá, in 2009.

DESIGN AND SETTING

This was a descriptive cross-sectional study conducted in Cuiabá, Mato Grosso, Brazil.

RESULTS

Thirty-nine accidental deaths of individuals aged 0 to 24 years were examined: 56.4% due to traffic accidents; 25.6%, drowning; 10.3%, aspiration of milk; 5.1%, falls; and 2.6%, accidentally triggering a firearm. Male victims predominated (82.1%). The presence of chemical, environmental and biological risk factors was observed in almost all of the homes. Regarding cultural factors and habits, a large proportion of the families had no idea whether accidents were foreseeable events and others did not believe that the family's habits might favor their occurrence. Delegation of household chores or care of younger siblings to children under the age of 10 was common among the families studied.

CONCLUSION

The results point towards the need to have safe and healthy behavioral patterns and environments, and to monitor occurrences of accidents, thereby structuring and consolidating the attendance provided for victims.

Accidents; Child; Risk factors; Mortality; Epidemiology


CONTEXTO E OBJETIVO

Ao analisar os acidentes sob o prisma dos segmentos populacionais, observa-se grande incidência em crianças, adolescentes e jovens. A frequência e as características e circunstâncias do evento estão intimamente relacionadas com fatores educacionais, econômicos, sociais e culturais, e a identificação desses fatores pode contribuir para minimizar essas causas, muitas vezes fatais. O objetivo foi identificar os fatores ambientais, químicos, biológicos e culturais associados com óbitos por acidentes, ocorridos entre crianças, adolescentes e jovens em Cuiabá, em 2009.

TIPO DE ESTUDO E LOCAL

Este é um estudo descritivo, transversal, realizado em Cuiabá, Mato Grosso, Brasil.

RESULTADOS

Foram analisados 39 óbitos acidentais ocorridos de 0 a 24 anos (56,4% por acidente de transporte, 25,6% por afogamento, 10,3% por aspiração de leite, 5,1% por queda e 2,6% por disparo acidental de arma de fogo). Houve predomínio no sexo masculino (82,1%). Observou-se a presença de fatores químicos, ambientais e biológicos na quase totalidade das residências. Quanto aos fatores culturais e hábitos, grande parte das famílias não soube referir se o acidente constitui evento previsível e outra parte não acredita que os hábitos da família favorecem sua ocorrência. Delegar aos filhos menores de 10 anos os afazeres domésticos ou o cuidado de irmãos menores é comum entre as famílias estudadas.

CONCLUSÃO

Os resultados apontam para a necessidade de adotar comportamentos e ambientes seguros e saudáveis, bem como monitorizar a ocorrência dos acidentes, estruturando e consolidando o atendimento às vítimas.

Acidentes; Criança; Fatores de risco; Mortalidade; Epidemiologia


INTRODUCTION

Unintentional events (accidents) give rise to direct and indirect costs. The former consists of expenditure on medical attention and treatment, complementary examinations, hospitalization and rehabilitation; the latter relates to the loss of working days, lower productivity and material damage.11. O impacto dos acidentes e violências nos gastos da saúde [Impact of accidents and violence on health costs]. Rev Saude Publica. 2006;40(3):553-6.

The highest incidence of accidents has been recorded among children, adolescents and young adults, with important peculiarities regarding frequency and the characteristics and circumstances of the event.22. Pickett W, Molcho M, Simpson K, et al. Cross national study of injury and social determinants in adolescents. Inj Prev. 2005;11(4):213-8. Worldwide, the main causes of death during childhood include traffic accidents (mortality rate of 10.7/100,000), drowning (mortality rate of 7.2/100,000), burns (mortality rate of 3.9/100,000), falls (mortality rate of 1.9/100,000) and poisoning (mortality rate of 1.8/100,000).33. Peden M, Oyegbite K, Ozanne-Smith J, et al. Conclusions and recommendations. In: Peden M, Oyegbite K, Ozanne-Smith J, et al (eds.). World report on child injury prevention. World Health Organization. Geneva; 2008. p. 145-55. Available from: http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf. Accessed in 2012 (Sep 18).
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In Brazil, the deaths among children under ten years of age are due to traffic accidents (29.3%), drowning (21.1%), suffocation (15.4%), aggression (7.0%) and falls (5.1%). In 2009, the mortality rate from traffic accidents for this age group was 3.6/100,000, followed by drowning (2.6/100,000) and accidental risks to breathing (1.8/100,000).44. Brasil. Ministério da Saúde. Indicadores de mortalidade. Ficha de qualificação. Comentários. Taxa de mortalidade específica por causas externas. Available from: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?idb2010/c09.def. Accessed in 2012 (Sep 18).
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Accidents in the infant-juvenile group stand out not only because of the deaths that they cause, but also because of the resultant trauma, which leaves sequelae and drastically interrupts the growth and development phase.55. Mascarenhas MDM, Silva MMA, Malta DC, et al. Atendimentos de emergência por acidentes na Rede de Vigilância de Violências e Acidentes: Brasil, 2006 [Unintentional injuries at the Emergency Department Injury Surveillance System: Brazil, 2006]. Ciênc Saúde Coletiva. 2009;14(5):1657-68.

Some authors have suggested that accidents are closely related to educational, economic, social and cultural factors, such as low income, low maternal education, inadequate spaces for leisure, poor facilitating physical structure within the environments, high levels of street exposure, inadequate supervision, dysfunctional family constitution, family conflicts and consumption of alcohol and drugs, among others.33. Peden M, Oyegbite K, Ozanne-Smith J, et al. Conclusions and recommendations. In: Peden M, Oyegbite K, Ozanne-Smith J, et al (eds.). World report on child injury prevention. World Health Organization. Geneva; 2008. p. 145-55. Available from: http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf. Accessed in 2012 (Sep 18).
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,66. Gilbride SJ, Wild C, Wilson DR, Svenson LW, Spady DW. Socio-economic status and types of childhood injury in Alberta: a population based study. BMC Pediatr. 2006;6:30.,77. Martins CB, de Andrade SM, de Paiva PA. Envenenamentos acidentais entre menores de 15 anos em município da Região Sul do Brasil [Accidental poisoning among children and adolescents in a county in southern Brazil]. Cad Saude Publica. 2006;22(2):407-14. Therefore, identification and reduction of such factors may contribute towards reducing accidents and, consequently, these traumatic situations and their often irreversible or fatal consequences.

OBJECTIVE

The present study aimed to identify environmental, chemical, social and cultural factors present in the homes of children, adolescents and young adults who died in an accident.

METHODS

This was an epidemiological investigation in which the study population comprised children, adolescents and young adults (0 to 24 years of age) who lived in Cuiabá, Mato Grosso, Brazil, and died in accidents between January 1 and December 31, 2009. All the accidental deaths among individuals aged 0 to 24 years that occurred in the municipality in 2009 were studied, thus including the whole population and not just a sample.

Identification data for the victims were obtained from their death certificates, which were available by the Births and Deaths Registry of the Municipal Health Department of Cuiabá. The inclusion criteria were as follows: age 0 to 24 years; resident in Cuiabá; death occurred in 2009; and accidental cause was the basic cause of death (chapter 20 of ICD-10; codes V01 to X59).

A domestic investigation among the victims' families was then performed using a form with closed questions.

The data were analyzed using the EpiInfo software, with simple and bivariate analyses, and P < 0.005 was taken to be the significance level.

The variables studied were: type of accident (subgroups) according to age and sex of the victims; circumstances of death; place of the accident; place of death; period of the day (morning, afternoon or evening) and day of the week (beginning, middle or end of the week) on which the accident occurred; who the victim was with at the time of the accident; and factors observed during the domestic survey (environmental, chemical, biological and cultural factors).

The “environmental factors” considered were: stairs, verandas, access ramps, windows and swimming pools without protection; furniture at windows; sharp pointed devices, tools, plastic bags, matches and lighters within reach of children; access to the bathroom, laundry, kitchen, stove and hot products; stove in an area without ventilation; cookware with handles projecting out from the stove or with lids that did not fit; tablecloths with corners that could be pulled; access to electrical wiring and sockets; glassware and cans in low places; toys and/or objects scattered on the floor; loose rugs; wet floors; buckets, basins or bath with water; objects on the stairs; piles of firewood, tiles, bricks or planks; garbage bins without lids; open water tank or cesspool; access to machinery or equipment; wire fences; hammocks suspended at 1.0-1.5 m from the ground; fans with the propellers exposed; uneven floors; slippery floors; or firearms in the home.

The “chemical factors” considered were: cleaning products (detergent, soap and sanitary water); volatile chemicals (alcohol, kerosene and gasoline); solvents (thinner); poisons; cosmetics (cream, nail polish, make-up and perfume); hygiene products (soap, shampoo and deodorant); and medicines within the reach of children, according to the way in which they are stored and accessed.

The “biological factors” considered were: presence of animals, a garden with tall grass, plants within the reach of children and trees in the yard.

The “cultural factors” considered were: the family's perception of predictability of the event; the family's beliefs about habits and lifestyle favoring accidents; the family's supervision of the child while in water (swimming pool, bucket, tank or river) or at leisure; use of a baby walker; the habit of leaving the child alone on a bed, sofa or diaper change table; the victim's habit of playing on stairs, roofs or verandas, or flying a kite near electric wires; and the habit of delegating household chores or the task of caring for small children to children under ten years of age.

The mortality rate per accident was calculated based on the population of the same age and year.

This research was authorized by the Health Department of Cuiabá and the Research Ethics Committee of the University Hospital Julius Müller University Hospital (Hospital Universitário Júlio Müller, HUJM) of the Federal University of Mato Grosso (Universidade Federal de Mato Grosso, UFMT) (protocol 929/CEP-HUJM/2010). The participating families signed a free and informed consent statement.

RESULTS

This study included 39 cases of death due to accidental causes among children, adolescents and young adults aged 0 to 24 years of age, who were living in Cuiabá, Mato Grosso, Brazil, in 2009. Regarding the accidents, 56.4% involved traffic accidents, followed by drowning (25.6%), risks relating to breathing/aspirating milk (10.3%), falls (5.1%) and accidental triggering of firearm (2.6%). Regarding gender, males predominated (82.1%) (Table 1).

Table 1.
Distribution of deaths due to accidental causes among children, adolescents and young adults, according to kind of accident, age and gender, Cuiabá, 2009

Transportation accidents occurred at a higher rate in the age group from 20 to 24 years (50.0%), as did drowning (drowning in rivers), although this was also present in the age groups from one to four years (drowning in pools and lakes) and from five to 9 (drowning in lakes). The cases of asphyxia (aspiration of milk) occurred most often among children under one year of age, falls in the age group from 15 to 19 years (from scaffolding during work) and accidental triggering of a firearm in the age group from five to nine years, while playing with the father's weapon (Table 1).

The mortality coefficient from accidents, calculated on the basis of the population and year of this study, showed higher mortality rates among males, especially after the age of 15 years (Figure 1).

Figure 1.
Mortality coefficient from cause of accidents among children, adolescents and young adults, according to age group and gender, Cuiabá, 2009.

Most victims of accidents died in hospital. Among the victims whose accidents occurred at home, 85.7% died in hospital and the remainder (14.3%) died at the location of the event (home). Among the victims whose accidents occurred on public thoroughfares (in the case of transport accidents), 57.1% died in hospital and 42.9% at the location of the accident. The workplace accidents also led to death in hospital.

Transportation accidents occurred predominantly in the morning (54.5%) and in the middle of the week (59.1%), whereas drowning occurred in the evening (90.0%) and on the weekend (80.0%). The cases of asphyxia (aspiration of milk) occurred in the morning and evening, falls in the morning and accidents with firearms in the afternoon. These last three events occurred in the middle of the week (Table 2).

Table 2.
Distribution of deaths due to accidental causes among children, adolescents and young adults, according to kind of accident, part of the day and part of the week in which they occurred, Cuiabá, 2009

At the time of the accident, 68.2% of the victims of traffic accidents were alone and 22.0% were with their parents, although all the victims were the drivers. In the cases of drowning, 70.0% of the victims were also alone and only 30.0% were in the company of their parents. The children who died from aspiration of milk were with their parents; the adolescents who died due to falls were alone; and the child who died from accidental triggering of a firearm was in the company of his grandfather while the parents were working.

Regarding environmental factors, most of the homes showed the risk factors mentioned in this study, with the exception of firearms (Table 3). These variables were listed in order to determine the frequency of each risk factor in the 39 houses studied. The findings show that none of the homes was absolutely risk-free. Sharp-pointed materials, tools, plastic bags and matches were observed to be within the reach of children in all the homes, and the children had free access to the kitchen, bathroom, laundry and stove. The only homes that did not present open water tanks or cesspools were the very ones that did not possess either a water tank or a cesspool.

Table 3.
Distribution of deaths due to accidental causes among children, adolescents and young adults, according to environmental factors observed in the victims' homes (n = 39), Cuiabá, 2009

In most of the homes, chemical factors were in easy reach of children and many of these products were even packed in food jars or bottles (Table 4).

Table 4.
Distribution of deaths (n = 39) due to accidental causes among children, adolescents and young adults, according to chemical and biological factors observed in the victim's home and cultural factors and habits of the victim's family, Cuiabá, 2009

Regarding biological factors, the presence of animals (82.1%), trees in the yard (92.3%) and plants and tall grass was common to most homes (Table 4).

Regarding cultural factors and the families' habits, most of the participants thought that accidents were neither foreseeable events nor preventable (92.3%), while only 7.7% believed that they were so. When inquired whether the family's habits favored occurrences of accidents, 51.3% said that they did (Table 4).

Table 4 also shows that many families were in the habit of supervising children and adolescents in the water (76.9%) but not during leisure time (74.4%). Moreover, playing on roofs and running a kite in the street were common activities among the children. It was also common for adults to delegate household chores or the care of younger siblings to children under ten years of age.

DISCUSSION

Among the various types of accidents, the concentration of victims among males, from transport accidents and at younger ages coincides with the results from other studies on causes of accidents.88. Fraga AM, Fraga GP, Stanley C, Costantini TW, Coimbra R. Children at danger: injury fatalities among children in San Diego County. Eur J Epidemiol. 2010;25(3):211-7.,99. Pearson J, Stone DH. Pattern of injury mortality by age-group in children aged 0-14 years in Scotland, 2002-2006, and its implications for prevention. BMC Pediatr. 2009;9:26. In view of this context, it has been suggested that legal measures (relating to implementation and enforcement), in association with preventive measures and traffic education, as practiced in developed countries, are essential.1010. Pinheiro Dantas MM, Cavalcante e Silva A, Almeida PC, Albuquerque Gurgel L. Caracterização dos acidentes de trânsito envolvendo crianças e adolescentes internados em um hospital público terciário [The characterization of traffic accidents involving children and adolescents admitted to a public tertiary hospital]. Revista Brasileira em Promoção da Saúde. 2009;22(2):100-6. Available from: http://redalyc.uaemex.mx/redalyc/pdf/408/40811734007.pdf. Accessed in 2012 (Sep 18).
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Our findings draw attention to occurrences of drowning in rivers and lakes, both at very young and at older ages. These cases may be explained by the great number of natural water areas in the region of Cuiabá, which are commonly used for leisure in view of the hot climate. Whereas in rich countries drowning occurs predominantly in swimming pools, in poorer countries this type of accident occurs mostly in rivers and public natural water areas.1111. Nonfatal and fatal drownings in recreational water settings - United States, 2001-2002. JAMA. 2004;292(2):164-6. Available from: http://jama.jamanetwork.com/article.aspx?articleid=199094. Accessed in 2012 (Sep 18)
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In view of the high lethality rate due to drowning, it is essential to implement surveillance of children and adolescents during leisure activities in water, as well as providing signs and infrastructure enhancements, with fences surrounding risk areas and the presence of lifeguards. Nevertheless, the vast hydrographic network with many waterfalls and natural water areas makes it difficult to provide lifeguards and surveillance, thus showing the importance of behavioral changes among families, such that safe behavior and surveillance of children become habits.

It is important to highlight the deaths resulting from aspiration of milk, which have also been mentioned in other studies as common among children under the age of one year.1212. Martins CB, Andrade SM. Acidentes com corpo estranho em menores de 15 anos: análise epidemiológica dos atendimentos em pronto-socorro, internações e óbitos [Accidents with foreign bodies in children under 15 years of age: epidemiological analysis of first aid services, hospitalizations, and deaths]. Cad Saude Publica. 2008;24(9):1983-90. This points towards the need for proper eructation after each breastfeeding session and proper positioning in the cradle to prevent suffocation in the event of regurgitation.1313. Million Death Study Collaborators, Bassani DG, Kumar R, et al. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet. 2010;376(9755):1853-60.

Falls while working, in turn, draw attention to the issue of safety in the workplace. Statistics show that accidents in the workplace are one of the main causes of occupational death throughout the world, although with different coefficients for economically developed countries (5.9 deaths per 100,000 workers), Asian countries (23.1 per 100,000) and Latin American countries (13.5 per 100,000).1414. Driscoll T, Takala J, Steenland K, Corvalan C, Fingerhut M. Review of estimates of the global burden of injury and illness due to occupational exposures. Am J Ind Med. 2005;48(6):491-502. In Brazil, the estimated coefficient is 11.4 per 100,000 workers,1515. Santana VS, Araújo-Filho JB, Silva M, et al. Mortalidade, anos potenciais de vida perdidos e incidência de acidentes de trabalho na Bahia, Brasil [Mortality, years of life lost, and incidence of occupational accidents in the State of Bahia, Brazil]. Cad Saude Publica. 2007;23(11):2643-52. which is much higher than in developed countries such as England (0.7 per 100,000).1616. Health and Safety Commission. Health and safety statistics 2004/05. Available from: http://www.hse.gov.uk/statistics/overall/hssh0405.pdf. Accessed in 2012 (Sep 18).
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However, these statistics relate to regular workers. In our study, the deaths from falls in the workplace involved children under the age of 15 years, who are considered under Brazilian law to be apprentices.1717. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto n° 5.598, de 1° de dezembro de 2005. Regulamenta a contratação de aprendizes e dá outras providências. Available from: http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Decreto/D5598.htm. Accessed in 2012 (Sep 18).
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Nonetheless, given that accidents in the workplace have a major impact on the productive and economic capacity of the country, since they generally involve young people at the beginning of their professional lives, reflection is required regarding the importance of prevention and safety measures and the use of appropriate equipment, in order to avoid this kind of accident and the consequent injuries, which are often fatal.

Accidental death caused by triggering firearms raises the discussion about the danger of keeping firearms at home, since children and adolescents have natural curiosity and lack of perception of imminent risk form a dangerous combination.1818. American Academy of Pediatrics. A guide to safety counseling in office practice. Available from: http://www2.aap.org/family/TIPPGuide.pdf. Accessed in 2012 (Sep 18).
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Therefore, it is better not to have a firearm at home; and if this is really necessary, keeping it unloaded and out of reach of children/adolescents are important preventive measures.

With regard to the place of death, the fact that many transport accidents occurred on public thoroughfares and that the victims died at the location of the accident is indicative of the severity of these traffic accidents and raises three important issues. Firstly, in relation to safety equipment that may reduce the severity of injuries, seat belts should be used in automotive vehicles and helmets should be used by drivers and passengers of motorcycles: these are mandatory devices according to the new Brazilian National Traffic Code.1919. Brasil. Ministério das Cidades. Departamento Nacional de Trânsito (DENATRAN). Departamento Estadual de Trânsito (DETRAN). Código de Trânsito Brasileiro. Available from: http://www.denatran.gov.br/detran.htm. Accessed in 2012 (Sep 18).
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Furthermore, children should always use the correct child restraint such as a child car seat or seat belt, and should travel in the rear seats.2020. Malta DC, Mascarenhas MDM, Silva MMA, Macário EM. Perfil dos atendimentos de emergência por acidentes envolvendo crianças menores de dez anos: Brasil, 2006 a 2007 [Profile of unintentional injuries involving children under ten years of age in emergency departments: Brazil, 2006 to 2007]. Ciênc Saúde Coletiva. 2009;14(5):1669-79. Many deaths can be avoided through correct use of such equipment. However, not all drivers and passengers are using this equipment.2121. Bernal ML, Daza C, Rincón O. Modelo conceptual para identificar factores relevantes en la seguridad de los niños en los autobuses escolares [Conceptual model for identifying factors relevant to the safety of children in school buses]. Rev Panam Salud Pública. 2010;27(6):423-34.

The second issue relates to speedy and skillful care soon after the accident, which is fundamental for reducing the injuries and improving the chances of survival.1010. Pinheiro Dantas MM, Cavalcante e Silva A, Almeida PC, Albuquerque Gurgel L. Caracterização dos acidentes de trânsito envolvendo crianças e adolescentes internados em um hospital público terciário [The characterization of traffic accidents involving children and adolescents admitted to a public tertiary hospital]. Revista Brasileira em Promoção da Saúde. 2009;22(2):100-6. Available from: http://redalyc.uaemex.mx/redalyc/pdf/408/40811734007.pdf. Accessed in 2012 (Sep 18).
http://redalyc.uaemex.mx/redalyc/pdf/408...

Finally, the third issue relates to the need to study the places in which the most serious accidents (with immediate fatal outcome) occur, since these places can be considered to present risks and require careful planning and study. Studying accidents according to their region of incidence (using geographical information systems, GIS) is now capable of generating effective solutions, particularly in relation to traffic accidents.2222. Souza VR, Cavenaghi S, Alves JED, Magalhães AFM. Análise espacial dos acidentes de trânsito com vítimas fatais: comparação entre o local de residência e de ocorrência do acidente no Rio de Janeiro [Spatial analysis of traffic accidents with fatal victims: comparing place of residence and place of occurrence in Rio de Janeiro]. Rev Bras Estud Popul. 2008;25(2):353-64. In healthcare, georeferencing has been highlighted as essential for evaluation and assessment of risks, especially considering that injuries due to traffic accidents (i.e. those responsible for deaths at the site of the accident, in the present study) are responsible for 23% of deaths due to external causes worldwide.2323. Organización Mundial de la Salud. Informe mundial sobre prevención de los traumatismos causados por el tránsito: resumen. Ginebra: Organización Mundial de la Salud; 2004. Available from: http://www.paho.org/Spanish/DD/PUB/resumen_informe_mundial_traumatismos.pdf. Accessed in 2012 (Sep 18).
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The period of occurrence of transportation accidents in the present study contradicts the findings of most other research, which indicated that greater numbers of traffic accidents occur on the weekends due to lower policing levels and greater numbers of inexperienced drivers, along with the intake of alcoholic beverages.2424. Gomes LP, Melo ECP. Distribuição da mortalidade por acidentes de trânsito no município do Rio de Janeiro [Distribution of the mortality by traffic accidents in the city of Rio de Janeiro]. Esc Anna Nery Rev Enferm. 2007;11(2):289-95. The difference found in the present study may have been due to the use of vehicles as a means of transport to go to work, which would explain the greater numbers of traffic accidents in the morning and in the middle of the week. The fact that most of the victims were alone may strengthen this hypothesis.

With regard to drowning, the fact that they occurred in the afternoon and on the weekend may denote a relationship between this kind of accident and leisure activities practiced by many families on the weekends. This result has also been pointed out by other researchers.2525. Espin Neto J, Soares JA, Uslar GDS, et al. Situação dos afogamentos em duas regiões do interior do estado de São Paulo [Drowning situation in two non-coastal regions of São Paulo State, Brazil]. Rev Ciênc Méd (Campinas). 2006;15(4):315-20. In the case of Cuiabá, with its high temperatures and great number of rivers, it is important to consider drowning to be a major cause of accidents. The fact that most of the victims were alone again raises the essential issue of surveillance. A study in China identified greater risk of drowning among children who swam in natural water bodies without supervision from an adult (over the age of 30 years).2626. Ma WJ, Nie SP, Xu HF, et al. An analysis of risk factors of non-fatal drowning among children in rural areas of Guangdong Province, China: a case-control study. BMC Public Health. 2010;10:156. In view of the extensive hydrographic network surrounding Cuiabá, public prevention policies, with indication of areas presenting risks, mandatory lifeguard supervision and educational prevention activities in schools and communities are also important, along with monitoring and rescue training that teaches children and adults the resuscitation techniques that are needed in order to help victims efficiently.

Aspiration of milk during the night and in the morning, which caused the death of children less than one year of age and occurred in the presence of the parents, may be related to times when the parents are tired, sleepy or even sleeping, with consequent carelessness in relation to a child who has just suckled. Aspiration of milk was singled out as the major event among small children. Effective prevention comes from the care provided by adults2727. Maranhão DG. O conhecimento para preservar a vida: um tema delicado [The knowledge to preserve life: a sensitive issue]. VERAS Revista Acadêmica de Educação do ISE Vera Cruz. 2011;1(2):255-71. Available from: http://iseveracruz.edu.br/revistas/index.php/revistaveras/article/viewFile/56/40. Accessed in 2012 (Sep 18).
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in feeding sessions.

Falls occurred in the morning and in the middle of the week, and this picture is consistent with workplace accidents. Accidents at work have been considered to be worrisome and to have a great social impact in Latin American and Caribbean countries.1515. Santana VS, Araújo-Filho JB, Silva M, et al. Mortalidade, anos potenciais de vida perdidos e incidência de acidentes de trabalho na Bahia, Brasil [Mortality, years of life lost, and incidence of occupational accidents in the State of Bahia, Brazil]. Cad Saude Publica. 2007;23(11):2643-52. Taking developed countries such as Denmark, with only 2.9 accidents per 100,000, as an example,2828. Giuffrida A, Iunes RF, Savedoff WD. Economic and health effects of occupational hazards in Latin America and the Caribbean. Washington: Inter-American Development Bank; 2001. Available from: http://idbdocs.iadb.org/wsdocs/getdocument.aspx?docnum=353816. Accessed in 2012 (Sep 18).
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the importance of policies for worker protection in its various dimensions (technical, social, economic, cultural and political) has been highlighted.2929. Santana VS, Araújo-Filho JB, Albuquerque-Oliveira PR, Barbosa-Branco A. Acidentes de trabalho: custos previdenciários e dias de trabalho perdidos [Occupational accidents: social insurance costs and work days lost]. Rev Saude Publica. 2006;40(6):1004-12. In the specific case of adolescents, besides raising awareness regarding the use of personal protective equipment, the safety conditions at work should be assessed in order to be able to reduce this important public health problem that affects the economically active population at its fullest stage of professional development.

The death caused by a firearm in the afternoon and in the middle of the week, at a time when the parents were working, reveals the risk of having firearms at home, often without the child's caregiver knowing about them, such that this person also becomes a victim of the circumstances. Since firearm injuries are in most cases fatal,3030. Nachif MCA. Homicide as a public health problem in the city of Campo Grande, Mato Grosso do Sul, Brazil. Psicol Soc. 2006;18(2):99-104. it becomes vital to resume oral discussions on this issue in order to move forward on disarmament.

The environmental factors found in this study are consistent with the warnings given by other authors, who considered such accidents to be the result from interaction between behavior and environmental factors.66. Gilbride SJ, Wild C, Wilson DR, Svenson LW, Spady DW. Socio-economic status and types of childhood injury in Alberta: a population based study. BMC Pediatr. 2006;6:30. Studies have shown that exposure to stairs, windows and swimming pools without grids and to sharp objects, among other factors, increases the risk of domestic accidents, with a high hospitalization rate,3131. Bernadá M, Assandri E, Cuadro MN, et al. Accidentes en la infancia: prevalencia, características y morbilidad determinada por los accidentes en una población de Uruguay [Childhood accidents: prevalence, characteristics and morbidity determined by accidents in the Uruguayan population]. Rev Méd Urug. 2010;26(4):224-37. often with injuries and significant sequelae.3232. Alptekin F, Uskun E, Kisioglu AN, Ozturk M. Unintentional nonfatal home related injuries in Central Anatolia, Turkey: frequencies, characteristics, and outcomes. Injury. 2008;39(5):535-46. Therefore, changing the home environment is essential, combined with behavioral changes among the family, focusing on prevention.

The chemical factors observed in this study have been acknowledged in the scientific literature as significant causes of intoxication that take many children and adolescents to emergency care worldwide.3333. United Nations Children's Fund. A league table of child deaths by injury in rich nations. Innocenti Report Card. 2001;2. Available from: http://www.kindersicherheit.de/repcard2e.pdf. Accessed in 2012 (Sep 18).
http://www.kindersicherheit.de/repcard2e...
Most accidents with chemical products relate to inadequate storage (within children's reach and stored in soft-drink bottles or food containers), along with people's lack of knowledge in relation to these products.3434. Mintegi S, Fernández A, Alustiza J, et al. Emergency visits for childhood poisoning: a 2-year prospective multicenter survey in Spain. Pediatr Emerg Care. 2006;22(5):334-8. The chemical factors combine with the family's behavior such that, in most cases of intoxication, the product is left within the child's reach.3535. Werneck GL, Hasselmann MH. Intoxicações exógenas em crianças menores de seis anos atendidas em hospitais da região metropolitana do Rio de Janeiro [Profile of hospital admissions due to acute poisoning among children under 6 years of age in the metropolitan region of Rio de Janeiro, Brazil]. Rev Assoc Med Bras. 2009;55(3):302-7. This once again highlights the importance of raising the awareness of the population regarding the hazards of these products and teaching people how to handle them correctly. Manufacturers' responsibility should also be taken into consideration, because many types of packing are attractive to children and easy to open. In this regard, special child-resistant packaging (which was initially implemented in the United States and Canada) has proven to be effective. It reduced the intoxication rate by up to 35% during the period after its deployment.3636. Litovitz TL, Klein-Schwartz W, White S, et al. 1999 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2000;18(5):517-74. In Brazil, two bills of law relating to this have been put forward: the first (PL 4841/94) makes special child-resistant packaging mandatory for medicines and hazardous household products; and the second (PL 5802/01) establishes different symbols on the packaging of cleaning products according to their degree of hazard. However, these bills are still going through the legislative procedures.3737. Brasil. Comissão de Constituição e Justiça e de Redação. Projeto de Lei n° 4.841, de 1994. Determina a utilização de Embalagem Especial de Proteção à Criança – EEPC em medicamentos e produtos químicos de uso doméstico que apresentem potencial de risco à saúde. Available from: http://www.camara.gov.br/sileg/integras/132437.pdf. Accessed in 2012 (Sep 18).
http://www.camara.gov.br/sileg/integras/...
Although no deaths resulted from chemical factors in the present study, reflection regarding occurrences of these events with emergency care and hospital internments is required, as shown by many other studies.3838. Moreira C da S, Barbosa NR, Vieira R de C, et al. Análise retrospectiva das intoxicações admitidas no hospital universitário da UFJF no período 2000-2004 [A retrospective study of intoxications admitted to the university hospital/UFJF from 2000 to 2004]. Cien Saude Colet. 2010;15(3):879-88.4040. Brasil. Ministério da Saúde. Fundação Oswaldo Cruz. Sistema Nacional de Informações Tóxico Farmacológicas. Registros de intoxicação. Brasil - 2006. Available from:http://www.fiocruz.br/sinitox_novo/cgi/cgilua.exe/sys/start.htm?sid=111. Accessed in 2012 (Sep 18).
http://www.fiocruz.br/sinitox_novo/cgi/c...
Hence, environmental change is an urgent preventive measure.

The presence of certain plants in people's backyards, seen in the present study, matches the findings from a study conducted at the Pediatric Clinic of the Pontifical Catholic University of Rio Grande do Sul (Pontifícia Universidade Católica do Rio Grande do Sul, PUCRS), in which 48.3% of the parents interviewed were growing toxic plants at home.4141. Salerno MR, Stein AT, Fiori RM. Situação sobre a prevenção de intoxicações exógenas em Ambulatório de Pediatria na década de 90 [Diagnosis of exogenous intoxication prevention in Pediatric Outpatient Clinic in the 1990's]. Sci Med. 2008;18(2):66-74. It has been pointed out that poisoning by plants is responsible for 2% of all poisoning cases and that lack of knowledge about hazardous species lies at the root of the problem.4242. Garcia RSM, Baltar SLSMA. Registro e diagnóstico das intoxicações por plantas na cidade de Londrina (PR). Revista Brasileira de Biociências. 2007;5(supl. 1):901-2. Available from: http://www6.ufrgs.br/seerbio/ojs/index.php/rbb/article/viewFile/65/771. Accessed in 2012 (Sep 18).
http://www6.ufrgs.br/seerbio/ojs/index.p...
This highlights the need for guidance regarding the toxicological characteristics of plants, including widely-used ornamental species.

The presence of animals, in turn, is of concern insofar as bites can cause significant injuries, with sequelae in various spheres: emotional (resulting from the stress of exposure), physical (determined by scars and disfigurements) and economic (due to the cost of treatment and administration of vaccine and serum for rabies prevention).55. Mascarenhas MDM, Silva MMA, Malta DC, et al. Atendimentos de emergência por acidentes na Rede de Vigilância de Violências e Acidentes: Brasil, 2006 [Unintentional injuries at the Emergency Department Injury Surveillance System: Brazil, 2006]. Ciênc Saúde Coletiva. 2009;14(5):1657-68. There are several reasons why young children are more likely than adults to be attacked on the head: first, children's smaller stature; second, children are more likely to lean towards or put their faces close to the dog's head, which is perceived by dogs as a threatening posture; third, adults tend to have better defenses against attacks.4343. Pinto FGC, Tavares WM, Cardeal DD, et al. Traumatismo craniencefálico por mordida de cachorro [Craniocerebral injuries from dog bites]. Arq Neuro-psiquiatr. 2008;66(2b):397-9. Since most of the accidents with animals occur in homes, there is a need for educational action regarding care measures in relation to domestic animals (castration and vaccination, and identification of symptoms that indicate the presence of diseases, especially rabies) and measures to be taken in the event of aggression (going immediately to a healthcare clinic for treatment against rabies).

Gardens with tall grass were examined, bearing in mind that this may attract poisonous animals.77. Martins CB, de Andrade SM, de Paiva PA. Envenenamentos acidentais entre menores de 15 anos em município da Região Sul do Brasil [Accidental poisoning among children and adolescents in a county in southern Brazil]. Cad Saude Publica. 2006;22(2):407-14. Trees in the backyard may give rise to falls, which have been reported to be the main cause of emergency care, leading to serious sequelae and deficits.55. Mascarenhas MDM, Silva MMA, Malta DC, et al. Atendimentos de emergência por acidentes na Rede de Vigilância de Violências e Acidentes: Brasil, 2006 [Unintentional injuries at the Emergency Department Injury Surveillance System: Brazil, 2006]. Ciênc Saúde Coletiva. 2009;14(5):1657-68. Keeping the grass properly under control and preventing children and adolescents from climbing trees are important measures.

Regarding cultural factors, the fact that the families were unable to say whether accidents and violence were preventable or had the belief that they were not preventable was inconsistent with the positive response given when asked whether the family's habits favored occurrences of these events. In this respect, a gap in knowledge was observed, and this was consistent with studies in which the families were unaware of the hazards at home and did not know what each stage of children's growth and development represented in relation to accidents.4444. Amaral JJF, Paixão AC. Estratégias de prevenção de acidentes na criança e adolescente [Accident prevention - strategies for children and adolescents]. Revista de Pediatria. 2007;8(2):66-72. Available from: http://www.socep.org.br/Rped/pdf/8.2%20Resumo%20Art%20Rev.pdf. Accessed in 2012 (Sep 18).
http://www.socep.org.br/Rped/pdf/8.2%20R...
Thus, it becomes important to bear to mind the epidemiological model of the accident, in which the circumstance that generated the event comprises an etiological agent (a form of energy that violates the organic tissues), a host (the child/adolescent whose stage of development makes it possible to identify the risk) and the environment (the situation in which the accident occurs),2727. Maranhão DG. O conhecimento para preservar a vida: um tema delicado [The knowledge to preserve life: a sensitive issue]. VERAS Revista Acadêmica de Educação do ISE Vera Cruz. 2011;1(2):255-71. Available from: http://iseveracruz.edu.br/revistas/index.php/revistaveras/article/viewFile/56/40. Accessed in 2012 (Sep 18).
http://iseveracruz.edu.br/revistas/index...
which replaces the concept of randomness.

The fact that the families supervised their children and adolescents in activities in the water but not in other leisure activities coincides with affirmations that the level of supervision is still insufficient.4545. Morrongiello BA, Ondejko L, Littlejohn A. Understanding toddlers' in-home injuries: II. Examining parental strategies, and their efficacy, for managing child injury risk. J Pediatr Psychol. 2004;29(6):433-46. Comparison between the findings relating to the families' perceptions of supervision and the fact that most of the victims of drowning were alone at the time of the accident reveals a large gap in the families' perceptions of the risks. In the literature, this has been considered to be a factor directly related to traumatic events.4646. Vieira LJES, Araújo KL, Abreu RNDC, et al. Repercussões no contexto familiar de injúrias não-intencionais em crianças [The repercussion from unintentional injuries in children on the family context]. Acta Sci Health Sci. 2007;29(2):151-8. The same holds for delegation of tasks, since the child is not always mature enough to take on certain tasks.4747. Kosminsky EV, Santana JN. Crianças e jovens e o trabalho doméstico: a construção social do feminino. Sociedade e Cultura. 2006;9(2):227-36. Available from: http://www.revistas.ufg.br/index.php/fchf/article/viewFile/474/400. Accessed in 2012 (Sep 18).
http://www.revistas.ufg.br/index.php/fch...

CONCLUSION

Occurrences of accidents involve multiple causal factors ranging from the family environment to cultural and social factors. Lack of knowledge among families, non-preventive culture, habits favoring occurrences of accidents, too little surveillance of children/adolescents, unsafe domestic environments with presence of hazardous products and materials, indiscriminate delegation of tasks that are incompatible with the child or adolescent's age, lack of structure in traffic, access to firearms, work environments without safety standards, lack of more effective laws and lack of communication are some of the challenges to be understood and overcome.

Prevention is a challenging task, in which broad intersectoral action that encourages behavioral change is necessary in several social segments and in schools (both in formal and in informal groups).

Our findings point towards a need to foster safe and healthy behavior and environments, and to monitor occurrences of accidents through intersectoral actions. The importance of structuring and consolidating the attendance provided for victims should also be highlighted, in order to prevent deaths and promote rehabilitation.

Further progress is still needed with regard to the involvement of professionals in implementing the policies that have been issued, as well as in relation to better quality of information. Intersectoral actions will also be necessary, in view of the various factors involved in occurrences of accidents.

In addition, there is still a need to incorporate the issues into the curricula of various healthcare, educational and social science courses, in order to encourage reflection and create actions that contribute towards transforming the cruel reality of accidents.

Detailed knowledge of the risk factors, within a preventive approach, is essential for enabling progress in controlling accidents. Therefore, direct action in relation to risk factors and promotion of education for children, families and society, along with priority for specific policies, is urgently needed for effective control over accidents.

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  • Sources of funding: None

Publication Dates

  • Publication in this collection
    2013

History

  • Reviewed
    27 Jan 2012
  • Received
    18 Sept 2012
  • Accepted
    9 Oct 2012
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