Pattern of fall injuries in Pakistan: the Pakistan National Emergency Department Surveillance (Pak-NEDS) study.

BACKGROUND: We aimed to analyse the frequency and patterns of fall-related injuries presenting to the emergency departments (EDs) across Pakistan. METHODS: Pakistan National Emergency Departments surveillance system collected data from November 2010 to March 2011 on a 24/7 basis using a standardized tool in seven major EDs (five public and two private hospitals) in six major cities of Pakistan. For all patients presenting with fall-related injuries, we analysed data by intent with focus on unintentional falls. Simple frequencies were run for basic patient demographics, mechanism of falls, outcomes of fall injuries, mode of arrival to ED, investigations, and procedures with outcomes. RESULTS: There were 3335 fall-related injuries. In cases where intent was available, two-thirds (n = 1186, 65.3%) of fall injuries were unintentional. Among unintentional fall patients presenting to EDs, the majority (76.9%) were males and between 15-44 years of age (69%). The majority of the unintentional falls (n = 671, 56.6%) were due to slipping, followed by fall from height (n = 338, 28.5%). About two-thirds (n = 675, 66.6%) of fall injuries involved extremities, followed by head/neck (n = 257, 25.4%) and face (n = 99, 9.8%). Most of the patients were discharged from the hospital (n = 1059, 89.3%). There were 17 (1.3%) deaths among unintentional fall cases. CONCLUSION: Falls are an important cause of injury-related visits to EDs in Pakistan. Most of the fall injury patients were men and in a productive age group. Fall injuries pose a burden on the healthcare system, especially emergency services, and future studies should therefore focus on safety measures at home and in workplaces to reduce this burden.

A framework for addressing implementation gap in global drowning prevention interventions: experiences from Bangladesh.

Drowning is the commonest cause of injury-related deaths among under-five children worldwide, and 95% of deaths occur in low- and middle-income countries (LMICs) where there are implementation gaps in the drowning prevention interventions. This article reviews common interventions for drowning prevention, introduces a framework for effective implementation of such interventions, and describes the Saving of Lives from Drowning (SoLiD) Project in Bangladesh, which is based on this framework. A review of the systematic reviews on drowning interventions was conducted, and original research articles were pulled and summarized into broad prevention categories. The implementation framework builds upon two existing frameworks and categorizes the implementing process for drowning prevention interventions into four phases: planning, engaging, executing, and evaluating. Eleven key characteristics are mapped in these phases. The framework was applied to drowning prevention projects that have been undertaken in some LMICs to illustrate major challenges to implementation. The implementation process for the SoLiD Project in Bangladesh is used as an example to illustrate the practical utilization of the framework. Drowning interventions, such as pool fencing and covering of water hazards, are effective in high-income countries; however, most of these interventions have not been tested in LMICs. The critical components of the four phases of implementing drowning prevention interventions may include: (i) planning-global funding, political will, scale, sustainability, and capacity building; (ii) engaging-coordination, involvement of appropriate individuals; (iii) executing-focused action, multisectoral actions, quality of execution; and (iv) evaluating-rigorous monitoring and evaluation. Some of the challenges to implementing drowning prevention interventions in LMICs include insufficient funds, lack of technical capacity, and limited coordination among stakeholders and implementers. The SoLiD Project in Bangladesh incorporates some of these lessons and key features of the proposed framework. The framework presented in this paper was a useful tool for implementing drowning prevention interventions in Bangladesh and may be useful for adaptation in drowning and injury prevention programmes of other LMIC settings.

Compliance to playpen usages to enhance parental supervision of under-five children in rural community of Bangladesh.

INTRODUCTION: In Bangladesh, injury is one of the leading causes of death and morbidity in children. All children under 5 years of age are at high risk for drowning though the risks are highest when children first learn to walk and crawl while they do not understand the danger of water. The Centre for Injury Prevention and Research, Bangladesh (CIPRB) in collaboration with Johns Hopkins International Injury Research Unit (JH-IIRU) has been implementing two drowning prevention interventions, providing playpens and community day care centres (anchal), or both in three rural sub-districts of Bangladesh under Saving of Lives from Drowning (SoLiD) project in Bangladesh. In CIPRB intervention areas, wooden playpens were distributed among the children nine months to three years at household (HH) level. OBJECTIVE: The aim of this study was to explore and understand the acceptability and perceptions of parents towards playpen and its relevance for drowning and injury related mortality and morbidity prevention. METHODS: Anchal mothers ('anchal maa' in Bangla) distributed 30,553 playpens and collected compliance information at the HH level using a structured questionnaire. 1600 trained anchal maas collected data via face to face interviews from May 2014 to November 2015. Playpen compliance visits were conducted periodically on the second and seventh days and every two months after delivering the playpen. Data were entered using standard data entry formats and analyzed using SPSS software version 23. RESULTS: Parents reported that playpen is a safe place and protects children from drowning and other injuries. During compliance data collection, anchal maa founds that 71.8% of all children were using playpen and 93.7% (of 71.8%) children were playing inside the playpen while mothers were busy with their household chores like cooking, washing dishes and clothes, taking care of their poultry and domestic animals etc. 95.7% parents reported playpen is being used for keeping the child safe. On an average, the children were placed two to six times per day in a playpen. 99.1% of the children who reported using a playpen did not get any injuries (falls, cuts and bruises) while using the playpen. Satisfaction level with the playpen intervention among mothers was 90.5%. Some respondents suggested improving the playpen utilization by providing toys, adding wheels for ease of mobility, and increasing the height. CONCLUSION: The playpens were found to be well accepted and utilized for the children, especially when mothers were busy with their household chores.

Traffic, training, and turnover: Experiences of research personnel in collecting road safety data in Hyderabad, India.

We describe the experiences of research personnel in collecting road safety data, using a range of quantitative and qualitative methods to collect primary and secondary data, in the course of monitoring and evaluating the impact of road safety interventions under the Bloomberg Philanthropies Global Road Safety Program, in Hyderabad, India. We detail environmental, administrative, and operational barriers encountered, and individual, systemic, and technical enablers pertaining to the conduct of road safety research in Hyderabad, India, but bearing relevance to broader public health research and practice and the implementation and evaluation of projects. From our experiences of the challenges and the solutions developed to address them, we set out recommendations for research teams and for administrators in road safety as well as in various other streams of public health research and practice. We propose actionable strategies to enhance data-collectors' safety; build effective partnerships with various stakeholders, including research collaborators, administrators, and communities; and strengthen data quality and streamlining systems, particularly in similar geo-political settings.

Large-scale evaluation of interventions designed to reduce childhood Drownings in rural Bangladesh: a before and after cohort study.

BACKGROUND: This paper estimates the impact on childhood drowning rates of community-based introduction of crèches or playpens or both in rural Bangladesh for children aged 0-47 months. METHODS: A baseline census of the whole population of 270,387 households in 51 unions, 451 villages from 7 rural sub-districts in Bangladesh was conducted in 2013. The baseline census determined retrospective, age-specific, and cumulative drowning incidence rates (IR) experienced in the target households in the 12 months prior to the intervention. Beginning in late 2013, creches for drowning prevention were established across the study area. Acceptance into creches was provided and written assent to attend a creche was obtained for all children aged 9-47 months in all participating unions. Playpens were provided to 45,460 of these children, of which 5981 children received only the playpens. All children were followed-up until their 48-month birthday or administrative censoring (fixed timepoint to stop observing the drowning deaths), after a two-year implementation period (2014-2016). Drowning IR were estimated for children and compared to corresponding baseline rates from 2012. Age-specific drowning IR under different "as treated" categories (playpen-only, creche-only, and playpen-plus-creche) were compared to the baseline rates experienced by the categorized households prior to intervention. RESULTS: A total of 3205 creches (average of 7 creches per village) were established, and 116,054 children aged 9-47 months were exposed to the intervention packages. Aggregated drowning IRs between age 0 and 47 were estimated per 100,000 population per year at 86.73 (95% CI: 69.67-107.97) and 43.03 (95% CI: 35.55-52.10) in the baseline and post implementation period, respectively. Risk ratios were 0.40 (95% CI: 0.28-0.57) overall, and 0.34 (95% CI: 0.13-0.90), 0.09 (95% CI: 0.02-0.36), and 0.04 (95% CI: 0.002-0.60) in children under the creche-only, aged, 1, 2, and 3 years old respectively. Inexplicably, drowning rates were statistically significantly higher post-intervention in children 0-11 months. There was no mortality reduction with playpen use (alone or in combination), and this group may actually have had a higher risk of drowning. CONCLUSIONS: Creches are effective for preventing childhood drowning in rural Bangladesh for children above age 1-year, and should be considered for further scale-up.

Animal-related injuries and fatalities: evidence from a large-scale population-based cross-sectional survey in rural Bangladesh.

OBJECTIVE: This study determines the magnitude and pattern of animal-related injury mortalities and morbidities in rural Bangladesh. DESIGN AND SETTING: A cross-sectional survey was conducted in 51 Unions of 7 subdistricts of Bangladesh from June 2013 to September 2013. PARTICIPANTS: A total of approximately 1.17 million individuals across all age and gender profiles were included in the survey. The participants had to be residents of the seven subdistricts and have provided consent to participate in the study. PRIMARY AND SECONDARY OUTCOME MEASURES: Animal-related injury characteristics and demographic information was collected in the study. Frequency, proportion and 95% CIs of variables such as type of animal, type of animal attack, activity of the person prior to attack and the seasonality of the injury were reported. Data was then statistically analysed for associations between injury and sociodemographic characteristics. RESULTS: The incidence rate of fatal and non-fatal animal-related injuries across all ages were 0.7 (95% CI 0.4 to 1.4) and 1635.3 (95% CI 1612.0 to 1658.0) per 100 000 populations, respectively. Non-fatal animal-related injury rates were highest among adults 18 years and older (1820.6 per 100 000 population (1777.2 to 1865.1)), and in males across all age groups. The most common animal injury was wasp/hornet/bee sting (49%), followed by cow/buffalo (25%), dog bite (9%) and snake bites (9%). CONCLUSIONS: Animal-related injuries are an important public health issue in rural Bangladesh. The incidence of animal-related morbidities was found high in the study area. Males, school-going and productive age groups were at high risk. Immediate attention should be given to prevent these events.

Epidemiology of Fall Injury in Rural Bangladesh.

Globally, falls are the second leading cause of unintentional injury deaths, with 80% occurring in low-and middle-income countries. The overall objective of this study is to describe the burden and risk factors of falls in rural Bangladesh. In 2013, a large household survey covering a population of 1,169,593 was conducted in seven rural sub-districts of Bangladesh to assess the burden of all injuries, including falls. The recall periods for non-fatal and fatal injuries were six and 12 months, respectively. Descriptive, bivariate and multiple logistic regression analyses were conducted. The rates of non-fatal and fatal falls were 36.3 per 1000 and 5 per 100,000 population, respectively. The rates of both fatal and non-fatal falls were highest among the elderly. The risk of non-fatal falls was higher at extremes of age. Lower limb and waist injuries were frequent following a fall. Head injuries were frequent among infants (35%), while lower limb and waist injuries were frequent among the elderly (>65 years old). Injuries to all body parts (except the waist) were most frequent among men. More than half of all non-fatal falls occurred in a home environment. The injury patterns and risk factors of non-fatal falls differ by sociodemographic factors.

Pattern of Road Traffic Injuries in Rural Bangladesh: Burden Estimates and Risk Factors.

Globally, road traffic injury (RTI) causes 1.3 million deaths annually. Almost 90% of all RTI deaths occur in low- and middle-income countries. RTI is one of the leading causes of death in Bangladesh; the World Health Organization estimated that it kills over 21,000 people in the country annually. This study describes the current magnitude and risk factors of RTI for different age groups in rural Bangladesh. A household census was carried out in 51 unions of seven sub-districts situated in the north and central part of Bangladesh between June and November 2013, covering 1.2 million individuals. Trained data collectors collected information on fatal and nonfatal RTI events through face-to-face interviews using a set of structured pre-tested questionnaires. The recall periods for fatal and non-fatal RTI were one year and six months, respectively. The mortality and morbidity rates due to RTI were 6.8/100,000 population/year and 889/100,000 populations/six months, respectively. RTI mortality and morbidity rates were significantly higher among males compared to females. Deaths and morbidities due to RTI were highest among those in the 25-64 years age group. A higher proportion of morbidity occurred among vehicle passengers (34%) and pedestrians (18%), and more than one-third of the RTI mortality occurred among pedestrians. Twenty percent of all nonfatal RTIs were classified as severe injuries. RTI is a major public health issue in rural Bangladesh. Immediate attention is needed to reduce preventable deaths and morbidities in rural Bangladesh.

The Burden of Suicide in Rural Bangladesh: Magnitude and Risk Factors.

The aim of the paper is to quantify the burden and risk factors of fatal and non-fatal suicidal behaviors in rural Bangladesh. A census was carried out in seven sub-districts encompassing 1.16 million people. Face-to-face interviews were conducted at the household level. Descriptive analyses were done to quantify the burden and Poisson regression was run to determine on risk factors. The estimated rates of fatal and non-fatal suicide were 3.29 and 9.86 per 100,000 person years (PY) observed, respectively. The risk of suicide was significantly higher by 6.31 times among 15-17 and 4.04 times among 18-24 olds compared to 25-64 years old. Married adolescents were 22 times more likely to commit suicide compared to never-married people. Compared to Chandpur/Comilla district, the risk of suicide was significantly higher in Narshingdi. Students had significantly lower risk of non-fatal suicidal behavior compared to skilled laborers. The risk of non-fatal suicidal behavior was lower in Sherpur compared to Chandpur/Comilla. Among adolescents, unskilled laborers were 16 times more likely to attempt suicide than students. The common methods for fatal and non-fatal suicidal behaviors were hanging and poisoning. Suicide is a major public health problem in Bangladesh that needs to be addressed with targeted interventions.

Epidemiology of road traffic injury patients presenting to a tertiary hospital in Hyderabad, India.

BACKGROUND: Road traffic injuries kill more people in India than in any other country in the world, and these numbers are rising with increasing population density and motorization. Official statistics regarding road traffic injuries are likely subject to underreporting. This study presents results of a surveillance program based at a public tertiary hospital in Hyderabad, India. METHODS: All consenting patients who presented to the casualty ward after a road traffic injury over a 9-month period were enrolled. Interviews were performed and data abstracted from clinical records by trained research assistants. Data included demographics, injury characteristics, risk factors, safety behaviors, and outcomes. RESULTS: A total of 5,298 patients were enrolled; their mean age was 32.4 years (standard deviation 13.8) and 87.3% were men; 58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used motorized rickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than female victims and were overrepresented among motorized 2-wheeler users. Patients were most frequently injured from 1600 to 2400. A total of 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of deaths were among motorized 2-wheeler users. CONCLUSION: This is one of the few prospective, hospital-based studies of road traffic injury epidemiology in India. The patient population in this study was similar to prior hospital-based studies. When compared to government surveillance systems, this study showed motorized 2-wheeler users to be more frequently represented among the overall population and among fatalities. Further research should be done to develop interventions to decrease mortality associated with 2-wheeled vehicles in India.

Characteristics associated with alcohol consumption among emergency department patients presenting with road traffic injuries in Hyderabad, India.

INTRODUCTION: Each year in India, road traffic crashes lead to more than 200,000 deaths and the country has seen an unprecedented rate of roadway fatalities in recent years. At the same time, alcohol consumption per capita among Indians is rising. Despite these increasing trends of road traffic injuries (RTIs) and alcohol use, alcohol is not routinely assessed as a risk factor for RTIs. This study aims to examine the involvement of alcohol among emergency department patients presenting with RTIs in the Indian city of Hyderabad. PATIENTS AND METHODS: As part of a prospective study, data were collected from 3366 patients (88.0% male) presenting with RTIs at an emergency department in Hyderabad, India, from September 2013 to February 2014. Logistic regression models were used to assess individual-level and road traffic crash characteristics associated with suspected or reported alcohol consumption six hours prior to the RTI. RESULTS: Alcohol was suspected or reported among 17.9% of the patients with RTIs. Adjusting for confounders, males experienced 9.8 times greater odds of alcohol-related RTIs than females. Compared to 15-24 year-olds, the odds of alcohol consumption was 1.4 times greater among 25-34 year-olds and 1.7 times greater among 35-44 year-olds, adjusting for confounding factors. Patients who were passengers in vehicles other than motorized two-wheelers had 90% reduced odds of an alcohol-related RTI than motorized two-wheeler drivers. Drivers of non-two-wheelers, passengers on two-wheelers, and pedestrians did not have significantly different odds of an alcohol-related RTI compared to two-wheeler drivers. Nighttime crashes were associated with nearly a threefold increase in the odds of alcohol consumption. CONCLUSIONS: Given that alcohol was suspected or reported in more than one in six injured ED patients with RTIs, it is clear that alcohol is a serious risk factor for RTIs; this evidence can guide prevention efforts. These findings suggest that evidence-based interventions to reduce drink-driving, such as random breath testing (where law enforcement officials stop drivers on the road to test them for alcohol use), could be more widespread in India. Future studies should assess the effectiveness of greater implementation and enforcement of policies to decrease alcohol's availability to reduce RTIs.

The validity of self-reported helmet use among motorcyclists in India.

BACKGROUND: Motorcyclists are the most vulnerable vehicle users in India. No published study has assessed the validity of self-reported estimates of helmet use in India. The objectives of this study were to assess helmet use by comparing observed and self-reported use and to identify factors influencing use among motorcyclists in Hyderabad, India. METHODS: Population-based observations were recorded for 68 229 motorcyclists and 21 777 pillion riders (co-passengers). Concurrent roadside observations and interviews were conducted with 606 motorcyclists, who were asked whether they "always wear a helmet". Multivariate logistic regression analyses were conducted to determine factors influencing helmet use. RESULTS: In the population-based study, 22.6% (n = 15,426) of motorcyclists and 1.1% (n = 240) of pillion riders (co-passengers) were observed wearing helmets. In roadside interviews, 64.7% (n = 392) of the respondents reported always wearing a helmet, 2.2 times higher than the observed helmet use (29.4%, n = 178) in the same group. Compared with riders aged ≥40 years, riders in the age groups 30-39 years and 18-29 years had respectively 40% (95% confidence interval [CI]: 0.4 to 1.0, P < 0.05) and 70% (95% CI: 0.2 to 0.5, P < 0.001) lower odds of wearing a helmet after controlling for other covariates. Riders with postgraduate or higher education had higher odds of wearing a helmet (adjusted odds ratio [OR]: 4.1, 95% CI: 2.5 to 6.9, P < 0.001) than those with fewer than 12 grades of schooling. After adjusting for other covariates, younger riders also had 40% (95% CI: 0.3 to 0.9, P< 0.05) lower odds of self-reporting helmet use, while those with postgraduate or higher education had 2.1 times higher odds (95% CI: 1.3 to 3.3, P < 0.01) of reporting that they always wear a helmet. Police had stopped only 2.3% of respondents to check helmet use in the three months prior to the interview. CONCLUSION: Observed helmet use is low in Hyderabad, yet a larger proportion of motorcyclists claim to always wear a helmet, which suggests that observational studies can provide more valid estimates of helmet use. Interview findings suggest that a combination of increased enforcement, targeted social marketing and increased supply of standard helmets could be a strategy to increase helmet use in Hyderabad.

E-mentoring for violence and injury prevention: early lessons from a global programme.

To address the growing burden of violence and injuries, especially in low- and middle-income countries, in 2007 the World Health Organization launched MENTOR-VIP, a global violence and injury prevention (VIP)-mentoring programme. The programme aims to develop human resource capacity through 12-month mentoring arrangements between individual VIP experts (mentors) and less-experienced injury practitioners (mentees). In this paper, we review the first five years of the programme (2007-2011) using a systems analysis and SWOT (Strengths, Weaknesses, Opportunities and Threats) frameworks, discuss programme findings and make recommendations. A well-defined programme with clear instructions, successful matching of mentorship pairs with similar interests and language, a formal accord agreement, institutional support and effective communication were identified as programme strengths. Overambitious projects, lack of funds and difficulties with communications were identified as programme weaknesses. Mentorship projects that require institutional permissions or resources could be potential threats to the success of mentorship. The study resulted in the four following recommendations to strengthen the programme: (1) institute additional steps in selection and matching mentor-mentee pair; (2) train mentors on e-mentoring; (3) conduct special orientation for mentees to the programme; and (4) maintain effective and open communication throughout the programme.

Qualitative study to explore stakeholder perceptions related to road safety in Hyderabad, India.

The Bloomberg Philanthropies Global Road Safety Programme in India focuses on reduction of drink driving and increase in helmet usage in the city of Hyderabad. During the early stages of implementation, perceptions of stakeholders on road safety were explored as part of the monitoring and evaluation process for a better understanding of areas for improving road safety in Hyderabad. Fifteen in-depth interviews with government officials, subject experts, and road traffic injury victims, and four focus group discussions with trauma surgeons, medical interns, nurses, and taxi drivers were conducted, analysed manually, and presented as themes. Respondents found Hyderabad unsafe for road-users. Factors such as inadequate traffic laws, gaps in enforcement, lack of awareness, lack of political will, poor road engineering, and high-risk road users were identified as threats to road safety. The responsibility for road safety was assigned to both individual road-users and the government, with the former bearing the responsibility for safe traffic behaviour, and the latter for infrastructure provision and enforcement of regulations. The establishment of a lead agency to co-ordinate awareness generation, better road engineering, and stricter enforcement of traffic laws with economic and non-economic penalties for suboptimal traffic behaviour, could facilitate improved road safety in Hyderabad.