2.1. (Brikama District Hospital), one major health

2.1.
Study settings and participants

From October 2016 through May 2017, we
conducted a case-control study with study participants recruited from emergency
rooms (ERs) and outpatient departments (OPDs) of government-managed healthcare
facilities located in six districts. These districts are located within the two
local 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 health
facilities were selected to represent the different tiers of the healthcare
system in The Gambia, which included one tertiary health facility (Serrekunda
General Hospital), one district hospital (Brikama District Hospital), one major
health centre (Faji Kunda), and five minor health centers (Gunjur, Bakau,
Banjul’nding and Serrekunda). These health facilities treat a broad range of
conditions including patients with all injury types. Private healthcare
facilities were excluded from the study
because they do not offer 24-h ER/OPD services to all patients.

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Cases were female patients aged ?15 years who
sought medical treatment for injuries from physical violence during the study
period. An injury from physical violence was defined as any injury or physical
pain that had been intentionally caused by another person Hirschinger et al., 2003. Controls comprised of female patients aged ?15
years 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 physical
violence and age and. Patients were excluded from the study if they were unable
to verbally communicate with data collectors, unable recall details of the
violent incident due to injury, could not provide a written consent, or were
minors. In total, 194 case-control pairs met the inclusion criteria and were
included in the analysis.

All participants provided written informed
consent before participating in the study. The study protocol was reviewed and
approved by the University of The Gambia Research and Publication Committee and
The Gambia Government/Medical Research Council Joint Ethics Committee on human
subjects’ research. The Ministry of Health Social Welfare also granted approval
to conduct the study at each participating health facility.

2.2. Procedure

ERs/OPDs staff trained on the administration
of 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. date
and 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 of
verbal abuse, physical threats or physical abuse in the past 12 months, social
supports, and risk-taking behaviors. 

To ensure data quality, twice
weekly visits by the researchers (PB and ES) were made to study sites to collect completed questionnaires, check
for accuracy, and to ensure adherence to the study protocol. Questionnaires
were doubled checked, double entered and cleaned in Microsoft Access.

2.3. Measures

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

Social support was assessed using the 12-item
Multidimensional Scale of Perceived Social Support (MSPSS) which measures the
level of support that an individual perceives in three domains (family,
friends, and significant others) Zimet et al., 1988. The MSPSS has been used
in the USA and Africa populations and reported to have high reliability (alpha
coefficients 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 behaviors
which evaluate the likelihoods that
respondents might engage in behaviors
from 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, and
cultures, including South Africa Szrek et
al., 2012 which
has similar demographic characteristics to The Gambia. Three domains of Health/Safety,
Recreational, and Social were used in this study. A high score indicates
greater risk-taking level for each of the three domains.

2.4. Statistical analysis

Injury patterns of case
patients 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 the
past 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’s
t-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 in
the bivariate logistic analysis were included in the multivariable analysis Maldonado and Greenland, 1993. A forward stepwise conditional logistic
regression was used to identify independent relationships of potential risk
factors for injuries from physical violence in which adjusted odds ratios (ORs)
and their 95% confidence intervals (CIs) were computed. Matching variables of
health facility, date of physical violence and age were forced into the multivariable
model, and variables with p-values of