Several findings are notable in this study. Earlier reports of trauma registries in Uganda show that the young male population is most affected by trauma, and the findings of this more updated study confirm the impact on this age group. Similar to previous studies, the data also show that road traffic injuries are the most common cause of injury overall, except for in children aged 5 and younger [13]. Worldwide, road traffic injuries account for approximately 30% of all childhood injury deaths [14], which mirrors our finding of overall injured people presenting to the hospital. While these results are no doubt partly a reflection of the underlying demographic patterns in sub-Saharan Africa, with a relatively younger population compared to more developed countries, these findings still have important potential implications for public health and for poverty eradication.
First, children and the economically productive segments of the population are most affected by injury, but the precise impact on household poverty (e.g., income forgone, impact on family members, household wealth lost) is poorly characterized, even in other sub-Saharan African nations with a similar burden of injury [15]. Though there was no specific variable to capture wealth or socioeconomic status, the preponderance of students and casual laborers that were injured suggests that poorer and more vulnerable groups are affected by injury, keeping with prior reports [16]. This could be further analyzed either through closer evaluation of patients hospitalized with injuries or as part of community surveys or ongoing demographic surveillance programs. Previous work has suggested that injury costs Uganda 2% of the GDP per year; however, the prevention and care of injuries has not been highlighted by the Poverty Eradication Action Plan of the Ministry of Finance or recognized as a key health-related aspect of Uganda’s progress toward the Millennium Development Goals [11].
In addition, the impact on school-age children suggests that more coherent policies for the prevention and care of injuries must be integrated into child health programs, as has been previously suggested from prospective studies in children and reviews of surgical conditions in the region [14, 17–19]. In the under-5-years age group, the preponderance of burns and falls points to areas of further research for prevention and care. Since the majority of child injuries occurred at home, one might consider how a household-based injury prevention program could be designed and implemented. In addition, though prior reviews suggest that school-based education programs for injury prevention have limited effectiveness, this may need to be reconsidered. Multiple randomized controlled trials have shown that safety education can change pedestrian behavior in high-income countries, although the effects on injury rates are not known. However, there have been no large-scale studies on pedestrian education in low and middle-income countries. Such interventions may need to be considered potentially in combination with other, more effective interventions at the household and primary care level to address the injury epidemic in Kampala [20].
Second, our findings also show that, within road traffic injuries, more passengers are injured compared to drivers in both motorcycle and vehicular injuries in Kampala. Not only are road traffic injuries the most common cause of injury, they are also responsible for the majority of fatal injuries that occurred in this study. This is in contrast to previous findings showing that pedestrians were the most commonly injured in road traffic injuries in urban Uganda. Prior studies have also shown the high impact on vulnerable road users such as pedestrians and motorcycle drivers [16, 21]. The increased numbers of non-driver injuries reflect the pattern of transport in Uganda, where few individuals own their own vehicles, and most use large vehicles that ferry numerous passengers at a time. This pattern provides a strong argument for interventions that increase the road safety of these large transportation vehicles.
This is also in keeping with prior work documenting that more passengers per crash are injured in LMICs compared to higher income countries. The authors have also noted that multiple casualty injuries are more the norm than the exception, and this has implications for the design of prehospital systems and the training and protocols in the casualty ward, which must be ready to receive several severely injured patients at a time.
Third, very few patients (less than 5%) were brought to the hospital by ambulance, with the majority of injured patients brought in private cars, by the police, and by bystanders. This rate has not changed significantly since earlier reports from the registry, suggesting that there has been limited progress in the development of a formal prehospital system. Though ambulances do exist in Kampala, they are privately run, and families must be able to afford the cost, which the majority cannot. Others have suggested that the majority of potentially avertable deaths in severely injured patients occur in the prehospital setting [2]. In Kampala, records of fatalities from the prehospital setting are captured by the police or by the public city mortuary. An analysis of trauma-related deaths from mortuary data may help to clarify the proportion of deaths and disabilities that may have been preventable by improved prehospital care. In the absence of an ambulance-based prehospital system, prior work has suggested that in regions of high injury incidence, initiatives to improve knowledge and skills of lay responders may be a feasible, cost-effective, and critical first step towards developing a formal emergency system [22]. These initiatives deserve further study [23, 24].
Finally, a primary finding of prior analysis is the preponderance of minor injuries presenting to the National Hospital, congesting the hospital and perhaps impeding the care of more severely injured patients. Our findings show a similar pattern and suggest that a more organized prehospital system might triage patients with less severe injuries to other health centers to decongest the tertiary care facility. This would require more thorough evaluation of the capacity of lower level health facilities to receive and care for injured patients. Qualitative interviews with Kampala residents during this study indicated that most patients prefer to attend Mulago Hospital because it is a government hospital with highly subsidized health care, unlike the only other options in the city, which are all private hospitals. Nevertheless, many injured patients still do not seek care because of other barriers to access to care, whether these are cultural, social, economic, or geographic. Prior work has suggested that up to 80% of patients with fractures present first to a traditional healer before coming to a hospital [25, 26]. Causes of this health-seeking behavior need to be further identified.
Hospital-based registries are limited because they do not capture injured patients who do not interact with the health system. A community survey in Ghana showed that 30% of patients with severe injuries did not access formal care [27]. Prior community surveys in Kampala have demonstrated that large proportion of injured patients die without reaching care, with a mortality rate of 2.2/1,000 per year, which is higher than that seen in this data [28]. There were 72 deaths recorded in the trauma registry, which is likely to be a gross underestimate of total deaths from injuries since a large proportion of deaths are likely to have occurred in the prehospital setting. Hospital-based death data should be analyzed with police and city mortuary data to calculate a better estimate of injury mortality in Kampala.
A large proportion of trauma deaths was due to head injuries in this study. Improving access to emergency neurosurgical care may have the potential to prevent a substantial proportion of these deaths. Prior reports have suggested that the human resources and infrastructure for neurosurgical care are very limited in sub-Saharan Africa. A more detailed mortality audit at the hospital level may help to determine how to improve care for patients with head injuries who reach the hospital [29]. Other strategies to decrease trauma mortality in similar settings have included the introduction of a trauma education course for health personnel [30]. This intervention is currently underway in Uganda, and an understanding of its effectiveness will add greatly to the provision of injury care in Kampala.
