Improving Estimates of Injury Burden in Nepal: A Qualitative Study.

BACKGROUND: Routinely collected injury data can help to identify populations at risk of injury, circumstances surrounding those injuries, and can be used to develop targeted interventions. However, routinely collected injury data in Nepal are at risk of being incomplete or poorly coded and are underutilised. Therefore, this study aimed to explore the strengths, and opportunities for improvement, of systems that routinely measure injury incidence in Nepal. METHODS: This study employed a qualitative design where data were collected through interviews with personnel working in four routine data systems; the Health Management Information System, the Road Accident Reporting System, the Daily Incident Reporting System, and the Civil Registration System. Interviews were conducted with front-line data collectors as well as strategic decision makers working in these data systems. Interviews were audio-recorded, transcribed, translated into English and analysed using framework analysis. RESULTS: A total of 32 interviews were completed, 19 interviews with front-line data collectors and 13 interviews with strategic decision makers. The data recording and reporting process of the four systems were identified and described. The analysis of data yielded 11 themes that described the strengths and limitations of the data collected through the four systems, challenges for effective data systems, and user recommendations for system improvement. CONCLUSIONS: This study identified the strengths, limitations, system challenges, and opportunities to improve data quality of each of the four routine data collection systems. These findings may be useful in engaging stakeholders in strengthening existing routine injury data collection systems or implementing alternative systems.

The Epidemiology of Injuries in Adults in Nepal: Findings from a Hospital-Based Injury Surveillance Study.

This study aimed to develop and evaluate a model of hospital-based injury surveillance and describe the epidemiology of injuries in adults. One-year prospective surveillance was conducted in two hospitals in Hetauda, Nepal. Data were collected electronically for patients presenting to emergency departments (EDs) with injuries between April 2019 and March 2020. To evaluate the model's sustainability, clinical leaders, senior managers, data collectors, and study coordinators were interviewed. The total number of patients with injuries over one year was 10,154, representing 30.7% of all patients visiting the EDs. Of patients with injuries, 7458 (73.4%) were adults aged 18 years and over. Most injuries (6434, 86%) were unintentional, with smaller proportions due to assault (616, 8.2%) and self-harm (408, 5.5%). The median age of adult patients was 33 years (IQR 25-47). Males had twice the rate of ED presentation compared with females (40.4 vs. 20.9/1000). The most common causes were road traffic accidents (32.8%), falls (25.4%), and animal/insect related injuries (20.1%). Most injured patients were discharged after treatment (80%) with 9.1% admitted to hospital, 8.1% transferred to other hospitals, and 2.1% died. In Nepal, hospital-based injury surveillance is feasible, and rich injury data can be obtained by embedding data collectors in EDs.

Development and Evaluation of a Community Surveillance Method for Estimating Deaths Due to Injuries in Rural Nepal.

Almost 10% of global deaths are secondary to injuries, yet in the absence of routine injury surveillance and with few studies of injury mortality, the number and cause of injury deaths in many countries are not well understood. This study aimed to develop and evaluate the feasibility of a method to identify injury deaths in rural Nepal. Working with local government authorities, health post staff and female community health volunteers (FCHVs), we developed a two-stage community fatal injury surveillance approach. In stage one, all deaths from any cause were identified. In stage two, an interview with a relative or friend gathered information about the deceased and the injury event. The feasibility of the method was evaluated prospectively between February 2019 and January 2020 in two rural communities in Makwanpur district. The data collection tools were developed and evaluated with 108 FCHVs, 23 health post staff and two data collectors. Of 457 deaths notified over one year, 67 (14.7%) fatal injury events were identified, and interviews completed. Our method suggests that it is feasible to collect data on trauma-related deaths from rural areas in Nepal. These data may allow the development of injury prevention interventions and policy.

Epidemiology of paediatric injuries in Nepal: evidence from emergency department injury surveillance.

BACKGROUND: Globally, injuries cause >5 million deaths annually and children and young people are particularly vulnerable. Injuries are the leading cause of death in people aged 5-24 years and a leading cause of disability. In most low-income and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited. METHODS: A new model of injury surveillance for use in emergency departments in Nepal was designed and piloted. Data from patients presenting with injuries were collected prospectively over 12 months and used to describe the epidemiology of paediatric injury presentations. RESULTS: The total number of children <18 years of age presenting with injury was 2696, representing 27% of all patients presenting with injuries enrolled. Most injuries in children presenting to the emergency departments in this study were unintentional and over half of children were <10 years of age. Falls, animal bites/stings and road traffic injuries accounted for nearly 75% of all injuries with poisonings, burns and drownings presenting proportionately less often. Over half of injuries were cuts, bites and open wounds. In-hospital child mortality from injury was 1%. CONCLUSION: Injuries affecting children in Nepal represent a significant burden. The data on injuries observed from falls, road traffic injuries and injuries related to animals suggest potential areas for injury prevention. This is the biggest prospective injury surveillance study in Nepal in recent years and supports the case for using injury surveillance to monitor child morbidity and mortality through improved data.

Home-related and work-related injuries in Makwanpur district, Nepal: a household survey.

OBJECTIVE: To describe the epidemiology of home-related and work-related injuries, their mechanisms, inequalities and costs associated with these injuries. METHODS: A household survey was undertaken in three palikas of Makwanpur district between April and June 2019. Data were collected electronically on non-fatal injuries that occurred in the previous 3 months and fatal injuries that occurred in the previous 5 years. FINDINGS: 17 593 individuals were surveyed from 3327 households. Injury rates were 8.0 per 1000 population for home injuries and 6.4 per 1000 for work-related injuries; 61.0% of home injuries were among women and 69.9% of work-related injuries among men. Falls were the cause of 48% home injuries, affecting 50.9% of men and 46.5% of women. Burns/scalds were higher in women than men, affecting 17.4% of women reporting home injuries. Cuts and piercings accounted for 39.8% of all work-related injuries and 36.3% were falls. Injury incidence varied by ethnic group: home injuries were highest in Brahmin (12.0 per 1000) and work-related injuries highest in Rai groups (21.0 per 1000). The total mean costs (transport and treatment) of work-related injury was US$143.3 (SD 276.7), higher than for home injuries (US$130.4, SD 347.6). The number of home (n=74, 64.9%) and work-related (n=67, 77.9%) injuries were higher in families below the poverty line than families in the next income bracket (home: n=22, 19.3%; work: n=11, 12.8%). CONCLUSIONS: Home-related and work-related fall injuries are common. The inequalities in injury identified in our study by rurality, age, sex, income level and ethnic group can help target injury prevention interventions for vulnerable groups.

Establishing injury surveillance in emergency departments in Nepal: protocol for mixed methods prospective study.

BACKGROUND: Globally, injuries cause more than 5 million deaths annually, a similar number to those from HIV, Tuberculosis and Malaria combined. In people aged between 5 and 44 years of age trauma is the leading cause of death and disability and the burden is highest in low- and middle-income countries (LMICs). Like other LMICs, injuries represent a significant burden in Nepal and data suggest that the number is increasing with high morbidity and mortality. In the last 20 years there have been significant improvements in injury outcomes in high income countries as a result of organised systems for collecting injury data and using this surveillance to inform developments in policy and practice. Meanwhile, in most LMICs, including Nepal, systems for routinely collecting injury data are limited and the establishment of injury surveillance systems and trauma registries have been proposed as ways to improve data quality and availability. METHODS: This study will implement an injury surveillance system for use in emergency departments in Nepal to collect data on patients presenting with injuries. The surveillance system will be introduced in two hospitals and data collection will take place 24 h a day over a 12-month period using trained data collectors. Prospective data collection will enable the description of the epidemiology of hospital injury presentations and associated risk factors. Qualitative interviews with stakeholders will inform understanding of the perceived benefits of the data and the barriers and facilitators to embedding a sustainable hospital-based injury surveillance system into routine practice. DISCUSSION: The effective use of injury surveillance data in Nepal could support the reduction in morbidity and mortality from adult and childhood injury through improved prevention, care and policy development, as well as providing evidence to inform health resource allocation. This study seeks to test a model of injury surveillance based in emergency departments and explore factors that have the potential to influence extension to additional settings.