2.1. (Brikama District Hospital), one major health

2.1.Study settings and participantsFrom October 2016 through May 2017, weconducted a case-control study with study participants recruited from emergencyrooms (ERs) and outpatient departments (OPDs) of government-managed healthcarefacilities located in six districts. These districts are located within the twolocal urbanized administrative regions (West Coast Region and Kanifing Municipality),which accounts for 60% of the country’s population GBoS, 2013. A simple random sample of eight healthfacilities were selected to represent the different tiers of the healthcaresystem in The Gambia, which included one tertiary health facility (SerrekundaGeneral Hospital), one district hospital (Brikama District Hospital), one majorhealth centre (Faji Kunda), and five minor health centers (Gunjur, Bakau,Banjul’nding and Serrekunda).

These health facilities treat a broad range ofconditions including patients with all injury types. Private healthcarefacilities were excluded from the studybecause they do not offer 24-h ER/OPD services to all patients. Cases were female patients aged ?15 years whosought medical treatment for injuries from physical violence during the studyperiod. An injury from physical violence was defined as any injury or physicalpain that had been intentionally caused by another person Hirschinger et al., 2003. Controls comprised of female patients aged ?15years who sought treatment for injuries from traffic crashes, falls, sports,and other non-violence causes and were matched to each case by health facility, date of injury from physicalviolence and age and. Patients were excluded from the study if they were unableto verbally communicate with data collectors, unable recall details of theviolent incident due to injury, could not provide a written consent, or wereminors.

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In total, 194 case-control pairs met the inclusion criteria and wereincluded in the analysis.All participants provided written informedconsent before participating in the study. The study protocol was reviewed andapproved by the University of The Gambia Research and Publication Committee andThe Gambia Government/Medical Research Council Joint Ethics Committee on humansubjects’ research.

The Ministry of Health Social Welfare also granted approvalto conduct the study at each participating health facility.2.2. Procedure ERs/OPDs staff trained on the administrationof the questionnaire, collected information on sociodemographics (e.g. age, height,weight, ethnicity, marital status, educational level, employment status,household income level and childhood upbringing), injury characteristics (e.g.

dateand time of injury, place of injury, mechanism of injury, nature of the injury,body part injured, severity of the injury and physical violence perpetrator),lifestyle behaviors in the past week (i.e. cigarette smoking, alcohol consumption,and illicit drug use), experience ofverbal abuse, physical threats or physical abuse in the past 12 months, socialsupports, and risk-taking behaviors.  To ensure data quality, twiceweekly visits by the researchers (PB and ES) were made to study sites to collect completed questionnaires, checkfor accuracy, and to ensure adherence to the study protocol. Questionnaireswere doubled checked, double entered and cleaned in Microsoft Access.2.3.

MeasuresInjury severity wasassessed using the Kampala Trauma Score II (KTSII) which was developed in 1996 by the Injury ControlCentre-Uganda Owor and Kobusingye, 2001. The KTSII scores five parameters during the patient’sassessment: age (in years), respiratory rate, systolic blood pressure,neurologic status and score for serious injuries on admission. The scores are furthercategorized into three levels:  mild (9~10), moderate (7~8) and severe (?6) injuries. The KTSII has been validated and found to be a goodmeasure of injury severity in most sub-Saharan African countries Weeks etal., 2014; Haac et al., 2015;Seid et al., 2015.

Social support was assessed using the 12-itemMultidimensional Scale of Perceived Social Support (MSPSS) which measures thelevel of support that an individual perceives in three domains (family,friends, and significant others) Zimet et al., 1988. The MSPSS has been usedin the USA and Africa populations and reported to have high reliability (alphacoefficients of 0.91~0.94) Canty-Mitchell and Zimet,2000; Stewart et al.

, 2014. The revised Domain-Specific Risk-Taking Scale(DOSPERT) was used to assess risk-taking behaviorswhich evaluate the likelihoods thatrespondents might engage in behaviorsfrom six risk domains (i.e., Ethical, Gambling, Investing, Health/Safety,Recreational, and Social) Blais and Weber, 2006. The DOSPERT has been validated and used in a wide range of settings, populations, andcultures, including South Africa Szrek etal., 2012 whichhas similar demographic characteristics to The Gambia. Three domains of Health/Safety,Recreational, and Social were used in this study. A high score indicatesgreater risk-taking level for each of the three domains.

2.4. Statistical analysisInjury patterns of casepatients were presentd as numbers with percentages. Distribution of sociodemographics,lifestyle behaviors in the past week, the experience of verbal abuse,  physical threats and physical abuse in thepast 12 months, social supports, and risk-taking behaviors were compared between cases and controls using Pearson’s Chi-squared test for categorical variables and Student’st-test for the continuous variables.To avoid large type II errors in variable selection and biased inferences,variables with a p-value of ?0.25 inthe bivariate logistic analysis were included in the multivariable analysis Maldonado and Greenland, 1993. A forward stepwise conditional logisticregression was used to identify independent relationships of potential riskfactors for injuries from physical violence in which adjusted odds ratios (ORs)and their 95% confidence intervals (CIs) were computed. Matching variables ofhealth facility, date of physical violence and age were forced into the multivariablemodel, and variables with p-values of<0.

05 were considered statistically significant. The Hosmer-Lemeshowgoodness of fit and likelihood ratio tests were used to evaluate the appropriatenessof the model Hosmer and Lemesbow, 1980. All analyses were performed using theStatistical Analysis Software (SAS) package (vers. 9.

4 for Windows; SASInstitute, Inc., Cary, NC, USA).  


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