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The objective of this study was to qualitatively evaluate young Egyptians’ perceptions, attitudes, knowledge and behaviour towards injuries before implementation of an extensive questionnaire about injuries among Egyptian youth. In 2008, five focus groups of three to nine participants each were conducted in Cairo, Egypt in Arabic to evaluate young Egyptians’ attitudes towards injuries, injury prevention, and their understanding of ‘accidents’ and fatalism. Participants were 14–26 years of age and were from medium to high socioeconomic status. Focus group participants noted that the concept of hadthah (‘accident’) signified an event determined by destiny, whereas esabah (‘injury’) was the result of human actions. The results of these focus groups indicate that young, educated Egyptians are interested in injury prevention programmes despite low confidence in the preventability of injuries.
Injuries are a leading cause of death and disability worldwide, and are projected to grow in proportional morbidity and mortality.1 The Egyptian Ministry of Health estimated that 24 222 deaths, 127 216 hospitalisations and 847 912 disability-adjusted life years occurred due to injuries in 1999.2 Road traffic crashes (RTCs) are thought to account for one-quarter of all injury deaths in Egypt, with ~28 000 people injured and 6000 killed in 27 000 RTCs in 2002.3 Approximately 45% of Egypt’s population is under the age of 20 years,2 which is noteworthy considering that RTCs are the leading cause of death for people aged 15–29 of both sexes in the Eastern Mediterranean Region of the World Health Organization.1 Despite the significant impact on the population, little public attention has been given to injuries and trauma in Egypt.
In this study, we report a series of focus groups designed to explore the knowledge, attitudes, and perception of injuries and their prevention among young Egyptians. These focus groups evaluated the comprehension and appropriateness of a survey about injuries before its administration among Egyptian secondary school students, and explored perceptions of the Arabic words hadthah (‘accident’) and esabah (‘injury’).
Focus groups were used to investigate knowledge and attitudes about injuries as well ideas about injury prevention in young Egyptians in Cairo. Convenience samples of young Egyptians, primarily from sport and social clubs in the Cairo metropolitan area, were gathered in August 2008. Several university staff members and students spread word of the focus groups to friends and family. Youth over the age of 13 were asked to assemble at a set location and time to meet the moderator. This study received institutional review board approval from University of Maryland and Ain Shams University. At the end of the focus groups, participants received a nominal gift (a pen or keychain) to thank them for their participation.
Five focus groups, of ~1 h each, were completed in sport and social clubs in Cairo during August 2008. Written informed consent was obtained from each participating adult, while assent plus parental consent was obtained for participants under 18 years. An experienced, bilingual (Arabic/English) focus group leader led the discussion in Arabic according to an established protocol. The protocol was developed by consensus of a subset of the authors (HRD, MAE, JMH, GSS) before assembling of the focus groups. All focus groups were audio-taped; a note taker assisted with recording, noting only age and sex to link each comment to an individual participant. Participants were encouraged to discuss topics from the protocol manual.
The focus group leader provided an Arabic transcription and an English translation, indicating comments by age and sex of participant only. The main method of analysis was long table analysis.4 The first author (HRD) was responsible for grouping and developing codes to represent themes that emerged repeatedly across the focus groups.
The five groups were made up of a total of 28 young Egyptians, 14–26 years old. Eleven participants (39%) were female. The education levels of the participants varied: four (14%) had finished preparatory education (approximately equivalent to early high school in the USA), six (21%) were still in secondary school, four (14%) had finished secondary school, eight (29%) were currently attending university, one (4%) had finished university, and five were employed (18%) (table 1). Focus groups were of mixed gender and age, as no participants were turned away if they desired to participate.
Participants generally concurred that an esabah (‘injury’) was some form of bodily damage. A hadthah (‘accident’) was usually perceived as more dangerous than injuries. In two groups, a hadthah required hospital attention, whereas an esabah was ‘simpler’ or ‘cured faster’. Three groups discussed the idea that a hadthah was due to ‘destiny’ or was ‘out of one’s control’, indicating ‘hadthah’ are less preventable than ‘esabah’. One young man stated that ‘(If) one knows that what he does could cause an esabah, this is an esabah. But a hadthah is related to destiny, something unexpected.’ One group mentioned that a hadthah occurred between someone and something.
Hadthah was more commonly used for describing traumatic events in general, such as animal bites, violence, bicycle crashes, falls, RTCs, drownings, poisonings, pedestrian injuries and burns. Most participants agreed that RTCs were hadthah and not esabah, with only one person considering RTCs as esabah (figure 1). Esabah was more commonly used for violence and bites. Interestingly, participants thought neither hadthah nor esabah correctly described fires and burns; no better word was mentioned.
Several themes emerged as causes of traumatic events including carelessness/lack of awareness, lack of responsibility and lack of commitment. Related to carelessness was the idea that the law, including lack of respect for it, played a large role in causes of traumatic events in Egypt. One participant stated: ‘People do not abide by the laws, when someone drives fast, he does not respect (the) law and this leads to a crash.’ Others felt that it was not only a lack of people’s respect for the law, but also the ease of circumventing it by paying money to avoid a fine.
Three groups mentioned that respect for laws should be an integral part of prevention; two groups mentioned increased penalties (punishments and fines). ‘If everyone (who) broke the law was punished and paid the fine, all people would abide by the law.’ Specific ideas for how to avoid crashes included increased/strict road surveillance, radar/camera use, and education on relevance of the laws. The need for laws regulating helmets and seatbelts, public transportation and trucks was emphasised.
Involving the police was discussed in three focus groups, although this action was controversial. One participant said he would contact the police only if he witnessed a crash. Another individual stated he would be willing to testify. A third focus group participant thought helping at an incident scene could lead to blackmail or accusations of responsibility.
Several participants felt that infrastructure problems, such as inadequate road design and crowding, lead to traumatic events in Egypt. Several participants discussed the importance of fire extinguishers and lack of fire alarms in Egypt. The need for pedestrian ‘bridges in the highways and streets’ was highlighted.
Overcrowding and lack of order on public transportation was seen as a problem. For example, ‘If each driver stands in the specified garage or bus stop, there would be no crashes. The microbus stops in any place to drop someone off or pick someone up.’ The dangerous practices of truck drivers were mentioned by two groups.
Injury prevention ideas focused on education, enforcement and engineering. The idea of educational or awareness campaigns in schools and public locales was strongly supported by the participants, especially through media such as television, email, newspaper, or even adverts in the metro. Participants were eager to point out changes that could reduce injuries in Egypt, and had many suggestions for how law enforcement and technology could be used to prevent injuries.
These focus groups qualitatively investigated injury-related knowledge, attitudes, perceptions and prevention ideas of young, educated Egyptians in the metropolitan area of Cairo. All participants involved in the focus groups thought injuries were an important cause of morbidity and mortality in Egypt and were receptive to the idea of injury prevention.
A key finding was that participants thought hadthah (accidents) were more serious than esabah (injuries) and that hadthah were less preventable (more likely to be out of one’s control) than esabah. This is interesting considering that, in English speaking countries, injury prevention researchers have pressed for the word ‘injury’ to be used instead of ‘accident’ in order to convey the idea of preventability.5,6 When translating injury questionnaires into Arabic, it is important to keep in mind that Egyptians may not identify with the use of the word esabah to describe certain events.
The idea that hadthah was out of one’s control was consistently expressed, suggesting that participants consider hadthah less preventable than esabah. Road traffic injuries were nearly unanimously thought of as hadthah. Of interest is the apparent conceptual inconsistency of the inevitability of hadthah compared with the frequent discussion of prevention strategies for RTCs.
Individual responsibility, as indicated by the concepts of carelessness and lack of respect for the laws, was viewed as the main human cause of injuries in Egypt.
Similar to our results, a recent study in Iran7 also found that people believed law enforcement was important for RTC prevention, and that education had an important role in the prevention of traumatic events in general. Like Egypt, rough and careless driving was a perceived cause of road traffic injuries in South Africa.8 Police deterrence and enforcement were two suggestions for preventing injuries in South Africa.8 Participants in our study felt law enforcement could play a positive role in injury prevention, but this will be a sensitive issue, as some participants were reluctant to be involved in legal matters related to car crashes or traumatic events.
The participants’ focus on aspects of infrastructure, including public transportation and city planning, suggests that Egypt is still in the early stages of injury prevention, and basic engineering measures are needed to prevent many injuries. However, participants were also open to educational preventive measures, which suggests they recognise some human responsibility in certain events.
These focus groups have served to re-evaluate the terminology recognised by lay people related to injuries in Egypt, and has uncovered an openness to prevention along with advice for how and where to implement educational and prevention methods in Egypt.
Limitations of this study include small sample size, potential bias due to mixed age/gender focus groups, and the fact that the focus groups were a convenience sample of young Egyptians. Although the groups only represented urban upper middle class young adults, these relatively well-educated young people were easily able to vocalise ideas for prevention and to discuss the problems they see in Cairo, where the majority of urban Egyptians live. Overall, the results of these focus groups uncovered language issues (hadthah vs esabah), which are important to keep in mind for future surveys in Egypt. It is important to note that causes, knowledge and prevention strategies related to injuries might differ in rural areas and should be the target for future research.
The results of these focus groups show that young, educated Egyptians are prepared for the implementation of injury prevention programmes. In one participant’s words: ‘It is not wrong to learn good lessons and practices from other countries like European countries. We can use the cameras in monitoring traffic like in Saudi Arabia.’ However, it is important to take into account the different concepts of the words hadthah (accidents) and esabah (injuries) in order to try to move beyond fatalism so as to change attitudes and behaviours towards injuries.
Funding This work was supported by a Junior Scientist Development Visit Grant Award, USDA award number 58-3148-8-109, and Fogarty Grant 5D43TW007296.
Other Funders: NIH; USDA.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was approved by the institutional review boards at the University of Maryland School of Medicine and Faculty of Medicine, Ain Shams University.
Contributors All authors contributed substantially to this work, including review and acceptance of the final manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.