This population-based survey provides the first national estimates on non-fatal injuries in Kenya. Our study additionally identified factors associated with injuries that include social, demographic, behavioral and biological. This is important as it helps to identify targeted interventions that could have a greater impact in reducing the burden of injuries. Fifteen percent of the respondents reported that they had been seriously injured in the past 12 months and required medical attention. This proportion is quite high and needs to be addressed as injuries have far reaching effects on individuals, societies and the health care systems [1, 8]. This is higher than what has been reported in developed countries such as Germany with 10.7% [25]. and developing countries such as Sierra Leone with 12.4% [26] and Uganda 14% [27].
Our findings are consistent with other studies that have found a higher risk of injuries among males than females [26, 28, 29]. The gender disparity in injury mortality, has been attributed to multiple factors and the same concepts can be advanced for the gender disparities in non fatal injuries [30]. There is increased exposure to injury risk factors such as alcohol use and occupational hazards among males compared to females [24].
Research findings also reveal the great role societal factors play in injury incident such as level of masculinity and perceived gender roles which in turn have a bearing on risk taking [31]. Masculinity is described as a set of characteristics, qualities or roles that are generally attributed to men [32]. The high burden of injury in males needs to be addressed. In addition we must also recognize that though prevalence of injury among females is low, injuries are still an important cause of morbidity and mortality in this group [10]. In addition to public health interventions that advocate for behaviour change such as stoppage of alcohol drinking, measures that advocate for societal changes must also be heightened.
The prevalence of injuries was significantly higher among rural residents than urban residents. Previous studies corroborate this finding [33, 34]. Other studies have found no difference in occurrence of injury by place of residence [26, 28]. Some studies conducted among children have found a higher preponderance of injuries among children living in urban areas [35]. The occurrence of injury in rural settings may be explained by the nature of work related activities that include farming which could carry a higher risk of injury. Majority of the country’s population reside in rural areas with faming as their primary mainstay, this difference in incidence of injuries between the two areas has to be factored in when setting priorities for injury prevention interventions in the country.
Injuries have been widely associated with low social economic status [5, 28]. A report released by the World Bank in January 2018 estimated that countries can lose between 7 and 22% in potential per capita gross domestic growth over a 24-year period [36]. In our study, this pattern was true for only other accidental injuries where respondents from the two richest quintiles had less likelihood of getting other unintentional injuries. Individuals from poorer backgrounds tend to live, work and travel in less safe conditions [1].
The strongest association between injuries and heavy episodic drinking (binge) was found among respondents who had been involved in a violent incident. Similar findings have been found elsewhere [18, 37, 38]. It should however be noted that our study did not directly link the injury to alcohol taking prior to the injury. However, frequency of alcohol taking is a good proxy to estimate alcohol related injury. Our study seemingly contradicted the preventive paradox theory which states that more alcohol related harm is found among the drinkers at low risk [39]. Respondents who drank alcohol but were not binge drinkers tended to have fewer injuries than binge drinkers and non-alcohol drinkers though this was not statistically significant. Nevertheless, alcohol control policies including drink driving measures need to be stepped up in the country. In particular domestication of the global strategy for harmful reduction of alcohol use needs to be fast tracked [40].
Our study explored the association between injury and smoking, an area with limited information. Respondents who smoke were more likely to be involved in a road traffic injury and violent injury than respondents who did not smoke. Prior studies have found evidence of this relationship between smoking and risk of injuries [41, 42]. It has been advanced that the association between smoking and injury is as a result of direct toxicity, distractibility, smoking-associated medical conditions and confounding factors, including personality or behavioral characteristics [41]. There is need to heighten public health awareness to healthcare workers and the public on this additional harmful association of smoking.
Road traffic injuries have been a long standing public health concern in Kenya [14, 43]. Nearly 4 % of the respondents had been involved in a road traffic crash and sustained injuries that required medical attention. Surprisingly there were a higher proportion of respondents injured in the rural areas than urban areas where the level of motorization is higher. It is possible that the a high influx of motorcycles and bicycles in the rural areas could be responsible for this [44]. The consistent use of seat belt and helmets was reported by 13% and 6% of the respondents respectively. A study conducted in two towns in Kenya, Thika and Naivasha, found the prevalence of helmet use among riders to be 25.7% and 37.2% respectively [45]. These levels remain worryingly low despite the numerous heightened mass media campaigns conducted by various road safety agencies. To bring meaningful change in this area, enforcement efforts have to be strengthened alongside the media campaigns. There was an admission of driving while drunk and riding while drunk by 8% and 7% of the drivers and riders respectively. The Traffic Amendment Act Cap 405 prohibits drink driving. There needs to be strengthened enforcement on drink driving and also the law needs to be amended to prohibit riders from riding under the influence of alcohol.
Nearly one in ten of the respondents had been involved in an unintentional injury other than road traffic injury. Cuts were the most common injury type followed by falls. Other studies have found falls to be the most frequently occurring injury [26, 29]. The difference in ranking in our study may be attributed to the occupation of the majority of the respondents as most of the cuts occurred at the farm. Nevertheless, these types of injuries are preventable and people should be educated on how to make home, school and work environments safe.
Our study provides the first national estimates for violence among adults in the country other than domestic and sexual violence. Four percent of the respondents reported that they were involved in a violent incident in the preceding 12 months. This is lower than what has been reported in other African counties. Sudan has recorded a prevalence of violence of 7.1% [28] while in Côte d’Ivoire the prevalence ranges between 12.2 and 21% [46]. It is important to note that however the two countries have been afflicted by human conflict in the past. Half of the violence was perpetrated without using a weapon implying that most of the incidents may not have been premeditated. Violence is preventable using the public health approach and therefore the relevant stakeholders need to work together to institute measures [1].
Our study had several limitations. The use of self reporting may have led to underreporting due to recall bias leading to underestimation of injuries. The period used to assess injuries was one year and it is possible that respondents may not have remembered the injuries they sustained. Nevertheless, it has been established that community based studies are less prone to underestimation compared to hospital based studies [13]. Secondly, the study is unable to tell the direction of some associations such as binge drinking. There is also a likelihood of under reporting of some of the variables such as binge drinking and smoking because of the way they are viewed by the society. Underreporting of intentional injuries because of social undesirability may also have occurred. Additionally, the findings of this study underestimate the injury burden because of exclusion of patient outcomes such as disability adjusted life years, years lived with disability and mortality [47]. Furthermore, the study did not assess the societal or economic effects of injuries. Lastly, the study excluded sexually based violence. Despite these limitations, the study gives important insights on the burden of non-fatal injuries in the country. Given the current situation where there is a paucity of data, this is a first step towards gathering information and further studies should be conducted to give comprehensive national information on patient outcomes and socioeconomic effects. The main strength of this study is that it is nationally representative and allows for the exploration of a diversity of associations which are useful for policy formulation.
